Category Archives: Post-Traumatic Stress Disorder

Mindfulness vs. PTSD

The Washington Post reported this week on new studies addressing Post-Traumatic Stress Disorder with mindfulness. Research has already found regular practice may help those with PTSD recover faster. New findings suggest it may do even more.

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, Ph.D is professor of security studies at Georgetown University. She’s not a psychologist, but she ‘s among those who’ve found regular mindfulness practice significantly eased their post-traumatic symptoms.  Per the Post’s article, Stanley’s new study tracked 320 marines through simulated combat training. The results showed those schooled in mindfulness weren’t just calmer during the exercises, they also responded faster to new threats.

This is crucial, says Tom Minor, a University of California at San Diego neuroscientist who was one of the researchers. “That was one thing we worried about: ‘Are we going to take a bunch of Marines and turn them into chanting monks who couldn’t generate a stress response?’ But they didn’t get too relaxed.”

“Too relaxed,” is a fear for many traumatized people. With a constant perception of danger, it can be unnerving to think one might be lackadaisical about threats. Clinical evidence that mindfulness reduces response time can be a major selling point to the hypervigilant.

Opens with the titular Vietnam vet practicing mindfulness in a Buddhist monastery. Discuss.

In the “Baba Rum Raisin” days of the late 1960s and early 1970s, meditation was peddled as a cure for everything. Skepticism bordered on cynicism. This article cites peer-reviewed, clinically-validated studies such as  Thomas F. Minor‘s research, which indicates meditation boosts the hormones that repair stress-related damage and decreases the chemicals that cause it. It also mentions Martin M. Paulus’ work that shows mindfulness boosts activity in areas of the brain devoted to awareness and control of emotions.  The sample sizes are too small and the results need to be reproduced a few more times,  but the findings on mindfulness and PTSD have started to verge on Maharishi-esque territory.

Of all the goodies in the Post article, the most tantalizing (and least empirically-supported) is the suggestion that mindfulness practice may reduce the risk of developing post-traumatic symptoms:

(Marine medic Del) Cochran says he believes meditation helped him stay much calmer during his second tour in Iraq. “The first tour, I was freaked out all the time,” he says. “There was so much static. With meditation, you’re much more in tune — what is a target, what is not a target. You are much more focused on what you are doing.”

Meta-analyses of studies of traumatized children shows pre-existing anxiety may increase one’s vulnerability to PTSD. Who wants to fund a study comparing PTSD rates among veterans from countries with a cultural tradition of mindfulness practice and those without?

Citations:

Kohn, David (2013, February 18) Mindfulness and meditation training could ease PTSD symptoms, researchers say. The Washington Post. Retrieved on February 22, 2013.

Examining the protective effects of mindfulness training on working memory capacity and affective experience. By Jha, Amishi P.; Stanley, Elizabeth A.; Kiyonaga, Anastasia; Wong, Ling; Gelfand, Lois
Emotion, Vol 10(1), Feb 2010, 54-64.
 

@ 2013 Jonathan Miller All Rights Reserved

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Trauma, Addiction and Ouroboros

Therapists are often reluctant to see clients who just kicked their addiction. We know therapy can be wrenchingly difficult. We worry we’ll trigger a relapse if we see someone before they’re firmly grounded in sobriety. Maybe we shouldn’t.

A new study from University of South Wales researcher Katherine L Mills  and her team tested their program, COPE: Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure. As the name makes clear, COPE combines addiction treatment with prolonged exposure therapy for post-traumatic stress disorder. Most would fear the grueling exposure process would cause the clients to relapse. It didn’t. After nine months, the COPE  group and an addiction-treatment-only control group both saw the same decline in substance dependence. Among those who were still addicted, both groups’ members saw their addiction grow less intense by roughly the same amount.  The only statistically significant difference between groups? Those in the COPE group had significantly lower rates of post-traumatic symptoms.

Ouroboros, in a medieval engraving.

Critics have rapped the study for comparatively small effect-sizes. One would suggest they’ve missed the point. Dually-diagnosed clients can feel like Ouroboros – the mythical serpent forever swallowing its’ own tail.  Alcohol and other drugs might be their only way to cope with emotional problems, even while their addiction makes those problems worse.  Emotional pain and the struggles of recovery may be the right choice, but it’s a hard choice when the option is to get wasted one more time.  In this study, even those clients who weren’t fully abstinent saw their PTSD symptoms dwindle.

Ouroboros, as experienced by many dually-diagnosed clients.

The authors are clear that a client can’t get blotto every day and still get somewhere in therapy. They do say:

“These findings challenge the widely held view that patients need to be abstinent before any trauma work, let alone prolonged exposure therapy, is commenced. Although we agree that patients need to show some improvement in their substance use and an ability to use alternative coping strategies before prolonged exposure therapy is initiated, findings from the present study demonstrate that abstinence is not required.”

