Wednesday, June 19, 2013

Julian Ford, Ph.D. - PTSD Becomes (More) Complex in the DSM-5


Julian Ford is one of the experts in the field of complex PTSD (an as yet un-approved diagnosis in the DSM, and not for a lack of effort). Over at his Psychology Today blog, Hijacked by Your Brain, he has posted a two-part examination of the changes to the PTSD diagnosis in the DSM-5.

I like the addition of the dissociative subtype for PTSD. The research suggests that 15-30% of those who have PTSD have persistent dissociation as a key feature. This sub-type is very strongly coorelated with childhood abuse and neglect, which is where the notion of complex PTSD comes from - research has shown that of those who develop PTSD following an adult experience of trauma (war, rape, other violent crime, natural disasters, and so on), there is also a strong correlation to childhood abuse and neglect.

When we are abused, neglected, belittled, and shamed as children, we do not develop the resilience necessary to get through traumatic events without serious complications. This is not a perfect cause and effect, but the link is clear and there are piles of research in support of this thesis.

Dr. Ford, along with Jon Wortmann, is the author of Hijacked by Your Brain: How to Free Yourself When Stress Takes Over (2013), after which the blog is named.

About the Author:
Julian Ford is a Professor of Psychiatry at the University of Connecticut School of Medicine and Director of the University of Connecticut Health Center Child Trauma Clinic and Center for Trauma Response Recovery and Preparedness (www.ctrp.org), the creator of the TARGET© treatment model for adult, adolescent, and child traumatic stress disorders, and CEO of Advanced Trauma Solutions, Inc., the exclusive licensed provider of the TARGET© treatment model.
Ford is also co-author of Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach (2012, with Christine A. Courtois) and co-editor (along with Courtois) of Treating Complex Traumatic Stress Disorders (Adults): An Evidence-Based Guide (2009).

PTSD Becomes (More) Complex in the DSM-5: Part 1

Heading in the right direction, but still not as complex as the brain

Published on June 11, 2013 by Julian Ford, Ph.D. in Hijacked by Your Brain


The diagnosis of posttraumatic stress disorder (PTSD) has undergone much more than a minor tweaking or superficial facelift in the American Psychiatric Association's DSM-5. This guidebook to psychiatric diagnoses, released in May, now defines PTSD as a trauma and stressor-related disorder, not a disorder primarily of anxiety alone. Like our understanding of the brain and behavior, PTSD has become much more complex—and for millions of trauma survivors who have experienced difficulties that go well beyond the symptoms included in PTSD up to now, and the tens of thousands of clinicians who provide treatment to affected trauma survivors, the change is long overdue, but extremely welcome.

Bottom line, PTSD is now described as a disorder of persistent reactivity in all of the domains of self-regulation, and not just troubling memories and chronic anxiety[1]. Distressing memories of past traumatic events and intense stress reactions to reminders that occur in current life continue to serve as the cornerstone of PTSD.

Now, however, these forms of "intrusive re-experiencing" of traumatization are understood as playing out across the full range of ways in which we regulate ourselves: emotions, body functions and health, thinking, motivation, behavior, relationships, and ultimately our sense of self or identity.

Trauma doesn't just terrify or horrify us—it also forces us to make profound biological adaptations in how our brain operates. Basically, the brain is a control system that keeps our body functioning properly. In other words, the brain regulates how our body functions to keep us alive, and when our body is safe and working well, the brain extends its efforts to the "higher" functions that enable us to not only survive but also to become a conscious individual—a self or an identity that makes each of us and our lives unique and not only pleasurable (or tolerably painful) but meaningful.

When the brain detects serious threats to our bodily survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and literally hijacks the rest of the brain's operations in order to put all systems in emergency mode until the threat is escaped or overcome.

This might seem like a simple shift in brain functions that leads to a temporary fight-flight reaction or adrenaline rush that is intense but quickly passes. And in many cases, both with ordinary stressors that are not traumatic threats to our lives as well as with traumatic survival threats, the alarm reaction in the brain does rapidly subside. We’re left somewhat shaken or jangly, but no worse for the wear with a brain that re-sets automatically to its normal modes.

However, as we've described in Hijacked by Your Brain, PTSD is what happens when the brain's alarm system doesn't automatically or rapidly re-set itself. When the brain's alarm continues to signal danger even though safety has been restored, the brain's overall functioning remains in an altered state that is the chronic stress response. Survival trumps self-regulation in this case: staying alert and ready to react in fight-flight mode to the next assault or betrayal takes precedence over sorting out our emotions and thoughts, taking care of our body's health, considering our core values and who we aspire to be.

In service of a commendable goal, survival, the brain's alarm system has hijacked the "higher" operations of the brain itself, keeping us alert and ready for action, and therefore alive. In this state, however, life becomes a constant struggle that involves unbearable tension and ultimately emotional as well as physical exhaustion (hence the depression and physical health problems that so often occur with PTSD).

People living with PTSD, therefore, are not just troubled by terrible memories, worries, and anxieties. More fundamentally they have high functioning brains that have become trapped in survival mode. That's why PTSD is complex, because it's about a fundamental change in how the brain (and body, and mind) are operating. It is not a disease, and not an injury to the brain (although when this has happened as well, such as when the survival threat is a blast explosion or another severe physical injury to the head, the combination of PTSD and traumatic brain injury creates additional major challenges).

How can someone re-set a brain's alarm that's stuck in PTSD (survival mode), so that self-regulation can be restored? That is the $64,000 question, which I'll tackle in Part II of this series on the implications of PTSD becoming defined in a way that is appropriately more complex in the DSM-5.

