Cannabis For PTSD: A neurobiological approach to treatment

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Nurse Practitioner:
16 January 2016 - Volume 41 - Issue 1 - p 50 - 54
Feature: THERAPEUTIC CANNABIS

Cannabis for posttraumatic stress disorder: A neurobiological approach to treatment
Krumm, Bryan A. MSN, RN, CNP, BC

Article Outline

Bryan A. Krumm is a Psychiatric Nurse Practitioner at Sage Neuroscience Center, Albuquerque, N.M.

The author has disclosed that he has no financial relationships related to this article.

Abstract: The endocannabinoid system is intricately involved in regulation of the neurobiological processes, which underlie the symptomatology of posttraumatic stress disorder (PTSD). This article discusses the neurobiological underpinnings of PTSD and the use of cannabis for treating PTSD in the New Mexico Medical Cannabis Program.

The State of New Mexico has approved posttraumatic stress disorder (PTSD) as an indication for its Medical Cannabis Program, and patients with PTSD currently comprise the largest segment of any approved indication.

Cannabis remains in Schedule I of the Controlled Substances Act (CSA) in the United States, making it illegal to use under federal law. In the case of Krumm vs. Holder, the Drug Enforcement Administration argued that they did not need to defer to state laws regarding scheduling decisions for controlled substances. (1) Due to the federal prohibition against cannabis, research looking into its therapeutic value has faced significant barriers, rendering it nearly impossible to conduct controlled clinical trials of cannabis in treating PTSD. However, the U.S. Supreme Court has upheld that practitioners have a right to recommend cannabis to patients when it is deemed appropriate. (2)

PTSD can occur when a patient is exposed to one or more traumatic events leading to the development of characteristic symptoms following exposure. Patients may exhibit fear-based re-experiencing with emotional and behavioral symptoms. Others may present with anhedonic or dysphoric states and negative cognition. Patients may exhibit arousal and reactive-externalizing, while others may exhibit dissociative symptoms. Some individuals may have combinations of symptom patterns. (3) PTSD is considered the fourth most common psychiatric disorder, affecting 10% of all men and 18% of women, with rates approximately 40% in high-trauma populations, such as soldiers in combat, low-income individuals, and those living in inner cities. (4) PTSD often occurs comorbidly with other psychiatric disorders. (4) Originally, PTSD was considered a normative response, related primarily to stressor intensity, but individual response to trauma depends on stressor characteristics as well as neurobiological factors. (5)

The endocannabinoid system appears to be involved in the extinction of aversive memories, and patients with PTSD claim that cannabis use helps alleviate their symptoms. (6) Cannabinoids stimulate receptors in the prefrontal cortex, amygdala, and hippocampus, activating signaling pathways, which appear to inhibit anxiety. (7) Alterations in the endocannabinoid system are seen in depression, including changes in levels of cannabinoid 1 (CB1) receptors and endogenous CB1 receptor ligands. (8) Stimulation of cannabinoid receptors enhances stress-coping behaviors and increases spontaneous firing of serotonergic and noradrenergic neurons in the midbrain. (9) Phytocannabinoids, including delta 9 tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabichromene exert antidepressant-like actions and may be useful in the treatment of mood disorders.

High rates of suicidal behavior have been found among patients with PTSD. (11) It appears that sensitization of CB1-receptor-mediated G-protein signaling in the prefrontal cortex contributes to the pathophysiology of suicide and likely contributes to suicidal behavior. (12) The role of the endocannabinoid system in the pathophysiology of PTSD suggests that cannabinoids may be an effective modality to treat both PTSD and suicidal behavior in patients with PTSD. (11) Many patients in New Mexico's Medical Cannabis Program for PTSD have reported reductions in frequency and severity of suicidal thoughts at Medical Advisory Board meetings. Some reported complete cessation of suicidality.

The military is currently facing an epidemic of suicide, and the U.S. Department of Veterans Affairs has called on all mental health and substance abuse healthcare providers to share responsibility for zero tolerance regarding suicide. (14) An estimated 22 veterans die via suicide daily, accounting for at least 22.2% of all reported suicides. There were also 349 suicides among active duty troops in 2012, accounting for more deaths than by enemy fire. (15) Developing new treatment modalities for PTSD is critical given the number of returning veterans who require psychiatric help and are at high risk for suicide.

Raphael Mechoulam, PhD, perhaps the world's leading authority on cannabinoids and the endocannabinoid system, points out the following:

It has been suggested that pharmacologic treatments in psychiatry have been overly reliant on neurotransmitter systems and their agonists. In the last several decades, advances in psychopharmacology have reduced adverse reactions but have failed to lead to major disease improvement. The endocannabinoid system may shed new light on the physiologic basis of psychiatric diseases, leading to new and more effective treatments. (6)

The neurobiological basis of PTSD

After exposure to a traumatic event, patients may experience recurring memories of the event, including distressing dreams, dissociative reactions/flashbacks, or increased stress responses to external cues and physiological reactions to external cues resembling aspects of the traumatic event. They try to avoid distressing memories or external reminders of the event. They experience negative changes in mood and cognition associated with the event in addition to marked alterations in arousal and reactivity, beginning or worsening after the traumatic event. These disturbances continue for over 1 month and cause significant disturbances in social, occupational, or other important areas of function. These disturbances cannot be attributable to the physiological effects of substances or other medical conditions. (3)

