Living with PTSD: “My Name is Jim”
by Jim Bauer
I served with the 82nd Airborne Artillery in Viet Nam
from 1968 – 1969. I still have flashback memories and
trauma built up from years of pushing memories back
into my subconscious – or wherever one pushes such
things – so that I don’t have to think about Viet Nam.
I was diagnosed in 2001 with PTSD. I have also been
diagnosed with anxiety disorder.
“ ... they didn’t
want to know
about Viet Nam.” |
One of the many things that happened in Viet Nam
that keeps coming back to me is the time my first
sergeant, his driver, and I were in a small convoy to
haul food to an artillery position outside our main
base camp around Saigon. The first sergeant had me
ride with him in his Jeep, pulling a small trailer. I rode
in back, manning an M-60 machine gun. The road
was narrow and overgrown with jungle foliage. I was
very frightened — anyone could stick out a hand and
drop a grenade in the back of
the Jeep at any point along the
way. When we made it back
safely, they asked if I wanted to
go again the next day. “No way
will I go back again,” I said, but
I got up the next day and got
ready to go. As it turned out,
the convoy had already left by the time I got there.
Later, I learned that the first sergeant’s Jeep had hit a
mine and that he’d been killed.
This is still one of my nightmares today: it could have
been me . I also feel very bad – guilty — that I didn’t
go with him, as I’d been asked. I have recurring
dreams of standing at the gate watching them drive
away. In another memory, I was on a convoy carrying
pallets of supplies to the U.S. Army base at Cu Chi. I
was in the last truck in the convoy, which included
three other units as well as mine. Suddenly I saw a
blast of smoke and fire at the front of the column, and
heard a loud explosion from the same place. The
convoy stopped. Since we had one of the radios, I
ran to the front to find out if I needed to call for help.
I saw something on the ground and discovered that it
was body parts. I was very shook up. I made a
vow that I was going to make this person’s life
mean something by doing the best I could.
Some of us vets turned to drugs or alcohol – or
both – to self medicate because at the time, no one
knew what Post Traumatic Stress Disorder was or
how to treat it. When I got out of Viet Nam, I went back to my home town, but no one had even realized I’d
been gone. Even my friends thought I’d been working out
of town. They didn’t know I’d been in Viet Nam and they
didn’t want to know about Viet Nam. My own parents didn’t
ask me questions about what had happened, so I pushed
the memories all back inside.
In those Viet Nam days, I was taught we needed to get a job
done right now, as if someone’s life depended on it. We
were also taught that there was only black and white, that
there weren’t any gray areas. I finished my tour in the Army
by drinking every bit of money I had saved.
After I got back from Viet Nam, I went to work for a corporate
grocery chain. I never asked for promotions, but I
received them. I ended up working as hard as I could to try
to stay away from managers and the people around me. I
ended up working for that company for 29 years. I
moved nine times and with at least two moves, I
had to have open spaces – there couldn’t be
houses on all sides. I finally learned though
counseling that I was trying to protect my family
by setting up a fire zone.
I would hear a helicopter go by and be startled, and I could
hardly stand the 4th of July. I could not figure out why
these things were going off in my mind, but I’d try to get
out or be pretty well medicated with a lot of alcohol. I would
come home from work and take out my anger and frustration
on my family, which I regret to this day. Though I needed
an outlet, I did not know why I was feeling this way, nor
how to handle my anger and frustration. I just knew I
needed a safe place. I would go into my bedroom to eat my
meal, to watch television, and drink. I would stay there until
I went to bed. I also had a safe place at work: I would go
into a place where no one else would be around and try to
get this anger and anxiety to go away.
I used to think that some of the Viet Nam veterans were
trying to get something for nothing. After all, I went to work
every day and people thought I was doing great. Between
my PTSD and anxiety, every day was a living hell, but I
thought I needed to made good on my vow to make something
of my life in order to validate the life that had been
lost. I finally got to the point that I could hardly validate my
own life, let alone another man’s.
Through counseling, I have learned from a quote: “I fight
against the very thing I cry out for. But I am told that love
is stronger than strong walls, and in us together lies my
hope.”
Season’s Greetings!
The elves have been busy around MMHA this season. We’re busy interviewing for a new Executive
Director, have put on a conference on bipolar disorder and are getting ready for a conference on
medications that will be held December 4 & 5 in Missoula.
This time of year brings with it many feelings, both joyous and painful. Many of us will share wonderful
times with our families – others will be alone. During this special time of the year I can’t help but
think about Montana’s suicide rate. We’ve recently gone from a ranking of 3rd in the nation to 2nd,
with the most suicides. One way or another, the effects of suicide creep into all of our lives, and yet
we don’t talk about it. This is tragic.
