How Psychological Trauma Leads to the Signs and Symptoms of Depression
At what point do painful memories cause the signs and symptoms of depression or anxiety? The following checklists are from the standard diagnostic manual used by mental health professionals. It’s a summary of the criteria for Posttraumatic Stress Disorder of PTSD.
Posttraumatic Stress is the persistent or delayed reaction to a life-threatening event that involves:
- Reexperiencing the event in distressing ways (nightmares, flashbacks, anxiety attacks, depression)
- Various tricks of the mind to avoid any reminders of the event
- Symptoms that show that the person is much more keyed up than they used to be (sleep problems, irritability, outbursts of anger, exaggerated startle response). Sleep problems push the brain in the direction depression. Anger or irritability often cause problems with relationships and friendships. Often a breakup of marriage can be traced back to the anger that results from trauma. The loss of friendships and other important relationships helps to bring out the signs and symptoms of depression.
This type of stress becomes a disorder when it negatively impacts one’s life in significant ways. When this happens it is often referred to as Posttraumatic Stress Disorder or PTSD. While it is classified as an anxiety disorder, the signs and symptoms of depression are often the most devastating to a person’s happiness. Many professionals, including me, believe that PTSD is just as much a mood disorder as it is an anxiety disorder.
A trauma is an overwhelming event or situation that forces a person to develop a cluster of symptoms. Traumatic stress is the cluster of distressing symptoms. It is called posttraumatic stress because it often has a delayed onset. Many New Yorkers who seemed to be doing well after the September 11 attacks began to develop major problems months later.
It is important to understand that people usually cannot make these signs and symptoms of depression disappear just by trying hard to “put the past behind them.” The American Psychiatric Association diagnostic manual (DSM-IV) defines Posttraumatic Stress Disorder with specific clinical criteria in order to make a diagnosis:
1. Exposure to a Life Threatening Event
Exposure to a life threatening event or one in which there is a threat of serious injury. Whatever causes it, there must be intense fear at the time of the event. This can also include witnessing a violent act or being in a situation of extreme danger.
2. The Sadness of the Traumatic Event Floods the Mind Repeatedly
This means that the event is re-experienced, over and over. Some examples of the ways are:
- Distressing memories of the event that intrude suddenly or will not go away
- Persistent nightmares
- Acting or feeling as if the frightening event is happening all over again, such as with flashbacks or distorted perceptions
- Intense mental anguish that is triggered by cues or symbols that mimic some aspect of the original traumatic event
- Intense physiological reactivity such as tension or pain also triggered by reminders of the event
3. Numbing and Avoidance
Emotional numbing and a strong tendency to avoid triggers or reminders in at least three of the following ways:
- The person makes efforts to avoid thoughts and feelings related to the trauma (he or she won’t talk about it)
- The person avoids activities, people or places that might remind them of the trauma
- The person can’t remember the event or can’t recall aspects of what happened
- The person shows a noticeable loss of interest or participation in significant activities
- He or she has the feeling of being estranged, disconnected or detached from other people
- The person has awkward barriers to the full range of emotions such as an inability to feel affection from another or to have loving feelings
- He or she has a distorted and short view of the future such as not expecting to have a career or normal life span.
4. Feeling Tense and Tightly Wound in Various Ways
Persistent symptoms of increased arousal as shown by at least two of the following:
- Difficulty falling or staying asleep
- Outbursts of anger or irritability
- Difficulty concentrating
- Hypervigilance (scanning the surroundings for possible danger)
- Exaggerated startle response
To be diagnosed with PTSD the symptoms have to continue beyond one month. Also, it has to clear that the anxiety and/or the signs and symptoms of depression are creating dysfunction in a person’s life. But the syndrome can have a life of it’s own even if the diagnostic criteria are met precisely.
This definition of PTSD is very useful as a checklist of symptoms that can arise after an overwhelmingly dangerous event. However, I do not find it very useful in deciding who actually suffering from PTSD. Apparently, I am not alone. Dr. John Briere, a trauma specialist at USC Medical School once said that the most traumatized individual he had ever treated did not meet the exact criteria for PTSD. The definition is so tightly crafted (by a committee) that many people who suffer intensely from posttraumatic stress end up with another diagnosis that does not highlight the trauma-based roots of the problem. The signs and symptoms of depression might be treated with medication, but the underlying posttraumatic syndrome is missed entirely.
The real value of the diagnostic criteria is in providing a partial list of trauma-related symptoms. When it comes to evaluating the signs and symptoms of depression this list can be helpful in identifying whether or not treatment for trauma (such as EMDR therapy) should be incorporated into the treatment of the signs and symptoms of depression.