Most psychiatric research has studied the post-incident suffering and disability of raped patients using the PTSD symptom clusters found in the
Diagnostic and Statistical Manuals (DSM) of the American Psychiatric Association. The World Health Organization’s (WHO),
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) mental disorders classification system is similar, though it has been used to a lesser extent in the United States. The WHO’s ICD–10, like the DSM-5, (both of these the current iterations of the publications), places an emphasis upon the defenses of dissociation and conversion. Both the DSM-IV and -5 contain a criterion for PTSD that states the patient must have been exposed to an event of threatened death, or dangerous threats, or sexual violence. The target population systematically studied to establish and validate the PTSD diagnosis in the DSM has been war veterans, and for the recent DSM-5 reliability research (2012–2013), the adult population was found mainly in the United States Veterans’ Administration hospital system. But the PTSD diagnosis also has been applied broadly to assessing the trauma of rape. Women have a greater risk of developing PTSD after physical assault than do men (
Betts et al, 2013).
The validity of all the DSM has often been criticized, but particularly DSM-5. While I have contributed to this negative view especially with regard to the PTSD diagnosis (
Barglow, 2011,
2013), I consider this nosology to be a comprehensive, quantifiable description of the consequences of traumatic experience. The
Diagnostic and Statistical Manual criteria are the best current source of research data to compare alternative methods of treatment with many varieties of psychopathology including those specific to rape trauma. The psychiatric diagnosis PTSD first included in the 1980 DSM-III lists the symptoms of intrusive recollections, nightmares, psychic distress, or physical reactivity to reminders that leads to avoidance of some thoughts or situations, insomnia, irritability, and hyper-vigilance. There may be poor recall of disturbing experiences with a new “numbing of general responsiveness” or restricted affect. The description remained the same in DSM IV-R, and its nosology demonstrates very high reliability for the PTSD diagnosis after its transfer to DSM-5 (
Freedman, Lewis, Michels et al, 2013). The DSM-5 with regard to PTSD mentions psychological symptoms and feelings often tantamount to numbing, citing decreased involvement in habitual activities, a new detachment from formerly important persons, and absence of habitual pleasures. However, it uses the term “numbing” as type of culture-related symptom. The DSM-5 classification of PTSD appends the presence or absence of coexisting symptoms of depersonalization or derealization, which are separately considered to constitute a Dissociative Disorder in the DSM-5. To qualify for inclusion, these two symptoms, often associated with psychotic states, must not be the product of intoxication or another medical condition. I prefer to consider them to be more malignant aspects of severe numbing, as they were in DSM-IV.
Typical post-trauma responses to rape comprise a Posttraumatic Rape Syndrome compatible with descriptions in the DSM-IV R of flashbacks, nightmares, startles, phobias, depression, avoidance, and numbing for PTSD. The relevant emotional defense process, extrapolating from concentrated combat exposure research, is “peritraumatic dissociation.” In a study of 251 male Vietnam veterans with high war-zone stress, “the greater the dissociation during combat stress exposure, the greater the likelihood of meeting criteria for later PTSD,” (
Marmar, Weiss, Schlenger et al, 1994, p. 902. In the first two patients described here, besides numbing there were considerable symptoms of depersonalization and derealization, also emphasized as related to PTSD descriptions in DSM-5. Comorbidity with substance dependence, depression, and anxiety disorders other than PTSD is typical of a large portion of the population of women who have been raped. To introduce my effort to comprehend more thoroughly the numbing feeling, affect, defense or syndrome, I will start with a self-report of a young woman, for whom this condition was paramount among her disabling post-trauma symptoms.
Case Example I
On the day my patient, aged 25 years, was raped she had almost completed a PhD. On that Thanksgiving Day my patient was taken hostage and brutally raped by three strangers who broke into an abandoned house of a friend where she was living temporarily. She reported:
Afterwards, I was unable to stagger more than a few steps at a time, due to genital [damage] and eye injury from being punched in the face. I was getting over a cocaine binge without any friends or family, with no possessions or money, in an unfamiliar empty neighborhood. The cops forced me into a psych-ward for suicide danger, where I was examined coldly, detoxed, medicated and thrown out.
Numbing came soon afterwards, described as follows:
It came as a surprise to me that as time passed I still felt little to nothing about the rape. I was increasingly bewildered at the odd numbness surrounding the entire rape incident. I would check up on it every so often in my mind, like a person whose tongue wiggles a broken tooth or cavity, to see whether my mind had changed—or rather, whether any new feelings had developed. But it all still feels like a blurry sequence of dreams, it’s a videotape with the sound turned off. Drugs did play some part in buffering my terror or remembering it, but they seemed not to affect my clear recall of every detail.
