Monthly Archives: November 2014

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How Genetics and Early Trauma Increase Your Risk of PTSD

If your mother or father had PTSD, you have an increased risk of developing the problem. But that doesn’t prove that it’s genetic. Family life with a stressed out parent carries it’s own morbidity. In a study of the children of Holocaust survivors, the mom’s trauma history was significantly more important than the dad’s, suggesting that the quality of mothering might be more relevant than genes.

Early Trauma:

The long-term effects of early deprivation have been well documented for over forty years. We now know that babies raised by depressed, absent, or stressed mothers have changes not only in behavior but also in their neurochemistry.

In these kids the hypothalamus to pituitary to adrenal gland (HPA) pathway, when compared to normal kids, shows changes in the timing and amounts of cortisol released during times of stress.

But these changes can take different forms. They can increase or decrease the person’s odds of developing anxiety, depression, or PTSD. It looks as if a little deprivation can actually build up your resilience, but a lot leaves your nervous system over-sensitive.

Epigenetic Changes:

More recent research shows that early stress also changes which genes we use. Stress can turn our genes on and off by adding a methyl group to the nucleotide cysteine. This epigenetic change is permanent. It can even be passed down to future generations, much like a real mutation.

Scientists are trying to develop medications that remove methyl groups and free the genes, but whether these will prove both helpful and safe is still untested and unknown.

Genetic Mutations:

With our new knowledge about the human genome, there’s been a rush of studies linking genes to disorders. Several gene mutations are more frequently found in people with PTSD, suggesting that those mutations may increase the risk. More studies are underway on genes that are known to increase anxiety or depressive illness, particularly those that effect the neurotransmitter serotonin. But if PTSD acts like other mental problems, we’ll find many mutations that can weaken our resistance and no single gene that is the cause.

One study released last year in JAMA Psychiatry by collaborators at University of Michigan and Columbia University School of Public Heath described a specific mutation of the ADRB2 gene, which when combined with childhood adversity, significantly increased the risk of PTSD. Two groups were studied, a group of combat soldiers in the National Guard, and a group of black, inner city women. All the folks with this particular mutation AND aversive childhood experience, were more likely to develop PTSD as an adult. However, the increased risk for people with both the mutation and childhood adversity was only a fraction of the total risk—like being near to a disaster instead of farther off.

Twin studies are a cornerstone of genetic research since identical twins share the same genetics but may live very different lives. Twin studies done in Vietnam showed that 30% of the risk for PTSD could be traced back to genetics.

In one twin study the researchers measured hippocampal size, since previous research found smaller hippocampal volumes in MRIs done on veterans with PTSD. This research studied twin pairs where only one twin had PTSD symptoms, but MRIs found no difference between the two twins’ hippocampal volumes. This argues that a smaller hippocampus is caused by genetics and not stress. The researchers suggest that a smaller hippocampus might put you at greater risk of PTSD, which would explain this finding among PTSD diagnosed veterans.

BOTTOM LINE:

Some people have a higher risk of PTSD symptoms due to early trauma, epigenetics, and genetics, but these factors explain only 30% of the total risk and pale beside overwhelming trauma. We don’t yet know enough to effectively screen people so we can protect those who will suffer most. The length of time you’re exposed and severity of trauma are still the most accurate predictors of your risk.

 

 

 

 

man on bench

ABC’s of Treatment for PTSD

When I worked at the VA treating young men coming back from Vietnam, we didn’t have a diagnosis nor a treatment for what we now call PTSD. During the intervening years, we’ve learned a lot. I will cover more in the following blogs, but this one is a synopsis.

We know that most PTSD symptoms are caused by:

1) An overactive sympathetic nervous system sending toxic stress chemicals to our brain.

2) Traumatic memories, which are stored—thanks to the stress chemicals—in a way that makes them difficult to access and treat but allows them to surface suddenly when triggered.

This knowledge has helped us to come up with new treatments that actually work for most people.

 

WHERE DO YOU START?

First off, you need a diagnosis. In short, you need:

1) A history of trauma that occurred at least a month ago. (If it’s more recent, you may have Acute Stress Disorder)

2) Symptoms of arousal like trouble with sleeping, irritability, aggression, self-destructive behaviors, or easy startling, that started after the trauma.

