Before deciding on a course of action think about your goals - especially long term. 

Hopefully you want to live a long, productive and meaningful life. You want to balance career and relationships, work and recreation. You don’t want to be “okay”, you want to be the best you can be.

In Man’s Search for Meaning, Viktor Frankl describes his philosophy and approach to treatment of mental health problems. He speaks not only as a psychiatrist but as a survivor of years in a Nazi concentration camp during WWII. One exercise he recommends is to imagine yourself on your death bed. Who is there with you? From the vantage point of the end of your life look back and ask yourself, “do I have any major regrets?”

Most of us have some regrets. If we had it to do over again we would make some different choices. Obviously we can’t change the past but we can change the past that hasn’t happened yet. On your death bed will you be happy with the choices you’re making today?

Stephen Covey admonishes us to be careful what mountain we climb. We don’t want to struggle to the top only to realize we climbed the wrong mountain. There won’t be many people on their death bed saying, “I wish I hadn’t spent so much energy taking care of my physical and mental health.” There won’t be a lot of regrets like, “I wish I hadn’t taken that medication that helped me feel better and live a fuller life.”

To some extent we all have a life script. (Steiner) Somewhere in our intuitive mind we have a basic game plan. In some ways it’s as though we are actors in a play. We have to follow the script.

For healthy individuals the outcome is a happy one with lots of “lieben und arbeiten”, (love and work, Freud) Unfortunately for many it’s more like “I’ll be relatively successful but never really happy.” For a few the outcome is some form of tragedy.

One problem with our script is that we write it in the context of our early life experiences before we are smart enough to know what’s going on. Sometimes our life script is going along fine when some kind of tragedy beyond our control impacts us or a loved one and dramatically alters our script.

Fortunately scripts can be rewritten. Do you need to rewrite yours? How do you know? If you are making a lot of bad choices you are probably going the wrong direction. Change starts with awareness.

As May 1968 approached my feelings were mixed. I was proud and excited to be graduating from medical school. For the rest of my life my name would be followed by M.D. I was also nervous (o.k. scared) because I was now going to have primary responsibility for patient care. I would at times be the only doctor in the emergency room or maybe even in the hospital where I would be a medical intern and where I would moonlight every Monday night for 3 years. I would literally have life and death responsibility. But I was also confused and concerned about the war in Viet Nam and the draft. Most medical school graduates had to go into the military one way or another. I didn’t believe in the war and I had no intentions to be sent there – I said l would move to Canada rather than go to risk my life for a war I didn’t and still don’t believe was right. But it’s cold in Canada. What about Mexico – I took Latin and German, no habla Espanol.

Fortunately I applied for and got permission to complete all my training and then go into the Air Force for 2 years. The way we were compensated for 12 years of advanced education was to be given rank. So I became Major Wayne Jones. Of course career military officers who had spent years climbing up the ladder were really pleased with me and my fellow physicians getting to start with rank. I actually made myself even more conspicuous my first day by putting my gold leaves on backward. I had requested assignment in San Antonio where they had 2-3 Air Force bases including a teaching hospital atmosphere.

It was a mixed blessing that I was assigned to Sheppard Air Force Base in Wichita Falls, Texas. At Sheppard we had the largest psychiatric hospital facility in the world with 120-150 beds. It turned out to be a great learning experience – especially long interviews with prisoners of war released when the war ended. Some of them had spent over 10 years in solitary confinement.

On the other hand, Wichita Falls, shall we say, is not a tourist attraction. One of my favorite memories is sitting in one of the best restaurants in town – Kings’ Quest. It had linoleum floors, vinyl table cloths and a wine selection that included a $150 bottle of wine – needless to say I never tried it.

After 2-3 days of basic training, yes, "days", I reported to duty as the officer and physician in charge of a 30 bed unit. Several times per week we received new patients from acute psychosis to behavioral problems. We had to keep things moving but our task was made more difficult because of administrative obstacles.

In medical training I was driven by 2 goals – the highest level of scientific understanding of symptoms, illnesses, and treatments and the most practical ways of helping people make their lives and stress symptoms better. In the Air Force the overwhelming emphasis was on the practical administrative options.

