Monthly Archives: October 2014

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can't sleep ptsd

Treatment for Hyperarousal Symptoms

Hyperarousal is often the first sign of PTSD, and it’s directly linked to activation of the sympathetic nervous system. The most common symptom is the inability to sleep.

Arousal Symptoms:

1) Irritable or aggressive behavior

2) Self-destructive or reckless behavior

3) Hyper-vigilance

4) Exaggerated startle response

5) Problems in concentration

6) Sleep disturbance

Remember your high school Biology class? The sympathetic nervous system is the fight or flight part of our autonomic nervous system. It automatically activates when you are faced with a life-threatening situation.

The parasympathetic system is our body’s maintenance system. It lubricates our eyes, digests our food, releases sex hormones, helps us go to sleep, etc.

The sympathetic system takes over during periods of extreme danger and stress, focusing all the body’s resources on immediate survival. To do this, it overrides our normal maintenance.

WHAT DOES THE SYMPATHETIC NERVOUS SYSTEM DO?

It prepares us to fight for our life or run away. More specifically, it slows down or shuts off the parasympathetic nervous system and activates the brain, which in turn triggers the release of adrenaline, noradrenalin, and glucocorticoids (stress chemicals). These dilate the pupil, increase the flow of air into the lungs, accelerate the heart, and release glucose (fuel) from the liver. They also increase blood flow to the muscles and brain, increase strength, increase endurance, reduce inflammation, increase mental alertness, and focus attention on the danger.

This is exactly what you want if you’re in a life-threatening situation. But prolonged exposure to those same stress chemicals is harmful to your physical and mental health.Emotional Center of the Brain

WHAT HAPPENS IN THE BRAIN:

The colored areas in this brain highlight the parts involved in emotion. The long green part is the hippocampus and is important in memory recall. The round red part at its lower end is the amygdala, which promotes emotions like sadness, fear, and anger. The blue area is the hypothalamus, which controls the gray area below it, the pituitary gland.

So when the sympathetic nervous system is activated, it alerts the hypothalamus, which alerts the pituitary gland, which tells the adrenal gland (atop your kidney) to make stress chemicals. Those chemicals travel through the bloodstream and affect your whole body. In your brain, they inflame the amygdala (increasing the intensity of sadness, fear, and anger) and block the hippocampus from laying down memory tracks.

If these chemicals continue for any length of time, the hippocampus shrinks and the amygdala enlarges. You can see these changes on an MRI brain scan. Parts of the cortex (the gray area on the outside that does most of your thinking) are also affected, including the VMPF (ventral medial prefrontal cortex), which controls emotions by calming the amygdala. Other areas in our cortex that help us speak and think coherently also can decrease in size.

THE LONGER THE SYMPATHETIC NERVOUS SYSTEM STAYS ON, THE MORE DAMAGE IT CAN DO TO YOUR BRAIN.

Treating PTSD quickly can avoid these wounds, since our brain is designed for short bursts from our sympathetic nervous system. Luckily our brain can make new cells, especially in the hippocampus, which can repair itself once the toxic chemicals subside. That means you can heal—although the longer hyperarousal goes untreated, the harder it will be to reverse.

TREATMENT OPTIONS:

1) MEDICATIONS:

Alpha-blockers: Prazosin and Clonidine

Sedating Antidepressants: Trazodone, Remeron, Luvox,

Nonsedating Antidepressants: SSRIs: Lexapro, Paxil, Zoloft.

SNRIs: Cymbalta, Effexor, Pristiq

Antipsychotics: Old: Thorazine, New: Seroquel, Risperdol

Anticonvulsants: Gabapentin, Tegretol, Trileptal, Ketamine, Depakote, Lamictal,

Alpha-blockers block receptors to adrenaline and noradrenalin, chemicals secreted by the adrenal gland. Developed to treat high blood pressure, researchers have found that two of the alpha-blockers, Prazosin and Clonidine, can sneak into the brain. These medications work well to increase sleep and prevent nightmares in people suffering from PTSD.

The dose varies widely between people, so you start low and increase the medication every night until it works. Both Prazosin and Clonidine have fairly short half-lives, so they won’t effect you the next day unless you take another dose. Common side effects that occur immediately are sleepiness and dizziness. Side effects are less serious if you increase dose gradually. Sleepiness can be a blessing.

Other medications may contain alpha-blockers, like Trazodone, Seroquel, and low dose Remeron. These medications not only reduce arousal, but also work as antidepressants.

