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Recovering From Post Traumatic Stress Disorder

Traumatic events, such as fire, earthquake, bombing, and hurricane, occur daily. Such devastating circumstances often cause an acute reaction of fear and terror for individuals who experience them.


September 17, 2009
By Pamela Fitch & Trish Dryden

Topics

Traumatic events, such as fire, earthquake, bombing, and hurricane, occur daily. Such devastating circumstances often cause an acute reaction of fear and terror for individuals who experience them.

War, rape, and physical assault or abuse, whether of a child or an adult, produce equally frightening results, known as post-traumatic stress. It occurs when traumatized individuals cannot safely assign to the past what has happened in their life. The experience of trauma undermines one’s expectations of safety and security in the world. Traumatized individuals continue to be aware of what others know to be true but tend to keep hidden from their consciousness: That life is fragile and can be gone or forever changed in an instant, and that our expectation of control in the world is often an illusion.

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As they struggle to make sense of what has happened to them the majority of individuals who experience severe trauma develop such acute, short-term symptoms as sleep disturbances and physical pain.

Others, unfortunately, develop chronic symptoms related to their experience of trauma. These symptoms, when they occur together, are indicative of Post-Traumatic Stress Disorder, or PTSD. The impact of such symptoms has a neurobiological basis and crosses physical, emotional, and spiritual boundaries. Such clients present significant challenges to the massage therapist’s skills and knowledge in the treatment room.

This article examines the signs and symptoms of chronic PTSD and the role of the massage therapist in dealing with them. The overall goal in the massage treatment of PTSD is to help the client to become safely “embodied within the self.”

Massage therapists can teach clients safe and effective ways of self-soothing and stress management. People who have been traumatized are no longer at home in their bodies. Talk therapy alone does not always adequately address the fear and mistrust that has been encoded into their bodies. In a multidisciplinary context, massage therapy can help bring clients back into themselves by increasing their ability to feel safety and mastery in the world, to be freely curious without fear, to feel comfortable with their body, and to experience boundaried intimacy with another human being.


Clinical Manifestations

It is important for massage therapists to understand the clinical manifestations and neurobiology of trauma, in order to understand the risks and benefits which massage therapy treatment offers to clients with PTSD.

Many clients have traumatic histories and exhibit the signs and symptoms of PTSD, whether or not the massage therapist is aware.

In a national comorbidity survey of more than eight thousand subjects, Kessler, et al,2 found that 6.5 per cent of the subjects studied had a lifetime prevalence of PTSD and another 2.8 percent had a 30-day prevalence of PTSD. Women were at twice the risk of men in developing PTSD, and those with PTSD were at increased risk of developing other psychiatric disorders, such as anxiety and mood disorders.3 Given that approximately 75 per cent of massage therapy clients are women,4 and that a large majority come into massage therapy treatment for what is generally described as “stress,” the percentage of clients presenting with PTSD may likely be much higher than the 9.3 per cent suggested by these figures.

Saakvitne and Pearlman5 postulate that the experience of trauma undermines five basic human needs:

  1. The need to be safe.
  2. The need to trust.
  3. The need to feel some control  over one’s life.
  4. The need to feel of value.
  5. The need to feel close to others.

Nowhere is this more evident than in the extraordinarily intimate surroundings of the massage therapy treatment room. Clients who, from time to time, experience emotional reactions to being touched often respond to simple human soothing. Crying, being held, being reassured by the massage therapist – “There, there. It’s over now. You are safe with me” – most often brings the client back from the terror of
remembered trauma and sadness to present reality. The world and the massage proceed as before.

Those who have experienced a deeply traumatic event may not be so easily soothed by simple words or touch. For them, trauma continues to live on in their body and spirit, as if it were still happening in the here and now. Soothing seems hollow, not to be trusted. The loss of confidence in the body’s ability to keep them safe is experienced as the ultimate betrayal of all that they have come to know and trust about the world and other people. The longing for safety remains but is buried very deeply under the guard of
perpetual mistrust and fear.

Clinical Definition
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)6, a client must meet the
following criteria to be classified as having PTSD:

Criterion A:
Has been exposed to a traumatic event involving actual or threatened death or injury, during which the individual responded with panic, horror, and feelings of helplessness.

Criterion B:
Re-experiences the trauma in the form of dreams, flashbacks, intrusive memories, or unrest at being in situations that remind the individual of the original trauma.

Criterion C:
Shows evidence of avoidance behavior-numbing of emotions and reduced interest in other persons and the outside world.

Criterion D:
Experiences physiological hyperarousal, as evidenced by insomnia, agitation, irritability, or
outbursts of rage.

Criterion E: The symptoms in Criteria B, C, and D persist for at least one month.

