Can the Wounds of PTSD Heal?

Q: Dear Frank, I hear some therapists say that the wounds of PTSD cannot heal. Some say it can. What is the trauma survivor supposed to think? What does the study of neurobiology tell us in terms of PTSD and living a good life? I’ve always thought that one can learn to manage their traumatic stress symptoms which means that life can go on…a new normal. I realize for some this is infinitely more complex.

A: Dear reader, I wrote the line, “I may never forget but I need not constantly remember,” in the Survivor Psalm ( Perhaps those who say “the wounds of PTSD cannot heal” really mean to say that some tragic events are so profound that a person cannot — and perhaps should not — be as they were before. My good friend, now in her seventies, saw her 15 year old daughter swept away by a raging river on a trip to India 40 years ago. The body was never found. My friend will never forget and says she can never be as she was before that terrible, life-changing moment. But her post-traumatic stress injury has healed. She does not have flashbacks, nightmares or unwanted memories every month. She is not numb and avoidant. She is not impaired by inappropriate hyper-vigilance. In fact, she is a leader in her field and her family life is joyful and fulfilling.

I admit I am unhappy with therapists who say “the wounds of PTSD cannot heal.” None of my trauma-expert friends say that, but I have seen postings from some who do. I hope they mean that in some cases, the imprint of profound trauma is indelible. The memory remains. The change to one’s sense of self is permanent. I can respect that way of thinking about the consequences of traumatic loss.

But I believe it is best to consider PTSD an injury that usually does heal. The duration of PTSD symptoms (, on average, last several months to several years after an event that qualifies as a trauma These traumatic events are always major threats to a person’s emotional health. We intended, in creating the PTSD concept, for a qualifying event to be the sort of sudden, profound, consequential episode that would be “markedly distressing to almost everyone” (DSM III), or that would elicit “intense fear, horror or helplessness” (DSM IV), or that involved “exposure to actual or threatened death, serious injury or sexual violence” (DSM-5). Now that images of the brain at work are possible, we are discovering more and more about brain anatomy and brain activity before, during and after traumatic episodes. We know that smaller volume of a brain area called the hippocampus is associated with greater risk of PTSD symptoms. Also, those who develop PTSD symptoms after a trauma show, on average, reduced hippocampal size. A different brain part, the amygdala, becomes more active during major threats and remains more active in those people who have PTSD symptoms, months after the threat or the traumatic loss is over. There is an alteration of the electrical pattern of the brain that is characteristic of PTSD. This injury pattern appears to last as long as PTSD symptoms are present and then appears to resolve. More work needs to be done by Apostolos Georgopoulos and his team at the Minneapolis VA, but I believe he has shown that the anatomical injury of PTSD is akin to a cardiac arrhythmia. Something profound has happened to the electrical activity of the brain as an organ. It wasn’t there before, although risk factors may have been present. A small hippocampus is a risk factor. An overactive amygdala is a risk factor. But the cardinal symptom of PTSD is a “hot memory.” It is a vivid, debilitating, unwanted return to the trauma scene. And when we have that, we have a wound. That wound appears on the MEG –the magneto-encephalogram– just as atrial fibrillation shows up on an EKG. When the wound heals, as it most often does, one no longer meets the definition of PTSD.

Some symptoms usually persist. Often a person will be uncomfortable in crowds and will avoid discussing intimate details. Many have occasional vivid memories, but less than once a month and therefore less than the frequency required for the diagnosis. When PTSD lasts for several years, time has often elapsed without fulfilling work, exercise or family activity. We are out of shape, physically and socially. Our brain chemistry and brain anatomy may look perfectly normal. The injury has healed, but we are still deeply affected by profound personal trauma. In a medical sense, we no longer have a diagnosis and a syndrome. We no longer have an unhealed wound. But are we different? Of course we are.

For those of you who are still feeling damaged and debilitated, but no longer technically meeting PTSD criteria, the idea of having an unhealed wound may seem useful. It would be better to think of it as an old war-wound. Old healed wounds of war do cause pain and disability. Compensation is warranted. Honor for service and sacrifice is merited. Civilians with persistent pain after post-traumatic stress deserve the same respect as the warrior who has been wounded. The injury is real and the impact may endure long after brain scans revert to normal. We do not have a diagnosis of post post-traumatic stress disorder: “P-PTSD.” But every survivor who is sadder and wiser after wounds have healed and pain remains, knows what I mean by that term.