Antidepressants repair chemistry in the VMPF (ventral medial prefrontal cortex) so it can calm the amygdala again. That decreases feelings of sadness, fear, and rage. Paxil and Zoloft are FDA approved, but the other SSRIs and SNRIs work just as well.

Most of the antipsychotics, like Thorazine, contain an alpha-blocker, so they calm you down. But many of them have serious side effects, so I wouldn’t use them unless other drugs have failed. Seizure medicines can control rage outbursts, but they also have a lot of side effects.

2) THE NEWEST TREATMENT IS THE STELLATE GANGLION BLOCK.

The Stellate Ganglion is a collection of nerve cells located in your lower neck. Nerve blocks in this area have been used for years to treat chronic pain due to over-activity in the sympathetic nervous system.

For the last two years this technique has been tested on PTSD patients by Walter Reed Hospital, Duke Anesthesiology, and a private group in Chicago. The doctors inject a local anesthetic into the Stellate Ganglion— with astonishing results.

A review of all the recent literature on Stellate Ganglion blocks reports that in PTSD cases resistant to medications and exposure therapy, 75% had immediate improvement with one shot. The improvement lasted from 3 months to a year or more and a second block brought increased relief. Side effects were minimal and PTSD symptoms were decreased by 30- 98%.

So far this technique is not FDA approved for use in PTSD patients, so insurance won’t cover it. The cost is $2000-$3000 a shot.

3) THE OLDEST TREATMENTS STILL WORK:

Since ancient times, men have sought ways to control their minds and bodies. The ancient Hindu art of meditation met this need. Yogis can lower their blood pressure and heart rate, both controlled by the autonomic nervous system, to almost hibernation levels. It takes a lot of time and practice to develop this technique, but if you want a non-medical approach, it still works.

Meditation may work because you successfully focus your total attention on a non-threatening idea. That may also explain the calming effect of animals. Many survivors find relief with their dogs, horses, and other animals. The non-threatening animal provides a sense of security that more challenging human friends can’t match. Service dog providers are available nationwide.

Other approaches that help you to let go of strong emotions will be covered in the  blog: Exposure Therapy for Flashbacks, etc. Check them out and see what works for you.

BOTTOM LINE:

If you’re having trouble with hyperarousal symptoms, it’s VERY important to find an approach that helps you sleep, calms your emotions, and gives your brain a chance to heal. If you’ve tried all the medicines and flunked exposure therapy, look into getting a Stellate Ganglion block. If you want an alternative approach, learn meditation or bond with a non-threatening animal.

PTSD and Addiction

Double Whammy: Substance Abuse and PTSD

(Image courtesy of  http://www.rehabcenter.net/post-traumatic-stress…)

The use of addicting and illegal drugs is an ongoing problem for many people suffering from PTSD. It’s estimated that about half of the men and a quarter of the women qualify for a Substance Abuse diagnosis. Among Vietnam veterans, it’s closer to 80%, probably because there were fewer treatment options forty years back. Unfortunately, people with both PTSD and Substance Abuse have a more difficult time with recovery, suffer more PTSD symptoms, and are at higher risk of suicide.

Alcohol and Benzodiazepines:

The most commonly used drug is alcohol, probably since it’s legal. When you can’t sleep, it’s easy to pour yourself a drink. At first it works. This encourages you to have one every night, or maybe two, or three.

What most people don’t realize is that alcohol, and also the benzodiazepines like Valium, Xanax, Klonopin, and Ativan, lull you with calmness while dragging you down into a very deep hole. Problems arise because these drugs work by releasing a chemical called GABA. GABA is the primary calming chemical in the brain, the off switch on our neural TV screen, so releasing GABA turns worries off and calms you down.

What’s wrong with that?

The problem comes with the word “release”. Our brains can make GABA, but not quickly. So if we release some GABA once a week—no problem. If we release it once a day—probably okay. But if we start releasing quantities of GABA several times a day for weeks or months, we get in serious trouble because we don’t have enough GABA left.

Since GABA is the off switch in the brain, not having enough means our brain gets very hyper. We start to shake, get irritable and angry, can’t sleep, and can progress to hallucinations— even seizures. Delirium Tremens, commonly called DTs, can be lethal, and benzodiazepine withdrawals are equally dangerous. Even if you keep on drinking or taking pills, they no longer work because there’s less GABA to release.

Bottom line: Go easy on the alcohol and benzos. They may help in an emergency, but they can make serious trouble if you use them all the time.

Marijuana:

Marijuana is now legal in some states. It’s reported to reduce both anxiety and flashbacks, and there is actually a scientific basis for this claim. Recent research shows a reduction in natural cannabinoids in the brains of people with PTSD and an increase in cannabinoid receptors (your brain is listening hard for a weak signal).

