What Actually Happens During a PTSD Trigger

I just came across this great article on triggers on the MyPTSD forum, and I wanted to share it. This is a great insight into the mind of a survivor of PTSD: Dylan breaks down the effects of triggering step by step:

1. The brain unconsciously evaluates stimuli at incredible speed, and sometimes the triggering process begins during this stage, which may make the survivor unaware that s/he is triggered.
2. Any vague resemblance to actual trauma sends of the "DANGER" meter in the brain. Ensuring survival means shutting down blood passages to little muscle groups (think hands and feet), and some cognitive functioning of the brain shuts down, triggering the fight/flight/freeze response.
3. Adrenaline shoots up, epinephrine and norepinephrine shoot up, cortisol levels spike, and when the trigger has ended and there's no actual danger, the body is exhausted, so it crashes.

These three processes are designed to keep us as humans safe and the ability to get out of dangerous situations when there are legitimate threats. However, in the case of PTSD, the danger alert is always high—managing symptoms is a constant battle (as I've previously discussed).

These processes can also be self-traumatizing if not coped with properly. A trigger causes the process to start, and sometimes, the brain has nowhere to go when the trigger stops. A survivor can be triggered by the process of triggering if the perceived danger is threatening enough.

The author of the article mentions coping methods like aerobic exercise to bring the levels of adrenaline, cortisol, epinephrine, and norepinephrine down; meditation to bring the cognitive part of the brain back into control; and yoga to reunify the body and mind (like a grounding exercise).

Compassionate self-communication rounds out the article, helping to reconcile the experience with oneself. Quietly reminding oneself that they are safe and accepting the experience helps to cope with the trigger.

Please read this article and the responses. They are quite enlightening, and definitely worth your while.

Mental Health and Decreased Sex Drive

I'm so glad that my wife suggested this topic for my next blog entry.

I know, it's an uncomfortable topic for some. It's a crucial part to a relationship, however. Sexual intimacy is important to the health of any relationship because of the intimacy it brings. Read my previous posts, and you'll discover that intimacy is absolutely priority one (along with a few other virtues) in maintaining a healthy relationship with a survivor of PTSD. I'm talking romantic relationships here, not necessarily friend relationships.

Libido inevitably suffers with the onset of PTSD. It is as sure as the calm after the storm. The entrance of SSRI and atypical antipsychotic medications bring this reality even more surely. Libido doesn't just affect the survivor in this case, it can also affect the survivor's partner.

Results of low libido

What's important to keep in mind is that this is not an uncommon problem among survivors and relationships. Research has surfaced that has formed the hypothesis that "sexual difficulties in PTSD may occur as the brain connects the sensation of arousal to aggression instead of healthy sexual function." Traditionally, research has posed that sexual difficulties occur only when the survivor is exposed to rape or sexual trauma, not necessarily PTSD. However, combat veterans and survivors of other trauma can also develop sexual dysfunction, rendering this conclusion faulty.

The connection of sexual arousal and PTSD is a direct relationship: the hyperarousal cluster of symptoms can take over (read: hijack) the normal sexual arousal response and substitute it for aggression. This happens involuntarily: physiological arousal brings feelings of fear or being threatened when this involuntary response occurs. This Reuters article by Lisa Rapaport explains in greater detail this involuntary, albeit unfortunate, connection.

Treatment options & education

So what can a survivor and their partner do to help? The answer might be right in front of the nose, but it bears repeating: couples therapy seems to be one of the greatest measures a couple can take to help address this connection.

This article explains in great detail a method of therapy closely aligned with cognitive behavioral therapy (CBT)—considered a gold standard in PTSD treatment circles—that can help survivors and their partners address the issues and symptoms (not just low libido) that PTSD and their SSRI counterparts bring with them. CBCT, or Cognitive-Based Conjoint Therapy. This particular article is a commentary on the potential benefits of CBCT versus no therapy at all.

If low libido or high PTSD symptoms are detrimental in your relationship (and often they are), couples therapy might be an option to explore. There is some good news regarding PTSD according to the preceding article: PTSD is highly treatable, and the best thing a partner can do is be supportive and be willing to seek help—together.

