Author Archives: kathleen.sales

40 years

Anniversary Reactions

Anniversary Reactions are exacerbations of your PTSD symptoms that occur on the date of your trauma. Not everyone experiences them, but they are common. They can vary from a few minor symptoms to severe reactions with dangerous repercussions. Typical symptoms may include:

  • Increased negative feelings such as: grief, sadness, anger, frustration, guilt, shame, anxiety, and fear.
  • Increased memories of the trauma, thoughts about it, and bad dreams.
  • Increased avoidance symptoms such as avoiding thoughts or reminders of the trauma, or avoiding other people.
  • Physical symptoms such as: heart palpitations, weakness, fatigue, pain, and difficulty sleeping.
  • Mental symptoms such as: trouble focusing, thinking clearly, making good decisions, or controlling your emotions and behavior.

I divide Anniversary Reactions into two types: Known Anniversaries that you can anticipate and Unexpected Anniversaries that catch you unawares.

With Known Anniversaries, you can make plans beforehand to soften the blow. It’s best to choose a safe person and safe place for the event.

A safe person is someone who is familiar with your problem, your history, and your symptoms, and who has the ability to calm you down without overreacting or becoming panicked. You can also choose a larger group, or many people prefer to be alone.

A safe place is where you feel relaxed and at ease. It can be at home, a favorite vacation spot, or visiting a friend.

It also helps to keep your mind busy, distracting yourself from bad memories and feelings by engaging in something new or interesting to you.

If you can’t think of a safe person and safe place, you might consider a familiar treatment setting—especially if you know the staff and they know you. A war buddy, your AA/NA sponsor, or a therapy group can be supportive at this time.

Unexpected Anniversary Reactions can be very problematic. Like any other trigger, they may throw you into chaos before you even understand what happened.

If this occurs, you can always fall back on desensitizing behaviors mentioned in my blog on “Treating Triggers”. These include:

  • Use deep slow breathing
  • Call a helpful person
  • Get to a safe place
  • Ground yourself to time, place, and person by focusing on the reality around you.
  • Try walking or sitting meditation
  • Be aware of and label your emotions
  • Use your mind to help orient yourself in the present and connect the physical/emotional reactions to your past.
  • Take care of your body’s needs for sleep, food, and comfort.

Talking with an understanding person is most helpful, and if they have experience, they will help you find a safe place to reorient and chill. However, it’s more prudent to avoid the unexpected. Many people recall the exact date and time of their trauma, like 9/11/2001, but if your memory has holes in it, like mine, you can keep a calendar of problematic dates. That allows you to avoid nasty surprises.

Using Anniversaries for Healing:

There is a positive side to anniversary reactions—they can become opportunities to heal. Re-experiencing the memories allows you to explore the past trauma in detail. And if you get the chance to talk with someone who was there, you may be able to work through the strong emotions and see the past from a different perspective. Commemorating the traumatic event, like attending a memorial service for the dead, also offers you a chance to share your feelings and concerns.

Suggestions for Family and Friends:

It’s important to respect how the survivor feels. They can’t “just get over it”, so listen to their needs and see if you can find a way to help them. They may need to acknowledge this anniversary with some healing ritual. Or maybe they’d prefer to do something that distracts them from painful and distressing memories. They may need time alone, but if so, make sure they are safe.

If the survivor wants to talk about the past, try to listen with a nonjudgmental ear—they need your support, not a critique. And if their symptoms continue several days or start to worsen following the anniversary, you should encourage them to seek professional care. There could be something else gone amiss. As a psychiatrist, I’ve found serious medical problems hidden behind PTSD symptoms.

Bottom Line:

It takes a long time to heal from trauma, but as you look back on the traumatic event you may find that time has changed your view. Look closely at yourself and see how the trauma changed you, and if it has had any positive effects.

It may help to catalogue your progress, such as changes in the frequency and intensity of symptoms, new coping skills you’ve learned, and times when your experience led you to understand and help another injured person.

Human compassion is a powerful force for good, but it seems to grow from our greatest distress before it shapes us into kinder, gentler people. Don’t give up!







veteran smoking weed

Invitation to Veterans with PTSD

If you are a veteran with PTSD and have used marijuana or related chemicals to treat your symptoms, you are invited to send me your story of how it works—for better or for worse. I consider all experiences equally valid.

I plan to send copies of your letters to the Senators and Representatives in Washington, D.C., but I will need their permission to add a lengthy attachment. So once I have your letters, I will email each of them and send your stories to the people who respond.

