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About Medications For Combat PTSD
Jonathan Shay, M.D., Ph.D.
Staff Psychiatrist, Boston VA Outpatient Clinic
(continued)

Things to avoid

One of the useful things I do for veterans I see is help them identify and get off of drugs that they use (whether prescribed by doctors of not) that are harming them. Some of what I say here is likely to be controversial.


Benzodiazepines: diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), etc.

Disinhibition: All the drugs in this class are similar to alcohol. Some people who "lose all their inhibitions" on either alcohol or benzos or both. This "dis-inhibition" can affect practically anything that a person thinks he might like to do -- but doesn't do -- when sober. It has included suicide and murder, but most often involves saying things that cumulatively do great damage to a veteran's life. A lot of family stress among veterans comes from things said to wives and children the veteran wishes he hadn't said, the moment it was out of his mouth. One of the inhibitions that benzos weakens is the inhibition about saying hurtful things to people we love. Memory loss: All of the benzos weaken the ability to remember what happened a short time ago, including things you yourself did or said. The more potent the benzo, the more it wipes out short-term memory -- this is probably why Halcion (generic name: triazolam) has been such a bad actor, it's one of the most potent. Here's a little scene that everyone has experienced one way or another:

"I'm going out for cigarettes -- want anything?""Quart of orange juice and a box of Pampers.""OK" Half hour later you're back -- with your cigarettes! No one is 100% on things like this, but people on benzos are sometimes close to zero.

Short-term memory is something that everyone needs to make relationships work, at home, at work, or anywhere. There's the additional stress that combat vets have when they find themselves forgetting -- they have been in real situations where people died because someone forgot. The tension and guilt that this creates in everyday life can be unbearable, and veterans often do not know that their benzodiazepines are responsible for memory lapses.

Confusion of pleasant side-effects with main effect: The pleasant, couple-of-drinks, or drowsy feeling that you get when you first take a benzo (especially the ones that are rapidly absorbed into the blood) is a side-effect that most (not all) people get tolerant to. Because it comes on at the same time as the anti-anxiety effect, it is natural for patients to think that this pleasant feeling is the anti-anxiety effect. One of the strengths of the benzos is that people do not get tolerant to the therapeutic anti-anxiety effect. A very common problem is that people feel the drug is quitting on them when they become tolerant to the pleasant side-effect, and become very afraid that their anxiety symptoms will return. Often out of fear of fear, they double up on their meds and pressure their doctors to increase their dose. This natural confusion of a gradually weakening, pleasant side-effect with the main effect is responsible for some addictive properties of the benzos.

Mini-withdrawal syndrome between doses: Benzos differ from each other mainly in their pharmacokinetics, that is, how fast they go into the body and how fast they leave. Mini-withdrawal reactions are particularly likely to happen with the benzos that leave the body quickly, such as Halcyon (generic name: triazolam). This is why people who take this drug for sleep often wake up in the middle of the night because they are in the withdrawal phase. Though Xanax does not leave the body quite as fast as Halcyon, it is particularly prone to giving mini-withdrawals between doses. My observation has been that many combat vets on Xanax have periods of anxiety and irritability during each day that do them great harm, and which, in my view are mostly mini-withdrawal reactions between doses.

Possible dangerous peculiarities of Xanax in PTSD during withdrawal: The staff of the in-patient PTSD unit at the American Lake VA in Washington State have published a paper reporting extreme violence by combat vets treated for long periods with Xanax and then taken off of it. This was apparently more frequent and more severe than what they found taking their patients off of other benzos, such as Valium. Several Vietnam combat veteran peer counselors whom I respect very highly, feel that Xanax has done a lot of harm. Xanax has some unique properties among its cousins in the benzodiazepine family. In lab tests Xanax acts the opposite at low blood levels of how it acts in the larger amounts actually used in medical practice. When you think about it, everybody passes through a low blood level twice when they take a pill -- once when the pill is just being absorbed in the body and once when the body is almost done getting rid of it (unless, of course, the person takes the same pill again, before the first one is completely gone). Whether this is what causes the problems with Xanax is not clear right now.


Caffeine

The pharmacology of caffeine is horribly complicated: it's not just one drug, it's really three, each of which can have a different effect on different people. The way it's three drugs is that it's the original caffeine, then the body converts it into theobromin, which the body then converts into theophyllin. The peak effects of these three successive drugs are roughly two hours for caffeine, four hours for theobromin and six hours for theophyllin. The good effects that any of these three drugs can have is feeling more awake, energetic, and optimistic. The bad psychological effects that any of these three drugs can have are anxiety and depression. A given person does not necessarily react to all three the same way. (I'm not talking here about the well-known effects of caffeine on sleep -- this is another important topic in itself. What many people are unaware of is that at very high doses -- like 15+ cups of coffee a day -- caffeine can reverse on you and it can be impossible to stay awake, unless the caffeine is stopped.)

Someone who reacts badly to caffeine itself has usually found that out long ago, because the anxiety and/or depression hits them soon after the big mug of coffee. These people know it's not for them. But there are literally millions of people who feel good after caffeine itself but have bad reactions to either theobromin or theophyllin (four or six hours after that big mug of coffee) and just think it's their life that's out of whack, not their brain chemistry THERE IS NO WAY TO TELL WHETHER CAFFEINE AND ITS METABOLITES ARE RESPONSIBLE FOR YOUR ANXIETY AND/OR DEPRESSION UNLESS YOU TAKE YOURSELF OFF IT COMPLETELY FOR SEVERAL WEEKS. This means coffee, tea, Coke, Pepsi, Mountain Dew, Jolt, headache pills with caffeine. Some people are so sensitive to it that even the small amount of caffeine in decaffeinated coffee and in chocolate causes psychiatric symptoms. If you decide to take yourself off caffeine to see what your life is like, don't go cold turkey. Taper yourself off over a week or so, or you are likely to get severe withdrawal headaches.


Yohimbine

Yohimbine (brand names: Actibine, Aphrodyne, Yocon, Yohimex) is absolutely contraindicated in combat PTSD. It causes flashbacks and panic attacks. This drug is sometimes used to treat impotence.


Any illegal drug

The problems and appeals of specific illegal drugs in combat PTSD is a very big subject that can't be covered here, but all illegal drugs cause the following problems for combat vets with PTSD.Expense is the first problem -- I know there are Vietnam vets who have been very successful financially, but the men I know who have severe, chronic PTSD have a heroic struggle to make ends meet. I know it's stating the obvious, but the first problems of illegal drugs is the expense.

The second problem is much more subtle -- Getting illegal drugs involves you in relationships with and obligations to people you normally wouldn't let within a mile. Most of the combat vets I know have a very sharp eye for quality in human beings, and feel constantly tainted by the people they get involved with to support their habits. The third problem is that situations of real danger and the presence of weapons gets in the way of healing from PTSD. In this country and time it's not possible to sustain a drug habit over a period of years without running into situations that rekindle PTSD because of their real combat elements.

The fourth problem is the worst -- using illegal drugs often puts veterans in situations where they bring down other vets. Calling for rescue is a very common way of bringing down other vets, even if the rescue is "successful." Users need to be rescued from the medical complications of their habits, from the pressure of debts to dealers, and so on. Vets who have been on rescue missions are put back into combat-mode and are wired for weeks after a rescue. Sometimes users bring down other vets by asking them for dangerous favors (e.g., "hold this for me till I come for it" where "this" is a parcel of drugs or drug-related weapons or money). And finally -- this is really obvious but it needs to be said -- if a fellow vet is trying to stay clean and you're using, this amounts to a standing invitation to break out.

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HAND ME DOWN HURT: PTSD ACROSS THE GENERATIONS
by Thomas G. Shafer, M.D.

Post Traumatic Stress Disorder (PTSD) is a Psychiatric syndrome characterized by behaviors such as poor sleep, frequent nightmares, œflashbacks? (a vivid reliving of traumatic events), intrusive memories of said events, social isolation, difficult relationships at home and work, problems relating to authority, hypervigilance, mood swings and/or episodes of irrational or excessive anger. PTSD clients also commonly have a foreshortened sense of survival and exhibit signs of a hyperactive nervous system such as œnervous tics,? tremors, chronic motor restlessness, etc. And, by definition, PTSD is caused by exposure to a trauma that the individual finds severe or overwhelming. Or is it?

The truth is that PTSD can be a sort of œinfectious? psychiatric problem passed on to others, especially close family members. The old Biblical maxim about the sins of the fathers being passed down to the third or fourth generation is true, in a sense, because it can take three or four generations for the effects of trauma to dilute out in a family.

Our diagnostic texts are not fully cognizant of this butat least the therapeutic community is responding. The Holocaust Survivor™s projects in New York have treated the children of survivors for many years and are now seeing some grandchildren. The Alanon Adult Children of Alcoholics program now includes adult grandchildren.

It can be fascinating to treat the second generation œG2™s?, though. One of the things which especially strikes me is how common it is, at least in my patient population, for the G2 to actually experience nightmares or flashback like events, reliving the trauma of their family member.

I personally recall a case of a young woman in her late 20™s who practically turned into a Vietnam veteran herself after her husband™s suicide. She took to wearing pieces of Army uniforms, using GI slang, and quickly progressed to having vivid nightmares of being in combat herself. (This was an individual with no military experience or even military background at all.) She even quit a secretarial job to work as a laborer in a Government warehouse so she could be around œother veterans.?

And, early on in my career, I saw the young adult son of two Holocaust survivors. He had suffered bouts of severe depression for years and had finally gone totally psychotic with delusions that he was some sort of red blood corpuscle and there were bad white corpuscles trying to ferret him out and totally destroy him. It doesn't take Freud to see the symbolism there. Interestingly, his psychosis had a very minimal response to the best treatment available at that time, Haloperidol and Lithium, even though this typically is still an effective combination.

Cross generational PTSD is becoming a common theme in current fiction. Pat Convoy™s novel œBeach Music? portrayed a young Jewish woman, Shyla, who was the child of two Holocaust survivors. She suffered progressively worsening bouts of depression and finally committed suicide. Also, the film œComing Home? starring Bruce Willis does an excellent job of portraying a young woman whose father got killed in Vietnam and her battle with severe emotional constriction and detachment.

How is the œinfection? transmitted, so to speak? One all too common way is through child abuse. Adults with PTSD have a higher than average incidence of alcohol use, affecting up to 60% of men presenting for treatment of Vietnam related PTSD in one study, and can be prone to sudden, irrational rages. Obviously this is a high risk situation. And this creates much confusion for adult children trying to sort out their lives or help others do the same because it can be very difficult to separate the effects of the direct abuse as a first generation (G1) survivor from the effects of being a second generation G2.

A friend who reviewed this article, Dr. Russell Davis, pointed out that this situation quickly gets more confusing because of the tendency of some abuse survivors to identify with their abusers, thereby achieving some degree of control over both their anger and their feelings of fear and helplessness. Needless to say, this complicates the problem of unraveling G1 from G2 effects even further.

Another more subtle œhand me down? situation are parents who tell œgory stories,? describing their trauma in graphic detail around the children. There is always a œjudgment call? element here but PTSD parents must take care to not give their children more than they can handle. While it may be appropriate to tell a teenager about a buddy who died in combat, it would be best to simply tell a younger child that daddy sometimes gets sad about some things that happened in the war. And there is never any justification for detailed descriptive accounts with your kids. Save it for a therapy group.

There are pure G2™s, persons who suffer purely from the indirect effects of their parent™s experiences. Again, I refer you back to the Conrad novel, œBeach Music.? Shyla had a perfect childhood, all that a girl could ask. Her parents were financially secure and gave her most enough of what she wanted but not enough to spoil her. They attended to her every physical need, almost compulsively. They kept a perfect home, never drinking to excess and never, ever having even a minor argument.

But, emotionally, there was nothing there. Her mother was riddled with fear and obsessed with the gold coins she had kept hidden to help her survive the war. Shyla™s father was overwhelmed with guilt about collaborating with the Nazis but still losing his first family in the camps. He was an urbane and polite man but he was beyond emotionally constricted; he was totally shut down. So, the lack of emotional nurturance and feedback is a major part of the G2™s problem.

Another major issue is blaming oneself for the G1 parent™s changes in mood, commonly seen in younger children. All they see is that their parent sometimes gets very sad or angry and, with the typical narcissism of childhood, they assume it™s all their fault. These childhood misperceptions often carry over into feelings of chronic inadequacy in adulthood.

Many G1 parents try so hard to create a œperfect? life for their children that they smother them with excessive expectations or respond to normal adolescent anger and attempts at differentiation with, œHow could you? You™ve had it so easy. After all we™ve done for you....?

What to do about the G2 syndrome is beyond the scope of the present article. Let me just say, if you think you are a G2, get help and find a therapist who is familiar with PTSD. Antidepressants and anxiolytic drugs can be helpful, even life saving, but do not get trapped in a misdiagnosis like œpanic disorder? or œrecurrent biological depression.? You need someone to talk to.

And how do you know if you may be a G2? Well, the first step is to review the symptom checklist at the start of this article. How many do you have? And pay special attention to looking for œsecond hand? phenomena. If daddy was a combat veteran, do you have œcrazy? dreams, fantasies and even flashbacks like you were in combat yourself? If your mother is a rape survivor, do you also jump whenever someone walks up behind you?

Whether you are the client or the therapist, I believe the most important diagnostic tool is an accurate family history. Is one of the parents a combat veteran? (Remember here that women in wars before Desert Storm were often assigned to medical duties, which means an especially high risk for PTSD.) Was one parent or both of them physically or sexually abused? Are any of the grandparents excessive drinkers or were they when their children were young?

If you think you may be a G2, gathering this information may require a frank talk with your parents. In other words, don™t trust your memory because many families have their œlittle secrets?. I recommend talking to each parent separately here. And, of course, show sensitivity for their feelings and possible pain. But is okay to ask, œWere you abused?? or œWhat happened to you in the war?? In fact, you have a right to know.

Remember, you don™t want to necessarily take œNo? for an answer. Did you receive a basic œNo? with perhaps a touch of indignation? Or did you receive an angry œHow could you think such a thing?? Here, especially, close contact with an experienced PTSD therapist is essential. False accusations and even false memories occur and it takes a real pro to sort things out.  

Finally, don™t give up hope. More and more work is being done almost daily on treating second generation PTSD and the tools you need to help yourself or your client recover are out there. And, just being aware of the problem is more than half the battle. G2™s have a tendency to feel responsible for their parent™s problems and, it can seem, the problems of the whole world. Just knowing what they are dealing with can give an empowering sense of œIt wasn™t my fault? and this is where healing begins.

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You may have PTSD if you experienced or witnessed a terrifying event or events, and if the memories of those events have effected your life in a negative way for a long time after the events occurred. Some symptoms to look for are:

1) Re-experiencing the traumatic event through vivid memories or flash backs  

2) Feeling œemotionally numb?  

3) Feeling overwhelmed by what would normally be considered everyday situations and diminished interest in performing normal tasks or pursuing usual interests  

4) Crying uncontrollably  

5) Isolating oneself from family and friends and avoiding social situations  

6) Relying increasingly on alcohol or drugs to get through the day  

7) Feeling extremely moody, irritable, angry, suspicious or frightened

8) Having difficulty falling or staying asleep, sleeping too much and experiencing nightmares  

9) Feeling guilty about surviving the event or being unable to solve the problem, change the event or prevent the disaster  

10) Feeling fears and sense of doom about the future  

11) Experiencing health problems

12) Being constantly on alert and hypervigilant


And if you're interested, below I've reproduced the actual criteria psychiatrists and psychologists use, from the DSM-IV:

Diagnostic Criteria of PTSD:

The person has been exposed to a traumatic event in which both of the following were present:

the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

The traumatic event is persistently reexperienced in one (or more) of the following ways:

recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

efforts to avoid thoughts, feelings, or conversations associated with the trauma

efforts to avoid activities, places, or people that arouse recollections of the trauma

inability to recall an important aspect of the trauma

markedly diminished interest or participation in significant activities

feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)

sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

difficulty falling or staying asleep

irritability or outbursts of anger

difficulty concentrating

hypervigilance

exaggerated startle response

Duration of the disturbance is more than 1 month.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. These individuals often are diagnosed with borderline or antisocial personality disorder or dissociative disorders. They exhibit behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), extreme emotional difficulties (such as intense rage, depression, or panic) and mental difficulties (such as fragmented thoughts, dissociation, and amnesia). The treatment of such patients often takes much longer, may progress at a much slower rate, and requires a sensitive and highly structured treatment program delivered by a team of trauma specialists.

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Here's something else I found on complex PTSD and BPD, taken from http://www.biologicalunhappiness.com/. I thought it might be interesting, considering our recent discussions:


Can You Stop My Grief, And Is It "Complex PTSD"?


Dear Dr. Heller,

I get hit out of no where with waves of grief as if someone close to me has just died - alternating with the dysphoria.  I can not take this anymore.  I was just told by the head of the trauma center here that new studies show that BPD is another name for complex PTSD (i.e.  they are one and the same thing).  I also have recurrent major depression.  I don't like these episodes of intense grief.  How do I get rid of these if I don't have all the memories yet?  I am constantly feeling suicidal.



ANSWER:

There are many similarities between PTSD and the BPD, but they are clearly separate entities that commonly co-exist.  PTSD apparently has a strong association with an elevated serotonin #2 receptor and responds well to Remeron (Remeron blocks that receptor).  Because many individuals with the BPD have PTSD, SSRI medications like Zoloft have been successful in treating PTSD.  SSRI's, Tegretol and neuroleptics work for the BPD.  There are individuals with PTSD who do not have the BPD, and vice-versa.  There are also cases of BPD from head trauma and brain infections.  There is also a 50/50 correlation between BPD and ADHD.  Many borderlines were not traumatized as children.

"Complex PTSD" is not an official diagnosis, and is likely a term that those involved with PTSD choose to describe the BPD without using that diagnosis.

BPD symptoms treated by Prozac are unprovoked mood swings, chronic anger, emptiness, boredom and emotional pain (feeling like one's friend died).  Higher Prozac doses are sometimes necessary to stop these symptoms.

Those with the BPD experiencing grief, suicidal thoughts and chronic or frequent dysphoria (anxiety, rage, depression and despair) need Prozac combined with Tegretol (patients do better if the Prozac is taken for a week prior to adding the Tegretol).  Sometimes temporary use of an atypical antipsychotic such as Seroquel is needed.  Geodon is an alternative and has additional PTSD effects by also blocking that serotonin 2 receptor.

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Types of PTSD
National Center for PTSD


There are five main types of post-traumatic stress disorder: normal stress response, acute stress disorder, uncomplicated PTSD, comorbid PTSD and complex PTSD.

Normal Stress Response

The normal stress response occurs when healthy adults who have been exposed to a single discrete traumatic event in adulthood experience intense bad memories, emotional numbing, feelings of unreality, being cut off from relationships or bodily tension and distress. Such individuals usually achieve complete recovery within a few weeks. Often a group debriefing experience is helpful. Debriefings begin by describing the traumatic event. They then progress to exploration of survivors' emotional responses to the event. Next, there is an open discussion of symptoms that have been precipitated by the trauma. Finally, there is education in which survivors' responses are explained and positive ways of coping are identified.

Acute Stress disorder

Acute stress disorder is characterized by panic reactions, mental confusion, dissociation, severe insomnia, suspiciousness, and being unable to manage even basic self care, work, and relationship activities. Relatively few survivors of single traumas have this more severe reaction, except when the trauma is a lasting catastrophe that exposes them to death, destruction, or loss of home and community. Treatment includes immediate support, removal from the scene of the trauma, use of medication for immediate relief of grief, anxiety, and insomnia, and brief supportive psychotherapy provided in the context of crisis intervention.

Uncomplicated PTSD

Uncomplicated PTSD involves persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, emotional numbing, and symptoms of increased arousal. It may respond to group, psychodynamic, cognitive-behavioral, pharmacological, or combination approaches.

Comorbid PTSD

PTSD comorbid with other psychiatric disorders is actually much more common than uncomplicated PTSD. PTSD is usually associated with at least one other major psychiatric disorder such as depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. The best results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse. The same treatments used for uncomplicated PTSD should be used for these patients, with the addition of carefully managed treatment for the other psychiatric or addiction problems.

Complex PTSD

Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. These individuals often are diagnosed with borderline or antisocial personality disorder or dissociative disorders. They exhibit behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), extreme emotional difficulties (such as intense rage, depression, or panic) and mental difficulties (such as fragmented thoughts, dissociation, and amnesia). The treatment of such patients often takes much longer, may progress at a much slower rate, and requires a sensitive and highly structured treatment program delivered by a team of trauma specialists.


http://psychcentral.com/

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Complex PTSD
A National Center for PTSD Fact Sheet
By Julia M. Whealin, Ph.D.

What are the differences between the effects of short-term trauma and the effects of chronic trauma?

The diagnosis of PTSD accurately describes the symptoms that result when a person experiences a short-lived trauma. For example, car accidents, natural disasters, and rape are considered traumatic events of time-limited duration. However, chronic traumas continue for months or years at a time. Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma. For example, ordinary, healthy people who experience chronic trauma can experience changes in their self-concept and the way they adapt to stressful events. Dr. Judith Herman of Harvard University suggests that a new diagnosis, called Complex PTSD, is needed to describe the symptoms of long-term trauma.

What are examples of captivity that are associated with chronic trauma?

Judith Herman notes that during long-term traumas, the victim is generally held in a state of captivity. In these situations the victim is under the control of the perpetrator and unable to flee.

Examples of captivity include:

·        Concentration camps

·        Prisoner of War camps

·        Prostitution brothels

·        Long-term domestic violence

·        Long-term, severe physical abuse

·        Child sexual abuse

·        Organized child exploitation rings



What are the symptoms of Complex PTSD?

The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include:

·        Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger

·        Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one™s mental processes or body

·        Alterations in self-perception, which may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings

·        Alterations in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

·        Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

·        Alterations in one™s system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair

What other difficulties do those with Complex PTSD tend to experience?

Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.

Survivors may use alcohol and substance abuse as a way to avoid and numb feelings and thoughts related to the trauma.

Survivors may also engage in self-mutilation and other forms of self-harm.

There is a tendency to blame the victim.
A person who has been abused repeatedly is sometimes mistaken as someone who has a "weak character."

Because of their chronic victimization, in the past, survivors have been misdiagnosed by mental-health providers as having Borderline, Dependent, or Masochistic Personality Disorder. When survivors are faulted for the symptoms they experience as a result of victimization, they are being unjustly blamed.

Researchers hope that a new diagnosis will prevent clinicians, the public, and those who suffer from trauma from mistakenly blaming survivors for their symptoms.

Summary

The current PTSD diagnosis often does not capture the severe psychological harm that occurs with prolonged, repeated trauma. For example, long-term trauma may impact a healthy person™s self-concept and adaptation. The symptoms of such prolonged trauma have been mistaken for character weakness. Research is currently underway to determine if the Complex PTSD diagnosis is the best way to categorize the symptoms of patients who have suffered prolonged trauma.

