Post Traumatic Protective Disorder (PTPD) – The Child of PTSD

Just over two years ago a SUV sped through a red light and hit my car.

I survived. My car did not.

It took over a year before I could drive through that same intersection, and I still prefer other travel routes if possible. Big black SUV’s continue to peak my defensive awareness. It’s not a fair thing to so profile other SUV’s and their drivers.

I slow down and take extra looks at each intersection. I do so more than I realized —  others asked me why I’d become like a school bus driver at railroad tracks.

It was by chance that I realized that my PTSD changed into a PTPD.  PTPD, as term, does not officially exist, so I’ll coin PTPD as a new term. It ought to be granted the status of a formal label because it is the child of  PSTD and because it makes sense.  PTPD has made me more careful, more aware of vulnerabilities, reduced the anger over an event that I cannot undo,  and added just a touch of fear sufficient to better avoid additional accidents. PTPD has worked for me several times in similar driving situations where I took extra notice of other’s driving habits (or, to be more accurate,of their driving sloppiness and arrogance’s) to avoid a collision.

PTSD  kept me stale and relatively un-moving; the metabolite of PTSD , which is PTPD, make me better. Therapists unknowingly, as was I, had long been using this unknown metabolite as a therapeutic tool.

Some folks think we should work to the point where the original injury is defused and deflated such that  we do not allow it to be such a big part of our daily lives. (“You need to have something else and good  in your life…”) If I’d been hurt and every step I took since then made pain shoot into my body or mind, then the injury is still living.  My PTSD is unlike the combat implanted ones because the gestalt of combat is one of the truly ultimate and risky of businesses, and once removed from the war theater, there ought not to be the chance of another, additional combat  PTSD event. My PTST-PTPD refers to the ordinary dangers of everyday life, without the combat levels of risk, though many with horrible and lasting non-combat injuries do wonder if another injury will fall upon them.

PTSD reminded me of how random life can be and that other people will still make decisions that can hurt me. None of us live in a bubble, and now I work extra hard to help my patients know that the best help I can give them is the developing of a non-self-destructive mental approach to the randomness and unfairness  in life. Part of this treatment is the development of a philosophy or attitude that allows for what had happened, and to put it into a workable perspective with a goal. Substance abuse or other reactive mental health problems too commonly reflect the lack of this understanding and goal. (Appropriate medications may be needed but not to the exclusion of verbal therapies.) If there is no other perspective to soften the fear and pain (e.g., “you can’t erase that I was in a war zone,” or “I was a crime or abuse victim.”), then the task is to build a life around it.  One way is to convert the PTSD into PTPD  — this uses the event to help prevent it from happening again. The pain can still exist, but pain cannot be wasted –with the right help,  pain can be the strongest of  the healing and changing driving forces.

This is the season of gift giving. PTPD was an unexpected gift. Actually, PTPD is more like a kit, with ‘lots of assembly’ required. I prefer kits to pre-assembled items because the kit gives me an hands-on experience into how and why the item works.

I’m pleased to have PTPD.

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Psychotherapy Notes — IQ’s and the death penalty

The US Supreme Court has agreed to hear this Florida case about the death penalty and IQ.

Conceptually key too, for us, is the search for a ‘bright-line’ diagnosis  Arriving at a precise psychiatric diagnosis is challenging; it is not always possible. A good psychiatric diagnosis is the product of current symptoms and the person’s history. This court case stems from another process –the assigning of a number to rate a psychiatric condition. The punishment — in this case a death penalty — depends on the number.

The bright line diagnosis hopes to give us a clear and ‘bright’ line of demarcation between a condition or not. At issue is whether the mentally retarded can be executed; In 2002 the US Supreme Court held that execution of the mentally retarded violates the 8th Amendment. The Florida defendant in this 2013 case, Freddie L Hall, has an IQ that has varied from 60 to 71. The bright line for retardation in Florida is an IQ of 70.  One of the issues is the accuracy of the testing instruments, which is known as SEM – the standard error of measurement. The court’s ruling may impact some of the how’s and why’s of precise psychiatric diagnosing.

