The diagnosis of posttraumatic stress disorder (PTSD) has undergone much more than a minor tweaking or superficial facelift in the American Psychiatric Association's DSM-5. This guidebook to psychiatric diagnoses, released in May, now defines PTSD as a trauma and stressor-related disorder, not a disorder primarily of anxiety alone. Like our understanding of the brain and behavior, PTSD has become much more complex—and for millions of trauma survivors who have experienced difficulties that go well beyond the symptoms included in PTSD up to now, and the tens of thousands of clinicians who provide treatment to affected trauma survivors, the change is long overdue, but extremely welcome.
Bottom line, PTSD is now described as a disorder of persistent reactivity in all of the domains of self-regulation, and not just troubling memories and chronic anxiety . Distressing memories of past traumatic events and intense stress reactions to reminders that occur in current life continue to serve as the cornerstone of PTSD.
Now, however, these forms of "intrusive re-experiencing" of traumatization are understood as playing out across the full range of ways in which we regulate ourselves: emotions, body functions and health, thinking, motivation, behavior, relationships, and ultimately our sense of self or identity.
Trauma doesn't just terrify or horrify us—it also forces us to make profound biological adaptations in how our brain operates. Basically, the brain is a control system that keeps our body functioning properly. In other words, the brain regulates how our body functions to keep us alive, and when our body is safe and working well, the brain extends its efforts to the "higher" functions that enable us to not only survive but also to become a conscious individual—a self or an identity that makes each of us and our lives unique and not only pleasurable (or tolerably painful) but meaningful.
When the brain detects serious threats to our bodily survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and literally hijacks the rest of the brain's operations in order to put all systems in emergency mode until the threat is escaped or overcome.
This might seem like a simple shift in brain functions that leads to a temporary fight-flight reaction or adrenaline rush that is intense but quickly passes. And in many cases, both with ordinary stressors that are not traumatic threats to our lives as well as with traumatic survival threats, the alarm reaction in the brain does rapidly subside. We’re left somewhat shaken or jangly, but no worse for the wear with a brain that re-sets automatically to its normal modes.
However, as we've described in Hijacked by Your Brain, PTSD is what happens when the brain's alarm system doesn't automatically or rapidly re-set itself. When the brain's alarm continues to signal danger even though safety has been restored, the brain's overall functioning remains in an altered state that is the chronic stress response. Survival trumps self-regulation in this case: staying alert and ready to react in fight-flight mode to the next assault or betrayal takes precedence over sorting out our emotions and thoughts, taking care of our body's health, considering our core values and who we aspire to be.
In service of a commendable goal, survival, the brain's alarm system has hijacked the "higher" operations of the brain itself, keeping us alert and ready for action, and therefore alive. In this state, however, life becomes a constant struggle that involves unbearable tension and ultimately emotional as well as physical exhaustion (hence the depression and physical health problems that so often occur with PTSD).
People living with PTSD, therefore, are not just troubled by terrible memories, worries, and anxieties. More fundamentally they have high functioning brains that have become trapped in survival mode. That's why PTSD is complex, because it's about a fundamental change in how the brain (and body, and mind) are operating. It is not a disease, and not an injury to the brain (although when this has happened as well, such as when the survival threat is a blast explosion or another severe physical injury to the head, the combination of PTSD and traumatic brain injury creates additional major challenges).
How can someone re-set a brain's alarm that's stuck in PTSD (survival mode), so that self-regulation can be restored? That is the $60,000 question, which I'll tackle in Part II of this series on the implications of PTSD becoming defined in a way that is appropriately more complex in the DSM-5.