Tuesday, May 5, 2009

Flashbacks By Laurieann Chutis, A.C.S.W.

What are they?

Flashbacks are memories of past traumas. They may take the form of pictures, sounds, smells, body sensations, feelings or the lack of them (numbness). Many times there is no actual visual or auditory memory. One may have the sense of panic, being trapped, feeling powerless with no memory stimulating it. These experiences can also happen in dreams.

The Massachusetts Hospital School made it difficult to see my Parents. The visitation time, was to bring you home was Saturday mornings, return you Saturday evenings, then Sunday mornings return you Sunday evenings. For most of my life, I intellectualized my feelings; to put it another way, I was feeling "numb"! It was few months short of my tenth birthday, when I was admitted to the Massachusetts Hospital School.

Do you think a ten year child who can fully understand like an adult? To this day, I still do not understand for what reason the Massachusetts Hospital School made it difficult to visit your Parents! Oh yes, "Politics and Money"! All "state institutions" take "head count" each morning to determine how much money it was going to receive.

As a child (or adolescent), we had to insulate ourselves from the emotional and physical horrors of the trauma. In order to survive, that insulated child remained isolated, unable to express the feelings and thoughts of that time. It is as though we put that part into a time capsule until it comes out full-blown in the present.

For many years, most probable even now, I {felt/feel} trapped in a ten year old body!

Yes, the Massachusetts Hospital School did teach me "survival skills"! Is that good or bad? Sometimes, I think it is good to know "survival skills" it did enriched my characteristics in my personality. Is it good when it comprised my sense to feel emotions?

On June 16, 2004, I had two surgeries in one day{my Colostomy and my Supra Pubic Catheter}, consulting and coordinating doctor George Klauber (Pediatric Urologist). Most of you are probably saying to yourselves, "What a crazy person to have two surgeries in one day!"

I was fifty-five years old, and your body and mind have to repair themselves after surgeries. I knew at the time that I was putting a great stress on my body. Nonetheless, I wanted to have these surgeries in the same day so that I could move on with my life.

Oh yes, a great stress on my body and mind! I do not know how long my mind and body repaired themselves. Perhaps they are continuing to repair themselves. I do not regret having my surgeries however, I would recommend that anyone else think carefully before having two surgeries on the same day.

A few events happened in the year of 2004, that put great stress on me. One day in the beginning of November, due to a lack of Caregivers; my Live-in Caregiver persuaded me to picked up the phone to ask someone that I knew to see if he could do anything for me, such as shopping. He began to shout in my ear and that is the last thing I remember until January 2005. I only remember voices, shadows... not any of the actual events that took place.
I paid a great price in losing two cats that I dearly love.

When that part comes out, the little one is experiencing the past as if it were happening today. As the flashback occurs, it is as if we forget that we have an adult part available to us for reassurance, protection and grounding. The intense feelings and body sensations occurring are so frightening because the feelings/sensations are not related to the reality of the present and many times seem to come from nowhere.

We begin to think we are crazy and afraid of telling anyone (including our therapist) of these experiences. We feel out of control and at the mercy of our experiences.

We begin to avoid situations, and stimuli, that we think triggered it. Many times flashbacks occur during any form of sexual intimacy, or it may be a person who has similar characteristics to the perpetrator, or it may b a situation today that stirs up similar trapped feelings (confronting aggressive people).

If you are feeling small...you are experiencing a flashback.

If you are experiencing stronger feelings than are called for in the present situation...you are experiencing a flashback.

Flashbacks are normal

Vietnam vets have normalized this experience and have coined the term post traumatic stress syndrome.

Even the diagnostic category book for psychiatry defines post traumatic stress syndrome as the normal experience of all people experiencing an event that is outside the range of normal human experience.

Flashbacks feel crazy because the little one doesn't know that there is an adult survivor available to help.