Please help by reaching out to those around you who may need a friendly ear or an invitation to
dinner. This season, take joy in sharing yourself with others. You’ll be surprised at what a difference it
makes.
Wishing you the happiest of holidays,
Cindy Dolan,
MMHA President
Effective Cognitive Therapy for PTSD
by Christine A. Padesky, Ph.D.
Treatments for PTSD have become more effective
over the past fifteen years, with cognitive-behavioral
treatments proving the most consistently effective
(Foa, Keane, & Freidman, 2000). A revised cognitive behavioral
model, developed in England by Anke
Ehlers and David M. Clark, may prove the most
effective to date. Ehlers and Clark report empirical
evidence to show that particular beliefs and the
nature of the traumatic memory might be better
predictors of chronic PTSD than other factors
(Ehlers & Clark, 2000).
For this reason, their treatment helps clients (1)
identify and test problematic beliefs about the long term
effects of trauma and symptoms experienced
post-trauma, (2) organize and complete the trauma
memory in order to integrate it in one’s life, and (3)
overcome the avoidance, safety behaviors and
ruminations that prevent memory elaboration and
interfere with belief reappraisals. Overcoming
avoidance, safety behaviors and ruminations also
help clients “reclaim” their lives, by resuming
activities that were common pre-trauma.
This revised treatment model has been used with
clients following physical and sexual assault, motor
vehicle accidents, and other personal traumas
(Ehlers & Clark, 2000). In addition, it was used in
Omagh, Northern Ireland following a terrorist
bombing in which 29 people were killed and more
than 370 were injured (1998). In the Omagh study, 91
consecutive patients with PTSD were assigned to
five clinicians (from psychiatry, nursing and social
work) in a community treatment center. There was
significant improvement from pre- to post-treatment
(p < .001) with no patients worse at the end of treatment, 3 percent showing no improvement, and 97
percent showing some improvement on the Posttraumatic
Diagnosis Scale (PDS). Most were in the 70-
90 percent range (Gillespie, Duffy, Hackmann, & Clark,
2002). These results are very encouraging, especially
because the bomb had physically injured one-third of
the clients and many had previous histories of trauma
and/or comorbid diagnoses. The median number of
CBT sessions received was 8; nearly two-thirds of the
patients were treated in less than 10 sessions.
Thirteen percent of the patients were seen for more
than 20 sessions; most of these patients were from
the portion (54 percent) of the treated group that had
additional comorbid diagnoses. None of the clinicians
in the study had previously specialized in the
treatment of trauma. After the bombing and prior to
the study, all received training in CBT for trauma and
case supervision by CBT trauma experts.
Those who wish to learn more about this treatment
approach can download a free reprint of the Ehlers
and Clark (2000) article by visiting the website for
the Academy of Cognitive Therapy, at
www.academyofct.org, and following the links to
“Trauma Information,” then “Mental Health Professionals,”
and then “Ehlers and Clark.” That website
also offers trauma-related summary reports written by
an Academy of Cognitive Therapy committee chaired
by Christine A. Padesky, Ph.D.
Padesky to Present in Great Falls:
The Great Falls Chapter of the
MMHA will host Dr. Padesky in a 2-
day workshop, Cognitive Therapy
Unplugged: Fine Tuning Essential
Therapist Skills, in Great Falls April
1-2, 2004. The workshop will teach
essential cognitive therapy skills including guided
discovery, constructing individualized case
conceptualizations in session, integration of therapy
alliance and structure, the use of constructive language
and symbolic synthesis.
Posttraumatic Stress Disorder (PTSD) Submitted by Vonnie R. Brown, LCSW
It is estimated that almost 70 percent of
Americans will be exposed to a traumatic event
in their lifetime - up to 20 percent will go on to
develop Posttraumatic Stress Disorder (PTSD).
Approximately 3.6 percent (5.2 million) of those
between the ages of 18-54 have PTSD in a
given year. One out of ten women will develop
PTSD at some point in life.
Lisa M. Najavits
has suggested
using “after
trauma anxiety
reaction” as an
alternative name
for this disorder.
This bears some
contemplation. |
PTSD was first recognized in combat soldiers
and veterans during the Viet Nam War, and has
been more intensely studied since that time.
Much later, PTSD was also recognized in other
populations. In 1980, PTSD was included in the
American Psychiatric Association’s Diagnostics
& Statistical Manual of Mental Disorders.
