Wiebke Pape, MD - A Medication to Gain Self-Awareness: Treatment of Dissociative Symptoms in Trauma-Related Disorder II

 

Wiebke Pape, MD - A Medication to Gain Self-Awareness: Treatment of Dissociative Symptoms in Trauma-Related Disorder II (2017 Conference) (LDN, low dose naltrexone)

Complex trauma has a deep impact on the development of personality and lasting consequences in patients’ further life. LDN can be a very helpful medication in their treatment. Emotional regulation, self-empathy, and mindfulness are likely to increase. Clients find it easier to stay present, even in difficult situations. Development of self-care is also likely to improve.

Wiebke Pape: I'm going to talk about my experiences with LDN as a part of the psychotherapeutic treatment of trauma-related disorders and in particular, the treatment of dissociative symptoms. I want to have a closer look at the possibility of this new medication.

Dissociative symptoms like derealization, emotional numbing, the so-called losing time, the lack of mindfulness - these are symptoms that occur in most of the cases of complex trauma-related disorders. Psychotherapeutic treatment is difficult and very slow-moving. And there is hardly any pharmacologic strategy that is consistently recommended. I want to show how LDN is able to help in the treatment of these symptoms, report our experiences with the medication, and discuss them. First, I would like to give my view as a clinician and describe what we are confronted with when treating clients with complex trauma, what our goals of treatment are, and how we try to achieve them. 

First, a few words to where I come from. I am a senior physician in the Rhein-Klinik in Bad Honnef, North Rhine - Westphalia, near Cologne in Germany. It's a hospital treating psychosomatic disorders in an inpatient setting. I am working in a unit specialized in trauma-related disorders. In our clinic, there are two units having this specialization, each of them treating 24 adult clients. Inpatient treatment allows us to get a close look at the client's everyday life and to see the consequences of childhood trauma in the present. We work in teams in the units with physicians, psychologists, nurses, dance and movement therapists, art therapists, and we all get to know a special part of the client and put it together in our team sessions. And then we get quite a complete picture of our clients and get to see the situations that are difficult for them. And we can work on these situations. 

First, I want to explain complex trauma a little bit, cause we mainly treat clients with this diagnosis. These are people who suffered from repetitive, prolonged, and/or cumulative stressors in childhood and adolescence. For example sexual abuse, cruelty, neglect, abandonment, antipathy by primary caregivers, continuing humiliation and excessive demands by caregivers, lack of emotional security, being left alone often, or an early loss of important attachment figures. These events usually have a deep impact on the development of personality and lasting consequences in further life.

Sometimes the clients suffer from chronic depression, instability of emotions, difficulties in affective regulation, distortion of self-perception - for example, deep-rooted beliefs of helplessness, worthlessness, guilt, and shame, which are often the cause of isolation from other people. Most of the clients suffer from attachment disorders. For example, there is a fear of getting close to others, distrust, but also dependency, often in destructive relationships. There are dissociative symptoms I want to explain further later on. Often the clients suffer from chronic pain, anxiety disorders, eating disorders, addictive disorders. And these symptoms occur in addition to symptoms of post-traumatic stress disorder. 

The symptoms of post-traumatic stress disorder include, for example, intrusive memories of traumatic events - that is the reliving of traumatic experiences. Clients experience nightmares, fragmentation of the memories concerning traumatic events, emotional numbing, avoidance of trauma-related stimuli and chronic hyperarousal.

Our clients often complain that they are triggered by multiple stimuli related to traumatic situations. Then these situations are re-lived. The clients feel as if they are in the past again, often feeling as helpless as in the traumatic situation itself. In these situations, they often describe regression of age “As if I suddenly lost my adult skills and were a child again, and I can’t protect myself, and just freeze and try to bear the situation until it is over”.  Often there are amnesias for these situations.

Most clients have severe attachment problems. They fear other people, and especially in new situations, many withdraw from social contexts because of interpersonal stress. A certain word, a look or a gesture from another person may relate to a former traumatic situation and activate haunting memories. Self-regulation is difficult, and many of the clients tumble from one emotionally overwhelming state to another and are very anxious about occurring emotions. 

