FDA Consumer

Escaping the Prison of a Past Trauma

Escaping the Prison of a Past Trauma – an account of a rape that led to post-traumatic stress disorder; treatment details are included

Tamar Nordenberg

New Treatment for Post-Traumatic stress Disorder

January 18 marks the anniversary of a mighty adrenaline rush for Kellie Greene. She went sky diving on that day last year, in search of a high-flying thrill to overwhelm her traumatic anniversary memories of the rape she had endured exactly five years earlier.

“Sky-diving, you’re screaming,” says 34-year-old Greene, founder of the Orlandobased rape education group SOAR (Speaking Out About Rape), “but you’re screaming because you’re excited. `Oh my God, I’m doing this!’ The whole world is underneath you, and it’s so amazing. It just looks like the Earth’s standing still, not like you’re falling toward it.”

“Sky-diving, I controlled the adrenaline rush,” Greene continues. “I had gotten tired of getting so anxious every year around that day. Now, it’s no longer the date that I was raped, but the day I went sky diving.”

It was on Jan. 18 in 1994 that a knife-wielding stranger raped Greene inside her own apartment as she returned there from the laundry room in her complex. The intruder smashed Greene on the head with a tea kettle as she opened the apartment door, paying no mind to her pleas, “Take my money. I have money!”

Since the day she was raped, Greene has battled mental demons previously unknown to her. “For someone who had been pretty normal her whole life and had never needed counseling, it was frightening to be so out of control with my feelings and not know why,” Greene recalls. “I would cry uncontrollably at any time. It was just a sadness that was so heavy, some days I wouldn’t even want to get out of bed. Not being able to organize my daily routine–deciding what to wear or what to eat–because those might be the wrong choices to make. I would lock myself in the house an hour before it got dark, and not answer the phone and not answer the door. I was afraid to drive places or to be alone. I wasn’t able to sleep at night, then was so tired during the day it’s all I did. There were bad flashbacks, too, but they were strange flashbacks because they were dark. It was just darkness.”

The flashbacks, troublesome sleep, and other symptoms Greene experienced are not uncommon for someone who has lived through the stressful ordeal of rape. Her types of symptoms are among the tell-tale signs of post-traumatic stress disorder, sometimes called PTSD. PTSD is a debilitating condition that can beset anyone who has felt fear, helplessness or horror during a traumatic event that caused or threatened to cause that person or someone else to die or be seriously injured.

“All of us have had experiences that are sufficiently upsetting that we go over and over them in our minds,” says Thomas Laughren, M.D., head of the Food and Drug Administration’s psychiatric drag products group. “But with PTSD, it’s an order of magnitude worse. It can be a very severe kind of illness that limits people to an extent that is completely foreign to most of us.”

About “Shell Shock”

In a given year, more than 10 million Americans (about 4 percent) will experience the life-disrupting symptoms of PTSD, which was first widely recognized during World War I and known as “shell shock” or “battle fatigue.”

Like combat horrors, other “manmade” tragedies such as criminal assaults or sexual attacks can provoke PTSD symptoms, as can a fire, earthquake, or other natural disaster. Accidents–car and airplane crashes, for example–are also common precipitators of PTSD.

By definition, the disorder can only develop in response to a traumatic event, says Edna Foa, Ph.D., director of the University of Pennsylvania’s Center for the Treatment and Study of Anxiety. It can’t arise from other seriously stressful occurrences that are less extreme–losing a job, say, or going through a divorce.

And, while not all life stressors are traumatic enough to lead to a PTSD diagnosis (but instead might cause “generalized anxiety”), not everyone who experiences a trauma will develop post-traumatic stress disorder, either.

As many as 70 percent of American adults have been through at least one major trauma, according to the “Expert Consensus Treatment Guidelines for Post-Traumatic Stress Disorder: A Guide For Patients and Families,” a guide written by Foa and others based on a survey of 100 PTSD experts. But, Foa explains, “Most people who go through a traumatic event may be more frightened and act more cautiously than they used to, but don’t develop the disorder. That is, they don’t get symptoms that would disrupt their daily life in a significant way and render them dysfunctional on some level.”

