Tag Archives: PTSD

July 26, 2010 · 10:53 am

Ecstasy (MDMA) as treatment for PTSD?


Back from vacation and reading up on my piles of emails. This one came via my Medscape.com subscription to psychiatric news–Ecstasy-assisted Psychotherapy May Help Patients with Treatment-Resistant PTSD. You can read about it here on WebMD.

Interesting…a date rape drug being used to treat PTSD. There is some irony here I think in that many a date-raped woman was taken advantage of when slipped this drug.

How is it purported to work? By reducing or blocking symptoms (intrusive, emotionally laden feelings when thinking about traumatic events) and thereby allowing therapy to do its work. The therapy was done in an intensive manner rather than spaced out as most people do therapy. One wonders if prolonged exposure therapy was used as the therapy. If not, would PE therapy do as well or better than traditional PTSD therapy and MDMA?

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May 20, 2010 · 5:39 am

Frontline on PTSD in soldiers


Caught a portion of the PBS Frontline show, The Wounded Platoon, documenting the extensive combat trauma in the 3rd Platoon, Charlie Company, 1st Battalion, 506th Infantry stationed in Fort Carson, CO. Click the above link to watch it on-line if you missed it.

It is heartbreaking and mind-boggling to consider that so many of these young men are now in jail or dead due to suicide. The PTSD is evident to all. The men admit to massive drug and alcohol addiction, trauma, domestic violence, etc. What is even more mind-boggling is the interviews with some of the platoon leaders–some of whom are quite matter of fact. Yes, they say, it is bad. But it is part of what we get. Too much demand for soldiers, too few to meet the demand. This equals spending longer rotations in theatre thus more PTSD.

They discuss the amount of psychiatric meds prescribed for these soldiers while in Iraq. While this means they are getting some treatment, others see this as merely allowing them to suffer more damage while still being able to fight the next day.

I’m thankful for my freedom in the US. But never forget the cost. And do remember that few of these men get any decent treatment once they return.

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April 22, 2010 · 5:23 pm

Staff Mtg on Prolonged Exposure treatment for PTSD


Had a fabulous staff meeting at our practice today given by fellow colleague, Marta MacDougall. Marta also works at the Philadelphia area VA. She presented an overview of Edna Foa’s Prolonged Exposure Therapy for PTSD. You can find the book here.

PE looks at trauma this way: PTSD is maintained by avoidance behaviors. One avoids memories, triggers, emotions, places of traumatic experiences. While avoidance works in the short-term, it exacerbates the symptoms over the long haul since they are not fully processed. In fact, the better able one can avoid these feelings, the more likely their PTSD will be worse later. Hence why you can have some very functional people become unable to function later in life. She used this illustration. For many Vietnam Vets, Vietnam is part of a book they keep trying not to read. They shove it away over and over but it has a habit of falling off the shelf and opening to the same page, even the same couple of very painful sentences. Thus, despite their attempt to avoid, the only thing they keep rereading is the same couple of sentences; thereby reinforcing and even rewriting the whole experience as if it were only those two sentences.

Thus, the goal is break the “phobic reaction” to painful thoughts and feelings. How? By two prongs: (a) imaginal exposure (memory encounters), and (b) in-vivo exposure to avoidant stuff in the present.

The therapy consists of 12-20 sessions (1.5 to 2 hours each). In the sessions, the person develops a current list of avoidance in their life  or other subtle safety behaviors. They begin to daily pick easy to hard avoidant tendencies to expose themself to in order to break the fear pattern. Now, these are things that aren’t actually dangerous. Second, in session 3 they begin to recount the most salient trauma from the point in the story where they were safe to unsafe to safe again. So, it could be a story of waking up to a rape, going out for a particular traumatic battle, etc.). This portion of the story may only take 5-10 minutes to recount. That same memory is recounted, in the first person with eyes shut, repeatedly for up to 45 minutes. During the exposure, the therapist asks for their subjective units of distress level (0-100) every five minutes. This exposure to the same memory is repeated in each session with time to talk about and process at the end. The levels of distress are tracked over time (both from imaginal and in-vivo exposure experiences. On top the therapy intervention, the in office imaginal exposure experience is recorded and the client is to listen daily to that recording.

