PTSD AND TREATMENT
PTSD’s overall impact depends on the severity of the disorder, associated co-morbidity (i.e., substance abuse, mTBI, chronic pain), the duration of the disorder, and of course the individual sufferer’s predisposing neural, genetic, and psychological framework. This all needs to be taken into account when a therapist determines which psychotherapeutic approach is warranted.
Early assessment by the right source will help cultivate a comprehensive and individually tailored treatment plan. Informed treatment is the key to healing, and the treatment of trauma is as delicate as the subject matter itself. Pushing “too hard” or not using treatments well validated in the scientific literature will only decrease chances for improved functioning and increased quality of life.
The course of treatment with someone suffering with PTSD is a long term one, as the capacity of the traumatized “self” is limited. When working with people who are traumatized it should be universally understood that the basic tenants of empathy, creating trust and positive rapport, strengthening positive transference, and making the therapy a “safe space” are probably never more relevant.
That being said, there are a number of different therapeutic techniques implicated in treatment for PTSD. Three common treatment protocols include: Cognitive Behavioral Therapy (CBT) including Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Psychopharmacologic Treatment.
Different clinicians use different techniques, but meta-analytic findings indicate that CBT elicits the most robust results. A particularly effective type of CBT is called Prolonged Exposure. Exposure is used to enhance emotional processing of traumatic events and helps someone face traumatic memories and situations associated with them. A goal in therapy is for the person suffering with PTSD to learn to distinguish memories and associated situations from the actual event itself. Most importantly, the one is encouraged to gradually learn to safely experience reminders, as well as tolerate any resulting stress, which will hopefully decrease in time.
Imaginal exposure to the trauma entails having someone describe a traumatic experience at an increasing level of detail. A key factor in exposure is an understanding that confronting situations or memories of trauma triggers increases the urge to escape and avoid (which is a primary characteristic of PTSD in general). When this occurs, the therapist acknowledges the one’s feelings and reminds the person suffering with PTSD that avoidance reduces anxiety in the short-term, but will maintain fear and also prevent the learning that the feared situations or memories can eventually be perceived as less dangerous in the long-term.
A more general CBT approach might include the therapist helping the someone to explore schemas and self-talk, which mediate trauma-related fears, challenge negative biases, and generate appraisals that correct for the biases (cognitive restructuring), which helps build confidence.
A well known, effective, but still slightly controversial treatment for PTSD is known as EMDR. According to the theory behind the treatment, when a traumatic or distressing experience occurs, it may overwhelm usual cognitive and neurological coping mechanisms. The memory and associated stimuli of the event are inadequately processed, and are dysfunctionally stored in an isolated memory network.
The goal of EMDR therapy is to help process these distressing memories, reducing their lingering influence and allow someone to develop more adaptive coping mechanisms. EMDR integrates elements of many different therapies, including cognitive therapy, imaginal exposure, interpersonal, psychodynamic, and somatic therapies, to name a few. EMDR is distinguishable from these other therapies by its use of bilateral stimulation during each session (i.e., eye movements, tones, tapping, etc). Briefly, in EMDR a qualified therapist guides someone in vividly but safely recalling distressing past experiences (“desensitization”) and gaining new understanding (“reprocessing”) of the events, the sensations, feelings, thoughts and self-images associated with them. The “eye movement” aspect of EMDR involves the client moving his/her eyes in a back-and-forth (“saccadic”) manner while recalling the event(s).
In general, one of the greatest challenges in the field of PTSD is that there has been relatively little study of medications. The Selective Serotonin Reuptake Inhibitors (SSRI’s) are, according to the research, most effective with the lowest side effect profile. Yet, only two, Zoloft (Sertraline), and Paxil (Paroxetine), have been FDA-approved for actually treating PTSD. New studies are exploring the possibility of Ketamine treatment. Ketamine works on the glutamate pathway in the brain, pathways involved in memory and mood regulation, which might explain some preliminary results of positive outcome. Research is ongoing, and Ketamine is a long way from being used in clinical practice specifically for PTSD. Consulting with a trained psychiatrist or psychopharmacologist is most prudent.
