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The Valor of Stress

James_DixonUnlike for physical injuries, no formal recognition is currently given by the US military for the biopsychosocial injuries sustained in combat, known as posttraumatic stress disorder or PTSD.  It is as if the many behavioral, emotional, and social consequences of traumatic stress are perceived to be of lesser impact, and thus less deserving of acknowledgement.  That they can be serious enough to warrant medical and psychological attention is now fairly well established.

The evidence is certainly not lacking, as serious outcomes of PTSD continue to occur. Most recently, the blog The Soldier’s Load reported  the story of  James “Rooster” Dixon III, an ex-Marine and long-time sufferer from PTSD who was killed by a State Police SWAT team in front of his house in Baxley, Georgia.

James sought treatment from the VA for his Post-Traumatic Stress Disorder (PTSD), but was unable to shake the constant anxiety and depression that are hallmarks of the disorder. On February 19, 2012 James decided to end his struggle by walking into the bullets of law enforcement: as much a casualty of the war as any service member who died in Iraq.

The blog’s editor, as someone with direct experience of war zone and combat stress and its psychological consequences, also offer insights into his own struggles with PTSD.

I became a functional recluse—avoiding social situations and new experiences that might trigger a panic attack. Friends and acquaintances got accustomed to me declining their invitations to socialize. Eventually they stopped asking. I drank heavily and destroyed romantic relationships in a depressing cycle of thrilling novelty, fear of entrapment and cold dismissal. After three years of struggling with the symptoms of my unknown malady, I chose to leave the Marine Corps. On my way out the door, the VA finally diagnosed me with combat-induced PTSD.

A Purple Hart for PTSD?

images Events such as the tragic end of James Dixon highlight the important questions that still surround how PTSD is perceived, labeled, acknowledged and treated—including the idea of awarding a Purple Hart in recognition of this very serious constellation of injuries that are sustained by so many service men and women. According to the Military Order of the Purple Heart, the Purple Heart medal “is awarded to members of the armed forces of the US who are wounded by an instrument of war in the hands of the enemy and posthumously to the next of kin in the name of those who are killed in action or die of wounds received in action. It is specifically a combat decoration.”  Should this wording be applicable to PTSD?

The Soldier’s Load asks,

Why do we fail to classify veterans with PTSD as combat wounded? I suggest that the reason has less to do with logic and more to do with the emotions surrounding a small bronze portrait suspended from a narrow purple ribbon. (…) Until we correctly label combat-induced PTSD as a “wound” suffered from contact with the enemy, we as a society will continue to view its sufferers as a shadow legion of men with strange habits and questionable character. We will not methodically identify the trauma, apply medical treatments, and provide appropriate rehabilitation and therapy during the recovery process. In short, we will draw distinctions between segments of combat veterans based on an arbitrary and antiquated determination that only the visible wounds of war are worth recognition, honor and treatment. Such a view will not be helpful to the thousands of combat veterans waging a daily war within, nor prevent some from ending that struggle before victory is won.

Read the full blog post. Do you support a Purple Hart for PTSD?

When Stress Becomes Trauma

aaHiroshige_TakanawaThere have been considerable advances in the last few years of our understanding of stress, its origin, its antecedents and the course of its manifestations. Significant progress has also been made in understanding what can help reduce its effects on functioning and mood. In spite of the barrage of advertising that promotes such “remedies” as prescription opioids and “benzos” and the ever-present allure of alcohol or marijuana, many people now know that exercise can work just the same, if not better, in reducing stress and anxiety.

There are certain stressors, however, that produce effects that go beyond and cross into a different domain, that of traumatic stress. Recent research places posttraumatic stress disorder (PTSD) within a theory of pathological anxiety, whereby the individual becomes vulnerable in two very important ways.

The first vulnerability precedes the traumatic stressor and is an innate, and therefore genetic, biological predisposition of the individual toward experiencing intense, negative emotions that can easily escalate into panic or degenerate into depression. This biological vulnerability can have many effects, chief among which is the inability to correctly assess the difference between true and false alarms and the subsequent inability to correctly decide on the most appropriate response between fight, flight or freeze. A true state of alarm arousal is the normal and most appropriate reaction to a truly threatening event or situation, i.e. what most people would find dangerous or risky. A falsely perceived state of alarm is one that causes a sudden and involuntary mobilization of the body and the mind’s defenses, in the presence of a situation or event that is objectively non threatening but is assessed as such by the individual who is genetically predisposed to an intense alarm reaction.

The second vulnerability is psychological in nature. Individuals who develop this sensitivity report a greatly reduced sense of control over events and situations. They tend to approach the present and imagine the future with anxious apprehension. Their mood is often characterized by an anxious state of exaggerated vigilance, whereby it is inherently hard to relax and enjoy life. Cognitively, they expect and anticipate the appearance of various threats, external and internal, with an attending constellation of negative emotions (fear, obsession, panic). This complex system of cognitive and emotional arousal usually promotes avoidance and triggers a near-constant state of worry.

