War-Related PTSD
What is PTSD?
What is Post-traumatic Stress Disorder?
What exactly is Post-traumatic Stress Disorder (PTSD)? Post-traumatic Stress Disorder, also known as PTSD, is a type of anxiety disorder. PTSD can develop after you are exposed to a traumatic event. An event qualifies as traumatic if it is terrifying, shocking, or overwhelmingly stressful for the person who experiences it. Traumatic events that could lead to PTSD include: • Combat exposure • Terrorist attacks • Assault • Serious accidents, such as a automobile wreck • Physical or sexual abuse • Natural disasters, such as a fire, tornado, or flood What is traumatic for one person may not necessarily be traumatic for someone else, and there are a number of factors that go into whether or not someone experiences an event as traumatic. An event is more likely to be traumatic if: •It was unexpected •You were not prepared for it •You felt powerless to prevent itIf you go through a traumatic experience and develop PTSD, you may feel that the world is no longer a safe place. You may have moments where you start to feel anxious all of a sudden, or you may notice that you are more anxious throughout the day. Upsetting thoughts or memories may pop up when you least expect it. Contrary to what many people in the general public believe, a physical injury is not a requirement for developing PTSD. In fact, many people go through traumatic experiences without ever having been hurt physically, yet still develop PTSD. The Symptoms of PTSDPTSD is diagnosed if someone has a certain number of symptoms that started after the trauma. PTSD symptoms fall under three main categories and they can cause significant distress or impairment in an individuals ability to function on a day-to-day basis. The symptom categories are: 1. Re-experiencing the event 2. Avoidance and/or feeling emotionally numb 3. Feeling keyed-upLets take a closer look at each symptom category:#1: Re-experiencing the event. Memories of the traumatic event can come back at any time and without warning. When this happens, you may feel the way you did when the incident occurred. You may experience: •Unwanted memories of the traumatic event that keep coming back •Upsetting dreams •Flashbacks: acting or feeling like the trauma is happening again •Strong physical reactions when reminded of the trauma (sweating, pounding heart, feeling like you cannot get enough air) •Intense emotions when you are reminded of the trauma#2: Avoidance and/or feeling emotionally numb. You may try to stay away from things that remind you of the traumatic event. This can affect your normal daily routines. You might: • Avoid people places or things that remind you of the trauma • Feel distant or emotionally separated from other people • Feel numb or unable to experience certain emotions • Lose interest in the things you used to enjoy • Sense that your life is going to be cut short • Struggle to remember certain parts of the trauma#3: Feeling keyed-up. You may feel like you are always on guard. This may result in: • Having trouble falling asleep or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Feeling jumpy or easily startledThese symptoms can be annoying, upsetting, or even terrifying. They can also make you feel isolated and alone. When symptoms begin to interfere with your life and impact your relationships, it is time to get help. Remember these things: PTSD is treatable. Having PTSD does not mean that you are crazy. Recovery requires persistent effort and hard work.
What Causes PTSD?
Theories about what causes PTSD There is no universally accepted explanation for what causes PTSD. Scientists continue to debate over the factors that cause it, although we do have several decades of evidence informing the theories about PTSD. Some of the most well-known theories are listed here:Cognitive Theory- The cognitive theory of anxiety holds that anxiety disorders like PTSD develop when we get into the habit of viewing events and situations in set ways. We may have thought patterns that over-predict the severity and likelihood of threats. Treatments based on changing thinking patterns have proven effective in treating anxiety disorders in study after study over the past several decades. Behavioral Theory- Behavioral theories of anxiety usually focus on two types of learning, including how we learn fear: Classical and Operant conditioning: Classical Conditioning: This is a learning process that all animals have which allows us to pair the occurrence of one event with another. For example, hearing a bell ring before a painful shock happens will trigger fear when we hear the bell again. This type of learning is basic and automatic. It happens outside of our awareness, and we cant choose to have the reaction happen or not. Operant Conditioning: Another basic form of learning is operant conditioning. When we avoid something that is painful or unpleasant (like a painful shock or a panic attack), we are rewarded by not having the pain or anxiety. In learning terms, we are reinforced by the removal of something bad (negative). Behaviors that remove anxiety are likely to be repeated, because they are rewarding. Chemical imbalance- A popular theory for the cause of anxiety is the chemical imbalance theory. The idea here is that disorders like PTSD are caused by an imbalance of chemicals in the brain. Indeed, medications that help normalize chemical levels in the brain can help manage PTSD symptoms. But, the imbalance theory does not explain why so many people continue to have anxiety even when they are taking medications. Genetics- Related to the chemical imbalance theory is the idea that genetics plays a role in anxiety disorders like PTSD. There is strong evidence that anxiety tends to run in families - meaning that if your parent has an anxiety disorder, you are more likely to develop one during your lifetime. You can, however, develop an anxiety disorder even if no one in your family has had an anxiety disorder. Conversely, even if both of a persons biological parents had a disorder like PTSD, it doesnt mean that their child will develop PTSD. The child is simply at a higher risk of developing it.How PTSD Develops None of the above theories completely explains what causes PTSD; however, most modern theories about the cause of PTSD take into account something called classical conditioning. In fact, one of the most effective treatments, called exposure therapy, is directly based on classical conditioning. In this section, well cover what classical conditioning is, and how it relates to anxiety disorders like PTSD. Classical ConditioningClassical conditioning is the scientific term for a very basic type of learning where the brain makes associations, or connections, between things. Humans and most animals learn in this way. Classical conditioning has a lot to do with the development of PTSD.Pavlov's DogsA very famous example of classical conditioning is the story of Ivan Pavlov's experiments with dogs in the 1920s:Dr. Ivan Pavlov was interested in studying how much dogs salivate (drool) when they taste meat. He began conducting experiments to measure salivation, by feeding the dogs meat