Image via Wikipedia

Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes.

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how.

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself.

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way.

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008).

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process.

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

Researchers have added another piece to the puzzle of Post Traumatic Stress Disorder. It seems that the memory of the trauma is burned into memory involving the amygdala. But unlearning the experience is not so simple. The amygdala becomes chronically over reactive. One can be taught to be more calm in certain circumstances, but then it won't work in other similar situations.

One of the treatments that is being used by the VA is virtual re-esposure to battle via video. But this will have limited usefulness using the simple "extinction" paradigm.

The idea of extinction is to gradually introduce simulations of the traumatic event, slow enough to minimize the provoked anxiety. For example, imagine being traumatized by the sound of incoming mortar rounds. A treatment program might gradually turn up the volume of a similar sound until the recovering soldier can hear the noise without a strong emotional response. This new research demonstrates that this approach may have limited usefulness, and may not at all effect the response if the soldier re-experiences incoming mortar rounds. The new learning may be limited to the location the treatment was done and to the simulated sound.

Thus it would seem to indirectly support a previous research that found the technique called "prolonged exposure" more effective than historically standard treatments. In prolonged exposure, the stimulus is introduced with less consideration for the comfort of the client. After the client is virtually flooded with similar stimulation and the resulting emotions while being offered support, and counseling regarding his feelings and survival. This approach may promote a more adaptive skill related to surviving all kinds of trauma. Theoretically, the resulting raised threshold for a panicked response may be applicable to more situations less similar to the traumatic event.

Anxiety Insights

It is estimated that nearly 15 percent of U.S. soldiers returning from Iraq and Afghanistan develop PTSD, underscoring the urgency to develop better treatment strategies for anxiety disorders. These disorders can lead to myriad problems that hinder daily life - or ruin it altogether - such as drug abuse, alcoholism, marital problems, unemployment and suicide.

Functional imaging studies in combat veterans have revealed that the amygdala, a cerebral structure of the temporal lobe known to play a key role in fear and anxiety, is hyperactive in PTSD subjects. Potentially paving the way for more effective treatments of anxiety disorders, a recent Nature report by Denis Paré, professor at the Center for Molecular and Behavioral Neuroscience at Rutgers University in Newark, has identified a critical component of the amygdala's neural network normally involved in the extinction (pdf), or elimination, of fear memories. Paré's laboratory studies the amygdala and how its activity impacts behavior.

Earlier research has revealed that in animals and humans, the amygdala is involved in the expression of innate fear responses, such as the fear of snakes, along with the formation of new fear memories as a result of experience, such as learning to fear the sound of a siren that predicts an air raid.

In the laboratory, the circuits underlying learned fear are typically studied using an experimental paradigm called Pavlovian fear conditioning. In this research model on rats, a neutral stimulus such as the sound of a tone elicited a fear response in the rats after they heard it paired with an noxious or unpleasant stimulus, such as a shock to the feet. However, this conditioned fear response was diminished with repetition of the neutral stimulus in the absence of the noxious stimulus. This phenomenon is known as extinction. This approach is similar to that used to treat human phobias, where the subject is presented with the feared object in the absence of danger.

Behavioral studies have demonstrated, however, that extinction training does not completely abolish the initial fear memory, but rather leads to the formation of a new memory that inhibits conditioned fear responses at the level of the amygdala. As such, fear responses can be expressed again when the conditioned stimulus is presented in a context other than the one where extinction training took place.

For example, suppose a rat is trained for extinction in a grey box smelling of roses, and later hears the tone again in a different box, with a different smell and appearance. The rat will show no evidence of having been trained for extinction. The tone will evoke as much fear as if the rat had not been trained for extinction.

"Extinction memory will only be expressed if tested in the same environment where the extinction training occurred, implying that extinction does not erase the initial fear memory but only suppresses it in a context-specific manner," notes Paré.

Importantly, it has been found that people with anxiety disorders exhibit an "extinction deficit," or a failure to "forget." However, until recently, the mechanisms of extinction have remained unknown.

