Cannabis use issues (also known as Cannabis Use Disorder, or CUD) are on the rise among military veterans with posttraumatic stress (PTSD). “Indeed, rates of PTSD diagnoses among veterans increased 60% between 2002 and 2007, and rates of CUD diagnoses within the Veterans Affairs (VA) hospital system increased more than 50% between 2002 and 2009,” said Marcel O. Bonn-Miller of the National Center for PTSD and Center for Health Care Evaluation at the VA Palo Alto Health Care System in California. However, when these vets enter treatment and discontinue their cannabis use, their symptoms linger.

Anxiety increases when individuals stop using cannabis to cope with their symptoms, but until now, the cessation of cannabis in relation to PTSD symptoms had not been explored fully. To address this gap, Bonn-Miller and his colleagues conducted a study on veterans who entered treatment for PTSD with a CUD and theorized that they would have smaller treatment gains after abstaining from cannabis use than veterans without a CUD.

The researchers evaluated 260 male veterans that were receiving inpatient treatment for PTSD. They assessed the veterans at two different times over eight years, using the PTSD Checklist-Military Version. They found that the veterans who had CUD realized less change in symptom severity than those without. “Specifically, individuals with a CUD diagnosis who discontinued use, compared with those without a CUD diagnosis, had lower levels of change in total PTSD symptoms, PTSD avoidance/numbing symptoms, and PTSD hyperarousal symptoms,” said Bonn-Miller.

“In addition to these results being statistically significant, they are clinically meaningful.” In particular, those with CUD saw treatment gains similar to veterans who received no treatment at all. Additionally, with more states legalizing cannabis for medicinal purposes, veterans with PTSD who use cannabis may be unknowingly negatively impacting their recovery. This study also demonstrates the relationship between PTSD and cannabis use, underscoring the importance of further research in this area. Bonn-Miller added that clinicians should provide their clients with adaptive coping techniques before they recommend cannabis cessation for the purpose of treating PTSD.

Reference:
Bonn-Miller, M. O., Boden, M. T., Vujanovic, A. A., & Drescher, K. D. (2011, December 19). Prospective Investigation of the Impact of Cannabis Use Disorders on Posttraumatic Stress Disorder Symptoms Among Veterans in Residential Treatment. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0026621

Even when it is unintended, some people find it intolerable to hurt someone they love. To experience hurting the other can create shame, guilt and strong “I am a bad person” feelings. As a result, we may avoid saying what is on our mind and put aside our own feelings and needs. This inhibiting of the self can be harmful to our relationships and can create the conditions for developing anxiety and depression.

Marlene, a 27 year old married woman, came into my therapy office feeling anxious and depressed. She described how unhappy she was in her marriage to Ben. She told me she loved her husband but was feeling like she was in a straight jacket. If she expressed a need that conflicted with his wishes, his feelings would get hurt. She couldn’t tell him that she didn’t want to play tennis with him every weekend or that she was tired of going out every Friday night with his friends from work. She explained to me that when she told him these things, he told her that she made him feel unimportant, criticized and pushed away. She felt ashamed that she was the cause of his feeling so terrible. She would apologize to him and try to keep her feelings to herself, but then she would attack herself and feel like a bad person. She was shutting herself down and feeling depressed. She also reported that when she was aware of a need that she felt she shouldn’t express to Ben, she would get anxious for fear that she couldn’t contain herself.

What Marlene described to me suggested that she had issues she needed to work on as an individual and that as we did this she would be more able to address the difficulties in her relationship with Ben.

While Ben might be particularly subject to feeling hurt or slighted, Marlene’s inability to tolerate hurting Ben and talk with him about these issues, made the relationship difficult. It also became apparent as I spoke with Marlene that she suffered in all of her relationships by worrying how she was impacting on everyone. She had never considered that we all hurt people, even those we love, unintentionally. She didn’t understand that it is impossible to be in a relationship without hurting those we love. When I suggested this to her, it didn’t make sense.  How could she possibly bear watching Ben be so hurt? She would have to give him what he wanted.

