Psychological Trauma and Brain- Part 2

Carrying on from the previous post one can argue whether PTSD or traumatic symptoms following trauma are ‘disorders of memory’ or ‘disorders of forgetting’. The virtue of understanding these concepts lies in understanding what happens in the brain when memories are laid down. So let me spend sometime on that.

What we know from knowledge of memory systems in our brain is that during exposure to the traumatic incidents, the ‘action systems’ are set in motion and settle down to adaptation as one comes through to the other side of the traumatic event. The memories of the event initially are ’emotionally charged’ and get stored in a specific part of the brain. Now as the processing is complete- a narrative quality to the memory is established and it gets stored as yet another complete memory (almost like a photograph in an old picture album). Whenever one needs to access it, it becomes almost a case of going back to the album, picking the photo and describing it as a story in the broader timeline of an individual’s life. A personal example could be demonstrative here- when I learnt to ride my bike without stabilisers, I can recollect from my life’s picture album a memory where my brother, a cousin and dad supported me from behind and I rode round and round in circles in the back garden of my cousins house in Watford and suddenly realised that on my last round I was riding on my own with two of them standing and just watching me ride whilst my dad was in the middle of the garden stopped at the spot where he had left me on my own.

A negative event, similarly, gets processed and on complete processing gets a narrative quality. One could go and access that memory as well without getting unduly distressed or even if does experience a subjective distress, it is but just a memory in the story of life. However, people suffering with sequalae of trauma are not able to process that event completely and the emotional aspects of that event get stored as the main memory with the primitive systems being in a state of ‘chronic activation’ thus restricting the processing from happening, and hence they are ‘not able to forget’ the event and life becomes pre-occupied and organised around the traumatic event. This is seen in various clinical presentations in Psychiatric practice.

So how can psychiatric treatments work? Working in my capacity of a private psychiatrist in Wales, I use both to pharmacological treatments including anti- depressants, Prazosin and others along with Eye Movement Desensititation and Reprocessing (EMDR). The idea behind EMDR is the facilitation of complete processing of the traumatic memory thus helping the establishment of the narrative quality and being able to move on in life.

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Psychological Trauma and Brain- Part 1

Bessel van der Kolk is a name that most professionals working with psychological trauma recognise. Recently attended his webinar and was re- assured to hear that the things that I have seen in my practice as a private psychiatrist and my conceptualisation of trauma and it’s consequences are similar to his.

Whilst writing about the full description is for a scientific journal, I thought it may be useful to put things in a simple way. So here is a simple explanation- there are some inherent stress action systems in human beings that make us function as a ‘whole organism’-

1. The Freeze system
2. The Flight system
3. The Fight system

These help us in situations of danger and being ‘primitive systems’ get modulated by the ‘Neocortex’ (Newer developed parts of brain), so that the person in a stressful situation such as trauma, eventually derives a ‘context’ and puts a meaning to the stressful or traumatic life event in the wider context of his/her life, the ‘primitive systems’ are reset and life moves on.

What happens in PTSD or in people suffering with consequences of trauma is that the ‘primitive systems’ remain active for a longer period of time than what is necessary for adaptation and the individuals are in a state of ‘Chronic Hyperarousal’ leading to living life in a sense of fear with constant alertness or hyper vigilance to ensure their safety and experience symptoms of anxiety.

At the same time the memories of the event are laid down in a disjointed manner. More on memory in trauma in my next post.

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EMDR for Travel Anxiety after RTA

Eye Movement Desensitisation and Reprocessing (EMDR) is a psychological treatment used for improving symptoms of post trauma sequeale. Whilst NICE recommends its treatment for PTSD, newer indications and it’s application as a treatment have increased over the years. Working as a Consultant Psychiatrist in Wales and as part of my medico-legal practice in Personal Injury, recently I have treated someone for Travel Anxiety following a RTA who had been struggling to pass a particular point on the road and had anxiety symptoms when on the road in general. The outcomes were very good as the EMDR phases were very useful and all the symptoms improved within 6 sessions. The desensitisation phase was one phase that was very useful to get past the particular point on the road for the patient and by the end of sessions, the patient had commenced driving, had gone past the struggling point, felt more relaxed on the road in general and scored 0 on all scales used in the therapy.