The fact these clients improved without firmly-established sobriety, some without even being fully abstinent, is more significant than the extent to which they recovered.  More studies on therapy with the recently-sober, please.

Citation:

Mills KL, Teesson M, Back SE, Brady KT, Baker AL, Hopwood S, Sannibale C, Barrett EL, Merz S, Rosenfeld J, Ewer PL  Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. [Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov’t] JAMA 2012 Aug 15; 308(7):690-9.

@ 2012 Jonathan Miller All Rights Reserved

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Trauma Treatment: Tetris

This seemed too good to be true, but by Godfrey, the results have been duplicated:

Researchers are now corroborating what some trauma sufferers have happened upon by chance: Focusing on a highly engaging visual-spatial task, such as playing video games, may significantly reduce the occurrence of flashbacks, the mental images concerning the trauma that intrude on the sufferer afterwards.

Video game play immediately after a traumatic incident may prevent flashbacks by keeping the brain's visual circuits busy.

When clients call in panic after a traumatic experience,  this could be an immediate it’s-worth-a-try intervention to recommend. One with no wait time, no need for insurance company panels, and virtually no risk of harm. The researchers don’t claim  Tetris should be recommended above other games, but it’s worth noting the game is cheap or free for smart phones and other platforms.  It’s an abstract geometry game unlikely to trigger emotional memories. Compared with some, it’s downright pacifying – one would hardly recommend Call of Duty to a client who just witnessed a shooting.

One point of fascination:

To test their idea, researchers asked subjects to view a disturbing film — an admittedly poor but sufficient simulation of real trauma. Within six hours of viewing this film, the period during which memories are thought to be consolidated for long-term storage , test subjects were randomly assigned to one of three tasks: answering trivia; playing Tetris, a 1980s video game that involves optimizing visual-spatial cues; or engaging in nothing in particular. Over the following week, subjects who had played Tetris reported experiencing significantly fewer flashbacks of the film than the others did. (For reasons that are unclear, those who answered trivia actually had the most flashbacks.) (emphasis added)

Neurologists have suggested traumatization may work as a memory problem, in that the traumatic memories can’t be remembered well enough to be filed and stored correctly.  The researchers in this study believe the game occupied the visual and spatial circuits of the subjects’ brains, and kept them from consolidating the traumatic images. Could  it be that recalling bits of trivia hampered the hippocampus‘  ability to cope with the memory of the film?

Promising first-aid for trauma: video games.  Asterisk: Tetris, yes. You Don’t Know Jack, no.

@ 2012 Jonathan Miller All Rights Reserved

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Can Trauma Make Us Stronger?

Stephen Joseph, PhD, professor of psychology at University of Nottingham, UK. (Photo credit: Maria Tanner at Lace Market Photography)

Great – another f***ing growth opportunity,” reads the classic bumper sticker. “Classic” here means, “old”, especially given that ‘personal growth’ seems as outdated as Esalen, hot tubs and encounter sessions. In his new book, “What Doesn’t Kill Us”, Stephen Joseph, PhD pries the concept free from associations with self-indulgence by linking it to Grandpa’s good, old-fashioned ‘character building’ – finding strength through suffering.

In 1990, Joseph conducted three-year follow-up interviews with survivors of the Herald of Free Enterprise sinking. Those who lived through the tragedy reported all of the pain, guilt and sleeplessness researchers expected. Yet, surprisingly, 43% also made comments like, “I live everyday to the fullest now,” and “I am more determined to succeed in life now.” Joseph, professor of psychology at the University of Nottingham, UK, used these findings to develop his Changes in Outlook Questionaire (CiOQ), and found it repeatedly confirmed such signs of personal growth in hundreds of trauma survivors.   Like Viktor Frankl, Joseph “… saw two sides of suffering, noting that while there might be nothing inherently good in misfortune, it might be possible to extract something good out of misfortune.” He argues against Freud’s view that therapy’s role is to get clients back to common unhappiness. Rather, the therapist’s job should be to help people lift themselves above their pre-trauma level of functioning – to grow.

"... 'terror'... 'torment'... 'tragedy' .... here it is, 'trauma'."

Every trauma survivor seeks information. They’re filled with questions such as, “ What happened? Why can’t I put it behind me? Why did this have to happen at all?” Joseph presents PTSD as an information-processing problem. To be traumatized is to be blasted with unbearable knowledge at an intolerable volume.  So much, so fast, creates an overload that destroys neurons in the hippocampus and hampers one’s ability to process the memory. These ‘uncategorizable’ recollections drift about the mind in the form of flashbacks and nightmares, like so many piles of paperwork on a desk. To file such memories away properly, the survivor’s understanding of the world must grow. A new file folder with a new category, (one that makes sense of the memory), must be labeled.  Unanswerable “Why me?” questions aren’t resistance or self-pity – they are the start of the search for meaning. 