in powder form. During this process, Pavlov discovered something he had not expected: the dogs actually began to salivate before they tasted or smelled meat they would start to salivate when they saw the person who was going to feed them. What happened with Pavlovs dogs was one of the first examples of classical conditioning: Dr. Pavlov expected the dogs to simply respond to the meat (the stimulus that normally evokes salivation). Instead, the dogs brains learned to connect the sight of the person feeding them (neutral stimulus) with the taste and smell of meat (stimulus that normally evokes the response). By making this connection, the dogs brains had learned to salivate without the smell or taste of meat. Figure 1.1 (see treatment manual) shows this process: in the top panel, the dog sees the experimenter several times, and food is then placed in its mouth, which triggers salivation. Eventually, the dog comes to start salivating as soon as it sees the experimenter, even when there isnt any meat placed in its mouth (bottom panel). Fear ConditioningSo, what does classical conditioning have to do with PTSD? It explains how we acquire fears in this sense classical conditioning is also referred to as fear conditioning. A standard fear-conditioning experiment would look something like this: a researcher places an animal, such as a rat, into a small chamber. The researcher then waits several minutes and switches on a yellow light. After the light comes on, the rat receives painful shocks to its feet from an electrified grid floor in the chamber. Besides experiencing physical pain, the animal getting shocked will also have certain circuits in its brain fire. These circuits act like an alarm system, raising the animals heart rate, respiration rate, and causing it to try to escape the shocks. In the Figures used in this manual, well refer to this as a Neural Alarm, the brains alarm system being tripped. The rat is aware of all the sights, sounds, and smells in its environment (the chamber, the yellow light coming on and the painful electric shocks). Before the shocks started, the chamber and yellow light did not cause it to react with fear and during the procedure the light and chamber dont actually cause the shocks. Before classical conditioning the light and chamber are neutral, but after being shocked, the rat learns to connect them to the feelings of pain and fear. The following diagram illustrates the fear conditioning process for the rat. The yellow light and the experience of being in the chamber are two neutral things (meaning they do not cause fear) that happen before the shock. The yellow light turns on right before the shock, and becomes a predictor of future shocks. (Figure 1.2 -see manual)In the diagram above, the yellow light comes on right before the shock, so the light becomes a predictor of the shock. The thicker line shows a strong connection between the light and the pain/alarm.Animals that have experienced this type of experiment have a very dramatic and predictable reaction later. If this same animal is put back in the chamber and then the light is turned on, the animal will have a marked fear reaction even though the light isnt followed by shocks. See Figure 1.3 below, which illustrates that if the rat is put back in the chamber and the light is turned on, the animal has a fear reaction. The yellow light has become a Trigger for fear. (Figure 1.3 -see manual)The reaction is similar to human anxiety: the rat breathes rapidly, its heart rate increases dramatically, its glands release stress hormones, and he frantically tries to escape the chamber. Note that in the figure below the two arrows from the potential triggers to the reaction are different strengths. The line for the yellow light is thicker; because the light has a stronger association with the pain and neural alarm compared to the chamber. The Little Albert Experiment: Fear Conditioning in HumansThere are hundreds of other studies that demonstrate that humans and other animals learn fear through classical conditioning. The most famous study involving a human subject is the one involving Little Albert. In the 1920s, two researchers took a baby named Albert and placed a white rat in front of him. One of the experimenters stood behind the child (where the child could not see him) and struck a metal pipe with a hammer. It made a very loud noise, and Albert was understandably very scared. Later, Albert showed a fearful reaction whenever the rat was put back in front of him even in the absence of the loud noise. This type of research is now considered to be unethical, and performing a similar experiment today would be illegal. Nevertheless, the Little Albert study demonstrated that humans can acquire fears by being exposed to a traumatic experience. Combat Trauma and Fear ConditioningPTSD involves being exposed to some terrible event, and feeling a sense of panic and horror at the time of the trauma. Because combat inherently involves witnessing injury, death, or having near-death experiences, its easy to see how fear conditioning can occur during deployment. Take for example a soldier in a convoy that is hit by an IED. The soldier was riding in a HUMVEE in the rain, when an IED detonated nearby. The soldier felt pain from being slammed around in the HUMVEE and being hit by shrapnel. Following the blast, the soldier remained inside the HUMVEE, heard the rain outside, the sounds of men screaming, smelled rubber tires burning and witnessed general chaos around him. While this is all going on, he was in physical pain, and felt intense fear. In conditioning terms, the period immediately after the IED blast was when the soldier formed associations to the pain and panic with the things in his immediate environment. This is exactly the same process that generates fear in the laboratory; however its not as simple as a chamber with foot shocks and a light. In examples like this one, there are all kinds of things going on during an IED blast that can be paired with the alarm and pain, explaining why individuals with PTSD can have so many different types of triggers. After going through a traumatic event like an IED attack, a persons brain may form associations to the sights, sounds and smells that were around at the time. The figure above shows that this soldier formed strong associations to some triggers (connected to thicker lines), but not to others (connected to fine lines). Long after the trauma, coming into contact with one of these associated sights or sound can cause an automatic fear reaction. This happens even if the new situation is perfectly safe. When this soldier encounters one of these sights, sounds or smells later it can set off a learned fear reaction. For example, when this soldier has to ride in a humvee again back in the States, being back in a humvee triggers anxiety. Even if he knows that he is not in a combat situation and is safe, the learned association will still be there. His heart will speed up, his breathing will become more rapid, and he will start to sweat. This physical reaction is involuntary. It is not something the soldier can choose to turn off or not have happen.
