PTSD PROTOCOL

Over the past few years, I've come to recognize that many of my patients have been misdiagnosed- especially as bipolar, but sometimes labeled with schizophrenia, personality disorders- when actually they are suffering from a severely traumatic childhood, making it difficult to sustain an adult functioning personality on a reliable basis.

As I've worked with patients, and looked at my own situation- as I've unraveled the mysteries of this kind of PTSD-  I've come up with a protocol that works pretty well.  Perhaps it can help you.

PTSD consists of intrusions of memories into your everyday life, in a manner that is disruptive.  The disruption can last for a few seconds, or for weeks.  They can make concentration and task completion difficult. 

Sometimes they are so frequent and prolonged that they take over everyday life, making it difficult to build a life or sustain a life activity, such as school, jobs, family.  You may not be aware of what is happening, and think you are “in a bad mood”, or “spacing out”, or “just messed up”.

I call these memory intrusions "PTSD episodes".  One patient describes it as falling off a cliff.  Another as falling into a memory hole.  There is a sense of being taken over, spaced, and emotionally distraught.   Nightmares often continue the episodes, disrupting sleep.

The memories are of childhood, and you tend to regress emotionally to the age at which the memory took place, whether 14, or 6, or 1.  Sometimes the trauma took place before you could talk, and so your reaction is non-verbal.   This can manifest as a childish display of emotions- tantrums, rages, curling into a ball.  It also can manifest as harmful acting out- self-medicating with alcohol or drugs, hurting yourself, hurting others.  It can show up as illnesses of various sorts- irritable bowel, asthma.

Before you can start working on the memories, you have to be able to manage the PTSD episodes so that they are less disruptive, and you can carry on everyday life.  Working on them in depth prematurely can lead to weeks of inner disorganization, and inability to function.

So the first piece of advice is to use a mantra-  "I'm xx years old".  This keeps you in current reality, serves as a lifeline to your adult personality.

Second, is to learn to recognize the onset of an episode.  If you can catch it early, it can be aborted by using the cooling breath- rolling your tongue and breathing through it like a straw.  If you can’t do it (it’s a genetic thing) you can purse your lips instead.  This yogic breathing technique can stop panic attacks, rages, and PTSD episodes. 

I also give people a beta blocker called propranolol, to use as needed.  It cuts off the adrenaline rush.   Beta blockers can trigger asthma, so anyone with that tendency can’t use them.   Otherwise, they are benign and non-addictive.

Third, start keeping a PTSD journal.  This consists of making a brief note about each episode, covering 4 items:

1) what triggered it;

2) how long did it last;

3) content- just the headline- age at time of memory and a few words- try to stay out of the memory itself when making the journal entry;

4) exit- how did you get the episode to end- could be a nap, a walk, talking to someone, watching TV, working.

The diary serves several purposes. 

1) It objectifies the episodes, the first step toward gaining control of them.

2) It gives you a sense of the pattern- the frequency, the time of day, whatever information you can get.

3) It gives you a way to monitor the variations as healing takes place.

4) It gives you clues on how to manage the episodes, so they are less disruptive.

If you bring the diary to therapy sessions, we can look at the entries together, and I can help you understand the childhood trauma and correct the emotional reactions which are still obstructing your adult life.  

DEALING WITH PARTNER’S RAGES

People who are borderline or narcissistic tend to become enraged when provoked, and are easily provoked.  Those who are conventional borderlines often take this out on themselves.  uBPD refers to unconventional borderlines, a term invented by Randi Kreger, author of Stop Walking on Eggshells and other useful books. 

Randi runs an online group for people dealing with partners or family members with these conditions.  MovingForward@groups.io   I wrote the following piece for this group.

1) Prevent the rages whenever possible.

uBPDs are supersensitive and easily triggered.  It helps to notice the triggers and avoid them.  