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Discussing Trauma and PTSD with Your Doctor
A National Center for PTSD Fact Sheet
By Pamela Swales, Ph.D, and Joe Ruzek, Ph.D.

The experiencing or witnessing of traumatic events can lead to psychological (emotional) problems and to physical problems (in addition to any that occurred at the time of the trauma). These symptoms can last for a relatively short time after the event, can last for months or years, or can "surface" months or even years later.

Not everyone who experiences trauma will develop full PTSD. Treatments are also available for those who exhibit only some PTSD symptoms.

You may find it helpful to talk with your primary care physician about your experience(s) and any symptoms you have. Keep in mind that your doctor may not know about the emotional or psychological after-effects of trauma or about the many associated medical problems. You can help your doctor understand you and plan your treatment better by sharing this crucial information about yourself.

At first, individuals may find it hard to discuss their experiences. Because it may be difficult to discuss the trauma and your symptoms, it may be helpful to show your doctor the checklist below.

Brief Checklist of Trauma Symptoms

Check the symptoms below that you experience (that may or may not be related to a traumatic event) and make notes as needed:

I experienced or witnessed a traumatic event during which I felt extreme fear, helplessness, or horror.

The event happened on (day/month/year).

What happened?.

1) I have symptoms of reexperiencing or re-living the traumatic event:

·        Bad dreams or nightmares about the event or something similar

·        Behaving or feeling as if the event were actually happening all over again (this is known as having flashbacks)

·        Having a lot of emotional feelings when I am reminded of the event

·        Having a lot of physical sensations when I am reminded of the event (e.g., my heart races or pounds, I sweat, find it hard to breathe, feel faint, feel like I™m going to lose control)

2) I have symptoms of avoiding reminders of the traumatic event:

·        Avoiding thoughts, conversations, or feelings that remind me about the event

·        Avoiding people, places, or activities that remind me of the event

·        Having difficulty remembering some important part of the event

3) I have noticed that since the event happened:

·        I have lost interest in, or just don™t do, things that used to be important to me

·        I feel detached from people; I find it hard to trust people

·        I feel emotionally "numb" and I find it hard to have loving feelings even toward those who are emotionally close to me

·        I have a hard time falling or staying asleep

·        I am irritable and have problems with my anger

·        I have a hard time concentrating

·        I think I may not live very long and feel there™s no point in planning for the future

·        I am jumpy and get startled easily

·        I am always "on guard"

4) I experience these medical or emotional problems:

·        Stomach problems

·        Intestinal problems

·        Gynecological problems

·        Weight gain or loss

·        Chronic pain (e.g., in my back, neck, pelvic area (in women))

·        Problems getting to sleep

·        Problems staying asleep

·        Headaches

·        Skin rashes and other skin problems

·        Irritability, a quick temper, and other anger problems

·        Nightmares

·        Depression

·        Lack of energy, chronic fatigue

·        Alcoholism and other substance use problems

·        General anxiety

·        Anxiety (panic) attacks

·        Other symptoms such as:

Other questions that you may want to ask your doctor or counselor:

"What do people have to do to recover from PTSD?"

"Why do I have PTSD and other people don™t?"

"Does having PTSD mean that I™m crazy or mentally ill?"

"What will happen if I go for treatment?"

"How long will treatment last?"

"What will be the likely effects of treatment?"

"What should I tell my spouse/partner/other family members about PTSD?"

If medication treatment is discussed, you may want to ask some of these questions:

"How is this medication supposed to help me?"

"How will it affect my symptoms?"

"How long will I have to take it?"

"Can I stop it if I don™t like it?"

"How will we know if it is working?"

"What will happen if it doesn™t work?"

"What are the side effects of the medication?"

"How will it affect the other medications that I™m taking?"

"Why do I need to go for counseling if I™m receiving medication treatment?"

"How will medication treatment fit in with my PTSD counseling?"

"How will medication affect my substance abuse recovery?"

Again, if you think you have PTSD, or even just some of the symptoms, it is important for you to let your primary care physician know. This information is invaluable for planning your medical treatment. It can also help your doctor provide you with appropriate referrals for other services (e.g., to a psychologist, a social worker, child abuse protective services, lab tests, etc.).

You may find it helpful to download and print this and other fact sheets on this website to show your doctor.

[firelizardee]

About Medications For Combat PTSD
Jonathan Shay, M.D., Ph.D.
Staff Psychiatrist, Boston VA Outpatient Clinic


Point of view

Everything I say here is my point of view, and carries no claim of special authority. Also, what I say here is no way complete. I have left out many important subjects, such as drug interactions, what medical conditions forbid the use of a given drug, overdoses and toxicity, and most specific side-effects. Also, many psychiatrists who also care about combat veterans will disagree with what I say here, particularly about the benzodiazepines like Ativan. Combat PTSD is moral, social, philosophical, and spiritual injury. The biological nature of human beings is to be moral, social, philosophical, and spiritual, so the injury also shows itself as medical disorders.

Healing is psychological, social, spiritual -- no medicine can cure combat PTSD. However, healing can never mean a return to 17-year old innocence. Healing means building a good human life with others -- a life that a veteran can embrace as his own.

Combat trauma brings about long-lasting changes in brain chemistry. We do not know whether these are permanent or can be reversed by psychological/social healing. A few existing medications can help some men with some symptoms of PTSD. We also do not know whether this changes the long-term outcome for the better, but the human payoff in reduced suffering is unmistakable.

A brief course in pharmacology

Therapeutic effects (benefits) and side-effects

Drugs are dumb chemicals -- they don't know what they are. They aren't born in a laboratory with a word spelled out across their foreheads "Anti-depressant!" or something like that. Most have been discovered by accident. Almost every drug known has multiple effects on the body. Which effect is a therapeutic (beneficial or main) effect and which is an unwanted side-effect is a human decision, not a chemical decision.

Illustrations: Think of the well-known drug Elavil (generic name: amitriptylene). What is it? An anti-depressant you say? Why is it used in the Intensive Care Unit to stabilize the heart beat of certain patients? Not because depression causes their irregular heart beat. Why is it used by neurologists to treat migraine? Not because depression causes migraine -- and the doses that work for migraine are usually too small to touch a depression. The point is, of course that a drug doesn't know what it is. Its successful human uses make it an anti-depressant, a migraine drug, an anti-arrhythmic.

What about side-effects? Again, this is a matter of the human purposes involved. Think of the anti-depressant trazodone (most common trade name: Desyrel). Its most prominent side-effect is drowsiness. I prescribe trazodone fairly often as a sleep medication to veterans who are on fluoxetine. It has the advantage that it doesn't lose its effect with repeated use (which also means there's little withdrawal syndrome when the veteran stops it), and it's almost useless as a pill to **** yourself with. So here the side-effect is the main effect and the anti-depressant effect is a side-effect. --Is anybody confused yet?

Important to remember: When a drug has several different effects, each effect has its own way of unfolding in time. How long a drug takes to produce its different effects, is often different for each effect. The side-effects may hit immediately and the main effect only develop after several weeks! With another drug it's the opposite, with the main effect coming on immediately and the side effects happening later. An analogy: Think of a plant on your window sill. You've been away for the weekend and its gotten dry and droopy. You give it water and the leaves begin to respond almost as soon as the water goes on -- the plant responds as soon as the water reaches the roots. If the roots dry out, again the plant wilts again. This is like a pharmacokinetic effect. If you put some fertilizer in the water, on the other hand, this reaches the roots as fast as the water reaches them, but you may not see any result for days or weeks. This is because the plant has to build new parts in its own cells. This is like a pharmaco-dynamic effect.

Example: Most anti-depressants reach the brain quickly, but take several weeks to have an anti-depressant effect. This is probably because the changes that have to take place in the cells take that long to happen. However, some side-effects like a dry mouth or drowsiness happen quickly because they do not require cells to make anything new, but only to do what they're already doing faster or slower.


Tolerance and withdrawal

I will use alcohol as the example, because most people have considerable knowledge about it. They just haven't realized that they can transfer this knowledge to other drugs. Pharmacologic tolerance is a critically important subject.

Consider a very heavy drinker, who drinks every day and more or less all day. Most of the time he is not drunk, in the sense of staggering or slurring or not thinking clearly. He may function quite well at his job with a blood alcohol level that would put a non-drinker almost in a coma. This is because the drinker has developed a tolerance to alcohol. His brain has adjusted to alcohol's presence and slowly adapted its machinery to get everything back to normal. This adjustment is called pharmacologic tolerance, and it takes a while to happen. The brain has developed a steady, compensating excitation to balance the steady sedating effect of chronic alcohol. When the two are exactly in balance, the drinker thinks and behaves more-or-less normally. If the alcohol is suddenly removed, the brain becomes dangerously over-excited, resulting in delirium tremens, DTs. The compensating excitation corrects itself much more slowly than the alcohol leaves the body. This whole set of events is called a withdrawal syndrome.

The same kind of DT-like withdrawal syndrome of dangerous over-excitement (seizures, hallucinations, etc.) happens after sudden withdrawal from high doses of other sedating drugs that people get tolerant to, such as barbiturates, benzodiazepines (such as Valium), etc. A good rule of thumb is that a patient who has become tolerant to a given drug effect will get a withdrawal syndrome if he or she stops it suddenly. Often, the withdrawal syndrome is the "mirror image" of the original effects of the drug.

Not all of the effects of a drug are detectable by the person taking it, so tolerance to these changes may not be subjectively felt, either. However, during cold-turkey withdrawal from the drug, a withdrawal syndrome may develop that is the mirror image of effects that the person was never aware of. An example of this is caffeine withdrawal headaches. Most people are unaware of the blood-vessel-narrowing effect of caffeine, but once tolerant to this effect, abrupt discontinuation of caffeine can cause headaches due to blood-vessel dilation.

The greatest tolerance and the most severe withdrawal reactions happen with long-term use. However, with some drugs, there can be a miniature version of the whole picture with a single dose. Again, alcohol gives a good example: A man who knocks many drinks back one after another and then stops is much more drunk when his blood alcohol level passes a given point on the way up, than later when his blood alcohol level passes the same point on the way down. This is called acute tolerance, because his body has already adjusted to the presence of the alcohol in the few hours since he started drinking. The next morning, during the hangover, he has a mini-withdrawal syndrome making his nervous system overly sensitive -- how loud every sound seems! -- is the mirror image of how much alcohol deadened sound when he was drunk.

An analogy: You are running a motor boat on a certain compass heading, say due north, on a windless day (no alcohol). Now a cross-wind begins to pick up (gradually increasing steady drinking) and you gradually adjust the rudder to keep on the same heading. Now you are still heading due north, despite the heavy cross-wind. Suppose the wind suddenly dies (suddenly stopping drinking, cold-turkey) and you keep the rudder where it was -- you start going in circles (withdrawal syndrome).

How much tolerance develops to each drug effect varies a lot from effect to effect and from person to person. A person may develop rapid tolerance to a nasty side-effect, such as dizziness. This means the dizziness actually goes away, not that the patient just gets used to it. So this person can bear with the drug and wait around for the therapeutic effect to kick in. Another person may never get tolerant to the dizziness side-effect and cannot make use of that particular drug. There's no iron-clad way to predict a given person's sensitivity to each of the effects of a given drug or how fast, if at all, he will become tolerant to each effect.


Things that help

Characteristics of good drugs for combat PTSD

Makes something better for the veteran

Does not lead to tolerance

Does not lead to abuse

Cannot be used to commit suicide

Does not require blood tests

Does not cut a person off from the world or from himself

Causes few, bearable side-effects


Some good drugs for combat PTSD

Serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.

The main effect of fluoxetine on combat vets with PTSD whom I've worked with is to allow them more time to think before they act, particularly in anger. It does this without sedation or cutting a man off from himself or the world. The duration of anger, once aroused, is also shorter. Greater self-mastery of anger leads to an increase in self-respect and relief from a sense of humiliation. Most men feel humiliated after they go off on people in situations they really would not have, if they had had the freedom to choose. In addition to this, fluoxetine may have a direct anti-depressant effect in combat PTSD. Fluoxetine effects on self-control and rage may take many weeks to kick in, although I've seen it as soon as a week.

Fluoxetine is practically useless as a drug to overdose on, if the goal is suicide. All anti-depressants have been known to give long-time depressed people the energy to **** themselves, and fluoxetine is no different. Many combat veterans go through brief periods of intense despair during the first few months that they are feeling generally better, more alive, and are coming out of their bunkers. Support from other veterans, family, therapists is especially important during those times -- nobody should try to go through it alone, or have to. Someone trying to go through it alone, might try to **** himself during one of these times of despair. Remember that this is no special risk with fluoxetine, but is a risk when anyone recovers from severe depression. Several vets I've treated have had bouts of despair like this, but none has ever tried to **** himself during one, because support and therapy are built into the program I'm a part of. The much publicized claim that Prozac has special powers make a previously non-suicidal person violently suicidal is without good foundation. Fluoxetine does have side effects, which not everyone can stand, and it doesn't work for everyone. A full discussion of side-effects, some of which depend on the dose and others not, would be too long for this summary.

Fluoxetine is the first drug of its type to be released for use. Other drugs in the same family have now come along, sertraline (Zoloft) and paroxetine (Paxil). They have been tried by many combat vets around the country, and from what I hear they are not a lot different than fluoxetine as far as main and side-effects. In the relatively limited number of men I have treated with paroxetine and sertraline, this has been what I have heard from them. Paroxetine has a 24 hour half-life and no active metabolites [what the body turns the parent drug into], so if the actions of the drug are otherwise identical to fluoxetine, it will be a superior drug from a safety point of view, because it doesn't hang around in the body so long. But on the down side, paroxetine may be expected to (and is reported to) have a withdrawal syndrome because it leaves the body so fast.


Buspirone (Buspar)

This anti-anxiety drug works differently from the benzodiazepines (like Valium). Like anti-depressants it takes a few weeks to kick in. It takes effect gradually, like the tide coming in. It usually has few side-effects and may help some people with intrusive thoughts and nightmares. Buspirone has no street value and is almost useless as a suicide pill. I am not aware of other drugs in this family coming along, but I hope there will be. I have recently read the report of a colleague who works with combat veterans that the best results with buspirone come at doses above 60mg/day. I do not yet have enough personal experience with patients who have tried this, to confirm or deny this report.


Beta-blockers: propranolol (Inderal), nadolol (Corgard), atenolol (Tenormin), etc.

This family of drugs breaks the mind-body-mind vicious cycle in rage reactions, by blocking the body effects of adrenalin. For example, if someone at work says something offensive about Vietnam vets, the words start the mind working into rage. The rage starts in the mind -- but within a second the body responds with adrenalin, which makes the gut burn, the heart pound, the muscles tense. These body changes send loud messages back up to the mind. For some veterans, the roar of the body drowns out all thought and shuts out everything else coming in. When adrenalin is roaring, it's impossible for most people to think clearly and to take in non-combat possibilities in the situation. This is the mind-body-mind vicious cycle that beta-blockers break up. By blocking the adrenalin effect on the body they prevent the roar of the body from drowning out all thought and choice about what you really want. "Is it really in my interests to rip this guy's lungs out? Is it really what I want to do?" When adrenalin is roaring these questions sometimes cannot be heard.

Some vets feel that these medications weaken them, because they associate being pumped up with adrenalin with their personal strength. When someone is over-medicated on these drugs (which started life as blood pressure meds) he is weaker because his blood pressure is too unstable, but this is usually not a problem with a correct dose.Tolerance does not develop to the anti-adrenalin effects of these drugs. Massive overdoses of a beta-blocker can be fatal, by dropping the blood pressure and slowing the heart to the point that the brain is not getting enough blood flow.


Low-dose lithium

Some respected practitioners of PTSD pharmacotherapy speak highly of lithium to help veterans maintain their self-control when they are angry. This means doses of about 600mg/day, far less than is usually need to treat bipolar affective disorder (manic-depressive disorder), and does not imply that the doctor recommending this thinks that the veteran is manic-depressive.

I agree that this can help some veterans, but I have found fluoxetine to be more reliable. It is also safer, in that lithium is readily fatal in a large overdose. For a veteran who cannot tolerate fluoxetine and whose life has been blighted by explosive violence, low-dose lithium may be a good thing to try. [no blood tests because of low dose]


Other drugs for special circumstances

Trazodone (Desyrel) for sleep

Trazodone is a non-toxic anti-depressant that has a useful side-effect: It causes drowsiness, and people don't get tolerant to this effect. Because fluoxetine slows the rate that the liver breaks down trazodone, much lower doses are needed for sleep by patients on fluoxetine than people who are not on fluoxetine.


Quinine for nocturnal myoclonus

This is the "sleep jerks." If quinine works, the veteran himself may not notice much but his wife has much better sleep.


Low-dose antipsychotics for violent urges: thioridazine (Mellaril), mesoridazine (Serentil), etc.

The key here is brief treatment on an as-needed basis, controlled by the veteran himself. [for a limited time, when hospitalization is not possible] The doses needed have been low, and I prefer the sedating anti-psychotics like thioridizine and mesoridizine, which appear to carry the least risk of dangerous (neuroleptic malignant syndrome) or possibly irreversible (tardive dyskinesia) complications. An unexpected additional use for these drugs also involves brief, low-dose treatment: to help someone who wants to get off illegal drug get through the withdrawal syndrome.


Future drugs

Many combat veterans with PTSD feel dead inside. It is possible that this psychic numbing comes from the brain making its own opium-like substances, and that opiate blockers can give people back their feelings. It is not yet clear whether this works.

I hope the future will bring a drug like clonidine (trade name: Catapres) that people do not develop a tolerance to. In my experience, about one out of five combat veterans with PTSD experience major improvement of almost all of their PTSD symptoms on clonidine -- but the heartbreak has been that they grew tolerant to it in about a week. Any future drug in this family that does not induce tolerance to this effect will relieve much suffering. A new drug in this family, guanfacine (tradename, Tenex) has recently appeared, but I have no experience with it and have not heard any reports of usefulness to combat veterans with PTSD.

The most helpful drugs are likely to be ones that don't yet exist.

[firelizardee]

PTSD: What It Is and How to Recover - (continued)

Text of First Issue of
the Post-Traumatic Gazette
(May-June 1995)

©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice)
and is distributed free of charge.


RECOVERING FROM PTSD:

It is normal to be affected by trauma. That is the most important message in this newsletter. Recovery is healing your life. You'll have a scar. You'll also know what to do if the pain comes up again. Trauma never stops affecting most trauma survivors. Those who forget or deny how much pain they were (or are) in can't help others, can barely help themselves. They hurt others with remarks like "I was in a real war," or "Put it behind you!"

PTSD symptoms, numbing, hypervigilance and reexperiencing, are hints to get help! They helped you survive, but they do not go away by themselves. People have to warp their lives to control them. They can become both ineffective and a source of constant pain. When that happens, it is possible to change.

If you are in pain because of the way your life is today, you can change your life. It will be a slow process. Pain will come from the memories of what you survived and from frustration at new stresses and slow progress. It is okay to be in pain. That is the first principle of recovery. Your experiences were painful. You survived the pain of the actual trauma, and you can survive the memories. To recover you need to know at least a part of what you survived, to reconnect your feelings to those events, and mourn your losses.

Treat yourself with respect. Respect your experiences and your problems. Your symptoms are circumstantial evidence that you have been through a lot. PTSD is normal when you have been traumatized. You are not weak, weird, or unusual. If we could live through something without it affecting us, it wouldn't be trauma and we wouldn't be human. Admitting we're human and we have problems is respectful of ourselves. Many trauma survivors minimize the effects of what they've been through (It didn't affect me!) and then wind up resenting people for not respecting their pain. This is human but not very effective.

There is no rush in recovery. Recovery is based on acceptance. I have been traumatized. It did affect me. Why wouldn't it? I have skills that kept me alive which are now causing me trouble. I'm closed off from my feelings and from others. This makes my life lonely and difficult. I am in pain from my memories because what I went through was painful. I need help.

It's ok to need help.

It is ok to ask for help.

Help is available from therapists who are well trained in the field of trauma. Ask about training and experience and pick someone you are comfortable with.

For years 12 step programs were the only help available to survivors who self-medicated with alcohol or drugs. Thousands of veterans, incest and domestic violence survivors and others have dealt with PTSD by going to Alcoholics Anonymous, Al-Anon, Overeaters Anonymous and other 12 step programs. I started going to one to get help with my problems in living with a guy with PTSD, but since I knew about PTSD, I saw it everywhere. It was clear to me that the people who get diagnosed and get help from the psychiatric community are the tip of the iceberg. Many 12 steppers mistrusted everyone and everything except the 12 step fellowship they were in for good reason. Their traumatic experiences had been ignored and discounted and their self-medication called willful misconduct or self indulgence. They had been insulted, misdiagnosed, drugged and told it was all in their head.

There were people who thought they were stupid because they couldn't concentrate in school but thought being battered hadn't affected them because they always had a job and could take a beating from anyone, people who had stayed drunk for 20 years, married a series of alcoholics, or weighed 300 pounds and never connected it to their traumas. Trauma was invisible to the survivors who thought it shouldn't bother them. Yet, using the steps they were slowly recovering; some simply through working the steps of the program. Others needed and became able to seek outside help.

It takes time to get better. Getting better is the reward for taking the time to recover. Getting better is a slow process. The physiological arousal which many trauma survivors live in makes it difficult for survivors to take in the kind of information needed to heal. This is part of the brain chemistry of survivors. It is not resistance. People can talk about changing but all survivors see is their lips moving. The words and concepts make no sense. This is because they are taking in survival information: who's in the room, where are they sitting, where is the door, how are they reacting to me? In twelve step meetings we have a saying which describes this process: "came, came to, came to believe," meaning we got ourselves to meetings (or therapy), eventually we started to be able to hear what was being said, and finally we came to believe it could work for us too.

Safety first. Survivors won't feel safe with a therapist or group until they have, over time, experienced safety. Why should they? When they have been treated with respect, not discounted, not pushed to hurry up and recover (which are secondary wounding experiences and make PTSD worse), they will feel safe and know it because they will be able to hear and understand what the therapist or group is saying in a new way. A good therapist or 12 step group will let you take your time and treat your traumas with respect. Badly trained therapists often exhibit what I like to call "a profound and pervasive narcissistic sense of entitlement," which manifests itself as "I'm a therapist. You should trust me. I can fix you." An honest therapist will say he or she may be able to help you work on this problem..

When they can hear, survivors can begin to work on safety issues, understanding and protecting themselves from triggers, learning to handle anger and fear. Survivors can develop the capacity to respond rather than react, like having a pause button instead of an on-off switch. Sobriety is necessary if you've been using alcohol, drugs, food or some behavior to numb your feelings. You can't heal what you can't feel.