Now there is further evidence that cannabis can help with PTSD. Recent research suggests that using MJ right after a trauma may actually prevent PTSD. It also can be useful during exposure therapy as it helps to disconnect your triggers from your memories. Hopefully MJ will soon become available for medical use in all fifty states, but be very sure your state has approved it before using. Being arrested and incarcerated is a very serious side effect that creates more problems in your life.

Side effects from MJ include reduced short-term memory and reduced focus and motivation. There may be new strains that have reduced these problems, but both standard marijuana and cannabinoids synthesized by pharmaceutical companies. (Yes, they would love to make money off of you) can produce these side effects.

Finally, if you’re under twenty-five your brain is still maturing and MJ poses a more serious risk. Cannabinoids have been proven to increase both depression and psychosis in young brains, and the problem continues long after you stop use.

Bottom line: Cannabinoids found in marijuana can be helpful in PTSD, but they can impair your memory and focus. If you use, please evaluate for side effects and keep yourself safe.

Narcotics:

Opiates are popular with PTSD clients for two reasons. First, opiates have an alpha-blocking component which helps calm down hyper-arousal symptoms. Second, they block pain. Many survivors have physical injuries, and emotions associated with traumatic memories can also cause distress, so a drug that reduces that discomfort is tempting.

But if you take opiates for any length of time, you develop tolerance and they no longer work. That’s because the opiates replace your natural pain reducing chemicals—endorphins. The more opiates you use, the less natural pain chemicals you make.

Then you face a difficult decision. You can’t keep increasing your dose indefinitely. Using the same dose of opiate doesn’t work. And if you stop, you’re body reacts with serious discomfort and intestinal distress until it can remake it’s own endorphins. Luckily, opiate withdrawals aren’t lethal, but they’re painful.

Bottom line: Instead of narcotics, try alpha-blockers like Prazosin, or sedatives containing alpha blockers like Trazodone or Seroquel. Then work on letting go of your emotional pain using techniques in the blog: Treatment for Flashbacks, Nightmares, and Intrusive Memories. If you need them for pain, work with a professional to find appropriate alternatives to reduce the amount of opiates you need.

Cocaine, Crack, Methamphetamine:

These drugs work by releasing dopamine, a chemical that activates the pleasure center in our brain. That makes them the most addicting drugs around– and the most dangerous. They release so much dopamine so fast they can burn out your dopamine receptors. After that nothing can make you feel good for a long, long time.

Worse yet, these drugs can kill you with a heart attack or stroke. When a person under 30 shows up in the ER with symptoms of MI or stroke, the doctors always test them for cocaine and meth, and usually find it.

Bottom line: Just don’t. If antidepressants aren’t working for you, try X-sports. They’re safer than these drugs.

MDMA:

MDMA was used as an adjunct to therapy back in the 1970s and ’80s, and now there is renewed interest in the drug. Research shows that MDMA can raise serotonin and norepinephrine levels and improve functioning in the medial lateral prefrontal cortex, which in turn down-regulates the amygdala and controls negative emotions. It also increases prolactin, our “love” hormone.

That certainly suggests it should help PTSD. I just read a pilot study on 25 PTSD patients in exposure therapy.  They found that the group receiving MDMA did better than the control group following two or three therapy sessions, and the medicated group continued to improve through the next year. There were no serious side effects noted.

I expect MDMA to rejoin the list of medications that help people process traumatic memories.

Psilocybin, LSD, and other hallucinogens:

In spite of the fascinating stories I’ve heard, I’ve found no scientific research to show these actually help PTSD symptoms. If you disagree, keep me informed.

Bottom line:

If you’re addicted to a drug, don’t give up hope. Calming your arousal symptoms (see Treatment for Hyper-Arousal) can greatly reduce your need for drugs.

Research suggests that it’s best to find a counselor who can work with both your addiction and PTSD, but an integrated group where the professionals confer will also work. In most cases, your PTSD symptoms will drive the substance use, so you need to treat them simultaneously.

Avoidance picture

Avoidance Symptoms in PTSD

It’s normal to avoid pain and that certainly includes painful emotions. So it’s not at all surprising that the last two groups of symptoms in PTSD involve Avoidance.

First there is Conscious Avoidance. This is described in DSM V as:

Persistent effortful avoidance of distressing trauma-related stimuli after the event:

1) Trauma-related thoughts or feelings.

2) Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Simply said, you learn your triggers and intentionally avoid them. If you’re still having trouble with Arousal symptoms (like anger, self-destructive behavior, irritability, hyper-vigilance, and inability to sleep), or Re-experiencing symptoms (like intrusive memories, nightmares, and flashbacks) then avoiding triggers makes perfect sense. However, you can treat those symptoms as discussed in the previous blogs on Problems with Arousal and Reactivity, and Exposure Therapy for Flashbacks, etc. Successfully completing those treatments will help desensitize you to your triggers and reduce the need for avoidance.

Then there is Unconscious Avoidance. These symptoms are often hard to recognize because your brain is playing tricks on you. The DSM V groups these under Negative Cognitions (thoughts) and Mood. Here’s their list:

Negative alterations in cognitions and mood that began or worsened after the traumatic event:

1) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).

2) Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).

3) Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

4) Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).

5) Markedly diminished interest in (pre-traumatic) significant activities.

6) Feeling alienated from others (e.g., detachment or estrangement).

7) Constricted affect: persistent inability to experience positive emotions.

The inability to recall parts of the trauma is a “dissociative” symptom. Dissociation is the process your brain uses to wall off traumatic memories. I see it as similar to how our body walls off an infection in an abscess. Often the worst part of the trauma memory is totally dissociated and not available to conscious recall, but triggers to the trauma still release it in flashbacks and/or nightmares. The survivor usually can’t remember or talk about the dissociated part of his/her trauma.

Calming down the sympathetic nervous system may help to bring dissociated memories into conscious awareness. Or this may happen while other memories are being explored and the survivor becomes aware of missing pieces. Massage and body work can also help. But since the forgotten parts are often very ugly, caution should be used to protect the survivor from the negative emotion and pain that will accompany their recall.

Distortions in thinking about the trauma are common and can be dealt with in the process of detoxifying memories (see blog on Exposure Therapy for Flashbacks, etc.). As the survivor is able to look at the trauma with less intense emotion and less pain, he/she starts to engage the cortex—the thinking part of our brain—which may change the previously held beliefs.

Persistent negative emotions and the inability to experience positive emotions often lead to withdrawal from activities and people, all four symptoms suggest that the amygdala hasn’t settled down and the prefrontal cortex, which calms the amygdala, isn’t yet functioning properly. These problems are tied to the sympathetic nervous system and the wounds that its stress chemicals are making in the brain. To treat it, see the blog on Problems with Arousal and Reactivity.

The biggest problem with unconscious avoidance is that symptoms become truth for the survivor, which prevents him/her from seeking treatment. If you’re constantly in a negative mood and previous attempts to get help have failed, it’s easy to believe there is nothing anyone can do. Please be aware this is just another symptom, one that newer treatments are designed to overcome. Family and close friends can assist by supporting survivors in their effort to seek help.

Bottom line: Avoidance is understandable, even inevitable, but it doesn’t treat the problem. If you want to get better, you need to check out the earlier blogs on Problems with Arousal and Reactivity and Exposure Therapy for Flashbacks, etc. Then find a well-trained doctor and therapist to help you.

DSM V doesn’t mention a third type of avoidance, but between a quarter to a half of all survivors use it. I’m talking about Substance Abuse, and I’ll tackle that in my next blog.

EMDR

Exposure Therapies for Flashbacks, Nightmares, and Intrusive Memories

So far I’ve written about treatments for Arousal symptoms such as irritability, anxiety, and insomnia, and introduced Intrusive Symptoms like flashbacks, intrusive memories, and nightmares. Please remember that it’s important to address the hyperarousal of the sympathetic nervous system before trying any of the exposure therapies discussed below. If you can’t calm down and sleep, it’s not wise to add fuel to the fire.

Exposure therapy comes in many forms, but all have the goal of gradually detoxifying the traumatic memory and integrating it into your normal memory. They all contain the same steps, but some are more formalized than others. The steps are:

1) LET GO of negative emotions and pain

2) Explore the memory in detail

3) Reexamine your feelings, emotional and physical, about the memory

4) Reexamine your beliefs about the memory

5) REPEAT the PROCESS until the memory loses its power

This is a highly repetitive process, like peeling skin off an onion one layer at a time. The first time you approach the memory, you probably won’t do much letting go of feelings or exploring the memory in detail. But as you repeat the process, it should get easier each time. If not, you may be repeating a flashback and need to choose a different therapy approach. But whatever your approach, you’ll undoubtedly repeat these five steps many times before you find yourself at peace.

The first step, letting go of emotions and pain, is the hardest for most folks. We all avoid terror, fear, grief, disgust, anger, shame, guilt, and other negative emotions. If the memory involves a physical injury, the pain can be remembered by the body, and bodywork in the form of exercise or massage can release it. Different approaches work at different times and for different personalities and traumas. Pick what works for you, but don’t be afraid to experiment.

