by Kenneth Gilbert, MD, Dr. Gilbert is a Board Certified Psychiatrist whose practice is in Illinois
What I know about Post Traumatic Stress Disorder (PTSD) at this point in my life is a lot different than what I knew about PTSD when I was a newly minted Board Certified Psychiatrist in the 70‘s. I suppose that a lot of what I know now will be proven wrong by the time another forty years has passed.
I was trained in a residency program that assumed Freudian Analysis was the core of what psychiatry did and most of my fellow residents were in analysis during residency with the intent to become analysts. Freudian trained psychiatrists certainly knew that trauma played a causative role in the symptoms of many patients. Freud knew that keeping the trauma secret was part of the problem, and developed the concept of ‘Remembering, Repeating and Working Through’, publishing a book by that name in 1914. In Freud’s view, the use of free association was superior to the previously developed idea of Catharsis as a way to deal with trauma. Freud’s case studies include examples that we would now categorizes as PTSD, but that category was not established until, in the context of the Viet Nam War experience, the DSM IV of 1980 included a category by that name. [ go to http://historyofptsd.wordpress.com/timeline-2/ for a very complete time line of prior efforts to categorize the issues of trauma caused behavioral symptoms].
Psychiatry as a discipline, and the Veterans’ Affairs Hospitals as an organization, recognized that they needed new tools to assist those who returned from the trauma of the Viet Nam war with these very difficult symptoms. Many articles were published about the similarities between this PTSD and the clinical picture of soldiers sent home from war in prior conflicts. Reading those articles today, one has to note the absences of awareness that PTSD might ever occur in trauma other than wartime, or to anyone other than a soldier – more specifically a male soldier. The VA responded by setting up dedicated hospital units to support soldiers suffering from PTSD. Those units relied upon the training of their psychiatrist leaders and put together very rigorous programs to assist or even to compel soldiers to overcome their reluctance to talk about these events and engage in highly organized remembering, repeating, and working through. These programs were considered to be state of the art and although the VA was very proud of the new units and their record of rigorous treatment efforts, there were never enough bed spaces to accommodate all who were suffering from PTSD. There were always at least as many veterans simply left to struggle along with their monthly visit to an outpatient psychiatrist as there were those fortunate enough to get into one of the specialized hospital unit.
Many years later (1992?), a retrospective study looked at outcomes of those veterans who had managed to get into one of the specialized units for their PTSD treatment, and those who had been stuck in the treatment as usual outpatient programs. This study revealed that on all relevant scales (number of times arrested, days living on the street, amount of illegal substances being consumed, subjective rating of current symptom load, employment status, marital status) the veterans who had been treated only with routine outpatient visits were doing much better than those who had been given the opportunity of treatment in the special PTSD inpatient trauma recovery units.
For the record, a subsequent VA trial of trauma focused outpatient therapy compared to present focused out patient therapy also found that a therapy that is predicated on repeating traumatic memories did not improve clinical outcomes [Schnurr, PP. et al: ptsd.va.gov/professional/newsletters/research-quarterly/V19N3.PDF ].
With this study, and others like it, the “fact” that trauma recovery (at least trauma serious enough to be categorized as PTSD), requires remembering, repeating and working through, turned out to be completely wrong.
In my outpatient practice, I did not have any veterans struggling with trauma, but I did have many women victims of childhood sexual and physical abuse. Their suffering was every bit as real as that of the soldiers returning from Viet Nam, but the DSM did not acknowledge them with any particular diagnosis. Even more problematic, the mid eighties saw a time of great medico-legal tumult as therapists were accused of somehow “causing” their female patients to falsely remember the trauma that they had incurred as children. A substantial number of therapists and institutions were sued under a new concept of malpractice that gave the person who was accused the right to sue the therapist who had helped his or her patient understand the linkage between her symptoms and the prior trauma. It is worth noting that none of these suits involved male patients. The memories of male soldiers (and more recently male victims of sexual assault by priests) have been considered more reliable than the memories of female sexual abuse survivors. Whatever the merit of the idea that false memories in females could be created by careless therapy, this series of legal suits has effectively closed down any further attempts at treatment of PTSD by doing any sort of memory-based therapy.
