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. 

WHAT IS SO GOOD ABOUT LISTENING TO OTHERS WITHOUT OUR PERSONAL REACTIONS INTERFERING?

People who have come to me for help have taught me the importance of actually listening to others without our reacting to what we are hearing. This can be very difficult to do unless we actually tell ourselves that this is what we want to do. It is easy to react [and self righteously respond] in order to inform or educate or castigate the other person. The outcome is to disrupt the relationship to the other person and make it easier for the other person to put the responsibility for their actions onto you. If we listen to someone, without reacting, then we are actually with that person, sharing their life experiences and acting like their lives really matter. Another reason that it is hard to listen without reacting is that we can convince ourselves that our reacting is necessary and the right thing. This is either because we are protecting ourselves from our fears by taking on responsibility for others or feeling like we are doing the right thing by confronting that person as if that actually helps change the other person's view or outlook. An example is when people feel that they must react and confront people who are saying or doing bad things as this is required of us. Unfortunately, even with good intentions based on trying to right wrongs that are being promoted or actually happening, when we react we are allowing the other person to avoid taking responsibility for themselves. So what can we do? I believe that we can still listen without reacting and also respond to what we are hearing in a helpful manner. If we are able to not react then our brains will tell us what we need to do, if we are able to listen to ourselves as well, without reacting. We then are responding and not reacting and by responding we are able to encourage and support these people so that they are more likely to take responsibility for themselves and make changes that are good for them and likely for the universe as well.`

For us to realize how important listening without reacting is no matter what we are hearing does require that we give it a chance and if we start reacting then we should walk away from the interaction and return after we are again able to listen without reacting. It is also important that frequently we react to things in self defense as past stresses have programmed our brains to instantly react. This happens frequently in people who have had traumatic events happen in their lives and are suffering from post traumatic stress disorder [PTSD]. I have helped many people to stop this automatic reacting by helping them understand what is happening, supporting coping skills that reduce the likelihood of them responding to stresses and I have also identified a few medications that reduce the frequency and intensity of reactions to past stresses. This makes it much easier to not react to past stresses and allows them to be more themselves as their stress reactions are temporary and not their typical way of responding. 

What do you think?

PTSD AND PMS...IS THERE A CONNECTION?

A woman who comes to me mentioned that every month she has intense emotions and irritability during the 5-7 days before the onset of her period representing symptoms of a premenstrual sydrome [PMS].  This person also has post traumatic stress disorder [PTSD] and I wondered if there is a connection between her PMS symptoms and PTSD. I was aware that stress and anxiety can influence hormones. I started to research the possible influence of estrogen and progesterone on PTSD symptoms. There have been a number of studies that have suggested that PTSD symptoms intensify when estrogen and possibly progesterone levels are lower and conversely PTSD symptoms are lower when these levels are higher. During the prementrual period estrogen levels rapidly decrease and it is possible that this triggers an increase in PTSD symptoms. The monthly cycle for women starts with menses when estrogen and progesterone are lowest followed by the follicular phase with an increase in estradiol that triggers the release of follical stimulating horomone [FSH] that stimulates follicle [egg] development. Then leutinizing hormone [LH] increases triggering the release of the egg [ovulation] with a rapid drop in estradiol. This is. followed by the luteal phase when estradiol increases again in preparation for fertilization of the egg. Without fertilization, estradiol and progesterone levels drop late in the luteal phase triggering prementrual symptoms followed by the onset of menses. Estrogen levels increase in the later follicular phase and then drop around ovulation with leutinizing hormone peaking and then increases again halfway through the luteal phase before dropping rapidly leading to onset of menses. The progesterone increases in the late follicular phase and then peaks and levels off during the middle of the luteal phase with rapid drop off just before menses. Leutinizing hormone and follicular stimulating hormone both peak in late follicular phase and then rapidly drop off after ovulation. 

What is the point of elaborating on the fluctuations of hormones during the mentrual cycle? Well, PTSD symptoms are reported to increase with decreasing estrogen and progesterone levels and this is correlated with later luteal phase of the cycle including the several days leading up to menses. So if PMS is accentuated by PTSD symptoms then these PMS symptoms will be increased especially during the luteal phase until just before menses. This is when my patients experience their PMS symptoms. 

So, if the PTSD symptoms increase as they are triggered by the hormone level changes and if these symptoms are lower with increased estrogen levels then they should be lower during pregnancy and other times when estrogen levels are high. Focusing on the hormone levels  would support the liklihood of PMS occuring during a signficant part of the luteal phase up until near the onset of menses. This seems to be true for the woman who came to me for treatment. 

I wonder if it is possible to reduce PMS by lowering PTSD symptoms. This would make sense if for some women PMS represents a coping mechanism dealing with traumatic memories. 

What do you think?

IS LONELINESS AT THE HEART OF ADDICTION?

Recently I listened to a TED talk by Rachel Wurzman entitled: "How isolation fuels opioid addiction." She discribes her experience of having tics [Tourettes Disorder] that she calls "unvoluntary." Dr. Wurzman experiences her involuntary tics as unvoluntary meaning that she feels like she is doing the tic movement and not an external force. However, Dr. Wurzman recognizes that her tics are not related to her conscious intentions or attention. Dr. Wurzman then makes the point that we all have things that we do in healthy ways and other things that are not healthy and this can help us to understand what others are experiencing, including those with tic disorders and addiction. So, why is it important that we can understand each other? Dr. Wurzman goes on to talk about the opioid epidemic and it's connection to being lonely. She states that this epidemic is killing 91 people every day and it is getting worse. Dr. Wurzman understands that addiction is a medical, neurobiological problem and yet she feels that we can help people with addictions by changing how we respond to them. To change how we respond to people with addictions she feels that it is helpful if we understand how and why our brains cause behaviors like urges to use substances. Dr. Wurzman's research suggests that loneliness may be reinforcing the brains of addicts to seek comfort from substances as their striatum's are seeking things that have most frequently been associated with reducing their feelings of loneliness. These responses [seeking things] are like they are on autopilot, so that when there is a stimulus there is then a very rapid and automatic response from their brains. 

Importantly, according to Dr. Wurzman, feeling socially connected to others is part of what the striatum does. The experience of feeling pleasure in social interactions is modulated by opioid receptors in the striatum. If some one is experiencing intense loneliness the opioid receptors are sensitized so that anything that reduces this sense of loneliness, such as taking opioids, is intensely and very rapidly sought. Therefore, loneliness may keep people addicted and social connections may help people not be addicted. However, those social connections need to be strong enough to convince the striatum that it is safe to let go of the immediate and reliable relief that taking opioids [and other drugs] represents. Dr. Wurzman also believes that to establish powerful social connections, it is better to connect with each other not focused on one aspect of ourselves/others [like addictive behavors] but recognize how we all have unvoluntary or automatic type behaviors. This helps us to realize that we are connected to people who happen to have different unvoluntary or automatic type behaviors. 

After listening to Dr. Wurzman, I wondered about a connection between the social isolation experiences of people with addictions and those who suffer from Post Traumatic Stress Disorder [PTSD]. If so, then does the isolation theory apply to people who have PTSD? And how would this influence treatment of PTSD?

What do you think? 

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.