PTSD, Flashbacks and Triggers Ch. 2

Michael C., a pharmacist for 30 years, had spent a pleasant evening at a basketball game before he went home and tried to kill his wife. “I thought she was a German,” he explained to doctors and nurses after summoning a taxicab to the nearest emergency room (ER), in a frantic effort to find out why he’d mistaken her for a World War II enemy. Mr. C* had been shocked to realize that there was no soldier from the Third Reich – it was the woman he loved. As he huddled at the back of his closet, searching for his gun, he was sure he was thwarting an adversary. He’d recognized the helmet and uniform. It was only after he heard his name repeatedly called that he was able to see that there was no helmet and there was no uniform, only his frightened wife. After arriving at the ER, he reported that he’d consumed quite a lot of beer while at the game and afterward. But he’d gone to sleep, as usual, after returning home. Then he found himself in that dark closet. At first, Mr. C’s case looked baffling. After all, he’d survived D-Day; He’d gone to college; He’d worked for decades to build his pharmaceutical business; He’d become an avid golfer. Nothing like this incident had ever occurred before. On closer reading of his personal history, however, Mr. C revealed the classic symptoms of a workaholic, and his slavish devotion to his profession had provided a barrier to intrusive wartime recollections. In fact, he engaged nightly in fairly moderate drinking to encourage the onset of sleep. 1 This made his treatment relatively straightforward. He was told to keep up the exercise, to avoid violent movies, to stay active and to abstain from heavy drinking. He was also told that he’d had an event that night that might – or might not -- ever happen again. It was a flashback. Back in 1988, when the case of Michael C was published in a medical journal, the word “flashback” wasn’t even in common use. In fact, it was so poorly understood that some health personnel at the time confused it with the phrase “déjà vu,” because both terms referred to a mental state in which there was an overwhelming feeling of time re-enactment.2 But flashbacks soon were seen as quite distinct from déjà vu. As the 1960s gave way to wider availability for street use of hallucinogenic drugs, one in particular –- lysergic acid diethylamide (LSD) – finally brought flashbacks into the medical lexicon.3 Descriptions of re-living events on LSD became relatively common, often occurring in the days, weeks or even months after ingestion of the drug. Such accounts arguably painted the clearest clinical picture to date of what flashbacks actually are: a psychological re-entry to a past incident – so lifelike that past sights and sounds, including pain, are experienced all over again. But it is the deep emotional responsiveness, such as fear, that can make flashbacks so life-altering. Nothing short of losing consciousness in an otherwise healthy individual causes such a complete change in perception. By taking a scientific look at flashbacks in patients who visited the now- historic Haight Ashbury Free Clinic in San Francisco during the decade in which LSD reached its highest peak use as a recreational drugs, two of the clinic’s founding physicians deduced not only the characteristics that constituted a flashback, but other aspects about them. They found that those patients who’d had a “bad acid trip” – LSD that led to frightening or even hostile hallucinations – seemed to have the most recurrences.4 But why? The implication, of course, is that disturbing images -- not just the reaction of the brain to LSD -- had fostered construction of neural pathways that could be reactivated. Such visual hallucinations have been likened to phantom limb pain, in which individuals who have lost a leg or hand or arm continue to suffer periodic discomfort despite the fact that the body part is clearly not there.5 Now there is much better understanding of why these memories can appear all over again, what provokes them and how they can seem to be a step back into past reality. There is evidence that the greater the exposure to fear-inducing situations, the more indelibly etched they become in brain circuitry. Wartime recollections are painful, often characterized by feelings of guilt and trauma, but flashbacks occur in the present tense and are often horrifying – causing extraordinary fear. Ordinary memories can be mulled over when they are recalled. Flashbacks are like a thought invasion, able to swoop in with old scenarios and to block out rational thinking. In one study of several dozen veterans who had been diagnosed with PTSD, for example, two distinct patterns of memory from trauma emerged showing this difference in flashbacks.6 Memories of battle and war that could be retrieved and talked about were seen as voluntary – they were described while being recalled by study participants. Conversely, flashbacks, tended to occur by triggering – and they swamped mental faculties. Indeed, at some points during the study, some of the veterans who were asked to speak or write about a traumatic memory and who were doing just that -- narrating a recollection – were overcome by a flashback. This finding led the investigators to conclude that accessing painful memories could be a precursor to flashbacks, even though the two memory patterns were distinct .7 To men and women who have suffered wartime trauma, a trigger doesn’t require fully remembering the trauma at all. A flashback can be a new variation on a former scene, like Michael C becoming convinced a German soldier was in his American house. But if triggers for flashbacks are limited to parts of the human memory conjured up by written or verbal narrations, flashbacks should be both fairly predictable and somewhat preventable. And they aren’t. A flashback can be caused by something as seemingly innocuous as the clicking of a door or a piece of clothing. But why? Because memory is like a track that can be re-run with stunning accuracy based on cues, an effect known as “the memory trace theory, in which the mind is believed to preserve a copy of the original stimulus. The theory is rarely challenged, though other mechanisms have been proposed. 8 However, there is little argument that much of the brain’s circuitry is the accumulation and processing of personal events, thanks in part to the classic study of a rat-fearing baby called “Little Albert,” who around the year 1920 gave science one of its first glimpses into how fragments of an experience can become triggers. That study established that an infant taught to be afraid of an albino rat would learn to fear anything with a white hairy appearance, even Santa Claus. Nine- month-old Little Albert, at first, seemed to fear nothing in the lab – he let a white rat sniff and crawl on him, and he even seemed curious and happy with the tiny creature. Soon, however, Little Albert grew upset by these encounters, as loud clanging noises were made during the period when the rat was allowed be with him. The harsh sounds made Little Albert cry, and soon he began to cry at the very sight of the rat. 9 He became so fearful that even a glimpse of white cotton or a piece of white fur would send him into a spell of agitation. In fact, when one of the researchers dressed as Santa Claus, the snowy beard had the same effect on him. It’s unknown how long Little Albert’s fear of white furry objects persisted. He is thought to have died at the age of six, making later follow-up studies impossible. However, other research has shown that the human response to such triggers can be life-long, particularly when linked to a traumatic experience. Primitive humans who encountered threats from wild animals, for example, had to learn what the beasts’ movement in vegetation sounded like in order to escape them. Sometimes, the sounds in the brush were simply a leafy rustle from a breeze -- but that didn’t erase the possibility a razor-toothed animal might be lurking nearby. As a result, prehistoric humans benefited from such long-term fears. This is why a truck parked in a hometown neighborhood might make someone with PTSD explode in anger, labeling the driver “a piece of shit,” according to journalist and former marine David J. Morris, who reported he reacted just that way upon seeing a flatbed truck in an alley near his apartment. “My face was hot, the blood suddenly loud in my ears,” he recounted in his non-fiction book, The Evil Hours (Houghton Mifflin Harcourt, 2015). Later, “I was able to piece it together,” he wrote. Though not a flashback, the incident was strikingly reminiscent of an ambush. “The truck blocking my way, the dirt piling up at the verges, the heat coming off the concrete, the smell of old garbage, the diesel smell of the truck; these various stimuli had put part of my brain back in Iraq.” Yet this kind of neurophysiologic reaction to trauma also is evidence of a phenomenon that is deeply human. “I kept seeing this round bloodstain in my peripheral vision,” recalled trauma surgeon Katrina Firlik MD, remembering a day when her white lab coat bore a drop of blood from a dying patient -- an image she couldn’t seem to escape. If every patient left a stain, “life would be unbearable,” she recounted in her book Life in the Frontal Lobe (Random House, 2006). However, her emotional response to that tiny blot of red – evidence of the loss of another person – also signifies the stubborn sensitivity and loyalty of the human bond. Being reminded of that by “a stain every once in a while,” she concluded, “can probably keep us human.”

