PTSD The Approach/Avoidance Disorder

PTSD The Approach/Avoidance Disorder

As I look at each symptom of PTSD in this section I will repeatedly bring that symptom back the varying attachment dynamics that can be precursors to the approach/avoidance strategy.

B-1) Recurring distressing recollections of the traumatic event or events.

This symptom is more inclusively stated by saying; having an over-powering need to talk to someone about an intrusive, distressing memory, along with the seemingly intuitive sense it will be painful to relive it.  This need to tell gets stronger over time if not expressed, with a felt sense of attunement from the listener.  The sufferer believes the memories will get less intense over time.  This phenomenon has some components similar to a frog not noticing the difference in temperature increases in a pan of water until they boil to death.  If you drop frogs into boiling water they jump out so fast their skin hardly gets scalded.  As the person fights off the memories it is hard to notice they are getting more emotionally intense.  It seems natural and intuitive to expect them to lessen.  This “hallmark” symptom of re-experiencing thoughts and feelings of the traumatic event may also seem to stand alone to the sufferer.  When he or she finds out this symptom has lend to the rest of the symptoms it is a great relief for most people.

I use the example of how compelled you feel to tell anyone you can find about the big fish you have caught.  The compulsive need to tell about experience outside the usual range of human experience is natural.  We seek out people who are likely to attune to our feelings, either by knowing us or knowing what it is like to catch a big fish. After about the twelfth telling the need to tell the story has diminished.    Now drop yourself in the middle of a desert where you don't know anyone and they have almost no experience with fish.  The compulsion to tell someone may not get satisfied.  Without the telling it is likely, and healthy to continue have the need to tell “the big fish story” no matter how long you are in the desert.

The need to tell is somewhat centered in our body-based sense of ourselves.  Developmentally it is the child rushing into the living room saying to her parents, "Look at me! Look at me!"  Healthy parents make sure the child knows they attended to her.  She goes away from that experience knowing it is natural to express feelings stronger than usual.  If instead the parents ignore her she eventually bottles up the need to tell someone her feelings.  If these two girls go through the same traumatic event their probability of seeking soothing from outside themselves is very different.  In one of them the need to tell about the trauma resurfaces and is expressed until it is relatively exhausted.  With the other girl the need to tell only shows up when she can't stop the compulsion to tell.  Even if she does tell someone who could be attuned to her, she has learned to not look for cues of someone attuning to her.  With one girl the story of the trauma becomes integrated inside her with the felt sense of being attuned to by her support system.  With the other girl the need to tell about the trauma wars with the known fact of feeling more alone with the story if she does ever tells someone. 

Consider a 19 year old medic in Vietnam in 1967.  His training is condensed into eight months.  In his first three months he has the need to perform two tracheotomies, both of whom die.  On the second one he remembers some subtlety of his training he wasn't doing.  Even if his saves 100 soldiers through performing great tracheotomies the next nine months, the part of him that feels less than others fixates on the two deaths. 

When a person’s developing psyche comes upon an extreme life event there is a tendency to retreat to an earlier survival based coping strategy.   The younger the disturbing situation the more problematic the reactions to it can be.  The infant or toddler who learned to survive the lack of an attuned response to their affective states may develop a strategy to compensate for the lack of attunement.  When later life traumas happen the individual will likely use the same coping mechanism as they did in their youth.  There may be a short term gain to this strategy, however in the long run it is necessary to seek and find affective attunement to the disturbing feelings.  PTSD has been proven to be developed from the lack of an attuned response, rather than the effects of the trauma.

There is an accumulation of factors bringing a client into my office for distress from symptoms of PTSD.  These factors need to be observed from the perspective of representing strengths in the individual’s ability to hold their identity together.  An example would be a combat veteran who was physically abused as a very young child by their parent.  He may develop a Disorganized Attachment, because the person he needs to be soothed by is the one who is causing the distress.  Soothing means a felt sense of attunement.  Another example is the rape survivor who was ignored as a child, especially when in distress.  She may develop an Avoidant Attachment imagining she will never be attuned to.  Both examples create internal tension with no avenue for action.  For the Avoidant person they can predict their environment won’t attune to their distress.  The Disorganized person keeps finding attunement in people who feel abusive to him.  We are neurologically organized to seek out attachment.  It requires massive energy to block the need to feel soothed.

