PTSD, Triggers, & Treatments
Many individuals have suffered a trauma in their life, but not all who experience trauma develops post traumatic stress disorder. This article will explain what PTSD is, and how it can be treated.
What is PTSD?
Post-Traumatic Stress Disorder or PTSD, is a psychiatric disorder that can occur following the experience of witnessing of a life threating events or traumatic event such as military combat, natural disasters, terrorist incidents, serious accidents, physical or sexual assault in adult or childhood, etc.
How common is PTSD?
Even though about 60% of men and 50% of women experience at least one traumatic event in their life time only about 7-8% of the U.S population will have PTSD at some point in their lives, with 10% of women developing PTSD at some point in their lives, and 4% of men. Each year about 8 million adults suffer from PTSD.
What are the symptoms of PTSD?
There are four distinct features of PTSD:
1. Re-experiencing: Spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.
2. Avoidance: Avoiding distressing memories, thoughts, feelings or external reminders of the event.
3. Negative cognitions and mood: Myriad of feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
4. Arousal: Aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance or related problems.
How does re-experiencing work?
One of the most common symptoms of PTSD is re-experiencing or is often referred to as “flashback,” they are often disorganized and incomplete, and are unpredictable and intrusive. They are often caused by “triggers,” which are things or experiences that are indirectly or superficially reminiscent of an earlier traumatic incident and causes an individual to recall a memory. These memories are out of control of the individual and often make the individual feel like they are reliving the experience. These memories are very different from regular autobiographical memory which is a combination of personal experiences that is in context and general knowledge about the world. Flashbacks cannot be controlled and are often triggered, they are more vivid and clear, and are remembered by being re-experienced. The more emotional or aggressive an event is the more likely it can be recalled both consciously and automatically.
Memories are stored in two different formats, they can be stored as a verbally accessible memory (VAM) or a situationally accessible memory (SAM).
Verbally accessible memory:
Verbally accessible memories are what we see with regular autobiographical memories. They can be edited and retrieved automatically or consciously with deliberate processes. The trauma is put into context reflecting what happened before and after the event and has received enough processing that it can be stored in the long-term memory and later retrieved. These memories are ready for verbal communication, but are limited by the person’s attention. An individual with a high level of arousal would have less attention and would not be able to register all the details of the event and be able to communicate them. The emotions that accompany these memories are processed both during and after the event as the individual reflects on the consequences of the event.
Situationally accessible memory:
Situationally accessible memory are more related to PTSD and flashbacks. These memories are created through lower levels of processing and are much more extensive during the trauma and involve the body’s emotional response. This causes these memories to be more vivid and detailed and there is a larger effect than regular memories on the individual. They cannot be easily controlled because they are often triggered by sights, sounds, smells, that are reminiscent of the event. The emotions that are felt when the memory are recalled only consist of the emotions felt during the trauma and other moments of intense arousal such as fear, helplessness, horror, and shame.
What is the role of fear in PTSD?
Fear often accompanies the memories that PTSD patients suffer. Even after psychotherapy, fear can easily be reactivated in PTSD patients. To get rid of this fear response individuals need to have a new representation of the event which can deter the activation of original memories. The individual recognizes that the stimuli no longer represents threat, and therefore will create new memories surrounding the experience and stimuli. An individual can be trained to encounter similar experiences in a way that promotes a more positive outlook on the event, but if they are confronted by something that is very similar to their previous experience it can lead them to be fearful again. The amygdala, which is a structure in the brain, is essential for fear. It releases stress hormones, activates the sympathetic nervous system and behavioral responses such as fight or flight and freezing. Information from the sensory organs provide information to the amygdala which in turn creates a response. Defensive responses can be induced fairly quickly by stimuli signaling threat. Pathways from the prefrontal cortex can both stop and control the amygdala. The hippocampus can also stop the amygdala from responding, but this is believed to occur because the hippocampus projects to the prefrontal cortex. As stress increases the function of the hippocampus increases until stress peaks and hippocampal function drops. The amygdala’s function on the other hand continues to increase as stress increases. This gives evidence for flashbacks because the memory itself is non declarative, therefore they are non-hippocampal. The amygdala tends to project to visual areas of the brain which mirrors with the vividness of the flashbacks.
