Paramedics and PTSD: Trauma and Memory

tumblr_n2whvtmopn1sn5q1vo1_500

In this post we’ll look at the impact of trauma on memory and what that means for someone living with PTSD.

This is one of the things that I struggled to convey to people after experiencing my trauma. Each time I complained that I thought my memory wasn’t working the way it should, the way I was used to it being, I was told that inability to concentrate was a common symptom of PTSD. It was explained to me that the brain was attending to too many things in my environment and that it had little resource left to move things from short term to longer term storage. I was reassured that everything would return to normal once I was “healed”.

It was difficult to explain exactly what it was that I was experiencing that felt so disturbing to me. I would say things like, “My timelines seem screwed up in my memory.” and again, I would be met with the “inability to concentrate” excuse which didn’t quite fit what I was sensing, especially since my re-experiencing symptoms had lessened and were far less impactful to my day to day. It wasn’t until I heard it actually explained to me via Bessel Vander Kolk in the Treating Trauma series through NICABM, that any light-bulbs popped on in my head. I spent 8 years looking for this answer that had been out there all along.

Okay, so this may be a little bit difficult to follow but I’m going to try to keep it as clear as I possibly can. To fully understand how trauma impacts our memory we first have to understand that there are two major categories of memory and four subtypes of memory and that because trauma directly affects the brain, it also directly impacts these four types of memory.

The first major category of memory is called Explicit or Declarative memory, it is a conscious memory and involves awareness of facts or events that have happened to a person. It sounds pretty straight forward but this category is further subdivided into two additional types of memory, semantic and episodic.

Semantic memory is the memory of general knowledge and fact; these are memories that help you to identify things in your environment, like to know a bicycle is a bicycle, or know what a television is. It is essentially our general knowledge of the world around us.

Episodic memory is the other sub-type of our declarative memory system, and it is our autobiographical memory of an event or experience – the who, what and where of that event. Take for example, a bad call at work, you will remember who was there, what street you were on and when that particular event happened. This is autobiographical memory at its best.

Before I go into how trauma effects these memory systems I want to go over the second major category of memory, the Implicit or Non-declarative memory system. This system is a subconscious system, that is, it operates below our level of conscious awareness and is made up of our Emotional and Procedural memories.

Emotional memories are just that, they are memories of an emotion that you felt at the time of the experience or event. We can often look at something, an object perhaps or hear a melody and be overwhelmed by intense feelings associated with a past experience or event related to that object or melody, this is how emotional memories are expressed.

Procedural memories are basically our knowledge of how to do things without having to resort to conscious memory. Examples of procedural memory are things like riding a bike, once we’ve learned how to ride the bike, we don’t have to sit and relearn those procedures over and over each time we pick up the bike, we merely employ our procedural memory system and ride away. Things like starting an IV or driving your vehicle all rely upon procedural memory.

Okay, so now we have a basic knowledge of our memory systems and what each of them does for us, so lets look at how trauma impacts each of those types of memory.

So lets go back to our Implicit memory system, specifically our semantic memory  (remember, bike, television, car, etc.), these memories are created in the temporal lobe and inferior parietal cortex using information from different areas of the brain. When we experience a trauma this ability to collect and store the information can be disrupted. Sounds, words, images, etc. all arise from different areas of the brain and usually would combine in these brain areas to form a semantic memory, unfortunately, trauma prevents the combination of these incoming information signals and thus a semantic memory of the environment cannot be formed.

Our next Implicit memory system is Episodic memory, and this is the one that was most relevant to my concerns. We form and recall episodic memory in the hippocampus, and we already know that the hippocampus is a major site of dysregulation in terms of PTSD. When we experience trauma, it can shut down our episodic memory system and fragment the sequence of events. The thing with this is it doesn’t only effect the moment of trauma or the trauma memory itself, it has a longer term effect in that it can fragment our sequencing timeline for newer events as well. So when I am asked a question about whether I remember X event, I often respond with confusion because where the person is talking of an event months ago, I am swearing it only happened days or a week ago – my autobiographical memory is fragmented because that memory system is not working properly.  (I am not crazy!!!).

