The Psychoanalytic Study of the Child, Volume 41: Pages 221-236, 1986.
p("Clifford Yorke, F.R.C. Psych., D.P.M."); p("A symposium on trauma organized by the Association for Child Psychoanalysis and held in London in 1984, bore witness to the continuing interest in the subject. Prepared papers by Jules Glenn (1984) and by Edgecumbe and Gavshon (1985) stimulated lively debate; but it was clear from the very active discussions that a number of issues remained unresolved. Twenty years earlier a symposium on the same subject led to an extensive collection of papers edited by Sidney Furst (1967) and did a great deal to map out the ground and clarify some important points. The contributions to this symposium led Anna Freud (1967) to point out that a number of technical terms in psychoanalysis had, in the course of time, suffered a widening use which had blurred meaning to a point at which valuable concepts were lost. She continued:");p("We are in the position of witnessing this typical process with regard to the definition of trauma which extends at present from the original notion of the break through the stimulus barrier at one extreme to the notions of the accumulative, the strain, the retrospective, the screen trauma, until it becomes difficult at the other extreme to differentiate between adverse pathogenic influences in general and trauma in particular [p. 235f.].");p("She added that, like everyone else, she too had tended to use the term trauma rather loosely until then, but that she would find it easier to avoid this in the future."); p("Careful consideration of these papers, including Anna Freud's own contributions, together with subsequent writings on the subject, suggest that this is more easily said than done. There is a repeated difficulty in restricting the definition of trauma to a serviceable theoretical concept that meets clinical needs and experience. This paper makes no such attempt, but argues that, if full benefit is to be derived from the many important contributions made to the subject, it is necessary to draw clear distinctions between three different conditions. Two of these were repeatedly discussed by Freud, namely, traumatic neurosis and traumatic (automatic) anxiety. The third, which may be called the post-traumatic neuroticlike state, requires separate discussion and illustration."); p("Freud's view of the nature of the traumatic neurosis was particularly clearly set out in Beyond the Pleasure Principle (1920) in the course of discussion of the significance of the compulsion to repeat. The disturbance arises when the ego is totally unprepared for a "traumatizing" event of an external kind. A contemporary example would be that of a car crash coming totally out of the blue, of which the driver had no anticipation and no opportunity for psychic preparation. Freud's view was that, in such conditions, the stimulus barrier broke down and the ego was overwhelmed with a degree of anxiety that it was totally unable to master at the time. The ego was "knocked out" and was temporarily unable to function. This period of loss of functioning follows immediately on impact and continues for a short and slightly variable period. In the current example an observer would see the victim as dazed, and would no doubt refer to him as suffering from "shock." The inference that ego functioning is lost is supported by the fact that the subject retains a clear recollection of the circumstances of the crash, but has no memory for the period immediately following the collision."); p("The subsequent clinical picture is well known. It is characterized by restlessness and variable but diffuse anxiety. A striking feature is the recurring dream in which the circumstances of the crash are vividly relived. These frightening dreams were, in Freud's view, not really "dreams" at all in the sense in which these are understood psychoanalytically. They are a vivid reexperience of the disturbing event during sleep, in the course of which the excess excitation, bounded by the ego in its attempted restoration of functioning, is fractionally and repeatedly discharged. The traumatic event may be relived in the form of daydreams or preoccupations during the day."); p("In the present context, two clinical points must be made about this condition. The first is that even the fully blown picture tends to resolve itself, without treatment, is somewhere around 8 months, although there are exceptions. Even a minor degree of anticipation may allow sufficient preparation for the "shock" to be less pronounced and for recovery to take place within a comparatively short time. The factors which occasionally lead to an extremely protracted result are not always easy to understand. The second and related point is that, if the victim can be invited by the therapist to recollect the trauma over and over again, with appropriate affective discharge, the period during which the condition persists can be effectively reduced. In World War II, psychiatrists dealing with traumatic neuroses (as opposed to battle exhaustion) arising in the front line found that chemical abreactions using ether or pentothal restored the victim to normal functioning within something like three weeks. We now know that the abreaction can be carried out without chemical assistance. The traumatic neurosis can therefore be conceptualized in terms of Brueur and Freud's notion of "strangulated affect" (1895) and, indeed this was explicitly foreshadowed by Freud (1893) and was considered in relation to the abreactive process.
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