Dispelling the nightmares of post-traumatic stress disorder

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avoidance, behaviour, cbt, distress, Ehlers and Clark, flashback, hyperarousal, interpretations, low mood, Memory, negative thoughts, nightmares, post traumatic stress disorder, psychological effects, psychotherapy, PTSD, reliving, reminders, symptoms, threat, trauma, trauma memories, traumatic event, treatment, triggers

Dispelling the nightmares of post-traumatic stress disorder

On Wednesday morning we woke to the news that a passenger ferry had sunk off the coast of South Korea, with at least four people confirmed dead and 280 unaccounted for. Meanwhile, though the search has continued for the missing Malaysia Airlines plane, relatives’ hopes of a safe landing have long since been extinguished.

Human tragedies like these are the stuff of daily news, but we rarely hear about the long-term psychological effects on survivors and the bereaved, who may experience the symptoms of post-traumatic stress disorder for years after their experience.

Although most people have heard of PTSD, few will have a clear idea of what it entails. The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) defines a traumatic event as one in which a person “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”. PTSD is marked by four types of responses to the trauma. First, patients repeatedly relive the event, either in the form of nightmares or flashbacks. Second, they seek to avoid any reminder of the traumatic event. Third, they feel constantly on edge. Fourth, they are plagued with negative thoughts and low mood.

According to one estimate, almost 8% of people will develop PTSD during their lifetime. Clearly trauma (and PTSD) can strike anyone, but the risks of developing the condition are not equally distributed. Rates are higher in socially disadvantaged areas, for instance. Women may be twice as likely to develop PTSD as men. This is partly because women are at greater risk of the kinds of trauma that commonly produce PTSD (rape, for example). Nevertheless – and for unknown reasons – when exposed to the same type of trauma, women are more susceptible to PTSD than men.

What causes it? In one sense, the answer is obvious: a specific trauma. Yet this is only part of the story, because not everyone who is raped or badly beaten up develops PTSD. Of the contemporary psychological attempts to answer that question, the most influential is the one formulated by the clinical psychologists Anke Ehlers and David Clark at the University of Oxford.

They argue that PTSD develops when the person believes they are still seriously threatened by the trauma they have experienced. Why should someone assume they are still endangered by an event that happened months or even years previously? Ehlers and Clark identify two factors.

First is a negative interpretation of the trauma and the normal feelings that follow, for example believing that “nowhere is safe”, “I attract disaster”, or “I can’t cope with stress”. These interpretations can make the person feel in danger physically (the world seems unsafe), or psychologically (their self-confidence and sense of well-being feel irreparably damaged).

Second are problems with the memory of the trauma. Partly because of the way the person experiences the event, the memory somehow fails to acquire a properly developed context and meaning. As a result, it constantly intrudes. Ehlers and Clark liken the traumatic memory to “a cupboard in which many things have been thrown in quickly and in a disorganised fashion, so it is impossible to fully close the door and things fall out at unpredictable times”.

These factors change the way people behave. They may avoid situations that might spark a memory of the trauma, and will sometimes try to deaden their feelings with drink or drugs. Yet these strategies tend to entrench and exacerbate the problem.

PTSD can be treated with antidepressants or various kinds of psychotherapy, including prolonged exposure therapy and eye movement desensitisation and reprocessing. However, a recent meta-analysis of 112 studies conducted over the past 30 years found that cognitive behavioural therapy (CBT) was the single most successful type of treatment.

CBT typically comprises three main strands. First, it evaluates the individual’s excessively negative thoughts about the trauma and its aftermath – for example by helping them understand that they are not to blame or that their feelings are normal and natural. Second, the treatment works on the person’s memory of the trauma: the individual might be asked to write a detailed account of the event; relive it in their imagination; revisit the site of the trauma; or be shown how to cope with the kind of objects or situations that trigger the traumatic memory.

The final strand involves tackling the kind of behaviours that tend to fuel PTSD, for example by demonstrating that attempting to suppress a thought is futile (if you doubt it, try right now not to think of a white bear) or that avoiding a situation only strengthens one’s fear.

