Tour of Duty

Inside the mind of a vet

Separateness

Traumatic events keep us in the past

When most people talk about Post Traumatic Stress Disorder (PTSD), they focus on the event and how it changed a person. People labeled with PTSD are often seen as distant, irritable, or different from before the trauma. There might not be much discussion about how the world now seems to the traumatized person. What does the word “different” mean from the inside? People who have survived horrific traumatic experiences experience the world differently from others, and differently than they did before the shattering experience of trauma. From my perspective, they experience an intense sense of separateness.

Family members and friends of those who have been traumatized have it right when they say the person is distant. Seeming distant is one of the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual (DSM-IV-TR). What they and the DSM-IV-TR are describing comes from the person with PTSD no longer living in the present. Their minds are still in the time of the event in those moments. They struggle to live in the present with those they love, because their minds frequently return to that traumatic experience they cannot escape. Events in the present, such as the news, similar smells, mentioning the traumatic event, or even idle time, can put the person with PTSD back in those horrific moments. It is more than remembering the event. I think re-experiencing, another diagnostic criteria for PTSD in the DSM-IV-TR, does not quite capture the experience either. The person, instead, is living in that moment again. Along with images and other senses from the moments such as smells or sounds, the person lives the same emotions again. The time between the event(s) and the present is suddenly gone. Time has collapsed back to those moments of horror. It can be just as terrifying as it was when it was actually happening. When a traumatized person is back in that moment again, he or she is “over there” again. Present experiences and circumstances lose importance, even meaning, for them.

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There is another part of this separateness that might be called a haze. I have heard people with severe PTSD described as having poor concentration, even appearing as if there is something wrong with their brains. There is, but it is linked to their experience and not to a direct physical brain injury. I understand this haze as part of remaining “over there” most of the time. They cannot focus on the present because they are too preoccupied with the past. That horror is the only experience that makes sense to them anymore. Their present experiences, that seem safe to the rest of us and free of the dangers they experienced before, feel only like an illusion. They now know that horrific things happen to people, and that people can die or be assaulted at any moment. They witnessed it “over there.” Now, when death seems far away in the present, like something not openly happening and guarded against, life no longer feels real. Traumatized people feel they have to be on guard all the time. Living in circumstances that do not seem to warrant guarding against death do not make sense. Peaceful surroundings might even seem fake to them and cause more anxiety, because they know that death is lurking and they no longer know where it is. So they stay separate from the present, including others who do not share the sense that present safety is only an illusion. Rejecting them along with the illusion of safety might even feel less dangerous to them, because you have to stay on guard for death or violence to burst through the illusion of safety at any moment. How can you guard against death if your family wants you to relax and pay attention to them?

I understand this separateness due to PTSD as the mind trying to process and put these events into a meaning that makes sense. Treatment helps to process these horrific experiences and to make sense of the world again. Treatment does not prevent a return to that time and moments again. The trauma will not be forgotten. Instead treatment makes the transitions between the past and present less consuming and intense. The person, hopefully, gets closer to remembering the events in ways that seem more like memories, and no longer living them, intensely separate from their current circumstances and their loved ones.

Russell Carr, M.D., is a naval psychiatrist who heads up adult outpatient psychiatry at the Walter Reed National Military Medical Center in Bethesda, Maryland.

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