Entries in PTSD (5)



Recently one of my patients came in and announced that "I don't care and I don't care that I don't care."  She said that she realized this just the day before.  She reflected on this and indicated that it was a relief not to care.  She feels less stressed and yet still feels responsible for others and realizes that she takes care of others better than she takes care of herself.  She believes that "not caring" is helping her to feel less stress and take better care of herself.  

So, what is this "not caring?"  I am treating this person for severe PTSD symptoms that include paranoid thinking, frequent flashbacks and dissociative symptoms.  One of the treatment goals has been to not feel a need to react to the past and also to no longer fear past traumatic experiences, recognizing that they have no power anymore. The growing success not reacting to the past seems to have led to being able to "not care" about things from the past, and "not care" about things that are happening now or that might happen in the future.  It is like a weight has been lifted as worries about the past and fears about the future have lessoned. There is a calm more of the time now and it is easier to be around people. A feeling of responsibility for others is still a problem but is also more contained than before. It is also easier to focus on self care.

My wish for the universe is that all living things can learn to "not care" what happens, so that they can experience the joys of living, without being distracted by "caring."

Confusing? Imagine that you don't care and don't care that you don't care, and see what happens.  



My patients have made it clear to me how important their feeling responsible for others is in maintaining PTSD symptoms. It seems that taking responsibility for others develops as a way of coping with abuse.  It makes sense in that people who are being abused are not being protected by adults around them and therefore they can feel more in control by taking on responsibility for others.  However, I have wondered what the nature of the control experience is.  Now I believe that it is to prevent things from getting worse. This idea has surfaced with many of my patients who come to me for help with PTSD. They believe that the abusing person will be less likely to lose control if they do this. They also do not feel confident enough to resist taking responsibility for others and standing on their own. Any person who loses control, or threatens to, can cause someone who has PTSD to respond by feeling responsible for them. This maintains the old pattern and as I have previously discussed the brain is very good at helping us to maintain old patterns of behavior.

The significance of feeling responsible for others is that when we act this way because of a fear that things will get worse tells our brains that we need to be on guard to be alert in case the something worse happens.  For this reason it is very important for people with PTSD to have a goal of no longer doing things to keep things from getting worse.  They need to be able to identify all the ways that they act this way and make it clear to themselves [their brains] that they want to stop doing this.  It also helps to be able to tell themselves that they no longer need to fear past stressful situations as they do not have any power over them now.  This requires that we choose to think of past stressful events and then, staying calm, tell ourselves that we no longer need to be stressed by these memories.  Even with this accomplished, the behavior pattern of doing things to keep things from getting worse can continue unless stopping it is addressed directly.  If it is not stopped, automatic stress reactions to past events will continue.  





Abilify [aripiprazole] and Seroquel XR [quetiapine XR] are called atypical antipsychotic medications with their atypicalness relating to the fact that they increase levels of the neurotransmitters serotonin and norepinephrine as well as decreasing the neurotransmitter dopamine which the typical antipsychotics do as well.  Research studies have shown that Abilify and Seroquel XR can treat bipolar and depressive mood symptoms as well as psychotic symptoms.  Both Abilify and Seroquel XR have low doses available that are helpful for people with mood symptoms without psychotic symptoms as they are more likely to respond to lower doses.  

I have also found that low doses of Abilify and Seroquel XR are helpful in reducing the anxiety that people with Post Traumatic Stress Disorder [PTSD] experience.  PTSD is felt to be caused by someone experiencing an overwhelming event and then recalling the traumatic nature of the event by having a very sudden intense recalling of the event [a flashback], and/or avoiding situations that are likely to lead to a recollection of the event, and/or re-experiencing smells, or sounds or emotions connected to the event. It used to be thought that only people who have been in combat situations developed PTSD.  It is now recognized that many types of events can lead to the development of PTSD.  This is very important as in my experience,  PTSD is often overlooked as people adapt to chronic stress and are reluctant to report past traumatic events as they are afraid that they will re-experience the trauma, especially as avoidance is a commonly used coping mechanism.  

So, why are powerful medications with the risk of metabolic and glucose metabolism side-effects necessary to help in the treatment of PTSD? [As a side note, these side-effects are not common and if any occur the medication is stopped and the side-effects also are stopped with return of normal functioning].  When we are traumatized and we continue to react like we will be traumatized again, our brains are ever alert to any possible threat and will   react instantly to alert us to possible danger.  This reaction causes stress and anxiety and yet from a survival standpoint is better than not reacting and being overwhelmed and possibly going into shock.  In other words, the brain seems willing to have many false positive reactions to avoid the one false negative non-reaction. It seems that our brains would rather have us react thousands of times when we don't need to in order to avoid not reacting when it is critical that we do react. Other medications can help to lower anxiety levels and reactivity but frequently do not stop the majority of the brains instantaneous anxiety reactions.  To stop our brains from reacting to these perceived threats we need to have our anxiety levels lowered so that our brain's alarm system is not triggered.  We can then learn ways to cope with stress that keep our anxiety levels low and then we will no longer need these medications.

Non-pharmacological treatments for PTSD include: Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]. This treatment can be very helpful in reducing or even eliminating symptoms of PTSD if someone's anxiety level is low enough that they do not feel threatened with being re-traumatized. Interpersonal therapy has also been shown to be helpful in treating PTSD. In addition, mindfulness practices are also helpful and I have blogged about studies that support using these treatments for PTSD.



Earlier, I wrote about the impact of being bullied and being a bully, ten years later.  One study showed that children who were bullied were at significantly inreased risk for anxiety and depressive disorders while males were also more likely to be suicidal and girls to have agoraphobia [fear of public spaces and crowds]. The bullies had an increased risk of antisocial personality disorder.  I felt that the bullied children were also at increased risk for post traumatic stress disorder.

Another study by S.T. Lereya, Ph.D., et al, in the June, 2013 issue of the Journal of the Academy of Child and Adolescent Psychiatry reported on the impact of being bullied in childhood on adolescent self-harm [cutting and suicidal] behavior. They controlled for a number of other variables that also can lead to self-harm behavior and found that about 20% of the total self-harm behavior was caused by the bullying.  This is a very large effect from the bullying. 

It is a critical problem, especially as children [and adolescents] very often suffer in silence and do not tell their parents or teachers.  They also tend to  hold their feelings in so it is not easy to detect depressive symptoms.  Frequently they will complain of a number of different nonspecific symptoms that include headaches, stomach aches, backaches, dizziness, sleep problems and they may resist going to school and be withdrawn. When they do tell an adult they often feel that it doesn't help as they expect the adult to get the bullies to stop.  It would seem that a focus on helping the victims of bullies to cope with this stress so that they are no longer feeling overwelmed and can ignore the bullies more successfully.  Another focus, of course, would be to stop bullying from occuring in the first place.  Zero tolerance for violence or the threat of violence, so why not zeo tolerance for bullying?  I wonder if educating children and adolescents on the impact of bullying and the different forms it takes and then how to resist being part of bullying, wouldn't help reduce bullying significantly.  I am interested in your thoughts about how to prevent or at least reduce significantly, the bullying of our children and adolescents. 

Of course, it happens with adults, too.



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.