by Jennifer Wolkin | Jun 22, 2015 | Brain Health, PTSD, Wellness
PTSD AND TRAUMATIC BRAIN INJURY (TBI)
As a neuropsychologist, I’ve had humbling interactions with those who have suffered trauma, in both mind AND brain. That’s why I feel it is incumbent to create awareness regarding co-occurring PTSD and TBI.
TBI is a traumatic injury to the brain as a consequence of an external impact injury and/or from the influences of rapid violent acceleration and deceleration of the head (impact of your brain moving in your skull). TBI can cause a host of Physical, Cognitive, Social, Emotional, and Behavioral symptoms. TBI is categorized as mild, moderate or severe; most TBI’s in general are mild in nature (mTBI). They are typically characterized by:
- A period of lost or decreased consciousness (30 minutes or less).
- Retrograde or anterograde amnesia (loss of memory for events immediately before or after the injury) which lasts less than 24 hours.
- A variation in baseline mental status at the time of the trauma (i.e., confusion, disorientation, etc.)
- Neurological and Neurocognitive deficits including sensory loss, aphasia (difficulties with speech), sensory perception, loss of balance, weakness, etc.
Both independently and additively TBI and PTSD are responsible for most post-deployment impairments. They often, however, coexist.
It is difficult to differentiate between symptoms caused by PTSD and those by TBI, because they are often so similar. For example, both PTSD and TBI produce symptoms such as confusion, impaired learning, forgetfulness, attention and concentration difficulties, decreased processing speed, impulsivity, reduced insight, impaired work and school performance, fatigue, insomnia, headaches, and reduced motivation. This overlap makes diagnosis, and subsequent treatment, that much more complex.
In a large military sample, almost three times as many troops who sustained a mild TBI screened positive for PTSD versus those who sustained “only” a significant bodily injury. It is said that TBI actually increases the risk of PTSD.
From a neurobiological standpoint, it is likely that neural damage sustained during the injury compromises the fine-tuned circuitry required to regulate fear following a traumatic experience (most of our fear reaction is mediated by fronto-temporo-limbic regions).
On a cognitive level, the effects of TBI at the time of trauma could influence the encoding of the traumatic event, how emotions are processed, and the degree to which trauma-related memories and feelings can be retrieved in a controlled, verbally accessible manner during therapy.
One of the most crucial steps in early mTBI management is dispensing information outlining the nature of expected symptoms and providing ways to best cope with them. This information should be imparted in the context of reassurance that symptoms will likely resolve: The literature indicates that individuals who assume the damage is permanent might actually be more vulnerable to a prolonged presentation of symptoms because they are more likely to become anxious over them.
A challenge for clinicians is to determine whether self-reported, non-specific symptoms, long after an injury, are related, partially related, or unrelated to the original injury and to make a proper diagnosis. Of course, the sooner an mTBI is identified, the sooner proper care is received.
Both mTBI and PTSD are complex and multifaceted, and therefore both require multifaceted treatment. Studies supporting the simultaneous treatment of both are sparse.
Some clinicians therefore, treat whatever is treatable to try and reduce overall suffering and improve functioning. Treating specific complaints (such as pain and insomnia) might result in concomitant benefit in other realms (such as cognitive difficulty and anxiety).
After all, any potential decrease in suffering is a step in the right direction.
To Thriving,
Jennifer Wolkin, PhD
by Jennifer Wolkin | Jun 15, 2015 | Brain Health, PTSD, Wellness
PTSD AND HEART HEALTH
As aforementioned trauma can literally render sufferers unable to connect with/to love either their SELVES or OTHERS. Therefore, in the philosophical sense, it is no shock that PTSD can lead to the proverbial ‘broken’ heart, which is not a cardiovascular disease, but a disease of the soul and spirit.
Ironically, PTSD has recently been deemed a major risk factor for cardiovascular disease. Research studies over the last decade have illustrated that people who experience PTSD are at increased risk of heart attack and cardiovascular death. As with pain, many mechanisms have been implicated in this relationship. Why are veterans likely to experience co-morbid cardiovascular disease (CVD)?
On a purely biological level, PTSD leads to physiological changes, including states of “hyper-arousal,” characterized by increased sympathetic system activity (i.e., increased blood pressure, heart rate, etc). This constant physiological arousal (constant “fight or flight” mode) can damage the cardiovascular system. Meaning, the actual physical toll that constant hyper-arousal takes is that it places a huge BURDEN on one’s heart.
