Dissociative PTSD….

In this post, I’m reviewing a few old papers I’ve written on PTSD….

As this blog develops, I find it is serving two purposes.  The first is as a brain dump, where I can purge all the thoughts and feelings lurking in my mind after a long way.  The second function for this blog is as a study tool.  As a verbal processor, my greatest successes in retaining information comes through reading it and then summarizing information in a manner that makes sense to me.  That is the purpose of this post.

A Multifactorial Perspective…

Ultimately, therapists seek to make sense of human nature, one client at a time. As a PTSD sufferer, I have both a professional & personal interest on the subject of dissociative PTSD.  What follows is a gathering of all research I’ve done thus far on the subject.   In my studies, I am fascinated at how complex human nature truly is.  As I learn more, I become increasingly aware of my expansive ignorance is: there is much to learn.  The first conclusion I came to was that “making sense of human nature” requires a multidimensional perspective.

*For example, systems theory can help us understand individuals as byproducts of their family & community environment.  
*Eric Berne’s work is useful in making sense of complex social transactions. 
*Finally, DBT’s biosocial perspective can provide understanding of how our mental health exists as a byproduct of the interaction between one’s biology and environment. 

Lambert & Kinsley, (2011) describe this multidimensional perspective by noting that biological, developmental, environmental, interpersonal, psychological and cultural perspectives are all useful in this endeavor to study human nature.  From within each perspective is another unique piece of the puzzle.

Biomedical Perspectives

imagePreston, et al, (2013) state that “the brain is a complex ecosystem that depends on a large number of interrelated variables” (p8). For this reason, it is important for therapist to understand the influence of neurochemical, neuroanatomical, and neurophysiological changes on behavior and mental health (Lambert & Kinsley, 2011).  Therapists need an understanding of how brain anatomy correlates with various cognitive functions. A basic knowledge of brain physiology and underlying electrochemical processes are also vital.   For example, when helping an individual recover from a stroke, the nature of the injury is important. Whereas, right sided strokes result in higher emotional lability, left-sided strokes are correlated with compulsive behaviors and aphasia. Another useful example of this comes from recent research on dissociative PTSD.   Lanius, et al, (2010) state that dissociation is best understood as a defense mechanism to prolonged trauma.   Alterations in the brain function associated with some PTSD sufferers, include an overly-inhibited limbic system, and hyper-regulation in the prefrontal cortex (Lanius, et al, 2010). These changes correlate with the dissociative symptoms often found in PTSD sufferers. Examples such as these shed light on the importance of understanding the biological underpinnings to observed symptoms. This background of knowledge is critical in the development of effective treatment plans for clients.

Developmental Perspectives

Lambert & Kinsley, (2011) also mentions genetics and the importance of a developmental perspective as yet another critical point of understanding human behavior. Genetics is vital in determining’s one’s overall mental health predisposition. A developmental perspective is useful in understanding the influence of one’s early childhood experiences on their mental health. In reality, these perspectives are two sides of the same coin from a nature vs. nurture standpoint. For example, my oldest son has a congenital heart defect imagecalled pulmonary atresia. As a “hidden disability”, while my son appears physically normal, he has had to adjust to an array of developmental issues.  My mother is a retired Geneticist, and has provided a useful perspective on this matter.   She states that her job is best understood as a “G.P. of rare and unusual conditions”. Additionally, she notes that since her diagnoses have no cure, her biggest role is helping parents work through difficult information. Her advice has been that genetics only provides part of the picture.  How parents handle and adjust to this information greatly influences the developmental course of children with congenital defects. Applying my mother’s insight to personal research on this subject has provided confirmatory evidence of her advice.   For example, a study by Berant, et al, (2001) looks at the influence of mothers’ attachment styles on the development of infants with heart defects. Securely attached mothers are found to develop better coping methods in response to the prolonged stress (Berant, et al, 2001) Additionally, research on the long-term effects of congenital heart defects on psychosocial development indicate family coping styles have a huge impact on a child’s well-being (Brown, et al, 2008). While this is only one example, it provides a convenient illustration of the importance of nature and nurture in one’s overall lifelong development.

