The Body Keeps the Score
Page 28
INTEGRATING TRAUMATIC MEMORIES
People cannot put traumatic events behind until they are able to acknowledge what has happened and start to recognize the invisible demons they’re struggling with. Traditional psychotherapy has focused mainly on constructing a narrative that explains why a person feels a particular way or, as Sigmund Freud put it back in 1914 in Remembering, Repeating and Working Through:32 “While the patient lives [the trauma] through as something real and actual, we have to accomplish the therapeutic task, which consists chiefly of translating it back again in terms of the past.” Telling the story is important; without stories, memory becomes frozen; and without memory you cannot imagine how things can be different. But as we saw in part 4, telling a story about the event does not guarantee that the traumatic memories will be laid to rest.
There is a reason for that. When people remember an ordinary event, they do not also relive the physical sensations, emotions, images, smells, or sounds associated with that event. In contrast, when people fully recall their traumas, they “have” the experience: They are engulfed by the sensory or emotional elements of the past. The brain scans of Stan and Ute Lawrence, the accident victims in chapter 4, show how this happens. When Stan was remembering his horrendous accident, two key areas in his brain went blank: the area that provides a sense of time and perspective, which makes it possible to know that “that was then, but I am safe now,” and another area that integrates the images, sounds, and sensations of trauma into a coherent story. When those parts of the brain are knocked out, you experience something not as an event with a beginning, a middle, and an end but in fragments of sensations, images, and emotions.
A trauma can be successfully processed only if all those brain structures are kept online. In Stan’s case, eye movement desensitization and reprocessing (EMDR) allowed him to access his memories of the accident without being overwhelmed by them. When the brain areas whose absence is responsible for flashbacks can be kept online while remembering what has happened, people can integrate their traumatic memories as belonging to the past.
Ute’s dissociation (as you recall, she shut down completely) complicated recovery in a different way. None of the brain structures necessary to engage in the present were online, so that dealing with the trauma was simply impossible. Without a brain that is alert and present there can be no integration and resolution. She needed to be helped to increase her window of tolerance before she could deal with her PTSD symptoms.
Hypnosis was the most widely practiced treatment for trauma from the late 1800s, the time of Pierre Janet and Sigmund Freud, until after World War II. On YouTube you can still watch the documentary Let There Be Light, by the great Hollywood director John Huston, which shows men undergoing hypnosis to treat “war neurosis.” Hypnosis fell out of favor in the early 1990s and there have been no recent studies of its effectiveness for treating PTSD. However, hypnosis can induce a state of relative calm from which patients can observe their traumatic experiences without being overwhelmed by them. Since that capacity to quietly observe oneself is a critical factor in the integration of traumatic memories, it is likely that hypnosis, in some form, will make a comeback.
COGNITIVE BEHAVIORAL THERAPY (CBT)
During their training most psychologists are taught cognitive behavioral therapy. CBT was first developed to treat phobias such as fear of spiders, airplanes, or heights, to help patients compare their irrational fears with harmless realities. Patients are gradually desensitized from their irrational fears by bringing to mind what they are most afraid of, using their narratives and images (“imaginal exposure”), or they are placed in actual (but actually safe) anxiety-provoking situations (“in vivo exposure”), or they are exposed to virtual-reality, computer-simulated scenes, for example, in the case of combat-related PTSD, fighting in the streets of Fallujah.
The idea behind cognitive behavioral treatment is that when patients are repeatedly exposed to the stimulus without bad things actually happening, they gradually will become less upset; the bad memories will have become associated with “corrective” information of being safe.33 CBT also tries to help patients deal with their tendency to avoid, as in “I don’t want to talk about it.”34 It sounds simple, but, as we have seen, reliving trauma reactivates the brain’s alarm system and knocks out critical brain areas necessary for integrating the past, making it likely that patients will relive rather than resolve the trauma.
Prolonged exposure or “flooding” has been studied more thoroughly than any other PTSD treatment. Patients are asked to “focus their attention on the traumatic material and . . . not distract themselves with other thoughts or activities.”35 Research has shown that up to one hundred minutes of flooding (in which anxiety-provoking triggers are presented in an intense, sustained form) are required before decreases in anxiety are reported.36 Exposure sometimes helps to deal with fear and anxiety, but it has not been proven to help with guilt or other complex emotions.37
In contrast to its effectiveness for irrational fears such as spiders, CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse. Only about one in three participants with PTSD who finish research studies show some improvement.38 Those who complete CBT treatment usually have fewer PTSD symptoms, but they rarely recover completely: Most continue to have substantial problems with their health, work, or mental well-being.39
In the largest published study of CBT for PTSD more than one-third of the patients dropped out; the rest had a significant number of adverse reactions. Most of the women in the study still suffered from full-blown PTSD after three months in the study, and only 15 percent no longer had major PTSD symptoms.40 A thorough analysis of all the scientific studies of CBT show that it works about as well as being in a supportive therapy relationship.41 The poorest outcome in exposure treatments occurs in patients who suffer from “mental defeat”—those who have given up.42
Being traumatized is not just an issue of being stuck in the past; it is just as much a problem of not being fully alive in the present. One form of exposure treatment is virtual-reality therapy in which veterans wear high-tech goggles that make it possible to refight the battle of Fallujah in lifelike detail. As far as I know, the US Marines performed very well in combat. The problem is that they cannot tolerate being home. Recent studies of Australian combat veterans show that their brains are rewired to be alert for emergencies, at the expense of being focused on the small details of everyday life.43 (We’ll learn more about this in chapter 19, on neurofeedback.) More than virtual-reality therapy, traumatized patients need “real world” therapy, which helps them to feel as alive when walking through the local supermarket or playing with their kids as they did in the streets of Baghdad.
