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Depression
Anxiety Disorders:
Agoraphobia
Generalized Anxiety Disorder
Panic Disorder
Obsessive-Compulsive Disorder
Sociophobia/Social Anxiety Disorder
Post-Traumatic
Stress Disorder (PTSD)
TRAUMA
AND DISSOCIATION:
What is trauma - small t and big T
Complex PTSD
Dissociative Disorders
Ways of dealing with emotional pain
Flashbacks need Grounding Skills
Case Studies
http://www.anna
foundation.org
Web Site Links to Tomkins Affect, adolescent
mood disorders,
depression and anxiety disorders
Reference
manual for Sociophobia: "Diagonally Parked in a Parallel Univers"
by Signe A. Dayhoff published by Effectiveness-Plus Publications
2000 - an excellent resource for social anxiety
Reference
for BDD
"Feeling Good About The Way You Look" by Sabine Wilhelm
2006
Reference manual for OCD:
"The OCD workbook" by Bruce Hyman and Cherry Pedrick published
by New Harbingerís Publication 2005
Reference
manuals for PTSD
"The PTSD workbook" by Mary Beth Williams and Soili Poijula,
published by New Harbinger Publications, 2002 - this book does a
good job on explaining complex PTSD and dissociation
"Growing beyond Survival" by Elizabeth G. Vermilyea 2000
published by the Sidran Press. Their web site: www.sidran.org is
an excellent source re books on trauma and PTSD
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The
key in any psychotherapy is to learn how to identify and pay attention
to our body sensations in order to help us work with our primary
feelings and avoid the secondary feelings which tend to go round
and round and process nothing. If feelings are really overwhelming,
such as occur in children who are hurt badly with no one to turn
to for comfort, the feelings are often ‘dissociated’,
repressed, not expressed, and become hard to contact. And yet the
primary emotions are essential for helping us to ‘process’
events which have hurt us in our past - both recent as well as distant
past. Learning to process feelings helps put painful past events
truly in the past where they can serve as lessons from which we
are given gifts, rather than nightmares.
DEPRESSION
What is depression?
Depression is a clinical diagnosis which consists of at least FIVE
out of the following NINE criteria. It must include one of the first
two symptoms which must
last at least over a
2 week period.
1.
Depressed mood
2. Interest - a lack of interest in doing the usual activities the
person has enjoyed in the past.
3.
Sleep - either too much or not enough
4.
Feelings of worthlessness or excessive or inappropriate guilt nearly
every day (not merely self-reproach or guilt about being sick).
5.
Energy - is low
6.
Concentration - diminished ability to think or concentrate, or indecisiveness,
nearly every day
7.
Appetite is depressed or may be elevated
- there may have been weight loss or weight gain.
8.
Psychomotor activity - by this I mean, speech and movement is very
slowed down. On the opposite side some folks are very restless and
can’t sit still
9.
Suicidal thoughts, sometimes suicidal plans, and a sense of hopelessness.
Severe depression with weight loss and lack of sleep is really best
treated initially with medications. Psychotherapy along with medication
in the form of Cognitive Behavioral Therapy (CBT) has been shown
to be very effective and helps prevent relapse.
A
CASE STORY
Maria is a 22 year old college student who complains that she has
been feeling depressed the last 3 months. She has lost 15 lbs without
intending to, her appetite is poor, she is not participating in
the team sports she used to enjoy, she is having trouble with her
school work because she is both exhausted and cannot seem to read
as she used to. She cannot make decisions. This is very unlike her
– she has never had problems with depression before. After
education re the treatment of depression, she consents to a course
of anti-depressant medication and brief (over 3 month period) psychotherapy
. She does very well – she takes the medication over the following
year to help prevent relapse, learns how to do CBT and is in complete
remission.
ANXIETY DISORDERS
ANXIETY consists of the worry and severe panic causing a state of
hyperarousal and what I mean by this is that when a person becomes
stressed to the max - the heart rate goes up, you breathe more quickly,
you may sweat, feel shaky, dizzy and experience a lot of frightening
physical symptoms.
