Monthly Archives: February 2015

can't sleep ptsd

Treating Hyper-Arousal Symptoms

Hyper-arousal symptoms are often the first sign of PTSD, and they’re directly linked to activation of the sympathetic nervous system. The most common symptom is a problem with sleep.

Hyper-arousal Symptoms:

  • Irritable or aggressive behavior
  • Self-destructive or reckless behavior
  • Hyper-vigilance
  • Exaggerated startle response
  • Problems in concentration
  • Sleep disturbance

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

The autonomic nervous system consists of 2 parts:

  1. 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.
  2. 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 the normal maintenance of our body.



  • It slows down or shuts off the parasympathetic nervous system
  • It activates the hypothalamus in the brain, which in turn activates the pituitary gland.
  • The pituitary gland triggers the adrenal gland to release adrenaline, noradrenalin, and glucocorticoids (stress chemicals), which:
  • Dilate the pupil,
  • Increase the flow of air into the lungs,
  • Accelerate the heart
  • Release glucose (fuel) from the liver.
  • Increase blood flow to the muscles and brain,
  • Increase strength and endurance,
  • Reduce inflammation,
  • Increase mental alertness,
  • Focus attention on the danger.

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



Emotional Center of the Brain

  • 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 strong emotions like grief, terror, and rage.
  • The blue area is the hypothalamus, which controls the gray area below it, the pituitary gland, which then sends signals to the adrenal glands atop your kidneys.
  • The stress chemicals produced in your adrenal gland travel through the bloodstream and effect your whole body.
  • In your brain, stress chemicals inflame the amygdala (increasing the intensity of grief, terror, and rage).
  • Stress chemicals block the hippocampus from laying down and recalling memories.
  • If these chemicals continue for a prolonged time, the hippocampus may shrink and the amygdala will enlarge. (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 effected.
  • The VMPF (ventral medial prefrontal cortex), which controls emotions by calming the amygdala, becomes chemically unbalanced and dysfunctional.
  • Other areas in our cortex that help us speak and think coherently also can decrease in size.


Treating PTSD quickly can avoid these wounds because our brain is designed to handle short bursts of stress chemicals. Luckily our brain can make new cells, especially in the hippocampus, which repairs itself once stress chemicals subside. That means you can heal—although the longer PTSD goes untreated, the harder it can be to totally reverse.




We’ve seen that hyper-arousal is a physical problem, and we now have medications to help fix it. Below is a list of the medications used:

  • Alpha Blockers: 
    • Prazosin
    • Clonidine
  • Sedating Antidepressants: 
    • Trazodone,
    • Remeron,
    • Luvox,
  • Nonsedating Antidepressants:
    •  SSRIs: Lexapro, Paxil, Zoloft
    •  SNRIs: Cymbalta, Effexor, Pristiq
  • Antipsychotics:
    •  Old: Thorazine
    •  New: Seroquel
  • Anticonvulsants:
    • Gabapentin,

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. Prazosin especially has been shown to work well to increase sleep, calm anxiety, and prevent nightmares in people suffering from PTSD.

The dose is variable, 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. Dizziness is less if you increase dose gradually. Drowsiness can help you sleep.

Other medications contain alpha-blockers, like Trazodone, Seroquel, and Thorazine. They not only help reduce arousal but can also work as antidepressants and antipsychotics. Unfortunately, they tend to have more side effects than prazosin.

Antidepressants repair chemistry in the VMPF (ventral medial prefrontal cortex), which helps to calm down the amygdala (the part of your brain involved in negative emotions). Activating your VMPF decreases your feelings of grief, terror, and rage. Paxil and Zoloft are FDA approved for PTSD, but the other SSRIs and SNRIs probably work just as well. It may take several trials to see which one works best for you.

Gabapentin is a seizure medication that works on GABA–the primary calming chemical in the brain. It helps with severe anxiety and isn’t addicting like the benzodiazepines (valium, xanax, klonopin) and alcohol can be.



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, Bethesda and Balboa Naval Hospitals, Duke anesthesiology group, and Chicago Medical Innovations, among others. The doctor simply injects a local anesthetic into the Stellate Ganglion—sometimes with astonishing results.

