It is my life’s goal to help people suffering from Post-Traumatic Stress Disorder

I emphatically disagree with the decision to remove the term “numbing “ from the diagnosis of PTSD in the DSM-5 (American Psychiatric Association, 2013). Numbing is the most common symptom of dissociation, which includes having flashbacks, and experiencing derealization, depersonalization, amnesia and fugue states. The phenomenon of numbing was much studied, examined and discussed within the field of PTSD prior to the publication of the DSM-5. Some combat veterans were referred to as being the “walking dead.” 

Glover Numbing Scale (GNS)© 

What does it mean when a person says he/she feels numb? Feeling numb indicates that a person lacks access to or is disconnected from emotions such as happiness or joy, and cannot feel love, care and concern or intimacy with others. When feeling numb, a person also cannot experience feelings of sadness, depression, guilt, low self-esteem, suicide or self-hatred. It should be apparent that a numb state does protect a person from feeling depressed. People who feel emotionally numb invariably report that they would prefer to be numb than depressed. Similarly, the numb state protects a person from feeling embarrassed or ashamed. One frequent source of confusion for clinicians regarding the phenomenon of numbness includes the fact that patients often mistakenly report symptoms of depression occurring at the same time as feeling numb. The vast majority of individuals who are numb do not stay in that mood state all the time – they typically switch between feeling numb and feeling depressed, but they are not in both states simultaneously.  Symptoms synonymous with numbing include feeling hollow, dead, shut down and empty-no feelings . The term “dead” denotes a more profound state of emotional withdrawal  and lack of relatedness to others. Individuals who feel dead may complain of difficulty falling asleep because lying still intensifies the feeling of “deadness.” These individuals may value being in a state of movement when alert. Numb individuals may self-medicate with street opioids such as heroin in order to feel energetic and active, which can lead to addiction to opioids. Interestingly, drugs such as heroin can have the opposite effect on people who are numb.

Individuals who feel profoundly hollow have reported to me that they experience their bodies as being transparent, and feel as though others can literally see through them. They also reported believing they could walk through walls because their bodies have no physical substance. 

Numbing, just like depression, can manifest as a circumscribed complaint or as a syndrome with an array of associated symptoms. Both depression and numbing can be associated with a loss of interest, pleasure, motivation, apathy, impaired concentration and memory, mental fog and fatigue. A person who is numb will not, however, experience the other symptoms unique to depression such as loss of self-esteem, sadness,  guilt and suicidal ideation. I have only encountered one individual who was suicidal while in a numb state. This person became suicidal and was consequentially hospitalized because she could not tolerate her inability to experience normal human feelings. Depressed people are invariably troubled and preoccupied by memories and events that occurred in the past, whereas people who are numb are very present oriented and not concerned with the past or the future, unless they are consumed by anger and thoughts of vengeance and revenge for past perceived grievances. In a numb state, a person may only be able to experience intense emotions such as anger and rage. I became acutely aware of this while treating a Vietnam veteran who had completed three tours of duty and was persistently numb. While attending a funeral of a loved one, he exploded into a rage in front of others who were mourning. Rage was the only emotion he was  able to access. When people who are numb go into a rage, the event is especially intense, explosive and long lasting. While in a state of rage, people can lose all feelings of care and concern for others and for the consequences of their behavior. Afterward, they typically become withdrawn and unresponsive for a protracted period of time. Oftentimes they experience amnesia and cannot recall the event. Others recall seeing the color red in the center of their tunnel vision during their rage. There are also other profoundly numb people who are unable to access feelings of destructive anger and rage. They are completely unresponsive, like a rock; they have a flat affect and no facial expressions, their speech is monotonic. Many chronically numb individuals learn to pretend to have feelings which they do not truly experience. Others are unaware they are projecting facial expressions, such as anger or sadness, that are disconnected from and do not accurately reflect the numb state they are in.

Cognitive impairments in people who are numb tend to be more severe than in depressed individuals. For example, a numb person may experience  mental blankness, periods of amnesia, and loss of self-awareness and the ability to monitor his/her own behaviors. In the case of people who report having severe depression, it is crucial for a clinician to make certain that the person is truly depressed and not numb. Antidepressants are not effective in treating numbness. Somatic symptoms are also different in people who are numb verses people who are depressed. For example, people who are numb may experience analgesia (loss of bodily sensations), pins and needles and transient periods of paralysis while awake. It is not unusual for people who are emotionally numb to feel disconnected from their own identities and to wonder who they are because they feel so detached from themselves. 