Once safety has been established, trauma work may begin. Rushing through trauma work is to be avoided. When you feel safe enough, you will remember. Some people use hypnosis to speed this up. Experienced therapists now prefer to let memories surface when they will.

Today in many communities, after a crisis all the rescue workers are debriefed. They get to talk about what happened, what they saw, smelled, heard, felt, what they wanted to have happen and how it all turned out. Debriefing is what trauma work is about. You don't have to know every detail or relive every moment of trauma. As you talk about what happened to you and feel the feelings you had to suppress to live, you will relearn the broad variety of human feelings, because they have all been suppressed along with the painful ones. Recovery will help you understand yourself and be understood. This is a very healing experience for people who have felt like no one could ever understand what they have been through.

Groups are particularly helpful in recovering from trauma. You are not alone. Others have been through similar pain. It helps to see others progress, to learn ways to grow yourself, and to help those who come after you.

Searching for the right help is important. You need to be comfortable enough with the therapist or group. On the other hand searching for the perfect group or a therapist who will never make a mistake can put off recovery for life. The therapist or group is not going to fix you. They (therapist, other group members) provide you with information and a variety of skills, and you do the work.


HELPFUL CONCEPTS

It is okay to hurt. As a survivor, you need to go through the process of mourning which takes about two years if your mother dies of old age in her bed at home and you were expecting it. Traumatic losses take longer.

Mourning has five stages:

**Denial: is screaming "No! No!' at the time of the trauma. It is also "Never Happened!" and "Didn't affect me!" People can get stuck in denial for years.

**Rage: People get stuck in the rage stage, too, screaming and lashing out at everyone around them, or coldly angry and unable to change.

**Bargaining: Stuck bargaining includes veterans who will only get well if the VA gets perfect or if Nixon or Fonda goes to jail, the child abuse survivor who will only get well when patriarchy is gone, or the survivor who will only get better when he or she finds a perfect therapist.

**Sadness: The sadness stage is very difficult for most survivors because of our feelgood culture. Being sad is practically illegal. Sadness refused leads me to deep depression, but today if I start to feel depressed, I ask myself what do I need to feel sad about. If I can identify and feel it, I don't get depressed. Sadness needs to be felt. What happened to you was sad, painful, grevious. The only way out is through. Those feelings won't **** you. It is okay to grieve. Grief is part of life.

**Acceptance: The final stage. Yes this did happen. It was bad and it has affected me. I have a scar, but I survived. In time, I may be able to use my experiences to help other survivors.

Recovery takes persistence and patience. "Progress not perfection" is a good motto. Recovery is not a smooth swift rise out of the depths of pain or numbness. It is a rough climb with many slips and lots of hanging on at new rough places in the climb.

"We recycle" is a slogan that will help you laugh when you slip. Acceptance of the slowness of the process is hard but it's reality. Since PTSD symptoms can come back with new stress, knowing that it is normal to recycle can help you continue to recover.

It takes what it takes and it takes as long as it takes. Human beings hardly ever change quickly except under extreme stress, so be easy on yourself. In response to the idea, I should be over this, remember this slogan (made up by yours truly) "Everything after the word should is bullsh*t."

H.O.W.? Honesty, openness, and willingness are characteristics that will help anyone recover. These things did happen and do affect us (honest). We can find help if we look (open). We try suggestions from others who have recovered or have worked with others who have recovered (willing). This is not to say that every idea or suggestion will work for you. Some won't. Some will be very uncomfortable, but will have a healing effect on your life, like getting sober

Yet. If those ideas scare you, the most healing word in the English language is yet, as in I can't do that yet... Someday you will when you are ready.

Willing to vs Wanting to: There is also a great deal of difference between the words "want" and "willing." Spelled differently. Mean different things. Willingness may mean I do things I don't want to do! If I wait till I want to do the things that will help me recover, I may never recover.

We heal by degrees. You don't have to heal perfectly or on someone else's schedule. People do this work in stages and have to take breaks from it.

Feelings are facts: you feel what you feel. It doesn't have to be reasonable, justified, or what other people feel. Feelings do not have brains. They are not logical! Part of recovery is learning what you do feel so you can take care of yourself. Trying to take care of yourself without knowing what you feel is like trying to budget without knowing your income.

Feelings are not facts: Emotional reasoning is a distorted way of thinking common in our society: I feel it therefore it is true. I feel hurt therefore he/ she meant to hurt me. I feel guilty therefore I am guilty. Many of us tend to feel hurt by or guilty about everything. It comes with our culture, but we don't have to believe it.

It is ok to feel more than one contradictory emotion at the same time.

Respect your emotions but don't necessarily believe them and don't act on them in old ways. People can change by acting in new ways until new feelings come. Waiting till they feel like changing is a dead end for most people!

When trauma survivors begin to get better it is very scary for family members. Underlying this is the fear that if you change you may not love them any more. You may wonder why they have problems since they weren't traumatized. Next month I'll talk more about the effects of living with PTSD, of seeing someone hurting and doing all you can to help and having it all be useless.

Don't compare: Compassion is something that develops in recovery. You will see that what each person has lived through is the worst thing he or she has been through. Remembering how you felt after the first firefight, the first beating, the first time someone in your neighborhood was gunned down, before you got so numb, will give you empathy for others.

Recovery leads to autonomy, the feeling of being whole, the ability to change when necessary and the ability to regulate yourself. These are important concepts to people who may feel they have lost great parts of themselves. You may not get all of yourself back, but you can get some of it back. For people who have been stuck in survivor skills, being able to change is freedom, and for people who could be blowing up one minute and numb as a stump the next, the ability to regulate these reactions is pure joy.

Recovery will bring back joy into your life. It will be mixed with pain because this is real life, but learning to feel the pain lets it pass and the periods between the pain will get longer and longer and better and better.

One final word, no matter what you did to survive, you do deserve to recover. Many survivors feel guilty for surviving or for not doing enough or for overreacting. During the recovery process, your feelings about this may change. If you find that some of your guilt has a realistic basis, you can make amends for your actions.

--Patience Mason

[firelizardee]

Note:  topic started originally by bluelicorice

what is PTSD ... here is an explanation from the American Psychiatric Association:

POSTTRAUMATIC STRESS DISORDER (PTSD)

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.

Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult.

PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person--such as a rape, as opposed to a flood.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.

Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.

Specific Symptoms of this Disorder:

The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror.

The traumatic event is persistently reexperienced in one (or more) of the following ways:

recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

recurrent distressing dreams of the event.

acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).

intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

efforts to avoid thoughts, feelings, or conversations associated with the trauma

efforts to avoid activities, places, or people that arouse recollections of the trauma

inability to recall an important aspect of the trauma
markedly diminished interest or participation in significant activities

feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)

sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

difficulty falling or staying asleep

irritability or outbursts of anger

difficulty concentrating

hypervigilance

exaggerated startle response

The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition.
Washington, DC: American Psychiatric Association.

National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995)

[firelizardee]

Note:  I am not the original poster of this info.  


The APA description of PTSD does not tell the whole story.

<The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. e i>

The specific part missed is a complete definition of helplessness. The helplessness part is the most distructive and hardest to heal from in many cases.

I will go indepth for those who can follow me.

The overwhelming job of the brain is to make sense out of our environment. Our senses receive far more information (stimulus) that our concious mind can tolerate. At a very subconscious level, the brain acts as an filter and organizer sorting out all the information brought in by the senses. It forward the important information to the conscious mind.

During a traumatic event, this part of the brain goes into hyperspeed and can overload. The stress of observing the trauma may be made sense of or be completely chaos. How the mind processes the trauma makes the difference from a simple high stress situation and a PTSD situation. Many traumas can be relieved by prompt counselling, appropriate compassion, and good follow up. A lack of counseling or a long enduring trauma can cause the PTSD.

One of the critical issues is "helplessness". When there is helplessness, the mind can not put understanding to the trauma. If the victim knows how to handle the event but is prevented from helping, the traumatic impact get worse. This can be a court issue where the Legal system has failed to provide relief, watching a disaster but not being able to help due to some other restraint, sensing a loss of control or input or dignity as in an assault by a person of authority (common at the airport security check point but to a minor extent)
When this happens, the brain can actually be damaged. The repetitive attempts to make sense of the situation can get  burned into the brain. This patterned thought can be very difficult to erase or overwrite. This is why we have such good memories of traumatic events. It is also why some people completely block out the event (the brain puts up a barrier to the bad memory to stop the replaying of the event). The traumatic triggers connected to this bad memory can cause the flashback to reappear. The fear of the flashback or other memory triggers can cause the constant or reoccuring state of anxiety.

Some of the healing therapies are CBT, Cognitive Behavior Therapy, Light therapy, meds, and other counseling therapies.

The basis of the CBT is to redirect the thought from the trauma trigger to an understanding. For instance, if one was assaulted by a bald man, seeing a bald man might trigger the anxiety. The cognitive thought is practiced to understand that only a specific bald man committed the assualt, as a result, one is not going to be assaulted by every bald man. It could go further into developing positive concepts of bald men. Hopefully, the sight of a bald man will lead to a miriad of non-traumatic memories or understandings or be ignored.

If the trauma happens in conjunction with a physical head trauma, or to someone who has suffered a lasting physical head trauma, (post concussion syndrome, etc) the PTSD can be much more severe and difficult to overcome.
The physical head trauma could be a drug overdose, alcohol poisoning, oxygen deprivation, high or low blood pressure, high or low blood sugar, high fever, long term emotional stress and many other events that compromise the brain.  

Personally, I suffered over ten concussions and one extremely high fever before being severely traumatized in a helpless situation before my PTSD became simptomatic. Two concussions since then has just made matters worse.

My med is Paxil at 60 mg daily and serious vitamin and nutrition discipline. The Paxil has been a life saver. I still suffer from many symptoms of the brain injury, but my conscious thoughts (anxiety,OCD etc) are under much better control. It has been three years since I started meds.

A big help for me is my Christian beliefs. I have a very brief understanding of the outrageously complex but ordered body God has put us in. It helps me grasp the futility of my attempts at fixing things by worrying and fretting.

I hope I have helped some of you.

Idaho Dad

[firelizardee]

Boundaries
by Patience Mason


From Issue 8 of the Post-Traumatic Gazette ©1996 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice) and is distributed free of charge.


I've been thinking a lot about boundaries this month because they have always been a difficult issue for Bob and me. I suspect it is for all trauma survivors and their families. Bob seemed to me to have walls that shut me out, and I didn't seem to have any boundaries in either direction. When we disagreed about something, he thought I was saying that he was crazy, and I always thought he was being deliberately bad (because I was always right). Our boundary problems led to a lot of pain.

For trauma survivors developing healthy boundaries is important. Often in the most literal physical sense, trauma is a boundary violation: the bullet entered your body, the fist hit your face. Recovering the sense of your rights over your body, that it is safe to be in your body in this world, can be a monumental task.

Family members can also have difficulty with boundaries, as can therapists. This shows up as efforts to fix people because we need other people to be fine to prove our worth. I used to let Bob™s actions and feelings control how I felt about myself. (If Bob was depressed it meant I was a bad wife, not that he'd been through a lot in Vietnam). I invaded his boundaries by trying to control his actions and feelings to "fix" him. (Don™t be sad.) Boundary violations were my way of life. Therapists and people in 12 Step programs who tell you you don™t need whatever (usually whatever they are not doing, therapy or program) are having a boundary problem. Only you can know what helps you, and you can only find out by experience. Experience is how one develops boundaries and a sense of self. Many of us have never seen a healthy example of boundaries.

Unhealthy Boundaries:

Too Weak: when you become enmeshed in someone else's life and wind up feeling what they feel, doing what they do, and not being you, you have weak boundaries. Under traumatic conditions, however, that can be a survival skill. Many combat vets could read each other like a book. Hyperalertness to each other kept them alive. Traumatic bonding between abuser and abused is also a survival skill. Reading the emotions of the abuser and becoming what they want you to be can save your life. It also carries a great price. Being able to sense others' moods is helpful in relationships, but always being what someone else wants you to be (the woman who doesn't mind if he gets drunk/ the guy who will do anything for his wife) is a form of dishonesty which prevents real intimacy. No one can be intimate with someone who doesn't know what s/he feels, wants, likes or dislikes, or who can't be honest about it, even though such dishonesty developed as a survivor skill.

The weak boundary experienced by survivors who are endlessly triggered because they are so open to sensing danger is a very painful state of affairs. What's outside you controls your inside. Avoiding triggers is helpful, but developing boundaries so things don't set you off is part of recovery. Furthermore, another safety issue is that hyperalertness can lead you to reading danger into a situation where it doesn™t exist, causing unnecessary defensiveness or even violence.

Too strong: Walls don™t make you safe either. When you hear about the sexual abuse survivor who gets raped by some guy she met in a bar, realize that her wall of numbness prevented her from reading the danger signs. She's not dumb, she's numb. If his buddies died, a veteran may try never to care for anyone again, putting up walls which prevent him from getting the support he needs to heal.

Although aggression (yelling, bossing, rejecting) or isolation (putting up a wall, or simply not being around others) are the usual forms of too-strong boundary, during prolonged inescapable abuse dissociation can be a way of creating a boundary in order to survive. Denial, too, can serve as a boundary (didn™t happen/didn™t affect me). So can compulsive behaviors like alcoholism or relationship addiction. Overeating puts up a wall of fat to keep others out. (At the other extreme, the person who always wears skintight clothes may be sending an unconscious message, "I have no boundaries.") Reality keeps breaking through this kind of boundary, sometimes traumatically.

Putting up a wall of numbness or anger can lead you to be abusive because if it "didn™t bother me," you may be unable to perceive how it could bother someone else. You can™t tell that you are hurting them (or that your numbness is evidence that it did bother you).

Overly strong boundaries require a lot of effort to maintain. Nothing affects you but nothing can get through to help you either. Lots of survivors alternate between weak and too strong boundaries, getting close and then cutting people off, or trusting no one and then quickly becoming totally enmeshed.

Healthy boundaries: Ideally human beings have healthy boundaries that are like the semi-permeable membrane that surrounds a cell. Boundaries allow you to let out bad feelings so you don™t drown in your own waste products. They close to protect you from harm, but they open to let good things through. They allow you to give and receive support, become really close at times (like during lovemaking or intimate conversations or quiet cuddling) yet operate independently at other times. Healthy interdependence is the result.

For me it has been important to recognize that small actions taken one day at a time will help me recover, while great resolutions to change completely and forever (I™ll never do that again!) have been both futile and led me to self hatred (What™s wrong with me? Why can™t I change?) So here is a bunch of suggested small actions to help strengthen your sense of self, and your respect for and knowledge of yourself, and your ability to accept others because you have boundaries. Take what you like and leave the rest. This works if you are a survivor, family member, or therapist.

Pause Button: Visualize a pause button when something upsets you and take a moment to pick out an action that might help you rather than reacting in the same old way. Here are a few actions you can take:

Locating yourself in the here and now: When you are struggling with intrusive PTSD symptoms, it can be very valuable to write out on a 3x5 card an appropriate statement for you to read and say over and over:

"I am_ and no one here wants to hurt me." Add to this whatever affirmations are helpful. I need to feel this pain so I can let it go. It™s okay if I make mistakes. Having it written out and in your pocket can be a lifesaver. I works best if you pull it out and read and say it till you get relief.

Using the word "I:" People often say "You make me feel..." or "That made me feel..." One of the smallest most empowering changes you can make in your thinking is to use the word "I" when you talk about yourself. Replace "you made" or "that made", which is giving away your power, with the words, "I feel..." Even if you feel other people do make you feel good or bad, just phrase it differently. Say "I feel when you__." Eventually this new way of talking will strengthen your boundaries. Your perspective on your feelings will shift. You may even feel you have more power over what you feel.

Using the word "I" when talking about yourself can also change your perspective. Many of us habitually use generalities, say "You want to be nice," when what we mean is "I want to be nice." or "You don™t want/need that," when what we mean is "I don™t want you to want/need that." Using "I" really made me think! Today I prefer to say what I mean. It helps me to know myself better and see if I™m in your business.

Separating my feelings from yours: When someone else™s mood controls yours, it means your boundaries need strengthening. Automatically reacting is a lot of work. Identifying it is the beginning of healing. How? Ask yourself is this my feeling or his/hers? If it is not your feeling say to yourself, "I am not whatever. S/he is whatever, (depressed, angry, numb). Or say "I™m me, and I don™t have to feel what s/he feels or think what s/he thinks." A simple but effective technique is to keep repeating it to yourself. This seems awkward and stupid at first but it really helps over the long haul. These phrases block the emotion and remind you that you are separate from others. Visualize a boundary if it helps, a fence between your garden and his or hers. When you can separate what you feel from what others feel, you will find yourself more able to tolerate other peoples™ bad feelings, even sympathize, because they will not longer control how you feel. Letting other people feel what they feel (acceptance) is a big part of intimacy. Learning to have a good day when those around you are having a bad one lifts the burden off them of ruining your day.

Another thing that helps me is to visualize a glass globe separating me from another™s emotions. When someone picks on me, sneers at me, says something painful, I see the words hit the glass, but they bounce back because, it™s their problem, opinion, attitude. I might want to examine it, but I don™t have to take it in as the truth about me, nor even react to it, because I have healthy boundaries. Criticism becomes not at all devastating, just information I may or may not find interesting or useful

Another technique is active listening which I discuss in Recovering From The War. By listening to others and reflecting back what they say, you practice having a boundary with them and you sharpen your perception of the difference between you and them. It's a self correcting process, too. When you listen and hear it wrong, they tell you! You can see how you hear things as opposed to what they actually said. It's really interesting. Learning to actively listen takes a lot of practice. We're usually composing an answer before the other person it through speaking, (which is not listening). Survivors have trouble listening, too, because stuff seems so petty or because they have trouble concentrating, a symptom of PTSD. Active listening helps with concentration by focusing you on what the other person is saying, because you are going to paraphrase it : "I'm so angry! My boss moved my desk to where I can't see out the window." Old pattern: "So what!" (minimizing) or "So quit!" (solution) both of which lead to an argument. Active listening: "He really p***** you off!" As you identify the other person's feeling (confirming the boundary) they feel heard and supported and you get practice in healthy boundaries. It's the same when a trauma survivor expresses pain. Instead of saying, "Get over it," learn to paraphrase. Recently a WWII vet was telling me some of his experiences and my paraphrase was, "you really went through hell," which was exactly what he was trying to tell me.

Trauma survivors need to be able to have and tolerate painful feelings because they are normal when you™ve been traumatized. They are also evidence of what you™ve been through. Your family, friends and therapists need to respect that and learn to tolerate them, too. As they develop healthier boundaries, your bad days won™t ruin their days.

Tolerating painful feelings instead of running from them eventually leads to healing (see the HEALS acronym in V2, N2). By tolerating a feeling, I mean actually feeling it for a short period. HEALS means flashing the letters "Healing" in your mind, which is a good pause button. Explain to yourself what you are feeling and feel it for about 30 seconds. Apply self compassion, Love yourself, and then Solve the problem. Feel the feeling without necessarily believing rhat the feeling reflects reality. I may feel hurt, but that doesn™t mean someone meant to hurt me. I may feel guilty, but that doesn™t mean I am: it may just be something I™m used to feeling. Most of us were brought up on large doses of guilt.

Identifying what you feel is another way of working on your boundaries. Keeping a list of feelings written down on paper is a good way to start identifying your feelings. Pull it out and look at it if you are having trouble identifying what you feel. You can also start a journal entry describing your immediate reaction (I™m feeling tense... I just yelled at someone...) and look at when you™ve felt that way before (the strength of many feelings comes from a different time zone, often the time of your trauma or childhood) or what that action has been caused by in the past (usually when I™m yelling it™s because I™m afraid I won™t get some need met. What need am I afraid about now?). This kind of examination can become a very useful habit.

[firelizardee]

Boundaries - Part 2
by Patience Mason


From Issue 8 of the Post-Traumatic Gazette ©1996 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice) and is distributed free of charge.

Many trauma survivors are angry and defensive. These feelings are a natural result of having one™s boundaries violated. Anger may have saved your life. People who are defensive have healthy fear behind it. However when the traumatic situation is long gone, anger and defensiveness can linger and hurt relationships, leaving you without community or love. Behind anger and defensiveness, there are painful feelings needing to be felt. Stifle them long enough and they blow ***** in your wall, shrapnel hits those you care for, and you feel so bad you retreat behind the wall determined to make it thicker.

It™s better to work on making it healthier rather than thicker.

We all hate to be told we™re angry. I can™t tell you how many times I™ve said "I AM NOT ANGRY," while smoke was probably coming out of my ears. Ditto defensiveness. "Yes, but”" is my clue there. You may have others like black and white thinking (You™re either for me or against me).

It can help to identify the physical part in your body where you feel: for instance some angry people grind their teeth or clench their jaw or sigh a lot, so if you have trouble knowing when you are getting angry check you body for physical signs or ask your family and friends how they know when you are mad. You may feel fear as a churning stomach. I feel it as total numbness, so whenever I can't feel anything, I know I'm scared. Then I write about the fear till I can feel it, and it passes.

Developing a healthy boundary can also help you sort out feelings. You feel pain because of the trauma you were involved in (combat, battered wife, house fire.) That is your right. You don™t have to be over it no matter what someone says. It is okay to be in pain. You can feel the pain at your own rate and it will pass. If you feel shame at having been hurt, you can feel it without believing it. You can visualize yourself handing that shame back to your abuser. You may have to do that many times in your head before it becomes part of your boundary, but you didn™t cause your abuse, you didn™t want it, and you didn™t deserve it, whatever anyone says.

Learning who you are: For people who don™t think they have the right to be, much less be themselves, deepening your sense of self is an important part of recovery. Start writing a list with the heading: I like....

Start one with Things I might like... Trying new things to see if you like them is one way to get to know yourself. This can be as simple as changing the radio station you usually listen to, driving a new route to work, trying a new food. You can also keep a list of Things I don™t like. Trying something and not liking it is good. It means you are not afraid to make mistakes and be human. These lists may change with time. Good. It means you are growing.

Other ways of finding out more about who you are include working the 12 Steps especially the written ones (4 and 10), getting into therapy, keeping a journal, or working some sort of recovery book. My experience has been that I do better when I have support. If you start to work a recovery book and become overwhelmed, get help. We weren™t meant to handle either trauma or the effects of living with someone who has PTSD alone.

Another way to start working on boundaries is to figure out who owns the problem? If Bob is depressed because of his experiences in Vietnam, he owns the problem. If I cannot tolerate his depression and insist on trying to fix him, I have made it my problem. I'm violating his boundaries and making work for myself. I need to detach and let him have his problem. The work I need to do is on becoming able to tolerate his feelings, not either adopt them (getting as depressed as he is or more) nor try to change them. There are 22 readings on detachment in the Alanon One Day at a Time, (available from Al-Anon Family Groups, 1600 Corporate Landing Parkway, Virginia Beach, VA, 23462). When I was first learning to detach, I read all 22 every day for weeks. Loving detachment isn't ignoring someone. It is listening without adopting or fixing the problem. Practice detachment and you practice boundaries.