The Comingling of Burnout, PTSD, and ADHD

Rarely do I discuss topics that overlap ADHD and PTSD, but this one is a doozy. A loaded topic with lots of variables and risk factors, burnout is detrimental and dissipating for a survivor with PTSD and/or ADHD, but it can also take a toll on the survivor's loved ones.

The "H" component in ADHD stands for "hyperactive," as in (grossly simplified): go, go, go, go, go. As one is "often on the go" or "driven by a motor", the energy level starts to wind down. Couple that with the hyper-arousal cluster of PTSD symptoms, and the risk of burnout skyrockets. ADHD is always co-morbid with something, and if your survivor has both PTSD and ADHD, the risk of burnout is especially something to watch closely.

I recently came across an article written by Gunilla Brattberg (Stress and Health, 2006) on this very topic of burnout when PTSD and ADHD take center stage in the survivor's brain.

Risk of burnout
There is a specific correlation between the type of trauma a survivor faces and the risk of burnout. Remember, PTSD is the result of constant feeling of being on alert because of a threatening situation out of the survivor's control. Brattberg postulates that, "there is a great probability that trauma, particularly sexual assault and ‘severe human suffering’ (a term used in the LEC, Deykin et al., 2001) in some cases with accompanying PTSD, is an underlying factor of burnout" (p. 6).

On the ADHD side, the risk of burnout lies in the hyperactive/impulsive side of the spectrum. "ADHD in childhood often stays with the individual into adulthood and makes her/him extra vulnerable to stress, which can result in burnout" (p. 7). What the article doesn't necessarily discuss is the presence of different types of ADHD symptoms. Medically speaking, three types of ADHD are documented: the inattentive type, the hyperactive/impulsive type, and a combined type—incorporating symptoms of inattentive and hyperactive-impulsive types. Most adults with ADHD have a combined type of ADHD. One of the flagship symptoms of the hyperactive-impulsive type is the feeling of "on the go" or "driven by a motor". This is the area of symptoms that increase the risk of burnout in ADHD survivors.

Comingling of PTSD and ADHD
There's no doubt that the comingling of PTSD and ADHD increase the risk of burnout, especially if the survivor's PTSD is based in a particular trauma centered around human suffering (including themselves). Brattberg hypothesizes that, "Burnout includes a hyperactive phase which can be difficult to differentiate from the hyperactivity due to ADHD" (p. 7). What seems more plausible to me; however, is that the hyperactivity due to ADHD actually facilitates the hyperactive phase of burnout. ADHD's hyperactivity and PTSD's hyper-vigilance play a crucial role in beginning the burnout process, as we'll see later.

Defining and Recognizing Burnout
There are three stages of burnout that occur in a nearly sequential pattern. First is the stress arousal stage. Persistent irritability, anxiety, insomnia, headaches, inability to concentrate, all comprise this phase of burnout. Perhaps not coincidentally, a lot of these are physical and mental manifestations of ADHD symptoms.

Second is the energy conservation phase. Here is the actual stage that burnout takes hold: procrastination, decreased libido, social withdrawal, missing deadlines, inability to concentrate; these are all indicative of burnout taking hold.

Burnout is preventable at any phase, but it's not often noted until phase three: the exhaustion phase. This is where depression, fatigue (both mental and physical), suicidal ideation and/or planning, desire for distance among attachments take hold. It is where most people really see that something is wrong.

Hopefully it is clear that there is some serious overlap between ADHD, PTSD, and burnout. The hyper vigilance of PTSD, the hyperactivity of ADHD, and the irritability, anxiety, and other arousal symptoms of burnout all can go hand-in-hand. Social withdrawal, procrastination or the inability to concentrate might be mistaken for avoidance in PTSD or inattentiveness in ADHD, but they also might be the onset of burnout's energy conservation.

How to cope
For our family, often the key to dealing with burnout is recognizing it on the present path before it actually happens. Prevention is a great deterrent to actualization. This isn't necessarily easy, since burnout is a sequential process that isn't often realized until it's too late. However, remember that burnout can be stopped at any point during the cycle.

Over time, you and your survivor will learn the cues of approaching burnout, and taking steps to prevent burnout from occurring will come more naturally. Start by looking at the stress arousal stage. Is your survivor overcommitting himself/herself? Is your survivor not sleeping well or constantly irritable? This might be the hyperactive part of ADHD, or the hyperarousal part of PTSD, but it also might be the onset of burnout's stress arousal.