A recent study at Balboa did not find a significant difference between real and sham injections, but a review of all the literature found that 70-75% of the participants had immediate improvement, even in older PTSD cases resistant to medications and exposure therapy. Further studies are in progress to determine which patients will respond.

This treatment is currently available through Chicago Medical Innovations, a not-for-profit organization started by Dr. Eugene Lipov to treat PTSD.



  • Service dogs—research is underway on this favorite therapy. Dogs and other animals have been shown to help calm down the sympathetic nervous system.
  • Mindfulness and meditation—these work if you are consistent in the practice. MRIs have shown positive changes in the brains of experienced meditators.
  • Time—some peoples’ hyper-arousal symptoms will improve over time, others just get worse. I’d suggest a consultation as soon as you see symptoms. Although watchful waiting may be appropriate, it’s good to have a knowledgeable outsider’s point of view.



If you’re having trouble with hyper-arousal symptoms, it’s important to discuss this with your doctor and find a treatment that helps calm you down, improves your sleep, and gives your brain a chance to heal.




soldier with head in hand

Treating Flashbacks, Nightmares, and Intrusive Memories

If you have stabilized your sympathetic nervous system and reduced your daily Hyper-arousal symptoms but still suffer from Intrusive Symptoms like flashbacks, nightmares and intrusive memories, you might want to consider Exposure Therapy . The goal here is to disconnect your triggers (those “normal” things that set you off) from your traumatic memory and integrate a revised memory back into your normal memory flow.

There are many different ways to accomplish this goal, but they all contain the following steps:

1) Let Go of negative emotions and pain

2) Explore the trauma in detail

3) Reexamine your feelings, both emotional and physical, how have they changed?

4) Reexamine your beliefs about the memory

5) Repeat the process until the memory no longer triggers you

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 be able to let go of feelings or explore the memory in detail. But as you repeat the process, it should get easier each time. If not, you could be triggering into a flashback and may need to choose a slightly different approach.

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 also be remembered by the body. Different approaches work at different times and for different personalities and traumas.

Ways to Let Go:

1) Share with others and accept support.

2) Cry, scream, curse

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 on something in the present like your breathing or walking)

7) Meditation (emptying your mind of emotions and thought, while focusing on a higher concept)

8) Eye movements (side to side, like in REM sleep or EMDR)

9) Massage and body work

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


Medications that help with Exposure Therapy:

1) Propranolol is a beta-blocker developed for treating hypertension, but it’s been widely used to reduce anxiety, especially in stressful situations like public speaking. There is also evidence that it helps with exposure therapy and may prevent PTSD if given right after a trauma.

2) D-Cycloserene is an older medication used at high doses to treat tuberculosis and more recently at low doses shown to enhance the effects of NMDA in the brain. NMDA appears to be important both in the formation and extinction of traumatic memories. Research in mice found it helped mice recover from fear induced by electric shock. Also in people with a fear of heights, it was given right before exposure to a terrifying virtual reality film of riding in an open elevator. After two therapy session with D-Cycloserene given before the film, the patients showed marked improvement in their phobia, and their improvement persisted for months afterward. Some desensitization programs are currently experimenting with this approach.

3) Cannabinoids also effect the amygdala, as many sufferers of PTSD have already discovered. 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 help desensitize people to their triggers. With the increasing legalization of medical marijuana, there will soon be more research in this area.WARNING–MJ is still illegal in many states.

4) MDMA was used in the 1970s to facilitate psychotherapy. Then it became a party drug and was banned. But research done in the 70s supports that it aids in the separation of triggers from traumatic memories. WARNING– MDMA is still illegal.


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

The first time you describe a traumatic memory, you may feel overwhelmed by your emotions. Don’t let that scare you off. The affect should decrease with each telling. Encouragement and supportive feedback are essential. 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– even if you don’t consciously recall it.

Prolonged Exposure Therapy is a favorite of the VA. Assisted by a therapist, you’re asked to look at your worst memory in great detail, over and over, until the details no longer trigger you. This works very well for about 60% of people. But the other 40% get badly triggered and drop out. Medications have been shown to improve tolerance for the therapy–see above. The VA  can combine this with Virtual Reality Exposure to battlefield scenes that are similar to your trauma.

