| “I
have suffered through many therapists that know
squat about PTSD. All my "ah ha" moments
have come from reading articles like yours and
the few good books that are out there.
I wish someone would write
an article just for family members and friends
that helps them to understand PTSD, and directly
addresses their roles and responsibilities. They
should have some, should they not?
An alcoholic wouldn't be
offered a drink, a diabetic some forbidden food.
I know my analogies are not clear but hope you
understand. Often I have some pretty good days
only to be sabotaged by those I love most. At
least it feels that way.”
This email request arrived recently.
I don't know who voiced this legitimate call for
help, but I hope to provide just what the writer
seeks: an article for family members and intimate
friends who want to understand PTSD, and to assume
effective roles and responsibilities as caring
partners.
If you are a partner of someone
with PTSD, I thank you for reading this. Somebody
who relies on you wants you to appreciate and
respect the condition that haunts them. With so
much in the popular press, on television and in
movies that touches on trauma, it is easy to have
partial information about traumatic stress, but
to miss the full impact of this profound condition.
When I ask my patients, “Does
your husband or wife or closest friend really
understand?,” I seldom hear a confident,
“Yes they do!” And when a spouse or
loved one does understand, I feel relieved. The
prognosis for improvement goes up considerably.
I have an ally.
So if you are that person -
the partner who is willing to set aside preconception
and take the time to learn about PTSD, thank you
again for your attention. Here goes!
What is PTSD?
Post Traumatic Stress Disorder is a medical condition.
It is a specific alteration in brain function
due to experiencing something real, shocking,
and profoundly disturbing. Not everybody responds
to trauma with the PTSD pattern of mental change.
Because of inherited and acquired predispositions,
some will and some will not develop PTSD after
very similar traumatic events. But once the circuits
in the brain are affected by the PTSD pattern,
a survivor has the following three problems:
Uncontrollable, Intrusive
Memory
First: their memory is seriously impaired. This
is not amnesia: in fact, it is almost the opposite!
The trauma comes back, bursting into awareness,
when it isn't wanted or welcome. This “hot
memory” lasts minutes to hours and may be
clear or altered, like a dream. It is very disturbing
for two reasons. The person with PTSD becomes
flooded with something frightening, or disgusting,
or tragic. And she or he may feel entirely out
of conscious control. Some of my patients fear
they are going crazy. Often the trauma comes back
in subtle ways - a fleeting feeling, a vague sense
of dis-ease. This may not be terrifying, but when
it occurs frequently it changes one's whole sense
of being the person they once were. Unwanted mental
experiences can also include nightmares, and the
nightmare may have images that were never seen
before, but resemble old demons from childhood.
The worst memory symptom is the waking nightmare,
the flashback. This is as vivid as reality, and
may actually seem like reality. I've been there,
with a patient having a flashback, several dozen
times. It frightens me! We'll talk about managing
your partner’s flashback later.
Emotional Anesthesia
Second: a person with PTSD feels like a shadow
of their former self. I call this “emotional
anesthesia.” Some tell me they have no feeling.
They are distant and detached. They wish they
had more zest for life and they know they disappoint
those who want them to be interactive and lively.
But the genuine desire to socialize just isn't
there. Your partner may or may not be depressed.
Being depressed is feeling helpless, hopeless
and worthless, and having no energy for the activities
one feels she or he was put on earth to do. PTSD
is not quite the same as depression, but may bring
on an episode of depression (1).
This second element of PTSD
is often called “being numb and avoidant.”
Your loved one just isn't fully alive. You, the
caring spouse or friend, can't make this medical
symptom go away. But you can help your partner
feel less guilty and embarrassed about having
the affliction. We'll come back to managing this
later, too.
Anxiety
Finally, PTSD makes a person anxious. Anxiety
affects each of us differently. The usual pattern
includes irritability, impaired concentration,
sleep disturbance, being “jumpy” (easily
startled), and worried about threats and threatening
individuals. This last element of PTSD pattern
anxiety is called “hyper vigilance.”
It isn't paranoia, but it may seem similar. Some
of my patients are too nervous to be intimate.
Sexuality is often sacrificed in the early weeks
of PTSD.
It returns, but shouldn't be
rushed. When partners can't communicate easily
and effectively about sex and other private, personal
subjects, matters inevitably grow worse. Your
friend or loved one may be embarrassed and inhibited.
Or you may be the one who would rather not discuss
“touchy” issues. Or one of you could
be the partner who talks too much, contributing
to discomfort in the other. Remember, partners
with PTSD are far more anxious than they were
before they developed the disorder. They have
too much adrenalin and it makes them less efficient,
less effective, less able to control their behavior.
They aren't sleeping restfully. They cannot concentrate
fully. Loud noises make their hearts jump.
