PTSD in Patients AND Caregivers

     "Dr. Gary Rodin, head of supportive care at Princess Margaret Cancer Centre in Toronto, says the trauma of going to the hospital for a life-threatening illness isn't so different from someone who has seen military combat or been the subject of a physical assault.
     Jordan's case (mother of a 6yo boy who had extensive, painful maxillo-facial surgery) also exemplifies how PTSD can affect the patient's loved ones just as much as the patient, he said — especially parents, spouses and partners.
     "She doesn't have the illness, but one of the people she cares most about — probably in the world — does," he explained. "Some of the highest rates in PTSD are in mothers of children who have a serious or life-threatening illness."
     Rodin says hospital PTSD is far more common than many people realize. He's seen it develop in up to 25 per cent of patients who have cancer and other life-threatening conditions.
     "What's not recognized is that one of the most common traumas human beings face is a serious medical illness," he told Goldman. "So especially at the time of diagnosis, or a complication, or when there's screening, all these things may trigger enormous anxiety."
     Rodin and his team at Princess Margaret Hospital developed a program called Emotion and Symptom-focused Engagement (EASE) provides emotional support and anxiety management for people who are suffering from hospital-related PTSD.
     "We know this kind of proactive intervention reduces PTSD symptoms ... and also reduces all kinds of other distress," he said.
     Rodin says a short course of treatment can do wonders when PTSD is recognized early.”
       “PTSD in the Hospital: Why the Emotional Scars of Serious Illnesses Linger Long after Treatment.” CBC’s White Coat Black Arts: http://www.cbc.ca/radio/whitecoat/ptsd-in-the-hospital-why-the-emotional-scars-of-serious-illnesses-linger-long-after-treatment-1.4590370

Bad Behavior, Self-acceptance & Interoception

     There's often far more to disturbingly "inappropriate" or "bad" behavior than immorality or poor parenting. Significant trauma enters the equation much more often than we think. "Knowing the difference between right & wrong" and "trying one's best" have very little influence when a posttraumatic reaction is triggered.
     We may suspect, but usually have no idea about peoples' past history, even of those we've known for a long time. Trauma is not something most of us want to revisit, much less share with others.

     “Paradoxically, the more we try to change ourselves, the more we prevent change from occurring. On the other hand, the more we allow ourselves to fully experience who we are, the greater the possibility of change."
       Laurence Heller, Aline LaPierre. "Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and the Capacity for Relationship.” North Atlantic Books, 2012.


     “…trauma is much more than a story about something that happened long ago. The emotions and physical sensations that were imprinted during the trauma are experienced not as memories but as disruptive physical reactions in the present. 
     … the engines of posttraumatic reactions are located in the emotional brain. In contrast with the rational brain, which expresses itself in thoughts, the emotional brain manifests itself in physical reactions: gut-wrenching sensations, heart pounding, breathing becoming fast and shallow, feelings of heartbreak, speaking with an uptight and reedy voice, and the characteristic body movements that signify collapse, rigidity, rage, or defensiveness.
     …the rational brain cannot abolish emotions, sensations, or thoughts (such as living with a low-level sense of threat or feeling that you are fundamentally a terrible person, even though you rationally know that you are not to blame for having been raped). Understanding why you feel a certain way does not change how you feel. But it can keep you from surrendering to intense reactions (for example, assaulting a boss who reminds you of a perpetrator, breaking up with a lover at your first disagreement, or jumping into the arms of a stranger.) However, the more frazzled we are, the more our rational brains take a backseat to our emotions.
     The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and the emotional brains, so that you can feel in charge of how you respond and how you conduct your life. … 
     Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity. 
     If we want to change posttraumatic reactions, we have to access the emotional brain and do ‘limbic system therapy’: repairing faulty alarm systems and restoring the emotional brain to its ordinary job of being a quiet background presence that takes care of the housekeeping of the body, ensuring that you eat, sleep, connect with intimate partners, protect your children, and defend against danger. 
     The neuroscientist Joseph LeDoux and his colleagues have shown that the only way we can consciously access the emotional brain is through self-awareness, ie by activating the medial prefrontal cortex, the part of the brain that notices what is going on inside us and thus allows us to feel what we’re feeling. (The technical term for this is ‘interoception’ – Latin for ‘looking inside.’) Most of our conscious brain is dedicated to focusing on the outside world: getting along with others and making plans for the future. However, that does not help us manage ourselves. Neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going on inside ourselves.”
       Bessel Van Der Kolk. “The Body Keeps the Score. Brain, Mind, and Body in the Healing of Trauma.” Penguin Books, 2015.