Criterion F: The symptoms have significantly affected the person’s social or vocational abilities or other important areas of life.
PTSD may be either acute or delayed in onset. Acute PTSD occurs within 6 months of a traumatic event. Delayed onset may occur any time later than 6 months after the traumatic event. This may be a year, 20 years, or even 40 years after the event.

Signs and Symptoms
In addition to a history of trauma, there are certain signs and symptoms to watch for when assessing a client for PTSD. Singly, the symptoms are not diagnostic; however, when observed as a cluster of signs and symptoms, the therapist should consider the possibility of PTSD.7

  1. Hypervigilance (wariness of others) and hyperarousal (fight or flight response).
  2. Emotional absence and/or unresponsiveness.
  3. Avoidance of triggers that spring up memories of the trauma.
  4. Dreams, nightmares, insomnia.
  5. Difficulty in concentration.
  6. Irritability or outbursts of anger.
  7. Depression.
  8. Suicidal thoughts or gestures of self-destructive behaviour.
  9. Exaggerated startle response or extreme ticklishness.
  10. Numbness or hypersensitivity to touch over parts or all of the body.
  11. Overwhelming feelings of anger, sadness, fear, despair, shame, guilt, or self-hatred.
  12. Migrating symptoms of physical pain.
  13. Migraines, fibromyalgia, extreme myofascial tension.
  14. Disassociation from self, actions, or parts of the body.
  15. Loss of connection with spiritual aspects of life or the ability to imagine a positive future.
  16. Distorted relations with the perpetrator or others who remind the client of the perpetrator.

Massage therapists should be aware that there are many clients who may have experienced significant trauma, but their symptoms will appear more consistent with depression. For a concise description and delineation of responses other than PTSD to trauma, refer to Trauma and Recovery by Judith Herman.8 As with all medical and psychiatric conditions, it is extremely important that the client be diagnosed by an appropriate health care practitioner. Massage therapists are advised to develop a reliable list of practitioners to whom they can refer clients for diagnosis and with whom they can work to co-ordinate an effective multidisciplinary, client-centered treatment plan.

Neurobiology

Individuals experience traumatic events differently. For example, one individual who experiences being mugged at knife point may respond in the moment by complying with the mugger, handing over her wallet while memorizing the mugger’s face. She thinks that when she gets out of this situation she will go to the police station, identify the perpetrator, and have him charged. Another individual may become frozen with fear and go to a place inside herself that is often described as a place of “speechless terror.” She cannot communicate rationally with herself, or reassure herself about a course of action she will take in the future. At the time of the traumatic event she is convinced that she will die.

How individuals respond to traumatic events may partially come down to the differences between how they process information and feeling.

Those individuals who are able to keep talking to themselves while a traumatic event is occurring,
and who keep planning for a possible future, are engaging the left side of their brain. These persons process sequentially and logically. They still feel intense fear, but their left-brain approach to understanding prevents them from being overridden with terror.

Those individuals who process from the right side of their brain experience the world from a more sensory, emotion-laden place. They receive the whole image of the event all at once, with emotion, sensation, and perception heightened. They cannot, in the instant of terror, manage a sequential understanding of the event, nor can they decide in a rational or logical manner what to do next in order to protect themselves.

They no longer experience the world through the filters of their cerebral cortex and are entirely, at the moment of trauma, in the right side of the brain. They are, in other words, in a place of “speechless terror.” Those who experience this are far more likely to develop PTSD.9

The brain is exquisitely organized into three basic and highly inter-related parts and functions. The brain stem and hypothalamus monitor regulation of one’s internal environment and the fight or flight mechanisms.

The limbic system balances the internal and external worlds and processes raw emotion.

The neocortex analyzes and solves problems and is the part of the brain through which we largely interact with the external world. Together these parts of the brain co-ordinate the unconscious and conscious functions of feelings, thoughts, memories, communication, and actions.

One of the functions of the limbic system, the center of emotions, is to store fear-based experiences. Rapid and accurate access to experiences of fear and its associations is highly necessary for survival. For example, if a person walks down a forest path and sees a long cylindrical object lying across the path, he may gasp, stop quickly, or run away. The reaction to the object happens before the neocortex gives any information about what that object might be.

Part of the limbic system, the amygdala, records fearful experiences and feelings in intense sensory detail, and alerts the person to the possibility that the object is a snake, long before the word “snake” occurs in
the person’s left-sided cortex. The amygdala also sends messages to the hypothalamus to activate the hypothalamus-pituitary-adrenal (HPA) axis, the fight or flight mechanisms, so that the person will stop, look, and get ready to run, if necessary, before even knowing what the object is.

