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In the aftermath of an experience of overwhelming danger, the two contradictory responses of intrusion and constriction establish an oscillating rhythm. This dialectic of opposing psychological states is perhaps the most characteristic feature of the post-traumatic syndromes. Since neither the intrusive nor the numbing symptoms allow for integration of the traumatic event, the alternation between these two extreme states might be understood as an attempt to find a satisfactory balance between the two. But balance is precisely what the traumatized person lacks. She finds herself caught between the extremes of amnesia or of reliving the trauma, between floods of intense, overwhelming feeling and arid states of no feeling at all, between irritable, impulsive action and complete inhibition of action. The instability produced by these periodic alternations further exacerbates the traumatized person’s sense of unpredictability and helplessness. The dialectic of trauma is therefore potentially self-perpetuating.
In the course of time, this dialectic undergoes a gradual evolution. Initially, intrusive reliving of the traumatic event predominates, and the victim remains in a highly agitated state, on the alert for new threats. Intrusive symptoms emerge most prominently in the first few days or weeks following the traumatic event, abate to some degree within three to six months, and then attenuate slowly over time. For example, in a large-scale community study of crime victims, rape survivors generally reported that their most severe intrusive symptoms diminished after three to six months, but they were still fearful and anxious one year following the rape. Another study of rape survivors also found the majority (80 percent) still complaining of intrusive fears at the one-year mark. When a different group of rape survivors were recontacted two to three years after they had first been seen in a hospital emergency room, the majority were still suffering from symptoms attributable to rape. Trauma-specific fears, sexual problems, and restriction of daily life activities were the symptoms these survivors reported most commonly.
The traumatic injury persists over even a longer period. For example, four to six years after their study of rape victims at a hospital emergency room, Ann Burgess and Lynda Holmstrom recontacted the women. By that time, three-fourths of the women considered themselves to have recovered. In retrospect, about one-third (37 percent) thought it had taken them less than a year to recover, and one-third (37 percent) felt it had taken more than a year. But one woman in four (26 percent) felt that she still had not recovered.
A Dutch study of people who were taken hostage also documents the long-lasting effects of a single traumatic event. All of the hostages were symptomatic in the first month after being set free, and 75 percent were still symptomatic after six months to one year. The longer they had been in captivity, the more symptomatic they were, and the slower they were to recover. On long-term follow-up six to nine years after the event, almost half the survivors (46 percent) still reported constrictive symptoms, and one-third (32 percent) still had intrusive symptoms. While general anxiety symptoms tended to diminish over time, psychosomatic symptoms actually got worse.
While specific, trauma-related symptoms seem to fade over time, they can be revived, even years after the event, by reminders of the original trauma. Kardiner, for example, described a combat veteran who suffered an "attack" of intrusive symptoms on the anniversary of a plane crash which he had survived eight years previously. In a more recent case, nightmares and other intrusive symptoms suddenly recurred in a Second World War combat veteran after a delay of thirty years.
As intrusive symptoms diminish, numbing or constrictive symptoms come to predominate. The traumatized person may no longer seem frightened and may resume the outward forms of her previous life. But the severing of events from their ordinary meanings and the distortion in the sense of reality persist. She may complain that she is just going through the motions of living, as if she were observing the events of daily life from a great distance. Only the repeated reliving of the moment of horror temporarily breaks through the sense of numbing and disconnection. The alienation and inner deadness of the traumatized person is captured in Virginia Woolf’s classic portrait of a shell-shocked veteran:
"’Beautiful,’ [his wife] would murmur, nudging Septimus that he might see. But beauty was behind a pane of glass. Even taste (Rezia liked ices, chocolates, sweet things) had no relish to him. He put down his cup on the little marble table. He looked at people outside; happy they seemed, collecting in the middle of the street, shouting, laughing, squabbling over nothing. But he could not taste, he could not feel. In the tea-shop among the tables and the chattering waiters the appalling fear came over him—he could not feel."
The constraints upon the traumatized person’s inner life and outer range of activity are negative symptoms. They lack drama; their significance lies in what is missing. For this reason, constrictive symptoms are not readily recognized, and their origins in a traumatic event are often lost; With the passage of time, as these negative symptoms become the most prominent feature of the post-traumatic disorder, the diagnosis becomes increasingly easy to overlook. Because post-traumatic symptoms are so persistent and so wide-ranging, they may be mistaken for enduring characteristics of the victim’s personality. This is a costly error, for the person with unrecognized post-traumatic stress disorder is condemned to a diminished life, tormented by memory and bounded by helplessness and fear. Here, again, is Lessing’s portrait of her father:
"The young bank clerk who worked such long hours for so little money, but who danced, sang, played, flirted—this naturally vigorous, sensuous being was killed in 1914, 1915, 1916. I think the best of my father died in that war, that his spirit was crippled by it. The people I’ve met, particularly the women, who knew him young speak of his high spirits, his energy, his enjoyment of life. Also of his kindness, his compassion and—a word that keeps recurring—his wisdom. . . . I do not think these people would have easily recognized the ill, irritable, abstracted, hypochondriac man I knew."
Long after the event, many traumatized people feel that a part of themselves has died. The most profoundly afflicted wish that they were dead. Perhaps the most disturbing information on the long-term effects of traumatic events comes from a community study of crime victims, including 100 women who had been raped. The average time elapsed since the rape was nine years. The study recorded only major mental health problems, without paying attention to more subtle levels of posttraumatic symptomatology. Even by these crude measures, the lasting, destructive effects of the trauma were apparent. Rape survivors reported more "nervous breakdowns," more suicidal thoughts, and more suicide attempts than any other group. While prior to the rape they had been no more likely than anyone else to attempt suicide, almost one in five (19.2 percent) made a suicide attempt following the rape.
The estimate of actual suicide following severe trauma is riddled with controversy. Popular media have reported, for example, that there were more deaths of Vietnam veterans by suicide after the war than deaths in combat. These accounts appear to be highly exaggerated, but mortality studies nevertheless suggest that combat trauma may indeed increase the risk of suicide. Hendin and Haas found in their study of combat veterans with post-traumatic stress disorder that a significant minority had made suicide attempts (19 percent) or were constantly preoccupied with suicide (15 percent). Most of the men who were persistently suicidal had had heavy combat exposure. They suffered from unresolved guilt about their wartime experiences and from severe, unremitting anxiety, depression, and post-traumatic symptoms. Three of the men died by suicide during the course of the study.
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