The Unified Theory of the Nervous System
and Behavior
Cognitive Philosophy /Brain Theory by Steven Michael Harris
Trauma's Aftermath: Coping with PTSD (Healthology, 11/3/2004) (link retired)
The best approach to preventing and treating PTSD has been hotly debated in trauma centers and in the media in recent years. And a controversial drug now under study may help suppress memories that could lead to PTSD. Below, James Chu, MD, the chief of hospital clinical services at McLean Hospital in Belmont, Mass. and an associate professor of psychiatry at Harvard Medical School, discusses how PTSD, and the way one copes with it, varies from person to person.
Do they have any idea how problematic for the health of the patient this kind of theory or practice in medication can be? To suppress the memory is to reduce function in the brain which is a medication version of shocking the brain into amnesia. This is the same thing that happens with antidepressant medications that eliminate some access to depressive memories as well. When you medicate the memories away you are further inhibiting the function of a brain that is suffering from inhibition already. This leads you closer and closer to the kind of denial of reality that occurs in a brain that is manic. (Prediction: Watch the studies of this new treatment for PTSD and look out for side-effects of some patients developing schizophrenia or bi-polar disorder and see how the doctors backpedal away from this side-effect by saying that they “unmasked” an underlying condition - of bipolar disorder or psychotic disorder - with the use of this new medication treatment.)
PTSD is a kind of withdrawal from stress just like a drug withdrawal. When the stress goes away the denial of the stress or amnesia for the stress starts to go away and the return of function (the return of memory which, in these cases, is a painful memory) causes pain and interferes with other subsets of functioning. The concept that needs to be learned here is the concept that a withdrawal event can be permanent or stuck. The function returns (painful memory) but the stress in this subset of brain processing interferes with the functioning of other subsets for a greater or lesser (or, apparently, permanent) amount of time depending on the patient.
The problem with PTSD is that the function (memory) returns but it is stressful and it involves many aspects of emotion which is closely linked to many physical and mental processes (switchboard of the brain) and so it interferes with many kinds of functioning until, through therapy or time or, usually, both, it becomes a less stressful memory through greater perspective about the current situation being different than the time of the trauma or through habituation (as any thought repeated over time becomes “habituated” to lose its impact or influence if the obsession with the pain can be broken). Since stress increases in the body with time, this can be a difficult cycle to break until the concept of another kind of medication treatment that increases function but, temporarily, causes an increase in pain like a drug withdrawal event is a concept that is grasped by the pharmaceutical establishment and put into practice.
What is PTSD?
Exposure to extremely traumatic events-including situations where one witnesses death or serious injury to somebody else, or where someone is in fear for their own life-is actually fairly common. Many people get through these events without many residual effects. But some people who have such an experience later go on to develop post-traumatic stress disorder. They can either develop it immediately after the event, or in some cases they may develop it months or years after the event occurred.
Notice how the PTSD is described as happening after the stress is removed here: either directly after the event or long after the event. This matches the timing of the concept I mentioned above showing PTSD to be like a drug withdrawal where the unpleasantness occurs after the stress (trauma or drug) is removed from the experience of the patient. (Most who experience PTSD “shut off” their feelings during the actual stressful event. This is one of the common defining characteristics in the PTSD patient compared to the others who don't have as much as a problem with PTSD after experiencing the same traumas. You are more likely to develop PTSD if you are the kind of person who goes “numb” during the actual stressful experience, which might make it more likely for you to get through the experience, paradoxically.)
How do you know you have PTSD?
A diagnosis of PTSD is usually made when four symptom clusters come together. The first is that event itself took place. The second cluster is the experience of intrusive memories, thoughts, nightmares and/or flashbacks of the event. The third cluster has to do with trying to avoid thinking about or remembering the event. People might try to avoid situations that might remind them about the event, and they tend to feel emotionally constricted or numb and avoid social contact. The fourth cluster has to do with how the body responds physically. People develop what psychiatrists call chronic hyperarousal, which is bodily activation that results in chronic anxiety, jumpiness, panic attacks, irritability and disturbed sleep.
The flashback is a kind of withdrawal. The denial, the repressed memory, awakens, but it is a very stressful experience to have this function return so the stress of this memory shuts itself off again into denial or repression until another day when it returns with the same pain again. (You can stop this cycle with therapy that forces the patient to stay with the painful memory until it loses its power to be repressed again and loses some of its impact emotionally. In this sense, many psychology theories are actually right in that they are increasing brain function by bringing the patient through repressed memories but psychological theory does not yet embrace how many parallels to drug withdrawal are involved here.)