This is the "hallmark" symptom of PTSD.  The other re-experiencing symptoms can almost always be related distressing to memories and thoughts of the trauma, or distressing memories and thoughts of the other re-experiencing symptoms developed after the traumatic experience.  We know a lot about healthy expression of distress over critical life events of loss.  We call it the grieving process. Depending on the degree of attachment, suddenness of the loss and the temperament of the griever the intensity, frequency and duration of out-pourings of distress take place.  It is healthy for these out-pourings to continue with decreased frequency, intensity and duration for at least a year.  The anniversary of the loss is a particularly likely time for the feelings to re-surface.  Two years is not considered overlong to feel swept up in the feelings of a critical life event.

In the original description of PTSD the stressful event needed to be something as life threatening as a bullet hitting the wall behind your head.  Integrating the experience of being centimeters away from sure death into your self-story, requires you to relinquish fantasies of immortality and omnipotence.   Freud and I agree we all harbor these fantasies.  In a sense, those healthy parents responding to the "Look at me" are perpetuating the child's fantasy of their felt sense of importance in the world.  This healthy nugget, around which the developing psyche organizes itself, is highly challenged by the stark reality of the dangers of the world.  It takes the time and the processing of the internal tension of the felt sense of increased endangerment.  PTSD can only be diagnosed when the felt sense of endangerment remains exaggerated for a long enough time and leads to distress for the client.  Reconciling the infantile sense of being omnipotent with the mature realization of the dangers of the world is part of growing up.  Retreating to an earlier strategy for coping with distressing feelings is the opposite of maturation.  The earlier the strategy developed the less likely we are to know we are using it.  It feels intuitive to isolate and push away the distressing memories.  The fact that we blow up easily or can’t sleep does necessarily feel related.  Short-term it works better to deny the memories access to our consciousness.  Long-term we want to be able to access the memories and feelings when we want to and not be over-powered by them.  Learning when we are capable of allowing the feelings to go through us is maturity.

Another internal tension that we all carry which feeds into feeling an exaggerated sense of endangerment is "rapprochement".  This is the tension between a desire for independence and a desire for dependence.  It is exemplified in the moment the exploring toddler notices his mother walking out of the room.  Does the child respond to his internal need to explore, or the internal need to have mother caring for him.  If either he or his Mom is omnipotent he thinks he will be okay.  As the reality sets in that she can't be two places at once, or join him in all his explorations, a sort of disbelief in the parameters of his existence sets in.  This really never gets reconciled in us.  Therefore, when a traumatic event happens in life there is more fuel for this tension.  The subliminal dialog might go something like this: "I can't survive without someone taking these horrible feelings away from me", or "I have to be able to hold onto these horrible feelings by myself".

PTSD recovery is allowing the person's development to take place.  This requires the person developing a felt sense of being attuned to in their most challenged states.  The states of coming to terms with the immediate, practical dangers of the world, and the irreconcilable needs for independence and dependence are two of these ongoing challenges. If you have ever been the care giver for a child going through a tantrum you have experienced some of what a therapist needs to be able to do.  The client's emotional expression is seldom as dramatic as a childhood tantrum.  The client does need a feeling of having survived an "affect storm" in the presence of another.   This survival of self and the therapy (therapist as respecting other) is essential for the integration of memories that are outside of the parameters of what we have learned to expect from our world.

Anxiety Attacks

 

Panic Attacks—Most of the clients I have seen have had at least one Anxiety Attack in their lives.  They find tremendous relief in the first session finding out what is physically happening to them. (see section on A Handy way to see the Brain).  My job is to be sure the client knows they are experiencing an activation of the Flight, Fight, Freeze and Flop (FFFF) response.  Prior the 1995 revision of the Diagnostic and Statistical Manual (DSM-IV) two types of acute anxiety reactions were differentiated. I still find the difference useful because of the likely difference in the recovery process.  A Panic Attack generally comes on quickly, lasted from 1-20 minutes and ends abruptly.  People report the end being so sudden it takes their breath away.   An Anxiety Attack comes on gradually, lasts up to two hours and slowly loses its force.  People reporting Panic Attacks almost always say they felt like they were going to die. Both types of episodes have residual effects.

The worst part of Anxiety Attacks is their chronicity.  People become worn-out from the effects of the last one and fear of the next one.  The worst part of a Panic Attack is its intensity.  Sufferers will be exhausted afterwards and may remain afraid of the next one for years or decades.  The sudden onset of a Panic Attack often gives us an advantage of having a recognizable set of circumstances we can help the client illuminate.  Recognition at an ever earlier moment is the primary part of recovery.  When the client can notice precursors and relax before the Frontal Lobe turns itself off, they have a much greater likelihood of the FFFF response not being initiated.

