Bruce Dow, M.D.

Take Control of your Triggers

In the world of PTSD sufferers, a “trigger” is a sensory experience (a sight, sound, smell, taste, touch, or pain) that brings back (or “triggers”) memories of their original trauma.  The memories, in turn, trigger flashbacks, and the flashbacks trigger nightmares.  Flashbacks and nightmares pull the PTSD sufferer back into the trauma itself, causing retraumatization, and thereby setting the stage for new triggering.  This process of triggering and retraumatization keeps PTSD active and disabling.

PTSD symptoms can include not only flashbacks and nightmares, but hypervigilance, irritability, dissociation, memory loss, depression, chronic aches and pains (sometimes referred to as “somatization”), weakened immune response (infections), bowel irregularities, etc.  Given the apparently global nature of the illness, it often comes as a surprise when I inform PTSD sufferers that simply getting rid of nightmares can be sufficient to eliminate all symptoms associated with PTSD.

The reason that nightmare revision can be so efficacious is that it breaks the vicious cycle of triggers, flashbacks, and nightmares.  Without nightmares, triggers gradually fade in their triggering capability, flashbacks become weaker and less frequent; people sleep better, and are more rested during the day, giving them more energy for useful work.  Working helps put their trauma behind them, as they replace older traumatic memories with newer more positive ones.

Another way to break the vicious cycle is to work on triggers.  I encourage PTSD sufferers to become aware of their triggers.  Triggers for Vietnam veterans include the sounds of helicopters overhead, of empty Coke cans rattling together (recalling Viet Cong coming through barbed wire perimeter fences in the dark), of heavy rain in a forest (recalling the monsoon season in Vietnam).  Other triggers involve the Vietnamese people themselves: the distinctive sound of the Vietnamese language being spoken, the smell of Vietnamese food wafting out of a restaurant, the sight of Vietnamese (or other Asians) in a shopping mall.  Survivors of rape may be triggered by images that remind them of the rapist or the rape setting.  Each individual PTSD sufferer has a unique set of triggers, depending on the nature of their trauma experience.

Some triggers are avoidable, others less avoidable, some nearly unavoidable.  Avoidable triggers should be avoided whenever possible.  I advise Vietnam veterans with PTSD to avoid movies dealing with the Vietnam War (Platoon, Full Metal Jacket, The Deer Hunter, Born on the Fourth of July, Hamburger Hill, Jacob’s Ladder, Apocalypse Now).  Veterans of the wars in Iraq and Afghanistan now have their own growing set of movies to avoid (The Hurt Locker, The Messenger, In the Valley of Elah, Restrepo, Zero Dark Thirty).  I advise clients with a history of sexual or physical abuse/assault to avoid movies or news reports that deal with these subjects.  It may be important for trauma survivors to avoid certain settings (e.g., jungle, desert, mountains, dark alleys, parking garages) that remind them of traumatic experiences.

However, avoidance can be carried too far.  Some people with PTSD mistakenly stay home, or even in one bedroom in the home, to avoid the possibility of being triggered.  Such extreme avoidance doesn’t work.  Something eventually will break through to their sensory systems, causing triggering and re-traumatizing by memories, flashbacks, and/or nightmares.

Some level of exposure to milder triggers is helpful in maintaining one’s capacity to experience triggers without retraumatization.  I realized that my Vietnam veteran patients were improving when they could go to a busy supermarket or a July 4th fireworks celebration without being triggered.

Emotional memory is an important intermediary in the vicious cycle of triggers, flashbacks, and nightmares.  Trauma is associated with particular types of memories involving fear, anger, guilt, shame, disgust, and a few other “negative” emotions.  Dream revision typically involves the substitution of “positive” emotions (relief, gratitude, satisfaction, pride, joy, hope, admiration, respect, and many others) for the negative emotions listed above.

In treating PTSD, it is not useful to dwell upon negative emotions.  The goal is to substitute positive emotions and let the negative ones gradually fade away.  The technical term for this fading away is “extinction”.  Successful treatment of PTSD involves the extinction of negative emotions like fear, anger, guilt, shame, and disgust and their replacement with positive emotions.