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 then questioning those. It works well for treating Obsessive Compulsive Disorder and Anxiety Disorders, and is effective with medication for Depression.

Some CBT therapists are trained to use behavioral desensitization–through progressive exposure to a feared object–to reduce fear, avoidance, and obsessive thinking. This is a type of exposure therapy and works best if combined with one of the medications above.


When talking fails. If talking about the trauma always triggers you into a flashback, then the talking therapies may fail. I found the following approaches to be more helpful for those memories.

EMDR is an abbreviation for “Eye movement desensitization and restructuring” and accomplishes the same goal of separating triggers from memories and integrating healthier memories 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 your 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 the technique, 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 private practice.

Somatic Re-experiencing is bodywork that helps your body remember and work through both the physical and emotional aspects of the trauma. Physical sensations often form the core of a traumatic memory and mastering them is a crucial step often overlooked in talk therapy. Like EMDR, somatic work does not require you to talk about your memory, although you may. It has been shown to provide significant relief. I would recommend finding a trained therapist as bodywork often triggers flashbacks.

Rewriting your Trauma is a creative approach. This was formalized for treating traumatic nightmares but may work equally well for flashbacks. You have to start at the beginning, at the same place the nightmare or memory always starts, and write the memory out like a story. Then you change the story’s ending so it makes you feel better.

The new story you create doesn’t have to be real. You’re working with a dream, after all. But it must satisfy your emotional needs. Once you’re comfortable with your story,  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 the original or the revised dream again.


Other Treatments:TMS image

Transcranial Magnetic Stimulation is a new treatment that is currently awaiting FDA approval but is offered in some facilities. Already approved for depression and showing promise in treating autistic spectrum disorders, TMS had been shown to make a significant difference in PTSD symptoms.

The procedure involves putting a strong magnet close to your head. The magnetic field creates an electrical current in the frontal lobe of your brain. The prefrontal cortex in your brain normally calms the amygdala (in charge of strong emotions) and increases focus and concentration. When stimulated by the electrical current, the prefrontal cortex turns on and works better. Perhaps TMS works much like ECT without the seizures or memory loss, and there is no need for medication.

Clinical trials are still underway, but so far the results are good and the side effects are minimal—often a headache that quickly resolves. The most prominent areas of improvement have been marked reductions in both flashbacks and intrusive memories.


Bottom line:

It’s important to have your sympathetic nervous system calm before you address traumatic memories. (see Treatments for Hyper-Arousal). If after treating those symptoms you’re still struggling with intrusive memories, flashbacks, or nightmares, then you can add Exposure Therapy.

All of the therapies listed above can be helpful. If one doesn’t work, try another, and the addition of medication right before exposure can make the process faster and more tolerable.

If you’re fed up with Exposure Therapy and want to try something new, sign up for a clinical trial of TMS. The results are very promising.


Introduction to Flashbacks, Nightmares, and Intrusive Memories

Re-experiencing past trauma is the classic symptom of PTSD and can occur as a nightmare, flashback, or intrusive memory.

The difference between a flashback and an intrusive memory is simple. In a flashback you’re actually reliving the memory, which means you’ve lost touch with your current situation. With intrusive memories, you know where and when you are, but the memory keeps intruding in your mind.

Trauma nightmares are often recurrent, may include details of a past trauma, can be terrifying, and often wake you out of sleep. Sometimes they disrupt sleep so badly that you don’t want to sleep!  Their origins lie both in your trauma and in your high arousal state.

You can also experience severe emotional or physical distress without the actual memory attached. This can lead to misdiagnosis, as it may resemble a panic attack, an episode of acute pain, a seizure, or a cardiac event.

All of the above are examples of a traumatic memory that’s resurfaced and interfering with your daily life.


What are Traumatic Memories?

Traumatic memories are different from normal memories. In normal life, your brain lays down a sequential memory track, kind of like a video but including all the senses. This is managed by the hippocampus, a kind of filing cabinet for locating memories in your brain.

But in a terrifying situation, the brain grabs sequential snapshots, usually combined with very strong emotions, which it then isolates from your normal memory. This process is handled by the amygdala, a part of your brain that controls strong emotions. I like to think of a traumatic memory as an emotional abscess that your brain has carefully walled off.