An US Federal statute, Rosa’s Law (Public Law 111-256) replaces mental retardation with intellectual disability, and the severity of the condition now in DSM-5 (started May 2013) is ranked as mild, moderate, severe or profound – there is no direct use of  numbers. It will be fascinating to watch the court grapple with these DSM changes since the older DSM-IV used ranking numbers.  Read the section on comprehensive assessment:  DSM-V

The defendant in this case is reported to have also been horribly abused as a child.

This is the link to US Supreme Court Case

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Psychotherapy Notes – Cyberbullying

The BBC produced a remarkable documentary on cyber bullying.  The recent Florida events highlight its critical importance. The link is posted below.

People rationalize their bullying in a manner that becomes just another type of domestic violence; it is all in the process of getting some sort of joy in those who bully as they get a controlling and painful reaction from the victims. It is a despicable side of human nature. It is sadism. 

There is no social benefit to cyber bullying. It is a perverse and greedy rationalization fed by the apparent shield of anonymity because people do not have to stand in front of their victim. It is a cowardly way of making a point. And an added element exists because the victims have no real mechanism of stopping it. Imagine the psychological trauma of knowing that there is no way to protect oneself from the onslaught; one cannot at least try to physically fight back, and running away  to freedom is not possible. Too many people have been emotionally traumatized by this cruel game, and we know of too many cases where the trauma was only ended by suicide.

I’m struck by how there is a similarity to the very bad side of some video games. The video game is a two-dimensional experience, but the concept is three-dimensional – an enemy is found and beaten. The third dimension is the joy of the success. This same third dimension exists for those who cyber bully.

Those who cyber bully reflect the cruel side of people; those who suffer do not find any comfort  in  the expression of free speech notions. Victims find no justification of any bullying.  I wonder how many of those who bully would still do so if they were forced to do this sitting face to face with their victim?  And would those who join in with the bully also do so in public?  Massive cyber-bullying is akin to a pathetic feeding frenzy, a crowd who applauds while watching a death at the Coliseum. What human comfort follows knowing they have watched someone else’s pain and suffering. Is there a joy? Is there some sense of decency and human bonding? Do those who bully believe it cannot happen to them? It rings of arrogance and cockiness.  It’s also amazing how many from around the world join in with the bully — the joiners have no connection at to the victim other than the adrenaline from the frenzy.

Bullying can be lethal, just as a gun is.

This no way we can easily limit or regulate a world as internationally massive as the Internet. Stronger laws, other than of malicious communications, need to be written, but would they apply across political boundaries?  

The answer is to dilute out the response to bullying. Teachers, parents,  older siblings, politicians, and everyone else,  need to teach how to pull away from any bullying. The process may require rapid maturation. It may require getting off of all social medias for a long while. It’s as simple as turning off the computer.

But mostly it requires that the victim be reassured that the comments being made are not valid.

But  for the very sensitive, or with those with a fragile ego, or if some other vulnerability exists that is being abused by the bully, then help and guidance must immediately start to build their ego up enough so they can resist the allegations. It’s not always easy. But it certainly is possible. Even the stronger but naively curious person needs to understand what windows in their lives they open when then ‘go online’.

Teenagers should not look to allegedly benign sites, such as littlegossip.com, for emotional guidance and reassurance.  The internet is not inherently dangerous, but there is a blind trust that it is safer than it is. The Internet knows no boundaries and thousands fall into its black holes every day. It’s safer to talk to our friends face-to-face than message them on Facebook. Facebook says “look at me!” We need to accept that it is not always necessary for the world to know all our business.

Be able to physically touch your friends.

Click here for the BBC link.

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Psychotherapy Notes – Navy Yard Shooting -Sept 2013

Every shooting seems to be followed by questions of whether or not mental health treatment might have stopped the tragedies.

The honest answer is maybe. But maybe is better than not at all.

Things are particularly tragic if we also learn that the assailant was refused mental health treatment because of the financial or bureaucratic crevices in our healthcare system. Apparently Aaron Alexis, the Navy Yard shooter, was suspected by friends to be paranoid; likewise, when Alexis heard voices and called the police, little was done other than make reports.

Ironically it seems Alexis wanted some level of help.