Many people, especially men, are solution oriented (giving solutions violates boundaries, by the way, unless the person has said "What should I do?"). People who have a problem want you to listen to it and say "that must be hard for you," not "Do this. Do that." Each time a person with a boundary problem listens to someone else's problem without trying to ignore or fix it, he or she is strengthening his or her sense of self and increasing his or her tolerance for other people's emotions instead of avoiding them, i.e. growing boundaries!

Saying no: Another step in developing boundaries is learning to say no to others and learning to accept no. For trauma survivors, being able to say no to activities that might trigger them is important. As part of learning what you like, saying no to things you don™t like is important even if you™ve always said yes before. Screaming no is a sign that you don™t yet feel you have the right to say it. As time passes and your boundaries strengthen, you™ll be able to say it politely because you will know inside that you do have the right to say no. Other people do to. Today I can accept no for an answer because it is no longer proof of my worthlessness but simply that person setting his or her limits.

Saying yes: Once you can say no, you can also begin to say yes for healthy reasons. You may say yes to things you™d like to do but have been afraid to try. You may say yes to people who ask you to do things because you would like to do them and can do them for free and for fun (not because you should or for a payback). You may even say yes to some things you don™t necessarily want to do but are willing to do because they fit your values and help you be the kind of person you want to be (not they want you to be”not people pleasing).

Asking for what you want: once you have more of an idea of who you are, what you feel, what you like, you can ask for what you want. This stops a lot of people because they feel that if they don™t get what they want it was all for nothing. That™s where the phrase "do the footwork and turn the results over" helps me. Asking early and asking often, so that saying no is okay, also helped me. I used to only ask when I was desperate so it wasn™t a request. It was a demand.

Today I do not have to have other people do what I want. I ask for what I want, but I don™t have to get it, because someone else™s behavior is not a reflection of my worth. The fact that they don™t do what I want probably has nothing to do with me. It has to do with their issues, because they are separate from me, and I am not central to their lives like I am to mine. (I can trust that they are human and are going to put their interests before mine.)

By the way, when I haven™t gotten people to do what I wanted, things have often turned out better than anything I could have imagined.

Perfectionism: Once I learned I stop at my skin, I learned to accept myself and to believe that I was okay even if I wasn™t perfect. I™m just me. You are you. When I could accept me, I could accept you and begin to stop trying to violate your boundaries to make you perfect. Perfectionism and healthy boundaries are not compatible. Perfectionism is another big issue for trauma survivors who may feel if they had just been good enough or done it right, the trauma wouldn™t have happened. So they try to be perfect or to raise perfect kids. Another variation is the trauma survivor who says it didn™t affect him or her but is heavily invested in proving it by being perfect and having a perfect family.

When I™m violating you to make you perfect I do not have healthy boundaries. If I™m letting you violate me to make me perfect, I don™t have them either. With boundaries, I can set limits, say no, have and express my own opinions, keep out of other people™s business, especially business between two other members of my family (no triangulating), learn who I am, and let other people be and grow.

Physical boundaries: No one has the right to touch you or your stuff without permission. "Please don™t touch me," is a perfectly polite statement and no explanation is required. "Why not?" on the other hand is rude and intrusive.

Physical boundaries also include having your own space. After being very close one way to return to normal boundaries without quarreling is to simply go do something in a different part of the house from your partner.

You don™t have the right to touch others or their things without permission unless you are a parent pulling your kid out of harm™s way. Please don™t take it personally if someone doesn™t want a hug. You don™t know what they™ve been through. Please don™t make your kids hug you or anyone else. You set them up for abuse that way. Please don™t hit them either. It makes them hyperactive and confuses love and violence in their minds. Try to see what the child needs that s/he isn™t getting and meet that need directly. It is usually attention. If you fail and spank, don™t give up. You can always say you made a mistake because you are human and you are sorry and start over again the next minute. This sets a good example that no one is perfect.

Spiritual boundaries: One of the worst forms of abuse is spiritual abuse. True spirituality is something you find for yourself not something that is thrust down your throat along with a bunch of rules. No one has the right to tell you what to believe. Different people need different answers. I think that™s why there are so many different spiritual and religious paths. Not because one is right and the others wrong, but because they all have something that someone needs. I have no argument with someone who says "X is the answer that works for me." Someone who says "X is the answer for everyone," doesn™t have good boundaries. They usually want your money too.

For years, I practiced my boundaries by writing out the Serenity Prayer every morning: Grant me the serenity to accept the things I cannot change (I wrote in people, places, and things that were bothering me), the courage to change the things I can (I wrote in "my own actions, reactions, perceptions, what I™ll put up with"), and the wisdom to know the difference.

The wisdom (and the willingness) to know the difference comes with practice. The courage to change the things I can showed me what was inside my boundary; accepting the things I can™t showed me what was outside my boundary. Seeking a higher power also helps with boundaries. If I™m playing God of course I have no boundaries, but if I™m not God then I am finite and do have boundaries. Accepting help from others and learning to take what I like and leave the rest strengthened my boundaries, too. When I thought we all had to think and be alike, I didn™t have boundaries. Today I do.

Living with healthy boundaries is far easier than living without them. I am no longer the prey of emotions that fluctuate with every outside influence. Sometimes I get more reactive, but I know I don™t have to continue to react. I call it recycling. I choose to use the tools I™ve learned to change my reactions by taking new actions. I don™t give up when my old patterns come back. I look inside to see what™s going on with me. If you find yourself saying "I should be over this," let go of that perfectionism and black and white thinking, get out your feelings list and your journal, figure out whose problem it is, practice your boundaries. It™s another opportunity to grow.

[firelizardee]

PTSD: What It Is and How to Recover

Text of First Issue of
the Post-Traumatic Gazette
(May-June 1995)

©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice)
and is distributed free of charge.


STATEMENT OF PURPOSE: The Post-Traumatic Gazette is a newsletter for all trauma survivors, from veterans to rape victims, earthquake survivors to prisoners of war, their families, friends and therapists. It is dedicated to the idea of healing one day at a time from experiences which forever change a person's view of the world.

This first issue is intended to set out a healing perspective on PTSD which has developed from my own experiences and from the work of respected professionals. In this perspective we see trauma as the problem, and PTSD reactions as creative and life-saving solutions to the problem of trauma. They worked. The survivor is alive.

We believe it is normal to be affected by trauma, there is help, and it is okay to ask for help. PTSD is not rare. It is not unusual. It is not weak to have PTSD. It is normal to be affected by trauma. We can't repeat that too often.

Traumatic experiences bring to the fore survival skills which are valuable and useful at the time of the trauma, but which usually become less valuable, less useful and less effective with time.

We believe that survivors become stuck in problem behaviors when their pain is not acknowledged, heard, respected, and understood. Denial plays a great part here (didn't happen/ shouldn't affect you). Putdowns, dismissal of their pain, misdiagnosis and other forms of secondary wounding keep survivors stuck.

Recovery is a slow process which doesn't come easily or painlessly. The survivor must be heard, feel understood, and reconnect to a community. The Gazette is aimed at helping to form such a community. Recovery takes time. The survivor sets the pace. Recovery is not a race, and recovery doesn't erase the trauma as if it had never happened. Trauma will always affect survivors. PTSD symptoms may come back under further stress, but the negative effects can be minimized as the survivor learns what they are and feels empowered to take care of him or herself. True healing is knowing it is okay to ask for help again. Rather than trying to put trauma behind us and forget it, I believe in another deeper kind of healing where we never forget, where we keep the memory alive of what happened to us and to others and we use our knowledge to keep traumatic things from happening to others. We also reach out, acknowledge the pain of other trauma survivors and encourage them to talk. We can make a difference.

This perspective also emphasizes that survivors and family members and therapists are human and are doing the best they can. Recovery is about learning better ways and letting go of fear, even fear of change. Slow growth is good growth.

This perspective differs from the sometimes still prevalent attitude that trauma couldn't affect a really well balanced person and also from the hurry up and get it all out so you can get well school of treatment. Respect for the survivor is implicit in this perspective. We don't rush survivors and we don't dismiss their pain. Instead of comparing pain, survivors and survivor groups are encouraged to respect each other's pain and to focus on what they have in common and to share recovery. Each person's unique experience and pain is respected.

In this perspective we also acknowledge the pain of the families of trauma survivors which often develop ineffective patterns as they try to cope. We seek to create a caring community of people who have been affected by trauma and share information on how to heal one day at a time.

The PTG would like to know what you--survivors, family, friends and therapists--have found helpful in your recovery work. If you send in a letter that I publish, you will recieve a year's free subscription. I hope the PTG will be packed full of stuff which will be helpful to every reader. Other goals of the PTG are:

**To work towards a more scientific diagnosis of Post Traumatic reactions based on observation of what is traumatic and on all the trauma related behaviors of people who have been traumatized,

**To provide new information on the treatment of PTSD and up-to-date sources of good information on safe and effective help

**To illuminate the connection between PTSD and substance abuse and compulsive behavior.

**To raise public awareness of the epidemic of PTSD and it's enormous cost to society in rising rates of violence and substance abuse.

**To discuss implications of the intergenerational transmission of PTSD in professions, families and cultures.

**To develop public policies which will be helpful for trauma survivors.


WHY I'M PUBLISHING THE POST-TRAUMATIC GAZETTE

My husband, Robert Mason, wrote about his experiences as a helicopter pilot in Vietnam in his bestselling memoir, Chickenhawk. His second memoir, Chickenhawk: Back In The World and my book Recovering From the War: A Woman's Guide To Helping Your Vietnam Veteran, Your Family, and Yourself describe how we lived with Post-Traumatic Stress Disorder when it didn't have a name and wasn't supposed to exist. I felt there was something wrong with me because I couldn't make my husband happy. He thought he was crazy. Many survivors of trauma and their families have had the same experiences. As I researched Recovering From The War, I interviewed survivors of all types of trauma, read scientific papers and books, and found help in 12 Step groups. Today my life contains a lot of serenity and peace which I'd like to share.

Patience Mason, editor.

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PTSD: What It Is and How to Recover - (continued)

Text of First Issue of
the Post-Traumatic Gazette
(May-June 1995)

©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice)
and is distributed free of charge.



WHAT ARE POST-TRAUMATIC STRESS REACTIONS?

Post-Traumatic Stress reactions start with a traumatic stressor "outside the range of usual human experience and that would be markedly distressing to almost anyone," according to the American Psychiatric Association's Diagnostic and Statistical Manual, III-R. Since it is almost impossible for a non-survivor or a numb survivor to understand or imagine what the survivor experiences at the time of the trauma, and therefore to identify what is traumatic, the DSM III-R offered four categories of traumatic stressor for diagnosticians and therapists:

(1)-threat of death or loss of physical integrity to the survivor (combat, rape, incest, earthquake, etc.)

(2)-death, threat of death or loss of physical integrity to family or close friends (survivor does not have to be present)

(3)-sudden loss of home or community, and

(4)-seeing another person who has recently been seriously injured or killed.

These were derived from reality: real nurses and body-baggers had terrible PTSD just like combat vets, rape and incest survivors, and people who lost their homes in fires or floods, or lost their kids on Flight 103 over Lockerbie.

As a person is traumatized, at least for the first time, (Many trauma survivors have multiple traumas.) the sense of personal safety is shattered. Two things start to happen immediately. The person will strive to survive using three available systems: fight, flight or freeze. What they called the reptile brain in high school biology seems to take over and choose. Military training is designed to get soldiers to always choose fight, but they wouldn't have to train us to do that if we were natural born killers. Culture and religion often train women to freeze, to take it and endure. In nature, flight is most common.

Simultaneously, while survival is at stake, feelings will shut down and information taken in and processed will become very focused so the person can do whatever it takes to survive.

Whatever it takes! This is not a polite, well-behaved part of us. It p*sses and sh*ts in its fear. It scratches and bites and goes berserk, beating people to death with the rifle-butt when the bullets are gone. It kicks and gouges. It runs out on its friends, trampling whoever gets in its way. It cowers, unable to get up or to fight, unable to protect those it loves. It may freeze or follow orders that are against all the survivor personally believes in. Survivors may feel shock or shame over what this part of them did.

Let me emphasize something: this ability to do whatever it takes to survive is God-given or evolution-given, depending on your point of view, but we all have it, and in traumatic enough situations, it will come out or we die. Extreme situations which trigger this reaction again and again may cause survivors to do things in order to survive which can be hard to look back on later.

This survivor part of us is not able to listen to "reason" either. It is going to be looking for danger from now on whether or not others think it is reasonable.

Real physiological changes occur in the brains of survivors which make them quick to react. In order to live through the trauma, survivors may develop the capacity to go from fine into a ******* rage in seconds. That helps them live. They may stop sleeping soundly. Sleep can get you killed. Survivors may be uncannily able to read the moods of those around them because the moods of their abusers defined their lives. They also become hypervigilant, searching for physical danger all around and all the time. Due to hypervigilance and lack of sleep, it is hard for them to concentrate on everyday things. They may do poorly in school and believe they are stupid when what they have is a symptom of PTSD. Survivors react faster and more completely to sudden noises. These are lifesaving skills as long as the survivor is still at risk, still in combat, still living with the batterer or the molester, still living in the bad neighborhood, the bombed city. These are reality based, effective survival skills. They keep you alive.

They don't go away by themselves.

Similarly shutting down feelings in order to do whatever it takes to survive, or do your job and help others survive, is a reality based survival skill. If you sit down and cry in combat you will get killed. If you keep screaming while Daddy hurts you, he may **** you. If you cry in the aid station or emergency room, you won't be able to save as many lives. Numbness is the answer. It is effective. It will help you live. It will help you keep others alive.

It doesn't go away by itself either.

Unfortunately when survivors numb fear, despair and anger, all their feelings, even good ones, are numbed. Numbness is comfortable. Thinking about what they have been through is so painful survivors wind up avoiding thinking about, feeling, or doing anything that reminds them of the trauma. For example, if they feel the trauma was their fault they may spend the rest of their life having to be right so they won't ever be at fault again. If they were happy when the trauma hit, they may avoid happiness forever. If they lost those close to them, they may give up closeness.

Most trauma survivors do not know anything about PTSD, so instead of seeking help, they will turn to whatever is available, self medicating to maintain numbness. Addictions and compulsive behaviors often are rooted in attempts to numb the thoughts and feelings associated with trauma. Until recently, a diagnosis of alcoholism or drug abuse made the effects of trauma invisible: because he's (or she's) an alcoholic, alcoholism is the cause of all these problems so he (or she) can't have PTSD

"Inability to recall important aspects of the trauma," is another of the ways avoidance and numbing may work. This means the person cannot remember exactly what happened. Many trauma survivors forget in order to survive. This is well documented in the scientific literature for combat veterans, torture survivors, battered women, child sexual abuse survivors, natural disaster survivors and others, as well as in personal narratives. The current attack on traumatic amnesia by the parents of incest survivors, involving memory experts who know nothing about trauma and therapists who were trained back in psychiatry's denial and delusion period (from Freud to 1980), will be the subject of a future issue.

Survivors may also feel that no one can understand what they've been through, (which is reality-based). Another form of numbing and avoidance is that they may feel like they're not going to have a long life. This is realistic if the survivor has seen a lot of people killed. Survivors may also lose interest in what they once liked to do. What is the point? Small children are likely to go back to baby talk or forget their toilet training. Survivors may also feel like they have no emotions or be told by their loved ones that they have none. They may even be so numb to the damage that was done to them that they become perpetrators and cannot understand what the fuss is all about. "What are you crying for? I'm pulling my punches."

Survivors may also have learned to dissociate, to literally not be there, to survive. Automatically checking out of stressful situations will make it hard to have relationships or to work in therapy.

Numbness will make it hard for survivors to take care of themselves. Feelings are there to tell us how to do that. If you can't tell what you feel, you can't choose healthy behaviors for yourself.

I've just described two of the symptom categories psychiatrists use to diagnose PTSD: hypervigilance and numbing. I've described them in this way because I think it is important for survivors, families and therapists to understand that this is not some random collection of weird behaviors, but appropriate and effective biologically based reactions to extreme stress. They have a purpose: survival. These reactions develop under conditions that most of us cannot imagine or comprehend, although such conditions are common in our society.

A person has to have two hypervigilant symptoms and three numbing symptoms, not present before the trauma, to be diagnosed with Post-Traumatic Stress Disorder. That means if the survivor already had PTSD from a previous trauma which the therapist doesn't know about and is already numb, the survivor may be misdiagnosed.

Most trauma survivors turn out to have multiple traumas, but the diagnosis of PTSD was formulated as if trauma was rare and only happened in isolation from the rest of life.

It is normal to be affected by trauma, but not every one who is traumatized gets diagnosable Post Traumatic Stress Disorder. There is a great range of post traumatic reactions because people are different, have had different life experiences, and have different capacities and skills. Some people do okay during the trauma, others hole. Some people have no reaction till another trauma, years later. Most people will find that post-traumatic reactions come back when there is subsequent trauma. Some people seem to alternate periods of extensive numbing with periods of explosive hypervigilant behavior or intrusive reexperiencing (the third category of PTSD symptoms). If the alternation is severe enough, they will never be diagnosed with PTSD because the symptoms won't be present at the same time, but their lives will be scarred by the trauma nonetheless.

These PTSD survival skills tend to become less appropriate and less effective with time and can wind up being really crippling ineffective behaviors. For a healing perspective, we need to keep in mind that the behaviors of trauma survivors are direct evidence, sometimes the best evidence, of what they have survived, of their experience. Reframing the behaviors in this light can be an enlightening experience for the survivor, families, friends, and therapists. Instead of being bad behaviors, they become useful evidence about the nature of the trauma or traumas.

Along with three numbing symptoms and two hypervigilant symptoms, survivors must also reexperience the trauma in some form. The most dramatic of these reexperiencing phenomena, the flashback, forced the recognition of PTSD by psychiatrists.

Psychiatrists were trained to deny that traumatic events did affect people despite evidence from concentration camp survivors and World War II veterans. When Vietnam veterans were having flashbacks in the halls of the VA hospitals, some professionals were able to break this denial and see real people really suffering. They had to acknowledge the flashbacks, so they created a diagnosis centered around reexperiencing reactions. They tend to think of it as a wierd reexperiencing disorder instead of a natural-but-now-not-so-useful survival skill disorder. I think a more healing perspective focuses on the effectiveness of the skills the person developed to survive, (hyperalertness and numbing). The other approach makes it easy to stigmatize survivors for the very behaviors which helped them survive.

Apparently sharing traumatic experiences is also necessary for human beings because people who can't, for whatever reason, develop reexperiencing symptoms. Survivors are reexperiencing when they cannot stop thinking (or talking) about the trauma, when they are dreaming about it, or flashing back to the experience, feeling like it is happening again, even if they are drunk or on drugs. Reexperiencing also includes being upset on anniversaries of the trauma or by things that remind the survivor of the trauma. New wars, highly publicized rape, murder, battering and incest trials all affect survivors. Having a physiological reaction to something that reminds the survivor of the trauma is also a form of reexperiencing. The sound of a helicopter overhead sends a rush of adrenaline through many veterans. Someone raped in a stairwell may find herself sick and dizzy in any stairwell.

A healing perspective on reexperiencing is that this is an appropriate and effective message from the survivor's inner self that he or she has been through something that is too much to deal with alone. We are human, a species that is interdependent, that forms families, bands, tribes, communities, and talks about stuff. Survivors were not meant to face this alone as if they were polar bears or some other solitary non-verbal species (although they may wish they were).

Reexperiencing is circumstantial evidence that a person has been through too much to handle alone. Reexperiencing can also be seen as appropriate and effective because it sends more people to get help than anything else.

Although this is not part of the current diagnostic criteria, I believe the message from the inner self can come as a physical symptom. Somatization (the development of physical symptoms) has disappeared from studies about PTSD although it was the primary symptom in soldiers' heart, hysteria, railway hysteria, shell shock and combat fatigue. People who will not listen to their own need for healing often experience a lot of physical symptoms. The body is trying to tell the story that can't be told. In light of George Vaillant's recent findings that 56% of WWII Harvard-educated combat vets without "diagnosable" PTSD were chronically ill or dead by age 65, this looks like a field ripe for study.

Many trauma survivors appear to reenact their traumas, self-mutilating, getting themselves into the same type of trouble over and over, or doing to others what was done to them. These behaviors probably serve the same unconscious purpose of speaking the unspeakable. Although such behaviors have been observed, they are not enumerated in the diagnosis yet, and may never be. That doesn't mean we can't keep them in mind in our search for healing.

For a survivor to be diagnosed with PTSD, three numbing, two hypervigilant and one reexperiencing symptom have to last a month. If you have seventeen numbing symptoms, one hypervigilant and are not reexperiencing this month you won't be diagnosed with PTSD, but traumatic events will be ruling your life.

Symptoms may come on soon after the trauma or fifty years later. That is the post in PTSD. It is normal for symptoms to come up again in the face of further trauma and in times of high stress. It is normal to be affected by trauma. 17 % of the teenagers in Detroit have diagnosible PTSD according to one study. Another study showed that 69% of the surviving spouses of police officers killed in the line of duty have diagnosible PTSD. 66% of Vietnam veterans exposed to high war zone stress have had diagnosible PTSD and 33% still do today. Several studies of WWII combat/pow veterans in the hospital for other problems have shown that at least 50% of them have had PTSD and about 30 % still do.

Israeli studies show that people who have been traumatized react faster and more deeply to each subsequent trauma. In addition, the effects of a traumatic stressor are worse when the cause is human neglect or human cruelty.

There are other post traumatic reactions which have not been studied including workaholism which might be invisible to workaholic doctors. Family system effects are just beginning to be studied, but many survivors manage to look good at great expense to their families. A child playing the role of family hero is not seen as a sign of family dysfunction, but as proof of good psychosocial adjustment. As a community of survivors, family, friends, and therapists, we need to look at our experiences, examining everything to see how it relates to trauma because what happens to people affects them.

Denial and discounting are the skills society has developed to deal with trauma, as expressed in "It wasn't that bad," and "Aren't you over that yet?" Statements like these cause secondary wounding in trauma survivors. They reinforce the mistrust trauma evokes in all survivors who no longer can believe that the universe is fair and just. Secondary wounding by the medical community has been a serious problem, from the incest survivor, revealing her rape by her father and being told by the male psychiatrist (trained to believe this), "You know you wanted it," to the thousands of misdiagnosed, mistreated Vietnam veterans of the seventies,( many of whom are now dead).

