PTSD

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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Jepsen, E. K., Langeland, W., & Heir, T. (2013). Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults. European journal of psychotraumatology, 4.
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Preston, J.D., O’Neal, J.H., & Talaga, M.C. (2013). Handbook of clinical psychopharmacology for therapists (7th Ed.) Oakland, CA: New Harbinger Publications, Inc.
Taylor, K. (2006). Brainwashing: The science of thought control. Oxford University Press
Wabnitz, P., Gast, U., & Catani, C. (2013). Differences in trauma history and psychopathology between PTSD patients with and without co-occurring dissociative disorders. European journal of psychotraumatology, 4.

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…and cancer trumps PTSD

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(((This post provides additional commentary regarding subject matter from the previous post.  Click here to start “at the beginning”))

Hopefully, since you read the previous post I can provide a bit of context and why I am choosing to drudge up ancient history.  Around late fall of last year as I was entering my final year of coursework, I was assaulted by a patient at work.  This re-traumatizing experience forced me to seek the help of my old therapist, whom I now visit with monthly.  In our initial session she was quite direct with me about her disappointment about my lack of self care.  This much-needed wake up call has resulted in a new exercise and nutrition regimen. Other steps taken included reaching out to others and taking time to de-stress.  I made a conscious effort to avoid isolating myself and reached out to others.  I got to get together with some coworkers a few times for lunch.  Finally, after the holidays, my sister and I decided to meet up at a local mall to shop.  This was our first “get together” after a much needed break.  The experience was truly serendipitous in a way I am unable to put into words.  It’s as if all old hurts had melted away and I was able to simply enjoy spending time with my sister.

While I would like to discuss this experience in greater length during a later post, my therapist shared some interesting perspective on healing trauma that is worth mentioning briefly.  In the aftermath of a splendid afternoon  with my sister that produced no “triggery” experiences,  I couldn’t help but wonder how the effects of past traumas could have melt away suddenly – even if for only one splendid day?   Keep in mind, I could write a novel on the intricacies of my own self-understanding (as you can see).  Despite my best efforts, it wasn’t the cognitive work or self-awareness that mattered.  Simple tasks like remaining present when a trigger hit, meditation, EMDR and daily exercise allowed my body to process old hurts, in the way my mind alone was unable to.  Reviewing insights from Bessel Van der Kolk’s book “The Body Keeps The Score”, in our session, my therapist provided interesting insights on healing trauma (2014).  His insight contradicts “conventional wisdom”, Bessel’s description of how healing happens, coincides my experience better than any other work I’ve ever written.  For those of you interested in “Cliff’s Notes” version of this book, what follows is an excerpt from a recent New York Times interview:

“Exposure therapy involves confronting patients over and over with what most haunts them, until they become desensitized to it…desensitization is not the same as healing…CBT seeks to alter behavior through a kind of Socratic dialogue…trauma has nothing whatsoever to do with cognition….the way to treat psychological trauma [is] not through the mind but through the body….paying careful attention to physiological states…” (Interlandi, 2014, p4)

In the aftermath of having experienced a serendipitious “healing” event, I have a renewed appreciation my therapist’s wisdom, of the critical importance of self-care.  As a perpetual caregiver, student, mother, and PTSD sufferer, attending to my own well-being is a vital.  Coming to terms with this diagnosis has meant accepting that interventions exist as a form of management and are not a cure.  Accepting the fact that there is not cure means acknowledging how my past traumas have changed me in ways which are unalterable.  Letting go of “what I was” has been an essential component in moving forward.