Your letters should be about a page in length, and they don’t have to follow any set protocol EXCEPT they may not be threatening or disrespectful to our country or to government officials. With that exception, I will send exactly what you write. True stories are powerful persuaders, so you don’t need to embellish. Just tell the truth about what happened before you tried marijuana and after.

You may send your letters to my email: Please type “veteran’s story” in the subject line so I will recognize it. You need to put your name, service, rank, and contact info (email or phone) in the letter, so the recipients know you are an actual veteran. Please also put in writing whether or not you give me permission to publish your letter, as that would be another way to get out the word and influence public opinion.

It will take a lot of letters to make an impression, so please pass this request on to all your buddies who suffer with PTSD. If everybody helps, I’m certain we can change some hearts and minds.

stack of pills

Why Can’t the VA treat PTSD?

The VAH has earned a bad reputation for treating PTSD with piles of pills. Why do they persist in doing this? Are there any medications or techniques that work better? What should they do instead?

I worked for the VA over 40 years ago when we didn’t have the diagnosis “PTSD”. We definitely had the patients, mostly young veterans just back from Vietnam. At that time there were very few medicines available to treat a “psychiatric” problem, and we didn’t understand what was wrong. Veterans with flashbacks were diagnosed “schizophrenic” and put on thorazine, mellaril, or haldol. One officer I saw had episodes of violence, was labeled “manic-depressive”, and put on lithium. Those medications calmed their nerves, but kept them in a haze, dysfunctional.

The one thing we did that seemed to help was create groups just for Vietnam veterans where they felt supported and could talk. Talking is cheap and it still works.


Fast-forward 40 years and what has changed?

  • We know PTSD is a physical injury caused by stress chemicals run amok in your brain.
  • We know the sympathetic nervous system plays a vital role in producing those stress chemicals.
  • We have medications that block those chemicals and can reverse many of the symptoms.
  • We have procedures to help reset the sympathetic nervous system.
  • We know what parts of the brain are most effected: the amygdala (in charge of fear related emotions) and prefrontal cortex (in charge of controlling the amygdala—among other duties)
  • We have medications that reactivate the prefrontal cortex so it can resume control of the amygdala.
  • We have procedures that can do the same.
  • We know how traumatic memories are laid down, and how they are triggered.
  • We have medications that work to reset those triggers when used with exposure therapy.
  • We have medications that can prevent PTSD if used in a protected setting.


How should we treat PTSD?

  • The best medicine available for PTSD is the alpha-blocker Prazosin. It blocks the stress chemicals that cause PTSD, normalizes your sleep, calms your nerves, and gets rid of nightmares. Side effects like low blood pressure and sedation tend to self-correct over time. Luckily the VA has backed this trend, and this is one thing they do RIGHT.
  • Stellate Ganglion Blocks can shut down an overactive sympathetic nervous system with one, or sometimes two, injections. Not yet approved for PTSD but may be available if you pay out of pocket at the Anesthesia Department in a hospital near you.
  • Service dogs are great for calming veterans down, but are not yet approved for PTSD. They are widely available through many local projects, but you’ll probably have to wait, and they are pricey. Check out the internet for financial help.
  • Antidepressants (Prozac, Paxil, Zoloft, Lexapro, Celexa, Remeron, Effexor, Cymbalta, Trazodone, etc.) can reboot the prefrontal cortex, (which controls the amygdala and defuses not only depression but also rage.) These work well in some people, but may have side effects, including sexual problems and more nightmares.
  • Another approach to improved self-control is meditation/mindfulness. Some VA facilities are now offering classes. It’s a side effect free approach to rewiring your brain, and research shows that meditation can calm your sympathetic nervous system, improve the functioning of the prefrontal cortex, and actually enlarge other parts of your brain involved in attention and emotional control.
  • New approaches to Exposure Therapy use medications (D-cycloserene, propranolol, medical MJ, and MDMA) to disconnect triggers from traumatic memories. These are not available at most VA facilities—although some veterans have been known to use their own.
  • Trans-Cranial Magnetic Stimulation has been shown to reduce both depression and traumatic flashbacks, but it’s not yet approved for PTSD.
  • Propranolol and medical MJ may PREVENT PTSD if given immediately following a trauma, especially in folks who develop Acute Stress. But this needs to happen in a protected setting since the person will be slowed and not able to protect themself on meds. That may be why this preventative approach is rarely used in combat zones, but it has been tested after natural disasters and found helpful.


So why can’t we get the newest treatments?

The FDA bureaucracy. The FDA has not yet approved many of the treatments mentioned above, or at least not for PTSD. Some are approved for other diagnoses.

