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 symptoms in PTSD involve Avoidance.
First there is Conscious Avoidance. This is described in DSM V 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 intentionally 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 as discussed in the previous blogs on Problems with Arousal and Reactivity, and Exposure 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 DSM V 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 inability to recall parts of the trauma is a “dissociative” symptom. Dissociation is the process your 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 usually 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 very ugly, caution should be used to protect the survivor from the negative emotion and pain that will accompany their recall.
Distortions in thinking about the trauma are common and can be dealt with in the process of detoxifying memories (see blog on Exposure Therapy for Flashbacks, etc.). As the survivor is able to look at the trauma with less intense emotion and less pain, he/she starts to engage the cortex—the thinking part of our brain—which may change the previously held beliefs.
Persistent negative emotions and the inability to experience positive emotions often lead to withdrawal from activities and people, all 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 its stress chemicals are making in the brain. To treat it, see the blog on Problems with Arousal and Reactivity.
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 and close friends can assist by supporting survivors in their effort to seek help.
Bottom line: Avoidance is understandable, even inevitable, but it doesn’t treat the problem. If you want to get better, you need to check out the earlier blogs on Problems with Arousal and Reactivity and Exposure Therapy for Flashbacks, etc. Then find a well-trained doctor and therapist to help you.
DSM V 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.