Richard G. Petty, MD

An Extraordinary Memoir

Regular readers will know that I am very interested in helping people with posttraumatic stress disorder (PTSD), and you will find a number of articles here.

The problem is growing as more people are returning from the conflicts overseas. But it is also important to return to another point: the difference between categorical and dimensional diagnosis. Few problems fit into neat little boxes. Instead they tend to lie on spectra. At one end you have people who have never had a day’s trouble in their lives, at the other you will find people who have been incapacitated by the most terrible things that have happened to them.

And in between is a huge number of people who do not fit any diagnostic criteria, but nonetheless suffer from many of the signs and symptoms of illness. How many people suffer from some of the symptoms of PTSD because they found a dead relative? Or had an important relationship that went terribly wrong?

They do not, of course, have diagnosable PTSD, but it can sometimes be helpful to reframe their suffering as a reaction to trauma.

I have just reviewed a book on the Amazon website that I hope is read very widely.

The book is called The Dancer Returns: From Victim to Victory, by Susan Lee Titus.

It tells an extraordinary true story about a young businesswoman who is brutally assaulted. She suffered from such severe PTSD that she actually needed to be admitted to hospital for a short time.

She transcends the terrible experience, and she is herself transformed by compassion and forgiveness. She moves on to teach dance to incarcerated women, each of whom carries her own scars.

The book is short but profoundly moving and can be life-changing.

If you have any interest in PTSD in all its manifestations, and also if you are interested in alternative ways of living with and transcending distress, I strongly recommend the book.

Memory and Emotion

Your humble reporter has had more than his fair share of major life events. As a sixteen year old I was a passenger in car that had a meeting with another vehicle driving down the wrong side of the road. This was in England, where folk always do drive on the “wrong” side, but the fellow who was kind enough to arrange the collision could never explain why he was driving on the “American” side.

The interesting thing is that the memory of the crash is seared into my memory: I can remember the license plate of the vehicle that hit us. Some people call that a “flashbulb memory.”

If you live in the United States you probably have clear and fairly accurate memories of where you were and what you were doing on September 11th 2001.

This kind of experience is not uncommon: most of us have noticed that events that occur during heightened states of emotional arousal, such as fear, anger, happiness and sex are far more memorable than less dramatic occurrences. The emotional “load” of an event is a key factor in remembering it. Previous studies have confirmed that heightened states of emotion can facilitate learning and memory.

This makes good evolutionary sense: emotionally charged events are likely to be the ones that we need to remember. From an evolutionary perspective, it is more important to remember where Mr. Saber-tooth Tiger lives, rather than the names of the Kings and Queens of England.

Therefore the regions of the brain that are responsible for the storage of memories need to distinguish between important experiences and those that less significant for survival. The brain must have some mechanisms for giving priority to emotionally charged memories, so that they are converted and stored in long-term memory.

The downside is that in some situations, for instance posttraumatic stress disorder (PTSD), this process can become pathological and people can be tormented by persistent vivid memories of traumatic events.

Writing in the journal Cell, researchers from Johns Hopkins University and their collaborators at Cold Spring Harbor Laboratory and New York University may have identified the biological basis for this phenomenon. Memories in the brain are held in neurological circuits and each new experience creates a new circuit. The investigators have found that the hormone norepinephrine, which is released during emotional arousal, serves to “prime” nerve cells to remember events. They do this by increasing the neurons’ chemical sensitivity at the precise sites where nerves rewire to form new memory circuits.

Norepinephrine is often described as one of the “fight or flight” hormones and it is likely also involved in the third type of response to a threat, which is “freeze.” In the brain norepinephrine energizes the circuit-building process by adding phosphate molecules to a nerve cell receptor called GluR1. The phosphates help guide the receptors to insert themselves next to a synapse.

So when the emotionally-charged brain needs to form a memory, the nerves have plenty of available receptors to quickly adjust the strength of the connection and lock that memory into place.

The researchers targeted the GluR1 receptor after discovering that if it is disrupted in mice, the little creatures develop spatial memory defects. They tested the idea by either injecting healthy mice with adrenaline or exposing them to fox urine, both of which increase norepinephrine levels in the brain.

They then analyzed the brains of the mice and found increased phosphates on the GluR1 receptors and an increased ability of these receptors to be recruited to synapses.