Further to this, we can now understand why some people who experience trauma have a relative amnesia to the event or parts of the event/experience. We can now see why, when someone is trying to describe their traumatic experience, they can have difficulty with the sequencing of events within that memory and it is a very distressing and disturbing experience for the sufferer. It also alludes to the experience of actually “being further away” from the traumatic event but not feeling like you are. I am currently 9 years from the traumatic call that ended my career, but in my recall, it seems to sit only within the 2 or 3 year autobiographical timeline. (Our brains are truly fascinating organs.)

Okay, so that was our conscious awareness, now lets see how trauma impacts our Implicit memory system, starting with our Emotional memory.

Emotional memory is regulated by the amygdala – yep, that’s a huge area of concern in terms of PTSD. Now what trauma does, is it causes dysregulation of emotional signalling and so someone whose suffered trauma can experience emotional memories that are out of context to the environment they are in. Highly emotional and painful reactions can seem to appear out of nowhere and have little to no relevance to the environment the person finds themselves in. That is because the majority of emotional memory processing is occurring below the level of conscious awareness, so while the brain may be attending to the processing of the traumatic event, the person is consciously doing something completely innocuous and unrelated to the trauma. You may think you’re doing something to get your mind off the trauma, but your brain is not.

Finally, we have procedural memory.  New habits are formed in the striatum of the brain and procedural memories are just that, a type of habit that is so routine it does not require conscious thought to perform. Trauma can change the patterns of procedural memory and not allow those patterns to extinguish. Let’s put it this way, a procedural memory requires learning a coordinated sequence of physical movements to the extent that you don’t require conscious thought to perform the task or movement. When you experience an overwhelming traumatic event, your brain and body remember the pattern of reactions that were activated in response to that threat/trauma, it forms a procedural memory which does not extinguish and prevents us from restoring the body to a calm, peaceful state. Any reminder of a threat/trauma will activate that procedural memory. Ducking or running when you hear a loud noise, or automatically going into a protective stance upon interpretation of the slightest threat are examples of procedural memories acquired at the point of trauma.

It is all well and good to identify where our brains are fouling up and simplistically think that all we need to do is over ride that mistake but for people with trauma, a lot of what they are experiencing is below the level of conscious awareness, they are not in control of what their brain is doing at that level and so these behaviors will surface as if out of nowhere from the perspective of an outsider. Truly they are not out of nowhere, and if we can all understand and accept this as sufferers, it can drastically reduce the experiences of  embarrassment or shame we feel when these things happen. It’s not you, it’s how the PTSD affects your brain.

I hope that helps to clear up some issues for those out there who don’t understand why they are reacting the way they are after their trauma. I hope it helps to normalize the  things you are experiencing now in your post trauma world.

Always remember, it’s not You, it’s just the PTSD.

In Solidarity.

 

Advertisements
Posted in PTSD | Tagged , , , , , , , | Leave a comment

Paramedics and PTSD : What Is Wrong With Me??

4649749639_e67a906d65_m

photo courtesy Sander van der Wel

This is the question that repeated in my head over and over for years after I was diagnosed with PTSD. I had understood PTSD to be a merely psychological occurrence so it made no sense why it was happening to me, I wasn’t a “disturbed” or abnormal person, in fact, I’d taken great pride in the fact that I could handle things that the average civilian couldn’t (and shouldn’t) see. I had a loving and supportive upbringing with no history of abuse or direct trauma. How could I be suddenly malfunctioning and couldn’t “handle” my job???

