December 17, 2012

People with PTSD suffer from emotional dysregulation. They have trouble controlling their emotions. A Vietnam veteran patient of mine with combat-related PTSD once told me “we have no feelings, only emotions”. His comment makes good sense in relation to our present understanding of how emotions are generated and managed in the brain.

Our brain has two major emotion centers: the amygdala, located deep in the brain beneath the temporal lobe, and the anterior cingulate cortex (ACC), located in the prefrontal lobe, near the midline. Our most basic emotions, like anger and fear, related to “fight or flight”, are processed in the amygdala, which is overactive in PTSD. Our more subtle social emotions or “feelings”, like guilt, shame, envy, gratitude, pride, admiration, and love, are processed in the ACC, along with anger and fear. Regulation of basic emotions in the amygdala involves the creation of feelings in the ACC. The ACC is underactive in PTSD, which may account for my veteran patient’s, and his veteran buddies’, reported lack of feelings.

PTSD nightmares are dominated by anger and fear. Dream revision therapy seeks to add social emotions or feelings to the dream, tempering the basic emotions in the process. Often, when I work with people’s PTSD nightmares, we bring out and strengthen buried feelings involving guilt, shame, envy, pride, gratitude, admiration, love, or other social emotions, that had previously escaped their awareness.

One of my patients, a policeman with recurrent nightmares about being pursued by a manacing “junkyard dog”, came to realize that he himself was the junkyard dog, and he was being pursued by what amounted to an embodiment of his own guilt at having killed a young bank robber at close range. Prior to having his “junkyard dog” nightmare, he told me that he thought of himself as a junkyard dog: short tempered, mean, a loose cannon with a short fuse.

Another of my patients, a police woman with recurrent nightmares about being pursued by a giant snake, was filled with anger at having been molested by her grandfather as a young girl. She came to terms with her shame as we reviewed another nightmare of hers that involved her and her sister discovering the dead body of their grandfather in a river. Both she and her sister had been molested by that grandfather. Only after reporting the river dream did she fully disclose to me the full story regarding the molestation.

Effective therapy for PTSD manages to connect the patient with their missing social emotions, thereby taming their out-of-control basic emotions. Recovery becomes a kind of rebirth of their fully developed adult personality. The process is wonderful to observe as a therapist, and apparently joyful to experience as a patient.