Now I want to explain the dissociative symptoms, a little more detailed, the origins, the functions, the appearances, and the consequences in everyday life. A usual response to a trauma-related signal is dissociation - to shut down, to distract one's attention from the threatening surroundings and to turn it inward, to drift away. Often it's described as blankness - their brain goes blank. 

Triggers for dissociative reaction are not only external signals but very often internal ones such as emotions. Victims of continuing traumatization during the early years learn that emotions usually are overwhelming, like existential fear, horror, loneliness, sadness, or anger. As they never can properly learn emotional regulation because of unstable living conditions and lack of emotional care, they often were forced to separate their feelings from consciousness in order to keep functioning in everyday life and to survive.

As a result of this, they fear their emotions when they occur, and try to hold them back, as they are unfamiliar and threatening. In their adult lives, these people often describe that they feel like robots, numb, depressed, not feeling alive, joyful, or responsive to other people. They describe themselves as disconnected from their inner life, alienated in their own body. Emotions often are either numbed or overwhelming when occurring.

When emotions are released, for example, in a situation that reminds them of a former stress situation, it often leads to a similar reaction as in the traumatic situation: the person freezes with terror, is not able to act or react appropriately, feels helpless and ‘left to the mercy of the perpetrator’.

A dissociative reaction in a traumatic situation originally is a protective mechanism. It helps not to realize the horror that happens, like anaesthesia. When dissociating in a traumatic situation - the so-called peritraumatic dissociation - perception changes. Everything seems to be distant, less important; those affected often describe out of body feelings. On the one hand, this is a helpful mechanism of our brain, but in continuing traumatization, when the organism gets used to this protective skill, dissociation happens automatically in situations which are slightly similar to traumatic situations.

So one may say that the body reacts over-protectively, even when traumatization came to an end years ago. As a result, traumatized people dissociate very often in their everyday life, especially in challenging situations, because these evoke emotional reactions rather than situations that are familiar and safe. To minimize dissociation, they focus on safety and being in control, trying to avoid challenges. 

Dissociation can appear in very different modes. For example, derealization - feeling the external world seems to be unreal - and depersonalization - the perception of their own body is distorted. And emotional numbing, lack of perception of their own body, amnesia for long periods of the past or amnesic episodes in everyday life. There are intrusive memories of traumatic events, of emotions or body sensations associated with traumatic events. And there can be immobilization. And also hearing voices. 

Maybe I should explain hearing voices a bit more detailed because, in this context, it should not be misunderstood as a symptom of schizophrenia. It appears when, as a result of severe traumatization, the personalities split into paths that are separated or functioning separately. This is a mechanism to cope with trauma. There is one part that doesn't know anything about trauma and just functions in the present and everyday life. And another part which carries traumatic memories. And at the beginning of psychotherapy, often these paths don't seem to know each other. Their other part is perceived as a voice in the brain that is strange and unfamiliar and doesn't seem to belong to the person. And in treatment, there can be an integration of these two parts. 

What trauma-specific therapy wants to achieve. Safety and stability in the present as the first goal of therapy.

The next step. Is to try to work through traumatic events that happened in the past to minimize their consequences on the present life. To overcome former traumatization and to cope with everyday life, clients have to learn new coping strategies, to differentiate dangerous situations from harmless ones, to know their own strengths and weaknesses to protect themselves. They should develop awareness in the present and mindfulness and self-empathy. And they should learn to face a new situation to make new experiences that are different from traumatic ones. But if a client is highly dissociative, it is very difficult for him or her to focus on the present situation, especially if it is challenging and provokes fear.

Working on dissociative symptoms is laborious and slow-moving. Mostly, dissociation is an automatically-running mechanism, because it has been trained for many years. The dissociation often happens very silently and undramatically. For example, in therapy, you get to a significant point and do an important piece of work, which is demanding but helpful, and the session seems to be a success. In the next session, when the therapist wants to resume the last one, the client says, “Oh, I can't remember anything of the last session. It must have been too much and I just passed out”. Clients usually report an enormous fear of self-perception, of being aware of what is going on in inner life, because it could evoke trauma-related feeling. So it's just becoming obvious that there must be ambivalence in the clients when they want dissociation to cease.  On the one hand, dissociation is an impairment in everyday life. On the other hand, it is a protective strategy and avoidance of realizing what is going on inside. 

