Posttraumatic Stress Disorder: Psychodynamic Explanations

child with post-traumatic stress disorderThe link between trauma and mental illness has been known for many decades. As early as 1896, Freud hypothesized that sexual trauma resulted in hysterical illness (Chu, 1991). He later adjusted his theory to suggest that intra-psychic conflict and not the external trauma causes many illness and several aspects of this later theory have been applied to the understanding of PTSD and its main presenting symptoms.

Most individuals react with shock and disbelief when faced with a harrowing ordeal (realistic anxiety). In the weeks and months to follow, they may also experience nightmares, episodes of intrusive thoughts and images, as well as hyperarousal. In time, however, they are able to process and incorporate such negative events into their views of the world and self and are able to carry on with their lives. On the other hand, some individuals, especially children, have difficulty coping with traumatic experiences and integrating such events into their psyche. These experiences may be repressed and dissociated from consciousness, only to re-emerge later in the context of disorders such as PTSD. [showmyads]

In Freud’s view, not only does repressed trauma re-emerge later in life, it also reactivates previously repressed but unresolved conflicts from childhood. The combined anxiety (neurotic anxiety) resulting from the reawakening of this earlier conflict and from the more recent trauma results in other defense mechanisms such as regression, denial, reaction formation and undoing, which are all responsible for some of the symptoms of PTSD (Sadock & Sadock, 2004). For example, regression to an early stage of development, such as the oral stage which was characterized by ego disorganization, could result in some of the numbing symptoms characteristic of PTSD. These include depersonalization (feeling detached from one’s mental processes or body), derealization (experiencing the external world as strange or unreal) and anhedonia (an inability to experience pleasure from normally pleasurable activities) (Fink, 1988).

In explaining one of the major symptoms of PTSD – the re-experiencing of trauma – a helpful concept from Freud’s theory is that of repetition compulsion. This is the reemergence of repressed intrapsychic conflicts which become superimposed on reality (Chu, 1991). According to Freud:

The patient cannot remember the whole of what is repressed in him, and what he               can’t remember may be precisely the essential part of it. He is obliged to repeat the repressed material as a contemporary experience instead of remembering it as something in the past. (Chu, 1991, p.328)

This phenomenon of repeating past traumatic events is actually a compulsion. According to Freud, the need for repressed material to enter consciousness is more powerful than the pleasure principle, so despite the best efforts of the individual to keep memories of the experience repressed, the psyche forces them into consciousness. The purpose is that by reliving the experience, the ego thereby tries to master and reduce the anxiety. At first, the events are repeated in dreams and nightmares over which there is no conscious control, and later on in waking hours. According to Chu (1991), the compulsion to relive these experiences is almost a matter of biological urgency and can be likened to the need to urinate. One can postpone this event for some time but eventually, one has to give in to the urge.

From a psychoanalytic perspective, therefore, the dreams and flashbacks which PTSD patients often experience are a result of repetition compulsion. An important point to remember is that the reliving of the trauma in PTSD patients is usually experienced as a real and contemporary event. Patients do not simply recall the ordeal, they usually feel as if they are reliving it in the present. Some individuals are pulled back so far into these experiences thata they even lose awareness of their present surroundings and realities (Chu, 1991).

Since not all persons who experience trauma actually develop PTSD, what differentiates those who do from those who do not? In the words of Verhaeghe and Vanheule (2005): “a traumatic event leads to the development of PTSD if the victim has a pre-existing psychological structure that can be understood as Freud’s actual neurosis” (p. 493). They explain that this pre-existing structure prevents the individual from processing the traumatic incident in a normal, symbolic or representational way, which they believe is the main problem in PTSD.

The basis for this argument lies in the similarities between Freud’s actual neurosis and PTSD. In both disorders, anxiety is the core component and there is no psychical processing of this anxiety. There is also an inability to produce a normal (associative) representation and meaningful elaboration of the underlying cause of anxiety (Verhaeghe & Vanheule, 2005). Both disorders also involve some degree of somatization. Although these similarities are significant, some may argue that they are not enough to confirm that a pre-existing neurotic structure predisposes an individual to PTSD. However, research supports the theory that such a structure is present in individuals before the development of PTSD as there is a high incidence of disorders, especially somatization and anxiety disorders in PTSD patients before exposure to a trauma.

Theories emerging from self psychology, another orientation within psychodynamic theory, also help to elucidate the causes of some PTSD symptoms. Ulman and Brothers (1988, cited in Fink, 1988), self psychologists, view many of the symptoms as a dissociative defense. Dissociation, in their view, is a splitting of the ego into the ‘experiencing self’ and the ‘observing self’ and it serves two functions. Firstly, it protects the individual from the overwhelming intensity of the trauma, allowing them to view the occurrence as a dream (derealization) or to feel as if they are merely onlookers and not engaged in the trauma (depersonalization). Dissociation is also believed to have a restorative function in that it allows individuals to create fantasies in which they can undo traumatic injury to their psyche. However, dissociation prevents individuals from processing the trauma psychologically, resulting in somatosensory symptoms. Basically, instead of the trauma being inscribed in their psyche it is instead inscribed on their bodies.

References

Chu, J. A. (1991). The repetition-compulsion revisited: Reliving dissociated trauma. Psychotherapy, 28(2), 327-332.

Fink, D. L. (1988).[Review of the book The shattered self: A psychoanalytic study of trauma]. Dissociation, 1(4), 59-60.

Sadock, B. J., & Sadock, V. A. (2004). Kaplan and Sadock’s concise textbook of clinical psychiatry (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Verhaeghe, P., & Vanheule, S. (2005). Actual neurosis and PTSD: The impact of the other. Psychoanalytic Psychology, 22(4), 493-507.

Photo courtesy of Arvind Balaraman / FreeDigitalPhotos.net

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