It is a problem that still persists. In DSM IV, published this year (1995), the APA has dropped the list of what is traumatic, and the all important sentence which points out that if it would be upsetting to almost anyone and it isn't to this person then maybe that's one of the symptoms of PTSD, and added the peculiar phrase that the person has to have felt "fear horror or helplessness" at the time.

Most trauma survivors that I know can't feel. The diagnostician or therapist is the one who may be able to call up appropriate feelings (eg. grief, rage) about the incident. The survivor shouldn't have to and probably can't without a lot of healing. What this really says is that if bad things happen to you and you don't feel the authorized feelings, they weren't bad things. This is neither logical nor scientific. It will create a class of good survivors who get diagnosis and treatment, and another (bad) class who due to numbing get misdiagnosed and mistreated, just as veterans were after Vietnam. If the APA really needs to list feelings, a more realistic and more diagnostic set would include disbelief, betrayal, feeling nothing, and feeling comfortable. The latter two would signal to any experienced therapist that this person already had PTSD before this latest stressor. Many people have multiple stressors over the course of a lifetime, and have already developed PTSD long before they see a professional.

The words fear horror or helplessness were added to the diagnosis because trauma turned out to be far more prevalent than the APA expected. (Yes, I am laughing!) The whole diagnosis of PTSD reflects the upper middle class idea that trauma itself is rare. It ain't!

Rather than redefining trauma as evoking particular emotions, I'd like to see us open our eyes to the invisible effects of trauma. We must become aware of the costs to survivors, society and families of all forms of numbing and hyperarousal including socially acceptable dysfunctional behavior. By ignoring it, we often simply put off to the next generation the cost and effort of recovering from trauma, and the effects of trauma increase geometrically. This is particularly true because something which might be mildly traumatic to a grownup, particlarly one who is numb, is terrifyingly traumatic to a small child. As Beverly James points out, the well known phenomena of the "good" hospitalized child who "misbehaves" when the parent shows up is actually a terrified traumatized child displaying learned helplessness and the freeze response who becomes brave enough to voice his or her terror when the parents are around.

What else can't we see?

One of the facts we need to face is that PTSD is an epidemic. For every incest survivor, every battered woman, every combat veteran, every holocaust survivor, every survivor of a fire, plane wreck, night club fire, rape, torture, mugging, hurricane, tornado, earthquake, every cop, nurse, firefighter, EMT, for everyone whose pain is not listened to and felt and accepted and healed, the effects of the trauma spread geometrically. Drug abuse, AIDS, heart disease, obesity and alcoholism are all related to the epidemic of PTSD through the compulsive behaviors people use to numb their pain and the inability to take care of one's self which numbing causes.

If 17 % of the teenagers in Detroit had tuberculosis, it would be a national emergency. Because they have PTSD, and PTSD is not acknowledged nor well understood, no one is talking about it. But we can. --Patience Mason

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1. See a family doctor and get a complete physical.

It's a good idea to go to a family physician, to make sure your body is healthy. For example, many people might tell you that a persistant stomach ache is just anxiety, but it could be an ulcer or worse, so it's best to be on the safe side. Some serious medical conditions mimic the symptoms of depression and anxiety. If you turn out to have a physical condition on top of the PTSD, being treated for that physical condition will improve the quality of your life and lessen your PTSD symptoms.

2. See a psychiatrist for an assessment and medication, if necessary.

Medication really helped my depression and my angry outbursts. And I have a very good psychiatrist who really takes time with me. He sees me for talk therapy about once a month, makes sure my medication is controlled, and encourages me in various ways. Since I do happen to have a serious physical condition as well as the PTSD, I am glad to have a psychiatrist rather than a psychologist, because with his medical training, he has certain understandings that someone who's not a doctor wouldn't have.


Here's a bit more info on medication:

A number of medications have been shown to be useful for treating PTSD. The most common of these are the antidepressants particularly the SSRIs. In addition, mood stabilizers such as divalproex (Depakote) may be used in cases where a person experiences only a partial response to an antidepressant. The addition of a mood stabilizer (along with an antidepressant) is also recommended for particular PTSD symptoms, such as marked irritability or anger.

In addition to antidepressants and mood stabilizers, anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonapin or Rivotril), and lorazepam (Ativan) may be useful on a short term basis. Caution should be used with these medications, due to the potential for dependence.

Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following psychological treatment. Among medications, selective serotonin reuptake inhibitors (SSRIs) have the most data supporting them. These medications are most effective for PTSD in nonveterans.

When symptoms have lasted less than three months (acute PTSD) it is generally recommended that medication be continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication be continued for one to two years. Longer treatment may be required if significant symptoms are still present.

The decision of whether to take medication for PTSD, and which medication to take should be based on the individual™s past treatment history, the individual™s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors.


3. See a therapist

Make sure the therapist you go to has experience in treating people with PTSD. You may also want to see a therapist who will do Cognitive Behaviour Therapy (CBT) with you. I am in this type of therapy, and it is relatively short term and goal-oriented. It is considered to be one of the best therapies for people with PTSD. Here's a bit more info on CBT:

The psychological treatment shown to be most effective for PTSD is cognitive behavior therapy (CBT). CBT for PTSD involves a number of useful strategies including:

Psychoeducation “ includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individual™s emotional reactions and need to retell the event.

Anxiety Management “ involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training.

Cognitive Therapy “ involves identifying anxious thoughts (e.g., guilty thoughts about the trauma, exaggerated thoughts about danger) and replacing them with more realistic thoughts. For example, if an individual has the thought œI will never be safe again, the world is a very dangerous place,? cognitive therapy would focus on helping the individual to consider evidence for and against the belief.

Exposure to Trauma Cues and Feared Situations “ involves confronting feared situations or triggers repeatedly, in a gradual way, until fear is extinguished. For example, a person who is avoiding driving after being in a very severe car accident is encouraged to drive again, beginning in easier situations (e.g., light traffic) and gradually progressing to more difficult situations (e.g., heavy traffic, night, in the rain).

Exposure to Trauma Memories “ involves confronting trauma memories repeatedly until they are no longer associated with extreme distress. This strategy is combined with anxiety management strategies and cognitive therapy.


4. Join a support group or a therapy group.

I have been to 3 different groups and have found them all to be helpful. The first group I attended was a support group for women who had experienced trauma, and it ran for 8 weeks, 2 hours a week. It consisted mostly of personal sharing and dealing with anger, grief, and other difficult emotions. Then I went to a 6-week long anxiety/panic group, which used CBT and other methods to deal with specific concerns. it ewas very educational. Upon graduating from the second group, I was invited to attend the panic/anxiety support group, which is once a week. This group is ongoing and I can attend for as long as I want to.


5. Take care of yourself

Eat well, get enough rest, keep your home fairly comfortable and clean, and get regular exercise. Exercise is very good for people with depression and PTSD. And - haha - I'm laughing because this is something I need to practice a lot more - don't do too much or expect too much of yourself. Allow yourself to have fun. Create a balance in your life.

6. Practice relaxation techniques

Relaxation breathing is an important one to learn. Many people with PTSD and panic hold their breath and never breath properly. You can also try meditation, yoga, tai chi, listening to soothing music, a hot bath or whatever else relaxes you. Certain herbal teas and comfort foods (in moderation) can also he helpful.

7. Learn as much as you can about your illness(es).

Knowledge is Power!! The more you know about yourself, the more you can understand what's going on, and the more you can challenge your doctors and therapists and get the best possible care for yourself.

8. Keep a Journal

Keep a journal or diary in which you can write down all your thoughts and feelings, whenever you feel the need to. It can very powerdul. For more info on journal keeping, here is an excellent website:

http://www.writingth...cises/index.htm

I also keep a dream journal. It gives me further insight into myself, especially when I go back and read what my dreams were like several months ago, compared to what they are like now.

Sort of along the same lines as keeping a journal is art therapy. You can draw, paint, make collages out of old magazine clipping, etc. to release feelings. I find it very cathartic at times. You don't have to be artistic, either. No one has to see the art except you, and a psychiatrist or therapist, if you choose to share with them.


9. Develop a support system

Make sure there are people in your life you can count on if you need help. Limit the time you spend with family members who are not supportive, and drop "friends" who aren't. Surround yourself with people who care about you and who will accept you as you are. it's very important that doctors and therapists be on this list as well. If you don't feel that a doctor or a therapist is supportive of you, change to a different one or get a second opinion if possible. I even make sure my dentist and eye doctor are people I really trust and like, even though I don't see them often. It just makes life so much more bearable.

10. Have a hobby and/or do volunteer work

This helps to pass the time in an enjoyable way, so that you aren't always thinking about the trauma. Volunteer work can be very rewarding, and it helps you to get out and meet new people as well.

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http://www.writingth...cises/index.htm

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PTSD Nightmares
A National Center for PTSD Fact Sheet
By Julia M. Whealin, Ph.D. and Mary Lou Francis, Ph.D.

After a traumatic event, many people experience one or two nightmares that relate to the trauma. For some people, however, these nightmares recur several times. Such repetitive nightmares are one of the main hallmarks of PTSD.

PTSD nightmares are often confused with night terrors and ordinary nightmares. These other sleep phenomena need to be distinguished from nightmares related to trauma.

Night terrors occur during deep non-REM sleep early in the sleep period and involve considerable body movement. Night terrors usually awaken the dreamer, who does not remember the content of the dream.

Ordinary nightmares, which are experienced occasionally by nontraumatized persons, are also different from PTSD nightmares. They tend to differ from one nightmare to the next, although they often feature the dreamer being chased or threatened by a hostile attacker(s).

PTSD nightmares, in contrast, usually involve "reliving" the past or a situation related to a past event. During PTSD nightmares, people often experience the same strong emotions that they felt during the trauma, such as fear or rage. Often the emotion is one that would have been appropriate to express during the original trauma.

Common themes of recurrent nightmares experienced by veterans are combat, being trapped, being pursued, being paralyzed and unable to act, or witnessing the death or mutilation of others. They can occur during any stage of sleep or during waking.

Dreamers often awaken feeling terrified, typically with physical signs of arousal such as sweating or labored breathing. They are often unable to return to sleep quickly and may go back to sleep only after several hours, or they may not go back to sleep for the remainder of the night.

Many veterans report that their recurrent nightmares are the single most distressing symptom of their PTSD.  This is probably so because, through the nightmare, they continue to relive an experience in which they felt intense horror, fear, and helplessness.

Who is likely to suffer from PTSD nightmares?

Studies of combat veterans show that those who experience nightmares as part of their PTSD also have other similarities (Wilmer, 1996). Some studies have shown that, in comparison to veterans who do not experience nightmares, sufferers of PTSD nightmares tend to:

Have lost a combat buddy in the war

Be younger when the trauma occurred than those who didn™t get nightmares. In one study of Vietnam era veterans, the nightmare sufferers were, on average, 17.4 years old when the trauma occurred.

Have had less experience with traumatic situations before entering combat

Avoid expressing anger or aggression

Why do PTSD nightmares tend to repeat?

Although not all scientists agree about why PTSD nightmares recur, it has been suggested (Wilmer, 1996) that PTSD nightmares are a memory intrusion into dreams rather than an ordinary nightmare.

Both ordinary nightmares and typical dreams appear to connect recent events with memory paths from the past. Thus, they are said to integrate new information with old. However, because the PTSD nightmares occur repeatedly, they are thought to reflect an absence or failure of this connecting process. Rather than assimilating the traumatic events into the present, survivors experience the content of a PTSD nightmare as being "encapsulated" into itself. Unless a connection between the trauma and the present can be established, the dream will repeat.

What can be done to reduce nightmares?

Understandably, some veterans try to prevent their nightmares, sometimes by using alcohol or drugs to induce a (seemingly) dreamless sleep. Sometimes sufferers try to avoid sleep altogether. Both "solutions" usually create a number of new problems. These include substance dependence or all the symptoms characteristic of sleep deprivation: irritability, difficulty concentrating, poorer sleep, poorer memory, increased anxiety, and fatigue.

Addressing the nightmare directly in treatment can reduce the frequency and intensity of a recurring nightmare (Daniels & McGuire, 1998). Targeted, time-limited treatment of recurrent traumatic nightmares is available at many Veterans Affairs PTSD programs. Often the therapy is performed in dreamwork groups that treat PTSD nightmares.

During group therapy, the nightmare is "worked" by the group. Traumatic themes are identified and the group offers alternative perspectives on the dream that help "connect" the content with events from the past. With these new perspectives and perhaps some valuable insights into the dream, the dreamer leaves the group with an action plan to implement. Preliminary evidence suggests that dreamwork therapy for nightmares can decrease the frequency and intensity of nightmares.

Selected References:
Daniels, L. R., & McGuire, T. (1998). Dreamcatchers: Healing traumatic nightmares using group dreamwork, sandplay and other techniques of intervention. Group, 22, 205-227.

Wilmer, H. A. (1996). The healing nightmare: War dreams of Vietnam veterans. In D. Barrett (Ed.), Trauma and Dreams (pp.86-99). Cambridge, MA: Harvard University Press.

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PTSD Nightmares
A National Center for PTSD Fact Sheet
By Julia M. Whealin, Ph.D. and Mary Lou Francis, Ph.D.

After a traumatic event, many people experience one or two nightmares that relate to the trauma. For some people, however, these nightmares recur several times. Such repetitive nightmares are one of the main hallmarks of PTSD.

PTSD nightmares are often confused with night terrors and ordinary nightmares. These other sleep phenomena need to be distinguished from nightmares related to trauma.

Night terrors occur during deep non-REM sleep early in the sleep period and involve considerable body movement. Night terrors usually awaken the dreamer, who does not remember the content of the dream.

Ordinary nightmares, which are experienced occasionally by nontraumatized persons, are also different from PTSD nightmares. They tend to differ from one nightmare to the next, although they often feature the dreamer being chased or threatened by a hostile attacker(s).

PTSD nightmares, in contrast, usually involve "reliving" the past or a situation related to a past event. During PTSD nightmares, people often experience the same strong emotions that they felt during the trauma, such as fear or rage. Often the emotion is one that would have been appropriate to express during the original trauma.

Common themes of recurrent nightmares experienced by veterans are combat, being trapped, being pursued, being paralyzed and unable to act, or witnessing the death or mutilation of others. They can occur during any stage of sleep or during waking.

Dreamers often awaken feeling terrified, typically with physical signs of arousal such as sweating or labored breathing. They are often unable to return to sleep quickly and may go back to sleep only after several hours, or they may not go back to sleep for the remainder of the night.

Many veterans report that their recurrent nightmares are the single most distressing symptom of their PTSD.  This is probably so because, through the nightmare, they continue to relive an experience in which they felt intense horror, fear, and helplessness.

Who is likely to suffer from PTSD nightmares?

Studies of combat veterans show that those who experience nightmares as part of their PTSD also have other similarities (Wilmer, 1996). Some studies have shown that, in comparison to veterans who do not experience nightmares, sufferers of PTSD nightmares tend to:

Have lost a combat buddy in the war

Be younger when the trauma occurred than those who didn™t get nightmares. In one study of Vietnam era veterans, the nightmare sufferers were, on average, 17.4 years old when the trauma occurred.

Have had less experience with traumatic situations before entering combat

Avoid expressing anger or aggression

Why do PTSD nightmares tend to repeat?

Although not all scientists agree about why PTSD nightmares recur, it has been suggested (Wilmer, 1996) that PTSD nightmares are a memory intrusion into dreams rather than an ordinary nightmare.

Both ordinary nightmares and typical dreams appear to connect recent events with memory paths from the past. Thus, they are said to integrate new information with old. However, because the PTSD nightmares occur repeatedly, they are thought to reflect an absence or failure of this connecting process. Rather than assimilating the traumatic events into the present, survivors experience the content of a PTSD nightmare as being "encapsulated" into itself. Unless a connection between the trauma and the present can be established, the dream will repeat.

What can be done to reduce nightmares?

Understandably, some veterans try to prevent their nightmares, sometimes by using alcohol or drugs to induce a (seemingly) dreamless sleep. Sometimes sufferers try to avoid sleep altogether. Both "solutions" usually create a number of new problems. These include substance dependence or all the symptoms characteristic of sleep deprivation: irritability, difficulty concentrating, poorer sleep, poorer memory, increased anxiety, and fatigue.

Addressing the nightmare directly in treatment can reduce the frequency and intensity of a recurring nightmare (Daniels & McGuire, 1998). Targeted, time-limited treatment of recurrent traumatic nightmares is available at many Veterans Affairs PTSD programs. Often the therapy is performed in dreamwork groups that treat PTSD nightmares.

During group therapy, the nightmare is "worked" by the group. Traumatic themes are identified and the group offers alternative perspectives on the dream that help "connect" the content with events from the past. With these new perspectives and perhaps some valuable insights into the dream, the dreamer leaves the group with an action plan to implement. Preliminary evidence suggests that dreamwork therapy for nightmares can decrease the frequency and intensity of nightmares.

Selected References:
Daniels, L. R., & McGuire, T. (1998). Dreamcatchers: Healing traumatic nightmares using group dreamwork, sandplay and other techniques of intervention. Group, 22, 205-227.

Wilmer, H. A. (1996). The healing nightmare: War dreams of Vietnam veterans. In D. Barrett (Ed.), Trauma and Dreams (pp.86-99). Cambridge, MA: Harvard University Press.

[firelizardee]

PTSD and Anger

If you have PTSD, it is very likely that you also have problems controlling your temper. Anger problems are very common for people with PTSD. You may feel as if your anger comes on suddenly and as if it comes from out of nowhere. It might seem that before you even have a chance to realize that you are feeling angry, you find yourself acting aggressively and doing or saying things that you later regret. This can be scary and confusing - like you are out of control. It is difficult to feel this way. It is hard to live with the fear that one day you might seriously hurt someone. The good news is - there are things that you can do to get control over your anger.

One of the first steps to take in order to feel more in control of your anger includes learning to monitor it. This means learning to recognize that you are getting angry before you become so angry that you can't control yourself. Right now, you may feel as if your anger is "all or nothing", like you are either in a rage or not angry at all. You may also feel like you suddenly "Fly into a rage" without any warning. This feeling is very common in people with PTSD. With practice you can learn to recognize the signals that tell you that you are getting angry. Once you are aware of these signals, then you can do something about your increasing anger before you wind up doing or saying something you regret.

Learning to monitor your anger takes time. It can be helpful to work with an individual counselor with experience in PTSD or to take an anger management class. However, there are also things that you can do on your own:

Learn to think in terms of an "anger meter", with your anger being on a scale between 1 to 10, instead of thinking of anger as "all or nothing". Other feelings are not all or nothing. You would probably be happier if you won the lottery than if you found ten dollars, for example. Some hurts are worse than others. Anger is the same way. Irritation, annoyance, frustration and many other feelings are actually lower level anger and are easier to control than more intense anger. If you can learn to keep these lower level angers from turning into stronger anger or rage by using an anger control plan, you will have better control over your anger.

Practice using the "anger meter" by keeping an "anger log."
In your "anger log", write down things that made you angry during the day and then rate the level of anger you felt between a 1 and a 10. A 1 is almost complete calm, a 10 is when you blow up and say or do something that could lead to negative consequences for you.

Make sure you include small things, like getting irritated waiting in a short line for example. Paying attention to these lower level angers is important because they can lead to more intense anger.

If you can learn to recognize these smaller angers then you can have some warning and not feel like you will suddenly blow up.

Find out what the warning signs are that that indicate to you that your anger is increasing. These signs are different for everyone, but fall into three general categories:

Physical signs: things that you can notice inside your own body, like tense muscles, tunnel vision, feeling flush, clenching your jaw or trembling.

Behavioral signs: things that someone watching you might notice, like pacing, your voice getting louder, turning red or clenching your fists.

Thinking signs: ways that your thoughts start to change, like having thoughts of revenge, using more swear words in your self-talk or having violent fantasies.

These signs are just examples. Your own warning signs may be different. But take the time to think about what your own signs are. Then you can tell when you are escalating on the anger meter.

Anger problems can be very scary. They can make you feel out of control and hopeless about recovering from PTSD. But with time and practice, you can learn to monitor your anger. Then you can do something to control it before you end up doing and saying things that you regret.

Copyright © 2001, MIRECC, VA Palo Alto Health Care System. All rights reserved.

[firelizardee]

This article on Survival Guilt alludes specifically to the events of 9-11, but I read through it and think it applies to other traumas as well:

Survivor Guilt

While the number of people dead or unaccounted for in the September 11th terrorist attacks on the United States continues to rise, there are also many survivors who were profoundly affected. While one's survival is a joyous fact for one's friends and family, many survivors themselves find it hard to celebrate. They feel guilty that they survived the attacks and someone else did not. Many survivors question why they survived and someone else perished, particularly when their survival seemed to have more to do with coincidence or luck than some conscious choice. This reaction is called "survivor guilt" and it is a very normal response to a traumatic event. It is difficult for human beings to feel grateful for being alive while at the same time feeling intense sorrow for those who did not survive. The following are some suggestions to assist in managing feelings of survivor guilt:

Acknowledge and accept your feelings and understand that they are perfectly normal. Celebrating your own life does not in any way diminish your sorrow and grief over those who were lost. All of your feelings are an important part of the grieving process and should not be suppressed.

Talk about how you feel with other survivors. You will find that you are not the only one with these feelings, and simply knowing that will help you to resolve them.

Recognize that the fact that you survived while others did not is a total mystery. No one can answer the ultimate question, "why" so try not to spend too much time trying to answer the unanswerable. Instead, look to find a purpose in your life and meaning in the things you can do as a result of having survived.

Find ways to keep alive the memory of those who were lost. This can be done on a small scale by creating a memory book, or by donating to or participating in larger memorial events.

For those who are second-guessing any of their decisions on September 11, 2001, remember that everyone involved in the crises made the absolute best decisions they could make under incredibly chaotic, traumatic and uncertain circumstances. It is pointless to focus any energy on "what ifs," and unfair to apply the knowledge you now have to a moment in time when that information did not exist.

Don't let feelings of guilt keep you from responding to your own needs. There is a difference between mourning the losses and punishing yourself.

Recognize your powerlessness over any of the negative outcomes of that day and focus instead on the things that you have control over today. Being present-focused will help you channel your energy in the most productive way.

Consider turning to spiritual resources for help in finding a framework for the events that took place and for resolving strong guilt feelings.

If your feelings of guilt are so overwhelming that you find it difficult to care for yourself or perform necessary activities, please seek the help of a grief professional.  

© 2001 CIGNA Behavioral Health

-------------

There is also a specific book called Survivor Guilt. I haven't read it, but I read another book by this same author and it was excellent:

Survivor Guilt
By Aphrodite Matsakis

Most people who survive a traumatic event feel guilty -- especially if other people were killed or severely injured. This breakthrough book, by a psychotherapist who specializes in PTSD, shows survivors step by step how to overcome chronic guilt and related psychological problems.