In addition to a biological explanation, there are many poor health behaviors associated with this risk as well.
- People who experience psychological stress, including PTSD, are more likely to be non-adherent to medication and other treatment recommendations. Those with PTSD suffering from, for example, hypertension (high blood pressure) or diabetes are more likely to suffer a related cardiac event if they don’t take medication and leave the disease uncontrolled.
- People suffering with PTSD are at increased risk for tobacco use (almost twice as high as the general populations) as a way to self-medicate to decrease anxiety levels. Smoking, however, can cause CVD through atherosclerosis (hardening of the arteries) and increased risk for thrombosis (blood clot). Quitting also becomes more difficult because the withdrawal period will likely also lead to amplified physiological hyper-arousal.
- Those with PTSD are not future-oriented and are often shortsighted about their health, making it appear unnecessary to take any preventive measures, such as physical exercise, which is essential for heart health.
- Additionally, many with PTSD fear that exercise might actually cause increased health difficulties. Increased physical activity leads to increased physical arousal, and therefore, exercise is avoided so as not to recreate that “fight or flight” feeling.
Overall, on a behavioral level, those suffering with PTSD have a greater tendency toward the adoption of high-risk behaviors (i.e., smoking, drug use, etc). At the same time they are less likely to take preventive measures.
It is crucial that those with PTSD are informed about the need to adopt a healthy lifestyle. In addition to interventions specifically tailored to symptoms of PTSD, interventions geared toward specific lifestyle changes are warranted (i.e., smoking cessation programs, treatment compliance programs, etc) to prevent cardiovascular events.
What are YOUR thoughts? We always love to hear what you have to say in the comments section below.
To Thriving,
Jennifer Wolkin, PhD
by Jennifer Wolkin | Jun 8, 2015 | Brain Health, PTSD, Wellness
PTSD and CHRONIC PAIN
PTSD is mostly known for its impact on overall mental health. There is research, however, to support the fact that PTSD is increasingly being recognized for its effect on physical wellness as well. Many who suffer with PTSD (veterans in particular) have higher lifetime prevalence of circulatory, digestive, musculoskeletal, nervous system, respiratory, and infectious disease. There is also an increased co-occurrence of chronic pain in those who suffer with PTSD.
In 1979, the International Association for the Study of Pain (IASP) officially redefined pain as, “An unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage”. This definition takes into account the fact that pain involves thoughts and feelings. Meaning, pain is real whether or not the biological “causes” are known, and it is ultimately a subjective experience.
Pain experienced by veterans is reported as significantly worse than the pain of the public at large because of increased exposure to injury and psychological stress during combat. Rates of chronic pain in veteran women are even higher.
All veterans with chronic pain often report that pain interferes with their ability to engage in occupational, social, and recreational activities. This leads to increased isolation, negative mood, and physical deconditioning, which all actually exacerbate the experience of pain.
Why are veterans and others who suffer with PTSD more likely to experience co-morbid chronic pain?
Well, for veterans in particular, the pain itself is a reminder of a combat-related injury, and therefore can act to actually elicit PTSD symptoms (ie, flashbacks). Additionally, psychological vulnerability such as lack of control is common to both disorders. When a person is exposed to a traumatic event, one of the primary risk factors related to developing actual PTSD is the extent to which the events and one’s reactions to them are unfolding in a very unpredictable and therefore uncontrollable way. Similarly, those with chronic pain often feel helpless in coping with the perceived unpredictability of the physical sensations.
Some say that those who experience PTSD and Chronic Pain share the common thread of “anxiety sensitivity.” Anxiety sensitivity refers to the fear of arousal-related sensations because of beliefs that these sensations have harmful consequences. A person with high anxiety sensitivity would most likely become fearful in response to physical sensations such as pain, thinking that these symptoms are signaling that something is terribly wrong. In the same vain, a person with high anxiety sensitivity will be at risk for developing PTSD because the fear of the trauma itself is amplified by a fearful response to a “normal” anxiety response to the trauma (meaning, it is very “normal” to have a strong reaction to trauma, but most sufferers actually tend to be fearful of their own response).
What has YOUR experience been? Feel free to share in this forum. We are sensitive and respectful to the emotional burden of the topic.
