Results tagged “Psychological trauma” from Ψ Dare To Dream...

Researchers have added another piece to the puzzle of Post Traumatic Stress Disorder. It seems that the memory of the trauma is burned into memory involving the amygdala. But unlearning the experience is not so simple. The amygdala becomes chronically over reactive. One can be taught to be more calm in certain circumstances, but then it won't work in other similar situations.

One of the treatments that is being used by the VA is virtual re-esposure to battle via video. But this will have limited usefulness using the simple "extinction" paradigm.

The idea of extinction is to gradually introduce simulations of the traumatic event, slow enough to minimize the provoked anxiety. For example, imagine being traumatized by the sound of incoming mortar rounds. A treatment program might gradually turn up the volume of a similar sound until the recovering soldier can hear the noise without a strong emotional response. This new research demonstrates that this approach may have limited usefulness, and may not at all effect the response if the soldier re-experiences incoming mortar rounds. The new learning may be limited to the location the treatment was done and to the simulated sound.

Thus it would seem to indirectly support a previous research that found the technique called "prolonged exposure" more effective than historically standard treatments. In prolonged exposure, the stimulus is introduced with less consideration for the comfort of the client. After the client is virtually flooded with similar stimulation and the resulting emotions while being offered support, and counseling regarding his feelings and survival. This approach may promote a more adaptive skill related to surviving all kinds of trauma. Theoretically, the resulting raised threshold for a panicked response may be applicable to more situations less similar to the traumatic event.

Anxiety Insights

"It is estimated that nearly 15 percent of U.S. soldiers returning from Iraq and Afghanistan develop PTSD, underscoring the urgency to develop better treatment strategies for anxiety disorders. These disorders can lead to myriad problems that hinder daily life - or ruin it altogether - such as drug abuse, alcoholism, marital problems, unemployment and suicide.

Functional imaging studies in combat veterans have revealed that the amygdala, a cerebral structure of the temporal lobe known to play a key role in fear and anxiety, is hyperactive in PTSD subjects. Potentially paving the way for more effective treatments of anxiety disorders, a recent Nature report by Denis Paré, professor at the Center for Molecular and Behavioral Neuroscience at Rutgers University in Newark, has identified a critical component of the amygdala's neural network normally involved in the extinction (pdf), or elimination, of fear memories. Paré's laboratory studies the amygdala and how its activity impacts behavior.

Earlier research has revealed that in animals and humans, the amygdala is involved in the expression of innate fear responses, such as the fear of snakes, along with the formation of new fear memories as a result of experience, such as learning to fear the sound of a siren that predicts an air raid.

In the laboratory, the circuits underlying learned fear are typically studied using an experimental paradigm called Pavlovian fear conditioning. In this research model on rats, a neutral stimulus such as the sound of a tone elicited a fear response in the rats after they heard it paired with an noxious or unpleasant stimulus, such as a shock to the feet. However, this conditioned fear response was diminished with repetition of the neutral stimulus in the absence of the noxious stimulus. This phenomenon is known as extinction. This approach is similar to that used to treat human phobias, where the subject is presented with the feared object in the absence of danger.

Behavioral studies have demonstrated, however, that extinction training does not completely abolish the initial fear memory, but rather leads to the formation of a new memory that inhibits conditioned fear responses at the level of the amygdala. As such, fear responses can be expressed again when the conditioned stimulus is presented in a context other than the one where extinction training took place.

For example, suppose a rat is trained for extinction in a grey box smelling of roses, and later hears the tone again in a different box, with a different smell and appearance. The rat will show no evidence of having been trained for extinction. The tone will evoke as much fear as if the rat had not been trained for extinction.

"Extinction memory will only be expressed if tested in the same environment where the extinction training occurred, implying that extinction does not erase the initial fear memory but only suppresses it in a context-specific manner," notes Paré.

Importantly, it has been found that people with anxiety disorders exhibit an "extinction deficit," or a failure to "forget." However, until recently, the mechanisms of extinction have remained unknown."

Trauma recovery is a major part of what psychotherapists do. There is much made about the traumatic effects of major disasters like the Typhoon in Myanmar, the Tsunami in the Indian Ocean, Hurricane Katrina, the war in Iraq, and the tragic events of 9/11. There have been many reports about the walking psychologically wounded from these events. There has been considerable effort to training emergency responders in "Psychological First Aid".

Does everyone who was traumatized need therapy? The answer is a resounding "No". There is research to show that many if not most people adjust to trauma as a matter of course. It's as if their own built in coping mechanisms are sufficient for recovery. So, unless there are symptoms of "Acute Stress Disorder" treatment is not indicated and could do more harm than good.