3) Problems with intrusive memories, flashbacks, nightmares, or panic attacks.

4) A pattern since the trauma of avoiding things, places, and people that remind you of what happened.

5) A negative change in how you see the world, yourself, other people, or an inability to engage in work and/or previously enjoyed activities.

6) No other mental or physical illness that could better explain all your problems.

 

IF YOU HAVE PTSD, WHAT DO YOU DO NEXT?

STEP ONE: Calm down your sympathetic nervous system and rebalance your brain chemistry.

1) The fastest way to treat hyper-arousal symptoms is to take a medicine that blocks the effects of norepinephrine (noradrenalin) in the brain. To accomplish this, many doctors use Prazosin, a blood pressure pill that gets into your brain and calms you down. For 75% of people, this allows them to sleep and reduces other hyper-arousal symptoms. Trazodone, cannabinoids, and other medicines can also help, but all medications can have some side effects.

2) Now you need to rebalance the chemistry inside your brain, which was upset by all the stress chemicals. Antidepressants like Paxil and Zoloft are commonly used, but they can increase nightmares, cause sexual side effects, and don’t work for everybody. Remeron, Effexor, or Pristiq may work better. If you can’t take any of those, try SAMe, which is available over-the-counter. Cannabinoids like THC and CBD actually do help rebalance the natural cannabinoid pathways in the brain, but they also cause short-term memory loss and other side effects in some people.

There are some new medical approaches that don’t require pills. They are considered experimental for PTSD but have been used successfully to treat other disorders. The best tested are:

1) The Stellate Ganglion Block is a nerve block in your neck, which blocks the sympathetic nervous system and its effects inside your brain. Studies have shown this to be effective in 75% of PTSD clients who did not respond to medication and exposure therapy.

2) Magnetic stimulation of your brain changes the electrical impulses in your brain allowing it to reset and reorganize. It’s been used for depression and autism, and it seems to help with flashbacks in PTSD.

 

STEP TWO: Exposure Therapy

By now you should be able to sleep most nights and have better control of your emotions—except when you get triggered. It’s very important to take this second step because the triggers reactivate your sympathetic nervous system making it hard to stay calm.

My favorites:

1) Telling your story is the simplest and cheapest approach. Just talk about what happened to somebody you trust. You need to go into all the details, because those can become triggers. And you need to get feedback from your listener as he or she may have a more objective viewpoint on what happened. Repetition and detail are essential for this approach to work.

2) Eye Movement Desensitization and Restructuring (EMDR) works even if you can’t talk about what happened. Here you need a trained therapist, but once you learn the technique it’s very portable and you can use it yourself if you get triggered.

3) Cognitive Behavioral Therapy is helpful if you’re stuck in a negative mindset with regards to yourself, other people, or the world in general. This requires a trained therapist who will help you look into your negative beliefs, discuss their roots in your trauma, and help you reevaluate your new place in the world.

4) Some medications help with therapy. Talk with your therapist about using propranolol, D-cycloserine, or Marijuana- where it’s legal.

 

STEP THREE: Need more help? Try one of these Alternative Therapies:

1) Meditation and Mindfulness have been proven to reduce PTSD symptoms, improve focus and concentration, and help you get control over runaway emotions. It does require you to practice on a daily basis.

2) Exercise, animal therapy, service animals, art, writing, comedy, acting, and getting involved in helping other people. All have been shown to reduce PTSD symptoms and make it possible to get out in public and start  figuring out who you are now and what you really want to do with your new life.

 

AFTER TREATMENT:

People who’ve had PTSD symptoms are more prone to suffer it again, either from new trauma or discovering an old trigger that’s been overlooked. Treat a recurrence quickly so you prevent the sympathetic nervous system from going on a rampage and damaging your brain. If you go without sleep for several days after a trauma, consider taking a pill that blocks norephinephrine, like Propranolol or Prazosin. They can help prevent PTSD, as can MJ. You can also use whatever has worked for you before. It’s easier to treat PTSD once you know what to do and have the tools.

Don’t expect your life to go back the way it was. Trauma changes you, permanently. You’ll never look at yourself, or other people, the same way because you’ll never again be that naïve. But you’ve learned a lot which can be helpful, both to you and other people. Try sharing your experience and knowledge or using it in a unique creative way.

