From Posttraumatic Stress Disorder to Posttraumatic Growth: A Paradigm Shift or Paradox?

Posttraumatic Stress Disorder

PTSD is somewhat unique as a psychiatric diagnosis in that it is a condition that follows a specific event (APA, 2013), which is now described as Category A of the criteria for the diagnosis. The type of events seen as sufficient to cause PTSD are those situations where persons thought they were going to be killed or might be; serious injury, or the threat of serious injury; sexual violence, or threat of it; or the witnessing of such events happening to someone else. A key symptom of having PTSD is unwanted intrusion of thoughts of the event, persistent efforts to avoid stimuli associated with the trauma, and ongoing and disabling cognitions and moods. For some people, the condition is associated with dissociative reactions, intense or prolonged distress, and marked physiological reactivity (APA, 2013). Common posttrauma cognitive and mood symptoms include negative beliefs and expectations, blame, uncomfortable emotions, diminished interest in activities, and feeling alienated with constricted affect. Trauma-related hyperarousal or reactivity has also been seen as a common element of the condition, including irritable and aggressive behavior, self-destructiveness or recklessness, hypervigilance, exaggerated startle response, problems in concentration, and sleep disturbance. In the United States, it is the Department of Veteran Affairs that houses the National Center for PTSD, rather than the National Institute of Medicine, or the Department of Health or Health and Human Services, which reveals something of the political issues connected with the construct and diagnosis. A recent (12/29/17) PubMed literature search on the term PTSD uncovered over 34,000 citations.

Before considering the construct of PTG, it is important to consider critically some issues related to PTSD. As with any psychiatric diagnosis, it is a label that makes it more difficult for persons so diagnosed to have a healthy self-image, because of the stigma of mental illness. For example, Matt Mika, who is a lobbyist and longtime coach of the Republican congressional baseball team, was one of four people shot on June 14, 2017 while the team was practicing in a Virginia suburb of Washington, DC. According to The New York Times, “he has since sought to escape the attention showered on the victims of high-profile shootings in the United States, trying to resist the feeling that his identity is solely that of a survivor” (Weiland, 2018). He does this despite living with ongoing reminders of what he can no longer do because of the shooting.

While many people do report that it is good to have a name to describe what they are experiencing and being so diagnosed does provide some social benefits and access to entitlements, considering that only 10% of those who experience trauma develop the condition suggests that something is wrong with these people. They have pretraumatic event vulnerability, which may be genetic (Young, 2014), making them prone to development of the condition, which in the context of a negative social stigma becomes a barrier rather than an aid to full recovery, or growth. The diagnosis of PTSD is a label that is associated with mental illness, disability, and deficit of character.

Another problem with the PTSD diagnosis, which has been made worse with the DSM V criteria, is how broad the range of stressful events and experiences that qualify as traumatic is. According to Galatzer-Levy and Bryant (2013), it is such an amorphous classification that there are 636,120 ways to get the diagnosis of PTSD. According to Young, Lareau, and Pierre (2014), when you add the common comorbidities of PTSD there are quintillion ways to have PTSD comorbidity. The heterogeneity of individuals who could be so diagnosed adds to the confusion of what constitutes a trauma and increases the ease of malingering (Zoellner, Bedared-Gilligan, Jun, Marks, & Garcia, 2013). There is also the question of whether the diagnosis can be used if persons exhibit the symptoms of PTSD, without a clear trauma (Roberts et al., 2012). For these reasons, of the WHO’s International Classification of Diseases (ICD), 11 have restricted the diagnosis to a stress-induced fear-based anxiety disorder, while the DSM V no longer considers it an anxiety disorder.

When one considers the Syrian civil war and Syrian refugee situation, rather than a single traumatic event, there are persistent traumatic stressors that are not only experienced by individuals but by an entire nation (Bensimon, Solomon, & Horesh, 2013). A recent New York Times (Beech, 2017, Dec. 31) story warns of a massive mental health crisis anticipated for Rohingya children who are now in Bangladesh. Beech quoted a mental health advisor as saying “you have trauma on a huge scale, children seeing brutal killings and being forced to leave home with nothing . . . you have hunger. You also have significant developmental delays due to malnutrition and under stimulation that predate the recent trauma. It’s absolutely devastating for an entire community” (para 12), with another spokesperson adding “we have no idea how all these children are going to process this trauma” (para 19).

