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Gift From Within - Questions & Answers with Frank Ochberg on PTSD

	PTSD: Definition of PTSD How common, who gets PTSD? Does PTSD Affect the Brain? Duration Emotional Abuse Childhood Trauma & Intrusive Images Revisiting the scene of trauma and abuse PTSD Symptoms: Anger Flashbacks Loneliness Feelings of Loss and sense of self Anxiety Numbing Re-traumatization Depression Memory Loss Relationships: Helping friends Helping loved ones Explaining PTSD to Children Workplace Issues False Memory Toxic Family of Origin Caregivers/Partners with PTSD Inadequate Therapy Recovery: Frank Ochberg's Color Wheel of Postive Emotion Triggers Rebuilding Self Esteem Life After Trauma Coping During the Holidays Substance Abuse Improving a Damaged Self-Concept Dialectical Behavior Therapy (DBT) Veterans & PTSD: PTSD A Disease Seasonal PTSD & Anniversary Reaction. Emotional Injury Professionals: Compassion Fatigue Consequences of Emotional Numbing School Teachers and PTSD Using The Counting Method with Clients Other Conditions: Borderline Personality Disorder Social Phobia Complex PTSD Dissociation Obsessive-compulsive disorder (OCD) Cutting & Self Harm Link between PTSD, BPD and Bi-Polar
		Questions & Answers with Joyce Boaz & Dr. Frank Ochberg Read "Survivor Psalm" by Frank Ochberg
				Definition of PTSD Q: Dear Frank, There will be a new definition of PTSD in two years, when the Diagnostic and Statistical Manual (DSM) is revised. Are the planned changes significant, from our point of view? Or are the changes relatively minor and of concern mainly to academics and researchers? A: Dear Joyce, Those of us who diagnose PTSD, who teach the subject to doctors and therapists, and who testify about trauma in court will need to know the new criteria. But the answers to your questions are, in my opinion, "No" and "Yes." That is, the changes are not significant from the perspective of the trauma survivor with PTSD and the changes are mainly meant to confirm current research and to clarify some ambiguous elements of the diagnosis. Another way to put it is if you have PTSD according to the current criteria, you will, in all likelihood, have PTSD according to the planned, new criteria. PTSD is PTSD. The basic concept is this. You are a perfectly normal person and something dreadful happens. You don't recover in several weeks, in fact, you have a recognizable pattern of difficulty that lasts at least a month. That pattern includes three different, overlapping dimensions. The first is a problem with trauma memory. The memories of being traumatized are too intense, too uncontrolled, too much "in the present" rather than in the past, and too likely to cause physical and emotional consequences. This dimension is currently defined as having any one of the following five symptoms: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. This, in my opinion, is the core feature of PTSD. To have PTSD is to have a trauma memory that haunts you, that comes when you don't want it, that isn't always there, but is there too often. And it is different from a "normal" memory of a terrible thing. Many of us have lived through natural disasters, unnatural death of loved ones, abuse, humiliation, bullying and sudden, catastrophic loss. We were traumatized and we were victimized. We remember and we hurt. But we are NOT plagued by any of the 5 symptoms listed above. We have autobiographical memory. The past feels as though it is in the past. We know the bad details. The bad details do not spring out at us every month, causing palpitations, nightmares, flashbacks, terror, or a sick thud in the chest. Without this category of unwanted re-experiencing, we do not have PTSD. The new plan for DSM 5 "tweaks" these definitions slightly: 1. Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5. Marked physiological reactions to reminders of the traumatic event(s) From the perspective of the survivor, there is no meaningful difference here. As a teacher, the 3rd criterion helps me explain to a medical student that a flashback is a dissociative episode. It involves an altered state of consciousness, similar to a trance or a fugue. The individual has the strange sensation of being in the past, possibly hearing or smelling things from the past. This new definition isn't meant to change who qualifies for the diagnosis, but to improve a clinician's understanding of the phenomenon. It's not just what you remember. It's how you remember. PTSD always involves a condition of "hot memories" that come like epileptic fits, sometimes triggered, sometimes out of the blue. As the PTSD condition improves, these "hot memories" occur with less intensity and less frequency. When they no longer occur at least once a month, the PTSD is "in remission." The bad memory is still there, but the way the mind remembers is no longer impaired. This dimension of PTSD was defined in DSM III, tweaked in DSM IV and will be tweaked again in DSM V. It's academic. The new wording doesn't really matter to the survivor or the significant other. The second published dimension of PTSD, called the "negative symptoms," have to do with numbing and avoidance. Despite being subjected to "aftershocks" of traumatic memory, there is a form of emotional anesthesia. This constriction of feeling, this walling off of responsiveness, is both automatic and intentional. The PTSD survivor avoids contacts and situations likely to cause emotional pain, and the capacity to feel anything is reduced. The current list of symptoms is: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g., unable to have loving feelings) (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) To make the diagnosis of PTSD, a clinician needs to establish that at least three of these seven symptoms have been present in the last month and