When applied to traumatic stress, these vulnerabilities magnify the experience of a traumatic event and trigger a significantly more severe state of alarm at the time of the trauma. It is well known fact that some individuals appear able to remain relatively calm in the face of traumatic events, while others (who are more likely to have bio-psychological vulnerabilities to intense stressors) seem to quickly “fall apart” and be seemingly “destroyed” by the circumstance.

When the intense trauma passes, these individuals remain in a state of arousal that continues to trigger alarms in response to internal and external stimuli associated with the trauma, and their
initial response to it. For example, a sudden noise may trigger the stimulus associated with a bomb blast, or a burst of anger by another may trigger a stimulus associated with physical abuse. These learned responses to real or perceived threats produce a state of anxious apprehension which, in PTSD, includes the re-experiencing of emotions. This near-continuous state of alarm may, in time, be mitigated by coping mechanisms which generally consist of an individual’s efforts at avoiding the triggers of the learned alarms and the strong emotions associated with them. Intense avoidance of any stimulation that may results in a re-experience of the traumatic events and its associated emotions can eventually developed into a state of emotional numbing, where even those stimuli that should provoke a reaction do not.

Just 14 of the Many Facets of Stress

aaTintoretto_SanGiorgioDragoMRI scans have revealed that children of depressed mothers have a larger amygdala, a part of the brain associated with emotional responses, researchers from the University of Montreal explained in the Proceedings of the National Academy of Sciences (PNAS).

A new study published in the American Journal of Industrial Medicine reveals that the World Trade Center attacks affected the health of the New York City Fire Department (FDNY) resulting in more post-9/11 retirements than expected.

Researchers in the Hotchkiss Brain Institute (HBI) at the University of Calgary’s Faculty of Medicine have uncovered a mechanism by which stress increases food drive in rats.

Do you run when you should stay? Are you afraid of all the wrong things? An enzyme deficiency might be to blame, reveals new research in mice by scientists at the University of Southern California.

Constant bitterness can make a person ill, according to Concordia University researchers who have examined the relationship between failure, bitterness and quality of life.

Listening to music or sessions with trained music therapists may benefit cancer patients. Music can reduce anxiety, and may also have positive effects on mood, pain and quality of life, a new Cochrane Systematic Review shows.

Researchers at Harvard-affiliated McLean Hospital have found that those who believe in a benevolent God tend to worry less and be more tolerant of life’s uncertainties than those who believe in an indifferent or punishing God.

Knowing the right way to handle stress in the classroom and on the sports field can make the difference between success and failure for the millions of students going back to school this fall, new University of Chicago research shows.

An 8-week course of stress-reducing Transcendental Meditation resulted in a 50% reduction in PTSD (post-traumatic stress disorder) symptoms among Iraq/Afghanistan veterans, researchers reported in Military Medicine. The pilot study involved five veterans aged 25 to 40 years with PTSD symptoms – they had all served between 10 and 24 months and had been involved in moderate or heavy moderate combat.

When parents fight, infants are likely to lose sleep, researchers report. "We know that marital problems have an impact on child functioning, and we know that sleep is a big problem for parents," said Jenae M. Neiderhiser, professor of psychology, Penn State. New parents often report sleep as being the most problematic of their child’s behavior.

By helping people express their emotions, music therapy, when combined with standard care, appears to be an effective treatment for depression, at least in the short term, said researchers from the University of Jyväskylä in Finland who write about their findings in the August issue of the British Journal of Psychiatry.

Young adults whose mothers experienced psychological trauma during their pregnancies show signs of accelerated aging, a UC Irvine-led study found. The researchers discovered that this prenatal exposure to stress affected the development of chromosome regions that control cell aging processes.

A child who has a psychological adversity or a mental disorder that starts during childhood has a higher chance of developing a long-term (chronic) physical condition later on, researchers from the University of Otago, Dunedin, New Zealand reported in Archives of General Psychiatry. The authors explain that child abuse has been linked to a higher chance of adverse physical health outcomes.

Individuals with anxiety-related symptoms who self-medicate with drugs or alcohol have a higher risk of having a substance abuse problem and social phobia, researchers from the University of Manitoba, Winnipeg, Canada, revealed in Archives of General Psychiatry.

Female Soldiers At Greater Risk for PTSD

US_Flag_Flying_1Results of a 3-year longitudinal study of 2665 female National Guard soldiers began in 2008 of their mental health status before and after their deployment to Iraq provides new evidence that women have more than twice the risk of developing combat-related posttraumatic stress disorder (PTSD) than their male counterparts, 18.7% vs. 8.7%. Women soldiers, with the same level of combat exposure, are also much less likely than men to feel prepared for combat (14.3% vs. 32.2%) or to take advantage of unit cohesion, which are the two most important protective factors against PTSD.