Evolution & Sociocultural Perspectives

Lambert & Kinsley, (2011), also briefly mention the importance of environment, evolution, and culture as key factors in understanding our clients. Together evolution and environment are useful in contextualizing how individuals adapt to their environment. Recent research on the brain has shown a surprising degree of lifelong neuroplasticity that allows us to adjust and adapt to our surroundings.   Culture provides an excellent example of how widely varied environments can be and their influence over our. For example, a book by Kathleen Taylor (2006) provides the following definition: “Brainwashing is characterized in wholly negative terms as a kind of mental rape…[the] intention is to destroy the victim’s faith in former beliefs to wipe the slate clean so that new beliefs can be adopted” (p4). This westernized perspective on brainwashing, is likely to be met with a divergent interpretation from collectivist societies. As Kathleen Taylor (2006) states individuals from China, tend to view this experience as “morally uplifting and harmonizing” (p5). While reading this, I was reminded of a recent conversation with my mother, who is from the Philippines. As a culture with a more collectivist background, she has stated that American individualism, can often appear as prideful and selfish to foreigners.  This convenient example, is also effective in illustrating the influence of culture. Culture is more than a set of beliefs and values. It defines our way of being in the world, by predefining our way of understanding it. In this respect, culture determines our emotional and cognitive responses to life events.

Conclusion

Preston, et al, (2013) state that “a single model for understanding and treating mental disorders is too narrow and simply inadequate” (p13).

In fact, in an attempt to better understand human nature, it is clear that the whole is not equal to the sum of its parts. We influence our world and are influenced by it in turn.  An understanding of human nature from a biomedical, sociocultural and developmental perspective are all critical. For example, a biomedical perspective is important in observing a client’s response to medications. In contrast, sociocultural competency and developmental psychology are important in understanding the effects of one’s environment and life experiences. In light of all this, a lifelong commitment to personal development is critical, since it appears we give to others on the basis of who we are.

Having described my approach to therapy, I’d like to discuss what I’ve learned do far about PTSD…

What is Dissociative PTSD?

In the new DSM-5 manual, PTSD is no longer classified as an anxiety disorder.  Instead it is classified under a new category titled “Trauma and Stressor-Related Disorders”, (American Psychiatric Association, 2013).  Gateway criterion for this disorder define trauma as an “exposure to actual or threatened death, serious injury or sexual violence” (American Psychiatric Association, 2013, p. 271).  Additionally, while PTSD’s traumatic stressors can include either direct or indirect, the requirement of “fear, helplessness and horror” (Friedman, 2013, p. 550) is no longer required.  Other symptoms include (1) a persistent avoidance of triggers, (2) alterations in mood and cognition, (3) flashbacks; and (4) alterations in arousal and reactivity (American Psychiatric Association, 2013).   Finally, two new subcategories of PTSD are included in the new DSM-5 Manual, including a developmentally relevant subcategory for children, and dissociative subtype.

Symptoms & Life Situation.

imageWhat is it like to experience symptoms of dissociative PTSD and what are their consequences for one’s daily life? Dissociation causes a fragmentation of one’s awareness and an inability to utilize cognitive processes to perceive the “real self” in relation to the environment (Armour, et al, 2014, Lanius, et al, 2012).  Dissociation includes symptoms of depersonalization and derealization.  Depersonalization is a feeling of detachment that is often described as an outer body experience.  In contrast, derealization results in the feeling that one’s world is unreal and dreamlike (American Psychiatric Association, 2013).  While PTSD is associated with emotional under-modulation and symptoms of hyper-arousal, the dissociative subtype is associated with persistent emotional over-regulation (Lanius, 2010).  A study by Griffin, et al, (1997), is helpful in understanding the consequences of this unique feature of dissociative PTSD.  In this study, 85 rape victims were interviewed and asked to discuss details surrounding the traumatic event (Griffin, et al, 1997).  Measures of heart rate and skin conductance were taken during the interview (Griffin, et al 1997).    Upon completion of the interview, participants filled out the PTSD symptom scale.  A subset of individuals was shown to have high levels of incongruence between their own report of distress in comparison to physiological measures (Griffin, et al, 1997).  Research like this supports the conclusion that dissociation is a defense mechanism of prolonged trauma, especially of a sexual nature (Armour, et al, 2014; Griffin, et al 1997; Lanius, et al 2012).  The following lasting consequences exist as a result of this maladaptive defense mechanism:

*Unmanageable disconnection:  Individuals with Dissociative PTSD describe an unmanageable disconnection well after trauma exposure.  While this dissociation is a useful defense mechanism during trauma, it prevents individuals from fully engaging in life.  For this reason, sufferers often experience anhedonia, diminished interests, and a higher rate of depression and anxiety (Lanius, 2012).
*Difficulty processing Trauma: Persistent avoidance and dissociation interfere with the habituation process that occurs during exposure therapy (Wabnitz, et al, 2013).  Until sufferers can begin woking through these experiences, they will have little insight how these past traumas have affected them.  Additionally, since dissociative PTSD is associated with prolonged trauma, the effects of underlying symptoms are profound.  This disorder is associate with high rates of divorce and job insecurity (Armour, et al, 2014; Griffin, et al 1997).
*Insecure Attachment & Perceived Hostility:  dissociative PTSD is associated with “exaggerated negative beliefs [and] expectations…of others” (American Psychiatric Association, 2013, p. 272).  Armour, et al, (2014), describes a hostile attitude, defined by distrust and an over-arching perception of ill intent, in sufferers of this disorder.  Additionally, sufferers of this disorder frequently exhibit dysfunctional attachment styles.  As a result, sufferers of dissociative PTSD have an array of belief systems that act as self-fulfilling prophecies in all relationships.  Until these issues can be worked through, they will continue to influence all present and future relationships in a “like-attracts-like” fashion.
*Anxiety & Persistent Avoidance:  Exposure to reminders of past trauma produce feelings of anxiety and hyper-arousal.  In order to prevent re-experiencing old traumas, sufferers will engage in a hyper-vigilant avoidance of anything that triggers these memories.  When this is not possible, dissociative symptomatology arrises as described earlier.

Controversies & Validity…

Support for Dissociative PTSD…

Research providing rationale for inclusion of Dissociative PTSD indicates that this disorder has a unique clinical presentation and responds differently to treatment.  Dissociative PTSD is associated with ‘”chronic child abuse, sexual abuse, and prolonged trauma” (Wabnitz, et al, 2013).  Early studies on prevalence rates indicate that 70% of PTSD sufferers fall into the re-experiencing category and 30% qualify for the dissociative subtype (Lanius, et al, 2012).  Additionally, while the re-experiencing group shows lower activity in the prefrontal cortex and hyperactivity in the limbic system, the opposite can be said of the dissociative subtype (Lanius, et al, 2012).  Finally, in support of the validity of dissociative PTSD, research shows a differential response pattern to conventional exposure therapy (Lanius, et al, 2012).

A  Continuum of Dissociation.

imagePrior to inclusion in the DSM-5 manual, dissociation has been considered to be a predictor of the development of PTSD (Wabnitz, et al, 2013).  Smptoms of dissociation found in the DSM-5 disorders can be arranged from simple to complex (Wabnitz, et al, 2013).  While the dissociation found within acute stress disorder has a simple presentation, it is much more complex within dissociative identity disorder.  In contrast, Dissociative PTSD, can be found at a midpoint between these extremes.  Currently, no research exists which has studied the varied presentation of dissociation within these diagnoses.  For this reason, critics question whether Dissociative PTSD is indeed a unique subtype or if it is a component of one’s adaptive responses to a trauma (Armour, et al, 2014; Wabnitz, et al, 2013).

Component vs. Subtype Models.

A wealth of research exists to support the connection between PTSD and experiences of dissociation (Armour, et al, 2014).  However, there is disagreement on the specific relationship between trauma and dissociation.  Armour, et al, (2014), describe two causal models with different proposed relationships between dissociation and trauma.  While both models conclude that dissociation is a defense mechanism to trauma, they disagree on whether research supports inclusion in the DSM-5 Manual (Armour, et al, 2014).   Supporters of the component model point at the varied presentation of dissociation across diagnoses and state they are simply co-occurring factors (Armour, et al, 2014; Wabnitz, et al, 2013).  In contrast, the subtype model points at the fact that heightened levels of persistent dissociation change the nature of PTSD symptoms (Armour, et al, 2014).  In an effort to encourage research to clarify the matter, dissociative PTSD has been included in the new DSM-5 Manual (Friedman, 2013).

Accurate Diagnosis….