What helps

  1. Tell yourself that you are having a flashback.
  2. Remind yourself that the worst is over. The feelings and sensations you are experiencing are memories of the past. The actual event took place long ago when you were [younger] and you survived. Now it is time to let out that terror, rage, hurt and/or panic. Now is the time to honor your experience.
  3. Get grounded. This means stamping your feet on the ground so that the little one knows you have feet and can get away if you need to. ([If the trauma occurred as a child]. . . you couldn't get away: Now you can.}
  4. Breathe. When we get scared we stop normal breathing. As a result, our body begins to panic from the lack of oxygen. Lack of oxygen in itself causes a great deal of panic feelings: pounding in the head, tightness, sweating, feeling faint, shakiness, dizziness. When we breathe deeply enough, a lot of the panic feeling can decrease. Breathing deeply means putting your hand on your diaphragm and breathing deeply enough so that your diaphragm pushes against your hand and then exhaling so that the diaphragm goes in.
  5. Reorient to the present. Begin to use your five senses in the present. Look around and see the colors in the room, the shapes of things, the people near, etc. Listen to the sounds [around you]: your breathing, traffic, birds, people, cars, etc. Feel your body and what is touching it: your clothes, your own arms and hands, the chair or floor supporting you.
  6. Speak to the little one and reassure him/her. It is very healing to get your adult in the now, that you can get out if you need to, that it is OK to feel the feelings of long ago without reprisal. The child needs to know that it is safe to experience the feelings/sensations and let go of the past.
  7. Get in touch with your needs for boundaries. Sometimes when we are having a flashback we lose the sense of where we leave off and the world begins; as if we do not have skin. Wrap yourself in a blanket, hold a pillow or stuffed animal, go to bed, sit in a closet... any way that you can feel yourself truly protected from the outside.
  8. Get support. Depending on your situation, you may need to be alone or may want someone near you. In either case, it is important that your close ones know about flashbacks so they can help with the process, whether that means letting you be by yourself or being there.
  9. Take time to recover. Sometimes flashbacks are very powerful. Give yourself the time to make the transition from this powerful experience. Don't expect yourself to jump into adult activities right away. Take a nap, or a warm bath, or some quiet time. Do not beat yourself up for having a flashback. Appreciate how much your little one went through. . . .
  10. Honor your experience. Appreciate yourself for having survived that horrible time [when you were younger]. Respect your body's need to experience those feelings of long ago.
  11. Be patient. It takes time to heal the past. It takes time to learn appropriate ways of taking care of self., of being an adult who has feelings, and developing effective ways of coping in the here and now.
  12. Find a competent therapist. Look for a therapist who understands the processes of healing from [trauma: incest, rape, war.] A therapist can be a guide, a support, a coach in this healing process. You do not have to do it alone . . . ever again.
  13. Join a self-help group. Survivors are wonderful allies in this process of healing. It is a healing thing to share your process with others who understand so deeply what you are going through.
  14. Know you are not crazy . . . you are healing!


Posttraumatic Stress Disorder in Children

Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Updated: Mar 4, 2008



Posttraumatic stress disorder (PTSD) in children and adolescents occurs as a result of a child's exposure to one or more traumatic events that were life-threatening or perceived to be likely to cause serious injury to self or others. In addition, the child or adolescent must have responded with intense fear, helplessness, or horror. Traumatic events can take many forms, including physical or sexual assaults, natural disasters, traumatic death of a loved one, or emotional abuse or neglect. Severe emotional trauma has widespread effects on children's development, in that it clearly obliterates the belief that their parents will protect them. The premature destruction of these beliefs can have profound negative consequences on development.

Traumatized children and adolescents are understandably frequently preoccupied with danger and vulnerability, sometimes leading to misperceptions of danger, even in situations that are not threatening. Multiple researchers (eg, Kardiner, van der Kolk1 ) note that, once posttraumatic stress symptoms emerge, PTSD leads to neurophysiologic correlates that impact brain function in developing children and adolescents.

In 1980, the term PTSD first came into existence in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III).2 Only in 1987 did the DSM series make reference to traumatized children. The first major studies of the effects of large traumas on children were Bloch's 1956 study of the effect of a tornado in Mississippi, Lacey's 1972 study of the effects of an avalanche on a Welsh school, Newman's 1976 work on the Buffalo Creek disaster,3 and Terr's 1979 research on the Chowchilla bus kidnapping.4  border= border=


Evidence indicates a genetic predisposition for PTSD, suggesting that it may be linked to the individual's temperament and to reactivity of the hypothalamic pituitary axis.


United States

Lifetime prevalence of PTSD is 8%.5 The incidence and course of PTSD vary and depend on various factors, including the type of trauma, the proximity to the stressor, and the reaction of the child's parents. After being kidnapped, witnessing the death of a parent, or suffering domestic violence, the rate of PTSD may be 95-100%. Following a sniper attack at school, 40% of children experienced moderate-to-severe PTSD. In one study of children in foster care, 64% who had experienced sexual abuse had PTSD, and 42% who had experienced physical abuse fulfilled the PTSD criteria. Moreover, 18% of the children who were not abused also met PTSD criteria, presumably because they had witnessed violence.