A course of CBT for PTSD normally involves meeting with a therapist once or twice a week over several months. Given how debilitating the problem can be, that can seem like a very long time to wait to get one’s life back on track. However, pioneering research published in last month’s issue of The American Journal of Psychiatry suggests that there may be an alternative. Instead of months, it may be possible to tackle the symptoms of PTSD in just seven days.

Anke Ehlers at the University of Oxford and her colleagues randomly assigned 121 patients with PTSD (about 60% female, 40% male) either to a seven-day course of intensive CBT; weekly sessions of CBT for three months; a type of psychotherapy known as emotion-focused supportive counselling; or to a 14-week waiting list. Participants in the first three groups all received the same amount of therapy (18 hours).

The results were striking. The intensive CBT proved almost as successful as the standard three-month course, with respective recovery rates from PTSD of 73% and 77%, and the intensive version produced its effects more quickly. For the supportive counselling group, recovery was 43% (another finding that undermines the idea that all types of psychotherapy are equally effective). Among the waiting list group, just 7% had recovered. Both courses of CBT also led to large reductions in levels of anxiety and depression.

Most importantly, the benefits lasted: 40 weeks after entering the study, about two-thirds of the CBT patients were still free from the symptoms of PTSD. The therapy isn’t easy – it confronts highly distressing events and feelings, after all – but it works.

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Brain-damaged man ‘aware’ of scientists’ questions

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Brain activity, brain damage, brain scans, conscious, fMRI, Memory, thought, treatment, vegetative state

Brain-damaged man ‘aware’ of scientists’ questions

A crash victim thought to have been in a vegetative state for more than a decade has used the power of thought to tell scientists he is not in pain.

Canadian Scott Routley, from London, Ontario, communicated with researchers via a brain scan, proving that he is conscious and aware. It is the first time such a severely brain-damaged patient has been able to provide clinically relevant information to doctors.

British neuroscientist Professor Adrian Owen, who leads the research team at the Brain and Mind Institute of Western Ontario, said: “Scott has been able to show he has a conscious, thinking mind. We have scanned him several times and his pattern of brain activity shows he is clearly choosing to answer our questions. We believe he knows who and where he is.”

Prof Owen was speaking on a BBC Panorama programme to be broadcast on Tuesday night.

He said the breakthrough could lead to improvements in the treatment of severely brain-damaged patients who cannot move or speak.

“Asking a patient something important to them has been our aim for many years,” he told the programme.

“In future we could ask what we could do to improve their quality of life. It could be simple things like the entertainment we provide, or the times of day they are washed and fed.”

Prof Owen’s team uses functional magnetic resonance imaging (fMRI) brain scans to detect hidden awareness in patients and open up channels of communication. The scans produce images of “active” regions of the brain by tracking the flow of oxygen-rich blood. Patients are asked to imagine playing tennis or walking around their home – two thought processes that produce distinct patterns of activity in different parts of the brain.

By monitoring the activity on an fMRI scanner, the researchers can ask yes or no questions. One type of brain activity is taken as a “yes” and the other as a “no”.

Routley suffered traumatic brain injuries when his car was in collision with a police vehicle. Until Prof Owen’s intervention, he was assumed to have been in a vegetative state for more than 12 years.

Vegetative state patients are not aware of their surroundings or capable of conscious thought.

Neurologist Professor Bryan Young, from University Hospital in London, Ontario, who has cared for Routley for 10 years, said the scan results overturned all previous assessments of the injured man’s condition.

“He had the clinical picture of a typical vegetative patient – no emotional response, no fixation or following with his eyes,” said Prof Young. “He didn’t have any spontaneous movements that looked meaningful and I was quite impressed and amazed that he was able to show these cognitive responses with fMRI.”

Prof Owen has previously shown that nearly one in five vegetative patients may in fact be conscious.

Another of his patients, road accident victim Steven Graham, was able to answer “yes” when asked if he knew about his two-year-old niece, Ceili. Since she was born after his car accident, this demonstrated that he was able to create and store memories.