My first morning I met my head nurse, Ray. He was short, somewhat overweight and very friendly. He would become my greatest ally. To him we were like a large family. He believed in the community approach to psychiatry. For the next 12 months we would be like two parents with a very large family. Ray and I had a few things in common - we were both conscientious and had a sense of humor - although I was more inclined to the dramatic or occasionally the outrageous. He was also a Major but he had earned his rank over a long Air Force career. I never felt that he resented me getting instant rank and I always felt the appropriate respect as the medical "captain of the ship". We mostly complemented one another. He was more sensitive and I was more practical. He had a more maternal, cooperative, communication oriented personality, I was more typically paternal, competitive, decision making, and performance oriented. We shared pride when one of the "kids" shaped up or grew up and went on to do good things. We shared a sense of failure when one made bad choices and ended up in some not ok outcome. He wanted patients to say how they felt. I wanted patients to improve their thinking and behavior. Not that he was too soft nor I was insensitive. We of course played "good cop bad cop" on occasion.

My first decision was to move morning rounds from the nursing station behind closed doors to the day room where everyone would participate. Getting input from everyone was especially helpful in an atmosphere where a lot of patients were not there by choice or they had a very specific agenda, e.g., getting out of the Air Force. Patients learned that if they shot straight with me and helped me understand what was going on with others in the milieu that I would go the extra step in helping them. On the other hand, if they were primarily negative, manipulative, dishonest, or splitting they would learn that I could make their life miserable – I had the "power of the pen".

During our larger daily family meetings I was able to use skills I learned in doing group therapy. If the group was mainly attacking someone verbally I would be supportive of the patient. If the group was enabling or being supportive of inappropriate behavior I would be confrontive and tough. The balance usually worked out well.

I would frequently give mini-lectures during our morning "family" meetings. This helped to train the staff - nurses and psych techs (corpsmen) and to teach some basic principles to the patients. It was then that I discovered my passion for teaching. I also learned at the risk of sounding immodest, that like Geena Davis said after her first holdup in "Thelma and Louise", "I think I’ve got a knack for this shit".

One of the most useful ideas I came up with is that there are 3 types of thinking:

WHY DO SOME PEOPLE DEVELOP PTSD AND OTHERS GET STRONGER AND HOW CAN WE HELP?
Senator Bob Dole stands in sharp contrast to the many veterans who suffer from chronic Post Traumatic Stress Disorder. What made him different? Why was he resilient - able to live life by Nietzsche’s words, “what doesn’t destroy me makes me strong”? Was it his genetics? Both of his parents were hard working Midwesterners that were successful though not prosperous despite neither having graduated from high school. Was it the example his father set of going to work at his store every day in his overalls? Or was it his close relationship with his mother who contributed to the family’s support by selling sewing machines and teaching sewing? His mother’s love for him can be pictured as he tells of her holding his cigarettes for him while both his arms were paralyzed from his severe war injury - even though smoking was disgusting to her. He certainly wasn’t spoiled growing up living in the basement since his parents rented out the main house to help make ends meet. Was it because he’s a man? In general, men genetically are more resistant to stress for better and worse. Women suffer more symptoms in response to stress or trauma and women are generally more emotional, sensitive and reactive. Maybe it was because he was in WW II and not Viet Nam.

What made Viet Nam so different from WW I and II and even the Korean War? Arguably it was not just that we lost but that our returning soldiers weren’t received as heroes. It was more like they were co-conspirators in an immoral, politically motivated war. We didn’t ask, “why are they so traumatized?? We did ask, “why don’t they all have PTSD?” By researching this question we started a new chapter in the understanding of PTSD. Studies found that it was the young men/women who had abusive childhoods or who had suffered early life trauma or major losses that were vulnerable to the trauma of war. We learned that these experiences early in life - even the experience of being a fetus in a mother suffering from clinical depression or abusing drugs sensitized the brain to react much more powerfully to later experience.

