Many of my patients who have been diagnosed with PTSD describe their traumatic memory as if the event just happened yesterday. They tell me it feels dangerous to examine the memory and to allow it into their minds. They tell me that any reminder of the memory also feels dangerous. This makes sense for a variety of reasons.

First, thinking about the worst day or days of your life will understandably feel awful. Second, one component of PTSD is experiencing intrusive thoughts about the traumatic experience and other symptoms related to feelings of re-living the trauma, otherwise known as re-experiencing symptoms (American Psychiatric Association, 2013). Intrusive symptoms reflect the nature of PTSD as a recovery disorder (Resick et al., 2017). Although most people experience PTSD symptoms after a traumatic event, most people recover in a month or less. What does recovery mean? In part, it means that these individuals are able to think of the traumatic experience without feeling significant anxiety or distress. However, if the memory continues intruding into your conscious awareness and causing significant distress, it generally is a sign that the brain did not properly process the memory and place it into long term memory storage (Foa & Kozak, 1985). The brain thereafter keeps prompting intrusive thoughts about the traumatic memory in order to remind the individual to process and properly store the memory. Unfortunately, this means that the memory continues feeling very fresh, in a way that some patients describe as ‘hot.’

​These intrusive memories provoke anxiety symptoms because the brain continues believing this event to be a recent occurrence that we must be vigilant of and prevent from happening again. In addition, without proper processing and storage, the brain will continue forcing the memory into awareness but instead of allowing the memory to be present, individuals with PTSD push the memory away. The longer we try to avoid something, the harder it becomes to face and the more anxiety one will experience when the intrusion comes to mind. Therefore, from a psychological perspective, avoidance is one of the main reasons memories continue feeling dangerous. When we tell our brains, “hey, don’t think about that, it’s scary,” we develop a stronger fear response if we do not look. 

From a biological perspective, memories feel dangerous because they are activating the part of our brain that detects danger, the amygdala (Resick et al., 2017). Specifically, experts have explained this activation as part of the neurocircuitry model of PTSD (Rauch et al., 2006; Hughes & Shin, 2011) which suggests that three areas of the brain contribute to an extreme fear response to traumatic memories when an individual has PTSD. While the amygdala is over-reactive to the memory, creating a fear response to the memory, various regions in the part of our brain involved in rational processing, known as the prefrontal cortex, is under-reactive (Hughes & Shin, 2011). Therefore, the prefrontal cortex fails to remind individuals with PTSD that they are not rationally in any danger when they experience the memory (Rauch et al., 2006; Hughes & Shin, 2011). In addition, the part of our brain responsible for long-term memory storage, the hippocampus, functions abnormally in individuals with PTSD (the exact nature of these abnormalities are still being examined by researchers; Hughes & Shin, 2011). The abnormal functioning in these three regions interfere with fear extinction (Hughes & Shin, 2011). For these reasons, when I ask my patients with PTSD if it feels like the event is still happening, they often say yes, even if the event or events took place a decade or decades ago. 

Many of my patients feel like these memories will always feel dangerous. This is a fair assumption because, since the event or events occurred, the memories have likely triggered. The good news is, the memories are not actually dangerous and they do not need to be avoided. In fact, one major aspect of PTSD treatment is reducing and eventually eliminating avoidance of traumatic memories so that your brain can properly process and store these memories. We will eventually even help you process what are known as, hotspots, or the aspect of the traumatic memory that triggers the highest levels of anxiety or distress when re-experienced (Nijdam et al., 2013); oftentimes, hot spots represent the most terrifying aspects of a memory. Your provider will help you do so by using treatments and techniques that challenge avoidance of memories. One technique is called an imaginal exposure, in which processing takes place by imagining the event. By doing so, the brain will learn that the memory is actually not dangerous and is not still happening. The memory is in the past and we are here to help your brain recover from the past.

Please call 630-570-0050 or email us at [email protected] to get started with your healing process. 


References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007) Prolonged Exposure for PTSD: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press.

Foa, E. B., & Kozak, M. J. (1985). Treatment of anxiety disorders: Implications for
psychopathology. In A. H. Tuma & J. D. Maser (Eds.), Anxiety and the anxiety
disorders (pp. 421–452). Erlbaum.

