PTSD: A Conversation with Dr. Christina Biedermann

Can you start by giving us an overview of PTSD?
Let’s start with a broad conceptual frame. I think about PTSD as a collection of symptoms that constitute the body’s response to an extreme stress, particularly when somebody’s life or bodily integrity have been threatened or when they’ve seen somebody else’s threatened. The body responds to this kind of extreme stress in a number of different ways. PTSD emerges when those responses persist after the threat has subsided. PTSD can emerge from a range of traumas, from a single incident trauma (like a car accident) to something that’s still pretty specific but chronic (like combat) — to something that is chronic and more diffuse (like childhood abuse).

How does it manifest? In other words, what do people suffering from this condition feel like and think like?
That varies pretty widely, depending on the nature of the original trauma and on what resources a person has available to them to process it. PTSD is diagnosed when there are specific clusters of symptoms that get in the way of someone living as they want to. One cluster has to do with re-experiencing the trauma —through intrusive memories, for example, or recurrent nightmares. Some people also experience flashbacks, when the body thinks it’s back, re-experiencing the trauma. People sometimes describe feeling flooded by traumatic memories.

A second cluster of symptoms is an effort to avoid triggers, or reminders, of the traumatic experience. People’s lives become more narrow as they try not to think about or do things related to the trauma — sometimes it can be blocked out so that it is not even fully remembered. People may start to change their activities—not going places where there are crowds, for example, or avoiding places with loud noises. When there’s been trauma in the context of relationships, they may even avoid or destroy relationships where there might be intimacy or closeness. People with PTSD often don’t feel motivated to do the things they once enjoyed, and they can feel at a distance from people they care about. They also may have the sense that their lives are going to be short-lived, as if there’s no chance for a meaningful future.

A third cluster of symptoms has to do with the body being in a state of hyper-arousal all the time, as if it’s always on guard for threats. People may live in a constant state of vigilance and startle easily. This constant defensiveness often leads to irritability and difficulties sleeping or concentrating. Difficulties regulating arousal can also lead to dissociation, where a person’s experience over time is discontinuous. People often feel like they lose time—they can’t remember what happened.

So there’s many ways PTSD can actually look, depending on which symptoms are present. It grows even more complicated when it overlaps—or is co-morbid—with other disorders like mood, anxiety, or personality disorders. As clinicians and researchers put together the next edition of the diagnostic manual, the DSM-V, there has been discussion of fine-tuning the diagnosis by creating another, related diagnosis, “Complex PTSD.” That would describe the kind of PTSD that happens when there’s been some kind of trauma in relationship, often in early childhood relationships. Right now, as it stands, a person with that kind of trauma gets diagnosed with the same PTSD as someone who has suffered a car accident.

What we see most often at Riggs is this kind of complex trauma. When trauma happens chronically and during childhood, it becomes especially problematic, including relationships in and of themselves that can become triggers, which can then pose serious problems for treatment. In treatment, you’re in relationship with a provider. If you have a history of chaotic—or traumatic—relationships, it may compromise your ability to understand or even tolerate relationships.

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