Specific Symptoms
Article 1
Guilt: A common emotion in combat-related PTSD
No matter how much training or preparation a person has prior to entering a combat situation, there is bound to be a psychological impact to situations where people are injured and lives are lost. One of the major psychological impacts of war is guilt. Service men and women are put into situations where they may have to pull a trigger, release a bomb, mortar a target, or perform other duties that have the potential cause harm to other people. They often witness or are aware of intense human suffering and death. Combat situations may require a service member to kill others. Guilt can sometimes be a hard emotion to shake. After combat experiences, guilt usually comes in a few forms:Survivors guilt- Why did my buddies have to die while I survived? This is one of the most publicized forms of combat-related guilt. Many service members die in wars; however, many more survive---and these members naturally find themselves wondering why they survived when their friends did not. Suppose you were driving your humvee but then had a friend take over when you got tired. If this friend then died when an IED exploded near the vehicle while you and the other person in the back seat survived, this could lead to intense survivors guilt. Arriving home and seeing a buddys wife and kids coping with the loss of their husband/father can also heighten survivors guilt. While it is normal to wonder Why them and not me? dwelling on it can lead to intense feelings. You could even start to think that you should not have been allowed to survive. Guilt about killing enemy combatants- Many people assume that service members dont think much about killing enemy combatants (as opposed to losing buddies or accidentally killing civilians). But the truth is that many service members do struggle with issues related to the morality of war. After killing an enemy combatant, a service member may feel intense guilt about the person they shot: Was he someones father or husband? This can be especially hard in situations where the enemy combatants involved are very young.Decisions resulting in death of friends/teammates-In war, very fallible people are sent to fight and make the best decisions they can. In combat, decisions have to be made that we know will cost the lives of people with whom we have engaged in combat, even some civilians. Guilt can result from: 1) Friendly fire-accidently shooting a team member who runs in front of your line of fire; strafing a convoy at night that turns out to be fellow Americans, mortaring a position after getting bad intel and finding out there were allied troops there, etc. 2) Losing subordinates- Ordering your men into a situation you knew would cost many of them their lives (We have orders to take this section of the city-no matter what), making a call in the heat of the moment, like not falling back and people are killed (I made a decision that cost peoples lives), sending people into a trap/ambush, etc.Other decisions or actions that are combat related-Theres a range of other things people do in order to survive or cope in war zones that they regret. Some examples are:Freezing during battle-This is something that occurs more than soldiers like to admit, with estimates from Vietnam as high as 1 in 4 soldiers in combat freezing up for at least a part of the firefight. Very often the person blames themselves for not acting or feels like they acted cowardly. This reaction, however, is not something that we can control. Many times in traumatic situations, humans and other animals will have an involuntary mechanism activated-and they will lose the ability to move. This state is called tonic immobility, and is present in nearly all mammals. This type of freezing response is pre-programmed into people; if it is triggered, its completely involuntary.Collateral damage- In WWII, both axis and allied planes regularly bombed major cities, causing widespread civilian deaths. In modern warfare however, there is a strong emphasis on minimizing civilian deaths. While we try to minimize civilian deaths, war is associated with accidental deaths of non-combatants. Accidentally killing civilians, including women and children, is an unfortunate part of warfare, especially in battling an insurgency that is known to use human shields.Aggression towards non-combatants- This is another part of combat that people dont like to talk about, but its a part of every war. After losing a friend or several members of your unit to an IED or mortar blast, its natural to want some revenge, to see justice served. The next time you are around civilians, it is possible that you would act more harshly towards them. Battling an insurgency makes this type of reaction more likely. It is also easier to be hostile towards non-combatants in an insurgency situation, where anyone in a town who appears friendly could in fact be a hostile. Managing guiltWhile combat-related guilt is normal, it can become a major problem for some service members. This usually happens when a person gets stuck in a pattern of thinking that is unrealistic and unhelpful. Dwelling on what your lost friends would be doing now, and how you werent able to save them can make you miserable. Changing some of the dysfunctional beliefs and patterns of thinking that lead to severe guilt has been shown to help servicemen cope with and get past combat-related guilt. Using the Thought Monitoring Sheets, practice changing your guilt-producing thoughts to more rational and practical thinking. Examples of this type of corrective thinking are listed in a table in the treatment manual you can download from this site. Here are a few samples from the manual- Dysfunctional Thinking:If people knew what really happened-they would never speak to me..Corrective Thinking:People know by now that bad things happen in combat-and that soldiers are put into situations where they have to make hard choices. Your family doesnt have to know everything that happened-but even if they did, its very likely they would be sympathetic to what you had to live through, and not stop speaking to you. Dysfunctional Thinking:Im a changed person-Im damaged, and Ill never be the same person I wasCorrective Thinking:Im not damaged, most of the things that make me think that (feeling overwhelmed, nightmares, quick temper) are symptoms of PTSD-and will go away, so I will be back to who I used to be soon. I survived something bad-and I have PTSD, which is a change. Its also something that goes away, just going through this program is going to help bring my life back to normal. Additional ways to manage guilt: TAKE THINGS AT YOUR OWN PACE. After making it through combat and experiencing horrific things, some of your friends and family will assume you need to talk about things, and bring it up often in order to get you to talk it over. While its a good idea to eventually be able to talk about experiences, you have to listen to your gut and let people know when you are ready to talk about things. If someone is pushing you to talk, or just mentioning things over and over again, let them know that they have to give you space. There will likely be some things that happened that you never discuss with your family. FIND PEACE IN SPIRITUALITY. Many combat veterans have found that becoming more connected with their religion helps them cope with combat-related guilt. By attending religious services, talking with their clergyman and through prayer, they find some meaning in what they have lived through.ALLOW TIME TO HEAL YOUR WOUNDS. Many think its a cliché to say that time heals all wounds, but there is truth in the idea that guilt and sorrow related to combat tend to get better as time goes by. While you will always remember lost friends, these memories will come to feel less like they are haunting you and become more like other memories youve experienced. HONOR THE DEAD. Another way that combat veterans have used to cope with guilt is by finding some way to honor the people they knew that died. Many veterans honor their fallen friends and others that were killed by doing such things as:Staying connected with a lost friends family, visiting or calling on holidays and the anniversary of their loss. Writing a letter to a lost buddy that you put away or destroy. Putting your thoughts and feelings about the person on paper isnt just symbolic, its very often a good way of getting some measure of closure. Going to your place of worship or some place that reminds you of your friend and saying a prayer for them.