Numb people may adapt to feeling disconnected by creating an image for themselves that is associated with a strong visual identity such as “fashion queen” or  “combat warrior.” If a person who is numb is not cognitively impaired in terms of his/her concentration and memory, this person may be able to function well in a business environment that does not require relating  to others empathically. These individuals may function well in the workplace but very poorly in a family environment.

What kind of situations may precipitate the numb response? First and foremost is exposure to serious injury or possible loss of life.  Overwhelming stress in some individuals such as loss of income, divorce or death of a family member may precipitate an acute numb response rather than depression. Chronic unremitting depression or physical illness may ultimately lead to a numb response. Numbing resulting from exposure to trauma is more likely to be a conditioned (automatic) response, which predisposes that person to becoming numb in reaction to future stressors. Numbness becomes the predominant mode of response. Individuals who are chronically numb may experience waves of  numbness that appear to come out of the blue. In these cases, the numb response appears to take on a rhythm of its own which seems at times to be independent of any identifiable stressor. 

Dreams can vividly portray the mental state of the dreamer.  One World War II veteran dreamt that he saw himself in the passenger seat of a space capsule constantly orbiting the earth.  What a powerful way of illustrating the veteran’s sense of isolation and emotional  distance from others. Interestingly, somatic analgesia and paralysis are two responses that can be found in lab rats and mice when they are exposed to stressful situations. Somatic analgesia is referred to as stress induced analgesia, when, for example, a laboratory animal’s foot is exposed to an electric shock while inside of a cage. Once conditioned, merely placing the animal in the same cage will induce analgesia, even in the absence of being shocked. Studies of stress induced analgesia gave me the first important clue as to what was causing emotional numbing in humans.  First I reasoned that the body and mind are one. Therefore, what was causing numbing or analgesia of the body could also be causing emotional numbing centrally. I learned there are four different neurochemicals that can be associated with stress induced analgesia, but only endogenous opioids can induce a conditioned form of stress induced analgesia. This was an important step in my realization that numbing (both somatic and central) has to be mediated by the endogenous opioid system. Not all people who are emotionally numb also have somatic analgesia, but in people who have both phenomena, invariably it is the somatic analgesia that appears first. Thus, a milder stressor is likely to induce somatic analgesia first without necessarily also inducing emotional numbing.

Application of the Glover Numbing Scale

The GNS is a 35 item self-report scale that assesses the frequency of numb responses (emotional, somatic, cognitive, identity) in the past week. GNS scores significantly discriminated levels of numbing found in veterans in different Vietnam veteran facilities (in-patient veterans had the highest score on the GNS, out-patient veterans had a moderate score and veterans in veteran outreach centers had lower scores). Non-combat Vietnam vets had the lowest scores of all four groups. Another study reported that women hospitalized with the diagnosis of either Dissociative Identity Disorder (DID) or the repetitive behavior of Self-Injurious Behavior (SIB) scored significantly higher on the GNS than women hospitalized with the diagnosis of Major Depressive Disorder (MDD).Therefore, the GNS distinguished women exposed to trauma (the first two groups mentioned above) from women with the diagnosis of MDD. Furthermore, both the inpatient female MDD population and an outpatient male MDD population showed a bimodal distribution of scores on the GNS with a significant difference between the two subgroups of each population. Both the females and the males who scored significantly higher had histories of exposure to trauma. The Beck Depression Inventory (BDI) had also been administered to the women. The BDI did not distinguish between the two subgroups with MDD in contrast to findings using the GNS. This result highlights the importance of using the GNS in people with the diagnosis of MDD in order not to confuse symptoms of numbing with depression. The 2019 Revised GNS is a 35 item self-report scale with some additional information concerning the subjective state of the numb response. 

Glover Vulnerability Scale (GVS)© 

Vulnerability has been reported to be a significant problem for Vietnam veterans suffering from PTSD. Behavioral science literature has highlighted the important fact that vulnerability is closely associated with mistrust and paranoid ideations. The Glover Vulnerability Scale represents my effort to  operationalize the construct of vulnerability based on information found in this literature, coupled with my own clinical observations. I initially became interested in studying vulnerability after observing combat veterans with PTSD keeping their backs against a wall at all times. This was usually near a doorway. I surveyed scores of  veterans concerning what they felt or experienced while positioning themselves like this. Without exception, they reported or agreed to feeling vulnerable and/or easily hurt. They denied feeling anxious or afraid. Because this behavior was so characteristic of combat veterans with PTSD, the experience of vulnerability had to be important to that condition. 