 

BOTTOM LINE:

Don’t sell yourself short! Treatment helps most people, and if it doesn’t work for you, keep trying new approaches until you find one that does. I’ll be publishing more blogs that describe PTSD treatments in more detail.

 

 

 

meditation and the brain

Mindfulness, Meditation, and PTSD

If you look back in history, meditation has always been a part of martial arts and associated with a warrior culture. There may be good reasons behind this intertwining of two such very different skills. Warriors have always dealt with trauma, and trauma was as wounding then as it is today. Perhaps in ancient times, they found relief in meditation.

Meditation is a generic word that refers to a number of techniques including transcendental meditation, mantra meditation, mindfulness meditation, and Zen Buddhist meditation (practiced in Japan by the Samurai). Similar techniques are also practiced by devotees in almost all religions. The different types vary in their focus, but all techniques have the same basic approach.

REQUIREMENTS FOR MEDITATION:

1) A quiet location with few distractions.

2) A comfortable posture, which may be lying, sitting, standing, or walking.

3) A focus of attention such as breathing, a mantra, chant, or an object.

4) A nonjudgmental acceptance of what happens. In meditation you learn to calmly focus your attention. When your focus wavers, you can gently refocus or observe whatever is passing through your mind without judging it as bad or good.

EFFECTS OF MEDITATION:

About 9% of adults in the United States use some kind of meditation. This number has been steadily increasing as people seek alternative approaches to deal with both physical and mental distress. A number of formal scientific studies now support the positive effects of meditation, including those in the list below:

1) Meditation calms the Sympathetic Nervous System

We already know that PTSD symptoms of hyper-arousal are initiated by an overactive sympathetic nervous system, and that prolonged activation of the sympathetic nervous system produces chemicals that can damage your brain. Now there is scientific evidence that practicing meditation has a marked effect on both the sympathetic nervous system (our fight or flight response) and the parasympathetic nervous system (our body’s maintenance system).

Scientific studies now show that meditation calms the sympathetic nervous system and activates the parasympathetic. This means it will lower your blood pressure and reduce your body’s chemical reaction to stress. That makes meditation a potentially useful tool not only for relieving active PTSD symptoms, but also for protecting your brain from future stress.

2) Meditation Reduces Activity in our “monkey brains”

A study from Yale University found that mindfulness meditation decreased activity in the brain network responsible for mind-wandering and self-referential thoughts – a.k.a., “monkey mind.” Since activity in this area is typically associated with being less happy and more anxious, suppressing it could be beneficial, especially for folks with PTSD. Studies now show that anytime our thinking wanders into this area, meditators are better at snapping out of it.

 3) Meditation Rivals Antidepressants for Depression and Anxiety.

Anxiety, depression can be serious problems for folks with PTSD. A study at Johns Hopkins looked at mindfulness meditation and its ability to reduce these symptoms. Researchers found that the effect size of meditation on anxiety and depression was moderate at 0.3, the exact same effect size you get by taking an antidepressant. So if you hate taking pills, meditation may help you to reduce them over time.

There’s also a new type of meditation, called Mindfulness-Based Stress Reduction (MBSR), developed at the University of Massachusetts’ Center for Mindfulness, that aims to reduce both physical and mental stress. Studies show that the resulting reduction in anxiety can last for years after the initial 8-week course.

 4) Meditation can Increase and Decrease Brain Cells  in Key Areas of the Brain

A team at Harvard found that mindfulness meditation can actually change the structure of your brain: Eight weeks of Mindfulness-Based Stress Reduction (MBSR) was found to increase cortical thickness in the hippocampus, which governs learning and memory, and in other areas of the brain that help regulate emotion.

There was also a decrease in the size of the amygdala, which is responsible for negative feelings like fear, anger, and despair. Previous research had found enlarged amygdalas in veterans with PTSD, so reducing their size could be helpful.

More important than the lab findings, however, were changes in the participants’ sense of well-being. When the MRI changes were matched against the participants’ self-reported emotional state,  it was evident that meditation had changed more than their brain; it had also improved their mental health.

5) Meditation Improves Concentration after only a Few Days of Training.