The readiness to realize is a very important topic in therapy for complex traumatized clients. Many of them are only able to manage their life, pretending “everything is okay with me as long as I keep going and functioning, as long as I don't take a close look at the state I’m in”. Our experience as therapists is that the easier it is for a client to be aware of the present situation, to be there with all the senses, and to stay present when things get rough, the easier it is to cope with everyday life and also with the traumatic experiences of the past. So in therapy, the main focus is to motivate clients to keep their awareness on the present and to increase their ability of acting and feeling as safe as possible in the present, and to decrease the dissociative symptoms. 

Psychotherapy is the best method of choice to treat dissociative symptoms, But as described, itt is very slow-moving. There is no established pharmacological intervention to influence dissociation itself. Medication used in the treatment of psychiatric diseases can be helpful in treating clients with dissociative symptoms to calm them down, or to achieve a certain mood stabilization, but they all have to be applied in off label use. 

And now I would explain how LDN can help

As a clinician, I use LDN without completely understanding its complex working mechanisms, but I think it is not completely understood by anyone. I am very grateful to Ulrich Lanius from whom I learned about LDN, and who motivated me to try it out as a medication to support treatment of dissociative clients. So I will refer to his publications and only provide a few and oversimplified facts in this place. 

So what is the connection between dissociation and LDN? Dissociation is at least partially mediated by the release of endogenous opioids. Endogenous opioids are released in situations of inescapable danger when active defence -  flight or fight - is not possible anymore. Opioids activate the parasympathetic defence response, which is immobilization, pain-reducing analgesia, numbing of emotional pain. There's a quotation from Krystal describing it very well: “In the state of surrender and catatonic reaction, all pain is stilled and a soothing numbness ensues”. Active defence reactions, fight-flight and avoidance of danger, are inhibited by endogenous opioids. It can be concluded that the blockage of opioid-mediated passive defence response supports active defence reaction. 

A traumatic event is characterized as an inescapable shock, with activation of passive defence reactions, mediated by endogenous opioids. When traumatic stress gets chronic, a continuously increased release of opioids results, followed by a reduction of opioid receptors. With less remaining receptors, even a minor release of opioids leads to a saturation of receptors and to a passive defence response and dissociation. Furthermore, the endogenous opioid system is mainly involved in affective modulation and regulation of attachment. Caused by the down-regulation of opioid receptors, the modulating capacities are massively impaired. As a result, coping with stressors gets less flexible. Already little stressors lead to parasympathetic activation and dissociation. Long term changes in the activity of endogenous opioids can occur very early as a result of early life stress. 

Since the 1990s, the blockage of opioid receptors with naltrexone or Naloxone has been the subject of pharmacological research in order to regulate this imbalance and to diminish dissociation. Naltrexone was used in the normal dose from 25 to 100 milligrams a day, that's partially led to overshooting effects with mobilization of traumatic memories or suicidal tendencies. Supposedly, a treatment with high dose naltrexone leads to an almost complete blockage of opioid receptors, and also blockage of the ability to dissociate. This could be a massive overburdening of highly dissociative clients because of the lack of alternative coping strategies. A less extensive diminishing of dissociation, which is the effect of LDN, and the remaining possibility to dissociate when necessary, seems to be better tolerable for the clients. Furthermore, LDN seems to reactivate the affect-modulatory competence of the endogenous opioid system. This appears to be the special effect of LDN in the treatment of dissociative symptoms.

When we first applied LDN. After learning about LDN from Ulrich Lanius in 2009, we informed clients with severe dissociative symptoms about the new medication that might be helpful. We informed them about the mechanism of functioning as we knew it. And when agreeing, they had to sign an individual contract for the treatment. They furthermore agreed to observe and document any occurring changes of symptoms. Reliability in therapy, especially in case of a crisis, and to continuing outpatient treatment after dismission from the clinic were conditions to start the treatment. 