Disturbed sleep occurs because the lower stress levels during sleep make it easier for the repressed memory to return as it is the stress that causes the memory to automatically shut off. Stress causes cells that would normally fire during a certain combination of influences to stop firing in a very basic way throughout the brain. (Actually it is both lower stress and higher stress during sleep that causes the memories to return during sleep because the switchboard of the brain pretty much shuts off during sleep - higher stress - which allows the memory to return without the emotion attached to it, at first, but the memory is strongly associated with the emotion so it wakes up the emotion in short order and often wakes up the person too at this time.)
Who is particularly vulnerable to PTSD?
There are probably some people who are born with more potential to be traumatized than others. Conversely, people who have had a lot of personal support in their lives, who have good coping mechanisms, and who maintain positive attitudes may be at slightly less risk for developing PTSD.
All mental disorders are expressions of stress (experiential, genetic, chemical - it is the same thing). Examine if the patients already had any other disorder such as ADD and you will find a difference in the way they respond to a traumatic event. (The tendency to get “calm” or “numb” during a very stressful event and then feel it later is a common characteristic of those with ADD/ADHD or Aspergers.)
How is PTSD treated?
Treating PTSD very much depends on how severe it is and what people bring in terms of their own personal strength and abilities to the treatment. There is some general agreement that if someone can confront the traumatic events and feelings and gain some perspective over them, what was once overwhelming is then much better understood, accepted and integrated into their other experiences.
This is in agreement with what I wrote above concerning habituation along with the association of less stressful information (concerning perspective about the current situation relative to the past stressful event).
However, people come to treatment with a very wide range of abilities to confront the traumatic events themselves. People must have a kind of solid ground to stand on-in terms of structure in their lives, solid coping abilities and a good social network-before starting to cope with memories of the trauma. Trying to confront traumatic events without developing such skills can lead to persons once again to feeling overwhelmed and out of control.
In this paragraph the author lays out evidence that supports what I wrote earlier regarding how people with different underlying disorders have different ability to cope with PTSD, but then the author misses that observation in the explanation of how coping strategies or a solid social network are necessary to cope with the trauma. All disorders cause a problem with developing social networks or social awareness. If a greater problem with PTSD is indicated by a weak social network, then an underlying social disorder or developmental disorder might be indicated as a contributing factor to the severity of the PTSD.
What kind of therapy is recommended?
Most of the therapy that's done for people who are traumatized is a mixture of different approaches that include psychodynamic, interpersonal and cognitive behavioral perspectives. There are some kinds of specific cognitive behavioral approaches that have been shown through research to be helpful. For example, there is stress inoculation training (SIT) through which people learn a series of skills in terms of coping with anxiety, coping with their bodily reactions, such as jumpiness, and learning how to deal with stress. There are also types of exposure therapies such as progressive desensitization, in which people gradually approach remembering the trauma in increments that they can tolerate.
Are psychiatric medications a part of treatment?
There are a number of psychiatric medications that do have an official FDA indication for PTSD. Those are mostly some of the newer antidepressants, the selective serotonin reuptake inhibitors (SSRIs). However, the effectiveness of those medications and a variety of other psychiatric medications varies enormously by patient. Anti-anxiety drugs can be used to try to deal with the panic, jumpiness, and insomnia. Some PTSD patients may do well on mood stabilizers, beta blockers (which help control the manifestations of bodily overactivation) or even antipsychotic medications that may help agitation and anxiety.
I am willing to bet that the progressive desensitization therapy mentioned above does not work as well if the patient takes any of these medications mentioned above. The drugs further stress the system so the memory stays away (avoids withdrawal).
Can be PTSD be prevented?
In the wake of the 9/11 tragedies, help was rushed to the various sites to do grief counseling and to provide early interventions that might prevent the emergence of PTSD. The problem is that there really isn't any time schedule whereby people develop PTSD. Some people will immediately feel the stress and continue to be symptomatic. Other people may feel numb and not have much in the way of symptoms until much later. In fact, two years after 9/11, when some people were just starting to have symptoms, many of the programs that have been put in place immediately after the event were being dismantled.
(More evidence of the parallel between drug withdrawal and post traumatic stress.)
Can the drug propranolol affect memory and prevent PTSD?
The use of propranolol to prevent the development of PTSD is still highly experimental. In studies it has been given immediately after traumatic events, for example, in the ER following a car accident. It blocks some of the body's normal "fight or flight" hormonal reactions. These hormonal reactions are thought to heighten and enhance memory of the events, so that if they are blocked, the event is remembered in a more normal, non-traumatic manner.
The theory that a drug blocks “fight or flight” is only a theory and is as much a mistake as the entire “fight or flight” concept is a mistake, especially concerning how it is associated with “brain chemistry” which is another concept that leads to mistaken concepts of how the brain works.
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