have persisted for more than a month. When a person falls just short of qualifying for the PTSD diagnosis, it is most often because they have only one or two of these seven, but they meet the other requirements. For example, I just examined a man who lost two fingers when his muzzleloader exploded. He has flashbacks and anxiety. He is very worried about his career as an electrician. He is embarrassed about his disfigured hand. But he has no trouble returning to the scene, he can talk about the accident, he remembers every detail, and his diminished participation in significant activities is due to physical, not emotional impairment. He just falls short of the current PTSD criteria. The new criteria reformulate this dimension into two sections: C. Persistent avoidance of stimuli associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by efforts to avoid 1 or more of the following: Avoids internal reminders (thoughts, feelings, or physical sensations) that arouse recollections of the traumatic event(s) Avoids external reminders (people, places, conversations, activities, objects, situations) that arouse recollections of the traumatic event(s). D. Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: Note: In children, as evidenced by 2 or more of the following:**** Inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia; not due to head injury, alcohol, or drugs). Persistent and exaggerated negative expectations about one's self, others, or the world (e.g., "I am bad," "no one can be trusted," "I've lost my soul forever," "my whole nervous system is permanently ruined," "the world is completely dangerous"). Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s) Pervasive negative emotional state -- for example: fear, horror, anger, guilt, or shame Markedly diminished interest or participation in significant activities. Feeling of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing) My patient would still fail to qualify, since he does not meet C.1 or C.2 and he falls short of the D criteria as well. I believe that in raising the bar for these "negative symptoms" some people who met the diagnosis as written in DSM 3 and 4 will fail to qualify in DSM 5. These definitions do include and clarify many symptoms suffered by survivors, such as "Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s)," but this criterion is not always seen, particularly after natural disasters. Again, the changes are useful for the academics who do research on the subject, and the changes help with inter-rater reliability. But they do not change the essential quality of PTSD. The last dimension of PTSD is a lowered threshold for anxious arousal, currently requiring two out of five symptoms: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response This is being modified to require three out of six criteria: Irritable or aggressive behavior Reckless or self-destructive behavior Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance -- for example, difficulty falling or staying asleep, or restless sleep. The new criterion is "Reckless or self-destructive behavior." We do see this, but including it and raising the requirement from two to three arousal symptoms may exclude some survivors from the diagnosis. It is not a big change. It isn't designed to make it more difficult for traumatized people to receive the diagnosis. It may have that unintended effect. Finally, and most significantly, the definition of a traumatic event has been edited. This will have an impact on court cases and on reimbursement arguments. It will affect veteran's benefits. It is meant to reduce ambiguity and clarify the intent of those who define PTSD. The current definition is DSM 4 is: A. The person has been exposed to a traumatic event in which both of the following have been present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. The new proposal is: A. The person was exposed to one or more of the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: Experiencing the event(s) him/herself Witnessing, in person, the event(s) as they occurred to others Learning that the event(s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or accidental Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. I do believe this is an improvement and will eliminate certain non-qualifying traumas such as being taunted or receiving threats, and it will make it easier to include those who learn their loved ones have been badly injured, assaulted or raped. The fourth criteria helps tort claims against employers who send medics, social workers and reporters into harms way without adequate training or recovery time. So, in sum, the next definition of PTSD will benefit the academics who do research, the clinicians who make diagnoses, and the advocates who seek remedies for traumatized clients. It will not change the fundamental definition of PTSD. It may make it harder for some survivors to meet the threshold for diagnosis, but it will make it easier for others, particularly the loved ones and the trauma workers. PTSD remains PTSD. It is an injury to the function of the brain and nervous system, caused by one or more terrible, real, life-altering events. It affects otherwise normal people, but it also affects those with pre-existing disabilities. PTSD is a significant injury. Not every traumatized person develops PTSD. Labels do not define people, but they help science move forward and they help deserving people receive benefits. I support the work of those who are refining the criteria, particularly the chair of the committee, Dr. Matt Friedman. He is an advocate for all of us who deal with PTSD, whether we have the diagnosis or give the diagnosis or care for those affected. Tweet Was this helpful to you? If so, please consider supporting our work.

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