Is your survivor missing deadlines at work? Is there some unexplained social withdrawal? These might be the avoidance symptoms of PTSD, but they also could be the onset of energy conservation due to approaching exhaustion. The weight on your survivor's shoulders is a constant one that causes your survivor to struggle with their symptoms on a daily basis (even when they're asleep). The best thing, I think, is to strive to cultivate safety and trust by open communication and careful, active listening. Keep your survivor's needs at the forefront, and foster an atmosphere of open communication. This will help both of you recognize burnout in the early stages, and will allow you both to help prevent it from getting worse.

What a Survivor Loses With PTSD

In an effort to truly understand what a survivor goes through on a day-by-day basis, I have been seeking what the survivor actually loses when they are forced to take on PTSD (remember, PTSD develops out of circumstances outside of the survivor's control—that's why safety is so important). From my research, these four losses occur, though to varying degrees.

Loss of control in everyday circumstances

In a constant state of F-F-F (fight-flight-freeze), it can be difficult for a survivor to maintain control of themselves and their situation. PTSD always develops due to a loss of control, so the loss of control itself can be triggering. It is important for the survivor and the survivor's loved ones to reassure and reaffirm the survivor's control. For example, in social situations, it is helpful to provide a way out if the survivor begins to feel uncomfortable or that they can't maintain control of the situation.

Loss of identity

Your survivor endured a great deal, and now they are at the mercy of the every day symptoms of PTSD (and I do mean every day). Survivors lose interest in activities they once enjoyed; it's difficult to recapture the motivation that they once had to get things done or accomplish long-term goals. The sense of who the survivor was before the trauma is just a memory, fostering regret, emptiness and depression.

Loss of normalcy

Closely related to the loss of control and loss of identity is the loss of normalcy. Every moment becomes a fight to survive and manage symptoms—an exhausting feat that occurs all the time. Just getting out of bed in the morning can be an all-day chore. Because symptom management becomes a 24/7 activity, burnout can occur much more frequently.

Loss of trust

The sense of hyper alertness and hyper vigilance can play a detrimental role to people not remotely involved to the survivor's trauma. Even a walking pattern can be a trigger and cause the survivor to put distance in place, simply as a measure of self-protection (remember the F-F-F response). Distance is a form of flight, so it's natural for the survivor to increase their distance if the survivor can't influence the other party to move away (circumstances like social situations).

The Silver Lining

From my research, one of the good things about PTSD as a disorder is that it is never too late to begin treatment. Though the survivor may not be able to reclaim the time lost due to these four losses, the survivor can begin to create new memories and behaviors that foster control, safety, re-identity, normalcy, and trust. Remember, your utmost goal as the survivor's partner is to foster an environment of safety. The survivor will probably not feel safe 100% of the time, and that's normal, but it's important to help validate and cultivate that sense of safety, even if the survivor flees, fights, or freezes. It's up to you and your partner.

This website puts things in much more prolific perspective.

Grounding

One of the more detrimental symptoms of PTSD, I think, is the flashback. The survivor literally lives in the past: as if the trauma was happening around him or her. It can be excruciating and even dangerous. The survivor leaves the present world and enters the world of the trauma: sights, sounds, smells.

The brain can't distinguish between the past world of the trauma and the present world, but the survivor can pull through the flashback through grounding. Grounding takes some self-discipline, and if the survivor's loved one(s) are around, they can help. Grounding is like meditation: it's pretty easy to do, but it takes practice to develop effective techniques.

I found a great site that has a handy PDF file for PTSD grounding techniques by Lisa Najavits. There's a bunch of grounding techniques that engage all the human senses, but it's important to note in the first sentence, "Grounding is a set of simple strategies to detach from emotional pain".

I think we tend to think of detachment as a bad thing, especially if we're talking about it as a form of dissociation (another set of PTSD symptoms). In this case, grounding is a way to distract or bring back the survivor from the past back into the present. Again, it takes some time to develop, but here are three things that are super simple to do:

1. Try starting with some simple deep breathing from the diaphragm. Hold your breath and silently count to 10 slowly.
2. Look at things around the room that you are in, name them, and describe them. Play the "5-4-3-2-1" game described on this site. The whole idea behind grounding is to engage the present environment around the survivor. This technique has helped my wife and I get through flashbacks. I'll ask, "Do you hear the fountain outside?" or "Do you see the cat under the chair?" or "Can you hear my voice?" It helps with keeping the survivor in the present.
3. If you can, have your survivor run cool or warm water over their hands. This is designed simply to get the present senses engaged.