I think it's probably a human trait that we seek the simplest solution to a problem even when more complex and proven methods are well known. Even scientists seem to do this, even in their area of study!

Our culture seems to have decided thousands of years ago that negative emotions are bad and should be avoided. Everywhere in the psychological literature is examples of researchers seeking to find ways to help people avoid psychological pain.

Has it occurred to anyone that psychological pain has a purpose? For those of us that believe we evolved to be human beings, we have to assume that most attributes that make us human in some way enhance our survival, or that trait would have been selected out of the gene pool. Negative emotions help us. I make that assumption and help people make sense out of their misery, rather than find ways to avoid it. Misery is the single most powerful motivation for change.

Here is a good example. Surviving a traumatic event involves recurring "flashbacks" of the trauma that persist for sometimes many years. So in keeping with the tradition of helping people avoid their "flashbacks", we have this report from New Scientist.

"It might be the case that people with memory disturbances have to gain some control over the memory representation by remembering it and trying a different emotional response to the memory before successful suppression," he adds.

A drug targeting specific brain regions might eventually boost the ability to suppress, said John Gabrieli, at the Massachusetts Institute of Technology, Cambridge, US.

For a mother haunted by the memory of her son's suicide, he said, "it is hard to imagine that you would ever get her to forget that the event occurred. But the more you could weaken the memory in any dimension, the better it would be."

Ok, lets try the assumption that flashbacks are somehow helpful. Just how is it helpful for the mother in the example above is haunted by memories of her son's suicide? It's a challenging stretch to the assumption surely. But how is it we would expect there be a way to somehow "forget" the memory? That seems impossible without brain damage and considerable collateral damage to other structures and abilities.

What is there in the psychological literature that might explain recurrent unpleasant memories? Recall that phobia is treated by "exposure", gradually introducing the anxiety or fear provoking stimulus while the patient tries to relax. There is good research to say this works pretty well.

What if the flashbacks were the human body's attempt to provide it's own crude exposure treatment? What if the patient were advised to sit with his feelings, talk about the experience with a trusted counselor and to make sense of the experience in his current life. Might this be a way to find meaning in the seemingly meaninglessness of traumatic event?

Indeed, there are examples of research showing how exposure therapy is effective for PTSD.

Here is an even sillier example.

Monitor on Psychology

So, again, this suggests that verbalizing an emotion may activate the right ventral lateral prefrontal cortex, which then suppresses the areas of the brain that produce emotional pain.

"[In talk therapy] we tend to focus primarily on content and enhanced understandings and changed understandings," said Lieberman. "But it's not entirely irrelevant that they all involve putting feelings into words."

Duh! Talk about being blind to anything not in front of your face!

Tragically high suicide rates among Iraq War Vets have been a topic of this blog before. More recent information in the press have been about high rates among Vets in Great Britain.

Now we may have some answers and a suggested course of action. A recent report by the Veterans Affairs Department's inspector general finds that at least one factor is that Veterans returning from Iraq and Afghanistan are at increased risk of suicide because Veterans Administration health clinics do not have 24-hour mental health care available.

Sometimes I forget that, unlike Minnesota, most states don't have 24 hour emergency mental health care. Here such care is manditory, required by state law and funded by a variety of sources, including Federal Medicaid, state grants, and county fee for service contracts.

It found that nearly three years after the VA adopted a comprehensive strategy of mental health care, services were inconsistent throughout its network of 1,400 clinics. Many facilities lacked 24-hour staff, adequate screening for mental problems, or personnel who were properly trained.

With about one-third of veterans reporting symptoms of post-traumatic stress disorder, it is "incumbent upon VHA to continue moving forward toward full deployment of suicide prevention strategies for our nation's veterans," the five-page executive summary stated.

The report comes as already-strained troops and veterans say they are suffering more psychological problems due to repeated and extended deployments to Iraq and Afghanistan. In a study earlier this month, a Pentagon task force issued an urgent warning for improved care, citing a strained health system.