Ways to Let Go:

1)Cry, scream, curse

2)Share with others and accept support.

3)Use art, music, poetry, theater, or dance to express yourself

4)Visualize draining the feelings and pain into an object, another person, or pet.

5)Exercise

6)Mindfulness (keeping focused in the present) and Meditation (emptying your mind of emotions and thought, while focusing on a higher concept)

7)Eye movements (like in REM sleep or EMDR)

8)Massage

9)Spirituality (giving your problems over to a higher power) and Forgiveness (of both yourself and others)

To make exposure therapy a little easier, therapists use a variety of approaches. We’ll look at them one at a time.

Telling your story is the oldest approach and still widely used. Back in ancient times warriors told stories around the campfire about their most dangerous adventures. This approach was formalized in Latin America for victims of governmental torture. It involves simply telling your story in detail to a receptive and supportive audience. You can tell it, write it, draw it, or even act it out, but you need at least one person to provide an audience. The more detail you include, and the more you repeat your story, the better. Both detail and repetition are essential. The first time you tell a memory, the affect may get overwhelming. Don’t let that scare you off. The affect should decrease with each telling. Encouragement and supportive feedback help. Listeners need to listen and support, not judge, but their realistic feedback can positively change how you perceive the memory. Remember to include all the details. Even a song playing in the background may become a trigger if you don’t mention it in your reprocessing.

When talking fails. If talking triggers you into a flashback, then the previous therapy won’t work. I found that EMDR was helpful for those memories. Medications or massage may also help.

What is EMDR? It’s an abbreviation for “Eye movement desensitization and restructuring” and accomplishes the same goal of detoxifying memories and integrating them into your normal memory flow. But EMDR uses a natural mechanism that we use every night when we sleep—eye-movements. You’ve heard of REM sleep? That stands for rapid eye movements. It’s a very important stage of sleep, and if you’re deprived of REM sleep, after a few days you will hallucinate. We’re taught that REM sleep helps us process the previous day’s memories. Aha! That’s what we want to do with traumatic memories—right? EMDR is as simple as moving the eyes back and forth while remembering the trauma in detail. Initially it requires a trained therapist, but it doesn’t require you to talk, and once you learn it, you can use it anywhere, anytime. This treatment is specific for PTSD, is proven to work, and there are many licensed therapists who use it both in the VA and in private practice.

The VA offers virtual reality exposure programs for veterans with PTSD. These are another form of exposure therapy designed to reproduce the combat situation in which the trauma originally occurred. Medications may be given and the exposure is done in time-limited bursts. Then a therapist helps the veteran to talk about and reprocess the associated traumatic memories. I’ve heard that this works but have no experience with it, and it’s only available in certain VA treatment centers.

Somatic Re-experiencing is a formal approach to massage and bodywork that helps your body remember and work through both the physical and emotional aspects of the trauma. Like EMDR, it does not require you to talk about the memory, but it can provide significant relief. I would recommend using a trained therapist as bodywork may trigger flashbacks.

A creative approach is Rewriting your Trauma. This was formalized for treating traumatic nightmares, but may work equally well for some flashbacks. You have to start at the beginning of the trauma at the same place the nightmare always starts. But then you change the story so it has a happy ending. The story you create doesn’t have to be real. You’re working with a dream, after all. But it must satisfy your needs emotionally. Then you practice visualizing it, over and over. I explain to folks that the old dream wore a rut into their brain, and they have to practice their revised dream until it makes an even deeper rut. What usually happens is they never dream either dream again. I see it as another approach to detoxify the traumatic memory.

CBT stands for Cognitive Behavioral Therapy and is widely taught to social workers and psychologists. It’s a modern therapy that grew out of Behavioral approaches, like reinforcement of positive behaviors, and Cognitive approaches, like following your thinking back to your assumptions and questioning those. It works well for treating Obsessive Compulsive Disorder and Anxiety Disorders, and is effective with medication for Depression. . In CBT the therapist helps the client examine the problem and the thoughts and behaviors related to that problem. Some therapists are trained to use behavioral desensitization, like progressive exposure to a feared object, to reduce fear, avoidance, and obsessive thinking. In my personal experience, this doesn’t work as quickly as EMDR, especially if your dealing with bad flashbacks.

Bottom line: Once the sympathetic nervous system is under control, you still need to work on your traumatic memories using some type of exposure therapy. If you can talk about the memory, that approach is the least expensive and can work. If you can’t talk without triggering a flashback, try EMDR.

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