Sound like torture to you? It does to me. Here’s the reaction rationale. The avoidance of memories and emotions tied to them is causes even greater distress. Thus, getting the client to face that distress and process the emotions as well as uncover subtle lies believed about self and other is only dealing with reality directly.

You can imagine that many refuse this kind of therapy. Those who do it…about 80% see a significant reduction in PTSD.

Not sure I’m going to begin doing this kind of therapy as I’m not set up for it being in the office only 1 day per week. However, I will pay more attention to the ways avoidance behaviors or safety seeking behaviors accentuates PTSD and will be more likely to give daily homework to address this problem.

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March 10, 2010 · 10:28 am

Here’s a cache of info on abuse trauma


If you are interested in reading some of the most recent research literature on complex trauma and treatment, take a look at the Trauma Center at JRI in Brookline, MA. Click their “publications” tab for a host of full-text articles on the topic. Bessel van der Kolk, MD is one of the foremost researchers exploring trauma’s impact on the brain.

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October 26, 2009 · 9:13 am

PTSD and surgery mortality rates


Today I begin “Counseling & Physiology”, a crash course (6 weeks!) for my students to explore the mind/body connections and how counselors pay attention to the body even if not their primary focus.

Last week I saw this news item on my Medscape.com feed: “Veterans with PTSD twice as likely to die after surgery”

Here are some of the highlights from a research study done at the San Francisco VA and UC San Francisco:

  1. 10 year retrospective study of 1792 vets (ending in 2008). 7.8% had established dx of PTSD. On average vets with PTSD were 7 years younger than those without the diagnosis (you would think then, younger = higher survival rates). Surgeries studied were elective surgeries.
  2. 25% increase in mortality 1 year post surgery for vets with PTSD, even if surgery happens years after getting out of the service
  3. Mortality rates for these vets were higher than those with Diabetes
  4. PTSD is an independent risk factor for mortality
  5. DX of PTSD was associated with increased cardiac issues (may point to why the mortality rates are higher

Sobering research if you ask me. Let us not become lazy in our thinking. Emotional problems such as severe depression and anxiety (which PTSD tends to bring both together) have a substantial impact on the entire person, affecting every part of the person from cells to spirit. Neither let us believe that if the cells are involved in such a disorder that there is nothing that counselors can do. Clients can learn to manage and even defeat some of the symptoms of PTSD by taking control of their thought life.

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October 13, 2009 · 5:21 am

Fear and trust hand in hand?


This week I’ll be speaking to a group of counselors about complex PTSD. One of the hallmarks of C-PTSD is the combination of chronic relational fear AND chronic shame/guilt over having said fear. It manifests itself as, “I’m afraid of you but I know it’s my fault for being afraid.” (NOTE: the reverse is not necessarily true: that those who have chronic fears, trust problems, and self-condemnation have PTSD or C-PTSD.) My focus at that training will be on this question: How do you lead someone (in therapy) in the repetitive work of “Do not give in to fear”?

On Sunday, Tim Lane of CCEF preached a sermon about fear and disappointment. In that sermon he mentioned our propensity to “flail ourselves”–assuming that we must be doing something wrong–if we experience fear. Instead of focusing on the experience, we ought to examine our responses to fear. Do we shut down? Do we believe that we are alone and isolated? Do we turn inward and act only in self-interest?

He gave us this quote from CS Lewis (Screwtape Letters): “The act of cowardice is all that matters, the emotion of fear is, in itself, no sin.”

Here’s my question: Is it possible to be afraid and to trust nonetheless without much reduction in the level of fear? Don’t we assume that if we act in a trusting way that our fears should abate? Especially in light of trusting God? Is it possible to trust God fully and yet fear? What might such fear and trust together look like? If we could do both at the same time, would it reduce inappropriate self-condemnation?