The Panorama team spent more than a year filming several vegetative and minimally conscious patients taking part in pioneering research at the Brain and Mind Institute and Addenbrooke’s Hospital in Cambridge.

The programme, The Mind Reader: Unlocking My Voice, airs on Tuesday night at 10.35pm on BBC1.

How would it feel if you couldn’t recognise your own family?

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'face blindness', Alzheimer's, autism, brain impairment, brain injury, Children, dementia, face processing, facial perception, Memory, new national centre to study, parents, prosopagnosia, stroke, treatment

How would it feel if you couldn’t recognise your own family?

Imagine waking up and not knowing who’s sharing your bed. Imagine collecting a child from school – but picking up the wrong one. Or being a mother and not being recognised by your own child. These are all the problems faced by around a million people in the UK today. Among the famous sufferers are Duncan Bannatyne of Dragons’ Den, playwright Tom Stoppard and Jane Goodall.

It’s called face blindness – or prosopagnosia. It affects more people than Alzheimer’s and autism and, just like dyslexia before it, it’s a hidden handicap that gets people in trouble every day.

But a new national centre to study the condition has been established and pressure is building up on the NHS to recognise the condition and to get the public to understand it and sympathise with the sufferers. There’s also pressure for children to be tested because, after an experiment in Australia there may be hope of treatment. There, in Sydney, an eight-year-old boy identified only as “AL” was put through a long series of tests using grey scale photographs to retrain his brain. For the first time psychologists here are hoping there might finally be a solution. In a letter to the British Medical Journal Dr David Fine, himself a sufferer, revealed the torment of his early life. He wrote that the condition “has shaped my life”. He added: “I often fail to recognise my children or even my wife.” The doctor, from Southampton, is calling for a simple children’s test “so that the next generation of sufferers grows up in a society that understands and recognises our disability”.

Leading researcher Dr Sarah Bate, of Bournemouth University, also wants to develop a way of training sufferers with the condition. She’s just got funding to start a new national centre to study prosopagnosia and she’s already been contacted by 700 individuals offering to be tested. A number of parents who think their children might be sufferers have been in touch and now a joint project with the University of St Andrews is under way – the first attempt to improve these children’s skills at face processing.

Bate has found that part of the problem is the British tradition of wearing school uniforms. She says: “We had one boy of five and the only friend he could make – simply because her face was different – was a Chinese girl.”

In the United States, where they don’t use school uniforms, there was no such problem. And some children, she found, couldn’t even recognise their own parents. One teacher with the condition only coped by the use of seating plans. But when the pupils played up by swapping seats he got depressed and got a post at the Open University corresponding by email.

Dr Bate says: “We’re wondering whether, if we could test children at, say, seven, there might be a chance that some training could help. It’s going to be an uphill battle but we do need those tests – just as they have them for dyslexia.”

A classic case is former IT teacher Jo Livingston, 67, from Bexley. She suffers from the condition and, having retired, is now touring schools and giving talks to make people aware of the problem. Even now, she only recognises her husband “because he has a beard and talks a lot”. They met in their 20s as members of a climbing club.

She says: “When you’re climbing you always wear the same clothes and if someone wears a red anorak they’ll be in a red anorak next week. So I married the one in the red anorak because that was the one I was looking for. Now I do the talks so that people can know about it – so they can have that ‘that’s me’ moment.”

Livingston has found instances where a woman could only be sure it was her baby in hospital if it was the one with a cuddly toy in the cot. Another woman said she was at a festival, looking for someone she’d planned to meet and only later found she’d been chatting to Ronan Keating. And a Hollywood engineer couldn’t even recognise Brad Pitt when they shared a lift.

“Television’s very difficult because characters change clothes and hairstyles and sometimes the plot hinges on that,” Livingston says. “You see two young blond women and you think they’re the same person until they appear on screen together and then you mentally have to rewrite the entire plot. It’s quite exhausting.”