The broad range of symptoms seen in PTSD have made treatment challenging. PTSD involves central neurotransmitter imbalances and neuroanatomical disruptions, with potential dysregulation of immune, autonomic, endocrine, and cardiovascular function. (16) Recent neuroimaging studies have helped elucidate the underlying neurobiological processes involved in the symptomatology of PTSD as well as the role of the endocannabinoid system in managing these neurobiological pathways. CB1 receptor availability is upregulated in an amygdala-hippocampal-cortico-striatal neural circuit implicated in PTSD and in brain regions outside this circuit. This may result from a combination of both receptor upregulation and low receptor occupancy by anandamide, an endogenous cannabioid. This suggests that abnormal CB1 receptor-mediated anandamide signaling is implicated in the PTSD etiology. (17)

PTSD is associated with amygdala dysfunction, the anterior cingulate cortex (ACC), the medial prefrontal cortex (mPFC), and the hippocampus. Structural impairments include decreased hippocampal volume and decreased ACC volume. Dysregulation in threat-related processing in response to trauma exposure leads to a cascade of neural changes, causing a state of amygdala hyperresponsivity, which triggers hyperarousal and vigilance. Inadequate top-down control by the mPFC and ACC perpetuates the state of amygdala hyperresponsivity, increasing attention to trauma-related stimuli. (18)

The hypothalamic-pituitary-adrenal (HPA) axis coordinates neuroendocrine stress response systems and has been a major focus of scrutiny in patients with PTSD. Exposure to stress triggers neurons in the hypothalamic paraventricular nucleus to secrete a corticotropin-releasing hormone, which stimulates the production and release of adrenocorticotropic hormone (ACTH) from the anterior pituitary. ACTH then stimulates the release of glucocorticoids from the adrenal cortex, which modulate metabolism, immune function, and brain function to manage stressors. Sustained glucocorticoid exposure leads to reduced dendritic branching, loss of dendritic spines, and impaired neurogenesis of the hippocampus. (5)

Role of the endocannabinoid system in PTSD

THC has a significant and selective impact on amygdala reactivity to threat signals in humans. 19) Endocannabinoids are crucial for the extinction of aversive memories. (20,21) Activation of CB1 receptors in the amygdala blocks reconsolidation of aversive memories, which suggests that cannabinoids might help patients with PTSD prevent relapse after a stressful experience. (22)

The endocannabinoid system plays a significant role in the function of the prefrontal cortex. The PFC receives and modulates information processing throughout the brain and projects to subcortical arousal systems, regulating monoamine and cholinergic inputs. Activation of cannabinoid receptors in the mPFC enhances serotonin 5-hydroxytryptamine (5-HT) neurotransmission, eliciting potent antidepressant effects. (24) Disinhibition of excitatory projections from the mPFC to serotonergic neurons in the dorsal raphe may underlie antidepressant activity in the mPFC. (25) The endocannabinoid system may be involved not only in the extinction of conditioned fear but also adaptation to aversive situations in general. (26)

Cannabinoids have diverse effects on hippocampal memory and plasticity. The effects of cannabinoids on anxiety appear to be biphasic, with low doses being anxiolytic and high doses being ineffective or possibly anxiogenic. (27) However, chronic high-dose cannabinoid treatment has been shown to induce hippocampal neurogenesis, which may contribute to the anxiolytic and antidepressant effects of cannabinoids. (28) Modulation of hippocampal memory and plasticity by targeting the endocannabinoid system may aid in the treatment of impaired extinction-like processes seen in PTSD. (29)

Endocannabinoid signaling negatively modulates function of the HPA axis. Short-term activation of the HPA axis is beneficial to survival; however, long-term activation can impact mood, cognition, and metabolism. Chronic activation of the HPA axis is associated with a variety of neuropsychiatric disorders. (30)

Cannabinoids, through action on both limbic and paralimbic brain areas, reduce activity of the amygdala and hypothalamus. Retrograde endocannabinoid signaling in the hypothalamus is responsible for regulating HPA output. (32) Acute administration of exogenous cannabinoid ligands also activates the HPA axis indirectly through an increase in serotonergic and noradrenergic neurotransmission. (33) Chronic exposure to desipramine (and perhaps other antidepressants and therapies) has been shown to upregulate the endocannabinoid system, which, in turn, dampens the stress axis in a manner similar to habituation. (34) Endogenous cannabinoid signaling is essential for stress adaptation and is fundamental to the intrinsic regulation of the HPA axis. (35)

Discussion

Because PTSD is often difficult to treat with a single medication, it is common to see the use of “drug cocktails,†which may cause significant adverse reactions. This may include treatment with combinations of antidepressants, antipsychotics, benzodiazepines, anticonvulsants, sedative/hypnotics, and antihypertensives. Cannabis may address symptoms across all 3 major symptom clusters in PTSD with few clinically significant adverse reactions.

