GFW PTSD Home | Site Map
Gift From Within
PTSD Resources for Survivors and Caregivers
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| Dear Friends: Every month I will ask Dr. Frank Ochberg a PTSD related question. These are questions based on conversations I've had with Gift From Within Support Pals, and other trauma survivors. We will also have guest clinicians answering questions. I hope you find this exchange helpful. Please keep in mind that the info on this page and website is not a substitute for the advice given you by your own health professional and is for informational purposes only. Please check back often. If you would like to add this link to your website, please contact Joyceb3955@aol.com |
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| Borderline Personality Disorder Q: Dear Frank, We received an email asking what is Borderline Personality Disorder. Can you give us a short synopsis of this condition? A: Dear Joyce, Diagnoses, particularly personality disorder diagnoses, tend to pigeon-hole people and diminish their complexity and humanity. Borderline Personality Disorder (BPD) certainly has been used by some mental health professionals to label rather than to explain. Let me do my best to explain what is intended and what can be learned about this complicated condition. |
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| First, borderline was intended, almost half a century ago, to be the boundary between psychosis and neurosis. Some people were observed to have difficulty managing anxiety (neurosis), but they also lost touch with reality (psychosis) when extremely distressed. Unlike persons suffering from schizophrenia or bipolar disorder, they were usually free of prolonged episodes of disordered thinking or of mood fluctuations. But they often had relatives who were diagnosed with these disorders (schizophrenia; bipolar). So some psychiatric researchers, particularly those who focused on biological issues, believed "borderline" was linked genetically to the spectrum of major disorders of thought and mood. Some "borderlines" are also "bipolar," less frequently, "schizophrenic." Second, borderline, or BPD, appears to be driven by problems of attachment to the mother, beginning in late infancy or early childhood. The very first criterion for giving the diagnosis is "frantic efforts to avoid real or imagined abandonment." Therapists who follow Freudian and similar theories look for significant events in the early stages of life, formative events, and they place great weight on such life-shaping experiences. In the case of BPD, these therapists believe that the little child, one and one half years to three years old, was separated, physically or emotionally from the mother, and there were no other sources of reliable comfort available. The child felt abandoned. The emotion was one of extreme fear and it turned into rejection of the mother. With child-reason, full of fantasy, the youngster began a fruitless search for ideal protectors (guardian angels) and became vulnerable to the second criterion of BPD: "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation." I have been on the receiving end of this pattern, admired beyond reason then reviled with rage. Most therapists understand and tolerate borderline emotion, realizing it is based on child-like reason. Most unfortunately, this condition includes feeling dead inside. Some people with BPD will cut themselves, not because they are suicidal, but because they want to feel something real. Physical pain is, on occasion, preferable to feeling dead. Persons with BPD are confused about who they are and what their life really means. Because BPD includes such intense emotion, interpersonal relationships are roller-coaster affairs and are very confusing, sometimes infuriating, to the partner. Violent abuse or insensitive rejection follows. Persons with BPD are often victims of trauma. From the perspective of the therapist, this is a real challenge. Warmth and collegiality are misinterpreted as deep, personal friendship or as sexual signals. It is a mistake for a therapist to encourage anything but a professional relationship when treating a person with BPD. You have to keep boundaries clear with a borderline person. It just helps to know that our biology and our earliest experiences may make us exquisitely sensitive to rejection from a parent-like person, setting us on a very difficult path of being drawn to such persons, seeking love in all the wrong places, then causing us to turn on the person we were once attracted to --attracted to for reasons that have more to do with our infancy than with current reality. |
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| Social Phobia Q: Dear Frank, Could you discuss Social Phobia? One GFW correspondent asks, "Is social anxiety hereditary at all? My father is agoraphobic to a degree and will only leave the house for 1 of 3 places. I am not agoraphobic, but I have social anxieties in crowds, with people, in waiting rooms (a lot), etc. So I'm just wondering if there's a connection. My psychiatrist gave me Ativan to use in social situations. Besides talk therapy and medication are there any other forms of treatment (say exposure to social situations)?" Another notes, " I don't have it (Social Phobia) as a disorder, but being away form home or out in groups can freak me out. I try not to fall apart or get too anxious when alone at parties or at events when I don't know anyone. I have currently joined an agoraphobic, general anxiety and panic group so its interesting being on line with people who haven't been grocery shopping outside for years." This may be a condition that several GFW website visitors have encountered in themselves or others. A: Dear Joyce, There is a recognized diagnosis called Social Anxiety Disorder and it is also called Social Phobia. I knew about it as a psychiatrist, but hadn't met many people with the condition until recently. Now, probably by coincidence, but perhaps because I am on the lookout for it, I find that five of my patients fit the description exactly. And they never knew they had the diagnosis, nor did their closest friends and relatives. Just knowing that the condition exists can be a powerful source of help, with relief from confusion and embarrassment. There are many forms of anxiety in which people experience fear, dread, physical symptoms such as rapid breathing, palpitations, tremors, sweats and a sense of being near death. Extreme anxiety is no simple matter. Some people describe it to me as suffocating or drowning. I always take it very seriously. When the anxiety is always caused by a particular trigger -say the sight of blood or a spider or a snake- it is called Simple Phobia. There is nothing simple about Simple Phobia because it results in a state of terror. But it is called Simple because one specific creature or condition is the cause. When the anxiety is caused by certain types of environments -wide open spaces or crowded marketplaces- it is called Agoraphobia (from the Greek agora meaning market and phobia meaning fear). Agoraphobics often isolate themselves at home. The poet, Emily Dickinson, ended up living in her bedroom. But Social Anxiety Disorder isn't exactly Agoraphobia or Simple Phobia. People with this phobic condition can make friends and trust certain individuals, but they have a strong negative response to social situations that place them on the spot. A college student who is my patient can go to class, which he finds impersonal and non-threatening, but he can't go to a party unless he is with well-trusted friends. If his friends were to leave him at the party he would "freak," just as the second writer above describes. "Freaking" means needing to escape but fearing that leaving would be rude, attention-getting and might create a scene. Staying with strangers feels like drowning. This is far worse than ordinary fear, and seldom understood by classmates. Another patient feels betrayed by best-friends who think they do her a favor by introducing her to their friends, then leaving her. A person with Social Phobia is extremely vulnerable to abandonment, because the trusted friend is like a scuba suit and an oxygen tank for a person underwater. Take away the airway and you can't breathe. In some cases, this Social Anxiety condition has been present since earliest memory. The person was "born shy." About 20% of people are shy from infancy and this is most likely a genetic trait. By the time these people are in their late teens, half have overcome shyness due to experience, learning and peer pressure. In other cases, the person was not of a shy temperament, but in late childhood or early adolescence, they began to experience Social Anxiety, exactly as described above. They don't know how to explain it. They are usually embarrassed. They cover it up or adapt through avoidance. The condition has secondary effects, impairing school performance, social adjustment, occupational choices and self-esteem. This is a shame, because the disorder can be diagnosed, de-stigmatized and overcome. Yes, Social Anxiety has a hereditary component. It runs in families. Relatives may have a different form of anxiety, but the common thread is a low threshold for the fear response -and a high degree of fear. Think of it as too much adrenalin or as an easily triggered nervous system, or both at once. The trigger may differ among relatives, but the over-reaction is much the same. And usually, this biological tendency was there before any traumatic experience occurred. Trauma may shape the response and may result in certain triggers. But some of us are more prone to an over-anxious reaction from birth, even though this doesn't become evident until teen-age years. Yes, there are good treatments besides medication and talk therapy. Exposure therapy involves careful, well-timed, constructive exposure to the feared situation. I've seen patients do this on their own, once they knew more about their diagnosis, could explain it to others, and met a few others with the same condition. Without prompting from me, they went to a social event that would have terrified them before. In other cases, the exposure was carefully planned in discussions we had, and was calibrated to succeed. Cognitive-behavioral treatment involves learning how to think about emotional circumstances, changing the things one tends to say to oneself. CBT, added to exposure, support, talk-therapy and other sources of assistance, is very useful. Learning about this condition can help oneself and others. There are some excellent websites out there, and some sites that bring people with Social Phobia together. Gift From Within specializes in self-help and peer-help for persons with PTSD. But there is an overlap between PTSD and Social Phobia, even if one condition does not necessarily cause the other. I'm glad that Joyce asked about Social Anxiety and I hope that the GFW network helps to bring information, dignity and respect to those out there who have a very difficult time among strangers. |