As Marlene and I talked, I wondered what made it so painful for Marlene to consider that something she said or did had the unintended consequences of hurting someone she cared about. I asked Marlene how she thought she got the idea that it was totally unacceptable to hurt someone she loved. We also explored Marlene’s idea that when someone feels hurt they are horribly harmed. Marlene thought my questions were strange. How could it not be painful to see someone you love hurting because of you? How could you not feel like a very bad person? Of course hurt causes terrible damage. I replied that it was appropriate to feel sorry or sad that you had been the cause of someone’s hurt, but that it didn’t have to make you feel like such a bad person. I said that you can’t always be sure how the hurt is affecting someone unless you are told or ask.  Each hurt is different. I said that these experiences could be talked about and the other person might be able to listen and understand the intent. I added that this was something she could work on with Ben.

Marlene considered my ideas with some skepticism. She remembered how her mother would get so hurt when she was little. She had one memory where her mother started to cry and tell her how hurt she was when Marlene didn’t like the dress she was given for her sixth birthday. She recalled how her mother told her how much Marlene hurt her feelings and how could Marlene not appreciate all the time and money her mother had spent to pick out such a perfect dress. Marlene remembered how scared she was when her mother was so distraught and how much shame she felt to have done such harm to make her mother feel that way.

Over the many months that Marlene and I continued to talk in therapy, she began to make connections between how her mother, on many occasions would be hurt if Marlene didn’t have the “right” response. She became clearer that she would do anything to ensure that she was not the cause of her mother’s distress. In fact, Marlene had given herself the job of making her mother happy. As Marlene became aware of this, she also began to realize that with her strong need to keep her mother happy and not cause her any hurt or distress, she had learned to overlook her own needs and desires, especially when they conflicted with what she knew her mother needed.

When Marlene talked about how she had learned to disregard her own wishes and squelch her own voice, she started to make connections to her behavior with Ben. Her fear of increasing Ben’s hurt when their needs conflicted, gave way to the idea that maybe she could talk with Ben about this. She recognized that Ben’s reaction when he was hurt was nothing like her mother’s intensely distraught response. Perhaps, there was a way for them to talk and negotiate and consider both of their needs.

In fact, Ben was surprised to learn that Marlene was scared to assert her needs for fear of hurting him. He told her that even though he felt hurt, he didn’t feel she had done any harm to him. He told Marlene that he didn’t think he was so fragile. He thought he could try to consider that when she expresses her needs, it didn’t have to mean that she was dismissing him. He told her he wanted to keep talking about this. He knew he could get hurt easily, but he didn’t want it to affect Marlene by causing her to inhibit her thoughts and feelings.

Marlene continues to come to therapy to work on becoming more comfortable expressing her own thoughts and feelings and dealing with her impact on those around her. She has gotten much better at dealing with conflict and asking for what she wants in the world. She is worrying less about being a bad person.  Marlene has become more tolerant of herself and more respectful of her right to say what she wants. She is increasingly able to say no to what someone she cares about wants and risk the possibility that they will feel hurt. As she is able to allow fuller expression to her true voice, she is feeling less anxious and depressed. She and Ben are doing better at talking with each other and they are much more able to address the conflicts between their needs in a constructive and loving way.

When we become overly interested and vigilant about the impact we have on others and design our behaviors to make sure they don’t have feelings we can’t tolerate, we are putting our authentic selves on hold. This denial of who we are causes us to build up feelings consciously and unconsciously. Preventing ourselves from expressing what we think and feel, and shutting up our true selves, puts us at risk for anxiety and depression. If we can learn to become more comfortable with how we impact others, and address what we think our impact is, instead of trying to control the other’s feelings, we will be promoting the development of our true selves.

Maybe you’ve been struggling with anxiety and panic and you’ve tried everything: medication, progressive relaxation, meditation, exercise, deep breathing, herbs, watching TV till your eyes glaze over in a stuporous fog—and still you’re feeling nervous, irritable, unable to focus, panicky, and tense.

What you’re missing might surprise you: you could be suffering from lack of sleep.

Studies show sleep deprivation to be one of the primary contributors to anxiety problems, depression, and other psychiatric disorders. Sleep appears to be very important for emotional regulation and processing.

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At University of California Berkeley’s Sleep and Neuroimaging Laboratory, assistant professor Matthew Walker’s experiment with sleep deprivation in humans showed that without sleep, the brain reverts back to more primitive patterns of activity. People then become less able to put emotional events into context and respond appropriately.