When the researchers put mice in a cage, gave a mild shock, took them out of that cage and put them back in it the next day, mice who had received adrenaline or fox urine were likely to “freeze” in fear, compared with mice who had not been exposed to the adrenaline or fox pee. This implies an enhancement of their memory of the cage and its unpleasant associations.

In a similar experiment with mice genetically engineered to have a defective GluR1 receptor, adrenaline injections had no effect on mouse memory. So this provides us with further evidence of the “priming” effect of norepinephrine on the receptor.

There has been a lot of recent interest in using medications like beta-adrenoreceptor blocker propranolol – which prevents some of the actions of norepinephrine – to prevent the development of PTSD in people who have been exposed to extreme trauma, and this research may provide the scientific basis for this kind of therapy.

On the other hand, this research leads me to predict that people with overactive GluR1 receptors may be constantly curious about their environment, but also likely to be chronically anxious and more likely to develop PTSD.

We have known for years that propranolol and other beta-blockers may attenuate some of the physical symptoms associated with anxiety. Most people had assumed that the medicine worked by reducing heart rate, shaking and sweating. But experienced clinicians usually find that beta blockers that cross the blood/brain barrier work best, and it may well be that these drugs also have direct actions in the brain itself.

“Recollection is the only paradise from which we cannot be turned out.”
–John Paul (a.k.a. Johann Paul Friedrich Richter, German Novelist and Humorist, 1763-1825)

“The existence of forgetting has never been proved: We only know that some things don’t come to mind when we want them.”
–Friedrich Wilhelm Nietzsche (German Philosopher, 1844-1900)

“The moment we find the reason behind an emotion … the wall is breached, and the positive memories it has kept from us return too. That’s why it pays to ask those painful questions. The answers can set you free.”
–Gloria Steinem (American Feminist, Political Activist and Editor, 1934-)

Fears, Phobias, Posttraumatic Stress and Cortisol

If the prospect of standing up to speak in front of hundreds of people or the sight of a giant hairy spider has you quaking with fear, you may be surprised to learn that the cure may be a dose of the stress hormone cortisol.

In a study from the University of Zurich in Switzerland, Dominique de Quervain and his team gave either cortisol a.k.a. hydrocortisone, or its precursor, cortisone, to volunteers with arachnophobia – a fear of spiders – or phobias linked to social situations. A control group received a placebo. An hour later, the volunteers were confronted with a picture of a spider or given a public-speaking assignment. Their anxiety levels were evaluated both by heart rate and by asking them how they felt.

The people who had been given a dose of cortisol or cortisone were less anxious than those given the placebo. In the case of the people with arachnophobia, who had several testing sessions, fear levels dropped progressively with each session. In the placebo group, the volunteers who naturally had higher levels of cortisol were less anxious. The researchers concluded that the hormone damps down, rather than causes, the fear response.

This is in contrast to most theories that say cortisol triggers stress: it actually seems to be the other way round. Cortisol has a protective effect, a finding that could lead to new phobia therapies.

This finding follows the demonstration that cortisol may prevent the development of posttraumatic stress disorder (PTSD) following critical illness and major surgery, probably by inhibiting the formation of traumatic memories.

This makes good sense. If you are exposed to acute stress the last thing that you want to have happen is to be hamstrung by constant intrusive memories of the event. By this line of reasoning, the question is instead why the system failed in people who went on to develop PTSD. It may be that the genetic component has something to do with a short circuit in this protective mechanism.

Personality Style, Coping and Posttraumatic Stress Disorder

I have written a fair amount about posttraumatic stress disorder (PTSD) not only because it can be such a nasty problem, but also because it is beginning to give up many of its secrets, and it is one of the illnesses that can really show the benefits of Integrated Medicine.

There is new research just published in the journal Psychosomatic Medicine. The report is a prospective study that was done in Israel.

180 undergraduate students at the University of Haifa were coincidentally evaluated 2 weeks before a terrorist explosion in a bus heading toward their university and reevaluated 1 week, 1 month, and 6 months after the explosion.

