How do people with PTSD come back to normal? - Trauma Series by David Campell, MD

Last week, we shared what is PTSD and who gets it.    

So, how do you know you if you have it? What are the signs?

Symptoms of PTSD usually start soon after a traumatic event, but in some cases, symptoms may be delayed months or years — often triggered by a new traumatic episode.  Symptoms may come and go over time, and fall into four different categories: [1]

·      Re-living the event.  You may have disturbing memories of the trauma, even when you are not trying to think of it.  You may have nightmares about the event.  Some people experience “flashbacks,” which is the feeling that the past trauma is happening in the present.  This is usually triggered by a reminder of the original trauma.

·      Avoidance.  You may go out of your way try to avoid situations or people that trigger memories of the traumatic event.  You may even try to avoid talking or thinking about the event.  

·      Negative beliefs and feelings.  The way you think about yourself and others may change because of the trauma.  For example, you may feel guilt or shame about the trauma or your reactions to it.  You may lose interest in activities you once enjoyed.  You may feel that the world is dangerous and that you can’t trust anyone.  You might feel emotionally numb, or find it hard to feel pleasure.

·      Feeling anxious.  You may feel jittery, always alert and on the lookout for danger; or, you may have trouble concentrating or falling or staying asleep.  You might suddenly get angry or irritable, startle easily, or act in unhealthy ways — like smoking, using drugs and alcohol, or driving recklessly. 

Other problems are often associated with PTSD, such as:

•   Feelings of hopelessness, shame, or despair that things will never get better

•   Depression, anxiety or panic attacks

•   Excessive drinking or drug use

•   Development or worsening of addictions

•   Unexplained physical symptoms

•   Chronic pain

•   Difficulties on the job or inability to work

•   Relationship difficulties

Treatments for PTSD

While it has become apparent that supportive talk therapy by itself is not very helpful for PTSD, specific trauma-focused therapies that address the way trauma is stored in the mind/body are effective.  There are three methods that research has shown to be effective for treating trauma and are now promoted as first-line treatments for PTSD: 

·      Cognitive Behavior Therapy

·      Prolonged Exposure Therapy

·      EMDR (Eye Movement Desensitization and Reprocessing)

These methods are protocol-driven, brief, cost effective and work especially well for those who are able to complete the treatment.

CBT [Cognitive Behavior Therapy]

People who have been exposed to a traumatic event often have erroneous thoughts that haunt them and affect how they think about themselves and the world.  These recurring thoughts are a major factor in causing distress.  CBT is a skill-based treatment that helps people change the way they think about their trauma.  It is based on the idea that thoughts cause feelings and behaviors — changing your thoughts changes how you feel. 

Methods include talking and writing about your emotions — such as anger, sadness and guilt, questioning the fixed ways of thinking about the trauma, and understanding ways that your life has been affected by the trauma.  The goal is to gain a new perspective on the past event.  When this is successful, there can be improved sense of safety, trust, control, and self-esteem.  

PE [Prolonged Exposure therapy]

While CBT focuses on thoughts, PE focuses on the feelings (panic, fear, anger, anxiety) that occur after a traumatic event.  Therapy includes an educational component, breath training for relaxation, and use of exposure to reminders of the trauma.  Exposure may be imagined, such as recalling and describing the traumatic event in great detail; or, real world experiences, such as visiting the intersection where a car accident occurred.  When successful, the repeated exposure causes the emotional reactivity to reminders of the trauma to gradually subside.   

EMDR [Eye Movement Desensitization Reprocessing therapy]

EMDR therapy facilitates the processing of traumatic memories by use of brief sets of alternating left/right stimuli while the client is instructed to think about their traumatic event.  After each set of stimuli the client reports their emotional and bodily response, which then guides the content of the next set.   

Various types of alternating stimuli may be used:  i) moving your eyes side to side as you follow a moving light (or the therapist’s fingers), ii) holding a small paddle in each hand that vibrates in alternating fashion, iii) using headphones that deliver a brief sound that alternates from side to side, or iv) a combination of these.

Through a brain mechanism that is not fully understood, the traumatic thoughts and images becomes less and less disturbing with successive rounds of stimulation.  EMDR also addresses negative beliefs that formed about the self as a result of the trauma.  With successful treatment, the client can recall the past trauma with little to no distress and the negative emotional meaning that was once attached to the painful event can transform into something more positive and self-empowering. 