A review by Grant and colleagues found that inhaled cannabis is a rapid and efficient method of delivery for THC, allowing for self-titration of medication. (36) Although cannabis may cause dizziness, anxiety, paranoia, dry mouth, fatigue, or weakness, tolerance to adverse reactions develops rapidly. There are no reports of fatal overdose with cannabis, and long-term use is not associated with increased risk of lung or gastrointestinal cancers. There is little evidence of important CYP 450 system drug-drug interactions, and the acute medical risks of THC as used in clinical trials are low. (36)

Inhaled cannabis is generally well tolerated and has been shown to reduce the pain intensity, decrease anxiety, and improve sleep. (37) Cannabinoids may reduce or entirely eliminate nightmares; patients using cannabinoids report improvement in sleep time, quality of sleep, and reduction of daytime flashbacks and night sweats. (38)

Alcohol abuse has been significantly linked to PTSD, (39) and cannabis has been shown to act as a substitute for alcohol. (40) Many patients with PTSD struggle with alcohol abuse, often in an attempt to self-medicate. The majority of these patients referred to the Medical Cannabis Program, who have co-occurring alcohol abuse issues, have reported significantly decreased use, and in many cases, complete cessation of alcohol. A patient survey conducted by Berkeley Patient's Group, a medical cannabis dispensary in Berkeley, CA, found that 65% of those surveyed reported using cannabis as a substitute because it has less adverse reactions than alcohol and illicit or prescription drugs. (41)

Cannabinoids have been shown to reduce aggressive behavior, which has important implications in PTSD. (42-44) Patients commonly report significant reductions in irritability and anger. Patients are often accompanied by family members, friends, and/or treatment team members who confirm reductions in aggressive behavior.

Many patients with PTSD have co-occurring psychotic disorders. Although use of cannabis in patients with schizophrenia has typically been reported to worsen psychosis, increases in population cannabis use have not been followed by increases in psychotic incidence. (45,46) THC has been shown to improve symptoms in treatment-refractory patients with schizophrenia, including reduction in core psychotic symptoms, with no clinically significant adverse effects. (45) When compared to non-using patients, patients with schizophrenia who use cannabis and patients with a history of cannabis at first episode of psychosis have superior neuropsychological functioning. (47) Medical cannabis patients with co-occurring psychotic disorders often report reductions in both positive and negative symptoms of schizophrenia, which have failed to resolve with traditional antipsychotic medications, consistent with the findings of Schwarcz and colleagues. (45)

Strains of cannabis-containing CBD in addition to THC may prevent the psychotic-like symptoms sometimes caused by strains with high levels of THC but a lack of CBD. (48) Cannabis of the sativa and ruderalis biotypes typically contain higher levels of CBD and lower levels of THC, while indica biotypes tend to have higher levels of THC and more variable levels of CBD. (49) Unfortunately, finding consistent access to CBD-rich strains is difficult for many patients, and finding the best strain for any individual is largely a matter of trial and error.

A comprehensive study of 4 legal, medical cannabis patients in the federal Investigational New Drug Program found only mild changes in pulmonary function associated with long-term, heavy use. No functionally significant adverse effects were noted in any other physiologic system examined in the study. (50) Although changes in pulmonary function can be seen with chronic high use of cannabis, occasional and low cumulative marijuana use of up to 1 joint a day for 7 years is not associated with adverse effects on pulmonary function. (51)

New Mexico incorporated a definition of “practitioner†that allows advanced practice nurses with prescriptive authority to refer patients to the Medical Cannabis Program. (52) Unfortunately, most states with medical cannabis programs do not allow advanced practice nurses to refer patients. Many providers are not able to refer patients to medical cannabis programs due to institutional regulations. Some providers may have concerns about potential adverse reactions reported with cannabis. However, for those who are able and willing to refer patients to medical cannabis programs, these programs offer a unique opportunity to investigate the safety and efficacy of cannabis while providing relief from pain and suffering.

Marijuana as medicine

Cannabis is effective in treating PTSD, even when there are other co-occurring psychiatric and/or medical disorders. The broad range of therapeutic effects seen in treating PTSD with cannabis suggests that it may be beneficial in treating other disorders as well. Rather than targeting neurotransmitter systems and their agonists, cannabinoids target the underlying neurobiological processes that lead to imbalances in these neurotransmitter systems, helping to return them to a state of homeostasis.

As with any medication, caution must be used when recommending medical cannabis. Patients should be warned of potential risks, including the potential legal and occupational repercussions that can arise the use of cannabis. Some patients may experience increased levels of sedation, anxiety, or paranoia, and cannabis may induce psychosis in certain individuals. Many patients may opt to use cannabis in spite of these risks.

"Based on evidence currently available, the Schedule I classification is not tenable; it is not accurate that cannabis has no medical value or that information on safety is lacking.†(36) Healthcare providers have an obligation to provide the best possible care based on the best available scientific evidence. Until cannabis is removed from Schedule I of the federal CSA, the barriers to controlled clinical trials of cannabis in treating PTSD and other medical conditions will remain.

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Keywords:
cannabinoid; cannabis; endocannabinoid; marijuana; neurobiology; posttraumatic stress disorder; PTSD

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
 
Thank you SweetSue.:Love::hugs::hugs::ciao:
 
Canyon said:
Thanks Sue,

PTSD is my qualifying condition. I skimmed it and will go through it tomorrow.

Best
Click to expand...

Canyon.... :hugs::Love: This made the time worth every minute.

Jacobsenji said:
Thank you SweetSue.:Love::hugs::hugs::ciao:
Click to expand...

You're so welcome Jacob. :Love::hugs::hugs::Love:

There's a second class that will be offered sometime in the future on Bryan's program for enhancing the ECS. When that gets offered I'll be adding the info to this thread.
 