Problems with attention and concentration are common in folks with PTSD, and one of the key benefits of meditation is that it improves both of these problems. Since a strong focus of attention (on an object, idea, or activity) is one of the central aims of meditation, it’s not too surprising that scientific studies show a significant increase in focus on tests after only a few days of meditation. Other studies also show an increase in nerve cell volume in areas of our brain associated with attention and concentration in people who have meditated for years.

6) Meditation Can Help with Addiction

A growing number of studies show that meditation can be helpful in recovery from addictions. One study pitted mindfulness training against the American Lung Association’s freedom from smoking (FFS) program, and found that people who learned mindfulness were many times more likely to quit smoking by the end of the training, and at 17 weeks follow-up, than those in the FSS treatment.  Other research using mindfulness training, mindfulness-based cognitive therapy (MBCT), and mindfulness-based relapse prevention (MBRP) have found improved recovery rates in many types of addiction.

 7) Meditation Helps Preserve the Aging Brain

A study from UCLA found that long-term meditators had better-preserved brains than non-meditators as they aged. Participants who’d been meditating for an average of 20 years had more grey matter (nerve cells) volume throughout the brain. Older meditators still had some volume loss compared to younger meditators, but it wasn’t as pronounced as the non-meditators. It surprised the researchers to find that this improvement was wide-spread throughout the brain.

MEDITATION COMPARED TO STANDARD PTSD TREATMENT:

Advantages:

1) No pills or doctors required

2) No known side effects

3) Improves general health and blood pressure

4) Improves depression and anxiety

5) Improves focus and attention

6) Calms the sympathetic nervous system

7) Changes your brain structure for the better

8) Helps your brain stay healthy as you age

Disadvantages:

1) No scientific proof that it treats PTSD.

2) No scientific comparisons to other forms of PTSD treatment.

3) Requires training

4) Requires time to meditate on a daily basis

5) If you take medicine to calm down, you should continue it, at least until you’re experienced at meditation.

6) You may still need Exposure Therapy for flashbacks.

BOTTOM LINE:

Current scientific research suggests that if you meditate daily, you can calm down your sympathetic nervous system, improve attention and concentration, reduce depression and anxiety, reduce negative thinking, reduce addictions, and better preserve your brain. All it costs you is one hour of your day. What have you really got to lose?

Memory problems

Memory Problems in PTSD

Memory problems are universal in PTSD and come in several forms including:

1) Formation of traumatic memories.

2) Amnesia for all or part of your trauma.

3) Difficulty storing new information.

4) Difficulty finding words.

Obviously, memory problems interfere with learning, especially in a school or work setting. Verbal memory (remembering what you hear) seems to be more strongly effected than visual (remembering what you see or read). Further damage to speech areas in the cortex can also lead to a type of aphasia (difficulty finding the right word) when you speak.

CAUSES:

A lot of research had been done on these problems, and it all points to a biological cause— the high levels of noradrenalin and cortisol present in acute PTSD. In previous blogs, I’ve mentioned that these chemicals cause damage to the brain, and this is the cause of memory problems.

Memory problems can occur in both laying down new memories and retrieval. Noradrenalin strengthens the storage of new memories, but cortisol only helps in storing emotionally charged events and interferes with laying down more neutral material, like schoolwork. Cortisol also damages the hippocampus, which then causes problems with memory recall.

How stress chemicals effect memory:

1)Excess cortisol shrinks the hippocampus. This area of the brain normally helps you catalogue, store, and retrieve normal memories. But when you’re under severe stress, the hippocampus is less able to lay down new memories or retrieve them.

2) Excess noradrenalin activates the amygdala, an area responsible for negative emotions like terror, rage, and despair. The overactive amygdala increases your sense of fear, increases startle response, and aids in the storage and retrieval of traumatic memories.

3) Low and high levels of noradrenalin effect the prefrontal cortex (PFC) differently. Normally the PFC calms down the amygdala, inhibits distractions, and helps you pay attention and plan. With a mild increase in noradrenalin, the PFC actually works better. But higher levels block it. Then you can’t inhibit either the amygdala’s negative emotions or other distracting input.

4) Though not as well understood, stress chemicals also activate the amygdala, which grows larger, lays down traumatic memories, and intensifies your negative emotions such as fear, anger, and despair.

5) Stress chemicals also cause damage in areas of the cortex responsible for speech. This plus hippocampal damage may explain problems finding words.