[firelizardee]

Exposure Therapy

Exposure therapy is based on the principle that we get used to things that are just annoying and not truly dangerous. This is called habituation, and it occurs naturally in over 95% of people. For example, if you visit a friend in a large city who lives in a second-floor apartment just beside an elevated railroad, it would be very annoying every time a train screeched by, shaking the building and rattling the windows to the point that conversation became difficult. One might even say to the friend, "How do you live in this din?" The friend might answer, "What din?" If we only visit, we leave with a belief that our friend lives in an impossible situation; if we stay in the apartment for a week or two, we are no longer annoyed by passing trains and may not even be aware of them.

Exposure therapy is based on the idea that this kind of habituation must occur in the person who has been traumatized if they are to overcome PTSD. Exposure therapy asks patients to confront, in a safe way, the very situations, objects, people and memories they have attached to the trauma (and are probably very consciously avoiding).

Exposure therapy is the opposite of the typical, self-prescribed avoidance approach. Because while avoidance may provide temporary relief, it just doesn't last. Facing these triggers is the key to reducing the frequency and severity of PTSD symptoms.

Exposure may be done in vivo (in real life) or in imagination. In vivo exposure is more effective than imaginal exposure. While anxiety or other discomfort may get worse in the first few minutes of in vivo exposure, it is important to continue exposure until the discomfort has diminished. Escaping discomfort only reinforces avoidance as a coping tactic, and produces all the limitations associated with avoidance”like avoiding safe places or situations that might be fun, beneficial or essential for a career and a full family life. It also increases the likelihood that the anxiety might spread, first to similar triggers and eventually to triggers that have little or nothing to do with the original anxiety. Examples of exposure in vivo are resuming driving after being in a traumatizing accident or returning to a now-safe site where an assault once occurred.

Exposure in imagination involves the person recounting traumatic memories until they lose their sting. This can be done by saying them aloud repeatedly, writing, reading and rewriting a biography of the events or recording them on a tape and playing them over and over until they are no longer distressing.

[firelizardee]

There are three kinds of exposure therapy: in vivo, imaginal, and introceptive. Up until this week, imaginal exposure therapy was the sole focus of my sessions. Here's a brief explanation of imaginal exposure therapy:

Imaginal exposure therapy is often used to help prepare an individual for entering a real life situation. Prior to going into phobic situations the person can visulalize the entire procedure, imagining exactly how they might feel and think.  The person can rehearse various coping strategies in imagination, rehearse specific statements (called "positive rehearsal") to repeat when in the actual phobic situation and practice maintaining a state of relaxation.

There are many situations where in vivo exposure is impratical, such as experiencing a thunderstorm, driving on icy roads, taking an airplan flight. When anxiety is triggered by thoughts or images of catastrophic events, using imagery is an effective way to provide exposure to the experiencing of frightening physical sensations and thoughts and reduce the body's response to the thoughts or images (such as, the image of dying or going crazy).

So basically, and I think I've mentioned this previously... every week I go into my therapist's office, close my eyes and imagine the traumatic event, in as much detail as possible. I describe the event from the beginning, over and over again, until I get desensitized to talking about it. While remembering, I make note of specific details that might be triggers to me now (for example, the smell of my father's aftershave or the sight of a pool of blood). I have made a long list of triggers. I have been doing this now for 7 weeks. I still have about another 7 weeks to go, but this week I begin in vivo exposure as well. Here is a definition of in vivo exposure:

This is the most effective treatment for anxiety and phobic avoidance. It refers to going into the actual fearful situation which has been avoided in the past. This technique is necessary for people who have developed established patterns of phobic avoidance. We teach people to proceed in a systematic fashion by breaking each task into maneagabel steps. By entering less threatening situations first and gradually working through a hierarchy of increasing difficulty the phobic person is able to learn that many of the frightening things he thought would happen didn't and that there were many manageable things that could be done to diminish the intensity of the remaining problems.

This is where my long trigger list comes in... last week in therapy, I chose some of the triggers that were the least scary to me, for example, my father's chosen brand of toothpaste.  I also chose a CD that I was listening to at the time of the shooting. Then I broke the triggers down into steps of exposure, for example:

Triggering toothpaste:

1. Think about my father's toothpaste and say the brand name out loud.

2. Go to the store and walk down the aisle where the toothpaste is displayed.

3. Pick up the toothpaste and look at it.

4. Buy the toothpaste.

5. Take the toothpaste home and display it in my bathroom.

6. Smell the toothpaste.

7. Use the toothpaste to brush my teeth.


Triggering CD:

1. Take out the CD and look at the front cover.

2. Take out the CD and look at the back cover and read the song titles.

3. Rank the song titles from least to most upsetting and write this down.

4. Slowly being listening to the song titles, starting with the least upsetting and moving to the most upsetting.

5. Listen to the CD in its entirety.


These steps are meant to be done VERY slowly, and definitely not on the same day... basically I am starting on step 1, keeping in mind my anxiety level, and repeating step 1 over and over again until I feel comfortable. Then I will do the same thing with step 2, 3, etc. So if just saying the name of my father's toothpaste upsets me, then I won't go out and buy and use the toothpaste right away... that would be too traumatic. I will continue to say the name of the toothpaste over and over again, until it no longer upsets me, and then I will move on to Step 2.

Oh and I should probably mention that, if you have severe PTSD, you should not do exposure therapy without the guidance of a therapist or psychiatrist. It can be scary and deterimental if you do too much at one time. So proceed with caution...

[firelizardee]

The follwoing article was written by Captain William Cox, to a fellow combat vet who is new to PTSD therapy:

There was much more to this therapy than making a conscious decison to "bury" the warrior in us and following through as best we could with that. We did relaxation therapy, recreational therapy, desensitization therapy, rap sessions full of our personal war stories--expressed with anger, courage, fear, outrage, tears, shame, guilt, fear, helplessness, anger, shouting, trembling, hopelessness, fear, tears, determination, courage, heroism, fear--you get the picture. In short, we were urged and helped (facilitated) to ease our way into the full range of emotions combat had blunted for us, and we did this while learning to share our PTSD causing experiences--a very difficult thing for most of us to do, both emotionally and rationally.

We had the care and direction of Doctoral level therapists, though. I don't recommend this kind of therapy in a lay environment. It is possible to open psycholigical doors where there's a bomb with a friction fuse on the hinge, and there's definately gonna be an explosion if that door opens without first disabling the fuse AND removing the explosives. It wasn't unusal to hear on entering a session that one of our members had emergency admittance to the "flight deck" at the VA for lockdown, preventive care with medication adjustments, or simple maintenance until the crisis passed. As I'm sure you're aware, any therapy for PTSD is a difficult process, not a panacea, and it won't work at all without a deep personal commitment, a lot of heart, gut, and mind-wrenching while moving toward personal insight, and total honesty with oneself, the group, and the therapists throughout the process.

And yes, PTSD does cause a myriad of physical problems as well, affecting endorcrine output, the pancreas and the heart [cardiovascular], gastrointestinal, and musculoskeletal disorders. As you mentioned, stress itself causes physical damage, but when you throw in combat survival chemicals like adrenaline into daily living activities, which happens to many chronic/severe PTSD cases, untreated, througout their lives . . . you're gonna see some pretty terrible health problems as a result of the psychological damage done by untreated, or unsuccessfully treated, PTSD. These problems show up early, of course, and we're aware we have health problems, like acid stomach, for example, early on. But the problems don't usually put us down hard until we reach about the age we're at now.

This is a sad thing: When I was being treated in the early 80s for PTSD, I remember all these middle fifties WWII vets being treated for their medical disorders, and whenever we'd get off the flight deck to go downstairs for Bingo or whatever, it came up in conversations that the medical vets were d*** proud they weren't in for psyche like us PTSD people were. They were like, "Hey, the war never bothered me, pal." And the truth was, lots of them were there for medical because their PTSD had gone untreated since WWII.

Taken from http://www.williamcox.org/ Edited by bluelicorice on Mar. 08 2003,16:28

[firelizardee]

Cognitive behavior therapy: The Basics
John Winston Bush, PhD
New York Institute for Cognitive and Behavioral Therapies


Cognitive behavior therapy is a clinically and research proven breakthrough in mental health care. Hundreds of studies by research psychologists and psychiatrists make it clear why CBT has become the preferred treatment for conditions such as these . . .

-Depression and mood swings
-Shyness and social anxiety
-Panic attacks and phobias
-Obsessions and compulsions (OCD and related conditions)
-Chronic anxiety or worry
-Post-traumatic stress symptoms (PTSD and related conditions)
-Eating disorders (anorexia and bulimia) and obesity
-Insomnia and other sleep problems
-Difficulty establishing or staying in relationships
-Problems with marriage or other relationships you're already in
-Job, career or school difficulties
-Feeling œstressed out?
-Insufficient self-esteem accepting or respecting yourself)
-Inadequate coping skills, or ill-chosen methods of coping
-Passivity, procrastination and œpassive aggression?
-Substance abuse, co-dependency and œenabling?
-Trouble keeping feelings such as anger, sadness, fear, guilt, shame, eagerness, excitement, etc., within bounds
-Over-inhibition of feelings or expression


Just what is CBT? How does it work?

Cognitive behavior therapy combines two very effective kinds of psychotherapy ” cognitive therapy and behavior therapy.

Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.

Cognitive therapy teaches you how certain thinking patterns are causing your symptoms ” by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.

When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.

CBT is active therapy

In CBT, your therapist takes an active part in solving your problems. He or she doesn't settle for just nodding wisely while you carry the whole burden of finding the answers you came to therapy for.

You will receive a thorough diagnostic workup at the beginning of treatment ” to make sure your needs and problems have been pinpointed as well as possible.

This crucial step ” which is often skimped or omitted altogether in traditional kinds of therapy ” results in an explicit, understandable, and flexible treatment plan that accurately reflects your own individual needs.

In many ways CBT resembles education, coaching or tutoring. Under expert guidance, as a CBT client you will share in setting treatment goals and in deciding which techniques work best for you personally.

Structured and focused

CBT provides clear structure and focus to treatment. Unlike therapies that easily drift off into interesting but unproductive side trips, CBT sticks to the point and changes course only when there are sound reasons for doing so.

As a CBT patient, you will take on valuable œhomework? projects to speed your progress. These assignments ” which are developed as much as possible with your own active participation ” extend and multiply the results of the work done in your therapist's office.

You may also receive take-home readings and other materials tailored to your own individual needs to help you continue to forge ahead between sessions.


What else is different about CBT?

Most people coming for therapy need to change something in their lives ” whether it's the way they feel, the way they act, or how other people treat them. CBT focuses on finding out just what needs to be changed and what doesn't ” and then works for those targeted changes.

Some exploration of people's life histories is necessary and desirable ” if their current problems are closely tied to œunfinished emotional business? from the past, or if they grow out of a repeating pattern of difficulty. Nevertheless, 100 years of psychotherapy have made this clear . . .


Past vs. present and future

Focusing on the past (and on dreams) can at times help explain a person's difficulties. But these activities all too often do little to actually overcome them. Instead, in CBT we aim at rapid improvement in your feelings and moods, and early changes in any self-defeating behavior you may be caught up in. As you can see, CBT is more present-centered and forward-looking than traditional therapies.


The levers of change

The two most powerful levers of constructive change (apart from medication in some cases) are these . . .

Altering ways of thinking ” a person's thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and ways of directing his or her attention ” for the better. This is the cognitive aspect of CBT.

Helping a person greet the challenges and opportunities in his or her life with a clear and calm mind ” and then taking actions that are likely to have desirable results. This is the behavioral aspect of CBT.

In other words, CBT focuses on exactly what traditional therapies tend to leave out ” how to achieve beneficial change, as opposed to mere explanation or œinsight.?

In particular, CBT has been shown to be better than drugs in avoiding treatment failures and in preventing relapse after the end of treatment. If you are concerned about your ability to complete treatment and maintain your gains thereafter, keep this in mind.

Other symptoms for which CBT has demonstrated its effectiveness include problems with relationships, family, work, school, insomnia, and self-esteem. And it is usually the preferred treatment for shyness, headaches, panic attacks, phobias, post-traumatic stress, eating disorders, loneliness, and procrastination. It can also be combined, if needed, with psychiatric medications.

No other type of psychotherapy has anything like this track record in outcome research.


What about drug treatment?

CBT can be employed with or without psychiatric drugs. For some people, however, drug treatment is needed to obtain a partial reduction in symptoms before CBT can be fully effective.


CBT is usually brief

Most CBT patients are able to complete their treatment in just a few weeks or months ” even for problems that traditional therapies often take years to resolve, or aren't able to resolve at all.

Meanwhile, for people with complex problems, or who are forced to live in adverse conditions beyond their control, longer-term treatment is also available.

As a rule, most people can expect to begin their treatment with weekly visits.

A few ” particularly if they are in crisis ” may begin with two or more sessions a week until their condition is stabilized enough that they can safely come only once a week.


What happens further on in treatment?

Again, the answer depends on how you are progressing, and on your therapist's and your own preferences. These are among the options that are often recommended . . .

Individual sessions every other week or monthly, combined with weekly group therapy meetings.

Individual sessions every other week or monthly, without participation in group therapy.

A planned break of several weeks, followed by resumption of weekly individual sessions for a period of time.

A trial termination of therapy ” with the option of resuming if the need develops. Quite often, a follow-up session or phone contact is scheduled for a future date.


Do it when you need it, and not when you don't

In addition, most CBT practitioners subscribe to the principle of intermittent brief psychotherapy, as and when needed.

In this treatment model ” espoused by Dr. Nicholas Cummings, a world leader in therapeutic advancement and former president of the American Psychological Association ” you don't œgo into therapy? and (like Woody Allen) stay for year after year, regardless of whether you're making significant progress or not.

Instead, you consult your therapist when there's a problem you need professional help with ” and not in between. After all, isn't this sensible approach the one you follow with your physician, your dentist, your attorney or accountant, and all those other professionals?

Excerpts from: http://www.cognitive...or-therapy.org/

[firelizardee]

Wellness Tips: Sleep and Posttraumatic Stress Disorder

Many people suffer from problems with their sleep. This can be especially true for those who have witnessed or experienced one or more traumatic events, such as rape, military combat, natural disasters, beatings, or neighborhood violence. Some individuals exposed to traumatic physical or psychological events develop a condition known as posttraumatic stress disorder(PTSD). It is well known that sleep problems are one of many problems for those with PTSD. Sleep problems such as difficulty falling asleep, waking frequently, and distressing dreams or nightmares are common to those with PTSD. In fact, sleep disturbance may be understood as a normal response to past trauma or anticipated threat.

What are the Major Reasons that Sleep Problems are Common in PTSD?

Severe psychological or physical trauma can cause changes in a person's basic biological functioning. If you have been traumatized, you may be constantly hypervigilant, or "on the lookout", to protect yourself from danger. Restful sleep and always having to be alert do not "go together".

What are Common Sleep Problems Associated with PTSD?

Difficulty falling asleep

Difficulty staying asleep

Basic biological changes

Actual biological changes may occur as a result of trauma, making going to sleep difficult. In addition, a continued state of hyperarousal or "watchfulness" is usually present. It is very hard to fall asleep if you think and feel that you have to stay awake and alert to protect yourself (and possibly others) from danger.

Medical problems

Medical conditions are commonly associated with PTSD. They can also make going to sleep difficult. Such problems include: chronic pain, stomach and intestinal problems, and pelvic-area problems (in women).

Your Thoughts

Your thoughts can also contribute to problems with sleep. For examples, thinking about the traumatic event, general worries and problems, or just thinking , "Here we go again, another night, another terrible night's sleep," are also common reasons for difficulty falling asleep.

The use of drugs or alcohol

These substances are also commonly-associated with difficulty going to sleep.

Distressing dreams or nightmares

Nightmares are typical for those with PTSD. Usually, the nightmares tend to reproduce either the event or some aspect of it. For example, in Vietnam Vets, nightmares are usually about traumatic things that happened in combat, or about other things that happened "in country". In dreams, the person with PTSD may also attempt to find a way to express the dominant emotion of the traumatic event; this is usually fear and terror. For example, it is not uncommon to dream of being overwhelmed by a tidal wave or of beingswept up by a whirlwind.

Night terrors

These are events such as screaming or shaking while asleep. The person may appear "awake" to an observer, but is not responsive. Thrashing movements: because of overall hyperarousal and possibly during bad dreams or nightmares, active movements of the arms or legs (perhaps as in fleeing an aggressor) may cause awakening.

Anxiety (panic) attacks

Attacks of anxiety or outright panic may interrupt sleep. Symptoms of such attacks may include:

*Feeling your heart beating very fast
*Feeling that your heart is "skipping a beat"
*Feeling lightheaded or dizzy
*Having difficulty breathing (e.g. tight chest, pressure on chest)
*Sweating
*Feeling really hot ("hot flashes")
*Feeling really cold (cold sweat)
*Feeling fearful
*Feeling disoriented or confused
*Fearing that you may die (as a result of these symptoms)*Thinking and feeling that you may be "going crazy"
*Thinking and feeling that you may "lose control"

Hearing the "slightest sound" and waking up to check for safety

Many people with PTSD,especially combat veterans, wake up frequently during the night. This can be the result of various reasons. However, once awake, a "perimeter check" or checks of the area are oftenmade. For example, a Vet may get up, check the sleeping area, check locks on windows and doors, and even go outside and walk around to check for danger. Then the Vet may stay awake and vigilant and "stand guard"; he (or she) may not return to sleep that night.

What Can You Do If You Have Problems Sleeping Due to PTSD?

Talk to your doctor.

Let your doctor know that you have trouble sleeping. Tell your doctor exactly what the problems are; he or she can help you best if you share this information about yourself. Let your doctor know that you have (or think you have) PTSD. It is not your "fault" that you have these symptoms. Tell your doctor exactly what they are.

Let your doctor know about any physical problems that you think are contributing to your sleep problems. For example, chronic pain associated with traumatic injuries can cause trouble sleeping.

Let your doctor know about any other emotional problems you have---these may also be contributing to your sleep problems. For example, depression or panic attacks can cause trouble falling or staying asleep. There are a number of medications that are helpful for sleep problems in PTSD. Depending upon your sleep symptoms and other factors, your doctor may prescribe such for you. Your doctor may recommend that you work with a therapist skilled in dealing with emotional and behavioral problems. Psychologists, social workers, and psychiatrists fall into this category. They can help you take a closer look at, and possibly change, a variety of factors which may be preventing you from sleeping. They can help you with PTSD and other problems.

Do not use alcohol or other drugs.

These substances disturb a variety of bodily processes. They impair your ability to get a"good night's sleep". For example, alcohol may help you get to sleep, but it interferes withyour ability to stay asleep.If you are dependent on drugs or alcohol, let your doctor know, and seek assistance for this problem. Limit substances that contain caffeine(e.g. sodas, coffee, some over-the-countermedicines)

Try to set a regular sleep-wake schedule.

A regular schedule helps you to regulate and set your body's "internal clock" which, among other things, tells you when you are tired and when it is "time to sleep".

Make your sleeping area as free from distractions as possible.

Aim for quiet surroundings, keep the room darkened, keep television out of the bedroom.

Consider a light nighttime snack.

A light snack may help you to prevent hunger from waking you up in the middle of the night.

Avoid overarousal for at least 2-3 hours prior to going to sleep.

Try not to get your body and mind in "arousal mode". Things that may tend to do this are: heavy meals, strenuous exercise, heated arguments, bill-paying, and action-packed movies.

Don't worry that you can't sleep.

Remember, there may be a number of reasons for your sleep problems. The first step is to talk to your doctor.

Adapted from a National Center for PTSD Fact Sheet by Pamela Swales, Ph.D.

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Facts About PTSD from NIMH, The National Institute of Mental Health

Post-traumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat. PTSD can be extremely disabling.

Military troops who served in the Vietnam and Gulf Wars; rescue workers involved in the aftermath of disasters like the terrorist attacks on New York City and Washington, D.C.; survivors of the Oklahoma City bombing; survivors of accidents, rape, physical and sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of the 1994 California earthquake, the 1997 North and South Dakota floods, and hurricanes Hugo and Andrew; and people who witness traumatic events are among those at risk for developing PTSD. Families of victims can also develop the disorder.

Fortunately, through research supported by the National Institute of Mental Health (NIMH) and the Department of Veterans Affairs (VA), effective treatments have been developed to help people with PTSD. Research is also helping scientists better understand the condition and how it affects the brain and the rest of the body.


What Are the Symptoms of PTSD?

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than 1 month.

How Common Is PTSD?

About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million people) have PTSD during the course of a given year. About 30 percent of the men and women who have spent time in war zones experience PTSD. One million war veterans developed PTSD after serving in Vietnam. PTSD has also been detected among veterans of the Persian Gulf War, with some estimates running as high as 8 percent.

When Does PTSD First Occur?

PTSD can develop at any age, including in childhood. Symptoms typically begin within 3 months of a traumatic event, although occasionally they do not begin until years later. Once PTSD occurs, the severity and duration of the illness varies. Some people recover within 6 months, while others suffer much longer.

What Treatments Are Available for PTSD?

Research has demonstrated the effectiveness of cognitive-behavioral therapy, group therapy, and exposure therapy, in which the patient gradually and repeatedly relives the frightening experience under controlled conditions to help him or her work through the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help promote sleep. Scientists are attempting to determine which treatments work best for which type of trauma.

Some studies show that giving people an opportunity to talk about their experiences very soon after a catastrophic event may reduce some of the symptoms of PTSD. A study of 12,000 schoolchildren who lived through a hurricane in Hawaii found that those who got counseling early on were doing much better 2 years later than those who did not.


Do Other Illnesses Tend to Accompany PTSD?

Co-occurring depression, alcohol or other substance abuse, or another anxiety disorder are not uncommon. The likelihood of treatment success is increased when these other conditions are appropriately identified and treated as well.

Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common. Often, doctors treat the symptoms without being aware that they stem from PTSD. NIMH encourages primary care providers to ask patients about experiences with violence, recent losses, and traumatic events, especially if symptoms keep recurring. When PTSD is diagnosed, referral to a mental health professional who has had experience treating people with the disorder is recommended.


Who Is Most Likely to Develop PTSD?

People who have suffered abuse as children or who have had other previous traumatic experiences are more likely to develop the disorder. Research is continuing to pinpoint other factors that may lead to PTSD.

It used to be believed that people who tend to be emotionally numb after a trauma were showing a healthy response, but now some researchers suspect that people who experience this emotional distancing may be more prone to PTSD.


What Are Scientists Learning From Research?

NIMH and the VA sponsor a wide range of basic, clinical, and genetic studies of PTSD. In addition, NIMH has a special funding mechanism, called RAPID Grants, that allows researchers to immediately visit the scenes of disasters, such as plane crashes or floods and hurricanes, to study the acute effects of the event and the effectiveness of early intervention.