When we investigated the reasons for this we found men felt much more prepared for combat than women, and they were also much more likely to feel they had the support of their unit than women.—Anna Kline, Ph.D. Principal Investigator, Department of Veterans Affairs–New Jersey Health Care System, East Orange

The results of this study, presented May 17 at the American Psychiatric Association 2011 Annual Meeting, confirm previous studies among the general population, which have shown a higher prevalence of PTSD from all causes among women compared with men. What made this study among servicewomen possible was the higher percentage of female soldiers in combat zones, which in Operation Iraqi Freedom and Operation Enduring Freedom reached a high of 14% of total deployed forces.

According to the researchers, these findings may be more accurate because the study was conducted in anonymity. This factor alone may have improved the reliability of findings, as asking sensitive questions about mental health and substance use among identifiable servicemen and women has been shown to produce less that candid responses.

"The military now has integrated gender-based basic training so men and women do prepare together. However, it is possible that even if they get exactly the same training, their perceptions [of training] could be very different. It is also possible that training is geared more towards the strengths of men, so they feel more prepared to handle the rigors of combat. These are areas that need further investigation," said Dr. Kline.

Stuck On Wide Open: Emotional Dysregulation

domesticviolenceEmotional regulation is perhaps the most dramatically visible and the prototypical feature of an individual’s personality. Many people appear to be mostly in command of their emotions at critical moments, while others appear to be particularly (and sometimes explosively) reactive to environmental and interpersonal challenges. In general, affective or emotional instability, inordinate bursts of anger, intense efforts to avoid real or perceived abandonment, and unstable interpersonal relationships point to an underlying attribute of emotional dysregulation. This set of features has been popularized as belonging to “drama queens,” or persons who tend to react to every situation in an overdramatic or exaggerated manner.

Sometimes, instances of emotional dysregulation in children (“acting out” behaviors) or in adults under the most severe stressors can be viewed as the only available response in circumstances in which overwhelmingly strong emotion must be expressed, such as in the context of an emotionally abusive family environment or in times of great personal upheaval.

DramaQueen1A large body of research suggests that alcohol use can increase underlying emotional disturbance and disrupt cognitive functions that are very important in emotional self-regulation. Support for this hypothesis comes from studies that find associations between alcohol use and short- and long-term emotional change. In the short term, alcohol can disrupt emotional stability by effectively removing barriers against violence, verbal abuse, and inappropriate behaviors. In the long term, alcohol dependence and addiction can create a false persona in which it becomes difficult if not impossible to distinguish between the individual’s genuine personality traits and those modified or instigated by alcohol use.

Emotional disorders, particularly when they are characterized by pervasive emotional dysregulation, are often characterized by high negative emotionality and low positive emotionality. A significant challenge in trying to downregulate negative emotions is to become less vulnerable to negative or distressing emotions, with the objective of increasing calmness and resilience in stressful situations.

To achieve better emotional regulation, biological change and contextual change are needed. Biological change is achieved by reducing individual reactivity to emotional stimuli. Even when this reactivity may be due to genetic dispositions (temperament) and early developmental experiences (nurture), most people can learn ways to better control their emotional expression. There is a combination of skills and interventions that is particularly helpful in promoting biological homeostasis and emotional stability. These include treating any underlying physical illness that may have a negative effect on mood, balancing nutrition and eating to replenish and maintain physical resources, staying off non-prescribed mood-altering substances, getting sufficient but not excessive sleep, and getting adequate physical exercise.

Contextual change refers to learning and practicing emotional resiliency, which is the ability to minimize negative effects of stressful events and situations, and to maximize the positive effects of positive outcomes and opportunities. The skill of resiliency is learned and reinforced by intentionally accumulating positive life events, i.e., making a conscious and deliberate catalog of what’s positive in one’s life and referring to it often until it is present and readily available in time of need. It also consists of developing practical skills that build a sense of generalized mastery and promote self-esteem, e.g., completing school, obtaining additional job training, taking an assertiveness course, and the like.

What Causes (And Cures) Emotional Dysregulation

The amygdala has been implicated in emotional dysregulation, aggressive behavior, and psychiatric illnesses such as depression. Anxiety disorders and dysregulation may be the result of too much activity in the amygdala and not enough activity in the prefrontal cortex (PFC), which is the executive center of the brain that sets boundaries of behavior and responds to criteria of calm, assertiveness, and emotional regulation.

BDNFStress, coupled with a genetic vulnerability, decreases the production of brain-derived neurotrophic factor (BDNF). BDNF is a protein that acts on the nervous system by helping the survival of existing neurons and promoting the growth and differentiation of new neurons and synapses. A reduction in BDNF production causes a thinning of neuronal structures, which can results in emotional disturbance. These structural changes make the prefrontal limbic governing system vulnerable to disruption and dysregulation. Thus, emotional stress, loss, or  other significant psychological factors cause the system to lose self-regulation.

