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Questions & Answers
with
Joyce Boaz & Dr. Frank Ochberg

Read "Survivor Psalm" by Frank Ochberg
Dear Friends:

Every month I will ask Dr. Frank Ochberg a PTSD related question. These are questions based on conversations I've had with Gift From Within Support Pals, and other trauma survivors. We will also have guest clinicians answering questions. I hope you find this exchange helpful. Please keep in mind that the info on this page and website is not a substitute for the advice given you by your own health professional and is for informational purposes only. Please check back often. If you would like to add this link to your website, please contact Joyceb3955@aol.com
How common is PTSD, Who is more likely to get PTSD?

Q: Dear Frank, We have support pals who have been through domestic violence, child abuse, ritual abuse and rape. Becoming survivors and thrivers are our goals. I have been asked just how common is PTSD? Who is more likely to get it and why? And how do normal post-trauma symptoms differ from PTSD symptoms? What role does resiliency play in healing and recovery? Why do some take longer to heal than others?

A: Dear Joyce,There are several important but different questions in this month's list. The first one, "How common is PTSD?" comes up whenever large groups are exposed to very dangerous circumstances, such as combat, and we need to anticipate the specific emotional outcomes. In that regard, PTSD is not as common as some other consequences of trauma, tragedy and abuse. For example, the British Ministry of Defense reports more depression and alcoholism than PTSD in its returning veterans from Iraq. This is true of women as well as men.

Among adult survivors of incest, I find PTSD to be relatively rare, but concerns about trust and intimacy quite common. The chances of developing PTSD after rape at gunpoint are quite high (one study found 80%). Among Vietnam vets exposed to combat, 15 % developed PTSD. The factors that increase the risk of PTSD include the suddenness and severity of the traumatic event, the intensity of exposure, the presence of complicating conditions (physical, emotional and interpersonal), and both genetic and personality factors. A readable but technical article in the latest PTSD Research Quarterly by Mark Miller is titled, "Personality and the Development and Expression of PTSD." A personality that tends toward "negative mood and adversarial interactions" is, according to Dr. Miller, more prone to PTSD. Moreover, one's personality predicts the way someone with PTSD will feel and act. Some are more introverted and self-destructive; some more aggressive and harmful to others.

Therefore, the answer to the question, "How common is PTSD?" depends upon the traumatic event and the person who is exposed to the event.

"Who is more likely to get PTSD and why?" There is more than one factor determining the answer to this question. But in my opinion, most of the reasons do come down to the way your brain is structured. Some of us have a pattern, from our earliest years, that makes us more likely than others to respond to a significant trauma with "hot memories." These memories are connected to the fear center of the brain and they turn themselves on when we do not choose to remember. They come with feelings that vary from minimal (vague dis-ease) to maximal (sheer terror). Recent brain imaging studies show that identical twins are similar in this regard.

Environmental factors, such as effective or abusive parenting, have more to do with the way we handle PTSD. As troubling as PTSD symptoms are, some cope relatively well while others find the symptoms overwhelming. But the presence or absence of PTSD symptoms after a traumatic event is, in my opinion, related to our genetic map and our brain structure.

Normal post-trauma symptoms include feeling shocked and stunned (which often includes a fast pulse and difficulty standing), having thoughts that return to the event, wanting to talk or to be silent (depending upon personality) and trouble sleeping. There actually is a long list of common reactions. But these are all proportional to the traumatic event and they clear up in days or weeks.

By definition, resilient people cope well with trauma and with most other life circumstances. They have an optimistic, yet realistic view of themselves and the world; they have a good sense of humor; they engage others effectively; they have skills that lead to productive and valued work. In my opinion, they are candidates for PTSD when extreme trauma befalls them, but they find accurate information and they make good use of it. I've had several such persons in my care. One is the mother of a murdered boy. She still has PTSD symptoms. But she is a terrific Mom to her other kids, and she copes. She helps other survivors.

Some of us take a long time to heal. That Mom may take a lifetime. PTSD is a group of symptoms that include "hot memories" (flashbacks and nightmares and images that burst into awareness when you wish you could forget); reduced or numb feelings (diminished joy and hope and love); and easily triggered anxiety. All of these symptoms fade with time, but they often reappear and when they do, it is easy to feel overwhelmed and demoralized.

It is no sign of danger or of weakness to take a long time healing. PTSD can be "tamed" and managed. It helps to learn as much as possible about the condition, and to take comfort from the others out there who are also enduring the long struggle.
Does PTSD affect the brain?

Q: Dear Frank, I read recently that prolonged and extreme fear or stress, including PTSD (especially prolonged) can cause damage to the brain. If it's true, what part of the brain, and what are the consequences or symptoms? I know in children it can affect the frontal lobe development. But this article claimed even adults can be affected by brain damage.

A: Dear Joyce, Stress can damage the brain. Recent studies of combat vets with PTSD, compared to identical twins without stress, showed statistically significant brain-scan changes. There was a reduction of grey matter (nerve cell bodies) in a part of the brain known to connect thought centers and emotional centers. That part of the brain is called the anterior cingulate gyrus. But there have not been long term follow-up studies to see if the brain recovers those losses. We do know that PTSD is treatable and the symptoms usually improve.

This recent finding is interesting, because a similar twin study showed there was no reduction in the size of another brain part called the hippocampus. We know that a small hippocampus correlates with vulnerability to PTSD. The hippocampus is a switching station for memory.

The larger hippocampus seems better able to manage terrifying life events without generating the kind of trauma memory that bursts forth later as flashbacks and unwanted, piercing recollections. In this older study, the scientists looked at combat veterans, some of whom developed PTSD and some who did not. All the vets had identical twins who were not exposed to trauma. The vets with PTSD had smaller hippocampi than the vets without PTSD, but those PTSD vets had twins with smaller hippocampi.

These studies seem to say that a small hippocampus is a risk factor for PTSD, but PTSD is a risk factor for a reduced anterior cingulate gyrus.

Does brain anatomy affect stress-resilience? Yes.
Does stress affect brain anatomy? Yes.

Is the brain damage from stress permanent? We do not know. I doubt it, however. The brain is an organ with amazing recuperative powers. Unless it is very old or very damaged, the human brain forms new pathways, new cellular connections and new ways of responding to anatomical disruption.
How long does PTSD last.

Q: Dear Frank, I was recently asked, "Is there any study that knows how long the average intense symptoms to PTSD are after initial diagnosis by a professional?" What do you know about the duration of PTSD symptoms?

A: Dear Joyce, The answer to this question is like so many other situations: It depends.

It depends on the trauma that resulted in PTSD. If your spouse was murdered you have the possibility of survivor guilt, death imagery, prolonged grief and a feeling of rage that complicates and fuels the usual PTSD symptoms. If you survived a plane crash you may never be comfortable in a plane again, but your PTSD may be relatively uncomplicated and brief.

It depends upon whether you were physically injured as well as emotionally scarred. A physical wound can be a source of continuing or episodic pain, triggering traumatic memory. A loss of a limb or an eye can change ones ability to work and to function as before. Any significant disability extends the duration of emotional strain.

It depends upon the number of traumatic events in your life, particularly in formative years. A body of research evidence now concludes that the duration and the difficulty of current PTSD is related to the presence of childhood trauma and to multiple traumas. Think of it this way: victim status is the belief that things will go wrong. Survivor status is the belief that something did go wrong, but you can prevail. Faith in oneself is shaken after multiple traumas and is undermined by childhood trauma. The self-confident person has a shorter period of PTSD than the person with less self-esteem.

It depends upon whether you get effective treatment. Some flashbacks persist for years then turn into unwanted traumatic memories. Without some form of exposure therapy (voluntarily re-experiencing the original trauma in the company of a trusted professional who helps you face your past with confidence) these symptoms may last years longer.

The National Comorbidity Survey found that the median duration of PTSD associated with worst lifetime trauma is between 3 years among respondents who obtained treatment and 5 years among respondents who did not receive treatment. (Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060)

In my recent attempt to find a study that answers the question, "How long is the average duration of PTSD?," this three to five year estimate is the best overall figure. It doesn't say that the symptoms are intense. It just says that the definition of the disorder is met. The definition of PTSD includes this paragraph: "The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning."

So the short answer to the question of average duration of PTSD, according to Ron Kessler, a Harvard psychologist, is, "three years when treated and five years when untreated." An even shorter answer is, "It depends." But please note, although the median duration of PTSD is 3 - 5 years, that is a median of all diagnosed cases. The median would be higher for chronic PTSD (longer than 3 months). Once PTSD lasts many months, there is a good chance it will last many more years. But that short answer has a long explanation based on some important considerations. GFW helps everyone with PTSD by sharing ideas, improving morale, and reducing the stigma of the diagnosis and its treatment.
Emotional Abuse.

Q: Dear Dr. Figley, Thank you for being a guest clinician. One of our support pals said that her PTSD is the result of emotional abuse from significant others. She has low self esteem. She says she feels "locked into behaviors, relationships and interactions that are dysfunctional and that on a subconscious level, she relates to others by being too helpful and too caring." Then she feels that this leads her to feeling used. Any suggestions on how she can change old patterns and learn new and better ways of coping with her mood disorder? What are your thoughts about cognitive behavioral therapy as it relates to severe trauma?

A: Dear Joyce, Thanks for asking! First, I am sorry that she is suffering as a direct result of emotional abuse. The low self esteem is certainly understandable if you feel you are trapped by the cycle described in the question. Replacing these with new patterns to better cope may be very difficult if you have been diagnosed with a Bipolar Mood Disorder without medication. There is an excellent questionnaire on line that will help you decide if you need to see a physician for this problem. It is at http://www.bipolar.com/mdq.htm. However, if you believe you are at times moody because of your PTSD and poor coping, psychotherapy can be helpful in more effectively managing your PTSD symptoms and self-defeating behaviors. I would highly recommend, however, that you get a thorough evaluation from a competent psychiatrist or psychologist trained in psychometric evaluations.

Cognitive behavioral therapy (CBT) is the treatment of choice for treating PTSD. However, if you find that it is too overwhelming for you, don't hesitate to tell your therapist. Frequently clients report that CBT is too powerful because the exposure to the past traumas cause more harm than good. The exposure can be adjusted to meet the special circumstances of the client or another treatment approach can be used. Establishing and maintaining a good and trusting working relationship with your therapist is a key ingredient for any successful trauma therapy.

Charles Figley is a highly published university professor in the fields of psychology, family studies, social work, traumatology, and mental health. He is the Florida State University Traumatology Institute Director. He is also a full professor at the Florida State University College of Social Work. Dr. Figley is a member of Gift From Within's Professional Advisory Board.
Childhood Trauma and Intrusive Images.

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

I knew from the time I was a child that I was somehow different and some children picked up on this as well as adults. I began seeking counseling at age 22 and it wasn't until I was around 40 that I finally found out, on my own, what my symptoms meant. I found a therapist a few years later who specialized in trauma and knew EMDR. I can say the therapy has helped me to accept myself and show compassion to myself. However many of my symptoms are worsening and imposing more and more upon my daily life. The intrusive images, and nightmares and inability to control my racing thoughts at times are becoming very upsetting. I'm not even sure when I say "racing thoughts" that I'm describing it that well. The thoughts are always fearful thoughts. When Joyce sent out the article about how trauma can affect the brain in children and cause life-long struggles it all made sense. I have been doing more research on this subject. One very helpful article is in Cerebrum, Fall of 2000 by Teicher, "Wounds That Time Won't Heal: The Neurobiology of Child Abuse". I realize that I am diagnosing myself but I am an intelligent person and I know myself better than anyone else does. I was right-on about the PTSD. My therapist validated that finding and told me it's a miracle I have survived as long as I have for what I have gone through. I have often commented to people that I feel my situation is rather hopeless and have pretty much closed up and stopped talking to anyone about it. If childhood trauma really damages healthy brain function, do you recommend any particular type of therapy for such life-long symptoms? I understand I have to pretty much live with PTSD and will never completely heal. But I think I am a good person and can have a decent life and be of service to others if I can get the proper help.

A: Dear Joyce, this long and thoughtful question mentions some specific items that stand out and that could help GFW readers with similar personal issues. First, the writer explains that since childhood, she knew she was different and this difference was evident to children and adults. The difference may have been caused by abuse, but it may have been inherited. Or it may have been a combination of "nature and nurture" as are most long standing emotional conditions. Second, the writer describes her current symptoms: Intrusive images, nightmares and inability to control racing thoughts. The first two problems, intrusive images and nightmares, sound like PTSD - but they are only PTSD when the intrusive images and nightmares reflect events that are known to have occurred. If they never occurred, they are symptoms of a different condition. Racing thoughts are seldom seen in PTSD, but often occur in bipolar disorder. Without more information, I'm not sure what is really going on here. But as a GFW Q & A, the chance to discuss general concerns is really more important than trying to make a diagnosis with limited evidence. If you know that things have not been right since childhood you may have a sensitive emotional system that is easily triggered, whether you were abused, neglected or simply born that way.

The brain is a self-correcting, resilient organ that has amazing recuperative powers. Of course parental mistreatment of children is tragic and sometimes criminal -- but being the recipient of such mistreatment does not mean that hope is lost. It may mean the road through life is rough and difficult, and you have to learn ways to manage a brain that tilts in various directions, from time to time.

One common "tilt" is in the direction of fear. An excellent book by Gavin De Becker is titled, "The Gift of Fear." We need fear to warn us away from danger that could be fatal. To have an autonomic nervous system that makes our heart race, our guts churn and our mind worry is a good and necessary thing. But to be a fearful person, shrinking from opportunity and intimacy, is obviously an impediment. Anxiety is, by definition, an excess of fear-- fear without reason for being afraid. PTSD causes anxiety. Anxiety may interfere with calm thinking. But having many fearful thoughts at once is NOT the same as racing thoughts. A good therapist listens very carefully to the way a person describes her pattern of thought. If the speed of thought is unusually fast, and comes fast without fear, the underlying problem usually has to do with mood regulation, not fear regulation. When mood regulation is impaired, there is usually a medical, biological cause. Drugs used for PTSD such as Paxil and Prozac may make the condition much worse if racing thoughts are involved. There are newer, effective "mood stabilizing" medications that help this medical condition.

PTSD is a complicated condition and complex PTSD, dating from childhood abuse is even more complicated. It is possible to have intrusive thoughts, nightmares and racing thoughts due to trauma and inherited emotional challenges. EMDR and other forms of post-traumatic therapy are helping with fear management and with a sense of personal worth. But further diagnosis is needed and modern medication should be considered to control the racing thoughts, which may very well be a symptom of bipolar mood disorder and not PTSD. If the "racing thoughts" are always fearful thoughts it is NOT bipolar disorder. The writer is probably correct: this is a result of trauma, not an inherited mood disorder.

I have a patient who was a truck driver. A drunk driver veered into his path at night and my patient was forced to hit another car. Six people died. My patient had PTSD with nightmares and flashbacks. But he also had episodes of racing thoughts and anger and depression. When I treated his mood disorder with Lamictal he improved. It took me a while to realize that he had bipolar disorder in addition to PTSD. I don't believe the accident caused his bipolar disorder and his racing thoughts, but his PTSD may have made his mood disorder worse. I think he managed his mood disorder with alcohol before he met me.

The worst forms of parental abuse to the brain are drinking alcohol and using drugs during pregnancy, then refusing to stimulate the child during infancy. Those forms of abuse and neglect do cause permanent damage to brain architecture. Being a cruel or selfish parent may result in psychological damage, but that is usually something that can be overcome with good personal experience later in life.

In summary, child abuse can be bad for your mental health, but it isn't the same as permanent brain damage. Hope for a good outcome is reasonable. Inherited conditions like bipolar are commonly seen along with PTSD and not caused by PTSD, but made worse by it. Racing thoughts make me think of bipolar, not PTSD. The implications for treatment are profound, since the usual PTSD meds make bipolar worse.
Revisiting the scene of trauma and abuse.

Q: Dear Dr. Ochberg, My therapist feels that it is not important to try to recall traumatic events, but rather to deal with the feelings that bother me now. However, I have felt haunted for years about the need to remember a specific house and the surrounding neighborhood where I lived during a traumatic time. I've gone as far as doing research on my own and calling complete strangers in the town in an attempt to get photographs of important places. I asked my therapist what she thought about exposure therapy and hypnosis in an attempt to help me remember, firmly believing that if I could revisit this place it would lose it's power over my life. Revisiting the house in person is out of the question since it's been demolished. I would love to know what Dr. Ochberg thinks about this.

A: Dear Joyce, There certainly are situations in which ghosts from the past can be confronted and overcome. Consider this marvelous example of three women who called themselves the Marvellas:

Twenty-five years have come and gone since Margie last visited the old man's farm. She's not sure she can even find the place. She's not sure she wants to.

The 51-year-old Anchorage travel agent has made a lot of progress lately confronting her fears. But she still has trouble talking about what happened in the barn.

So fragmented are the memories. She remembers her Uncle George carrying her piggyback across the horse pasture, her bony legs, black patent-leather shoes and white-lace socks poking out from under his arms. She remembers staring up at the barn's rafters, and how the hay scratched her skin. She remembers her ankles being strapped down, legs apart.