Another sufferer is social worker Nerina Parr, 44, from Brighton. She says: “It’s the new dyslexia… nobody could explain what it was and half the time they didn’t have any sympathy with it anyway. It’s always getting me into trouble. For instance, my partner changed the picture of us on my bedside and I got really jealous and demanded to know who this new person was… then there’s the nightmare of walking into work meetings and not knowing who the people are – even though you work with them.”

Anna Cady, a 60-year-old artist from Winchester, thought at one stage that she had Alzheimer’s or dementia. “So when I found out what it was it was a tremendous relief. Then again, I did some tests on the internet and ended up sobbing my eyes out because I couldn’t even tell when they changed the faces. The awful thing is that you dread going outside because you might offend someone by not recognising them. When someone says ‘hello, Anna’ your heart sinks because you just hope you aren’t going to offend someone.”

If you think you have face blindness and would like to be part of the research you can register at prosopagnosiaresearch.org

Face blindness: Causes and cures

Prosopagnosia or face blindness can be caused by stroke or brain injury, but some people are born with it or develop it despite having no other signs of brain impairment. Recent research suggests it may sometimes be genetic.

It is thought to be caused by abnormality of or damage to a part of the brain that controls memory and facial perception.

In extreme cases, those with the condition are unable to recognise their own faces or tell the difference between a face and an object.

Treatment focuses on teaching coping strategies and the use of a variety of prompts and cues to recognise people by other means. But research is under way and it is hoped an effective prevention or cure may be found.

PTSD: The pain of reliving trauma years after the event

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anxiety, Depression, dissociation, flashback, Memory, PTSD, rape, Refugees, reliving, sexual abuse, stress, Therapy, Torture, trauma, war

http://blogs.independent.co.uk/2012/03/29/ptsd-the-pain-of-reliving-trauma-years-after-the-event/

One of my first experiences of PTSD came as a psychologist working with African and Kurdish refugees.

Many had fled oppressive regimes and been referred to our service by their GP suffering severe anxiety, depression and stress. We discovered the root of the problem often lay in terrible personal experiences including rape, torture and witnessing the murder of loved ones.

These mental scars have a long and insidious reach in the shape of PTSD whose victims can repeatedly relive a traumatic event years after the original incident took place.

I remember my shock the first time I worked with a woman who, as she described what had happened to her, lost all sense of where she was. She verbally and physically tried to fend off an imaginary attacker as well as crying and shaking with fear as part of her episodic ‘flashbacks.’

The problem can be complicated by people having great feelings of shame and guilt about what happened as if they were somehow to blame. PTSD’s victims can also include perpetrators of violence who, on reflection, feel enormous regret for their actions.

Soldiers are the most high profile casualties of PTSD but it is even more prevalent among the civilian population.

It can affect anyone involved in a near death experience and includes ‘single incident’ traumas, such as a car crash, earthquake or tsunami.

The recent sinking of an Italian passenger ship that made headline news is another example as were the terrorist bombings on London’s transport network.

It’s important to recognise that PTSD symptoms are a perfectly normal part of the healing process when they occur immediately after a trauma. Our mind is often too pre-occupied with survival to process what happened at the time so revisits the experience helping us make sense and gain perspective on what happened. In the normal process of producing memories the mind knits the various strands of an experience together based on our senses, such as sight, sound, touch and taste as well as other aspects of what we were experiencing at that time.

It also puts a ‘date stamp’ on the memory so we know when and where something has happened. When a trauma is occurring the mind is using all of its energy to keep us alive so memories often don’t get properly formed.

In the hours, days and weeks following the trauma bits of the semi-formed memory will ‘pop’ into consciousness. This can be upsetting but gives the mind the opportunity to link the various fragments together to form a normal memory.

In cases of PTSD, the healing process effectively gets stuck and, like a scratched CD, the mind repeatedly replays the trauma.

This produces a vicious circle in which the distress generated by the memories continues to stop the brain’s ability to process the memories to a level that they cause less discomfort. As a result, patients find themselves vividly reliving the experience over and over with the same intense feeling of fear they experienced during the original incident. These ‘flashbacks’ can be triggered by something that the victim associates with the original trauma, such as a sound, colour or smell.