There are hosts of other techniques and suggestions mentioned in the two links above, so your options are virtually limitless. It's important for your survivor to find techniques that work for them. Remember, It does no good to invalidate the flashback. Instead, it's better not to resist it. Help your survivor get through it by gently (keyword here) asking your survivor about grounding techniques. Always keep safety at the forefront, especially during flashbacks. Grounding is a great way to perpetuate safety.

NAMIWalks 2015: May 17

Folks, I have an announcement to make.

This coming Sunday, May 17, I'll be walking to help de-stigmatize mental illness in Portland. Please, please, please support this extremely worthy cause by donating to NAMI.

Thank you for your support.

PTSD and What It Means for a Relationship

Many of you know this, but my wife has PTSD and ADHD. I don't have either. However, because I love someone that does have PTSD, I encounter it on a near-daily basis. Over the last few years, I have learned several things, and over the last couple of years, I have learned a lot about this loaded disorder. What I want for this post is to relay some of the things that I have learned as I reflect on the relationship I have with my wife. Now, let me say this right up front: I am not a medical professional, nor am I a marriage therapist or counselor of any kind. None of the things in this post (or this blog for that matter) should be taken as medical or relationship advice. Also, I want to say that survivors with PTSD do not all have the same circumstances. I will do my best to generalize, but it is difficult when no two people have the same experiences.

My wife and I were together for several years before she received a diagnosis of PTSD, so the last few years have been a quest for knowledge and understanding on both our parts.

1. PTSD means that conflict will happen and vary in intensity.
2. It is imperative to create an environment of safety and to make sure your partner has control when he or she is in flashback mode. Not only that, make sure your partner knows that he or she is in control when their symptoms are high.
3. At times, PTSD means deep, intimate discussions about PTSD. Other times, it means greater distance.
4. PTSD triggers are [sometimes] unpredictable. A way of thinking about this is "connecting the dots". For example, say you hear a loud motor whiz by as you're driving down the highway. For a PTSD survivor, a loud motor can be a trigger that connects to all sorts of other triggers and effects: A loud motor connects to a car accident that connects to medical bills that connects to avoidance of opening mail that connects to not answering phone calls...
5. Some days are easier to manage than others—but symptom level management is something a survivor will deal with on a daily basis.
6. Healthy coping methods should be in place at all times. This varies from person to person, so it's important to keep active discussions about them.
7. At times, the partner's role is more active. Other times, the partner's role is more passive.
8. Never, never, never, ever invalidate a partner's trigger or PTSD.
9. Both of you: Get extra support and vent frustrations.
10. Above all, communication and safety are two keys to deep intimacy.

PTSD and Hypervigilance: Maintain Safety

PTSD has three categories of symptoms: hyperarousal, reexperiencing, and numbing. All three categories can exist at the same time, or they can be experienced in stages.

For this blog entry, I'll focus on one part of the hyperarousal category: hypervigilance. This is the feeling of intense alert to perceived danger. It's important to note that the danger doesn't have to be there; it can just be perceived. However, to the survivor, it is there. The survivor may feel a threat when in fact there is none. Therefore, it is important for the partner not to dismiss the survivor's sense of danger, but rather, validate it and concentrate on maintaining a safe environment.

I know I stress safety a lot in these posts. Remember, PTSD always comes from a set of circumstances outside the survivor's control, and they are always put in a position of danger—that is, not safe. When helping your survivor, safety is always of the utmost concern. It is the single greatest thing you can do as the partner to help your survivor get through whatever set of symptoms are plaguing your survivor.

Is It ADHD or PTSD?

I feel as of late that I have spent a lot of time researching PTSD and blogging about it, but I haven't given enough time to ADHD. My wife has both.

Sometimes, the lines of these two acronyms are so blurred that it can be extremely difficult to tell which is which. Is a lack of motivation because your partner is in flashback mode, relapse mode, or depression, or is it that they don't know where to start, or that they feel overwhelmed by the day's tasks?

