Showing posts with label post traumatic stress disorder PTSD. Show all posts
Showing posts with label post traumatic stress disorder PTSD. Show all posts

Dialectical Behavior Therapy

Earlier, I discussed emotional control through the practice of Stoicism. This article about Dialectical Behavior Therapy (DBT) goes deeper into the 'reflective' stage of that process. DBT is a type of psychotherapy that can help you to manage your psychosocial pain points; like situations over which you have no control,  common trauma response of reliving serious trauma, other post-trauma maladaptive responses, ongoing circumstantial vulnerability caused by complex trauma, etc.

Complex trauma often results from prolonged exposure to distressing events, leading to intricate psychological effects that can manifest as C-PTSD. Individuals may continue to experience symptoms such as flashbacks, emotional disregulation, and difficulties in relationships. In this context, the general public's impatient assertion that such people choose to cling to the past, to not "let go" can feel overwhelming or even invalidating, because it overlooks the depth of suffering involved. However, DBT is a more empathetic and solutions-oriented response to the suffering. The DBT approach does not imply forgetting or minimizing the impact of trauma. Rather, its compassionate take on the 'letting go' idea suggests a shift in how one relates to those experiences to foster resilience and healing. 


Interrelated Core Principles of DBT (dialectics, validation, radical acceptance) for resetting your perspective and coping:

  • Dialectics: DBT recognizes that two seemingly opposing ideas can be true at the same time. The following examples illustrate how dialectics can be applied to complex and challenging situations, allowing individuals to hold multiple perspectives and work toward integrating other perspectives to have an overall more balanced approach. This is key because focusing on the negative extreme is a human default. In fact, it is a defense mechanism to prepare oneself for potential danger. Unfortunately, it is easy to become polarized in difficult circumstances by being hyperfixated on negativity. However, dialectics is a form of de-polarization and balance (and reminiscent of the purpose of the hermetic principle of polarity; ie to become depolarized). Dialectics demands your cognitive agility. On that basis, I remember the 2 of Pentacles tarot card ... and even 5 of cups tarot card that encourages you to recognize that; while 3 cups have indeed spilt, if you turn around, you will see that 2 other cups remain un-spilt behind you and a bridge is also there to the other shore. In short, rather than see circumstances as 'either negative or positive', DBT encourages one to see challenges from the 'negative AND positive' angles. So rather than feel stuck in feeling vulnerable, you may find ways to pivot situations to say “While I am vulnerable in this situation (negativity), I am also strong (positive)” or “while I am capable of taking care of myself (masculine energy), I also need support (feminine energy).” While discussing emotional control through stoicism, I mentioned that, during a painful stoic 'pause', exploit your brain's neuroplasticity. In other words, train your mind to use dialectical reasoning to form new neuropathways. Here are some more examples.
    • Accepting a traumatic past while preparing for change in the future
      • A person with complex PTSD may need to acknowledge their traumatic experiences are a part of their history, while also working towards creating safer circumstances for a more hopeful future.
    • Embracing vulnerability while maintaining self-protection
      • Someone who has experienced trauma learns to be vulnerable and open with others (the right people), while also maintaining healthy boundaries and self-protection strategies to ensure their safety and well-being.
    • Acknowledging powerlessness while taking control
      • A person in an abusive situation acknowledges their powerlessness, while also taking control of their own actions and making decisions to prioritize their safety and well-being. This includes the empowerment that learning DBT and creating new neuropathways provides.
    • Practicing self-compassion while holding oneself accountable
      • Someone with a traumatic past is self-compassionate by acknowledging that maladaptive responses (like PTSD, anxiety disorders, dissociative disorders, cognitive distortions, social anxiety & awkwardness etc) are natural responses to their circumstances, while also learning better ways of responding to stressors.
      • A woman may feel overwhelmed and helpless due to a chronic illness. Erotical acceptance involves acknowledging the reality of her condition, accepting the limitations and challenges it brings, and focusing on her response and coping strategies, such as self-care and seeking support, rather than resisting or fighting against the illness.
    • Accepting the need for support while striving for independence
      • Someone accepts that they require meaningful support (like therapy or support groups), while also striving for independence and self-sufficiency (researching and shadow working on their own).
    • Recognizing the complexity of emotions while simplifying self-care
  • Validation: DBT emphasizes the importance of acknowledging and validating painful emotions and experiences. I must stress that if you are among those without support systems, like family, mental health professionals, police and or legal remedial services, prepare to do this for yourself.
    • A lady who has suffered trauma validates her emotions, such as anger or sadness, while also learning to counteract the distressing cognitive distortions that occur as a consequence.
  • Radical Acceptance
    : Accepting reality as it is, not as you want it to be. You can neither change nor avoid the painful reality. This is a painful, hard pill type of skill that involves pulling the plug on hope of some resolution of undesirable situation. Example(s) of applications.
    • Toxic relationships. You now accept that your best efforts through overexplaining and overcompensating will NOT make a difference. These attempts never have in the past and never will. This is because the other party, abusers (whether narcissistic individuals or groups, their flying monkeys, and so on) will never stop the abuse. This is a no-holds-barred turning point of knowing that there is absolutely nothing more you can do or will try to resolve the situation. For instance, you will no longer live in hope that 'maybe after X happens, or if I just do X more, or accomplish X.' as it relates to relatives, professional colleagues, distinct social groups, and so on. Radical acceptance therefore means 1) grieving loss, often significant loss; such as hope of having a secure childhood, secure parent-child bond, meaningful friendship, marriage, acceptance in a community, working relationship, and fulfillment of dreams. Radical acceptance also means 2) you no longer hide in denial and are therefore consciously facing heavy emotions due to your loss.            Dr Ramani 'A painful look at narcissistic relationships. Radical acceptance' (above video)
    • Self-relationship. You now accept yourself fully, regardless of shortcomings, imaginary, real or set by society. This is a matter of unconditional self-love. Self-lovers see their 'imperfections' as elements of cherished uniqueness. In social circumstances, this involves not trading one's authenticity (which may simply be a difference from the social norms) to get approval from others. In other words, you are unapologietically yourself. Dr Femke Bakker used a fitting analogy of how loving parents would respond by encouraging their child who falters while learning to walk. Rather than be critical, shout at or condescend their child, they accept their child as she is in the present moment. They are patient, recognizing that their wish for a walking child will not happen overnight. This heart posture means they handle their child's daily struggle with empathy and compassion. Listen to her Ted Talk about 'self-gentleness (aka radical self-acceptance)', especially if you are driven to perfectionism in situations but are not performing perfectly. Since perfectionism is often a trauma response, the concept of self-gentleness is particularly important as you 'learn to walk' (thorny situations). Be patient with yourself. Example(s): being overwhelmed by simple tasks is not laziness but executive dysfunction; anxiety disorders is a symptom and not a reflection of your stupidity; open admittance of trauma response disorders that you had previously tried to hide through shame (by others); binging on your guilty pleasure is self-soothing / a search for a dopamine fix; neurodivergence is a symptom and not a reflection of your intelligence; etc. To be clear, this is not about being complacent with poor habits. Instead, it is a first step that can lead to positive change because openly acknowledging an issue is a way of bringing it to the forefront of your consciousness so that it can be resolved. Example(s): AA attendees usually openly introduce themselves as 'alcoholics' in group meetings in which they attempt a 12-step healing program.
    •   YouTube TEDx Talks video 'The power of self-gentleness | Femke Bakker | TEDxLeidenUniversity'
      YouTube short-form video by DoctorRue 'Radical self acceptance'
      YouTube short-form video 'Why you should practice radicatl self-acceptance'

How to apply DBT in your daily life 
Here are the 4 key components of any DBT practice. Since each component is customizable, own the design of your process so you can enjoy and remain committed.
  • Mindfulness: mindfulness practices emphasize the importance of being present and fully engaged in the present moment without judgment or distraction. Examples 
    • deep breathing, meditation (seated, guided, ecstatic dancing), progressive muscle relaxation, adult coloring books
    • Individuals with PTSD often experience flashbacks, which are intrusive memories that can feel as though they are reliving the traumatic event. Mindfulness skills can help you to stay grounded in the present moment. Examples. You can practice the “5-4-3-2-1 technique”. This requires you to focus on your 5 senses by identifying: 
      • 5 things they can see around them,
      • 4 things they can touch,
      • 3 things they can hear,
      • 2 things they can smell, and
      • 1 thing they can taste.
By focusing on these sensory experiences, you redirect your attention away from the flashback and back to their current moment, reducing the intensity of the trauma-related symptoms.