A helpful article I came across on helping someone with PTSD.

How to Help Someone with PTSD

The link to the original article. These people put a lot of time and expense into collecting this information and maintaining the site. If you visit, consider a donation to their cause. There's a link on the site to do so, should you desire to help them out.

Helping a Friend or Loved One with Post-Traumatic Stress Disorderhttps://www.helpguide.org/articles/ptsd-trauma/ptsd-in-the-family.htm

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When someone you care about suffers from post-traumatic stress disorder (PTSD), it can leave you feeling overwhelmed. The changes in your loved one can be worrying or even terrifying. You may feel angry about what's happening to your family and relationship, or hurt by your loved one's distance and moodiness. But it's important to know is that you're not helpless. Your support can make all the difference in your partner, friend, or family member's recovery. With your help, your loved one can overcome PTSD and move on with his or her life.

The impact of PTSD on relationships

PTSD can take a heavy toll on relationships. It can be hard to understand your loved one's behavior–why he or she is less affectionate and more volatile. You may feel like you're walking on eggshells or living with a stranger. You may have to take on a bigger share of household tasks, deal with the frustration of a loved one who won't open up, or even deal with anger or disturbing behavior. The symptoms of PTSD can also lead to job loss, substance abuse, and other problems that affect the whole family.

It's hard not to take the symptoms of PTSD personally, but it's important to remember that a person with PTSD may not always have control over his or her behavior. Your loved one's nervous system is "stuck" in a state of constant alert, making him or her continually feel vulnerable and unsafe. This can lead to anger, irritability, depression, mistrust, and other PTSD symptoms that your loved one can't simply choose to turn off. With the right support from friends and family, though, your loved one's nervous system can become "unstuck" and he or she can finally move on from the traumatic event.

6 tips for helping someone with PTSD

Provide social support
Be a good listener
Rebuild trust and safety
Anticipate and manage triggers
Deal with volatility and anger
Take care of yourself

Tip 1: Provide social support

It's common for people with PTSD to withdraw from friends and family. While it's important to respect your loved one's boundaries, your comfort and support can help the person with PTSD overcome feelings of helplessness, grief, and despair. In fact, trauma experts believe that face-to-face support from others is the most important factor in PTSD recovery.

How to support your loved one

Knowing how to best demonstrate your love and support for someone with PTSD isn't always easy. You can't force your loved one to get better, but you can play a major role in the healing process by simply spending time together.

Don't pressure your loved one into talking. It can be very difficult for people with PTSD to talk about their traumatic experiences. For some, it can even make things worse. Instead, let them know you're willing to listen when they want to talk, or just hang out when they don't. Comfort for someone with PTSD comes from feeling engaged and accepted by you, not necessarily from talking.

Do "normal" things with your loved one, things that have nothing to do with PTSD or the traumatic experience. Encourage your loved one to participate in rhythmic exercise that engages both arms and legs, seek out friends, and pursue hobbies that bring pleasure. Take a fitness class together, go dancing, or set a regular lunch date with friends and family.

Let your loved one take the lead, rather than telling him or her what to do. Everyone with PTSD is different but most people instinctively know what makes them feel calm and safe. Take cues from your loved one as to how you can best provide support and companionship.

Manage your own stress. The more calm, relaxed, and focused you are, the better you'll be able to help a loved one with PTSD.

Be patient. Recovery is a process that takes time and often involves setbacks. The important thing is to stay positive and maintain support for your loved one.

Educate yourself about PTSD. The more you know about the symptoms, effects, and treatment options, the better equipped you'll be to help your loved one, understand what he or she is going through, and keep things in perspective.

Accept (and expect) mixed feelings. As you go through the emotional wringer, be prepared for a complicated mix of feelings–some of which you'll never want to admit. Just remember, having negative feelings toward your family member doesn't mean you don't love them.

Tip 2: Be a good listener

While you shouldn't push a person with PTSD to talk, if they do choose to share, try to listen without expectations or judgments. Make it clear that you're interested and that you care, but don't worry about giving advice. It's the act of listening attentively that is helpful to your loved one, not what you say. A person with PTSD may need to talk about the traumatic event over and over again. This is part of the healing process, so avoid the temptation to tell your loved one to stop rehashing the past and move on.

Some of the things your loved one tells you might be very hard to listen to, but it's important to respect their feelings and reactions. If you come across as disapproving or judgmental, they are unlikely to open up to you again.

Communication Pitfalls to Avoid

Don't . . .

Give easy answers or blithely tell your loved one everything is going to be okay

Stop your loved one from talking about their feelings or fears

Offer unsolicited advice or tell your loved one what they "should" do

Blame all of your relationship or family problems on your loved one's PTSD

Invalidate, minimize, or deny your loved one's traumatic experience

Give ultimatums or make threats or demands

Make your loved one feel weak because they aren't coping as well as others

Tell your loved one they were lucky it wasn't worse

Take over with your own personal experiences or feelings

Tip 3: Rebuild trust and safety

Trauma alters the way a person sees the world, making it seem like a perpetually dangerous and frightening place. It also damages people's ability to trust others and themselves. Anything you can do to rebuild your loved one's sense of security will contribute to recovery.

