Chapter 1. Principles of Psychological Responses to Stressor Events

Incompletely assimilated memories are retained in various strata and categories of storage. The intensity of potential meanings and feelings associated with the events can mark some memories for later conscious representation, review, and reappraisal. The potential for unthinking rage, anxiety, shame, guilt, and prolonged sadness may remain until the completion of that processing.

Disturbances in identity, relationships, and emotional regulation may occur and may undergo phases of resolution or return. Social connection may be disrupted just when the impacted person needs more support. Self-esteem may collapse, and self-coherence may falter.

Stress response syndromes may include a sense of being unable to rely on one’s previously learned capacities for how to solve current problems. The mismatch between the trauma and the coping skills that previously had been effective may lead to self-criticisms and blaming. Loss of coherence in self-organizing beliefs may contribute to dissociative experiences.

Extreme affective potentials may continue as disturbed states of mind. The person may have attacks of confusion, rage, or despair. An individual may experience a sense of loss of control over feelings just when he or she needs heightened capacity to regulate emotions. However, with successful assimilation and accommodation, memory systems can be integrated, and a coherent sense of past, present, and future can be achieved.

Emotional blunting and dissociative states can alter patterns of social interaction. The individual may develop phobic avoidance of places and situations that remind him or her of the trauma, even inhibiting exposure to colors and odors associated with the trauma. Socially, members of an individual’s support network may take offense with what appears to them as withdrawal due to numbing of feelings and avoidance of previous levels of warm connections. Family life, friendships, and work relationships may deteriorate. If this happens, others’ withdrawal may limit support and repair of the individual’s sense of coherent self-organization.

Memories tend to repeat in conscious representation in spite of avoidance maneuvers. Intrusive experiences include nightmares, bad daydreams, flashbacks, perceptual memories, and frightening expectations of “What’s next?!” Recurrent cycles of avoidance and intrusive states of mind are common (Horowitz 1976, 2011; Horowitz et al. 1979). Processing takes longer than most people expect. For example, when in someone is mourning, it may take a year or more before the individual feels that a new equilibrium is in place.

Individuals may maintain hyperalert attention deployment as if they were in perpetual danger even though they are not in danger. Compulsive behavioral reenactments may occur. For example, after an assault, an individual may provoke a fight with a stranger or assume the role of an aggressor instead of a victim.

Recurrent intrusive memories and imaginary elaborations can range from a minor fragment of the traumatic perceptual experience (such as a flashback to a single smell or image) or a larger complex of experiences (such as seemingly reliving a sequence of events). They can also take the form of the individual compulsively engaging in risky behavior as if to prove to himself or herself that the trauma or loss cannot recur. Intrusive trauma memories may also include imagined scenarios of what the individual wishes he or she had been able to do or would want to do should a similar event ever happen again.

In nonpathological reactions to stressor events, individuals can expect to see a decrease of intrusive, avoidance, and alarm states of mind over time. This is due to a combination of automatic mental processes that include habituation (getting used to the safety of a somewhat similar situation in which the threat does not repeat), extinction learning (learning that the perceptual stimuli associated with the trauma are no longer associated with traumatic probabilities), and desensitization (the body learning to remain calm in similar perceptual situations).

In psychopathological syndromes, alarmed reactions in response to trauma-associated percepts may be intense, frequent, and prolonged. For example, a person mugged in a dark garage may feel his or her heart race and stomach clench when driving into the same garage years later or even any dark place with cars. The goal of adaptation is the controlled review of experiences with cognitive reappraisals until acceptance occurs, coping strategies are fully mobilized, and new schemas are formed. The revised schematization affects the person’s sense of identity and connectivities to significant others as well as beliefs about attachments to social communities.

Reactions to stressor events can take several forms. Clinicians should look for the five Ds: dissociation, disavowal, denial, depersonalization, and derealization. Dissociation can reduce terror by effectively telling one’s mind, “I am not really here.” Disavowal of aspects of traumatic experiences can be used to lessen negative emotions that otherwise threaten to disorganize thought. Denial can include misappraisal of the meanings of the event. Depersonalization can be a sense of no longer being the same person as before the event, and derealization can be a sense that current perceptual reality is unreal or somehow dreamy. The five D experiences are maladaptive and distressing when the individual reflects on them, but they are part of defensive coping because emotional flooding may be reduced for a time.

Patients often seek a first clinical evaluation long after the conclusion of a stressor event and perhaps midway in the phases of reaction. The prototypical phases of reactions after a stressor include the following (Horowitz 2011):

These general phases of stress response syndromes may seem similar to the five stages of grief described by Kübler-Ross (1969) as denial, anger, bargaining, depression, and acceptance. However, control of thought and regulation of emotion are emphasized in the phases of reaction of stress response syndromes, whereas the ideational and emotional content is emphasized in the progression through the Kübler-Ross stages of resolving grief. In addition, in psychotherapy, patients move in and out of the different phases of stress response syndromes, and each of these phases is worked through while taking into account the patient’s preferences, cultural beliefs, and social supports.

Individuals experience trauma in terms of their prior life experiences and personality characteristics. Appraisals and reappraisals are influenced by patients’ identity and schematic structure of relationships between self and various others, including ethnic and spiritual communities. In addition, their experience of prior stressor events will have left enduring and only slowly changing attitudes. Adverse childhood events may have inscribed a sense of excessive vulnerability (Caspi and Moffitt 2018; Herman 1997; Horowitz 2002). These are reasons why recovery from trauma often involves reorganizing narratives about the self in the world in the time frames of past, present, and future (Classen et al. 2006; Cloitre et al. 2009).

Schemas for relationships develop throughout life and build toward wisdom with life experiences. Various personality configurations can lead to adaptive responses to trauma and loss, such as seeking help and building self-supportive connections with others. Preexisting personality problems can lead to maladaptive responses, as shown in Figure 1–1. The individual may seek risky, exploitative supports for self-coherence or react too negatively to possible helpers.

The next case example illustrates how a stressor event can become entangled with preexisting personality issues.

Traumatization may result in a variety of psychopathological syndromes (Horowitz 1976, 2011; Spiegel and Classen 1995; van der Kolk et al. 2005). In DSM-5 (American Psychiatric Association 2013), the common disorders are posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorder. Trauma can occur with comorbidities of traumatic brain injury (TBI), mood and anxiety syndromes, and substance use disorders in addition to PTSD (Aupperle 2018; Berenz and Coffey 2012; Kaysen et al. 2014). Reactions to recent traumas may also be influenced by the occurrence of previously unresolved personality issues, which can cause complex reactions, described in ICD-11 as complex PTSD (CPTSD; Herman 1997; Maercker et al. 2013; World Health Organization 2018).

Treatment stages are described in this book in terms of syndromes that are simple, comorbid, or complex. Table 1–1 depicts these typologies.

Psychotherapy is an effective treatment for stress response syndromes. The patient in psychotherapy goes through various phases of change, and the therapist uses various teachings in each phase. These phases are described in the ensuing chapters and are summarized in Table 1–2. Formulation and therapy techniques are typically revised as the treatment proceeds.

Stress response syndromes are characterized by intrusive mental experiences and avoidant behaviors with psychological numbing and inhibitory operations. These signs and symptoms may be prolonged in individuals who have comorbid conditions or predisposing complications from personality configurations. The use of phase-oriented therapy techniques and individualized formulations will lead to symptom amelioration and even personality growth. The goals of treatment are providing sufficient support, helping cognitive and emotional processing, and providing ways to learn how to enhance capacities for coping and reflective reasoning.