  • Distress tolerance skills. To describe this practice in short form; it is about accepting pain without unnecessary and additional suffering. This is achieved by using healthy distractions. These healthy destructions help you to select thought patterns that are better than ruminating and causing intense emotional suffering and to be clear healthy distractions are not the same as avoidance. Examples.
    • Self-talk in your head or allowed when triggered as by the news or when hearing about or from someone who caused you pain. 
      • I cannot change what has already happened. [Do not relive the painful moments trying to figure what you should have or could have said or done instead Develop some type of releasing, aka 'defusion', like imagining the memory as a black balloon that you release into the wind as you redirect your focus to something else, perhaps a white or colorful balloon with something specific .... Or you can focus intensely on the present moment.]
      • This moment is the outcome of multiple turns in the past do not agonize over 'what-if' scenarios like if you had just returned the call the night before, given x detail and so on.
      • Read about Mel Gibbon's What if it all works out mantra that frees her brain from focusing on only the worst, most catastrophic of multiple probabilities 
    • To cope with nightmares through Distress Tolerance Skills. self-soothing is a form of distress tolerance to cope with overwhelming emotions and situations without resorting to avoidance or harmful behaviors. This involves engaging in calming bedtime routine activities like:
      • taking a warm bath,
      • Listening to soothing music,
      • Practicing deep breathing exercises
      • Using aromatherapy
      • Declaring sleep time intentions 
    • In acute distress situations that might trigger dissociation, use these distress tolerance steps.
      • Step 1: Identify a distressing situation or feeling (e.g., feeling overwhelmed by memories).
      • Step 2: Use the “TIP” technique (Temperature, Intense Exercise, Paced Breathing) to manage acute distress:
        • Temperature: Splash cold water on your face or hold ice cubes; this can help anchor you to reality.
        • Intense Exercise: Engage in physical activity like jumping jacks or running in place for a few minutes.
        • Paced Breathing: Practice slow, deep breathing like 'box breathing' to calm the nervous system.

  • Emotion Regulation Skills: Strategies such as identifying and labeling emotions, understanding emotional triggers, and using coping skills to manage emotions.
  • Interpersonal Effectiveness Skills: Techniques such as active listening, assertiveness, and boundary-setting to improve communication and relationships.
    • Assertiveness in interpersonal relationships might help you if you fear rejection or misunderstanding (that might arise from expressing your needs or feelings). Use “I” statements to express your needs and feelings (ie versus'you' statements). Example; Instead of saying, “You never listen to me,” say, "I really need to be allowed to complete each idea without interruptions/ for someone to take action on XYZ / the direct communication I" or “I feel ignored when I share my thoughts but [describe the person's triggering behavior] like do not get any kind of response.” If the counter party is worthy, this approach is likely to be received as not blaming them.
    • Unapologetically set boundaries to prioritize your mental health while remaining being polite and respectful towards others. Example; say, “I appreciate the invitation, but I need some time for myself right now or I need time to think about that before committing or I needed the scores from your professional observations so I can keep track and really engage in my progress.” 
    • Assuming that the other person is worthy and has good intentions but does not yet understand how to meet your needs, say "If someone does x (like grab me suddenly), that makes me feel  unsafe because it triggers my anxiety.


Who Can Benefit from DBT:

  • People with post-traumatic stress disorder (PTSD): DBT can help individuals manage symptoms of PTSD, such as flashbacks, nightmares, and avoidance behaviors.
  • Anyone seeking to improve emotional regulation and relationships: DBT can be beneficial for individuals looking to enhance their emotional intelligence, communication skills, and overall well-being.
  • Those struggling with emotional dysregulation: DBT can help individuals manage intense emotions, reduce self-destructive behaviors, and improve relationships.


CONTENT RELATED TO DIALECTICAL BEHAVIOR THERAPY


Post Traumatic Stress Disorder PTSD

Post Traumatic Stress Disorder or PTSD for short (or previously shell shock or battle fatigue syndrome), is a 'disorder of extinction' (abilities) in response to an extremely terrifying traumatic event, either through experience or as a witness. The new DSM-5 classification of this disorder as one of extinction emphasizes the fact that sufferers are disordered in the normal extinction process of an understandable fear response. Sufferers are unlike the general population that usually recovers or 'extinguishes' normal fear response within 1 month. In short, a pivotal characteristic of this diagnosis is persistence or the inability to cause extinction. 

PTSD may also be considered as a group of symptoms that may occur as a result of the trauma. The US Diagnostic & Statistical Manual, 5th Edition (or, for short, DSM-5) of 2013 has recently re-classified PTSD (from among 'Anxiety Disorders') to  'Trauma & Stressor-Related Disorders'. (Read an article or see the video below for an introductory summary about this classification). This classification therefore reinforces the idea that the inability to extinguish fear relates specifically to some type of trauma.