• Sometimes there are patterns - eg the person might be tired and more easily triggered in the evening, or obviously when drinking, etc.  It might be good to minimize contacts at those times.

• It helps to tune in to the uBPD's rhythms.  Slow down when he's irritable, listen when she needs to talk on and on, etc.
• Time difficult subjects- eg money- for when the uBPD is receptive.

2) Notice the onset of an episode and try to abort it.  Here are some suggestions-

• Say something soothing- "it's ok",  "take it easy".  If the uBPD is remorseful after a rage, you can ask what would soothe next time.
• leave the room briefly to go to the bathroom, get some water "I'll just be a minute- do you want anything?"
• Change the subject to something grounding- if possible- "What shall we do about dinner?",  "We're out of bananas- I'll get some."
• Express concern-  "You seem upset", "I know you've had a hard day"
• Stand up, or sit up straighter, or stretch- use body language to show you are present and won't be intimidated.
• Apologize, if you've done something to trigger the episode.

3) If none of this works, protect yourself.

• Leave, if practical.
• Sit up straight, put your feet on the floor, breathe slowly and deeply, be aware of your body and state of arousal, keep calm.
• Cover your solar plexus with your hand or arm.  This is relaxing, and blocks the bad vibes.
• Use a mantra, if you have one, to block the hateful messages, or repeat to yourself- "It's not about me, it's about him/her".
• If you pray, pray for the uBPD to feel loved and be healed.

I'd like to hear other people's thoughts.

ADDtips

A.D.D. TIPS FOR ADULTS

Overall- don’t just rely on electronic devices.  Writing on a piece of paper with a pen creates a mark in the brain.

1)     LISTS- People with ADD tend to make lots of lists, and lose them.  Here are some ways to make effective lists that help one stay organized.                                                                                                                                                                                                          

          a) Get a clipboard for your lists.  Keep it handy, write things on it as they come to mind, cross them off when done.          This way,   you don’t lose lists.

          b)  Always put a date at the top of the page. 
        c)  You need 3 lists-

i)      a back sheet with long-term projects, that you get to when you have a chunk of time.  If appropriate, put a deadline on each one.

ii)     a main sheet with daily tasks, divided into 3 areas with horizontal lines- internet tasks (balance checkbook, read and answer email, etc), household tasks (phone calls, cleanup, meal preparation, etc.) and out-of house tasks- (appointments, errands, dog walking, etc.)  Change this sheet often, carry things over, and if they keep reappearing, move them to the back sheet.

iii)    A long narrow sheet on top for shopping items- groceries above, other stuff at the bottom. 

2)     THINGS- People with ADD waste lots of time looking for things.  A few guidelines should help. 
       a) A place for everything and everything in its place- especially small, frequently used items like glasses and keys.  If something doesn’t have a place, take the time to make a place for it, and put it there consistently.

               b) Put things away after you use them. 

               c) Use visual cues.  Put an item down on a contrasting background, so it is  easy to see next time.  Or put it in a line of sight- eg by the door if you are taking it with you when you go out.

               d) Think circulation- if you buy new clothes, give the old ones away- likewise with books- so things don’t just accumulate.             
             e) Have files for papers, clearly labeled and accessible- for bills, receipts, flyers, announcements, etc, and a place for the files, of course.  Have a handy place for bills that need to be paid, pay them every two weeks. 
              f)  On your back sheet list, write down areas that you need to organize- your desk, your closet, your email folders, and do one when you have time.