Agency, Interoception and Healing from Trauma

     “ ‘Agency’ is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances. The veterans who put their fists through the wall at the VA are trying to assert their agency – to make something happen. But they end up feeling even more out of control, and many of these once-confident men are trapped in a cycle between frantic activity and immobility. 
     Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilize to manage them. But we can’t do this unless our watchtower, the medial prefrontal cortex (MPFC), learns to observe what is going on inside of us. This is why mindfulness practice, which strengthens the MPFC, is a cornerstone of recovery from trauma.”

     Bessel Van Der Kolk. “The Body Keeps the Score. Brain, Mind, and Body in the Healing of Trauma.” Penguin Books, 2015.

Avoidance vs Acceptance & Mindfully "Leaning In" with Curiosity

     “A wide range of research reviewed shows that many forms of psychopathology can be conceptualized as unhealthy efforts to escape and avoid emotions, thoughts, memories, and other private experiences.”  
       Hayes SC, Wilson KW, Gifford EV, Follette VM, Strosahl K. “Emotional avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment.” Journal of Consulting and Clinical Psychology 1996; 64(6): 1152–68.

     “Elvin Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people ‘acknowledge, experience, and bear’ the reality of life – with all its pleasures and heartbreak. ‘The greatest sources of our suffering are the lies we tell ourselves,’ he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel.”
       Bessel Van Der Kolk. “The Body Keeps the Score. Brain, Mind, and Body in the Healing of Trauma.” Penguin Books, 2015.

     “The theoretical framework of mindfulness holds that the continual practice of bringing one’s attention to the present moment, and allowing what is in that moment simply to be, eventually leads to a shift in perception in which thoughts and feelings may be observed as arising events. With increased ability to become witness to thoughts, rather than immersed in their valence and content, there follows increased psychological flexibility, enhanced emotion regulation, and reduced rumination.
     An interesting observation in this study was that participation in MBSR was associated with reductions in PTSD symptoms, most strongly among them avoidance. Recent thinking in the field of trauma asserts that avoidance, the effort to escape or hide from traumatic thoughts, feelings, or memories, is the core psychological process underlying the development and continuation of PTSD. Avoidant coping strategies include attempts to suppress intrusive thoughts, to take oneself away from negatively evocative situations, engage in substance use, or through emotional numbing. Therapeutic approaches that prescribe the opposite of avoidance, i.e., acceptance, can serve as a form of exposure and work to alleviate avoidant tendencies. In offering acceptance of the present moment, MBSR may be such a therapy. The mindfulness approach is that through openness, curiosity, and acceptance of the present moment, one’s relationship with negative thoughts is altered. By fostering a greater comfort level with thoughts previously avoided, mindfulness practice allows them to surface and, as such, mindfulness may serve as a form of exposure in its impact on PTSD symptoms. 
     In addition to contributing to a survivor’s ability to be present to his or her own painful emotional experience, mindfulness skills also may enhance one’s capacity to be present in psychological therapy. In this way, mindfulness may potentiate therapeutic work. The exploration of this synergy should be a topic of future empirical investigation. Thus, MBSR may serve as a widely available, potentially cost-effective way for clients to gain a foundation in mindfulness skills.”  
       Kimbrough E, Magyari T, Langenberg P, Chesney M, Berman B. “Mindfulness intervention for child abuse survivors.” Journal of Clinical Psychology 2010; 66(1): 17–33.


 

Courtesy of Buddha Doodles www.buddhadoodles.com

Many Causes of Trauma & PTSD

     Individuals vary in their sensitivity (vs resilience) to trauma. There's a much wider variety of possible sources of trauma than most of us suspect.

     “While some people are able to recover from trauma on their own, many individuals do not. 
     Tens of thousands of soldiers are experiencing the extreme stress and horror of war. Then too, there are the devastating occurrences of rape, sexual abuse and assault. 
     Many of us, however, have been overwhelmed by much more ‘ordinary’ events such as surgeries or invasive medical procedures. Orthopedic patients in a recent study, for example, showed a 52% occurrence of being diagnosed with full-on PTSD following surgery. 
     Other traumas include falls, serious illnesses, abandonment, receiving shocking or tragic news, witnessing violence and getting into an auto accident; all can lead to PTSD. 
     These and many other fairly common experiences are all potentially traumatizing. The inability to rebound from such events, or to be helped adequately to recover by professionals, can subject us to PTSD – along with a myriad of physical and emotional symptoms.”

       Levine PA. "In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness." North Atlantic Books, 2010. 

The Scream by Edvard Munch

What is Moral Injury?

     Donald Trump, before his election bragged that he wouldn't loose a single follower if he pulled out a gun in Times Square and shot someone. Rodrigo Duterte, president of the Phillipines, repeatedly brags about having murdered several suspected drug dealers, and encourages his people to do the same. Trump and Duterte have a lot of supporters at home and abroad. 
     How do you feel when you hear about such things?