Studies in animals and humans have focused on pinpointing the specific brain areas and circuits involved in anxiety and fear, which are important for understanding anxiety disorders such as PTSD. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response in many systems of the body. It has been found that the body's fear response is coordinated by a small structure deep inside the brain, called the amygdala. The amygdala, although relatively small, is a very complicated structure, and recent research suggests that different anxiety disorders may be associated with abnormal activation of the amygdala.

The following are also recent research findings:

In brain imaging studies, researchers have found that the hippocampus”a part of the brain critical to memory and emotion”appears to be different in cases of PTSD. Scientists are investigating whether this is related to short-term memory problems. Changes in the hippocampus are thought to be responsible for intrusive memories and flashbacks that occur in people with this disorder.

People with PTSD tend to have abnormal levels of key hormones involved in response to stress. Some studies have shown that cortisol levels are lower than normal and epinephrine and norepinephrine are higher than normal.

When people are in danger, they produce high levels of natural opiates, which can temporarily mask pain. Scientists have found that people with PTSD continue to produce those higher levels even after the danger has passed; this may lead to the blunted emotions associated with the condition.

Research to understand the neurotransmitter systems involved in memories of emotionally charged events may lead to discovery of medications or psychosocial interventions that, if given early, could block the development of PTSD symptoms.

For further information, please visit the website of the National Institute of Mental Health: http://www.nimh.nih.gov/ Edited by bluelicorice on Feb. 10 2003,04:56

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This article  from the Society for Neuroscience is fairly technical in nature, but I found it very interesting:


Post-Traumatic Stress Disorder


When the dust settles after a traumatic event, some people experience a condition marked by intense anxiety, known today as post-traumatic stress disorder. Researchers have recently started to look at the ailment on a biological level and found evidence that it's rooted in the brain, arising from a complex interaction of several chemical and brain area changes. The findings highlight the seriousness of the condition and may lead to new treatments that could help the more than 5 million Americans estimated to have the disorder during the course of a given year.

A plane crashes. Fires erupt. Walls tumble down. You escape the chaos physically unscathed, but how's your brain?

For years, many doctors believed that people who experienced an extraordinarily traumatic or life-threatening event such as a terrorist attack, war or natural disaster should be able to tough it out and move on. Some individuals, however, found that these events stuck with them. They relived the experience through nightmares and flashbacks; had trouble sleeping; and felt detached, depressed and anxious. Today, increasing research indicates that the effects, now collectively referred to as posttraumatic stress disorder (PTSD), are not some sign of a weak personality, but the result of troubles in the brain. The findings are leading to:

*An improved understanding of the mental affects of intense stress.
*New ways to biologically treat PTSD.

Although the work is still in an early stage, studies indicate that PTSD links to a complex interaction between several chemicals and brain areas.

One of the chemicals involved is corticotropin-releasing factor (CRF), which plays a role in the brain's ability to manage an internal response to daily stressful situations. Many scientists believe that during a stressful event CRF puts your guard up. You may feel extra vigilant, fearful or anxious. CRF also sets off the release of other stress chemicals that arouse various body systems and prepare them to cope with a challenge. In people with PTSD, however, CRF seems to be on perpetual overdrive, possibly creating increased feelings of fear and anxiety. For example, researchers found that, compared with healthy individuals, Vietnam veterans suffering from combat- related PTSD have increased concentrations of CRF.

The vets' intense stressful experience may have inappropriately triggered this CRF boost. In earlier research, infant rats that experience the stress of being separated from their moms end up with increased CRF as adults.

Another example is norepinephrine. It's part of the internal stress response and also may strengthen emotional memory. One study shows that men with PTSD from Vietnam or Desert Storm in Iraq have increased concentrations of this chemical in their cerebrospinal fluid, which bathes the brain, compared with healthy men. The excess norepinephrine may create excess fear and anxiety as well as abnormal memory formation and the flashbacks that PTSD patients experience.

As a next step, scientists are studying ways to target these and other chemicals to prevent or treat the disorder. For example, one drug developed to treat anxiety and depression by blocking CRF activity is currently being tested in people. If successful, it may also benefit those with PTSD. Another drug thought to target the norepinephrine system appears to ward off the development of PTSD, according to a recent small study. Patients took the drug, named propranolol, after they experienced a trauma. Some three months later they had milder reactions to a mental imagery task designed to generate flashbacks as well as the fear and anxiety associated with the original event.

In addition to the chemicals, a variety of brain structures are likely to help produce the memory and emotional symptoms of PTSD. Included are the amygdala and hippocampus, which share connections and normally help maintain healthy formation of memories and emotions like fear. The amygdala in Vietnam veterans with PTSD, however, seems to get overexcited, according to studies. It produces an exaggerated response after patients hear combat sounds, reminiscent of the traumatic time that launched the PTSD. General pictures of scary faces also trigger this exaggerated amygdala response. Furthermore, researchers report some evidence that the hippocampus is smaller in those with PTSD and probably impaired.

Scientists are continuing to examine the underlying components of PTSD to determine how they interact with each other. Added insights into the exact blueprint of the disease won't stop terror but can help uncover increasingly better ways to fight its effects.

Copyright © 2003 Society for Neuroscience, http://apu.sfn.org/Splash.cfm

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Diagnotic Criteria for Acute Stress Disorder (from the DSM-IV):

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness

(2) a reduction in awareness of his or her surroundings (e.g., "being in a daze")

(3) derealization

(4) depersonalization

(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association

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WHAT IS ACUTE STRESS DISORDER?

Like PTSD, acute stress disorder is an anxiety disorder that involves a very specific reaction following exposure to a traumatic event or stressor (e.g., a serious injury to oneself, witnessing an act of violence, hearing about something horrible that has happened to someone you are close to). However, the duration of acute stress disorder is shorter than that for PTSD. For a diagnosis of acute stress disorder, the full range of symptoms must be present for at least two days and no more than four weeks. If the symptoms persist for longer than four weeks, a diagnosis of PTSD should be considered. It is normal to have some symptoms following a trauma and a diagnosis of acute stress disorder is given only if all the necessary features are present.

EXAMPLES OF TRAUMAS THAT CAN LEAD TO PTSD or ACUTE STRESS DISORDER

¢ military combat

¢ violent personal assault (e.g., sexual assault, physical attack, mugging, robbery)

¢ being kidnapped or taken hostage

¢ torture

¢ incarceration as a prisoner of war or in a concentration camp

¢ natural disaster (earthquake, fire, tornado, hurricane)

¢ terrorist attack

¢ severe automobile accident

¢ severe accident at work or in the home

¢ sexual abuse during childhood

¢ sexual assault or abuse

¢ being diagnosed with a life-threatening illness

¢ unexpectedly observing serious injury or unnatural death of another person


EFFECTIVE TREATMENTS FOR PTSD and ACUTE STRESS DISORDER

Biological treatments (i.e., medications), psychological treatments, and their combination, have been found to be effective for treatment of PTSD and related problems.

Biological Treatments

A number of medications have been shown to be useful for treating PTSD. The most common of these are the antidepressants particularly the SSRIs. In addition, mood stabilizers such as divalproex (Depakote) may be used in cases where a person experiences only a partial response to an antidepressant. The addition of a mood stabilizer (along with an antidepressant) is also recommended for particular PTSD symptoms, such as marked irritability or anger.

In addition to antidepressants and mood stabilizers, anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonapin or Rivotril), and lorazepam (Ativan) may be useful on a short term basis. Caution should be used with these medications, due to the potential for dependence.

Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following psychological treatment. Among medications, selective serotonin reuptake inhibitors (SSRIs) have the most data supporting them. These medications are most effective for PTSD in nonveterans.

When symptoms have lasted less than three months (acute PTSD) it is generally recommended that medication be continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication be continued for one to two years. Longer treatment may be required if significant symptoms are still present.

The decision of whether to take medication for PTSD, and which medication to take should be based on the individual™s past treatment history, the individual™s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors.

Psychological Treatments

The psychological treatment shown to be most effective for PTSD is cognitive behavior therapy (CBT). CBT for PTSD involves a number of useful strategies including:

Psychoeducation “ includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individual™s emotional reactions and need to retell the event.

Anxiety Management “ involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training.

Cognitive Therapy “ involves identifying anxious thoughts (e.g., guilty thoughts about the trauma, exaggerated thoughts about danger) and replacing them with more realistic thoughts. For example, if an individual has the thought œI will never be safe again, the world is a very dangerous place,? cognitive therapy would focus on helping the individual to consider evidence for and against the belief.

Exposure to Trauma Cues and Feared Situations “ involves confronting feared situations or triggers repeatedly, in a gradual way, until fear is extinguished. For example, a person who is avoiding driving after being in a very severe car accident is encouraged to drive again, beginning in easier situations (e.g., light traffic) and gradually progressing to more difficult situations (e.g., heavy traffic, night, in the rain).

Exposure to Trauma Memories “ involves confronting trauma memories repeatedly until they are no longer associated with extreme distress. This strategy is combined with anxiety management strategies and cognitive therapy.

For children, play therapy is often used to treat PTSD. Topics are addressed in an indirect manner using games to facilitate processing of traumatic memories.

Controversial Psychological Treatments for PTSD and Related Problems

Eye Movement Desensitization and Reprocessing (EMDR) “ EMDR is a therapy that was developed in the late 1980s by psychologist, Francine Shapiro. It involves bringing to mind an image of a traumatic event while visually tracking a therapist™s finger as it moves back and forth in front of the patient™s visual field. A number of variations on this treatment have been developed, including tracking a light moving back and forth, or listening to tones alternating from one ear to the other. Research on EMDR suggests that it does lead to a reduction in PTSD symptoms, though it is no more effective than other forms of CBT. Interestingly, the eye movements and other forms of sensory stimulation appear to have nothing to do with the effectiveness of EMDR. Critics of EMDR have argued persuasively that the main reason EMDR works is the exposure to the traumatic image. In other words, EMDR is thought to be no more than œdressed up? form of imaginal exposure.

Critical Incidence Stress Debriefing (CISD) “ CISD is a procedure that is often used with groups of individuals within one to three days of having experienced a trauma (e.g., a natural disaster, accident, terrorist attack, etc.). The treatment encourages trauma victims to share their thoughts and experiences, and the therapist discusses thoughts and emotional reactions that the individuals are likely to experience. Participants are typically encouraged to stay with the procedure. The strategies listed here are similar to those listed earlier in the section on psychoeducation for PTSD. The difference is that in CISD, all trauma victims are exposed to the treatment, not just those who develop PTSD or other adjustment problems. The data on CISD are mixed, but generally not supportive of the procedure. Some studies have shown the people having undergone CISD following a trauma are no better off than people who did not receive this treatment. Furthermore, a few studies have actually shown that people who undergo CISD are functioning more poorly later on, relative to those who have not undergone the procedure. Critics of CISD have recommended against using this procedure for all trauma victims. Instead, they encourage professionals to help victims with their basic needs (e.g., contacting insurance companies, etc.), provide support, and allow them to discuss the trauma only if they want to. More intensive treatment should be reserved for people who are still experiencing anxiety symptoms some time after the trauma has passed.

Combined Treatments

There is a lack of research comparing CBT to medications or examining the combination of these approaches for treating PTSD. In other anxiety disorders, CBT, medications, and combined treatments are often similar in effectiveness across groups of individuals, although any one person may respond better to one of these approaches than to the other treatments. For most anxiety disorders, the effects of CBT tend to be more long lasting than the effects of medication. In other words, once treatment has stopped, anxious individuals who have been treated with CBT are less likely to experience a return of their symptoms than are individuals who have been treated with medication. In light of these findings, CBT may be the best approach initially. For individuals who do not respond to CBT, adding an SSRI is a reasonable next step in treatment. More research is needed before recommendations regarding the relative and combined effectiveness of medications and CBT can be made with confidence.

DID YOU KNOW ...?

¢ PTSD is generally more severe or long-lasting when the trauma is of human design (e.g., torture, terrorist attack) vs. a natural disaster (e.g., earthquake)

¢ The chance of developing PTSD increases as the severity, duration, and physical proximity to the trauma increases. Other factors that increase the risk for developing PTSD include history of previous trauma and negative reactions from friends and family.

¢ When the duration of PTSD symptoms is less than three months it is termed acute. If the duration of PTSD symptoms is three months or more it is termed chronic.

¢ Although symptoms of PTSD usually begin within the first three months after the trauma, there may be a delay of months or even years before symptoms appear. Delayed onset of PTSD is said to have occurred when the symptoms begin at least six months after the trauma.

¢ PTSD is related to increased rates of major depressive disorder, substance-related disorders, and other anxiety disorders.

¢ Research on individuals at-risk for the development of PTSD has found the highest rates of onset (30 to 50%) in survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

¢ PTSD can occur at any age, including childhood.

¢ Individuals with PTSD often report painful feelings of guilt about surviving when others did not or about things they had to do to survive.


Taken from the website of the Department of Psychiatry and Neuroscience, McMaster University, Hamilton, Ontario, CANADA.

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What are the differences between PTSD and Acute Stress Disorder?

Similar to PTSD is an anxiety disorder known as acute stress disorder. Also in response to a traumatic event, acute stress disorder involves symptoms of re-experience, avoidance, and increased arousal as well. The main difference between the two disorders is twofold. First of all, acute stress disorder features a greater element of dissociation-those with the disorder experience detachment, a sense of withdrawal from reality, or, even sometimes amnesia. The other major distinction between PTSD and acute stress disorder is in the length of time the symptoms are experienced. Acute stress disorder is only diagnosed if the disturbance occurs within four weeks of the traumatic event and lasts for a minimum of two days and a maximum of four weeks. What is first sometimes thought to be acute stress disorder is often eventually diagnosed as PTSD.

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PTSD & Secondary Wounding

As important to the healing process as other people are, it's an unfortunate truth that often people do more harm than good. Strangers who don't understand your situation can be unintentionally cruel, but so can those who should know better: family, friends, and helping professionals. Instead of being supported, you have been made to feel ashamed of having been a part of the traumatic event in the first place, of your reactions to the event, or the symptoms you have developed as a result, or even for asking for help.
You may have heard, for example, "You weren't hurt enough to be entitled to benefits, " or "It happened years ago. You should be over it by now." Such attitudes exist even in the most obvious and horrendous cases of victimization.

Secondary wounding occurs when the people, the institutions, caregivers, and others to whom the survivor turns for emotional, legal, financial, medical, or other assistance respond in one of the following ways:

Disbelief:

Commonly, people will deny or disbelieve the trauma survivor's account of the trauma. Or they will minimize or discount the magnitude of the event(s), its meaning to the victim, its impact on the victim s life.

Blaming the Victim:

On some level, people may blame the victim for the traumatic event, thereby increasing the victim's sense of self-blame and low self-esteem.

Stigmatization:

Stigmatization occurs when others judge the victim negatively for normal reactions to the traumatic event or for any long-term symptoms he or she may suffer. These judgments can take the following forms:

¢ Ridicule of, or condescension toward, the survivor
¢ Misinterpretation of the survivor's psychological distress, as a sign of deep psychological problems or moral or mental deficiency or otherwise giving the survivor's PTSD symptoms negative labels.
¢ An implication or outright statement that the survivor's symptoms reflect his or her desire for financial gain, attention, or unwarranted sympathy.
¢ Punishment of the victim, rather than the offender, or in other ways depriving the victim of justice.

Denial of Assistance:

Trauma survivors are sometimes denied promised or unexpected services on the basis that they do not need or are not entitled to such services or compensation.


Causes of Secondary Wounding

In essence, secondary wounding occurs because people who have never been hurt or traumatized have difficulty understanding and being patient with people who have been hurt. Secondary wounding also occurs because people who have never been confronted human tragedy are sometimes unable to comprehend the lives of those in occupations that involve dealing with human suffering or mass casualties on a daily basis.

In addition, some people simply are not strong enough to accept the negatives in life. They prefer to ignore the fact that sadness, injustice and loss are just as much a part of life as joy and goodness. When such individuals confront a trauma survivor, they may reject, depreciate or ridicule the survivor because that individual represents the parts of life they have chosen to deny.

On the other hand, it also happens that trauma survivors are rejected or disparaged by other survivors those who have chosen to deny or repress their own trauma and have not yet dealt with their loses or anger. When trauma survivors who are not dealing with their traumatic pasts see someone who is obviously suffering emotionally or physically, they may need to block out that person in order to leave their own denial system intact.

The following sections give a brief run-down of some of the common causes of secondary wounding.

Ignorance:

Some secondary wounding stems from sheer ignorance. Especially in the past, there were few, if any, courses on PTSD available to medical, legal, and mental health professionals. Today such courses are available in many locations; however, they are not a required part of the training in any of those fields.

Burnout:

Another cause of secondary wounding is that many helping professionals are themselves suffering from some form of PTSD or burnout. As a result of having worked for years with survivors, they (like those survivors) are emotionally depleted. They may also, like many survivors, feel unappreciated and unrecognized by the general public and by those in their workplace.

Just World" Philosophy:

Another hurdle victims face is the prevalence and persistence of the "just world" philosophy. According to this philosophy, people get what they deserve and deserve what they get. The basic assumption of the "just world" philosophy is that if you are sufficiently careful, intelligent, moral, or competent, you can avoid misfortune. Thus people who suffer trauma are somehow to blame for their misfortune. Even if the victims aren't directly blamed, they are seen as causing their own victimization by being inherently weak or ineffectual.

The Influence of Culture:

Our nation was founded by individuals who overcame massive obstacles by means of hard work, self-sacrifice, and physical and emotional endurance. As a nation today, as in the past, we pride ourselves on the can-do spirit and our American ingenuity we are certain we can overcome almost any hardship. The American dream tells us that our country is so bountiful and so full of opportunities that anyone who wants the good life can have it; all they have to do is pull themselves up by their own bootstraps.

Abraham Lincoln is quoted as saying, "People can be happy as they make up their minds to be," implying that in the personal realm, man can be master of his own fate. If only he were right.


Excerpts from I Can't Get Over It - A Handbook for Trauma Survivors by Aphrodite Matsakis, Ph.D.

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PTSD Humor
compiled by Deb

Signs you are experiencing PTSD:

1. Overwhelming urge to strangle any person who suggests that you should stop wallowing in the past.

2. You fear that nothing really exists unless you kick it really hard.

3. Total familiarity with the concept that your mind exists separately from your body, and who knows where your emotions have gone, or the other way around.

4. Your friends accuse you of being antisocial because instead of socializing, you are spending your time contemplating either, bombing your therapist's office, bombing your family home, bombing your county mental health building, bombing your local social service agency, or trying to solve puzzles that open portals to Hell, you scream, "NO! I'm not being antisocial, I'm being obsessive-compulsive! If I were being antisocial, I'd beat the crap out of you right now..."

5. Your future is canceled out, deactivated and corrupted by your past. Your past can also corrupt the futures of others and should be recalled to prevent any further corruption.

6. You stop to think and then forget to start again.

7. You always assume that your gut feeling is wrong, even though you just knew that sign saying, "DANGER MINE FIELD AHEAD" was something you should have paid attention to.

8. You assume your friends hate you when they don't smile at you, or when they do smile at you, or when they sleep or when they wake.

9. You avoid hating yourself in the morning by sleeping until noon.

10. Your main purpose in life is to serve as a warning to others.

11. You use self help books as walls, dividers, room partitions and paper weights.

12. You question the nature of knowledge when you still can't figure out the nature of college.


This disorder may be caused by one or more of the following...

1. Having to try to reason with people who are totally out of contact with reality - e.g., family members, psychiatrists, social workers, just about any mental health practitioner, employers or anyone in a position of unquestioned authority.

2. Being born female.

3. Being born male, but you were treated like a female.

4. An average of 3 hours sleep per night.

5. A steady diet of either no food, only comfort food or fast food when all of a sudden you realize you are starving and haven't eaten between flashbacks.

6. Your parent's belief that dysfunction and corruption would not have a bad effect on their children and that through denial they could pretend that you didn't exist, and through lack of protection, you would learn how to fend for yourself.

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"PTSD and Me" by Patience Mason

We lived with PTSD for 14 years without knowing its name, because it didn't have one until 1980. I felt tremendous guilt, became very controlling, and started an other-centered quest for the thing that would fix my life: when I got Bob straightened out. I had no idea what was wrong but I was sure it was my fault.

I thought he didn't love me because of his emotional numbing, his attempts to isolate himself, and his lack of interest in things we had done together. I concluded I was unlovable. I saw his substance abuse not as self-medication to maintain numbness in the face of unbearable thoughts, feelings, and memories, but as deliberate naughtiness. Wild rides on his Honda 750 looked to me like stupid immaturity (except when I joined in) instead of a sense of a foreshortened future. The fact that he couldn't sleep became a joke. Rage attacks meant he was a jerk. When he couldn't remember something I'd told him, I got mad because I had never heard of the inability to concentrate, another symptom of PTSD.

My whole life became centered on fixing Bob. My upbringing told me that I could make other people happy. He wasn't happy. I wasn't happy. I figured I just wasn't trying hard enough. I knew you can do whatever you put your mind to. It never occurred to me to try another way. Even after I found out what PTSD was, my quest was still what we should do to fix Bob. I had no idea that I had problems and that my actions and reactions were making it impossible for Bob to get better. We were stuck in a series of ineffective patterns.

Finally a very caring Vietnam veteran nurse said to me, "And who is taking care of Patience?"; I realized no one was taking care of Patience. I had no idea how to do this and I was afraid to try in case I did it wrong. I felt if I made a mistake I was a mistake. I also felt like after all I'd been through and done for others they should take care of me. I resented that they didn't. I also thought I didn't deserve care or I'd be getting it. At that time I was writing Recovering From the War and first discovered Adult Children of Alcoholics literature. I really identified with the list of symptoms. Finally, I started going to an ACOA meeting (after I tried for a year to recover by just reading the books).

As I analyzed the patterns I grew up with and had developed since my marriage, I noticed that I had been affected by PTSD. My father was a surgeon in Europe during World War II. Once his hospital became part of the front line during the Battle of the Bulge. Something about the way he told me that made me realize he was talking about an experience that had really affected him. I was about eleven. He said he didn't like to talk about the war. We never did again.

Our family was organized around the principle don't bother Dad. He was brilliant, always on call, worked tirelessly, never took vacations, invented operations, had a few drinks every night to unwind. We thought this workaholics(ism) was normal. So did everyone else in America. My mother, like many other wives of WW II veterans, was left a desperately lonely woman, emotionally deprived, angry, lost. She tried to have a perfect family which entailed a lot of correcting of us kids. I grew up feeling there was something intrinsically wrong with me, that no one could love me just for myself, but maybe if I were good enough I could earn love. I consider this feeling, which is very common, a direct legacy of trauma. We had things, but we didn't have emotions or permission to be imperfect, human.

I've worked on myself since then, learning to change patterns of behavior in myself that are not the way I want to be. I can only change one day at a time, (much more slowly than I'd like), but that gives me compassion when I see how hard it is for others to change. This has let Bob recover in his own way: His symptoms are much less distressing to him and to me than they were. Five years ago, I wrote in Recovering that Bob absolutely could not say when he was having a bad day. Today he can. That is a miracle.