As LDN is not available in Germany, our hospital pharmacy manufactured the capsules from the 50 milligrams, milligram tablets, but informed us that they only could produce two-milligram capsules because the content of only one milligram in one capsule, it could not be reliably measured. So we had to set two milligrams LDN as the dose for the beginning of treatment. At the moment we apply two doses, from two to six milligrams a day. 

Our first client was a woman, 47 years old. She works as a professor, and she was suffering from dissociative symptoms for many years. She had amnesia for the first seven years of her life and had some fragmentary memories of traumatic experience, which probably was sexual abuse. Within the last four months before admission to the clinic, her symptoms got worse. The traumatic memories increased. She was often losing time in her everyday life, combined with injuring herself severely and not remembering it. It was becoming difficult for her to focus on complex matters like her lectures. For example, her mood was unstable with depressive episodes, and she was admitted to our hospital because she couldn’t cope with her job anymore. Most embarrassing for her was that she often behaved like a child in challenging situations, especially in her job.

But she was ambivalent concerning her sensitive symptoms. On the one hand, she was worried because she was losing control because of dissociation. On the other hand, she stated “Disassociation helps me to get away when it's too much. It's a kind of relief”. 

When she took two, two milligrams of LDN, she reported, “I can't just switch off my perception anymore”. Before taking the medication she only perceived her surroundings as a murmuring. Now she could differentiate noises and properly listen to conversations. Her ability to concentrate increased, but she felt more challenged by her surroundings. Before taking LDN she stated, “I never get angry. I don't know the feeling at all”. With LDN she began to feel anger and reported that angry responses to other people came into her mind, which she found very frightening. But when she started to develop appropriate reactions from the change of perception, she learned to protect herself properly when reaching her own limits. And she made more experiences of being capable of acting, and felt “Aware of myself and alive”.

The automatic dissociation decreased, but she could willingly dissociate when necessary. She wanted to increase the dosage from two milligrams to four and then to six milligrams because she made more progress in dealing actively with her surroundings. A few weeks later, she described that “I feel being in contact with my fellow man, and my environment”. Affects like the anger of sadness weren’t threatening her anymore. She could use them to develop new strategies of self-care. Concentration and awareness improved day by day. 

After 19 months of taking LDN, she described the changes as follows. “Before taking LDN I spent much time in states of dissociation, often without purpose. Just to be in my own world and to protect myself from the demanding environment. Partially, I was fascinated by this condition. On the other hand, dissociation impaired me as I couldn't have controlled it/ Since taking LDN I notice when I begin to dissociate and then I have the choice to withdraw from the world or to go back into the present. I'm able to stop it. I'm in control. Overall dissociation occurs more seldom and has lost a lot of its fascination.”

“I feel much more alive and can stand many challenges. Only in excessively demanding situations, I need to dissociate, but in this case it is an ability to cope with these situations. There is more progress in therapy, as I can keep my awareness when things get strenuous, and that can go on working.”

Another case is a 38-year-old woman diagnosed with dissociative identity disorder who was working through traumatic events in our inpatient setting. Before taking LDN she reported, “After a session of confrontation, I was dissociating the whole night long. In the morning I awoke with a feeling of immense horror. I felt exhausted and weak after confrontation for several days. On the second day of LDN medication, I could differentiate the emotions that were just horror before/ My never-ending ruminations vanished, my thinking was clear and worth structured.”

Several weeks later, she described, “LDN restructured my emotional life. Before taking LDN I felt as if there was a foggy wall surrounding me, partially for my protection. It vanished completely. So I could see and feel the emotions resulting from the trauma-confrontative work. I learned to deal with them. Before taking LDN I had to mobilize all my strength to struggle against dissociation when emotions occurred, when flashbacks occur, which were overwhelming before taking LDN. And it is now much easier for me to use my stabilization strategies and to cope with them.”

Some more descriptions of LDN:

• As if somebody turned on the light in my head, or 
• I can feel my body, I feel the strength of my body. For the first time in my life, I can climb the stairs without being exhausted. 
• I recognized for the first time that the carpet has got a pattern, and I understood for the first time what it means and how it feels to put the feet on the ground for stability.
• I dare to do new activities. I am able to be part of a group of people I don't know properly. I don't have to be on the watch all the time. 