PsyBlog

"These techniques are in line with the 'hydraulic theory' of the emotions - a popularly held view of how the emotions work. In this view, people's emotions work in the same way as a pressure cooker. Emotions build up inside until the mind can no longer contain the pressure. Then steam is 'let off', releasing the pressure inside and improving the mood.

[..]People who choose not to let off steam in this way are popularly seen as being in denial, and this denial is often seen as pathological. Dr Seery's study extends these criticisms to attack the broader idea that talking about a traumatic event soon after it has occurred is usually beneficial. Mounting evidence suggests that those who do not talk about a traumatic event are simply more resilient, rather than being in a state of pathological denial."

BPS RESEARCH DIGEST reviews recent research articles in professional journals. It's a good place to try to keep up with the literature. It has been a pleasant surprise indeed that many psychodynamic principles have recently demonstrated in research. Unconscious motivations, emotion based early learning have repeatedly been demonstrated. Now I was pleased to find the begins of a research demonstration of one of the most important insights into the obstacles for change that emerge in therapy: the labeling effects of diagnosis and the self-destructive nature of shame.

"Psychological outcome research tends to follow the same model, matching therapy to diagnosis. The client is again little more than the holder of the diagnosis and the subject of the therapy: their individual decisions and personality are rarely considered (again, except where these are part of the diagnosis or lead to non-compliance).

Contrary to notions of the 'miracle therapy' or 'super-shrink', recent research suggests that the client contributes as much to the chances of a successful outcome in therapy as either the therapist or their technique. In fact, client factors may predict more of the outcome than therapeutic rapport and technique combined.

Anne Hook and Bernice Andrews (2005) surveyed people who had received psychological therapy for depression. Half of the current clients and a third of ex-clients reported withholding some information about their depressive symptoms (e.g. low self worth, suicidal thoughts) and behaviour (e.g. substance abuse, aggression) from their therapist.

The main reason given for withholding information was shame. People who had concealed symptoms were more depressed on completion of therapy than those who had 'revealed all'.

As their previous research had linked a tendency to feel shame to higher levels of depression, this seems a fairly obvious result: shame and related non-disclosure are simply part of the clinical picture of depression."

I like to describe shame as the self-destructive expression of guilt, the natural feeling associated with making a mistake that serves to motivate self-assessment and behavior change. Shame goes much further. A person who feels shame believes that their mistake is another demonstration of how much of a hopeless loser they are. Ultimately it becomes the core of a chronic self-loathing that leads on-going disappointment, discouragement and a sense of being a victim to one's own ineptitude, with no hope of change.

Shame provides the motivation for much long standing self-destructive and self-defeating behavior. If a person feels overwhelming shame after making a mistake, they are unable to examine their personal responsibility closely so as to facilitate behavior change. It's too painful. Instead, they engage in ruminative self-punishment that robs the individual of any remain energy to do the examination or make any changes. Such penance, because it goes well beyond a symbolic act of contrition leads to long standing self-destructive patterns of behavior. Misery extends well beyond what is helpful in motivating change into a self-imposed purgatory.

Eventually, the person becomes so desperate to escape that they engage in compulsive behaviors, what I call "temporary feel goods." These behaviors include drug and alcohol abuse, excessive gambling, or any bad habit, taken in isolation may appear harmless enough, but when it is routinely used to escape self-motivating misery, it creates problems that complicate the picture dramatically. Other behaviors are more obviously self-destructive such as sexual addictions, raging and controlling angry behavior and violence, self-injurious behavior, compulsive spending, or excessive risk taking like speeding. Even seemingly innocuous behavior like day dreaming, fantasizing, or computer game playing can take up tremendous amount of time and energy in interfere with productive functioning. That just leads to more misery, more shame and more escapist self-destructive behavior.

Breaking the pattern is more than just a matter of "cognitive restructuring". A shame-based person may already recognize their self-destructive ways. But some inner compulsion drives this incessant self-punishment. I've found that the source of much of this shame comes from early emotion-based learning, the learning that occurs in early often during school age and pre-school experiences. Another source is abuse and neglect, especially from parents or other caregivers, but can also come from abusive adolescent/adult relationships. Another common source is trauma survivors. There is strong association between the severity of PTSD and shame-based ruminations about the trauma. Feeling somehow responsible for witnessed trauma can be particularly debilitating.

Emotional learning has been conceived by Freud as internal conflict and by behaviorists as "conditioned emotional responses." Such learning is particularly persistent and difficult to change. Making those changes often looks like what has been called "reprogramming" treatment of cult and brainwashing survivors. A repeatedly revisiting of the traumatic event, or intensive prolonged exposure, has been shown to be particularly effective in changing the shame-based patterns associated with PTSD. (Journal of Consulting and Clinical Psychology 2006, Vol. 74, No. 5, 898-907, Journal of Consulting and Clinical Psychology 2007, Vol. 75, No. 3, 409-421). Gut wrenching recollection of childhood and traumatic events allows learning new emotional responses to future eliciting events.

