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Joyce Boaz & Dr. Frank Ochberg, M.D.

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PTSD Symptoms: Flashbacks
FAQ 1: Flashbacks and How to Cope
FAQ 2: What does a flashback consists of?
FAQ 3: Can a flashback happen while you are asleep?

PTSD Symptoms: Flashbacks and How to Cope


Q: Dear Frank, I am continuing to see Facebook posts from people who are discussing their flashbacks even after seeing a therapist...I am wondering if you are seeing a therapist and you are having flashbacks what treatments help with flashbacks? How long does the average PTSD person have to deal with flashbacks before finding relief? And what do you do if you can't find a therapist or can't afford one....what would you recommend to probably the majority of PTSD sufferers.

A: Dear Joyce, The flashback is, in my opinion, the core of PTSD. When a person has flashbacks, they almost always have the other hallmarks of PTSD: nightmares, unwanted memories, anxiety, quick temper, avoidance of "triggers," numbing of positive emotion, withdrawal from others. So the flashback is part of a cascade of symptoms. One symptom precipitates another. During a flashback you think you are somewhere else, confronting dangers that are no longer real. The flashback may be followed with sensations of fear or exhaustion or self-criticism. "Why did I let myself believe I was in Iraq?" Or, "That was not my step-father, but I felt like I was back there and it was him." When trauma survivors feel they are going crazy, it usually involves flashbacks. Your brain is not working the way it should and you know it. Not every PTSD sufferer has flashbacks. Some only have memories that feel like memories (they are definitely in the past). Like flashbacks, they tend to come soon after a major trauma, then diminish in frequency and intensity. But when the trauma is severe or prolonged, unwanted memories, including flashbacks, can persist for years and years.

A flashback always feels as if it is occurring now, in the present tense. So it may be dangerous. An armed veteran may fire a weapon at "the enemy," but the enemy is an illusion, created from a frightening image of events long past. Flashbacks may have sounds, sights and smells that were so acute at the time they were encountered, and so realistic as they are being replayed in the mind of a survivor, that deadly action is stimulated, and deadly action is a terrible consequence. Most people with active, persistent PTSD recognize that a flashback is not real and poses no danger to themselves or others. But the flashback is never pleasant and may be so disturbing that suicide is contemplated. Suicide is rare, compared to the prevalence of PTSD. But suicide is such a significant issue that even rare cases require the attention and dedication of all of us. A flashback is not simply a vivid memory. If you have flashbacks, and you are reading this, you know exactly what I mean. I hope you have people in your life who understand this, too. Not everyone does. While every therapist should have a clear idea of what a flashback is, and how you feel when you experience one, some therapists are unfamiliar with PTSD. If they are mature and reasonable, they will want to learn about your flashbacks; they will respect you; they will help you learn how to tolerate the flashback and how to reduce its impact.

Among my patients, flashbacks have occurred in the first few weeks after a deadly accident, in the first few months after an assault and have persisted somewhat longer after rape or combat in which friends were killed. But then the frequency of the flashback diminished sharply, occurring on rare occasions. Sometimes a frightening experience having nothing to do with the original trauma would precipitate a flashback. Sometimes a reminder, a "trigger," would set one off.

As the other PTSD symptoms quieted down the flashbacks would also quiet down. When I examine survivors as an expert witness I ask about every PTSD marker. In these cases I usually find a history of flashbacks, but approximately half the time there has only been one in the past month. In rare instances there are several in a month. Many times the flashbacks have ceased and there were none in the past few months. Every case is different. If you have flashbacks, you deserve to have them treated - that is, reduced in frequency and intensity and dangerousness.

