James Knipe on PTSD

This is a 25 minute talk that James Knipe gave at the IDA Brain Ideas Symposium last year 2015.

A good introduction to traumatic memory and treatments for them.

Video Transcript

In this segment, I'll delve into post-traumatic stress disorder (PTSD) for 20 minutes. Within that time, I'll touch on one of the two primary successful treatments for PTSD. While we can't cover everything in detail, I aim to highlight essential aspects of PTSD and its treatments. Fortunately, many of you already possess a good understanding of PTSD. It's been around for centuries, but it only gained diagnostic recognition in 1980. Previously, it had names like 'war insanity' during the Civil War, 'shell shock' in World War I, 'combat neurosis' in World War II, and 'post-Vietnam stress syndrome' in the 1970s. Since 1980, we've been using the term PTSD. While it was initially thought to be untreatable, this is a myth. PTSD is highly treatable, contrary to the belief that people 'will never get over this.' Let's explore further.

Another common misconception about PTSD is the belief that if people just apply enough willpower, they'll overcome it. Those with this condition often encounter others suggesting that it's time to move on and forget about it. However, it's not that simple, and there are reasons behind it. Let's explore why. These ovals serve as a visual representation of PTSD. The green area symbolizes an individual's entire conscious mental life, encompassing their understanding of the world and themselves. The red portion represents a memory of a traumatic event.After a traumatic event, an extremely distressing experience that is beyond comprehension at the time, the memory of it becomes incorporated into the person's usual way of thinking. However, in the case of PTSD, the traumatic event can flood into a person's awareness, disrupting the normal process of information processing. Typically, when something distressing occurs, our brains process it in a way that doesn't necessitate therapy. For instance, passing by a highway accident might lead to images flashing in your mind, discussions about it, or even dreams. Yet, as time passes, the memory naturally becomes less disturbing, and its impact diminishes. This adaptive learning occurs for most of us as we process distressing information. However, for those with PTSD, the way the brain responds to events becomes dysfunctional.

Trauma, on the other hand, is an experience that falls outside of a person's normal ways of functioning, making it challenging for the brain to incorporate the event into its existing narrative of life. This failure in the information processing system results in two simultaneous states of mind within the individual. For instance, consider a person who escapes from a burning house. In the immediate aftermath, they may have a brief moment of feeling like they are about to die, but then they manage to get out. The next day, everything in their life remains the same, yet now they carry the memory of the traumatic event.

In cases of trauma, there's a distinct pattern: when the person starts to think about the traumatic event, flashing images flood their mind, accompanied by intense terror. This leads to avoidance behaviors, like not wanting to revisit the area where the event occurred or avoiding reminders of it altogether. Additionally, there might be heightened arousal or a constant sense of alertness.

Traditional psychotherapy offers some help for PTSD, though its effectiveness is limited compared to newer methods. The two primary approaches I'll discuss are Eye Movement Desensitization and Reprocessing (EMDR) and cognitive behavior therapy, including prolonged exposure and cognitive restructuring. These methods have garnered endorsement from numerous national health organizations as effective treatments for PTSD.

EMDR and cognitive behavior therapy (CBT) have been endorsed by various national health organizations as effective treatments for PTSD. Traumatic memories stem from a failure in the brain's natural information processing system. The goal of therapy is to transform traumatic memories into what we can call "normal memories," memories that don't flood into consciousness unwelcome with flashing images.

For example, a survivor of sexual assault reported experiencing unprocessed re-experiencing of traumatic memories triggered by certain reminders. Despite having talked about the trauma in therapy and feeling safe with her partner, these traumatic memories would disrupt her thoughts and feelings, preventing her from connecting with safety and a sense of normalcy.

PTSD is characterized by hyperactivation in brain areas such as the hippocampus, amygdala, and insula. During PTSD flashbacks, the frontal lobes' activation, especially Broca's area responsible for language, is relatively weak. This results in a speechless experience of reliving, where individuals struggle to articulate their experience.

Trauma isn't merely a distortion in memory recall; it's a distortion of perception in the present and prediction of the future. The unprocessed traumatic memories can create a blockage between the two, causing an inability to connect and hindering the individual's experience of safety and normalcy.

This provides an overview of PTSD and the mechanisms behind its impact on memory processing and perception. Effective treatment methods aim to alleviate these effects and help individuals regain a sense of normalcy.

Individuals with PTSD might perceive present events through the lens of their traumatic past. For instance, someone who has experienced sexual abuse might view new people as potential threats. Similarly, individuals who have survived auto accidents may become hyper-vigilant while driving, constantly checking their rearview mirror due to trauma triggers. PTSD also skews expectations about the future.

CBT is one of the two effective methods for treating PTSD. It aims to increase a person's present orientation and cultivate a sense of safety. This helps the individual recognize that they are more than their traumatic memories. The therapy involves discussions that challenge illogical thinking patterns, fostering a new cognitive understanding of the traumatic event.

During CBT, therapists engage in discussions with clients to help them develop a new cognitive perspective. For instance, an individual blaming themselves for the trauma might progress to realizing it wasn't their fault. These discussions lead to a revised cognitive understanding that diminishes the power of the traumatic memories.

This overview demonstrates how PTSD distorts perception and how cognitive behavior therapy works to reshape cognitive perspectives, reducing the impact of traumatic experiences.

