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VOL. 5 • NO. 8
© July 2011
post-traumatic stress disorder In U.S., nearly 8 million suffer from condition — and not all are combat vets Nearly 20 years have passed and Tina Chéry still remembers the shock of hearing the news that her son had been murdered. Louis was 15 years old at the time when he was caught in crossfire near Field’s Corner. Ironically, he was on his way to a Teens Against Gang Violence meeting. For Chéry, dreams of what Louis might have become — he often told his mother that he would be the first black president — turned into a debilitating mix of nightmares, anger and guilt. She blamed herself for allowing her son to walk the dangerous streets. She often lashed out and started having headaches. She avoided the spot where he died. Most of all, she was just plain numb, unable to concentrate or focus on anything. “I didn’t know what it was,” she said. “But I was a walking basket case.” What Chéry did not know at the time was that she was probably suffering from post-traumatic stress disorder (PTSD), an anxiety disorder that results from a major trauma that involves the threat of injury or death. It has many sources — natural disasters, plane or car accidents, physical or sexual abuse, assaults, even the sudden violent death of a loved one. Though most people are able to bounce back from such episodes — and continue on relatively unscathed — many are not. According to the National Institute of Mental Health (NIMH), 7.7 million adults in this country suffer from PTSD. PTSD can be quite varied. Its impact can change from person to person. Symptoms can develop within hours or days of the trauma.
For some it takes weeks to months to appear. It’s not necessary to actually experience the traumatic episode. Merely witnessing the traumatic incident or involvement in the aftermath is all it takes. And the more severe the trauma or the more traumas experienced, the more significant the PTSD. People living in crimeridden neighborhoods may suffer continuous trauma, thereby increasing its risk. Marie Pierre-Victor, LICSW, clinical manager of the behavioral health department at Codman Square Health Center, has seen her share of PTSD. Not everyone who experiences horrible trauma will get the disorder. Two people may experience the same trauma with completely different outcomes. “People process things differently,” PierreVictor explained. “Some people get frozen in time. Their thoughts put them back at the place of trauma.” Such was the case for many responders of the September 11 attack on the World Trade Center. A study of roughly 29,000 persons who performed rescue and recovery work there found that they had an increased risk of PTSD for up to three years later, especially if they lost co-workers as a result of the attack. Anxiety in itself is not a bad thing. It’s natural to be fearful when in danger. The “fight or flight” response kicks in to protect a person from harm. But people with PTSD often still feel stressed or frightened when the danger has passed. It is not uncommon for people to suffer anxiety after a horrible trauma, but if the symptoms persist several months later, a person might be experiencing PTSD. The cause of PTSD is not well under-
Tina Chéry (in cap and gown) received an honorary Doctor of Law degree from Mt. Ida College. Shown (from left to right) are her mother, Zoila Wedborn, Rev. LeSette Wright and her daughter, Alexandra Chéry. Tina founded the Louis B. Brown Peace Institute following the murder of her 15-year-old son. (Photo courtesy of Louis D. Brown Peace Institute)
stood and is the subject of several studies. Researchers from Emory University found that women, but not men, with higher blood levels of a particular stress hormone displayed more symptoms of PTSD. A recent study published in Biological Psychiatry suggests that the size of the region of the brain (hippocampus) that controls memory may have an impact. The symptoms of the disorder are varied and tend to fall into three main cat-
egories — reliving the event, avoiding the event or hyperarousal. People with PTSD most often experience flashbacks and relive the trauma over and over. The backfire of a car — a sound very similar to a gunshot — can set the symptoms in motion. Sleep does not always provide a respite. Replays of the event can occur in bad dreams. Avoidance causes afflicted people to stay away from locations or activities — such as Chéry, continued to page 4
For the young, overcoming trauma requires a safe place To this day, Alexis doesn’t remember how she ended up on Massachusetts Avenue in the middle of the night, high on drugs, wandering aimlessly along one of Boston’s busiest thoroughfares. Nor does Alexis recall how her mother and grandmother ended up there as well, ordering her to get into their car. But it happened and, as it turned out, it was the best thing to ever happen to Alexis. As a college freshman nine years ago, Alexis was enjoying her life and making plans for a career in criminal justice. All of that changed when she was raped by an acquaintance. She was 19 years old at the time and had little idea how to deal with the trauma. She kept the attack to herself. “At first I wanted to act like everything was fine,” she said. “But eventually, things started to crumble.” Though she considered herself just a recre-