Post Traumatic Stress Disorder is one of the most challenging disorders that I treat. A physician came up to me after a recent presentation in El Paso and told me that a lot of the soldiers returning from Iraq were suffering from the classic triad of PTSD symptoms:
• Flashbacks
• Hyperarousal
• Emotional numbness
He knew that I had been an Air Force psychiatrist during the war in Viet Nam when the symptoms of PTSD were first clearly recognized. He was looking for any suggestions on how to help these people.
I was an Air Force psychiatrist during the last part of the Viet Nam war and its immediate aftermath from 1972-74. I worked in the largest Air Force inpatient psychiatric facility in the world at Sheppard Air Force Base in Wichita Falls, Texas. We were sent almost daily admissions from Viet Nam and other bases around the world. At the end of the war we received over 40 just released POW’s. Many of them had spent over 10 years in solitary confinement. Many of the POW’s survived mainly by thinking about their families only to return to find their wives had remarried and they had no family to return to. Of course many of them had been assumed dead and it was understandable that their wives had moved on. It’s impossible for most of us to truly know the pain of their trauma. They survived with the hope to be freed and reunited with their families only to be retraumatized by loss.
I tell doctors that PTSD does to the brain what being run over by a truck does to the body. It messes up everything! In our Diagnostic and Statistical Manual or DSM IV (the “bible” of psychiatry) the diagnosis of PTSD is included as one of the anxiety disorders. I have always believed that anxiety is only one of the components of PTSD. I write down each patient’s diagnosis in the upper left hand corner of their patient information sheet. Then later I add other diagnoses in the same place above with the date that I add it. I noticed a common pattern for patients that I would later realize were actually PTSD. They would initially come in with a mood disorder, an anxiety disorder, an eating disorder, or substance abuse, etc. Over time I would keep adding one diagnosis after another until they would usually have one or more from each category. Eventually the trauma or abuse would come out and the underlying condition that was the primary cause of all the others was PTSD. It is certainly not just an anxiety disorder. PTSD affects every area of mental functioning.
Childhood histories of repeated physical or sexual abuse are often not initially revealed. Guilt, shame, and embarrassment are frequently the strongest legacies of abuse. Men with a history of sexual assault are especially reluctant to bring it up because of severe shame that they have as a result. Women will often choose abusive relationships as though they don’t deserve better because they are “damaged.” This is usually a subconscious decision.
One of the most unfair consequences of victimization is that it is only the victims who suffer all the emotional consequences. I can’t remember a patient ever telling me “I abused someone and I feel a lot of guilt.” The perpetrator invariably rationalizes past behavior. I remember asking a DSM committee member who helped formulate the PTSD criteria a question about the trauma of childhood sexual abuse. Amazingly, he said that it is not included in the causes for PTSD because it is too common. I said, “I guess the victims of the holocaust are not included because there are so many of them too.”
How is trauma different from normal loss or stress?
Normal losses are like the death of a parent or grandparent, or loss of a job. Divorce is unfortunately very common and is not usually considered to be a trauma. However, some divorces are handled in such a way that they can be traumatic to one or more of the parties involved. Murder, suicide, or death of a child are never normal and therefore always traumatic.
There are 3 clusters of symptoms that are found with PTSD.
The first cluster is re-experiencing phenomena, including flashbacks, nightmares, and panic attacks. Traumatic memories are different than normal memories. They are recorded deep in the emotional brain (amygdala) and are like a videotape or DVD recording. They retain all the associations and feelings. These memories are often induced by a reminder in the immediate environment or especially watching TV or a movie. I remember one Viet Nam veteran who stopped for gas along the highway. The station’s bathroom smelled like urine. He immediately felt like he was back in Viet Nam on the battlefield holding his buddy who had just been killed and had urinated on himself. He felt the pain of loss and guilt because he had talked his friend into joining the army with him. Worse yet his friend’s parents would later blame him for their son’s death. The sound of a helicopter would also cause panic attacks.
The second cluster of symptoms is all the problems associated with hyperarousal including constant vigilance, anxiety, nervousness, and insomnia. It is as though they are always in an acute danger situation. They are easily startled and are in a 24/7 state of fight or flight. Sometimes after months or years there is total burnout causing exhaustion and fatigue.
The third cluster of symptoms is emotional numbing. There is a general lack of even normal feelings. It is as though they are under emotional anesthesia.
All three clusters of symptoms can lead to general withdrawal from normal life.
What can we do to help?
It helps for them to talk about the trauma - but not necessarily right away. Studies of relatively immediate debriefing have been shown to actually increase symptoms. Later it helps to talk about it and ventilate. Processing any loss means going through all the stages of grief including anger, sadness, guilt, bargaining, and eventually acceptance. It’s very hard to resolve feelings without knowing what happened and who/what was responsible or to blame. Some traumatic events like the recent tsunami are “acts of God.” Others aren’t really anyone’s fault and fall under the category of “shit happens.”
Medication can be very helpful in not only easing the immediate pain of trauma but actually protecting the brain from some of the negative impact. Propranolol (Inderal) if given within hours of a traumatic event can decrease the impact and actually reduce the intensity of the memory of the event. Medications that provide normal sleep, (Sonata, Ambien, Lunesta) can be helpful immediately for insomnia associated with acute or chronic PTSD. Anxiety medications like Xanax or Klonopin can be helpful for acute symptoms or in some cases stronger mood stabilizers like Abilify or Seroquel are required.
For chronic PTSD most patients need an antidepressant (almost all suffer from clinical depression) like Effexor XR, Lexapro, Wellbutrin, Zoloft, Paxil, or Prozac. Many require long-term anxiety medications. Most of these patients also have poor concentration and loss of interest/motivation and many times adding a stimulant like Adderall XR or Concerta, or Provigil can be very helpful. It is not uncommon to also need a mood stabilizer.
Processing traumatic events and working toward resolution, while at the same time being able to work and have healthy relationships requires that the mind be working well. This means getting good sleep and not being overwhelmed with anxiety, having panic attacks or being emotionally disconnected. The right medications at the right doses can facilitate the recovery process and help those suffering with PTSD to get back their life.