The GVS includes the following thematic ideas: Trust/mistrust, including of family members, fear of intimacy and rejection, anxiety, feeling vulnerable, physically threatened, indecisive, discomfort in new situations, sensitivity to criticism, social anxiety, feeling emotionally distant  and alienated from others, expecting others to take advantage, feeling/believing others stare and/or talk about them and fears others will retaliate against them. The severity of feeling vulnerable may be mild, moderate or severe, based on the persistence and intensity of symptoms. Individuals with milder forms of vulnerability may actively seek out alliances and relationships with people or organizations who are perceived to be powerful and protective. People with a moderate degree of vulnerability may repeatedly seek out relationships and then push them away once they become fearful of intimacy. People with a severe degree of vulnerability may choose to isolate themselves from all meaningful relationships, even if they feel lonely for companionship. It is important to note that the GVS was constructed while I treated Vietnam combat veterans with PTSD who reported significant symptoms of emotional numbing. I believe that numbing protects and prevents a person from feeling embarrassed or ashamed. I learned from clinical experience that embarrassment and shame are important symptoms associated with the syndrome of  vulnerability in people who are not numb.

How is the experience of anxiety associated with vulnerability different from the experience of anxiety associated with Generalized Anxiety Disorder (GAD)? Diagnostic criteria for GAD includes anxiety, worry, impaired concentration and memory, sleep impairment, muscle tension and irritability. Difficulties with social interactions and social functioning are entirely secondary to the intensity of anxiety symptoms enumerated above. In contrast, problems with vulnerability primarily focus on difficulties a person experiences with regard to relating to other people and becoming fearful of environmental threats. A person who feels vulnerable is acutely aware of being easily hurt by what others might say or do, or any potential threat within the environment. It is of interest that both natural and man-made disasters can induce symptoms of PTSD and vulnerability. Feelings of vulnerabilty can engender mistrust and paranoia, even if unrelated to the actual stressor experience. One clinical experience I observed clearly illustrated the intimate connection between vulnerability and mistrust. A Vietnam veteran I treated returned to his home and saw that his wife and children had abandoned their residence permanently and without prior notifice. The experience left him feeling vulnerable and distraught. It caught my attention that he generalized intense feelings of mistrust even to his mother, who had  been the one constant loving and supportive figure throughout his life. 

Application of the Glover Vulnerability Scale 

The GVS is a 21 item self-report scale that measures the frequency of experiences from the previous week. GVS scores were found to significantly distinguish levels of functioning within the population of Vietnam combat veterans diagnosed with PTSD. GVS scores also significantly distinguished outpatient male veterans with PTSD from outpatient males diagnosed either with Anxiety Disorder or Major Depressive Disorder. GVS scores  demonstrated that the scale was a useful measure for assessing  severity of vulnerability within the PTSD population. The GVS scores also demonstrated an ability to distinguish between populations exposed to trauma and populations identified to be either depressed or anxious but not exposed to trauma.

An additional study demonstrated that GVS scores were found to be significantly higher in two inpatient groups of females with histories of trauma suffering from Dissociative Identy Disorder (DID) and Self-Injurious Behavior (SIB) than in a group of in-patient females diagnosed with Major Depressive Disorder (MDD) and a control group of females. Within the female control group, those who reported a history of exposure to trauma scored significantly higher on the GVS than those who did not. Again, this emphasized the salient connection between exposure to trauma and vulnerability.

Combat veterans reported having dreams that illustrated the experience of vulnerability, such as seeing glaring eyes staring at them and being encircled in the night by enemy soldiers or wild predatory animals. People who do not experience numbness, but feel vulnerable, may dream of being embarrassed and ashamed in public, for example, by finding themselves exposed and naked in a public situation. Numbing does not protect someone at all from feeling vulnerable. In fact, there was a high positive correlation between scores on the numbing and vulnerability scales. The more numb a person reported feeling positively correlated with the more vulnerable he/she felt. The exception to this may be individuals who become profoundly numb and lose all sensation, including that of fear or feelings of vulnerability. These people may become sensation-seekers and thrill-seekers.  There are certain mental states that are incompatible with feeling vulnerable, such as mania and rage. Psychopathy, although not listed in the DSM-5 as an independant disorder, would also be incompatible with feeling vulnerable.