Patients can benefit from reliving their trauma only if they are not overwhelmed by it. A good example is a study of Vietnam veterans conducted in the early 1990s by my colleague Roger Pitman.44 I visited Roger’s lab every week during that time, since we were conducting the study of brain opioids in PTSD that I discussed in chapter 2. Roger would show me the videotapes of his treatment sessions and we would discuss what we observed. He and his colleagues pushed the veterans to talk repeatedly about every detail of their experiences in Vietnam, but the investigators had to stop the study because many patients became panicked by their flashbacks, and the dread often persisted after the sessions. Some never returned, while many of those who stayed with the study became more depressed, violent, and fearful; some coped with their increased symptoms by increasing their alcohol consumption, which led to further violence and humiliation, as some of their families called the police to take them to a hospital.
DESENSITIZATION
Over the past two decades the prevailing treatment taught to psychology students has been some form of systematic desensitization: helping patients become less reactive to certain emotions and sensations. But is this the correct goal? Maybe the issue is not desensitization but int
egration: putting the traumatic event into its proper place in the overall arc of one’s life.
Desensitization makes me think of the small boy—he must have been about five—I saw in front of my house recently. His hulking father was yelling at him at the top of his voice as the boy rode his tricycle down my street. The kid was unfazed, while my heart was racing and I felt an impulse to deck the guy. How much brutality had it taken to numb a child this young to his father’s brutality? His indifference to his father’s yelling must have been the result of prolonged exposure, but, I wondered, at what price? Yes, we can take drugs that blunt our emotions or we can learn to desensitize ourselves. As medical students we learned to stay analytical when we had to treat children with third-degree burns. But, as the neuroscientist Jean Decety at the University of Chicago has shown, desensitization to our own or to other people’s pain tends to lead to an overall blunting of emotional sensitivity.45
A 2010 report on 49,425 veterans with newly diagnosed PTSD from the Iraq and Afghanistan wars who sought care from the VA showed that fewer than one out of ten actually completed the recommended treatment.46 As in Pitman’s Vietnam veterans, exposure treatment, as currently practiced, rarely works for them. We can only “process” horrendous experiences if they do not overwhelm us. And that means that other approaches are necessary.
DRUGS TO SAFELY ACCESS TRAUMA?
When I was a medical student, I spent the summer of 1966 working for Jan Bastiaans, a professor at Leiden University in the Netherlands who was known for his work treating Holocaust survivors with LSD. He claimed to have achieved spectacular results, but when colleagues inspected his archives, they found few data to support his claims. The potential of mind-altering substances for trauma treatment was subsequently neglected until 2000, when Michael Mithoefer and his colleagues in South Carolina received FDA permission to conduct an experiment with MDMA (ecstasy). MDMA was classified as a controlled substance in 1985 after having been used for years as a recreational drug. As with Prozac and other psychotropic agents, we don’t know exactly how MDMA works, but it is known to increase concentrations of a number of important hormones including oxytocin, vasopressin, cortisol, and prolactin.47 Most relevant for trauma treatment, it increases people’s awareness of themselves; they frequently report a heightened sense of compassionate energy, accompanied by curiosity, clarity, confidence, creativity, and connectedness. Mithoefer and his colleagues were looking for a medication that would enhance the effectiveness of psychotherapy, and they became interested in MDMA because it decreases fear, defensiveness, and numbing, as well as helping to access inner experience.48 They thought MDMA might enable patients to stay within the window of tolerance so they could revisit their traumatic memories without suffering overwhelming physiological and emotional arousal.
The initial pilot studies have supported that expectation.49 The first study, involving combat veterans, firefighters, and police officers with PTSD, had positive results. In the next study, of a group of twenty victims of assault who had been unresponsive to previous forms of therapy, twelve subjects received MDMA and eight received an inactive placebo. Sitting or lying in a comfortable room, they then all received two eight-hour psychotherapy sessions, mainly using internal family systems (IFS) therapy, the subject of chapter 17 of this book. Two months later 83 percent of the patients who received MDMA plus psychotherapy were considered completely cured, compared with 25 percent of the placebo group. None of the patients had adverse side effects. Perhaps most interesting, when the participants were interviewed more than a year after the study was completed, they had maintained their gains.
By being able to observe the trauma from the calm, mindful state that IFS calls Self (a term I’ll discuss further in chapter 17), mind and brain are in a position to integrate the trauma into the overall fabric of life. This is very different from traditional desensitization techniques, which are about blunting a person’s response to past horrors. This is about association and integration—making a horrendous event that overwhelmed you in the past into a memory of something that happened a long time ago.