Experts divide symptoms that rise to the level of PTSD into these main types:

* Re-experiencing the traumatic event. Re-experiencing can refer to having intrusive memories of the ordeal, flashbacks when awake, recurring nightmares, and exaggerated emotional and physical responses to triggers that .remind the person of the event. “Sometimes I’ve thought I was back in Vietnam. When you start dreaming, you can smell the flesh of your buddies burning,” says veteran John Palmer Sr., who recalls being among 19 wounded survivors of a 1968 ambush by the North Vietnamese that killed the rest of his 59-strong battalion.

* Avoidance. After a trauma, people may lose interest in and avoid certain activities, places, and thoughts and feelings related to the trauma. July 4th is “really hard” for 51-year-old veteran Palmer because the loud noises remind him of wartime. And Palmer avoided seeing the critically acclaimed “Saving Private Ryan.” “I chose not to go,” he explains, “even though some people thought it was pretty good … if there could be anything good about it. Watching movies about the war bothers me, and I start having nightmares.”

* Emotional detachment. Foa’s patients have told her, “I’m not the person I used to be. I don’t trust people. I can’t feel loving anymore.” One of her patients, who had been injured in an explosion at his factory that killed many others, was “like a zombie emotionally,” Foa says. The man’s daughter complained, “He’s not there for us. All he cares about is himself, and indulging in his own misery.”

* Increased arousal. This symptom can show itself in difficulty sleeping, irritability or angry outbursts, difficulty concentrating, and unusually startled reactions in certain situations. Palmer says, “When I first came back [from Vietnam], people were afraid to be around me. I got in a lot of trouble, drinking and fighting, and I didn’t really care.”

People can have wide-ranging reactions to a certain stressor. Some people will have no long-lasting effects, while on the other end of the spectrum, people can have problems that last for months or years. The symptoms must last for at least a month, however, to be classified as post-traumatic stress disorder.

While symptoms usually begin immediately after a trauma or within the following few weeks, sometimes they can show up months or years later. Many of the World War II prisoners of war that Veterans Administration counselor James Boehnlein, M.D., talks with have had stable lives–were married long-term, raised children, and worked steadily–and developed delayed PTSD symptoms after they retired and when people their age began to die of natural causes. “Their losses brought back memories of their wartime sadness and loss,” Boehnlein explains, “and they would start having nightmares of combat experience and being prisoners of war.”

So far, science can’t predict precisely how a certain individual will react to a traumatic event. But certain factors can provide clues about the likelihood and severity of PTSD:

* How severe and long-lasting was the trauma? The more intense and long-lasting the traumatic experience, the more likely it is that the victim will develop PTSD.

* How close was the person to the trauma, and how dangerous did it seem? Foa’s patient who was injured in the factory explosion was more vulnerable to PTSD than if he had been across the street, merely heard the bang, and only later found out about the explosion’s tragic consequences. Foa cites one recent study that found that women who perceived their lives were in danger during a rape had 2.5 times the incidence of PTSD than did others who didn’t fear for their lives during the rape.

* Has the person been traumatized in the past, and if so, how many times? One of Foa’s patients didn’t develop PTSD until the third sudden death in her circle of friends and acquaintances. The third time, “that was it,” says the therapist. “Now she’s thinking, `What’s next? Next it will be me.'”

* Was the trauma inflicted by other people? PTSD is more likely after a rape or other manmade trauma than after an earthquake, hurricane, flood, or other naturally occurring disaster. Psychologically, it seems to matter whether the trauma is intentionally aimed at the victim or is random and suffered by many people together.