And then there's the time she was tied by her wrists and hoisted. Did things like this happen a couple of times? Every visit? Why didn't her aunt come looking for them? Did she not want to know?

Margie wants to remember more. No, she wants to forget. But she knows she has to go back there if she ever wants peace. And so she studies a local map.

Although Uncle George has been dead for more than 20 years, the courage to go through with this comes from two friends.

A year ago they were strangers - Vivian Dietz-Clark, 41; Ezraella "Ezzie" Bassera, 44; and Margie (to protect their own privacy, her children asked that the family name not be used). Now they call themselves sisters.

Their demons brought them together. Within the past few years, memories have surfaced, forcing them to deal with what had long been buried - the sexual abuse they're convinced they experienced as children.

A tremendous amount of energy goes into locking things up inside, Ezzie's therapist, Joan Bender, explained. It's like sitting on a huge, bulging chest to keep it from popping open. Any added stress drains energy from that chore. The lid creaks open. Memories escape.

The three Anchorage women met in a support group for adult survivors of childhood sexual abuse offered by STAR (Standing Together Against Rape). And when that group ended, they continued to meet on their own.

The Marvellas, a combination of their first three names, is what they call themselves now that they're a team. The melding of their identities is a metaphor for the journey they've taken on together.

That journey comes at a controversial time. Repressing memories has long been recognized by mental health experts as a way victims cope when events are too horrible to face. But more recently, some victims of childhood sexual abuse have been accused of concocting memories - and therapists of planting ideas in their heads.

To read the whole account, see http://www.dartcenter.org/dartaward/1994/winner/00.html This is the first news story to win the $10,000 Dart Award for Excellence in Reporting on Victims of Violence. It explains Margie's voyage back in time and her success at accomplishing just what your writer desires: a visit to a place in order to cause that place to "lose its power over my life." But was it Margie's journey -- or Margie's bond to other women-- that defeated her childhood demons? Perhaps it took many factors, including time, distance, death of the offender, maturity and a secure connection to others.

Therapists are not all in agreement when it comes to answering this month's question. And even when we support the idea of revisiting the scene of trauma and abuse, we wouldn't recommend it for everybody.

There are people who have vague, unclear images of abuse. They believe it must have happened, but they have no proof. Decades ago, Freudian psychoanalysts would have used hypnosis, free association, dream analysis and even sodium amytal to recover repressed memory. But most trauma experts are very cautious nowadays, knowing that there is no way to be sure that such memory is accurate, and fearing as well that horrifying images may make matters worse.

But if childhood abuse actually did occur and if a person has matured in a healthy way and if there is excellent support from true friends, a visit to the scene might be liberating. Think about veterans returning to battlefields (the opening scene of "Saving Private Ryan"). Think about trips by relatives of Hitler's victims to Auschwitz or the Holocaust Museum. For some descendants and some survivors, these experiences are too painful too contemplate. For others, they are meaningful exercises in mastery and in the exorcism of evil.

I wouldn't go back there alone. But with the right friends at the right time, I'd consider emulating the Marvellas.
PTSD Symptoms- Anger.

Q: Dear Dr. Anderson, A support pal with PTSD asked me how to deal with her PTSD symptoms, particularly anger and irritability. She gets angry and then takes it out on the people around her even though they are not the ones who traumatized her in childhood. It is distressing to her because she doesn't want to hurt those dear to her and she doesn't want to lose her friends and the family she does talk to.

A: Dear It sounds like she is describing a very common reaction of posttraumatic stress disorder. The hyperarousal symptoms, of which irritability is one, include problems with attention and concentration, impatience, hyperactivity, anxiety, sleep difficulties, lethargy, and fatigue. Events that normally would not cause an anger reaction often do bring an angry response in people with PTSD. It's very distressing for the individual and everyone around the person.

The behavior is often followed by feelings of guilt and shame because the person has lost control. So, what do you do about it? Dr. Frank Ochberg describes "Posttraumatic Therapy" quite well and I find that it is helpful for people to read his chapter on the subject. Two thoughts come to mind, however, in answering this person: (1) Medication with an SSRI (Selective Seratonin Reuptake Inhibitor); and (2) Therapy

While some people do not like the thought of using a medication, we have found it very useful. Paxil (one such medication) is one that seems to cause the most weight gain so we do not recommend this one for our clients. However, the others are useful. We recommend the smallest possible dose just to help "take the edge off."

I am not a medical doctor so we refer our clients to a psychiatrist who diagnoses and prescribes. Therapy is also important to process the traumatic events and weave them into the fabric of one's life so that they do not continually intrude into the "here and now." It is important for individuals to understand that the hyperarousal symptoms are a byproduct of PTSD; however, it is also important to take responsibility for one's actions and do something about them, to include taking medication. The combination of therapy and medication is a tried and true road to recovery. Good luck.

Dr. Beverly J. Anderson, B.C.E.T.S. is a member of Gift From Within's advisory board. Dr. Anderson has twenty years of experience in employee assistance programs, human services administration, psychological evaluations/psychotherapy with law enforcement officers, teaching, critical incident debriefings, trauma consultations and expert witness testimony.
PTSD Symptoms- Flashbacks.

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.
PTSD Symptoms- Loneliness.

Q: Dear Frank, A support pal emailed, "I'm scared to death to be alone because...you know, who am I? Existential loneliness feels like a physical pain, and I sense it must have to do with brain chemistry and the childhood trauma I suffered. Somehow I sense that it also deals with no established identity, hence a feeling of not being able to be alone with myself because I do not exist. How can one deal with this?"

A: Dear Joyce, There is a profound difference between loneliness and aloneness. Loneliness is a feeling, like hunger, of missing nourishment. Words used to describe this feeling include aching, empty, longing, yearning, missing, needing, gnawing, bereft, bereaved, grieving, isolated, rejected, and blue. To be lonely is to be unhappy due to the absence of another. That other may be a specific person. Or it may be any desirable company. The sudden, painful loss of another results in grief. It takes years to recover from tragic and traumatic losses, although the condition is an inevitable aspect of human experience. Common feelings of loneliness occur whenever we want but lack sufficient human contact.

To be alone is, according to some philosophers, the essential human reality. It does not mean the absence of companionship. It means being the only one inside your skin; the one and only you; the only one you really know; the only one you can really rely on; the one who is there at every moment of your life. By this definition, you can be among loved ones and still experience aloneness. Learning to tolerate aloneness is worthwhile. Learning to appreciate aloneness far better. The mystic Osho writes of "the bliss of aloneness" explaining that "the only freedom from the fear of loneliness is to become aware of your aloneness, and the beauty and power of it. Your innermost center, where you are always alone, is so full and overflowing with all the beauties and benedictions of existence, that once you have tasted it, the pain in your heart will disappear."
(http://www.newearthrecords.com/Catalog_/Osho/Discourse/BlissofAloneness.htm).

But for someone who experiences existential aloneness as physical pain, these words of an Eastern philosopher have little comfort. You do not travel from childhood trauma and feelings of nothingness inside to a blissful state of self-regard in an instant of enlightenment. Many who take comfort from the Gift From Within family are painfully rather than blissfully alone. It takes relentless work to overcome this condition. I If you have "no identity" and feelings of "I do not exist" you probably have had serious issues with attachment as a child. This may or may not be a post-traumatic condition. It usually derives from complications in an early stage of child development called "individuation," when a toddler is supposed to overcome infantile, dependent attachment to the mother. It also has brain chemistry components which may have been present from birth - extra sensitivity, an almost physical need for human contact, an innate fear of abandonment, a low threshold for anxiety and dissociation. This combination of challenges is very difficult for the individual, for their loved ones, and for their therapists. There are therapists out there who rise to the challenge. Finding them is not easy. GFW pen pals could share examples of good therapists and good therapies, encouraging one another to seek and find effective help.

Therapy for the feeling, "I do not exist," takes many years and will not cure loneliness. But it may bring the self-esteem and self-reliance that all survivors deserve. And then, the inevitable and universal condition of aloneness will be tolerable, if not blissful.
PTSD Symptoms: Feelings of Loss and sense of self.

Q: Dear Frank, A cause of dissatisfaction I've heard and read from survivors is about their feeling of loss -- the loss of one self after their traumatic event. People say that they are not the same person. Who I am now is not who I was. How do you feel about this expression of pain and grief?

A: Dear Joyce, The famous anthropologist, analyst and author, Erik Erikson, described an elderly gentleman who complained to his physician, "Oh, doctor, my head hurts, my bowels don't move, my joints are sore, and doctor, I myself don't feel so good."

I can picture this scene so clearly!

It makes one think about the meaning of "I, myself."

Surely we are more than our body parts, than our feelings and thoughts, than the way we appear to others. So it doesn't surprise me to hear that many of our gift from within survivors express a sense of being somehow different after profound trauma. I assume the change is in some aspect of that difficult-to-describe thing we commonly call "I, myself."

What is the self? Let's go back to Dr. Erikson. He described identity and the identity crisis. Identity crisis is something we face in adolescence and it is a confusing, turbulent transition from childhood to maturity. As adults, we achieve "self-sameness through time." We are no longer children. We have times of stress and change, but we are essentially molded and we have a feeling of knowing who we are. We have, according to Erikson, identity.

After certain traumas, our identity is shaken. We have more than PTSD symptoms. We have an altered sense of self. At best, this is a loss of innocence. At worst, it is a loss of capacity for trust. I want to be very careful here because individuals are different, "capacity for trust" is a complicated concept, and readers who suffer impaired capacity for trust need encouragement, not gloomy forecasts. Post-traumatic therapy is an individualized search for optimum outcome - not for return to a former sense of self. Once major symptoms are overcome, survivors re-examine their goals and values and the meaning of their lives. They are NOT the same as they were before. Often, they are sadder and wiser. When they are relatively confident in their new circumstances and, in a manner of thinking, in their new skins, they can trust and relate and recover human connection. Later, perhaps much later, there is a sense of integrity (Erikson's word, again). He doesn't mean honesty, he means that the whole journey of one's life adds up, makes sense, and feels coherent. In looking back, one recalls losses and gains, tragedies and magical moments. One knows who one is and where one has been. The sense of self is clear. One no longer feels lost or damaged or diminished.

To admit to "loss of self" is a candid and thoughtful insight. It is common among victims of major trauma. As a rule, it does not last a life-time. But the "self" that is found may feel different for a long while. It can feel as different as the difference between childhood and adulthood. But it is the same self - and eventually, if all works out as it should, that sameness of self is felt and understood.
PTSD Symptoms: Anxiety.

Q: Dear Frank, One of our support pals reports that she has constant intrusive thoughts of danger and tragedy and she wants to know how to deal with them. They occur daily and seem to be a normal part of her life and as she says (a rotten part of life).

A: Dear Joyce, There is an important difference between "thoughts of danger and tragedy" and memories of actual events. Both are part of PTSD. I'm going to assume that this support pal has PTSD as a result of one or more major traumatic events. (There are people who have not experienced major trauma, but, through no fault of their own, over-react to stimuli with debilitating anxiety. They panic easily, they worry constantly, and they focus on threats and losses. These people often need counseling and medication to adjust their body's alarm system, and control their overactive adrenal glands. They have conditions known as GAD -generalized anxiety disorder or Panic Disorder or both.)

When PTSD includes intense intrusive recollections or flashbacks, the brain's memory system is altered. "Hot" memories come spontaneously, intruding on normal life, causing a sense that the event is happening now and is not just a bad scene from the past. Therapists work with these intrusive memories, coaching a PTSD client on ways to start and stop the flashback. I use "The Counting Method" for just this purpose, and the GFW website explains it.

Usually, flashbacks and severe "hot" memories diminish with time. But our support pal may need help from a trained trauma therapist, using a technique to confront and control traumatic memories.

When PTSD includes anxiety in general (it almost always does) one is expected to have intrusive thoughts of danger. This could be because the feeling of danger is there and the thoughts follow the feeling, or it could be because one lives in a family or an environment that is filled with real reasons for fear. A professional trauma worker knows that security comes first: you make sure that steps are taken to minimize danger. Then coaching is used to improve survival skills. But often, a self-defeating pattern of pessimism, low esteem, and inadequate coping with reality (including poor choices about trustworthy friends) must be discussed and changed.

The pen-pals deal with this situation in a supportive, constructive email environment. Once in a while, professional assistance is needed, too. And if the therapist is not quite up to the task, the task becomes searching for a new therapist. I won't discuss medication here, but meds may be part of the remedy. Once the anxiety pathways are calmed, it may be possible to reduce or eliminate medication, and face life's ups and downs with improved confidence.
PTSD Symptoms: Numbing.

Q: Dear Frank, Your last Q&A on numbing in regards to trauma sparked another question. One of our support pals, Patti asked "Is it possible for numbing to only occur at stressful times that are related to the original trauma?"

A: Dear Joyce, Patti asks if numbing could appear only at times of stress that mimic the original trauma -and the answer is, "Yes." One of my patients uses the phrase, "...and that's when I go numb...I have no feelings.." She is describing a particular situation, usually in the presence of her husband, in which she has no route of escape and he becomes emotionally abusive. He doesn't hit or threaten, but he harangues and he escalates and he offers no sign of recognition of her growing anxiety. He knows that she is a survivor of torture and rape, almost 20 years ago. He thinks of himself as the victim although he is four times her size and is an accomplished attorney. He can't control his temper and he fails to understand his impact on others, Ironically, he is the one who rescued her from her original trauma. Perhaps that is why she is still with him.

Numbing may be episodic rather than continuous. When it is episodic, it usually appears at times of high stress with no clear escape route. The high stress may or may not be related to the original trauma. In Patti's case it is related. But with other survivors, the body (and to some extent, the mind) grows numb as anxiety (for any reason) intensities.
PTSD Symptoms: Re-traumatization.

Q: Dear Frank, What do you say to your clients when they feel they have been re-traumatized? What does it mean and what can someone do about it?

A: Dear Joyce, Re-traumatization is the opening of old emotional wounds and the anxious anticipation of such re-wounding. This second episode may be worse than the original trauma because it implies a string of "bad luck" - a sense of endless travail rather than one bad experience that has come and gone. Survivors tell me it feels like the old trauma plus a new trauma plus a loss of psychological safety. Psychological safety may be a myth (the thought that everything will eventually turn out right) but it is a helpful myth. It lets us live denying death. It saves us from the searing reality of biological truth.

Trauma therapists deal with re-traumatization all the time. In treating traumatic stress, we try to avoid opening a wound that is still too painful to be explored. Clumsy interviewing, bad timing, getting to a memory before rapport is developed - is bad therapy because it reinjures and destroys trust.

When my patients call, sometimes years later, to describe a recurrence of PTSD, they usually feel unlucky, unable to cope, and they say, "I'm back to square one." It as though all they learned about overcoming traumatic stress has vanished. The cause is usually a second trauma, but it may be a physical illness or a prolonged misfortune that falls short of the kind of trauma that causes PTSD. I review the progress they made before this happened. I search with them for sources of self-confidence. I remind them of their skills in surviving and coping. And I let them know that PTSD is real and it cannot be wished away. They may need more therapy. They may need medication, but I never assume that. They always need understanding and supportive friends.

If you are a successful survivor but your personal hurricane hits again, and PTSD returns, what should you do? First, make sure you are safe. Physical safety requires effort, friends and may require experts in security, law, or health. When the risks are high, you don't need psychoanalysis. You need a safety net. Second, when physically safe, but full of fear, flashbacks, numbing and self-isolation, remind yourself that you are better off than a rookie who knows nothing about emotional trauma. PTSD destroys your time sense and fools you into thinking that every bad thing is happening now. It isn't. These are aftershocks. Practice what you have learned. Get your conscious mind telling you what you know is good for you: PTSD passes. You are worthwhile. People can understand. There is no shame being human, having fear or deep sadness or confusion. Finally, Reach out to those you know are trustworthy. Tell them you have PTSD (or anxiety, depression or whatever term you can use). Don't wall yourself off. If you need professional help, get professional help. The return of PTSD seems to be worse, but usually it isn't. You have conquered it once. The skills kick in after the first shock wears off.
PTSD Symptoms: Depression.

Q: Dear Frank, In your recent program, Surviving Trauma & Tragedy: Lessons For Future Physicians you discuss that major depression is more likely to take place than PTSD. The panel members courageously discussed their traumatic events like Linda, who was pregnant and assaulted at gunpoint while shopping for her family, and a couple whose 20 year old son was a victim of homicide. Can you talk more about major depression and why this is something health professionals and survivors should be aware of? What are the major differences?

A: Dear Joyce, Depression is often confused with sadness and grief. Who would not be sad when robbed of dignity, integrity or a loved one by a rapist or a murderer? Who would not grieve the loss, with an aching sense of degradation or loneliness? The emotion of sadness is normal, even when it is profound sadness, proportional to the circumstance. The condition of bereavement or grief is also normal, and is always associated with loss. But depression is different. In a depressed state, a person feels hopeless and helpless and worthless. In addition, they have a specific type of lethargy that stops them from doing what they have been put on Earth to do. The cook cannot prepare a meal; the seamstress cannot sew; the writer cannot summon the energy to compose a sentence. Each of these people could climb a flight of stairs. They are not like the anemic or the heart patient without stamina and strength; they simply lack the energy to do what they usually do to be productive and to feel alive. Worthlessness is particularly important. If your spouse is killed and your life is suddenly changed forever, you would be expected to feel helpless and, for a while, without hope. But feeling worthless is a sign of depression. You shouldn't feel worthless during "normal grief."