ational user of drugs, the next thing anyone knows, Alexis is on Massachusetts Avenue. “I just lost it,” she said. Alexis had never heard of post-traumatic stress disorder (PTSD). She says she knew she had a problem but “had no idea what I was going through at the time.” According to Kathleen Monahan, a licensed mental health counselor at Dorchester House, Alexis’ story is all too typical of teenagers suffering from PTSD. “Some kids are reactive,” Monahan said. “They get tough and fight. They get scared when they are triggered. Others can close down. [But] if a person
cannot put it [trauma] away, the problem is that at some point in time, something will trigger it.” Even now, more than nine years later, Alexis still has triggers. “I do not associate with people who remind me of my attacker,” she admitted. For instance, if she sees a rapper who looks like the man, she won’t watch his videos. If someone grabs her, especially by the wrist, she has a reaction. Some causes of PTSD are harder to treat, according to Marie Pierre-Victor, the clinical manager of the behavioral health department at Codman Square Health Center. For instance, physical trauma and
Alexis, continued to page
Anxiety: When you need to worry Everyone experiences anxiety. It’s impossible to skate through life without it. Anxiety and fear are natural reactions when you’re faced with a threat to your well-being. In fact, a jolt of anxiety can drive you to study for a test, polish a presentation or hop out of the way of danger. “A little anxiety is motivating,” says Dr. Ken Duckworth, a psychiatrist and associate medical director for behavioral health at Blue Cross Blue Shield of Massachusetts. “But large amounts of anxiety are debilitating.”
How we react to anxiety
Anxiety stamps its mark on us physically and psychologically. Physical symptoms may include a pounding heart, sweating, trembling, feeling hot or icy, blushing, agitation, being hyper-alert, faintness, dizziness, chest pain, nausea or a sensation of smothering. Psychological symptoms may include worry, dread, unease, uncertainty, fear, nervousness, panic, outbursts of anger, an out-of-body sensation or even the conviction that you’re about to die. When persistent anxiety interferes with your daily tasks, activities, or enjoyment of life, it’s best to seek professional help (see “Getting Help”). At this point, your coping behaviors may be hurting you, too. Perhaps you can’t leave home because you’re afraid you’ll have a panic attack in public. Maybe you’re driven to perform certain rituals — washing hands, for example, or repeatedly touching, checking on or counting things — to relieve distress. Perhaps you’re isolating yourself because any social occasion makes you unbearably nervous, or abusing alcohol or drugs to help calm anxiety.
A common thread
Anxiety disorders are very common, affecting roughly 40 million Americans 18 or older each year. Some often start in childhood or teenage years, such as obsessive-compulsive disorder (OCD) and social phobia. For anxiety to cross into the realm of a disorder, it must affect daily functioning.
Common anxiety disorders are:
• Generalized anxiety disorder: Excessive worries, tension and varied concerns about money, work, rela-
tionships and health with little rational reason. Affects 6.8 million American adults. Continual spikes in worry and tension, skipping from one anticipated disaster to the next are a few symptoms. • Obsessive-compulsive disorder (OCD): Persistent, upsetting thoughts (obsessions) and rituals (compulsions) that relieve the anxiety sparked only temporarily. Fear of germs that prompts repeated hand washing is one example. Affects about 2.2 million American
adults. Repeated rituals and behaviors — counting, hoarding, arranging items symmetrically — are a few symptoms. • Panic disorder: Sudden attacks of terror, usually peaking within 10 minutes and often accompanied by a sense of unreality, impending doom, or fear of losing control. Inability to predict when the next attack may occur causes great anxiety. Affects about 6 million American adults. Pounding heart, sweating and faintness are a few symptoms. • Post-traumatic stress disorder (PTSD): Witnessing or being the victim of violence, natural disasters or combat may lead to PTSD, which affects about 7.7 million American adults. Not everyone in these circumstances develops PTSD, however. Nightmares, intrusive thoughts, startling easily are a few symptoms. • Social phobia (or social anxiety disorder): Feeling extremely anxious, excessively self-conscious and watched and judged in everyday social situations. Affects about 15 million American adults. Trembling, blushing, feeling that all eyes are watching are a few symptoms. • Specific phobia: Intense, irrational fear of something — dogs, small spaces, flying — that poses relatively little or no danger. Affects about 19.2 American adults. Severe anxiety, pounding heart, sweating are a few symptoms. Very often, anxiety disorders co-exist with depression. Or they are compounded by substance abuse, a self-medication strategy likely to hamper improvement and cause additional problems. If necessary, seek professional help for these issues, too.
