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Section 2
Posttraumatic Stress Disorder in Depression

Question 2 | Test | Table of Contents

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♦ Loss of an Orderly World
The second loss we have found clients experience due to terrorist acts is the Loss of an Orderly World. Have you discovered this with clients you have treated? I and my colleagues find that clients who have either been direct or indirect victims of terrorism have a heightened sense of “wrongdoing” because of their feelings of the loss of an “orderly world.” Here’s an example of a paraphrase of what one therapist said to such a client who believed justice prevails.

He stated, “Your confusion seems to be because your 'just world' philosophy of life cannot explain what happened in New York. You used to think that if you were careful, honest, and good, you could avoid disaster. But, the loss of your brother in the Twin Towers attack taught you that all your best efforts could not prevent the worst from happening. You saw others who were also innocent die or be unfairly injured. So, while you would like to believe that the world is orderly, and that good is rewarded and evil is punished, you’ve had experiences that contradict these beliefs. Because, you feel your brother was punished precisely because he was trying to be a good and competent person by going to work. So now it’s even harder for you to hold to your just world philosophy of life.”

Certainly the loss of an orderly world occurred after the attack on the Twin Towers and the anthrax incidents that followed. Several of my anxiety disordered clients reported a fear of leaving their homes. Thus, their orderly world, so to speak, was rocked to its very core.

Loss of a Positive Self-Image
Let’s look at another loss due to terrorism in addition to the loss of a just world. That is the loss of a positive self-image. As you know, one of the most profound losses many trauma survivors experience is the loss of a positive self-image. This loss often affects their ability to excel at work and to relate to others; for, as so often happens, no matter how much someone else may assure them that they are valuable and worthy of love, if they’ve been deeply traumatized, they have trouble believing it.

A colleague treated a client who survived a fire in which his roommate was badly burned. He stated, “I feel almost as if I had been exiled from my circle of friends for committing an unforgivable crime or as if I were carrying a deadly communicable illness; a part of me feels 'bad like I am a bad person,' scarred, diseased, or otherwise unacceptable. I should have been harmed in the fire as well.” Did you treat a client following the Twin Towers attacks who suffered from loss of a positive self-image due to his survival when others did not?

My colleagues and I have found survivors of a trauma might even feel ugly - ugly as Dr. Frankenstein’s monster, regardless of how attractive they really are. It is an established fact that women with histories of sexual abuse often feel “ugly.” They believe they look ugly on the outside, because they feel ugly on the inside, or because ugly things have happened to them. Thus, post-traumatic stress reactions, such as depression, and other aftereffects of trauma can cause the loss of self-image and self-esteem. After the attack on the Twin Towers, as a nation, we suffered from loss of a positive self- image, that being terrorism cannot happen within our national borders. The idea we are not immune from attacks has forever changed our positive self-image as a nation.

♦ Trauma and the Loss of Trust
Trauma is about loss, and one of the first casualties of having been traumatized is the capacity to trust, especially if your client’s trauma truly involved human evil or error, as in the case of terrorism. Trauma survivors not only lose trust in some of the basic premises that keep them functioning (such as I mentioned previously about the assumptions of personal invulnerability and that the world is just and fair) but they can also lose trust in people, including themselves. “To trust, or not to trust?” is the question trauma survivors ask most frequently. “I want to trust, but I know better,” is the usual reply.

Can your client trust going to the mail box, checking the mail and not contracting some form of a disease planted by a terrorist? Do you have a client that questions trusting his or her chances of going on an air trip, arriving, and returning safely?

There is another side to this coin: have you found the tendency for clients to automatically and completely trust others, after witnessing such a terrorist attack as September 11th or other trauma? For example, we have observed some combat veterans instantaneously trusting another combat veteran, without taking time to find out if they are indeed reliable. While in combat, a soldier could safely assume that members of his unit would treat him like family. Back in civilian life, the code of “your blood is my blood” may no longer operate. Trusting another soldier may have saved a soldier’s life on the front lines; however, trusting all fellow soldiers implicitly might cause problems back home under non-traumatic situations. This trusting behavior was exhibited by New Yorkers immediately following the September 11th attack. Story after story was told of a more open and loving attitude in the city.

For trauma survivors, this fear of imminent danger often persists in post-trauma relationships that are not dangerous. A “pervasive sense of doom” is part of post-traumatic stress disorder and is related to depression, another common reaction to trauma. While expecting the worst makes perfect sense given the trauma survivor’s experiences, have you found friends and family members of your client labeling them as “cynical,” “paranoid,” or “too negative,” and find their non-trusting attitude oppressively burdensome?

Posttraumatic Stress Disorder Following the September 11,2001, Terrorist Attacks

- Neria, Y., DiGrande, L., & Adams, B. G. (2011). Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: a review of the literature among highly exposed populations. The American psychologist, 66(6), 429–446. doi:10.1037/a0024791.
Reviewed 2023

Peer-Reviewed Journal Article References:
Byllesby, B. M., Durham, T. A., Forbes, D., Armour, C., & Elhai, J. D. (2016). An investigation of PTSD's core dimensions and relations with anxiety and depression. Psychological Trauma: Theory, Research, Practice, and Policy, 8(2), 214–217.

Gonzalez, O. I., Novaco, R. W., Reger, M. A., & Gahm, G. A. (2016). Anger intensification with combat-related PTSD and depression comorbidity. Psychological Trauma: Theory, Research, Practice, and Policy, 8(1), 9–16.

Himmerich, S. J., Ellis, R. A., & Orcutt, H. K. (2020). Application of PTSD alcohol expectancy symptom clusters to the four-dimensional model of PTSD: Support from moderations of the association between symptoms of posttraumatic stress and alcohol use. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 347–355.

Larsen, S. E., Fleming, C. J. E., & Resick, P. A. (2019). Residual symptoms following empirically supported treatment for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 11(2), 207–215.

McGuire, A. P., Frankfurt, S. B., Anderson, L. M., & Connolly, K. M. (2020). Pre- to posttreatment changes in trauma-cued negative emotion mediate improvement in posttraumatic stress disorder, depression, and impulsivity. Traumatology.

Salcioglu, E., Urhan, S., Pirinccioglu, T., & Aydin, S. (2017). Anticipatory fear and helplessness predict PTSD and depression in domestic violence survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 117–125.

QUESTION 2
What is part of post-traumatic stress disorder that is related to depression? To select and enter your answer go to Test.