When I was a psychiatric resident in the late '60s we were taught to consider two different types of depression. Exogenous depression, or depression from the outside, was a reaction to stressful life events. We thought of it as "situational" rather than "biological." If drugs were to be prescribed, we used minor tranquilizers like Librium and Valium. We expected the depression to improve as life conditions improved. Endogenous depression, or depression from within, was thought of as a genetic disorder with episodes lasting weeks or months, best treated with antidepressants like Tofranil or Elavil. Endogenous depression could come out of the blue, and was not thought to be caused by stress or loss. Now we know that endogenous depression often appears after extreme stress. In other words, a trauma can cause an episode of the type of depression that looks "biological."

Think of it as having your mood thermostat impaired. While it is medically normal to be sad when life is miserable, the brain's mood thermostat allows you to feel good when life improves. But if you are stuck in sadness, and the sadness includes feeling worthless and unable to summon the energy to do what you used to thrive on doing, you are depressed. And you need therapy for depression.

Therapy for depression is relatively straight-forward. There are ways to learn to correct self-defeating thoughts and there are medicines that repair the brain's broken mood thermostat. Both approaches, used together, give the best chance of recovery.

Often, working with extreme trauma, I'll find a combination of depression and PTSD. Both can be treated together. The numbness and avoidance that is part of the definition of PTSD may feel like depression. But people who spend the day in bed feeling worthless are beyond PTSD. They are not just numb and avoidant. They have broken mood thermostats and they cannot experience normal feelings until those pathways are restored. It helps to have the diagnosis of depression and the treatments that go with that diagnosis.

When journalists cover war they are vulnerable to PTSD and depression. Because of the strict criteria for giving the PTSD diagnosis, not every shell-shocked reporter qualifies for the PTSD diagnosis. So research suggests that depression is slightly more common than PTSD in this group. When I say that depression is often more common than PTSD after trauma, I am not minimizing the occurrence of PTSD. I'm just alerting survivors, doctors and government officials to the problem. Let's not ignore post-traumatic depression. It is a significant problem - but it is a treatable problem, particularly when friends and loved ones know enough to help.
PTSD Symptoms: Memory Loss.

Q: Dear Frank, This question is from a female veteran writing a senior seminar paper on PTSD and memory loss.

Hello, I was hoping you might be able to answer a few questions about the physiology of PTSD and memory loss? I have much research but yet I'm not satisfied with the thesis and argument. Any suggestions? I am also a veteran who was diagnosed back in 2001...I had a traumatic event happen in 1976 but no memory until 2001 - nothing until up it came and then all hell broke loose! I couldn't stop it. I'm much better now thank God! So, I would really like to target why things need to be looked at closely with PTSD due to what happens in the brain during the terror event.

A: Dear Joyce, The problem with PTSD is usually the opposite of memory loss. Memory is all too vivid. In fact, some memory seems to have a different pattern with PTSD, showing up in brain scans as closely linked to the "fight-flight" centers of the brain. Certain shocking events are repressed or suppressed or forgotten, only to show up later. Freud knew this and based much of psychoanalysis on recovery of repressed memory. He perfected techniques of dream analysis, free association and transference (in which feelings from unconscious experiences with significant persons from the past—usually parents--are "transferred" to the therapist and are eventually made conscious, analyzed and understood). Post-traumatic therapy is very different from Freudian therapy.

My job as a therapist is to help someone master their all too conscious memories, not to dredge up unconscious, unremembered traumas from the past. Perhaps you have experienced both problems. Traumas from the past have been hidden, then they erupted. Traumas from more recent experience have haunted you in the usual pattern of PTSD, with episodes of intense, unwanted re-experiencing. Researchers have different theories to explain this. Our brains are not all wired the same way. Some of us are more likely than others to respond to trauma with a PTSD pattern. Trauma causes release of adrenalin and related biochemicals. A vulnerable brain responds by capturing the images at the time of adrenalin rush in a trauma memory system. This system responds later in life, triggered by unconscious or conscious reminders. To get over the PTSD pattern of response, one has to "master the memory" and transform it from the trauma system into the regular memory system. You never forget. But you need not constantly remember. Repressing is not the same as forgetting. It is a way of sparing yourself awareness of what is under the surface, silently but powerfully affecting your behavior and your emotions.
Relationships: Helping Friends.

Q: Dear Frank, A support pal who I shall name Cathy, to protect her identity, recently wrote me a question about PTSD and friendship. Do you have an answer?

Joyce, Good Morning !! I got a request to correspond with another support pal and I am going to try this again. I still frequent the Web site and enjoy your e-mails. I do find that I sometimes get stressed when I think about my trauma. The approach my therapist and I take is not to focus on the trauma unless it needs to be addressed. When I discuss the current issues related to the trauma, I tend to "shut down" emotionally and become numb. So,what to do with my support pal when I need to take a break and do not want my pal to feel I am rejecting her? I have not handled this so well in the past with other support pals and feel bad about that. The last thing I want to do is hurt my support pal. I hate this trauma stuff and wish it would go away and NEVER happen to another person. BUT, it will not go away (believe me I have tried all available options) :-( Thank you Joyce for the services you are providing.

A: Dear Joyce, This is a very important, sincere question, from a survivor who clearly has the compassion to help others and the wisdom to protect herself. She asks, "So,what to do with my support pal when I need to take a break and do not want my pal to feel I am rejecting her?" Let me offer a few thoughts. There is an implicit contract between support pals, and it includes the fact that a pal is not a therapist and is not a next-of-kin. The support pal system depends upon the ability of the one in the role of supporter to back away when the emotional burden is too heavy, and the understanding of the one in the role of support-receiver to accept that with grace and thanks. When this works as it should both parties come out ahead. It is a good idea to talk this over before, during and after the issue arises. Within families, and among close friends, there often are feelings of rejection and resentment. Even without trauma histories, close relationships are fraught with similar challenges.

Who hasn't been short with a family member and said something in frustration that escalated into a regrettable war of words? Or into a cold-shoulder and a period of estrangement? Intimacy isn't easy to sustain under ideal circumstances. The survivor with PTSD has a condition that includes a higher probability of anxiety and hyper-vigilance, regardless of the topic of discussion. It also includes a risk of re-experiencing a memory that one wants to forget. And it includes the reflex reaction of numbness and avoidance--shutting down and losing the full and normal range of emotion. Survivors with remnants of PTSD are, in a way, like cardiac surgery patients. It is good to gradually build up strength, endurance and resilience, but not to overdo the exercise and damage recovering muscle. With our support pals, both parties are fully capable of understanding this. Both should pace themselves and one another. So let your support partner know if it is a bad time for communication, or if a particular theme is difficult to handle. You are not rejecting your support pal when you ask for a break. You are explaining your own needs to someone who is in a good position to understand and care about these needs.

There are many GFW friends with a condition called "rejection sensitivity." This is a feature of atypical depression, but occurs without depression, too. You who read this may be very sensitive to slights from others. Or you may have family members and friends with that condition. It usually is a feature of personality, unchanged through time, but more or less in evidence as life becomes more or less stressful. I am heartened to learn that "Cathy," the support pal who wrote to Joyce, is concerned about the way another survivor might feel if "Cathy" backs away. Sometimes, however, this is a matter of too much empathy. The one who worries about another person's sensitivity may be very sensitive herself. And in that case, out of well-meaning concern, the support pal opts out of the system entirely. It is just as likely that a receiver of support, learning that a "pal" needs a break, will feel honored to bestow that break. It is a gift. And when looked at in that light, the friend who says, "Of course. Take care of yourself," has given a gift and therefore has something to feel good about.

This is complicated business - helping others and receiving help from others during recovery from traumatic and tragic episodes. Naturally, there are feelings of responsibility and, at times, obligation. GFW support pals are pals, and with any form of friendship, there are risks. We all have to do our best to share and manage those risks, to be honest with ourselves about when we are ready and able to empathize, sympathize and handle the burdens -- and the rewards-- of contact with others who share the experience of PTSD.

I'm suggesting we be as open as possible with support pals. It is always OK to back off. It is not a rejection of the person. It is a wise decision to take exposure to trauma stimuli in small, measured, tolerable doses.
Relationships: Helping Friends.

Q: Dear Frank, I recently received this question:

"PTSD is obviously a huge part of my life. Try as I might to keep my symptoms hidden, they sometimes surface. After many years in a relationship that soon may become binding or legal do you feel that I should reconsider if the person involved is unable to accept that I cannot get over the past. I know that I have to make my own decisions but I would like hearing the insights from you as well as from others in the GFW family. I constantly feel I have to act okay when I am desperately stressed. My way is of coping is more and more self medicating to hide my pain. (Ativan and wine) I am getting down on myself for my inability to heal. I do have a therapist but we seem to be at a standstill in our therapy. It took me forever to find this therapist. Knowing her she would say be patient. My fiancé doesn't believe in therapy. What are your thoughts on this situation?"

A: Dear Joyce, My answer:

The fact that you ask this question leads me to believe that you doubt the wisdom of marrying a man who does not accept you as you are. And because you have serious doubts, so do I. Obviously, I am in no position to know what is really best for you. There must be very strong assets that this man brings you, or you wouldn't even consider a life commitment. But hear yourself:

"...my symptoms...surface"

" ...the person involved is unable to accept that I cannot get over the past"

"I feel I have to act OK...to hide my pain"

It appears that you have to be false to yourself and false to him to make a marriage work.

Furthermore you are at a standstill in therapy and your fiancé doesn't believe in therapy.

An ideal life partner would believe in you. He might have doubts about this therapist, if you are getting nowhere. But he would support your choices. He might help you feel confident about the future, which is necessary if you are trying to let go of the past.

Might it be that this man is being honest with you? That he believes you can make some significant psychological changes, and succeed in living your life with him, rather than living his life with him? Or is he incapable of appreciating and respecting your interests, your priorities, and your desire to escape traumatic memories?

I do hope you can win this long struggle to step out from the shadow cast by past trauma. Good partners and true friends do not say, "Get over it." They may wish you will get over it. But they join you for the long haul and they become sources of hope, comfort and validation.

If he is none of those - comforting, validating, and inspiring - I'd really wonder why he remains in your life. But if he is merely aggravated that your demons continue to plague you and he loves you despite your burdens, I'd think twice about saying , "Sayonara." Many men are angry at PTSD, while they care deeply for the one who suffers from it.
Relationships: Loved Ones.

Q: Dear Frank, A customer asked me this question in reference to his girlfriend. How do you tell someone close to you about PTSD if they've never heard about it and how do you encourage someone to look into getting help. He listened to your Sage Advice for Trauma Survivors and Caregivers Audio CD. I guess it's difficult for a loved one to figure out how to start off the conversation.

A: Dear Joyce, Thank you for sending me this question. As you know, I've written a few pieces for GFW and made a DVD for partners of people with PTSD. My messages informed about PTSD, encouraged partners to become as knowledgeable as they possibly could be, and to recognize that loved ones might prefer to keep painful memories to themselves--protecting their loved ones, but risking loss of trust and intimacy.

In this answer I'll try to focus on the assumption you raise, "I guess it's difficult for a loved one to figure out how to start off the conversation." That is often very true. People with PTSD have symptoms and suffer and withdraw. Hiding from help is actually part of the diagnosis. PTSD includes retreating from social situations, self-isolation, loss of hope for a full and rewarding future, and irritability. Sometimes that irritability is angry and violent, pushing away the family and friends who care most.

So I will not say, "Just go ahead and talk to your loved one." It pays to show that you respect a person's desire for privacy and dignity. It is often a good idea to wait for a sign that your partner is ready to talk. Even as a therapist, paid to help a client, I often say, "We needn't get into painful parts until you are sure you are ready."

PTSD is a set of symptoms but it is also a memory of something real. Your partner may want help with symptoms, like insomnia and irritability, but may not want to recall details of a rape or
violent death that was witnessed. So when you sense that your loved one is as open as he or she will ever be, you might say, "I think your insomnia (pick a symptom that is least embarrassing) may be part of PTSD and PTSD can be treated. Could we talk about treatment?"

Instead of, "Could we talk about treatment?," you might be more assertive and say, "I'd like to get you an appointment with an expert for treatment." Or, "Let's get help together, because I'm hurting, too."

I never know exactly what someone else should say, but I do often work with partners and try a few ideas, sometimes using role-play in which I play the spouse who wants to help and the spouse plays the loved-one with PTSD.

So I might say, "I've been reading about PTSD and I think that could be the cause of your insomnia. Could I look into an appointment for you with a PTSD expert?" And the wife, playing the role of her angry husband, might say, "I don't want you to bug me." That's not a good sign. I'd then say, "OK. I don't want to fight about this."

In those cases, I usually advise waiting for another chance and trying again, cautiously and politely. Sometimes the caregiving spouse goes for treatment and eventually the person with PTSD overcomes his or her resistance. That is like going to Al-Anon when you really want your partner to go to AA.

But far more often the role-play works out and so does the application in real life.

For example, I say that line above about insomnia and wanting to set up an appointment, and the partner, in role-play says, "I guess that would be OK." They often add, I never thought of saying it just like that. Some actually want to write the line down and practice it.

I'm not suggesting that the words make the difference. The anxiety that both partners come to share gets in the way of progress. There is discomfort and embarrassment on both sides.

So talk with a friend, or actually see a therapist. Overcome your awkwardness. You certainly are not alone. It may not work the first time, but it is worth a few tries. Try and try again.
Explaining PTSD to Children.

Q: Dear Frank, What is the best way to explain PTSD to children if they live with a parent who has PTSD? Children and siblings would react differently than a spouse or close friend. Do you take them to a therapist? What else can you do? Since there are so many vets returning I'm sure this is something that affects the family.

A: Dear Joyce, this is a good, tough question. I've explained PTSD and other conditions to kids whose parents were affected, but it is very different from case to case, depending on the age of the child, the personality of the child, the relationship that the child has with that parent and with the other parent, and the rapport that I'm able to establish with the child. It isn't that easy for me to set up an ideal situation for the conversation. I'm thinking of a case quite a few years ago where the mom wanted to be present and she wasn't all that helpful. "Tell the doctor how you feel," she coached, deflating my attempts to be less of a doctor and more of a down-to-Earth friendly adult. I wanted the pre-teen daughter to let me know her fears and concerns, and I had a feeling that the daughter might benefit from counseling. Her mom had been seriously abused as a child and later developed bipolar disorder with deep depressions. Years later the daughter did see me for counseling (age 17) and I was able to help her with her social phobia (unrelated to her mom) and then I could explain her mom's condition.

So let me start answering your question by saying that the best way to explain anything to children is to meet them at their level, discovering what they want to know, and giving clear, honest answers. Young children are not likely to want to know details. They usually want to know that things will turn out well, that strange behavior (eg, withdrawal, crying, anger) is not their fault, and that parents are confident about the future. Some kids are very curious and ask, "Why?" rather frequently, and can be intrusive. A child might ask, "Why does Mommy go to the doctor every week?" Explaining PTSD is not necessarily a helpful response. Ducking the question is not necessarily helpful. Something along the lines of "She learns how to relax and fall asleep at bedtime" could be useful, followed up by, "Do you ever think you would like lessons like that?"

Older children might benefit from hearing the medical facts about PTSD from the non-affected parent: eg, "It is a condition in which troubling memories return when they aren't wanted (therefore it is helpful to ask me, not Daddy, about the accident)." And, "It is a condition that includes feeling irritated, nervous and withdrawn (so it isn't your fault if Daddy seems angry at times)." Of course, add that PTSD gets better with time, that some people would rather not talk about it, that others benefit from talking, at times, and describing how they feel.

Explaining the facts of a trauma can be very difficult for a parent and child. Some family therapists advise getting the family together and being sure everybody understands what happened, all rumors are shared, and everyone ends up on the same page. These therapists are not only interested in explaining PTSD; they want to get a "functional family" working together to help with healing. Some families choose to exclude young children from this process.

If you are concerned about a child's understanding of PTSD, it never hurts to ask. If a child expresses interest in learning more, you can explain symptoms, reasons and remedies in a simple honest way, as long as the child knows about the trauma. For example, "Since Mom was in the car crash, she has bad dreams and sometimes she has a feeling like a bad dream during the day. It is getting better now. She sees a doctor who knows about dreams and knows how to help. Let me know if you have any ideas about helping, too." Obviously, it is much more difficult in cases of sexual assault where the details of the trauma are unspoken. But supportive families with a history of comfort in conversation find ways to get these trauma stories told, destigmatized, and turned into opportunities for healing.

A final word: Explaining PTSD symptoms may be easier and more productive than trying to convey the whole syndrome. Anxiety can be explained as a medical condition in which your heart beats faster (emphasize that this is not dangerous - but that it makes you look like you are afraid and feel like you feel when you are afraid). Depression can be explained as a medical condition in which your ability to feel happy is impaired. You may know that everything is OK, that you should feel happy, but you just are numb and can't fully experience the good feeling. Memory and concentration deficits can be explained, too. I'd stay away from using terms like "thinking disorder" or "brain impairment." But it never hurts to help your child be tolerant of concentration and memory lapses by explaining how this happens when adults are recovering from certain conditions. Then use the words your child understands about these conditions (eg, "bad dreams during the day").