Express your commitment to the relationship. Let the person know you're here for the long haul so he or she feels loved and supported.

Create routines. Structure and predictable schedules can restore a sense of stability and security to people with PTSD, both adults and children. That may mean help with groceries or housework, for example, maintaining regular times for meals, or simply "being there" for the person.

Minimize stress at home. Try to make sure your loved one has space and time for rest and relaxation.

Speak of the future and make plans. This can help counteract the common feeling among people with PTSD that their future is limited.

Keep your promises. Help rebuild trust by being trustworthy. Be consistent and follow through on the things you say you're going to do.

Emphasize your loved one's strengths. Tell your loved one you believe he or she is capable of recovery and point out all your loved one's positive qualities and successes.

Encourage your loved one to join a support group. Getting involved with others who have gone through similar traumatic experiences can help some people with PTSD feel less damaged and alone.

Tip 4: Anticipate and manage triggers

A trigger is anything–a person, place, thing, or situation–that reminds your family member of the trauma and sets off a PTSD symptom, such as a flashback.

Sometimes, triggers are obvious. For example, a military veteran might be triggered by seeing his combat buddies or by the loud noises that sound like gunfire. Others may take some time to identify and understand, such as hearing a song that was playing when the traumatic event happened, for example, so now that song or even others in the same musical genre are triggers. Similarly, triggers don't have to be external. Internal feelings and sensations can also trigger PTSD symptoms.

Types of PTSD triggers

Common external triggers
Sights, sounds, or smells associated with the trauma

People, locations, or things that recall the trauma

Significant dates or times, such as anniversaries or a specific time of day

Nature (certain types of weather, seasons, etc.)

Conversations or media coverage about trauma or negative news events

Situations that feel confining (stuck in traffic, at the doctor's office, in a crowd)

Relationship, family, school, work, or money pressures or arguments

Funerals, hospitals, or medical treatment

Common internal triggers
Physical discomfort, such as hunger, thirst, fatigue, sickness, and sexual frustration

Any bodily sensation that recalls the trauma, including pain, old wounds and scars, or a similar injury

Strong emotions, especially feeling helpless, out of control, or trapped

Feelings toward family members, including mixed feelings of love, vulnerability, and resentment

Talking to your loved one about triggers

Ask your loved one about things he or she did in the past in response to a trigger that seemed to help (as well as those that didn't). Then you can come up with a joint game plan for how you will respond in future.

Ask what your loved one would like you to do during a nightmare, flashback, or panic attack. Having a plan in place will make the situation less scary for both of you. You'll also be in a much better position to help your loved one calm down.

How to help in the middle of a flashback or panic attack

During a flashback, people often feel a sense of disassociation, as if they're detached from their own body. Anything you can do to "ground" them will help.

Tell them they're having a flashback and that even though it feels real, it's not actually happening again
Help remind them of their surroundings (for example, ask them to look around the room and describe out loud what they see)

Encourage them to take deep, slow breaths (hyperventilating will increase feelings of panic)
Avoid sudden movements or anything that might startle them

Ask before you touch them. Touching or putting your arms around the person might make him or her feel trapped, which can lead to greater agitation and even violence

Tip 5: Deal with volatility and anger

PTSD can lead to difficulties managing emotions and impulses. In your loved one, this may manifest as extreme irritability, moodiness, or explosions of rage.

Understanding anger in PTSD

People suffering from PTSD live in a constant state of physical and emotional stress. Since they usually have trouble sleeping, it means they're constantly exhausted, on edge, and physically strung out–increasing the likelihood that they'll overreact to day-to-day stressors.

For many people with PTSD, anger can also be a cover for other feelings such as grief, helplessness, or guilt. Anger makes them feel powerful, instead of weak and vulnerable. For others, they try to suppress their anger until it erupts when you least expect it.

Watch for signs that your loved one is angry such as clenching jaw or fists, talking louder, or getting agitated. Take steps to defuse the situation as soon as you see the initial warning signs.

Try to remain calm. During an emotional outburst, do your best to stay calm. This will communicate to your loved one that you are "safe" and prevent the situation from escalating.

Give the person space. Avoid crowding or grabbing the person. This can make a traumatized person feel threatened.

Ask how you can help. For example: "What can I do to help you right now?" You can also suggest a time out or change of scenery.

Put safety first. If the person gets more upset despite your attempts to calm him or her down, leave the house or lock yourself in a room. Call 911 if you fear that your loved one may hurt himself or others.

Learning how to control anger

Anger is a normal, healthy emotion, but when chronic, explosive anger spirals out of control, it can have serious consequences on a person's relationships, health, and state of mind. Your loved one can get anger under control by exploring the root issues and learning healthier ways to express their feelings.

See: Anger Management

Tip 6: Take care of yourself

Letting your family member's PTSD dominate your life while ignoring your own needs is a surefire recipe for burnout. In order to have the strength to be there for your loved one over the long haul, you have to nurture and care for yourself.

Take care of your physical needs: get enough sleep, exercise regularly, eat properly, and look after any medical issues.

Cultivate your own support system. Lean on other family members, trusted friends, your own therapist or support group, or your faith community. Talking about your feelings and what you're going through can be very cathartic.

Make time for your own life. Don't give up friends, hobbies, or activities that make you happy. It's important to have things in your life that you look forward to.

