The inner world in the outer world: the phenomenology of posttraumatic stress disorder from a psychoanalytic perspective.
The intrapsychic processes underlying the phenomenology of PTSD symptoms appear to derive their fate from the states of consciousness at the time of traumatic experiences. The operative mechanisms of consciousness-condensation, avoidance of censorship, representability, and secondary revision-are the elements of trauma work as they are of dream work. These mechanisms establish an ever-present dynamic mental state of space consciousness, which is defined as an essential component of mental activities. This state of space consciousness exists beyond any experience of the self and beyond any processes regulated by the pleasure principle. When the sensory impressions derive from perceptions of and interactions with the mother, the matrix consists of the relationship between infant and mother. When the sensory impressions relate to traumatic circumstances the matrix reverts from the epigenetic context to the genetic one. The genetic matrix is manifest through disturbances in the activities of the higher mental functions. Under the impact of trauma, the epigenetic experiences are akin to a population floating without direction on a boat at the mercy of the elements-the raging higher mental functions. The factors operating on the higher mental functions create an inner world under traumatic circumstances, leading to an interpretation of the outer space according to the mental activities of the inner space. The concept of a dynamic process producing numerous modifications in mental scenes, thought, feelings, and reactions provides no surprise to psychoanalysts. The higher mental functions are seen as operating at the juncture of the physical and the mental. This juncture is the place where spatial consciousness and memories begin their common journey. Goodman wrote, "The conventional dichotomy between physical (organic) and mental (functional) is linguistic/conceptual rather than inherent in nature, and all events and processes involved in the etiology, pathogenesis, symptomatic manifestation, and treatment of psychiatric disorders are simultaneously biological and psychological" (Goodman, 1991, p. 553). The subjective experience of the dynamic unconscious activities of the higher mental functions form the inner nucleus selecting the relevant sensory impressions from the outer world. The juncture between the physical and the mental could be a crossroad for the psychic events occupying space and the psychic events determined by time factors. The psychic events that begin at this juncture find their composition evolving in time, in sequence, and in simultaneity. They follow a course determined by the four mechanisms responsible for the creation of dreams, of memories, of behaviors, and of narratives. The descriptive criteria of PTSD have in common the quality of persistence. The associated features show more variability and their appearance coincide with the appropriate circumstances that stimulate their arousal. Internal genetic factors remain persistent factors in the arousal of the reexperiencing phenomenon, of the avoidant behaviors and of the physiological reactivity. They furnish the impetus for the construction of the inner world, which is an indispensable tool in the management of ourselves, our bodies, and our environment. To paraphrase Freud's quotation used at the beginning of this article, there is a process in the inner world, stimulated by unconscious factors, that give rise to our view of the world and of our soul. The contents of this article-the ideas, the concepts, and the discourse itself-are a product of a continuing, evolving psychoanalytic way of thinking. The total of the analytic considerations gathered under the theory of trauma psychology could not be presented without the contributions of Freud, Hartmann, Rapaport, Erikson, Holt, Klein, Schafer, and others. We believe trauma psychology to be in its infancy, at a stage comparable to the stage of the libido theory at the time of the writing of The Interpretation
Emery
P E
PE
VA Medical Center, Manchester, NH, USA.
D000223:Adaptation, Psychological / Q000502:physiology; D000328:Adult; D001143:Arousal / Q000502:physiology; D003243:Consciousness / Q000502:physiology; D004325:Dreams / Q000502:physiology; D006801:Humans; D008297:Male; D008568:Memory / Q000502:physiology; D011574:Psychoanalytic Theory; D013313:Stress Disorders, Post-Traumatic / Q000503:physiopathology*