Over the next decade, treatment attempts with PTSD could not be described as exuberant. Literature on the topic became less robust. But our awareness of the problem grew stronger thanks in large part to several highly publicized legal cases in which the issue of PTSD was offered as a defense for the action. Gradually, the application of the diagnosis of PTSD was broadened to include events such as rape. In December 2003 the Seattle Times published an article about use of Prazocin in the local VA facility to help quiet “the nightmares of war“. A more accurate headline would have identified the flashbacks of war. It turns out that Prazocin is often good for flashbacks, but never works for nightmares. I had always known that my traumatized patients suffered from very severe flashbacks during which they would re-experience the trauma as if it were happening all over again. These flashbacks repeatedly disrupted their sleep, and often were so horrible that they would try to avoid sleep for days on end rather than be subjected to flashbacks. Prazocin was gratefully received by many. It didn’t “fix” the other issues in their troubled lives, but we can all manage a lot more stress if we are reasonably rested. I later stumbled across the fact that in the same way that Prazocin can often stop flashbacks, Cyproheptadine ( Periactin) can often stop nightmares. Flashbacks and Nightmares are typical of the hyper arousal elements of PTSD, so figuring out how to get control over those issues greatly enhanced the lives of many of my traumatized patients.
Also in this decade, the option of EMDR (rapid eye movement desensitization therapy) was invented. As a strategy to help process discrete traumas, it has proven to be far superior to any prior PTSD treatment. Although I’m not trained or qualified to engage in EMDR with my patients, I have come to regard it as so important that I consider it malpractice to fail to get a patient suffering from discrete traumatic events to a competent EMDR therapist.
There have been literally hundreds of medication treatment trials undertaken and published on the treatment of PTSD and except for Prazocin and Cyproheptadine, none have proven consistent benefit against the symptoms of PTSD itself – although persons with PTSD can also have another illness such as major depression or even schizophrenia and in those cases appropriate medications are helpful to the symptoms that arise from those illnesses and certainly should be undertaken.
During this period, there were quite a few articles in the literature, and even more lectures and talks that reflected on the problems involved when the diagnosis of PTSD entitles a person to ongoing financial benefits. Simply put, if it is going to take hard work to get better, and the person is financially rewarded for staying sick, the probability of getting well is very remote. The literature for physicians had a lot of articles about how to detect a person who was malingering the symptoms of PTSD. I began during this time to think about the usual sequence following trauma is that the traumatized person can be very disabled for many weeks, then gradually the intrusive recollections (hyper arousal), disturbance of attention (dissociation) and attempts to avoid disturbing stimuli (numbing), fade. The Diagnostic and Statistical Manual (DSM) specifies that for a full month post trauma, the typical symptoms are simply called adjustment reactions. The human capacity for healing is so remarkable that the majority of traumatized persons are finished with the adjustment reactions within a month’s time. After a month, the diagnosis of PTSD can be applied, but even during this second month many people show continued reduction of symptoms. By the third month, the diagnosis officially changes to Chronic PTSD, and at this point we see many fewer people who spontaneously get to the point that they are having fewer than three emotional disturbances in a week. One survey concluded that 85% of the population has experience with trauma severe enough to result in chronic post traumatic stress disorder, but of these people, only 10% are still symptomatic at the three month mark. Some sorts of trauma are more likely to produce chronic PTSD than others. We know that 46% of women who are raped develop PTSD, and the same study found that 65% of men who are raped develop PTSD. So my attention was increasingly on the question of why do these normal healing processes fail to work in some people and those people end up with long-term disability from their traumatic experience.
By mid 2006 and going on into 2007 there were several studies published about resilience in relationship to PTSD. I was very hostile to that line of research. It seemed to me to be headed in the direction of blaming the person with PTSD for their illness. “If you had been more resilient, you would not be complaining like this about your PTSD. It is your lack of resilience that leads you to suffer so”. I agreed that it was relevant to consider that most people who suffer trauma seem eventually to get over it on their own, but I was opposed to the whole concept of resilience studies. As a profession, we have already gone through way too many cycles of blaming women for their psychiatric symptoms. I wanted to go on record very clearly with my patients saying “NO! Your PTSD is not because of your lack of resilience. It was the fact that you were gang raped in an elevator that led to your PTSD. It is not your fault that you have suffered so”. But I also had to agree that many patients with PTSD were just not getting better, and we had to figure out some new approach to their care.