There
are six major types of anxiety disorders:
1. Agoraphobia
2. Generalized Anxiety Disorder
3. Panic Disorder
4. Social Phobia (or Social Anxiety Disorder)
5. Obsessive-compulsive disorder
6. Post-Traumatic Stress Disorder (PTSD)
1.
AGORAPHOBIA consists of avoidance about being in places or situations
from which escape might be difficult (or embarrassing). It typically
involves situations where one is outside the home alone and feels
trapped or panicked. This deep anxiety creates a barrier to seeking
treatment and can lead to complete isolation in one's home, even
for years. Typically avoidance makes the anxiety disorder worse
- and requires active treatment to overcome it.
2. GENERALIZED ANXIETY DISORDER happens
to the worrier – a person who has difficulty controlling worry
and as a result has many physical symptoms, such as ‘I can’t
sit still’, easily fatigued, difficulty concentrating or going
blank, irritability, muscle tension, sleep disturbance.
3. PANIC DISORDER – this happens to
a person who misinterprets and then catastrophizes the physical
symptoms of anxiety, which send the person off to the emergency.
He is then advised there is ‘nothing wrong’. This is hard
for the person to understand because the symptoms are very real.
Panic Disorder symptoms are related to a genetic predisposition
that makes the body overreact in this way to stressful situations.
It often takes several trips to the local emergency before you and
your doctor figure out what is going on. Then the treatment needed
may include medication – but much better yet is a form of treatment
called Cognitive Behavioural Treatment (CBT). Often it is both.
PANIC
DISORDER/CASE STORY:
She had finished everything at home, packed lunch for John and the
kids. Dinner prep ready. Running late, as usual en route to work.
Tough drive each day - over three hours round trip. First meeting
at nine, new client lunch. Car needs service. Two extra kids for
dinner and swim team. Suddenly, a bullet of fear, a jangle of nerves,
dry mouth, heart racing dizzy, can't see right, short of breath.
Judy lurched the car over to the side of the road. A heart attack?
A stroke? What's wrong? Can I get to the nearest hospital? I'm stuck
here alone. I think I'm going to die.
This was the beginning of a long road for Judy. She began to fear
driving. She left her job. Tried to find one close to home. She
avoided the car, feared repeat incidents. Her established patterns
fell apart as she tried to understand what was happening to her.
Panic disorder is part of our biochemistry. Some people are extra-sensitive
to life stressors. They are biochemically keyed up when life's demands
go too far. They will misinterpret and catastrophize panic symptoms,
which in turn make the symptoms more fearful, and leave Judy, and
many men and women who suffer this way, extraordinarily vulnerable.
After three months of medication and ongoing cognitive behavioural
therapy, Judy is coming to grips with her stresses. She has restructured
her thinking and understands the reasons behind her frightening
experiences so that this no longer interferes with her life.
4. SOCIOPHOBIA is the most
common anxiety disorder and the third most common disorder after
depression and alcoholism This is a form of shyness in which people
begin to avoid social interaction or contact with the public because
of fear of being judged. For someone with Sociophobia, social situations
cause severe anxiety symptoms and so it is understandable that the
person would try to avoid these situations. Unfortunately the more
the person avoids, the worse the symptoms become. CBT is very effective
treatment for this problem – and requires exposure to situations
previously avoided to resolve the situation.
Body
Dysmorphic Disorder (BDD) is very similar to Sociophobia. Here,
the focus is on a particular part of the body. BDD can lead to Agoraphobia.
Note reference to Sabine Wilhelm's book.
SOCIOPHOBIA/CASE
STORY:
Fat ran in her family. Dora was always aware of eyes on her mom
and dad and brothers and her. Fat. Ugly. Lazy. That's what those
eyes said. She married and had her own children. Being pregnant
made it ok to be fat - but this was followed by times of debilitating
fatigue. More and more, she wants to stay hidden. Stay in the car.
Go shopping when the store might be empty. Die inside if she saw
someone she recognized. Over time, she'd avoid picking up the phone
or answering the door or making the most basic personal appointments.