None of Joseph’s ideas fit on a bumper sticker, and all are ripe for misinterpretation. One can sense his desire for a rubber stamp reading, “OF COURSE”.  Of course trauma survivors suffer, he says. Of course no one would choose trauma for the benefits of post-traumatic growth. Of coursePositive Psychology” doesn’t mean clients censor their pain with smiley-face stickers. He makes it clear that growth is not a guaranteed result of trauma, and lack of growth is not evidence of poor character. First, Ryan and Deci’s basic needs (such as acceptance and belonging) must be met. A client must choose to engage in the growth process before that process can begin. When a person is traumatized enough to meet criteria for post-traumatic stress disorder, growth won’t happen until those symptoms ease in treatment. A more specific, less marketable title might have been, “What Doesn’t Kill Us or Give Us PTSD.”

The last issue is particularly relevant, given Salon.com’s try at shoehorning the author’s ideas into an “over-diagnosis” narrative.  Joseph straddles the diagnosis debate. He observes that a PTSD diagnosis validates a client’s story. It’s undoubtedly a good thing  survivors have been moved from the file marked, “Malingering coward,” into the one labeled, “Someone with an understandable, treatable illness who is deserving of our compassion.” He’s troubled, though, that the same redefinition moves trauma from the, “I will survive this and grow stronger,” category  to the, “This is something the doctor needs to fix,” file.  In his view, our current understanding can file trauma survival under stiff-lipped perseverance or a treatable illness, but not the process of becoming someone new.

Friedrich Wilhelm Nietzsche (1844-1900). Personal-growth pioneer - not actually to blame for WWII.

Perhaps this critique of the medical model explains why the book is weakest when it addresses treatments for post-traumatic symptoms. It’s clear Joseph’s focus is to break up our thinking about trauma. He encourages therapists to speak in the disease model’s terms long enough to engage the client in the process of growth, but rushes past descriptions of how specific symptoms can be eased so growth can begin. With all of the book’s valuable advice for clients on coping with stress and finding professional help, one wishes the author spent more time on why, how, and how well different treatments work.

In “What Doesn’t Kill Us”, the author wire-walks his way between the fact-free fluff of self-help and the rigid, symptom-focused empiricism of insurance panels, to show how Nietzche‘s maxim can apply to leading a fulfilling life, not just survival in a vicious world. What doesn’t kill us provides the opportunity to nurture changes in our thoughts, behaviors and understanding of how life works. We can grow enough from adversity that the answer to, “Why did this have to happen?” becomes, “So I could be a stronger, more compassionate, more fully-alive person.”

(The New York Times has an excellent article about post-traumatic growth among members of the U.S. military here.)

@ 2012 Jonathan Miller All Rights Reserved

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PTSD is Overdiagnosed Unless … Part 2

I’m reading “What Doesn’t Kill Us“, by Stephen Joseph, mentioned in this earlier post.  No mention of over-diagnosis yet. Reader Christy wrote in to say:

Same issue at one of my old jobs. Clinicians diagnosed all the kids with PTSD because they were abused. I remember sitting in group supervision explaining why experiencing trauma does not necessarily mean that one will develop PTSD.

Grieving? Clearly. Traumatized? Possibly. Post-Traumatic Stress Disorder? The odds are 2-to-1 against it.

Unfortunately, I’ve heard similar stories at my community mental-health job. Allen Frances, MD, psychiatrist and chair of the chair of the DSM-IV Task Force, suggests that PTSD is both the most over- and under-diagnosed disorder around.

The Other Side of Sadness is an excellent book on grief and resilience. In it, author George A. Bonanno describes New Yorkers’ surprisingly low rates of post-traumatic symptoms  after the 9-11-01 attacks. He writes of how he and the original researchers sifted the data [i] to focus on the people closest to the tragedy – those who witnessed the WTC towers fall with loved ones inside:

“The people who experienced this kind of bereavement had the greatest proportion of severe trauma reactions. Just under one-third met the criteria for PTSD. That is about the highest proportion of PTSD that any event will produce. And yet just as many people who had experienced this same horror — one in three — had no trauma reaction at all.”

Exposure to trauma is not the same as post-traumatic symptoms.  Post-traumatic symptoms are not the same as Post-Traumatic Stress Disorder.  These days, there’s a lot of heat on the American Psychiatric Association over the upcoming DSM-5.  Evolving criteria for diagnosing mental illness is a much less serious threat to accuracy than those who don’t or won’t take the time to use the DSM properly.