* a pseudonym

1) Brockway, S. Case report: flashback as a post-traumatic stress disorder (PTSD) symptom in a World War II veteran. Military Medicine 1988; 153: 372-373. 2) Sno, H.N & Lindzen, D.H. The Déjà vu Experience: Remembrance of Things Past? Am J of Psychiatry 1990; 147:1587-1595. 3) Klee, G.D. Lysergic Acid Diethylamide (LSD-25) and Ego Functions. Arch Gen Psych 1963; 8(5):461-474. 4) Schick F and Smith, D. Analysis of the LSD Flashback, J of Psychedelic Drugs, 1970; Vol. 3 (1): 13-19. 5) Schwartz, S.H., Visual Perception: A Clinical Orientation, p 340 4th ed. (McGraw Hill, 1999) 6) Hellawell, S.J., Brewin, C.R. A Comparison of flashbacks and ordinary autobiographical memories of trauma: cognitive resources and behavioral observations. Behaviour Research and Therapy. 2002; 40(10):1143-1156. 7) Hellawell, S.J., Brewin, C.R. A Comparison of flashbacks and ordinary autobiographical memories of trauma: content and language. Behaviour Research and Therapy. 2004; 42(1):1-12. 8) Treisman, M, Lages, M. On the Nature of Sensory Memory. Chapter 6 in Human Information Processing: Vision, Memory, and Attention. Chubb, C., Dosher B.A., Lu, A-L, Shiffrin, R.M. editors. American Psychological Association. (Washington, DC). 2013. 9) Watson, JB, Rayner, R. Conditioned Emotional Reactions. Journal of Experimental Psychology, 3(1), 1-14, 1920.

Trammart News, Anne Scheck