The crucial element was the use of ‘Eclectic’ tools to help the individual to regain control over the situation and in Neuroanatomical terms, what we now know in Trauma work is that once the ‘Chronic Hyperarousal’ is modulated and regulated, the symptoms begin to improve.

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PTSD- What to do with nightmares?

Nightmares associated with PTSD are a common occurrence in patients whom I see in my clinical and medico- legal practice as a Consultant Psychiatrist. And Prazosin is used as a medication to treat these. Evidence from a recent systematic analysis, (abstract presented in the 20th European Congress of Psychiatry) confirms its efficacy. In addition to this, in my clinical experience it is important to address the trauma memories by psychotherapy so that the memories become ‘narrative’ in quality as opposed to being emotionally laden and this brings about resolution of nightmares. This can be achieved by EMDR, which allows for the procession of the memories to eventually give them this quality. A common debate is whether use of medication can interfere with therapy, but this systematic analysis and current opinion highlights that Prazosin may actually be helpful when doing trauma work in Psychotherapy.

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Trauma, Dissociation and EMDR Workshop

As promised, here are some clips of the Trauma, Dissociation and EMDR workshop done recently. The workshop covers main models of processing and the phases of treatment in EMDR. The Preparatory phase is very important and enables an individual to learn some grounding skills which can range from learning Simple Breathing, Relaxation, Establishing a Safe Place to give you some examples. I personally use a combination of Simple breathing and Meditation along with Safe Place as fundamental tools with good results.

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Post Traumatic Stress Disorder (PTSD) and Eye Movement Desensitisation & Reprocessing (EMDR)

Experiencing trauma is an essential part of being human; history is written in blood……Van der Kolk & McFarlane

A few weeks ago a junior colleague of mine asked me about the mechanics of EMDR (Eye Movement Desensitisation & Reprocessing). And I decided to do a workshop for not just one colleague but for all in our department. I believe in the “greatest goodness for the greatest number”. It is important to bear in mind that EMDR is one form of Psychotherapy where ‘desensitisation’ is but just one of the eight phases of the therapy. Of course the desensitisation phase grabs the main attention of any one not familiar with the therapy. In this phase, the dissociated trauma memories are reprocessed and once the memories are completely reprocessed, they do not spark off any distressing emotions. EMDR is one of the therapies which has been subject to neuro- imaging (Imaging PTSD) and has shown changes in the blood flow of the brain in areas which are deemed necessary to dampen the arousal mechanisms of the brain, thus helping in deriving meaning of the trauma in the wider context of the person’s life. I will put the magic movie of the workshop in my next post shortly.

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Post-war Soldiers Thoughts Revealed in New Play ‘ReEntry’

“Right now, I’m just happy that I’m not being shot at,” says John, a Marine captain who has returned from Iraq. “But at the same time, I’m kinda upset that I don’t have anyone to shoot.”

As Aaron Levin, the author of this insightful article from Psychiatric News/Psychiatry Online comments, “Well, that is a dilemma, isn’t it?”

ReEntry‘ explores the realities of dealing with the fallout of a military life in a ‘theatre of war’. The above quote may be the words of an actor, but they play’s script was informed by extensive interviews with U.S. Marines and their family members by writers KJ Sanchez and Emily Ackerman. Ackerman’s two brothers served in both Iraq and Afghanistan, the younger surviving a roadside bomb blast in Iraq while his sister was creating the play. “That event ultimately became a core element in the play, combining personal trauma, disfiguring injury, and the deaths of comrades in arms.”

Levin remarks, “But one thing is clear: they may have posttraumatic stress disorder symptoms or skate too close to suicide, but these guys aren’t asking for or expecting pity. ” Read the article in full here.

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