Monthly Archives: December 2014

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Therapy for Traumatic Memories

Traumatic memories are not the same as normal memories. In normal life, your brain lays down a sequential memory track, kind of like a video but with all the senses. This is mediated by the hippocampus, the memory center of your brain. But in a truly terrifying situation, the stress chemicals turn off the hippocampus and turn on the amygdala to produce a traumatic memory. Trauma memories don’t deteriorate with time. Our normal memories diminish or get lost over the years, but if you activate a traumatic memory 50 years later, it recurs with the same emotional intensity you experienced at the time .

Triggers:

Reminders of the trauma, or Triggers, can evoke the release of traumatic memories. Triggers are everywhere. They can be anything your mind recognizes as similar to the traumatic situation. Triggers cause your brain to retrieve the traumatic memory in a “flash”.

Common triggers include:

Environment: heat, cold, rain, storm, etc.

Senses: smell, hearing, seeing, feeling, pain

Thoughts: about self, about the past, about a similar situation

Emotions: fear, anger, distress, disgust, guilt, shame

Media: news or movies about a similar situation

People associated with the trauma.

Your trigger may be as simple as a smell, a sound, a name, or the temperature outside. It may be a scene in a TV show, or a subject of conversation over dinner. It’s a good idea to keep a list of your triggers and share them with family and friends.

Exposure therapy:

The purpose of Exposure therapy is to separate the trigger from the traumatic memory and integrate the memory back into your normal memory (hippocampus). There are many different ways to accomplish this goal, but they all contain the same steps:

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 is normalized

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 approach. But 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 is remembered by the body, and bodywork in the form of exercise or massage can help 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 with others.

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 your focus 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)

Medications that help with Exposure Therapy:

1) D-Cycloserene is an older medication used at high doses to treat tuberculosis and more recently at low doses to enhance the effects of NMDA in the brain. NMDA is a chemical in the brain used in both the formation and the extinction of traumatic memories. Research in mice found D-Cycloserene helped mice recover from fear of a sound that was previously paired with shock. It was also  given to people with a fear of heights right before exposure to a terrifying virtual reality experience of riding in an open elevator. After only two therapy sessions with D-Cycloserene, patients showed marked improvement in their phobia, and that improvement persisted afterwards. Some desensitization programs have experimented with this approach, but D-Cycloserene stops working over time.

2) Cannabinoids also act on the amygdala, as many sufferers of PTSD have found. Our natural cannabinoid, anandamide, is decreased in PTSD and there is an increase in receptors in the amygdala, listening hard for a weakened signal. Cannabinoids in marijuana can activate these receptors and have been shown to desensitize people to triggers. With the increasing legalization of medical marijuana, there will hopefully be more research in this area.

3) Propranalol is a beta-blocker used to control blood pressure and arrhythmias by blocking beta-receptors to noradrenalin. Folks who took it right before exposure therapy showed significantly improved tolerance for trauma triggers. Perhaps the most available and best tested of the medications listed here, it also has the most side effects, but these can be minimized with the sporadic, low-dose treatment needed for exposure therapy.

Different Approaches to Exposure Therapy:

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 often you repeat your story, the better. Both detail and repetition are essential.

The first time you tell a memory, the affect may feel 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 your 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 talking therapies will fail. I found 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 designed to reproduce the combat situation in which the trauma originally occurred. Medications may be given first and the exposure can be done in time-limited bursts. Then a therapist helps the veteran to talk about and reprocess the traumatic memories. I’ve heard that this works but have no experience with it, and it’s only available in 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.

Rewriting your Trauma is a creative approach. 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 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 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, progressive exposure to the feared object, to reduce fear, avoidance, and obsessive thinking. In my personal experience, this doesn’t work as quickly as EMDR, especially if you’re dealing with bad flashbacks.

Bottom line:

It’s important to have your sympathetic nervous system under control before you address your traumatic memories. (see Treatments for HyperArousal). Then if you’re still struggling with recurrent memories, flashbacks, or nightmares, you need to do some kind of Exposure Therapy. The addition of D-Cycloserene, propranolol, or a cannabinoid right before exposure seems to make this process easier.