Spread the responsibility. Ask other family members and friends for assistance so you can take a break. You may also want to seek out respite services in your community.

Set boundaries. Be realistic about what you're capable of giving. Know your limits, communicate them to your family member and others involved, and stick to them.

Trauma can be "contagious"

Caring for someone with PTSD can lead to the potential for secondary traumatization. You can develop your own symptoms from listening to trauma stories or being exposed to scary symptoms like flashbacks. The more depleted and overwhelmed you feel, the greater the risk that you may become traumatized.

Support for people taking care of veterans

If the person you're caring for is a U.S. military veteran, financial and caregiving support may be available. Visit VA Caregiver Support to explore your options, or call Coaching into Care at (888) 823-7458. For military veterans in other countries, see the Resources section below for helplines.

If you want to learn skills for connecting to others in ways that reduce stress and anxiety, read FEELING LOVED.

More help for PTSD

Emotional and Psychological Trauma: Symptoms, Treatment, and Recovery
PTSD in Military Veterans: Symptoms, Treatment, and Self Help: Helping Yourself on the Road to Recovery for Post-Traumatic Stress Disorder
Alcoholism and Alcohol Abuse: Signs, Symptoms, and Help for Drinking Problems
Resources and references
General help for family members

National Suicide Prevention Lifeline — This 24-hour U.S. hotline for anyone in emotional distress: 1-800-273-TALK (8255).

IASP — Find crisis centers and suicide prevention helplines around the world. (International Association for Suicide Prevention).

SIDRAN Institute — A nonprofit organization that helps people understand, recover from, and treat traumatic stress. Includes a referral list of therapists for PTSD.

National Alliance on Mental Illness (NAMI) — Call the Helpline at 1-800-950-NAMI (6264) or check out the Family-to-Family Education Program for caregivers of people with severe mental illness in the U.S.

Help for U.S. veterans' family members

Coaching Into Care — Call (888) 823-7458 for free, confidential coaching designed to help family members learn how to talk to their veteran about their concerns and about treatment options.

Veterans Crisis Line — A confidential, free hotline for veterans and their families and friends. Call 1-800-273-8255 (Press 1) or connect via chat or text (838255).

Military OneSource — Call 1-800-342-9647 for confidential counseling, non-medical services, and other resources for veterans and their family members. The line is open 24/7.

Help for Veterans with PTSD — Learn how to earn how to earn how to enroll for VA health care and get an assessment. (National Center for PTSD)

Give an Hour — A nonprofit organization that offers free mental health services to U.S. military personnel and their families affected by the ongoing conflicts in Iraq and Afghanistan.

24/7 Outreach Center for Psychological Health & Traumatic Brain Injury — Get help for traumatic brain injury and other psychological health issues. Call 1-866-966-1020 or connect through chat or email. (DoD's Defense Centers of Excellence)

A Guide to VA Mental Health Services for Veterans & Families (PDF) — Comprehensive guide to VA mental health services, including programs and resources for PTSD.

Help for veterans and their families in other countries

Canadian veterans: visit Operational Stress Injury Social Support (OSISS) or call 1-800-883-6094 to talk to a peer who has been through similar experiences.

UK veterans: visit Combat Stress or call the 24-hour helpline 0800 138 1619.

Australian veterans: visit Veterans and Veterans Families Counseling Services (VVCS) or call 1800 011 046

General information about PTSD in veterans and the family

Effects of PTSD on Family — When someone in the family has PTSD, everyone feels the effects. Learn about common feelings and reactions among family members. (National Center for PTSD)

About Face — Hear the stories of veterans who live with PTSD. Listen to personal experiences about how PTSD affected their families and how treatment turned things around.

Returning from the War Zone (PDF) — Learn about issues families face when a spouse returns from war and what can be done to prepare for the reunion and cope with the transition to civilian life.

What other readers are saying
"I cannot express how much your article helped open my mind to something I thought I understood. My daughter is dealing with a significant trauma. After many years concealing the event she found her voice and is dealing with the underlying catalyst of her most recent challenges and behaviors. I found the article valuable and afforded me the opportunity to wrap my mind around emotions and thoughts she will be dealing with now." ~ Florida

"Our daughter recently experienced a very stressful "workplace bullying" incident involving a relentless superior. While not a traditional cause of PTSD, the after effects are similar. Thank you for an informative, insightful article. Glad I stumbled on it and was able to share with my daughter." ~ Maryland

Authors: Melinda Smith, M.A., and Lawrence Robinson. Last updated: October 2016.
 
Another valuable resource from Heal My PTSD. I typed this one through tears. I'm so damned empathetic that I couldn't stop thinking of those of you that I love that deal with this on a daily basis. :hugs::hugs::hugs::hugs::hugs: I'm gonna go have a good cry now and get it out of my system.

I hope this is as helpful for you as it feels.

10 Tips for understanding someone with PTSD

10 Tips for Understanding Someone with PTSD
A guide for friends, family and colleagues.

PTSD makes communication difficult.

Many survivors can’t find the words to express what they’re feeling. Even when they do, it’s very normal for them not to be comfortable sharing their experience. Elements of shame, fear, anger, guilt and grief often get in the way of a calm, focused discussion.