I don't know what your situation is. Whether you grew up with PTSD or your partner has recently been traumatized, whether you see a family member as the problem and the rest of you as fine, or you know that no one will be unaffected by a trauma even if it only strikes one of you, read and educate yourself about trauma and work at recovery for all family members. A lot of books reviewed in this issue can help. Families are systems.

What affects one member will affect others. In "Bridging Normative and Catastrophic Family Stress", in Stress and The Family, Vol 1. McCubbin and Figley, eds., 1983, Charles Figley describes the ways functional and dysfunctional families cope with trauma. Functional families acknowledge and accept that there has been a trauma. The problem belongs to the family and they look for solutions and are willing to change rather than seeing it as the survivor's problem and blaming him or her for it. They seek outside help and are flexible about family roles. It is pretty humbling to go through such a list and see yourself in the dysfunctional column every time, but today I can forgive myself for that. I was doing the best I could do at the time, following patterns I grew up with or developed out of ignorance. If you are in that situation and you've picked up this Gazette, please read on and find the help that works for you. There was nothing available like the PTG or the books I am reviewing in this issue when my Mother was struggling with my Dad's unavailability. Nothing was available to me either when Bob got back from Vietnam. Years later I wrote the book I wish I had had, Recovering From The War. Today there is lots of help, lots of books are available for all types of trauma, PTSD has a name, and there is treatment available. I am grateful that today no one has to get as dysfunctional as I did.

©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice) and is distributed free of charge.
Edited by bluelicorice on Feb. 16 2003,13:40

[firelizardee]

How Does PTSD Affect Families? by Patience Mason

Lots of families struggle with some of these:

¢Everyone focuses on the survivor's problem: The family system becomes focused around the survivor's symptoms of PTSD. Feeling good about ourselves depends on how well the survivor is doing. We're brought up to believe that if we are a good enough wife, mother, father, husband, child, our family members will have no problems. (Don't believe it. Everyone has problems). The trauma survivor often will agree. Survivors often have no idea that their behavior is in any way related to the trauma. Yeah, I'm upset because you don't keep the kids quiet. Yeah, I'm having these problems because you're so messy. Yeah, if you kids were good, I'd be fine. Don't believe this either. Nothing we do, no perfection in us, can change what happened to our survivors in the past. There are no time machines.

We tend to think we are fine and the survivor is not, that if the survivor would get better, our lives would be fine. To keep the family system running smoothly, we may develop patterns which are ineffective for dealing with our loved ones, patterns which keep them stuck, like always rescuing them, calming them down, cheering them up, looking for a solution.

I used to do this all the time, trying to fix Bob. I didn't know he had PTSD, but I knew he had problems (not me) so I kept coming up with solutions: read this book, see a shrink, move, new job, read this book. None of them ever worked, partly because I did not know what the problem was (PTSD) but mainly because I didn't know whose problem it was. I thought it was my problem. I thought he was my problem. I saw no egoism in this. I saw myself as a very loving giving person who would do anything to help her husband. I didn't see that I also couldn't tolerate his very natural emotions because I thought trying to cheer him up and keep him from expressing anger was nice. I could not allow him to express anger, sadness, despair and so he was unable to heal. I failed to see the resentment and fear his pain raised in me but it came out in the occasional tearful indignant bout of recrimination or in sweetly self-pitying remarks like "Honey, why aren't you ever nice to me? and; followed by helpful hints on how to be nice. I was a bit hard to live with.

Despite my intentions my actions (nagging, instructing, demanding, hovering anxiously over them, being unable to let them feel what they felt) were often quite painful to my family. Everything I did was for a payback (not that I knew this). Bob was supposed to love me and make me feel good about myself. When he couldn't, I could feel better than him, after all I did for him. It was not an effective way to get love.

¢ Co-dependency: Not all people become as dysfunctional as I did. On the other hand if you think PTSD hasn't affected you, maybe it has and you can't see it. I couldn't and I'm a magna *** laude college graduate. I spent years trying to control Bob's PTSD symptoms without knowing what PTSD was. I felt I caused them, I could control them if I could just figure out how to be a better wife, and I could cure them if we just found the right self-help book, treatment or whatever. These are the three C's of co-dependency. I once heard Janet Woititz (author of Adult Children of Alcoholics) say and How do you tell if you're codependent? If you're dying, someone else's life flashes before your eyes." How I laughed! If I had been dying, Bob's life would have flashed before my eyes because I didn't have a life. He was my life!

Some of us also try to control whatever it is the survivor is using to cope with PTSD: drugs, alcohol, food, sex, risk taking. The word co-dependency, like the diagnosis of PTSD, developed from work with actual people, the wives of alcoholics who did not suddenly become happy when their husbands got sober. I find it a really useful concept. If you don't like the word use another one. For me the essence of codependency is that other-focus. I will be fine when something outside my control is the way I want it to be. For me it was "when Bob gets better." (There's a parallel here to the bargaining stage of grief and I was feeling a lot of grief over my failure as a wife.) As a result of this other-focus, codependents become reactors and lose the capacity to act. They tend to forget themselves while focusing on the someone else, on helping or fixing him or her. Losing track of what you want, what you like, dislike, need, and of what you feel means you don't know how to take care of yourself. A person who is incapable of taking care of herself is not someone I would turn to for advice, yet I expected Bob to follow mine!

¢A vicious cycle: If like me, you have been dealing with PTSD for a long time with no (or bad) help, and without taking time out to take care of your own needs, you may be caught in a cycle. We start out full of love and pity (the rescuer) to help the survivor , but if we don't know what the problem is, our solutions don't work. Furthermore, PTSD is not our problem, so we can't solve it. It is the survivor's problem. (This is called a boundary issue.) When our solutions don't work, we get p***** (the persecutor) and start saying things like, "If you just did what I suggest, you'd be fine!" or worse, "Why aren't you over that yet?" Then we start Biotching to our friends (the victim), "Let me tell you what he/she did to me this week!" After we've been mad for a while, some new solution comes to us and we go through the cycle again. And again. I did.

It never occurs to us that our solutions can't work for our survivors because we are not them. Part of recovery for trauma survivors is regaining control of their lives, so following our directions is not healing. Resistance to codependent suggestions can be a sign of healthy individuality as opposed to unhealthy enmeshment.

¢Personalizing: The families of trauma survivors may personalize everything due to our very natural frustration. I feel hurt, therefore he or she meant to hurt me. Feeling Good, by Dr David Burns talks about this kind of cognitive distortion. The book was very helpful to me and Bob. Family members feel the survivor is doing this to me. Angry at me! Depressed because of me! Jumpy because of me! Numb because he doesn't love me anymore! It may have nothing to do with you, but if you are wrapped up in someone else's life the way I was it is almost impossible to conceive of the idea that something not related to the relationship is at the root of the survivor's reactions. And of course being human, survivors will tell you it is your fault, especially if they don't know about PTSD. Yeah, if you kept the kids quiet, I wouldn't be so jumpy. It's not true, but it seems reasonable so we try harder and harder so the survivor won't be upset. It doesn't work. There is also a seductive egotism in personalizing everything”we are so important. This can also lead to the idea that after all I've tried, if I can't fix it, nothing can. Don't believe it.

¢ Develop survivor thinking: We also may take on the world view of the survivor: become isolated because our friends dump us or we dump them over the survivor. We may live in a state of constant anger based on "Why is this happening to me?" We become mistrustful after the cruel things people say to us about our survivor or because of misdiagnosis and mistreatment by professionals. Makes it hard to trust that getting worse in therapy is going to get them better. (It will.) We become depressed because we keep trying and nothing works. We feel guilty because we can't fix this and that proves we are bad people. We have low self esteem because we know if we were doing this right our loved ones would not be having these problems. When everything is on a downhill spiral we become fearful. We can't act, only react to whatever happens so our lives feel totally out of control. We develop tremendous self-doubt. I used to wonder if it was normal to want hugs. Bob didn't seem to think it was and I couldn't tell anymore. That was why I found ACOA books so helpful in understanding my own life: the first characteristic on the ACOA list was "ACOA's do not know what normal is." Neither do people who live with undi agnosed untreated PTSD. We wind up walking on eggshells, trying to keep from upsetting our survivor. We are numb, because after all we've tried, all the times we've gotten our hopes up, all our effort, we can no longer afford to have feelings. We feel helpless, hopeless and that it is all our fault because we know that if we were good enough wives, partners, parents, children our loved ones would not have problems. We are also exhausted by the multiple roles we may wind up assuming to keep our family together: spouse, friend, confidante, wage earner, sole parent. Children of trauma survivors are often forced into parental roles at an early age, sacrificing their childhood to help hold the family together.

¢Denial: Denial that there is a problem rears it's head, and then denial that anything can help because we've tried everything. We wind up blaming each other and trying to be perfect so no one can blame us for anything that goes wrong.

¢A stable dysfunctional system: We cycle through this stuff over and over. It's not comfortable or flexible. This kind of family system is not good at dealing with change. New problems are catastrophes to which we can only react. The family gets progressively more dysfunctional. Both survivor and family become more stuck, more ineffective, more unhappy. Behavior that would not have been tolerated at first eventually becomes everyday.

¢Perpetuating the problem: Family members do not identify how their behavior can help perpetuate the problem. After all we are only trying to help.

Over the course of time our genuine loving caring can become directing or manipulation. This quite naturally leads to resistance. Even if what we are advising would help, the survivor is not going to do it because he or she needs to keep some feeling of control in his or her life. That is what they lost when traumatized. Traumatized people develop very sensitive control/manipulation detectors because they could not control the trauma. Autonomy is one of the goals of recovery. (Many therapists fail so miserably with trauma survivors because they, too, are codependent. Rather than empowering the survivor to recover, they believe they have the power to fix people if they'll just follow directions.) We also may care so much we lose our ability to tolerate the survivor's pain and start telling them to get over it.

Trying to be helpful can become shameless having to be right. Bob used to tell me I would die before I would admit I was wrong. I remember thinking it was too bad he was such a sore loser, because if I had been wrong, I would have admitted it. It just so happened that in the course of the first 25 years of our marriage, I was never wrong. Today I'm often wrong. I no longer mind making mistakes. I tell myself I'm working on my perfectionism.

Finally, our victim attitude (look what you did to me/ made me do) leads to healthy resistance in the survivor or to feelings of shame and hoplessness if they believe you. The fact is we have problems, too. Every one does. Healthy survivors resist our view that everything is their fault and we have no faults.

We develop these characteristics because we are human, want to help, but don't really know what would be helpful.

PTSD can affect even functioning families in many ways. In one study of families of Vietnam veterans with PTSD, all of whom were successful enough to have private insurance, Linda Reinberg, PhD, a psychologist in private practice, found that the mothers were just as or more depressed than the veterans. The kids were depressed too. The families felt different from other families and felt grief over that fact. The dads were overprotective and emotionally distant. The kids thought they and their mothers had to take care of dad. The kids had a cluster of symptoms: aggressiveness, underachieving at school, feeling they had to take care of their parents, numbness, problems with concentrating, an impaired feeling of belonging, and a tendency to self medicate with alcohol and drugs.

Other family effects of PTSD: Childhood abuse survivors may pass the abuse on because they are often so numb they cannot tell how much it hurts. "It didn't hurt me to be whipped," they say, trained to think of abuse as discipline. "My dad messed with me and I'm ok. Why is she whining so much?" a numb incest survivor says.

PTSD can lead to violence and terror in the home. People in flashbacks or rages are terrifying. So is the sound of someone screaming in a nightmare. Survivors hit out in their sleep, and if you get hit, it's traumatic. Rage attacks can wind up in beatings. The traumatized families of trauma survivors have PTSD of their own. Remember a traumatic stressor is worse when the cause is human neglect or human cruelty. Think how much worse the effect is when the neglect or cruelty is from your beloved partner or parent.

Dual survivor families are pretty common. Sometimes the very thing that attracts two people is their perhaps unconscious recognition that someone else has been through the fire and can understand. It turns out not to be so easy to live with, however.

Denial and numbness affect families profoundly. Secrecy becomes a family pattern: Don't talk, don't trust, and don't think or feel. This causes major problems because you not only keep what is going on at home secret from others, you keep it secret from yourself and you cannot take care of yourself.

Numbness hurts family members. We don't feel loved. Numbness discounts us. We feel we don't matter. We become defensive. 'So what's your problem?' comes up a lot in numb households. Denying the affects of trauma makes it hard to be accepting or helpful to the everyday problems of others. Kids especially get discounted.

The survivor's numbness teaches family members not to feel either. We can't take care of ourselves because feelings are what tell us how to do that. Numbness teaches us that we are not important and we become people who will do anything for love, like the generation who went off to Vietnam to earn America's love or became hippies to get free love.

The PTSD family may produce kids who have to look good so the parents can feel good about something (family heroes); or who have to be bad (scapegoat) so the parents can focus on the problem child and try to straighten him or her out instead of facing their personal PTSD and relationship problems. If you have a perfect child and a bad child, you might want to look at this.

Spouses and children from undiagnosed, untreated survivor families are often afraid to hope, afraid of what will happen next. We try to control everything which makes us bone weary and desperate. We, too, need help.

Today there is more information available on PTSD and more help. People do not have to reach this level of dysfunction if they are willing to educate themselves about PTSD and then to work together as a family to get the help they need to recover.


©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice) and is distributed free of charge.

[firelizardee]

How Families Can Recover by Patience Mason

As I said before, families are systems and what affects one family member affects the rest of the family. To expect a trauma survivor to do all the recovering is to place an unfair burden on him or her. It is also unrealistic to expect to be unaffected by the problems of your nearest and dearest.

If someone you love has recently been traumatized or has recently disclosed something traumatic to you, self examination is in order. Do I expect miracles (just put it behind you)? Am I willing to see that I may have been attracted to this person because he or she was numb, hypervigilant, needy, etc? Am I willing to face this possibly long and painful journey as I would if my partner had cancer, or am I going to bail out? No one can answer this for you, but remember that all people have problems. This one is treatable. If you work together the prognosis is good. If the survivor isn't willing to work, you can still have a good life if you work on your own recovery. And your recovery will rub off on your family.

Even if you are new at this and have not become as focused in on fixing the survivor as I was, it is going to be difficult to watch someone else go through the pain of recovering from trauma. What are you going to do when your survivor is upset or crying and you suddenly want to "cheer" him or her up? It is the wrong thing to do. How do you find the strength to let the survivor feel what he or she feels? You need your own support system whether it is friends who understand, a professional, or a group of people who have been through something similar. You need to know that it is okay to take care of yourself. Listen when you can and when you can't, be honest about it. Get help for yourself. Trauma is disaster, but it doesn't have to stay disaster. It can be an opportunity to grow. I'm not glad that Bob saw so much blood and death in Vietnam, but I am grateful that coping with the aftermath gave me the chance to grow, change, and do something that has been of value to others.

One of the reasons I've focused so much on the long term affects of living with PTSD is because there are so many families struggling with undiagnosed PTSD out there.

To recover, family members need to take the focus off the survivor. By focusing on ourselves we take the burden of "making us happy" off the survivor. That makes it easier for them to deal with their problems if they choose to. It also makes it less easy for them to blame their problems on us.

We also put the focus on what we actually do have the power to do, changing our own actions and reactions. We cannot change others but we can waste our whole life trying.

Furthermore, when we start to take care of ourselves, we show (not tell) our survivors that it is okay to take care of themselves. Playing the Lone Ranger, doing for others and never asking for help, does not fit with what we're telling the survivor to do and get help! Why should they if we don't?

When I started getting help, Bob became more open to taking care of himself. He didn't do it in ways I wanted him to, but that is okay. I have to let him be him. I do not rub it in if he makes a mistake. I am also able to accept and learn from my own mistakes. The only way people learn is from their mistakes. Two-year-olds don't give up on walking because they stumble or trip and fall. They keep trying 'til they develop the skill they need. Grownups can do that too.

When either partner gets help the family patterns change and that is upsetting for everyone. It doesn't feel safe. Keep that in mind.

If your survivor goes for help, you may go through a process of mourning. Denial (we were just fine 'til you got into therapy/AA, etc.), anger (you and your d*** therapist/group), bargaining (stay home and I'll love you), sadness (I'm afraid you'll change and not love me), and finally acceptance are the stages you may cycle through a number of times. I had to give up my clear rescuing focus (no one else cares, but I do). I had to admit I was powerless to fix Bob. I felt like I had lost so much because of his PTSD, I didn't want to lose the idea that I had the power to fix this and just wasn't doing it right. It was reality, however, and although I cried over it, I realized it was true.

Then I had to admit I had become dysfunctional over the years as I tried to cope with PTSD. This about killed me. I was really ashamed of it. I thought I should have known about PTSD and codependency before the terms were even invented and should have known better than to become codependent. Today I have a recovery slogan I invented for when I'm should-ing on myself: everything after the word should is bulls***. It was very hard to admit I had problems, and it hurt.

Even though I had never been a group person, I went to a support group. I simply could not change my behavior on my own. I could not stop telling Bob how to feel, drive, think, talk, etc. Nor could I stop obsessing about his problems long enough to work on mine. In a 12 step ACOA group I found what I needed: tools I could use and time to use them and other people who were using them. I learned from seeing them take new suggested actions that I could, too. Progress not perfection was one motto I loved. Another was Whoops! I used to say, "Whoops! That was an entirely free sample of my codependency. No charge and sorry about that!" when I slipped back into control. Bob would laugh instead of getting mad.

Getting help for yourself may feel selfish and your survivor may accuse you of selfishness. It's a sign of caring. Survivors usually don't say will you still love me if you change? What they usually say is why the hell are you going to that dumb meeting again! I want you here. Translated, that means "I love you and I am scared." Use a "broken record" to deal with that. Say over and over in a kind, caring and concerned voice, "I love you and I'm going to the meeting because it helps me feel good about myself and I'll be back at __."

Recently in the Al-anon Forum, I saw the essence of good communication phrased thus, "Mean what I say, say what I mean, but not say it mean." Not saying it mean was the hardest part for me because I thought I didn't have the right to say what I felt or wanted, so I'd scream or snarl or sulk. Now that I know I have that right, I can say things in a kind caring and concerned way. Somehow people hear me better.

Learning to listen was probably the healthiest thing I did for myself. When I'm listening to Bob, we're being intimate. I also had to learn to ask for what I need. "Bob, I need to whine and snivel about something for a minute, but I don't need you to give me a solution." That's how he learned to listen to me. I read PET (Parent Effectiveness Training) by Dr Thomas Gordon which is a book about how to listen and empower children to solve their own problems. Straight Talk by Miller, Wackman, Nunnally and Saline, and Messages by McKay, Davis and Fanning are two other communication books I read and found very helpful. There's a whole chapter on this in Recovering. Learning to communicate effectively is respectful of both yourself and your survivor. If you already know how to do this it will help in the recovery process for you both.

Principles of Recovery:

Respect the trauma and the survivor.
Respect the pain of your partner who has been affected.
Rethink your lives in a no-fault way.
Develop and practice respect for each other.
Don't compare pain but share it.
It takes time.
It is okay to hurt.
We heal by degrees.

For me it is important for me to respect Bob's experiences of trauma. He has been affected. He will never be innocent and unaffected, but that is okay today. I had to rethink our lives in a no-fault way. His PTSD is circumstantial evidence of the hell he went through. My codependency is evidence of how much I care. Our problems are evidence of how hard it has been for us both, but we can recover. It is not our fault that we have had this particular problem in our life.

Finding good help is important. Most of the books I've reviewed in this issue cover finding a therapist or group. Next issue is on 12 Step recovery which is where I've gotten most of my help.

To recover we have to develop and practice respect for each other. We don't compare pain but we can share it. I feel about Bob the way he felt about the wounded guys he tried to save in Vietnam. He can identify with that.

I had to give up blame and develop compassion (which I thought I had). I had to learn to agree to disagree, that having to think alike was a sign of a dysfunctional family. I had to learn to respond rather than react, which is like having an emotional pause button. I had to detach and work on me.

It says in the Al-anon One Day at a Time, "I do have the power to change myself and nothing can prevent it but my own unwillingness. Never let me imagine that my satisfaction with life depends on what someone else may do..." (August 21) Those are words to live by for me today. That doesn't mean that I don't sometimes want to change Bob or fix him. I suspect I'll recycle those feelings occasionally for the rest of my life. That's okay. But when they do come up, I look within to see what is going on with me and work on that. Bob is fine just the way he is. He went through hell, he has scars, and I love him anyhow.

Recovery from fixing others is a slow process. It takes time. It is okay to hurt. We heal by degrees. We don't have to do it perfectly or on someone's timetable. We are pioneers in a new field (PTSD families), and we are working out the ways we can recover, one day at a time.

If you haven't developed a lot of the dysfunctional patterns I did, focusing on family recovery will help you. Remember, it is okay to say you are overwhelmed and can't listen any more. It is okay to ask your survivor for help. They aren't helpless. They survived. It is okay to take care of yourself. Look for help and you will find it.

If someone as defensive and dysfunctional as I became could recover, anyone can.

Good luck!

©1995 by Patience H. C. Mason. All rights reserved, except that permission is hereby granted to freely reproduce and distribute this document, provided the text is reproduced unaltered and entire (including this notice) and is distributed free of charge.

[firelizardee]

All posts were originally posted by blueliquourice on the original DF board.

[firelizardee]

POSTTRAUMATIC STRESS DISORDER (PTSD)

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.

Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult.

PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person--such as a rape, as opposed to a flood.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.

Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.

Specific Symptoms of this Disorder:

The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror.

The traumatic event is persistently reexperienced in one (or more) of the following ways:

recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

recurrent distressing dreams of the event.

acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).

intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

efforts to avoid thoughts, feelings, or conversations associated with the trauma

efforts to avoid activities, places, or people that arouse recollections of the trauma

inability to recall an important aspect of the trauma
markedly diminished interest or participation in significant activities

feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)

sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

difficulty falling or staying asleep

irritability or outbursts of anger

difficulty concentrating

hypervigilance

exaggerated startle response

The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition.
Washington, DC: American Psychiatric Association.

National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995)

[melpointy]

Just curious if anyone agrees with this.  My therapist states I suffer from PTSD along with bipolar and bpd.  He said the PTSD comes from my childhood because I was stabbed 3 times by my birth mother who was psychotic and bipolar, I was only 22 months old.  I argued with him because I do not remember any of this happening.  I do not remember the pain, almost dying, the foster homes etc..  I only have memories from age 10 on up.  He states my body holds the memories but I am confused on this I feel if I don't remember or have any memories how can I suffer from PTSD.  I do get startled easily and have bad anxiety but that is the only symptom.  

Does anyone else agree with not having memories and still suffering from PTSD.

Melissa