I use "The Counting Method" to treat flashbacks and intrusive memories. You can read about The Counting Method and see it in action on several webcasts and DVDs:

http://www.giftfromwithin.org/html/counting.html
http://www.countingmethod.com
http://www.youtube.com/watch?v=S0jtr4WcmYs
https://www.psychotherapy.net/video/ptsd-counting-method

Essentially, this technique allows you, the person with flashbacks, to have your flashback in my office while I count out loud to 100. You don't talk. You "run the tape" as you sit there, letting yourself recall the day that the trauma happened. It may come back to you vividly. It may feel more like a memory than a flashback. When the counting method works, you have the flashback contained within an interval of 100 seconds. I coach you to let the feelings crest while I'm counting in the 40s, 50s and 60s, but then to let the feelings lessen, and to bring yourself to a safe place in the memory when I'm in the 80s and back to me and the room and the present time when I'm in the 90s.

After that, we both catch our breaths, and then you tell me what you just experienced. I write it all down as you talk. Then I read it back and I comment as we both go through it together. That's it. That's the Counting Method. Often, doing it once is enough. In many situations, we do it 2 or 3 times. I've seldom done more than 4 "counting methods" with the same person. Usually the counting method diminishes the frequency and intensity of the flashback. It is as though your mind learned to turn it on, turn it off, and store it in a different memory pattern. Some of us believe that a trauma memory is stored differently from an autobiographical memory. The trauma memory is "hot" and the autobiographical memory is "cool." These memory systems deal with the exact same event, but they do it differently. You dial up an autobiographical memory. The trauma memory dials you up. It comes when do not want it. It is vivid and intense. Colors may "bleed" out of their outlines. Smells may come back. We never remember smells with the actual scent in our nostrils. But in a flashback we do. We remember the body odor of an assailant and the sulfuric stench of a battlefield. In the process of allowing a trauma memory to run while I'm counting, you may have those odors return. But as we go through the notes together, you no longer are in flashback mode; you are in a more normal, autobiographical mode.

There are other methods that therapists use to help diminish all PTSD symptoms, including flashbacks. Prolonged exposure and EMDR are among the most common. Anything that reduces anxiety, that helps a person calm their "nerves," that contributes to self-soothing and self-control, is beneficial. There is a large literature on "The Relaxation Response" and many approaches to achieving that response. Eastern and Western medicine use different techniques including meditation, mindfulness, acupuncture, Yoga and holistic attention to diet and exercise.

Medication is approved for PTSD, particularly the SSRIs, but there is no one drug for flashbacks. Research is well underway to find the "magic bullet." Some PTSD experts believe that medicating soon after a trauma can prevent a trauma memory from forming in the first place. Some believe that a trauma memory can be elicited and erased. Experiments on rats and mice are showing how fear-memory is retained and how it can be extinguished. If the fear factor can be taken away from the recollection of a traumatic event, the memory can be tolerated. And that is the ultimate goal - to have, in our heads, the truth of what happened, no matter how tragic or terrifying- but to have the emotional impact dialed down to a level at which we can bear the burden.

Flashbacks make those burdens extremely difficult to bear. We do need to help one-another face the fact that flashbacks are real, are painful and can be overcome. With or without professional help, we can learn to respect, even to honor, ourselves and anyone else who carries the invisible injury of PTSD, including episodes of flashback memory. We can learn self-soothing and self-respect. We can tell those who live with us what we would like them to do if they see we are having a flashback. (Some want to be held; some want to be reminded that the past is the past and we are in the present; some want to be left alone). Having access to deadly weapons is a critical issue and not one for me to tackle here. But it makes good sense to talk this over with family members or housemates and reach a sensible agreement.

In sum, the flashback is the hallmark of PTSD. No other diagnosis has flashbacks. Usually, having a flashback means having PTSD. PTSD is an honorable condition. It is the invisible wound of surviving trauma. It improves by itself. It is not a sign of weakness. If you have PTSD with flashbacks, you deserve a trauma-therapist who can use specific techniques to help, as I have described here. If you cannot find or afford a trauma therapist, do your best to learn relaxation methods that work for you. See if you can find a friend who "gets it" and who is willing to offer peer-support. Stay connected to Gift From Within. Share your experiences so we can learn how to help others. We are all in this together.PTSD Symptoms: Flashbacks.



FAQ 2:
Q: Dear Frank, Here is a question about flashbacks.