It can be especially difficult if the trauma brings about hypersensitivity that runs over into daily routines.

The result is looking at a Venn diagram with a very blurry middle. As you might expect, this is a largely loaded subject. There are overlaps of co-morbidities and symptoms. Both PTSD and ADHD require constructive coping techniques. Both require lots of attention and self-awareness.

Let's talk about some constructive ways to keep grounded and maintain self-awareness. This list is by no means inclusive, but it should provide some ways to help manage symptoms.


Make an interest box or closet to combat idleness and possible dark moods
Any time you or your partner comes across something that the survivor feels would be interesting but don't want to get into it at the present moment, put it into an interest box. This could be anything from magazines, CDs, arts or crafts projects, what have you. The idea is that this box will provide stimulation and creativity when things seem to be at a lull. 

Practice constructive coping techniques [exercise, meditation, art]The interest box is a constructive coping technique itself, but it's also the gateway to other constructive coping techniques. When your survivor is bored, bring out something to do from the interest box. Make some suggestions. Go jogging with your partner to get the blood flowing. Meditate wherever it feels comfortable. Meditation is a great activity that stimulates and focuses the brain.

Break bigger problems down into smaller ones
The idea of a big project can seem overwhelming to anyone (I know it does to me). But, if I think of the big project in terms of many little projects, things seem smaller. If I pace myself, or come up with a schedule equally spreading the work load (or as equal as possible), things get even easier.

What constructive coping techniques do you keep in your arsenal?

The Role of Dissociation

One thing (of many) that fascinates me about PTSD is the role of dissociation: that is, the distancing of oneself during or when reliving a traumatic experience. Think of dissociation as someone experiencing a trauma, but watching it happen from another's point of view.

What is the role of dissociation? Simply to cope with the trauma as it is occurring. When someone experiences trauma that is so psychologically uncomfortable or traumatizing, a natural defense mechanism is to avoid it completely.

This can be helpful in the short-term, but as Professor Richard Bryant from the University of New South Wales points out, it has some serious psychological consequences, but it prevents the trauma from being processed, and it could lead to PTSD. However, it doesn't always mean that PTSD will develop.

When we as people experience any type of hyper-arousing or stressful circumstance, we experience dissociation to a degree. We have temporary lapses in memory, we can't remember certain details, we stifle emotions related to the event, and the like.

In PTSD, this is a uniquely manifesting degree of symptoms, because while it initially may strive to help by distancing the survivor from the trauma, it comes back in ways like flashbacks, blind rages, the sense of being out of body, detachment, or other similar symptoms. What might start by appearing to be an escape of sorts can easily turn into a tonic for a type of amnesia or repression. It doesn't take a lot to come to the conclusion that this is a destructive coping pattern, not just for the survivor, but for the survivor's closest circles.

My wife has experienced this several times on several occasions brought on by several stimuli and environments. There are a few common results of a highly dissociative episode (especially in the form of blind rages):

1. The survivor remembers little to nothing of what happened during the episode. The survivor might remember feelings, fragments of thoughts or conversations, or other elements of the episode. We usually can't talk about everything that was said because she says, "I don't remember."

2. The survivor has feelings of guilt or remorse afterwards (when the survivor comes back to the present).

3. Depending on the responses during the conversation, the episode can last from several seconds to several hours. Flashbacks or blind rages can usually bring heated conversations, and it's important to recognize when they are happening and stay grounded (see my other blog post on developing a safety checklist to help you and your survivor cope before, during and after a flashback).

It is crucially important to help your survivor by maintaining an atmosphere of safety. The degree of safety depends on your relationship, but safety begets trust, and trust begets intimacy. True intimacy is what keeps a couple together. Your survivor is on a rough road, no doubt, but there's no fooling yourself into thinking that you're on a separate path. Maintain an atmosphere of safety, and you'll go a long way to helping your survivor manage their symptoms and trauma in a constructive and safe way.

Safety Checklist: Before, During, and After Flashbacks

Your partner has PTSD, you might or might not. This is a world that is most likely foreign to you, filled with chaos that seemingly comes out of nowhere and brings about a host of reminders of problems that might have happened long before you two met. Whatever happens during a flashback or a trigger, it is important to seek understanding. The first thing that you can do to start to understand is to validate the other person. Even if the person is remembering something that happened differently than what you remember, validate it. To them, it is true.

