Post-traumatic Relationship Syndrome



Karen Rodman, Director and Founder of FAAAS Inc has proposed that when the affected person is still in the relationship then this Syndrome should be called Ongoing Traumatic Relationship Syndrome. (OTRS)

Adapted from: Social Behaviour and Personality, 2003 by Vandervoort, Debra, Rokach, Ami. This is a description of a trauma-based syndrome called Posttraumatic Relationship Syndrome (PTRS) which may afflict individuals who have been traumatized by physical, sexual, and/or severe emotional abuse within an intimate relationship. In PTSD, there is overutilization of avoidant coping, but PTRS involves the overuse of emotion-focused coping.

"History, despite its wrenching pain cannot be unlived,
but, if faced with courage, need not be lived again."


People are social animals who cannot survive alone. From birth to death we are in the company of, and depend upon, significant others for survival. The relationships we partake in, may be life sustaining and nurturing and may promote personal growth and health, or may be abusive, destructive and traumatic. In this day and age we are surrounded by abuse and violence. Domestic violence and abuse is one of the most frequent crimes in our nation as well as one of the most underreported. Research has amply documented there are short- and long-term mental and physical health benefits when the relationships we partake in throughout life are positive, whereas abusive, restricting and non-nurturing relationships have been found to impair mental and physical health

Sexual, physical or severe emotional abuse (e.g., abandonment, betrayal, malevolent intent, or repeated victimization) often has devastating effects on the recipient. These effects can be long-lasting and broad ranging. Untreated trauma not only has dire effects on the individual (e.g., intense psychological distress, lost productivity, permanent disability, and increased industrial accidents), but also has broader ranging effects (e.g., social and community disorganization).

Why Post-Traumatic Relationship Syndrome?


The original impetus for the development of Posttraumatic Relationship Syndrome (PTRS) was clinical experience with clients whose symptoms were distinct from those with Posttraumatic Stress Disorder (PTSD) and to whom the traditional approaches to treatment of PTSD were inappropriate in a number of ways. Most notably, a major focus on getting in touch with the repressed traumatic memories is contraindicated in PTRS. The numbing of emotional responsiveness is not present in PTRS and with an overuse of emotion-focused coping, the client chronically approaches the traumatic memories too eagerly, leading to a harmful reliving of the trauma. In PTSD, there is a tendency to err on the side of too much constriction; in PTRS there is a tendency to err on the side of too much intrusion.

Another reason for the development of PTRS is adherence to the concept of a spectrum of posttraumatic disorders. Posttraumatic Stress Disorder has so dominated our concept of post-traumatic illness that it is often "perceived, albeit incorrectly, as a generic term for posttraumatic illness... [However], not all posttraumatic illness is posttraumatic stress disorder". The definition of posttraumatic illness in which the full criteria of PTSD are not met is the case in PTRS.

Interpersonal traumatic Stressors are particularly likely to create severe and long-term trauma responses. Even in the DSM-III-R's discussion of PTSD, it is noted that PTSD is likely to be "more severe and longer lasting when the Stressor is of human design". Further, research has shown that one of the biological functions of attachment is the regulation of physiological arousal. This may explain, in part, why people are more vulnerable in intimate versus non-intimate relationships and why traumatic Stressors in the intimate type of relationship are often harder to bear than those in the non-intimate and also harder to bear than traumatic Stressors attributable to nature or accidents.

Despite the devastating effects trauma in relationships can have, there is no diagnostic category specific to these effects. The fact the American Psychiatric Association (APA) is considering the possibility of proposing a relationship induced disorder ("Relationship Disorder", 2002) suggesting there is interest in and a need to develop such a concept. In light of the above, the present paper describes the symptoms of a relationship-induced posttraumatic illness entitled Posttraumatic Relationship Syndrome. Posttraumatic Relationship Syndrome can be defined as an anxiety disorder that occurs subsequent to the experience of physical, sexual or severe emotional abuse in the context of an emotionally intimate relationship. It involves a state of psychological crisis that exceeds the capacity of the individual's psychic structure to handle. It is a process that occurs over time and has debilitating effects on the individual.

The following symptoms characterize PTRS:

Initial response: The person's response involves intense fear/terror or horror and rage at the perpetrator.

Intrusive symptoms: (which were not present before the trauma):

        (1) Persistent re-experiencing of the event(s) in images, thoughts, recollections, daydreams, nightmares, and/or night terrors;
        (2) Extreme psychological distress (which may be accompanied by physiological reactivity) in the presence of the perpetrator or symbolic reminders
             of the perpetrator (e.g., uncontrollable shaking).