Share ideas that you find effective with your adult friends and family and GFW pen pals. We can all learn together.
Relationships: Workplace Issues.

Q: Dear Frank, A support pal asked me if you had any suggestions for low stress jobs, for people with PTSD. After a long while of doing really well, she is feeling totally overwhelmed.

A: Dear Joyce, "Are there low stress jobs for PTSD people?" a GFW writer asks. This reminds me of a time nearly 30 years ago when I was investigating hostage situations. I spent a week in Holland during a tense episode in which terrorists controlled a school and a train. Preparing for the worst, the Dutch authorities set up an emergency hospital in a tent near the train, with cots, IVs, ambulances, and a rather young retired surgeon in charge. He explained to me, "I had a triple by-pass operation a few months ago and my doctor told me to retire to limit my stress." I looked him, there in the shadow of a train with armed assailants, scores of passengers, the whole country watching, no telling what would happen. This was a dangerous, difficult job for a man on medical retirement. I finally said, "Aha. I see. You couldn't stand the stress of NOT being here." He grinned in agreement.

Some jobs are stressful because of time pressure, responsibility, and heavy consequences of failure. Some are stressful due to boring repetition. Most job stress comes from lack of respect and understanding from those in charge. In PTSD cases, any reminder of the original trauma can be a source of stress. My friend, the plucky Dutch retired surgeon, probably thrived on responsibility and was bored by inactivity. If you are looking for a low stress job, you need to think carefully about the conditions that push your buttons. Are they related to people--coworkers or bosses who make life miserable? Or are the environmental conditions stressful--noise, close quarters, distraction?

Has a job become stressful because it seems too demanding? That could mean concentration difficulties are limiting your performance, and trouble concentrating is part of PTSD. It could also mean that fatigue associated with depression or with a medical disorder is the underlying cause. Burnout is a non-medical term that describes a condition of relentless responsibility, with little positive feedback for loyal effort. When a worker is "burnt out" the job is no fun, humor is gone, coworkers are unhappy with you, and a change, if at all possible, is healthy.

Workers with simple, straightforward PTSD - a result of an obvious and overwhelming traumatic event - often need time off to recover, to learn coping skills, and to receive expert help from a qualified therapist. They may need a job change. (I'm working right now with a trucker who was involved in a multi-vehicle fatal accident. In my opinion, he can never be a trucker again. He is highly motivated to become a nurse and I'm working with enthusiasm on that plan.)

Workers who find they have difficulty long after a trauma or a series of stressful events may be suffering from conditions that are different from PTSD. High in the list is dysthymia - a continuous low grade depression. Therapy, with or without medication, may be very helpful. A switch to a less demanding or less demeaning or less boring job may also be indicated. But choosing the right job is a matter of careful analysis. One persons stress-free job could be very difficult for another person. Work with a mature, sympathetic advisor to figure out what are your personal job-related stressors, and seek employment opportunities that eliminate those particular conditions.
Relationships: Workplace Issues.

Q: Dear Frank, I recently received this question:

"I can't afford to lose my job, but I have PTSD after a serious injury and now that I am physically healed my boss wants me to return. I'm afraid I'll be awkward around people and below par in handling responsibilities. I have a demanding job and a demanding boss. What can I do?"

A: Dear Joyce, thank you for this question. Here is my response to Mrs J.

You need a doctor's letter to your employer that spells out the situation, making your needs abundantly clear. Although every case is different, most PTSD patients require accommodations as they return to work. In almost every state, there are laws that require employers to accommodate medical conditions. This arose recently with a new patient who was injured with a deadly weapon by a drunk and delusional husband. Fortunately and amazingly, her physical wounds were minor, healing in a matter of weeks. Had the wounds been an inch to the right or left, she would not be alive today. After seeing a therapist for a month who meant well, but didn't have much experience with this type of trauma, she came to see me. We discussed her symptoms, her family and her work history. Within two weeks she made enough progress with emotional issues to consider resuming her job. But she knew she couldn't handle all the demands as effectively and efficiently as before. It was up to me to help her return to work on her terms. We agreed to the following letter (altered slightly here to protect privacy):

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To Whom it May Concern:

Mrs. J. has Post-traumatic Stress Disorder (PTSD) due to stab wounds to the neck and chest, an assault that could have killed her. She is under the care of a specialist in treating her condition and is progressing well. Disabling symptoms are in remission. It is time to return to work, on or about May 8, with accommodations: (1) avoidance of social circumstances that may trigger flashbacks; (2) limited duty to assure slow and steady mastery of tasks and return of confidence. The pace of return to full duty should be gradual, over a six-week period, but may be more rapid if well tolerated by Mrs. J.

This is a highly motivated, experienced and dependable worker who may push herself or allow herself to be pushed to full employment prior to full recovery from PTSD. PTSD may return to disabling levels under stressful circumstances.

Let there be no doubt about the severity of PTSD in conditions such as this one. The medical disorder affects mood, memory, concentration and morale. Despite widespread public familiarity with the condition, it is still stigmatized and misunderstood. With appropriate support from friends, family and workplace colleagues, the recovery period can be relative short (within a year). This individual will have a recovery complicated by the stress of criminal and civil legal proceedings, financial concerns, publicity, family stress, and the need for weekly therapy visits.

My prognosis is good, based upon the experience, intelligence, work ethic and support system of this patient. I thank the intended recipient of this letter, Mrs. J's employer, for care and concern and willingness to work with this plan for gradual return to full employment.

Yours truly,

Frank M Ochberg, MD

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A letter like this, written with a firm but friendly tone, supports the patient and gives guidance to the employer. Some employers will object to a plan that seems reasonable to the doctor and patient, but they risk a costly lawsuit if they do.

I can't assure that you will find a doctor who is both expert in PTSD and willing to write this type of letter. But if the facts fit Mrs. J's situation, you are well advised to look for the professional who can meet your needs as both therapist and advocate. I try to teach the medical students and psychiatric residents at my university to step up to their obligations (and opportunities) as physicians. They carry clout. They should not be afraid to use it when their patients face legal, financial and vocational challenges.
Relationships: Workplace Issues.

Q: Dear Frank, several support pals have asked about dealing with co-workers who do not understand PTSD and may say things that trigger bad memories or that invite discussion about traumas - private memories that the support pal is not ready to reveal. How should these situations be handled?

A: Dear Joyce, when well meaning colleagues at work ask the simplest of questions, even a friendly, "How are you today?" a survivor might feel choked-up, anxious or confused. The rush of feelings to the surface can be embarrassing. This is not the time or the place for an intimate, revealing conversation. Sometimes we can sense a person's kindness and willingness to listen, but we are not ready to reveal details. In fact, we are trying hard to push a bad memory down where it doesn't disturb us, so we can appear in control and we can get on with business at hand. The feeling is different -and perhaps easier to handle- when someone is a bit pushy or rude, asking inappropriate questions. Then our anger kicks in and we are better defended. We still do not like the awkward situation, but we are more in control of our space. PTSD does this. It reveals itself to us and to others when we do not want it to.

The hallmark of PTSD is "intrusive re-experiencing." Who wants an uninvited guest like that, appearing at work? In most larger work places there is a person, or several people, who are natural helpers and healers. I call them "the indigenous rabbis." They may be a bit older. They usually avoid higher managerial positions. They are respected and liked by most, if not all. When you have such a person at work, you might risk asking them for help. You could say, "I have a problem and I think you could help. Is there a time when we can talk?" You could ask them to read the GFW essay that I wrote for partners of people with PTSD: http://www.giftfromwithin.org/html/partners.html. You needn't spell out details of your trauma, but you could enlist the aid of a colleague who could quietly spread the word in a way that preserves your dignity and privacy, without mentioning any details.

Some work places have employee assistance programs with specialists who are very good at this. GFW senior advisor Angie Panos has a lot of experience in that role and could add her insights, if you write to Joyce with a specific job-site problem. Journalists are facing the issue since they are often traumatized and their culture requires a very stiff upper lip. Visit www.dartcenter.org and wander around that site to learn how journalists face PTSD on the job and deal with co-workers and managers.

But you are under no obligation to share any aspect of PTSD with someone you do not trust at work. These experiences belong to us who have them. We own our minds and our personal histories, just as we own our bodies. We can choose to reveal and we can choose to keep our own counsel. Often, it is our traumatic experience that makes us who we are - less innocent, less carefree, but wiser and more able to appreciate others.
Relationships: False Memory.

Q: Dear Dr. Ochberg:

I'm sure you receive countless e-mails from people needing your expertise, as I know you are the best in mental health. My sister really needs some help and she doesn't know it! I'm so sorry to bother you, but our family doesn't know where to turn, we are desperate!! .... You see, my sister thinks my mom molested her and my other sister as children. My other sister who is involved in these vivid memories says it is absolutely not true, which we as a family already know, as that is an oxy-moron of my mom. In the beginning of all of this, she also accused my dad of molesting them, too (If you ever met my dad, that would be laughable, as that is also an oxy-moron of my dad!). After seeing a psychiatrist, the psychiatrist said that she probably walked in on my parents and got mixed up from that, so she has now dismissed my dad of doing anything.

My parents have been the most loving, giving and God loving parents that anyone could ever dream of having. It is tearing my parents and all of us siblings up!! She is not allowing my parents (we don't understand why she is doing this to our dad as well) to see her 2 year old and will not allow them to have any contact with her, her spouse and her child, unless she does the contacting. My mom and she had a great relationship in all of her growing up years. Once my sister moved to California (we live in IL) for a teaching position, she was "really busy" and not able to talk much. Once she got married, she started distancing herself more, and then after her baby was born, she called all of her siblings with these terrible memories she had and asked if we had any memories of things happening to us. Of course, we didn't. Then she approached my mom with it and my mom was speechless ... she didn't know what to say, except of course that she did not do these horrific things she's been accused of. My sister doesn't have a history of mental health problems, or medical problems as far as that goes. This has just come out of the blue for us, for her it has been progressing into more vivid memories for the past 5 years.

I know you can read this and know what it is, can you help us? What can we get her to do? Our family was so close, and we really miss her!!! Like I said, I'm so sorry to bother you with this; I'm just hoping you can find it in your heart to help an unknown family.

Thank you for anything you can guide us with!

A: Dear K,

My heart goes out to you and your family--all of them, including your sister who may have "false memories." There is quite a literature out there on the topic "false memory syndrome." Unfortunately, some of the advocates have been rather strident and the field had too much anger, animosity and litigation. That phase has subsided, with cooler heads prevailing.

My area of expertise is PTSD. To make the diagnosis, you must have a clear memory of a true trauma, not a delusion based on a misperception, nor a "recovered memory" of doubtful authenticity. PTSD treatment is different from Freudian and related therapies. Those therapies are usually based upon repressed, unconscious events from childhood that result in neuroses or personality disorders. The Freudian therapist helps the adult expose, explore and resolve these unconscious residues by making them conscious.

I'm usually faced with memories that are all too conscious, like the repetitive and horrifying memory of a rape or a child's violent death.

When a family member like you comes my way I do offer counseling to the healthy family members, once I become convinced that there was no incest or abuse. The diagnosis is "family problem." Insurance never pays for that. The therapy is quite collegial, sometimes in the form of facilitated family therapy (which amounts to focused, friendly conversation). Sometimes, in the course of those conversations, new ideas arise. At least, tensions and frustrations are managed. But getting the family member who believes she was abused to accept the view that her convictions are wrong and that she needs help is never easy.

If your sister has symptoms that bother her, she might be motivated to find a good therapist who is skilled working with adults who are fixed on unproved early events. But she might also find poorly trained therapists who confirm her convictions. There is actually a page in the World Almanac with an AMA finding that such therapy is unscientific and unethical.

So to sum it up, many of us are very familiar with similar family issues. There are professionals who could assist, but it will be costly and may not solve the whole situation. You can read about the problem, starting with a Google search of false memory or recovered memory.
Relationships: Toxic Family of Origin.

Q: Dear Frank:

Several GFW pen pals write about very upsetting visits with family members on holidays or on obligated trips to visit sick or aging relatives. Any words of wisdom on this situation?
A: Dear Joyce:

The "toxic family of origin" is well known to me as a therapist. We select our friends, but not our relatives and some relatives have a knack for opening old wounds. I find this particularly true of older sisters of my female survivor patients. I don't intend to extend this observation to all older sisters or even to most. But there is a pattern affecting some, and it may have a lot to do with secrets. Most of my patients are survivors of trauma. If they come from healthy, loving families, they have a foundation of self-esteem that helps them cope with adversity, and they have empathic relatives to provide support when stress arises. But the "toxic family" is typically one in which individuals have been emotionally abused AND neglected. The abuse may be as profound as incest or as common as teasing. The neglect may be icy indifference or distance due to parental ill-health and overwork. Sibs learn to cope for themselves. Older sibs may try to protect younger ones from an abusive parent, but deny the struggles that they, themselves have had. A big sister may identify with the aggressor, becoming the "kapo" of the camp - the one who carries out a sadistic policy of a punitive parent.

Regardless of the details, this means that my patient suffered as a child, and an older sib made her feel worse. When this leads to complete alienation with no meaningful contact, the problem is not so problematic. But most of my patients have a longing for an ideal family. They visit when expected to "come home" although the family of origin is no longer the place called home. And when they visit (or even when they call on the phone) there is a terrible sense of oppression. My patient feels assaulted, belittled, isolated and helpless. She may be able to express her feelings, but she cannot win the support of her sister. Her sister may have suffered similar abuse and neglect growing up, but her defense was to pretend it didn't happen. She may have a form of survivor guilt, having weathered storms herself, but failing to protect a younger sib. She may be jealous of a younger sib who managed to escape the family while she, the big sister, remained.

At any rate, all this unfolds through the years without truthful conversation. Roles become fixed. Family members play their parts. These parts become caricatures-- exaggerated archetypes. The Cinderella story is an example of that exaggerated scenario. Reality seldom provides a fairy-tale ending, so the question, "How do I cope with my toxic family?" needs a more practical answer.

If you are one who struggles with painful contacts with toxic relatives, consider these suggestions:

1. Don't visit. You have a right to protect your sanity, self-esteem, and mental health. Although the pressure may be enormous and a parent or sib may be extremely critical, you can stand up for yourself and say, "No." There are many who have taken this course and they eventually feel better, with more self-esteem and more reserves of good feelings for their own children, partners, and friends.

2. Keep visits short and superficial. This is really a variant of #1 and it requires a deliberate plan to avoid exposure to old issues and old wounds. It is perilous, since the expression on a sister's face may be enough to cause an upheaval in the gut and sense of dread throughout the body. These are reflexes from times of helpless immaturity. They are very unpleasant. So limit your exposure and dose.

In the case of #1 and #2 you may need a ready explanation. Nothing will work perfectly. Some possibilities are, "My doctor told me to avoid certain situations that trigger my stress. I have discussed this and am doing it for medical reasons." Another, especially for suggestion #2 is, "Let's just keep it light." --then change the subject.

3. Bring a cell phone and be sure to have contact with a dependable friend during a family visit. For GFW support pals, this may already be occurring. Those conversations can be relatively brief. They shouldn't "stir the pot" with details of demeaning behavior. Some venting could be good. The main idea is to have a "lifeline" during the visit, serving as a source of oxygen when the air is thin, reminding you that you have friends who understand and have endured similar stressors.

4. Practice everything you have learned about stress management, enhancement of self-esteem, and recognition of reality. By recognition of reality, I mean saying to yourself, "This is now, not back then when I was a child. I have my own home and friends. This visit may be stirring feelings from the past, but I need not live in the past." You might even carry a list of what you admire about yourself, and review it during the visit. It is not to be shared with the toxic family. It is just for you.

5. Family therapy or therapy about your family of origin is always an option. But let's face it. The pattern is usually well established by the time one faces this situation in adulthood. Although I have some direct experience as a therapist with toxic families, it seldom works well. What does work well is counseling about strategies to manage specific events, like weddings and funerals - when to arrive, where to stay, whom to bring along.

In sum, the "toxic family" was dysfunctional to begin with and is a source of profound stress during every visit decades later. We have obligations to our families and may choose to "pay our respects" although those payments come with great emotional pain. There are no hard and fast rules that can be applied to all relatives and all survivors. But GFW does provide links, pals, ideas and resources. This Q & A is meant primarily to validate your reality and your self-worth if you come from a toxic family, if you choose to maintain contact, and if you suffer the inevitable emotional cost when you pay your dues to your clan.
Relationships: PTSD may complicate partnerships.

Q: Dear Frank:

I just received a compelling and complicated request from a GFW website reader. Could you offer us some reflection on these issues?

I came across your website and have a very strange/interesting situation that I desperately need advice on. I have PTSD from childhood abuse and am currently in a serious relationship with someone who has war related PTSD. The problem that we have is that I am very emotional and want him to know about my past and the things that I've gone through- because I feel like it's an important component of what makes me who I am. Every time I try to talk to him about anything he blocks me and I feel completely unsupported. I also try to talk to about his past, but he cannot because most of it is classified... That said, he can't get therapy because it's classified and because it would effect his future job prospects (if he went to a high ranking military therapist with a clearance). He explains to me that he is really emotionally numb and can't feel most of the time. He has also had flashbacks (he has never been violent or anything) and is very hyper vigilant.