Social occasions were agonizing. She didn't want to talk to anyone,
because in their eyes she knew what they were thinking about her
and the humiliation made her feel sick inside. She increasingly
felt caged in her own body.
5. OBSESSIVE COMPULSIVE DISORDER
is an inherited disorder in which there is a bad circuit in the
brain making one think over and over and over thoughts which may
be about harming others, about germs and contamination, about keeping
order, about worry if you have done things like turn off the stove
or lock the door. Because of the fear of the thought becoming action,
there is often either a ritual action to avoid the feared thought
becoming reality (such as handwashing, or checking, or spending
an inordinate amount of time cleaning and organizing or being overly
attached/hoarding things) or avoidance of any situation that the
person associates with OCC thought. Unfortunately avoidance makes
it worse and as a rule professional intervention using CBT is required
– although there are readily available manualized versions
of treatment as there are for all anxiety disorders.
OBSESSIVE
COMPULSIVE DISORDER/CASE STORY:
The good news is that OCD is 85% treatable. Living with OCD is agonizing.
Typically, people hide their symptoms, trying to live with them,
thinking that "telling" will condemn them to be considered
crazy.
Susan's symptoms started following a period of depression. She had
continuing thoughts that she might have hurt someone. These fears
progressed to murderous thoughts and repetitive dreams of chopping
up bodies. Her dreams were like a loop in her brain, that she couldn't
get rid of. She was afraid to fall asleep. She started to live her
days in fear of acting on these thoughts - that she actually could
and would hurt someone - by isolating herself.
Cognitive Behavioural Treatment (CBT), following a set manualized
step-by-step therapy, has helped Susan realize that a thought does
not necessarily equate with an action. Her dreams and fears are
the result of OCD - a faulty electrical circuit in her brain. With
medication + CBT, her life is back on track.
6.
POST-TRAUMATIC STRESS DISORDER This disorder occurs about 1/3rd
of the time in people who experience a life threatening event -
or in the case of children, an event (usually many events) which
overwhelm your ability to cope. As a result, whenever you talk about,
think about, or are reminded of the event(s) either with an obvious
trigger or one related in some way to the original event, you have
a flashback. As a result you avoid thinking of the event and avoid
situations which might serve to remind you of the event. Your world
becomes smaller and smaller. In avoiding the overwhelming emotions
that accompany a flashback, you tend to numb all feelings, including
pleasurable feelings. As well, there are signs of excess arousal
such as a hyper startle reflex, difficulty sleeping, and anxiety.
If these events occurred in childhood, the symptoms of hyperarousal
can be experienced since childhood.
Big T Trauma. WHAT IS TRAUMA?
Trauma is an event or events that overwhelm your ability to cope.
While a ‘traumatic event’ by definition is witnessing
or being in a life threatening situation, more recently the definition
has broadened to include the situation children find themselves
in when they are neglected and abused by those who are supposed
to be there to protect them.
TRAUMA/CASE
STORY:
It is painful to be in the same space with Vic. Once a loving, kind,
and caring man, he became really sick. A lifetime of difficulties,
starting from childhood, has left Vic incapable of coping with the
demands of his life today.
At a time when his job was challenged, his wife was conducting an
affair with a close family friend, his teenagers were in increasing
trouble at school and in the neighbourhood, Vic was involved in
a four- car crash. Over the months that followed, Vic blamed himself
for the accident, though visibility, road conditions and three other
drivers were key players in the accident. The accident was the crushing
end to Vic's ability to function. He suffered a character structure
collapse - becoming the reverse of what he used to be as a person.
A man who had always been unflinchingly responsible to work and
family, who had been capable and caring in his personal and community
life, now believes that he is lazy, unable to do anything right,
frightened of sounds, willing to take blame and be blamed for everything
that goes wrong. Two years after the accident, his work is over,
his wife has abandoned the family, one son is in jail. He sits in
a room, hunched in a heap, staring at a spot in the distance, unable
to make eye contact.
Slowly, through therapy, he comes to understand that the man he
used to be has not just evaporated. He is starting to connect. He
remembers to eat, to make and keep personal care appointments. A
couple of close friends have helped to draw him out. He is starting
to understand the deeper wounds of Post Traumatic Stress, the ones
that remain after the bones and cuts of the accident are long healed.
