Women and Trauma

TRAUMATIZED WOMEN

Causes and treatments

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Psychological trauma affects millions of Americans , women in particular . This problem alarms psychotherapists , who must treat the traumatized , and negatively impacts society in general . Trauma is a direct result of abuse , whether that be physical , sexual or emotional Such abuse has a strong tendency to repeat itself from generation to generation , because victims often reenact the evil that has been visited upon them

The suffering of the traumatized patient manifests itself

in various feelings , from anger to depression , and in various psychological defenses , such as aggressive outbursts , verbal provocation , disavowal and guilt feelings . Post traumatic stress dis (PTSD ) is one of the most commonly discussed psychiatric syndromes in the popular press The term is self-explanatory , referring to the host of problems which trauma sufferers experience after the stressful event (s

A climate of openness has replaced the veil of secrecy which once enshrouded the subject of abuse . The media has played a role in this too , taking us deeply into the lives of people who have survived natural and manmade disasters . Hardly a day goes by without some reference to the painful effects of trauma on people 's lives and how they attempt to wrangle away from it or adapt to its consequences (Brown , 1995

Although tornadoes and other natural disasters can be the cause of trauma in women , abuse , particularly violent abuse , is the main cause Furthermore , violence seems to be moving out of the home and into the schoolyard , workplace , and neighborhood . No one is protected from the impact of trauma and its potentially overwhelming effects , and no physician can avoid seeing its ravages in his medical practice

Trauma victims are frequently incapacitated , as their capacity to cope is overwhelmed . Psychiatrists and counselors note that no two individuals handle stress in the same way . Whether a woman builds up psychiatric symptoms within days or decades - or not at all - after a traumatic event , depends on many factors : psychological health before the trauma , age , the unique personal meaning she attaches to the event as well as her support system during recovery

In the course of a lifetime , of us escape traumatic events . We all must deal with death of loved ones , even if the rest of our life is idyllic . Often , abuse victims are left to cope with the psychological consequences alone , if friends and loved ones don 't take the time to sympathize . Devastating rage and a sense of vulnerability are the most common responses , particularly after an unexpected catastrophe , a malicious or random act , or the death of a loved one

Susan Cohen was the mother of 20-year-old Theo Cohen , who was murdered when terrorists blew up Pan Am Flight 103 over Lockerbie , Scotland , on December 21 , 1988 . Susan expressively captures for many the "nightmare world " of personal catastrophe when she writes

Of all the emotions I have held since Theo 's murder , anger is the best . Rage gives me energy . Rage makes me strong . I live my diminished life . But grief is always there . I am in pain all the time . Call it living defensively , this always being prepared for the unexpected reminder , always being on guard against the shock that creates panic , this eternal vigilance against the innocent remark that will bring on depression . Like a child going through nightly rituals to ward off fear of the dark , I too must be especially careful at bedtime . If I fall asleep , I dream : Catastrophic dreams , sad dreams dreams of searching for Theo (Cohen , 1996 ,

. 50 )er

In studies of community samples , several stressors were found to precipitate the syndrome of PTSD : motor vehicle accidents catastrophic medical problems , such as burns or myocardial infarctions and different types of employment in which the individual is exposed to "life-threatening situations and violent or grotesque scenes , such as the military . But the most common cause of PTSD is childhood abuse the after-effects of which can last a lifetime (Freud S . 1896 /1998

Then , in adulthood , between three and four million women are victims of domestic abuse each year . Murder at the hands of an intimate partner is a major cause of death among women and the most frequent cause of death for African-American women age fifteen to thirty-four (reference . Depression , anxiety and eating diss are recurrent comorbid symptoms of trauma and are likely to be refractory to psychiatric intervention unless the trauma is addressed

Violence occurs at least once in sixty-six percent of all marriages (reference ) Ninety-five percent of domestic abuse victims are women , who are also three times as likely as men to be victims of a violent crime by any family member . Wife beatings result in more injuries requiring medical treatment than do sexual assaults , automobile accidents , and robberies , combined (reference ) Twenty-one percent of pregnant women are abused , and these women are twice as likely to miscarry as those who were not (reference

Rigorous epidemiologic research shows that one woman in four in the United States will be raped at some time during her life , and that one in three has been sexually abused in childhood (reference ) However even these stark findings do not take into account the high rate of verbal abuse and physical violence missed by even the most thorough studies . Experts in the field of domestic violence estimate that one in four women visiting an urban emergency room has in fact experienced domestic or sexual battery within the past year (reference