Again, no matter the treatment of choice, the goals of the therapist should be maintained throughout. These include emphasizing a sense of self-esteem and personal empowerment, helping someone make sense of confusing and disturbing experiences, working collaboratively with someone at his/her individual own pace, keeping a sense of hope alive when the one is unable to do so, and gently guiding the patient to increased self-awareness.
What is YOUR experience with these treatment techniques? As always, your comments are heeded with care.
Jennifer Wolkin, Phd
PTSD AND TRAUMATIC BRAIN INJURY (TBI)
As a neuropsychologist, I’ve had humbling interactions with those who have suffered trauma, in both mind AND brain. That’s why I feel it is incumbent to create awareness regarding co-occurring PTSD and TBI.
TBI is a traumatic injury to the brain as a consequence of an external impact injury and/or from the influences of rapid violent acceleration and deceleration of the head (impact of your brain moving in your skull). TBI can cause a host of Physical, Cognitive, Social, Emotional, and Behavioral symptoms. TBI is categorized as mild, moderate or severe; most TBI’s in general are mild in nature (mTBI). They are typically characterized by:
- A period of lost or decreased consciousness (30 minutes or less).
- Retrograde or anterograde amnesia (loss of memory for events immediately before or after the injury) which lasts less than 24 hours.
- A variation in baseline mental status at the time of the trauma (i.e., confusion, disorientation, etc.)
- Neurological and Neurocognitive deficits including sensory loss, aphasia (difficulties with speech), sensory perception, loss of balance, weakness, etc.
Both independently and additively TBI and PTSD are responsible for most post-deployment impairments. They often, however, coexist.
It is difficult to differentiate between symptoms caused by PTSD and those by TBI, because they are often so similar. For example, both PTSD and TBI produce symptoms such as confusion, impaired learning, forgetfulness, attention and concentration difficulties, decreased processing speed, impulsivity, reduced insight, impaired work and school performance, fatigue, insomnia, headaches, and reduced motivation. This overlap makes diagnosis, and subsequent treatment, that much more complex.
In a large military sample, almost three times as many troops who sustained a mild TBI screened positive for PTSD versus those who sustained “only” a significant bodily injury. It is said that TBI actually increases the risk of PTSD.
From a neurobiological standpoint, it is likely that neural damage sustained during the injury compromises the fine-tuned circuitry required to regulate fear following a traumatic experience (most of our fear reaction is mediated by fronto-temporo-limbic regions).
On a cognitive level, the effects of TBI at the time of trauma could influence the encoding of the traumatic event, how emotions are processed, and the degree to which trauma-related memories and feelings can be retrieved in a controlled, verbally accessible manner during therapy.
One of the most crucial steps in early mTBI management is dispensing information outlining the nature of expected symptoms and providing ways to best cope with them. This information should be imparted in the context of reassurance that symptoms will likely resolve: The literature indicates that individuals who assume the damage is permanent might actually be more vulnerable to a prolonged presentation of symptoms because they are more likely to become anxious over them.
A challenge for clinicians is to determine whether self-reported, non-specific symptoms, long after an injury, are related, partially related, or unrelated to the original injury and to make a proper diagnosis. Of course, the sooner an mTBI is identified, the sooner proper care is received.
Both mTBI and PTSD are complex and multifaceted, and therefore both require multifaceted treatment. Studies supporting the simultaneous treatment of both are sparse.
Some clinicians therefore, treat whatever is treatable to try and reduce overall suffering and improve functioning. Treating specific complaints (such as pain and insomnia) might result in concomitant benefit in other realms (such as cognitive difficulty and anxiety).
After all, any potential decrease in suffering is a step in the right direction.
Jennifer Wolkin, PhD
PTSD AND HEART HEALTH
As aforementioned trauma can literally render sufferers unable to connect with/to love either their SELVES or OTHERS. Therefore, in the philosophical sense, it is no shock that PTSD can lead to the proverbial ‘broken’ heart, which is not a cardiovascular disease, but a disease of the soul and spirit.