I saw a therapist who told me it was all in my head, it was merely a matter of looking at what happened in a different manner. I was instructed that the only way to clear this aberrant thinking pattern was to rehash the story over and over and over until I could do it without reacting emotionally – as though the reaction was something I was doing to myself. I kept insisting that I wasn’t fully in control of what was happening, if it was merely a matter of Buck Up and Suck It Up I’d been doing that all my career and  it was suddenly beyond my control to do so…I wasn’t reacting this way on purpose to avoid my work. In fact, I was punishing myself daily to try to get back there to the familiar and comfortable chaos that was my life.

I didn’t get PTSD. I didn’t understand how I one day suddenly became a “weakling” (thinking error, judgement statement). I knew myself inside and out, so I knew something was inherently wrong with my biology, my nervous system. I kept screaming this to the top of the walls and it always fell on deaf ears – nope, it was just a simple matter of how I was reacting and workers comp and my workplace treated me like some kind of criminal for not just snapping out of it.

Let me explain to you why this thinking and behaviour was unacceptable and extremely uneducated.

I was diagnosed close to 10 years ago. Fundamentally, the global public viewpoint of psychological trauma has been changing rapidly in that time, however, the actual field of traumatology (yes, that’s actually a field of study that’s been around for decades), hasn’t changed all that dramatically, they’ve just gotten more recognized thus better funded. The positive changes that have come in this field to enable it’s  growth and validation are in the incorporation of imaging and neuroscientific findings to support the theories that clinicians have operated on in the treatment of trauma since the early 80s.

I’m talking about the pioneers, now experts, like Peter Levine (Waking the Tiger), Bessel Van der Kolk (The Body Keeps the Score) and others. These are the original people who told you that it was all in your head, but not just your head, your nervous system as a whole and your body. Trauma exists in your biology and psychology, not simply in your conscious mind. It is a malfunction of our instinct centers, a rewiring that causes over-reactivity of the “emotional centers” of the brain and disconnects the “logic centers”. You are not in conscious control of the things your body is experiencing as your brain relives a trauma, you are acting out of instinct. Fight, Flight, Freeze.

I recently had opportunity to watch a few broadcasts of a teaching series for clinicians working with traumatized clients. In it they went over how trauma impacts our neurobiology and ways to help patients release this hold by attempting to re-establish connections and restore how the brain operates at a non-threat level. They were quick to point out that treating trauma is extremely difficult because of the fact that the things a traumatized patient is experiencing are happening below a conscious level, thus telling someone to stop doing something doesn’t work, or telling them to perform certain movements or therapies is not always guaranteed successful.

One thing that was pointed out, and it’s VERY important current knowledge for both clinicians, workers compensation workers and human resources personnel dealing with PTSD patients – repeatedly telling the story of a trauma will not make it better, in fact, it can make it much worse because the pathways of reactivity or stimulation in the brain can habituate and solidify, if you will, causing the trauma to go deeper and become more resistant to treatment. Van der Kolk went so far as to say that repeating the story of a trauma is not actually necessary for the clinician, what is far more important is understanding the client’s bodily reactions and targeting those. The goal of treating trauma is to target the “limbic system” and restore the normal reactivity of the brain.

So where 10 years ago, the go-to treatment for trauma was Exposure Therapy from the minute you walked in the door, it is now understood that this method does more harm that good. In this way, my second therapist was on to something when she realized that my symptoms seemed to be getting worse over the course of treatment and began to back off in favor of grounding therapies and calming exercises. This is where she began to butt heads with workers compensation who was paying her and insisting that Exposure Therapy was the ONLY successful method of treating psychological trauma.  We now know this to be incorrect. We were then faced with stubborn opposition to any alternative forms of treatment we posited, threatened with termination and I was subjected to repeated psychiatric assessments, all of which backed up my therapists findings and were thus ignored.

