PTSD Becomes (More) Complex in the DSM-5: Part II
Recovering from (complex) PTSD by regaining self-regulation
Posted June 16, 2013
In the DSM-5 released in May, PTSD just got more complex. It added a new symptom domain of "negative alterations in cognitions or mood," and expanded the hyperarousal domain to include aggressive, reckless, or self-destructive behavior. It also added a sub-type characterized by dissociation (drastic reductions in physical arousal and conscious emotion and thought). These changes reflect advances in science and clinical practice, which echo what trauma survivors have been saying for decades (if not centuries): PTSD is a radical shift from normal self-regulation to being trapped in a constant state of alarm.
To understand, and recover from, PTSD, it's essential to understand what the brain and body do to "self-regulate" under ordinary circumstances—because this is what's lost in PTSD and must be regained in recovery. Self-regulation is a delicate and complicated balancing act in which the brain and body constantly adjust to maintain a balance between mobilizing (being highly activated) and re-grouping (down shifting into less activated states).
Mobilization is essential to experiencing pleasurable excitement, enthusiasm, and achievement. But too much mobilization for too long leads to tension, frustration, recklessness, and even self-harm. Similarly, when the body and brain re-group, this can produce pleasurable and healthy states of relaxation, calm, and mindful acceptance. However, when re-grouping becomes extreme and persistent, the result can be emotional shut-down and exhaustion, depression, despair, or dissociation. Self-regulation is the constant balancing act between mobilization and re-grouping that enables us to be optimally effective and to feel true satisfaction.
Trauma is a threat or injury that requires self-protective stress reactions—essentially fight or flight—which hijack the brain and body in order to achieve the one goal that is a higher priority than being effective and satisfied: survival. Post-traumatic stress disorder derives its name from this key fact: PTSD is a disorder because the the brain and body have become trapped on a roller coaster of dysregulation. PTSD involves rocketing into extreme states of stress reactivity (mobilization in the form of terror, rage, and uncontrollable impulses) and plunging into equally extreme states of being shut-down (exhaustion, emotional numbing, despair, and dissociation). From this vantage point, PTSD clearly is about much more than fear and anxiety, involving the full range of emotions and undermining our body's health, our ability to think clearly, to set and achieve goals, and to fully participate in and benefit from relationships.
A particularly important new symptom of PTSD highlights an important aspect of the loss of self-regulation: "Persistent and exaggerated negative expectations about one’s self, others, or the world (e.g., “I am bad,” “no one can be trusted,” “I’ve lost my soul forever,” “my whole nervous system is permanently ruined,” "the world is completely dangerous")." PTSD thus is inherently complex, and all about the loss of self-regulation that occurs when survival dominates how a person thinks, feels, and behaves in every area of his or her life. PTSD replaces the "me" who was growing, learning, and becoming a unique person before the trauma(s), leaving only a desperate survivor who may have no clear sense of identity and who may even hate or loathe herself or himself.
Although the dilemma of post-traumatic self-dysregulation is indeed complex, as is the array of therapies that have shown promise in treating (complex) PTSD , the key to recovery is not rocket science. Survival threats can cause the brain to be hijacked by its own alarm system, so the key is to re-set that alarm system so it's no longer in survival mode.
Re-setting the brain's alarm requires seven steps, which are at the heart of every effective treatment for (complex) PTSD despite their many differences:
Focus mentally on a single thought that you choose because it is what's most important and positive in your life at this moment—not what's most urgent or problematic, nor what's a lifetime away, but what you value most and what represents the very best part of your life right now.
Recognize the triggers that signal problems or danger: don't ignore them, but don't obsess or ruminate about them, just make a mental note to be alert.
Experience the emotions that are signals from your brain's alarm, but also the sustaining emotions that seem to get lost in the midst of stress reactions but actually are always present if you just look carefully for them; emotions like joy, hope, love, pride, security, enthusiasm, determination.
Evaluate your thoughts not to judge or alter or eliminate them, but to distinguish between the defensive (or offensive) thoughts that are generated by your brain's alarm from the sustaining beliefs that also can get lost in alarm reactions (but actually are always available when you focus on your core values).
Define your goals so that you can tell the difference between defensive (or offensive) goals that are potentially useful warnings from your brain's alarm and the sustaining goals that are based on your core values.
[Choose] Options that enable you to achieve your sustaining goals and to live according to your core values, while being aware of and open to using other options that are more defensive (or offensive) if you are faced with a genuine threat to your, or others', survival.
Make a contribution by doing the one thing that each of us can do to make everyone safer, healthier, and more effective: continue to practice these simple steps in your own individual ways, and in so doing become a role model for responsible self-regulation.
These seven steps spell FREEDOM. They are not a pre-packaged set of techniques for self-improvement. They have to be done by each person in their own individual way. They enable you to use your mind to shift out of survival mode and your body to resume the natural state of self-regulation that is lost whenever anyone becomes trapped in the alarm state that the DSM-5 calls PTSD.