Senator Bob Dole apparently did not suffer from PTSD - at least not on a long term chronic basis in spite of very severe trauma. Part of the explanation is his strength of character but he also had loving parents and a good support system. He could have felt sorry for himself and become chronically disabled. Instead he has given more than 60 years of public service. He has appeared on Meet the Press, more times than any other individual (63). Even in his 80’s he continues to contribute. What does he want people to get out of his new book, One Soldiers? Story? It is hope for those with PTSD, handicaps, and encouragement for seniors to be productive and keep giving.
Vulnerability to PTSD after trauma is much higher in those that had abuse or trauma in childhood - all the more reason that sufferers deserve our compassion, understanding and support.

I felt sad when I read this week that Joan Kennedy, former wife of Senator Edward Kennedy, was found lying on a sidewalk in the rain. She had suffered a concussion, a laceration on her forehead, and a broken shoulder.

The story goes on to say that her son has been trying to get appointed as her legal guardian, so that he can ensure that she cooperates with treatment for chronic alcoholism. She has been through several rehab programs after a series of arrests for drunken driving. She obviously has unlimited financial resources and political connections and has undoubtedly had the best treatment available in the world, and yet here she is basically lying in the street like a homeless person.

Why can’t we help her? One reporter described Mrs. Kennedy as shy and reserved, unlike the other strong Kennedy women. Apparently her major problems with drinking started after her husband’s scandal.

Two general principles are demonstrated by Mrs. Kennedy - using alcohol to cope with stress and social anxiety. In one study 60% of alcoholics were using alcohol to help reduce social anxiety.

Understanding Addiction

The good news is that addiction is easy to understand. There are only two symptoms: “denial”, and “dyscontrol”. Addicts lie to themselves, “I’m not really an alcoholic, I just drink too much occasionally”, or “I just drink socially”.

One of my favorite all time books is titled, I’ll Quit Tomorrow by Vernon Johnson. That title tells you everything you need to know about how an addict thinks. Two other great book titles on addiction are: The Craving Brain by Ronald Ruden and The Selfish Brain by Robert Dupont.

Addicts also lie to others - “I only have one or 2 beers a day” - unfortunately they buy 2 cases per week, and there’s never any left and they always drink alone. The math doesn’t work.

Dyscontrol means it controls you, you don’t control it. The first step in AA admits to being powerless over ________ (fill in the blank). But of course, it’s not just alcohol.  It’s food, drugs, gambling, work, sex, etc.  Even people who pull out their hair or cut on themselves are addicted to the body’s response to bodily injury - it may be as simple as causing a release of endorphins. These are chemicals released by the body that act like morphine or heroin in low dose.

A great prototype for addiction is smoking. Addiction means compulsive behavior in spite of negative consequences. People who smoke die 13-15 years earlier than nonsmokers on average. How negative is that? Of course the smoker rationalizes “I didn’t want to be an old person anyway.”

Do you have to drink every day to be an alcoholic? No. The rule that I have used in diagnosing addictions over the years is, “does the behavior result in harm to health, jobs, grades, or relationships?”

What causes addictions?

The single strongest factor is genetics. The part of the brain that learns what substances or actions lead to pleasure or escape from pain is genetically less reactive to normal life pleasures or serves to help reduce pain.

There are two primary goals of addiction - getting high, especially when bored and getting numb when feeling overwhelmed.

Why would someone jeopardize their marriage or custody of children just to get drunk? They don’t actually make a conscious decision, “I’m going to get drunk and I don’t care what the consequences are.” It’s more like self-manipulation. They forget to take their medication or they set themselves up to desperately need a drink - of course just one, or maybe two larger ones. For some people, their judgment is soluble in the first drink.

