PTS not PTSD

PTSD or PTS?

Ever since the term PTSD or Post-traumatic Stress Disorder was coined, in the years following the Vietnam War, it has been a topic of interest for me, and becoming a therapist ten years ago only increased the need to try and understand this most misunderstood of 'conditions'. The word 'disorder' is, I believe, grossly misleading, and I hope to explain my stance in the course of this blog post. With better understanding, I think we can do so much more to support armed forces personnel who are suffering unnecessarily, giving them insight and access to the facts about the symptoms of post traumatic stress. Knowledge is power.

A search of the information available about PTSD is revealing, as it's hard to find any references that do not 'pathologise' the symptoms of trauma. Worse still, the Wikipedia entry regarding PTSD goes into great detail about which psych medications are recommended for 'treating' the condition, the drug of choice being SSRIs such as Prozac. What it doesn't reveal is that these medications do not actually 'treat' anything, but may provide a temporary relief from the symptoms. Although this is most welcome when suffering is extreme, what is also unclear are the possible dangers involved in prescribing these drugs, particularly long term, when some can increase the potential for self harm and suicide. It seems clear that the medicalisation of this particular kind of distress has been deliberate and thorough, the very word 'disorder' suggesting that there is some kind of fault in the sufferer of the symptoms, and further, if given a pathologising label, a fault that can be put right with medication.

But what if the sufferer of the distress is actually reacting perfectly normally, given his or her circumstances? What if it is the situation(s) that the individual has found themselves involved in that are abnormal and not their reactions to it? What if we are labelling veterans as 'disordered' when their response to trauma is exactly what one would expect to see, given the nature of the experiences that many have lived through? What if the question needs to be 'what happened to you?' rather than 'what is wrong with you?'

One major problem is the way the human brain has evolved, and the more primitive early response mechanisms that we are still stuck with. For sure, if we were designing a brain from scratch today, we would discard or redesign some of the more primitive features but that is unfortunately not an option. We are dealing with an organ that has slowly evolved over the millennia and is now coping with threats and dangers that are unlike those it was originally designed to face. Modern day stress situations are very different to the threats faced by early man, but when the fight, flight, freeze mechanism is activated, in times of great pressure, we find ourselves at the mercy of a survival system that has the potential to make matters worse instead of better. It's important to understand that this response is not a conscious choice or decision. Once triggered, it bars the way to rational thought and logic, which will only return when calm is finally restored.  In some cases, this can tragically be too late.

In many ways, these mechanisms seem to have been better understood a century ago than they are now. I have in my mind the work of army psychiatrist, W H R Rivers, during the First World War at Craiglockhart Hospital, Edinburgh, where he treated officers diagnosed with 'shell shock', notably war poets Siegfried Sassoon and Wilfred Owen. Rivers believed that the distress of shell shock or war neurosis was rooted in the attempt to repress traumatic memories of events, a particular problem amongst the officers in his care, obliged to keep a 'stiff upper lip' to set an example to the men under their command. Rivers' 'talking cure' was based on the ancient practice of catharsis, or bringing repressed memories and unacceptable feelings into the light of consciousness by expressing them in the safety of his consulting room. He believed that expression of the memory robbed it of it's power to cause unconscious distress. He further believed that if repressed, memories could bubble to the surface when the sufferer was asleep, their guard down when unconscious, allowing intrusive thoughts, flashbacks and nightmares to re-emerge. He prepared his patients to bring memories and feelings safely into the light by educating them about the physiology of repressed memory, and how expressing and processing the memories could indeed free them from the distressing symptoms. Today I feel we are much more inclined to treat post traumatic stress as an illness, and to look to medication as a first or only resort. Of course, medication will further suppress troublesome memories and will be unlikely to aid the process of mindfully bringing them into the light of consciousness. Unfortunately, the medicalisation of distress has brought huge profits for pharmaceutical companies during the course of the last half century, and the work of William Rivers and others has been passed over in the pursuit of making money. But this is a battle for another occasion.

The Regeneration Trilogy by author, Pat Barker, describes in some detail the work of William Rivers at Craiglockhart, with Siegfried Sassoon and others, and a film of the book, 'Regeneration' was made in 1997. Both provide a fascinating insight into the mechanisms we are discussing here. The trilogy of books by Barker is an enlightening read.