To Thriving,
Jennifer Wolkin, PhD
by Jennifer Wolkin | Jun 3, 2015 | Brain Health, PTSD, Relationships, Wellness
PTSD AND INTERPERSONAL RELATIONSHIPS
Trauma calls into question the basic foundation of trust in human relationships. Traumatic events not only have effects on the psychological structures of the self, but also on the attachments that link an individual to a greater community. A trauma sufferer is likely to feel as though every relationship is infused with a sense of alienation and disconnection.
The impact of trauma pulls and pulls at the threads of relationships until they tear, or in many cases, disintegrate completely. Sometimes, when I work with the significant other of a trauma sufferer, I am shocked by how far the trauma reaches. It goes inward and outward. Its tentacles have few boundaries.
It is so pervasive, that I often wonder: Is Trauma Contagious?
The literature has demonstrated that PTSD affects family cohesion, parenting satisfaction, romantic partnership, and functioning and emotional security of children. Consequently, poor functioning in these domains is associated with higher rates of divorce and higher occurrences of clinically significant levels of relationship distress in the families of veterans with PTSD than in the families of veterans without PTSD or in the general population.
It probably can’t be overemphasized that poor health outcomes for children (poor development, higher rates of illness, lower academic performance, and cardiovascular disruption) are closely linked to this now-stressful family environment, which is created when the symptoms of PTSD literally intrude upon the family or relationship structure.
PTSD symptoms affect personal relationships indirectly as well. For example, veterans with PTSD are more likely than members of the general population to have clinically significant levels of depression, anxiety, anger, and violence. They are more likely to abuse substances and less likely to hold steady employment. All of these play a role in the breakdown of interpersonal functioning.
The nature of interpersonal problems experienced by combat exposed veterans appears to be correlated with the presence in particular of the avoidance and numbing characteristics of PTSD. In families and relationships, avoidance and numbing may create social isolation, a cold, and unresponsive parenting style, anger, and an absence of emotional warmth.
One of the most consistent relationships observed in trauma research is the inverse relationship between PTSD symptoms and social support (that is, the more social support, the fewer symptoms). The ultimate sad irony is that the people in the world of the trauma survivor are pushed away, though connection is the very thing that is needed.
A supportive response has shown to mitigate the impact of trauma, as the survivor yearns to establish a basic sense of safety and trust. The trauma survivor needs the help of others to rebuild his or her shattered sense of self. Yet, it is a long arduous process during which the survivor cycles between the need for extreme closeness and the need for distance and time to reestablish self-autonomy.
During this process, the toll that these cycles take is hard to gauge. In some cases, members of the support system suffer their own kind of trauma. If merely witnessing the person you love suffering through trauma is not a sort of trauma unto itself, then I don’t know what is.
Recovery for the sufferers and support systems is possible. It is crucial that health professionals understand the impact of PTSD on interpersonal functioning in order to provide the best treatment approaches for the sufferers and their social systems.
This is the third in a series of BrainCurves posts that I will be sharing on the topic of Trauma and PTSD throughout the month of June, National PTSD Awareness Month. Next week I will post about PTSD and Chronic Pain.
To Thriving,
Jennifer Wolkin, PhD
by Jennifer Wolkin | Jun 1, 2015 | Brain Health, PTSD, Wellness
PTSD AND GENDER
Both women and men are at risk of enduring unfathomable trauma, but it’s important to emphasize gender differences here, with the hopes that they can ultimately be a much-needed catalyst for improved preventative measures, diagnosis, and treatment.
In 2006, Tolin and Foa reviewed the results of about 25 studies, and indicated that women are approximately 2x as likely to meet criteria for PTSD than men, and also approximately 4x as likely to have more chronic iterations of PTSD.
The question that is begged is, what might account for the higher rates of diagnosis in women?
- Women are NO more likely to experience trauma in general, but ARE more likely to experience certain types of trauma, including sexual abuse and assault. These types of trauma are associated with greater risk for PTSD.
- When compared with male trauma survivors, women tend to react with self-blame, belief that their incompetence lead to trauma, and coping skills that are maladaptive such as mental disengagement and suppression of traumatic memories. This seemingly gender-specific expression of emotional distress post-trauma might explain greater rates of PTSD in women.
- Increased baselines of anxiety and depression might put women at greater risk for developing PTSD. Most studies assess participants after trauma has occurred, without taking into account base rates of premorbid psychological distress. This limitation can inflate the risk of PTSD.