There had been three separate research presentations at the 2003 meeting of the International Society for Traumatic Stress Studies that showed reduced volume of the hippocampus in persons with Post Traumatic Stress Disorder and persons with Dissociative Identity Disorder. (see articles by Villarreal,Gerdo; Lindauer, Ramon; Vermetten, Eric) Since the hippocampus (and related amygdala) appear to deal with fear processing, these studies opened up a new way of looking at symptoms such as PTSD. The newly developing capacity to scan and measure both brain activity and the size of specific brain areas lead up to a study done by Kyoon Lyoo which was published in July 2012 in Archives of General Psychiatry. This study started with a group of people with PTSD and carefully measured their brains by a scanning method. The study then followed this group of thirty survivors of a subway fire for the next five years, along with age and sex matched controls. Some of the patients showed significant reduction in symptoms over those five years. Comparison of the brain scans of those who did and did not recover from the trauma revealed that their had been measurable thickening of the area of their brain called the dorsolateral prefrontal cortex. These increases in thickness are very small – measured in tenths of millimeters. But the cortex is composed of millions of neuron cell axons which make connections between neural cell bodies. It takes many thousands of these axons to make up a tenth of a millimeter of thickness in the cortex, so this tiny increase in thickness means that a massive number of new axons have developed in the brains of those who recovered from PTSD.
The commentary in the article mentioned that, “In nonhuman primates…stress exposure helps develop resilience…and increase the … thickness of the prefrontal cortex.” There it was, that word resilience again! The article went on to say that the reasons why a greater desolater prefrontal cortical thickness might undergird and promote psychological recovery are apparent. For example, the role of this brain region “in controlling negative emotions has been well documented in healthy individuals,” “Emotion-regulating cognitive strategies, such as reappraisal of negative events and suppression of unpleasant memories, are associated with an increased dorsolateral prefrontal cortex and decreased limbic activities” (The Neurobiological Role of the Dorsolateral Prefrontal Cortex in Recovery was published in Archives of General Psychiatry, July 2011. [ Online abstract at http://archpsyc.ama-assn.org/cgi/content/short/68/7/701 ] .
The appearance of this article two years ago lead me to rethink the material I had read about resilience – but from the perspective of what elements of resilience might be promoting brain growth. Broadly summarized, the resilience studies have noted five elements in more resilient people. These are:
> regular physical exercise (yes, this will promote brain growth through a variety of effects, including for example, increased blood flow with exercise that carries more nutrients to the brain tissue)
> Substantial social network (yes, having friends causes endorphins to be released which are known to promote brain growth).
> Positive Coping Style/ Positive Outlook – this is a shorthand way of saying that the person characteristically makes the best of a bad situation in that they figure out something that the unwanted situation has promoted in themselves that they see as positive.
> Strong Moral Compass – This odd phrase is research jargon to say that there are people with strong religious connections or other ways of judging and confirming the behavioral choices that they make.
> Cognitive Flexibility – a pattern of thinking flexibly about how to achieve goals when the first idea doesn’t work. (yes, it is consistent with what we now know about brain adaptation and self repair that challenging the brain with cognitive expectations would trigger more neurons to sprout and make connections between neural cell bodies).
Cognitive flexibility is promoted by the process called cognitive therapy. Cognitive therapy has become the treatment of choice in the VA system for treatment of people with symptoms of Post Traumatic Stress Disorder.
So I could see how three of the five elements thought to be characteristic of resilience would directly relate to growth of cortical tissue in the brain. This point in my own life was influenced by the occurrence of a major brain bleed into my own brain two years earlier. This had left me near death for several weeks and with substantial neurological loss when I left the neuro ICU. So I had lots of motivation to pay attention to the rising research on how brains repair damage and “assign” and occasionally revise assignments of tasks to different areas of neural tissue over a person’s life time. I knew a lot about the sort of brain therapy exercises that stimulate brain tissue growth. I began to think about how to organize brain therapy for my patients with chronic symptoms of Post Traumatic Stress Disorder. This idea that somehow I had to encourage my patients brain growth in the same way that my therapists had encourage my own brain recovery led me to consider something that I now call “retrofitting for resilience” as my primary treatment approach.