The prevalence in a location overwhelmingly depends on the endemicity of violence in the region.


Alone, PTSD is not a fatal disorder. Nevertheless, it frequently leads to conduct disorder, substance abuse, depression, and risk-taking that poses considerable danger.

PTSD has a considerable morbidity rate, particularly for children. In addition to the symptoms of numbing, hyperarousal, and recollections of the event that adults experience, children suffer from a decreased ability to participate in the normal academic and social activities of childhood. Therefore, a traumatic event can send a child down a new developmental path, one that is less favorable than the one the child was previously on.

A host of emotional and behavioral problems frequently arise as a result of PTSD and are not part of the criteria for categorical diagnosis. These include disruptive behavior disorders, eating disorders, sexual acting out, other risk-taking activities, depression, the full range of anxiety disorders, dissociation, mood lability, violence, and difficulty concentrating.

Studies of adults who were sexually or physically abused as children demonstrate significantly higher rates of PTSD (72-100%) than studies of children who were abused (21-55%). This finding indicates that the full impact of abuse may not be experienced until a child reaches adulthood, engages in adult relationships and responsibilities, and develops more sophisticated cognitive capabilities.


No major racial predominance is observed; however, PTSD is more common among individuals in low socioeconomic groups and among those living in areas in which violence is endemic.


PTSD is more common in women than in men.


PTSD occurs in people of all ages, but younger and elderly persons are the most vulnerable.



Diagnostic criteria

  • Posttraumatic stress disorder (PTSD) arises subsequent to a serious traumatic event that causes or threatens serious harm, injury, or violation of bodily integrity. The individual experiences intense fear, helplessness, or horror in response. Children may experience disorganized or agitated behavior. The individual does not need to be the actual victim. The individual could have witnessed the traumatic event or have been told about it happening to a close associate. For example, a child who is told about the sexual abuse of another child can develop PTSD.
  • The trauma results in the development of 3 types of symptoms. Category A refers to the initial response to the trauma, which involves the experience of horror, helplessness or fear, or disorganized behavior in children. Categories B, C, and D are as follows:
    • Category B - Intrusive recollections
    • Category C - Numbing and withdrawal
    • Category D - Persistent symptoms of increased arousal
  • Diagnosis requires reexperiencing of the trauma in one or more of the following ways:
    • Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
    • Recurrent distressing dreams (In children, the dreams are frightening but may not have recognizable content.)
    • Acting or feeling as if the traumatic event is recurring
    • Intense psychological distress upon exposure to cues that symbolize or resemble an aspect of the traumatic event
    • Physiological reactivity upon exposure to cues that symbolize or resemble an aspect of the traumatic event
  • Diagnosis requires persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
    • 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 (including regression and loss of skills such as toilet training)
    • Feeling of detachment or estrangement from others
    • Restricted range of affect (eg, unable to have loving feelings)
    • Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or normal lifespan)
  • Diagnosis requires persistent symptoms of increased arousal (not present before the trauma), as indicated by 3 or more of the following:
    • Difficulty falling or staying asleep
    • Irritability or outbursts of anger
    • Difficulty concentrating
    • Hypervigilance
    • Exaggerated startle response
  • Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than one month
  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnosing posttraumatic stress disorder in children