…and then life throws a curve-ball

In the months since this experience, life for me has been fairly unremarkable.  My kids are thriving, school is progressing and I’m wrapping up the final coursework necessary for my program. I am looking forward to a few promising internship opportunities, and have even started a new weight loss regimen.   In the midst of these events, I receive a call from my sister “out of the blue”.  She informs me she has breast cancer.  With a hysterectomy, oophorectomy and possible bilateral mastectomy in her near future, we are waiting the results of a genetic test which determines my risk for developing it.  My mother (a clinical cytogeneticist) thinks the results are probably negative in light of no family history of breast cancer.  However, there is no guarantee of this until we receive the results of my sister’s test.  In light of these recent events, I have developed a renewed appreciation of life as a gift to behold.  As a woman in today’s world who is “north of 40” and struggling to lose weight, I have issues with the qualities defining my “meat suit”.  In the aftermath of this news I suddenly realize these appearance-related insecurities are irrelevant to me now. Instead, I appreciate my good health, and the fact that this body has given birth to life beyond itself. Having said all this, my struggles with PTSD and family relationships are ongoing. Recent events have been triggery, yet I’ve managed them quietly.  In the hopes that I might find an appropriate place to begin “processing”,  I’m turning to this blog as a place to “do my dumping”…

And the dumping begins…

My immediate reaction to this news has been strangely reminiscent to other experiences of this variety. At two months of age my son went into cardiogenic shock  while at home with me.  He was later diagnosed with pulmonary atresia, and has endured five open heart surgeries thus far.  I was in shock during the ensuing events that unfolded when he was first diagnosed.  Doctors and nurses hovered over him, and struggled to keep him alive.   The idea that he require a series of surgical repairs was met with an outer-body response and complete numbness which prevented any emotionality from “peaking through”.  As I have later come to understand, this dissociative response (common to PTSD sufferers) is a double-edged sword.  As I like to put it, PTSD is a normal response to an abnormal situation.   Effective coping tools necessary when in the midst of “extreme situations” have allowed me to survive them.  At the same time, when these coping tools became permanent life-altering modes of adaptions to daily life, the price has become painfully huge.

As I reflect now, I’m still troubled by the fact that my emotions aren’t peaking through.  In light of the very real fact that my sister’s life is now “held in a delicate balance”,  due to a nasty and insipid disease, why is it I can’t allow myself to feel anything?  Fortunately I have a therapy appointment next week in which I can begin “processing”.   In the meantime, I need a place where I can “be me”.  I desire to “own my story” and claim my “role in it” in order to move forward.  I need a place, where I can speak those “unspoken thoughts” and share “unpleasant feelings” openly.  Since my family is VERY technologically challenged, I feel the chances they run across this blog highly unlikely.  In fact, I’m at peace with the idea, that I’m creating these posts for “nobody”, since I really get no traffic.  This brings me to the subject matter of the previous posting.  Events have unfolded that have resulted in the re-emergence of old misunderstandings that leave me in the midst of a troubling ethical dilemma.

“How to insert foot in mouth…”

Last week, my sister sent a group email with a link to an article titled “How not to say the wrong thing”.  Written by a breast cancer survivor and psychologist by the name of Susan Silk.  This Los Angeles Times article delineates her “Ring Theory” of support for those facing a crisis.  Referring to the image at the beginning of this post, this “Ring Theory” describes concentric circles of relationships surrounding the person at the center of a crisis:

“Draw a circle.  This is the center ring.  In it put the name of the person at the center of the current trauma…Now draw a larger circle around the first one.  In that ring put the name of the person next closest to the trauma…In each larger ring put the next closet people…” (Silk & Goldman, 2013).

While viewing this ring, it is important to remember that the person in the center requires comfort and support from loved ones to endure the oncoming crisis.   In order to provide the support a sufferer needs, everyone associated with this “crisis sufferer” needs to be aware of what they bring to the table in interactions with that individual.   Providing comfort and support, means listening to this sufferer while they dump on others.  This might mean listening to the sufferer discuss their current “life is unfair…why me” (Silk, & Goldman, 2013), moanings, while providing an empathic “I’m sorry this must be hard for you” (Silk & Goldman, 2013) response.  Supporters need to be aware of their needs to dump, and avoid doing so in the sufferers presence.  Bitching and moaning, rather than offering comfort, while with a sufferer means they need to utilize precious psychological resources to comfort you.  Susan silk describes this experience in the next quote:

“When Susan had breast cancer, we heard a lot of lame remarks, but our favorite came from one of Susan’s colleagues.  She wanted, she needed, to visit Susan after the surgery, but Susan didn’t feel like having visitors, and she said so.  Her colleagues response?  ‘this isn’t just about you’…’It’s not?’ Susan wondered. ‘My breast cancer is not about me? Its about you?'” (Silk & Goldman, 2013).

As the above quote implies we make another person’s crisis ‘about us’ when we dump upon them and share our reactions to their trauma and expect them to comfort us.  For example, in the aftermath of my own trauma recovery process, I remember having to console my sister and parents much of the time. As I described in the previous post, while overlooking my own emotional needs I provided the comfort they needed as revelations pertaining to past traumas came to light.  This resulted in a disturbing turn of events in which the sufferer (me) felt it necessary to comfort others at a critical turning point in my own recovery & healing.  Instead of “Comfort IN and Dump OUT”, it was Dump IN and Comfort OUT. 

“When you are talking to a person in a ring smaller than yours, someone closer to the center of the crisis, the goal is to help.  Listening is more helpful than talking.  But if you open your mouth, ask yourself if what you are about to say is likely to provide comfort.  If it isn’t, don’t say it.” (Silk & Goldman, 2013).

a re-emergence of old misunderstandings…

As I stated earlier, the above article was included in a link to my sister who provided the above article link to me in an email a few days ago.  In it she included the following comment:  “…I wish I had read a long time ago in ministering to friends/family who are in the midst of a trial. It talks about having circles or rings around the person in the center of the trial and to be mindful of how we speak to those affected by the trial. Very insightful.”

With the benefit of clarity, I can see my sister’s sharing of this article comes from a place of self-reflection and desire to assert her own needs at this time.  I appreciate her ability to communicate her needs in this respect.  However, when first receiving this email, it caused an old familiar twinge of anxiety as I was reminded me of our history.   I couldn’t help but wonder in frustration why “The Man Upstairs” was doing this to me?  How could it be, that I’m expected to be there for my sister in a “Ring Theory” fashion, when she failed to do so with me during my PTSD recovery?  This whole expectation wreaked of a hypocrisy which infuriated me.  Since I received this email over the weekend, I was “jet lagged” when receiving it.  Working three 12-hour weekend night shifts back-to-back, I responded only briefly.  In retrospect, I should have responded when I wasn’t tired, I’m afraid I dumped when I should have consoled:

“Thx for article.  Throughout my own trauma recovery, the sentiments from this article succinctly describe my own needs.  I regret I was unable to effectively state this need at the time….it was hard at at first to witness M&D reflect empathetically on what you had to go through…that old regret popped up in which I would have wanted the same from them.”

Her response to this email was the following:  “I am sorry that the way M&D are responding to my cancer is difficult for you. I’m having major surgery in 4 days….It is the opposite of helpful for me to know any information as it relates to your emotions….I would appreciate you talking to someone else about things…Like the article said ‘comfort in, dump out’. I hope you get the help that you need.”  

While her response shows an amount of understanding, it still produced some negative emotions. I was impressed with how effective she was at asserting her needs.  As a result, I wonder about whether  I handled things correctly throughout the last five years of trauma recovery?  At a critical point during the process, I remember a visit with my family about 3-4 years ago.  After a weekend of the same ongoing triggery familial dynamics, I stated my frustrations honestly to them.  I made it clear that I couldn’t deal with this any more and “maybe we should cut off contact”.  At the time, this reaction was a logical assessment of matters in light of how my relationship with them provided the greatest difficulties.  Additionally, the emotions contained in this statement reflected the burdens of having to provide comfort to them, while I was trying to get better.   Their failure to provide a comforting presence as Silk describes in her Ring Theory created a huge burden, in which their presence was more hurtful than helpful.  Nonetheless, aware that this may be the PTSD talking, I told myself this was a harsh and irrational decision.  I was left to contend with their anger, and made to feel I should do whatever possible to maintain and heal these relationships.  In the process, I’ve had to settle for something less than the “Comfort in, Dump out” expectations my sister describes.  Throughout this journey, I’ve had to tend to my family’s processing of my traumas.  I’ve learned to let go of the expectation that they can be anything other than what they are now.  The process has been quite wearisome.  I’m left with lots of questions….