Arousal symptoms: (which were not present before the trauma):

        (1) Hyper vigilance (which may be the result of not feeling safe in the world)
        (2) Sleep disturbances (insomnia)
        (3) Persistent feelings of rage at the perpetrator
        (4) Restlessness
        (5) Difficulty concentrating
        (6) Weight loss
       
Relational symptoms:

        (1) Not feeling safe in the world
        (2) Mistrust and fear of intimate relationships (or a particular type of intimate relationship)
        (3) Sexual dysfunction, especially for those who have been sexually abused
        (4) Disruption in the victim's social support network, isolation

Thus, PTRS applies to individuals who have suffered physical, sexual, or severe emotional abuse in the context of an intimate relationship, and who consequently display the above symptoms. As the person's basic personality structure remains intact, it does not include the development of a character disorder and rather than being akin to a personality disorder, PTRS is a syndrome - the ultimate cause of which is outside the self. Hence it falls into the category of a posttraumatic illness, since it develops along with the experience of trauma and would not have occurred if the person had not experienced the traumatic stressor(s). It is clearly a less severe syndrome than complex PTSD as it does not include the array of symptoms which characterize complex PTSD (e.g., dissociation, pathological changes in identity).

Posttraumatic Relationship Syndrome stressors:

        (1) In PTRS, the traumatic Stressor may be physical, sexual, or emotional (whether or not there is an actual threat to one's physical integrity),
        (2) PTRS requires direct involvement with the abuser and actually experiencing the abuse; and
        (3) In PTRS, the Stressor must be in the context of an emotionally intimate relationship.

Response to the Stressor:
        Rage at the perpetrator and anger is a possibility. Such symptoms are normal for victims of interpersonal trauma.

Coping with the trauma:
There is a more conscious experience of the trauma. There is, a state of psychological crisis, as the subjective experience of trauma shatters the psyche's ability to maintain equilibrium. The person remains too acutely aware of being in a traumatized state, so for counsellors, an overuse of emotion-focused coping can lead to unnecessary re-traumatization of the individual. In PTRS, the client needs to be taught to use desensitization techniques to make the processing of the trauma more manageable.

Clients with PTRS appear to be overly courageous in taking on more than they can handle with a concomitant failure to engage in adequate psychological self-protection.



Traumatic Stressors and the Nature of Psychological Trauma


The experience of extreme terror during traumatic events creates images of the events that are inscribed in memory. Because of the vividness of the memories, the memory frequently returns to consciousness and evokes the same emotions as the original experience. This creates the classic intrusion and arousal symptoms characteristic of the state of psychological crisis caused by the original trauma, signifying that the experience has not yet been able to be integrated into the self because it cannot be assimilated into one's current beliefs about the self and/or world.

Although an individual may become traumatized by a single act (e.g., one's spouse kidnapping one's children; getting AIDS from one's spouse), often there are multiple traumatic acts. According to Khan (1977), a traumatic intimate relationship does not have to include behaviours which are consistently traumatic. However, they acquire traumatic qualities when a series of intermittent traumatic experiences accumulate within one's interactions which may finally lead to a state of crisis or psychological breakdown. That changes the emphasis from "trauma" to a "traumatic situation", and converts it into a process - a process whereby the interactional framework, becomes a source of trauma for the victim.

Abusive behaviour may be overt or covert. Not only is behaviour that is motivated by an attitude of malevolent intent extremely traumatic, but such behaviour done covertly is likely to be even more traumatic. This is due to the fact that it renders one helpless to protect oneself until one discovers the behaviour that is being hidden or denied by the perpetrator. Thus, issues central to the experience of trauma, namely helplessness, powerlessness, sense of control and predictability of the world, as well as the ability to protect one's life and/or psychic integrity are even more important. Although one can leave the relationship upon discovery of the abuse, one may not be able to escape the ensuing psychological crisis such knowledge yields.

There are a myriad of bio-psychosocial factors that determine whether an individual will be traumatized by a given event(s). The physiological literature indicates that the biology of stress is different from the biology of trauma and posttraumatic disorders. Just as this literature is based on the assessment of symptoms in the client, so must the assessment of PTRS be. That is, the critical point in determining whether the individual has succumbed to PTRS is whether the symptoms developed subsequent to the experience of an identifiable traumatic event(s) in the context of an intimate relationship. If the patient's functioning before the trauma is drastically different from their post-morbid functioning, the logical conclusion is that it is a posttraumatic illness.

Psychosocial Effects of Post-Traumatic Relationship Syndrome


Traumatic Stressors challenge one's knowledge of the self and/or world. Maimed or shattered beliefs create a state of psychological crisis until new paradigms can be adopted, for these are the basis of our psychological stability. Trauma can destroy our functional illusions of individual invulnerability.

There are four core assumptions fundamental to our belief in such invulnerability:

    (1) The world is benevolent or at least benign;

    (2) Life is meaningful;

    (3) We have control over our lives; and

    (4) Positive self-worth.

The experience of trauma makes one acutely aware that these assumptions are not true and thus one's ability to act as if these basic assumptions about the world are valid; is lost. One can no longer believe that people are basically good and that good things happen to good people or that by engaging in the "right" behaviours, one can create positive outcomes and avoid negative outcomes.