Article 2
Re-experiencing Symptoms:
What are Re-experiencing Symptoms?Just like the name implies, re-experiencing symptoms involve a service member experiencing the traumatic situation again in some way. This can be in the form of images or thoughts that come into ones mind even though you dont want to have them, or nightmares. Flashbacks, where you feel as if you are actually back in the traumatic situation, are also a re-experiencing symptom. Dealing with Flashbacks-Flashbacks are defined as an intense feeling that one is actually back in the traumatic situation, where the veteran may also act as if they are back in combat. Individuals may have hallucinations (seeing something that isnt actually there), and illusions (where they misinterpret an actual thing as something else). Flashbacks feel very real for the person experiencing them and they can be very upsetting.Many episodes of dissociation present in the form of flashbacks. When this happens, the person may not remember re-living the situation. Most flashbacks happen when a service member comes into contact with a strong trigger, or when they are under a lot of stress. Flashbacks are one of the symptoms of PTSD that most of the general public has heard about and associate with the disorder. While a lot of people know about flashbacks, they are fortunately not a common symptom for patients.The same general advice that people use for dissociation (see above) also applies to dealing with flashbacks: •Try to reduce or eliminate the things that cause you stress. •Use grounding exercises to stay in the present. •Distract yourself from the content of the flashback when you feel it coming on. •In the early stages of therapy for PTSD, avoid things that trigger flashbacks. Intrusive thoughts/images: A symptom thats far more common than flashbacks is intrusive thoughts or images. These are memories or images related to a trauma that pop into your head even if you werent thinking about combat. These tend to be unwelcome and most service members find them disturbing. Sometimes a string of thoughts and images come flooding in after encountering a trigger. For example, a service member who sees a small child playing in the mall back in their hometown may experience intrusive and intense images of a dead Iraqi child they saw in a town that had been mortared. Other intrusive images can be triggered by someone mentioning a lost friend or seeing a person who looks like the friend. Our first reaction to such disturbing images and thoughts is to try to avoid them. Avoidance of conversations, places and activities that spark up thoughts and images of traumatic experience like combat is actually a symptom of PTSD. While its natural to try to avoid thinking about and having memories of combat experiences, trying to suppress these thoughts can make them worse. Research shows that the more upsetting we find something and try to suppress thinking about it, the harder it can be to keep it out of our minds. If you structure your whole day around keeping your mind busy so you dont have memories, you are still thinking about the memories in the back of your mind. In fact, youre thinking about memories all day, dreading them and trying to avoid having them, which is actually counter-productive. Theres an old adage that if you try not to think about a pink elephant, youll spend all of your time thinking about the pink elephant. Trying to suppress thinking about something can make you more likely to think about it. So-what do I do about them? Understand that you cannot prevent intrusive thoughts. When they come, let the intrusive thoughts and images happen without trying to fight them. As much as you can, you should try to detach yourself from the images. Detaching may take some practice. It requires that you acknowledge the intrusive thought or image and then allow it to pass out of your mind. Also, if you can stop spending your energy suppressing the thoughts, you will find you are better able to deal with them and they will happen less often. Its easier to just let the images and thoughts occur if you can separate the thought/image from your reaction to the thought/image. This is an absolutely essential skill. The image popping into your mind is just an image even if its something gruesome. Its just a picture. You can manage your emotional reaction to this image by reassuring yourself that the feeling will pass and that the image cannot harm you or make you lose your mind. The reaction people have to such images or thoughts is often made worse because they think things like Having these images all day will make me go crazy, or I cant stand having these happen again and again! This type of thinking puts more and more focus on the memories, and drives us to be more stressed. Being more stressed and thinking about memories makes you more likely to have even more intrusive thoughts. Its an illusion to think we can control what comes up in our minds. We arent able to do it at times when were not stressed out, and we are even less able to control our thinking when were emotionally distressed. If you can accept that combat-related thoughts and images are going to be a part of your day-to-day life while youre in treatment, you can spend less time trying to fight them and you will actually find that you have them less often. Some things to keep in mind as you are trying to deal with intrusive memories: • They are just images. Its not happening again. • No one ever went crazy from having intrusive thoughts. • Pushing them away entirely isnt an option. In fact, doing so paradoxically can make them worse. Dealing with Nightmares-Nightmares can be a very frustrating symptom of PTSD. Early on, an individual usually has nightmares directly related to their traumatic experience. Over time, the nightmares will become more generic and start to include new material: instead of seeing teammates killed, they may have nightmares about family members dying. This is a natural progression and doesnt mean things are getting worse or that youre going crazy. Our minds will insert whatever material we think about during the day into our dreams, and if our dreams are about people being harmed, this can lead to having dreams about people we know being killed. It