* What is the person’s coping style–does he or she tend to stay enraged? And, does the person get support from friends and family, or negative reactions? People are less likely to have PTSD, elaborates Foa, if they think about the trauma, talk to other people about it, and let go of their anger over the incident. Foa encourages people to face the trauma: “Talk to someone you trust, write about it, do anything but push it away.” And, she says, if the symptoms still cause suffering after several months, professional help should be sought.

But many people don’t seek professional help for their condition, according to mental health experts. Possible reasons cited in the PTSD expert consensus guidelines: Sufferers may feel withdrawn, guilty and mistrustful and naturally want to avoid dealing with unpleasant feelings, and they may not even realize they have a problem or that it can be treated.

But PTSD is treatable–with medication, psychotherapy, or both.

Like many trauma victims, at first Greene was reluctant to seek professional treatment. “I was afraid if I told anyone how out of control I was really feeling, they would commit me to a mental institution.” When Greene did finally confide in a therapist, he explained that her symptoms were a common reaction to a traumatic event and she wasn’t going insane. Greene learned to manage her anxiety by breathing deeply and counting until she felt calm. And her doctor prescribed Zoloft (sertraline hydrochloride), the first FDA-approved drug for PTSD.

First PTSD Drug

Before its approval last December for post-traumatic stress disorder, Zoloft was already approved by FDA for depression, panic disorder, and obsessive-compulsive disorder. Its effectiveness for PTSD is in line with its benefit for depression and the other disorders, says FDA’s Laughren. Studies show that about two-thirds of PTSD patients improve with Zoloft, while one-third improved when taking placebo.

Zoloft’s approval for PTSD was based on two 12-week studies of the drug that demonstrated its effectiveness. While Zoloft’s benefit over placebo was clear in women patients, little effect was seen in the male group. Scientists aren’t certain why the gender difference exists, but some have theorized that PTSD in veterans, a mostly male population, might differ somehow from the disorder in the mostly female population of sexual assault victims.

After her rape, Greene says, Zoloft played a big part in helping her heal. “It really took the edge off. I had been playing the attack over and over in my mind, like a broken record, and Zoloft helped me get out of that groove. It didn’t make me a zombie or make me ecstatically happy, either. But all of a sudden I woke up and said, `I can handle the day.'”

Greene took Zoloft for about a year, which was within the typical range of six to 24 months. She didn’t notice any bothersome side effects, though some people do experience dry mouth, nausea, sleepiness, or other negative reactions.

While Zoloft is the only drug approved by FDA to treat PTSD, doctors sometimes prescribe other drugs that they believe may improve a patient’s condition. For PTSD, doctors sometimes prescribe drugs in the same class as Zoloft. These selective serotonin reuptake inhibitors, or SSRI’s, include Paxil (paroxetine), Prozac (fluoxetine), Luvox (fluvoxamine), and Celexa (citalopram). Based on an individual patient’s medical circumstances, a doctor may in some cases choose to prescribe other types of antidepressants or anti-anxiety medications.

Facing Fears

As an alternative to medication or coupled with it, some patients opt to rely on group or individual psychotherapy to manage their PTSD symptoms. Three types are considered especially effective, according to the expert consensus guidelines:

* Exposure therapy. To help patients confront the everyday reminders of their trauma, therapists sometimes use “exposure in the imagination” or “exposure in reality.” In the first type, patients imagine the trauma and recount the memories in detail, over and over again, with a therapist they trust and at home between sessions. The goal of therapy: to give people an opportunity to reprocess what happened until the thoughts lose their distressful impact. Lyn Rezer, 35, reexamined a traumatic gang rape that had occurred when she was 12 years old and had haunted her for more than 20 years. Using this approach, Rezer says she conquered her feelings of worthlessness and despair. “I walked around for 23 years feeling extremely suicidal, wanting to flee, wanting to cry. I thought I was bad, I was filthy, I was nothing. I detached myself emotionally from a lot, and today I’m not detached. I feel everything, like a normal 35-year-old woman with normal impulses and instincts. I haven’t had a suicidal thought since midway through treatment.” With exposure in reality, therapists ask patients to gradually expose themselves to situations or places they had been avoiding because they are reminders of the trauma.