To complicate the situation more, he is taking a job that further puts him in harms way- this is terrifying to me, but he doesn't care that it hurts me... And I fear that it could worsen his PTSD if he makes it out alive. I ask him why he does this and he responds "because it's my career" and that's that. In order for him to take this job we have to move across the country where I have no support network. I think he may feel I am blocking his career path because I am pretty anti-war, but in reality I am just scared he will be hurt. However, he won't let me communicate this to him because he refuses to talk about anything.

I am willing to stay with him even if he takes this job because he is my life partner... But I don't know how to have a conversation with him about my past, and have him be receptive and understand the risks of moving very far without a support network. How do we meet both of our needs, where he insists on emotional space and I need proximity? Further, why is he so terrified about having me open up to him and how should I initiate a conversation?

Your advice would be incredibly appreciated.

A: Dear Joyce:

This is difficult, indeed. Our web readers may not face challenges exactly like this, but they may have related issues and concerns. First, let's consider the survivor of childhood abuse with PTSD who craves understanding from a reluctant spouse. The spouse's reluctance can stem from any of several legitimate reasons. (I'll refer to the spouse as "he" although genders could be reversed and partners could be of the same gender). He could have his own demons and want to keep them at bay. That appears to be the case here. He could have rage at his partner's abuser, and find it difficult to control. He could have an idealized image of his wife (or loved one) and find it humiliating to imagine her violated. This is an unfortunate norm in certain cultures where the extreme result is a so-called "honor killing." Far more common is the situation where the man lacks the emotional maturity to tolerate his partner's feelings. He hasn't learned to listen without needing to fix things.

And fixing the consequences of incest or abuse is way above his pay grade. But there are many husbands and male partners who can learn to listen, and can be coached in the "ministry of presence." Skilled couples counselors, chaplains, family docs, peer supporters and mental health professionals all have the ability to model the "ministry of presence." So if you are reading this and you are a survivor of childhood abuse and you need your partner to tolerate your truthful story of persistent anguish, you might let him know that you do not need him to fix anything. You want him to learn to stand by you as you recover some painful memories. You might even say, I'm just going to let a memory in without saying a word. But I want to know that your are there. (In a way, that's what I do when I use the Counting Method: http://www.giftfromwithin.org/html/counting.html ). If he is willing to go with you to a therapist (or any of the helpers mentioned above) you could make it clear that you do not want him to be put on the spot or to feel as though he has a problem. You want to work toward a better relationship in which he feels his strength while you feel your pain. Admittedly, this is not an easy journey and having a skilled, experienced guide can make a big difference. The GFW community could share good news and not-so-good news about couple counseling for just this problem.

Now let's turn to the man (or woman, although it is more likely a male) who has a security clearance and a mental challenge related to trauma. I had a clearance when I was deployed with the US Secret Service to identify and help agents (and top management) deal with these issues. I had colleagues in other agencies where the issues were as delicate or more so. In some circumstances, a person with a high security clearance was not allowed to see a psychiatrist who was not similarly vetted. In some circumstances, a psychiatric visit was mandated. In many situations, a known visit to someone like me would interfere with advancement. So I can confirm the fact that an agent with PTSD may risk a loss of security clearance by seeking proper treatment. There are ways to improve PTSD symptoms without creating a paper trail of psychiatric treatment. There is self-help. There is spiritual help. There is confidential peer support. There may also be a way to have conversations with psychiatrists that are off-the record and more informational than clinical. The "old boys" network can assist. "Old boys" exist in the CIA, FBI, and the military. Sometimes they are called, "rabbis." They have been around a long time. They do not seek managerial positions, but they may have advanced in rank. They are discrete, wise and trustworthy. They give good advice. If you are the husband of a wife who is suffering from PTSD, but you don't want to trigger your own PTSD, get as much help as you can for your own PTSD.

PTSD is real. It will hurt you on the job and in your marriage if you can't cut it down to size. Treatment is like the oxygen mask on an airplane. Put your own mask on first before assisting others.

So, in sum, there are partnerships where PTSD complicates life for husband, wife and the marriage itself. In most cases, the issues can be brought to one or two therapists who offer guidance, support and treatment. The condition improves. But in some situations, the stigma of PTSD and the prejudice against therapy is real. It takes careful, diplomatic efforts to find the way. The way may be "off the books" and available through informal contacts. But the agents who most need to find the way are also expert at this sort of covert discovery. They do it for a living. I encourage them to search for help, to minimize their own PTSD, and to become better able to serve their missions and their marriages.
Recovery: Inadequate Therapy.

Q: Dear Frank:

A colleague wrote about a fairly common situation, dealing with a therapist who just isn't getting the job done... "This man's wife was in therapy for DID. The husband felt that after years with this therapist that his wife was not getting any better. He asked the doc to talk with another trauma specialist. The doc really did not want to do this and said a consult was unnecessary. Long story short...the consultant advised the husband and wife to find a more qualified therapist after speaking with the doctor. He advised her to find someone who knew about EMDR and other therapies for DID and trauma related symptoms. Outcome was excellent. Turned out the wife feels more optimistic about recovery with her new counselor and was appreciative that her husband made this effort.

What do you do when you find yourself with an inadequate therapist?"

A: Dear Joyce:

Good question!

There are some websites out there that offer very reasonable perspectives. See
http://www.stopbadtherapy.com/test/therapy.shtml and also our pages where GFW support pals talk about finding a good therapist in the first place,
http://www.giftfromwithin.org/html/spfind.html. And here is an article by Sidran on choosing a therapist, http://www.giftfromwithin.org/html/therapy.html

A good therapist has training in techniques for reducing anxiety and overcoming traumatic memories. A good therapist has education in science and the humanities, and should let you know where he or she received that education. A good therapist is ethical. The various codes of ethics for psychologists, social workers, nurses and medical doctors (including psychiatrists) require practicing according to scientific principles, respecting the privacy and confidentiality of clients, and doing no harm. Good therapists may be firm and strict at times, but they need not be unpleasant. Inadequate (rather than unscrupulous) therapists often waste the hour talking about themselves, or allowing meaningless small talk, or being "supportive" but not really tackling obvious issues. They will not go the extra mile. They charge for things that they ought to do free, like sending records and writing reports and talking with colleagues about your case. They do not keep up with advances in the field. And they are not particularly respected by colleagues.

I've supervised a few of these inadequate therapists at various times in a long career. They are not necessarily bad people. But, in my opinion, they are bad therapists and I wouldn't send a client to them. George Carlin once said, "If you ranked all the doctors from best to worst, you could find the worst doctor in the world. And somebody has an appointment with him at 9AM tomorrow morning." So don't you be that doctor's patient!

It isn't easy to leave a therapist. They can act in ways that make you feel responsible for their hurt feelings or they can assert authority and be intimidating. They may write notes in records that suggest that you are a difficult client. They may make it difficult for you to get your own records, short of a lawsuit against them.

(I read my notes to my patients so that they know what is in the record and so that I know if I have made a mistake. But I also want the therapy to be collaborative and I don't want to record something that I wouldn't say out loud to my patient. We are a team, dealing with a common adversary: the lingering impact of trauma and tragedy. And even when my patient has a self-defeating personality disorder, we can be honest and clear about that, figuring out ways to retrain inter-personal habits.)

So let's assume you have decided that your therapist does not meet your needs for progress. You have some hard choices. You could be frank with your therapist. If your therapist takes offense and says anything demeaning, you'd be best off with a polite but firm statement that you are terminating therapy. You have no obligation whatsoever to help a therapist recover from a "divorce." Our professional training prepares us for this and our ethics require us to shoulder the complete responsibility for our own feelings, should this happen.

If your therapist has a mature and enlightened response, she or he will make it easy for you. A therapist could and probably should question whether the issue is related to your own sensitivities and stressors. For example, as you get close to a painful piece of personal history, say a betrayal by a relative you trusted, you may be particularly sensitive to innocuous statements or mannerisms of a therapist who reminds you of an abuser. This is VERY common. And you would be advised to stay with therapy if that is the case. But you can't always tell, and it may be that your decision to change therapists is the right decision. That mature therapist could suggest others, could agree to a "second opinion," could seek consultation for herself, or could simply wish you well and do it in a reassuring way.

Since most of us therapists are somewhere between the extremes of very enlightened and just plain inadequate, we will probably complicate this awkward situation to some degree. And that means you can use support from the outside. In the case that raised this issue, the support came from a terrific spouse. There are supportive GFW correspondents. There are web resources. There are also professionals who will be willing to see you, whether or not they end up as long-term therapists. These may be general physicians, nurses, mental health professionals or others who have "been around the block." Think about the mature, selfless, experienced people that you know. And avoid the sort of friends or relatives who have a knack for making you feel worse about yourself. A supportive person will help you transition from one therapist to another, feeling as good as possible about yourself, considering reasonable options, and avoiding too much stress and loneliness as you take a difficult but necessary step.

What if your therapist is really bad? They might be abusive, sexually inappropriate, or alcoholic. Some become senile. Some use illegal drugs on the job. I had a patient whose previous psychiatrist prescribed tranquilizers and asked the patient to "kick back" a portion of the drugs for the therapist's own use. I asked that patient to help me report the doctor to the licensing bureau, but she really didn't want to do that. State law did not allow me to complain without confirmation from the patient. So I did what my patient preferred since I was a doctor, not a law enforcement officer. (I followed the career of the offending psychiatrist and was relieved to learn of her early retirement). If you have a really bad therapist, your first duty is to yourself. Get away. Get a good therapist. Don't blame yourself. If you have the will and the time and the fortitude to report a bad therapist, there are ways to do it effectively. A trial lawyer can let you know if you have a malpractice or personal injury case. (I've written elsewhere on finding a good lawyer: http://www.giftfromwithin.org/html/findlaw.html This article is addressed to therapists, but it can help you, too.) My state has an Office of Recipient Rights. See: http://www.michigan.gov/mdch/0,1607,7-132-2941_4868_4901---,00.html Your state may have a similar department. They are particularly sensitive and skilled in helping clients of public sector therapists report abusive therapy situations. But if you are seeing someone who has a private practice, this office has no jurisdiction. They will suggest contacting the state licensing authority to discipline a practitioner, or the police to report a crime.

What if your therapist is young, or is still in training? I'd hope that a therapist in her or his twenties, just starting out, would accept advice to call a mentor, to involve a supervisor, and to let you speak with such a person. I've seen this happen, sometimes successfully and sometimes, not successfully. A client of a young therapist became romantically attracted to her therapist. The therapist ended therapy, and placed disparaging notes in the chart. I got involved through a friend of a friend and counseled the therapist to seek consultation for her own "countertransference problems." It worked for a while, but then broke down. I got the Office of Recipient Rights involved, and that resulted in the client getting a senior therapist. Some young therapists have room for growth and need to learn how to deal with clients who present challenges. And let's face it. There aren't enough senior, experienced, wise therapists to go around. So working patiently with a promising young therapist can create, in time, a wonderful older therapist. I've made my share of mistakes, and am thankful for the patients who helped me grow up on the job.

In sum, there are bad therapists. You may have encountered one. If you are being treated by someone who isn't really helping, you have a right to find someone better. You needn't fret too much about the therapist's feelings (although it is perfectly normal and rather nice of you to have caring concerns). Therapists should be trained and equipped to handle their own stress. You may need professional help to deal with the damage done by a really bad therapist. A good lawyer is prepared to offer the ultimate help - a lawsuit to obtain security and justice for you, and to protect future clients from a predator with a license. You deserve support during the transition from one therapist to another. There is no "one size fits all" transitional support. Think carefully about friends, family and web resources that are truly in your corner. We certainly try hard to make GFW one of those resources that you can count on.
Recovery: Triggers.

Q: Dear Frank:

I received this question from a GFW support pal member.

I am a trauma survivor and would like to know what is the difference between a person being triggered from a horrible past event and a person with PTSD being triggered? I really thought about how two people can experience a horrible event together and one person gets PTSD and the other does not. So at a later date if both people are triggered how would the person with PTSD differ? I often hear people say that we all have crap in our pasts and why is it any different for somebody with PTSD. I would be very interested to hear your thoughts on this.
A: Dear Joyce:

The short answer is that the person with PTSD has a much higher risk of being "triggered" into any or all of the PTSD symptoms, while the other person would be reminded. as we all are, of bad times. Being reminded of times of tragedy or danger evokes "autobiographical memory." That is normal memory, whether pleasant or unpleasant. PTSD involves flashbacks, "re-experiencing" and a host of other psychiatric elements. The webcasts I have made on the SAM and the VAM explain this in more detail. See my webcast called Trauma Memories at http://www.giftfromwithin.org/html/webcasts.html
Recovery: Triggers.

Q: Dear Ms. Joyce: Thank you for being a guest clinician. This question is not unusual and I believe a lot of survivors have this problem. I was asked, "What do you do when you have a friend who triggers your PTSD stuff? I have a friend whose behavior is basically reminding me of my mother in a huge way. I am getting angry with her for valid reasons, but I think the intensity of my rage at her is exaggerated and I'm over reacting. How do you separate the present from the past when emotionally they feel the same?"

A: Joyce, Thanks for asking me to be a guest clinician. This sounds like a tough situation. If the friend knows about her trauma I might say something like, "when you do _______ I feel upset because it reminds me of my Mom. Right now I don't know how to cope with it except to ask you to stop doing ____." If the friend doesn't know about the trauma it's a big decision in itself deciding whether to tell her. If the friend doesn't know and you don't opt to tell her, I might take a 3x5 card and write yourself a nurturing reminder/note. Right before you're going to visit with this friend take a look at the card, or during the visit excuse yourself, get some air and read the card. The card can say something like "I am safe and I am can end this interaction with my friend when ever I want to."

Separating the present from the past starts with the awareness that you conveyed in your question. It's important for us to first be aware of when this is happening and, as you said, it usually is when we find ourselves feeling an intensity of emotion disproportionate to the event at hand. With this awareness, we can learn to interrupt our cognitive, emotional and/or physiological reaction to the event. This is quite a process and can be done with the help of Cognitive-Behavioral Therapy or EMDR, etc. We can also use various cues (such as the 3x5 card) to indicate to ourselves that we've been triggered and to remind us of what to do. The visual cues are helpful because, once triggered, our minds are unable to think very clearly; we're in the fight, flight or freeze mode. Anything that will calm us (deep breathing, repeating affirmations, rubbing lotion on our hands and smelling the comforting scent) will contribute to redirecting our bodies' response to the trigger. Babbette Rothschild and Dusty Miller have written about breaking these patterns in "The Body Remembers" Rothschild) and in "Women Who Hurt Themselves" (Miller).

Answered by Patty Joyce, LCSW
Recovery: Rebuilding Self Esteem.

Q: Dear Frank, many PTSD survivors talk about their lack of self esteem. What suggestions do you have on how to start rebuilding one's self esteem after a trauma?

A: Dear Joyce, many PTSD survivors struggle with issues of self-esteem. Sometimes the difficulty stems from issues dating back before the trauma that caused PTSD. Having family members, particularly parents, who were abusive and demeaning and deflating leaves an echo of self-rebuke. One of my patients realized this and said, "I'm going to kick my mother off my board of directors (she was talking about the chorus in her head that evaluated her with merciless criticism). She added, "I'm going to replace her with Arlo, my gay brother. He likes me!" I thought this was a wonderful advance.

PTSD itself includes anxiety and emotional anesthesia and a desire to avoid intimacy. These feelings and behaviors result in a loss of friendship. It is difficult to be your own friend if you are not a good friend to others.

Gift From Within is all about friendship. One of the best ways to recover self-esteem after PTSD is to share stories of losing esteem, and to do it in a way that encourages growth and self-respect. And if the obstacle is a voice of authority from the past-- sounding like Tony Soprano's mother-- try to replace that voice with a different authority. One who cares.
Recovery: Life After Trauma.

Q: Dear Dr. Nader: Thank you for being a guest clinician. I've been asked this question many times by support pals and other trauma survivors with PTSD. Survivors want to know if they have a chance of "living a normal life" with PTSD.

A: Dear Joyce, To help answer your question about "living a normal life," I would like to tell you about two people (their names have been changed):

Case Examples

Anna was molested by her babysitter as a toddler, almost died from injuries as a preschooler because of her mother's neglect, had a variety of scarring but less life threatening experiences in elementary school, was raped as an adolescent, and was assaulted as an adult. She finally found a therapist after a group of men tried to burglarize her house, pointed a gun at her, and fired missing her. Fortunately they were scared away by sirens. She had numerous symptoms. For example, she was constantly afraid, plagued by images such as the barrel of the gun pointed at her, the fire in the barrel, and the huge foot of the huge man trying to kick in the glass door. She had extreme difficulty functioning normally and was completely unable to work. Stomach and skin problems flared up repeatedly...

Robert seemed to grow attached to each of his stepfathers just as they left never to be seen again. He was molested once as a young boy. He was in school when two boys walked in shooting, killed more than 20 students and teachers, and injured others. His best friend and his favorite teacher were killed. He and another person were shot and badly injured when he dropped his lunch tray drawing attention to his side of the room. He hid in terror with other students for more than an hour before someone they trusted gave them the "all clear"...

