In the previous section, we discussed dissociation as a possible indicator of intrusive symptoms. We also discussed how some symptoms of trauma disorders overlap with other classes of disorders making diagnosis more complicated. But there is also symptom overlap between and among symptoms of the same disorder. In other words, the same symptom can be viewed or interpreted differently. For instance, the way some trauma survivors dissociate can also be described as avoidant.
Avoidance symptoms represent an effort to withdraw from certain situations that bring about body-level distress of trauma-related symptoms. We can also view these symptoms as the activities that people engage in to limit other types of distressing experiences. For instance, using alcohol or other drugs can be an activity someone engages in self-medicate anxious feelings.
In previous editions of the DSM, these avoidance symptoms were spelled out. However, this was very limiting. The new DSM (5th edition) leaves the specific determination of avoidance symptoms open to clinical interpretation-it does not describe specific symptoms, but instead, indicates: Avoidance behaviors occur in an attempt to avoid:
- Distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
- External reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s)
These external reminders can include sounds; smells; physical symbols; exposure to people, places, or things connected to the traumatic event; or, many of the intrusive symptoms described in the previous section. It was a great improvement to leave avoidance symptoms open to individual meaning and interpretation. Some reminders are very personal and unique. For instance, a rape victim assaulted in a dry cleaning store at 6pm on the way home from work, may avoid the use of any cleaning products; may have panic attacks upon walking past facilities that smell like these dry cleaning chemicals; may begin drinking at the end of the work day (avoidance); and may avoid a favorite coffee shop because it happens to be located along a dark alley, similar to the site of the assault.
Children may not want to go to school for many reasons. It's worth considering that a child's unwillingness to attend school may translate to avoidance of school or work triggers. Likewise, not wanting to be around a specific family member or friend may suggest avoidance of social triggers. Some general examples of avoidance indicators include substance use; compulsive behaviors; isolation; withdrawal; dissociation; steering clear of reminders; diving into technology like social media and text messaging compulsively; using romantic relationships to avoid dealing with oneself; simple denial; or staying away from intimacy with anyone (even those who are well liked and safe). These are also symptoms of many other disorders. This is why we keep advising a professional evaluation.
Avoidance behaviors can be both helpful and unhelpful. For instance, sometimes it's good to avoid movies that you know will upset you. However, avoidance can also cause impairment or problems in life. For instance, consider someone who got into a car accident and is now afraid of getting back into a car. What if they have to drive to go to work every day? Without alternative transportation (such as bus or train) avoiding a car has now caused impairment and created more life problems, especially financial. There are many ways that we can be blind to the ways we are attempting to avoid things. This makes is all the more difficult during a healing process too. This is how professional guidance can help us; by recognizing our patterns of avoidance.
As mentioned, patterns of avoidance are evident in many other diagnoses besides PTSD and trauma-related disorders. Therefore, it is important to consult with a qualified professional who understands trauma. For instance, there can be overlap between substance use or eating disorders, and the avoidance symptoms that we associate with trauma. To complicate things further, someone can have more than one diagnosis. So, although their substance abuse may represent an avoidance symptom related to trauma, they may also have a full-blown addiction that merits its own attention.
Rachel is a good example of this type of complexity. She was sexually abused by an uncle during her elementary school years and was never able to tell anybody. The abuse stopped by the time she was 8 years old. However, during her teenage years and young adulthood, her family still required her to go to holiday gatherings at her grandmother's house, where she had to see this uncle. Sometimes, social etiquette required her to make small talk with him. Rather than cause a problem and call attention to herself, Rachel just endured these family affairs as best as she could; i.e., until she discovered marijuana. After Rachel tried marijuana for the first time at age 14, she surmised that if she had to go to these family affairs, smoking a joint before and after she went would sure make it easier to endure. So she did just that. She needed to avoid feeling the overwhelming sense of anxiety that emerged from having contact with her abuser. These experiences with smoking a joint to avoid the pain crystallized within her. It was so effective it became a strategy that she carried into her adult life for dealing with uncomfortable emotions.
Here are some other examples of avoidance behavior:
- Efforts to avoid thoughts, feelings, or conversations associated with the trauma;
- Efforts to avoid activities, places, or people that arouse recollections of the trauma;
- Inability to recall an important aspect of the trauma;
- Markedly diminished interest or participation in significant activities;
- Feelings of detachment or estrangement from others;
- Restricted range of affect (e.g., unable to have loving feelings);
- Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span); and,
- Self-medicating behaviors like drug/alcohol use, or engagement in problematic behaviors like gambling, compulsive sex or pornography use, or even eating or self-injurious behaviors.
Due to symptom overlap, these symptoms are also characteristic of other disorders. For instance, "markedly diminished interest or participation in significant activities" is a powerful indicator of depression as well.