  1. The HPA axis is triggered by fear (among other emotions).
  2. Hypothalamus secretes CRH (corticotropin-releasing hormone).
  3. CRH activates the pituitary gland to release ACTH (adrenocorticotropic hormone).
  4. ACTH activates the adrenal glands to release cortisol.
  5. Cortisol stimulates heart, brain, glands, and skeletal muscle for the fight or flight response.
  6. Cortisol suppresses the immune system.
  7. The presence of cortisol in the blood eventually signals the hypothalamus to stop secreting CRH and the hypothalamus-pituitary-adrenal axis slows.

Under ordinary circumstances, high levels of cortisol in the bloodstream, an indicator of stress, will activate the process of homeostasis in the body. From the Greek meaning “to keep things the same,” homeostasis is a complex process wherein the body maintains a finely tuned balance between all the systems that it needs to survive. After the danger (real or perceived, external or internal) has passed, the neurohormonal system will usually right itself. However, the neurohormonal systems of persons who experience PTSD are often stuck in the fight or flight mode, remaining hypervigilant or hyperalert. Clinically high levels of the hormones cortisol and norepinephrine result in hypervigilance and its related wariness and neural hyperreactivity. Another way that this break in the neurohormonal cycle manifests is as a cortisol and norepinephrine burnout. In this type of stress hormone burnout, clients may experience numbness in parts of their bodies, lethargy, and depression. PTSD clients may present with one or both of these conditions.

Time Heals Not

PTSD has been described as the failure of time to heal all wounds, because the experience of trauma, for some individuals, is encoded entirely in the amygdala without reference to time and space. The cerebral cortex, which helps to shut off the floods or cascades of hormones, cannot be accessed. For people with PTSD, flashbacks of the traumatic experience occur when the flood gates of the amygdala are triggered to open. Then sights, sounds, smells, and feelings of the trauma return unexpectedly and intrusively, causing the person to experience yet again aspects of the original trauma as if it were happening in the here and now.10

For example, a woman survives a severe car accident that occurs during a storm. She develops intrusive flashbacks of the pressure of the seatbelt on her chest at the time of the accident, symptoms which have persisted long after the physiological damage to her chest muscles has healed. She comes to massage therapy complaining of chest pain for which she has no clear explanation. She also is baffled by the fact that the chest pain gets worse when it rains. At the time of the accident it was raining heavily. The intense fear and pain experienced and encoded in the amygdala was encoded with the accompanying sensory awareness of rain.

Now she has a conditioned response: A sensory stimulation (especially rain) reminds her (however subtly and unconsciously) of the car accident and triggers chest pain. In addition, at the moment she is flooded with the memory, she again experiences many of the sensations that occurred during the accident: sweating, racing heart, intense fear, and shallow breathing. This woman may now actively find ways to avoid stimulus that triggers these floods of stress hormones, such as staying indoors when it rains, or self-medicating with drugs and alcohol.

It is not uncommon for individuals with PTSD to develop addictions to alcohol or drugs, to work extremely long hours, or find other ways to reduce or ignore the unwanted and frightening sensations.

Bessel van der Kolk11 refers to the normal neural encoding of experiences as narrative memory (located in space and time, without the intrusive neurohormonal cascade) and the kind of memory that people with PTSD suffer from as traumatic memory. He theorizes that the fundamental task of therapy – whether it is psychotherapy or massage therapy – is to help clients regain a sense of safety in their bodies, free of the flooding of stress hormones. Perhaps Freud was right when he said, “The task of therapy is to transform neurotic misery into ordinary unhappiness.”

In talk therapy, or psychotherapy, intrusive neural symptoms are transformed, in the context of a safe, boundaried, therapeutic relationship. By encouraging the client to talk about the traumatic event, the unpleasant memories get re-encoded from traumatic memory into narrative memory. In other words, people learn to use their left brains (cortex) to coordinate their right-brained feelings. This prevents the discharge of stress hormone from the amygdala.

Once talk therapy has helped the client establish some degree of narrative memory and experience of safety, clients may face intrusive body sensations with a massage therapist. Massage therapy can help clients to reframe their experience of trauma from a kinesthetic perspective.

Seratonin, along with the body’s natural painkillers or opiates, is produced in the brain. Since PTSD clients cannot easily access the seratonin needed to soothe the fight or flight response, medications such as Prozac, Zoloft, and Paxil (known as SSRIs, or selective seratonin reuptake inhibitors) are often used to help control inappropriate reactivity to internal stimuli such as impulsivity, aggression, and involuntary preoccupation with traumatic memories.12

Some clients may, with such therapy, be able to enhance their bodies’ seratonin pump. Other clients, who have severe PTSD, may require SSRI medication on an ongoing basis in order to balance their reactions to general life stressors.

Massage therapy, in the hands of a skilled practitioner, also can aid the co-ordination of the left and right hemispheres of the brain, thereby reducing intrusive symptoms and inducing the creation of self-soothing strategies for clients with PTSD.


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