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PTSD – a speculation

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“Are you abandoning me? Have you given up on me?”. These were the questions my wife was asking me in my dreams, a week or two, prior to my planned recent travel abroad. No, my wife and I were not engaged in a bitter marital discord or about to break up. Rather, as I have catalogued elsewhere on this blog, my wife endured and fought a very painful battle with cancer before finally succumbing to it. That was almost three years ago. This dream highlights something important about our minds. It draws attention to the fact that although I have never felt it overtly, there is a lingering feeling of guilt that I could and should have done a lot more for her.  Then, of course, there are always undercurrents of hopelessness, and thoughts contemplating the fleeting nature of our existence not to mention inexplicable feelings of sadness, the onset of which could be triggered by a piece of music or a story in the news.  In short, existential angst amplified by looking at life through the lens of a departed individual who is of deep emotional significance to you. Left unchecked, these thoughts and feelings could create a positive feedback loop leading to a full blown depression, and complete withdrawal from society. The checking comes from a grieving process involving intense rationalization or cognitive effort and a constant readjustment of our worldview (could be rational or irrational) to accommodate these life shocks. In fact, most people are able to regain their bearings, given adequate time (note: the recovery period is not the same for everybody).  [ Fortunately for me, this experience has translated into a passion :  to help transform the practice of medicine and delivery of healthcare through innovative use of technology. That is now my singular focus.]

The Wall Street Journal published an article – Last Marine Standing : A Life Tormented by Survival.  It chronicles the life of Marine Lance Cpl. Williams post-Iraq. It is a very poignant article. It has been seven years since 11 members of his team were blown up in a roadside bomb. Cpl.Williams remains tormented by guilt, hopelessness, and other debilitating symptoms that  make it difficult for him to lead a “normal” life. The article offers some clues on how the Army psychiatrists are approaching the treatment of these individuals, as in the following excerpt:

“….The VA’s Dr. Maguen hasn’t met Lance Cpl. Williams. But she says his symptoms are typical of these more-complicated cases “where there are many different elements of moral injury and loss acting together, making it challenging for [the patient] to recover.”

Researchers are just beginning to study the prevalence of these  types of psychological injury among combat veterans and seek treatments to supplement PTSD therapies. In small-scale studies, researchers have found that about 30% of Marines and soldiers seeking treatment reported that moral-injury experiences were the incidents that most haunted them on their return from war.

In a pilot program with the Marines, clinicians used “adaptive disclosure” therapy to treat traumatic loss and moral injury. Patients held mock conversations with dead friends and imagined aloud how their buddies would respond.

The Pentagon has agreed to fund a larger-scale trial among Marines, according to psychologist Brett Litz of the Boston VA, who along with Dr. Maguen is a pioneer in the field. Dr. Maguen, meanwhile, is recruiting candidates for a VA study of treatment for troops troubled by having taken the lives of others…..”

Pioneers they may be, but I don’t think techniques like “adaptive closure” go far enough. Neither do the standard assortment of available drugs in the psychiatrist’s toolkit. As an alternative, I want to propose a cognitive neuroscience framework that may help illuminate the underlying mechanism and motivate approaches to treatments that may prove more effective.

Ever heard of Theory of Mind (ToM). If you have not, don’t worry. From Wikipedia,

Theory of mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires, and intentions that are different from one’s own…”

We tap into this ability for everything, from buying a gift for our beloved to anticipating the reactions of our bosses when asking for a raise. In short, we have the ability to running simulations of imagined events and predict behaviors of the other actors in the scene. Wearing my scientific hat, I have always wondered whether grief intensely engages the ToM system (because emotional centers are also included)  in our brains. More specifically, I view a large portion of grieving as involving simulations in the brain taking the departed person’s point of view or reliving moments of joint interactions and anticipating how they may have  reacted emotionally (happy, angry, etc.,). “Moving on” is then an disengagement from the simulation behavior (or, at a minimum, significant blunting of the emotional components) specific to the departed individual(s). Disengagement is a function of intense rationalization, which I alluded to earlier.

I believe this can be extended to, at least, certain flavors of PTSD experienced by the veterans returning from war. In these individuals, it is the exaggerated response of the ToM system. In some sense, the systems engaged in “theory of mind” have gone awry. In the link below, is a very interesting conversation with the commander of a bomb diffusion unit.


He mentions that in crowded places like airports, he is constantly looking at “who he needs to kill” to get to an exit, an example of “theory of mind” misfiring.

My prediction is Transcranial Magnetic Simulation knockout of  selective parts of the ToM system (particularly regions involved in emotions) would help provide relief (at least temporarily) for such individuals or those trapped in the local minima of “overuse of simulations”. The neural correlates of the ToM system are being actively studied by experts in the field and I am pretty sure what I noted above can be mapped onto actual brain sites for targeted therapies.