MJ PTSD

Marijuana Use in PTSD

It’s a well-known fact that folks suffering from PTSD use street drugs, especially marijuana. But it’s only in the last few years that scientists have asked the obvious question, “Does it work?”

RESEARCH FINDINGS:

Dr. Mechoulam in Israel has spent his life researching marijuana. Years ago he identified THC and went on to discover the presence of cannabinoid receptors and anandamide, a natural cannabinoid, in human brains. He also did work in mice with brain damage and found that marijuana was neuroprotective.

Our natural cannabinoid system appears to moderate the ill effects of stress. Dr. Mechoulam studied mice with and without active cannabinoid receptors. After receiving shocks associated with a sound, the ones with an intact cannabinoid system quickly recovered when the sounds were no longer accompanied by a shock. They were able to “forget” that connection. Those without an intact cannabinoid system continued to cringe every time they heard the sound.

It appears that the cannabinoid system in the brain allows mice, and people, to forget. When the cannabinoid system is weak, it’s almost impossible to disconnect the triggers from the traumatic memories. Then the tendency to trigger into nightmares and flashbacks can remain a life-long problem.

Low levels of anandamide, our natural cannabinoid, may be responsible for re-experiencing symptoms. Scans reveal that people with PTSD have lower levels of anandamide than people without. Research in veterans has been slow in coming due to legal concerns about the use of marijuana. Israel has a human study underway, and it now appears that the aborted US study will be sanctioned to proceed.

CANNABIS RELATED MEDICATIONS:

The pharmaceutical companies are competing to come up with a cannabinoid that helps PTSD symptoms but does not produce a “high.” So far their efforts have been thwarted by the side effect of reduced memory. Apparently cannabinoids encourage forgetting of all kinds. Getting around that disabling side effect requires a more specific medication.

Kadmus Pharmaceuticals have focused their attention on a different approach. They’ve synthesized a chemical that inhibits the breakdown of anandamide by the enzyme FAAH, and they’re currently testing this FAAH inhibitor in humans. By returning anandamide levels back to normal, the new drug not only helps disconnect your triggers, but it also relieves anxiety, pain, and depression without getting you “high”.

USING MARIJUANA for PTSD:

Until more sophisticated drugs reach the market, folks currently suffering with PTSD may benefit from medical marijuana. Undocumented research suggests that low to moderate doses work the best. Oral marijuana lasts longer than inhaled, which helps to maintain a steady state. But it can make you sleepy, so oral marijuana is best taken before sleep.

Unfortunately, high doses of THC can cause anxiety, depression, and psychosis, especially in immature brains. So children, teens, and young adults should not use marijuana. (Your brain doesn’t mature until your early twenties.) If MJ makes you feel anxious or depressed, it’s recommended that you REDUCE your dose and quit if those side effects recur.

BOTTOM LINE:

Marijuana doesn’t cure PTSD, but it does help with re-experiencing symptoms. Taking low-dose marijuana before  exposure therapy, could help you to disconnect your triggers and as a result, have fewer flashbacks.

BUT WE NEED THE GOVERNMENT’S APPROVAL before we can legally use marijuana to treat PTSD. If it works for you, ask the lawmakers in your state to approve medical marijuana and add PTSD to their list of diagnoses.

Oregon medical MJ

 

 

 

 

 

 

 

 

Stellate GB image

Three Promising New Treatments for PTSD

STELLATE GANGLION BLOCK for PTSD

Although the VAH has not yet approved it, the FDA has just given a waver to Dr. Lipov, an anesthesiologist at Chicago Medical Innovations, to use this approach in treating PTSD. The cost of $1000 can be covered by his 501 not-for-profit corporation. Doctors at Walter Reed Hospital and Naval Medical Center San Diego are also pursuing this new treatment, which can provide  immediate relief and allow active duty soldiers who develop PTSD symptoms to return quickly to their posts.