 Gateway Criterion….

imageAs stated earlier, PTSD is no longer classified as an anxiety disorder.  This change reflects research that shows PTSD is not best understood as a fear-related issue (Friedman, 2013).  Instead, the updated version of PTSD  provides a diagnosis for the DSM-5 manual based on a cause (Levin, et al, 2014).  Changes to gateway criterion of PTSD no longer require a specific emotional response such as fear or horror (Friedman, 2013).  Instead, the definition of trauma has been expanded to aid diagnoses.  Based on these observations, Levin, et al, (2014) suggest a structured interview of an individual’s trauma history, is now vital for accurate diagnosis.  the clinician administered PTSD scale for DSM-5 (CAPS-5) is an example of a tool that can aid in this assessment (Bauer, et al, 2013).  Developed by the U.S. Department of Veteran’s Affairs, This tool is designed for use as a semi-structured interview (Bauer, et al, 2013).  In addition to clustering scores in accordance with DSM-5 criteria, it assesses the impact of symptoms on an individual’s overall functioning (Bauer, et al, 2013).  In this respect, subsequent administrations of this tool, are useful in assessing a client’s response to treatment.

Consequences of a Broad Definition.

While a narrow definition of PTSD simplifies diagnosis, a broad construct was designed to provide the most accurate clinical picture of PTSD (Friedman, 2013).  Levin, et al, (2014), note that this broad definition makes diagnosis much more complex.  Some symptom categories are difficult to assess objectively and require client self-report (Levin, et al, 2014).  This adds an extra layer of complexity to the diagnosis of dissociative PTSD (Levin, et al, 2014).  For example, criterion D refers to persistent belief of oneself in relation to others.  Dissociative PTSD is associated with a prolonged history of trauma, insecure attachment and a hostile perception of others (Armour, et al, 2014).  With low levels of insight into these issues, assessing Criterion D symptoms in dissociative PTSD sufferers is problematic. An accurate diagnosis of dissociative PTSD must account for its unique clinical presentation including the consequences of persistent emotional over-regulation.

Differential Diagnoses….

As stated earlier, dissociation is a symptom that can be found in varying degrees throughout the DSM-5 (Wabnitz, et al, 2013).  To avoid any confusion, it is important to note that not every exposure to trauam or extreme distress causes PTSD.  While a careful assessment of gateway criterion for this disorder is important, alone it is not enough.  In order to differentiate PTSD from other trauma-related diagnoses, a traumatic event should precede other PTSD symptoms (American Psychiatric Association, 2013).

imageAnother source of diagnostic confusion, is the need to differentiate personality disorders from criterion D of PTSD which describes a “persistent and exaggerated negative belief about oneself [and] others” (American Psychiatric Association, 2013, p. 272).  Personality disorders present interpersonal disturbances that reflect pervasive and lifelong patterns of beliefs, behaviors and inner experience (American Psychiatric Association, 2013).  It is also worth noting that personality is defined as a pattern of thoughts and behaviors, unique to an individual that define how they relate to others.  The interpersonal issues experienced by PTSD sufferers can be understood as a byproduct of unresolved traumatic events. They are coping responses and not evidence of one’s character.

A final source of confusion worth mentioning, is the difference between dissociative PTSD and DID, (dissociative identity disorder).  Dissociative symptoms in DID, involve a pervasive amnesia related to everyday events followed by flashbacks and a loss of time.  Additionally, DID includes a disruption of identity states that cause the compete loss of a personal sense of agency that is unrealted to trauma (APA, 2013).  In contrast Dissociative PTSD is associated with transitiry experiences of amnesia, falashback, depersonalization, adn derealization (American Psychiatric Association, 2013).

Final Comments on Diagnosis…

Diagnosis of dissociative PTSD must include an assessment of the severity of dissociative symptoms alongside relevant v-codes.  These diagnostic considerations are critical for treatment planning. For example, individuals with low levels of dissociation can show successful outcomes with cognitive therapy alone (Lanius, et al, 2012). In contrast, higher levels of dissociation require a stage-oriented approach that provides a form of DBT skills training, in emotional regulation, distress tolerance, and mindfulness for grounding purposes, prior to EMDR or exposure therapy (Lanius, et al, 2010; Lanius, et al, 2012).  Finally, it is also worth noting that sufferes with dissociative PTSD have complicated abuse and trauma histories.  This has a profound affect on one’s attachment style and interpersonal relationship habits.  Assessing this issue thoroughly and addressing it in family therapy may also be warranted (Armour, et al, 2014).