The amygdala is the part of the brain that prepares the body to protect itself when it perceives danger. When it senses danger, it sends a message to the prefrontal cortex, which then interprets and assesses the situation and decides whether to activate the fight or flight response. Under normal circumstances, the amygdala and prefrontal cortex work together to respond appropriately to danger while also keeping people from overreacting to emotional experiences. Under conditions of sleep deprivation, subjects’ amygdales and prefrontal cortexes stopped working together. Emotional centers were 60% more active, resulting in slower reflexes, increased irritation, problems with focus and concentration, and higher feelings of anxiety.

Other studies suggest that lack of REM sleep causes or worsens psychological problems. REM sleep, also known as dreaming sleep, is very important for processing emotions and memories, clearing the mind of the stressful events of the day, and dreaming. During this stage of sleep, the areas of the brain used in learning and developing new skills are stimulated. About 70 to 90 minutes after falling asleep, the first REM cycle occurs; ideally, people will have three to five REM episodes per night. Getting more and better REM sleep has been shown to boost people’s moods during the day. Fortunately, improving the quantity and quality of REM sleep you get is relatively easy.

Many experts recommend getting seven to nine hours of sleep per night, although some say that the quality of sleep is more important than quantity. Getting six hours of high-quality, uninterrupted sleep is more beneficial than eight hours of restless, interrupted sleep. You can immediately improve the quality of your sleep by making two important changes: change what you put into your body and what you do with your body, both during the day and when getting ready for sleep.

Change What You Put into Your Body

• Eating, drinking, and medication habits may be disrupting your sleep more than you think. Too much food, especially rich, fatty food, can keep your stomach working overtime to digest, and spicy food can cause heartburn. Too much liquid can cause numerous trips to the bathroom at night. Your first step to better sleep is to limit your intake of rich, fatty, or spicy food, especially during your evening meal. Stop eating and drinking fluids several hours before you go to bed for the night.
• Alcohol and caffeine use can also be very disruptive to your sleep cycle. Although you may feel temporarily relaxed after using alcohol, it causes you to wake up later at night, interrupting deep sleep and REM sleep. Caffeine can disturb sleep for up to ten to twelve hours after ingestion, so cut out the caffeine after lunchtime. Nicotine is another stimulant which disrupts sleep, so cut down or eliminate smoking to improve your sleep—although if you’ve been a smoker for a while, nicotine withdrawal may temporarily make it harder for you to sleep.

Change What You Do with Your Body

• Regular exercise can help you fall asleep easier and achieve better rest. It doesn’t even have to be intense or rigorous: a brisk walk or bike ride is plenty. As little as twenty or thirty minutes per day of moderate exercise can be very helpful, and you can even break your activity up into ten- or fifteen-minute segments if you wish. You will want to schedule your exercise in the morning or early afternoon, because your body needs sufficient cool-down time to sleep well.
• Set up a consistent, relaxing routine before bed. This trains your brain to recognize that it is time to wind down, making it easier for you to fall asleep. For thirty minutes to an hour before bed, find peaceful, quiet things to do to relax your body and mind. You might try things such as reading a light, entertaining book or magazine, listening to soft music or audiobooks, enjoying a hobby such as knitting or doing puzzles, or making simple preparations for the next day. A cup of hot tea or a glass of warm milk can also be helpful.
• Although many people use watching TV as a way to relax or fall asleep, television actually stimulates your brain rather than relaxing it. Watching disturbing, violent material on the news or prime-time shows stimulates thinking as well as your physiology. Even if you do manage to fall asleep with the TV on, the continuous flickering of the screen can interfere with your body’s clock, which is sensitive to any light. You will get higher-quality sleep with the TV and computer off. If you have a hard time getting used to sleeping without the television, try turning on soft music, a sleep sound maker, or a fan.
• Avoid napping during the day, which interferes with your body’s clock. Set up your nightly relaxation routine and stick to a consistent sleep schedule, and your quality of sleep will improve.

Getting adequate, quality sleep is extremely important for emotional regulation and processing. Fortunately, it is relatively easy to make changes in this area. Start today, and the effects can be felt almost immediately.

Reference:

1. Yoo, S., Gujar, N., Hu, P., Jolesz, F.A., Walker, M.P. (2007) The human emotional brain without sleep: A prefrontal amygdala disconnect. Current Biology 17: 877-878