Treatments such as antidepressant medications, lithium, electroconvulsive therapy, exercise, psychotherapy and good social support can reverse this process, increase the production of BDNF, renew neuronal growth, build more resilient self-regulating circuits, and return the individual to a healthy mood.

Disorders of Emotional Dysregulation

PTSD, or posttraumatic stress disorder, is characterized by very significant emotional dysregulation. Its sufferers experience unwarranted arousal—often caused by stimuli processed Depressed-Soldier-02outside of conscious awareness—and exhibit an exaggerated startle response, vivid intrusive thoughts, and flashbacks and nightmares related to past traumatic events. PTSD victims may frantically try to avoid physical or psychological reminders of their trauma, and may experience dissociative symptoms or emotional numbing. PTSD is a disorder of emotional dysregulation characterized by excessive fear, triggered by a severe and often life-threatening traumatic event.

Borderline personality disorder (BPD) is characterized by emotional dysregulation, the temporary but frequent inability to change or regulate emotional cues, experiences, actions, verbal responses, and nonverbal expressions. Individuals with BPD experience greater emotional sensitivity, greater emotional reactivity, and slower return to normal levels of arousal after intense stimulation.

Frontal lobe disorders, which have become rather common among combat survivors, are the product of traumatic brain injury and are characterized by emotional dysregulation, attention deficit, impulsivity, lack of inhibition,  poor insight, impaired judgment, and low motivation. These frontal-subcortical disorders can result not only from war zone trauma, but also from infection, cancer, stroke, and neurodegenerative disease. Explosive violence, often directed at family members, is a common occurrence, particularly in individuals in whom impulsivity, disinhibition, and emotional dysregulation are the most dominant features.

Finally, obsessive-compulsive disorder (OCD) is characterized by emotional as well as cognitive dysregulation, brought on by a disruption of both the “thinking” prefrontal and the “feeling” paralimbic networks.

In these and other disorders that feature emotional dysregulation, it is interesting to note that the anatomic structures that are affected have emotional as well as cognitive functions. This coincidence highlights once again the close interdependence of affective and cognitive operations in the human brain. We can’t feel deeply without thinking intensely, and vice versa.

The Ineffable Madness of War

guernica-picasso
Over 2.2 million American service members have served in Iraq or Afghanistan since September 11, 2001.

Detailed statistics have been recently released that reveal the enormous cost in lives and health of these two ongoing American wars:

  • The US Veteran’s Administration (VA) has diagnosed 167,000 new cases of post-traumatic stress disorder (PTSD), 195,000 cases of depressive conditions and affective psychoses, and 103,000 cases of anxiety disorders among these troops.
  • The suicide rate in the Army and Marine Corps has, for the first time, equaled that of the US civilian population.
  • An estimated 18 US veterans are dying by suicide each day, according to the VA.
  • In 2009 throughout the Army, 160 soldiers died by suicide, at the same time as 160 soldiers died while serving in Iraq, i.e. one suicide for each combat casualty.
  • In 2009 worldwide another 146 Army soldiers died from unintentional drug overdoses, murders, or from other causes that the Army labels as risky behaviors.
  • The Army reported over 1700 known suicide attempts in 2009.
  • The suicide rate in 2009 for the US Marines was 24 suicides per 100,000 marines, which was even higher than the 22 suicides per 100,000 rate of the US Army.

Stress Like an Egyptian

hosni-mubarakPower stresses. Absolute power stresses absolutely. This easy paraphrase of a famous saying about the corruptive effect of political power can perhaps convey the enormous stress that tyrannical political power can cause at the micro and macro levels of a nation-state. The classic fight-flight-freeze stress reaction is magnified by the stark reality of the actual physical danger, and enormous emotional cost, that comes with ruling a country with an iron fist. An absolute ruler is nearly always unloved, feared, and only forcibly respected by his immediate entourage and of course even more so by his countrymen at large. This must be Mr. Hosni Mubarak’s plight right now, as his country of Egypt is in the throes of a more or less peaceful, and some say long overdue, revolution to overthrow his 40-year-old quasi-dictatorship. How is he coping?

The 82-year-old Mr. Mubarak is nothing if not a survivor of trauma. A seemingly perennial victim of acute traumatic stressors, he has survived three wars, an Islamic uprising and multiple assassination attempts. His beloved 12-year-old grandson, Muhammad, died suddenly of a brain aneurism. He came to power on October 7, 1981 when the president of Egypt, Mr. Anwar el-Sadat was assassinated not three feet away from then-vice president Mr. Mubarak in a hail of gunfire and grenades. It is possible that, since that day, Mr. Mubarak may suffer from posttraumatic stress disorder (PTSD).