Traumatic memories are extremely potent. They contain strong negative emotions like terror, rage, shame, and despair, which makes their reappearance in flashbacks and nightmares overwhelming and disturbing.

Trauma memories don’t deteriorate with time. Our normal memories diminish or get lost through the years, but if you activate a traumatic memory, even 50 years after the event, it recurs with the same emotional intensity it held when the trauma just occurred.

Why do our brains do this? I assume it serves some life-preserving function. If you survived the first event, then you can draw on this experience and repeat it whenever a similarly dangerous situation occurs. That’s why reminders of the original situation immediately trigger your old trauma memory.


 What are Triggers?

Triggers are reminders of the trauma, and can evoke the release of traumatic memories. Triggers are everywhere. They can be anything your mind sees as similar to the situation where you were traumatized. They cause your brain to retrieve the trauma memory in a “flash”.

Common triggers include:

  1. Environment: heat, cold, rain, storm, etc.
  2. Senses: smell, hearing, seeing, feeling, pain
  3. Thoughts: about self, about the past, about a similar situation
  4. Emotions: fear, anger, distress, disgust, guilt, shame
  5. Media: news or movies about a similar situation
  6. 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. In fact, we all do this with good memories, hear a song or smell a food that reminds us of a pleasant occurrence in our past.

Two-way communication about traumatic triggers is very helpful. If you have PTSD, it’s good to learn and keep a list of your own triggers. That helps you to anticipate problems and understand what’s happening when re-experiencing occurs. If you live around someone with PTSD, it’s good to know his or her triggers. That way you won’t unintentionally upset them.



Exposure Therapy is considered the gold standard. It involves revisiting the traumatic memory until it no longer evokes such strong emotions and physical responses. This utilizes the brain’s ability to become desensitized to a recurring situation. Some people don’t tolerate it well, but if you can complete the process, it does work.

There are a number of different kinds, including:

  • CBT for trauma
  • EMDR
  • Telling your story
  • Rewriting your story (often used with nightmares)
  • Reenacting the trauma
  • Virtual reality programs through the VA
  • Massage or body therapies.

The following Medications can help to disconnect triggers from the trauma memory, or prevent the creation of a new trauma memory if used immediately after trauma:

  • D-cycloserene
  • Propranolol
  • Cannabinoids
  • MDMA

Not usually taken as a daily medicine, they can be used before or immediately following exposure.

Trans-cranial Magnetic Stimulation (TMS) is now available. It involves a strong magnetic field placed near your brain and has been shown to decrease intrusive symptoms.

My next blog will discuss all these treatments in more detail.


Bottom Line:

Memories of severe trauma are stored separately and can return abruptly if you encounter a similar situation. This tendency to trigger can be significantly reduced using exposure therapy (desensitization) alone or with appropriate medications, or taking a series of Trans-cranial Magnetic Stimulation treatments.




PTSD symptoms 2

Do You Have PTSD?

In my 40 years of practice I saw all types of people, but when they had a grocery list of psychiatric diagnoses, I would always ask them about trauma. PTSD creates so many problems that the actual problem, the trauma, can get lost among the symptoms.

DSM V improved the diagnostic process. It’s still not a perfect system, leaves some survivors out, but if you meet all 8 of the criteria below, you definitely have PTSD.


I. You have to suffer a Traumatic Event.

The DSMV defines this as:

Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in one of the following ways:

1) Direct exposure.

2) Witnessing, in person.

3) Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

4) Repeated or extreme indirect exposure to aversive details of the events), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.


II. You must experience Intrusive Symptoms

DSM V requires one of the following:

1) Recurrent, involuntary, and intrusive memories.

2) Traumatic nightmares.

3) Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness.

4) Intense or prolonged (emotional) distress after exposure to traumatic reminders.

5) Marked physiologic reactivity (physical distress) after exposure to trauma-related stimuli.


III. You must have Avoidance

DSM V requires one symptom of persistent, effortful avoidance of distressing trauma-related stimuli starting after the trauma, such as:

1) Trauma-related thoughts or feelings.