Treatment & Medication

Understanding Dissociation…

imageIn an article by Jepsen, et al, (2013), research was conducteed on the effect of dissociation and interpersonal dysfunction on the treatment of chronically sexually abused adults.  A group of 48 individuals were followed on a year-long treatment process.  results of this study indicate that pathological dissociation and interpersonal difficulties significantly affected treatment outcomes (Jepsen, et al, 2013).  Since dissociation is best understood as a defense mechanism to prolonged trauma it isn’t surprising.  Additionally, evidence such as this, indicates a careful assessment of dissociation is essential for effective treatment in cases of complex trauma.

Dissociation affects an individual’s arousal response to triggers.  In dissociative PTSD, the prefrontal cortex over-regulates the limbic system (Lanius, et al, 2010).  As a result the system is overly-inhibited and dissociative symptomatology is a result.  Dissociative symptoms, impede the effectiveness of interventions aimed at effective trauma processing.  The habitual learning processes associated with classical conditioning in these trauman processing techniques are also interfered with through dissociative symtomatolgoy.  Exposure therapy alone, is not effective for this reason.

Neurobiology of PTSD

“The human stress response is…a complex biological system…built around the capacity for rapid recognition of potentially harmful stimuli to mobilize the specific-specific defense response.” (Friedman, 2015, p9). In PTSD, this stress response is sustained longer, becoming maladaptive. A basic knowledge of the maladaptive neurobiology underlying PTSD is critical to understanding how medications can be utilized to treat and prevent this disorder.   What follows is a listing if biochemical alterations in the nervous system of individuals with PTSD:

  1. Thalamus: PTSD is associated with an impaired relay of information from the thalamus to cortex during arousal, causing symptoms of both dissociation and hyper-arousal.
  2. Amygdala: Receiving information from the thalamus, the amygdala provides information regarding any potential threat (Weiss, 2007). The emotional valance of a potential threat is a byproduct of messages sent from the amygdala to the HPA axis as well as the skeletal muscles (Friedman, 2015).
  3. Hypothalamic-Pituitary-Adrenal (HPA) Axis: The HPA axis, comprises the flight-or-flight response of the neuroendocrine system (Lambert & Kinsley 2011).   It is responsible for producing many of the physical symptoms associated with prolonged stress. Evidence of HPA axis dysregulation in PTSD is most readily evident in elevated levels of corticotrophin releasing hormone (CRH) and glucocorticoids (Friedman, 2015).
  4. Prefrontal Cortex (PFC): The PFC is responsible for making cognitive decisions about emotional responses, and acts as a regulator in this respect (Weiss, 2007). In PTSD, alterations in emotional regulation can be seen as correlating with maladaptive responses. Dissociation correlates with an overregulation of the limbic area by the PFC (Friedman, 2015). In contrast, hyperarousal is the result of under-regulation by the PFC of the limbic system (Friedman, 2015).
  5. Hippocampus: The hippocampus is responsible for establishing conscious experiences into memories. Trauma victims have been found to have smaller hippocampal regions (Weiss, 2007). It is felt this is related to symptoms of avoidance, dissociation, and numbing (Friedman, 2015).
  6. Neurochemical Alterations: Elevated levels of cortisol and epinephrine are related to flashbacks, hyper-arousal, and panic attacks (Weiss, 2007). Norepinephrine, effective in maintaining alertness, and focus, is associated with PFC impairment, and ineffective amygdala restraint (Friedman, 2015). Chronic serotonin activation, common in PTSD, is associated with symptoms of hyper-vigilance, irritability, and re-experiencing (Weiss, 2007). In contrast, altered Dopamine levels in PTSD are associated with dissociative symptoms as well as hyper-vigilance (Friedman, 2015).

History of Medications Utilized to Treat PTSD

imageChanges in the classification of PTSD and addition of new subtypes, indicate that the presenting symptoms for this disorder are likely to vary. Consequently, these “different phenotypes of PTSD…might be best addressed by different therapies” (Friedman, 2015). Research is currently ongoing that can provide a better understanding of the symptomatic variations for the PTSD subtypes.   Hopefully, in time, this can lead to medications that are specifically designed to address these varied PTSD subtypes more effectively. In the meantime, what follows of a review of treatments utilized currently in the treatment of PTSD symptoms.