is a normal part of the process and is not something to necessarily be concerned about.Because nightmares can be very intense, triggering strong memories, its easy to see why veterans want to avoid them. Some veterans will deliberately keep themselves up for 36 hours just so they will lapse into a deep sleep in order to avoid nightmares. People will play video games, call relatives, watch TV, browse the Web, work out, nearly anything to keep themselves awake until they are too exhausted to have nightmares. Another strategy is to drink alcohol to sleep through nightmares. Alcohol will put you to sleep-but comes with its own set of problems and will slow down your recovery (see module #6). ADVICE ON HANDLING NIGHTMARES•As much as you can, you need to de-catastrophize having nightmares. Like intrusive thoughts and other re-experiencing symptoms, the more emotional energy you devote to dreading and suppressing nightmares, the harder it is to deal with them. Combat veterans sometimes go over the last few terrible nightmares in their heads for hours before going to bed-wondering why they keep happening, if they have some special meaning, or similar lines of thinking. This is counter-productive, because we generally tend to dream about the things weve been thinking about during the day. So, even if youve been thinking about what you can do to avoid those recurring nightmares, and dreading having them, youre still thinking about the nightmares. At some point you have to accept they are a part of the disorder and will fade once your other symptoms fade. •Before going to bed practice good sleep hygiene and relaxation techniques (these are covered in Modules #1 and #2). As much as possible, have a bedtime routine, something you consistently do every night in the hour or two before going to bed. This routine should include avoiding anything that sparks memories likely to lead to nightmares, such as watching a documentary on the war, talking on the phone to a buddy who mentions combat experiences, or doing exposure exercises. • Have a plan for what to do if you have a nightmare, and stick to that plan every time it happens. Stay calm, use grounding techniques, distract yourself, dont re-hash the content of the dream, and do something that doesnt involve getting your heart rate up. • If nightmares are a significant problem for you even after following the advice covered so far, there are two specific types of treatment for this symptom you can discuss with your provider. 1)The medication Prazosin® has shown some promise in blocking nightmares in people with PTSD (see Module #6), and may help you as well. 2) A psychotherapy technique called Imagery Rehearsal Therapy (IRT) involves having people with chronic nightmares re-write their usual nightmares without the disturbing portions. This new story line is then mentally rehearsed (visualized) several times during the day. Using the IRT technique has been shown to reduce nightmares in a few studies. Advice for spouses and other family members: •Do not, under any circumstances, awaken a person who is having a nightmare by shaking them! Combat-related nightmares are often about being harmed, seeing other people dying, and trying to fight back, triggering the service members defensive alarm (fight or flight reaction). If you lean over a person and shake them trying to wake them up you could be hit or even choked by the veteran as they come out of the nightmare. If their fight or flight reaction is in full swing and someone is hovering over them, they may automatically try to defend themselves. If you want to wake the veteran, walk to the foot of the bed and shake the persons foot gently, staying out of range of being kicked. Say their name in a calm, non-urgent manner-and help re-orient them as they wake up. For example John, youre having another nightmare. Youre here in bed, and everything is ok.its just a nightmare.•If a service member is having nightmares and thrashes a lot in their sleep or is violent (wakes up grabbing you), you should sleep separately for a short time until this symptom is under control. Some spouses feel that this is abandoning their husband or wife by leaving them to face these alone. If you are in the house, you are not actually abandoning them. You are making sure that you and they are safe. If they awaken from a nightmare they can come see you in the other room. Its already hard enough to deal with the stresses associated with having a spouse with PTSD; the added resentment that would result from them accidentally hitting you will only make things more difficult.
Article 3
What is Dissociation?
Do you ever feel like you are in a fog? Have family members or friends ever told you that spaced out, or seem to have been in a trance? Do you ever get lost in thought or have daydreams?Do you ever feel taken over by a feeling that doesnt seem to make sense at the time?If you have answered yes to any of these questions, then you have probably dissociated. Dissociation is an experience where a persons normal thought processes are interrupted. Dissociation can cause someone to feel disconnected from themselves or the world around them. Most people experience mild dissociation on a daily basis and this is normal. We are more likely to dissociate if we are tired, feeling anxious, or intoxicated. Dissociation can also happen during highly stressful or traumatic situations. In intense situations, dissociation protects us when there is too much for the brain to process at one time. Dissociation during these stressful situations is a protective physical response and it is not something we can control.We may do or feel different things when we dissociate. While dissociating during a traumatic event you might do things like: •lie very still •be slow to respond to others •feel like you are moving in slow motion •have flat or dull emotions •not feel pain •stare off into space •tune out of a conversation or experience •feel as if you are observing a situation but not actively participating •have lapses in your memory •feel like you are observing your actions from outside your own body •feel as if you are in fogDuring a traumatic experience, dissociation can occur in the following ways: 1.Depersonalization One feels as if they are having an out-of-body experience. They may also be unable to recognize themselves in the mirror or feel completely disconnected from their own bodies. 