All of these situations can produce immediate reactions, but there may also be, sometimes years later, post-traumatic syndromes of a malignant and often persistent sort. It is characteristic of these syndromes that, in addition to anxiety, heightened startle reactions, depression, and autonomic disorders, there is a strong tendency to obsessive rumination on the horrors which were experienced—and, not infrequently, sudden flashbacks in which the original trauma may be reexperienced in its totality with every sensory modality and with every emotion that was felt at the time.66 These flashbacks, though often spontaneous, are especially liable to be evoked by objects, sounds, or smells associated with the original trauma.
The term “flashback” may not do justice to the profound and sometimes dangerous delusional states that can go with post-traumatic hallucinations. In such states, all sense of the present may be lost or misinterpreted in terms of hallucination and delusion. Thus the traumatized veteran, during a flashback, may be convinced that people in a supermarket are enemy soldiers and—if he is armed—open fire on them. This extreme state of consciousness is rare but potentially deadly.
One woman wrote to me that, having been molested as a three-year-old and assaulted at the age of nineteen, “for both events smell will bring back strong flashbacks.” She continued:
I had my first flashback of being assaulted as a child when a man sat next to me on a bus. Once I smelled [his] sweat and body odor, I was not on that bus anymore. I was in my neighbor’s garage and I remembered everything. The bus driver had to ask me to get off the bus when we arrived at our destination. I lost all sense of time and place.
Particularly severe and long-lasting stress reactions may occur after rape or sexual assault. In a case reported by Terry Heins and his colleagues, for example, a fifty-five-year-old woman who had been forced to watch her parents’ sexual intercourse as a young child and then forced to have intercourse with her father at the age of eight experienced repeated flashbacks of the trauma as an adult, as well as “voices”—a post-traumatic stress syndrome that was misdiagnosed as schizophrenia and led to psychiatric hospitalization.
People with PTSD are also prone to recurrent dreams or nightmares, often incorporating literal or somewhat disguised repetitions of the traumatic experiences. Paul Chodoff, a psychiatrist writing in 1963 about the effects of trauma in concentration camp survivors, saw such dreams as a hallmark of the syndrome and noted that in a surprising number of cases, they were still occurring a decade and a half after the war.67 The same is true of flashbacks.
Chodoff observed that obsessive rumination on concentration camp experiences might diminish in some people with the passage of time, but others
communicated an uncanny feeling that nothing of real significance had happened in their lives since their liberation, as they reported their experiences with a vivid immediacy and wealth of detail which almost made the walls of my office disappear, to be replaced by the bleak vistas of Auschwitz or Buchenwald.
Ruth Jaffe, in a 1968 article, described one concentration camp survivor who had frequent attacks in which she relived her experience at the gates of Auschwitz, where she saw her sister led off into a group destined for death but could do nothing to save her, even though she tried to sacrifice herself instead. In her attacks, she saw people entering the gates of the camp and heard her sister’s voice calling, “Katy, where are you? Why do you leave me?” Other survivors are haunted by olfactory flashbacks, suddenly smelling the gas ovens—a smell which, more than anything else, brings back the horror of the camps. Similarly, the smell of burning rubble lingered around the World Trade Center for months after 9/11—and continued as a hallucination to haunt some survivors even when the actual smell was gone.
There is a large body of literature on both acute stress reactions and delayed ones following natural disasters like tsunamis or earthquakes. (These occur in very young children too, though they may tend to reenact rather than hallucinate or reexperience the disaster.) But PTSD seems to have an even higher prevalence and greater severity following violence or disaster that is man-made; natural disasters, “acts of God,” seem somehow easier to accept. This is the case with acute stress reactions, too: I see it often with my patients in hospital, who can show extraordinary courage and calmness in facing the most dreadful diseases but fly into a rage if a nurse is late with a bedpan or a medication. The amorality of nature is accepted, whether it takes the form of a monsoon, an elephant in musth, or a disease; but being subjected helplessly to the will of others is not, for human behavior always carries (or is felt to carry) a moral charge.