With all forms of Anxiety Disorders the thinking leading up to and during the episode will include a declarative internal statement of: “I can’t________, but I must___________”, or “ I have to________, but I don’t want to_________”.  The most frequently reported place people experience this trap in their thinking is in the grocery store.  The etymology of the word Agoraphobia  (one of the types of Anxiety Disorders in the Diagnostic Manual) is fear of the market place.  I always imagine a herder coming over the rise to see the longed-for market place.  He has been alone with his animals and thoughts.  On many levels he wants to go into the market place.  His business and resupply need to be done there.  He wants involvement with people. On the other hand he is afraid of being taken advantage of,  or be ridiculed or criticized.  The worst fear comes if he has experienced some type of anxiety reaction in the past. His  biggest fear is he will have an attack.  The modern day person has to go get their groceries to survive. It is a perfect setup for an Anxiety or Panic Attack.  “I have to go to the store, but I can’t do it if I have a Panic Attack”.  If they don’t go they increase their desperateness and add more tension to the next attempt.  If they do go and have an attack they get nothing accomplished they increase their desperateness and add more tension to the next attempt.  The word, “but” is used here as a contradiction.  The only way out of this dilemma is to consciously choose one side of the equation or the other.

If the herder chooses to not go into the market he will slowly starve to death, besides becoming less capable of being around people.  If he prepares by relaxing himself thoroughly and survives the encounters with others he can repeat this ritual the next time.  Most exaggerated fear of endangerment is built by avoiding the repetition of historical situations and feelings leading up to an episode of exaggerated fear of endangerment.  This self-fulfilling cycle only gets interrupted when the sufferer becomes aware of the cycle and relaxes.

Anti-anxiety medications have cause as much trouble as they have provided relief for anxiety.  They are a class of medicines called Benzodiazepines.  Benzodiazepine is the depressant chemical released when alcohol is broken down in the body.  It is particularly active as a Frontal Lobe depressant.  The Frontal Lobe will have diffuse activity and less over-all activity.  In order to modulate impulses from the brain stem, like anxiety, concentrated Frontal Lobe activity is required.   The benefit of these medicines comes because it is harder to be aware of brain stem impulses if you are compromised in your Frontal Lobe.

Valium was the first developed benzodiazepine.  It had a half-life of longer than a day.  A person took it to go to the grocery store and had a depressed Frontal Lobe for the rest of the day.  Xanax, one of the later developed benzodiazepines, has a much shorter half-life, which may mean the next dose needs to be taken sooner. The ability to observe an exaggerate sense of endangerment returned fairly abruptly.  People tended to need to take the fast dissipating benzodiazepines more frequently, or face the same feelings they avoided a few hours ago. This cycle can lead to a type of dependency.  Any prolonged use of a benzodiazepine challenges the Frontal Lobe’s inhibitory function of anxiety.  In the short-term, seven to ten days, benzodiazepines allow a person to not notice the anxiety welling up from their brain stem.

Recovery is definite if you are treated by a knowledgeable practitioner.  At the bare minimum the client will learn the phrase, “This too shall pass”.  Hippocrates, the father of medicine, wrote about Anxiety Attacks.   In all our document history since, no one has died yet of a Panic Attack.  People do build-up fatal musculature around their hearts because of the rapid heartbeat of FFFF.   Either type of attack is a built-in survival mode to deal with a life-threatening situation.  This built-in reaction won't kill you.  It is very unfamiliar and if you are afraid of it, it gets magnified.

In a psychoanalytic sense anxiety is caused by a lack of an attuned response to a felt sense of endangerment.  By feeling attuned to by a therapist who seems to understand their anxious feelings, the client is no longer alone with the unbearable affect.  The “I can’t, but I must” situation can be looked at objectively.  Recovery is about make a choice of which side of this contradiction to act on.  The beauty of the recovery process is related to the repetitive nature of the problem. If the client can develop a realistic response to thinking they are trapped, they can use the same response in many other situations.