BPS RESEARCH DIGEST

"In other words, our data suggest that effort and hard work offer the most promising route to happiness. In contrast, simply altering one's superficial circumstances (assuming they are already reasonably good) may have little lasting effect on well-being."

Temporary feel goods are just that. The only way to happiness is hard and persistent work on our difficulties.

I think it's probably a human trait that we seek the simplest solution to a problem even when more complex and proven methods are well known. Even scientists seem to do this, even in their area of study!

Our culture seems to have decided thousands of years ago that negative emotions are bad and should be avoided. Everywhere in the psychological literature is examples of researchers seeking to find ways to help people avoid psychological pain.

Has it occurred to anyone that psychological pain has a purpose? For those of us that believe we evolved to be human beings, we have to assume that most attributes that make us human in some way enhance our survival, or that trait would have been selected out of the gene pool. Negative emotions help us. I make that assumption and help people make sense out of their misery, rather than find ways to avoid it. Misery is the single most powerful motivation for change.

Here is a good example. Surviving a traumatic event involves recurring "flashbacks" of the trauma that persist for sometimes many years. So in keeping with the tradition of helping people avoid their "flashbacks", we have this report from New Scientist.

"It might be the case that people with memory disturbances have to gain some control over the memory representation by remembering it and trying a different emotional response to the memory before successful suppression," he adds.

A drug targeting specific brain regions might eventually boost the ability to suppress, said John Gabrieli, at the Massachusetts Institute of Technology, Cambridge, US.

For a mother haunted by the memory of her son's suicide, he said, "it is hard to imagine that you would ever get her to forget that the event occurred. But the more you could weaken the memory in any dimension, the better it would be.""

Ok, lets try the assumption that flashbacks are somehow helpful. Just how is it helpful for the mother in the example above is haunted by memories of her son's suicide? It's a challenging stretch to the assumption surely. But how is it we would expect there be a way to somehow "forget" the memory? That seems impossible without brain damage and considerable collateral damage to other structures and abilities.

What is there in the psychological literature that might explain recurrent unpleasant memories? Recall that phobia is treated by "exposure", gradually introducing the anxiety or fear provoking stimulus while the patient tries to relax. There is good research to say this works pretty well.

What if the flashbacks were the human body's attempt to provide it's own crude exposure treatment? What if the patient were advised to sit with his feelings, talk about the experience with a trusted counselor and to make sense of the experience in his current life. Might this be a way to find meaning in the seemingly meaninglessness of traumatic event?

Indeed, there are examples of research showing how exposure therapy is effective for PTSD.

Here is an even sillier example.

Monitor on Psychology

"So, again, this suggests that verbalizing an emotion may activate the right ventral lateral prefrontal cortex, which then suppresses the areas of the brain that produce emotional pain.

"[In talk therapy] we tend to focus primarily on content and enhanced understandings and changed understandings," said Lieberman. "But it's not entirely irrelevant that they all involve putting feelings into words.""

Duh! Talk about being blind to anything not in front of your face!

AlterNet has the best article I've seen in the media about PTSD and the Iraqi veterans. Unfortunately, the news is not good. The proportion of vets with PTSD is higher in this conflict than in any other previously monitored war. Suicide accounted for over 25 percent of all noncombat Army deaths in Iraq in 2006, that's double what it was in peace time and much higher than rates from Iraq War I and Vietnam.

With the VA reporting inadequate resources to treat returning veterans, slow response to those most at risk for PTSD: the National Guard and Reserve troops, and the continuing stigma of mental illness are greatly exacerbating the problem. Female vets are returning home with PTSD due to sexual trauma, too often allegedly perpetrated by fellow American soldiers.

There is some good news in all this. There is evidence that treatment is helpful to improving the quality of life of vets. Brief Cognitive Behavior Therapy can mitigate initial symptoms, but doesn't impact long-term prognosis. However, there is a promising new treatment called "prolonged exposure" that has demonstrated efficacy in a few studies.

"Post-traumatic Stress Disorder is the result of subtle biological changes in the brain chemistry as a response to severe stress, which alters the way the brain stores memories. During a particularly intense episode, the body releases massive amounts of adrenaline, and the physiological alterations associated with the intense emotional reaction create memories that disrupt normal life.