     "The sorrow, grief, and rage you feel is a measure of your humanity and your evolutionary maturity. As your heart breaks open there will be room for the world to heal."       Joanna Macy

      “… moral injury is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as ‘what’s right’ has not also been violated.”
        Jonathan Shay. “Achilles in Vietnam. Combat Trauma and the Undoing of Character.” Scribner, NY, 1994.

     "Moral injury is 
     • the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress their own moral and ethical values or codes of conduct
     • disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner
     • the inability to contextualize or justify personal actions or the actions of others and the unsuccessful accommodation of these … experiences into pre-existing moral schemas
     • a deep soul wound that pierces a person’s identity, sense of morality and relationship to society."
       The Moral Injury Project - Syracuse University http://moralinjuryproject.syr.edu/about-moral-injury/

     See also: "Ignoring 'Soft Skills' & Moral Injury": http://healthyhealers.blogspot.ca/2016/03/ignoring-soft-skills-moral-injury.html

Alexia Foundation http://www.alexiafoundation.org/stories/tradition-womens-rights-and-circumcision-in-guinea-bissau-africabr

Lessons from Combat Trauma

     Shay, an experienced psychiatrist, writes (in italics) about his experiences treating many Vietnam vets with PTSD. 
     I suspect that a surprising proportion of us, though never having physically been in an actual war, have nevertheless accumulated, not the same, but similar trauma over a perfectly imperfect lifetime. And have probably never received any timely counseling.

     “The child’s inner sense of safety in the world emerges from the trustworthiness, reliability, and simple competence of the family.”
     Children who grow up feeling unwanted, know no safety - have definitely been traumatized: http://www.johnlovas.com/2013/11/attachment-to-people-memories-concepts.html

     “… moral injury is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as ‘what’s right’ has not also been violated.”
     Children expect unconditional love, but none of us receive it. The greater the gulf between what we ardently need and what we feel we receive, the greater the sense of betrayal - the 'moral injury': http://healthyhealers.blogspot.ca/2013/07/the-inner-child-unconditional-love-and.html

     “Another veteran in our program wrote: ‘In my wildest thoughts I never expected or wanted to return home alive, and emotionally never have.’ 
     The sense of being already dead may contribute to the berserker’s complete loss of fear … It may also be the prototype of the loss of all emotion that defines for combat post-traumatic stress disorder the prolonged states of numbness – the inability to feel love or happiness or to believe that anything matters.” 
     How does a child appear when the expected source of unconditional love repeatedly says wildly hurtful things to the child? S/he may not reveal any change in expression. But there's inner amazement & profound confusion - 'Is this a Martian pretending to be my mother?' Also internally, there are earthquakes & aftershocks, with new layers of concrete hastily lathered around the heart.

     “What I want to emphasize here is the rapid transformation of grief into rage. For many of the (Vietnam) veterans in our treatment program for combat post-traumatic stress disorder, replacement of grief by rage has lasted for years and become an entrenched way of being. Much therapeutic effort aims at reawakening the experience of grief, which we regard as a process of healing, painful as it is.” 
     “I believe that the emergence of rage out of intense grief is a biological universal and that long-term obstruction of grief and failure to communalize grief can lock a person into chronic rage.” 
     I suspect many 'angry young men', as well as women, express their grief through rage.

     “There is growing consensus among people who treat PTSD that any trauma, be it loss of family in a natural disaster, rape, exposure to the dead and mutilated in an industrial catastrophe, or combat itself, will have longer-lasting and more serious consequences if there has been no opportunity to talk about the traumatic event, to express to other people emotions about the traumatic event, to express to other people emotions about the event and those involved in it, or to experience the presence of socially connected other who will not let one go through it alone. This is what is meant by communalizing the trauma.”
     It may not be until the late teens, when children of dysfunctional parents move away from home, and finally have the courage & safe opportunity to explore, and perhaps vent their grief.

       Jonathan Shay. “Achilles in Vietnam. Combat Trauma and the Undoing of Character.” Scribner, NY, 1994.