Sensory triggers can create powerful positive and negative anchors in our minds. You could be having a bad day at work when an old friend rings and your mood switches in an instant because the sound of their voice triggers a past association of feeling good. Likewise, hearing a favourite song on the radio often makes you feel better because you associate it with a previous experience of wellbeing.

This is also true of traumatic experiences, particularly when the ‘date stamp’ has not been associated with the memory so rather than being reminded of the events it can feel exactly as if they are happening again.

A refugee suffering PTSD may link the sound of footsteps echoing down a corridor with those of events years before when their protagonist came to torture them. The smell of burning rubber and smoke may bring back the experience of watching the family home burnt to the ground by soldiers or a family member killed in front of you.

PTSD creates a vicious circle in which the distress caused by the partially formed memories stops the brain from processing them to a level where they are less intrusive. This round-robin can lead to a number of associated conditions including anxiety, depression and stress as well as ‘avoidance’ where someone will increasingly isolate themselves to avoid triggering a flashback.

Flashbacks or vividly ‘re-living’ aspects of past events are one upsetting response to trauma. Another is ‘disassociation’ where the victim’s mind psychologically removes them from an experience. This can be emotionally protective at the time but if this dissociation happens when memories of the trauma are triggered it can be hugely upsetting and disruptive to normal day-to-day life. People experiencing this can often ‘lose’ pieces of time from their day and have no recollection of what happened to them unless someone tells them.

In our clinical work we tend to see this type of response in people who have gone through repeated trauma as a child, such as prolonged periods of sexual or physical abuse.

You can imagine that to ‘remove’ themselves mentally may be the only way that a child is able to escape what is being done to them. It serves to protect the child when nothing else can but also leads to problems later in life.

Medication can help reduce stress in some patients but the main treatment for PTSD is a ‘talking therapy’ in which the patient works with the therapist to help their mind find a way process the bits of trauma memory in a more complete way.

A number of question marks remain. Why are some of us more resilient to the effects of PTSD than others? And what role do the corrosive effects of guilt, grief and shame have on recovery?

It is an often distressing area to work in as a therapist but also incredibly rewarding in helping patients first understand what is happening to them and then interrupt the cycle of PTSD symptoms.

It is, for some, the start of the long journey back to more ‘normal’ day-to-day life helping them regain control over aspects of their lives they thought they may have had lost forever.

Doctors Stunned By Musical Memory

Tags

Alzheimer's, amnesia, dementia, Memory

http://www.huffingtonpost.com/2011/11/15/cellist-memory-wiped-out_n_1095448.html

When an infection attacked the brain of a 68-year-old concert cellist and wiped out his entire memory back in 2005, doctors were shocked to discover his musical memory remained intact.

First reported by The Guardian, the German musician known as PM could only recognize his brother and care worker, but had no recollection of people or events from his past.

Discover Magazine explains the cellist’s severe amnesia meant he couldn’t recall old and new memories thanks to the destruction of his medial temple nodes — a part of the brain responsible for storing facts and events.

But when it came to playing previous concertos, and learning new pieces of music, he had such no problem leaving doctors stunned.

Discussed at the Society for Neuroscience conference for the first time this past weekend, scientists say this case study suggests memory is more complex and autonomous than previously thought and that music could be the key to helping people with memory problems learn new skills in life.

“Musical memory seems to be stored independently, at least partially, of other types of memory,” Carsten Finke, a neurologist at Charite university hospital in Berlin told the Guardian. “If you contrast these two cases, you could argue the superior temporal gyrus, which is intact on the righthand side in our patient, could be the relevant structure that he uses to remember music.”

The link between memory and music is nothing new, of course. The LA Times points out that tunes are the last memory to go with Alzheimer’s patients. According to the American Health Assistance Foundation, people can prevent Alzheimer’s and dementia by playing a musical instrument in order to keep the brain active.

Another study out of Boston University showed music had healing affects on Alzheimer’s patients and allowed them to learn new things through lyrics rather than spoken word.