Allocating resources to mental health care is an emotional and political decision. It should not mostly occur in response to an illegal action.

Part of the problem is that treatment is not always successful. But the penny has another side, and many – if not most people – benefit from solid treatment. And yes, it is expensive in terms of introspection, time, and money. But how many of the shooters would have not shot because their treatments kept them on the good side of the penny.

Guns plus mental illness doesn’t automatically convert to danger. Guns plus certain types of uncontrolled mental illness could.

As for gun control, the problem is not that criminals will ‘get the guns anyway.’ The problem is when the non-criminal out-of-control mentally ill gets guns that end up causing violence, be it against themselves or others.

I’ve even heard talk that people with any mental health disorder will be stripped of their security clearances. The possibility of “veteran + PSTD = no job” is daunting. People will be less inclined to get help, enlarging the pool of the untreated.

Let’s prioritize: revamp the mental health system and spend less time arguing about the gun control system. The problem is that it is cheaper to buy a gun than pay for mental health care.

 

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The Medicine Already Inside Us

I am a firm believer in the proper mixing of verbal therapies and medications. But there is another medication that is already within us that it is often as powerful as other prescriptions. It comes from an attitude towards how we take care of ourselves. Occasionally we do need help from others, and we need to accept it as such. Indeed, so many times I’ve wished that I had the ability to more powerfully direct people away from their maladaptive behaviors and to get them to just listen to the experience of others, so that they could emulate and learn from their experience of doing something successfully. In this way they will learn about the real dimensions of human choices and human behaviors.

The supplementary elements already built into our lives are food and exercise. We are not meant to be sedentary. We are meant to walk to our food and to eat healthily.

We know that even adapting these endeavors cannot change all our ailments and pathologies, but they do help in a very large number of situations. Indeed, ask almost anybody how much better they feel after they started a program of regular exercise and it is almost universally “better.” Ask the same question about people who eat in a healthier manner and the same answer will come back – they feel “better.”

I find myself prescribing exercise. I tell patients that just like the medications I prescribe, it takes time for exercise to produce its effect as well. So while an antidepressant may take a couple weeks to begin to correct a problem, so too will exercise take time to do that equivalent rehabilitation. But it works.

Medicine knows that exercise and proper diet is so healthy. It is fully tied in to an attitude towards our own health, and it’s one that cannot be completed just by swallowing a pill. It is also tied into a laziness and assumption that the ‘rules of body-care’ do not rise to the level of concern such that some action takes place to improve the body. Depressions are often blamed for the lack of good diet and exercise. This can be true, but embracing exercise and diet will collaborate with other antidepressant treatments. Taking the time to let a medication work should be matched by taking the time to let our bodies make themselves as good as possible.

The question for the psychotherapy is why we are indifferent to or abuse ourselves. And course there are many layers of nuances controlling each one of us, but change is possible — it takes energy and willpower and patience to make it happen. We correct the psyche with medications and other therapies – why not correct the other systems in the body as well?

Let the body eat in a manner more normal to the animal that we are.

I wish that exercise and diet could reverse all aliments, such as removing obsessive-compulsive or thought disorders. It doesn’t, but it can make the rest of the person’s life so much better that the psychiatric issues can perhaps be less of a burden. This same logic applies to diabetes, blood pressure and a host of conditions.

A neurologist friend said that there may be a challenging disease affecting some part of the body, but it’s important to keep the rest of it as healthy as possible.

People very often ask me what I can do for them. It may sound trite, but I also tell them that if they put some energy into a better lifestyle then they could possibly do as much, if not more, to make their life better than I can do. A patient noted “humm, then there is already a medicine in me?”

Yes.

Let’s use the medicine within us.

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Psychotherapy Notes — The Nature(s) of Violence and Mental Health

Violence comes from different streams. We need to study it just as a civil engineer patiently plans where to build a dam to stop flooding. We can’t just put a dam anywhere. 