2.De-realization The person feels as if they are in a fog or detached from the world around them. One may feel they are watching things happen around them without feeling personally connected (like watching what is happening on TV). 3.Dissociative Amnesia forgetting all of a trauma or the most upsetting parts of a trauma. Amnesia is more than routine forgetfulness. Entire events or parts of conversations may be forgotten.Combat-related traumas can cause people to dissociate. Here are some real-life examples: •Service members have reported jumping out of their bodies a split second before an IED blast, and recall watching the scene of the blast with the sensation that they were floating above it. •Marines say they were emotionally numb during firefights when in combat. Some reported feeling as if they were standing next to themselves and observed themselves firing their weapon at an enemy combatant from just a few feet away. •Upon returning home, a service member who had engaged in a long, intense firefight and watched his buddy die was unable to recall several months of his deployment. Dissociation and PTSDDissociation can occur during a trauma and following a trauma. A person with PTSD is more likely to dissociate in everyday situations if they dissociated during a traumatic experience. In fact, dissociation during a traumatic experience is a risk factor for developing PTSD. Having dissociative episodes is also a common symptom of PTSD. When stressful situations occur, or when something unexpectedly reminds you of a traumatic event you experienced, it is normal to mentally tune out to dissociate. Others may experience dissociative flashbacks, having unexpected and intense memories of the trauma. Everyone dissociates from time to time. But it can become a cause for concern if it happens at inappropriate times, happens too often, makes you feel out of control, or if it is causing you to feel anxious. If any of these things are happening there are things you can do to manage dissociative episodes. Preventing and controlling dissociative episodes: Preventing Dissociation •Stress reduction: Believe it or not, episodes of dissociation can often be triggered by stress. Think about the times that you have dissociated. Most likely, your dissociative episodes occurred after feeling stressed. Examples of stressors could include arguments or being unexpectedly reminded of a trauma. Reducing the stressors in your life (if possible) or practicing simple stress reduction techniques can help prevent dissociative episodes. •Eliminate the fear reactions associated with PTSD: Dissociative episodes can occur when a fear response is triggered. By committing to treatment and engaging in cognitive behavioral therapy, you can address your triggers and fear reactions. With treatment, you should notice a marked reduction in fear reactions and, in turn, see a reduction in dissociative episodes.Controlling DissociationEducate your family and friends: Tell your family and friends about dissociation. Tell them what you need them to do - and not do - when it happens. It is important for people around you to understand dissociation and support you. When someone has a dissociative episode, family or friends may try to snap them out of it, or wake them up. This is not a good idea: the person who is dissociating may react by trying to defend themselves, possibly causing unintentional physical harm to the other person. We recommend that you tell your family to treat dissociative episodes the way they would sleepwalking. It is generally best to not try to wake a sleepwalking person suddenly. People shouldnt shake or startle you. If your family member has to bring you out of a dissociative episode, ask them to repeat your name calmly, while reminding you of where you are. Sometimes family or friends may feel that an individual is dissociating on purpose. If the people close to you are educated about dissociation and the fact that dissociation is an involuntary response, they can better support you. Grounding exercises:Even though dissociating is not something you can control, you may learn to recognize warning signals that an episode is coming on. If you are able to tell when you are starting to dissociate, there are things you can do to ground yourself, bringing yourself back to the reality of the moment. The following are methods you can use to help keep you from dissociating:1) Take note of your surroundings. For example, if SGT. G. begins to feel like he is spacing out again, he might look around his barracks room and tell himself, This is my bed, I just changed these sheets, over by the door is the umbrella I used earlier tonight, the sun is starting to come through the curtains. Describe what you are seeing, hearing, smelling, and feeling. By noting these things to yourself, you stay connected to the present and to your immediate surroundings. 2) Tell yourself, calmly and slowly, what the day and time is, and what your immediate situation is: For example- It is Tuesday afternoon, about 3 oclock, and I just woke up from a nap. 3) Do a quick body scan. Go over the sensations in your body just like you did the room. Here you want to pay attention to sensations like how your watch feels on your wrist, whether your scalp is itching, whether or not you feel comfortable in your chair, the feel of your socks on the skin of your feet. Try not to focus on your breathing or heart beat if you are already feeling anxious, as focusing on these can make some people more anxious. 4) Other ideas for keeping yourself centered on the present moment: •Wash your face with cold water. •Take an ice cube from the freezer and hold it in your hand. •Blink your eyes hard. •Practice juggling or playing jacks. •Clap your hands. •Sit and write down everyone you can remember from your high school senior class or boot camp platoon. •Sit and write down every animal you can think of that starts with the letter A (Antelope, Ant, Aardvark, Armadillo, etc..), then move to B, and so on. •Eat something that will get you focused on the flavor - like a sour or hot candy.