The findings were that there were premorbid personality characteristics that predicted the development of PTSD. This is in line with the research showing both genetic and neurological predispositions to developing PTSD. The research also indicated that
some people have more robust coping styles than others. And finally, as
expected, there is a relationship to how close people were to the

This is all useful information, and once again shows the futility of trying to psychological reactions to only genes, only the brain, only past experience or only the environment.

Any comprehensive understanding needs us to incorporate all of those factors.

Temporomandibular Joint Dysfunction and Posttraumatic Stress Disorder

Over the last few years I’ve had the privilege of visiting Croatia several times. I was one of the first Western academics to go back there to teach after the war, and I’ve made many good friends. It is a beautiful country with lovely people and it is a terrible shame what happened there.

One of the big problems that remain is the incredible number of people suffering from posttraumatic stress disorder (PTSD). There continues to be some debate about whether PTSD can only occur in response to one major traumatic event in which a person feels that their life is in danger, or whether it can also occur as a result of repeated less serious traumata. We have discussed the relationships between PTSD, resilience and neurological dysfunction, and of the association between PTSD and laterality.

There has also been at least one report of an association between PTSD and atypical facial pain.

A new paper from colleagues in Croatia has clarified this association by showing that people with PTSD are at increased risk of temporomandibular muscle and joint disorder, or TMJD, which used to be known simply as temporomandibular joint (TMJ) dysfunction. This is intuitively obvious, but it is an important finding. The main complaint was of headache, and it is important not to dismiss these headaches as migraine, tension headaches or as some kind of somatization.

There is currently an $8 million project underway to establish valid and reliable TMJD diagnostic criteria. It is to be hoped that the results of the study will advance the field of TMJD research and aid clinicians in their practices. At a meeting of the American Association of Dental Research in Orlando, Florida in March, Richard Ohrbach from the University of Buffalo presented data from the study indicating that 82% of People whose recurrent headaches have been diagnosed as tension-related actually had TMJD.

In April of this year, we had the first meeting of the National Institutes of Health Pain Consortium. There’s a good report in Clinical Psychiatry News about ongoing studies from the University of Washington in Seattle. Niloofar Afari presented data that confirms the findings in the Croatian study. And provides yet more useful information.

The investigators used state records to identify twins and surveyed more than 1,700 female twins by mail and by telephone. The results so far indicate that the association between PTSD and TMJD is real and that there may be a genetic predisposition to the association.

It is important not to miss this possible association. Misdiagnosis can cause a lot of needless suffering.

Treating Posttraumatic Stress Disorder

There is an important article in this month’s issue of the journal Psychological Medicine.

Researchers from the University of Heidelberg in Germany carried out a systematic literature review concerning two treatments that are widely used in the treatment of posttraumatic stress disorder (PTSD): Eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive-behavioral therapy (CBT).

They identified eight publications between 1989 and 2005 describing treatment outcomes of EMDR and CBT in active–active comparisons. Seven of these studies were investigated in a meta-analysis.

What they found was this. Both trauma-focused CBT and EMDR seemed to be equally efficacious and any differences between the two forms of treatment are probably not of clinical significance. Our main focus now should be to attempt to establish which trauma patients are more likely to benefit from one method or the other. The authors comment that it remains unclear is the contribution of the eye movement component in EMDR to treatment outcome.

This paper is interesting in light of our recent discussions concerning brain laterality and PTSD. It seems likely that part of the mechanism of both forms of therapy is to re-wire the brain. I tend to think that the eye movements probably are of importance, since they are also used in thought field therapy which appears also to be helpful to many people with PTSD.

Posttraumatic Stress Disorder and Brain Laterality

I’ve just received an intriguing article from an individual who’s really been through the mill with an array of psychiatric problems going back to childhood.

The last diagnosis that he attracted was posttraumatic stress disorder (PTSD), and he seems to have cured himself by a combination of omega-3 fatty acids and learning to play the banjo left-handed.

This may sound like a bit of an odd claim, but although the writer did not realize it, there is actually some solid science behind his observation.

For years now we have known that if someone is paralyzed down one side after a stroke, binding the good arm or leg leads to rapid reorganization in the cerebral cortex, as a result of which the paralyzed arm or leg may begin to regain function.