 

Trauma, Posttraumatic Stress Disorder - AND / OR - Growth

      "Over millennia and across disciplines, some variant of Nietzsche’s (1889) maxim ‘What does not destroy me, makes me stronger’ has resonated with scholars and laypersons alike. It serves as a poignant and compelling reinforcement to Tedeschi & Calhoun’s claim ‘that suffering and distress can be possible sources of positive change’. Emerging findings from the domain of posttraumatic growth (PTG), which involves a belief that one has grown through adversity, offer empirical corroboration of such claims as well as conceptual models that articulate the process and potential outcomes of dealing with life’s exigencies.
      Similarly, coping with very difficult, challenging life events has also been linked with wisdom, an ancient construct currently enjoying an academic renaissance within the field of psychology. Against very positive background characteristics (e.g., experiences of love, support, self-actualization), wisdom is believed to be partly forged in the crucible of difficult life experiences; graduates of the school of ‘hard knocks’ are assumed to manifest particular psychosocial strengths as a consequence of successfully negotiating life’s serious conundrums.
     Recently, these two independent research streams have been conceptually linked but not empirically tested. The types of cognitive-emotional processing of trauma-related information may serve as a catalyst for both posttraumatic growth and wisdom. Trauma, by definition, is a requirement for PTG. In contrast, trauma is not necessary for wisdom, and wisdom is enabled and enhanced by non-traumatic, positive life events as well (e.g., peak experiences, success, loving relationships)."
       Webster J, Deng XC. "Paths From Trauma to Intrapersonal Strength: Worldview, Posttraumatic Growth, and Wisdom." Journal of Loss and Trauma, 1–14, 2014 DOI: 10.1080/15325024.2014.932207

     Not mentioned above is that the world's wisdom traditions have the central raison d'être of intentionally cultivating wisdom, and have been doing so for well over a thousand years. A current, secular, evidence-based derivative of one of these wisdom traditions (Buddhism), is mindfulness-based stress reduction (MBSR).

     "... veterans who took part in MBSR experienced significant improvements in measures of mental health, including measures of PTSD, depression, experiential avoidance, and behavioral activation as well as mental and physical health-related quality of life over a 6-month period. The MBSR program appeared to be safe for participants with symptoms of PTSD, and improvements in clinical outcome measures were maintained from the point of time when subjects finished MBSR (2 months after enrollment) until the longest follow-up time point 6 months after enrollment. The changes demonstrated for measures of mental health had medium to large standardized effect sizes."
       Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. "Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample." Journal of clinical psychology. 2012; 68(1): 101-16. 

Trauma, Conscious Struggle, Reevaluation of Worldviews, & Posttraumatic Growth

     "The negative impacts of trauma (from war & events outside of war) have been well documented. Most commonly cited are stress, depression, anxiety, and Posttraumatic Stress Disorder (PTSD). However, researchers have recently begun to examine potential positive trauma outcomes as well.

     "Posttraumatic growth (PTG) is one such conceptualization of positive trauma aftermath. Individuals who have suffered a traumatic/stressful event cope with the negative impacts in various ways. There are those who are resilient & are more likely to carry on with their lives as though nothing out of the ordinary has occurred. Many others, however, struggle in their efforts toward recovery and are forced to reevaluate previous worldviews & interpretations. PTG occurs when individuals formulate more adaptive interpretations or worldviews. PTG is personal growth following a traumatic event and is measured by adaptations in perceived changes in self, relationships with others, philosophy of life, spirituality, and new possibilities."

       Gerber MM, Boals A, Schuettler D. The unique contributions of positive and negative religious coping to posttraumatic growth and PTSD. Psychology of Religion and Spirituality. 2011; 3(4): 298-307. 

 

Dalhousie University

 

US Marines Start Mindfulness Training

     "Camp Pendleton, the Marine Corps base in California, will host the pilot program for about 80 servicemen and -women, beginning Tuesday.
     The pilot program is being instituted after 2012 saw the highest number of U.S. military suicides -- 349 -- ever recorded in a single calendar year, as AP reported. Last year, the number of active- and reserve-duty personnel who took their own lives surpassed the number who were killed in combat in Afghanistan, 295.
     Experts have blamed the surge in military suicides in part on two long, controversial wars in Afghanistan and Iraq and in part on high levels of untreated depression and post-traumatic stress disorder, among other factors.
     ...
     'We have doctors, counselors, behavioral-health scientists, all sorts of people to get help for Marines who have exhibited stress-type symptoms, but what can we do before that happens? How do we armor Marines up so they are capable of handling stress?' Jeffery Bearor, the executive deputy of the Marine Corps training and education command at its headquarters in Quantico, Va., asked AP rhetorically.
     Bearor indicated this type of training may increase decision-making capabilities.
     'If indeed that proves to be the case, then it's our intention to turn this into a training program where Marines train Marines in these techniques,' Bearor said. 'We would interject this into the entry-level training pipeline ... so every Marine would be trained in these techniques.'"
http://www.ibtimes.com/marines-testing-meditation-training-may-teach-mindfulness-young-recruits-mental-stamina-1027058 

Comfort by Kristiina Lehtonen   http://www.kristiinalehtonen.fi/index_en.php