While I ‘did right’ by my family, has this been at the expense of my own personal well-being?   After all, I can’t extricate me from the triggery effects of our relationship.  Since they have asserted repeatedly that “they cannot validate me”, and will not respect my own needs in a “comfort IN and dump OUT” since, what do I do?   What does “being there” for my sister mean to me at this time, and am I indeed capable?  Should I jump in and attend to her needs throughout this healing process?  Or, am I wrong in allowing others to step in while I focus on myself.? After all, if the “Comfort IN and Dump OUT” rule is to be in effect, I feel all individuals should abide by it, not just me.  As much as it pains me to say this, maybe I need to reserve my mental powers of comfort for myself, since my family isn’t effective in this regard.  

I am still struggling with the above questions, but did receive a comforting email from my mother moments ago in which she stated the following: “She added you to the conversation…because she wanted you to also see the article that Dorene wished she had know of long ago (when you were in need).  Effectively it is an apology from Dorene (and me) for not realizing the depth of your grief…”  In a phone conversation later that day, I was reassured that Dorene has many people to help her and that I need to continue living my life.  As she noted focusing on my well-being is always a critical component of daily life for me.

Does Cancer Trump PTSD???

Before concluding, I hope to explain the meaning underlying the title of this blog.  It isn’t about a childish “my hurt is bigger than your hurt” conversation in which I compare my crises with my sisters. Instead I can’t help but note how mental illness elicits a very different reaction than physical ailments do.  For example, when I’ve had to discuss with somebody my sister’s diagnosis, I experience a  genuine and compassionate response.  In contrast, the PTSD diagnosis feels like a cross to bear, as a source of stigma.  For this reason, I try not to discuss it with others.  When the subject comes up, the responses are highly varied and reflective of an individual’s preconceived notions.  It is for this reason, as a useful counterpoint to the above insight from Susan Silk’s I’m including the following quote from Jamie Berube, who has written an article titled “10 Things You Should Never Say to Someone with a Mental Illness”.  If you click on the quote below, it will take you to the article.  I also found a useful video by Marriage and Family Therapist Katie Morton.

“One of my fears in talking about my mental health condition is knowing that somebody might treat me differently because of it.  The thought of someone interacting with me in a way that was shaped by their own personal prejudices…is depressing…the words we choose to use also perpetuate…toxic stigmas about mental health issues…For this reason its crucial to educate yourself about what things to say or not say…” (Berube, J., 2014).

References

Berube, J.  (2014, August, 12).  10 things you should never say to someone with a mental illness.  Retrieved from:  http://thoughtcatalog.com/jamie-berube/2014/08/10-things-you-should-never-say-to-someone-with-a-mental-illness/
interlandi, J. (2014, May, 22) A revolutionary approach to treating PTSD. New York Times Magazine.  Retrieved from: http://www.nytimes.com/2014/05/25/magazine/a-revolutionary-approach-to-treating-ptsd.html
Silk, S. & Goldman, B (2013, April, 7). How not to say the wrong thing. Retrieved from: http://articles.latimes.com/2013/apr/07/opinion/la-oe-0407-silk-ring-theory-20130407

Suggestions for Further Reading….

Van der Kolk, B. A. (2014). The body keeps the score. New York City: Viking.

