Saturday, May 11, 2019
Delayed Post-Traumatic Stress Disorder: An Autobiographical Example
It took the Vietnam War to barely wake up the globe to the reality of post-traumatic stress conditions—known most commonly as post-traumatic stress disorder (PTSD). Until the 1960s, sadly, traumatized soldiers, and others exposed to potentially life-threatening trauma, and who experienced reactive psychological symptoms, were generally considered weak, cowardly people.
Meanwhile, traumatic reactions to extreme stress, such as exposure to combat, has been part of the human condition since we evolved as a species. A complex of symptoms including flashbacks, intrusive recollections of the trauma, nightmares and generalized anxiety—now classified as PTSD—likely occurred as frequently when our ancestors faced saber tooth tigers as when they faced the horrors of war.
The mental health field has been slow to accept the legitimacy of PTSD as a diagnostic entity. The Diagnostic and Statistical Manual (DSM), the classification system used by the American Psychiatric Association, only included PTSD in its 1980 edition, the DSMIII. Before then, the same types of post-traumatic symptoms were commonly called shell shock or war neurosis.
As I suggested, they were unfortunately often seen as signs of weakness of character.
From a historical perspective, acknowledgement of PTSD ushered in an understanding that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis).
Lesser known is the idea of PTSD, delayed onset. It describes patients who develop symptoms after weeks, months, or even years have passed since the trauma occurred. Many years ago, I had a female patient who was brutally date-raped at a local university. The college’s physician, who evaluated her the next day, told her to avoid “rough sex play” with men.
Partially due to that shaming reception, she thought nothing of the event for two years. However, she began compulsively overeating—likely a form of unconscious self-soothing—and gained 75 lbs. over the next two years. She obtained work as a new accounts manager in a local bank.
While working in that position, a small earthquake shattered a plate-glass window around ten feet from her desk. No one was injured. However, the shock of the glass breaking brought the events of the date rape immediately to her mind. She consulted me for two years, striving to integrate the repressed memory. Her delayed PTSD resolved completely, she left the area, and later she wrote to tell me she was doing well in another state.
Of course, however, she’ll never be the same.
I turn now to describing my own recent bout with PTSD, delayed onset, with two goals. First, to inform readers of the nature of this condition and its existence as a legitimate psychological problem, and; second, to explain the concept of “binding anxiety.”
It took me some years to understand what the concept means, and it’s a useful one.
What the heck does “binding anxiety” mean?
I’ll get to that, and, meanwhile, on with the story.
As I’ve described in prior posts, I endured quite the medical mis-adventure in Fall of 2018. A weekend of fever elicited concerns I could have contracted the endocarditis which led to my having an aortic valve replacement—via open heart surgery—in July 2008.
I knew that prosthetic valve would need replacing at some point. However, I never thought what I presumed was a bad cold or flu with fever would lead me down the same awful rabbit hole.
I had been warned to lookout for a spiking fevers. Therefore, in late October, 2018, I contacted my personal physician, Claire, and my infectious disease (ID) doc, Kim. They both immediately ordered a blood culture.
(A blood culture is an unusual lab test where technicians squirt some of your blood into a petri dish and see if it grows bacteria. It should not. An argument in favor of Darwin rather than God, your mouth and GI system are full of bacteria while your blood, which circulates all through those systems, is supposed to be sterile).
On Tuesday, November 1st, 2018, the diagnosis was confirmed. Kim hospitalized me for three days to immerse me in IV antibiotics. These were needed to kill the bacteria having a sex, drugs, and rock ‘n roll party inside the lining of my heart.
(Who could blame them?)
The antibiotics were also intended to, hopefully, sterilize the prosthetic valve. As often happens, the valve could not be saved. In other words, and particularly since the prosthetic valve is made of pig rather than human tissue, antibiotics can’t get to it. Had I gone off the antibiotics, the infected valve would have just made me sick again.
In late November, I met with Robbin, the same cardiovascular surgeon who’d operated on me in 2008. A killer example of avoidance and denial, I expected he’d tell me the valve replacement could wait a few more years. Instead, he said,
Alan, dude, I don’t know where you got this “few more years” idea of yours.
(I kinda doubt he used the word, “dude,” but who knows).
This valve is infected, and needs to be removed and replaced in three weeks!
I broke into tears, and it took me hours to adjust to the need for another surgery, and one the quick. But no PTSD developed at that point, and here’s why:
I had plenty to focus on. Such focus provides an easy transition for me to now explain the concept of binding anxiety. Think of the binding as like you’d use the term for a book. The binding holds the pages of the book together. In like manner, certain life-events, real or imagined, serve to bind anxiety for all of us.
We all deal with anxiety in some way.
Perhaps I will soon expound upon this idea in another post. Meanwhile, consider, briefly, how vulnerable we are, essentially at all times.
We know we will die.
We never know when we, or someone we love dearly, will be felled by some accident or medical event.
In my case, the initial focus on killing off the bacteria became my unconscious form of binding. I channeled whatever unconscious fears of death, impairment, or disability into concentrating on killing the unwanted bacteria.