Ironically, PTSD has recently been deemed a major risk factor for cardiovascular disease. Research studies over the last decade have illustrated that people who experience PTSD are at increased risk of heart attack and cardiovascular death. As with pain, many mechanisms have been implicated in this relationship. Why are veterans likely to experience co-morbid cardiovascular disease (CVD)?
On a purely biological level, PTSD leads to physiological changes, including states of “hyper-arousal,” characterized by increased sympathetic system activity (i.e., increased blood pressure, heart rate, etc). This constant physiological arousal (constant “fight or flight” mode) can damage the cardiovascular system. Meaning, the actual physical toll that constant hyper-arousal takes is that it places a huge BURDEN on one’s heart.
In addition to a biological explanation, there are many poor health behaviors associated with this risk as well.
- People who experience psychological stress, including PTSD, are more likely to be non-adherent to medication and other treatment recommendations. Those with PTSD suffering from, for example, hypertension (high blood pressure) or diabetes are more likely to suffer a related cardiac event if they don’t take medication and leave the disease uncontrolled.
- People suffering with PTSD are at increased risk for tobacco use (almost twice as high as the general populations) as a way to self-medicate to decrease anxiety levels. Smoking, however, can cause CVD through atherosclerosis (hardening of the arteries) and increased risk for thrombosis (blood clot). Quitting also becomes more difficult because the withdrawal period will likely also lead to amplified physiological hyper-arousal.
- Those with PTSD are not future-oriented and are often shortsighted about their health, making it appear unnecessary to take any preventive measures, such as physical exercise, which is essential for heart health.
- Additionally, many with PTSD fear that exercise might actually cause increased health difficulties. Increased physical activity leads to increased physical arousal, and therefore, exercise is avoided so as not to recreate that “fight or flight” feeling.
Overall, on a behavioral level, those suffering with PTSD have a greater tendency toward the adoption of high-risk behaviors (i.e., smoking, drug use, etc). At the same time they are less likely to take preventive measures.
It is crucial that those with PTSD are informed about the need to adopt a healthy lifestyle. In addition to interventions specifically tailored to symptoms of PTSD, interventions geared toward specific lifestyle changes are warranted (i.e., smoking cessation programs, treatment compliance programs, etc) to prevent cardiovascular events.
What are YOUR thoughts? We always love to hear what you have to say in the comments section below.
Jennifer Wolkin, PhD
PTSD and CHRONIC PAIN
PTSD is mostly known for its impact on overall mental health. There is research, however, to support the fact that PTSD is increasingly being recognized for its effect on physical wellness as well. Many who suffer with PTSD (veterans in particular) have higher lifetime prevalence of circulatory, digestive, musculoskeletal, nervous system, respiratory, and infectious disease. There is also an increased co-occurrence of chronic pain in those who suffer with PTSD.
In 1979, the International Association for the Study of Pain (IASP) officially redefined pain as, “An unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage”. This definition takes into account the fact that pain involves thoughts and feelings. Meaning, pain is real whether or not the biological “causes” are known, and it is ultimately a subjective experience.
Pain experienced by veterans is reported as significantly worse than the pain of the public at large because of increased exposure to injury and psychological stress during combat. Rates of chronic pain in veteran women are even higher.
All veterans with chronic pain often report that pain interferes with their ability to engage in occupational, social, and recreational activities. This leads to increased isolation, negative mood, and physical deconditioning, which all actually exacerbate the experience of pain.
Why are veterans and others who suffer with PTSD more likely to experience co-morbid chronic pain?
Well, for veterans in particular, the pain itself is a reminder of a combat-related injury, and therefore can act to actually elicit PTSD symptoms (ie, flashbacks). Additionally, psychological vulnerability such as lack of control is common to both disorders. When a person is exposed to a traumatic event, one of the primary risk factors related to developing actual PTSD is the extent to which the events and one’s reactions to them are unfolding in a very unpredictable and therefore uncontrollable way. Similarly, those with chronic pain often feel helpless in coping with the perceived unpredictability of the physical sensations.