Reducing the tools of violence ought to reduce the ability to express the impulses that cause violence. The greater challenge is to remove those impulses. One aspect of this is for social pressures to clearly say that violence is not acceptable, and all efforts to settle problems need to be done otherwise. Shooters appear to be indifferent to prevailing social pressures, but some may sense violence is not accepted because they suicide before they are caught, knowing they will be punished. Do they dislike the punishment or is their own death part of their message as well?  People need to feel a community shame if they act violently, and an honor if resolution is done non-violently. Some sports release violent impulses, but modern rules limit the levels of violence from causing permanent damage, a safety net not known to many Romans and Mayans. (Think about cultures that are entertained by deadly sports; we do it symbolically.) Modern sports require reasonably, and equally, skilled and equipped competitors. School shooters or sexual abusers do not want resilient competitors.  

One form of common violence is done with clever manipulations of information or power, such as in legal or financial circles when one side tries to destroy or control the other. There may be no immediate physical violence, per say, but the effect can be quite violent in terms of what it does to the looser. We might call this a ‘gentlemen’s violence.’ No blood is spilled but it is still quite destructive. Verbal abuse falls into this category. Sometimes the competitors are equally matched, such as one political party or corporation competing with another similar group. But the competitors may be far from equal, such as a large corporation dealing with an improvised town or community. Violence is another way of saying “I want my way…” 

The other form of typical abuse involves intentional, physically damaging behaviors.  At times the two may cooperate in reaching a goal. 

So what causes violence? It is a mixture of a reaction to psychosocial stresses, our convictions, and our genes.

The genetic element is called a polygenetic phenomenon. There may be a predisposition to aggression during certain stress situations, lest these people would be violent all the time. Examples of these influences can be the gene code flaw for tryptophan hydroxylase, which modulates the production of serotonin, was has been found in people with impulsive or aggressive behavior. Or there may be abnormalities in catechol O-methyltransferase, which has been associated with hostility. Family histories of adult antisocial behavior increase the risk of conduct disorders, aggression, and antisocial behavior in children through mixtures of genetic and social-learning influences. Reduced 5-HIAA (a metabolite of serotonin) has been associated with aggressive acts, and increased dopamine in the mesolimbic pathways that respond to environmental cues is associated with irritability and aggression. Increased levels of norepinephrine in the central nervous system may produce increased aggression. Certainly other biological other systems are involved, but many of them still live outside of our knowledge base. 

Some medical conditions, such as a brain injury or seizures, might (rarely) manifest in violence. The combination of a grandiosity and delusional system could foster violence. And of course substance abuse is a pure venom to brain chemistry. Psychologically, violence seems to be associated with amalgams of self-rationalization, self-survival and self-importance. It is when “I want things done my way because …..”  

Mental illness might be described in social or religious terms, such as when a social group believes that anyone not agreeing with their convictions and life-style has a ‘mental illness.’ The actual numbers of the mentally ill, using general descriptions, that do violence is quite small. Violence can be from a type of mental illness because violence is ‘not valued a normal behavior’ in most societies, unless, of course the violence has a social sanction. (The victims might strongly disagree.) 

Violent people tend to have higher clusters of personality abnormalities. Our understanding of personality disorders is becoming more and more biological, but medications are still not as helpful in treating them as are sophisticated verbal therapies.  

When we hear that a shooter was on a psychiatric medication, we cannot assume that the basic diagnosis for which the medication was prescribed was correct. There is far too much under-diagnosing  of personality disorders, and medication use is often just an effort to soften some of the attached manifestations; it does not fix the problem. Increasing mental health screening may identify some of these folks, but it does little to both fund the proper training of therapists and to pay for the lengthy care these conditions require; good plans get watered down as the real costs begin to emerge. Many of these patients end up in jail because we lack the skills and resources to treat them in the open community.  

Then we see news reports like this: 

‘DES MOINES, Iowa (AP) (Jan 23, 2013) — Dozens of states have slashed spending on mental health care over the last four years, driven by the recession’s toll on revenue and, in some cases, a new zeal to shrink government. But that trend may be heading for a U-turn in 2013 after last year’s shooting rampages by two mentally disturbed gunmen.’ 

Huge increases in mental health money may not drop violence as much as wanted because the mental health filters may still miss this sub-group. Increased mental health funding will probably most reduce violence towards oneself, as in decreasing substance abuse or depression. There is no universal cause of violence. There are, however, many already known, measurable, and understandable triggers if we study and intervene, case by case. 