There are actually 2 subtypes of alcoholics. The first type starts usually in the teens and the goal is to get high. People who inherit this form have a high tolerance even when they first start drinking. The second type starts later, 20’s or 30’s and is primarily to treat chronic anxiety. Some people are unfortunate and have both types.

What about treatment?

Addicts, especially alcoholics are masterful at alienating everybody and using alcohol as their primary or only relationship. They can make people so angry with them that they get no social support. But effective treatment requires an alliance with the person against the problem - you have to separate the person from their addiction. It has to be you and them against the addiction.

The worst form of “pseudo” support is enabling. This is basically making it easier for them to continue with their addiction. The opposite of enabling is “tough love”.

Treatment ideally needs to include the significant other(s). In the movie When a Man Loves a Woman, the potential benefits of AA and Alanon were well depicted. Early in the movie the characters, played by Meg Ryan and Andy Garcia, seem like a normal healthy family. In retrospect we could see that the husband encouraged his wife’s drinking because she was more fun when she was drunk. I thought the treatment program in the movie was seriously flawed. Instead of involving the husband and children in couples and family therapy the treatment was mainly with her peers in the program. When she got out she continued to rely on her peers for all her social support and it almost destroyed her marriage.

Any couple dealing with an alcohol problem or other serious addiction should see this movie. It shows the secrecy, deception, and subtle way alcohol takes over one’s life. It shows how alcoholism is a family illness and everyone is effected. It ends by instilling hope - it’s possible to take back your life.

Since addiction is denial and dyscontrol, recovery is getting honest (with self and others) and getting control.

AA provides many tools like “one day at a time, sometimes one hour or one minute at a time”. Addicts should ask for help and may need medication.

What about medication?

Antabuse is often helpful. It’s not a medication that keeps you from drinking. It’s a medication that is taken in the morning and helps protect you from drinking impulsively later in the day. Antabuse interferes with the metabolism of alcohol and will cause you to get very sick - as in vomiting through your eye sockets. There has even been an occasional death resulting from drinking a lot of alcohol when on Antabuse.  Also, the longer you take it the longer you have to be off before you can safely drink - it means you have to premeditate your drinking up to a week in advance. Of course alcoholics don’t usually think, “I’m going to stop it so I can drink this weekend” - more like, “I don’t need it anymore”, and then oops!

One of the myths about recovering from addiction is that you have to want to do it and do it yourself.

Studies have shown that Antabuse works better when a loved one hands it to you every day. Treatment programs also work better when ordered by a judge.

One of the most annoying things about some programs is their negative attitude about medication. One alcoholic young man told me he liked taking Antabuse because he didn’t have to worry about drinking at night. But he was ordered by a judge to attend a program - the program wouldn’t let him attend if he was on any medication. Brilliant!

Just recently another medication has become available in the U.S. - Campral. It has been used in Europe with some success for 10 years. Early results here look promising. One disadvantage is that it has to be taken 3 times per day, two tablets each time. It apparently lowers craving by having one of the actions of alcohol in one part of the brain without itself being habit forming or having any reinforcing properties. It is not clear how well it will work if started while drinking, but getting people to stop drinking first is a major challenge - as in good luck!

Another treatment for alcoholism that has been around for several years is Revia. It works by blocking receptors for endorphins. In studies, 1/2 of alcoholics didn’t drink and 1/4 of alcoholics markedly decreased their drinking. The main draw back has been cost and insurance companies refusing to pay for it. It has been helpful for a few patients.

Since many times addictions are a self treatment for an underlying disorder, being able to diagnose the underlying problem and provide adequate treatment is often helpful. This is especially true when ADHD is the problem. Putting patients on stimulants has often significantly reduced or eliminated addictive behavior.

The TImberlawn Foundation did a study once of former cocaine addicts. They asked why and how they quit. The responses were vague and not especially convincing. But when they asked when did you quit and what was going on at the time they almost always found that addicts had gotten involved with something outside themselves. They became less self centered. Some became actively involved with a church or in other cases fell in love. They found a substitute. They found something that could help them achieve a “natural high”.

In other cases effective treatment of post traumatic stress disorder resulted in the addict no longer needing to get “numb”.

So we are left with the image of a woman of status and wealth, loved by her family found in her exclusive Boston neighborhood lying on the sidewalk in the rain with a concussion and multiple injuries. This was presumably a consequence of alcoholism - a medical illness that does not discriminate against any gender, race or social status. But as we learn more and more about the science of addiction and as we get better treatments there is much cause for optimism. Sadly, for some it may be too late.