An alternative model of stress and trauma response is described as the conservation of resource (COR) model. It assumes that people seek to conserve the resources they possess. Sustained or severe threat of loss of resources is central to one’s well-being. This model holds that the lack of material, cultural, and community resources available to persons is instrumental in the outcome of severe stress or trauma, as much as factors internal to the person. It also better appreciates the gravity of sustained stress and exposure to multiple traumatic events, such as has been experienced by Arabs and Jews in Israel (Hobfoll et al., 2008). Adequate social support, at the family, social network, and broader societal level, before, during, and after traumatic events, has been shown to be associated with lower posttrauma development of PTSD symptoms (Karstoft, Armour, Elklit, & Solomon, 2013; Ozer, Best, Lipsey, & Weiss, 2003).

This model appreciates that individuals, families, and communities can not only recover from traumatic events but also find new resources for possible future events from which to grow and develop in the wake of disasters. From the perspective of providers in low-resource countries, fidelity to standard treatments, such as trauma-focused treatment, which asks the client to address the memories of the trauma, may not be possible given the limited number of adequately trained clinicians or resources to pay for such services. In such situations, it is necessary to modify the treatment offered and approach the problem differently, which in some cases has turned out to fit with the cultural context better (Chen, Olin, Stirman, & Kaysen, 2017).

Posttraumatic Growth

According to Tedeschi and Calhoun (2004), PTG is a positive change that can occur after a trauma, not because of the trauma itself but because of the effort required to overcome the event with a new reality. It does not negate the seriousness of trauma or posttrauma suffering but seeks to consider that there is also, at least for some people, the potential to experience an increased appreciation for being alive, a shift toward more meaningful relationships, and an increased sense of personal strength that often emerges after traumatic and challenging events. PTG is different from resilience, which is usually considered persisting in the face of great stress and involves a return to baseline. Resilience is seen in persons who demonstrate flexibility in their response to severe stress and a reflective style that leads to learning from experiences and developing relationships (Rutter, 2012).

PTG involves uncovering new possibilities and capacities that surpass what existed before the stresses and challenges occurred (Tedeschi & Calhoun, 2004). PTG is considered by some to include an existential or spiritual rebuilding after traumatic events, such as an earthquake, which makes people who have been through it better able to deal with similar events in the future. PTG can be considered a paradigm shift in research and clinical practice, a perspective that looks for the glass half full.

A recent meta-analysis of 63 empirical studies done by authors in China found a correlation between PTG and PTSD, such that an increase in posttraumatic stress symptoms was associated with more PTG, at least for some people, in certain types of trauma (Liu, Wang, Li, Gong, & Liu, 2017). They reported that the positive correlation was greater for children than adults; it was a curvilinear association in terms of time, such that growth occurs later, over time; and it was more pronounced with certain types of trauma, such as caregivers of a child who suffered trauma and in war conflicts, and less correlated with sexual trauma and disease experiences. Bachner, Carmel, and O’Rourke (2018) found that Israeli holocaust survivors, even though older and less educated than comparison groups of Israelis and Canadians, had similar levels of life satisfaction. These authors concluded that the survivors of early life trauma reported “high life satisfaction not despite, but because of,” their early life traumas (Bachner et al., 2018, p. 45). These studies, like the case of Matt Mika, suggest that PTG may be a paradoxical experience.

As mentioned above, Syrian refugees, like other groups of political refugees, have often lived through multiple severe traumatic events and losses, before, during, and after fleeing their homeland. Also mentioned was that such complex and prolonged stresses do not fit the PTSD model. While not using the term PTG, El-Khani, Ulph, Peters, and Calam (2017) described successful coping mechanisms used by displaced Syrian refugee parents living with their young children in Turkey and northern Syria. Using interviews and focus groups, they uncovered three themes: adapting to a new norm, accepting changes in their children, and reaching out for support and keeping mentally strong using faith. In their discussion of these themes, the authors were impressed with the gratitude, sense of purpose, belonging, and religious-based meaning that was engendered by the experiences and struggles these parents faced (El-Khani et al., 2017, p. 34). The women also admitted that if they had stayed in Syria, they would have more likely relied on older Syrian women for help and guidance, but in the preresettlement camps, they had to rely more on themselves and turn to other types of people for help as well as develop their Muslim faith. They saw this as a benefit, which they associated with hope for the future. The authors saw this as maintaining mental health, but it can also be seen as PTG.

Conclusion

The author provided a brief consideration of the construct PTSD and PTG from a global perspective. Without seeking to minimize the severity or impact of trauma that many individuals, groups, and nations experience or deny the prolonged suffering that trauma often leaves in its wake, the author suggests that PTG is both a paradigm shift and a paradox, when compared with PTSD. The United Nations and other international and local groups need to continue their efforts to reduce the incidence of preventable trauma and help those who have experienced trauma, just as clinicians need to remain alert for the evidence of hidden trauma without stigmatizing persons who live with posttrauma distress or disability. What is also needed is a broad and open mind to the benefits of various conceptual models to understand trauma experiences.