This post will discuss the symptoms (the core ones of which include re-experiencingavoidance, and hyperarousaland conditions as set out by the DSM-5 that should be present in order for a diagnosis of PTSD

Criterion A: On of the following list of types of exposure to a traumatic event called a 'stressor' (at least one is required). Common traumatic events include the following. BTW, Interpersonal trauma are more likely to be a cause than other types. However, the other types are more likely for those with acute childhood trauma, especially if the person lacks social support systems. Example(s): war / combat; sexual violence, like rape or even THREATENED sexual violence; real OR threatened injury; violent muggings; accidents; natural disasters

  • direct exposure
  • witnessing the event
  • learning that someone close was exposed to the event
  • indirect exposure to details of the trauma, commonly in the course of professional duties, as in the case of first responders, and medics. 

 
Criterion B: At least one of the following symptoms of some type of INTRUSION (ie unwanted interference) aka re-experiencing. This criterion may be likened to a haunting by the ('ghost' of the) traumatic event. Essentially, although the event occurred in the past, it forces the sufferer to re-experience it. These intrusions can take several forms that include the following and are often triggered by something the sufferer perceives as similar to the initial traumatic event. Personal triggers are very personal and can include anything at all; from physical attributes (that resemble those of an attacker), tone of voice, a touch in a way that has some personal significance to the sufferer, certain type of behavior observed in others (like movements, mannerisms, speech, management style, etc), to objects and so on. In a sense, re-experiencing is like a mild form of dissociative identify disorder in that another fragmented part of your past self 'fronts' and as Dr Dawn Elise (aka on YouTube as Doc Snipes) said in her video while discussing C-PTSD, these fragments need to be fragmented.
  • Flashback re-experiences. Flashbacks can be very frightening. Unlike normal memories, a flashback is the sensation that the traumatic event is happening all over again, happening right now, replacing the present scene.
    • In severe cases, this may even cause dissociative states.
    • Video about somatoform symptoms, ie physical re-experiencing of past trauma: 'When Dissociation Gets Physical' by CTAD Clinic (Dr Mike Lloyd)
  • Frequently having unwanted, upsetting thoughts or memories about a traumatic event
  • Being physically responsive to reminders of the traumatic event (for example, feeling a surge in your heart rate, for starting to sweat)
  • Having very strong feelings of distress when reminded of the traumatic event
  • Nightmares
  • Distress (like emotional) after exposure to traumatic reminders
  • Physical reactivity after exposure to traumatic reminders

Criterion CAt least one of the following forms of AVOIDANCE. Avoidance is also a key component in the diagnosis of complex trauma and dissociative conditions. Avoidance is a natural and inevitable response to trauma. After a traumatic event, people generally try to avoid trauma-related stimuli / triggers, whether internal (like feelings) and or external (reminders). However, as discussed otherwise regarding anxiety phobic responses, avoidance becomes a diagnostic criterion when the sufferer's avoidance interferes with his or her ability to have a normal life. In the normal population, persons eventually overcome the  avoidant behavior and continue with their life as before. Unfortunately for those who can not do this, while avoidance offers short term relief (like a drug) to the sufferer, continuing to depend on it like one might an addiction can interfere with normal life over the long term. Too much avoidance eventually leads to simply engaging less in life. Essentially, the avoidance therefore creates a situation of loss of whatever the sufferer would have done in enjoyment of their life. Worse still, the actual phobia may remain unresolved over the long term. For instance, if you are fearful of driving again after a vehicular accident, the accident is still controlling you, even though you think that you are avoiding the reality of it. This is why treating trauma-related avoidant behavior is very important.
  • Trauma-related external reminders. Example(s):
    • avoiding the scene of an accident, taking smaller country roads versus major highways or being a passenger of a car after an accident
    • avoiding places like countries, homes of certain people, stores, neighborhoods, etc
    • avoiding situations like work places, employment characterized by bullying and other harmful behaviors.
    • avoiding contact with society by driving at only certain times of the day and avoiding public locations.
    • avoiding relationships (like sexual relationships) that are reminiscent of a toxic relationship (perhaps in which rape occurred).
  • Trauma-related thoughts or feelings / internal triggers. Example(s):
    • having dissociative amnesia or sinking into dissociative states push away emotional connection to traumatic events
    • forcing oneself to becoming emotionally numb (which avoids pain ... but also joy in life)
    • Addictions: substances (drugs, food, etc); gambling; escapist activities