In cognitive therapy, traumatic memories are gradually diminished and eventually healed through a process that helps reshape cognitive understanding. Research supports cognitive therapy as a legitimate treatment for adult-onset PTSD, typically requiring 12 to 20 sessions. Part of this method involves the client recording the traumatic event and listening to it daily.

Alternatively, I prefer using Eye Movement Desensitization and Reprocessing (EMDR). In EMDR, the process begins by creating a sense of safety in the therapist's office. The client must hold the traumatic memory in mind while maintaining dual awareness of the safety of the environment. Next, the therapist guides the client to focus on the traumatic event and associated sensations, following bilateral stimulation (eye movements, taps, or auditory tones) for short intervals.

This process continues, allowing the client to report their experiences at each stage. This dual focus and bilateral stimulation facilitate the processing and desensitization of traumatic memories, leading to their eventual healing.

Through EMDR, traumatic memories can be transformed from distressing experiences to normal memories, leading to their resolution. This healing process includes integrating the traumatic event into one's life story and boosting self-esteem. Skepticism about EMDR is common due to its unconventional nature—watching a therapist move their fingers as a form of therapy seems unusual. However, EMDR's efficacy is supported by numerous international organizations. While clients might initially doubt its effectiveness, belief is not a prerequisite for its success.

EMDR involves several phases. It starts with history taking, understanding the client, and explaining the process. Stabilization ensures clients can maintain awareness of their surroundings while reflecting on their traumatic experiences. Assessment targets the key elements of the traumatic memory, including visual imagery, negative self-cognitions, emotions, and body sensations. These elements are processed using sets of bilateral stimulation, leading to the reduction or elimination of emotional disturbance.

Research demonstrates the effects of bilateral stimulation, such as eye movements, during recall of emotionally charged memories. This process lowers sympathetic arousal and expands associations related to the event, allowing clients to view the memory in a broader context. Peer-reviewed studies support EMDR's effectiveness, and its unique approach sets it apart from other therapeutic methods.

Research results consistently highlight EMDR's effectiveness in comparison to no treatment and other therapeutic methods. EMDR has been shown to be on par with cognitive behavior therapy, though it boasts certain advantages. Unlike cognitive therapy, EMDR doesn't necessitate homework completion, which can be challenging for clients. Homework often involves listening to audio recordings of their trauma, which may not be appealing. This study was conducted after a major earthquake in Turkey, where EMDR was introduced as a method of treatment.

After the earthquake in Turkey, a training program was established for therapists to utilize EMDR as an alternative to conventional methods. The study involved a select group of 41 individuals who received EMDR therapy. The bar graph displays pre-therapy, post-therapy, and six-month follow-up scores on a PTSD measure. Significant improvements were observed across all measures, including re-experiencing, avoidance, and arousal levels. The average number of sessions required for this progress was 5.1 sessions.

Many participants in the study were already taking SSRI antidepressants, like Zoloft. Both those on medication and those not on medication saw notable reductions in PTSD symptoms. Notably, most individuals on medication at the start of the study had spontaneously discontinued their medication by the six-month follow-up. The study demonstrates the effectiveness of EMDR in treating single-incident trauma, though it should be noted that complex trauma cases also exist, often stemming from difficult childhood experiences.

Traumatic experiences are closely linked to various problems in adult life, as shown by a significant correlation between accumulated traumatic events and subsequent issues such as physical diseases, addictive disorders, and mental health problems. This indicates that traumatic experiences play a substantial role in the development of mental disorders. While it's recognized that certain conditions like schizophrenia and bipolar disorder involve brain functioning issues, histories of abuse and neglect are prevalent in these cases as well.

EMDR has been a significant focus for me, largely because it addresses a critical aspect that traditional therapies struggled to manage—the emotional aspect of trauma. While insight into one's problems can be gained through therapy, the emotional distress often persists. EMDR, which I discovered in 1992, fills this gap by effectively addressing the emotional dimension of trauma, making it a valuable tool in my therapeutic arsenal.

Research in various areas supports the effectiveness of EMDR in resolving specific problems associated with traumatic memories. This approach has shown positive results in treating problems such as pedophilia and phantom limb pain, which were previously considered challenging to address. EMDR's success is demonstrated not only through verbal claims but also through physiological measures, validating its impact.

Many individuals seek therapy with a history of multiple traumas, making it important to address these complex experiences. EMDR offers a method to effectively work through these multiple traumas, helping individuals find resolution and healing.

Psychological defense mechanisms come into play when individuals face multiple traumatic events or ongoing traumatic situations, which could lead them to adopt ways of protecting themselves from being overwhelmed by these memories. These defenses include denial, avoidance, excessive anger, addictive behaviors, and idealization. It's important to note that defense mechanisms aren't necessarily negative; they are strategies people unconsciously employ to manage the emotional impact of their trauma.

Dysfunctional life experiences can influence personality development in various ways. Some individuals may come to therapy with an experience like the first oval, where they have few traumatic memories. Others may have a vast amount of unprocessed traumatic material, leading them to form defenses that block the emergence of these memories. Defenses can take the form of avoidance, idealization, dissociation, or shame. Those who have experienced neglect early in life followed by traumatic events may struggle with access between different self-states.

Effective therapy can lead to the absence of intrusive traumatic memories, reduced feelings of fear, hopelessness, anger, and shame, as well as a shift in negative self-perceptions. Increased self-esteem and a clear understanding that the traumatic events are part of the past and don't define the present can be achieved through therapy. Unification of different self-states, particularly those presenting outwardly as "normal" and those harboring secret and painful memories, is an important outcome of therapy.