I wish to share with you what I believe are the often underappreciated aspects of the consequences of trauma, ones that for many individuals are the most painful aspects of living with trauma. (I have to apologize beforehand that this is a heavy topic and graphic too. But I hope you can travel with me on this journey, since as psychiatrists we’re asked to treat so many trauma survivors.)

And btw, the aspects of trauma I focus on today I believe are better addressed in the expanded DSM-5 PTSD criteria than they were in DSM-IV or DSM-III. Rather than launch into an explanation, allow me to start with a thought experiment.

Imagine you wake from a bad dream and recall the following: In your dream you’re running and fighting in a hellish landscape of screaming people, wounded bodies, and corpses. You dart inside a large darkened building. It turns out to be a theater and you are surprised that there is human activity on stage. As you approach you notice that there is a group of people – actors, you assume – situated in a family room setting on stage. Small children are playing on the floor as the adults sit around and chat. You climb on stage and say, “What are you doing here? Don’t you know there’s a war going on outside? Don’t you realize you’re in danger?” One of the women turns to you and says with a look of indulgence, “Oh, come now. Don’t exaggerate. Come join us for a moment.” You persevere, “No, there is mayhem out there, all around you. Don’t you see it? Come with me and I’ll prove it to you!” The woman replies, “Perhaps later, I’m rather tired right now.” She adds, while slightly rolling her eyes towards the other characters, “Perhaps you can show me around tomorrow.”

If you were the protagonist here, how would you feel? Confused? Frustrated? As this scene continued to roll out in this same way over a period of days, weeks, months, and years – what then? Would you feel increasingly angry? Enraged, perhaps? Eventually falling into despondency?

How about alone? Estranged? Isolated? Abandoned? Adrift? Like some sort of alien who landed in a strange land? Like someone stuck in a bad dream that never ends?

That’s what trauma does. We all go through life existing within a certain frame of unquestioned reality; it’s our Reality Frame. We expect that we will wake up tomorrow, that the sun will rise in the east, that our significant other and family members will be present and respond to us in much the same way as they always have.
It’s all so familiar that we don’t stop to question this reality’s contingency, the possibility that it can disappear or change drastically at any moment. All this is based on our expectations that the rules our reality follows will continue to be followed forever.

Then one day the fabric of reality tears, the veil is lifted, the curtain is drawn back, and behind it all is … what? A different reality? Certainly. Perhaps even a horror of incomprehensible violence, suffering, injury, or death. It is this tearing apart of reality that is particularly damaging to some people with PTSD.

Some types of ruptures in the Reality Frame happen in everyday life too. They don’t only occur if you’ve survived war or a sexual assault. Perhaps one day you develop a pain. You go see the doctor and find out you have cancer. Perhaps you’ve come home and found that someone broke in, rummaged through your things and stole some items. Perhaps, you were driving and cut someone off and that person then followed you, driving up close as if to ram you, pulled to the side while brandishing a gun, and the tried to follow you home.

All these events, big and small, whether they lead to post-traumatic stress or not, are traumatic. They all can lead to a rupture in your expected unquestioned Reality Frame.

Given this, this is how I think about the consequences of trauma: they are like expanding circles on water when a stone (a traumatic event) lands. The most concrete symptoms of PTSD include re-experiencing symptoms (flashbacks, recollections, nightmares) and chronic hyper-arousal (startle responses, anxiety, disrupted sleep).
In the next outer circle of trauma consequences, the person may experience chronic feelings of guilt and shame. One of the fascinating and not fully unexplained features of human nature is that often the victims of harmful acts feel a deep sense of shame. It would seem that shame should be reserved for the perpetrators of the harmful acts but often the victim is more overcome with shame and guilt than the perpetrator. Think of the soldier with a deep sense of survivor guilt. Or the patient who has been assaulted who blames herself for her “carelessness.”

And a still outer circle of consequence of trauma is the ripping apart of the person’s Reality Frame, as I’ve already introduced.  Expectations, certainties, rules of engagement are now seen as no longer valid. Worse still, the person’s relationship to their entire past is now altered too. The traumatized person can end up beating themselves up for their “stupidity” in not realizing until now how tentative, vulnerable and contingent a secure well-ordered life really is. “It’s all an illusion,” the traumatized person now tells themselves, “It always was.” The same applies to their view of the future. They will never be the same. A person cannot unsee what you have seen, unfeel what they have felt, and lose understanding of what they now understand.

This is bad enough, is it not? But from all of this, still another consequence flows. Now that a traumatized person has had their reality ripped apart, often there is no one available who understands. Some traumatized individuals are lucky in that there are others who do understand or are at least willing to try to understand. For example, there are many support groups for persons with cancer, or a terminal illness, or who have a child with a serious medical condition. Many other traumatized individuals are not so lucky, however.

Here’s an example: a young woman is standing at the bus stop alone late in the evening. Suddenly a group of male teenagers, intoxicated, loud and rambunctious, approach. They see this woman and surround her, emboldened by her reaction of fear. They taunt her and one reaches out to grab her breast while another rubs up against her from the back. In a moment they are gone; for them it seemed like some sort of transgressive, ill-considered high-jinx. But for our protagonist, how is she now? She had feared for her life in those moments. Now, her frame of reality is torn asunder. After three weeks of fearing to leave her apartment, of having difficulty sleeping, and having lost 10 pounds from loss of appetite, she steels herself to attend a women’s assault support group. There, she again steels herself to tell her story. During a coffee break, she overhears another attendee speak to a companion, saying, “I was raped at gun point in my own bed …” Our protagonist, rightly or wrongly, comes to believe that this woman said this as a way of discounting the seriousness of our protagonist’s assault. She leaves the support group and never returns. Now, she not only continues to suffer with post-traumatic symptoms, not only is she overcome with the ripping apart of her Reality Frame, but now also she feels completely isolated.

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Here’s another example: Imagine a combat veteran at home celebrating the sixth birthday of his son. His wife, friends, and a bunch of first grade friends of his son are at their home. Then, suddenly, our protagonist has a flashback to the classroom he entered in Ramallah years ago that was struck by a mortar. Many children were injured and some killed. Years later, our protagonist sees all the little kids at his son’s birthday party and is overcome with emotion and quickly leaves the house. Who can he tell that in his mind he sees dead children, their bodies torn apart, when he’s supposed to be celebrating his son’s birthday?

So, in my estimation, sometimes the most painful and damaging aspects of PTSD are the tearing asunder of the Reality Frame and the frequent sense of total estrangement from others that occurs as a result.

Next time, I will share with you ideas I’ve developed on helping people (and oneself, if it applies) overcome these damaging aspects of living with trauma.

Until next time,

Dr. Jack


Today’s Quotes

“The trauma said, ‘Don’t write these poems. Nobody wants to hear you cry about the grief inside your bones.”
– Andrea Gibson, The Madness Vase