Hughes, K.C., & Shin, L. M. (2011). Functional neuroimaging studies of post-traumatic stress disorder. Expert Rev Neurother, 11(2), 275-285. https://doi.org/10.1586/ern.10.198

Nijdam, M. J., Baas, M. A. M., Olff, M., & Gersons, B. P. R. (2013). Hotspots in Trauma Memories and Their Relationship to Successful Trauma-Focused Psychotherapy: A Pilot Study. Journal of Traumatic Stress, 26(1), 38-44. https://doi.org/10.1002/jts.21771

Rauch, S. L., Shin, L. M., & Phelps, E. A. (2006). Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research – past, present, and future. Biol Psychiatry, 60(4), 376-382. https://doi.org/10.1016/j.biopsych.2006.06.004

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD. The Guilford Press.

​As 2023 continues and a new month unfolds, I wanted to share some tools about staying motivated, identifying and resolving barriers, and engaging in healthy reflection in order to make & maintain progress toward goals using CBT.

Our thoughts are powerful. I think this becomes super evident during times of stress - all of a sudden, it's easy to downward spiral into thinking "nothing ever works out," "I always mess it up," and "nobody cares." The key is to slow down and recognize when words such as "always," "ever," "never," "nobody," and "everybody" play through your mind. Part two is to become curious. Some examples of becoming curious about these thoughts are: "Things have NEVER worked out before?", "Is there an example of a time when something did work out well?", "Do I ALWAYS mess things up?" "Is there a time where I did something and found success?"

Slow down, pause, and be mindful and curious about thoughts that include words such as "always," "never," "ever," "nobody," and "everybody."

Emotions are helpful in providing information. Here's some examples of how: anger is helpful and might inform a person that healthy boundaries need to be put in place in some area of life. Sadness is helpful and might inform other people that the person feeling sad may need some extra support and connection. Nervousness is helpful and might show a person what they care about. Fear is helpful and might alert a person to actual danger in order to stay safe. Emotions aren't "bad." 

It is common for clients to experience aversion to emotions, especially anger and sadness. The unfortunate reality is that emotions can't be cherry-picked, meaning I can't choose to avoid feeling angry and still hope to experience joy at full capacity. If I numb anger, overtime, I will also numb joy. Emotional identification, expression, and regulation are key techniques in experiencing healing & progress. 

To help clients identify emotions I sometimes ask clients to imagine what that emotion could look like. What color would anger be? How much room would it take up? Does it show up physically somehow - tensed muscles, an increase in body temperature? Using a feelings wheel can also prove to be beneficial in this stage of emotion identification.
To help clients express difficult emotions, I will reflect the emotion I see based on how the client identified it would look like. I pause for a minute. Silence is helpful in providing intentional space for emotions that may have been invalidated in the past. 
To help clients emotionally regulate, I'll invite clients to practice a grounding exercise and one of their favorite breathing techniques.

Emotions aren't "bad." However, sometimes the behaviors that follow as a result of the emotion can be unhealthy and unhelpful. This is part of the process where clients begin unlearning ways of being that are no longer helpful. Let's use this example: "I'm not good enough and always fail at things" --> leads to feelings of X (maybe anxiety, sadness, anger, etc.) --> leads to X behavior (avoidance of activity, numbing/excessive use of substance or social media, etc) and the cycle continues. Due to the behavior including avoidance of the activity in an attempt to minimize difficult emotions, the unhelpful thought of "I'm not good enough and always fail at things" is reinforced. 

The goal is to educate clients about the connection between thoughts, emotions, and behaviors and then to increase awareness of the internal thought process and how it impacts emotions and behaviors. 

I'd ask what type of behaviors would become easier if happiness was experienced and anxiety lessened? What barriers, if any, need to be identified and resolved? And then together, that's how an action plan is created. Action plans can be written down or they can be verbalized. Clients would also be encouraged to "give themselves credit" once they accomplish parts of their action plan that week - that could look like practicing verbal affirmation or writing a positive affirmation on a post-it note.

Prior to the end of a session, clients are asked to summarize what the action plan steps are for the week. This helps clients feel confident in being capable of producing change in their own lives.