Prof. Joseph Levine

Senior Psychiatrist




Conversation 37: The post-traumatic syndrome and the "directory of internalized characters"

By Prof. Levine & Dr. Salganik


In 2013, the American Psychiatric Association revised the diagnostic criteria for post-traumatic stress disorder [PTSD]—also called post-traumatic stress disorder—in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders [DSM-5]. PTSD is included in a new category in the DSM-5, Trauma and Stress Disorders. All the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion.

It should be noted that DSM-5 introduced a subtype of preschool PTSD for children aged six years and younger. The criteria below are specific to adults, adolescents and children over the age of six.

Below are the criteria required for a PTSD diagnosis.

Criterion A: stress factor (one section is required):

The person is exposed to: death, threat of death, actual or threatened serious injury, or actual or threatened sexual violence, in the following ways:

Direct exposure

Evidence of trauma

It became known that a relative or close friend was exposed to trauma


Emotional distress after exposure to traumatic reminders

Bodily reactivity after exposure to traumatic reminders

Criterion C: Avoidance (one section is required):

Indirect exposure to disturbing details of the trauma, usually within the framework of professional roles (for example, rescue service personnel and more)

Criterion B: Symptoms of the incident penetrating the conscious mind (one section is required):’

The traumatic event is consistently re-experienced in the following ways:

Memories of the event that trigger unwanted negative emotions


Avoiding trauma-related stimuli after the trauma, which include:

Thoughts or feelings related to the trauma

External trauma-related reminders

Criterion D: Negative changes in cognitions and moods (two items required):

Negative thoughts or feelings that started or worsened after the trauma, in the following ways:

Inability to recall central features of the trauma

Excessively negative thoughts and assumptions about yourself or the world

Excessive blaming of oneself or others for causing the trauma

Negative influence

Decreased interest in activities

Feeling of isolation

Difficulty experiencing positive affect

Criterion E: changes in arousal and reactivity:

Trauma-related arousal and reactivity that began or worsened after the trauma, in the following ways:

Irritability or aggression

Dangerous or destructive behavior


Increased panic response

Difficulty concentrating

Difficulty sleeping

Criterion 6: Duration (mandatory criterion for diagnosis):

Symptoms last more than a month.

Criterion 7: functional significance (mandatory criterion for diagnosis):

The symptoms create distress or functional impairment (eg, social, occupational).

Criterion H: Negation of conditions (mandatory criterion for diagnosis):

The symptoms are not due to medication, substance use or other illness.

Two aspects:

Dissociative Aspect In addition to meeting diagnostic criteria, a person experiences elevated levels of one of the following in response to trauma-related stimuli:

Depersonalization. An experience of external observation or detachment from yourself (e.g, feeling like "it's not happening to me" or you're in a dream).

Derealization. An experience of unreality, distance or distortion of the realistic perception (for example, "things are not real").

Aspect of the stay:

The full diagnostic criteria are not met until at least six months after the trauma(s), although the onset of symptoms may occur immediately.

Trauma [image]

Let us ask how the formation of PTSD can be explained on the basis of the key figures internalized within the individual and his sensitivity channels [see definitions in previous conversations]?

We will distinguish between:

1] the traumatic event in a person with a problem in certain Sensitivity Channels such as Threat and Attachment alongside internalized figures characterized by anxiety, difficulty in coping and phobic characteristics that in our opinion may be prone to developing PTSD, and:

2] the creation of the new representation of the person's own internalized figure that is related to the trauma.

The context of the threat-related sensitivity channel in relation to the risk of developing PTSD is quite clear. Below we will bring here an article linking the sensitivity channel of attachment in the individual and its relevance to the expression of post-traumatic reactions.

Emma M Marshall & Patricia A Frazier. Understanding post-trauma reactions within an attachment theory framework: Current Opinion in Psychology; February 2019, Pages 167-171.

This manuscript reviews recent research on posttraumatic reactions, including PTSD symptoms and self-reported posttraumatic growth, using attachment theory as a framework.

Here are its findings:

Attachment anxiety is more strongly associated with PTSD than attachment avoidance.

We will proceed and ask how insecure attachment orientations are related to PTSD symptoms:

According to the manuscript, insecure attachment orientations (specifically attachment anxiety) are positively related to PTSD symptoms, whereas attachment security is negatively related to PTSD symptoms. People with anxious attachment orientations may experience more intrusive thoughts and negative emotions related to the trauma, and may seek excessive reinforcement and support from others. On the other hand, people with an avoidant attachment orientation may deny their need for support and downplay or repress the severity of the trauma and their distress, which may negatively affect post-traumatic adjustment. In general, attachment orientations are closely related to thoughts and behaviors related to PTSD symptoms.

What are the possible mechanisms that the article explains exist behind the relationship between insecure attachment orientations and PTSD symptoms?

The manuscript suggests that several mechanisms may explain the relationship between insecure attachment orientations and PTSD symptoms. For example, cross-sectional studies have found several significant mediators of the relationship between attachment anxiety and PTSD symptoms, including characteristics of the trauma memory, perceived stress, event centrality and severity, poor self-regulation, negative self-cognitions, and lack of social support. There is also some evidence that social support and general interpersonal competence mediated the relationship between attachment avoidance and PTSD symptoms. In a particularly rigorous prospective study, pre-trauma attachment avoidance and anxiety were associated with fewer post-trauma social resources, which in turn predicted PTSD symptoms 2 months after the first post-trauma assessment. Finally, chronic and severe PTSD symptoms may increase attachment insecurities (especially among those who are already higher on attachment anxiety and avoidance indices) by fostering the development or exaggeration of negative models of the self's functioning in contact with others.