Anna (an adult) and Robert (an adolescent) (no they do not know each other) each went first to a therapist who was successful with people their age but had no real understanding of trauma. Their symptoms had worsened by the time they found the right clinician to assist them. By that time, Anna was suicidal and Robert frequently provoked and engaged in violent fights as well as taking addictive and numbing drugs. Even though these initial bad experiences and problematic delays complicated their recovery efforts, Anna and Robert now are among the friends most valued in their peer groups. They serve as valued support to others when needed.

About 6 to 8 months after her therapy started, Anna began to work part time. Several months later, she had returned to her original work schedule. She was enjoying parts of her life with intermittent setbacks. Sometimes there were setbacks because of life-stress; sometimes because she regressed when aspects of old traumas emerged for processing. After two years of facing and conquering her traumatic experiences and memories in treatment, she was functioning well. She was more often content than discontent. Anna had not completed processing all of her experiences when she moved away and discontinued treatment. Nevertheless, when an earthquake happened in her area some years later, Anna did better than her husband and her friends. She knew to protect herself from the frightening sounds and sights. She knew to make herself as safe as possible... She called to ask for a referral to a therapist in her area for her friend.

Robert has a family of his own now. He is very good at helping others through their difficult times. He became a little unhinged when the September 11 terrorist attacks happened. For the first time in years, he had the strong desire to use drugs again to numb himself. But a phone call to his old therapist and a good support system soon put him back on track. He likes his life.

A "NORMAL LIFE"

These examples are my way of saying that people can overcome horrible traumas and lead desirable and productive lives. Sometimes, after therapy, patients' friends comment on how much better they are doing-even better than before the trauma. After successful treatment, specific life events can cause set-backs but can be overcome. How long it takes to get to that better place depends on many factors such as the intensity and duration of the traumatization, the level of support following traumas, personality factors, coping style, personal and family history... How well the therapist and the therapy method fit the help-seeker's needs is also important to recovery. Finding a therapist who is skilled in treating trauma and whom you can trust and feel comfortable with is essential.

There are very many different versions of "a normal life." Life experiences affect and help to shape our lives. That can be true with simple or complex experiences. For most of us, life is a process of evolving. No one needs to tell you how intensely and profoundly the details or merged images of traumatic experiences can imprint themselves on a mind or how dramatically traumas can disrupt the body, its neurochemistry and functioning. The important thing is to face those effects of trauma, find healthy ways to relieve the focus on trauma for reasonable periods of time, process the aspects of traumatization that need processing, and do it at a pace that works for you with the assistance that matches your needs.

Recovery from trauma work (including some reasonable amount of avoidance or healthful self-soothing in between efforts) is different for different people. It is important to be prepared for the likelihood that good trauma work will be unpleasant and uncomfortable at least some of the time (maybe most of the time in the beginning of a new method). It usually requires remembering portions of the traumatic experience. Meanwhile, developing a good support system, improving coping skills and judgment, and making yourself safe without relinquishing living can be helpful. It usually is okay to err toward caution until good judgment (about safety and decision making) has been restored or gained.

One of the most wonderful things about human beings is their individual uniqueness. Although there are similarities in traumatic reactions, no two people have exactly the same experience or response. There are many different trauma methods that work. Many combinations of methods that are successful depending on individual needs. Whether you need to intersperse processing the trauma with coping techniques such as anxiety management or medication or you respond best to other methods depends on your beautiful uniqueness.

Dr. Kathleen Nader is a member of Gift From Within's Professional Advisory Board. Dr. Nader is a consultant who has worked for over 20 years in the field of Trauma, Violence and Bereavement. Dr. Nader is a humanitarian and scholar whose work with children suffering from the traumatic effects of school violence has been documented in our videotape called "PTSD in Children: Move in the Rhythm of the Child."
Recovery: Coping During The Holidays.

Q: Dear Frank, Holidays are very hard for families with recent losses, and birthdays can serve as reminders as well. What do you suggest for coping? In addition at holiday time, a lot of GFW members feel alienated from their families. And for those who decide to visit, what can you do to make it less painful?

A: Dear Joyce, Here is what I wrote a few years ago and still makes sense today.

Holidays are notoriously difficult for those among us who are acutely aware of loss. Days are short. Gaiety is for others. Ceremony reminds us of what we are missing, rather than what we have. Survivors of cruelty and catastrophe are particularly affected by the commercialization of compassion.

So how can we cope and how can we care? For those with PTSD and related conditions, we can limit our dose of exposure to difficult and dreaded stimuli. A previously abusive parent may be just such a stimulus. Small doses, buffered by supportive friends and relatives, may be tolerable. Complete avoidance may be a reasonable gift to ourselves.

We can bolster our resistance with reminders of our independence, maturity and network of kindred spirits. It's a good time for using the GFW email pen-pal service. We can overcome our understandable reluctance to exercise, eat sensibly and drink moderately -in other words, practice good health habits before making New Year's resolutions. And we can seek opportunities to help others. Nothing works as well as altruism at this time of year. If we are caregivers, relatives, friends of those with PTSD, we can be realistic. We can't change terrible reality. But we can acknowledge it. We can't give soul-saving advice. But we can simply be there. Being there, touching (if wanted), listening, sharing silence, and backing off when space is needed -these are sensible acts of real compassion. Easy to say, difficult to do.
Recovery: Substance Abuse.

Q: Dear Frank, We received a question about substance abuse. The reader reports her sobriety through AA -- and she asks, "Why do most people say do not drink alcohol if you have PTSD? Stopping drinking certainly does not take it away."
A: Dear Joyce,

Thank you for sending me this reader's question. It is a good question and a valid observation.

Alcohol is the most common self-medication for PTSD because it reduces awareness, blunts traumatic memory, helps with insomnia, and allows inhibited people to socialize. It covers-up the reality that caused PTSD and it delays the hard work of dealing with that reality. Most of my patients with PTSD have used alcohol before coming to see me. Usually, they have reduced their drinking by the time they reach me because they have decided to help themselves.

I value AA and all other proven approaches to sobriety, because alcoholism prevents serious work on the issues that cause PTSD and on the deficits that result from PTSD. Alcohol by itself is not the problem. Many people with PTSD can drink, in moderation. But alcoholism, by definition, is a condition in which the use of alcohol has reached levels that interfere with successful life, whether that means being a good parent, partner, worker or friend.

PTSD, unrecognized and untreated, may be the driving force behind alcoholism. It certainly was with my most recent patient, a veteran who nearly lost his marriage because he drank to avoid flashbacks, insomnia and a bitter feeling of neglect. But he lost his need for excessive alcohol once he decided to get professional help for his PTSD. He became optimistic about reducing his symptoms. He accepted medication for depression and insomnia. The whole cycle improved, including morale, performance and PTSD symptoms.

It is not unusual for PTSD to be more of a problem when alcohol use is curtailed. A drug that reduces rational thought has been taken away. Part of PTSD is the painful recognition of loss, vulnerability, shame and guilt. PTSD also includes too-realistic memory and too-intense anxiety. For these reasons, professional therapy may be needed to substitute manageable medication for self-medication, and to coach a survivor in ways to cope. PTSD treatment should be very practical and should begin with effective attention to pressing personal needs.

Some additional thoughts on why therapists ask clients with PTSD to ease up on alcohol intake, and, in some cases, eliminate alcohol completely:

1. If a person is a problem drinker, alcoholism interferes with mature, thoughtful relationships. This is true whether or not PTSD is present. Angry people get more angry and may become violent when inebriated. Withdrawn people may become more morose, reclusive and self-destructive. Suspicious people may become paranoid, seeing threats that aren't there. Careless and impulsive people may have accidents, misjudging their abilities to operate machinery, particularly motor vehicles, in a safe manner.

2. When the tendencies mentioned above are combined with PTSD symptoms, every negative outcome is multiplied. PTSD makes angry people angrier, reclusive people more withdrawn, anxious people more suspicious, and careless people more confused. PTSD symptoms include irritability, numbing, avoidance, hyper-vigilance and concentration deficit. It is easy to see how alcohol worsens many PTSD problems, particularly those that interfere with intimacy and trust.

3. Alcohol may complicate drug treatment. Booze is a CNS depressant. That means it reduces the activity of the central nervous system (brain function, overall). Some troubled people seek this dampening of brain activity because their minds are delivering bad dreams, bad memories and the bad sensations of fear, arousal and guilt. But proper medication for depression, anxiety and insomnia is far more effective than alcohol, without the damaging side-effects. Alcohol, in moderation, will not interfere with these prescribed medications--unless the combination occurs early in the course of treatment, when the body is still adjusting to the drug. Some doctors simply say, "no alcohol allowed." Some are more tolerant, talking through the way to include careful drinking as part of recovery from PTSD.

Freedom from the disabling symptoms of PTSD is such a relief. Reducing alcohol intake is almost always a significant step toward that relief. But it often requires the guidance and support of a professional who understands the treatment of both PTSD and alcoholism.

So I'll answer the reader's question by saying that the advice to stop drinking if you have PTSD is good advice if you are ready to face the source of your PTSD and to do something about the consequences of PTSD. Being honest with yourself places you on the path to recovery. There are many good people on that path: family, friends and professionals who will offer respect and support.
Recovery: Improving a damaged self-concept.

Q: Dear Frank, I received this interesting email inquiry from a website viewer. Michele asks: How would Dr. Ochberg suggest that PTSD sufferers bridge the gap between one self and the other? I know how I achieved it (through a lot of trial and error and that included reading a lot of Erickson), but I'm wondering if Dr. Ochberg would suggest a definable path, or a developmental perspective, or an organized process that would ease and encourage this evolution. If that's too broad, I wonder if Dr. Ochberg has defined one single act on the part of the victim that would encourage the evolution of the integrity he mentions.If it's possible for Dr. Ochberg to comment on how survivors might resolve this issue, I'd be so interested to know his opinion.

A: Dear Joyce:

Michele's questions are perceptive and challenging. Obviously, she knows that trauma, profound trauma, affects the sense of self we had before being knocked off our foundation, and she knows that PTSD is more than a menu of symptoms. Serious trauma and disabling post-traumatic stress changes our view of past, present and future. But even more disturbing, our sense of self is altered for the worse. We are diminished, fragmented, isolated and disliked--by ourselves. My job as a therapist is to help a survivor regain the ability to perceive personalities with some degree of accuracy, and then to perceive his or her own persona with respect. So often, PTSD is closely linked to depression. Flashbacks, numbing and arousal are half the story. My patients are self-critical. They punish themselves mercilessly for their inability to work, to play and to meet the needs of others. If they have a demanding and demeaning parent--who may, in fact, be long dead--they talk to themselves in that parent's voice about their failures. So I find myself doing everything I can to understand my patient's values, beliefs and pre-traumatic strengths. I know that there is a "self" in there somewhere that cared enough to find me and that wants to recover hope, connection and esteem. I search for the source of self-deflating comments. When I find it, I try to teach my patient to hear that voice from the past and set it aside. Send it to the back of the room. Trump it with a message from some previous friend or family member who was kinder, gentler and more perceptive. I've written elsewhere of the "Board of Directors" that constitutes our conscience. This Board need not be dominated by one loud voice, even if that voice is a powerful parent. Usually, a traumatized self is vulnerable to psychological self-condemnation, and, too often, the instrument of that psychological abuse is a ghost from the past.

So when Michele asks about bridging the gap between one self and the other, I believe she is asking for a path from a disparaged self to a respected self. And we are talking now about self-disparagement and self-respect. (It isn't always a matter of changing the self-concept. Some victims are surrounded by abusive others. They need to move. Or they need to say, "No," to requests and demands for contact with poisonous relatives. Never easy.) But when the path from a degraded self to a worthwhile self is blocked by obstacles from the mind, it takes mental retraining to clear that path.

The form of therapy that works best is called CBT- cognitive behavioral therapy. The therapist coaches the client in ways to recognize and change self-degrading thoughts. Ultimately, a better self-concept emerges.

Michele, the best single way to make this transition is to help others. Nothing is as nurturing to the self-image as the gratification that comes from being of benefit to other human beings. In some ways, these acts of caring are proof of progress, coming after recovery from disabling PTSD symptoms. But they are also avenues to recovery, restoring sensations of competence, worthiness and meaning.

I don't want to suggest that any of this is easy, or that one size fits all. Every individual has a route to integrity that is as personal as a fingerprint. We are unique. But the common impediment to a reasonable, rational perception of "the whole me" is a mindset that is far too critical. Changing that mindset is often accomplished with coaching on hearing and then overcoming negative messages from the past.
Veterans & PTSD: PTSD A Disease.

Q: Dear Dr. Ochberg, I read a statement by you and found it very interesting. "I used to believe that PTSD was a normal reaction to a terribly abnormal situation. Now I consider the diagnosis a dis-order that warrants respect for its power and its biological reality." Would you please differentiate what you used to think and what you now believe regarding diagnosis for PTSD. I hypothesize that to be a good grunt in the war zone, one must actively have PTSD. PTSD facilitates the model a soldier must emulate in combat. The counselor that I have seen for many years agrees with my hypothesis. Mostly, it is being acutely cognizant and hyper-vigilant. The Marines had given me the desire, power and authority to take human life and I was anxious to see how these things worked. My request was accommodated. Though very frightening, I performed as I had been trained and indoctrinated. Do I suffer from PTSD or do I suffer from conflict between my human nature and indoctrination programming that stuck and cannot be erased? Both civilian and military communities concur in opinion that I suffer PTSD.
A Vietnam Veteran

A: Dear Sir:

I used to think that PTSD was the medically normal reaction to extreme and traumatic stress. To have flashbacks and nightmares and all the rest were the brain and the mind's natural and healthy way to register such a profound and disturbing experience. While terribly painful and disabling, the symptoms were proportional to the events, just as normal grief, lasting years and years, is the medically normal response to loss of a spouse or child. Normal is a word with many meanings, including statistically average, morally appropriate, and healthy as opposed to diseased. I was one who, at the outset, thought we should place PTSD in the part of the diagnostic manual that dealt with disorders rather than the "V-Code" section of non-disorders so that Blue Cross would pay, but I really did not consider PTSD a disease. Now I do.

It doesn't mean I consider the condition stigmatized or dishonorable. Quite the contrary: I think PTSD earned on the battlefield deserves not only compensation, but honorable recognition. But thanks to brain imaging and advances in diagnosis and treatment, I believe PTSD causes damage to brain function, brain physiology and, at a very subtle level, brain anatomy. This damage is reversible. New pathways can form. Depleted neurotransmission can be corrected. Haunting memories will not be erased, but they can become part of the normal memory system rather than part of the traumatic memory system. The latter is the system that causes flashbacks and sudden, unbidden "re-experiencing."

I find that the medical model, relying on this concept of a treatable injury to brain function, helps me help others. There are research psychiatrists who know more than I do about MRIs and the specific parts of brain anatomy implicated in PTSD. But I do believe that the PTSD brain has altered neurotransmission in areas that regulate the fear response, the range of pleasurable emotion, and the capacity for "autobiographical memory." Autobiographical memory includes a language for extreme events and the ability to recall horror without evoking the horror so that it feels in the present rather than the past. I also believe that chronic PTSD (over several years) is near impossible to "cure." It can be managed, more or less. It may be fruitless and disrespectful to ones sense of self to consider "cure." When people with PTSD are able to help others, I believe a reasonable goal has been reached.
Veterans & PTSD: Seasonal PTSD & Anniversary Reaction.

Q: Dear Frank, Here is an email from a website viewer.

I am the girlfriend of an Iraq War Veteran and had some questions regarding PTSD and if it affects people more during the anniversary of the event or events that triggered them to have PTSD. Specifically, my boyfriend seems to display heightened symptoms around the months of April, May, and September. He started his first tour in Iraq around April or May in 2003 and his second tour in September 2005. Is there a correllation between the start of his combat tour and his PTSD getting quite severe during these months? I'm having trouble finding information related to this question. I thought it might have something to do with Seasonal Affective Disorder but the material I found said SAD related to weather conditions.

APRIL is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.

T.S. Eliot The Wasteland.


A: Dear Joyce, I am so glad that Ms. G asked these questions - first because any one who cares about our Iraq War Veterans should pay attention to their emotional wounds and learn about the significance of symptoms. Many veterans have understandable difficulty gathering information about PTSD. Trauma memories, particularly memories about fellow soldiers who were maimed or killed, can be easily triggered, causing one to feel as though the event is recurring. A loved one can learn about these symptoms and be a voice of comfort and reason, when the veteran chooses to seek such comfort and reason. Ms. G notes that her boyfriend served at least two tours (serving multiple tours increases the risk for PTSD), and she notes that each tour began in months that may be significant.. April and September are months when seasons change -the spring and fall equinox. They tend to be pleasant months in our country and times when one would want to be with friends and family. It could be that Ms. G's boyfriend associates these months with separation from home and also with the immersion in a life that included too much death. T.S. Eliot's famous line, "April is the cruellest month," signified just that confusion of feeling, being full of life and death at once. If the veteran was exposed to horror and tragedy in a particular month, he or she could have what is called an "anniversary reaction." This means that without needing to think about it, his or her body remembers something horrific. The season comes around to that time of year, the leaves come out on the trees -or the leaves turn red and fall- and suddenly the adrenalin flows, a memory springs from nowhere, and a person feels transported from Florida to Fallujah where comrades were killed. I wouldn't call it an anniversary reaction if Ms G's boyfriend suffers in spring and fall only because those were seasons of deployment. Deployment itself is not a traumatic stress. Yes, it is traumatic in the general sense of the word. But the kind of trauma that causes a PTSD anniversary reaction is something that causes the person to feel horror or terror or helplessness at the time -often all three feelings at once, and to an extreme degree.