And another one 

• I can concentrate on and understand complicated matters. I always thought that I was stupid because I used to understand so little and forget so much in the past.

In 2012, we made a first retrospective study based on the first 15 clients we treated with LDN since 2009. The dissociative symptoms the clients described were amnesias in everyday life occurring several times a day; freezing and being incapable of acting, triggered by a person with a threatening appearance; freezing and shutting down triggered by the perception of their own emotions; the perception of the environment is foggy, at a distance and distorted; switching in child-like stares; behaving like a traumatized child and experiencing like a traumatized child; perception of an appropriate reaction to one's own emotion is not possible; perception of their own body or parts of the body is not possible; difficulties to focus one's attention and to concentrate; self-injuring behaviour; and intrusive memories or flashbacks.

Eleven clients described a positive effect on the first or second day of taking LDN. Three clients finished taking LDN although they noticed a positive effect at first. The decreasing of dissociation led to an increasing perception of the inner life and the surrounding, which was too challenging for them. Two clients reported getting in contact with traumatic memories. 

These three clients also report being more easily stressed in everyday life. One client showed raised blood pressure, one reported pain all over the body like having the flu after a few weeks of taking LDN. The reported side effects disappeared after quitting the medication.

Two clients described a new and initially increasing irritation and anxiousness because of the clear perception due to LDN. They noticed inner impulses to be more active in situations of everyday life and motivation to learn things and make new experiences. One of these clients stopped taking early after a few weeks because she found this development as too much at the moment. The other one accepted the challenge and made much progress concerning self-regulation. In two clients, the medication with LDN didn't show any effect, so that we finished the treatment after they had taken four milligrams for two weeks.

Long-term effects.  

In our first evaluation, treatments from eight to 27 months were considered. Nine out of 15 clients continued taking LDN after dismission. Seven of them answered our questionnaire. All of them reported that the LDN effect continued and kept being helpful. One client reduced the dose from six to four milligrams due to occurring diffuse pain. With the reduction the pain vanished, the effect on the dissociative symptoms stayed on. One client had quit the medication in spite of a continuing positive effect because of multiple changes in her life and therapy setting and didn't comment on her actual dissociative symptoms. 

What happened to the dissociative symptoms? Most of the clients reported that the shutting down occurred less. It was easier to regulate. Perception and regulation of negative emotions were possible. The ability to keep awareness in stressing situations increased. Perception of the surrounding became clearer. Thinking, focusing one's attention and the understanding of complex contexts became easier. Perception of their own body became possible. Gain of control concerning self-injurious behaviour and less injury. Traumatic memories were partially clearer but could be regulated more easily with stabilization techniques. And the intensity of flashbacks decreased.

Side effects.

There were some side effects occurring in the first days of treatment, and then recurrent. There were headaches, tiredness, drowsiness, restlessness and sensation of repletion which most of the clients reported. And there were some side effects occurring after several days of treatment and persisting, that was increased blood pressure in one case, auditory hallucinations in one case; and in one case, the increase of traumatic memories.

And there were side effects occurring after several weeks of treatment. There was one case of muscle pain that was recurrent after quitting LDN, and one case got treated, and one case that's gained weight, but I'm not sure if this is due to LDN or because of other reasons. 

2017

By now, 50 clients have been treated with LDN in our hospital. Thirty-seven of them reported a positive effect and have continued taking LDN after dismission from the clinic. In our latest survey from September 2016, 21 from 37 clients gave feedback. Six clients out of 50 didn't notice any effect from LDN. Seven clients notice an effect that they described as “too much”. For example, emotions occurring they could not regulate or tolerate; they felt overstimulation when taking LDN, or the amount of realization concerning their own traumatic history was not bearable. 

What reports came from clients still take LDN.