In the VA's inspector general report Thursday, investigators echoed some of those concerns in citing a need for additional staffing and better training in VA facilities nationwide. It said about 1,000 veterans who receive VA care commit suicide every year, and as many as 5,000 a year among all living veterans.

Among the other findings:

-VA clinics and Pentagon military hospitals must improve their sharing of health information, particularly for patients who might return to active-duty status.

-VA should loosen criteria for inpatient PTSD care. Currently only veterans with "sustained sobriety" get treatment.

In a written response, Michael Kussman, the VA's acting undersecretary for health, concurred with many of the recommendations. He noted that the VA has recently installed suicide prevention coordinators in each medical center to better develop prevention strategies.

AlterNet has the best article I've seen in the media about PTSD and the Iraqi veterans. Unfortunately, the news is not good. The proportion of vets with PTSD is higher in this conflict than in any other previously monitored war. Suicide accounted for over 25 percent of all noncombat Army deaths in Iraq in 2006, that's double what it was in peace time and much higher than rates from Iraq War I and Vietnam.

With the VA reporting inadequate resources to treat returning veterans, slow response to those most at risk for PTSD: the National Guard and Reserve troops, and the continuing stigma of mental illness are greatly exacerbating the problem. Female vets are returning home with PTSD due to sexual trauma, too often allegedly perpetrated by fellow American soldiers.

There is some good news in all this. There is evidence that treatment is helpful to improving the quality of life of vets. Brief Cognitive Behavior Therapy can mitigate initial symptoms, but doesn't impact long-term prognosis. However, there is a promising new treatment called "prolonged exposure" that has demonstrated efficacy in a few studies.

Post-traumatic Stress Disorder is the result of subtle biological changes in the brain chemistry as a response to severe stress, which alters the way the brain stores memories. During a particularly intense episode, the body releases massive amounts of adrenaline, and the physiological alterations associated with the intense emotional reaction create memories that disrupt normal life.

The markers of post-traumatic stress include nightmares; avoiding reminders of the traumatic event; hyperarousal, a physiological response to stress that can lead to irritability and restlessness; and drug use and alcohol abuse. "Veterans screening positive for PTSD reported significantly more physical health symptoms and medical conditions than did veterans without PTSD. They were also more likely to rate their health status as fair or poor and to report lower levels of health-related quality of life."

Among soldiers who develop PTSD, "there was a strong reported relation between combat experiences, such as being shot at, handling dead bodies, knowing someone who was killed, or killing enemy combatants."

More than any previous war, the Iraq war is likely to produce the highest number of soldiers suffering from PTSD. There is considerable psychological distress associated with going into a country under the auspices of liberating a people, only to have them rise up against you, and it lingers long after the war has ended. Adding to the pressure is that many mental health officials believe that the nature of urban street fighting and insurgent warfare, coupled with heavy reliance on National Guard and Army Reserve troops, will result in higher rates of PTSD among this group of veterans than those in previous conflicts.

Another reason for the escalating mental health challenges is that while soldiers typically spent one tour of duty in Vietnam, troops are serving two, three and occasionally four rotations in Iraq. An additional challenge is the moral ambiguity of fighting a war without front lines, where the combatants are, or are dressed as, civilians. Many veterans are finding it difficult, if not impossible, to reconcile experiences such as shooting at civilians because they had failed to stop at a checkpoint.

"At least 30 percent of Iraq or Afghanistan [veterans] are diagnosed with PTSD, up from 16 percent to 18 percent in 2004," said Charlie Kennedy, PTSD program director and lead psychologist at the Stratton VA Medical Center. The number of Iraq and Afghanistan veterans getting treatment for PTSD at VA hospitals and counseling centers increased 87 percent from September 2005 to June 2006, and they have a backlog of 400,000 cases, including veterans from previous wars. The most conservative estimates project that roughly 250,000 Iraq war veterans will struggle with PTSD. MORE

Post traumatic stress disorder is an anxiety disorder caused by experiencing intense trauma where life is threatened in terrifying ways. This disorder has life long consequences as I've talked about before. AP Wire reported on a former Senator who is a Vietnam vet who has had a recurence of PTSD because of repeated exposure to images of war in Iraq.