    Criterion D: At least 2 forms of NEGATIVE ALTERATIONS IN COGNITION AND MOOD.
    Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
    • Inability to recall key features of the trauma. / altered sense of reality of one's surroundings or oneself
      • This is a dissociative state.
    • Overly negative thoughts and assumptions about oneself or the world
      • Feeling ashamed of one's own trauma response symptoms
      • Living, stuck in a constant state of fear.
    • Exaggerated blame of self or others for causing the trauma
    • Negative affect
      • Persistent inability to experience positive emotions like happiness, satisfaction or loving feelings.
    • Decreased interest in activities
    • Feeling isolated
      • Detachment from others.
    • Difficulty experiencing positive affect


    Criterion E: Sufferers may have alterations in arousal and reactivity. (This is not a required criterion). Hyperarousal refers to an abnormally heightened state of anxiety. This may make sufferers more sensitive and overly responsive to stimuli and events in the world around Signs and symptoms include the following.
    • Chronic anxiety
    • Panic attacks
    • Difficulty falling or staying asleep. This is very common. Note that many people with PTSD have comorbidity with major depression disorder (MDD), which has sleep disruption as one key feature.
      • Some people try to avoid nightmares (one form of intrusion), thereby disrupting their sleep cycle.
      • Night time is very scary by virtue of being dark with unknown sounds that can trigger fear.
    • Being constantly on guard for threats (hypervigilance)
    • Heightened startle reaction. Being easily startled (excessive startle reflex)
    • Sufferers often can no longer walk through life with the same level of pre-trauma calm. 
    • Difficulty concentrating
    • Anger and angry outbursts
    • Irritability or aggression
    • Risky or destructive behavior.
      • Reckless behaviors are common among sufferers like 
        • reckless driving among war veterans 
        • reckless sexual behavior among sexually assaulted children. 

    Criterion F: The symptoms are required to last for AT LEAST 1 MONTH for the diagnosis. This is noteworthy because anyone in the population is likely to demonstrate the symptoms of PTSD after a traumatic event. However, the difference between someone who can be diagnosed as having the condition is the persistence of the disorder beyond what occurs normally in the population (which is 1 month). In other words, under normal circumstances (for the majority of cases), people recover and 'extinguish the fear', ie stop having the symptoms over time. In contrast, someone suffering with PTSD does not get better. In fact, this disordered way of dealing with fear, ie the inability to overcome the fear as normal is the reason for the classification of this disorder. (This criterion is key for differentiating PTSD from acute stress disorder or ASD that can occur to anyone in the general population but not beyond roughly 1 month.)

    Criterion G: Significant functional impairment (social, occupational, etc) is required.

    Criterion H: Exclusions are conditions that should not be related to the symptoms. If they are, the sufferer can not be considered to suffer from PTSD.
    • the effect of substances
      • drugs (pharmaceutical or otherwise) and alcohol 
    • another medical condition 
      • mild brain injuries


    Correlations (biological factors)

    Correlations include the following. 

    • dysfunctions in hypothalamic-pituitary-adrenal axis (or HPA axis). The HPA axis relates to the interaction among the 3 and, by extension how the body responds to stress.
    • Deficits in the sleep and arousal regulatory systems. In other words, the person is likely to have challenges maintaining a healthy sleep cycle, likely due to insomnia. Their body and mind's responses are prone to anxiety disorders as they are unlikely to handle stressful situations with feelings of anxiety that are at normal levels for the general population, especially as they relate to circumstances that are similar or reminiscent of the original trauma. 
    • dysfunction in the endogenous opioid system. This system naturally creates and releases opioids throughout the body in ways that can promote pain relief, sedation, slowed breathing and euphoria. It therefore helps in managing mood, stress responses and pain. Its arsenal involves the central and peripheral nervous systems. 

    Considerations (Family History)

    PTSD is also correlated with a family history of mood and anxiety disorders.


    Treatment(s) for PTSD

    • Exposure therapy has proven very effective.
    • Group therapy
    • Medication 
      • anti-depressants like Selective Serotonin Reuptake Ibhibitora /  SSRIs
      • anti-anxiety medications that decrease psychological arousal like Clonazepam 
    • Sleep aids
    • Self medication, ie the use of alcohol and other substances. Unfortunately, when abused, these substances can worsen symptoms.


    CONTENT RELATED TO POST TRAUMATIC STRESS DISORDER (PTSD)
            
    • Food for thought

    Internal links

    Other
    • NF music


    Challenges with mental health and fatigue from masking neurodivergence are clues that helps in recognizing neurodivergence, especially for boomers and generation Xers.