One of the most potent ways to improve the functioning of regions of the brain is to try doing things with the opposite hand: if your are right-handed, brushing your teeth or writing with your left hand or using your knife and fork the other way round can all be very illuminating, and can help train your brain. A common tactic in couple’s therapy is to get people to change some habits, like switching the sides of the bed on which a couple sleeps.

The hippocampus of the brain is involved in many functions, but key amongst them is the laying down of short-term memories. People with several stress-related psychiatric disorders, including PTSD, borderline personality disorder with early abuse, depression with early abuse, alcoholism and dissociative identity disorder all have smaller hippocampi, presumably because this part of the brain is exquisitely sensitive to cortisol: high levels can damage and destroy hippocampal cells. Antidepressant medications and some types of cognitive training are thought to lead to the growth of new cells in the hippocampus. It is also possible that having a small hippocampus may predispose someone to the development of PTSD. There is also some evidence that mixed lateral preferences and parental left-handedness may all predispose someone to the development of PTSD.

In PTSD, the left hippocampus and two other brain regions: the left anterior cingulate cortex and both sides of the insula are all smaller than normal. Regions of this small left hippocampus associated with episodic and autobiographical memory is activated by stimuli that wouldn’t have much effect in people without the problem. Some researchers have also found that if the right hippocampus is smaller and more active, it correlates with the severity of PTSD symptoms.

Adults with PTSD have a higher incidence of mixed laterality with respect to handedness than the rest of the population. This has recently also been found in children: there is a positive correlation between PTSD symptom severity and mixed laterality. This strongly suggests that neurological abnormalities may be related to the severity of symptoms in PTSD.

In PTSD, the right amygdala, a region involved in fear and rapid emotional learning and processing, is smaller than the left. In healthy volunteers it’s the same on both sides.

When people with PTSD recall the traumatic event, especially if it involved assault, they over-activate the right hemisphere of the brain. It is not just cerebral blood flow: recent experimental work has shown that PTSD may be associated with a functional asymmetry of the brain, which favors the right hemisphere.

There are actually a number of therapeutic techniques that involve trying to switch the way in which the hemispheres interact. EMDR (which the writer had tried) is one. It is also amongst the techniques developed by Paul Dennison to aid learning.

I also wonder whether the writer has accidentally happened upon a method for treating psychological reversal.

I do wish the writer well, and I also hope that some of my colleagues in research might be interested in exploring some of these training techniques in PTSD.


I often think that I’m a lucky fellow to be bilingual in English and German. There are some priceless words in German that just don’t translate. It’s one of the reasons that so many books and papers translated from German become nonsensical when back translated. That is, translated from German into English and then back into German again.

There are some wonderful examples in the medical and psychiatric literature. English speaking psychiatrists are taught about “Schneider’s First Rank Features.” Which is a massive misquotation. And some of the collected works of Carl Jung are “interesting” in English.

There is a lovely German word – Ohrwurm – that can best be translated as “ear worm,” though in German it has a rather richer sense. The term was popularized by James Kellaris, a professor of marketing at the University of Cincinnati, to describe a song stuck in one’s head. Particularly an annoying one. I’m sure that we’ve all had them: some song or tune that you just can’t get out of your head.

Mark Twain wrote in a short story about an annoying ”jingling rhyme” that became indelibly lodged in the author’s mind until he passed the curse along to another hapless victim!

I first saw this research being talked about three years ago, in an article on the BBC website. At the time Professor Kellaris described the ohrwurm as "A cognitive itch is a kind of metaphor that explains how these songs get stuck in our head."

Kellaris has identified three major influences on whether or not a song stays stuck in your brain:

  1. Repetition:
  2. Musical simplicity:
  3. Incongruity: This one is very interesting and gives us another clue about why ohrwurms form. When a song does something unexpected, it can also spark a cognitive “itch.” Kellaris cites examples like the irregular time signatures of Dave Brubeck’s "Take Five" or the song "America" from West Side Story. Unpredictable melodic patterns or an unexpectedly articulated individual note can have the same impact.

Marketers and writers of pop songs are very interested in understanding how and why some tunes just get stuck in our heads. There have been some songwriters and producers who have created a load of ohrwurms. You may remember the string of hits produced by Mike Stock, Matt Aitken and Pete Waterman  in the late 1980s and early 1990s. There is even some brain imaging work going on to try and unlock the mechanisms responsible.