Former U.S. Sen. Max Cleland, who has battled bouts of depression since losing three limbs in Vietnam, is being treated for post-traumatic stress disorder. Cleland, who represented Georgia in the Senate from 1997 to 2003, said he believes the condition - cases of which are increasing rapidly among Vietnam war veterans - was in part triggered by the ongoing violence in Iraq.

"I realize my symptoms are avoidance, not wanting to connect with anything dealing with the (Iraq) war, tremendous sadness over the casualties that are taken, a real identification with that. ... I've tried to disconnect and disassociate from the media. I don't watch it as much. I'm not engrossed in it like I was," Cleland said in an interview with WSB-TV in Atlanta. He said he feels depressed, has developed a sense of hyper-vigilance about his security and has difficulty sleeping, the television station reported.

New Orleans was a social service nightmare before Katrina. It's mental health infrastructure was likely underfunded like many other inner city services. But the results of the devastating trauma of Katrina spawned flood, people are stressed beyond their ability to cope. Psychiatric beds have shrunk by 80% while many professionals have abandoned the city along with half it it's residents. It's often those without alternatives who are left to return, to conditions worse than they ever were.

New Orleans needs licensed mental health professionals. Looking for meaningful work? Here is your opportunity.

Newsweek

[...]the state-funded Central City Mental Health Center has chosen a more practical way to mark the anniversary of the nation's biggest natural disaster--one that may well be the most fitting. Free testing for depression and post-traumatic stress disorder (PTSD) will be conducted all day on Aug. 29, punctuated by a lunch at which overburdened staff members will reminisce about the tumultuous year that was.

[...]the most serious health problems directly attributable to the storm have been mental, not physical. In the four months between Aug. 29 and the end of 2005, the Orleans Parish coroner's office "conservatively" estimates that the suicide rate tripled.

[...]In April, a survey conducted by the local Council on Alcohol and Drug Abuse found that one in seven people were drinking more to deal with stress; another study, by researchers at the University of New Orleans, found that "symptoms of depression have at a minimum doubled"--and its responders were all homeowners and apartment dwellers, not residents of FEMA trailers whose unhappiness levels must surely be higher. Those not medicating themselves with alcohol are turning in greater numbers to antidepressants: sales of psychiatric drugs have held steady at their pre-Katrina level, despite the fact that less than half the population has returned.

As the stress has mounted, the infrastructure to deal with it has all but collapsed. "We are facing crisis," says Dr. Andrew Calhoun, the medical director of the Central City Mental Health Center. "We need more doctors, more social workers, more hospital beds." Pre-Katrina, the parishes of Orleans, Jefferson and St. Bernard boasted 480 psychiatric beds. Downtown New Orleans's Charity Hospital boasted 100 alone; now there are 80 total and only 27 psychiatrists. When patients are suicidal (and the number of them at Calhoun's clinic has risen to as many as five per month, up from some pre-Katrina months when there were none at all) Calhoun must refer them to a hospital emergency room where they may wait up to three days before a nurse can find them a bed somewhere in the state.

Dr. Jeffrey Rouse, deputy psychiatric coroner for Orleans parish, agrees with Calhoun's assessment. When people are suicidal, homicidal or too mentally ill to take care of themselves, authorities bring them to Rouse with orders for protective custody. "When a family member comes to us, they are desperate, and I have to look them in the eye and tell them that my best option--my only option--is to have them brought to an emergency room where there may or may not be a psychiatrist on duty," he says. "The travesty of the whole damn thing is that the federal government sent all these SAMSA [the federal government's Substance Abuse and Mental Health Services Administration] counselors down here at tremendous cost, and meanwhile Tulane University Hospital has had to cut its psychiatry department in half. [Louisiana State University] cut its psychiatry department in half. It's happening all over town. We got all these volunteer grief counselors, and meanwhile the mental-health structure and personnel have withered on the vine."