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| Complex PTSD Q: Dear Frank, Could you give a brief explanation of complex PTSD? How do we know if we have PTSD or Complex PTSD? Is the medication and/or therapy similar? A: Dear Joyce, Complex PTSD is a concept first defined by Judith Herman, MD (see http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_complex_ptsd.html?opm=1&rr=rr89&srt=d&echorr=true) to account for the effects of prolonged, severe interpersonal stress. She was thinking about cases in which a person is captured and humiliated or is sexually victimized within the family. But it is true of victims of war and victims of household war: battered spouses. When emotional trauma is continuous and inescapable, the mind and body adapts in several ways, from stoic to tragic. People can "zone out" or, technically, dissociate. They experience an altered state of consciousness. This might, in extreme cases, develop into multiple personalities. People can abandon hope. Without yearning for dignity and freedom, they accept psychological slavery. People can love their abusers. This is called Stockholm Syndrome (see http://familyrightsassociation.com/info/stockholm/syndrome.html). The therapy for oppression is different than the therapy for simple PTSD. It requires moving to a safe environment. It requires retraining survival instincts, once there is no real danger. The medication may be similar (anti-depressants, tranquilizers, sedatives) but medication is never enough. And therapy is never enough. It takes liberation and love and plenty of patience to emerge from complex PTSD. |
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| Complex PTSD Q: Dear Joyce, I googled Columbine PTSD to see if I could find any one else suffering from PTSD. I found your and Dr. Frank Ochberg's Q & A. I am a former Littleton, Colorado resident. Currently I am living in Italy because I can't handle the USA any more. April 19th, 1999 three parents, 2 elementary school teachers and 60 6th graders went on a field trip. We walked from Leawood Elementary school through Columbine High School grounds to the Columbine Public Library. We were the first responders after the event. The high school students fled the school running to the closest open building, us. The librarians, three parents and two teachers were the beginning of the command post. The police showed up with military, firefighters and then media. We supported the police the whole day until they allowed us parents to leave at about 6:00 p.m. One of the mothers and I with our kids walked on the school grounds that day after the event not being current on the news as we only saw from within our windows what was going on. It wasn't till we got home that we saw the full story on the news ands that there were bombs in the field we walked across after the event. I am suffering from severe complex ptsd and can barely handle it any more. I have a wonderful therapist here. I am currently out on disability with a private policy from an American insurance company. They do not believe me and contact with them is just an extension of abuse for me, though maybe I am not in reality. I have a life long list of trauma and was a high profile functioning person in society till I had open heart surgery a 1 1/2 ago at 44. New trauma in ICU came back 9 months later in horrible flashbacks. I know therapy is a must. I have done some PTSD. I do some meditation. I am an artist, and ex stock broker now. I search the Internet endlessly looking for that magic pill for fix this all. When the pain starts, I want out. Good days are good and some can be great. Though bad days are horrible and horrible days are on the edge of not wanting to live. If this is my furture, flashbacks and ghostly memories of all I have seem or experienced, I can not say I am going to make it long term. Logically I want to understand why the pain is sooooo bad and will it ever go away? I was disassociate for most of my life but the trauma in ICU brought the fear and feeling together for the first time in my life. Ever since them I can not stuff the pain. I lived with PTSD most of my life but know I can't seem to shake it. I want some one to be real honest with me. If my severity is at an 7 to 8 out of 10, with 10 being the worst, what can I expect long term? Thank you. Ms. O A: Dear Joyce, Ms. O. writes a compelling email, describing several profound traumatic events, including direct exposure to an infamous high school massacre (while caring for many elementary school children) and, approximately six years later, open heart surgery, and insurance company problems. Ms. O does not give details of other life traumas, but says there were many, that the pain is still powerful and debilitating, and that relocation to a beautiful part of Italy and the presence of an excellent therapist is helpful, but not enough. Dissociation (an altered state of consciousness that serves as a defense against overwhelming anxiety) once seemed to lessen the pain of searing memory. Meditation helps to a limited extent. There are good days. But bad days are so bad that, on those days, life seems not worth living. Ms. O does not ask for remedy, but rather for an honest prognosis. "What can I expect long term?," she asks of us. First, thank you Ms. O for writing and for the obvious inspiration and care you have given others. You are an artist and you have guided young people. Artists often distill human experience, seeing and feeling the essence of reality, suffering when others suffer. Having an eye for beauty may not balance the experience of traumatic and tragic loss. Finding grace and meaning in nature may not erase the memory of senseless harm to an innocent adolescent. But your artistic ability is worth emphasizing. Several of my patients with complex PTSD are artists or writers or reporters. They do see into the heart of things. That talent is a blessing and a curse. Try to remember the fact that it is a gift; try to use that gift; try to identify with others who used such gifts to enlighten the rest of us. CBT - cognitive behavioral therapy- works in a simple way. When the bad days and the bad feelings are too much with us, we learn to think about the talent we have and to respect it. We may not be able to use it during a period of fear, grief or depression. But we need to know it is there and it will be there to be used when the crisis passes. This is different from trying to be numb or from longing for respite from memory. This is saying to oneself, "I am an artist. I am more sensitive. Sensitivity is painful, but useful. Others have this condition and I respect them for it." The fact that your insurance company (and other bureaucracies) are oblivious to your condition and appear to care more about their bottom line than your legal right to just compensation is familiar to me -and to others with complex PTSD. Jonathan Shay, in his profound book, "Achilles in Vietnam," notes that since ancient times, the traumatically injured have suffered more from injustice than from horrifying wounds. Whether the source of betrayal is King Agamemnon's greed or an insensitive insurance adjustor, we are profoundly affected by the loss of honor, justice and humanity. My team, writing the diagnosis PTSD, had no language to capture this philosophical symptom -a loss of a sense of meaning. But anyone who works with complex PTSD knows to look for that ancient wound, to give voice to it, and in so doing, to guide a person toward recovery of dignity and worth. Your relocation from America to Italy speaks to this wound. It is not unusual to seek a different home when home has harbored trauma and injustice. And now to the question at hand. Can this complex injury in a sensitive person be tolerated? Can the long term prognosis include substantial recovery? I believe it can. I have seen it happen in cases that included the murder of ones children and the destruction of ones platoon due to incompetence of leadership. It never happens easily. Some denial of reality is often part of the path to tolerance. Shakespeare's line in Lear was not unreal: "As flies to wanton boys are we to the gods; they kill us for their sport." But reality is as beautiful as it is ugly and meaningless. The capacity to experience that beauty comes through deliberate acts of seeing and knowing. You cannot avoid seeing the tragic, whether is is the past, present or future. But you can learn to see the sources of hope and love. That does come back and it does prevail, despite cruelty and incompetence and indifference, which are the sources of complex PTSD. Recovery is never absolute. We do not reach a life that is free of sadness. But the sharp pain of traumatic memory does reduce in amplitude and surprise. You may need to work with a specialist who uses the counting method or EMDR or some form of re-exposure, if that has not yet been part of your therapy. You may need to work with someone who uses CBT as I suggest above, tailoring this CBT to your unique set of skills and losses. A good therapist is always wise and supportive, but a specialist may be needed to help deal with debilitating aspects of complex PTSD. With time and distance, new sources of fulfillment and meaning should emerge. One can't escape the past without a present and future that holds promise. There is every reason to believe that you will find those sources of fulfillment, and can say to yourself: "I may never forget, but I need not constantly remember." Shakespeare didn't write that line. I did. And I based it on many, many life stories. My very best to you, Ms. O. |