* Cognitive behavioral therapy. With CBT, therapists work on changing victims’ irrational beliefs, such as self-blame for a rape, criminal assault, or accident.

* Anxiety management. This classification refers to techniques such as slow abdominal breathing to relax and avoid hyperventilation, and positive thinking and self-talk to replace negative thoughts.

Therapist Foa, who at her University of Pennsylvania clinic uses exposure therapy, sometimes combined with other types, estimates that 80 percent of patients accomplish significant improvement in their lives over the 12 weeks or so of therapy.

Foa acknowledges that it’s difficult to directly face a traumatic memory that one has been avoiding, sometimes for years. But getting help is critical, she says, if the stifling symptoms of PTSD do not resolve themselves pretty quickly after a trauma. Immediately after the trauma, it’s normal to experience emotional swings, Foa says, so “you needn’t rush to treatment.” But if your symptoms begin to appear chronic, at four to six months, she says, they’re not likely to improve on their own.

In light of the healing effects of PTSD treatment in her own life, rape survivor and rookie sky diver Greene has committed herself to encouraging others to take brave steps to deal with their traumatic memories. Greene says she has been inspired by popular singer Tori Amos, a rape victim herself and cofounder of the trauma support organization RAINN (the Rape, Abuse and Incest National Network). Amos, who says she wrote her song “Me and a Gun” as a healing step for herself, wrote a public letter to others who have faced similar traumas. The message: “Healing takes courage, and we all have courage, even if we have to dig a little to find it!”

It’s worth digging up the courage, Rezer confirms. “It’s a lot of hard work, but your life doesn’t have to be dictated by your past. I never believed you could go back in time and change things, but I know now that you can change them–not the events, just the feelings and thoughts surrounding them that have taken over your life.”

Making the Diagnosis: Simple Stress or Post-Traumatic Stress Disorder?

Answering these questions may help your health-care provider determine if you have PTSD:

Have you experienced or witnessed a life-threatening event that caused you to feel intense fear, helplessness, or horror?

Do you re-experience the event in at least one of the following ways ?

* Repeated, distressing memories and/or dreams

* Flashbacks, or a sense of reliving the event

* Intense physical and/or emotional distress when exposed to things that remind you of the event

Do you avoid reminders of the event and feel numb, compared with the way you felt before, in three or more of the following ways?

* Avoiding thoughts, feelings, or conversation about it

* Avoiding activities, places, or people who remind you of it

* Being unable to remember important parts of it

* Losing interest in significant activities in your life

* Feeling detached from other people

* Feeling that your range of emotions is restricted

* Feeling as if your future has shrunk (for example, you don’t expect to have a career, marriage, children, or a normal lifespan)

Are you troubled by two or more of the following?

* Problems sleeping

* Irritability or outbursts of anger

* Problems concentrating

* Feeling “on guard”

* An exaggerated startle response

Do your symptoms interfere with your daily life?

Have your symptoms lasted at least a month?

(Source: Anxiety Disorders Association of America, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.)


Resources for Trauma Survivors

Anxiety Disorders Association of


11900 Parklawn Drive, Suite 100

Rockville, MD 20852


International Society for Traumatic

Stress Studies

60 Revere Drive, Suite 500

Northbrook, IL 60062


National Center for Victims of Crime

2111 Wilson Blvd., Suite 300

Arlington, VA 22201


National Center for Post-Traumatic

Stress Disorder

215 North Main St.

White River Junction, VT 05009


Rape, Abuse, and Incest National

Network (RAINN)

635 Pennsylvania Ave., S.E.

Washington, DC 20002

1-800-656-HOPE (1-800-656-4673)

(24-hour confidential hot line)

Tamar Nordenberg is a staff writer for FDA Consumer.

COPYRIGHT 2000 U.S. Government Printing Office

COPYRIGHT 2004 Gale Group