By intentionally focusing attention to the content of the flashback one can move the memory from the non-hippocampally (uncontrollable) dependent SAM memory to the hippocampally based VAM and be intentionally recoded. The memory, now being stored temporally and located in the past, will no longer make the person feel threatened and will allow them to feel safe. They will no longer have flashbacks of that particular experience and they will be able to control that particular memory. This allows the event to be located in proper context, so that if the memory is recalled it will not make the individual feel as if they are reliving the experience. It will rather be seen as a memory in a sequence of experiences. In order to recall memory in full detail so that it can be recoded into VAM an individual will have to have repeated flashbacks. This will allow the cortex to create a detailed representation of the memory that inhibits the amygdala. The amount of flashbacks depends on how much information is in each flashback and how closely the individual is paying attention to the flashback as well as their willingness to process the content. This can be difficult because the flashback is tied to many negative emotions and are often unwelcome. The failure to create a detailed representation of the memory will cause the trauma to reside only on the SAM, which can be reactivated by triggers and cues.
Why do certain individuals develop PTSD?
High levels of stress may also cause there to be issues encoding the memory to VAM. This may result in the memory being seen from a different point of view other than their own, or the individual may feel like they are in a different state. This may result in the individual developing PTSD because they dissociate themselves from the event. The dissociation may be related to the helplessness that is felt during the experience, therefore the individual gives up supervisory control of the memory and experience. The memory may also not be transferred to VAM if there is an avoidance of the trauma cues, triggers, and flashbacks. This interferes with the construction of detailed memories resulting in PTSD. There are two possible negative adaptions to trauma. The first one being that the individual may label too many things as possibly threatening, and therefore develop a lot of external triggers. The second would be to involve other emotions which increase the averseness of the flashback, such as anger or shame.
How is PTSD treated?
There are two approaches applied to PTSD treatment: exposure to the event and detail, and the changing of maladaptive behaviors. Both of these methods are proved to be effective in treatment. The treatment is more difficult if the memories themselves are more disorganized and fragmented. As stated previously fear is not always extinguished by psychotherapy, but as more of the triggers and cues are coded from SAM to VAM the reaction of fear is no longer prominent. These cues have to be put into context and associated with security in order to suppress that fear response. Instead of forcing the patient to piece together the incident, treatment can focus mainly on hotspots and triggers and reducing stress when being exposed to these triggers. Therefore, the individual will be able to recall the event without the feeling of fear or panic. It is important that the new representation of the stimuli is recoded in a distinctive way, so that is more easily processed in the VAM.
What are common treatments used?
Cognitive Therapy: The individual will identify what thoughts about the trauma cause them the most anxiety and make their symptoms worst. The individual will identify what it is about themselves and the world around them that creates fear. The individual will then learn how to replace these thoughts with less distressing thoughts and less damaging emotions.
Exposure therapy: The individual is to learn that fear is learned and in the same way the fear can be unlearned in terms of their traumatic event. The individual is supposed to talk about the event and learn how to control their thoughts and feelings, so that they are no longer afraid of the memories. The individual may also practice relaxation techniques and slowly expose themselves to memories, by tackling the memories that are less traumatizing and progressing to their hot spots.
Eye Movement Desensitization and Processing: The individual visualizes the worst memory involved in their experience with their current negative cognition concerning the event, while watching a stimuli presented to them by the therapists. It could be the therapists simply moving their finger. This allows the individual to distance themselves from the images and provides them with new thoughts, images, and associations. The performance of the real time action by the therapists is distinctive enough that it could be encoded into the VAM.
Imaginal reconstruction: This treatment involves envisioning the event and thinking about the current self intervening in the event. This brings about a reduction in anxiety.
Medication: Selective serotonin reuptake inhibitors are the most commonly used medications for PTSD. They are antidepressants so that the individual feels less sad and worried.
In addition, these are some other therapies that are often used:
Group therapy: This therapy allows individuals to talk with others with similar experiences. The group aspect makes individuals feel more comfortable sharing their stories and eventually leads them to feel more comfortable with the trauma and coping. The group therapy gives individuals the chance to build relationships with others and learn from those around them. The individual will learn how to focus on their present life, instead of being so involved with their past.
Brief psychodynamic psychotherapy: This treatment allows individuals to learn how to deal with their emotions that are caused by the traumas. The therapy helps individuals identify what triggers flashbacks, creates coping mechanisms for each individual, become attune to their feelings, and raise the individuals self-esteem.
Family therapy: This therapy is often coupled with an individual therapy. This therapy focuses on familial relationships and ensuring that the individual maintains a good relationship with their family. This treatment allows the family to learn how to work with the individual with PTSD and cope with their own feelings about the individual and PTSD.
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