 

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Anatomy of a Misunderstanding

“I am extremely hurt by this labeling Kathleen.  I am COMPLETELY misunderstood.  And I don’t think there is anything that I can do about it”

The above quote is my sister’s response to an email I sent to my family when I first entered therapy back in 2010. I became interested in the insights from therapy models (like the DBT Skills Group I was enrolled in at the time). I applied these skills daily and found them very beneficial. I also was fascinated by the results of some MBTI assessments of myself and immediate family members. It presented an honest reflection of everyone’s temperaments, and was useful in understanding areas of miscommunication in our relationships. With this in mind, I reflected on these results in order to gain perspective on unresolved misunderstandings. At some point during all this I wrote an email describing my insights to my parents and sister. The following is a quote which produced the above response:

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Missing Pieces & Triggers

65681With the benefit of 20/20 hindsight it’s clear that our misunderstandings were never what they “appeared to be” about.  Instead, they reflected something much deeper. This email reflects an attempt to examine “missing pieces”, (i.e. holes) in my own self-understanding.  As I have since learned, missing pieces are shame-based minefields of insight regarding how we are in relation to others.  They reflect our unwanted identities.  For this reason, addressing “missing pieces” is a bit of a double-edged sword. While facing the full truth of our life story empowers us with a unique and transformative self-understanding – it also forces you to face the unresolved hurts that come with it.  I guess what I failed to realize is my sister wasn’t as prepared to handle these honest realities as I had been.  I am at fault for failing to get this fact.

For both of us, underlying this misunderstanding are temperament-based coping mechanisms. Her methods of coping in childhood produced missing pieces that were reflected of the personal narrative I created in childhood. In other words, I lived in a reality that reflected those things she overlooked and ignored.  They pertained to hurtful pieces of information regarding who she was in relation to others.  Additionally, in a mirror-like fashion, her childhood narrative was rich with trigger-producing elements I hated to face, but needed to understand for the sake of personal growth.  Her perspectives on our childhood experiences have forced me to acknowledge those missing pieces in my own understanding.   It is for this reason, that I often marvel at how divergent our perspectives are on various childhood events.  How is it we could have experienced the same thing and yet each interpreted things so differently?  I have since come to the conclusion that there is much we can learn from one another. Allow me to explain…

“Dorene is afraid to open up to me because I’m unable to take criticism….”

“It seems as though all I’ve managed to do is cause you more hurt. I believe that the loving thing to do is to step back and give you space. I don’t feel it is a good idea to continue our relationship in the same way.. The truth is, the only way I can see of interacting with you without hurting you is to simply sit and passively listen until you are done sharing. That’s not a relationship.” – Dorene

This quote was pulled from an email my sister sent me a few years after I sent the above email. In the interim between these two exchanges we struggled – and mostly faltered – in our interactions. In fact, I now realize there are times in which her assessment of matters is correct.

Relationships require us to accept people as they are and not expect them to change to suit your needs. I failed to understand this and was wrong to expect what she was unwilling to give. As a pragmatic individual she is very direct states things as she sees them. As she had also admitted in this email, “I cannot be the source of validation for you. I will fail.” While I will touch upon this in greater length at a later point, I feel it is worthy of mention here. Interacting with my sister means taking things as she intends them, brushing aside misunderstandings, and clarifying my perspective only when absolutely necessary.  There are many respects in which her words provide useful insight into my own traumas and their pervasive effect over my entire life, ((More on this later)).

For now, I wish to make it clear that my goal is to utilize a “wise-mind” as described by D.B.T.  Wise-mindedness is a “decision-making process that balances the reasoning of your thoughts with the needs of your emotions”. (McKay, et al. 2010, p. 75). It is for this reason, I’m using this post to sort out and clarify my role in our past misunderstandings. I’m trying to remain diplomatic and am wary of the usage of sentences that include “buts” – since this conjunction creates a comparison out of two connected statements. For this reason a “but statement” implies an inherent oppositional negation of everything which lies before it.  Instead, I feel comfortable saying that my sister states things as I see them, and I have difficulty coping when verifiable proof is present that I still have “missing pieces” to resolve.   In this respect, the resulting emotions are evidence of an unresolved trauma and not the immediate event.  It appears that “claiming ownership of my story” is a lifelong struggle and not “end goal”.  It is my hope that I can learn to let go of what isn’t offered, and instead focus on myself.