Friends and family (and anyone else who is not the source of the PTSD but is standing by while someone attempts to heal) need something that translates PTSD language. Armed with knowledge, insight and awareness you’ll have an easier time knowing how to react, respond and relate to your PTSD loved one during the healing process. The more you appreciate things from the PTSD perspective the more helpful and supportive you can be. Now is the time for empathy, compassion and patience.

The list below will give you an overview of things to understand. For more in-depth information – plus content specifically geared for you, the caregiver – check out the free archives of our radio show, CHANGING DIRECTION, which features professionals and experts weighing in on what you need to know about PTSD and your role.


#1 – Knowledge is power. Understanding the process of a triggering event, the psychic reaction to trauma, the warning signs and symptoms of PTSD, and available treatment options for PTSD allows you to help recognize, support and guide your PTSD loved one toward diagnosis, treatment and healing.

We need you to be clearheaded, pulled together and informed.

#2 – Trauma changes us. After trauma we want to believe —as do you—that life can return to the way it was; that we can continue as who we were. This is not how it works. Trauma leaves a huge and indelible impact on the soul. It is not possible to endure trauma and not experience a psychic shift.

Expect us to be changed. Accept our need to evolve. Support us on this journey.

#3 – PTSD hijacks our identity. One of the largest problems with PTSD is that it takes over our entire view of ourselves. We no longer see clearly. We no longer see the world as we experienced it before trauma. Now every moment is dangerous, unpredictable and threatening.

Gently remind us and offer opportunities to engage in an identity outside of trauma and PTSD.

#4 – We are no longer grounded in our true selves. In light of trauma our real selves retreat and a coping self emerges to keep us safe.

Believe in us; our true selves still exist, even if they are momentarily buried.

#5 – We cannot help how we behave. Since we are operating on a sort of autopilot we are not always in control. PTSD is an exaggerated state of survival mode. We experience emotions that frighten and overwhelm us. We act out accordingly in defense of those feelings we cannot control.

Be patient with us; we often cannot stop the anger, tears or other disruptive behaviors that are so difficult for you to endure.

#6 – We cannot be logical. Since our perspective is driven by fear we don’t always think straight, nor do we always accept the advice of those who do.

Keep reaching out, even when your words don’t seem to reach us. You never know when we will think of something you said and it will comfort, guide, soothe or inspire us.

#7 – We cannot just ‘get over it’. From the outside it’s easy to imagine a certain amount of time passes and memories fade and trauma gets relegated to the history of a life. Unfortunately, with PTSD nothing fades. Our bodies will not let us forget. Because of surging chemicals that reinforce every memory, we cannot walk away from the past anymore than you can walk away from us.

Honor our struggle to make peace with events. Do not rush us. Trying to speed our recovery will only make us cling to it more.

#8 – We’re not in denial—we’re coping! It takes a tremendous effort to live with PTSD. Even if we don’t admit it, we know there’s something wrong. When you approach us and we deny there’s a problem that’s really code for, “I’m doing the best I can.” Taking the actions you suggest would require too much energy, dividing focus from what is holding us together. Sometimes, simply getting up and continuing our daily routine is the biggest step toward recovery we make.

Alleviate our stress by giving us a safe space in which we can find support.

#9 – We do not hate you. Contrary to the ways we might behave when you intervene, somewhere inside we do know that you are not the source of the problem. Unfortunately, in the moment we may use your face as PTSD’s image. Since we cannot directly address our PTSD issues sometimes it’s easier to address you.

Continue to approach us. We need you to!

#10 – Your presence matters. PTSD creates a great sense of isolation. In our post-traumatic state, it makes a difference to know that there are people who will stand by us. It matters that although we lash out, don’t respond and are not ourselves, you are still there, no matter what.

Don’t give up, we’re doing our best.
 
Thank you Sue.:Love:
 
SweetSue said:
Another valuable resource from Heal My PTSD. I typed this one through tears. I'm so damned empathetic that I couldn't stop thinking of those of you that I love that deal with this on a daily basis. :hugs::hugs::hugs::hugs::hugs: I'm gonna go have a good cry now and get it out of my system.

I hope this is as helpful for you as it feels.

10 Tips for understanding someone with PTSD

10 Tips for Understanding Someone with PTSD
A guide for friends, family and colleagues.

PTSD makes communication difficult.

Many survivors can't find the words to express what they're feeling. Even when they do, it's very normal for them not to be comfortable sharing their experience. Elements of shame, fear, anger, guilt and grief often get in the way of a calm, focused discussion.

Friends and family (and anyone else who is not the source of the PTSD but is standing by while someone attempts to heal) need something that translates PTSD language. Armed with knowledge, insight and awareness you'll have an easier time knowing how to react, respond and relate to your PTSD loved one during the healing process. The more you appreciate things from the PTSD perspective the more helpful and supportive you can be. Now is the time for empathy, compassion and patience.

The list below will give you an overview of things to understand. For more in-depth information — plus content specifically geared for you, the caregiver — check out the free archives of our radio show, CHANGING DIRECTION, which features professionals and experts weighing in on what you need to know about PTSD and your role.


#1 — Knowledge is power. Understanding the process of a triggering event, the psychic reaction to trauma, the warning signs and symptoms of PTSD, and available treatment options for PTSD allows you to help recognize, support and guide your PTSD loved one toward diagnosis, treatment and healing.

We need you to be clearheaded, pulled together and informed.