Some say that those who experience PTSD and Chronic Pain share the common thread of “anxiety sensitivity.” Anxiety sensitivity refers to the fear of arousal-related sensations because of beliefs that these sensations have harmful consequences. A person with high anxiety sensitivity would most likely become fearful in response to physical sensations such as pain, thinking that these symptoms are signaling that something is terribly wrong. In the same vain, a person with high anxiety sensitivity will be at risk for developing PTSD because the fear of the trauma itself is amplified by a fearful response to a “normal” anxiety response to the trauma (meaning, it is very “normal” to have a strong reaction to trauma, but most sufferers actually tend to be fearful of their own response).
What has YOUR experience been? Feel free to share in this forum. We are sensitive and respectful to the emotional burden of the topic.
Jennifer Wolkin, PhD
PTSD AND INTERPERSONAL RELATIONSHIPS
Trauma calls into question the basic foundation of trust in human relationships. Traumatic events not only have effects on the psychological structures of the self, but also on the attachments that link an individual to a greater community. A trauma sufferer is likely to feel as though every relationship is infused with a sense of alienation and disconnection.
The impact of trauma pulls and pulls at the threads of relationships until they tear, or in many cases, disintegrate completely. Sometimes, when I work with the significant other of a trauma sufferer, I am shocked by how far the trauma reaches. It goes inward and outward. Its tentacles have few boundaries.
It is so pervasive, that I often wonder: Is Trauma Contagious?
The literature has demonstrated that PTSD affects family cohesion, parenting satisfaction, romantic partnership, and functioning and emotional security of children. Consequently, poor functioning in these domains is associated with higher rates of divorce and higher occurrences of clinically significant levels of relationship distress in the families of veterans with PTSD than in the families of veterans without PTSD or in the general population.
It probably can’t be overemphasized that poor health outcomes for children (poor development, higher rates of illness, lower academic performance, and cardiovascular disruption) are closely linked to this now-stressful family environment, which is created when the symptoms of PTSD literally intrude upon the family or relationship structure.
PTSD symptoms affect personal relationships indirectly as well. For example, veterans with PTSD are more likely than members of the general population to have clinically significant levels of depression, anxiety, anger, and violence. They are more likely to abuse substances and less likely to hold steady employment. All of these play a role in the breakdown of interpersonal functioning.
The nature of interpersonal problems experienced by combat exposed veterans appears to be correlated with the presence in particular of the avoidance and numbing characteristics of PTSD. In families and relationships, avoidance and numbing may create social isolation, a cold, and unresponsive parenting style, anger, and an absence of emotional warmth.
One of the most consistent relationships observed in trauma research is the inverse relationship between PTSD symptoms and social support (that is, the more social support, the fewer symptoms). The ultimate sad irony is that the people in the world of the trauma survivor are pushed away, though connection is the very thing that is needed.
A supportive response has shown to mitigate the impact of trauma, as the survivor yearns to establish a basic sense of safety and trust. The trauma survivor needs the help of others to rebuild his or her shattered sense of self. Yet, it is a long arduous process during which the survivor cycles between the need for extreme closeness and the need for distance and time to reestablish self-autonomy.
During this process, the toll that these cycles take is hard to gauge. In some cases, members of the support system suffer their own kind of trauma. If merely witnessing the person you love suffering through trauma is not a sort of trauma unto itself, then I don’t know what is.
Recovery for the sufferers and support systems is possible. It is crucial that health professionals understand the impact of PTSD on interpersonal functioning in order to provide the best treatment approaches for the sufferers and their social systems.
This is the third in a series of BrainCurves posts that I will be sharing on the topic of Trauma and PTSD throughout the month of June, National PTSD Awareness Month. Next week I will post about PTSD and Chronic Pain.
Jennifer Wolkin, PhD