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| Dissociation Q: Dear Dr. Ochberg, My name is Patti. I'm a Gift From Within support pal. I've never paid much attention to dissociation as it relates to trauma, until I've begun having times here lately where I zone out. My therapist confirmed that there is always some dissociation associated with trauma. I'd like to understand how it manifests itself, what type of symptoms, and also why they begin so long after the trauma. Could you discuss this? A: Dear Patti, Dissociation is one of the least understood symptoms in psychiatry. It means an altered state of consciousness and can be very subtle, like deja vu, or quite frightening, like derealization. In deja vu, a common occurrence, a person has the sense of being in a familiar place, or having a familiar sensation, but they cannot remember the original scene. It is as though that part of the brain that gives us the sensation of similarity has been stimulated, without any good reason for the sensation to occur. In derealization, the surroundings are distorted. Objects may be larger or smaller; sounds may change volume or tone. The flaw is not in the organs of sense. Nothing wrong with the ear, the eyes or the receptors in the skin. The problem is in the brain, where perceptions are received, organized and interpreted. Derealization is episodic, not constant. Feeling "zoned out" -entering a trance-like state- is relatively common during or after severe trauma. The term "shell shock" refers to battlefield conditions with soldiers wandering in a daze after comrades are killed and the echoes of gunfire and mortar rounds slowly subside. Dissociation can be thought of as a defense against panic and terror. Instead of having acute awareness of the surrounding danger, instead of having accurate recollection of a devastating event, one has a hypnotic reverie, like being drugged. One of my traumatized patients experiences dissociative fugue. She drives long distances without knowing why or where. She awakens with no clear memory of the trip. But she is not psychotic. She can interact with people along the way, get gas, count change and appear to be perfectly normal. These varieties of dissociative states (deja vu, derealization, trance, fugue) do not respond well to medication and are not easy to treat with psychotherapy. Specialists in dissociation overlap with specialists in PTSD. When "zoning out" is a relatively minor component of PTSD, as it frequently is, the general principle of post-traumatic therapy apply (see http://www.giftfromwithin.org/html/trauma.html ). Any symptom of PTSD can appear long after the original trauma. Entering a trance or a fugue can be your body's way of avoiding anxiety. Coping with the cause of that anxiety is the best way to eliminate dissociation. Dissociation may feel better than anxiety, but it is not an effective way to face the world. Patty Joyce, LCSW has worked in community mental health for 7 years. |
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| How common is PTSD, Who is more likely to get PTSD? Q: Dear Frank, We have support pals who have been through domestic violence, child abuse, ritual abuse and rape. Becoming survivors and thrivers are our goals. I have been asked just how common is PTSD? Who is more likely to get it and why? And how do normal post-trauma symptoms differ from PTSD symptoms? What role does resiliency play in healing and recovery? Why do some take longer to heal than others? A: Dear Joyce, There are several important but different questions in this month's list. The first one, "How common is PTSD?" comes up whenever large groups are exposed to very dangerous circumstances, such as combat, and we need to anticipate the specific emotional outcomes. In that regard, PTSD is not as common as some other consequences of trauma, tragedy and abuse. For example, the British Ministry of Defense reports more depression and alcoholism than PTSD in its returning veterans from Iraq. This is true of women as well as men. Among adult survivors of incest, I find PTSD to be relatively rare, but concerns about trust and intimacy quite common. The chances of developing PTSD after rape at gunpoint are quite high (one study found 80%). Among Vietnam vets exposed to combat, 15 % developed PTSD. The factors that increase the risk of PTSD include the suddenness and severity of the traumatic event, the intensity of exposure, the presence of complicating conditions (physical, emotional and interpersonal), and both genetic and personality factors. A readable but technical article in the latest PTSD Research Quarterly by Mark Miller is titled, "Personality and the Development and Expression of PTSD." A personality that tends toward "negative mood and adversarial interactions" is, according to Dr. Miller, more prone to PTSD. Moreover, one's personality predicts the way someone with PTSD will feel and act. Some are more introverted and self-destructive; some more aggressive and harmful to others. Therefore, the answer to the question, "How common is PTSD?" depends upon the traumatic event and the person who is exposed to the event. "Who is more likely to get PTSD and why?" There is more than one factor determining the answer to this question. But in my opinion, most of the reasons do come down to the way your brain is structured. Some of us have a pattern, from our earliest years, that makes us more likely than others to respond to a significant trauma with "hot memories." These memories are connected to the fear center of the brain and they turn themselves on when we do not choose to remember. They come with feelings that vary from minimal (vague dis-ease) to maximal (sheer terror). Recent brain imaging studies show that identical twins are similar in this regard. Environmental factors, such as effective or abusive parenting, have more to do with the way we handle PTSD. As troubling as PTSD symptoms are, some cope relatively well while others find the symptoms overwhelming. But the presence or absence of PTSD symptoms after a traumatic event is, in my opinion, related to our genetic map and our brain structure. Normal post-trauma symptoms include feeling shocked and stunned (which often includes a fast pulse and difficulty standing), having thoughts that return to the event, wanting to talk or to be silent (depending upon personality) and trouble sleeping. There actually is a long list of common reactions. But these are all proportional to the traumatic event and they clear up in days or weeks. By definition, resilient people cope well with trauma and with most other life circumstances. They have an optimistic, yet realistic view of themselves and the world; they have a good sense of humor; they engage others effectively; they have skills that lead to productive and valued work. In my opinion, they are candidates for PTSD when extreme trauma befalls them, but they find accurate information and they make good use of it. I've had several such persons in my care. One is the mother of a murdered boy. She still has PTSD symptoms. But she is a terrific Mom to her other kids, and she copes. She helps other survivors. Some of us take a long time to heal. That Mom may take a lifetime. PTSD is a group of symptoms that include "hot memories" (flashbacks and nightmares and images that burst into awareness when you wish you could forget); reduced or numb feelings (diminished joy and hope and love); and easily triggered anxiety. All of these symptoms fade with time, but they often reappear and when they do, it is easy to feel overwhelmed and demoralized. It is no sign of danger or of weakness to take a long time healing. PTSD can be "tamed" and managed. It helps to learn as much as possible about the condition, and to take comfort from the others out there who are also enduring the long struggle. |
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| How long does PTSD last. Q: Dear Frank, I was recently asked, "Is there any study that knows how long the average intense symptoms to PTSD are after initial diagnosis by a professional?" What do you know about the duration of PTSD symptoms? A: Dear Joyce, The answer to this question is like so many other situations: It depends. It depends on the trauma that resulted in PTSD. If your spouse was murdered you have the possibility of survivor guilt, death imagery, prolonged grief and a feeling of rage that complicates and fuels the usual PTSD symptoms. If you survived a plane crash you may never be comfortable in a plane again, but your PTSD may be relatively uncomplicated and brief. It depends upon whether you were physically injured as well as emotionally scarred. A physical wound can be a source of continuing or episodic pain, triggering traumatic memory. A loss of a limb or an eye can change ones ability to work and to function as before. Any significant disability extends the duration of emotional strain. It depends upon the number of traumatic events in your life, particularly in formative years. A body of research evidence now concludes that the duration and the difficulty of current PTSD is related to the presence of childhood trauma and to multiple traumas. Think of it this way: victim status is the belief that things will go wrong. Survivor status is the belief that something did go wrong, but you can prevail. Faith in oneself is shaken after multiple traumas and is undermined by childhood trauma. The self-confident person has a shorter period of PTSD than the person with less self-esteem. It depends upon whether you get effective treatment. Some flashbacks persist for years then turn into unwanted traumatic memories. Without some form of exposure therapy (voluntarily re-experiencing the original trauma in the company of a trusted professional who helps you face your past with confidence) these symptoms may last years longer. The National Comorbidity Survey found that the median duration of PTSD associated with worst lifetime trauma is between 3 years among respondents who obtained treatment and 5 years among respondents who did not receive treatment. (Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060) In my recent attempt to find a study that answers the question, "How long is the average duration of PTSD?," this three to five year estimate is the best overall figure. It doesn't say that the symptoms are intense. It just says that the definition of the disorder is met. The definition of PTSD includes this paragraph: "The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning." So the short answer to the question of average duration of PTSD, according to Ron Kessler, a Harvard psychologist, is, "three years when treated and five years when untreated." An even shorter answer is, "It depends." But please note, although the median duration of PTSD is 3 - 5 years, that is a median of all diagnosed cases. The median would be higher for chronic PTSD (longer than 3 months). Once PTSD lasts many months, there is a good chance it will last many more years. But that short answer has a long explanation based on some important considerations. GFW helps everyone with PTSD by sharing ideas, improving morale, and reducing the stigma of the diagnosis and its treatment. |