Trauma impairs beliefs about the meaningfulness of life because one cannot make sense of an unpredictable, uncontrollable, and unjust world. Lack of control yields a sense of vulnerability because this person-outcome contingency is broken. The traumatized state reinforces this belief as one's physical and psychological stability has been eroded - one has literally lost control of one's normal modus operandi. A worthy self is deserving of positive outcomes, but trauma proves this too can be an unrealistic expectation. In trauma, fairness, justice, security and stability seem to be arbitrarily and universally removed. Thus, the defence mechanisms which enable one to maintain psychological stability break down, and as Freud (1949) so accurately pointed out, these mechanisms are critical to keeping intolerable levels of anxiety at bay. Without the so-called sweet lies about life - the distortion of reality that these defence mechanisms provide- we cannot maintain psychological equilibrium.

In the case of trauma by human design, one is confronted with the age old "existential dichotomy" of good against evil. One comes face to face with the existence of evil and the breakdown of a moral universe. Natural disasters, accidents, and life-threatening illnesses do not raise this issue as such events involve no intent to harm. Intellectual familiarity with evil is a universal phenomenon, but living it in the context of an intimate relationship, fortunately is not. This experience of evil/wrong infuses the problem of evil into one's subconscious mind, yielding a kind of soul knowledge that can never be forgotten - transcended in time perhaps, but never forgotten. Malevolent intent in the context of a close interpersonal relationship is particularly likely to create a maimed paradigm of interpersonal intimacy. Because one is more vulnerable in intimate relationships, serious violation of such basic principles as trust, honesty, non-maleficence, and fairness is likely to be more traumatic than in non-intimate relationships. For one's home; what is supposed to be one's harbour of greatest safety becomes a source of unfathomable terror. Lack of a sense of security and safety are associated with feelings of a loss of a sense of belonging in the world. Given that our intimate relationships are so strongly intertwined with our sense of identity and security, as human relations theorists and others have so aptly pointed out it is easily understood how feelings of loss of belonging and the generalized sense of unsafety, which are characteristic of PTRS, can be a result of the loss or alteration of one's basic understanding of intimate relationships.

Traumatic experiences can obviously lead to issues with trust, an issue likely to be problematic only in cases of traumatic Stressors of human design. Given that one's sense of basic trust develops early in life as a function of our interactions with caregivers, it is a long-held and well-ingrained part of our assumptions about our world. Because it developed in the context of some of the most important emotionally intimate relationships in our lives, it is tied very strongly to this type of relationship. Hence, trauma in this type of relationship, sometimes referred to as attachment trauma is particularly likely to create trust issues.

Issues of trust created by trauma in the context of an intimate relationship may become generalized to future relationships, creating problems in developing one's social support network. Terror of getting re-victimized in a new relationship is very common, which although unpleasant, helps prevent its occurrence due to the conscious awareness of it. Some forego new relationships, having great difficulty in initiating and/or maintaining them. However, given the lack of a tendency toward emotional numbing (which makes maintaining intimate relationships difficult), withdrawal from, or significant disruption of all social relationships is much less likely in PTRS than in PTSD. Others may struggle with trust issues and relationship difficulties only in the type of relationship in which the experience of trauma occurred. For example, trust issues in romantic relationships are particularly common for those who experienced trauma in this type of relationship. Similarly, sexual dysfunctions (e.g., loss of interest in sex, risky sexual practices, and infidelity issues) are strongly associated with a history of sexual abuse in an intimate relationship.

Not only does attachment trauma bring up issues regarding trust of others, but it also raises issues of trust of one's self by calling into question one's judgement of character. How one's view of others could be so erroneous becomes a puzzle, and if one's assessment of character was so wrong in the case of the perpetrator, how does one know that the assessment of the character of others in one's social world is accurate? Such self-doubt regarding one's perceptions of one's social world is another avenue via which impairment in one's social support network can occur for victims of PTRS.


CONCLUSION:

In sum, PTRS is a posttraumatic syndrome which results from trauma experienced in the context of an emotionally intimate relationship. As with other types of posttraumatic illness, the psychological world of those suffering with PTRS is a world filled with terror which results in psychobiological changes. The source of their anxiety is twofold. The first source is associated with the realization that their physical and/or psychic survival is no longer secure, that their self-preservation can be jeopardized by a world that is hostile and unsafe. The other source is associated with a breakdown of their knowledge of the self and/or world, a conceptual system that provided both the foundation for psychological stability and the ability to perceive the world in a coherent and meaningful way. The disintegration of this conceptual system impairs the ability of those suffering with PTRS to maintain psychophysiological stability and can create problems with intimacy until a new paradigm can be adopted and integrated into the self. Copyright Society for Personality Research Incorporated 2003

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