SAD, seasonal affective disorder, is a form of depression, not a form of PTSD, and it comes when days are short and there isn't enough morning light to stimulate certain brain centers. People prone to depression often find the winter months particularly difficult. If they suffer from this "SAD" condition, they need artificial, intense light for 30 to 60 minutes in the morning. It helps!

So I would say that Ms. G's boyfriend has a form of seasonal PTSD, but not SAD. PTSD symptoms include unwanted recollections of traumatic events, feeling numb and detached, and also being anxious, with difficulty sleeping, concentrating, and controlling anger. It makes sense to me that these feelings would be worse during the months of deployment and initial separation from home.

Gift From Within has many articles with information and encouragement and networks for partners of those with PTSD. PTSD affects veterans and civilians the same way. It causes normal people to feel abnormal, isolated and embarrassed. It shouldn't separate friends, family and loved ones. The best way to overcome the tendency to drift apart is to do just what Ms. G is doing - seek information, learn about the condition, and do not be ashamed to say, I have a boyfriend with PTSD. PTSD means having the courage to survive danger and the honesty to suffer inevitable consequences.

Frank
Veterans: Emotional Injury.

Q: Dear Frank, What do you make of recent news articles about high rates of suicide, PTSD, and other alarming statistics among military serving in Iraq and Afghanistan?

A: Joyce, I am deeply concerned. While I always want to emphasize the positives -- that most of our troops do NOT come home with PTSD and most of our military families lead healthy, fulfilled lives-- we simply must do more to prevent emotional injury, stigma, and alienation. I recently met Tom Mahany, a stonemason who attended West Point, served in Vietnam, and now campaigns tirelessly to improve our deployment policy and to honor veterans with PTSD. Tom believes that the "Stop Loss" program should be stopped. That program gives the Pentagon the authority to retain troops, to recycle them to the front over and over, and to place a profound burden on young families who live under pressures that we never had in previous wars. I wrote the following in support of Tom's campaign:

"The military and military families are currently threatened with a remarkably high rate of psychiatric casualty, including suicide, substance abuse, depression and a combination of traumatic brain injury and PTSD. These conditions have secondary effects on spouses, children and family units. Left uncorrected, this condition will eventually undermine the morale, resilience and fitness of our military and will alienate advocates for our military. I cannot say with scientific certainty that the stop-loss policy causes the high psychiatric casualty rate, but it appears implicated."
-http://thomasmahany.com/

Beyond the deployment issue, we still have stigma and silence. PTSD is a hidden wound, and it still is misunderstood, under-recognized and insufficiently treated. My most recent patient who I'll call Gary returned from Iraq with a fair amount of anger and anxiety, but he stuffed it down and said little about the incidents that haunted his dreams and returned in unwanted memories. He served in the national guard, saw combat, patrolled streets with IEDs, was ordered to shoot suspicious civilians and, on several occasions, came close to killing children. People were killed in front of him. One was beheaded. But after returning home all this became normal memory. He could recall details, but the details didn't come out of the blue and capture him. Three years passed, in civilian life. Then he was in a car crash. He and his friend had minor injuries. The driver of the other car needed attention, and in a daze, Gary attended to him. Then Gary blacked out. When he awoke, his Iraq war episodes returned with the full force of military PTSD. We have talked this over, tried a few medications (for insomnia and an irritable depression) and seem to be making progress. Gary isn't embarrassed about PTSD. He isn't at risk for re-deployment. He doesn't care one way or another about medals. He just needs help getting into school, having tuition covered, and becoming an EMT. He'll be a great EMT. He instinctively moves toward danger and knows he can help at an accident scene. I'm not sure how typical or atypical Gary is. I know that my efforts as his doctor are atypical. I've arranged for him to see a friend of mine who is a retired vice president of the community college that can train him to be an EMT. This man served in the Navy and will do what ever is possible to mentor a young man who wants to transition to a public service career. I'm not doing EMDR or Counting or other forms of re-exposure because the military memories are receding on their own and the first concern right now is a path to permanent employment. We have "destigmatized" PTSD between us, but realize that his classmates may not fully understand his military experience. We will talk about that, as issues emerge. I anticipate some anger management challenges in a classroom environment. Gary hasn't exploded, physically or verbally, but he is a aware of strong feelings. I'll try to be available every week until he has a feeling of confidence and competence in a new role. I'm optimistic. So is he.

But, Joyce, there simply aren't enough of us to go around -- doctors who can provide the meds that are useful, who understand PTSD, who can help a young man negotiate a whole new life while placing memories of a foreign war into the past, where they belong. Our job is eased considerably by the visitors to Gift From Within who know about PTSD and who are willing to support those who sacrifice and suffer.

Here's a link that Tom Mahany sent me with his note, "Best Commercial Ever."
Professionals: Compassion Fatigue.

Here is a recent correspondence between Dr. Ochberg and a mental health professional helping low income and vulnerable client populations.

Q: Dear Dr. Ochberg, I happened onto your website The Gift from Within by accident from an NASW webpage. I was curious about the title because for the past 6 months I have worked as a mental health therapist (the only one for 3 of those months) in a facility with one of the nation's highest adolescent suicide rates. I used the metaphor of a gift to reframe the traumatizing event and subsequent recovery process for my clients. I really enjoyed my work and had surprisingly positive results for a new counselor but unfortunately, I ran into several ethical dilemmas with the agency's increasing administrative directives that I felt put my client's lives at risk needlessly and I resigned, but not before a state senator's aid contacted me for information. Now I am being blacklisted by the agency for essentially whistle-blowing.

When I applied to a position in another facility the interviewer told me that I was suffering from compassion fatigue and no doubt there is some of that, especially since I was on my own here with a caseload of actively suicidal kids and grief stricken parents/families in a PTSD overloaded community and no clinical supervision or support. But I felt that I'm more stressed from my anger than compassion, anger about the lack of appropriate services here. Since I was told this by a competent therapist I am also a bit concerned about taking my anger back into clinical work if I am still struggling with compassion fatigue. How can I tell the difference between what I thought was simply healthy and appropriate anger towards a gross social injustice and compassion fatigue where I might need to get some help for myself?

A: Hello, What interesting, introspective questions! While I can't advise you from an email sketch, I can define terms and suggest a legal resource. Compassion fatigue means two entirely different things to authors Charles Figley and Susan Moeller. Charles, a psychologist and a pioneer in trauma science, uses the term to signify too much compassion --and fatigue from empathic overwork. Susan, a journalist and professor of media studies, means that compassion itself is fatigued, leaving the reporter cynical after covering too many tragic and traumatic human events. Susan's definition resembles our term, burnout. Burnout, to me, to Charles, and to most workplace consultants, means you no longer like your work and you aren't particularly effective. You have no sense of humor, your passion is gone, you are out of touch with the values and the optimism that brought you into the field in the first place.

If you have your humor and your spunk and spirit, but you are legitimately angry at administrators who may be burnt out and callous, or may be unqualified and blind, you don't need therapy -- you need a lawyer to help you fight for your own job rights and for rights of others. If you are emotionally damaged, suffering with signs of stress such as insomnia, substance abuse, poor health, or interpersonal tension, you would benefit from therapy. A good therapist would enjoy working with a highly motivated but stressed individual. The diagnosis would probably be adjustment disorder with anxious mood.

Finding a good therapist is not always easy, but you do have a background in the field and can find one by asking colleagues you respect. Don't settle for less than the best in commuting distance. A mediocre therapist is worthless. A good lawyer who cares about abuse of clients is even harder to find.

Try the NCVBA website (National Crime Victims Bar Association) for assistance. You are not a victim of crime. But if you or your clients faced anything approaching abuse of authority, reckless indifference, and commission of torts (civil rather than criminal wrongs), there may be legal redress and this group of lawyers are the ones who have the sensitivity and the experience to address such torts. I'm not recommending either course of action (retaining a therapist or a lawyer). That is up to you. Good luck no matter what, and thank you for caring enough about vulnerable people to get angry!
Professionals: Compassion Fatigue.

Q: Dear Frank, Here is a question from one of the people who attended your recent workshop on Compassion Fatigue.

"I attended your day-long workshop in Wausau, WI last week, and found that as days go by, the information shared continues to inform me - some big pieces falling in place about CF, especially how it relates to PTSD, and can be distinguished from burnout." I am a hospice chaplain working on a Doc/Ministry degree, and conducting my own research (pilot project at this point) on Compassion Fatigue among hospice staff (using ProQOL) as it relates to spiritual development.

I gather it makes sense to anticipate PTSD among certain populations: Vietnam vets, those who experience a natural or induced disaster of crisis proportions, victims of rape. But what about hospice patients? Do you think there would be an increased likelihood of PTSD among people (and their loved ones) who are told - usually in a doctor's office setting - that they probably have 6 months or less to live? (That's the primary Medicare criterion for hospice benefits, so it's often the yardstick that docs use and articulate.)

We as hospice workers, then, are the first group of people to step into the situation and begin processing it with patients, many of whom are numb, some of whom are really quite terrified. In any case, then we walk with them through their own process, which ends in death most of the time but not always, and sometimes painful death, but mostly not.

I'm just wanting to make sure: do hospice patients sound to you like people who would likely be traumatized, and would we as workers be vulnerable then to CF? The hospice experience sounds pretty gentle compared to rape or war, but it is SOOO primal - culminating in death. Like being slowly nudged off a cliff with your eyes open. And yet, not outwardly violent, either.

Up until now I have just ASSUMED entry into hospice as traumatic - now less sure.

Thank you for any reflections you might offer on this - or for any leads about how we as hospice people might informally or gently/easily identify PTSD in our patients - long term effects being irrelevant because of their life expectancy."

A: Dear Joyce, Thank you for this articulate and challenging email about hospice and PTSD. I'll do my best to reflect upon the questions raised. Of course hospice patients are shocked to hear the news about mortality and to know they will die. Loved ones are shocked as well. We all know we are going to die, but to absorb the news when it is real, finite, imminent -and associated with the risk of pain, isolation, stigma, dependency is traumatic, in the general sense of that word, "traumatic."

PTSD experts would limit the use of "traumatic" to the experience of a life circumstance that is not only shocking and stressful, but that evokes a particular image in the mind. To qualify as PTSD, that image must be unnatural, transforming the whole human into body parts, or the dignified and secure self into a helpless animal at the mercy of a predator -- or a home and community that was once traditional and harmonious into a shambles after an earthquake, with splinters and smoke and no solid earth under foot.

Natural death can be absorbed by the dying person as a stage of life - frightening but not "traumatic" in the special sense that defines PTSD. I suppose it is your job to help every member of the hospice family, including the patient and the next of kin, but also the co-worker, to accept this final chapter of life for what it is. If there are components of the PTSD diagnosis involved (because trauma imagery has occurred for any reason, and people have nightmares, flashbacks and haunting memories) then you and others can and should do everything possible to ameliorate these disturbing echoes of the past.

But if the real issue is overwhelming fearful anticipation of the future, then the PTSD model does not really pertain. The challenge is to find the best path through the present, knowing that "death, a necessary end, will come when it will come" (Julius Caesar, Act II, Sc ii).

My personal hope for my final chapter is that experts like yourself will do everything possible to assure minimal pain, reasonable dignity, and opportunity for communication with loved ones on MY terms -not having my preferences subordinated to those of institutional authorities or well-meaning relatives. In that regard, the hospice worker must be an effective advocate for the patient, not for the "system."

If I am haunted by the past (the day of receiving a "death sentence" in the form of a diagnosis) I will need help in freeing my mind of that obsessive rumination. Several of the techniques we discussed, based on post-traumatic therapy, would be worth consideration. But if I am frightened of the future, I would be best reassured by knowing the details of effective pain management, and of protocols assuring dignity and self-determination. If I requested some form of spiritual companionship, I should have that provided --but my religious beliefs are all about humanity and personal relationships, not about any organized religion. So I would need my form of religious freedom, which is freedom from the rituals of others (as much as I respect the rights that others have to practice as they believe).

My regard for hospice work and hospice workers is very, very high. I consider it a demanding and emotionally hazardous occupation. Compassion fatigue, vicarious traumatization and burnout are to be expected. But drawing strength from one-another and gaining gratification from assisting fellow human beings negotiate the final passage makes all the risk worthwhile.
Professionals: 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.
Professionals: School Teachers and PTSD.

Q: Dear Dr. Ochberg:

I have received calls and emails from teachers who want to know about PTSD, sometimes in order to explain the syndrome to students but more often because they want to be sensitive after a student has
been traumatized by violence or suicide at the school. Briefly, what should a teacher be taught about PTSD?

A: Dear Joyce, Teachers should know the essential facts:

PTSD is a medical condition that affects some but not all who experience severe trauma. The diagnosis is given only when three different clusters of symptoms persist for at least a month.

(1) The first of these clusters is called "re-experiencing" and differs from normal memory. The feelings and images from the horrifying or terrifying event come back unbidden as traumatic memories, flashbacks, nightmares or sensations. Because this cluster may be very debilitating and strange, some people are afraid they are "going crazy" and feel deeply embarrassed. "Triggers" may bring on these feelings or flashbacks. A "trigger" is a reminder such as a person who resembles a victimizer or a movie with a violent scene. Columbine students with PTSD did not enjoy Fourth of July fireworks.

(2) The second group of symptoms includes feeling numb or avoidant. It causes detachment from others and pessimistic feelings about the future. Students with this set of symptoms may seem aloof and unfriendly. It doesn't mean they dislike classmates. The PTSD creates a social barrier.

(3) Finally, the PTSD survivor feels anxious, irritable, jumpy and has trouble sleeping and concentrating. This dimension will interfere with academic performance and, in some instances, cannot be easily helped. A student with PTSD may appear similar to a student with ADHD, needing extra time for assignments or test-taking in a quiet room because of the concentration problem. Fortunately, PTSD resolves relatively quickly and students are not usually hyperactive or disruptive. Accommodations can and should be made in
consultation with family and counselors, to identify individual needs. A PTSD expert may be able to help by phone or email.

An educator friend who deals with this situation observed, "an act of kindness towards a struggling student goes much farther than detention."

Teachers should know that PTSD affects survivors without regard to intelligence, physical health, courage, age, race or gender -- although there are some interesting statistical difference by demographic group. My point is that no one is immune. Given enough trauma, almost anyone will suffer PTSD. And suffering is no sign of weakness.

PTSD deserves expert treatment. Not every doctor or therapist is experienced in treating the syndrome. Experts can be found through academic centers and the International Society for Traumatic Stress Studies (www.istss.org).

PTSD improves with time and, now-a-days, responds well to straight-forward treatment. There is no way to predict the duration of symptoms, because the type of trauma and the resilience of the survivor varies so much. A welcoming and supportive school community will shorten the duration of the disorder and reduce its negative impact.

Persons with PTSD and no other complicating condition are seldom dangerous to self or others. But PTSD does accompany depression, alcoholism and interpersonal estrangement. When all that is added together the outcome can be volatile. Soldiers who are armed, trained to respond to threat with aggression and cycled through many tours of duty can pose risks when they are badly stressed and poorly treated. The same can be said of combatants in urban war zones.

It isn't easy to be a teacher these days. Expectations are high, resources are scarce, respect is not what it was when I was a schoolboy after World War II. But knowing a bit about PTSD can make the job easier. There are many experts who would appreciate an invitation to talk about the problem in class. I've taught the subject as a guest in high school and middle school. It can be done in a way that promotes understanding. A faculty conversation with a PTSD expert has helped as well.

A colleague who was a high school principal and now teaches education in college has designed a "teen summit" program for secondary schools. Students spend a day teaching, learning and interacting with subjects that include bullying, abuse and self-respect. This program is especially useful after teen violence has been in the news (see http://www.seattlepi.com/local/303684_kian15.html ).

When a teacher wants more than this half-page of facts, she or he can browse the pages of the GFW website. If the survivors who visit GFW on a regular basis had teachers who recognized the signs of
abuse and trauma, and who were comfortable calling for help, all of us would be far better off.

And if you are a teacher, reading this, thank you, thank you, thank you. Teachers can do more than doctors to reduce the stigma and fear that haunts those who survive victimization. A little knowledge goes a long, long way.
Borderline Personality Disorder

Q: Dear Frank, We received an email asking what is Borderline Personality Disorder. Can you give us a short synopsis of this condition?