One of the hallmarks of PTSD is “stress”. Robert Sapolsky wrote a book called “Why Zebras Don’t Have Ulcers?”. The simple answer is, their stress levels are highest only when the predator is in sight. When this happens, they literally run for their life. If they survive, they go back to grazing. No more thinking about who is going to attack me next or what other danger should I worry about now. Out of sight, out of mind. But we on the other hand, have the brilliant twin abilities : running simulations and making predictions. One massive side-effect : grief and its really ugly cousin PTSD, witness Marine Lance Cpl. Williams.


Written by asterix98

February 18, 2013 at 1:49 am

Kara – Session Three

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We had a new (actually old to Kara) family join us this week.  The general topics of discussion revolved around children, photos and momentos, and general ups and downs. (Wow! I have to remember to try and rephrase this sentence. Three ands in a row. Should be avoidable).

The most striking thing, to me, that came out of the discussions, was the fact that the magnitude of the loss is greatest for the nuclear family, no matter how you slice it. This naturally impacts the time constant of the “moving on” component quite dramatically for the nuclear families compared to extended families (even after completely discounting any self-pity components). 

As an example, one person described how watching a particular video (a commercial cartoon movie) triggered a very emotional response, out of the blue, inspite of it being a few years removed from the loss. Later when they described this to the loved one’s brothers, they were incredulous and commented “I can’t believe you are stilling thinking about this person?”.

I shared that sometimes I permit myself some moments of fun/enjoyment but then there is a sense of guilt that the loved one is not able to do the same. Some others said that they experienced the exact same thing. I was struck by the universality of this human feeling.

The children engaged in expressing their feelings and emotions through colors. They did this for the head and the body. Mahati’s pictures showed a wide spectrum of colors, for both mind and body. She is getting better at expressing those feelings verbally.

I was curious to know if children with siblings discussed the loss amongst themselves. The surprising answer is that they don’t!

Written by asterix98

February 20, 2011 at 7:40 am

Posted in grief counseling

Kara – Session Two

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It was an interesting evening.  One person discussed how memorials now have a whole new meaning. I added likewise, celebrating birthdays, have taken on a whole deeper significance (what most people take for granted, remembrance of a day someone was born vs marking ” X is still here”). 

The topic shifted to the dilemma around what is to be done with the loved ones belongings , clothes to cars, box of chocolates to trinkets. There was a wide range of responses with consensus being do as you see fit.

Others shared some recent incidents where they felt they had received condescending or even insensitive remarks at social events (how their spouses were not helping and it was tough to manage things etc.,) .

Yet another topic that came up was the emotional maturity of kids post-incident. Some were of the opinion that there was some emotional stunting pegged around the time of the incident. This seemed to manifest mostly in the presence of the surviving parent. I commented that part of it may be due to the lack of  the alternative “go to parent” when there are disagreements or emotional upsets in the parent/child interactions.

The participants also wondered whether accepting offers to help was accompanied by the expectation of reciprocal behavior later (Note that this is the social norm in Western society).  However, the general agreement was that the offers to help were unilateral and if anything it was understood that the “debt” would be paid forward (meaning the receiver would in turn help someone in need, not necessarily the doer, in the future).

I also observed to the group that somedays I was really busy and the day would go by in a blur, but the minute I stopped that activity, thoughts of the loved one, popped right into the mainstream of consciousness, almost like they had been forcibly held down, from taking center stage.

It seemed that the kids had a good time sharing too. One of the facilitators said the theme was happiness and places of comfort (simulated by a large box that the kids could decorate to their choice).

I learned that Berkeley and Stanford do offer camps in Summer for the bereaved kids.

Written by asterix98

February 4, 2011 at 6:50 am

Posted in grief counseling

Kara – first session

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Last Wednesday, January 19th, Mahati and I attended our first group counseling session at the Episcopal Church on Hamilton Ave, Palo Alto. We were welcomed by the facilitators as well as Liz, Kara’s director. They were very nice and introduced us to the other families.

There were separate parallel sessions for the kids and adults. We introduced ourselves to the group and provided some background on the loved one we had lost.  The peer group was mostly well matched in terms of the circumstances surrounding the loss.  Some members in the group had been going to Kara for a long time. After some ground rules were established, the floor was open to the group for unstructured interaction. There was some comfort in finding out that the experiences faced by the group members were very similar. It was also abundantly clear that the loss was unique to each individual. More importantly, the atmosphere was very conducive to a free exchange of thoughts. (One person said she had been in another group at a different location and there was a bunch of older people who were feeling sorry or pity for her which was not very helpful).

Some in the group shared the difficulties they were facing and others responded by sharing what had worked for them in similar situations. It was amazing to see how easily strangers bonded in this environment of sharing. Sometimes members were just voicing their thoughts and not looking for any feedback. 

The feedback from Mahati was positive. She engaged in fun activities while sharing.  She has a time capsule that is to be opened a year from now. She is looking forward to going back.

One of the facilitators is trained in expressive arts. He explained through juggling (and accompanying commentary) how losing a parent increases the responsibilities for the remaining parent. This demonstration is intended for the children. Very powerful.

I now feel motivated to volunteer (as a facilitator) for future groups.

Written by asterix98

January 26, 2011 at 5:10 am

Posted in grief counseling

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