Anxiolytics for PTSD

            In the 1980’s, when PTSD first appeared in the third edition of the DSM, Benzodiazepines were the preferred medication to treat this disorder (Bernardy, Souter & Friedman, 2015). These anxiolytics are effective in enhancing the inhibitory amino acid GABA by binding with benzodiazepine receptors, and enabling calcium channels to open more fully (Lambert & Kinsley, 2011). Initially thought to be effective in reducing symptoms of hyper-arousal, clinical practice guidelines no longer support the use of benzodiazepines for PTSD (Bernardy, Souter & Friedman, 2015). Side effects of benzodiazepines can include, drowsiness, stomach upset, cognitive impairment, memory loss, nightmares, and changes in heart rate (Preston, et al, 2013). Examples of benzodiazepines include Diazepam, Temazepam, and Lorazepam (Preston, et al, 2013). With a lack of support regarding their effectiveness in alleviating PTSD symptoms, benzodiazepines are associated with withdrawal, tolerance and dependence. Most notably, Research in support of this clinical standard notes that “benzodiazepines may interfere with the extinction of fear condition…[and] worsen recovery” (Bernardy, Souter, &, Friedman 2015, p78).

Antidepressants for PTSD

            Since the 1990’s great progress has been made in how to effectively treat PTSD, due to an understanding that symptoms overlap depression and anxiety (Bernardy & Friedman, 2015). Based on this insight, recent research has focused on the effectiveness of Selective Serotonin Reuptake Inhibitors (SSRI) for PTSD. SSRI’s, currently a first line treatment for PTSD, enhance the effectiveness of Serotonin by increasing the availability of this neurotransmitter. It addresses symptoms of irritability, depression, anxiety, avoidance, and numbing (Bernardy & Friedman, 2015). Examples of SSRI’s include Celexa, Paxil, and Zoloft. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s), are another first line treatment of PTSD, found equally effective in clinical trials, improve resilience in handling stress (Bernardy & Friedman, 2015). These medications increase the availability of norepinephrine and serotonin and include drugs such as Cymbalta and Effexor (Preston, et al, 2013). Occasionally, Tricyclics and Monamine Oxidase Inhibitors (MAOI’s) are utilized to treat PTSD, although they are not considered a first line treatment for this disorder due to a long-list of side effects (Bernardy & Friedman, 2015).

Atypical Antipsychotics & Anticonvulsants

            Recent research has shown mixed results regarding the effectiveness of SSRI’s in the treatment of PTSD (Bernardy & Friedman, 2015). Additionally, there are currently “limited medication options available for the treatment of PTSD” (Jeffreys, 2015, p89). For this reason, research is now focusing on broadening the list of secondary options for PTSD. Atypical antipsychotics and anticonvulsants have been studied as potential treatments for complex presentations of PTSD that include comorbid diagnosis and a history of substance use (Jeffreys, 2015). While atypical antipsychotics target serotonin, anticonvulsants inhibit GABA in the central nervous system.   Their effectiveness in research is mixed-at best, and only suggested in complex cases of PTSD as described above (Jeffreys, 2015). They are to be utilized with caution due to a wide array of associated side effects.

Medication Utilized to Prevent PTSD

A new wave of research has been underway that addresses the question of whether or not it is possible to prevent PTSD with early pharmaceutical interventions (Lambert & Kinsley, 2011).   The theoretical perspective underlying this innovative approach states that PTSD occurs in those cases in which the fear response to a traumatic event doesn’t extinguish fully and instead becomes habituated (Kearns, et al, 2012). Exposure therapy is effective in extinguishing a condition fear response associated with PTSD since it involves the activation of fear memories, and the incorporation of corrective information (Kearns, et al, 2012). Preventative treatments for PTSD are based on the notion that inhibiting the process of memory consolidation during a traumatic event can halt the development of this disorder.

Beta Blockers

Overview of Medication. One class of medications thought to be effective in the prevention of PTSD are beta-blockers such as Propranolol (Carter & Hall, 2007). Beta Blockers are medications useful in the treatment of high blood pressure, chest pain, and anxiety.   As anxiolytics, they are useful in treating “peripheral manifestations of anxiety (increased heart rate, sweating, tremor), but are not very effective at blocking the internal experience of anxiety” (Preston, et al, 2013, p217). Side effects include anxiety, irritability, hyperventilation, sleep difficulties, shakiness, restlessness, GI upset, and dry mouth (Preston, et. al, 2013).