Stellate ganglion blocks have been used for years to treat chronic pain caused by an overactive sympathetic nervous system. Since an overactive sympathetic nervous system can also lead to PTSD, it made sense to try the same treatment. The Stellate Ganglion is a group of nerve cells deep inside the neck near the 7th vertebrae. It’s the top ganglion in a chain that extends along the spinal cord and controls the sympathetic nervous system. Recent research suggests that the Stellate Ganglion also has connections into the brain, especially to the hypothalamus, which controls the hypothalamus-to pituitary gland-to adrenal gland (HPA) axis. Blocking this connection may block the production of stress chemicals, which are thought responsible for PTSD.

The procedure requires an anesthesiologist trained to do nerve blocks in the neck. A needle is guided by fluorescent technology to a spot near the 6th vertebrae where a local anesthetic is released. A temporary drooping of the same side eyelid often accompanies a successful block. Misplacement of the needle can result in side effects including seizure and difficulty breathing. These occur in 1.7 out of 1,000 blocks and return to normal over time.

Case studies are promising and show marked improvement (at least a 50% decrease in symptoms) in 70-75% of clients with PTSD, including those unresponsive to the usual medication and therapy approaches. Most show an almost immediate response with improved sleep, fewer nightmares, and reduced anxiety. Some clients will require a second injection. Individual response varies from mild to complete, but even clients with long-standing PTSD and substance abuse have experienced significant improvement.

 

TMS image

TRANSCRANIAL MAGNETIC STIMULATION for PTSD

TMS is already FDA approved for the treatment of depression and autism. Current research suggests it also works for PTSD. Controlled studies show improvement in core PTSD symptoms when TMS is applied over the right frontal area of the brain, specifically over the right medial lateral prefrontal cortex (MLPFC). This coincides with findings in brains of PTSD sufferers, which show abnormal functioning in the MLPFC .

Psychological testing following a series of 10 TMS treatments showed significant improvement in the PTSD symptoms of arousal, re-experiencing, avoidance, and anxiety. To treat depression, the treatments must be focused over the left MLPFC.

How does it work? Magnetic stimulation induces an electrical current in the brain and may work much like ECT by releasing and rebalancing the brain’s chemistry. But TMS does not cause a convulsion, which eliminates the need to take any medication. In fact TMS has few side effects, headache being the most common. No sedation is required and the client can sit in a comfortable chair throughout the treatment.

The research above used 10 sessions. To treat major depression up to 40 sessions may be needed. The cost of the recommended 10 once/daily treatments could run from $5,000 to $10,000, but since successful controlled studies have already been published, this procedure may soon become FDA approved and hopefully covered by insurance.

 

HBOT image

HYPERBARIC OXYGEN THERAPY FOR TBI and PTSD

The use of HBOT in TBI with and without PTSD has created a heated controversy. On the Pro side, recent scientific studies done by Dr. Harch, and successfully repeated by Israeli scientists, show significant improvement in post-concussive symptoms following mild TBI. Both studies measured cognitive abilities, emotional lability, executive function, and quality of life. SPECT scans of the brains before and after treatment also showed a significant positive change. In addition, PTSD symptoms improve. This makes sense, since MRIs on folks with PTSD also show damage to the brain.

On the Con side of the argument, a study using room air (20% oxygen) at 1.3 bars (1 bar is normal air pressure) as a control group discovered that those patients improved as much as treatment group using 100% oxygen at 2 bars. The authors concluded that all the improvements seen in both their control and treatment groups were due to a placebo effect. The Israeli authors of the article above, argued that room air at 1.3 bars increased available oxygen in the brain by 50% and therefore worked as an active treatment. That would certainly explain why both groups improved.

Less scientific but still significant, some clients treated with HBOT have made remarkable recoveries, even achieving complete remission of both TBI and PTSD symptoms. The cost of HBOT is decreasing as more entrepreneurs open clinics, some offering the standard 40 treatment package for as little as $3000. In hospitals, a single treatment can cost $1800, and insurance won’t pick up the bill.

The treatment itself requires time, usually delivered as one 50-90 minute session per day and requires 40 sessions. During the treatment, you lie on a bed in a pressurized container. There can be complications at the higher pressures (4-6 bars), but the lower pressures used for these studies are usually benign.

BOTTOM LINE:

Although not officially FDA approved, all three of these treatments have shown good response and have very few side effects. If  you’re suffering from severe PTSD and haven’t responded to medication and therapy, what have you really got to lose?

 

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