Getting help
First, talk to your doctor, who can consider whether a health problem or medication could be prompting anxiety. For example, an overactive thyroid or stimulant drugs taken for attention-deficit disorder or another health issue could make you feel very anxious. After ruling out these issues, your doctor can refer you to a mental health
professional. Depending on how much anxiety affects you, you may want to try coping skills, such as exercise and relaxation techniques, first to see if this helps you sufficiently before seeing a mental health professional.
Treatments for anxiety
Generally, mental health professionals treat anxiety with a combination of coping strategies plus exposure therapy and cognitive behavioral therapy described below. When necessary, medications are added. • Cognitive-behavioral therapy (CBT): CBT helps change unhelpful thought and behavior patterns. Someone with OCD who fears germs might be encouraged to get his hands dirty, then wait before washing for increasing amounts of time. A woman who has panic attacks might first need to learn she’s not having a heart attack, then be taught strategies to help her tolerate symptoms. • Exposure therapy: A therapist helps you face your anxiety through a series of gradual steps. The goal is to learn to tolerate anxiety for increasing lengths of time. Exposure therapy is not typically used for PTSD, but works well for phobias like fear of snakes or flying and most other anxiety disorders. • Medications: Depending on the disorder, a doctor may prescribe anti-anxiety drugs, which can block physical symptoms of anxiety, or other medications. • Other emerging treatments, such as eye-movement desensitization and reprocessing (EMDR) for PTSD are being studied to see if they are effective. Anxiety is a very common, treatable problem. You don’t need to entirely erase anxiety, but you’ll be able to manage it better if you understand what level of anxiety you face and attend to it accordingly.
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Questions & Answers
1. Why do some people get post-traumatic stress disorder (PTSD) and others do not? Everyone is at risk of being exposed to traumatic events, but there is no certainty as to why some individuals are more susceptible or prone to developing signs and symptoms of PTSD. Research Orlando B. Lightfoot, M.D. is underway to determine Chief of Psychiatry if specific biological and Codman Square Health Center genetic differences play a role. Clinicians do know that people with supportive family and community relationships who readily seek help when needed and have solid methods of problem solving and coping with difficult situations may be more successful in avoiding PTSD. 2. Does the disorder differ between men and women? Both men and women are at risk for PTSD. Surveys have shown, however, that in non-combat community situations, women are impacted more — 20 percent versus 8 percent in men. A reason for the disparity is the type of trauma. Females are more subject to childhood sexual abuse, rape, domestic violence and family conflict. 3. Is alcohol or substance abuse associated with PTSD? Alcohol or substance abuse does not cause PTSD, but an individual suffering from the disorder is more likely to use alcohol or drugs as a way of escaping the feelings associated with the trauma. In most circumstances, alcohol and drugs can offer only temporary relief and escape, but can confound the long term management and recovery. Frequently alcohol or substance dependence is an accompanying diagnosis of PTSD. 4. Can people develop PTSD months or years after the trauma? The timing of PTSD can differ. Many people experience signs and symptoms soon after a traumatic event, but can bring their response under reasonable control within a few months. Some, however, do not identify the difficulties they experience in life, such as feeling isolated, feeling fearful in crowds, problems keeping a job or excess use of alcohol or drugs, as possibly related to prior traumatic events or experiences. The awareness that this could be PTSD can be delayed for many years. Still other individuals do well over many years until a life change “triggers” the past trauma. Generally, a detailed and complete history can uncover material that strongly points to a diagnosis of PTSD.