Fourteen are still taking LDN and reported that the effect is still positive, but they modified the mode of taking the medication. For example, “When I reduced the dose, dissociative symptoms came back, so I continued the medication”. Another one reported, “I adapted the dose of LDN to the particular situation I'm in. When I have to be fully focused, I increase the dose”. Another one reported, “I take LDN on demand when I think it's necessary to have the effect”. 

The clients who stopped taking LDN.

Six clients finished taking LDN. Four of them reported that they could do without LDN. They stated, “The medication gave an impulse, something got in motion and development is going on by itself now”. Or, “After having stopped LDN I noticed that I learned to minimize dissociation. I can use my new abilities without LDN  by now”. And two clients stopped taking LDN because the medication was too expensive for them.

Did the effect of LDN change?

Most of the clients treated reported a lasting effect that didn't reverse. Some clients had the impression that the effect decreased, so they had to increase the dose temporarily. Two clients reported that after a time they couldn’t notice the effect anymore. Up to now, it is not clear to us what the cause of the changing effect is. 

These are changes described in long-term medication, which is from a two and a half to seven years medication. “As I'm dissociating less I have been able to cope with the difficult tasks in therapy and my life. I am stabilized in my work life, had less sick days.” Or, “I am feeling alive and in contact with my emotions.” Another one reported, “I don't feel as isolated as before taking LDN. I'm in contact with other people and my environment”. “I'm able to sense my needs and my limits can protect myself.” And another one reported that she had fewer psychic crises.

Another one said, “But unfortunately I cannot dissociate my chronic pain anymore. The perception of my pain also increased”.

Questions that came up. 

Is it possible to predict who will benefit from taking LDN? 

Our impression is - whether the effect of LDN is helpful for clients seems at least partially to depend on their ability to cope with everyday problems. Clients who see themselves as being in need of protection and avoid challenges experience the LDN effect rather as a burden. Clients who are progressive or hands-on often experience a short-lived irritation and then remarkable progress in therapy and coping. It's not clear why some clients didn't notice any effect at all.

Is LDN to be used as a short term or long-term medication? Given our experience, LDN is suitable as short and long-term medication. Leaving off LDN for a time seems to be useful to verify whether the LDN effect is still present and medication is necessary. 

By the different ways clients dealt with the LDN taking, three strategies of treatment have evolved. First, permanent medication in case LDN is still helpful with an individual adaptation of the dose, depending on the situation. Secondly, short term medication in case LDN has given an initial impact to develop new abilities, in case the effect can no longer be felt or isn’t necessarily any longer. The next strategy is medication in case of the situational need, for instance when dealing with a difficult topic in therapy or to cope with a challenge in life.

Is there an effect of LDN on dissociative amnesia? We have the impression that LDN doesn't mobilize new traumatic material, and dissociative barriers don't seem to be broken. But, clearer and less fragmented perception and increased realization of biography can increase the burden by confrontation with traumatic content in the short run. On the other hand, it often appears that LDN can facilitate the use of techniques of stabilization and techniques of distancing from traumatic memories so that coping with traumatic memories become easier. 

What is new about LDN compared to other medications?

When clients get access to their emotions and gain self-empathy, they often describe that they feel alive, in contact with their inner life and other people. This usually is noticeable in the relationship to the client. And with my experience often it's a very touching moment, for the therapist too. Working with LDN I experienced many of these moments when clients describe their feeling of change after a few days of taking LDN. It is as if a connection is restored in the clients who often felt disconnected from their inner life and from themselves. 

And now I want to close with my conclusions. Concerning our previous experiences, LDN can be a very helpful medication in the treatment of complex traumatized clients. Emotional regulation, self-empathy, and mindfulness are likely to increase. Clients find it easier to stay present, even in difficult situations. Development of self-care is also likely to improve. As a result of this, the integration of traumatic memories and emotions is easier to be achieved, as the clients are able to stand stressing situations in trauma confrontation, to stay in the so-called window of tolerance, and to soothe themselves when threatening emotions occur. The medication with LDN should accompany psychotherapy, as the effects of LDN need to be handled with and to be integrated.

Thanks for listening, and for the interest in this topic. 

Linda Elsegood: Thank you for listening to this presentation. All past conference presentations can be found on our website,