This seminal traumatic event, and the others that followed, may have engendered in Mr. Mubarak a strong desire for safety and stability above all else. In the current circumstances, he has reacted to the calls for his resignation in true-to-character fashion with a staunch change-resistant response, which one Arab official has called, “his reflex adherence to the status quo.”

It is perhaps not coincidental that President Obama told reporters he believes that Mr. Mubarak’s decision not to seek reelection may represent an important “psychological break” that could transition the Egyptian president out of power. The decision must not have come easily for Mr. Mubarak, and must have required a significant departure from his usual modus operandi of maintaining the safety of the status quo.

Mr. Mubarak appears to have rationalized his deep-seated aversion to change and his need to ensure survival and safety for himself, his family and the country he rules, with a near-absolute belief that he is the only person who can guarantee Egypt’s political, economic and social stability. It is nothing short of a psychological drama that he is now the focus and the very symbol of Egyptian crisis, the very instigator of chaos on the streets and political and economic turmoil.

For 40 years, Mr. Mubarak has lived in splendid isolation from danger in the presidential palace in Cairo or at his private residence in the seaside community of Sharm el Sheik, both heavily guarded by a corps of bodyguards. His acquaintances describe him as a man who does not show emotion, who can be forceful and aggressive in pursuing his views, but maintains a near-absolute control over the privacy of his feelings. As if the world around him was just too dangerous to risk betraying the slightest hint of weakness.

PTSD Takes a Heavy Toll on Mind and Behavior

aaRenoir_NiniAuJardinPosttraumatic Stress Disorder (PTSD), regardless of its cause, takes a heavier toll than it is widely known on the mind and behavior of its victims. PTSD sufferers feel, think and behave as in a state of prolonged, and for some even unending, stress reaction. This disorder of the mind strikes after a traumatic event has disrupted a person’s life. Immediately following an experience such as combat, rape, assault, physical abuse or violence, a natural disaster or a terrorist act, most people react with acute stress. They may persistently re-experience the trauma in recurring images, thoughts, dreams, illusions, flashbacks, some form of dissociation or derealization, and in the inability to recall details of the event. Significant anxiety is also felt, with poor concentration, difficulty sleeping, irritability, hypervigilance, startle response and restlessness. For a minimum of two days and up to four weeks after the event, Acute Stress Disorder is the natural and expected reaction to the magnitude and seriousness of the psychological impact of the trauma. Even though the disturbance can cause impairment of functioning and significant distress during this time, many of these symptoms generally subside and even disappear within three to four weeks of the event. Except when they don’t.

The Many Forms of PTSD

In PTSD, all these symptoms, often in more severe form, persist well beyond the 4-week span of acute stress. In many cases, as in Acute PTSD, the symptoms last up to three months. In Chronic PTSD, they can continue indefinitely, especially if the disorder remains unacknowledged or is inadequately treated. In some cases, after the acute stress phase is over and life seemingly has returned to normal, PTSD can suddenly appear six months or longer after the trauma has occurred (PTSD with Delayed Onset).

This disorder causes great anxiety and a disruption of life’s activities that can have serious financial and social consequences. It also takes a heavy toll on the mind of its victims and affects their behavior in multiple ways, by inhibiting certain actions, modifying others, and removing barriers to self-injurious acts, including suicide.

The Heavy Toll on the Mind

Many survivors of severe trauma who suffer from PTSD develop self-focused beliefs that have a victim theme. They may see themselves as being continually and particularly vulnerable to physical danger. In the wake of the 9/11 terrorist attacks on New York City and Washington D.C., many people continue to experience pain, fear, threat and a heightened sense of vulnerability. They may also perceive themselves as being mentally defeated.

"Ball four… take your base."  Those were the sympathetic words of the umpire during my little league baseball pitching debut – after I had walked the 11th batter in a row, thus… run number seven.  My coach finally started to come out to relieve me, and I was glad to be taken out of the game.  Feeling mentally defeated and miserable, as he approached the mound, I desperately needed a little comfort and compassion from the adult leader of the team. Unfortunately, I was met with criticism and a few choice words that confirmed my perceived inadequacy as a baseball player. –-Dwayne K. Smith

It is not unusual for PTSD sufferers to continuously dwell on the negative implications of their traumatic experiences. Although they may protest that their trauma safely belongs in the past and no longer bothers them, they remain preoccupied with their own view of themselves and with others’ views of their behavior under fire, their inability to fend off their attacker, their shattered self-esteem. Lastly, a persistent imagining and a continuous ruminating about what might have happened (a “wishing the past could have been different”) blocks progress toward real healing and forgiveness. The experience continues to rerun on the horror channel, and is seldom if ever safely archived in the history channel.