Therapeutic Effects. The therapeutic effects of Beta Blockers in the prevention of PTSD are based on the notion that regulating catecholamine dysfunction can prevent PTSD symptoms. Research supporting this has indicated PTSD sufferers have decreased cortisol levels and elevated CRF, indicating an inability to regulate catecholamines (Searcy, et al, 2012). For example, one study compares the effects of Metopropolol, a noradrenergic antagonist with Yohimbine, a noradrenergic agonist on the recall of emotionally arousing events. Results showed that Yohimbine provided increased memory recall of emotionally arousing material, indicating that noradrenergic medications can modulate memory formation (Searcy, et al, 2012).

Research Evidence. In one study, participants were administered Propranolol within 2-20 hours after a motor vehicle collision (Searcy, et al, 2012). A follow-up of participants in this study showed that only one individual who received propranolol reported symptoms of PTSD (Search, et al, 2012). Another study, reporting similar effectiveness of Propranolol as a preventative, theorizes that this effect is due to a limited epinephrine-enhanced fear conditioning (Kearns, et al, 2012). However, despite this promising evidence, a thorough review of clinical evidence, shows mixed results in support of Propranolol (Searcy, et al, 2012).

Corticosteroid: Hydrocortisone

Overview of Medication. Another medication that may be effective in preventing PTSD, is the corticosteroid hydrocortisone. “Hydrocortisone is used to treat adrenal failure, shock, and inflammatory, allergic, and rheumatic conditions” (Hydrocortisone, 2014). All studies utilizing hydrocortisone as a preventative medication for PTSD in this paper were administered I.V.   The side effects of glucocorticoid treatment are too numerous to list and involve the GI system, cardiovascular system, immune system, central nervous system, and endocrine system (Schäcke, et al, 2002).

Therapeutic Effects. Glucocorticoids, such as hydrocortisone, play an essential role in modulating the behavioral and physiological responses to stress in order to maintain homeostasis (Zohar, et al, 2011).   Normally, in the aftermath of trauma, individuals work through a process of reconsolidation, in order to make sense of what has transpired, and develop an acceptable narrative of recent events (Glazer, 2011). Individuals at risk for PTSD, struggle in the aftermath of a trauma, to make sense of what has happened.   Neurobiological evidence of this difficulty can be seen in evidence of lower levels of cortisol after trauma, causing impairments in memory formation (Glazer, 2011). Hydrocortisone is thought to impact a person’s ability to reconsolidate memories through is effects on the hippocampus (Zohar, et la, 2011).

Research Evidence. Early studies on hydrocortisone as a PTSD preventative utilized rats and showed this medication modulated the fear response (Searcy, et al, 2012). Two subsequent studies involving human subjects involved the administration of IV Hydrocortisone to acutely ill ICU patients (Searcy, et al, 2012).   In both studies, this medication was very effective in reducing the incidence of PTSD symptoms of its subjects (Searcy, et al, 2012). In contrast, studies utilizing long-term sufferers of combat trauma, indicate a temporally based window of opportunity (Kearns, et al, 2012).   Studies such as these, which utilize long-term PTSD survivors, show a temporary reduction in symptoms that return over time (Kearns, et al, 2012).   To understand the neurobiological correlates of these therapeutic effects other research examines the neuroanatomy of animals with steroid-treated stress (Zohar, et al, 2011). “Steroid-treated stressed animals displayed significantly increased dendritic growth and spine density with increased levels of brain-derived neurotropic factor” (Zohar, et al, 2011, p796).

An Ethical Controversy

While there is scant evidence that other medications may prove effective in preventing PTSD, the Hydrocortisone and Propranolol, hold the greatest promise. The effectiveness of these drugs in preventing PTSD, are all based on their ability to affect on the establishment of long-term memory.   It is for this reason, that the utilization of these drugs is somewhat controversial. Carter & Hall, (2007), address this controversy by asserting that ethical objections of memory dampening medications such as propranolol, should be weighted against long-term negative consequences of PTSD.

Therapy for Dissociative PTSD???

In this final section, I set aside the research and speak from personal experience.  Therapy for my own process of recovery occured over the span of almost a decade.  It began when I entered individual therapy, and met an insightful therapist who encouraged me to enter a DBT skills group.  On completion, I began working toward utilizing these skills throughout my personal life.  Over the years, I came to understand how my entire existence became polluted by this issue.  I worked on my relationship with my kids, and how I parented them.  I addressed unhealed wounds within my family in the aftermath of the shared trauma of those “it years”.  Finally, once my therapist and I were certain my coping skills were strong enough, we did a some EMDR, for purposes of trauma processing.  The path was a long one, and took time, but well worth the effort…

References

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