The indwelling of trauma

How PTSD sufferers live, breathe and survive, 40 years after recognition as mental disorder

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While post-traumatic stress disorder — PTSD for short — is fairly commonplace in discussions surrounding mental health today, it’s a relatively new diagnosis.

In his book, “The Body Keeps the Score,” Dutch psychiatrist Bessel van der Kolk explained that the first real reference to what became PTSD was in the 1941 report “The Traumatic Neuroses of War,” written by Abram Kardiner. Kardiner met with veterans of World War I and found that they “were overtaken by a sense of futility” and “had become withdrawn and detached, even if they had functioned well before.” He referred to their issues as “traumatic neuroses.”

“Kardiner noted that sufferers from traumatic neuroses develop a chronic vigilance for and sensitivity to threat,” van der Kolk wrote. “His summation especially caught my eye: ‘The nucleus of the neurosis is a physic neurosis.’ In other words, post-traumatic stress isn’t ‘all in one’s head,’ as some people supposed, but has a physiological basis. Kardiner understood even then that the symptoms have their origin in the entire body’s response to the original trauma.”

Van der Kolk himself researched, consulted with and treated veterans of the Vietnam War in the late 1970s, and partly as a result of his work, helped get PTSD recognized as an official diagnosis by the American Psychiatric Association in 1980. Forty years later, this mental health disorder is still alive and well, affecting people in Chatham County and throughout the state, country and world.

Defining it

The DSM-5, the most recent edition of the psychiatrist’s “Bible,” says the primary driver of PTSD is an individual directly experiencing, witnessing, learning about or “experiencing repeating or extreme exposure to aversive details” of traumatic events, like military combat, a natural disaster, car accident or physical violence, like domestic abuse or sexual assault.

The National Center for PTSD — an agency under the U.S. Department of Veterans Affairs — says on its website that for those who have those encounters with trauma, “it’s normal to have upsetting memories, feel on edge, or have trouble sleeping after this type of event. If symptoms last more than a few months, it may be PTSD.” Other possible symptoms include depression, anxiety, irritable behavior, suicidal ideation and attempts and hyper-vigilance.

That latter symptom is one of the most visible to Susanne Saunders, a Pittsboro-based therapist who mainly treats young children.

“I see this in children when they maybe go to play with something, but they look back at me to make sure nothing’s going to happen or I don’t tell them they can’t do what they’re doing,” Saunders said. “It’s when you perceive that a threat is always there. Right now the world is hyper-vigilant because of COVID. It’s very much like that, that there’s a perceived threat going on.”

The National Center for PTSD says six of every 10 men and five of every 10 women will experience at least one traumatic event in their lifetimes. Additionally, around 7-8 percent of the U.S. population will have PTSD at some point — 10 percent of women and 4 percent of men — and eight million adults will have PTSD during a given year.

The DSM-5 says that PTSD rates are higher among military veterans and “others whose vocation increases the risk of traumatic exposure (e.g., police, firefighters, emergency medical personnel).” It adds that one-third to more than one-half of survivors of rape, military combat and captivity or “ethnically or politically-motivated internment and genocide” will have PTSD.

The disorder also has negative life consequences as well. PTSD sufferers will often change jobs regularly and get married multiple times. That’s something that David Kennedy, the veterans services officer for Chatham County, has seen in his work with veterans.

“Sometimes it’s a little uncertainty about themselves, or a dull effect,” he said. “They don’t have much ambition, much drive to do anything. They’re anxious a lot, or depressed. You can look at discharge papers and see what they did, maybe, or if they were awarded certain medals like the Purple Heart, like their life was in harm’s way. That’s a good starting point for post-traumatic stress disorder.”

For veterans

The initial defining of PTSD and its entry into psychiatry lingo came from the Vietnam War. Although it killed around 58,000 Americans — less than 10 percent of the death toll from the U.S. Civil War — the impact it left on those who served was palpable.

In “The Body Keeps the Score,” van der Kolk tells the story of a Vietnam veteran he treated named Tom. Tom came into van der Kolk’s office in July 1978 “so agitated and so clearly hungover.” Instead of celebrating the Fourth of July with his family, Tom holed up in his law office, hoping to avoid the noise, fireworks and heat, even the foliage backdrop of a backyard barbecue, that reminded him of his time in Vietnam.

“His sleep was constantly interrupted by nightmares about an ambush in a rice paddy back in ’Nam, in which all the members of his platoon were killed or wounded,” van der Kolk wrote. “He also had terrifying flashbacks in which he saw dead Vietnamese children. The nightmares were so horrible that he dreaded falling asleep and he often stayed up for most of the night, drinking.”

It’s not an uncommon story. Kennedy worked with the N.C. Division of Veteran Affairs for four decades, and in that time, he saw plenty of those effects.

“A great deal of Vietnam veterans came back suffering from post traumatic stress disorder,” he said. “I saw how it affected their marriages, their employment, the way they were able to deal with people. You hear their stories — battling and walking through the jungle and not knowing what’s around the next tree or walking in rice patties exposed.”

Initially, Kennedy said, doctors with the Veterans Administration were hesitant to treat the symptoms of PTSD, but “as more was found out about it,” the agency “accepted the fact that it was debilitating to a lot of people.”