  • The diagnostic criteria for PTSD are designed for adults, not children. Children have limited verbal skills and different ways of reacting to stress. This means that children may not fulfill the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) criteria, even though they clearly have a psychiatric disorder analogous to adult PTSD.2 In particular, children often do not have 3 of the adult signs of numbing and withdrawal because they lack the verbal skills to express these feelings. Children may also experience an alternation between hyperarousal and numbing/withdrawal.
  • Scheeringa et al (1995) recommend altering the criteria for PTSD when assessing very young children, taking into account their ability to report symptoms and the types of symptoms they are likely to have.6 The altered criteria do not require that the child be able to report fear, helplessness, or horror in response to the trauma.
    • Diagnosis using the altered criteria requires that the very young child undergo one of the following types of reexperiencing:
      • Posttraumatic play
      • Play reenactment
      • Recurrent recollections
      • Nightmares
      • Episodes with objective features of a flashback or dissociation
      • Distress at exposure to reminders of the event
    • The altered criteria also require only one of the following symptoms of numbing/avoidance (instead of the 3 needed for adults):
      • Constriction of play
      • Relative social withdrawal
      • Restricted range of affect
      • Loss of acquired developmental skills
    • Furthermore, only one of the following symptoms of hyperarousal is required:
      • Night terrors
      • Difficulty going to sleep that is not related to fear of having nightmares or fear of the dark
      • Night waking not related to nightmares or night terrors
      • Decreased concentration
      • Hypervigilance
      • Exaggerated startle response
    • Scheeringa et al endorse an additional class of symptoms to replace the eased category C and category D criteria.7 Symptoms of fear and aggression marked by one of the following is required:8 :
      • New aggression
      • New separation anxiety
      • Fear of using the restroom alone
      • Fear of the dark
      • New fears of things or situations not obviously related to the trauma
  • Posttraumatic play involves joyless repetitive play with traumatic themes. Children also may reenact what occurred or draw pictures related to the event. Posttraumatic dreams in children generally are vaguely formed dreams that the child may not be able to describe.
  • In adolescents, the primary symptoms are likely to include invasive images (which they may not talk about), restlessness and aggression, difficulty sleeping, and difficulty concentrating. Other common symptoms include loss of interest in previously enjoyed activities, withdrawal from family and peers, and changes in significant life attitudes. Adolescents with chronic PTSD arising from repeated or prolonged trauma may suffer primarily from dissociative symptoms, numbing, sadness, restricted affect, detachment, self-injury, substance abuse, and aggressive outburst. When interpersonal abuse is the precipitant, the development of dissociative phenomena, somatic complaints, learned helplessness, loss of affect control, hostility, aggression, eating disorders, sexual acting out, personality change, change in belief system, self-destructive and impulsive behavior, substance abuse, social withdrawal, and impaired relationships are a significant possibility.8


  • Numerous physical findings have been noted; however, whether these findings are a result of PTSD, predisposing factors, or the result of comorbid problems (eg, substance abuse) is unclear. Findings include the following:
    • Hippocampal volume is smaller in individuals with PTSD.9
    • Areas of the brain that are involved in threat perception (eg, amygdala) have altered metabolism in adult trauma survivors with PTSD.
    • Activity of the anterior cingulate (an area of the brain that inhibits the amygdala and other brain regions involved in the fear response) is decreased in people with PTSD.
    • Basal cortisol levels are low.
    • Cortisol response to dexamethasone is increased.
    • Concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus are increased.
  • Some studies have shown that children who have been abused have elevated cortisol levels compared with control subjects. Studies also indicate that adults with PTSD who were abused as children have higher cortisol levels than those who were abused and did not develop PTSD. Research evidence also indicates that girls who have been sexually abused have increased catecholamine activity. Trauma survivors have pituitary adrenocortical hyperresponsivity to stress. PTSD leads to increased pulse, blood pressure, muscle tension, and skin resistance.
  • One problem with the research is that studies tend to show that changes in physiological measures, such as heart rate and skin conductance, appear to be the same in individuals with current and prior PTSD. This indicates that the changes may represent either a predisposition or a permanent change resulting from PTSD (eg, trait rather than state).


  • PTSD may be caused by exposure to a severe traumatic stress that threatens death or serious injury or threat to personal integrity, as follows:
    • Rape
    • Sexual and physical abuse
    • Car accidents
    • Fires
    • Experiencing war
    • Receiving a serious medical diagnosis
    • Being subjected to invasive painful treatment of medical problems
  • Numerous factors increase the likelihood that a child will develop PTSD in response to a given stress, including the following:
    • Lack of social and parental support
    • Prior exposure to traumatic incidents
    • A preexisting psychiatric disorder
    • Repeated trauma
    • Trauma caused by a person (especially if by a trusted caregiver) rather than resulting from an accident
  • Parental reaction is a critical factor affecting the child's reaction. Parents' anxiety and difficulty coping with life as the result of the trauma may overwhelm a child, whereas parental ability to cope and to provide a safe haven for a child may markedly affect the child's ability to deal with the stressor or the propensity to develop protracted PTSD.
  • PTSD is particularly likely to develop if a child experiences dissociation at the time of the trauma.

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