The diagnostic criteria include experiencing an
event that is outside the range of usual human
experience and that would be markedly distressing
to almost anyone (e.g., a serious threat to
one’s life or loved ones, or the sudden destruction
of home or community). Nightmares have
been identified as a hallmark of PTSD, but the
traumatic event is persistently re-experienced in
at least one of the following ways: recurring and
intrusive recollections or
dreams of the event, acting
or feeling as if the traumatic
event were recurring, and
intense psychological
distress at exposure to
events that symbolize or
resemble an aspect of the
traumatic event, including
anniversaries of the trauma.
These are accompanied by
feelings of fear or panic along with the corresponding physiological
responses. There may be persistent avoidance
of stimuli associated with the trauma or
numbing of general response. Persistent
symptoms of increased arousal may be accompanied
by significant startle reactions, anger,
sleep disturbances, difficulty concentrating and
memory impairment.
There is a wealth of research supporting the
idea that PTSD is not just a psychological
phenomenon, but also a biological response to
stress gone awry. Recent studies reveal that
victims of childhood abuse and combat
veterans experience physical changes to the
hippocampus, a part of the brain involved in
learning and memory. Chronic stress may
produce elevated baseline levels of stress
hormones and abnormal daily rhythms of
hormonal release, transiently blocking hippocampal
functioning. Excessive and chronic
exposure to stress hormones may lead to the
death of neurons in this region, possibly
producing the decreased hippocampal volume
found in patients with persistent PTSD.
Additionally, chronic PTSD is associated with
biological changes primarily involving the
hypothalamic-pituitary-adrenal axis (HPA),
which plays a major role in the response to
stress. Exposure to stress initiates biochemical
activity known as the basic HPA “axis stress response
cascade.” Catecholamines and
cortisol hormone levels increase during this
response, relative to the severity of the
stressor. These systems appear to be synergistic.
Cortisol functions as an anti-stress hormone,
helping contain or shut down neural
defensive reactions initiated by stress, while
catecholamines facilitate the availability of
energy to vital organs. Studies reveal that
victims of motor vehicle accidents and rapes
who went on to develop PTSD had lower blood
cortisol levels at the time of admission to the
emergency room, as compared with subjects who did not develop PTSD. Other
studies examining cerebral activity in
relation to traumatic stimuli have found
the amygdala and anterior cingulate
(brain structures involved in generating
negative emotions and in forming
emotional memories) to be highly
activated. Thus, traumatic reminders
appear to cause excessive activation of
the brain areas linked with emotional
regulation in PTSD patients. Additionally,
the medial prefrontal cortex (brain
region involved in recalling emotional
experiences and processing emotional
responses) was found to show enhanced activity. This area of the brain is modulated by
norepinephrine, a key neurotransmitter in
generating a stress response.
Treatment
Treatment can be divided into psychological
and biological (pharmacological) approaches.
Psychological treatments include behavioral,
cognitive and psychodynamic approaches.
Many researchers believe direct exposure
therapies with a cognitive-behavioral framework
offer the most benefit. The majority of PTSD
treatment packages include anxiety management
techniques including relaxation training,
stress inoculation therapy, cognitive restructuring
and breathing retraining. The key element is
confrontation of the traumatic event through
techniques such as systematic desensitization,
flooding, prolonged exposure and implosive therapy. Helping patients gain a better
understanding of their disorder and learn
the neurobiology of fear often helps
promote understanding of the fact that fear
is associated with biological changes and
PTSD may be a failure to shut them off
properly.
Cognitive behavioral therapy is a psychotherapeutic
approach utilized by therapists
to promote positive change. This approach
aims to assist patients in making sense of
their experiences and mastering feelings of
anxiety and helplessness. Cognitive
behavioral therapy combines cognitive
therapy – which teaches how patterns of
thought contribute to problems – and
behavioral therapy – which helps adjust or
weaken connections between problematic
situations and habitual reactions to them.
The therapist takes an active role, and may
use techniques including challenging
irrational beliefs, self-monitoring, relaxation
education and training, grounding, social
skills training and others. Group therapy
also has value in treating PTSD in that it
reduces the sense of isolation and provides
emotional support.
Additional psychological techniques utilize
eye movement desensitization reprocessing
(EMDR). EMDR, pioneered by Francine
Shapiro, is an approved technique for
treating PTSD, and has been under
research since 1987. There are eight phases
of EMDR treatment, and clinicians interested
in utilizing EMDR are required to
undergo intensive training. Imagery
rehearsal therapy (IRT) is utilized to
address nightmares that frequently
accompany PTSD. It works on the premise
that PTSD nightmares are a combination of
trauma-induced and learned behavior, and
that the nightmares reinforce the trauma.
