Saturday, October 12, 2013

Early Sexual Abuse: And Related Symptoms of Post-Traumatic Stress Disorder (PTSD)

Post Traumatic Stress Disorder (PTSD) is a psychological syndrome first recognized by the Diagnostic and Statistical Manual of Mental Disorders in 1980 (American Psychiatric Association).

The literature on traumatic anxiety covers a wide range of varying circumstances and experiences. The effects of these experiences, whether from natural disasters or events of human creation, war, terrorism or single acts of violence against one person are often determined by the individual's capacity to cope with stress. This in turn is a function of each person's early developmental experiences with trust, constancy and mastery. Traumatic abuse, sexual or otherwise, in the first years of human life not only effects the child in the moment, but has a more lasting effect on the ongoing development of the defense system itself.

Individual psychology believes that traumatic anxiety is most often seen as resulting when the ego is "overwhelmed or disorganized" with the defenses employed in the service of maintaining a sense of self-constancy and continuity. More specifically, the defense function acts to ward off a sense of discontinuity or void in one's identity. Therefore, the trauma is considered an attack, real or potential, escalating the anxiety to terror as a consequence the protective rage is rendered unconscious and turned inward to depression and guilt, or outward to action discharge. This process is called into action to protect against these powerful threats to the integration of the self. It reminds one of the often-quoted words of Freud "that what makes us neurotic in adulthood is what we learned in childhood to stay alive." The key is the breakdown in the growing psychic apparatus and its ability to provide stimulus barrier. Therefore, effecting a breach in the ego's boundaries or protective shield.

These stimuli are experienced as overwhelming and producing a sense of helplessness, often leading to a sense of hopelessness. Clearly, the trauma can be psychological, emotional, physical, or sexual (most commonly, incest), often involving aspects of all four. In the case of incest what stands out - adding to the terror caused by the actual and potential attack, with its accompanying sense of helplessness - is the humiliation, shame, and feelings of degradation. Commonly, these feelings lead to an identification with the aggressor internalizing the sadistic and masochistic components (all rendered unconscious), resulting in intense guilt and self-blame. Perhaps the most crucial component of the trauma for survivors of sexual abuse is not only that it results from acts causing severe pain, suffering, humiliation and intimidation, but that it is inflicted by those deemed protectors. Another factor in this process is the strong demand from the instigators that the victim become part of a conspiracy of silence. This leads to further operations by the victim's defense system in order "to stay alive," primary among them being the defense of denial.

My interest in traumatic stress and anxiety began over two decades ago. At the time I was involved in a project working with Vietnam veterans addicted to various kinds of drugs. This project was designed to study the effect of psychotherapy as an adjunct to chemotherapy (methadone) on the addicted veterans. While working with this group, I noticed that many of the patients diagnosed with divergent kings of addictive disorders also exhibited symptoms of depression, anxiety, sadness, profound withdrawal, and brooding. Also, I observed that these veterans suffered severe mood swings, deep character change and survivior-guilt nightmares. At the core was always the overwhelming sense of helplessness and hopelessness. In the past these symptoms were most often associated with survivors of overwhelming trauma such as the Holocaust during World War II in Europe and the nuclear bombing of Hiroshima and Nagasaki in Japan. It was clear that for the patients exhibiting symptoms such as those mentioned above, the abuse of drugs was part of an effort to self-medicate and ease the emotional pain. The drug abuse, then, was seen as a serious, yet secondary problem, whose goal was both to mask and alter those feelings of being powerless to change one's intolerable emotional state. This same approach can be used to understand those individuals who survived early-life incest and sexual abuse.

However, there is a much more limited discussion as to how the wider understanding applies to adult survivors of early childhood incest experiences. Working with those suffering PTSD as a result of war experiences, we learned first to note the cluster of characteristic symptoms, and to see the connection between an overwhelming distressing and disorienting event, often beyond the normal range of human coping capacities, and the resultant later symptomatology. The stimuli producing these events were experienced with such an intense terror and helplessness notwithstanding all attempts to deny, internalize or act out, the traumatic event is relived as a series of intrusive recollections or as repetitious dreams and nightmares in which the trauma recurs. Though the symptomatology varies from person to person, it remains a number of common characteristics. Quite often there are dissociative disorders: fugue states, period of derealization, amnesias and trance state, lasting for a few moments, for several hours, and even for several days. Because of the extensive use of denial in most cases of sexual abuse, complete loss of memory of the abusive events are quite common. Of course, what is also quite common is that the individual becomes symptomatic (usually bouts of depression or intense free-floating anxiety), or given to explosive action discharge.

Another expression of the dissociative symptoms mentioned is found in the expression by incest survivors the feelings of depersonalization, feeling detached and estranged from others. Some survivors exhibit a need for a hypervigilance of their surroundings and talk of an exaggerated sensitivity to touch. Also commonly experienced is a kind of anhedonia, a loss of the experience of pleasure, an incapacity for happiness or to feel strong emotions, especially those associated with trust, intimacy, tenderness and sexuality. Still another affective disturbance commonly found in incest survivors and other sufferers of post-traumatic conditions is called alexithymia, it is characterized by poorly differentiated affects which inadequately serve the signal function. Sufferers often think in very pragmatic ways, almost robot-like, appearing super-adjusted to reality and quite stoical in appearance. In psychotherapy these individuals tend to recount trivial, chronologically ordered events of daily life in monotonous detail. They stifle imagination, intuition, empathy, fantasy, especially in relation to others. This phenomenon is seen from a psychoanalytic perspective as a group of developmental defenses against totally terrifying experiences of early life.

from a historical perspective, the disguised or hidden victims of incest and sexual abuse have long remained unrecognized or disbelieved. For many, in the mental health profession, the central nature of trauma in the development of psychopathology is indisputable. And, of the traumas in early childhood, the most damaging to the individual psyche is the trauma of incest. Its growing recognition in recent years has been a welcome turnaround from the earlier view that the individual's memory of incest and sexual abuse was invariably the expression of an infantile wishful fantasy.

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