I’m afraid to open up to her because she represents what I try to avoid – the potential judgments of others.”

“I have been afraid to open up to her because Dorene has represented for me through our childhood, everything that I’ve rebelled against.  She was convention and I was nonconformity.” – Kathleen.

I believe it is this statement in my initial email that yielded my sisters response:  “I am extremely hurt by this labeling Kathleen. I am COMPLETELY misunderstood. And I don’t think there is anything that I can do about it”. Naturally, hindsight is 20/20. There are some things better left unsaid.  We were both guilty of making statements that appeared neutral at the time, but brought up old hurts in the other. Sometimes there are truths that slap us in the face and cause a full-on rush of emotions, once a specific comment is brought to the forefront in a conversation. At the time this email was written (over 5 years ago), there was much I didn’t know about PTSD, and it’s pervasive effects. Its surprising how much the symptomatology associated with this issue became “my normal”. I didn’t know anything else. It is for this reason I had difficulty explaining what I was experiencing and the needs that result from this. In her latest book, “Rising Strong”, Brene Brown describes chandeliering as exquisite and unbearable pain:

“[Chandeliering is] used to describe the kind of pain that somebody can’t hide even if they’re trying their best to be stoic…chandelier pain…hurts so much to the touch that people jump as high as a chandelier…one of the outcomes of attempting to ignore emotional pain is chandeliering. We think we’ve packed the hurt so far down that it can’t possibly resurface, yet all of a sudden, a seemingly innocuous comment sends us into a rage or crying fit. (Brown, 2015, p. 60).

Time and time again, my interactions with my family have yielded emotive chandeliering.  Throughout the course of our get-togethers with my family of origin, events and/or comments would trigger a huge unresolved well of emotions. The comment might be something seemingly innocuous, regarding my childhood, yet it would produce a well of anxiety and pain I could not dissociate or numb my way thru. At the core of these comments was a realization of the extent of my family’s emotional absence.  Unaware of my childhood experiences due to an emotional absence they can only conceive of these events according to their own memory of things.  What’s more, since the “majority rules” notion is in effect, I’m understood to be the one who has the misunderstanding – not them.

What I’m sure they still do not realize is, the problem wasn’t what was said, but their inability to acknowledge my feelings.   The response, “I didn’t mean it that way” always came up.  Family events, where I had to “fake normal” also became a struggle, since my unique history made this impossible.  In the end, during this difficult time, my therapist warned me things get worse before they get better. (If you’re wondering, things are much better now). However, this time was a crazy-making experience.  I endured much exquisite chandelier pain in my interactions with them.  Their responses to my feelings mirrored experiences of childhood bullying and an emotionally abusive relationship. In both cases, when I was hurting, their reaction was either ignore me or utilize those “but” statements to indicate I implicity caused my own pain.  This was too much to bear with family. While not intentional, it was still exquisitely painful.  What follows is an email I sent to my family which summarizes my feelings during this time period:

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and the plot thickens….