Depressed-Soldier-02Alongside with bothersome thoughts and negative self-assessments, the constellation of symptoms also induces the development of negative beliefs about the world and the future. Most common are the belief that the trauma consequences are permanent and unchangeable; that the world has become unsafe, unpredictable, untrustworthy; that the future will be negative; and that life has lost its meaning. In the most severe cases of PTSD, these beliefs can lead to deep feelings of hopelessness and despair and culminate in suicide. According to recent US Army data, there are an average of 950 suicide attempts each month by veterans who are receiving some type of treatment from the Veterans Affairs Department. Seven percent of the attempts are successful, i.e. 18 veterans commit suicide each day, and 11 percent of those who don’t succeed on the first attempt try again within nine months.

How PTSD Negatively Affects Behavior

PTSD wreaks havoc on the individual’s behavior patterns, by inhibiting certain protective actions and inducing others that can be harmful or at the very least do not promote recovery. Among the actions that are most often induced by PTSD are behaviors associated with a continuous state of hypervigilance, such as barricading doors and windows, sleeping with a weapon nearby, frequently checking behind one’s back and scanning the environment for threats. In the same vein, the individual may also intentionally avoid any reminders of the traumatic events, dissociate, engage in “undoing” behaviors that more properly belong to compulsive disorders, withdraw from social contact, abandon normal and previously pleasurable routines, and engage in unsafe behaviors such as gambling or drug and alcohol abuse.

Among the behaviors that PTSD may inhibit are change behaviors that could help treat the disorder, such as psychotherapy, counseling or medication; communication behaviors that could help share one’s trauma story with others, including openly acknowledging the symptoms that are being experienced. The individual may also dismiss the notion that anything positive could result from trauma experience, and not read, watch or listen to information that would disconfirm their negative beliefs. Perhaps most harmful, PTSD also inhibits the seeking of social support from close relatives and friends, and the utilization of available means of coping (such as faith and religious practices).

Treatment Options for PTSD

Empirically-validated treatment options for PTSD that have been proven as effective include:

  • Cognitive-behavioral psychotherapy. This type of talk therapy is effective in desensitizing the individual by a gradual and guided exposure to negative and irrational thoughts, images, situations and feelings that are reminders of the traumatic event, in a safe environment. The treatment may last for a minimum of three months and up to one year of weekly session.
  • Family counseling. Family therapy is especially effective in treating not only the individual who is directly affected by PTSD, but also spouses, children and extended family that may also be affected by the symptoms. Family therapy promotes understanding, facilitates communication and helps address the relationship problems that almost always accompany a case of PTSD.
  • Medication. Psychotropic medication, most often fluoxetine (Prozac) or sertraline (Zoloft), is prescribed in PTSD to relieve severe symptoms of depression or anxiety. These medications have an effect on the symptoms, but they do not treat the causes of PTSD.
  • EMDR (Eye Movement Desensitization and Reprocessing). This treatment consists of cognitive-behavioral therapy combined with guided eye movements, hand taps or sounds. In EMDR, the bilateral stimulation of the brain works by reprocessing highly charged fragments of memory and emotion and integrates them into safer and less emotion-laden memories.

School Bullying Is Much More Than ‘Just What Kids Do’

aaMondrian_BroadwayIs school becoming an increasingly dangerous place for our children’s mental and physical health? A study of 43,321 high school students confirms that student-on-student bullying has become a serious problem in public and private schools across the United States. Its behavioral, health and social consequences are lowered academic achievement and aspirations, increased anxiety, loss of self‐esteem and confidence, depression and PTSD, general deterioration in physical health, self‐harm and suicidal thinking, feelings of alienation in the school environment such as fear of other children, and absenteeism from school. In response to recent high-profile bullying cases, the U.S. Department of Education has sent this letter to over 15,000 school districts across the country, in which school officials are reminded of their responsibility and legal obligation to protect the civil rights of all students, regardless of their nationality, race, sex or disability status.

The study, conducted by the Josephson Institute of Ethics, was released on Tuesday and is the largest ever undertaken of the attitudes and conduct of high school students. The truly sobering results show that 50% of all high school students admit they bullied someone in the past year, and 47% say they were bullied, teased, or taunted in a way that seriously upset them in the past year. 33% percent of all high school students say that violence is a big problem at their school, and 24% say they do not feel safe at school. 52% admit that within the past year they hit a person because they were angry. 10% of students say they took a weapon to school at least once in the past 12 months, and 16% admit that they have been intoxicated at school. The study clearly shows that there is almost no difference between public, religious private and non-religious private schools in the students’ perceived safety, or in the percentage of perpetrators and victims of bullying.

In the press release accompanying the results, Institute Director Michael Josephson said, “If the saying, ‘sticks and stones will break my bones but names will never harm me’ was ever true, it certainly is not so today. Insults, name calling, relentless teasing, and malicious gossip often inflict deep and enduring pain. It’s not only the prevalence of bullying behavior and victimization that’s troublesome. The Internet has intensified the injury. What’s posted on the Internet is permanent, and it spreads like a virus – there is no refuge. The difference between the impact of bullying today versus 20 years ago is the difference between getting into a fist fight and using a gun. The combination of bullying, a penchant toward violence when one is angry, the availability of weapons, and the possibility of intoxication at school increases significantly the likelihood of retaliatory violence.”