Finally, the manuscript states that the research findings on the relationship between attachment orientations and post-traumatic growth are mixed. The relationship between attachment orientation and posttraumatic growth, when significant, tends to be positive, as expected given the positive relationships between attachment orientation and posttraumatic growth and social support. However, the relationships between attachment anxiety and avoidance and posttraumatic growth are varied, with nonsignificant, positive, or negative relationships across studies.

PTSD symptoms directly map onto the thoughts and behaviors associated with attachment orientations. Research has shown that attachment orientations are related to PTSD symptoms and posttraumatic growth, but more rigorous research methods are needed to analyze the complex processes involved.

Some of the limitations of current research on attachment orientations and posttraumatic growth include the lack of longitudinal studies, focus on self-report measures, and the need for more diverse samples.

The question arises as to whether this article implies that in the treatment of PTSD one should also refer to early internalized figures in the individual such as the mother figure or her substitutes in the individual in order to strengthen his resistance and perceptions

Moving now to the human condition after the trauma. First we note that as a rule trauma is a defining event in an individual's life. In this situation, according to our assumption, the human figure is internalized with attitudes and the traumatic event and returns and emerges by itself, for example when there are flashbacks and repeated experiences of the event. In this state of emotional flooding and the increase in the experiences of the event, it seems that this traumatic introverted character increases in its influence on every other introverted character, including those that were dominant before in the hierarchy of introverted characters.

Thus the formation of post-traumatic stress disorder (PTSD) can be understood in our conception, in part, through the lens of key figures internalized within the individual. In addition, this is affected as mentioned by the composition of the individual's sensitivity channels [which include sensitivity to a change in status, a change between the internalized norms and the norms of the reference group, a change (or threat of change) in the level or nature of attachment to significant figures: a threat to the person's physical or economic survival: a significant change in the daily routine or routines, and changes (usually deterioration) in man's energetic resources].

In other words, the "directorate of internalized characters" includes key characters that influenced the person during his entire life and were internalized into his mental system [see in previous conversations that these characters can also include imaginary characters from literature, poetry and more, and even a general character of the subculture in which the person lives] but as mentioned also representations of his own character at different stages of his life when the trigger for creating another character of his is usually a defining event associated with a significant emotional activation.

We claim that when a person goes through a traumatic event with considerable and unusual emotional intensity, a new representation of him is created within the board of figures that we will call here "the traumatic figure of the individual created in event X" or for short "the traumatic figure X". The circumstances of the trauma, his attitudes, are conditionally linked to this figure, his feelings [for example helplessness, extreme anxiety, a sense of death in battle, etc.] and the individual's behavior during the trauma.

In psychology and psychotherapy, the concept of internalized key figures often refers to significant people from the individual's past, such as parents, caregivers or authority figures, whose influence and representations continue within the person's psyche while the person is usually not aware of it. In the theoretical background that we bring, we talk about a collection of significant figures in the individual's life that the individual internalizes and these metaphorically build his "board" of internalized figures that, according to our theoretical background, makes up his "social self". This collection of internalized figures includes also the figure of a person himself in a representative number created after key experiences and events in his life. Thus an individual can have a representation of himself as a child, a representation as a young man and more, each such representation is created after an emotionally significant event for the person.

Since we hypothesize that there is a hierarchy in the "character board" and that there is a character or characters that are higher in the hierarchy of their influence than others, then in a trauma with massive emotional intensity "traumatic character X" can compete with other dominant character or characters for dominance and according to characteristics and associations that emerge from the individual and the environment can sometimes become the most dominant character that dictates the emotional attitudes and behavior of the individual.

Now after the trauma, it is possible that these internalized key figures including the traumatic figure X might play a crucial role in the development and expression of PTSD. Here are possible explanations for how this process could work:

A. Activating trauma-related responses:

As mentioned, given intensity beyond a certain threshold, the traumatic character X will be created, which will be activated thereafter by clues, circumstances and associations arising from the environment and mental life of the individual and will result in the symptoms of PTSD including:

A. Re-experience of the traumatic event:

One of the main symptoms of PTSD is re-experiencing the traumatic event. This can include flashbacks, nightmares and intrusive thoughts.

Here apart from the influence of the individual's traumatic figure X as mentioned above, it is also possible that other internalized key figures [e.g. phobic figures] may appear behind the scenes in these experiences in a way that they interpret the experiences according to their attitudes.

B. Avoidance and emotional dullness:

Another symptom of PTSD is avoidance of reminders of the trauma and emotional dullness. Here internalized key figures that avoid facing threats may rise in the hierarchy and influence the individual's behavior when their activation regulates the circumstances and stimuli of the environment in that the person avoids circumstances that may activate the expression of the internalized traumatic figure X.

We’d like to mention here that, as a general rule, the treatment of post-traumatic syndrome includes a variety of methods, including cognitive behavioral treatments, desensitization treatments of various kinds, body-centered treatments, EMDR [eye movement therapy], providing an empowering interpretation of the trauma, drug treatment and experimental treatments, studies that are not yet approved on hallucinogenic drugs [don't try!] and more.

However, in our opinion, the treatment should also include the processing of the trauma while referring to the internalized figures with an emphasis on the internalized traumatic figure. In addition, the processing of the trauma in our perception also depends of course on the reference to the composition of the channels of sensitivity [especially those of threat and attachment] of the person and will be represented by internalized images as well.

That's it for now

Best regards

Dr. Igor Salganik and Prof. Joseph Levine

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