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People with PTSD experience a nexus of symptoms that include somatization, depression, anxiety, and dissociation. They may experience musculoskeletal pain that alternates with a lack of feeling and sensation, gastrointestinal problems (Ross, 1994), heart, respiratory (Litz, Keane, Fisher, Marx, & Monaco, 1992), and reproductive problems. Nightmares invade their sleep, and waking life is affected by recurrent visual images of the trauma itself. They feel out of control.
This perception, in turn, drives them to remain on guard, hypervigilant, and overly controlled. Affective outbursts that include irritability, aggression, and fear lead to withdrawal and detachment from activities and interpersonal connections. Decreased levels of neurochemicals in the brain contribute to the negative feedback loop of depression, irritability, self-mutilation, and eating disorders (Demitrack, Putnam, Brewerton, Brandt, & Gold, 1990; Favazza, 1987).
Because the causes of somatic symptoms cannot always be diagnosed, treating these conditions can be difficult for the general practitioner, who may lack the knowledge of the extent of the role of PTSD in physical health. Or they may call these symptoms psychosomatic (which technically they are, for they involved both psyche and soma), leading only to a prescription of an antidepressant.
Everyone who has experienced trauma has a unique experience, and their trauma manifests itself in different ways. Sometimes, we need to look beyond conventional diagnostics to identify cases of trauma. This was a lesson I took to heart with my former patient, Sara.
Case Story
Sara was a 14-year-old who had been sexually abused and had a diagnosis of Oppositional Defiant Disorder. She abused drugs and alcohol, which brought her into treatment, and she was disruptive and annoyed her teachers and her milieu therapists. She had very painful periods and kept complaining of pain in her pelvic region, but medical exams and testing revealed no precise cause. I told her that we were going to treat it and asked her to describe her pain in detail, to describe when it began, what she thought the cause was, and what she thought would help reduce the pain.
She spoke in detail about the abuse she had experienced, and I asked her to touch the areas of her pain as she spoke. We limited these discussions to 15 minutes each session over a period of 4 sessions. I suggested that we move slowly and that each time the pain might have something new to reveal, and as we discovered what the pain had to say, we would have more knowledge about how to treat it.
Setting limits on the exploration of pain created safety for Sara, and this approach honored her focus on the physical pain that was the story her body was telling about her experience. Simultaneously her “oppositional behavior” abated, and she made progress. Together we wrote a report to the physician about the nature of the pain and its cause. Often what is called ODD is really a reflection of Complex or Developmental Trauma. What we name things defines how we treat.
References
Demitrack, M., Putnam, F., Brewerton, T., Brandt, H., & Gold, P. (1990). Relation of clinical variables to dissociative phenomena in eating disorders. American Journal of Psychiatry, 147(9), 1184-1187.
Litz, B. T., Keane, T. M., Fisher, L., Marx, B., & Monaco, V. (1992). Physical health complaints in combat-related post-traumatic stress disorder: A preliminary report. Journal of Traumatic Stress, 5(1), 131-141.
Ross, C. A. (1994). Dissociation and physical illness. In D. Spiegel (Ed.), Dissociation: Culture, mind, and body (pp. 171-180). Washington, DC: American Psychiatric Press, Inc.