#2 — Trauma changes us. After trauma we want to believe –as do you–that life can return to the way it was; that we can continue as who we were. This is not how it works. Trauma leaves a huge and indelible impact on the soul. It is not possible to endure trauma and not experience a psychic shift.

Expect us to be changed. Accept our need to evolve. Support us on this journey.

#3 — PTSD hijacks our identity. One of the largest problems with PTSD is that it takes over our entire view of ourselves. We no longer see clearly. We no longer see the world as we experienced it before trauma. Now every moment is dangerous, unpredictable and threatening.

Gently remind us and offer opportunities to engage in an identity outside of trauma and PTSD.

#4 — We are no longer grounded in our true selves. In light of trauma our real selves retreat and a coping self emerges to keep us safe.

Believe in us; our true selves still exist, even if they are momentarily buried.

#5 — We cannot help how we behave. Since we are operating on a sort of autopilot we are not always in control. PTSD is an exaggerated state of survival mode. We experience emotions that frighten and overwhelm us. We act out accordingly in defense of those feelings we cannot control.

Be patient with us; we often cannot stop the anger, tears or other disruptive behaviors that are so difficult for you to endure.

#6 — We cannot be logical. Since our perspective is driven by fear we don't always think straight, nor do we always accept the advice of those who do.

Keep reaching out, even when your words don't seem to reach us. You never know when we will think of something you said and it will comfort, guide, soothe or inspire us.

#7 — We cannot just 'get over it'. From the outside it's easy to imagine a certain amount of time passes and memories fade and trauma gets relegated to the history of a life. Unfortunately, with PTSD nothing fades. Our bodies will not let us forget. Because of surging chemicals that reinforce every memory, we cannot walk away from the past anymore than you can walk away from us.

Honor our struggle to make peace with events. Do not rush us. Trying to speed our recovery will only make us cling to it more.

#8 — We're not in denial–we're coping! It takes a tremendous effort to live with PTSD. Even if we don't admit it, we know there's something wrong. When you approach us and we deny there's a problem that's really code for, "I'm doing the best I can." Taking the actions you suggest would require too much energy, dividing focus from what is holding us together. Sometimes, simply getting up and continuing our daily routine is the biggest step toward recovery we make.

Alleviate our stress by giving us a safe space in which we can find support.

#9 — We do not hate you. Contrary to the ways we might behave when you intervene, somewhere inside we do know that you are not the source of the problem. Unfortunately, in the moment we may use your face as PTSD's image. Since we cannot directly address our PTSD issues sometimes it's easier to address you.

Continue to approach us. We need you to!

#10 — Your presence matters. PTSD creates a great sense of isolation. In our post-traumatic state, it makes a difference to know that there are people who will stand by us. It matters that although we lash out, don't respond and are not ourselves, you are still there, no matter what.

Don't give up, we're doing our best.[COLOR]
Click to expand...


Truly one of the first posts I've read on 420 n several years that brought tears to me & softened me up back to human status.
I don't remember who wrote it, but thank you Sue for posting.
As a combat vet (3/75th Rangers; Iraq, Afghanistan, Bosnia, Moga City & a few others, plus an emotionally abusive marriage) I struggle with PTSD pretty often.
This post was right on.
Usually when i tell someone to "f" off, I mean please don't leave.
 
You're welcome Cajun. You were one of the members I couldn't forget about while I formatted this up. It's from a site called Heal My PTSD. The link to the site is at the top of the post.
 
I posted that, went off and took a shower, thinking about the ECS and Machoulam's postulation that the system determines personality expression. Suddenly it occurred to me that the early years of my life, the first two years, to be exact and the timeframe Danny talks about in this video with mothers and children sharing trauma, my father was beating my mother, and the emotional tone of my earliest memories were filled with violence and anger and frustration.

I have been suffering the after effects of that trauma and the ultimate disruption of the family unit when I was two, my entire life. Self-destructive habits that I fought with myself all these years over are classic symptoms of PTSD that no one, no one saw or responded to.

I've been out there working it out on my own, not even aware of what it was all about. A minute...........

It wasn't until this year that I found effective methods on my own, through divine guidance nonetheless, to calm my own inner storms. My newfound understanding of the ECS was the linchpin. Those self-destructive habits have been falling away, one-by-one, for the past year. This week alone I conquered two. Two habits that've dogged me most of my life and now are ancient history. All because I figured out how to reset my ECS.

cajuncelt, I know you're out there. There are no words adequate enough mon ami. You didn't realize your part was to light the fire. You did a damned good job. :kisstwo:

Well I'll be...... You were right mon ami. Knowledge is power.
 
AngryBird said:
That would explain my middle daughters behavior ?..aggressiveness towards hate
Click to expand...

Yes it would. Violence damages the psyche. The brain temporarily forgets how to let the memories go and move on. Memories only have the effect caused by the emotions we attach to them. Violence sometimes, but not always, causes a switch to stay on.

Cannabis helps the brain retrain the emotional response. With proper dosing you can control the storms until such time that your own ECS is strong enough to do the job on its own.

For patients who can't seem to get there on their own, cannabis offers a safe medication that not only brings you back into the present, but repairs damage while it's at it. As we go forward they'll begin to learn more precisely which cannabinoid ratios and overall synergistic combinations will be most effective. It'll be nice to be able to fine tune dosages for particular symptom clusters.
 
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