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August 31, 2009 · 5:44 am

Disorders of Extreme Stress Not Otherwise Specified (DESNOS)


I recently scanned a book, Healing Trauma(published by Norton in 2003), and ran across a new name (for me) for the problem of complex PTSD–Disorders of Extreme Stress NOS or DESNOS.  Because many christian counselors are only marginally aware of the research on complex PTSD I’ve decided to give a brief summary here.

The following symptom presentation may be found in those with prolonged and severe personal abuse (and often starting at an early age): 

  1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and being self-destructive,
  2. alterations in attention and consciousness, leading to amnesias and dissociative and depersonalization episodes,
  3. alterations in self perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed,
  4. alterations in relationships with others, such as not being able to trust and not being able to feel intimate with people,
  5. somatizating the problem: feeling symptoms on a somatic level when medical explanations can’t be found, and
  6. alterations in systems of meaning (loss of meaning or distorted beliefs)

Some folks include a 7th characteristic: (alterations of perceptions of perpetrator(s).

Check out the this paper(44 pages long) written on the assessment and treatment of DESNOS.  Though written for psychiatrists, I found the language easy to understand. The authors do a nice job of helping counselors differentiate between Borderline Personality Disorder and DESNOS. While they recognize significant overlap between the two constellation of symptoms, DESNOS folks tend to experience less relational push/pull (less manipulative behavior) and more push behaviors coupled with more intense sadness and grief.

Counseling work falls (per this paper) into 3 categories: stabilization, trauma processing, and re-integration into their world.

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July 16, 2009 · 5:16 am

Rwanda Day 7


Started the day as usual with some quiet meditative reading on the porch overlooking the lake and the distant sound of many children getting water on the other side (yelling Muzungu (white person) to get my attention). Diane read us this quote from John Fawcett’s “Christ’s Precious” (published by W. Milner in 1839, p. 82)

I am but a stranger in this world, wherever I may be situated, or however I may happen to be distinguished. And such, it is my privilege that I am so. [However] when I look not upon myself as a stranger and a pilgrim, when I am captivated with anything in this place of my exile, I forget myself, and act far beneath my character, as a candidate for an immortal crown.

Fitting. It is easy in the US to forget our “exile” status. We focus, instead, on our own status. But here in Africa, there is little to do but remember how fragile life is and how we must depend on God for our daily existence.

Today we met with Justin Remera, a psychiatric nurse at Gahini hospital. The hospital was built in 1920s. He is the head of mental health. He sees some 30 patients per day and has a caseload of 500 with PTSD. He sees lots of “epilepsy” and has documented some 350 new cases in the past 2 years. But they have normal EEGs, thus it is trauma related not brain injury. Justin told us that there is an openness to therapy here because they see the benefits.

Problems noted by him? no medications other than Haldol. Infrastructure needs. His office is the size of a small closet and he has had violent patients and no escape (his desk and chair are away from the door). Also, next to his office are rooms where patients were screaming (while we were there). Seems they may have been doing some minor surgery without anesthetic. He also mentioned problems with demobilizing military and their own trauma as well as his own burnout.

Next we went to Kigali and met with the the permanent secretary of Defense. One of the persons there talked about having 520 peer counselors in the military to deal with the problem of HIV. Nothing dealing with PTSD. They have NO chaplains in their military.

Next, we visited the National Council of Protestant Churches of Rwanda. Specioise told us that 52% of the country are protestant. They have a program to deal with gender based violence, to educate the the church about laws designed to protect women. Their booklet combines Rwandan laws and biblical passages.

For our final meeting, we visited with Jean Baptiste at World Vision. He is new to WV in Rwanda but not new to WV (previously in Mali). He is a tall man with much presence. He spoke very openly and honestly about the issues of NGOs in the country and the problem of lukewarm Christians. He suggested they were much more problematic than rank atheists or Muslims. He gave us some advice as how to work with both churches and government officials. Josephine, a woman Diane had worked in Rwanda on previous trips, was there and spoke of the continued need to train and care for Rwandan caregivers.

