Symptoms of PTSD (and other unprocessed traumatic memories)

BRAIN FREEZE – UNDERSTANDING PTSD (Chapter 8, pages 142-152)

Excerpted from Mark I. Nickerson and Joshua S. Goldstein's book "The Wounds Within: A Veteran, a PTSD therapist, and a Nation Unprepared (2015). 

The DSM-5 lists four clusters of PTSD symptoms.  They are: 1) alterations in hyperarousal and reactivity; 2) intrusion; 3) avoidance; and 4) negative alterations in cognitions and moods:

       1.      Hyperarousal and Reactivity

a.      Hypervigilence

b.      Sleep disturbance – Wired tired, nightmares, night terrors, and night sweats

c.      Anger , irritability, impatience, low frustration tolerance, hostile or cynical attitude, chip on shoulder, dislike/distrust of those exerting authority

d.      Anger brings on major physiological changes—release of stress hormones, increase in heart rate and blood pressure, heightened sensory perceptions, tightened muscles  in preparing for action

      2.      Intrusions

a.      Unwanted thoughts, images, sensory experiences, impulses, memories, feelings

b.      Traumatic event is persistently re-experienced in the present (not as a memory)

c.      When speaking, switches between past and present tense (from about to within)

d.      During sleep, memories may include small fragments or a mix-up of elements

e.      Triggers can be external or internal; common triggers for veterans include:

                                                    i.     Direct references to war (news, movies, conversations, questions)

                                                  ii.     Bad news (report of a death)

                                                 iii.     Loud noises (car doors, helicopters, heavy equipment, fireworks)

                                                 iv.     Smell associated with blood or fuel

                                                   v.     Driving in hot and dusty conditions, driving over potholes, seeing bags on the side of the road

                                                 vi.     Busy highways, overpasses, riding in the back seat

                                               vii.     Crowded places such as restaurants and shopping malls

                                              viii.     Hearing languages or seeing people whose nationalities are similar to the war zone where the veteran served

                                                 ix.     People who look similar or familiar to enemy-victims

                                                   x.     Feeling enjoyment (or seeing others enjoy) can activate unresolved guilt

 3.      Avoidance

a.      Persistent effort to avoid things (people, places, conversations, activities, objects, situations) that stimulate trauma memories

b.      Avoidance of therapy, frequently due to denial that a problem exists

c.      Can lead to strong urges to isolate (often enforced by intense feelings of guilt or shame), leading to relationship problems and social phobias

d.      Psychological numbing: disassociation from reality (what is going on around them) used to keep a mental distance from traumatic memories

e.      Substance abuse, primarily alcohol and marijuana, to dull the pain; “alcohol is everywhere in military culture…whatever someone says they drink, triple it”

      4.      Negative cognitions and mood

a.      Coldness and detachment; a leave-me-alone attitude; intense sadness and depression; an inability to have fun

b.      Formerly pleasurable activities, places, and people lose their meaning

c.      Thoughts of suicide, which also include:

                                                    i.     Amnesia about the trauma

                                                  ii.     Persistent negative beliefs about oneself or the world

                                                 iii.     Blaming oneself for a traumatic event

                                                 iv.     Inability to feel positive emotions

                                                   v.     Low self-esteem

                                                 vi.     Feelings of alienation

                                               vii.     Bitterness toward civilians for not understanding or respecting what the soldier had done for his country; bitterness toward commanders for putting people at risk

There is Hope! Treating PTSD and other unprocessed traumatic memories

FULL RECOVERY – TREATING PTSD (Chapter 9, pages 171-187)

Excerpted from Mark I. Nickerson and Joshua S. Goldstein's book "The Wounds Within: A Veteran, a PTSD therapist, and a Nation Unprepared (2015).

Trauma recovery has three phases—stabilization, trauma treatment, and integration

       1.  Stabilization – Identify the problems; reduce the most acute symptoms; build motivation and commitment to the recovery process.  The goal is for veterans to acquire enough coping strategies that facing traumatic memories won’t make matters worse.  Stabilization includes:

a.      Setting the stage for treatment success

b.      May require a secure 24-hour environment until the client feels safe enough on their own

c.      May mean addressing day-to-day struggles, such as substance abuse, life management problems, troubled relationships, finding a job, and making ends meet financially

d.      Teaching veterans how to build the capacity to observe what they are going through in a somewhat detached way so as not to be consumed or defined by their traumatic memories

e.      Helping veterans identify aspects of their healthier identities, which may also require helping them remember times in their lives that were not dominated by problems

f.       Creating a strong and secure relationship of trust between veterans and treatment providers—respecting and maintaining a veteran’s personal dignity are paramount

g.      Having a chance to tell their stories and being heard respectfully are key

h.     Crucial first steps may include helping veterans learn new techniques and strategies:

                                                    i.     Stress management

1.      Physical and mental relaxation

2.      Positive thinking

3.      Exercise

4.      Prayer

5.      Problem solving

                                                  ii.     Anger management

1.      Taking responsibility for one’s anger

2.      Identifying warning signs when triggered

3.      Developing strategies for calming down and distancing oneself from triggering situations

4.      Take action to ensure the physical and emotional safety of all involved

                                                 iii.     Making sleep the highest priority

1.      Sleeplessness exacerbates other difficulties

2.      Develop healthy routines and practice self-calming methods

3.      Avoid using alcohol and/or drugs to induce sleepiness

4.      Sleep during the day, if needed, to feel safe

                                                 iv.     Processing loss and sadness (strategies to avoid becoming overwhelmed)

1.      Take time to talk and grieve with other veterans (unprocessed grief can lead to depression)

2.      Plan symbolic activities on those dates that trigger sadness

3.      Journal good memories, regrets, current feelings, etc.

4.      Write a heartfelt letter to the deceased person and/or create a memorial or photo album to honor and document their life

5.      Share feelings of survivor guilt with others; learn to forgive oneself

6.      Mobilize energy to try things that used to be fun

         2.  Trauma Treatment – Involves directly facing and working with specific traumatic memories.  There are four recommended treatment approaches—exposure-based therapies (ET); cognitive-based therapies (CT); stress inoculation training (SIT); and eye movement desensitization and reprocessing (EMDR).  All four approaches meet the standards for evidence-based psychotherapies, meaning that the research has substantiated their effectiveness for PTSD treatment.  Each recognizes that PTSD symptoms include a mixture of cognitive, emotional, psychological, physiological, and behavioral symptoms.

a.      Exposure-based therapies (ET) – Bring up traumatic memories through imagined or acted-out scenarios, or through oral or written stories, while helping the client restructure thoughts (such as actual versus perceived danger) and learn relaxation techniques.

b.      Cognitive-based therapies (CT) – Work with clients to specifically change the thoughts and beliefs connected to the traumatic event; also often includes relaxation techniques and a general discussion of the event.

c.      Stress inoculation training (SIT) – Teaches methods of breathing and muscle relaxation and includes cognitive elements—i.e. self-dialogue, thought-stopping, role-playing—and exposure techniques.

d.      Eye movement desensitization and reprocessing (EMDR) – Uses alternating eye movements combined with an exposure component (recalling the traumatic event), a cognitive component (reassessing thoughts and beliefs), and a self-monitoring of emotion and body reactions component.

 3.   Integration – EMDR is aimed at repairing the indirect effects of PTSD, including the impact on relationships, health, opportunities in the world, self-regard, and blocks to personal fulfillment; working through grief is an important component of integration work.  As clients experience relief from their symptoms through EMDR therapy, they develop a more positive outlook, are able to move forward with their lives, and view their past differently.  Veterans are able to take satisfaction from the positive aspects of their war experiences.  Integration is about making sure the improvements last, which includes regaining vitality, breaking bad habits, and designing the next stage of life.

Note: What exactly is EMDR and how it works will be explained in next week's blog post.

PTSD - What is it?

Excerpted from Mark I. Nickerson and Joshua S. Goldstein's book "The Wounds Within: A Veteran, a PTSD therapist, and a Nation Unprepared (2015).

Psychological trauma is physical.  Brain scans show that the memory-related hippocampus in the brain actually shrinks in people with PTSD, but grows again after psychotherapy to resolve PTSD.

PTSD symptoms result from the incomplete processing of memories in the brain.  With traumatic experiences, memories do not get stored in the brain in the same way that normal memories get stored.  The emotional parts of the brain hijack the process, for reasons that make sense at the moment, and normal processing shuts down.  Memories get put aside intact.

The reason that traumatic experiences hijack normal memory formation is that the emotional parts of the brain take over in terrifying situations and the logical thinking parts shut down.  Traumatic situations activate the middle part of the brain—the part that involves motivations, emotions, and drives.  The amygdala responds to danger by activating the body’s survival response system.  In this state, the normal processing of memories becomes a casualty since it is not a priority at the moment.  The brain shuts away the disturbing information, without taking time to process it, and continues to function without becoming overwhelmed by distressing thoughts and feelings.  Months or years later, the experiences that have not been processed and integrated into the memory, eventually work their way to the surface as the intrusive symptoms of PTSD.

The result of incomplete processing is the mind and body continue to react as if the trauma is still happening in the present.  Bilateral stimulation (BLS) aka EMDR therapy can help complete the processing and integrate the traumatic memory with long term memory, thus making the memory a past memory.