TRAUMATIC MEMORIES are different from normal memories because they’re stored through the amygdala not the hippocampus. This means that traumatic memories:

1) Are more strongly engraved into your brain.

2) Can be difficult to purposefully recall.

3) Can be fragmented, disorganized, and difficult to describe.

4) Can be intrusive and difficult to block.

5) Are recalled abruptly and unintentionally when you are exposed to a trigger.

6) Can be traumatizing in themselves and cause the release of more stress chemicals, which further strengthen the traumatic memory.

 

Summary Chart of Memory Problems and their Causes:

Effects of Stress Chemicals on Memory

Some theories suggest a greater secretion of noradrenalin when the stressor involves DEFENSE, and a greater secretion of cortisol when the stressor involves DEFEAT. If you study the chart above, you can see how this could explain the difference in symptoms seen, for example, between veterans traumatized while defending themselves and children traumatized by abuse.

TREATMENT:

Memory problems can feel overwhelming, but the good news is the brain can heal. Once the cortisol levels go back to normal, the hippocampus can rebuild itself. And once the chemistry recovers in the prefrontal cortex, it gradually returns to normal, improving focus and attention, and calming down the amygdala and it’s negative emotions.

Turning off the stress chemicals:

You have to reset your sympathetic nervous system to reduce the stress chemicals injuring your brain. See my blog on Treating Hyper-Arousal for all the details about initial treatment of an overactive sympathetic nervous system. It discusses medications like Prazosin to block the effects of noradrenalin. My blog on Sleep Disorders in PTSD mentions Gabapentin, which may help to stabilize the amygdala’s overgrowth and overactive emotional response. The Stellate Ganglion Block is a newer approach that uses a nerve block to reset the sympathetic nervous system and decrease the release of stress chemicals. And finally support dogs can provide calming and naturally tune down your defensive system.

Rebuilding the damaged parts of your brain:

MRIs of veterans with PTSD show an enlarged amygdala (which controls negative emotions) and a shrunken hippocampus (the memory center of your brain), as well as shrinkage in other areas involved in focus and attention. But once the stress chemicals are reduced, the brain can grow new cells. Omega-3 fatty acids normalize the amount of BDNF (brain derived neurotrophic factor), which encourages the growth of new nerve cells, especially in the hippocampus.  Meditation is also proven to increase nerve cell growth in areas that involve focus and attention, and all of the Antidepressants normalize BDNF–encouraging nerve growth–and regulate the chemistry of the prefrontal cortex, which stabilizes the amygdala.

BOTTOM LINE:

It’s terribly frustrating when your brain doesn’t work, when you can’t remember what you learned, can’t find the words, or get blindsided by a flashback. But once you reduce the stress chemicals, you can help rebuild your brain and improve both your memory and your emotional control.

 

 

 

 

 

 

 

 

 

 

no sleep

Sleep Problems in PTSD

Sleep is a universal problem in PTSD, but early research in this area reported inconsistent findings. Luckily recent research focused on REM SLEEP has discovered an underlying problem.

People with PTSD have lots of REM sleep, but the cycles are very short, end abruptly, and may end in a nightmare or panic attack. It seems that the usual alternating cycle between non-REM and REM sleep has become seriously disturbed.

Most researchers view non-REM sleep (stages 1-4) as restorative sleep—a time when our bodies and minds rest and heal. By contrast, REM sleep is a time when our mind is very busy processing memories, emotions, and visual images—which produce dreams—while our bodies and muscles can relax totally.

The normal cycle of REM sleep begins after an hour or two of non-REM sleep. It’s followed by shorter periods of non-REM sleep and longer periods of REM until you’re awake. This cycle is mediated by a slew of chemicals from sleep control centers in our brain. Most relevant to PTSD is that REM sleep starts when the sympathetic nervous system and noradrenaline secretion are at their lowest level. And it stops when those levels get too high.

That may explain the irregular periods of REM sleep seen in PTSD. When the sympathetic nervous system is overactive and produces increased levels of noradrenaline, it may cause the sudden termination of REM sleep cycles into panic and nightmare attacks.

The disruption of REM sleep leads to a host of new problems including inflammation, reduced immunity, confusion, poor memory, difficulty making decisions, and more nightmares.

sleep deprivation

NIGHTMARES in PTSD are often traumatic memories being triggered into awareness and are closely related to flashbacks and panic attacks, which may also occur upon awakening. These events further activate the sympathetic nervous system, cause the secretion of more noradrenaline, and make it more difficult to sleep.

