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PTSD Questions & Answers
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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Professionals: Consequences of Emotional Numbing.

Q: Dear Dr. Ochberg:

I am a therapist, and I have a question about treating a client with PTSD."Emotional numbing" is a symptom of PTSD and often is defined as the inability to experience positive emotions. Yet, anger, irritability, and depression are denoted symptoms of PTSD. However, in some people with PTSD, it appears to me as an observer that emotions may not be numbed per se but absent and can cut across the full spectrum of emotions, including distressing ones. The absence of emotion and inability to experience emotional reactions to daily life and interpersonal relationships, be they positive or unpleasant, seems to be a significant problem affecting quality of life of these persons with PTSD. There is a curious awareness of what isn't being felt, based on the person knowing what they used to feel and what most people would feel in a given situation. The awareness of not feeling is cognitively appraised as a loss but still not felt emotionally. What treatment strategies do you recommend to alter this inability to experience emotion? By the way, I have observed the absence of feeling, as opposed necessarily to emotional numbing, in persons whose consciousness was limited at the time of trauma, such as TBI, being asleep, or having been drugged.

A: Dear Joyce, Thank you for sending me Dr. FB's interesting and perceptive question.

For the non-professionals who read this exchange, let me summarize the issue this way.

PTSD has three clusters of symptoms. The most dramatic and widely discussed of these is, essentially, a memory problem. Instead of being able to remember the terrible trauma when we choose to remember, the experience comes back when it chooses to return. And, for some, that returning experience has such intensity that it appears to be in the present rather than the past. Flashbacks are dramatic and debilitating symptoms of PTSD. Another common and well explored dimension of PTSD is a lowered threshold for anxious arousal. This means having way too much nervous energy. Different people experience and display this general condition in different ways. Most have trouble concentrating and sleeping. Most are easily startled and when startled, they literally jump or duck or flinch. Many are irritable. Continuous anger is not part of the official diagnosis, but irritability and episodes of anger are. Irritability easily moves into anger. And anger can become rage. But let me be clear: not every survivor with PTSD is angry. Anger can accompany PTSD.

The last category of PTSD consequences includes numbing and avoidance. Some survivors avoid people and places that remind them of the original trauma. Some avoid conversation that might evoke a flashback. Some feel numb. Some feel detached. Some have the belief that they will not live a long, full life. This overlaps with the feelings and beliefs of depressed people, but it is not meant to be the same as depression. When a survivor is depressed, that diagnosis should be added to the PTSD diagnosis. It is incorrect to say that PTSD includes depression, but it is correct to note that PTSD and depression often exist in the same person. The numbing and avoidance of PTSD is different from the hallmarks of depression: feeling hopeless, helpless, worthless and lacking the psychic energy to do what must be done. Again, these negative symptoms of PTSD and depression are closely related and often overlap, but should be diagnosed by the mental health professional as distinct and separate entities.

Now, let's get to Dr. FB's chief concern. What is numbing all about? Can you experience numbing of some feelings and not others? What are the consequences of emotional numbing? How can it be treated?

Dr. Henry Krystal, a pioneer of trauma science, coined the term, alexithymia. That means lacking a language to express emotion. Professor Krystal observed that traumatized survivors could not convey emotion, even when they could feel it. Other colleagues found brain scans of PTSD patients with reduced blood flow to the speech center. We all know the term, "scared speechless." So let's begin this conversation understanding that regardless of a survivor's perception of emotion, they may have a serious block when it comes to expressing that feeling. Unexpressed feelings interrupt intimacy. Therapists are usually gifted recipients of unexpressed feelings. They know how and when to encourage communication. They offer words without seeming impatient or arrogant. But that situation, alexithymia, refers to a survivor who has feeling and is willing to have help in getting that feeling communicated. The absence of feeling is a different story.

Many, many times have I (and, I'm sure, Dr. FB) heard the complaint, "Dr. I know I love my daughter. I just don't feel it the way I should." Just a few weeks ago a kind and mature gentleman told me how worried he is about this condition of emotional numbing. He survived a car crash in which his wife and granddaughter were killed. Three years have passed. He has found a woman who loves him and understands his grief. But the muted emotion on his part causes him to fear losing her.

Usually, PTSD numbing does reduce the positive feelings of joy and love, but not the anxious feelings of fear and dread. So it is common to have high anxiety but low mood. And PTSD, by definition, includes some "emotional anesthesia." We have no pill for numbing. If the numbing is combined with depression (sadness, worthlessness and the other signs) then depression should be treated with all the tools that work. I use antidepressants and cognitive therapy and lots of coaching and encouragement to restore social and physical activity in a stepwise fashion. But lacking a treatment for numbing does not mean neglecting the symptom. It may be the last of the PTSD symptoms to remit on its own. It usually does improve with time. It must be explained, put into words and tolerated. The therapist can help loved ones understand the condition. I asked that car crash survivor to have his new significant other contact me and Gift From Within (it hasn't happened yet, but may by the time this is posted). In my experience, as a PTSD survivor makes progress in therapy, overcoming other symptoms, the numbing improves, too.

A diminished emotion can be expressed to a caring partner. But it should not be artificially over-stated. Honesty and genuineness are important aspects of recovery. I would not coach a person to act as though feelings are present when they are not. But I do recommend overcoming inhibition. Explain that "I may seem remote and less responsive. But you still are so important to me."

PTSD knocks us out of the line up. We are, for a time, away from friends, family, work and play. It takes an adjustment period to return. A good therapist thinks about the whole person and her or his capacity for social interaction at every step of re-adjustment. Having a blunted sensation of joy or love is, indeed, a disability. But it can be managed like hearing loss or a severe laryngitis. Let others know it exists. Work around it.

And if you know you love your daughter, but no longer feel it as strongly as you used to, you can still state your love, and state it strongly. Knowing that your family deserves your love is, in a way, more important than having the strong sensation of love that existed before PTSD.

Having said all this, I admit to Dr. FB that the treatment of those with absence of emotion is a challenge. We do need to be inventive and persistent. Sharing ideas is a good idea. GFW may want to post a page for new notions of aiding those who have lost elements of normal emotional response. My general strategy is to work on everything else, to encourage honest exchange with significant others, and to hope for improvement at the rest of PTSD improves.

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