Army Suicides Highest Ever and Rising

aaCarignano_CrimeaThe number of suicides among active duty US soldiers is very high and it is rising at a faster rate: 125 Army soldiers have taken their own lives in the first eight months of this year. If suicides continue at this pace they will exceed the total for 2009, when there were a record 162 suicides. The trend shows little sign of abating, despite a now 20-month-old suicide prevention program and work aimed at removing the stigma of psychological counseling, the New York Times reports

Medical corps Army officers familiar with the situation have identified several factors that may be involved in the rising rate of suicides. While there is a widespread belief that repeated deployments are the principal cause of suicides, Army records show that 80% of soldiers who killed themselves were deployed in combat zones only one time or not at all. A significant number of the soldiers had experienced serious problems in their marriage. Many had sought counseling from Army psychologists for anxiety and posttraumatic stress symptoms. Interviews with family members indicate that in many cases, the soldiers believed that a diagnosis of posttraumatic stress disorder would ruin their careers. Additionally, many believed that their counselor or psychologist would not treat their condition as confidential, but would convey up the chain of command what the soldiers reported in private counseling sessions.

The Rising Cost of War: Military Sexual Trauma

RioAlseseca_EN-US608673953 The latest research on the long-term health consequences of Operation Enduring Freedom in Afghanistan (OEFA) and Operation Iraqi Freedom in Iraq (OIFI) suggests that US veterans are bringing home a significant number of psychological problems. The most recent study published in August by the American Journal of Public Health estimates that 19% to 42% of returning veterans have one or more clinically-diagnosable mental health conditions.

Returning servicemen and women are turning to the Veterans Health Administration (VHA) for health care in record numbers, with nearly 40% enrolled as of the end of July. In addition to posttraumatic stress disorder, depression, anxiety and stress disorders, and sleep impairment, another (somewhat overlooked until now) contributor
to this burden of mental illness is exposure to sexual assault or harassment during service. The newly categorized disturbance is referred to in military lingo as military sexual trauma.

This is not a new phenomenon, as military sexual trauma had been documented in veterans of previous wars. What is different this time, though, is that OEFA and OIFI veterans are the first generation of VHA users to return from a large-scale deployment and have access to comprehensive screening and treatment services.

The most recent study was conducted at the National Center for Posttraumatic Stress Disorder and the Center for Health Care Evaluation, VA of Palo Alto, California. It was the  first comprehensive assessment of the mental health profile associated with a history of military sexual trauma among Iraq and Afghanistan veterans.

The results show high rates of postdeployment mental health conditions among all OEFA and OIFI patients. Women and men who reported military sexual trauma were significantly more likely than those who did not to also be diagnosed with posttraumatic stress disorder (PTSD), other anxiety disorders, depression, and substance use
disorders.

Additionally, and not surprisingly, the study shows that the co-occurrence of military sexual trauma and PTSD is substantially more frequent among female soldiers than among males, suggesting that military sexual trauma may be a particularly relevant gender-specific clinical issue in PTSD treatment settings.

Stress, As Seen Through the Eye of Science

Bazille at Stresshacker.comWhen science looks at stress, the focus is on the body/mind interaction or, more precisely, on its psychophysiological mechanisms. Traveling back in time from our present condition to conception, we can see that our genes and the environment in which we grow up (in which our genes are expressed) determine how we respond to stress as adults. Our genetic and environmental differences (the nature or nurture of who we are) help explain how individuals exposed to the same stressful situation can have an entirely different reaction. Some can adapt successfully to the stressor (albeit not without discomfort), while others experience more severe immediate trauma and long-term emotional problems, such as PTSD.

During specific developmental periods, such as infancy, puberty, adolescence, adulthood, or maturity, certain stressors are almost certain to occur and are understood to be typical and appropriate to the process of maturation and change. The earliest such stressor is the effect of caregiving styles, which stems from the parents’ psychological state. An attentive and nurturing style produces vastly different effects on the child’s later adaptation to stress than a harsh, unforgiving or neglectful one. In adolescence, patterns of behavior and emotional reactivity—including the stress reaction—begin to crystallize and become fully set in early adulthood.

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Aroma Therapy to Ease Combat Stress?

The U.S. military is experimenting with aroma therapy, acupuncture and other unorthodox methods to treat soldiers traumatized by combat experiences, Defense Secretary Robert Gates said on Saturday. He said the experiments showed promise.

Gates touted possible treatments for post-traumatic stress disorder (PTSD) during a meeting with the wives of servicemen at Fort Riley, Kansas, when one woman asked him to explain why chiropractic and acupuncture therapies were not covered under her military health care plan.