  1. Stellate Ganglion Block is approved for chronic pain and severe sweating, but not for PTSD.
  2. Service dogs are approved for physical disabilities, but not for PTSD.
  3. Trans-Cranial Magnetic Stimulation is in use for depression and autism, but still experimental for PTSD.
  4. MDMA and medical MJ are still illegal at the Federal level.

Without government approval, the VA doctors treating PTSD can’t use or recommend these medications and procedures.

The VA focus on symptom control. Because of the stigma and fear our country exhibits toward most mental health issues, the VA is dedicated to protecting all of us through strict control of violent symptoms. That means their first job is to keep veterans calm so there is no way they can act violent.

Nowadays the doctors use the newer antipsychotics (Zyprexa, Seroquel, Risperdal, Abilify, Geodon, etc. and their generics), which may be somewhat less sedating than the old, but they still have many side effects. These include impaired cognition, increased fat and body weight, and increased blood sugar.

But if our veterans could access improved treatments that act on the cause and relieve their symptoms, the VA wouldn’t need to use so many drugs.


How do we change this situation?

We’ve already accomplished the first step, throwing a spotlight on the VA problem, but now we need to focus on the FDA approvals, and that requires research on the treatments that we need.

The FDA won’t approve anything that isn’t backed by scientific research. We need to push for more research on Stellate Ganglion Blocks, Trans-Cranial Magnetic Stimulation, medical MJ, and Service Dogs for PTSD.

There’s a new bill in the Senate (S.320) for innovative medical research. Pay attention to its passage through the Health, Education, Labor, and Pensions committee. You can check how your elected officials vote on this and other veteran related bills at:

Until things loosen up, what can you do? If you have the money, you can seek out private treatment. But if you’re stuck at your local VA clinic and the treatment you need is unavailable there but is available in a community nearby, you can request that the VA purchase community medical care. Guidelines for purchased care are here:





















Treating Triggers

If you have PTSD, there will be times when you get “triggered”. That means something in your current environment– such as a noise, or what you see, a smell, a place, a person, or an anniversary date–connects your mind to a traumatic memory. Most people try to avoid known triggers, but even when you’re careful, it happens


So what can you do?

Over the years, I’ve learned a number of techniques that help you calm down, ground yourself, and work through the worst of the emotional response. The goal is to get where you no longer react to that trigger. The process of getting there is called “Desensitizing.”

Steps for Desensitizing:

1) As soon as you realize that something has gone wrong, stop and breathe.

Your immediate reactions are suspect, may be driven by old trauma, and could be inappropriate in this current place and time. So give yourself a time-out and just breathe.

Breathing is very important—focus on your breathing, slow and deep, then slower and deeper. This is something over which you have control, and slowing your breathing will normalize your body’s chemistry and avoid a prolonged panic response.

2) Focus on your immediate surroundings. If these are dangerous or uncomfortable for you, get yourself to a safer location.

Inside a building, the nearest restroom may afford some quiet privacy.

Outside, move slowly away from whatever triggered you and find a safe, quiet place.

If you’re driving, you should look for a safe place to pull over.

Keep breathing deep and slow while you move to a safe place.

3) As you continue to focus on your breathing, you need to ground yourself in the here and now. There are a number of techniques that you can use. Test them out at home and see which ones work best for you.

“Where are my feet?” Feel your feet on the floor. Wiggle your toes and shift your weight so you can feel the solidness underneath your feet. You can stand or sit, just focus on the earth under your feet.

“5,4,3,2,1”. Use your senses, open your eyes and look around until you can name 5 different things that you see. Listen, to hear 4 different sounds and voices. Name the things you hear. Touch the things around you: your body, the floor, the wall, furniture with texture, grass, trees, and name 3 things that you can feel. Sniff the air and name 2 things that you can smell. If you have some mints or gum, put them in your mouth and taste the flavor, name 1 thing you taste.

Walking meditation. If you can walk around freely, pick a calming mantra and repeat it, either aloud or silently, as you walk and focus on your steps and your breath. I like the following meditation: “I have arrived, I am home, in the here, in the now, I am solid, I am free, and in the ultimate I dwell.” You can use any part that works for you, or choose a mantra of your own.

Sitting meditation. Choose a mantra and focus on your breathing while chanting the mantra, either aloud or silently. The mantra should be something soothing to you, such as “I am strong”.

EFT’s. This is a technique that uses tapping on acupuncture points in the body, and it actually works well. It’s best described in this introductory video:

Eye movements. Hold your head still and move just your eyes from side to side quickly for several minutes. You can also do other side-to-side behaviors, like tapping your right arm, then your left, back and forth, or tossing a ball from one hand to the other.

