A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script-driven imagery.

BACKGROUND: Previous studies have used symptom provocation and positron emission tomography to delineate the brain systems that mediate various anxiety states. Using an analogous approach, the goal of this study was to measure regional cerebral blood flow changes associated with posttraumatic stress disorder (PTSD) symptoms. METHODS: Eight patients with PTSD, screened as physiologically responsive to a script-driven imagery symptom provocation paradigm, were exposed sequentially to audiotaped traumatic and neutral scripts in conjunction with positron emission tomography. Heart rate and subjective measures of emotional state were obtained for each condition. Statistical mapping techniques were used to determine locations of significant brain activation. RESULTS: Increases in normalized blood flow were found for the traumatic as compared with control conditions in right-sided limbic, paralimbic, and visual areas; decreases were found in left inferior frontal and middle temporal cortex. CONCLUSIONS: The results suggest that emotions associated with the PTSD symptomatic state are mediated by the limbic and paralimbic systems within the right hemisphere. Activation of visual cortex may correspond to the visual component of PTSD reexperiencing phenomena.

Trauma and the development of borderline personality disorder.

Prolonged and severe trauma, particularly trauma that occurs early in the life cycle, tends to result in a chronic inability to modulate emotions. When this occurs, people can mobilize a range of behaviors that are best understood as attempts at self-soothing. Some of these attempts include clinging and indiscriminate relationships with others in which old traumas are re-enacted over time, as well as more self-directed behaviors such as self-mutilation, eating disorders, and substance abuse. Usually, these behaviors will coexist. Patients with complicated trauma histories often repetitively attempt suicide or engage in chronic self-destructive behavior, and need to address issues of childhood trauma, neglect, and abandonment, both in the past and as re-experienced in current relationships. When treating these patients, therapists must anticipate that painful affects related to interpersonal safety, anger, and emotional needs may give rise to dissociative episodes, which may, in turn, be accompanied by increased self-destructive behavior. The therapy must clarify how current stresses are experienced as a return of past traumas and how small disruptions in present relationships are seen as a repetition of prior abandonment. As part of this, it is essential that the therapist provide validation and support, and avoid participating in a re-enactment of the trauma. Fear needs to be tamed in order for people to be able to think and be conscious of current needs. This bodily response of fear can be mitigated by safety of attachments, security of meaning schemes, and by a body whose reactions to environmental stress can be predicted and controlled. One of the great mysteries of the processing of traumatic experience is that as long as the trauma is experienced as speechless terror, the body continues to keep score and react to conditioned stimuli as a return of the trauma. When the mind is able to create symbolic representations of these past experiences, however, there often seems to be a taming of terror, a desomatization of experience. As Ducey and van der Kolk found in the Rorschachs of Vietnam veterans, patients were unresponsive to outside influences (good or bad) as long as they remained in a state of psychic numbing. Faced with intrusions of past trauma in their current emotional life, patients' initial sense of being overwhelmed was mastered only when a link between past trauma and current perceptions became understood.(ABSTRACT TRUNCATED AT 400 WORDS)

The biologic basis of posttraumatic stress.

The psychological effects of trauma are accompanied by biologic changes in the stress response that persist when people develop posttraumatic stress disorder (PTSD). This article explores the nature of this altered stress response; provides a review of the symptomatology of PTSD; describes how developmental level affects the biology of the trauma response, the stress response, and the psychobiology of PTSD; and discusses the implications for psychopharmacologic treatment.

Childhood abuse and neglect and loss of self-regulation.

Secure attachments with caregivers play a critical role in helping children develop a capacity to modulate physiological arousal. Loss of ability to regulate the intensity of feelings and impulses is possibly the most far-reaching effect of trauma and neglect. It has been shown that most abused and neglected children develop disorganized attachment patterns. The inability to modulate emotions gives rise to a range of behaviors that are best understood as attempts at self-regulation. These include aggression against others, self-destructive behavior, eating disorders, and substance abuse. The capacity to regulate internal states affects both self-definition and one's attitude toward one's surroundings. Abused children often fail to develop the capacity to express specific and differentiated emotions: Their difficulty putting feelings into words interferes with flexible response strategies and promotes acting out. Usually, these behaviors coexist, which further complicates diagnosis and treatment. Affective dysregulation can be mitigated by safe attachments, secure meaning schemes, and pharmacological interventions that enhance the predictability of somatic responses to stress. The ability to create symbolic representations of terrifying experiences promotes taming of terror and desomatization of traumatic memories.