So there you have it. PTSD is
a physical condition and it is real. It is not
“in your head.” You can't talk someone
out of it, or ignore it and assume it will just
go away. It consists of three things:
- Haunting, unwanted, frightening recollections.
- Emotional anesthesia that diminishes and
distances a person.
- Anxiety that affects sleep, concentration,
serenity - and sometimes, sexuality.
By definition, PTSD lasts at
least a month but the difficult cases last several
years.
Before we get to your role as
help-mate, let me add a few more points about
traumatized people. Not all survivors develop
the whole PTSD pattern, but they may have some
of the symptoms mentioned above. The person with
“partial PTSD” doesn't qualify for
the medical diagnosis, but still needs your understanding
and help.
However, many survivors of trauma
have more than PTSD.
Complications of PTSD
Some survivors have additional medical and psychiatric
conditions that complicate and prolong PTSD problems.
Common among these are preexisting personality
disorders, alcohol and drug abuse, depression,
chronic pain, and bereavement.
Childhood Abuse
Personality disorders may last a lifetime and
include such traits as dependence, avoidance and
a very insecure sense of self. This is not the
place to discuss personality issues in depth.
But it should be obvious that anyone who was severely
harmed by a parent (incest, physical abuse, neglect)
will adapt in ways that may expose her or him
to further abuse from authority figures. Your
partner may have PTSD related to early abuse and
later abuse. Unfortunately, this is very, very
common. For these survivors of childhood oppression,
PTSD is less than half of their burden. A much
larger issue for these partners is knowing whom
to trust, when to trust, and how to trust. For
now, let’s just agree that exposure to cruelty
from a parent (or parent surrogate) creates more
than PTSD and requires more information than I
can give here.
Alcohol and Drug Abuse
Alcohol is such a common “fix” for
insomnia and anxiety that most of my patients
have reported dramatically increased use after
major trauma. Many become alcohol dependent. Sometimes
prescription drugs (often painkillers) or illicit
drugs (often marijuana) are chosen and used, not
for recreation, but for sedation. This may be
the case with your partner, and if it is you face
additional risks and burdens. PTSD plus alcoholism
is more likely to become a chronic condition.
PTSD plus pain from injury is likely to prolong
recovery and include self-medication. When the
trauma includes death of a loved one, normal grief
is complicated by inescapable images of unnatural
dying (see articles by E.K. Rynearson, M.D. on
the http://www.giftfromwithin.org/html/recovery.html
website). War creates the battleground for all
these complications.
Veterans of War and
Violence
Alcoholic survivors may be males with PTSD from
combat or from violent incidents that resemble
combat. We shouldn't stereotype by gender, but
I must point out that the “caregiver burden”
for the wife of the traumatized vet is usually
different than the role of the husband of the
victimized wife. The male veteran with PTSD has
a greater likelihood of being angry, aggressive,
uncommunicative, secretly embarrassed and difficult
to reach than the female with PTSD. Partners of
male veterans have been systematically studied.
A collection of these studies by Drs. Calhoun
and Wampler in the National Center for PTSD Clinical
Quarterly (2) includes the statement, “almost
half of these women (partners) reported having
felt on the verge of a nervous breakdown."
If you are a wife or significant
other of a veteran who has become seriously impaired
- and is also menacing to you because of PTSD,
you are advised to seek professional help for
yourself. However, Calhoun and Wampler caution,
“many veterans suffering from chronic PTSD
are openly distrustful and may view the involvement
of their partner (in therapy) as a threat.”
Somehow, you the wife of the veteran, need to
assure your own physical safety as you learn to
reduce your “caregiver burden” and
help your husband overcome the anguish and humiliation
of chronic PTSD.
The emerging literature on “caregiver
burden,” aimed at helping the help-mate,
justifies therapy and counseling and support groups
for the partner of the person with chronic PTSD.
Handling traumatic stress in a loved one is very
stressful for most normal, caring partners. And
the source of your partner’s PTSD need not
be anything as dramatic as combat or violent crime
to justify your own self-help. One of the most
common causes of PTSD is the automobile accident.
Partners Helping Partners
with PTSD
My guess is that, initially, most readers of this
article will be women who have been abused and
who want their partners to have reasonable expectations
and to be supportive. Their partners, primarily
male, will then read these words. But regardless
of your gender, let me now speak specifically
to you, the partner of the person with PTSD. I'll
use “her” to refer to the partner
with PTSD, but this applies equally to same-gender
partners and women helping men.
Flashbacks
Your partner may have had a flashback at some
point, or may be having them now. Do you know?