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


 IV. You must have an increase in Negative Moods and Cognitions (thoughts) starting after the trauma:

DSM V requires two of the following:

1) Inability to recall key features of the traumatic event (usually a 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.


 V.  You must have a marked increase in Arousal and Reactivity starting after the trauma. DSM V requires two of the following:

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


VI. Last but not least:

Your symptoms have to be severe enough to interfere with your daily functioning and NOT be due to another illness or injury or substance abuse.


Co-morbid PTSD

PTSD by itself is called simple PTSD, and PTSD with other mental health issues is called co-morbid PTSD. It’s actually more common to have several diagnoses.

Comorbid PTSD


Most common co-morbid diagnoses:

Major Depressive Disorder

Substance Use or Abuse (alcohol, benzodiazepines, opiates, cannabis, and others).

Sleep Disorders


Also possible:

Panic Disorder

Generalized Anxiety Disorder

Obsessive Compulsive Disorder

Bipolar Disorder

Intermittent Explosive Disorder

Personality Disorders (Borderline, Narcissistic, Antisocial, Avoidant, Schizoid)


Brief Psychotic Episode



Paranoid Disorder

Delusional Disorder

Somatization Disorder

Dissociative Amnesia

Dissociative Identity Disorder

Depersonalization Disorder



When you have other diagnoses along with PTSD, you’ll need treatment for each one. Sometimes treatments overlap. For example, an antidepressant may help both your depression and your PTSD. Some problems may remit with your PTSD treatment, especially anxiety, anger, and sleep disorders. Substance abuse may require separate treatment, but it’s important that ALL your problems get addressed.


Bottom line:

You need to share your history of trauma with your doctor and therapist so he/she can understand the source of your symptoms and clarify your diagnosis. You may have more than one problem to face. But If you’re given the wrong diagnosis, you will receive the wrong treatment, and that will significantly slow your recovery time.


boy with tear

The Growing Spectrum of Trauma Related Diagnoses

Considering all of the possible traumas and personal histories available, it is no surprise there are different reactions to stress. The age, gender, genetics, and background of each person interact with the specific trauma to create a unique set of problems and solutions. The DSM V team tried to separate them out, but they left some survivors in the cold.

Currently Recognized DSM V Stress Related Diagnoses:

  • Acute Stress Disorder:
  • Adjustment Disorders
  • Post Traumatic Stress Disorder:
    1. Sub-type: Dissociation.
  • Dissociative Disorders
    1. Dissociative Identity Disorder
    2. Dissociative Amnesia
    3. Depersonalization Disorder
    4. Dissociative Disorder NOS (now in 2 parts)

Wikipedia does an excellent job of describing these if you want more information. This blog looks at the survivors left behind.



I. Military soldiers and veterans who do not meet full PTSD criteria.

These men and women often have significant problems with hyper-arousal (hyper-alert, easy startle, irritability, trouble sleeping) but don’t exhibit enough symptoms of re-experiencing (flashbacks) or avoidance and negative affect and cognitions to qualify for a PTSD diagnosis.

They might better fit the diagnosis of Acute Stress Disorder, but their symptoms may last longer than the one month allowed. It’s been suggested they deserve a different label, like “Battle Stress” since their arousal symptoms are indicative of high levels of stress chemicals produced when the sympathetic nervous system is overactive. These symptoms can be beneficial in battle, but they are also precursors to PTSD and violence.

Not everyone who has hyper-arousal will go on to develop PTSD. Most returning combat soldiers have some arousal symptoms that will gradually diminish after they return to safety. But that process requires a supportive environment and may take several months to be complete.

And if the sympathetic nervous system fails to adapt, re-experiencing symptoms can suddenly occur when the soldier or veteran meets a triggering event. The resulting confrontations with family or police may pave the way to other problems.

Should we treat everyone with partial symptoms to, hopefully, prevent PTSD, or should we wait until the full diagnosis is established?

There are arguments both ways. Those who suggest waiting point out that it stigmatizes normal soldiers to treat them for a nonexistent illness. Those who suggest treatment argue that careful observation, counseling, and medication (as needed) are preventative behaviors that reduce their risk of serious illness and regrettable behavior. So far there is no research to support either side, but close observation of veterans with marked hyper-arousal symptoms is probably a safe middle-ground.