Our day ended in Gahini with a farewell dinner. Members of the church and community (the local mayor) attended a dinner at the Seeds of Peace retreat houses. The dinner was outside under a canopy. During dinner we watched the local youth perform traditional dances with drums, singing and costumes. The young women danced with wooden milk bottles on their heads. We learned their trick. A heavy stone in the bottom of the bottle helps it stay on their head. Ouch! The night ended with gifts from our hosts to us and a few words of thanks from us.

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March 20, 2009 · 5:43 am

Physiology Phriday: Repetitive thoughts?


Have you ever been tortured by a repetitive word, sound, phrase, song, or the like run through your head? Does it happen only during the day? At night when you wake up?

In psychological studies, there are a number of ways people talk about these experiences. Sometimes folks talk about intrusive thoughts/imagery, but this is usually in the context of PTSD or OCD studies. Others talk about rumination or repetitive thoughts, usually in the context of worry, depression, or anger. Finally, another batch talk about hallucinations in regards to psychotic disorders.

But what is going on in the more mundane repetitive thoughts? Diagnostically, they probably fit a bit more in the OCD genre than anything else (like counting, ordering, etc.).

1. Stress is usually a factor. They happen more frequently the more distressed a person is. It means the person is on higher alert than normal. The repetitions may be directly related to the stressor or may not. What is not know is whether the repetitions are a consequence of stress or a mediator of stress. What is known is that when a person, under stress, experiences repetitive thoughts salient to the stress, feels responsible to fix the problem, and attempts to suppress repetitive thoughts, their ruminations are MORE likely to increase.

2. Neuroticism is probably a factor as well. Sorry folks: those with anxious and depressive tendencies have more repetitive thoughts than others.

3. Emotional intensity as a native trait of the person may also be a factor. There is some evidence that individuals with strong emotions have a greater predisposition to PTSD (and therefore intrusive thoughts) if exposed to traumatic events.

But what to do about repetitive thoughts? Have you found anything helpful? There are certain things that are NOT helpful

1. Ruminating over the thoughts (Ugh, I can’t believe I’m still having that thought)

2. Trying to solve the problem they may be attached to

3. Trying not to think about pink elephants

Okay, so maybe those things don’t work. What does? Sad answer? We don’t know. Distractions do for a short time. Some actually give in to them and repeat them outloud to try to quell them. The more it is possible to pay them little notice, the easier it is to let them slide on out of the mind.

Maybe try to consider them an interesting mental quirk–like the lovable Monk (TV detective) 🙂

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August 14, 2008 · 5:28 am

Birth trauma? Maternal PTSD?


The August 5, 2008 Wall Street Journal ran a short article on a new postpartum illness akin to PTSD. The author, Rachel Zimmerman, reports that though”PTSD is commonly associated  with combat veterans and victims of violent crimes, but medical experts say it also can be brought on by a very painful or complicated labor and delivery in which a woman believes she or her baby might die.”

While Postpartum depression has received more attention of late (the paper reports the NIH statisticof 15% of mothers affected), there is some speculation that as many as 9% meet criteria for PTSD, and most of these who have given birth to children with serious and immediately life-threatening health issues. These find themselves re-experiencing the traumatic birth, avoidance of places that bring these flashbacks up, and persistent symptoms of increases arousal and hyper-vigilance. Per the article more states are now trying to screen and/or education new moms to this problem. NJ requires all mothers to be screened for depression prior to discharge.

As an adoptive father, I recall well the anxiety and hyper-vigilance of bringing home our first child when he was 4 days old. I didn’t sleep for days, or so it seemed. I worried about his breathing. I felt like I had lost my independence for the rest of my life (I was the stay-at-home dad at the time). It was an overwhelming time for us. And we were healthy, he was healthy, and we were not recovering from the trauma of even a normal birth.

So, I can well assume that if you add all of the normal birth trauma plus medical crises, helplessness, etc. that these experiences can result in symptoms like PTSD. I would suspect, however, that for most people these symptoms would dissipate quickly, especially if the medical crises passes in a day or two. So, we should be careful not to overreact to transitory symptoms and medicate everyone with a struggle. If it is PTSD, then the symptoms should persist for more than a month.

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