2. Trauma Clinics
Several psychotraumatic syndromes appear after experiencing rapes or assaults
[10]. They each have a distinct semiology and independent evolution. We isolated three of them
[9][10]:
dissociative and phobic traumatic syndrome, re-experiencing traumatic syndrome, and
borderline-like traumatic syndrome. They are generally triggered all at the same time or in close succession. Re-experiencing traumatic syndrome is profound; however, by many accounts, the other two are much more worrying, particularly in relation to children and adolescents, because they generate severe disorders in their psychological development
[11].
Dissociative and phobic traumatic syndrome represents the way subjects defend themselves during the traumatic event and then attempt to treat both their identity wound and their re-experiences, respectively, by fragmenting their memory and psyche and by avoiding the world. What we call “dissociation” is a phenomenon that is both intra-psychological and somato-psychological
[12]. Intra-psychological dissociation includes amnesia phenomena (about the traumatic event, or not), depersonalisation phenomena (for instance, with out-of-body experiences), derealisation phenomena (for instance, the feeling that they are watching their life as if it were a film on television), identity fragmentation phenomena (at worst, feeling like two different people), and automatisation phenomena (in particular, when running away from home). On various levels, these are responses to the pain of subjects who were unprepared for the emergence of a world-representation that contradicted the one they had until then. Somato-psychological dissociation in European psychiatric tradition, for example, a non-epileptic seizure or anaesthesia, means conversion. This responds to the pain that was also felt in the body, which used to be considered safe but has been proven not to be. It counteracts somatic re-experiencing
[13].
Table 1 shows the strong link between traumatic experiences and psychological dissociations, conversions, and phobias. As for phobias, let us point out the most specific one, agoraphobia, and the least specific one, social anxiety disorder. Indeed, social anxiety disorders may come from traumatic consequences, as well as from complications due to a temperamentally low ability to avoid hostile situations. We sometimes notice that while the
re-experiencing syndrome has disappeared, the only disorder that still remains consists of psychogenic amnesia or panic disorder with agoraphobia
[14]. These results concur with the most recent theorisations of panic attacks. Indeed, in order to understand the first attack’s trigger, specialists need to include an environmental wound along with the other involved factors
[15].
Table 1. Links between constituted (*) psychiatric disorders and persistent traumatic re-experiencing—a prospective study of raped subjects over six months.
Traumatic Re-Experiencing |
|
Still Re-Experiencing |
No Re-Experiencing |
Comparison |
|
at Six Months |
at Six Months |
of Both Groups |
|
% |
% |
p |
Psychological dissociation |
84 |
38 |
<0.0001 |
Conversions |
75 |
42 |
<0.01 |
Agoraphobia |
70 |
20 |
<0.0001 |
Simple phobia |
56 |
25 |
<0.02 |
Social phobia |
49 |
29 |
ns. |
Panic disorder |
18 |
0 |
<0.03 |
Depressions |
53 |
8 |
<0.001 |
Sexual identity disorder |
41 |
4 |
<0.001 |
Alcohol consumption excess |
29 |
include reminiscences, nightmares, and trigger associations which set off a re-experience of the pain tied to the traumatic experience, or even the illusion of the traumatic experience itself. They are the most specific and sensitive out of all post-trauma symptom groups
[1]. The American classification of mental disorders states that this syndrome is a necessary criterion for PTSD diagnosis but that it is not enough on its own. However, in practice, when we observe the presence of painful assault re-experiences, the other two symptom groups required for this category are rarely absent. Physically or sexually maltreated subjects prominently undergo painful re-experiences
[3]. The diagnosis still applies to the majority of raped subjects one year after the traumatic event took place
[16][14], and this chronologically constitutes one of the first therapeutic challenges at stake. Re-experiencing happens when an elementary sensory representation is recalled (for example, the image of the rapist’s eyes) through memories, nightmares, or trigger-associations (for example, a white car for someone who was assaulted inside a white car). It represents the traumatic event in its entirety and activates the emotions tied to it. Therefore, re-experiencing indicates a disordered representation of the past.
In spite of how frequent it is among traumatised people (one out of two people are affected), highlighting their depression symptoms could lead to assumptions that treating such patients is not any more difficult than treating isolated depression. However, let us point out that the British psychiatry professor Sir David Goldberg, who dedicated his entire life to studying depression vulnerability factors, has no hesitation in claiming that sexual assaults are the first aetiological factors of depression
[17].
Borderline-like traumatic syndrome can manifest in more psychological ways or more behavioural ways, depending on the cases or the moments in time. At first, “identity instability” is expressed on a psychological level and as a narcissistic depression (bad self-esteem, shame, guilt, abandonment disorder, feelings of emptiness, and the loss of vitality and identity) which can be so severe that it could evoke melancholy if its traumatic aetiology is not identified. The alteration of psychological development often complicates the identity disorder afterwards, sometimes quickly, particularly among children and adolescents. Indeed, an identity rebuilding process appears, with paranoid omnipotence fits or acting-out behaviours of various kinds. These well-documented borderline personality characteristics are rather typical of traumatic interactions between individuals
[18][19]. This intersubjectivity, which promotes alienating identifications (to the aggressor among other things) and masochism often associated with traumatophilia, results in the alteration of relationships to other people and to the world. This disorder happens all the more frequently depending on how chronic and severe the trauma was. Thus, in
Table 2, borderline-like characteristics are over-represented in incestuous rapes compared to non-incestuous rapes, in particular when it comes to bad self-esteem, abandonment disorder, feelings of emptiness, and a loss of vitality
[4]. One should keep in mind that among those most severely traumatised, this syndrome is often the last one to keep resisting therapeutic measures, long after re-experiences have disappeared. This syndrome affects the subject’s expectations and ideals; therefore, it is unsurprising that out of the three syndromes, this one proves to be the most detrimental for children and adolescents.
Borderline-like traumatic syndrome is a pathology that damages the representation of the future.
Table 2. Illustration of the increased suffering of rape victims in cases of incest, through borderline-like psychological or behavioural features (*).
Rapes |
|
Incestuous |
Non-Incestuous |
Frequent abandonment fear |
64% |
57% |
Idealising of friends |
28% |
44% |
Bad self-esteem |
68% |
37% |
8 |
<0.05 |
Running away from home impulsively |
33% |
21% |
Suicide attempts |
33% |
26% |
Drug use |
14 |
8 |
ns |
Obsessional disorder |
12 |
Emotional disorder of depressive nature |
49% |
31% |
Lingering feeling of emptiness |
76% |
56% |
Violence-inducing fits of anger |
54% |
42% |
Dissociative incidents |
84% |
60% |
At least five out of nine characteristics |
58% |
38% |
0 |
ns |
Average number of characteristics |
4.8 |
3.7 |
Generalised anxiety |
7 |
17 |
ns |
Psychosis or bipolar disorder |
7 |
13 |
ns |
Anorexia or bulimia |
20 |
8 |
ns |
Dissociative and phobic traumatic syndrome is the first traumatic syndrome to appear after the traumatic event takes place. It can become chronic. In that case, everything seems to indicate that experimenting with this defence mechanism during the traumatic event leads to using the same mechanisms with a much higher frequency later, during other hostile but non-trauma-inducing events, when other people could have reacted, for example, with depression symptoms. Its persistence must come as a warning that
re-experiencing syndrome may be present for a long period of time
[10].
The clinical features of
re-experiencing traumatic syndrome