Dr. Calhoun, whose office window is still covered with plywood from where it was broken by looters after the storm, says that in a perfect world he would like a new building (the roof leaked for years before Katrina), but that even incremental improvements would help the system enormously--new clinical social workers to replace the four he lost, for example. His facility has a case load of 3,000 patients, and 40 to 70 people--from walk-ins and those needing medication refills to patients scheduled for individual or group counseling--are seen per day. The majority of pre-Katrina patients were people with serious illnesses like schizophrenia and bi-polar disorder. Now, "in addition to the chronically ill," says clinic manager Sybil Wilson, "we have lots more cases of anxiety, grief, depression. Substance abuse has soared." Says Dr. Calhoun: "We used to be more selective about who we took and reserved our facility for those who had the most critical needs. But since there are now so few alternatives, we pretty much take all comers."

By some estimates, a third of the city's inhabitants are suffering from post-traumatic stress disorder, but Dr. Calhoun thinks those numbers do a disservice to those still struggling through. "The fanning of the flames of PTSD are not necessarily beneficial to the community," he says. "It is better if we look at the people here as survivors, who have persevered and who are still plugging away." Besides, it's hard to have PTSD when neither the trauma nor the stress have abated. "I liken it to a marathon," Calhoun says. "Right at the beginning you're moving along--and in the beginning people were gutting houses, getting on with things. But at one point you hit the wall, and we are definitely in the wall. You guess you're getting somewhere but it doesn't feel like it; the end is miles and miles away and you're really tired. You'll probably get there but it's so far away you can't see it."

What does he tell people to counter such a bleak outlook? He tells them to "expand their focus. It sounds corny but everybody needs to come together and pitch in and work. People who feel stressed in this environment are not sick. It's normal to look at what needs to be done to put this city back together and be unhappy. But we don't all need to be patients. We need to support each other."

A study published in the Journal of American Psychiatry has confirmed what clinicians have known for a long time, PTSD is a lifelong disorder with a varying course across sufferers. Some have an acute onset, an immediate stress reaction that ebbs and exasserbates indefinitely. Some have no symptoms for many years, then triggered by witnessing another traumatic event, even from afar, symptoms overwhelm the individual. Many veterans of various wars were overcome by witnessing the 9/11 attacks on television, some showing symptoms for the first time.

PTSD is a tragic aftermath of war and other trauma. Trauma survivors and our veterans need years of monitoring and professional assistance.

Reuters

At year 1, subjects in the combat stress reaction group had a 10.57-fold higher odds of meeting PTSD criteria than the comparison subjects. At years 2, 3 and 20, the odds were reduced to 5.15, 5.41, and 3.09, respectively. Those with a combat stress reaction also had significantly more PTSD symptoms at all four time points.

The authors observed that 19.8% of the combat stress reaction group and 61.4% of the comparison group did not meet PTSD criteria at any of the four tests. However, members of the comparison group were more vulnerable to delayed onset. Both groups exhibited a fluctuating course of relapses and remissions. Veterans in both groups were subject to recurrent thoughts and nightmares about the war. Loss of interest in social activities, feeling remote from people, hyperalertness, sleep difficulties and intensification of symptoms follow experiences reminiscent of the war were also common. Other symptoms, such as survivor guilt and constricted affect, were less common. While the number of symptoms dropped considerably in the third assessment, they rose again at year 20.

"The chronic nature of PTSD renders trauma victims vulnerable for life, and midlife is a particularly high-risk period for either delayed onset or reactivated PTSD," Drs. Solomon and Mikulincer report. They suggest that the many stressors of midlife, from the death of friends and illness, to the loss of structure after retirement, "bring down some of the protective shields that trauma survivors have against being flooded by memories."

Hat tip to Corpus Callosum.