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Consider 'hands-on' approach in PTSD therapy. (Symbolically Communicates Nurturing).

NEW YORK -- By dispensing pain medication, examining scars, and taking pulse and blood-pressure readings, a psychiatrist can communicate powerful symbolic messages to the patient with posttraumatic stress disorder, said Dr. Sharon Sageman at the annual winter meeting of the American Academy of Psychoanalysis.

Although it may be considered heretical for psychiatrists to touch their patients, patients with posttraumatic stress disorder--especially those who experienced trauma during early childhood--often have severe issues with authority, Dr. Sageman said. They fear that if they turn to an authority figure for help, they will be hurt and disappointed. This makes them difficult to reach until a basic sense of trust and safety can be established. The "hands-on" approach does just that, by providing a corrective emotional experience.

"As the medical director of the Women's Health Project [St. Luke's-Roosevelt Hospital Center, New York], patients will often turn to me as the one to help them with physical pain," said Dr. Sageman. "I have seen repeated instances in which patients with severe early abuse and trauma test the waters, and see how I respond to their complaints of physical pain, such as headaches or dyspepsia, before they will open up and allow themselves to be vulnerable enough to discuss their emotional pain and the intimate details of their trauma history."

Dr. Sageman makes a practice of keeping a supply of ibuprofen, chewable antacid tablets, and crystallized ginger in her office for patients who complain of physical pain or dyspepsia, and bandages and antibacterial ointment for patients with open cuts. She finds that the act of dispensing such medications communicates a number of profound symbolic messages, including: "It is okay to be vulnerable. If you reveal your needs to me, I will respond by helping you, not hurting you. We don't have to start off with emotionally painful topics. If you feel your physical pain needs to be helped first, that's okay"

Once the patient reports that her stomach pain has decreased as a result, for example, of the crystallized ginger, Dr. Sageman will tell her how she can find that product in a health food store. This amounts to a symbolic communication of self-soothing, autonomy, and empowerment as the patient learns to treat her own pain.

Dr. Sageman described several case histories, including one of a 39-year-old woman with a history of severe physical abuse in childhood at the hands of her older brothers. She had a severe distrust of authority, problems with impulse control, excessive sweating, hypervigilance, emotional lability, flashbacks, poor self-esteem, insomnia, hostility, and impaired concentration. She cried many times a day and was full of rage.

At first she refused any conventional psychiatric medication, angry about a previous diagnosis of bipolar disorder and a prescription for Depakote, which had been ineffective. Dr. Sageman responded by treating her with natural remedies, including melatonin for sleep, fish oil for mood swings, folic acid, and multivitamins. During the next session, the patient said that the natural medications were not helping enough, and that she was willing to use conventional psychiatric medications.

As part of the psychopharmacologic treatment, Dr. Sageman checked the patient's blood pressure weekly. "Since [the patient] had been so extremely traumatized by physical abuse, it was important to do this in a very gentle manner that would allow her complete control and that would communicate concern for her comfort," said Dr. Sageman. "I explained the need for checking her blood pressure and asked her if it was okay if I took it. She said yes and slowly rolled up her sleeve. I put the cuff on gently and asked her if it was too snug. After she said it was okay, I took her pressure and told her what it was, and said that it was very good. By the third session, [she] showed no hesitation and rolled up her sleeve and offered me her arm as soon as I took the cuff out of the drawer without my having to ask her to."

Dr. Sageman recommended that the psychiatrist and the patient examine scars together, but not until a substantial sense of trust has developed. This can have a powerful therapeutic effect, since it communicates that the psychiatrist is not afraid to share in the horror of the patient's trauma. When examining the scars, it's important for the psychiatrist to ask, "Do you remember how this happened?" since trauma patients frequently dissociate and have trouble remembering.

Dr. Sageman warned that one potential problem with the hands-on approach is that by establishing oneself up as the all-powerful, good parent, the psychiatrist is setting him- or herself up for an inevitable negative transference at some future point.
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Title Annotation:posttraumatic stress disorder
Author:Finn, Robert
Publication:Clinical Psychiatry News
Article Type:Brief Article
Date:Apr 1, 2002
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