PTSD & TMS

PTSD AND TMS

Post-traumatic stress disorder (PTSD) is a complex disorder which begins with one or more traumatic events and persists for many months or years. The trauma often occurs in childhood, usually stemming from physical, emotional or sexual abuse. Alternatively, it can arise in adulthood, again associated with abuse situations, witnessing or experiencing traumatic events, or combat situations.

Historically, the diagnosis was first applied to combat situations, applied to what had previously been called “combat fatigue” or “shell shock.” But as the mental health field learned more, it became clear that there were many more people who had PTSD arising from early childhood experiences, or noncombat-related traumatic events, and that these people exhibited very similar symptoms to the combat-related cases.

Many of the symptoms come under the heading of hypervigilance. This can include getting startled very easily, but also what might be called “enhanced situational awareness.” People with PTSD become very alert to what is going on around them. They walk into a room and immediately scan all the people in the room and evaluate whether they could possibly be a threat. They look to see where all the exits are and will often situate themselves with their back to the wall, with a clear view of the whole room, the entrances and exits. They are easily “triggered.” Any event that is at all reminiscent of their trauma produces a strong, rapid reaction. Sometimes the reaction is so strong that they actually reexperience their initial trauma and lose sight of the here and now. This is called a “flashback.”

Other symptoms can include nightmares which relate to the trauma and emotional numbing or dissociation. When people dissociate, they can appear robotic or emotionally constricted to an outside observer. They can often go through their day, but then will have no memory or only spotty memories of what happened during that time period.

There is also a significant amount of depression, anxiety and panic disorders found among those suffering from PTSD. People with PTSD often turn to substances as a way of “self-medicating.”

PTSD, the trauma that caused it, or the dysfunctional home environment that often is associated with childhood abuse, all have a way of leaving deep, lasting psychological scars that can affect one’s personality and ability to function, to establish good relationships, and to make healthy life choices.

PTSD can be thought of as a protective response to an extreme situation. The fact that the symptoms persist so long makes perfect sense. If someone has been through something as dangerous and life-threatening as a traumatic situation, it would be even more dangerous if the memory of it faded. The way that a current situation can trigger such a strong response also makes sense. One would want the reaction to be strong and immediate given how dangerous the situation can be. It is also adaptive that people have dramatic responses in situations where the current trigger is somewhat different from the original threat. For example, nature wouldn’t want an animal to think to itself “oh, that giant cat with stripes doesn’t have any spots like the one that almost killed me, and therefore I don’t have to be worried about it.” The dissociation can be thought of as a way of “mentally checking out,” of not being present while the trauma is happening. In fact, there is evidence that children who learn to dissociate during their trauma actually have better outcomes than those who cannot dissociate.

Treatment for PTSD often involves both medications and psychotherapy. Many different kinds of psychotherapy—cognitive behavioral therapy, DBT (dialectical behavioral therapy), EMDR (eye movement desensitization and reprocessing), internal family systems, as well as classic psychodynamic psychotherapy—can all be helpful.

Medications can be useful, but also somewhat tricky. The medications that we have tend to treat the anxiety, depression and panic that grow up around the PTSD, but often do not treat the core symptoms themselves. There is active research going on right now regarding MDMA, which is used as a street drug and known as “Ecstasy” or “Molly.” The results are encouraging: MMDA is actually on an FDA fast track, but it has not yet gained official approval.

TMS represents another alternative being actively researched, although again, one that has not received official FDA approval for PTSD. Several small studies, including a few that importantly compare active treatments to placebo or “sham” treatment have demonstrated effectiveness against core PTSD symptoms. Currently though, there is no consensus about what treatment protocol works best. Several have been tried—high frequency, low frequency, left hemisphere, right hemisphere—and all have shown some degree of effectiveness.

In battling major depressive disorder, it has long been thought by many clinicians that the presence of PTSD can complicate the treatment, making it more difficult to get a response to medications. My observation has long been that this is not the case for TMS. People who come in to get their depression treated, and who also have PTSD, appear to respond to TMS just as well as those who do not have it. This observation has been confirmed by a recent study in 2020 which demonstrated similar response rates in depressed combat veterans who did or did not have PTSD in addition.

The bottom line in terms of TMS treatment for depression is that the presence of PTSD does not appear to be a barrier to a good outcome, the way that it can be for medications. If, however, the patient has only PTSD and no depression, although TMS may well be effective, the research is still somewhat preliminary, and insurance approval may be more difficult.