Nonetheless, psychedelic substances are powerful agents with a troubled history. They can easily be misused through careless administration and poor maintenance of therapeutic boundaries. It is to be hoped that MDMA will not be another magic cure released from Pandora’s box.
WHAT ABOUT MEDICATIONS?
People have always used drugs to deal with traumatic stress. Each culture and each generation has its preferences—gin, vodka, beer, or whiskey; hashish, marijuana, cannabis, or ganja; cocaine; opioids like oxycontin; tranquilizers such as Valium, Xanax, and Klonopin. When people are desperate, they will do just about anything to feel calmer and more in control.50
Mainstream psychiatry follows this tradition. Over the past decade the Departments of Defense and Veterans Affairs combined have spent over $4.5 billion on antidepressants, antipsychotics, and antianxiety drugs. A June 2010 internal report from the Defense Department’s Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other controlled substances.51
However, drugs cannot “cure” trauma; they can only dampen the expressions of a disturbed physiology. And they do not teach the lasting lessons of self-regulation. They can help to control feelings and behavior, but always at a price—because they work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure. Some of my colleagues remain optimistic: I keep attending meetings where serious scientists discuss their quest for the elusive magic bullet that will miraculously reset the fear circuits of the brain (as if traumatic stress involved only one simple brain circuit). I also regularly prescribe medications.
Just about every group of psychotropic agents has been used to treat some aspect of PTSD.52 The serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Effexor, and Paxil have been most thoroughly studied, and they can make feelings less intense and life more manageable. Patients on SSRIs often feel calmer and more in control; feeling less overwhelmed often makes it easier to engage in therapy. Other patients feel blunted by SSRIs—they feel they’re “losing their edge.” I approach it as an empirical question: Let’s see what works, and only the patient can be the judge of that. On the other hand, if one SSRI does not work, it’s worth trying another, because they all have slightly different effects. It’s interesting that the SSRIs are widely used to treat depression, but in a study in which we compared Prozac with eye movement desensitization and reprocessing (EMDR) for patients with PTSD, many of whom were also depressed, EMDR proved to be a more effective antidepressant than Prozac.53 I’ll return to that subject in chapter 15.54
Medicines that target the autonomic nervous system, like propranolol or clonidine, can help to decrease hyperarousal and reactivity to stress.55 This family of drugs works by blocking the physical effects of adrenaline, the fuel of arousal, and thus reduces nightmares, insomnia, and reactivity to trauma triggers.56 Blocking adrenaline can help to keep the rational brain online and make choices possible: “Is this really what I want to do?” Since I have started to integrate mindfulness and yoga into my practice, I use these medications less often, except occasionally to help patients sleep more restfully.
Traumatized patients tend to like tranquilizing drugs, benzodiazepines like Klonopin, Valium, Xanax, and Ativan. In many ways, they work like alcohol, in that they make people feel calm and keep them from worrying. (Casino owners love customers on benzodiazepines; they don’t get upset when they lose and keep gambling.) But also, like alcohol, benzos weaken inhibitions against saying hurtful things to people we love. Most civilian doctors are reluctant to prescribe these drugs, because they have a high addiction potential and they may also interfere with trauma processing. Patients who stop taking them after prolonged use usually have withdrawal reaction
s that make them agitated and increase posttraumatic symptoms.
I sometimes give my patients low doses of benzodiazepines to use as needed, but not enough to take on a daily basis. They have to choose when to use up their precious supply, and I ask them to keep a diary of what was going on when they decided to take the pill. That gives us a chance to discuss the specific incidents that triggered them.
A few studies have shown that anticonvulsants and mood stabilizers, such as lithium or valproate, can have mildly positive effects, taking the edge off hyperarousal and panic.57 The most controversial medications are the so-called second-generation antipsychotic agents, such as Risperdal and Seroquel, the largest-selling psychiatric drugs in the United States ($14.6 billion in 2008). Low doses of these agents can be helpful in calming down combat veterans and women with PTSD related to childhood abuse.58 Using these drugs is sometimes justified, for example when patients feel completely out of control and unable to sleep or where other methods have failed.59 But it’s important to keep in mind that these medications work by blocking the dopamine system, the brain’s reward system, which also functions as the engine of pleasure and motivation.
Antipsychotic medications such as Risperdal, Abilify, or Seroquel can significantly dampen the emotional brain and thus make patients less skittish or enraged, but they also may interfere with being able to appreciate subtle signals of pleasure, danger, or satisfaction. They also cause weight gain, increase the chance of developing diabetes, and make patients physically inert, which is likely to further increase their sense of alienation. These drugs are widely used to treat abused children who are inappropriately diagnosed with bipolar disorder or mood dysregulation disorder. More than half a million children and adolescents in America are now taking antipsychotic drugs, which may calm them down but also interfere with learning age-appropriate skills and developing friendships with other children.60 A Columbia University study recently found that prescriptions of antipsychotic drugs for privately insured two- to five-year-olds had doubled between 2000 and 2007.61 Only 40 percent of them had received a proper mental health assessment.