DEPRESSION & THE CINGULATE GYRUS

 

Depression---Anger turned inward—cingulate gyrus

In between the left and right and just below hemispheres of the human brain is a group of nervous about as long and thick as a hotdog.  Its primary purpose is to switch our focus from one thing to another.  When we are focusing on a client we are accessing many areas of our memories of them, our disciplines as therapists, their histories and the current session’s interactions. If they ask us about the plant we have in the office our Cingulate Gyrus will quickly activate to gather relevant data of the history of our plant.  The Cingulate’s job is meant to be short-lived, like a switch. I point to the light switch. It turns the attention to the plant, then stops functioning until we want to switch back to our clinical awareness.  The Cingulate Gyrus is located above the Limbic Cortex and Corpus Callosum. It is high enough up in the brain to utilize language, however when it operates the brain reduces the use of the frontal lobe.  The logic circuitry isn’t nearly as important as the complex process of creating memory images. 

This is all well and good, however what does it have to do with anger turned inward?  The Cingulate has the capability of having a thought over and over again without the need to filter it through the logic circuitry. Thought distortions are what David Burns, MD, in his 1980 book Feeling Good, called the core of being depressed.  There is some hopeless, helpless exaggerated thought that resonates with the feelings in the Limbic System.  Without regulation from the Frontal Cortex the emotional low brain/body and repetitive thought re-enforce one-an-other.  The more we think our situation is hopeless the more it feels hopeless.  The more we feel hopeless the more we think the hopeless thought over again.  This Cingulate Gyrus/Limbic Cortex feedback allows the impulse centers of the brain/body to operate without the modulation the Frontal Cortex is responsible for.

If we experience anger toward ourselves or others while we are thinking and feeling hopeless we are compromised in our ability to modulate those feelings and thoughts.  As the seconds and moments develop into days and weeks a feeling of lethargy sets in. *****An aside about Shame/Narcissism.  Even when the Frontal Lobe can get involved, it is important to remember its default setting is to worry about what people are thinking and feeling about us. Our shame dynamic tells us there is something wrong with us and other people know it.  During moments of depression there IS something wrong with us, so rather than helping us become more realistic about our thoughts and feelings, the False Self turns the reigns back over to the Cingulate Gyrus and the Limbic Cortex. ******The diagnostic manual for mental disorders states that an essential criterion to meet the diagnosis of a Depressive episode is: a person must experience a feeling like hopelessness most of the hours, for most of the days, for at least two weeks.  Many people who have come to me for therapy have been experiencing thoughts and feelings of hopelessness almost every day for years.

So how do we get the logic circuitry back involved?  This is where Dr. Burns clarified for us Cognitive Behavioral Therapy.  One, identify the distorted thoughts. Two, determine the type of exaggeration it is. Three, develop a realistic thought about the same thing without the exaggeration; and practice all three steps when able to notice depressive thoughts or feelings.  This process of recognition of the distressing component requires the observation ability that only can come from the Frontal Lobe.  90% of the function of the cells in the Frontal Lobe is to inhibit impulse coming from the Limbic Cortex.  By being logical and starting an action of thinking differently, automatically the emotions are being modulated. This may not be powerful enough to inhibit the process of the emotions controlling the thoughts, however it is likely to be a useful component of most people's recovery from Depression.

Pain and psychotherapy

Pain and psychotherapy

All felt pain has physical and psychological components.  Sensory and emotional signals are sent up and down the body/brain systems. Suffering and agony are fear related to pain.  They are intrinsic to pain.  Fear, in a deep body/brain sense, is a requirement. It manifests as muscle guarding which tenses the muscle areas surrounding the pain.  This increased tension can cause more mechanical pain, leading to more muscle guarding, and more pain. I will explain pain in the brain/body, its relationship to involuntary contraction of muscle, and what to do about it to suffer less.

First let me clarify the basic working components of the nervous system. I have found my clients need this information in order to understand anxiety, depression, pain, medicines, anger, and impulsive behavior.

Nerves have three different types of dendrite receptors: mechanical, thermal and chemical. The brain interprets pain signals. Psychological processes have physical effects.  Physical processes have psychological effects. There is no separation between psychological and biological.  The cell wall of a neuron is made up of proteins, large molecules, whose shape and content determine the character and function of each protein.  The outfacing end of the long cell wall protein can be thought of as a key hole, it is the receptor site.  Neurotransmitters are the keys that fit in these locks.  Overly simplified, when a neurotransmitter lodges in these proteins they bond changing the electrical potential of the whole cell a tiny bit.  The nerve cell generally sets at -70 millivolts, when it reaches -40 millivolts it triggers the cell wall proteins to flip over, bring the cell to +30 millivolts. Neurotransmitters are discharged out of the axon end of the nerve, into the synapse between that axon and the dendrite of the next cell.  They diffuse into the area where the dendrite end of the next nerve has many receptor sites for them.  The electrical process causes the protien to flip, (actual Sodium-Na and Potassium-K, negatively charged (-) chemicals are pushed out while Chloride-Cl, positively charged (+) is drawn in). Those two nerves are now wired together. 