Yes, I still am eager to use Prazocin or Cyproheptadine (or occasionally another medication) to get patients to sleeping better. Nobody is going to successfully grow their brain tissue if they are sleep deprived. Yes, I am still eager to treat depression or psychosis, since those sets of symptoms seriously impair a person’s ability to do the therapy that is involved in development of Cognitive Flexibility and I want them to do well in the sessions with their cognitive therapist. But I am also very interested in getting them to exercise regularly. I’m always trying to help patients find a social network that accepts them even if they are having a lot of problems with symptoms. I strongly encourage engagement in the religious tradition that is their childhood heritage, but if that seems a bad idea for some reason I will encourage them to get to a church that is offering the program Celebrate Recovery, or to one of the many religious support groups that can be found on the website of Interfaith Network on Mental Illness http://www.inmi.us/fwconn.html. Most importantly of all (I believe), I regularly make reference to the fact that PTSD is not usually a lifetime illness, but rather it’s an unnatural prolongation of the usual response to extreme stress. I work with the expectation that natural healing systems will get back “on line” and gradually “grow” the connections that are needed to deal with these traumas.
I always want to think that I am in a strong alliance with each of my patients and we are allied in the task of getting him or her well. I acknowledge from the beginning that they have to do most of the work. My role is to share my experience of having supported many hundreds of people on the road to wellness so that I have a good idea about where to find that road, and I also know what roads will turn out to be dead ends. In contrast to my patient who feels locked into these problems, I have seen people get well. That gives me the perspective to be enthusiastic and realistically optimistic during the sometimes long process it is to get well. I emphasize a lot that people don’t get well by acting sick. I want each person who I care for to have a daily task that structures their day enough to give them a reason to get up and out the door “on time”, even if all they can manage is to get up and get out the door for a cup of coffee at a quiet café, or show up on time for their cognitive therapy session. Next week we will extend that expectation to walk a mile to a café that is a bit further from home. And the week after that (well, maybe the month after that), we will start talking about getting to the humane society and volunteering to socialize the animals for several hours two shifts a week.
It is important to remember that Psychiatry is about having a future, but you can’t think about a future unless you have been honest with somebody about your past. I do spend enough time to get clear what has happened to a patient that traumatized him or her. I do assure them that I will not be harmed by the telling of the story. For those who are afraid that if they ever let down their barrier of control they will be so angry that they will hurt somebody badly, or cry so hard that they will never stop crying, I help them construct ways that we can tell this story a little at a time, ratcheting down the strength of the long compressed emotions. And I daily help people figure out why they feel so much shame for the shameless acts that somebody else did to them. All at the same time, I am pushing them to be working outside of our meetings on the project to retrofit themselves for resilience.
Sometimes there are reasons why all of this optimism is not helpful. I so clearly remember the moment when one of the young men with whom I felt I had every reason to be very pleased, rebuked me sharply when I started talking about taking on a few short shifts at a paid job. “NO!“ He shouted, as he rose from his seat. “I am not going to get a job. If I get a job that means that I’m OK. If I’m OK that means that they didn’t really hurt me, and they did hurt me. They hurt me a lot.” And he collapsed in tears (and I still come to tears remembering that sad angry moment). Insights like this have to be respected as truthful, boundaries like this have to be acknowledged. There are times when a person may decide that he or she must choose to not get well. But the patient and psychiatrist are not ever going to figure out where those boundaries are unless we engage in this kind of honest collaborative work.
Can I say that all the persons that I now am treating for PTSD are suddenly getting “well”. I don’t have the tracking system to prove that is true. I know that I haven’t had a patient with PTSD be admitted to the hospital since I started thinking in terms of coaching them to grow their brains (or more specifically their neural networks), as a way to get out of their symptoms. I don’t routinely send my patients to the local neuro institute for brain scans, but I know that getting out every day is healthier than staying in an apartment by yourself. It has proven to be more productive to help people figure out how to restore their friendship network than it is to try to get them to review with me one more time about the moment by moment memories of their trauma. People who do daily exercise seem to have less demand for anti anxiety prescriptions and less propensity to be arrested for smoking marijuana than those who allow themselves sit at home most of their day.
The WRAP program, of course, would call each of these strategies to re-grow a neuro network, “wellness tools”. The people in the WRAP program didn’t need the evidence of brain scans to know that undertakings like exercise and social networking and maintaining a strong moral compass will help you feel more in control of your own life and stay out of the hospital. I hope my article will help those who have been on the sidelines as “doubters” get moving in their own self interest and understand the truth of the assertion that PTSD is a temporary disequilibrium, severe enough to be called an illness, but not a life long disability.
Also by Dr. Gilbert: Spirituality as an Evidence Based Practice