Abuse can escalate to murder in some cases . The risk of "femicide increases when there is a history of beating and the woman decides to leave . As Campbell clarifies concerning issues of power and control in the relationship between battered women and their spouses , the woman 's partner is essentially saying "If I can 't have you , no one can (Campbell , 111

The abuse of women unfortunately also carries over to have a deleterious effect on the lives of our children . In at least fifty percent of families where the mother is abused , the child is also abused (reference ) Children who witness incidents of violence are unavoidably traumatized , yet they rarely receive counseling or emotional support . Additionally , abused children may have severe behavioral and emotional problems , but are often unreachable through psychological intervention . These children make psychological adaptations to offensive situations and create lasting relationship patterns that present both obstructions and opportunities for treatment (Fraiberg , S . 1987

Physicians often fail to identify the problem due to time constraints lack of training and experience , and sometimes to avoid the inconvenience of reporting such touchy situations to legal authorities This failure to identify child abuse produces long-standing effects on children 's development and behavior , including learning problems depression and anxiety , tendency to express pent-up feelings in somatic problems , and imitative violent behavior

Children observe and imitate the behavior of the adults in their world Those who frequently witness or experience violence by adults do not learn how to restrain their own violent tendencies . Children with such poor role models often act out the violent behavior they learned on their own siblings , friends and pets .Children in these situations often have poor peer relationships , bully other children , and in extreme cases , engage in animal torture and killing . In one study of sixty-eight sexually abused children and seventy-five control subjects , noteworthy behavioral problems appeared much more frequently in the former group (reference ) These included depression , anxiety , and eating diss , as well as lower self-esteem , fewer social contacts , and more attempted suicides , with an elevated incidence of smoking and self-mutilations compared to the control subjects . The abused children were also more likely to have parents with drug and alcohol problems . of these research findings would surprise any clinician who has worked for even a short time in an emergency room setting or office-based practice and has seen the immediate and long-term psychological , physical , and social difficulties linked with child abuse (Fraiberg , 1987

A number of landmark studies explain the complex neurobiologic sequelae of childhood and adulthood (reference ) Brain researchers understand that endogenous stress hormones , such as catecholamines corticosteroids , serotonin , and endogenous opioids have an effect on how memories are stored in the brain . Traumatized individuals tend to remember merely bits and pieces of a horrific experience due to the massive secretion of these neurohormones , mainly norepinephrine

Trauma disturbs the functional integration of extensive cortical and subcortical regions , as evidenced by electroencephalography , positron emission tomography , and cortical event-related potentials . These neuroanatomic effects include decreased hippocampal volume , activation of the amygdala and its connected structures , as well as lateralization to the right hemisphere when traumatic events are remembered . Decreased activation of Broca 's area during flashbacks supports the clinical observation that traumatized individuals cannot use words to explain their experience . It appears that , Broca 's area actually "switches off when traumatic memories are activated (Yehuda , 2001

Researchers know that stimulation of the amygdala interferes with hippocampal functioning , but the actual effects on brain structure are complex and difficult to unravel . Trauma causes permanent changes in the limbic system , and impairs cortical control . Therefore , the trauma victim is not capable of consolidating , processing , and working through traumatic memories . Disruptions in the limbic structure cause an array of problems , including amnesia , exaggerated startle response hyperarousal , and dissociation (Yehuda , 2001

Patients with PTSD have decreased hippocampal volumes , leading to a loss of verbal memories . In addition , traumatic memories are activated in the right hemisphere of the brain , which processes emotion . For this reason , the clinically observable phenomenon of traumatized patients who "suffer from speechless terror " is commonplace Apparently , in trauma victims , the left hemisphere , Broca 's area , where language and communication occurs , suffers diminished oxygen utilization the right hemisphere independently recalls and facilitates emotional responses and sensory impressions based merely on fragments and unintegrated bits of information . The patient who is reminded of traumatic events has compounded neurophysiologic susceptibility that affects her capacity to name feelings , explain what has happened , and work through trauma (Yehuda , 2001