Limitations of First-Line Treatments

For clients who are able to complete one of the three therapies described above, these methods have been shown to be very effective in reducing symptoms of PTSD in a relatively short amount to time.  However, many trauma survivors cannot tolerate reviewing the details of their trauma in the way these treatments require and therefore they are not able to complete treatment. [2]  This is especially true for clients who are severely disturbed or destabilized by their trauma.  Adults with a history of “complex trauma” from childhood often fall into this category.  Such clients may become overwhelmed during treatment and may even experience a worsening of their PTSD symptoms. [3] 

Additionally, methods that depend on logic and cognition (CBT and EMDR) require that the client be in a state where they can clearly think and feel in order to successfully integrate their trauma.  In the case of a client who becomes physiologically hyper-aroused or dissociates in response to reminders of the trauma, the thinking part of the brain (prefrontal cortex) shuts down and cannot integrate the material that is being processed. [4]  This is where somatic (body-oriented) therapies can be of help.   

Somatic Psychotherapy

Somatic Experiencing ™ (SE) and Sensorimotor Psychotherapy™ (SP) are two well-established practices of body-centered treatment for the effects of trauma.  [5,6]

Unlike the first three methods described that treat trauma as a problem of cognitions and emotions, these trauma-focused somatic therapies approach the effects of trauma as a physiologic dysregulation of the nervous system.  By working with the body as a primary avenue in processing trauma, somatic therapies can work directly with sensation and movement to affect symptoms and promote change.  [7]

The instinctual response of fight/flight/freeze that is invoked during trauma, as well as later during reminders of the trauma, derives from the midbrain (limbic center), which is below conscious awareness.  Its influence is transmitted to the body via the autonomic nervous system (ANS) as well as the endocrine system, which signals the release of stress hormones.

In PTSD there is an imbalance of sympathetic and parasympathetic activity within the ANS with tendencies toward a state of either hyper- or hypo-arousal.  The initial goal of treatment is to restore the ability of the client to regulate these extreme states. Doing so addresses feelings of safety and self-control that are missing in many traumatized persons. 

Since sensation is the language of the ANS, it is the entry point for therapeutic change.  Clients are taught to track their own levels of arousal as indicated by changes in body sensation.  Then, when triggering events occur and they are able to recognize the earliest signs of hyper- or hypo-arousal, learned somatic resources can be applied to help maintain arousal within tolerable limits. 

At first, the therapist serves as an external biological regulator for the client as these skills are learned.  Once the client is able to maintain himself or herself within a tolerable level of arousal in response to triggering events, he or she is ready for the next stage of treatment: the processing of traumatic memories.  This can only be done within an optimal state of arousal (not too little and not too much) in order for the process material to be integrated.  This requires careful tracking by the therapist as small  “slivers” of traumatic memories are recalled and the body responses managed without overwhelm. [8]

With practice in and out of the session, this approach to trauma treatment helps expand the client’s self-regulatory abilities by disrupting the learned responses to trauma cues and replacing them with new experiences.  By encouraging practice of these new responses to old triggers in daily life, maladaptive patterns can eventually be replaced with new behaviors and clients can start to feel like themselves once again. [3]

Coming back to normal

While PTSD may improve with time in some people, it usually does not get better without treatment, especially if symptoms have been present for more than a year.  In fact, if untreated, it may get worse over time.  As described above, there are effective treatment options available, and getting treatment sooner is better.  [1]

The goal for all of the treatments for PTSD is to restore a sense of safety and calm, a trust in self, and a sense of feeling whole again.  Those who have benefited from trauma therapies come to a deep knowing that the traumatic event is over — it feels like a thing of the past.  This allows them to carry out their everyday activities, work and relationships with a feeling of regained freedom and hope.

David Campell, MD is a trauma specialist at Mind Therapy Clinic.  For questions, contact drcampell@mindtherapyclinic.com.

REFERENCES

1) Understanding PTSD and PTSD Treatment (2016). ptsd.va.gov/public/understanding_ptsd/booklet.pdf

2) Van der Kolk B. (2014). The Body Keeps the Score. Viking Press.

3) Fisher, J. (2003). Working with the neurobiological legacy of early trauma.  Annual Conference of American Mental Health Counselors.

4) Solomon, E. P., & Heide, K. M. (2005). The biology of trauma, implications for treatment.  Journal of Interpersonal Violence, 20(1), 51-60.

5) Somatic Experiencing Institute. traumahealing.org

6) Sensorimotor Psychotherapy Institute. sensorimotorpsychotherapy.org

7) Ogden P., Minton K., Pain C. (2006).  Trauma and the Body. Norton, p 166

8) Ogden P., Fisher J.  (2015) Somatic Psychotherapy: Interventions for Trauma and Attachment. Norton. p 493