Flashbacks are not the same as epileptic seizures,
but we can consider them equally sudden, violent,
and debilitating. You wouldn't want to elicit
a flashback by mistake. In general, you can help
with flashbacks by knowing whether your partner
has them, and learning whether your presence during
an episode is comforting or not
Don't ask about the details
of a flashback, since that might bring one on.
Do ask if you have ever been particularly helpful
in preventing or minimizing flashback effects.
Build upon your natural ways of being supportive,
and upon your partner’s individual needs.
Some partners want to be physically embraced.
Others are made more anxious by a man’s
touch. Some partners do want to tell you details
of terrifying memories, and they may want to repeat
these details as a way of overcoming the threat.
If it helps your partner, lend an ear. If you
can't take it because you become too angry with
a perpetrator or too overwhelmed with empathy,
point that out. But be caring as you explain your
limitation, and do your best to find ways of increasing
your emotional resilience so that you can be an
effective listener.
If your partner knows you are
working at being able to handle her trauma history,
you'll be respected rather than resented. If your
partner is in therapy and her therapist has not
done anything to help her overcome flashbacks,
she may need a better therapist. Not every licensed
mental health worker can treat the cardinal symptom
of PTSD. I use something called “The Counting
Method” (see http://www.giftfromwithin.org/html/counting.html
for details). Others use EMDR or “re-exposure
therapy.” These techniques all allow survivors
to remember their most traumatic moments (to the
point of having a flashback in the office) but
to get to the end of it and to eventually become
confident about their ability to remember at will.
In essence, your partner retrains her brain to
have “cool memories” rather than “hot
memories.”
She literally learns to remember
using the normal brain pathways rather than the
PTSD pathways. Unfortunately, it is a painful
process, like resetting a broken bone. I try to
keep it as brief as possible, while getting the
job done. You can help by assuring that your partner
finds her way to an effective PTSD specialist,
if she needs one.
Trigger Events
Does your partner have other, less dramatic problems
associated with unwanted recollection? She may
have “anniversary reactions” in which
a seasonal reminder causes her to have sensations
rather than memories. She may find that certain
people or places bring back ugly images and sweaty
palms. No harm in asking about this. In general,
help her avoid these unwanted triggers with dignity.
But if she chooses to risk confrontation (and
possible PTSD symptoms) help with the plan. It
may include a quick escape from her step-father’s
house. It may require you to be near-by as she
deals with a family dinner and formerly abusive
relatives. The worst thing you can do is to set
the agenda for her. That would be giving sugar
to a diabetic. You'll know if you are on the right
track. You'll get positive feedback.
Emotional Distance
What if your partner is numb? She has little or
no outward expression of feeling. You even wonder
if she loves you. Give it time. Do not add insult
to injury by blaming her for PTSD. Don't rush
her into intimacy. If she is seeing a counselor,
ask if you can come, too - or if you can visit
her therapist alone. This is called a “collateral
visit” and is covered by most insurance
companies. Not every therapist allows this but
I'm always interested, if my patient approves.
This is my chance to explain the issues that I'm
writing about here, and, more important, to listen
carefully to the partner so that I can help him
help her. Often I hear the question, “When
is she going to get over it?” This is a
proper question to ask, and if I cannot be accurate
to the day, I can often explain what is going
well, what is taking time, and what I expect in
terms of the rate of recovery. Overcoming that
numb feeling and the distance from a loved one
that accompanies emotional anesthesia is never
easy to accomplish or to predict.
Medication
Your partner may benefit from medication. One
of the newest anti-depressant drugs on the market
is Lexapro. A very small dose (10 milligrams)
taken daily for a few months could help with the
mood impairment of PTSD. Lexapro is the active
ingredient of Celexa and both drugs are selective
serotonin reuptake inhibitors (SSRIs). You can
read up on the medications and be able to discuss
them intelligently with your partner, should she
find herself undecided about medication. When
a person has major depression in addition to PTSD,
it really is a “no-brainer.” Antidepressants
are like insulin to a severe diabetic. Without
them, the risks are high (prolonged depression,
medical impairment, suicide). Antidepressants
help over 70% of people with first episode, biological
depression. I usually prescribe a SSRI for someone
with PTSD and depressed mood.
Minor tranquilizers such as
Xanax and Ativan are often helpful in the beginning,
when symptoms are most intense, or during times
of re-exposure to people and places associated
with the original trauma. Unlike the antidepressants,
however, these drugs can become habit-forming.
And they do not mix well with alcohol.
Several types of medication
help with sleep. Trazodone (originally marketed
as Desyrel) helps with early morning wakening.
If your partner awakens at 2 or 3 AM and cannot
get back to sleep, this medication may be a godsend.
And it is not addicting. It is actually an anti-depressant
rather than a sedative, but it is no longer used
as an anti-depressant. It does help most persons
with “early morning” insomnia.