The impact of domestic violence , rape , physical and sexual trauma , and natural disaster on the lives of women is astounding . Nobody is immune to the impact of traumatic events life is a high-risk proposition Some do manage to deal with stress better than others . By recognizing and treating victims of abuse and posttraumatic stress , physicians can make enormous inroads toward improving the mental and physical health of women

To deal with this massive public health problem , physicians need guidelines for patients who suffer the consequences of natural disaster childhood abuse , or adult trauma like rape or domestic violence . Some health problems can be triggered months and years , even decades after the traumatic event . Clinicians need to work with others as a team for effective treatment . Such care can be costly , but the cost of avoiding treatment is often much higher . Screening and early intervention are becoming integrated into the preventive health services of some insurance and managed care plans (reference ) They have come to understand the cost effectiveness of such interventions . These difficulties can be reduced if effective help is offered early

Intervention starts by creating a safe environment where the clinician can ask the patient in privacy if abuse has occurred . Once the traumatic stress is recognized , the clinician can work to stabilize the symptoms Sometimes the patient denies the abuse , When a woman is capable of expressing her pain or acknowledging a traumatic experience , crying may be her first release . Soon afterward , she may start to vent her anger and sense of hopelessness regarding how to deal with the pain . The primary care clinician must provide the patient with a sense of safety and assist her in formulating a plan to deal with the resurrection of the trauma , including finding extra emotional support

Generally , the patient benefits from individual and /or group psychotherapy , which assists her to process the traumatic event (s ) and to integrate the trauma into her world view . Throughout this process the primary care clinician plays an essential role by offering support and encouragement while providing medical care , including prescription drugs as needed

Primary care clinicians must be watchful regarding the occurrence of PTSD when even highly functioning patients are exposed to natural disasters , motor vehicle accidents , and catastrophic medical illnesses such as severe burns or myocardial infarctions . These patients can also benefit from treatment interventions that include individual and group psychotherapy and pharmacotherapy . For those patients who survive a disaster or other catastrophic stressor , community resources are very important . Support from family , relatives , and friends assists them to cope better than those who do not have such support . While mental health personnel are often available immediately after an event , patients may experience delayed effects , and they must be urged to seek out professional support . Family members can be helpful when they listen empathically to reports of past traumatic events , then redirect attention to the present and the future (Farmer ,1997

For those patients who lose a loved one in an unanticipated cataclysmic personal event , such as an automobile accident , survivor guilt can take a heavy toll . Why did I survive when they didn 't ? they often ask themselves , over and over . Frequently these survivors build up a plethora of somatic complaints , depression , anxiety , or lack of zest for living , as they have not been capable of effectively working through their loss by themselves . These patients require help in channeling their aggression constructively , as in social activism , working with Mothers Against Drunk Driving , for instance , and in fighting the propensity to blame themselves . They have to learn that the stressful situation was beyond their control , something which just happened to them . A treatment principle necessary for all forms of trauma is the working through and mastery of the residual effects in psychotherapy . In the process , psychopharmacologic modalities including SSRIs , clonazepam and clonidine can be very helpful to lessen arousal , insomnia , and anxiety . The majority of mental health experts believe that psychotherapy is a sine qua non to successfully processing traumatic events and memories and to adaptively integrating what has happened into the trauma survivor 's world view (Farmer , 1997

References

Brown , L (1995 . Not outside the range : One feminist perspective on trauma . Baltimore : Johns Hopkins

Campbell JC (1992 "If I can 't have you , no one can : power and control in homicide of female partners ' In : Radford J , Russell DEH (eds Femicide : The Politics of Woman Killing , pp . 99-113 . New York , Twayne Publishers

Cohen S (1996 . Rage makes me strong ' Time , July 29 ,

. 50

Farmer ,

(1997 . On Suffering and Structural Violence : Social Suffering . Berkeley : University of California Press . Pp 261-284

Fraiberg , S (1987 . Ghosts in the nursery : a psychoanalytical approach to the problems of impaired mother-infant relationships . In L Fraiberg (Ed . Selected Writings of Selma Fraiberg , 100-136 . Columbus Ohio State Press

Freud S (1896 /1998 . The etiology of hysteria ' In J Masson . The assault on truth : Freud 's suppression of the seduction hypothesis , NY Pocket Books , pp 259-290

Yehuda , R (2001 . Post-traumatic stress dis ' New England Journal of Medicine 246 (2 , 108-114

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Traumatized Women ...