Some of my recollections are weirdly new, and they change over time. I do often remember that during the rape by the crazy man who first took me captive, after he punched in the face and threw my cell phone away from me, I kept saying, “Sir, please stop doing this. Why are you doing this to me, sir?” I repeated “sir” over and over again, while this crack-addled street hustler was doing sexual acts on me. Yet now today I still feel totally nothing or numb about the event–people around me seem to feel worse and more awkward hearing about it than I myself do in thinking or talking about it. I recall the event like a third person observer of the vacant rooms and mechanical motions during the hours that I was held captive. The wasteland limbo in which I currently reside is a world between worlds, where I wait to be born like a Tibetan Bardo. I have an impersonal visual perspective on the events in which tiny details usually are clouded and nebulous. But without any prompting, silly clear things come up; like I can see like in a museum painting, that specific abandoned street in streaming rain having the odd idea that in a nearby shack, some family was having a cozy holiday dinner. My rape has forced me into a totally new life: It gives me terrifying nightmares, has ended my student days, and made me choose a nun’s lifestyle. It’s strange though that most daily experiences seem emotionally disconnected, unreal and impermanent.
While having considerable derealization, and transitory depersonalization during the attack she manifested some immediate resilience shown by her odd politeness to an attacker. Perhaps strength was shown also in the capacity to retain a positive image of group safety shown in the family dinner fantasy. The patient during her post rape-trauma emotional life experienced the pervasive perception of numbness as her single most painful and disabling symptom. A few details of her childhood are pertinent to her strengths and vulnerabilities. More nuanced early emotional memories were almost entirely missing fully compatible with generalized dissociative amnesia. But I doubt if she had any emotional numbing then, an observation compatible with recollections of her parents when they were asked about this in a recent year. (In this regard she differs from the patient in Case Example II who suffered more extensive and chronic childhood trauma, and who did have early numbness, and “zoning out” periods.)
The patient was born on a small farm near Banja Luka, Serbia, and while her overall memory of the first years of life was quite poor, she remembered the sweetness of being sprayed with warm cow milk. She recalled that she seemed older and more mature, and disliked same-age playmates from Croatia (implying that even then, as a child, she knew of current political reality). She recalled little adversity or pain, but suspected that much turmoil resulted from her biological father leaving the family when she was a child of three. Her mother left the rural area and studied music at a local college, where she met the patient’s stepfather, then a student journalist. Her mother married the student, and when she was seven years old, the family moved to Belgrade during the onset of the Third Balkan War.
Her stepfather was hired by a Serbian media propaganda group and was successful as a writer. She liked the sound of his voice, adored his reading books to her, and recalled that he gave her a small diary, which she treasured, and now associates with her pleasure in writing. Frenzied political struggles engrossed her father, who rarely lived at home for more than a couple of days at a time, and who started having numerous sexual affairs with a series of younger women. Her mother suffered from severe migraine headaches and chronic back pain, making it impossible for her to be employed. The patient recalled her mother not so much as in motherly role, but more as a friend who protected her from her father’s malice and condemnation of female fragility. Her mother avoided any display of irritation and when confronted by adversity often played the role of clown or buffoon.
During most of her childhood my patient felt she had been mistakenly “trapped in the body of an adult.” She always felt compelled to avoid trouble (as her mother did) and to exercise control over both positive and negative feelings. Since her father wrote for a radio station detested by members of other ethnic groups, he felt (possibly correctly) that he and the family were being spied upon. Because the patient was “super-smart” (by her own description), peers bullied her as a “teachers’ pet,” and adults were condescending or ignored her. To survive emotionally she attached herself to a popular athletic girl, and maintained a secret unrequited love for an older boy. At the age of eight, her main relationship was to her diary, in which she shared her unhappiness, resentments, and hatred of her lonely life.
At age 17 she was sent to the United States with a full scholarship to an Ivy League college. But soon after matriculation she established social ties with school dropouts, town vagrants, troublemakers, and “druggies.” She began using euphoriants, leading to intermittent mild addiction over the first three years of enrollment. Miraculously, she performed well in classes and was considered a gifted, brilliant student; she particularly excelled in fiction and writing classes. She recalled no numbing episodes during these years.
Since being attacked, there were a few occasions she barely survived physically, and she contemplated suicide. Eighteen months after treatment started, she required two more hospitalizations both much shorter than the one she needed after being raped.
At the initiation of treatment, she totally avoided both sexual life and emotional intimacy, was plagued by various obsessions about food, doubts about her work capability, and physical attractiveness. She controlled these doubts through prolonged exercise activities and dieting, which she regarded as soothing distractions, but which often exhausted her emotionally and physically. Her parents helped her a little financially, but still lived in Europe, and mostly ignored her. She was unwilling to have contact with American relatives who tried to reach out to her, perhaps because she was too ashamed of her addiction problems.
At times she worked as an administrator and peer counselor in a “safe-habitat house” treatment program for people with addictions, where she lived in an unheated attic room. She attended Narcotics Anonymous meetings regularly and did not have cravings for illegal agents or suffer a drug relapse. Abstinence was supported by a daily high dose of buprenorphine (24 mg.), an opiate maintenance agent. The use of this legal agent prevented menstruation during the first three years after the rape. She was comfortable with this situation in spite of a slight risk to her ovaries because menstruation reminds her of sexuality and rape. She also took small doses of antidepressants and benzodiazepines. Often, magical thinking attracted her to alternative medicines that were promoted in partial hospitalization programs. I discouraged the use of these, if they posed a risk.