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Effective treatments
What kinds of treatments are there for PTSD? This section covers several forms of treatment that are available for PTSD. We will focus on those that have a strong evidence base and cover therapies with little to no evidence base in another section. This isnt meant to be an exhaustive list, but a general overview of the treatments available. Cognitive Behavioral Therapy (CBT). By far the largest evidence base for effectively treating anxiety disorders lies in cognitive behavioral interventions. The general components of CBT for anxiety disorders are: 1) Cognitive therapy-a systematic effort to change anxious thinking and beliefs. 2) Exposure therapy-using exposure to feared objects and situations in order to decrease conditioned fear reactions. 3) Education regarding the disorder and its causes. 4) Arousal management strategies-using relaxation exercises and other techniques to lower the physical symptoms of anxiety. This manual iassiciated with thes website s based on Cognitive behavioral therapy, and incorporates all of these core components. There are several popular subtypes of CBT for PTSD. These subtypes have one or more of the core components of CBT (cognitive therapy, exposure therapy, education about the disorder and arousal management), with some variation in emphasis or procedures. Well look at some of the most popular variations on CBT for PTSD. Procedural variations of CBT for PTSD:Prolonged Exposure (PE): This protocol for PTSD has been well researched, with numerous studies demonstrating its effectiveness. The program has all of the core components for CBT for PTSD, including cognitive restructuring, education, arousal management strategies, and exposure therapy. The protocol strongly emphasizes the exposure component of therapy. Cognitive Processing Therapy (CPT): This is another CBT-based protocol for PTSD. This treatment program was originally developed for use with sexual assault victims, but has been successfully adapted for use with combat veterans. The protocol contains education, arousal management, and a heavy emphasis on cognitive therapy. The protocol has a much smaller exposure therapy component, with having patients repeatedly imagine their trauma as the main exposure therapy. Eye Movement Desensitization Reprocessing therapy (EMDR): This is a controversial but popular therapy and is currently listed as an effective therapy in the DoD/VA guidelines for PTSD. This therapy largely centers on having patients recall and describe their trauma memories, while the therapist makes movements with their finger or an object in front of the patients face. The patient holds their head still and follows the movement with their eyes, helping to reprogram and desensitize the traumatic nature of these memories. This obviously incorporates imaginal exposure to traumatic memories, and this is likely the reason that the therapy works. While the eye movements have been shown to be unnecessary, and the theory behind the use of eye movements has been show to be scientifically unsound, the overall therapy has been show to help patients with PTSD. What Medications are helpful in PTSD? Medications are commonly prescribed for managing the symptoms of PTSD. The majority of patients who take a medication for PTSD note some benefit. Medications are usually used in conjunction with some type of psychotherapy. Since PTSD is a complex disorder with many types of symptoms, it is not unusual to be prescribed more than one medication at a time, especially at first.The type of medication most often prescribed for PTSD is antidepressants. Besides being effective in treating depression, antidepressants are also effective in treating almost all of the anxiety disorders, including PTSD. Antidepressants are divided into subtypes, including 1) Serotonin Selective Reuptake Inhibitors (SSRI), 2) Tricyclic Antidepressants (TCA), 3) Novel antidepressants, and 4) Monoamine Oxidase Inhibitors (MAOI). SSRIsThe most frequently prescribed type of antidepressants is the Serotonin Selective Reuptake Inhibitor (SSRI). SSRIs are considered to be the first line of medication treatment for PTSD, meaning that they are usually the first type of medication tried. These medications work by blocking the re-uptake of a neurotransmitter in the brain (serotonin), making more of it available for binding to receptors. The SSRIs typically start to show an effect after 3-4 weeks, and dont reach full effect for weeks after that. This is why a person will usually take one of the SSRIs for at least 12 weeks in order to see if it works for them. TCAs/MOAIsIf a trial of an SSRI doesnt work for a person, a physician might recommend trying one of the TCAs or MAOIs. These are older antidepressant medications, but are generally agreed to be equally effective as the SSRIs. The main advantage of the SSRIs over these older medications is that the older medications have more side effects. The TCAs can cause dry mouth, constipation, dizziness, blurred vision, and some other side effects. Generally, these side effects go away after the first few weeks of taking the medication. The MAOIs have some side effects as well, such as insomnia and dizziness when changing positions. However, the main caution with MAOIs is that there are dietary restrictions. There are certain foods, beverages and medications that you absolutely cannot consume while on a MAOI. Novel antidepressantsThere are also several newer antidepressants that are available and have shown some promise in treating PTSD. These include Bupropion (Wellbutrin ®), Nefazodone (Serzone ®), Trazadone (Desyrel ®), and Venlafaxine (Effexor ®). While these medications do not have the same level of evidence that the SSRIs do, they may be very helpful for some patients. Mood stabilizers/anticonvulsantsAnother type of medications that have been used to treat PTSD are the Mood stabilizers / Anticonvulsants. Medications in this category include Lamotrigine (Lamictal ®), Topiramate (Topamax ®), Carbamazepine (Tegretol ®), Valproate (Depakote ®) and Gabapentin (Neurontin ®). These medications are primarily used to prevent seizures; they have been shown to be helpful in some cases of PTSD. These medications are usually used in addition to one of the antidepressants. Tranquilizers A commonly prescribed type of medication for PTSD is tranquilizers, specifically a type of tranquilizers called benzodiazepines. Medications in this class include: Clonazepam (Klonopin ®), Lorazepam (Ativan ®), Diazepam (Valium ®), and Alprazolam (Xanax ®). These medications are very effective in the immediate management of anxiety; they have a rapid effect. Unlike the SSRIs, which can take weeks to start showing effects, medications like Klonopin ® decrease anxiety in about half an hour. Despite being effective in the very short run, we caution people not to take benzodiazepines for longer than a few weeks, and advise them to avoid starting on them if they can avoid it. The rationale for this advice is that Benzodiazepines have: 1)High risk of dependence - Benzodiazepines can be very addictive. People will find that they develop tolerance to them, needing more and more to get the same level of relief, and having withdrawal symptoms once they run out or stop taking them. Much like drinking alcohol to manage anxiety, over-reliance on benzodiazepines can lead to even more problems. 2)Rebound anxiety- Once a person stops taking these medications after a long period, they can have rebound anxiety. This means that they have a spike in their anxiety levels after stopping the medication. Many times this anxiety will be worse than the symptoms which they took the medication for in the first place. It is estimated that up to 70% of patients experience rebound anxiety from benzodiazepines when they discontinue the medication. 