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With the above as the relational backdrop, I’d like to share how the misunderstanding referenced in these emails came to a conclusion. Things quickly got ugly for me when my mother sent me an email that included the above quote. I felt an immediate rush of anger at the fact that my mother required an apology from me when it seemed we were both saying things “that weren’t meant”. In my response to my mother’s request for an apology, I responded in email by describing events just prior to this whole exchange.  Interestingly enough, a similar “misunderstanding” came up between Dorene and I during Josiah’s B-Day just prior to this series of email exchanges. It was as a result of similar innocent comment – like the one in my email.  I was talking about the childhood bullying Josiah was going thru and how it reminded me of my own experiences. I shared my concerns since it triggered some old unresolved hurts and I was having difficulty coping.  Trying to get through my day meant attempting to keep chandelier emotions at bay. When I shared this, Dorene said what she felt was an innocent reflective observation – and mentioned how what happened was a byproduct of my own doing.  Stating, that I chose to be a victim, she believed I could have made more efforts to make friends.   In sum “I just needed to get over it.”  Mind you – like my email – it was intended as a casual observation regarding events in our childhood. This comment – while not intentionally hurtful, lacked compassion. What’s more, my emotions were glossed over, leaving me with the triggery blow of unacknowledge hurts to work thru as the evening dragged on.

As the day progressed I tried to shake it off. I tried to enjoy Josiah’s birthday – (and did for the most part). However, my emotions became overwhelming in the final hours of our get-together. My husband pulled me aside and asked me what was wrong.  As the pain kept building up, I reached a point where I could no longer ignore my feelings.  I quietly bawled like a baby with him for 30 minutes before returning to enjoy the ongoing festivities. Concerned, Kelly told me I should talk to my parents – because he thought it would be a good way for them to understand where I’m coming from. I then talked with them about it, simply to help them understand my hurt – and the nature of it.  They listened quietly and attentively, but chose to “stay out of it”.  No need for apology from my sister arose in the conversation.  With this in mind, what follows is an excerpt of my email response to my mother’s request for apology:

“You see I’ve buried it so deep, I’m not sure the family knows the extent of it. I’m also able to hide it from myself – so I’m assure I’m not aware of the extent of it either. Nonetheless, while hiding it from you guys, causes less drama – it hurts me. I need to get beyond it and heal it. This means speak my truth, owning it, and understanding how I created it that way.”

Now What???

Sometimes misunderstandings must be managed if they cannot be resolved. This series of events is reflective of an ongoing dynamic in my family of origin which I’ve learned to manage, (so it doesn’t drive me crazy). You see, these events aren’t just about a series of incidental occurrences.  Underlying these occurrences are repetitive patterns set at auto replay. By asking me to apologize for a comment made in an email, my mother is expressing acknowledgement of Dorene’s feelings. By responding to my own hurt feelings with a “just get over it” sentiment, I am left feeling like my emotions don’t matter.  This response of “get over it” implies a negative judgment of my feelings – as unworthy of compassion.  Jumping to my sisters aid when our misunderstandings cause her hurt feelings pains me to see.  Why is it I get the stoic and observational approach that expresses a desire to “stay out of it” – at those moments I needed them most???

By asking me to apologize to my sister in this email, I felt like I was asked to respect her perceptions of reality, when she was unwilling to do the same.   Keep in mind underlying these hurts are missing pieces we both need to resolve in order to achieve clarity.  In this respect, both perceived narratives of childhood events warrant examination. What’s so frustrating about repetitive experiences like these woven thru the familial dynamics, are the baggage they leave me with.  When my emotions are treated with a stoicism and implicit assertion that “no one can truly understand anyone else’s feelings” this really stings.  My other favorite is the family’s claim that “If valid means true, why should I acknowledge feelings based on misunderstanding (i.e. incorrect info)?”   Given the nature of the traumas woven throughout my childhood, listening with an intent to understand and provide a compassionate ear is essential.  I can only interpret refusal to do so as matters of unwillingness rather than incapability.  What follows is my final response to my mother’s request for apology:

“SHOULD I HAVE APOLOGIZED? if it means being made to feel I’m denying my reality – NO!!!. Sadly, I hate to say it but since you are all very ignorantly unaware of my reality that’s how the apology feels – to me.”

References

Brown, B. (2015).  Rising strong.  Random House:  New York.
McKay, M., Wood, J., & Brantley, J. (2007).  The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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