"I would like to know what a flashback consists of. I have heard or read that they are visual experiences only. Other people include body sensations and other senses. I often experience smells from the past and occasionally body sensations. Each smell is linked to a trauma. Prior to remembering my abuse I was told I was psychotic and hallucinating. Is there a difference between a flashback and hallucinations? And if so, what is it?" Thank you.

A: Dear Joyce, Flashbacks are memories that come suddenly and with such intensity that they feel as though they are in the present, rather than the past. They are usually visual, but they may include all the senses. Hallucinations are perceptions that are not real and may not have ever been real. So a rape victim who enters a room that resembles the room in which she was assaulted and smells her assailant's odor and feels his hand and sees his face is having a flashback rather than a hallucination. But if she hears him saying things he never said, it is an auditory hallucination and not a flashback. Psychosis or being psychotic means that the person is out of touch with reality. Having a flashback and knowing it is a flashback rather that believing the event is actually recurring is not psychotic. It is frightening and a likely sign of PTSD. It may have the force of a hallucination. But if it is a replay of an actual traumatic event, it is not a sign of schizophrenia, mania or other psychotic states.

PTSD Symptoms: Flashbacks.

Q: Dear Frank, Here is question from a support pal about flashbacks.

" Although knowing that I have PTSD is fairly new for me, I have had flashbacks for some time now. What I am curious to know, is what people are left with i.e. their feelings, after a flashback? For me the following day and even days, are especially sad for me. Flashbacks most always come while I am sleeping. I awaken either with a pounding heart or I could find myself out of my bed "escaping" etc. Do most people have these lasting feelings of sadness after re-experiencing their trauma? How long do flashbacks go on?"
A: Dear Joyce, PTSD always causes some form of unwanted, disturbing "flash" from the past. But when it comes during sleep, it is really not a "flashback." The term, flashback, should be reserved for intense experiences during wakefulness when the mind relives a traumatic event and does so with such intensity and immediacy that it seems less like a memory and more like a hallucination. The trauma appears to be occurring again. Now this may happen as a person awakens, or as a person falls asleep. The twilight zone between sleep and wakefulness is called "hypnogogic" going from awake to asleep and "hynopopic" going from asleep to awake. Even without a trauma history, these times can be frightening, trance-like states of mind. So I wonder if our questioner is experiencing a form of trauma memory as she awakens - half nightmare, half-flashback. This could be the case. She doesn't mention the content of the re-experiencing, but I assume it involves an abuser and a dream-like need to escape before harm is done, or after some harm is done and more is threatened. The pounding heart is surely evidence of fear, possibly panic, from anticipation of being victimized.

But this writer asks specifically about sadness. Is her sadness common? Is it part of her PTSD? How much longer will it last? In all probability, the sadness has to do with loss. And the loss that GFW community members often experience is the loss of a parent who cannot or will not understand abuse. In the classic incest situation, the abuser is a father figure, known and trusted by the mother. The abusing parent tells the little girl, "No one will believe you if you reveal this secret - and you will suffer if you tell." Incest is all about secrets.

The loss of trust and intimacy with the mother is often a more profound and disturbing outcome than the abuse by the father-figure. In any case, secret child abuse is a sad, sad burden that too often gets re-enacted and re-experienced through no fault of the victim. I just spoke with a survivor today who was coerced into degrading sexual activity by a prison guard. But worse than that was the triggering of terrifying and helpless feelings from age 5 and 6 when an 18 year old step-uncle, living in the home, forced himself on her over and over. I could see the sadness as she spoke. Her heart may have been pounding, but she learned to control her fear. She functions fairly well now, with a good partner, an excellent job and a resilient appearance.

The duration of flashbacks, true flashbacks, is usually less than a year. But certain life burdens are never completely laid aside. We are sad. Sadder and wiser. And we can, if we are lucky enough to find true friends, recover a sense of safety, hope and ability to help others.

Webcast: Nightmares Versus Flashbacks

In this webcast, Dr. Frank Ochberg talks about PTSD and the differences
between flashbacks and nightmares.

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