3)     TASKS- People with ADD tend to start lots of tasks and not finish them, also to procrastinate.  Here are some helpful hints.  Think of a task that you’ve started as an open Gestalt, whether it’s doing the dishes, writing a paper, getting dressed to go out.  As you finish the task, you close the Gestalt, and get it out of your mind.  Try not to have more than 3 open Gestalts at a time. 

               a) Break complex tasks into smaller steps- take each step as a Gestalt.                      b) Prepare for the task by assembling everything you need.  Do as much as you can.  If you finish, put things away.  If you don’t, make a note of what’s left to do, and tidy up.

               c) If you are on the web, close those distracting apps- games, facebook, whatever you use to avoid the task.  You can give yourself a reward and reopen one when you are finished.              
               d) Email is ongoing- I check mine often on the cell phone, delete the ones I don’t want, then take time in the evening to look at the remaining ones on line, answer them or file them.

                e) Getting started is the hardest part.  You might start your work time with something easy and fun, just to get going. 

4)     TIME- People with ADD tend to be late, rushed, forgetful of appointments.  Here are some hints.  
         a) Make time your friend, not your enemy- it’s YOUR time.  Give yourself time- take your time.  ADD people tend to take longer, so allow yourself plenty of time- it’s up to you.

              b) Get a physical pocket sized calendar, and write appointments in it- look at it in the morning, and before you go to bed. Take it with you.  Many also have mini address books in back where you can write phone #s.               
              c) Use cell phone alerts- morning of appointment, 2 hours before.

              d) Getting out of the house for school or work is especially difficult for some people.

i)      Get up a little earlier, which means going to bed a little earlier.

ii)     Take 5-10 minutes after you get up to do some sort of meditative practice- sit, yoga, a walk- prepare for the day.

iii)    Eat something, even if it’s just an energy bar.

iv)    Put out clothes, books, whatever you will need, the night before. 
e) Use playtime as a reward, when you’ve done your tasks, or at the end of the day.  Everyone needs to play, now and then.  But eat your spinach before you have dessert.

5)     SOCIALIZING- People with ADD often have trouble tracking conversations, especially if there are other people talking around them.  If the discussion makes one uncomfortable, one tends to space out.  Here’s some tips.             
         a) Look at the person who is talking to you, look at their eyes or their lips.

              b) Notice when your mind is wandering, and bring it back.            
              c) If you lose track, don’t be shy about asking someone to repeat themselves- it happens to everyone.  Much better to ask, than to say something off the topic, or not hear what was said and be embarrassed later.

              d) If you are bored by what is being said, change the subject, or end the conversation.            
              e) If you disagree, and are afraid to say so, don’t think about something else, indicate that you might have a problem with what is being said, and either state your objection, or change the subject.

6)     SELF-TALK- ADD begins in childhood.  Children with ADD are annoying to grownups, - either they are hyperactive and pesky, or inattentive and don’t follow directions well.  They get more than a normal amount of criticism and punishment.  These messages get internalized and persist in adulthood as negative self–talk.  Here are some ways to cope with this.           
       a) Notice when you are when you are telling yourself you are lazy, stupid, clumsy, bad- and realize that you got this message in childhood because you have ADD, not because you are actually lazy, stupid, clumsy, bad.

             b) Understand that ADD is a common condition.  It’s a handicap-  . everyone has some sort of handicap- you’re not a freak.           
             c) You can cope with this handicap, it doesn’t have to cripple you.

             d) Notice if you self-sabotage.  There are various mechanisms for this.

i)      Giving up too easily.  If you do this, take some breaths, give yourself more time, and try again.

ii)     Avoidance.  It’s always easier to face the devil head-on than to worry about the one hiding in the closet.  It’s probably not as bad as you think.

iii)    Defiance.  Many children react to excessive criticism by fighting back, refusing to take direction.  As an adult, you are just fighting with yourself, a waste of time and energy.  So tell the defiant child within you to grow up and take responsibility for getting the job done.

iv)    Spitefulness- sometimes people choose to fail in order to spite their parents “look what you did to me.”  Realize that’s what you are doing, and stop.  Forgive the people you are mad at- it’s in the past.           
e) Negative self-talk tends to be automatic, deeply ingrained.  When you notice it, tell that inner voice to shut up, and replace it with a positive voice- “I can do it”, “Look how well I did such and such”, “I have lots of talents”.