Nathalia has nightmares. Like in a movie, the same scenes play, again and again. The moment when she ran away. When such a flashback happens, triggered by noises or images on TV, she is panic-stricken. She sweats, shakes. The diagnosis is post-traumatic stress disorder (PTSD).
She has been receiving treatment for about five months from Meryam Schouler-Ocak, senior physician at the Psychiatric Outpatient Clinic at the Charité University Psychiatric Clinic in the Alexian St. Hedwig Hospital in Berlin. "What happened on New Year's Eve is that she was relieving the war trauma that she experienced," explains the Berlin-based physician.
Flashbacks and PTSD
According to the U.S. Diagnostic and Statistical Manual (DSM-5), trauma is present when a confrontation with death, injury, loss or sexual violence has happened. "And that's the case even if it didn't happen to the person themselves, but they witnessed someone experiencing it," says Schouler-Ocak.
During a war, she says, you don't just experience one trauma, but a string of traumatizing experiences — new traumas every day. That describes what Nathalia went through.
Flashbacks are the result of faulty storage of memories of the traumatic experience in the brain. Two brain areas play a central role here: the amygdala, where emotions are formed, and the hippocampus, the memory of place and time — effectively the brain's navigation system for space and time. Normally, emotions and navigation data are stored simultaneously. For this to succeed, the amygdala must not be too strongly activated.
The shock phase happens in the first few days after the trauma, and is often characterized by the impression of not being able to sense or feel anything. "Whether this later develops into post-traumatic stress disorder or you get back on your feet depends very much on whether you can process what you have experienced in the first two to four weeks after the shock phase, in a so-called impact phase," says Schouler-Ocak. This is the time when the brain decides how to process events, and whether it has developed strategies to deal with the stress.
The key often lies in childhood. People who have experienced emotional security are better able to cope with later traumatizing experiences. In a good 40% of cases, the symptoms improve on their own. But those who have not learned coping strategies to calm their troubled souls, and who do not receive support, are at risk of losing control of their emotions. With every experience of abuse from childhood and adolescence, the lack of a sense of security, and the risk of falling ill, increases disproportionately.
In addition to PTSD, it is often depression or anxiety disorder, or both.
Then the amygdala can inhibit the storage of memory content at a place and time in the hippocampus. As a result, memories of feelings are stored without temporal and local classification — as individual fragments, but not the memory of the experience as a whole.
If these memory fragments are later activated by a trigger, in Nathalia's case by the New Year's Eve bangs, then the affected person experiences the situation as if it had just happened. Each flashback means a new trauma. Feelings of fear, defenselessness, helplessness and loss of control reoccur. This is often compounded by additional suffering, such as addiction or eating disorders. "Nearly 70% of those affected have not one but even two of these trauma-induced disorders," Schouler-Ocak reports. "In addition to PTSD, it is often depression or anxiety disorder, or both."
Donetsk, Ukraine: two sisters along with their mother, luggage on the floor, waiting for an emergency evacuation bus to Dnipro, as the city is under heavy attack.
Alex Chan Tsz Yuk/SOPA Images via Zuma
Trauma and the body: a deep connection
Not only the psyche, but the whole body also suffers. Physical complaints such as abdominal pain, shortness of breath, a pounding heart and unsteadiness are often felt — sometimes only as a slight disturbance, and other times as a pronounced illness. "Traumatized people often appear physically prematurely aged," says psychologist and psychotraumatologist Iris-Tatjana Kolassa, who heads the Department of Clinical and Biological Psychology at the University of Ulm. She says a traumatized person is permanently at an elevated stress level and constantly on alert.
"Chronic, excessive and traumatic stress always leave traces in the cells of our body," Kolassa says.
Particularly affected, he says, are those cell types that require a lot of energy, such as brain, heart, and liver cells. Under very high stress, these cells' metabolism must perform at peak levels. To do this, they need energy, which their tiny cellular power plants produce. However, there is then also an "excess" of oxidative stress, which can damage the genetic material, fats and proteins.
As a result, more inflammatory processes occur. "If this condition persists for a long time, a normally well-functioning system can become overwhelmed," says the Ulm researcher. One then feels lacking in energy, is listless, has concentration and has thinking disorders. "In addition, post-traumatic stress leads to changes in the immune system of those affected, which would otherwise only occur later in life." Even their risk of developing type 2 diabetes, cardiovascular disease, cancer or immunological diseases such as rheumatism earlier increases.
Starting a psychotherapeutic treatment can help to significantly reduce the symptoms, according to Kolassa. The negative effects caused by stress could be improved, and inflammatory processes possibly reduced to normal levels again. Nathalia's psychiatrist Schouler-Ocak agrees. Her patient's PTSD has already improved, she says. And that's despite the fact that she can only communicate with her through an interpreter. Often, even non-specific help and support measures suffice. Nevertheless, she would like to see more for people who have to flee war and violence. The methods to do so already exist.
The patient keeps their head still and looks at the therapist's hand.
Eye Movement Desensitization and Reprocessing (EMDR) is a special form of psychotherapy for the treatment of trauma disorders. It was developed in 2001 by Francine Shapiro of the Mental Research Institute in Palo Alto. EMDR is a therapeutic journey into the past: following a precise protocol, the therapist asks questions in eight phases about what the patient has experienced and the feelings, thoughts and body sensations that were felt during the experience. The patient keeps their head still and looks at the therapist's hand. The eye movements address and connect both hemispheres of the brain simultaneously. They are intended to divert the patient's attention from the traumatic experience. The situation suffered through is re-evaluated and seen as something past.
But for Nathalia and other Ukrainian refugees, it is used far too rarely. "Because, for this, an interpreter not only has to know the language but should also have a good trauma-specific knowledge," says Schouler-Ocak.
EMDR is not easy for the patient: they are confronted with memories, which can be exhausting and lead to nightmares, and sometimes previously unknown traumas surface. For Nathalia, despite the recovery, the trauma is far from over. She can talk to her daughter almost every day, but her son is often unavailable for days at a time, leaving her filled with crushing uncertainty.