3)Do not address core symptoms- Benzodiazepines do help with anxiety, and to some degree decrease irritability and insomnia. But other symptoms of PTSD arent helped by taking these medications. For example, avoidance and dissociation. 4)Limit benefits of exposure therapy- In exposure therapy, the person has to experience anxiety, and stay in the situation until the anxiety goes down. Because benzodiazepines can chemically prevent a person from feeling anxiety, taking benzodiazepines can reduce the effectiveness of your exposure therapy sessions. Due to these factors PTSD experts advise against the long-term use of benzodiazepines in the management of PTSD. Atypical antipsychotics:Although primarily used to treat more severe psychiatric disorders like bi-polar disorder and schizophrenia, the newer antipsychotics have been shown to have positive effects in some studies. Medications like Risperdal (Risperidone ®) Ziprasidone (Geodon ®), Olanzapine (Zyprexa ®), Aripiprazole (Abilify ®), and Quetiapine (Seroquel ®) are atypical antipsychotics. Medications in this class have been used to enhance the effectiveness of SSRIs and other types of antidepressants. These medications have shown promise in decreasing overall symptom severity, particularly dissociative flashbacks and aggression. Antiadrenergic medications:A few medications normally used to control blood pressure have been shown to be helpful for some symptoms of PTSD. Prazosin (Minipress®) has recently been shown to reduce nightmares and some other symptoms in PTSD patients. Propranolol (Inderal ®) has also been shown to have beneficial effects in symptom reduction in some smaller studies. Sleep agents:There are several options for helping improve sleep. While most people should benefit from the interventions covered in Module # 2, some people may also need additional short term help with sleep. A commonly prescribed class of medications are non-benzodiazepine sedatives. Some examples include: Zolpidem (Ambien®), Zaleplon (Sonata®), and Eszopiclone (Lunesta®), all generally acting at the GABA receptor. While these medications arent as addictive as the benzodiazepines, they shouldnt be used for more than a few weeks at a time. If you are still having sleep problems after a few weeks, your physician may suggest trying another medication: Trazadone (Desyrel ®). Trazadone is actually an antidepressant that has sedation as a side effect and is prescribed at lower than antidepressant doses to help with sleep. You can take Trazadone for long periods of time with no worries about addiction. How to get the most out of medications: Medications prescribed by your doctor to manage PTSD symptoms can make a positive difference in the way you feel. Medication may also make it easier to participate in and benefit from cognitive behavioral therapy. Most people who take prescription medications use them responsibly. However, many medications carry a risk of abuse or dependency, and can be misused. Prescription drug abuse includes taking a medication that was prescribed for someone else, or taking the medication in a manner or dosage different from what was prescribed. Taking medications inappropriately can produce serious illness or injury. It can also result in an unhealthy dependence on the medication.Why you should only take medications prescribed to you by your physician: •The medication may interact with other drugs you are taking (even over-the-counter medications), and the combination could be very dangerous. •It is illegal to take certain medications without a prescription (tranquilizers, pain medications, etc.). Medications can be easily detected in urine and blood tests, so your provider will find out if youve been borrowing medications from another person. Follow the dosage and directions for use carefully. Learn what side effects the medication could have. Do not increase or discontinue taking medications without first getting approval from your physician. Many of the medications that are helpful with PTSD take several weeks to start working. This means that you may not see the full effect until 2-3 months. You may be tempted to increase your dosage to get faster results, but doing this can cause negative side effects or cause serious injury. You may be tempted to discontinue taking a medication if you are experiencing unpleasant side effects or if it doesnt seem to be working. If you have side effects, or arent seeing positive effects right away, hang in there. Sometimes medications take a while before you notice a difference in the way you feel. If you are experiencing side effects, contact your physician to discuss the issue before stopping or changing the dosage. Medications for PTSD and alcohol do not mix. You should not drink alcohol and take medications for PTSD. Alcohol interacts with several psychiatric medications in ways that can be dangerous, and even lethal. The combination can impair your thinking and coordination, increasing the risk for motor vehicle accidents and serious injury. This is especially true of the tranquilizers such as Ativan ®, Xanax ®, Klonopin ®, Valium ®, and Librium ®.
Unproven treatments
Therapies lacking adequate support:The following therapies are not generally supported by evidence, and have not gained widespread approval in the scientific community although you may encounter providers who practice them. Many of these therapies are called Power Therapies by practitioners who believe that this set of therapies are much more potent than usual therapies. Some of these therapies are claimed to resolve PTSD in as little as one session. A common theme for the therapies listed below is a failure to back up the claims made with clinical evidence. •Trauma Incident Reduction (TIR): This therapy involves having patients repeatedly imagine their traumatic memories-with the support of the therapist. This is done in an effort to gain insight into their trauma, and build positive emotions. There are few studies of this therapy-and they arent well designed. If this therapy is effective, its most likely due to the fact that patients are encouraged to use Imaginal exposure, which is a core component of CBT. •Thought Field Therapy (TFT): This very controversial therapy involves forming an image of a traumatic situation, and literally tapping on yourself at various parts of your body in order to release anxiety. The idea is that various thought fields in the body contain perturbations that cause symptoms, and by releasing them-you can cure yourself of these symptoms. There is no consistent scientific evidence for either the therapy, or the theory behind it. •Visual Kinesthetic Dissociation (VK/D): This therapy was founded on a set of ideas from Neurolinguistic Programming (NLP). NLP is a loose grouping of ideas and theories which has largely been discredited as pseudoscience. VK/D therapy basically asks patients to imagine themselves Observing their traumatic memories as if on a movie screen and changing aspects of what happens during the movie. This supposedly leads to reduction and resolution of the negative emotions associated with the trauma. Like trauma incident reduction, there are a very small number of studies that suggest this may be an effective therapy, but the studies do not meet rigorous scientific standards. If this technique is eventually shown to truly help PTSD patients it will likely be due to the inclusion of an exposure component (repeatedly imagining the traumatic event) and not due to the supposed mechanism proposed by the NLP based theory.
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