A current hot topic is if violent video games induce violent behaviors. A recent Florida Psychiatric Society podcast, The Experts Speak, (click here to listen) offers a good overview.

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Psychotherapy Notes – More questions than answers about school and other shootings

Perhaps the United States is just a violence prone society. The intentional homicide rate for the US is 4.8 per 100,000.  In Germany is it 0.8 per 100,000, and in the UK it is 1.2 per 100,000. In Germany 5.9% of homicides were with firearms; in the US it was 67%. (UN Office of Drug and Crime). Other areas or countries also have high rates, but let’s first focus on us because our numbers are so embarrassing.

 

The folks in Germany and the UK are biologically very similar to us, so there is no difference in this domain that ought to explain why our murder rates are 400% higher.  Therefore what non-biological differences exist to explain this? Is it a cultural mindset? Why, in what we self-declare as a civilized society, do we kill so many of each other with guns?  Has it become the easiest problem solving device?  Take away the deaths done with firearms and still the overall killing rate remains higher than our British friends. What is going on?

 

Would the impulse or choice to kill remain but simply be harder to carry out if there were no guns? Would the manner of killing merely shift? Might the core issue be that we do not mind killing each other as much as we would like to believe?  Why do we have so many more shooters in the US versus the UK?

I recall asking a prisoner charged with murder why he used a gun rather than a knife. He told me the gun meant he didn’t have to ‘get up close’ and he was less likely to endanger himself if he lost control of the knife.  Is it a different ‘murder temperament’ when a killer doesn’t mind ‘getting up close’? Another man said he loved the raw power and noise of a gun. “The gun said for me what I felt. And it was easy to get what I wanted.”

 

To understand the shooter we must go beyond the mental health of the shooter and look at the negotiating attitudes of our society.  We enjoy enemies and the process of defeating them. Much of our entertainment pivots on the fulcrum of using death to protect ourselves.  Do enemies give us individuality and strength?

 

School shooters are not soldiers or police because soldiers or police train to kill only if nothing else works; shooters rarely seek alternative non-violent solutions to problems. But maybe these school shooters felt they did try to solve their problems, but nothing worked for them? We must always wonder why any shooting “happened today and not yesterday? What made the difference?”

 

School shooters express their violence just once. It’s not a violence or crime spread out over time. It’s a stage show with its opening and closing at the same time, so therein rests a major difference between this group from a serial killer. The school shooter is not the typical killer. The school shooter is a public statement maker. How many school killings are unsolved murders? I suspect very few because they don’t hide their crimes. The ‘typical’ killer doesn’t want an audience. The question is what emotional statement lives within the school shooter, so explosive and uncontainable, that another venue won’t work for them? What mental process leads them to killing in order to publish their agony and arrogance?

 

We may never know if Lanza thought he could kill everyone in the school and then escape; this would be a very naïve miscalculation. I also wonder how many he emotionally needed to kill to ‘complete’ his statement? It would also be instructive to know the style of his relationships to his victims. Why these specific victims? Are they ‘symbols’ needing a demotion to death?

 

We don’t know.

 

But we do know he smashed his hard drive before the shooting. How odd – did he not feel a need to explain himself or his choices? The hard drive might have been his legacy to attempt to mitigate or absolve his actions. So he was violent both to others and to his own relics.  Perhaps his computer had been a friend that suddenly disappointed him.

 

Again, we don’t know. But this is the style of questioning we must develop to understand and hopefully reduce the likelihood of recurrent killings.

 

It’d be easy to drift away from the objective knowledge we have in this matter to lesser demanding notions that just happen to feel good because they ‘easily clarify and explain’ (accurately or not) his actions. It feels right when things make sense to us, even if the anchoring premise is wrong. That same process allows the shooter to shoot, for when any violence occurs, it is because the logic dealing with the situation suddenly says yes, it feels right or necessary to act in a violent manner.

 

Now a 15 year old killed five people in New Mexico.  Then a shooting in Texas!

 

We need lots of details and no opinions…

 

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