The field of trauma treatment leans more toward “limbic system” therapies now. It is not necessary to have a patient relive a trauma in order to target the limbic system (and they use the term limbic system loosely now as it implies sequential operation and we understand that a brain is far more complex than mere sequence). Types of therapy touted were Yoga, one of the more studied and supported, but also suggested were practices of a more eastern and body oriented nature, Tai Chi, Qigong, or other fluid movement martial arts that incorporate mindfulness and support the strengthening of the less reactive pathways within the brain.  As my therapist used to say, “You can’t be calm and excited at the same time.” Even though she didn’t understand the neurobiology behind it, she essentially told me there were two different brain mechanisms at work and both cannot be equally active at the same time.

Another practice mentioned was meditation, although Van der Kolk did point out that because it is the body storing the traumatic memory, meditation can be a very difficult practice for traumatized people. The heightened instinct in a traumatic reaction is flee, danger, unsafe. These are the things the brain and body are attuned to after the experience of a traumatic incident, these are post traumatic stress reactions. Once the stressor is gone the reaction remains and it can remain until it is released or we are somehow able to effectively, turn off the “switch”.  A person with PTSD will find sitting still extremely anxiety generating because of the fact that their instinct centers in the brain are telling them that they need to keep moving and it is dangerous to sit still. This is where mindfulness and fluid movement therapies can be more helpful.

One of the more illuminating (for me anyway) talks given in the series came from a leading neurobiology researcher in the field of PTSD, Dr. Ruth Lanius. Dr. Lanius gave an overview of the basic operation from what we now understand of the brainstem; our instinct center where things like heart beat and respiration are located. She spoke specifically of the periaqueductal gray, located medially beneath the cerebellum and how it is theorized to be necessary in regulating our hypothalamic regions and establishing a connection to the higher reasoning areas of the brain. The periaqueductal gray (PAG) is shown to have a role in defensive reactions within the body such as freezing/immobility, increased muscle tone, increased heart rate and blood pressure, but also the caudal ventrolateral aspect is responsible for quiescence within the body. The PAG is, in essence our instinct center. Dr. Lanius pointed out that if we can re-establish the proper flow of neurochemical information through this area, it would result in less reactivity in the amygdala and thus restore normal levels of reactivity to the basal ganglia and the cerebral cortex.

Now, where’s that magic pill?

What is extremely important to understand is that this area of your brain is instinctive, you do not have any conscious control over this area it is purely biology but that is not to say that you cannot influence this area by stimulating other areas of your brain. Every brain has an excitement and a relaxation mode and the two are understood to be mutually exclusive of one another. In PTSD the instinct centers of your brain are hyper-reactive and sending repeated signals to your hypothalamus causing it to operate in overdrive, during a trauma related trigger event, this hyper-reactivity essentially slams the door on signals to your higher reasoning centers, or your thinking brain. You can still think but the conscious ability to send those instructions back through your hypothalamus to the necessary brain regions is blocked because those pathways are too busy reacting to a threat.

It is all a very helpless experience and you feel like the thinking you is trapped somewhere in your own head screaming from the top of its lungs that your body needs to settle down and let you think through this…but you can’t because what you want to say doesn’t make it through to the vocal cords, what you want to move doesn’t make it to the motor centers, all of that pathway is blocked. So you may be thinking but it’s in isolation from your body which is operating wholly on instinct, and no matter what you’re thinking, you cannot override the instinct center.

Somehow inherently I knew this from the start of my whole ordeal and I asked repeatedly for someone to put this to me in a way I could understand it but no therapist I ever saw could ever do that for me. I get it now. I also get why I saw so much improvement when I started to practice meditation (which was extremely hard but not impossible) and when I started yoga and stretching. Until my brain is ready to re-establish the connections and function at it’s baseline reactivity, I will react to traumatic reminders, so I have to just keep plucking away at calming my limbic system so that I can help my brain fire in the right places. Like they say, neurons that fire together, wire together, so happy brain exercising!

Next time we’ll go over dissociation and how memory gets impacted by trauma. Until then, stay safe, stay breathing and know you can get through this. It’s not you, it’s just PTSD.

In solidarity.

 

 

Posted in PTSD | Tagged , , , , , , , , , | 2 Comments