II. Complex PTSD (C-PTSD), also known as Disorder of Extreme Stress (DOES)

Complex PTSD Symptoms:

  • Problems with emotional regulation: persistent sadness, suicidal thoughts, or explosive anger.
  • Changes in consciousness: forgetting traumatic events, reliving traumatic events, episodes of detachment from one’s mind or body.
  • Changes in self-perception: helplessness, shame, guilt, stigma, and feeling different from other human beings.
  • A distorted view of the perpetrator: as totally powerful, as very important, or as someone who needs to be destroyed.
  • Relationship problems: isolation, distrust, in search of rescue
  • Loss of meaning in life: loss of faith, sense of helplessness and despair

Traumas commonly associated with these symptoms: 

  • Concentration camps
  • POW camps
  • Prostitution brothels
  • Child exploitation rings
  • Long-term physical and/or sexual abuse
  • Long-term domestic violence
  • Prolonged kidnapping and hostage situations
  • Slavery
  • Forced conscription of youths into military service

Complex PTSD was not included in the DSM V as a separate diagnosis, instead many of the symptoms were added to the PTSD list. But a PTSD diagnosis requires other symptoms, such as re-experiencing or flashbacks, and lacking those symptoms can leave these badly traumatized folks without access to help.



Most treatment professionals agree that abuse perpetrated by a controlling person or group over a prolonged period of time is the most difficult to treat. Long-term outpatient therapy is standard, often with medication, as the diagnoses of depression and personality disorder often accompany Complex PTSD.

Therapy in Complex PTSD progresses slowly. At first the focus is on building a relationship that is strong enough that it can weather stress, teaching the client techniques for self-soothing and self-grounding, dealing with dissociative events and/or parts, and learning to recognize and regulate emotions. Only when those basic coping skills are in place can the therapist start working on the trauma.

Whether any of the new experimental treatments currently being tested for PTSD will be helpful to those with C-PTSD remains a still unanswered question.


III. Co-Morbid PTSD:

The problem here is misdiagnosis. Because most people with PTSD have several co-existing psychiatric diagnoses, the physician can get stuck treating those problems and totally miss the PTSD.

Depression and Substance Abuse are the most common co-morbid illnesses, but bipolar and anxiety disorders are also frequent, as well as certain personality disorders, and paranoid psychosis.

When a patient presented with multiple psychiatric problems, it was always a warning sign for me. When I saw that, I started asking questions about trauma. When the underlying PTSD is not diagnosed and appropriately treated, the person is unlikely to recover.

To protect yourself from misdiagnosis, make sure you always mention a past history of trauma, even if it doesn’t seem immediately relevant to you.


Research comparing different groups and diagnoses:

1) In a study of hospitalized veterans with chronic, severe, PTSD the researchers did detailed assessments of both PTSD and complex PTSD symptoms, military and childhood histories of trauma, and utilization of medical services.

Although 31% the veterans met criteria for both, there were 29% who only had PTSD and 27% who only had C- PTSD symptoms (13% had neither).

Comparing the groups, they found that Complex PTSD symptoms were significantly associated with childhood trauma, while the PTSD symptoms were significantly associated with war trauma. The witnessing of atrocities was common among those with PTSD, but participation in atrocities was limited to those with C- PTSD.

They also found that veterans with C- PTSD had utilized more services than those with PTSD.

(Ford, et. al. February 1999 issue of Journal of Consulting and Clinical Psychology, 67(1), 3-12.)

2) Research done in the production of DSM V found that 92% of the people who met Complex PTSD criteria also met criteria for PTSD, so they chose to combine the diagnoses. This statistic contrasts sharply with the research done by Ford (#1 above) suggesting that a lot of folks were left out in the cold.


Bottom Line:

We are just beginning to learn how different traumas effect different types of people and the physical changes that occur inside their brains. We still don’t know which treatments will work best for any given group.

Rather than stretch the PTSD diagnosis to include folks with only partial symptoms, it might be better to add in two new categories, Battle Stress and Complex PTSD. That would clarify the differences and allow treatment of folks who now fall between the cracks.


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