Signs and Symptoms Generally, the symptoms of post-traumatic stress disorder are subdivided into three main categories. Re-experiencing the traumatic event
• Flashbacks or repeated reliving of the event • Intrusive, upsetting memories of the trauma • Repeated nightmares or bad dreams • Intense physical reactions to reminders of the event (e.g. pounding heart, sweating)
Avoidance and numbing
• Avoiding activities, places, thoughts or feelings that remind you of the trauma • Inability to remember important aspects of the trauma • Loss of interest in general activities • Feeling detached from others and emotionally numb • Hopelessness about the future
Increased anxiety and emotional arousal • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance – on constant alert • Feeling jumpy and easily startled
Risk Factors
It’s not possible to predict who will get PTSD; it occurs in people of all ages and race s. Some factors, however, may increase its risk : According to the National Mental Health • Gender – more common in females Institute, to be diagnosed with PTSD a • Intensity and length of trauma person demonstrates symptoms in all • A previous trauma earlier in life three categories for at least one month: • Existence of other mental health problems, • At least one symptom in the such as anxiety or depression re-experiencing category • Family history of depression or PTS D • At least three avoidance symptoms • Abuse or neglect as a child • At least two symptoms of increased arousal • Lack of a good support system • Additional symptoms that interfere with of family and friends normal activities of daily living • Lack of coping skills A mental health professional should confirm the diagnosis
Diagnosis
5. Is the disorder curable? Some individuals respond after a traumatic experience with minimal impairment and require minimal intervention. Others involved in the same event suffer tremendously. The signs and symptoms of PTSD are treatable; improvement can and does occur consistently. Clinicians use a wide array of tools — support, guidance and medication — to help in the recovery process. Many individuals have demonstrated an ability to get better when they have access to and take advantage of these interventions. 6. What differentiates “normal” bad dreams and nightmares from symptoms of PTSD? One function of dreams is to allow an individual to “work through” the events of the day. Yet, disturbing dreams can occur in all individuals. Dreams associated with PTSD allow some revisiting of the traumatic event, and can offer a chance to revenge the hurt or shape a different outcome of an actual experience, making it more palatable. When PTSD dreams are frequent and disturbing they require an intervention by a mental health professional to help modify the intensity of the experience and assist with improved sleep. 7. Do children react differently from adults? Several traumatic experiences can result in PTSD in children: desertion and abandonment, improper and inadequate feeding, physical and psychological abuse and sexual abuse, to name a few. While some children are more resilient, others may respond by withdrawing, not eating or overeating, crying excessively, agitation or other dramatic change in behavior. Fortunately, children do respond positively to treatment including changes in the environment, loving attention and reassurance. 8. Are certain physical ailments, such as headaches or stomach aches, associated with PTSD? The relationship of physical ailments and PTSD has long been recognized. Studies have found that pain is one of the most regularly reported physical problems reported by people with PTSD regardless of the type of trauma. In many cases the pain is caused by physical trauma, such as automobile accidents. A special problem of the management and use of pain medication for legitimate chronic pain is an ongoing concern of medical practitioners. In some cases, however, pain, such as headaches, stomachaches or back pain that cannot be substantiated by diagnostic tests may be more closely linked to anxiety rather than a medical problem. The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Chéry, continued from page 1
fected and may respond differently to trauma driving a car — that bring back the memories. than adults. For instance, young children These people often lose interest in activities and may wet the bed or act out the event during feel detached from others. play or cling to an adult. Teens often deThose with hyperarousal symptoms velop disruptive behavior, feel guilt or have startle easily, feel “on edge,” or have difficulty thoughts of revenge. sleeping or concentrating. According to the Fortunately, PTSD responds to several NIMH, symptoms of hyperarousal are typically types of treatment including medications, talk constant feelings of stress and anger. therapy and cognitive behavior therapy. “People The disorder does not always exist in a do get better,” Pierre-Victor said. vacuum. Depression or physical aches and The key is recognizing and facing the pains can result if PTSD goes undiagnosed or trauma. Failure to do so begins to impact a untreated. PTSD sufferers might attempt to self- person’s ability to function. Unrecognized medicate with alcohol and drugs. and untreated PTSD can also take a toll on a Research by Boston University Schools person’s physical well being. Back pains and of Public Health and stomach pains, for Medicine bore that example, can result. out. In the PRISM Chéry admits she study, the schools never considered redetermined the ceiving mental health prevalence, predictors services from a trained and associations of specialist because of PTSD in a predomithe stigma, a sentinantly minority urban ment too often shared primary care practice. by many victims, The researchers found according to Pierrethat mental health disVictor. Instead she orders — most typirelied on a network cally heavy drinking, of friends, some of substance dependence whom are mental and major depression health specialists. — were closely linked “No one ever used to PTSD. those words [PTSD] Marie Pierre-Victor, M.S.W., L.I.C.S.W. Roughly 25 per- Clinical Manager, Behavioral Health Department with me, but I think cent of those studied they were trying to be Codman Square Health Center engaged in heavy gentle,” she said. drinking or substance dependence; more than Chéry credits her priest for her survival. 30 percent suffered major depression and more “He was a safe place for me,” she explained. than 40 percent had anxiety disorders. “He allowed me to talk and go through grief It wasn’t only mental health disorders that at my own pace. He did not let me get stuck. were disproportionately high in this group. A Sometimes it’s easier to get stuck. It’s easier to noticeable percentage suffered chronic pain not have to deal with things.” and various illnesses, such as irritable bowel Chéry readily admits she is a very different syndrome. Those with PTSD were hospitalperson from the one before her trauma. She ized more often with longer lengths of stay and says her life has changed, and surprisingly for utilized mental health services more than the the better. She established the Louis D. Brown group without PTSD. Peace Institute whose purpose is to “transform The perception of the disorder has changed pain and anger into power and action.” over the years. At one time it was considered More important, her healing journey a psychological condition suffered by combat allowed her to be a better mother to her two veterans and went by names such as “shell remaining children. shock” or “battle fatigue.” In 1980 it was recogAbout five years ago, Chéry said she nized as a disorder with specific symptoms that turned another corner. “I learned what joy can affect survivors of other trauma and was feels like and not feeling guilty that I can added to the American Psychiatric Association’s laugh again.” manual of mental disorders. And she did something else she had not Children and teenagers are severely afdone in years. She danced.