And so, the fight flight freeze response is the body's natural survival mechanism, albeit an outdated one for much of modern living. The situation is further complicated when you consider the effects of military training on this survival response. To illustrate this using another First World War analogy, imagine infantry emerging from a trench at the signal of a whistle, and instructed to walk steadily towards the guns that are aimed and firing directly at them. In order to carry out this order, every natural urge to run, or to dive for cover had to be overcome and suppressed. Despite being under orders, this is not a normal behaviour for any human being, and begs the question, is it any wonder that it messes up the body's subsequent reactions to stress, even in more normal situations? When considering some of the behaviours associated with PTS, irritability, aggressive behaviour, risk taking, withdrawal and numbness it's not a huge leap to link these with hyper vigilance and the virtually constant triggering of the fight flight freeze mechanism, which, like an over-sensitive smoke alarm, will go off whether you have burnt a piece of toast or set the whole house on fire.

There are many variables here too that will affect whether or not someone experiences the symptoms of post traumatic stress: the duration and severity of the stressful situation, the feelings of powerlessness to change or influence the situation, the chaotic and out of control nature of the situation, how often it occurred, the previous experiences of the person enduring the stressful situation (what other traumatic events have they encountered in their lifetime), and what support networks do they have? There are a million and one reasons why some will be affected and others not. And everyone, but everyone has a limit to what they can endure. This limit will be as unique to the individual as a fingerprint.

Lastly, as human beings, we are hard wired to seek connection and to be accepted, to feel heard and understood. To be misunderstood, isolated and unheard can be one of the most psychologically fearful things known to man, and I believe this to be one of the root causes of PTS. When military personnel are parachuted back into civilian life, many will lose contact with their comrades, brothers in arms, the very people who have shared in the extraordinary and abnormal situations and experiences. This can lead to feeling a sense of isolation, of not belonging, that no one can or will understand.

So what can be done to help?

Understand that Fight Flight Freeze (FFF) is a natural response to trauma:

Firstly to gain and promote the understanding that the survival fight flight freeze mechanism is the body's built in protection and survival system. In PTS it has been triggered and overstretched by extraordinary circumstances, but a re-balancing is possible with an understanding of the physiological responses to extreme stress, and a safe place to explore feelings and memories that have been suppressed. Just as with a reflex, like blinking to protect the eye, FFF is the brain doing what it was designed to do. This is key to developing the ability to develop a compassionate curiosity.

Developing compassionate curiosity:

It's a strange thing, but we are often our own worst enemies when it comes to self criticism, not allowing any perceived 'weakness' in ourselves, whilst often displaying an ability to offer empathy and compassion to others. Everyone without exception has an inner voice - fact - we all talk to ourselves. If that voice is super critical, it is unlikely to be of assistance in effecting a recovery from PTS. In order to override it, a useful practice is to become the compassionate observer of oneself, and as that observer to develop a compassionate curiosity about what is going on. By taking a step back from ourselves, it is possible to gently question thoughts or behaviours. Where do they originate from? Are the thoughts valid, fair and balanced or are they harsh and unjust? If the critical voice persists, intervene as the compassionate observer and effect a pause. Calling for time out from self criticism will facilitate a return to a calmer state. Become your own best friend and talk to yourself as a good friend would.

Establish a connection:

At the very time when we most need to feel connected, many of the effects of PTS can cause us to check out of the places where connection is possible and desirable. This can best be understood as a numbing or freezing, increasing the sense of feeling misunderstood and isolated. If you have a critical inner voice (and many of us do), being isolated will mean that this voice's inputs will be ones you are listening to most. Connecting to someone who will listen without judgement or trying to fix it, even if they have not shared the experience will help, whether that means enlisting professional help or calling on a trusted friend or relative, although someone neutral can be a bonus as they have no 'agenda' or expectation of you, and are likely to be more impartial.

Exercise:

Constant triggering of the fight flight freeze mechanism floods the body with the chemicals such as adrenaline and cortisol, in preparation to take action (or freeze). Exercising is the best means to disperse the unwanted chemicals and will help to speed up the return to equilibrium and calm. It's pretty much guaranteed to help alleviate symptoms of PTS, although it may seem like the last thing you feel like doing at the time.

Where the light gets in:

Enduring the effects of PTS can turn the world into a very dark place. But the wounded places in the psyche really are the cracks where the light gets in, when an acceptance is arrived at about the feelings surrounding traumatic events. The places that feel the most vulnerable and broken can be the source of greatest strength when properly understood. Giving yourself the gift of that understanding can be the beginning of a journey to a very different landscape.

https://www.amazon.co.uk/Regeneration-Trilogy-Pat-Barker/dp/024196914X

https://www.theguardian.com/theguardian/1999/oct/30/weekend7.weekend1 (SSRIs)

https://en.wikipedia.org/wiki/W._H._R._Rivers

https://www.youtube.com/watch?v=30fpaqNsEoM (clip from movie 'Regeneration')

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