A: Dear Joyce, Diagnoses, particularly personality disorder diagnoses, tend to pigeon-hole people and diminish their complexity and humanity. Borderline Personality Disorder (BPD) certainly has been used by some mental health professionals to label rather than to explain. Let me do my best to explain what is intended and what can be learned about this complicated condition. First, borderline was intended, almost half a century ago, to be the boundary between psychosis and neurosis. Some people were observed to have difficulty managing anxiety (neurosis), but they also lost touch with reality (psychosis) when extremely distressed. Unlike persons suffering from schizophrenia or bipolar disorder, they were usually free of prolonged episodes of disordered thinking or of mood fluctuations. But they often had relatives who were diagnosed with these disorders (schizophrenia; bipolar). So some psychiatric researchers, particularly those who focused on biological issues, believed "borderline" was linked genetically to the spectrum of major disorders of thought and mood. Some "borderlines" are also "bipolar," less frequently, "schizophrenic."

Second, borderline, or BPD, appears to be driven by problems of attachment to the mother, beginning in late infancy or early childhood. The very first criterion for giving the diagnosis is "frantic efforts to avoid real or imagined abandonment." Therapists who follow Freudian and similar theories look for significant events in the early stages of life, formative events, and they place great weight on such life-shaping experiences.

In the case of BPD, these therapists believe that the little child, one and one half years to three years old, was separated, physically or emotionally from the mother, and there were no other sources of reliable comfort available. The child felt abandoned. The emotion was one of extreme fear and it turned into rejection of the mother. With child-reason, full of fantasy, the youngster began a fruitless search for ideal protectors (guardian angels) and became vulnerable to the second criterion of BPD: "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation." I have been on the receiving end of this pattern, admired beyond reason then reviled with rage. Most therapists understand and tolerate borderline emotion, realizing it is based on child-like reason. Most unfortunately, this condition includes feeling dead inside. Some people with BPD will cut themselves, not because they are suicidal, but because they want to feel something real. Physical pain is, on occasion, preferable to feeling dead. Persons with BPD are confused about who they are and what their life really means.

Because BPD includes such intense emotion, interpersonal relationships are roller-coaster affairs and are very confusing, sometimes infuriating, to the partner. Violent abuse or insensitive rejection follows. Persons with BPD are often victims of trauma.

From the perspective of the therapist, this is a real challenge. Warmth and collegiality are misinterpreted as deep, personal friendship or as sexual signals. It is a mistake for a therapist to encourage anything but a professional relationship when treating a person with BPD. You have to keep boundaries clear with a borderline person.

It just helps to know that our biology and our earliest experiences may make us exquisitely sensitive to rejection from a parent-like person, setting us on a very difficult path of being drawn to such persons, seeking love in all the wrong places, then causing us to turn on the person we were once attracted to --attracted to for reasons that have more to do with our infancy than with current reality.
Social Phobia

Q: Dear Frank, Could you discuss Social Phobia? One GFW correspondent asks, "Is social anxiety hereditary at all? My father is agoraphobic to a degree and will only leave the house for 1 of 3 places. I am not agoraphobic, but I have social anxieties in crowds, with people, in waiting rooms (a lot), etc. So I'm just wondering if there's a connection. My psychiatrist gave me Ativan to use in social situations. Besides talk therapy and medication are there any other forms of treatment (say exposure to social situations)?" Another notes, " I don't have it (Social Phobia) as a disorder, but being away form home or out in groups can freak me out. I try not to fall apart or get too anxious when alone at parties or at events when I don't know anyone. I have currently joined an agoraphobic, general anxiety and panic group so its interesting being on line with people who haven't been grocery shopping outside for years." This may be a condition that several GFW website visitors have encountered in themselves or others.

A: Dear Joyce, There is a recognized diagnosis called Social Anxiety Disorder and it is also called Social Phobia. I knew about it as a psychiatrist, but hadn't met many people with the condition until recently. Now, probably by coincidence, but perhaps because I am on the lookout for it, I find that five of my patients fit the description exactly. And they never knew they had the diagnosis, nor did their closest friends and relatives. Just knowing that the condition exists can be a powerful source of help, with relief from confusion and embarrassment. There are many forms of anxiety in which people experience fear, dread, physical symptoms such as rapid breathing, palpitations, tremors, sweats and a sense of being near death. Extreme anxiety is no simple matter. Some people describe it to me as suffocating or drowning. I always take it very seriously.

When the anxiety is always caused by a particular trigger -say the sight of blood or a spider or a snake- it is called Simple Phobia. There is nothing simple about Simple Phobia because it results in a state of terror. But it is called Simple because one specific creature or condition is the cause. When the anxiety is caused by certain types of environments -wide open spaces or crowded marketplaces- it is called Agoraphobia (from the Greek agora meaning market and phobia meaning fear). Agoraphobics often isolate themselves at home. The poet, Emily Dickinson, ended up living in her bedroom. But Social Anxiety Disorder isn't exactly Agoraphobia or Simple Phobia. People with this phobic condition can make friends and trust certain individuals, but they have a strong negative response to social situations that place them on the spot. A college student who is my patient can go to class, which he finds impersonal and non-threatening, but he can't go to a party unless he is with well-trusted friends. If his friends were to leave him at the party he would "freak," just as the second writer above describes. "Freaking" means needing to escape but fearing that leaving would be rude, attention-getting and might create a scene. Staying with strangers feels like drowning. This is far worse than ordinary fear, and seldom understood by classmates.

Another patient feels betrayed by best-friends who think they do her a favor by introducing her to their friends, then leaving her. A person with Social Phobia is extremely vulnerable to abandonment, because the trusted friend is like a scuba suit and an oxygen tank for a person underwater. Take away the airway and you can't breathe.

In some cases, this Social Anxiety condition has been present since earliest memory. The person was "born shy." About 20% of people are shy from infancy and this is most likely a genetic trait. By the time these people are in their late teens, half have overcome shyness due to experience, learning and peer pressure.

In other cases, the person was not of a shy temperament, but in late childhood or early adolescence, they began to experience Social Anxiety, exactly as described above. They don't know how to explain it. They are usually embarrassed. They cover it up or adapt through avoidance. The condition has secondary effects, impairing school performance, social adjustment, occupational choices and self-esteem. This is a shame, because the disorder can be diagnosed, de-stigmatized and overcome.

Yes, Social Anxiety has a hereditary component. It runs in families. Relatives may have a different form of anxiety, but the common thread is a low threshold for the fear response -and a high degree of fear. Think of it as too much adrenalin or as an easily triggered nervous system, or both at once. The trigger may differ among relatives, but the over-reaction is much the same. And usually, this biological tendency was there before any traumatic experience occurred. Trauma may shape the response and may result in certain triggers. But some of us are more prone to an over-anxious reaction from birth, even though this doesn't become evident until teen-age years.

Yes, there are good treatments besides medication and talk therapy. Exposure therapy involves careful, well-timed, constructive exposure to the feared situation. I've seen patients do this on their own, once they knew more about their diagnosis, could explain it to others, and met a few others with the same condition. Without prompting from me, they went to a social event that would have terrified them before. In other cases, the exposure was carefully planned in discussions we had, and was calibrated to succeed.

Cognitive-behavioral treatment involves learning how to think about emotional circumstances, changing the things one tends to say to oneself. CBT, added to exposure, support, talk-therapy and other sources of assistance, is very useful.

Learning about this condition can help oneself and others. There are some excellent websites out there, and some sites that bring people with Social Phobia together. Gift From Within specializes in self-help and peer-help for persons with PTSD. But there is an overlap between PTSD and Social Phobia, even if one condition does not necessarily cause the other. I'm glad that Joyce asked about Social Anxiety and I hope that the GFW network helps to bring information, dignity and respect to those out there who have a very difficult time among strangers.
Complex PTSD

Q: Dear Frank, Could you give a brief explanation of complex PTSD? How do we know if we have PTSD or Complex PTSD? Is the medication and/or therapy similar?

A: Dear Joyce, Complex PTSD is a concept first defined by Judith Herman, MD (see http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_complex_ptsd.html?opm=1&rr=rr89&srt=d&echorr=true) to account for the effects of prolonged, severe interpersonal stress. She was thinking about cases in which a person is captured and humiliated or is sexually victimized within the family. But it is true of victims of war and victims of household war: battered spouses. When emotional trauma is continuous and inescapable, the mind and body adapts in several ways, from stoic to tragic. People can "zone out" or, technically, dissociate. They experience an altered state of consciousness. This might, in extreme cases, develop into multiple personalities. People can abandon hope. Without yearning for dignity and freedom, they accept psychological slavery. People can love their abusers. This is called Stockholm Syndrome (see http://familyrightsassociation.com/info/stockholm/syndrome.html).

The therapy for oppression is different than the therapy for simple PTSD. It requires moving to a safe environment. It requires retraining survival instincts, once there is no real danger. The medication may be similar (anti-depressants, tranquilizers, sedatives) but medication is never enough. And therapy is never enough. It takes liberation and love and plenty of patience to emerge from complex PTSD.
Complex PTSD

Q: Dear Joyce,

I googled Columbine PTSD to see if I could find any one else suffering from PTSD. I found your and Dr. Frank Ochberg's Q & A. I am a former Littleton, Colorado resident. Currently I am living in Italy because I can't handle the USA any more.

April 19th, 1999 three parents, 2 elementary school teachers and 60 6th graders went on a field trip. We walked from Leawood Elementary school through Columbine High School grounds to the Columbine Public Library. We were the first responders after the event. The high school students fled the school running to the closest open building, us.

The librarians, three parents and two teachers were the beginning of the command post. The police showed up with military, firefighters and then media. We supported the police the whole day until they allowed us parents to leave at about 6:00 p.m. One of the mothers and I with our kids walked on the school grounds that day after the event not being current on the news as we only saw from within our windows what was going on. It wasn't till we got home that we saw the full story on the news ands that there were bombs in the field we walked across after the event.

I am suffering from severe complex ptsd and can barely handle it any more. I have a wonderful therapist here. I am currently out on disability with a private policy from an American insurance company. They do not believe me and contact with them is just an extension of abuse for me, though maybe I am not in reality.

I have a life long list of trauma and was a high profile functioning person in society till I had open heart surgery a 1 1/2 ago at 44. New trauma in ICU came back 9 months later in horrible flashbacks.

I know therapy is a must. I have done some PTSD. I do some meditation. I am an artist, and ex stock broker now. I search the Internet endlessly looking for that magic pill for fix this all.

When the pain starts, I want out. Good days are good and some can be great. Though bad days are horrible and horrible days are on the edge of not wanting to live. If this is my furture, flashbacks and ghostly memories of all I have seem or experienced, I can not say I am going to make it long term.

Logically I want to understand why the pain is sooooo bad and will it ever go away?

I was disassociate for most of my life but the trauma in ICU brought the fear and feeling together for the first time in my life. Ever since them I can not stuff the pain. I lived with PTSD most of my life but know I can't seem to shake it. I want some one to be real honest with me. If my severity is at an 7 to 8 out of 10, with 10 being the worst, what can I expect long term? Thank you. Ms. O

A: Dear Joyce, Ms. O. writes a compelling email, describing several profound traumatic events, including direct exposure to an infamous high school massacre (while caring for many elementary school children) and, approximately six years later, open heart surgery, and insurance company problems. Ms. O does not give details of other life traumas, but says there were many, that the pain is still powerful and debilitating, and that relocation to a beautiful part of Italy and the presence of an excellent therapist is helpful, but not enough. Dissociation (an altered state of consciousness that serves as a defense against overwhelming anxiety) once seemed to lessen the pain of searing memory. Meditation helps to a limited extent. There are good days. But bad days are so bad that, on those days, life seems not worth living. Ms. O does not ask for remedy, but rather for an honest prognosis. "What can I expect long term?," she asks of us.

First, thank you Ms. O for writing and for the obvious inspiration and care you have given others. You are an artist and you have guided young people. Artists often distill human experience, seeing and feeling the essence of reality, suffering when others suffer. Having an eye for beauty may not balance the experience of traumatic and tragic loss. Finding grace and meaning in nature may not erase the memory of senseless harm to an innocent adolescent. But your artistic ability is worth emphasizing. Several of my patients with complex PTSD are artists or writers or reporters. They do see into the heart of things. That talent is a blessing and a curse. Try to remember the fact that it is a gift; try to use that gift; try to identify with others who used such gifts to enlighten the rest of us. CBT - cognitive behavioral therapy- works in a simple way. When the bad days and the bad feelings are too much with us, we learn to think about the talent we have and to respect it. We may not be able to use it during a period of fear, grief or depression. But we need to know it is there and it will be there to be used when the crisis passes.

This is different from trying to be numb or from longing for respite from memory. This is saying to oneself, "I am an artist. I am more sensitive. Sensitivity is painful, but useful. Others have this condition and I respect them for it."

The fact that your insurance company (and other bureaucracies) are oblivious to your condition and appear to care more about their bottom line than your legal right to just compensation is familiar to me -and to others with complex PTSD. Jonathan Shay, in his profound book, "Achilles in Vietnam," notes that since ancient times, the traumatically injured have suffered more from injustice than from horrifying wounds. Whether the source of betrayal is King Agamemnon's greed or an insensitive insurance adjustor, we are profoundly affected by the loss of honor, justice and humanity. My team, writing the diagnosis PTSD, had no language to capture this philosophical symptom -a loss of a sense of meaning. But anyone who works with complex PTSD knows to look for that ancient wound, to give voice to it, and in so doing, to guide a person toward recovery of dignity and worth.

Your relocation from America to Italy speaks to this wound. It is not unusual to seek a different home when home has harbored trauma and injustice.

And now to the question at hand. Can this complex injury in a sensitive person be tolerated? Can the long term prognosis include substantial recovery?

I believe it can. I have seen it happen in cases that included the murder of ones children and the destruction of ones platoon due to incompetence of leadership. It never happens easily. Some denial of reality is often part of the path to tolerance. Shakespeare's line in Lear was not unreal: "As flies to wanton boys are we to the gods; they kill us for their sport." But reality is as beautiful as it is ugly and meaningless. The capacity to experience that beauty comes through deliberate acts of seeing and knowing. You cannot avoid seeing the tragic, whether is is the past, present or future. But you can learn to see the sources of hope and love. That does come back and it does prevail, despite cruelty and incompetence and indifference, which are the sources of complex PTSD.

Recovery is never absolute. We do not reach a life that is free of sadness. But the sharp pain of traumatic memory does reduce in amplitude and surprise. You may need to work with a specialist who uses the counting method or EMDR or some form of re-exposure, if that has not yet been part of your therapy. You may need to work with someone who uses CBT as I suggest above, tailoring this CBT to your unique set of skills and losses. A good therapist is always wise and supportive, but a specialist may be needed to help deal with debilitating aspects of complex PTSD. With time and distance, new sources of fulfillment and meaning should emerge. One can't escape the past without a present and future that holds promise.

There is every reason to believe that you will find those sources of fulfillment, and can say to yourself:

"I may never forget, but I need not constantly remember." Shakespeare didn't write that line. I did. And I based it on many, many life stories.

My very best to you, Ms. O.
Dissociation

Q: Dear Dr. Ochberg, My name is Patti. I'm a Gift From Within support pal. I've never paid much attention to dissociation as it relates to trauma, until I've begun having times here lately where I zone out. My therapist confirmed that there is always some dissociation associated with trauma. I'd like to understand how it manifests itself, what type of symptoms, and also why they begin so long after the trauma. Could you discuss this?

A: Dear Patti, Dissociation is one of the least understood symptoms in psychiatry. It means an altered state of consciousness and can be very subtle, like deja vu, or quite frightening, like derealization. In deja vu, a common occurrence, a person has the sense of being in a familiar place, or having a familiar sensation, but they cannot remember the original scene. It is as though that part of the brain that gives us the sensation of similarity has been stimulated, without any good reason for the sensation to occur. In derealization, the surroundings are distorted. Objects may be larger or smaller; sounds may change volume or tone. The flaw is not in the organs of sense. Nothing wrong with the ear, the eyes or the receptors in the skin. The problem is in the brain, where perceptions are received, organized and interpreted. Derealization is episodic, not constant.

Feeling "zoned out" -entering a trance-like state- is relatively common during or after severe trauma. The term "shell shock" refers to battlefield conditions with soldiers wandering in a daze after comrades are killed and the echoes of gunfire and mortar rounds slowly subside. Dissociation can be thought of as a defense against panic and terror. Instead of having acute awareness of the surrounding danger, instead of having accurate recollection of a devastating event, one has a hypnotic reverie, like being drugged.

One of my traumatized patients experiences dissociative fugue. She drives long distances without knowing why or where. She awakens with no clear memory of the trip. But she is not psychotic. She can interact with people along the way, get gas, count change and appear to be perfectly normal. These varieties of dissociative states (deja vu, derealization, trance, fugue) do not respond well to medication and are not easy to treat with psychotherapy. Specialists in dissociation overlap with specialists in PTSD. When "zoning out" is a relatively minor component of PTSD, as it frequently is, the general principle of post-traumatic therapy apply (see http://www.giftfromwithin.org/html/trauma.html ).

Any symptom of PTSD can appear long after the original trauma. Entering a trance or a fugue can be your body's way of avoiding anxiety. Coping with the cause of that anxiety is the best way to eliminate dissociation. Dissociation may feel better than anxiety, but it is not an effective way to face the world.

Patty Joyce, LCSW has worked in community mental health for 7 years.

 
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