4) Take as much time as you need to feel grounded. Remember that it takes at least 10 minutes for the adrenaline in your body to subside.

After you’ve worked on breathing and grounding, take a measure of how upset you feel on a scale of 0-10, where 10 is the worst possible and 0 is completely calm.

If you’re at a 4 or calmer, you can go back to your original activity, if you still want to do it.

If you’re at a 6 or higher, you may want to head home and/or call a safe person to assist you.

It is not safe to drive while triggered!!! Please ask or call someone you know to take you home.

5) Once you are home, take care of your body. Take an inventory of your body’s needs. Is it hungry, exhausted, tense, antsy? Do what you can to make your body comfy. A hot shower or bath can be very calming, but so is walking in the sunshine. Do whatever makes you feel good.

6) Pay attention to emotions. Do you feel Angry? Embarrassed? Sad? Terrified? Put a label on the emotions that you feel. Remind yourself that there’s nothing wrong with having feelings.

While focused on your breathing and keeping your body as relaxed as possible, see if you can sit back and observe your emotions without acting on them.

View your emotions from a distance, like on a movie screen, or picture the emotion floating down a river while you stay safely on the shore.

Remember that emotions are temporary feelings and will pass.

7) Once your body and emotions are calm, it’s time to use your brain to figure out what caused your distress.

Write down what happened. Can you recall previous traumas that were, in some way, similar to this?

You might want to keep a list of triggers, not just to avoid them, but to help you remember the next time you face a similar event.

8) Helpful medicines. Research has uncovered several medications that help you desensitize to triggers.

Two are pharmaceuticals: propranolol, an old blood pressure medicine, and D-cylcloserene, an old antibacterial.

MJ also has been shown to help and is legal in some states.

The latest addition is MDMA, which was used for this purpose back in the ‘70s and ‘80s and continues to show promise as a therapy add-on.

Medications work best if taken right after you are triggered, although anytime in the next several hours can be useful.

Although benzodiazepines (Valium, Xanax, Klonopin, Ativan, etc.) make you feel calm, they do not help you desensitize.

Bottom Line:

It takes practice to get good at calming down. A gymnastics coach once told me that it takes 36,000 repetitions to internalize a new skill, or roughly 100X a day for a year. Luckily, 100 repetitions is roughly all you’ll need to desensitize most triggers, less if you use medicine.

While you’re learning, it’s good to have a “coach”, someone you can call who will walk you through the process. After several successes, you can manage on your own.

Why bother? Because each time you succeed in calming yourself down, you desensitize a little bit more to that stressor. Eventually your body learns that stressor isn’t dangerous, and it won’t trigger you again.


Avoidance picture

Avoidance Symptoms and Treatment

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 PTSD symptoms involve Avoidance.


First there is Conscious Avoidance. This is described in DSMV 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 intentional 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 (see previous blogs on Treating Hyper-Arousal and 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 DSMV 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 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, war buddies, and close friends can assist by supporting survivors in their effort to seek help.

Meditation and Mindfulness training have been shown to reduce PTSD symptoms, especially Avoidance. It may be the best therapy to get you out of Avoidance and into taking control of your own PTSD. Meditation has been shown to improve functioning in the prefrontal cortex, the part that controls the amygdala and all its negative emotions, as well as parts of the cortex involved in focus and attention and speech. Meditation and mindfulness have no side effects and they’ve been proven to work. You can find good meditations free on You Tube.

The inability to recall parts of the trauma is a “dissociative” symptom. Dissociation is the process our 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 often 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 the worst parts of the trauma, caution should be used to protect the survivor from the emotions and pain that will accompany its recall.

Distortions in thinking about the trauma are common and can be dealt with in the process of detoxifying memories (see blog on Treating Flashbacks, Nightmares and Intrusive Memories). As you are able to look at the trauma with less intense emotion and less pain, you can start to engage the cortex—the thinking part of your brain—which may change your previously held beliefs. But if the distortions prevent you from seeking help, you may get stuck. Sharing your concerns with a trusted friend can help you to sort out was is real and what is skewed.

Persistent negative emotions and the inability to experience positive emotions can lead to withdrawal from activities and people. These last 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 stress chemicals are making in the brain. To treat it, you can use meditation or medication and treatments in the blog on Treating Hyper-Arousal.


Bottom line:

Avoidance is understandable, even inevitable, but it doesn’t treat the problem. If you want to get better, you can start with mindfulness and meditation, but once you’re able to look clearly at your symptoms, check out treatment suggestion in the blogs on Treating Hyper-Arousal and Therapy for Flashbacks, Nightmares and Intrusive Memories.

DSMV 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.

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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