Small
‘t’ traumas, while not life threatening, are often
repetitive in childhood and can be not only acts of abuse like verbal,
physical and sexual violence either perpetrated on the child or
witnessed by the child. Perhaps even more important are acts of
omission, neglect of a child's needs- and by this I mean things
that are not done and need to be done for optimal care of the child.
Often needs of a child by a caretaker can be excellent for one stage
of development but poor at another stage. This is type of treatment
in childhood is responsible for misinformation about oneself and
the world, and is responsible for the quirks in the development
of our character/personality structure as we grow up.
Repetitive childhood traumas and neglect are particularly malignant
and can lead to a disorder that the experts in the field of trauma
call complex PTSD or disorders of extreme stress, as well as Dissociative
Disorder, a group of common disorders poorly understood by some
mental health workers.
COMPLEX PTSD OR DISORDERS OF EXTREME STRESS
This
is a very important new way of looking at what happens to children
who have little power in this world and so are particularly at risk
for developing this disorder. It is a very common disorder which,
to date, has not made it into the Bible of psychiatric diagnosis
called the DSM-IV – and it is felt that when it does, it could
dramatically change the face of psychiatric diagnosis and facilitate
treatment. When these traumas disrupt the normal development tasks
of childhood and adolescence there is a disruption in character/personality
structure.
Please
see these web sites for a complete description of this very important
concept, originally developed by Judy Herman. http://www.ncptsd.org/facts/specific/fs_complex_ptsd.html
http://www.caritas.ab.ca/Home/default.htm
DISSOCIATIVE
DISORDERS
What is dissociation ?
Dissociation is the ability of the mind to hide a memory, a
feeling, or a body sensation for a short or a long time. The mind
does this quickly when it feels that what is happening is too much
for us to handle. The mind acts like a light switch and turns off
all or parts of the event. It also keeps this event apart from other
information with which it would usually be joined. Dissociation
is a way for the mind to deal with the very hard things of life.
Dissociative
are very common disorders which result from repetitive traumas in
childhood which are hidden to patients and physicians alike and
difficult to diagnose without experience. Without the proper diagnosis,
effective treatment may not be possible. Medication is of limited
benefit to this group of disorders and hence psychiatrists often
do not treat this problem. I use a screening tool called the DES
in my practice which asks some questions concerning:
• memory,
• alterations in your perception of the world and yourself
(like feeling beside yourself or being an observer of yourself),
• confusion of who you are
• knowledge either directly or from friends and family that
you act very differently one time from another – this ‘switching
‘ in state occurs very suddenly at times of increased upsetness
and may cause lost time in your day.
• ‘Sneiderian symptoms’ which have been used to diagnose
schizophrenia – but are mostly symptoms of a dissociative disorder
and not of schizophrenia. These include questions about ‘made
thoughts, feelings and actions’ and by this I mean, thoughts
and feelings and actions which the person has no idea where they
come from.
DISSOCIATIVE
DISORDER (DID)/CASE STORY:
Karen switched back and forth between her multiple personalities,
literally in the blink of an eye. One part of this young woman was
good, nice and self-sacrificing - the sweet girl who always gave
in. Another part of her was vicious, aggressive, dangerous. There
were also parts that ranged from happy spontaneous child, to a very
frightened child. Karen suffered from multiple aspects of self.
Karen had a series of abusive relationships from the time she was
in her teens. She was regularly in and out of jail, the last time
after repeatedly stabbing her boyfriend in the supermarket, screaming
her father's name, as she attacked him, in fact doing what she had
wanted to do to her father since she was eight years old. Karen
had no memory at all of this period of time.
In DID, aspects of the brain psychologically separate from each
other, switch in seconds from one part to another, without transition,
a sudden, shocking, confusing change with absolutely no memory of
the switch.
Over
the year of therapy, Karen would swing in and out of phases, at
times accepting and believing the truth of her reality regarding
her other aspects of self, then yelling and denying them.