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| Explaining PTSD to Children. Q: Dear Frank, What is the best way to explain PTSD to children if they live with a parent who has PTSD? Children and siblings would react differently than a spouse or close friend. Do you take them to a therapist? What else can you do? Since there are so many vets returning I'm sure this is something that affects the family. A: Dear Joyce, this is a good, tough question. I've explained PTSD and other conditions to kids whose parents were affected, but it is very different from case to case, depending on the age of the child, the personality of the child, the relationship that the child has with that parent and with the other parent, and the rapport that I'm able to establish with the child. It isn't that easy for me to set up an ideal situation for the conversation. I'm thinking of a case quite a few years ago where the mom wanted to be present and she wasn't all that helpful. "Tell the doctor how you feel," she coached, deflating my attempts to be less of a doctor and more of a down-to-Earth friendly adult. I wanted the pre-teen daughter to let me know her fears and concerns, and I had a feeling that the daughter might benefit from counseling. Her mom had been seriously abused as a child and later developed bipolar disorder with deep depressions. Years later the daughter did see me for counseling (age 17) and I was able to help her with her social phobia (unrelated to her mom) and then I could explain her mom's condition. So let me start answering your question by saying that the best way to explain anything to children is to meet them at their level, discovering what they want to know, and giving clear, honest answers. Young children are not likely to want to know details. They usually want to know that things will turn out well, that strange behavior (eg, withdrawal, crying, anger) is not their fault, and that parents are confident about the future. Some kids are very curious and ask, "Why?" rather frequently, and can be intrusive. A child might ask, "Why does Mommy go to the doctor every week?" Explaining PTSD is not necessarily a helpful response. Ducking the question is not necessarily helpful. Something along the lines of "She learns how to relax and fall asleep at bedtime" could be useful, followed up by, "Do you ever think you would like lessons like that?" Older children might benefit from hearing the medical facts about PTSD from the non-affected parent: eg, "It is a condition in which troubling memories return when they aren't wanted (therefore it is helpful to ask me, not Daddy, about the accident)." And, "It is a condition that includes feeling irritated, nervous and withdrawn (so it isn't your fault if Daddy seems angry at times)." Of course, add that PTSD gets better with time, that some people would rather not talk about it, that others benefit from talking, at times, and describing how they feel. Explaining the facts of a trauma can be very difficult for a parent and child. Some family therapists advise getting the family together and being sure everybody understands what happened, all rumors are shared, and everyone ends up on the same page. These therapists are not only interested in explaining PTSD; they want to get a "functional family" working together to help with healing. Some families choose to exclude young children from this process. If you are concerned about a child's understanding of PTSD, it never hurts to ask. If a child expresses interest in learning more, you can explain symptoms, reasons and remedies in a simple honest way, as long as the child knows about the trauma. For example, "Since Mom was in the car crash, she has bad dreams and sometimes she has a feeling like a bad dream during the day. It is getting better now. She sees a doctor who knows about dreams and knows how to help. Let me know if you have any ideas about helping, too." Obviously, it is much more difficult in cases of sexual assault where the details of the trauma are unspoken. But supportive families with a history of comfort in conversation find ways to get these trauma stories told, destigmatized, and turned into opportunities for healing. A final word: Explaining PTSD symptoms may be easier and more productive than trying to convey the whole syndrome. Anxiety can be explained as a medical condition in which your heart beats faster (emphasize that this is not dangerous - but that it makes you look like you are afraid and feel like you feel when you are afraid). Depression can be explained as a medical condition in which your ability to feel happy is impaired. You may know that everything is OK, that you should feel happy, but you just are numb and can't fully experience the good feeling. Memory and concentration deficits can be explained, too. I'd stay away from using terms like "thinking disorder" or "brain impairment." But it never hurts to help your child be tolerant of concentration and memory lapses by explaining how this happens when adults are recovering from certain conditions. Then use the words your child understands about these conditions (eg, "bad dreams during the day"). Share ideas that you find effective with your adult friends and family and GFW pen pals. We can all learn together. |
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| Emotional Abuse. Q: Dear Dr. Figley, Thank you for being a guest clinician. One of our support pals said that her PTSD is the result of emotional abuse from significant others. She has low self esteem. She says she feels "locked into behaviors, relationships and interactions that are dysfunctional and that on a subconscious level, she relates to others by being too helpful and too caring." Then she feels that this leads her to feeling used. Any suggestions on how she can change old patterns and learn new and better ways of coping with her mood disorder? What are your thoughts about cognitive behavioral therapy as it relates to severe trauma? A: Dear Joyce, Thanks for asking! First, I am sorry that she is suffering as a direct result of emotional abuse. The low self esteem is certainly understandable if you feel you are trapped by the cycle described in the question. Replacing these with new patterns to better cope may be very difficult if you have been diagnosed with a Bipolar Mood Disorder without medication. There is an excellent questionnaire on line that will help you decide if you need to see a physician for this problem. It is at http://www.bipolar.com/mdq.htm. However, if you believe you are at times moody because of your PTSD and poor coping, psychotherapy can be helpful in more effectively managing your PTSD symptoms and self-defeating behaviors. I would highly recommend, however, that you get a thorough evaluation from a competent psychiatrist or psychologist trained in psychometric evaluations. Cognitive behavioral therapy (CBT) is the treatment of choice for treating PTSD. However, if you find that it is too overwhelming for you, don't hesitate to tell your therapist. Frequently clients report that CBT is too powerful because the exposure to the past traumas cause more harm than good. The exposure can be adjusted to meet the special circumstances of the client or another treatment approach can be used. Establishing and maintaining a good and trusting working relationship with your therapist is a key ingredient for any successful trauma therapy. Charles Figley is a highly published university professor in the fields of psychology, family studies, social work, traumatology, and mental health. He is the Florida State University Traumatology Institute Director. He is also a full professor at the Florida State University College of Social Work. Dr. Figley is a member of Gift From Within's Professional Advisory Board. |
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| Childhood Trauma and Intrusive Images. Q: Dear Frank, Here is a question from a support pal. I knew from the time I was a child that I was somehow different and some children picked up on this as well as adults. I began seeking counseling at age 22 and it wasn't until I was around 40 that I finally found out, on my own, what my symptoms meant. I found a therapist a few years later who specialized in trauma and knew EMDR. I can say the therapy has helped me to accept myself and show compassion to myself. However many of my symptoms are worsening and imposing more and more upon my daily life. The intrusive images, and nightmares and inability to control my racing thoughts at times are becoming very upsetting. I'm not even sure when I say "racing thoughts" that I'm describing it that well. The thoughts are always fearful thoughts. When Joyce sent out the article about how trauma can affect the brain in children and cause life-long struggles it all made sense. I have been doing more research on this subject. One very helpful article is in Cerebrum, Fall of 2000 by Teicher, "Wounds That Time Won't Heal: The Neurobiology of Child Abuse". I realize that I am diagnosing myself but I am an intelligent person and I know myself better than anyone else does. I was right-on about the PTSD. My therapist validated that finding and told me it's a miracle I have survived as long as I have for what I have gone through. I have often commented to people that I feel my situation is rather hopeless and have pretty much closed up and stopped talking to anyone about it. If childhood trauma really damages healthy brain function, do you recommend any particular type of therapy for such life-long symptoms? I understand I have to pretty much live with PTSD and will never completely heal. But I think I am a good person and can have a decent life and be of service to others if I can get the proper help. A: Dear Joyce, this long and thoughtful question mentions some specific items that stand out and that could help GFW readers with similar personal issues. First, the writer explains that since childhood, she knew she was different and this difference was evident to children and adults. The difference may have been caused by abuse, but it may have been inherited. Or it may have been a combination of "nature and nurture" as are most long standing emotional conditions. Second, the writer