The more a pathway in the nervous system is used the more it becomes resupplied with the necessary chemicals for it to operate. Blood veins, arteries and the muscles that surround them are strengthened and developed. It gets easier and easier to use that pathway.   This is part of the way chronic pain gets habituated in the body/brain.

As a pain sensation is felt in the body it sends a signal of the pain to the spinal column. As the signal arrives, the spinal column quickly makes available more receptor sites for noticing pain. The surrounding neural dendrites are quickly tuned to receive the same pain signal. Therefore, the signal is amplified, literally increasing magnitude of the pain signal.  The brain can also send signals back down the spinal column to interfere with the use of some of the receptor sites or add more. After the spinal column has processed it, the pain signal heads up to the brain.  There the signal goes through an amazing and complex matrix of receiving areas.

The following brain areas are some of important functions in the way we experience pain:

SENSORY CORTEX
This is a strip of brain tissue on both sides of the brain about the width of your index finger.  It processes our body sensations. How pain is felt depends on how cells in these strips are organized.  Every part of our body has an area represented on the brain’s sensory strip. It is a mini version of our body mapped onto our brain.  The size of the space dedicated for different body parts is related to that area’s degree of sensitivity. Therefore the mouth, face, finger, genitals and feet are related to much bigger areas than their physical size is.  This increased sensitivity allows us to feel two toothpicks pressed on our fingertip a quarter of an inch apart and it will feel like one toothpick on our backs. These areas can all get bigger or smaller depending on use.  If you have chronic pain in your right elbow the space related to it in the sensory strip enlarges and becomes more sensitive. (In recovery from suffering from pain the reverse of this process will be utilized.  The client learns many systems to focus on the non-painful areas of their life.)

LIMBIC SYSTEM

 
One of the first and most powerful matrixes for pain identification  is located in the Amygdala. The Amygdala can decide to pass the signal on up to more complex areas for evaluation, or the Amygdala can take over if it determines the signal to be life threatening.  If it feels life threatening all of the smooth muscles contract to force all the blood near the heart for rapid use where need.  This creates a lot more tension throughout the body.  At the same time in 40-60 milliseconds directions are sent to the heart to speed up, lungs to work faster using only the top parts that are closer to the heart, the stomach and other organs to shut off, the adrenal gland to secrete adrenaline,  and many other systems
 If a person has an exaggerated sense of endangerment due to life threatening experiences in their past, it is easier for the Amygdala to take over.  So, when the body sends a signal that is similar to the signal sent during an earlier life threatening event it is more likely a fear response will be initiated.

SITTING WITH THE RIGHT AMOUNT OF PAIN

So, how can we talk to someone about all of these complications with pain? I have never explained all of these concepts to any one client.  Even though several of my client knew more about some the pain related processes in their body/brain.  Many of them have been much smarter than I am.  Joining the client in where they are at with their knowledge of their pain and their hard fought strategy for dealing with, is the answer.  In a sense I am a knowledgeable person they are bouncing their plans off of.  My job with either depression or anxiety is to help the client relax in many layers of their organization of themselves. When their pain coping strategies sound and feel like the way they dealt with the deficits in their early life care-giver environment, I need to help them soften those ideas.  These defensive strategies invariably make pain worse in the long run, so helping them see what ideas help them and what ideas hurt them illuminates relaxing with the pain and focusing on how they want their life to be.

The problem and solution with chronic pain is neural plasticity.  Nerves. being able to add new connections to other nerves, leads to ever greater intensity, frequency and duration of suffering. Allowing the overgrown areas to atrophy is facilitated by growing new more dynamic connections in other areas.

Knowing the overall cascade effect, that is most obviously demonstrated by the either/or bifurcated functioning of the Amygdala, (flight or fight triggered on the left; empathy and frontal lobe connection on the right) helps patientss plan ways incremental progress in many areas of pain modulation, rather than looking for a quick fix.