The medications that help a
person fall asleep are habit-forming, and should
be used sparingly. You can help by learning about
these differences, by supporting the choices that
your partner makes, with her doctor, and helping
her feel good about herself, even if she requires
medical assistance to function at her best.
Ministry of Presence
You might also help your partner, if she is “down,”
by being there without imposing an agenda. As
a Red Cross volunteer, I have dealt with hundreds
of grieving loved ones, simply being there. We
call it “the ministry of presence.”
Nothing needs to be said. You do simple favors.
You find a way to be occupied while the survivor
does whatever she does.
Obviously, you reach a point
when being there, and nothing more, is hard to
do. The rules change as PTSD drags on. Some partners
can talk about this; some have a difficult time
communicating. Couples therapy can help - and
you needn't see a PTSD specialist for that. Any
good family or couples counselor can facilitate
effective exchange and mutual solving of problems.
There are support groups in some communities for
persons who care for loved ones with chronic medical
conditions. “First responders” to
traumatic events are learning ways of being present
for one another. Gift From Within produced a training
film called, “When Helping Hurts,”
to address this issue (available at http://www.giftfromwithin.org/html/video4.html).
You are now a “first responder,” too.
Ineffective Therapists
I realize, as I write about counselors and therapists,
there are good ones and bad ones. If you visit
http://www.ptsdinfo.org/ you will find a questionnaire.
The results of the questionnaire change as more
people post their answers, but a trend is already
evident. Most visitors to the PTSD Information
website are survivors of abuse. Most have been
in therapy. Two-thirds report that they were dissatisfied
with their therapist! While this may be a sample
who are seeking information because of ineffective
counseling, the startling fact is still worth
noting. My advice: don't stay with a therapist
whom you don't like or don't trust. Shop around.
Ask friends about good therapists. If your partner
doesn't feel good about her therapist, ask if
you can help her find another. It may be embarrassing
to leave a doctor. We are authority figures. Many
survivors don't know how to say, “No,”
to a father-figure. Of course, you have to be
careful about turning into a too-dominating figure
yourself. But you can succeed with some careful
thought
Anxiety
Finally, let’s consider the anxiety component
of PTSD. Your partner probably has too much adrenalin
in her system. It may not be quite that simple.
Her fear threshold has been lowered and she is
easily alarmed, even though a blood sample of
adrenalin would be normal. There is no biological
advantage in having one's fear threshold that
low. Eventually, she doesn't trust her instincts,
and that could be a bad mistake. So many people
without PTSD have anxiety problems. And there
are many, many ways to reduce anxiety. Alcohol
is the classic - and the worst - medicine. But
exercise, music, good food in healthy quantities,
laughter, spiritual and inspirational activity
are all tried and tested and true remedies. It
is a matter of individual taste and individual
choice. I have an essay on “Post-Traumatic
Therapy” that appears on several websites
(try http://www.giftfromwithin.org/html/trauma.html,
again). Read it for tips on increasing one's fitness
and humor and spirituality. If your partner is
anxious, but not depressed, she may be easy to
help. I'd try the non-medication approaches first
because the drugs that tranquilize are more addicting
by far than the antidepressants. But minor tranquilizers
do have a purpose and can make a huge difference,
particularly in the early weeks of PTSD.
Summing Up
To sum this up, I'd say that being a partner,
a friend, a spouse of someone with PTSD is both
a burden and a gift. The term “caregiver
burden” recognizes that you are at risk,
particularly when you care deeply. You may need
and deserve as much professional help as your
partner. Or you may do fine without a therapist,
as long as you take care of yourself, and then
learn how to be effective as a help-mate.
Helping fellow human beings
is the greatest gift any of us can experience.
It really is better to give than to receive. And
your opportunity to give begins with listening.
Then with learning. Then with understanding. Sometimes,
all you have to do is be there.
References:
(1) See www.dartcenter.org/oped/oped_030110.html
for a discussion of depression and PTSD in reporters
covering war at home. (back)
(2) Volume 11 (2) 2002, “Reducing
Caregiver Burden and Psychological Distress in
Partners of Veterans with PTSD”.(back)
Resource: Gateway to Post Traumatic
Stress Disorder Information.
© Gift From Within &
Frank M. Ochberg, MD
March 22, 2003
Please ask permission before posting or linking.
Email: Joyceb3955@aol.com
Frank Ochberg is a psychiatrist
and the former Associate Director of the National
Institute of Mental Health and a member of the
team that wrote the medical definition for Post
Traumatic Stress Disorder. He was the editor of
America's first PSTD treatment text. Dr. Ochberg
is the Founder of Gift From Within.
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