describes her current symptoms: Intrusive images, nightmares and inability to control racing thoughts. The first two problems, intrusive images and nightmares, sound like PTSD - but they are only PTSD when the intrusive images and nightmares reflect events that are known to have occurred. If they never occurred, they are symptoms of a different condition. Racing thoughts are seldom seen in PTSD, but often occur in bipolar disorder. Without more information, I'm not sure what is really going on here. But as a GFW Q & A, the chance to discuss general concerns is really more important than trying to make a diagnosis with limited evidence. If you know that things have not been right since childhood you may have a sensitive emotional system that is easily triggered, whether you were abused, neglected or simply born that way. The brain is a self-correcting, resilient organ that has amazing recuperative powers. Of course parental mistreatment of children is tragic and sometimes criminal -- but being the recipient of such mistreatment does not mean that hope is lost. It may mean the road through life is rough and difficult, and you have to learn ways to manage a brain that tilts in various directions, from time to time. One common "tilt" is in the direction of fear. An excellent book by Gavin De Becker is titled, "The Gift of Fear." We need fear to warn us away from danger that could be fatal. To have an autonomic nervous system that makes our heart race, our guts churn and our mind worry is a good and necessary thing. But to be a fearful person, shrinking from opportunity and intimacy, is obviously an impediment. Anxiety is, by definition, an excess of fear-- fear without reason for being afraid. PTSD causes anxiety. Anxiety may interfere with calm thinking. But having many fearful thoughts at once is NOT the same as racing thoughts. A good therapist listens very carefully to the way a person describes her pattern of thought. If the speed of thought is unusually fast, and comes fast without fear, the underlying problem usually has to do with mood regulation, not fear regulation. When mood regulation is impaired, there is usually a medical, biological cause. Drugs used for PTSD such as Paxil and Prozac may make the condition much worse if racing thoughts are involved. There are newer, effective "mood stabilizing" medications that help this medical condition. PTSD is a complicated condition and complex PTSD, dating from childhood abuse is even more complicated. It is possible to have intrusive thoughts, nightmares and racing thoughts due to trauma and inherited emotional challenges. EMDR and other forms of post-traumatic therapy are helping with fear management and with a sense of personal worth. But further diagnosis is needed and modern medication should be considered to control the racing thoughts, which may very well be a symptom of bipolar mood disorder and not PTSD. If the "racing thoughts" are always fearful thoughts it is NOT bipolar disorder. The writer is probably correct: this is a result of trauma, not an inherited mood disorder. I have a patient who was a truck driver. A drunk driver veered into his path at night and my patient was forced to hit another car. Six people died. My patient had PTSD with nightmares and flashbacks. But he also had episodes of racing thoughts and anger and depression. When I treated his mood disorder with Lamictal he improved. It took me a while to realize that he had bipolar disorder in addition to PTSD. I don't believe the accident caused his bipolar disorder and his racing thoughts, but his PTSD may have made his mood disorder worse. I think he managed his mood disorder with alcohol before he met me. The worst forms of parental abuse to the brain are drinking alcohol and using drugs during pregnancy, then refusing to stimulate the child during infancy. Those forms of abuse and neglect do cause permanent damage to brain architecture. Being a cruel or selfish parent may result in psychological damage, but that is usually something that can be overcome with good personal experience later in life. In summary, child abuse can be bad for your mental health, but it isn't the same as permanent brain damage. Hope for a good outcome is reasonable. Inherited conditions like bipolar are commonly seen along with PTSD and not caused by PTSD, but made worse by it. Racing thoughts make me think of bipolar, not PTSD. The implications for treatment are profound, since the usual PTSD meds make bipolar worse. |
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| Iraq War. Q: Dear Frank, Here is an email from a website viewer. I am the girlfriend of an Iraq War Veteran and had some questions regarding PTSD and if it affects people more during the anniversary of the event or events that triggered them to have PTSD. Specifically, my boyfriend seems to display heightened symptoms around the months of April, May, and September. He started his first tour in Iraq around April or May in 2003 and his second tour in September 2005. Is there a correllation between the start of his combat tour and his PTSD getting quite severe during these months? I'm having trouble finding information related to this question. I thought it might have something to do with Seasonal Affective Disorder but the material I found said SAD related to weather conditions. APRIL is the cruellest month, breeding Lilacs out of the dead land, mixing Memory and desire, stirring Dull roots with spring rain. T.S. Eliot The Wasteland. A: Dear Joyce, I am so glad that Ms. G asked these questions - first because any one who cares about our Iraq War Veterans should pay attention to their emotional wounds and learn about the significance of symptoms. Many veterans have understandable difficulty gathering information about PTSD. Trauma memories, particularly memories about fellow soldiers who were maimed or killed, can be easily triggered, causing one to feel as though the event is recurring. A loved one can learn about these symptoms and be a voice of comfort and reason, when the veteran chooses to seek such comfort and reason. Ms. G notes that her boyfriend served at least two tours (serving multiple tours increases the risk for PTSD), and she notes that each tour began in months that may be significant.. April and September are months when seasons change -the spring and fall equinox. They tend to be pleasant months in our country and times when one would want to be with friends and family. It could be that Ms. G's boyfriend associates these months with separation from home and also with the immersion in a life that included too much death. T.S. Eliot's famous line, "April is the cruellest month," signified just that confusion of feeling, being full of life and death at once. If the veteran was exposed to horror and tragedy in a particular month, he or she could have what is called an "anniversary reaction." This means that without needing to think about it, his or her body remembers something horrific. The season comes around to that time of year, the leaves come out on the trees -or the leaves turn red and fall- and suddenly the adrenalin flows, a memory springs from nowhere, and a person feels transported from Florida to Fallujah where comrades were killed. I wouldn't call it an anniversary reaction if Ms G's boyfriend suffers in spring and fall only because those were seasons of deployment. Deployment itself is not a traumatic stress. Yes, it is traumatic in the general sense of the word. But the kind of trauma that causes a PTSD anniversary reaction is something that causes the person to feel horror or terror or helplessness at the time -often all three feelings at once, and to an extreme degree. SAD, seasonal affective disorder, is a form of depression, not a form of PTSD, and it comes when days are short and there isn't enough morning light to stimulate certain brain centers. People prone to depression often find the winter months particularly difficult. If they suffer from this "SAD" condition, they need artificial, intense light for 30 to 60 minutes in the morning. It helps! So I would say that Ms. G's boyfriend has a form of seasonal PTSD, but not SAD. PTSD symptoms include unwanted recollections of traumatic events, feeling numb and detached, and also being anxious, with difficulty sleeping, concentrating, and controlling anger. It makes sense to me that these feelings would be worse during the months of deployment and initial separation from home. Gift From Within has many articles with information and encouragement and networks for partners of those with PTSD. PTSD affects veterans and civilians the same way. It causes normal people to feel abnormal, isolated and embarrassed. It shouldn't separate friends, family and loved ones. The best way to overcome the tendency to drift apart is to do just what Ms. G is doing - seek information, learn about the condition, and do not be ashamed to say, I have a boyfriend with PTSD. PTSD means having the courage to survive danger and the honesty to suffer inevitable consequences. Frank |