"We have an experimental unit … treating soldiers with PTS (post-traumatic stress) and using a number of unorthodox approaches, including aroma therapy, acupuncture, things like that, that really are getting some serious results, and so maybe we can throw that into the hopper as well," Gates said. Pentagon Tries Aroma Therapy to Ease Combat Stress

Aroma therapy and acupuncture have been shown to have some influence on the symptoms of stress. However, their therapeutic effectiveness is a different matter.

One systematic review conducted by researchers at the School of Postgraduate Medicine and Health Sciences, University of Exeter located twelve clinical trials: six of them had no independent replication; six related to the relaxing effects of aromatherapy combined with massage. Another review conducted by the Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University in Providence located 18 studies meeting stringent empirical criteria.

The results of these studies suggest that while there is credible evidence that odors can affect mood, physiology and behavior, aromatherapy can at best have a mild, transient anxiety-reducing effect. [B7AGFR3T8K2S]

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Research News: PTSD, Attachment and Healing

Leutze_1851_WashCrossDelaware The number of suicides reported by the Army has risen to the highest level since record-keeping began three decades ago. Last year, there were 192 among active-duty soldiers and soldiers on inactive reserve status, twice as many as in 2003, when the war began. (Five more suspected suicides are still being investigated.) This year’s figure is likely to be even higher: from January to mid-July, 129 suicides were confirmed or suspected, more than the number of American soldiers who died in combat during the same period. The New York Times

What Is PTSD?

Posttraumatic stress disorder (PTSD) can occur after the trauma of experiencing or witnessing  threatened or actual death or serious injury, or other serious threat to the physical integrity of self or others, such as assault. This type of trauma is usually accompanied by intense fear, helplessness, or horror at the time of the event. Symptoms of reliving the trauma and avoiding any reminder of it often create significant distress and negatively affect the individual’s  interpersonal and occupational functioning. In the acute phase, PTSD symptoms can last up to three months after the event. When the symptoms persist longer, PTSD is said to be chronic. Often, symptoms do not begin immediately and they can be delayed for six months or more after the event. When inadequately treated, PTSD can have fatal consequences such as homicide and suicide.

Who Is Affected?

It is estimated[i] that 50%–90% of all people are exposed to at least one serious traumatic event during their lifetimes. However, only about 6%-8% develop PTSD and a third of those suffer a severe form of the condition.

What Are the Causes?

The mechanism by which some individuals are vulnerable to PTSD and not others has been variously hypothesized. The most prominent theories are:

  1. The biological model
    Information about external stimuli and their assessment is processed by the amygdala. Traumatic stressors produce an emotional reaction of fight, flight or freeze and significant increases in stress hormones. The hippocampus and medial prefrontal cortex mediate the final response of the individual in trying to cope with the traumatic event. This theory suggests that posttraumatic stress disorder occurs when there is a failure to regulate the activity of the amygdala, which results in hyper-reactivity to threat (what is often referred to as the amygdala hijack).
  2. The early childhood experiences model
    Most researchers have found that childhood trauma, chronic adversity, and family stressors increase the risk for PTSD in adulthood.
  3. The traumatic memory model 
    A theory that has gained prominence in recent years, it distinguishes between memories that are easily recalled and are associated with emotions related to the trauma and repressed memories that cannot be deliberately accessed and are associated with typical PTSD symptoms such as nightmares and flashbacks.
How Is It Treated?

Most treatments for PTSD consist of techniques that expose the individuals to imagined re-experiencing of the trauma under safe therapeutic conditions, an approach that dates back to the treatment of World War II veterans. This type of treatment includes extensive emotional processing and narrative reconstruction of traumatic events in psychotherapy session, and may also include daily home review of audiotaped sessions.

Other efficacious treatments are cognitive behavioral psychotherapy and eye movement desensitization and reprocessing (EMDR). These treatments also induce patients to consciously review (and thus reprocess) painful details of their traumatic experience in a therapeutically safe environment.

PTSD and Childhood Attachment

A recent study[ii] by Columbia and Cornell researchers suggests that childhood attachment problems may play a crucial role in the development of adult PTSD and that exposure treatment may not be the sole important treatment mechanism.

According to attachment theory, secure and insecure childhood attachment to the primary caregiver (most often the mother) has important consequences for adult functioning and psychopathology. The theory, developed by British psychologist, psychiatrist and psychoanalyst John Bolwby, suggested that the innate human drive to form attachments that elicit protective, caretaking behaviors from adults is a crucial aspect of healthy infant development. When the caregivers are available and responsive, the infant develops a secure attachment “base” that facilitates the child’s exploration of the world and relationships. When the caregivers are absent or uncaring, an insecure attachment style results, with consequences for adult self-esteem, perceived safety and interpersonal functioning.
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