The best cures for a nagging ohrwurm appear to be to listen to the whole tune or song. And at the same time to think of something annoying. It can also go away with the simple technique of gently tapping the side of your hand: it is sometimes a manifestation of psychological reversal.

One of the reasons for being interested in ohrwurms, is that it is interesting to find out why things get stuck in our heads. Understanding the lowly ohrwurm may have some important implications for understanding PTSD and some kinds of addiction.

So what’s you best or most irritating ohrwurm?

“I was in yoga the other day.  I was in full lotus position.  My chakras were all aligned.  My mind is cleared of all clatter and I’m looking out of my third eye and everything that I’m supposed to be doing.  It’s amazing what comes up, when you sit in that silence.  "Mama keeps whites bright like the sunlight, Mama’s got the magic of Clorox 2.”
Ellen DeGeneres (American Actor and Comedian, 1958-)

Erasing Your Neurological Hard Drive

Did you ever see the movie Total Recall, and wondered if it might really be possible to erase someone’s memory and implant a new one? Well, that might just be a little closer than most people realize.

One of the mechanisms of the storage of memories in the brain is thought ot involve a process known as long-term potentiation (LTP), that strengthens synaptic connections between neurons. The mechanism of LTP has been a mystery, but recently it was discovered that there is a biochemical pathway that utliizes something called an atypical protein kinase C isoform,  protein kinase Mzeta (PKMz), that seems to be a key player in LTP.

New research from a team at  SUNY Downstate Medical Center, in Brooklyn, New York, using a PKMz inhibitor reverses LTP and produces persistent loss of 1-day-old spatial information, proving that PKMz is crucial to laying down memories in the brain.

There are many ways of losing memory. Apart from being belabored about the head and shoulders with a stout cudgel, alcohol and benzodiazepines are all fairly reliable ways of causing transient memory loss. But they also may fail, and each may have other unpleasant consequences.

But this is different: undestanding the basic mechanism of memory formation may enable us to obliterate unpleasant or wanwanted memories in conditions like chronic pain and posttraumatic stress disorder. It may also help us understand something more about the mysteries of illnesses like Alzheimer’s and Dementia of Lewy Body type, in which memory can be lost.

But it is also important to keep an eye on this research. I would not like either a government or a corporation to have a way reliably to erase our memories.

Though I’ve often thought that I’d quite like to have one of those little Neutralizers that they had in Men in Black…..

Fibromyalgia and Childhood Abuse

There is a small and growing literature about a link between fibromyalgia and a history of abuse, primarily in childhood or early adolescence.

A new study has shown that people with fibromyalgia who had experienced physical abuse in childhood did not have the normal daily fluctuations in the stress hormone cortisol. They also had sudden surges in the hormone as soon as they were woken up, which can be a good stressor. People who had been sexually abused also had this odd cortisol response on being awakened. These findings suggest that severe traumatic experiences in childhood may be a factor in causing hormonal disturbances in people suffering from fibromyalgia. This adds to the growing body of evidence that in women having pain early in the day, there is a high likelihood that the entire stress hormone system does not function normally.

Colleagues from the Department of Psychiatry, UMDNJ-New Jersey Medical School in Newark, New Jersey have reported that women who have been raped are ten times more likely to experience chronic pelvic pain as well as generalized pain.

Another study has found close correlations between childhood abuse and the subsequent development of chronic pain. The link between rape and the subsequent development of fibromyalgia seems to be mediated by chronic stress, in the form of posttraumatic stress disorder.

What this means is that professionals need to consider this:

  1. It is important careful to inquire about any history of past or present abuse or other severe trauma
  2. That empathy and constructive validation of disease and suffering can be very helpful
  3. That dysfunctional pain behaviors and personality traits may be a consequence of abuse together with a lack of resilience
  4. That multidisciplinary treatments including psychotherapy may be the best approach to helping people. Using the methods of Integrated Medicine is often far better than reliance on potentially habit-forming medications.

If we remember that there is more and more evidence of inflammation and other physical problems in fibromyalgia, and that stress and maltreatment in early life can alter the structure and function of specific regions of the brain, what this all shows us is that abuse in childhood can have a long term impact on the way in which both the body and the brain functions.

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