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| Revisiting the scene of trauma and abuse. Q: Dear Dr. Ochberg, My therapist feels that it is not important to try to recall traumatic events, but rather to deal with the feelings that bother me now. However, I have felt haunted for years about the need to remember a specific house and the surrounding neighborhood where I lived during a traumatic time. I've gone as far as doing research on my own and calling complete strangers in the town in an attempt to get photographs of important places. I asked my therapist what she thought about exposure therapy and hypnosis in an attempt to help me remember, firmly believing that if I could revisit this place it would lose it's power over my life. Revisiting the house in person is out of the question since it's been demolished. I would love to know what Dr. Ochberg thinks about this. A: Dear Joyce, There certainly are situations in which ghosts from the past can be confronted and overcome. Consider this marvelous example of three women who called themselves the Marvellas: Twenty-five years have come and gone since Margie last visited the old man's farm. She's not sure she can even find the place. She's not sure she wants to. The 51-year-old Anchorage travel agent has made a lot of progress lately confronting her fears. But she still has trouble talking about what happened in the barn. So fragmented are the memories. She remembers her Uncle George carrying her piggyback across the horse pasture, her bony legs, black patent-leather shoes and white-lace socks poking out from under his arms. She remembers staring up at the barn's rafters, and how the hay scratched her skin. She remembers her ankles being strapped down, legs apart. And then there's the time she was tied by her wrists and hoisted. Did things like this happen a couple of times? Every visit? Why didn't her aunt come looking for them? Did she not want to know? Margie wants to remember more. No, she wants to forget. But she knows she has to go back there if she ever wants peace. And so she studies a local map. Although Uncle George has been dead for more than 20 years, the courage to go through with this comes from two friends. A year ago they were strangers - Vivian Dietz-Clark, 41; Ezraella "Ezzie" Bassera, 44; and Margie (to protect their own privacy, her children asked that the family name not be used). Now they call themselves sisters. Their demons brought them together. Within the past few years, memories have surfaced, forcing them to deal with what had long been buried - the sexual abuse they're convinced they experienced as children. A tremendous amount of energy goes into locking things up inside, Ezzie's therapist, Joan Bender, explained. It's like sitting on a huge, bulging chest to keep it from popping open. Any added stress drains energy from that chore. The lid creaks open. Memories escape. The three Anchorage women met in a support group for adult survivors of childhood sexual abuse offered by STAR (Standing Together Against Rape). And when that group ended, they continued to meet on their own. The Marvellas, a combination of their first three names, is what they call themselves now that they're a team. The melding of their identities is a metaphor for the journey they've taken on together. That journey comes at a controversial time. Repressing memories has long been recognized by mental health experts as a way victims cope when events are too horrible to face. But more recently, some victims of childhood sexual abuse have been accused of concocting memories - and therapists of planting ideas in their heads. To read the whole account, see http://www.dartcenter.org/dartaward/1994/winner/00.html This is the first news story to win the $10,000 Dart Award for Excellence in Reporting on Victims of Violence. It explains Margie's voyage back in time and her success at accomplishing just what your writer desires: a visit to a place in order to cause that place to "lose its power over my life." But was it Margie's journey -- or Margie's bond to other women-- that defeated her childhood demons? Perhaps it took many factors, including time, distance, death of the offender, maturity and a secure connection to others. Therapists are not all in agreement when it comes to answering this month's question. And even when we support the idea of revisiting the scene of trauma and abuse, we wouldn't recommend it for everybody. There are people who have vague, unclear images of abuse. They believe it must have happened, but they have no proof. Decades ago, Freudian psychoanalysts would have used hypnosis, free association, dream analysis and even sodium amytal to recover repressed memory. But most trauma experts are very cautious nowadays, knowing that there is no way to be sure that such memory is accurate, and fearing as well that horrifying images may make matters worse. But if childhood abuse actually did occur and if a person has matured in a healthy way and if there is excellent support from true friends, a visit to the scene might be liberating. Think about veterans returning to battlefields (the opening scene of "Saving Private Ryan"). Think about trips by relatives of Hitler's victims to Auschwitz or the Holocaust Museum. For some descendants and some survivors, these experiences are too painful too contemplate. For others, they are meaningful exercises in mastery and in the exorcism of evil. I wouldn't go back there alone. But with the right friends at the right time, I'd consider emulating the Marvellas. |
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| PTSD Symptoms- Anger. Q: Dear Dr. Anderson, A support pal with PTSD asked me how to deal with her PTSD symptoms, particularly anger and irritability. She gets angry and then takes it out on the people around her even though they are not the ones who traumatized her in childhood. It is distressing to her because she doesn't want to hurt those dear to her and she doesn't want to lose her friends and the family she does talk to. A: Dear It sounds like she is describing a very common reaction of posttraumatic stress disorder. The hyperarousal symptoms, of which irritability is one, include problems with attention and concentration, impatience, hyperactivity, anxiety, sleep difficulties, lethargy, and fatigue. Events that normally would not cause an anger reaction often do bring an angry response in people with PTSD. It's very distressing for the individual and everyone around the person. The behavior is often followed by feelings of guilt and shame because the person has lost control. So, what do you do about it? Dr. Frank Ochberg describes "Posttraumatic Therapy" quite well and I find that it is helpful for people to read his chapter on the subject. Two thoughts come to mind, however, in answering this person: (1) Medication with an SSRI (Selective Seratonin Reuptake Inhibitor); and (2) Therapy While some people do not like the thought of using a medication, we have found it very useful. Paxil (one such medication) is one that seems to cause the most weight gain so we do not recommend this one for our clients. However, the others are useful. We recommend the smallest possible dose just to help "take the edge off." I am not a medical doctor so we refer our clients to a psychiatrist who diagnoses and prescribes. Therapy is also important to process the traumatic events and weave them into the fabric of one's life so that they do not continually intrude into the "here and now." It is important for individuals to understand that the hyperarousal symptoms are a byproduct of PTSD; however, it is also important to take responsibility for one's actions and do something about them, to include taking medication. The combination of therapy and medication is a tried and true road to recovery. Good luck. Dr. Beverly J. Anderson, B.C.E.T.S. is a member of Gift From Within's advisory board. Dr. Anderson has twenty years of experience in employee assistance programs, human services administration, psychological evaluations/psychotherapy with law enforcement officers, teaching, critical incident debriefings, trauma consultations and expert witness testimony. |
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| PTSD Symptoms- Flashbacks. Q: Dear Frank, Here is a question about flashbacks. "I would like to know what a flashback consists of. I have heard or read that they are visual experiences only. Other people include body sensations and other senses. I often experience smells from the past and occasionally body sensations. Each smell is linked to a trauma. Prior to remembering my abuse I was told I was psychotic and hallucinating. Is there a difference between a flashback and hallucinations? And if so, what is it?" Thank you. A: Dear Joyce, Flashbacks are memories that come suddenly and with such intensity that they feel as though they are in the present, rather than the past. They are usually visual, but they may include all the senses. Hallucinations are perceptions that are not real and may not have ever been real. So a rape victim who enters a room that resembles the room in which she was assaulted and smells her assailant's odor and feels his hand and sees his face is having a flashback rather than a hallucination. But if she hears him saying things he never said, it is an auditory hallucination and not a flashback. Psychosis or being psychotic means that the person is out of touch with reality. Having a flashback and knowing it is a flashback rather that believing the event is actually recurring is not psychotic. It is frightening and a likely sign of PTSD. It may have the force of a hallucination. But if it is a replay of an actual traumatic event, it is not a sign of schizophrenia, mania or other psychotic states. |
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| PTSD Symptoms- Flashbacks. Q: Dear Frank, Here is question from a support pal about flashbacks. " Although knowing that I have PTSD is fairly new for me, I have had flashbacks for some time now. What I am curious to know, is what people are left with i.e. their feelings, after a flashback? For me the following day and even days, are especially sad for me. Flashbacks most always come while I am sleeping. I awaken either with a pounding heart or I could find myself out of my bed "escaping" etc. Do most people have these lasting feelings of sadness after re-experiencing their trauma? How long do flashbacks go on?" A: Dear Joyce, PTSD always causes some form of unwanted, disturbing "flash" from the past. But when it comes during sleep, it is really not a "flashback." The term, flashback, should be reserved for intense experiences during wakefulness when the mind relives a traumatic event and does so with such intensity and immediacy that it seems less like a memory and more like a hallucination. The trauma appears to be occurring again. Now this may happen as a person awakens, or as a person falls asleep. The twilight zone between sleep and wakefulness is called "hypnogogic" going from awake to asleep and "hynopopic" going from asleep to awake. Even without a trauma history, these times can be frightening, trance-like states of mind. So I wonder if our questioner is experiencing a form of trauma memory as she awakens - half nightmare, half-flashback. This could be the case. She doesn't mention the content of the re-experiencing, but I assume it involves an abuser and a dream-like need to escape before harm is done, or after some harm is done and more is threatened. The pounding heart is surely evidence of fear, possibly panic, from anticipation of being victimized. But this writer asks specifically about sadness. Is her sadness common? Is it part of her PTSD? How much longer will it last? In all probability, the sadness has to do with loss. And the loss that GFW community members often experience is the loss of a parent who cannot or will not understand abuse. In the classic incest situation, the abuser is a father figure, known and trusted by the mother. The abusing parent tells the little girl, "No one will believe you if you reveal this secret - and you will suffer if you tell." Incest is all about secrets. The loss of trust and intimacy with the mother is often a more profound and disturbing outcome than the abuse by the father-figure. In any case, secret child abuse is a sad, sad burden that too often gets re-enacted and re-experienced through no fault of the victim. I just spoke with a survivor today who was coerced into degrading sexual activity by a prison guard. But worse than that was the triggering of terrifying and helpless feelings from age 5 and 6 when an 18 year old step-uncle, living in the home, forced himself on her over and over. I could see the sadness as she spoke. Her heart may have been pounding, but she learned to control her fear. She functions fairly well now, with a good partner, an excellent job and a resilient appearance. The duration of flashbacks, true flashbacks, is usually less than a year. But certain life burdens are never completely laid aside. We are sad. Sadder and wiser. And we can, if we are lucky enough to find true friends, recover a sense of safety, hope and ability to help others. |