@ 2012 Jonathan Miller All Rights Reserved


[i] Bonanno, G.A., Sandro Galea, A. Bucciarelli, and D. Vlahov. 2006. “Psychological Resilience after Disaster – New York City in the Aftermath of the September 11th Terrorist Attack.” Psychological Science, 17(3): 181-186.

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PTSD is overdiagnosed – unless maybe it’s not

Salon.com ran an interview with Stephen Joseph, professor of psychology, health and social care at the University of Nottingham,U.K., and author of, “What Doesn’t Kill Us: The New Psychology of Posttraumatic Growth”. The headline? “How PTSD took over America”.  The subtitle? “The diagnosis is now being applied to everything from muggings to childbirth. An expert explains why it’s bad news.”  Interviewer Alice Karekesi asks questions like, “Do you believe that PTSD is over-diagnosed?”, “Is the emotional pain overblown in such cases?” and “Are there some cultures that are more prone to post-traumatic growth?”  One quick scan and I was ready to ask Dr. Joseph blistering questions such as, “How long does a client need to suffer before they can skip the ‘growth’ and actually get some help?”

Until I re-read his answers. And noticed that Salon and Joseph were talking about different things. Joseph doesn’t claim post-traumatic stress disorder is over-diagnosed. He explains the definition of PTSD has expanded, but doesn’t argue that’s a bad thing. He notes some say the DSM over-medicalizes the human experience, but doesn’t take a stand on whether it does or not.  The only “bad news” he explains in the interview?  People who have a normal reaction to an upsetting event may believe they have PTSD.

I’ll be reading Joseph’s book in the near future. Blurbs for the book suggest it’s not about diagnosis, but the way one can grow during recovery from trauma, and emerge stronger and healthier than before. If there are meaty chapters claiming that PTSD is over-diagnosed, you’ll read the full update here.

Political observers note media coverage is often driven by pre-established narratives – storylines and stereotypes that journalists (overworked, underpaid, overstressed and under-respected, by definition) fall into. Why did Candidate X get labeled as a flip-flopper when Candidate Y changed positions, too? Because it fit a storyline, including people’s perceptions of X’s character. The narrative here seems to be that if you say you have PTSD (or any other DSM diagnosis), it’s more likely you’ve inflated mild symptoms into a mental disorder because you’re weak.

DSM-V comes out next year. Watch for more of this narrative as May, 2013 approaches.

@ 2012 Jonathan Miller All Rights Reserved

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Why mindfulness works – The behavioral view

Photo @2005-2011 Juanita de Paola - http://www.juanita.it/

Experts have known since 500 BCE that mindfulness practice can lead to greater feelings of equanimity and contentment.  Mindfulness- based therapies have been part of western psychology at least since 1979, when Jon Kabat-Zinn opened the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. Unlike many other “eastern” treatments, empirical studies have accumulated to support claims of effectiveness against depression[i] and anxiety disorders such as generalized anxiety disorder[ii], obsessive-compulsive disorder[iii], and even irritable bowel syndrome[iv].

What has been less well understood is how it works. Michael Treanor, of the University of Massachusetts published a meta-analysis[v] this February that suggests exposure is key. Since Joseph Wolpe’s time (and before), we’ve known if you expose yourself long enough to something that causes anxiety, your amygdala and sympathetic nervous system will (eventually) realize it’s not so dangerous. The difficulty has always been how to stay with the phobic object when every part of you wants to run. Treanor’s meta-analysis finds empirical support for the idea that mindfulness works as a conditioned inhibitor – meaning, in this case, it eases the urge to flee.

Treanor’s findings were anticipated in a 2005 article[vi] by Shapiro, Carlson et al. They defined mindfulness as choosing to focus one’s attention on the present moment, with an open, accepting attitude, and the intention of calming, exploring, or regulating oneself.  Marsha Linehan made it part of Dialectical Behavioral Therapy because it helped her chronically suicidal clients stay present with their emotions long enough to recognize and tolerate them.  For those overwhelmed by dysphoria, mindfulness can be like the difference between watching a football game from the 50-yard line, and being  tackled and trampled by players on the field.

Exposure, naturally, is the key intervention in Edna Foa’s prolonged exposure therapy, which is the U.S. military’s treatment of choice for Post-Traumatic Stress Disorder. This article tells how Sgt. Richard Low, a veteran of 280 combat missions in Iraq, recovered from PTSD symptoms with help from Sudarshan Kriya yoga:

When he came back from the service, he didn’t think his experience affected him in any major way. He had nightmares, and he startled easily, but he chalked that up to just something veterans live with.

Then he enrolled in a study he initially wrote off as “just some hippie thing,” where he learned about yoga breathing and meditation. A year later, Low, 30, sums up his experience with two words: “It works.”

Heads-up to tough guys of the world: Mindfulness is not just a hippie thing. It’s also a Shaolin Monk thing.

 

@ 2011 Jonathan Miller All Rights Reserved


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