MORE ABOUT PMS AND PTSD

Recently a woman who I have been treating for anxiety relate to post traumatic stress disorder [PTSD] had started taking a low dose of lithium to lower her anxiety level. It has been helpful and she then reported that instead of very intense prementrual syndrome symptoms that included anxiety and a strong feeling of impending doom, she was able to go through her prementrual period without stress and without any feelings of doom. She connects this improvement with her being less anxious and less reactive to events in her life. In the past she had tried changes in estrogen and progestin doses and taking ssri [selective serotonin reuptake inhibitor] type antidepressants with no change in her PMS symptoms.

I have wondered if a prementrual change in estrogen level can trigger PTSD symptoms and that this is a significant component of PMS. It seems that even a smaller change in estrogen level can trigger a reaction. So it may be the change in estrogen level triggers the PTSD symptoms as this change sends a message to her brain to have her instantly react as a way of protecting her from stress that her brain connects to past traumas.

So, successfully reducing PTSD related anxiety should reduce PMS symptoms. 

LITHIUM FOR PTSD: A LITTLE BIT GOES A LONG WAY

For a couple of years I have been prescribing low doses of lithium carbonate to help people with PTSD [post traumatic stress disorder] not react as much to past traumatic experiences when they are recalled.  Those who respond report feeling less anxious and less reactive when they think about past stressful events. It is like they are not as on guard and overall more able to experience events throughout the day without having to react with anxious feelings and a need to be vigilant.  

Unfortunately it has been hard to determine a range of optimal dosing as many of my patients do not respond to the lowest lithium carbonate dose of 150 mg [in a capsule]. Therefore, I have started prescribing a liquid form of lithium to see if a dose range from 6 mg to 120 mg would be helpful. I am also prescribing compounded doses of lithium. Once my patients respond to a specific dose range, I ask them if they are willing to change their doses to see if a small change leads to improvement and then seeing if their most positive response is replicable with repeated trials. This can lead to important information about the range of optimal dosing for lithium in treating PTSD.

DO WE NEED TO FORGIVE PEOPLE WHO ABUSE US?

I've had several patients tell me that they couldn't forgive people who had abused them but they were no longer troubled by thinking about them. Then a few other patients told me that they were finally able to forgive their abusers and felt more at peace about it now.  So, do we need to forgive those who abuse us to be able to not be troubled by these events anymore?  What is forgiving? Some definitions focus on it being deciding to stop feeling anger towards someone and others mention a willingness to allow room for error or weakness. Others use words like:merciful, lenient, compassionate, magnanimous, humane, softhearted, forebearing, tolerant, indulgent, etc. as ways to decribe someone who is forgiving. Now lenient, softhearted, tolerant and indulgent don't sound so good.  It makes it seem that forgiviing someone is being too kind and is letting them get away with it. What are they or have they gotten away with? They know that they have violated you and you know that you were violated.. They have to live with this and if you forgive them then maybe you won't have to live with it anymore. You will be able to shed the weight of this memory and let go of any lingering feeling of responsibility. 

So, it seems that we forgive to help ourselves be released from the anger and hurt that really is our problem and won't be resolved until we can stop reacting to something that is in the past.

MEDICATION FOR PTSD

A number of different medications have been prescribed for PTSD.  These mostly include antidepressants. At times this can be helpful as chronic stress associated with PTSD can lead to depression that can be relieved, at least in part, by medication.  I say in part because if the stress connected to PTSD is ongoing then depressive symptoms can be precipiated again or never resolved with medication and therapy.  

Anxiety triggerd by events that remind the brain of past traumas is the main symptom of PTSD.  This anxiety is related to the almost instantaneous alarm response of the brain as it tries to avoid a catastrophic response.  It seems that frequent alarm reactions is better than being completely overwelmed.  Anything that can reduce the intensity of the anxiety response or reduce the frequency of anxiety responses will be helpful.  Medications targeting this have included propranolol, atypical antipsychotic medications and benzodiazepines.  Propranolol reduces the physical reactions to stress and thus can reduce the intensity and frequency of these reactions.  Atypical antipsychotic medications are also able to significantly reduce anxiety reactions and at lower doses are usually well tolerated without side-effects.  It may be difficult to explain why an antipsychotic medication is helpful and yet the intensity of the anxiety response in PTSD benefit from this type of medication. Benzodiazepines can temporarily reduce anxiety but often have side-effects and will over time be less effective.  There can also be dangerous withdrawal symptoms for the shorter acting benzodiazepines.