Ask about it. Even when symptoms are highest, talking about what's going on might prove more helpful than detrimental. Our natural human instinct is avoidance (and I'm often guilty of this). If the time is right, it might help to sit down and discuss the degree of symptoms and offer support. Be careful here, as this is getting into dicey territory. It only takes a few phrases that can make the difference between a thoughtful and open conversation and the catalyst to a blind rage or intensified flashback. Ground your partner by saying things that are happening around you—the state of the weather, a pet running across the room, children talking, or even asking if your partner can hear you. When a survivor is having a flashback, they have no awareness of their surroundings. It's like they're there, but not really there [a future post on the role of dissociation is coming soon]. A few things that have helped with my wife and me has been calling out a term of affection for my wife, asking if she is going into flashback mode, or asking if she can see or hear things that are going on. Every situation is different, so you'll need to play each situation by ear: It is as important to talk about it as it is to give the other person the space they need. Sometimes talking about things afterwards makes for a better conversation. Always maintain that your partner has control.

PTSD comes out of trauma that is out of the person's control, so make sure that during elevated times of symptoms, triggers, and flashbacks that you communicate that the other person is in control. During these times, safety is the utmost priority and should not be compromised—period. If your partner tells you to stay away, back off. If your partner is belligerent, calmly validate the things they are saying, and calmly reassure that you are there for them. Do NOT under any circumstances threaten the safety of the survivor; it will only escalate the survivor's symptoms. When your partner is in flashback mode, it can seem like a minefield, but stay the course and watch what you say and do. It will pass eventually. If the flashback hasn't lifted for a few hours, it might be time to call a mental health crisis line or 911. If the survivor threatens the safety of themselves or you, it's always important to call 911.

Living with someone that has PTSD presents a new set of challenges to a relationship, so it's extra-important that communication be as strong as possible. My wife and I remind each other often, "Don't forget your Vitamin C [C meaning communication]." It helps us immensely, especially when her symptoms are high.

A concise checklist summarizing what was said above follows:

Before flashbacks begin:
1. Ask your partner if they are still in the present. Ask if they can hear things, see things, smell things that are going on. Help them by grounding them in what's going on around you.
2. Prepare a "grounding box"—together. Include things that will help your partner remain in the present as much as possible. Remember, the survivor is in control, and they know themselves best.
3. Be sensitive to their requests. If they need some space, give them space. If they need some alone time, give it to them, but check in every once in a while to make sure they're okay. Never threaten them or disrespect what they ask for when it comes to space or time apart, but don't abandon the situation, either.

During flashbacks:
1. DO NOT try to take control. You're now in the supporting role. Your job is to bring your partner back. Talk about what you see, ask what they're hearing, seeing, or feeling.
2. If they become physically belligerent, back off.
3. If things get too prolonged or unsafe, call 911 or a mental health crisis line.

After flashbacks:
1. If the mood permits, talk about what happened. Ask again if your partner is in the present.
2. Discuss possible prevention measures you both could have taken.
3. If you don't have a conflict management system in place, discuss it (I'll write about one in a future post).

Fight + Flight + Freeze: Automatic Survival Responses

I think it's safe to say that most people have heard about "Fight or Flight" as responses to stressful or threatening circumstances. We are confronted with a situation that beckons to make a choice: either fight back, run away, or freeze. There's only one thing: it's not really our choice. This choice is made for us automatically. Our body automatically gets put on alert when a stressful circumstance hits us, and then we are powerless.

Sometimes we fight back.

Sometimes we run away.

Other times we just stand (or sit or lie) there.

Regardless, it's not our fault if we run away or freeze when afterwards we say, "I should have fought back." Our bodies take over, and the response is automatic.

When we encounter a threatening or stressful circumstance in the context of PTSD, the response, I think, could become even more automatic, meaning that the body anticipates the response, especially if the circumstance is a potentially traumatic or triggering circumstance.

I have learned that if I say or do something that could in any way be triggering (even the way I walk), the FFF response begins way before things escalate.

If you live with someone that PSTD, please be careful about the FFF response and how it affects you. Learn your partners' triggers. Try to avoid them. The survivor needs to feel safe and in control at all times. << I cannot state that enough. Safety and in control are two things a survivor needs to feel all the time.