When the stress is too much to handle alone ask for help If PTSD is not diagnosed and treated it can lead to other mental health disorders, such as depression and alcohol or drug abuse. In some cases the person suffering from trauma has thoughts of suicide. If you are having thoughts of harming yourself or ending your life, or if you know someone who is having these thoughts, seek help right away. Call your doctor, 911 or the National Suicide Prevention Lifeline at 800-273-TALK.
Need more information? • National Center for Trauma-Informed Care 866-254-4819 nctic@nasmhpd.org • National Institute of Mental Health 866-615-6464 nimhinfo@nih.gov • Anxiety Disorders Association of America 240-485-1001 www.adaa.org • National Mental Health Association 800-969-NMHA www.nmha.org • Mental Health America 800-969-6642 www.nmha.org
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Do you think you have PTSD?
Ask yourself a few questions In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you: 1. Have had nightmares about it or thought about it when you did not want to? q YES q NO 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? q YES q NO 3. Were constantly on guard, watchful or easily startled? q YES q NO 4. Felt numb or detached from others, activities or your surroundings? q YES q NO Current research suggests that if you answered “yes” to any three questions, you might have PTSD. If so, it may be helpful to talk to a mental health professional. PTSD is highly treatable with psychotherapy (talk therapy), drug therapy or a combination of both. Source: Prins et alia, (2004). The primary care PTSD screen (PC–PTSD): Corrigendum. Primary Care Psychiatry, 9, 151
Alexis, continued from page
sexual abuse — trauma during which safe place for them.” a person is invaded — pack a stronParents play an important role. First ger emotional toll. “It affects trust,” of all, Monahan explains, they have to she said. “It affects everything else in be on high alert for telltale signs. “If kids a relationship.” stay in their room too much or they’re irMonahan agrees and takes it a step ritable or their grades are falling, that’s a further. PTSD is even worse in sexual clear sign that something’s wrong,” said abuse cases if the attacker is a family Monahan. “Kids that are scared, have member. “If they poor eye contact tell, they cause and are anxious or problems,” she depressed for no said. “They are known cause make torn. Their trust is me suspect PTSD.” destroyed.” Parents also Alexis readily play into the healing admits that therapy process. “They’re has helped. After the most important the night on Masthing in a kid’s sachusetts Avenue, life,” she said. Alexis finally broke Such was the down and — a year case with Alexis. after her attack — Though Alexis told her mother never completed what had hapher degree, she’s pened. Her mother not complaining. quickly took her to And she’s not a doctor. After a re- Kathleen Monahan, M.Ed. keeping quiet now. ferral to a therapist Licensed Mental Health Counselor She says she knows Dorchester House Alexis was diagwhat it was like to nosed with PTSD. suffer in silence, She says that her life has changed and she wants to make sure others do completely since the incident. “The pernot. She volunteers at the Boston Area son I was before no longer exists,” she Rape Crisis Center where she helps train said. “I am more guarded.” other volunteers. “People feel shame Monahan emphasized the need to [when they’re raped],” she said. “They attack the problem sooner rather than need to know that it is not their fault and later, especially with teens. But she also that they are not alone. Support is availstressed the need to be patient. “If you able to them.” go too fast and they’re not ready, they She remains in therapy and says she won’t come back,” she said. “It could is grateful for what it has done for her. lead to a crisis. You have to set up a “I’m in a happy place now,” she said.
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