She is getting better. She now has a sense of self that includes
and welcomes all parts of self, working together in a cooperative
fashion, learning to appreciate the strengths of each part.
Her relationships with people have improved. She is able to stand
up for herself. She has worked with many of her troublesome memories
so that they are now a part of her story and are not coming as 'flashbacks'
(that is having a sudden sense that she is back in time and feeling
the trauma as intensely as she did back then). She is feeling some
joy in life and a has a sense of moving forward.
To read about DES go to
http://www.rossinst.com/des.htm
to read about the DDIS go to
http://www.rossinst.com/dddquest.htm
to access the Colin A. Ross Institute web page go to
http://www.rossinst.com/index.html
I am proud to say that Colin Ross is a psychiatrist and a
Canadian – - who left Winnipeg some years ago (Canada’s
loss) and helps manage three trauma institutes in the USA.
SOME MALADAPTIVE WAYS TO DEAL WITH
EMOTIONAL PAIN INCLUDE:
1. impulse disorders such a self-harm, cutting, hitting, or burning
oneself
2. self-blame which leads to chronic depression and chronic suicidality
3. abuse of drugs and alcohol, gambling and shoplifting to name
a few.
4. dissociation which includes:
• Memory gaps - the more traumatizing the event, the more likely
an event will be completely forgotten or partially forgotten for
a long, long time only to appear later as ‘flashbacks’.
’.
•. altered perceptions of the world – “it seems fuzzy
and out of focus”
• altered perceptions of self – “I feel beside myself
or I am an observer watching myself”
• switching to another aspect of self
•
impulse to run, fight, submit or freeze - These 4 impulses are very
important concepts for the trauma survivor to understand –
as part of the treatment focuses on developing, at a body level,
a more adaptable way of your body responding to triggers then passive
ones like submit and freeze which lead to re-victimization and re-enactment
in relationships with significant others,
WHAT
ARE FLASHBACKS?
This is the remembrance of a traumatic event, triggered by a smell,
or feel or situation related in some way to the original event,
which feels like it is happening right now. The emotional feelings
are very intense, the pictures are vivid, the smells and sounds
are there (although those around you are not aware of them). The
lack of the ability to stay in the here and now is both the problem
and the answer in gaining mastery over these overwhelming experiences.
With a flashback one is in a state of hyperarousal and the experience
of a flashback will therefore only retraumatize. Until you can experience
a traumatic event along with a third party during which your level
of arousal is maintained at a lower and safer level - the traumatic
event will remain unmetabolized and subject to reactivation by triggers
in the environment.
HOW
TO DEAL WITH FLASHBACKS: It
is important if you are alone when you experience a flashback to
ground yourself.
What
does GROUNDING mean?
GROUNDING is a way to remind yourself that you are here in the present
and not there in the past like your brain is fooling you into thinking.
Thus you must be very mindful of the things around you when you
are experiencing a flashback by doing such things as noticing what
is in your surroundings: the sounds, the sights, the smells, the
tastes, and the feelings of sensations in your body and impulses
to fight, run away or submit and freeze.
To
do this I tell my clients to:
1. Look around and say out loud name 5 things you see, then 5 things
you hear, notice the smells in your environment, take a drink or
suck on a candy or an ice cubes and note 5 things you feel in with
your body.
2.
Put your feet flat on the floor and feel the floor. Rock on your
bottom in your chair.
3.
You can put your arms out against a cool wall or floor.
4.
Do anything that brings you back to the present. You might carry
a card in your pocket with your name, year and other things which
you find work to bring you back.
5. It is also helpful to tell close friends or family members how
they might help you when you have one. Often they want to touch
you and it is important usually to tell them not to touch you as,
in a flashback state, you may confuse your friend with the perpetrator.
They can talk to you in a soft voice reminding you of where you
are, who they are, what year it is, how old you are.
Ideally you would not have any spontaneous flashbacks at all because
each flashback is a painful re-occurrence of the original event
and only serves to re traumatize like a needle stuck on a record.
When a person has complete or partial memory loss of the traumatic
events, they will later in life have these very disturbing flashbacks
or vivid nightmares and this will often be the time at which the
person will seek treatment.
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