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| PTSD Symptoms- Loneliness. Q: Dear Frank, A support pal emailed, "I'm scared to death to be alone because...you know, who am I? Existential loneliness feels like a physical pain, and I sense it must have to do with brain chemistry and the childhood trauma I suffered. Somehow I sense that it also deals with no established identity, hence a feeling of not being able to be alone with myself because I do not exist. How can one deal with this?" A: Dear Joyce, There is a profound difference between loneliness and aloneness. Loneliness is a feeling, like hunger, of missing nourishment. Words used to describe this feeling include aching, empty, longing, yearning, missing, needing, gnawing, bereft, bereaved, grieving, isolated, rejected, and blue. To be lonely is to be unhappy due to the absence of another. That other may be a specific person. Or it may be any desirable company. The sudden, painful loss of another results in grief. It takes years to recover from tragic and traumatic losses, although the condition is an inevitable aspect of human experience. Common feelings of loneliness occur whenever we want but lack sufficient human contact. To be alone is, according to some philosophers, the essential human reality. It does not mean the absence of companionship. It means being the only one inside your skin; the one and only you; the only one you really know; the only one you can really rely on; the one who is there at every moment of your life. By this definition, you can be among loved ones and still experience aloneness. Learning to tolerate aloneness is worthwhile. Learning to appreciate aloneness far better. The mystic Osho writes of "the bliss of aloneness" explaining that "the only freedom from the fear of loneliness is to become aware of your aloneness, and the beauty and power of it. Your innermost center, where you are always alone, is so full and overflowing with all the beauties and benedictions of existence, that once you have tasted it, the pain in your heart will disappear." (http://www.newearthrecords.com/Catalog_/Osho/Discourse/BlissofAloneness.htm). But for someone who experiences existential aloneness as physical pain, these words of an Eastern philosopher have little comfort. You do not travel from childhood trauma and feelings of nothingness inside to a blissful state of self-regard in an instant of enlightenment. Many who take comfort from the Gift From Within family are painfully rather than blissfully alone. It takes relentless work to overcome this condition. I If you have "no identity" and feelings of "I do not exist" you probably have had serious issues with attachment as a child. This may or may not be a post-traumatic condition. It usually derives from complications in an early stage of child development called "individuation," when a toddler is supposed to overcome infantile, dependent attachment to the mother. It also has brain chemistry components which may have been present from birth - extra sensitivity, an almost physical need for human contact, an innate fear of abandonment, a low threshold for anxiety and dissociation. This combination of challenges is very difficult for the individual, for their loved ones, and for their therapists. There are therapists out there who rise to the challenge. Finding them is not easy. GFW pen pals could share examples of good therapists and good therapies, encouraging one another to seek and find effective help. Therapy for the feeling, "I do not exist," takes many years and will not cure loneliness. But it may bring the self-esteem and self-reliance that all survivors deserve. And then, the inevitable and universal condition of aloneness will be tolerable, if not blissful. |
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| PTSD Symptoms: Feelings of Loss and sense of self. Q: Dear Frank, A cause of dissatisfaction I've heard and read from survivors is about their feeling of loss -- the loss of one self after their traumatic event. People say that they are not the same person. Who I am now is not who I was. How do you feel about this expression of pain and grief? A: Dear Joyce, The famous anthropologist, analyst and author, Erik Erikson, described an elderly gentleman who complained to his physician, "Oh, doctor, my head hurts, my bowels don't move, my joints are sore, and doctor, I myself don't feel so good." I can picture this scene so clearly! It makes one think about the meaning of "I, myself." Surely we are more than our body parts, than our feelings and thoughts, than the way we appear to others. So it doesn't surprise me to hear that many of our gift from within survivors express a sense of being somehow different after profound trauma. I assume the change is in some aspect of that difficult-to-describe thing we commonly call "I, myself." What is the self? Let's go back to Dr. Erikson. He described identity and the identity crisis. Identity crisis is something we face in adolescence and it is a confusing, turbulent transition from childhood to maturity. As adults, we achieve "self-sameness through time." We are no longer children. We have times of stress and change, but we are essentially molded and we have a feeling of knowing who we are. We have, according to Erikson, identity. After certain traumas, our identity is shaken. We have more than PTSD symptoms. We have an altered sense of self. At best, this is a loss of innocence. At worst, it is a loss of capacity for trust. I want to be very careful here because individuals are different, "capacity for trust" is a complicated concept, and readers who suffer impaired capacity for trust need encouragement, not gloomy forecasts. Post-traumatic therapy is an individualized search for optimum outcome - not for return to a former sense of self. Once major symptoms are overcome, survivors re-examine their goals and values and the meaning of their lives. They are NOT the same as they were before. Often, they are sadder and wiser. When they are relatively confident in their new circumstances and, in a manner of thinking, in their new skins, they can trust and relate and recover human connection. Later, perhaps much later, there is a sense of integrity (Erikson's word, again). He doesn't mean honesty, he means that the whole journey of one's life adds up, makes sense, and feels coherent. In looking back, one recalls losses and gains, tragedies and magical moments. One knows who one is and where one has been. The sense of self is clear. One no longer feels lost or damaged or diminished. To admit to "loss of self" is a candid and thoughtful insight. It is common among victims of major trauma. As a rule, it does not last a life-time. But the "self" that is found may feel different for a long while. It can feel as different as the difference between childhood and adulthood. But it is the same self - and eventually, if all works out as it should, that sameness of self is felt and understood. |
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| PTSD Symptoms: Anxiety. Q: Dear Frank, One of our support pals reports that she has constant intrusive thoughts of danger and tragedy and she wants to know how to deal with them. They occur daily and seem to be a normal part of her life and as she says (a rotten part of life). A: Dear Joyce, There is an important difference between "thoughts of danger and tragedy" and memories of actual events. Both are part of PTSD. I'm going to assume that this support pal has PTSD as a result of one or more major traumatic events. (There are people who have not experienced major trauma, but, through no fault of their own, over-react to stimuli with debilitating anxiety. They panic easily, they worry constantly, and they focus on threats and losses. These people often need counseling and medication to adjust their body's alarm system, and control their overactive adrenal glands. They have conditions known as GAD -generalized anxiety disorder or Panic Disorder or both.) When PTSD includes intense intrusive recollections or flashbacks, the brain's memory system is altered. "Hot" memories come spontaneously, intruding on normal life, causing a sense that the event is happening now and is not just a bad scene from the past. Therapists work with these intrusive memories, coaching a PTSD client on ways to start and stop the flashback. I use "The Counting Method" for just this purpose, and the GFW website explains it. Usually, flashbacks and severe "hot" memories diminish with time. But our support pal may need help from a trained trauma therapist, using a technique to confront and control traumatic memories. When PTSD includes anxiety in general (it almost always does) one is expected to have intrusive thoughts of danger. This could be because the feeling of danger is there and the thoughts follow the feeling, or it could be because one lives in a family or an environment that is filled with real reasons for fear. A professional trauma worker knows that security comes first: you make sure that steps are taken to minimize danger. Then coaching is used to improve survival skills. But often, a self-defeating pattern of pessimism, low esteem, and inadequate coping with reality (including poor choices about trustworthy friends) must be discussed and changed. The pen-pals deal with this situation in a supportive, constructive email environment. Once in a while, professional assistance is needed, too. And if the therapist is not quite up to the task, the task becomes searching for a new therapist. I won't discuss medication here, but meds may be part of the remedy. Once the anxiety pathways are calmed, it may be possible to reduce or eliminate medication, and face life's ups and downs with improved confidence. |