Hijacked by Your Brain blogs are co-authored with Jon Wortmann. Visit our website at www.hijackedbyyourbrain.com. You can follow us onfacebook or join us on twitter @hijackedbook.

[1] http://www.tandfonline.com/doi/abs/10.1080/15299732.2013.769398#.UaZbsuCb8Rk


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PTSD Becomes (More) Complex in the DSM-5: Part II

Recovering from (Complex) PTSD by Regaining Self-Regulation

Published on June 16, 2013 by Julian Ford, Ph.D. in Hijacked by Your Brain

In the DSM-5 released in May, PTSD just got more complex. It added a new symptom domain of "negative alterations in cognitions or mood," and expanded the hyperarousal domain to include aggressive, reckless, or self-destructive behavior. It also added a sub-type characterized by dissociation (drastic reductions in physical arousal and conscious emotion and thought). These changes reflect advances in science and clinical practice, which echo what trauma survivors have been saying for decades (if not centuries): PTSD is a radical shift from normal self-regulation to being trapped in a constant state of alarm.


To understand, and recover from, PTSD, it's essential to understand what the brain and body do to "self-regulate" under ordinary circumstances—because this is what's lost in PTSD and must be regained in recovery. Self-regulation is a delicate and complicated balancing act in which the brain and body constantly adjust to maintain a balance between mobilizing (being highly activated) and re-grouping (down shifting into less activated states).

Mobilization is essential to experiencing pleasurable excitement, enthusiasm, and achievement. But too much mobilization for too long leads to tension, frustration, recklessness, and even self-harm. Similarly, when the body and brain re-group, this can produce pleasurable and healthy states of relaxation, calm, and mindful acceptance. However, when re-grouping becomes extreme and persistent, the result can be emotional shut-down and exhaustion, depression, despair, or dissociation. Self-regulation is the constant balancing act between mobilization and re-grouping that enables us to be optimally effective and to feel true satisfaction.

Trauma is a threat or injury that requires self-protective stress reactions—essentially fight or flight—which hijack the brain and body in order to achieve the one goal that is a higher priority than being effective and satisfied: survival. Post-traumatic stress disorder derives its name from this key fact: PTSD is a disorder because the the brain and body have become trapped on a roller coaster of dysregulation. PTSD involves rocketing into extreme states of stress reactivity (mobilization in the form of terror, rage, and uncontrollable impulses) and plunging into equally extreme states of being shut-down (exhaustion, emotional numbing, despair, and dissociation). From this vantage point, PTSD clearly is about much more than fear and anxiety, involving the full range of emotions and undermining our body's health, our ability to think clearly, to set and achieve goals, and to fully participate in and benefit from relationships.

A particularly important new symptom of PTSD highlights an important aspect of the loss of self-regulation: "Persistent and exaggerated negative expectations about one’s self, others, or the world (e.g., “I am bad,” “no one can be trusted,” “I’ve lost my soul forever,” “my whole nervous system is permanently ruined,” "the world is completely dangerous")." PTSD thus is inherently complex, and all about the loss of self-regulation that occurs when survival dominates how a person thinks, feels, and behaves in every area of his or her life. PTSD replaces the "me" who was growing, learning, and becoming a unique person before the trauma(s), leaving only a desperate survivor who may have no clear sense of identity and who may even hate or loathe herself or himself.

Although the dilemma of post-traumatic self-dysregulation is indeed complex, as is the array of therapies that have shown promise in treating (complex) PTSD , the key to recovery is not rocket science. Survival threats can cause the brain to be hijacked by its own alarm system, so the key is to re-set that alarm system so it's no longer in survival mode.

Re-setting the brain's alarm requires seven steps, which are at the heart of every effective treatment for (complex) PTSD despite their many differences:

Focus mentally on a single thought that you choose because it is what's most important and positive in your life at this moment—not what's most urgent or problematic, nor what's a lifetime away, but what you value most and what represents the very best part of your life right now.

Recognize the triggers that signal problems or danger: don't ignore them, but don't obsess or ruminate about them, just make a mental note to be alert.

Experience the emotions that are signals from your brain's alarm, but also the sustaining emotions that seem to get lost in the midst of stress reactions but actually are always present if you just look carefully for them; emotions like joy, hope, love, pride, security, enthusiasm, determination.

Evaluate your thoughts not to judge or alter or eliminate them, but to distinguish between the defensive (or offensive) thoughts that are generated by your brain's alarm from the sustaining beliefs that also can get lost in alarm reactions (but actually are always available when you focus on your core values).

Define your goals so that you can tell the difference between defensive (or offensive) goals that are potentially useful warnings from your brain's alarm and the sustaining goals that are based on your core values.

[Choose] Options that enable you to achieve your sustaining goals and to live according to your core values, while being aware of and open to using other options that are more defensive (or offensive) if you are faced with a genuine threat to your, or others', survival.

Make a contribution by doing the one thing that each of us can do to make everyone safer, healthier, and more effective: continue to practice these simple steps in your own individual ways, and in so doing become a role model for responsible self-regulation.

These seven steps spell FREEDOM. They are not a pre-packaged set of techniques for self-improvement. They have to be done by each person in their own individual way. They enable you to use your mind to shift out of survival mode and your body to resume the natural state of self-regulation that is lost whenever anyone becomes trapped in the alarm state that the DSM-5 calls PTSD.

Hijacked by Your Brain blogs are co-authored with Jon Wortmann. Visit our website at www.hijackedbyyourbrain.com. You can follow us onfacebook or join us on twitter @hijackedbook.
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