Other sleep problems in PTSD include MOTOR MOVEMENT DISORDERS and SLEEP BREATHING DISORDERS. The motor movements may also be due to high levels of noradrenaline causing our muscles to twitch during sleep. It’s less clear how sleep breathing problems are related to PTSD. Guess we’ll have to wait for better research.

 

TREATMENTS

A) MEDICATIONS:

1) PRAZOSIN:

To date the most effective treatment for PTSD sleep disturbances and nightmares has been Prazosin in doses from 1 mg to 15 mg at night. Prazosin is an alpha1-blocker blood pressure medicine that blocks the effect of noradrenaline on the brain. In studies it has worked to reduce nightmares and improve sleep in about 75% of military veterans and civilians with PTSD. Furthermore, the erratic REM sleep cycles seen in PTSD quickly return to normal on Prazosin, which supports the theory that excessive noradrenaline initiates and drives these symptoms.

2) TRAZODONE:

Trazodone works both as an alpha-blocker and by stabilizing serotonin levels, making it a very useful drug for sleep. Doses range from 25 mg to 150 mg with some people needing 300 mg. Not as short acting as some other drugs, it can hang you over the next morning.

3) GABAPENTIN:

Gabapentin may be useful if the others fail. The mechanism of action for this seizure medication is poorly understood but it seems to either mimic GABA (the primary calming chemical in our brain) or inhibit Glutamate (the primary stimulating chemical in our brain).  Either way, it is calming for most people and reduces nightmares and sleep disruptions. Gabapentin has some significant side effects, but lower doses are needed for sleep that for seizures, so usually it is well tolerated. But if you take too much, it can make you sleepy and depressed.

4) ANTIPSYCHOTICS:

Thorazine, Risperdal, Seroquel, and other antipsychotics also act as alpha-blockers and are often used for sleep. They have other actions on the brain which you may find useful or harmful. Many people with PTSD complain of feeling overmedicated and “blah” on these meds. Some folks have muscle twitches or tightness. They can also cause metabolic side effects of weight gain and increased blood sugar. Use with caution.

B) SLEEP HYGIENE:

Here are some non-medical ways to improve your sleep.

1) To induce sleep, you need a comfortable mattress in a cool, dark, and quiet room.

2) You need to keep regular sleep hours. This is best done by getting up at the same time every day and going to bed when you get sleepy.

3) Sleep is initiated by melatonin, a chemical made in your brain. Your first exposure to sunlight turns off melatonin production for the next twelve hours. After that, it gradually increases. That means you need direct exposure to sunlight at least twelve hours before you want to sleep. Morning exposures work well, even on a cloudy winter day.

4) Exercising during the day relaxes and prepares your body for deep sleep. DON’T exercise right before bed—it wakes you up.

5) Bedtime routines help prepare your body for sleep. Do something relaxing (shower, read a book, listen to music, meditate) before bed. Computers and TV screens have been shown to interfere with sleep.

6) Avoid caffeine and other stimulants in the afternoon and evening hours.

7) Avoid overuse of alcohol or benzodiazepines (Valium, Xanax, Ativan, etc.). Excessive use can lower GABA levels and make your brain more hyper.

8) Avoid arguments and stress before bedtime. Anger and anxiety keep you awake.

9) If you’re in pain, treat the pain before you sleep.

10) Try relaxation exercises like deep breathing and progressive muscle tightening and relaxing to get your body ready for sleep.

C) REWRITING YOUR NIGHTMARE:

This technique works well for recurrent nightmares that may have a trauma basis. You have to start at the beginning of the dream, 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, practice, practice visualizing the new story. Remember that the old dream wore a rut into your brain, and you have to practice the revised dream until it makes an even deeper rut. If you practice long enough, you’ll never dream the nightmare again.

 

BOTTOM LINE:

Sleep disturbance is central to PTSD and appears to be caused by an overactive sympathetic nervous system secreting increased levels of noradrenaline. Fixing that problem is essential to your mental and physical health. Try Prazosin or Trazodone plus good sleep hygiene. If you still have nightmares, try rewriting them.

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