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| PTSD Symptoms: Numbing. Q: Dear Frank, Your last Q&A on numbing in regards to trauma sparked another question. One of our support pals, Patti asked "Is it possible for numbing to only occur at stressful times that are related to the original trauma?" A: Dear Joyce, Patti asks if numbing could appear only at times of stress that mimic the original trauma -and the answer is, "Yes." One of my patients uses the phrase, "...and that's when I go numb...I have no feelings.." She is describing a particular situation, usually in the presence of her husband, in which she has no route of escape and he becomes emotionally abusive. He doesn't hit or threaten, but he harangues and he escalates and he offers no sign of recognition of her growing anxiety. He knows that she is a survivor of torture and rape, almost 20 years ago. He thinks of himself as the victim although he is four times her size and is an accomplished attorney. He can't control his temper and he fails to understand his impact on others, Ironically, he is the one who rescued her from her original trauma. Perhaps that is why she is still with him. Numbing may be episodic rather than continuous. When it is episodic, it usually appears at times of high stress with no clear escape route. The high stress may or may not be related to the original trauma. In Patti's case it is related. But with other survivors, the body (and to some extent, the mind) grows numb as anxiety (for any reason) intensities. |
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| PTSD Symptoms: Re-traumatization. Q: Dear Frank, What do you say to your clients when they feel they have been re-traumatized? What does it mean and what can someone do about it? A: Dear Joyce, Re-traumatization is the opening of old emotional wounds and the anxious anticipation of such re-wounding. This second episode may be worse than the original trauma because it implies a string of "bad luck" - a sense of endless travail rather than one bad experience that has come and gone. Survivors tell me it feels like the old trauma plus a new trauma plus a loss of psychological safety. Psychological safety may be a myth (the thought that everything will eventually turn out right) but it is a helpful myth. It lets us live denying death. It saves us from the searing reality of biological truth. Trauma therapists deal with re-traumatization all the time. In treating traumatic stress, we try to avoid opening a wound that is still too painful to be explored. Clumsy interviewing, bad timing, getting to a memory before rapport is developed - is bad therapy because it reinjures and destroys trust. When my patients call, sometimes years later, to describe a recurrence of PTSD, they usually feel unlucky, unable to cope, and they say, "I'm back to square one." It as though all they learned about overcoming traumatic stress has vanished. The cause is usually a second trauma, but it may be a physical illness or a prolonged misfortune that falls short of the kind of trauma that causes PTSD. I review the progress they made before this happened. I search with them for sources of self-confidence. I remind them of their skills in surviving and coping. And I let them know that PTSD is real and it cannot be wished away. They may need more therapy. They may need medication, but I never assume that. They always need understanding and supportive friends. If you are a successful survivor but your personal hurricane hits again, and PTSD returns, what should you do? First, make sure you are safe. Physical safety requires effort, friends and may require experts in security, law, or health. When the risks are high, you don't need psychoanalysis. You need a safety net. Second, when physically safe, but full of fear, flashbacks, numbing and self-isolation, remind yourself that you are better off than a rookie who knows nothing about emotional trauma. PTSD destroys your time sense and fools you into thinking that every bad thing is happening now. It isn't. These are aftershocks. Practice what you have learned. Get your conscious mind telling you what you know is good for you: PTSD passes. You are worthwhile. People can understand. There is no shame being human, having fear or deep sadness or confusion. Finally, Reach out to those you know are trustworthy. Tell them you have PTSD (or anxiety, depression or whatever term you can use). Don't wall yourself off. If you need professional help, get professional help. The return of PTSD seems to be worse, but usually it isn't. You have conquered it once. The skills kick in after the first shock wears off. |
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| PTSD Symptoms: Depression. Q: Dear Frank, In your recent program, Surviving Trauma & Tragedy: Lessons For Future Physicians you discuss that major depression is more likely to take place than PTSD. The panel members courageously discussed their traumatic events like Linda, who was pregnant and assaulted at gunpoint while shopping for her family, and a couple whose 20 year old son was a victim of homicide. Can you talk more about major depression and why this is something health professionals and survivors should be aware of? What are the major differences? A: Dear Joyce, Depression is often confused with sadness and grief. Who would not be sad when robbed of dignity, integrity or a loved one by a rapist or a murderer? Who would not grieve the loss, with an aching sense of degradation or loneliness? The emotion of sadness is normal, even when it is profound sadness, proportional to the circumstance. The condition of bereavement or grief is also normal, and is always associated with loss. But depression is different. In a depressed state, a person feels hopeless and helpless and worthless. In addition, they have a specific type of lethargy that stops them from doing what they have been put on Earth to do. The cook cannot prepare a meal; the seamstress cannot sew; the writer cannot summon the energy to compose a sentence. Each of these people could climb a flight of stairs. They are not like the anemic or the heart patient without stamina and strength; they simply lack the energy to do what they usually do to be productive and to feel alive. Worthlessness is particularly important. If your spouse is killed and your life is suddenly changed forever, you would be expected to feel helpless and, for a while, without hope. But feeling worthless is a sign of depression. You shouldn't feel worthless during "normal grief." When I was a psychiatric resident in the late '60s we were taught to consider two different types of depression. Exogenous depression, or depression from the outside, was a reaction to stressful life events. We thought of it as "situational" rather than "biological." If drugs were to be prescribed, we used minor tranquilizers like Librium and Valium. We expected the depression to improve as life conditions improved. Endogenous depression, or depression from within, was thought of as a genetic disorder with episodes lasting weeks or months, best treated with antidepressants like Tofranil or Elavil. Endogenous depression could come out of the blue, and was not thought to be caused by stress or loss. Now we know that endogenous depression often appears after extreme stress. In other words, a trauma can cause an episode of the type of depression that looks "biological." Think of it as having your mood thermostat impaired. While it is medically normal to be sad when life is miserable, the brain's mood thermostat allows you to feel good when life improves. But if you are stuck in sadness, and the sadness includes feeling worthless and unable to summon the energy to do what you used to thrive on doing, you are depressed. And you need therapy for depression. Therapy for depression is relatively straight-forward. There are ways to learn to correct self-defeating thoughts and there are medicines that repair the brain's broken mood thermostat. Both approaches, used together, give the best chance of recovery. Often, working with extreme trauma, I'll find a combination of depression and PTSD. Both can be treated together. The numbness and avoidance that is part of the definition of PTSD may feel like depression. But people who spend the day in bed feeling worthless are beyond PTSD. They are not just numb and avoidant. They have broken mood thermostats and they cannot experience normal feelings until those pathways are restored. It helps to have the diagnosis of depression and the treatments that go with that diagnosis. When journalists cover war they are vulnerable to PTSD and depression. Because of the strict criteria for giving the PTSD diagnosis, not every shell-shocked reporter qualifies for the PTSD diagnosis. So research suggests that depression is slightly more common than PTSD in this group. When I say that depression is often more common than PTSD after trauma, I am not minimizing the occurrence of PTSD. I'm just alerting survivors, doctors and government officials to the problem. Let's not ignore post-traumatic depression. It is a significant problem - but it is a treatable problem, particularly when friends and loved ones know enough to help. |
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| PTSD Symptoms: Memory Loss. Q: Dear Frank, This question is from a female veteran writing a senior seminar paper on PTSD and memory loss. Hello, I was hoping you might be able to answer a few questions about the physiology of PTSD and memory loss? I have much research but yet I'm not satisfied with the thesis and argument. Any suggestions? I am also a veteran who was diagnosed back in 2001...I had a traumatic event happen in 1976 but no memory until 2001 - nothing until up it came and then all hell broke loose! I couldn't stop it. I'm much better now thank God! So, I would really like to target why things need to be looked at closely with PTSD due to what happens in the brain during the terror event. A: Dear Joyce, The problem with PTSD is usually the opposite of memory loss. Memory is all too vivid. In fact, some memory seems to have a di | |||||||||||||||||||||||
