In my last post I listed the four symptom groups that are common to PTSD. Today I’ll discuss the Arousal and Hyper-Reactivity symptom group because treating this problem is essential to your healing.
Arousal Symptoms: (You have to have two of the following symptoms to qualify for a diagnosis of PTSD.)
Alterations in arousal and reactivity that began or worsened after the traumatic event:
1) Irritable or aggressive behavior
2) Self-destructive or reckless behavior
4) Exaggerated startle response
5) Problems in concentration
6) Sleep disturbance
I hear more complaints about this group of symptoms than any other. “I CAN’T SLEEP” being the most common. These symptoms have a real physical cause—prolonged activation of the Sympathetic Nervous System. Remember that stress chemicals can wound the brain? Activation of the sympathetic nervous system causes the release of those chemicals.
Above is a picture of the Sympathetic and Parasympathetic nervous systems.
(No quiz, I promise!)
The brain is at the top, the spinal cord in the middle, with the parasympathetic system on the left and the sympathetic nervous system on the right.
The parasympathetic system is our body’s maintenance system. It lubricates our eyes, digests our food, releases sex hormones, and helps us go to sleep, etc.
The sympathetic system takes over during periods of extreme danger and stress, focusing all the body’s resources on immediate survival. To do this, it overrides the usual maintenance behaviors of our body.
So what does the sympathetic nervous system do? It prepares us to fight for our life or run away from extreme danger. More specifically:
It dilates the pupil, increases the flow of air into the lungs, accelerates the heart, and releases glucose (fuel) from the liver.
It inhibits salivation, digestive activity, and relaxation behaviors such as sleep by blocking the parasympathetic nervous system.
It causes the release of adrenaline, noradrenalin, and glucocorticoids which increase blood flow to the muscles and brain, increase strength, increase endurance, reduce inflammation, increase mental alertness, and focus attention on the danger.
This is exactly what you WANT if you are in a life-threatening situation.
BUT prolonged exposure to stress hormones is harmful to both your physical and mental health. You’re probably familiar with the problems associated with taking too many steroids, like some of the professional athletes have done. Well glucocorticoids like cortisol are natural steroids that are released during prolonged stress.
Let’s take a closer look at your brain.
The outer part of your brain is the cortex, involved in thinking, voluntary movement, speech, and control of other areas of your brain. Underneath are unconscious, more primitive, parts. Some areas are involved in processing emotion, like the amygdala, which processes strong negative emotions like rage, terror, and despair. Nearby is the hippocampus, which processes our normal memories, and the pituitary gland, which tells glands in the body which chemicals to make.
So when the sympathetic nervous system is activated, it alerts the pituitary gland, which tells the adrenal gland to make stress chemicals. Those chemicals then inflame the amygdala, causing terror and rage, and block the hippocampus from laying down normal memories. If these chemicals continue for any length of time, the hippocampus actually shrinks and the amygdala enlarges. You can see this on an MRI brain scan.
Other parts of the cortex, the gray area on the outside of the brain that does most of our thinking, are also affected, including the medial prefrontal cortex which normally keeps the amygdala calmed down. And parts that help us speak and think coherently have been shown to decrease in size.
So the longer your sympathetic nervous system remains on high, the more it damages your brain. Treating PTSD quickly and effectively can avoid creating all these wounds. But the brain can make new cells, especially in the hippocampus, which can repair itself once the toxic chemicals subside. That means you can heal, but the longer you’ve been exposed to stress chemicals, the more likely that you will retain some damage, like a scar.
Let’s talk about treatment. Arousal is a physical problem, and we now have medications to help fix it. Below is a list of some of the medications frequently used:
Sedating Antidepressants:Trazodone, Remeron, Luvox,
Nonsedating Antidepressants:SSRIs: Lexapro, Paxil, Zoloft SNRIs: Cymbalta, Effexor, Pristiq
Antipsychotics:Old: Thorazine, Haldol New: Seroquel, Risperdol
Anticonvulsants for irritability and rage outbursts: Gabapentin, Tegretol, Trileptal, Ketamine, Depakote, Lamictal,
Alpha and beta-blockers block the effects of the sympathetic nervous system. They are commonly used to treat high blood pressure, but researchers have found that one of the alpha blockers, Prazosin, can sneak into the brain, and works well to increase sleep and prevent nightmares in people suffering from PTSD. The dose is variable, so you start low and increase the medication every night until it works. Prazosin has a fairly short half-life, so it doesn’t stick around to affect you the next day, unless you take another dose. Common side effects are sleepiness and dizziness. The dizziness usually gets better with reduced dose or over time, and this drug is widely used by the VA to improve sleep and stop nightmares.
Propranalol is an old beta-blocker, which also gets into the brain. Used both to decrease blood pressure, stop heart arrhythmias, and decrease anxiety, it has been shown to prevent PTSD if given right after a traumatic event.
Other medications that include an alpha-blocker, like Trazodone and Seroquel, also work for sleep but may keep you sleepy through the next day and have other side effects. Nevertheless, both are widely used as sleeping pills.
Antidepressants are very popular. They work to rebalance the prefrontal cortex so it can calm the amygdala and help you get control of anger, fear, and sadness. Paxil and Zoloft are FDA approved to treat PTSD, but the other SSRIs and SNRIs work just as well. Remeron is a unique antidepressant that has a different mechanism of action. It helps with sleep, depression, and anxiety. Luvox helps with sleep, obsessive thinking, and anxiety.
Most of the antipsychotic medications contain an alpha-blocker, so they can also help, but they also have a lot of side effects, so I don’t usually recommend them unless other drugs have failed. Seizure medications are also used to control anger outbursts, but again they have a lot of side effects. I would try a different approach first, if possible.
There are other medications that treat drug abuse and drug withdrawal and may be very helpful if you’re hooked on an addicting drug, but they don’t affect the PTSD symptoms, so I’ve not mentioned them here.
If you’re having trouble with hyper-arousal symptoms, it’s VERY important to discuss this with your doctor and find medications that help you to sleep, calm your emotions, and give your brain a chance to heal.