It’s normal to avoid pain, and that certainly includes painful emotions. So it’s not at all surprising that the last two groups of PTSD symptoms involve Avoidance.
First there is Conscious Avoidance. This is described in DSMV as:
Persistent effortful avoidance of distressing trauma-related stimuli after the event:
1) Trauma-related thoughts or feelings.
2) Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Simply said, you learn your triggers and intentional avoid them. If you’re still having trouble with Arousal symptoms—like anger, self-destructive behavior, irritability, hyper-vigilance, and inability to sleep, or Re-experiencing symptoms—like intrusive memories, nightmares, and flashbacks—then avoiding triggers makes perfect sense. However, you can treat those symptoms (see previous blogs on Treating Hyper-Arousal and Therapy for Flashbacks, etc.). Successfully completing those treatments will help desensitize you to your triggers and reduce the need for avoidance.
Then there is Unconscious Avoidance. These symptoms are often hard to recognize because your brain is playing tricks on you. The DSMV groups these under Negative Cognitions (thoughts) and Mood. Here’s their list:
Negative alterations in cognitions and mood that began or worsened after the traumatic event:
1) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
2) Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
3) Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4) Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5) Markedly diminished interest in (pre-traumatic) significant activities.
6) Feeling alienated from others (e.g., detachment or estrangement).
7) Constricted affect: persistent inability to experience positive emotions.
The biggest problem with unconscious avoidance is that symptoms become truth for the survivor, which prevents him/her from seeking treatment. If you’re constantly in a negative mood and previous attempts to get help have failed, it’s easy to believe there is nothing anyone can do. Please be aware this is just another symptom, one that newer treatments are designed to overcome. Family, war buddies, and close friends can assist by supporting survivors in their effort to seek help.
Meditation and Mindfulness training have been shown to reduce PTSD symptoms, especially Avoidance. It may be the best therapy to get you out of Avoidance and into taking control of your own PTSD. Meditation has been shown to improve functioning in the prefrontal cortex, the part that controls the amygdala and all its negative emotions, as well as parts of the cortex involved in focus and attention and speech. Meditation and mindfulness have no side effects and they’ve been proven to work. You can find good meditations free on You Tube.
The inability to recall parts of the trauma is a “dissociative” symptom. Dissociation is the process our brain uses to wall off traumatic memories. I see it as similar to how our body walls off an infection in an abscess. Often the worst part of the trauma memory is totally dissociated and not available to conscious recall, but triggers to the trauma still release it in flashbacks and/or nightmares. The survivor often can’t remember or talk about the dissociated part of his/her trauma.
Calming down the sympathetic nervous system may help to bring dissociated memories into conscious awareness. Or this may happen while other memories are being explored and the survivor becomes aware of missing pieces. Massage and body work can also help. But since the forgotten parts are often the worst parts of the trauma, caution should be used to protect the survivor from the emotions and pain that will accompany its recall.
Distortions in thinking about the trauma are common and can be dealt with in the process of detoxifying memories (see blog on Treating Flashbacks, Nightmares and Intrusive Memories). As you are able to look at the trauma with less intense emotion and less pain, you can start to engage the cortex—the thinking part of your brain—which may change your previously held beliefs. But if the distortions prevent you from seeking help, you may get stuck. Sharing your concerns with a trusted friend can help you to sort out was is real and what is skewed.
Persistent negative emotions and the inability to experience positive emotions can lead to withdrawal from activities and people. These last four symptoms suggest that the amygdala hasn’t settled down and the prefrontal cortex, which calms the amygdala, isn’t yet functioning properly. These problems are tied to the sympathetic nervous system and the wounds that stress chemicals are making in the brain. To treat it, you can use meditation or medication and treatments in the blog on Treating Hyper-Arousal.
Avoidance is understandable, even inevitable, but it doesn’t treat the problem. If you want to get better, you can start with mindfulness and meditation, but once you’re able to look clearly at your symptoms, check out treatment suggestion in the blogs on Treating Hyper-Arousal and Therapy for Flashbacks, Nightmares and Intrusive Memories.
DSMV doesn’t mention a third type of avoidance, but between a quarter to a half of all survivors use it. I’m talking about Substance Abuse, and I’ll tackle that in my next blog.