“I still have Vietnam veterans coming in who just now are getting around to admitting they have a problem with post-traumatic stress disorder,” Kennedy said. “I had a husband and wife come in, and the veteran was saying, ‘It doesn’t bother me that much,’ and the wife is saying, ‘Yes it does, yes it does.’”

But it’s not exclusively Vietnam War vets Kennedy expressed concern for.

“I feel especially for the guys in this Gulf War era who have had to make more than one tour over to Afghanistan or Iraq,” he said. “Some companies have gone three, four, five times. Those guys just can’t help but come home with something going on in their mind because they’re exposed to so much uncertainty and danger. I feel for the guys that keep getting sent back, knowing that it’s not good for them.”

For children

But as van der Kolk wrote, “war is not the only calamity that leaves human lives in ruins.”

“For every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes,” he continued. “This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers.”

It’s these growing children that Lara Kehle — the director of KidSCope Early Intervention and Family Support and vice chair of the Chatham Health Alliance — will often see in the agency’s office in Pittsboro or its developmental day center in Siler City.

“Many of the children that we see referred to the consultation program especially, those are the ones that are often deemed the ‘challenging-behavior children,’” she said. “So often challenging behavior is misunderstood. It’s rooted in trauma.”

But unfortunately, she said, many of those charged with training, teaching and overseeing children are not equipped to recognize the difference. School teachers are often asked to handle these cases, she added, but don’t have the training — and aren’t paid enough — to handle it.

“It’s new in the education world,” she said. “I’ve been doing this for a minute, and it wasn’t discussed when I was in school. You learned about trauma, you learned about different childhood disorders, but you didn’t necessarily discuss the connection like we are now.”

Saunders will often work with children in what’s termed play therapy. At first, she will let a child loose in a playroom to engage with sand or play cooking material and just observe, called “non-directive therapy.” Sometimes, she said, these children will “act out the trauma in their play” and use that as a jumping point for more “directed play.” She will also conduct breathing and body exercises as a way to help children “normalize the sensory world around” them.

Reaching children who experience trauma early, Saunders said, is critical, because it can get worse.

“If trauma is not resolved for children, in adult years there can be what we call ‘complex trauma,” she said. “If you can work with them as they’re young, it’s very important. So if another traumatic event happens, they (can) clear up any cognitive distortions that are there.”

For help

KidSCope steps in, Kehle said, when children or families are referred by schools or doctors and provides mental health consultations and services for children up to age 5. There’s also the Incredible Years Parent Training Program for parents and a Inclusive Child Care Program that includes educational activities and various types of therapy.

Kehle told the story of a pair of families working with KidSCope right now. One child receiving help was a foster child that was eventually adopted by the foster family, and another family is in the midst of fostering children. That type of change can be incredibly traumatic, she said, but having a positive, helpful adult can make a huge difference.

“The science of resilience says that one nurturing adult, one nurturing relationship can help buffer a significant amount of stress,” she said.

That type of adult support for children, Saunders added, is critical on both a systemic and individual level for dealing with trauma.

“Anybody who’s a caregiver for children needs to be looking for signs of either internalizing or externalizing,” she said. “Anybody who’s in a supervisory role with children, if they can find out more about what those signs are, or if you feel in your gut, ‘Something’s not right with my kid.’”

A stigma around mental health issues still exists — particularly among veterans, Kennedy said — but there are plenty of resources in and around Chatham County to get help. The county government has a webpage with a list of mental health resources — chathamnc.org/mentalhealth — and Chatham County Schools employs school counselors and social workers and contracts with other therapists in the area to provide services.

“What we do is, we give a choice of, ‘Hey, what agency would you like to go with?’ and we put in a referral,” Tracy Fowler, CCS’ executive director of student support services, told the News + Record last year for “The Age of Anxiety” podcast, “and they would go and meet with a parent to do an intake, and from there they would go to the school at a time we determined would be best for the kid and then they meet with them weekly, bi-weekly, dependent on the need.”

The VA offers benefits for veterans with PTSD, and that can provide help, but there are also things the layman can do, Kennedy said. Namely, just thank them.

“It seems like a cliche at times now, but you can always thank them for their service,” he said, “and depending on how old they are, you might ask them, ‘Where were you stationed while you were in service?’ Or ‘What did you do while you were in service?’ That often opens up a lot of communication.”

Sometimes that much can be an aid — simply having a conversation, being a friend, listening and hearing.

“It really breaks down to things like let’s have positive relationships with kids, let’s make sure they have an adult in the building that they can talk to,” Fowler said. “Let’s make sure that we’re putting things in place that they connect with people in the building and friends and they have appropriate social relationships with each other. And then from there, it’s a matter of, ‘OK, let’s see, are there areas of need? Are there areas of deficiency? What kind of interventions could we put in place for kids that need that?’”

Kehle added, “The importance of recognizing mental health in children, recognizing the importance of those nurturing and caring relationships, and providing the atmosphere and environment to build those relationships and learn those coping skills — it can make it seem less doom and gloom. While there is doom and gloom, there is hope.”

Reporter Zachary Horner can be reached at zhorner@chathamnr.com or on Twitter at @ZachHornerCNR.