I ate healthy foods.
I went to the gym regularly.
I dutifully injected myself with once-daily antibiotics at home via a portable IV, known as a PICC line, during the weeks leading up to the surgery.
Knowing my second open-heart surgery was scheduled for December 17, 2018, the procedure itself became my next unconscious binding agent. I spent weeks preparing patients, friends, and family, not to mention myself, for the serious surgery.
(The first one had a mortality rate of 3 percent; the second came with a whopping 15 percent mortality risk because of scar tissue from the first one).
I remember the end of November and the first two weeks of December as being unbelievably busy. My first encounter with endocarditis, in 2008, came suddenly. My only symptom was lower back pain. The diagnosis was also made on a Tuesday, that time June 17, 2008.
(I’ve become rather sensitive to Tuesdays).
Back in 2008, I was immediately hospitalized and the surgery performed ten days later (because first they have to kill all the bacteria living in your blood where, again, they don’t belong).
This recent time, just last December, I had at least some time to prepare. I remember telling friends that I expected to wake up from the operation feeling like I’d been hit by a truck. The description proved apt. Meanwhile, I worked out, ate well, rested, and otherwise prepared for what I knew would be awful.
The first week after open-heart surgery is definitely something to avoid.
I am almost at the delayed PTSD part (!), so please hang on just a minute longer.
It took me a full three months to fully recover from the operation. Because Robbin did such an awesome job, I was in pretty good shape, and I’d caught the endocarditis soon, I had no significant complications.
But there was plenty to distract me. I scared the hell out of every one I know, including my patients not to mention my family and friends. The pain in the sternum was severe for around a month. Also, particularly in the first month, you get first hand experience of what it feels like to be 100 years old. Just walking to the curb to get the newspaper leaves you weak and breathless for hours.
And now, finally, to the POINT.
Around late March of 2019, I remember mentally searching my body and NOT finding any signs of the surgery. The scar had healed nicely. My pre-morbid stamina returned to normal, if not better. I had neither pain nor limitations of any type.
Here’s where the PTSD, delayed, came on:
Fairly suddenly, I had neither killing bacteria nor preparing for or recovering from a major surgery on my mind. Instead, I began to face my new life, or what I like to call Alan V3.
Within a few days of realizing my “normalcy,” I began to experience a profound sense of terror. It lacked any kind of binding or focus. I just felt terrified, period. As I told some of my friends, when it was at its peak:
If I walked out of this restaurant and was held up at gunpoint, I could not feel any more anxious than I do right now.
Now, that’s another experience I’d recommend you avoid. Mental pain like that is so complex, and so multi-determined, that you never know for sure what caused it. I’ve been prone to anxiety my entire life. It runs through my ancestral tree like mad. One grandmother, my mother, and my auntie were anxious wrecks their entire life. Fortunately, I never got an anxiety problem as bad as theirs.
Nonetheless, the primary reason for that awful terror-filled month, which only broke up around a week ago, was—I believe—delayed PTSD.
Interestingly, when I look back on those tremulous weeks, I’m convinced it was, just as I noted, a delayed form of PTSD. I am, and was, surprised at how amazingly well I coped with the endocarditis, the surgery, and the post-surgical recovery.
I felt little fear during those periods because, again, the binding agents were significant. I had tons to do. I focused on health, preparation, consultations, and so on.
Once fully recovered, I believe, the multiple fears came crashing into my psyche like a tsunami. Again, I didn’t think of them consciously. But, I’ve since learned that open heart surgery is one of the most serious surgeries a human can undergo. I mean, consider these elements:
- Your heart is stopped and your blood shunted through a heart-lung machine while surgeons dissect out, and then repair, whatever is going on. How do you even think of yourself during that period? Was I dead? The heart stops and the lungs deflate until your heart is re-started by a chemical.
- The day after the surgery, you gradually come into consciousness almost wishing you were, instead, hit by a truck. I had four drainage tubes coming out of my chest, just below the rib cage.
- You have to seriously consider the real possibility of death or serious if normal complications like stroke or heart attack or blood clots or who the hell knows what else.
I hope this tale, if a bit wordy, adds to the public understanding of what delayed PTSD looks like, what the phrase, binding anxiety, means, and how to cope with same.
How did I cope?
Well, just barely.
I returned to work as soon as I could. I exercised like mad although with gradually increasing intensity. I talked, talked, talked to anyone who would listen—including total strangers during those first few weeks after the operation.
I remember a patient of mine telling me that her internist told her:
Your first fifty years are for free; you have to work for the next fifty.
It’s a total truth.
In my case, contracting endocarditis was like a freak accident. It is a disease commonly seen in IV drug abusers, because of the dirty needle problem. But I was never one of those. Certainly, however, my workout routine, plus healthy eating, helped me with both lousy experiences.
I end now with unsolicited advice:
Take care of your health!
Do all the well-understood preventive measures of diet, exercise, rest, and consulting medical professionals when something goes awry.
It’s time for me to move on and think of something else…
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Alan Karbelnig, PhD, ABPP