Dr. Barry J. Krakow, medical director of the
Sleep and Human Institute in Albuquerque,
NM, is one of the sleep experts pioneering
this therapy. He and his colleagues at the
University of New Mexico have conducted
several studies using IRT as a technique to
treat nightmares. In one study Krakow and
his colleagues worked with 168 women, of
whom 95 percent had moderate to severe
PTSD. They were divided into two groups,
and half were trained in IRT. The IRT
individuals were taught pleasant imagery
exercises and how to replace haunting
images with comforting ones. Individuals chose to rewrite one aspect of their nightmare
or the entire dream. “Generally speaking,
people were able to reduce their nightmares
anywhere from 50 to 80 percent,” says
Krakow.
Of some interest is a pharmocological
treatment strategy under investigation by
Arieh Y. Shalev, M.D. at the Hebrew University
in Israel which proposes the use of betablockers
and mood stabilizers as soon as
possible after trauma to minimize neuronal
imprinting. Some researchers propose that
beta-blockers generally used to treat hypertension
have the potential to block the
encoding of trauma. Receiving treatment with
a beta blocker as soon as possible after a
trauma might help ensure that the memory of
the trauma will not be so strongly preset.
Mood stabilizers are also used to help reduce
sensitization and to minimize memory consolidation
of the traumatic event. Brief cognitive behavioral
therapy may reduce fear conditioning
associated with prolonged terror and help
facilitate cognitive processing of the event. If
a patient develops PTSD, combinations of
psychosocial and pharmacological interventions
are recommended. SSRIs and low-dose trazodone are recommended for sleep enhancement
and may help reduce symptoms of PTSD
within the first several months. “Booster doses”
of cognitive behavioral therapy can be administered
during periods of high stress in order to
control symptoms. Several other pharmacological
approaches also show promise. The uses of
selective serotonin reuptake inhibitors (SSRIs)
have significantly reduced PTSD symptoms.
Benzodiazepines have been used with mixed
results, complicated at times by significant
withdrawal symptoms. Use of mood stabilizers
such as lithium and valproate have resulted in
reduced irritability and improved impulse control.
The anticonvulsant topiramate has also shown
positive results in treating PTSD.
The last decade has produced a wealth of
information instrumental in furthering the
treatment of PTSD. Surviving a traumatic event
is significant, but surviving and attaining a
healthy, vibrant, self-sufficient, and hopeful
lifestyle is much more worthwhile and satisfactory.
This outcome seems ever more promising
today.
Vonnie R. Brown is a Licensed Clinical Social Worker
in Great Falls. She can be reached at (406) 452-2662.
News Brief
Service Area Authorities
During Fiscal Year 2002, the Mental Health Oversight Advisory Council
(MHOAC) and the Department of Public Health and Human Services
(DPHHS) began developing Service Area Authorities (SAAs). This was
supported by the 2003 Montana Legislature through Senate Bill 347. The
SAAs divided Montana into three geographical regions for the purpose of
enhancing local control in the delivery of community-based, consumer centered
services. The MHOAC and the DPHHS envision promoting mental
health care and treatment for persons with mental illness through recovery
and outcome-based community service models. Representatives from the
SAA regions will work together to plan and implement mental health
services in each of the three areas. Persons with mental illness and their
families as well as other stakeholders will be included on the SSA boards to
ensure that the voices of those using mental health services are heard. If
you would like to participate on the SAA advisory body, please contact
Marlene Disburg at hhsamddmh@state.mt.us or 1-888-886-0328 or Joan
Nell Macfadden at Jnmacfadden@aol.com or 406- 452-4185.
Upcoming Calendar of Events
December 4-5, 2003
Psychotropic Medications: An in-Depth Analysis:
Double Tree/Edgewater Hotel, Missoula, MT. For
more information, call 1-800-823-MHAM or e-mail
mmha@in-tch.com.
April 1-2, 2004
Cognitive Therapy Unplugged, Essential Therapist
Skills for All CT Applications: presenter Christine
Padesky, PhD, Hampton Inn, Great Falls, MT. Sponsored
by MHA Great Falls. For more information, go
to: www.padesky.com
June 24-27, 2004
The Changing Faces of Rural Mental Health: Millennium
Harvest Hotel, Boulder, CO, For information call
320-202-1820
MMHA MEMORIAL QUILT
The Montana Mental Health Association is constructing a second Memorial
Quilt honoring Montanans who have lost their lives to suicide. If you would
like a fabric square and directions to create a special place on this quilt for
your loved one, please contact Betty at 1-800-823-MHAM. |