The markers of post-traumatic stress include nightmares; avoiding reminders of the traumatic event; hyperarousal, a physiological response to stress that can lead to irritability and restlessness; and drug use and alcohol abuse. "Veterans screening positive for PTSD reported significantly more physical health symptoms and medical conditions than did veterans without PTSD. They were also more likely to rate their health status as fair or poor and to report lower levels of health-related quality of life."

Among soldiers who develop PTSD, "there was a strong reported relation between combat experiences, such as being shot at, handling dead bodies, knowing someone who was killed, or killing enemy combatants."

More than any previous war, the Iraq war is likely to produce the highest number of soldiers suffering from PTSD. There is considerable psychological distress associated with going into a country under the auspices of liberating a people, only to have them rise up against you, and it lingers long after the war has ended. Adding to the pressure is that many mental health officials believe that the nature of urban street fighting and insurgent warfare, coupled with heavy reliance on National Guard and Army Reserve troops, will result in higher rates of PTSD among this group of veterans than those in previous conflicts.

Another reason for the escalating mental health challenges is that while soldiers typically spent one tour of duty in Vietnam, troops are serving two, three and occasionally four rotations in Iraq. An additional challenge is the moral ambiguity of fighting a war without front lines, where the combatants are, or are dressed as, civilians. Many veterans are finding it difficult, if not impossible, to reconcile experiences such as shooting at civilians because they had failed to stop at a checkpoint.

"At least 30 percent of Iraq or Afghanistan [veterans] are diagnosed with PTSD, up from 16 percent to 18 percent in 2004," said Charlie Kennedy, PTSD program director and lead psychologist at the Stratton VA Medical Center. The number of Iraq and Afghanistan veterans getting treatment for PTSD at VA hospitals and counseling centers increased 87 percent from September 2005 to June 2006, and they have a backlog of 400,000 cases, including veterans from previous wars. The most conservative estimates project that roughly 250,000 Iraq war veterans will struggle with PTSD. MORE"

A study published in the Journal of American Psychiatry has confirmed what clinicians have known for a long time, PTSD is a lifelong disorder with a varying course across sufferers. Some have an acute onset, an immediate stress reaction that ebbs and exasserbates indefinitely. Some have no symptoms for many years, then triggered by witnessing another traumatic event, even from afar, symptoms overwhelm the individual. Many veterans of various wars were overcome by witnessing the 9/11 attacks on television, some showing symptoms for the first time.

PTSD is a tragic aftermath of war and other trauma. Trauma survivors and our veterans need years of monitoring and professional assistance.

Reuters

At year 1, subjects in the combat stress reaction group had a 10.57-fold higher odds of meeting PTSD criteria than the comparison subjects. At years 2, 3 and 20, the odds were reduced to 5.15, 5.41, and 3.09, respectively. Those with a combat stress reaction also had significantly more PTSD symptoms at all four time points.

The authors observed that 19.8% of the combat stress reaction group and 61.4% of the comparison group did not meet PTSD criteria at any of the four tests. However, members of the comparison group were more vulnerable to delayed onset. Both groups exhibited a fluctuating course of relapses and remissions. Veterans in both groups were subject to recurrent thoughts and nightmares about the war. Loss of interest in social activities, feeling remote from people, hyperalertness, sleep difficulties and intensification of symptoms follow experiences reminiscent of the war were also common. Other symptoms, such as survivor guilt and constricted affect, were less common. While the number of symptoms dropped considerably in the third assessment, they rose again at year 20.

"The chronic nature of PTSD renders trauma victims vulnerable for life, and midlife is a particularly high-risk period for either delayed onset or reactivated PTSD," Drs. Solomon and Mikulincer report. They suggest that the many stressors of midlife, from the death of friends and illness, to the loss of structure after retirement, "bring down some of the protective shields that trauma survivors have against being flooded by memories."

Hat tip to Corpus Callosum.

A number of people maybe wondering just how we can best help children and their parents who have faced the disaster in New Orleans. Here is an approach that has produced convincing research results treating children and their families. Contact the authors for more information. The link is below.

SAMHSA

Trauma-Focused Cognitive Behavioral (TF-CBT) is a psychotherapeutic intervention designed to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse; traumatic loss of a loved one; domestic, school, or community violence; or exposure to disasters, terrorist attacks, or war trauma. It was developed by integrating cognitive and behavioral interventions with traditional child abuse therapies that focus on enhancement of interpersonal trust and empowerment. The program can be provided to children 3 to 18 years of age and their parents by trained mental health professionals in individual, family, and group sessions in outpatient settings. It targets symptoms of posttraumatic stress disorder (PTSD), which often co-occurs with depression and behavior problems. The intervention also addresses issues commonly experienced by traumatized children, such as poor self-esteem, difficulty trusting others, mood instability, and self-injurious behavior, including substance use.