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Arousal and Reactivity Symptoms

Jamie Marich, Ph.D., LPCC-S, LICDC-CS, RMT, edited by C. E. Zupanick, Psy.D.

This category of symptoms has also been called heightened arousal in previous editions of the DSM. As with all the symptom groups, there is symptom overlap with other diagnoses. Therefore, consult with a treatment professional for the best possible care.

sad man1. Jumpiness, exaggerated startle response, hypervigilance

Arousal and reactivity are arguably the most familiar symptom group of trauma-related symptoms. In movies and in literature, characters with PTSD or other trauma-related issues are depicted by the recognizable symptoms of jumpiness, startling, and being on edge. These symptoms often bely hypervigilance (i.e., always being alert, on guard for something bad to happen).

2. Sleep disturbance

Sleep disturbance (insomnia) includes problems of falling asleep, staying asleep, and restless sleep. This does not include vivid dreaming or nightmares. Those would be grouped with intrusive symptoms. Insomnia is usually treated with medication. Unfortunately, most of these medications are highly addictive. However, without adequate attention to their sleep problems, many trauma survivors resort to self-medication via alcohol or other drugs. This offers a potential explanation for relationship between unhealed trauma and addictive behaviors.

3. Irritability and/or aggressive behavior

We are all irritable, or even aggressive at times. However, this symptom refers to frequent, irritable or aggressive behaviors that occurs with little or no provocation. Think about the phrases we used to describe these sorts of behaviors: "lashing out," "flying off the handle," or even going into a rage. Hence the word "reactive" in describing this symptom category. Because of symptom overlap, these behaviors can be misattributed to another type of disorder called bipolar disorder. If a person with unresolved trauma feels cornered or trapped, reactivity in the form of aggression may result. Thus, if this sounds like it might apply to you, it is important for you to discuss your trauma background when you consult with any treatment professionals. This will help them to make the best possible diagnosis and plan for care. It is important that you be evaluated by a qualified professional with a solid understanding of trauma and its impact on human behavior.

4. Problems with concentration

A commonly overlooked symptom is a problem with concentration. As with other symptoms, problems with concentration are symptoms of many disorders and diseases. Therefore, if these symptoms apply to you, we urge you to get a professional evaluation by a qualified trauma professional.

During my initial education on PTSD in Bosnia-Hercegovina, children's limited ability to concentrate was one of the most visible signs of their distress. I taught children who clearly had difficulty with concentration. It seemed to me that it was rather obvious to relate these concentration difficulties with the massive amounts of stress they were trying to accommodate. I think back to one of my mentors, saying, "If you were abandoned in Mostar by your parents during the height of bombing and then moved from place to place during the formative years of your childhood, you would have a hard time concentrating in school too, wouldn't you?" Yet, when I returned to the United States I was amazed at the number of children who carried a diagnosis of ADD or ADHD to explain what was, in my clinical impression, concentration difficulties related to traumatic stress.

ADHD is diagnosed more frequently in the United States than in Europe. There is tremendous controversy about why this is so. The symptoms of ADHD and trauma-related disorders overlap. Therefore, clinicians must carefully consider if trauma-related disorders can best account for the symptoms. As mentioned previously, the difference is not just a word label. There are vast differences in the way these two types of disorders are treated, with ADHD relying heavily on medications. If someone has been minimally or virtually nonresponsive to the pharmacotherapies prescribed for either ADHD or bipolar disorder, and has a history of trauma, then, then there's good reason to carefully consider whether the symptoms are attributable to PTSD or other trauma-related disorder.

5. Reckless or self-destructive behaviors

The DSM-5 (APA, 2013) included a new set of symptoms called reckless or self-destructive behaviors. As with all other symptom sets, there is symptom overlap. These symptoms occur in other disorders. Therefore, professional evaluation is strongly encouraged.

Examples of these behaviors include self-injury, hyper-sexuality, compulsive overeating, binging and purging, restricting food, and continuing to put oneself into dangerous situations reminiscent of the original trauma or other risky situations. For this reason, people with trauma-related disorders can also have other disorders such as substance abuse or eating disorders. Note that some of these behaviors could also be considered a type of avoidance symptom.

Consider Mandy, an adult survivor of childhood sexual abuse. In telling her story, Mandy recalls that she was once a "very good student" and one of the smartest kids in the class. However, the quality of her schoolwork plummeted almost immediately when the abuse began. Mandy received an ADHD diagnosis at age 16 and was promptly medicated. At the height of her active cocaine addiction in her mid-twenties, a prominent West Coast psychiatrist labeled her as bipolar and put her on a cocktail of five psychotropic medications, including two benzodiazepines. None of the medical treatments helped to quiet her mind or bring her any relief. It was the practice of yoga that ushered in her recovery from both addiction and the wounds of her trauma. This natural recovery strongly suggests that an incorrect diagnosis resulted in poor treatment that did not adequately account for her trauma history. Later in life, when Mandy learned that her symptoms best fit a PTSD diagnosis, she was repulsed to learn that her behaviors had been simply explained away by ADHD, and Bipolar over the years. Once more, we highlight and encourage the importance of a professional assessment by a qualified professional who understands trauma and the entire range of mental health diagnoses.