- Women are more likely than men to experience multiple traumas across their lifespan and the cumulative effects of repeated traumas likely increase their risk of developing PTSD.
Research directed toward specific details regarding gender differences and veterans is still scarce. It is incumbent upon any clinician, who is screening for PTSD and related difficulties, to be sensitive to this difference.
Female Veterans and PTSD
Women veterans are particularly at risk of being involved in different types of traumatic incidences. There are reports of being sexually (rape) and physically assaulted during military duty, as well as experiencing “duty-related” trauma as part of their military exposure (i.e., warzone exposure).
Also, it is not uncommon to hear that many women in the military have suffered preliminary trauma that might predispose them to the development of full-blown PTSD following a subsequent traumatic exposure.
Recently, research indicated that screening positive for PTSD is associated with a range of self-reported health problems and functional impairments specifically among female VA patients. These include fibromyalgia, stroke, irritable bowel syndrome, chronic pelvic pain, and obesity. In some studies, women reported poor health-related quality of life (HRQoL) relative to both male veterans and non-veteran women. Veteran women with PTSD have significantly more somatic distress, co-morbid medical conditions, psychiatric difficulty, and substance abuse rates than non-veteran women.
Female Veterans and PTSD + Chronic Pain
Women veterans specifically diagnosed with PTSD usually have significantly higher rates of pain and overall poorer health than women in the general population. There is not a lot known about the context of “military culture” that might have implications for women’s health behaviors. Yet, veteran women’s increased prevalence of chronic pain is probably because their pain is compounded upon by extreme conditions that are not experienced by civilian women. The ability to manage chronic pain is probably egregiously limited within military context, such that pain is probably maintained or progressively worsens with little relief.
When chronic pain cannot be readily explained as the direct consequence of tissue damage, some people treating veteran women are apt to think, “It is all in the head.” Although at greater risk for experiencing PTSD and co-morbid pain, women veterans are usually under-diagnosed and also under-use mental health services. A reason cited is that even in our progressed society, women in this position continue to be stigmatized.
I want to take a moment to mention the obvious: both PTSD and Chronic Pain sufferers are often stigmatized. They are relegated to the “outskirts” of the community, and become “liminal” creatures. I see time and again that those who experience either trauma and/or pain are perceived as victims of their own devices rather than just as sufferers.
Fibromyalgia is a common diagnosis given to women post-deployment. As such, women are stereotyped as somatisizers and told that their pain is elicited from the mental construct called the psyche, and not the brain. This concept of somatization implies that pain symptoms are exaggerated or feigned and ultimately within the control of the sufferer.
A variety of social and medical critics view chronic pain in women as a post-modern illness sharing a lineage with nineteenth-century pseudo-maladies like hysteria. These illnesses, they contend, originate in vulnerable human psyches. Central to these suspicions is the seemingly unshakable belief that chronic pain is a psychosomatic disorder, with the implication that the sufferer’s pain is not medically “real.” Within this conceptual framework is the archetype of the traumatized woman who experiences her trauma symptoms in her body. I urge women to take a stand against stereotyping and to pursue quality treatment despite critics who might make it seem unwarranted.
As always…this is a stigma-free, nonjudgmental, open community. Your comments regarding intellectual, theoretical, and, of course personal accounts of trauma are cared for here. We’d love to hear from you.
To Thriving,
Jennifer Wolkin, PhD
by Jennifer Wolkin | May 22, 2015 | Brain Health, PTSD, Wellness
June: PTSD Awareness Month
This is the first of a series of posts that I’ve written on the topic of trauma and PTSD, especially for the month of June! I officially started this series last year, but I’m committed to revising it, adding to it, and updating it annually.
Trauma is one of the most sensitive issues I will ever speak about. In my writing, I want to make information as accurate and accessible as always, but to go to the nth degree to create a sensitivity and respect of all those who have been affected by trauma of any kind. I write this with the utmost respect for those who have and continue to suffer. My hope is that by creating awareness, I can increase health-care utilization and that more people are able to reach out for help.
CHARACTERISTICS OF PTSD AND TRAUMA
As a clinical health and neuropsychologist, I am witness to those suffering from trauma on a daily basis. Trauma is a broad term, and according to the American Psychological Association (APA), it is an emotional response to a terrible event. Unfortunately, the said terrible event can constitute a plethora of possibilities, including combat, rape, natural disasters and assaults. There are other potentially traumatic events, and though less talked about, are no less palpable. These can include illness, intra-psychic identity struggles and others’ responses to these struggles, divorce, and constant relocation as a child. Ultimately, any event might be considered traumatic if you have experienced and/or witnessed a threat to your life, a threat to your body, and/or moral integrity and/or witnessed or experienced a close encounter with violence or death.
Usually, when we are faced with danger, we go into fight or flight mode during which our bodies release hormones to help us act faster, to either fight or take flight. Trauma inhibits this very normal and evolutionary response to impending danger. What trauma does is render someone helpless; instead of reacting to trauma with a natural response, we are paralyzed, a sense of control is lost, and we lose any ability to do anything to be relieved from the circumstance.
Symptoms of PTSD:
Those experiencing PTSD often experience a negative change in one’s beliefs, including the way one thinks about oneself and others. Difficulty trusting someone, and guilt and or shame are often felt as well.
PTSD is most powerfully notable with the experience of three prominent symptoms, which include Re-Experiencing the event, Avoiding any reminders or feeling emotionally numb, and Hyper-arousal, which consists of a sensitive startle response. I am going to parse out each further.
In terms of Re-Experiencing, many people who experience PTSD relive the trauma after the threat has passed. The reliving feels as if the event was occurring at present as either or both nightmares or flashbacks. The trauma literally takes hold of someone’s life because it intrudes and fixates itself, and decreases someone’s ability to function day by day.
Many people who experience trauma actually feel compelled to re-experience the event, either literally or figuratively in order to “fix” the original outcome. As trauma is distinct in its feeling of utter helplessness, it is understandable that many want to reenact the trauma in order to take control and restore a sense of self-efficacy. This is very precarious, however, and creates a lot of suffering.
Avoidance/Numbing corresponds to a state of indifference, emotional detachment and passivity. Most people diagnosed with PTSD most blatantly restrict their lives by purposeful and conscious avoidance of any situation that would appear to elicit any reaction other than a sense of safety and security. Some actually dissociate from reality without conscious choice. When people cannot purposefully detach, or dissociate, they often look toward drugs and alcohol to numb the pain. So, to reiterate, those with PTSD go on to live a narrowed life because they avoid experience and shy away from new opportunities.
With regard to Hyper-arousal, many people with PTSD will react in such a way that they enter a state of permanent alertness. They are on guard at all times as if the danger will return at any point. This heightened state of arousal is induced really around the clock, like swimming in a constant pool of physiological stimulation. Many people startle to both factors associated with the trauma, as well as unpredictable stimuli (a door bell ringing for example).
In addition to the expressions of symptoms as described above, PTSD causes a huge deal of distress and severely limits functioning on social, personal, and occupational levels.
At the heart of PTSD is an exquisite attempt for the sufferers to try and find balance in their life. This is often reflected in the cyclical expression of re-experiencing and avoiding. There is a great attempt of the trauma sufferer to both deny the events of the past and at the same time proclaim their experience “out loud”; sometimes one will feel numb to the point of detachment and dissociation, and sometimes relive the event as if it was occurring at present. Neither symptom allows for the true integration of the traumatic event. Therefore this pattern is ultimately self-perpetuated.
Symptoms of PTSD can last from months to even years. Symptoms are sometimes experienced consistently, and sometimes an acute flare-up is experienced upon coming into contact with a precipitating reminder (i.e, anniversary of specific event). Regardless of the manifestations and progression of the difficulties, it is important to recognize that not all post-traumatic experiences fit neatly into a labeled disorder with established criteria. Being told you do not suffer from PTSD does not mean is that you are not suffering or experiencing many emotions and or physical changes.
Fear, anxiety, depression, anger and disconnection are all plausible feelings generated by unfathomable circumstances.
Early intervention might help stave off whatever you are experiencing from progressing for the worse. Being labeled or not labeled does not take away from the suffering. You do NOT need to be diagnosed with PTSD to receive the best treatment for what you are experiencing.
My next post will discuss PTSD and Gender. Spoiler Alert: Women are approximately 2x as likely to meet criteria for PTSD than men, and also approximately 4x as likely to have more chronic iterations of PTSD!
As always…this is a stigma-free, nonjudgmental, open community. Your comments regarding intellectual, theoretical, and of course personal accounts of trauma are cared for here. We’d love to hear from you.
To Thriving,
Jennifer Wolkin, PhD
