Warren

Warren was afraid he was going crazy. He was having nightmares, panic attacks, and an almost impossible time getting any sleep. He admitted to me… "I'm having a hard time concentrating and remembering what I'm supposed to do. I've also been snapping at my wife and son for no reason." Warren worked as an insurance salesman, had been married for two years, and had a one-year-old son and another child on the way. He told me during our first interview that everything had been fine until around six months ago when he and his wife moved from Kentucky to Southern California. 

"My wife thinks I'm under too much stress," he said. "She worries about me. She says it's because I miss Kentucky, and all the driving I have to do …" His voice trailed off, and then he added, "But we had to move here. I got a good promotion, and we need the extra money, so what else could I do?" He had already gone to his family doctor and a cardiologist to make sure he was not having problems with his heart, and had attempted to back off a bit on his work schedule and spend more time with his family. Even so, his symptoms persisted.

During our first few sessions, I learned about Warren's life and was especially interested in finding out whether he had had any traumatic experiences. He described his life as pretty normal, with a good childhood and a loving family. While searching his memory for any possibly relevant experience, he casually said, "Oh yeah, I did get my leg blown off." I sat there, managing my surprise, as he pulled his pant leg up to reveal a prosthetic leg and foot. "Well, that may have been traumatic," I said. "Let’s talk about that." 

Warren was an eighteen-year-old, just graduating from boot camp when Iraq invaded Kuwait. In the space of eight months, he went from his high school prom in rural Kentucky to driving a supply truck on the push toward Baghdad. He did his best to describe the exhilaration and terror he and his buddies experienced during this drive. They moved mostly at night, depending on GPS and night vision goggles, routinely getting lost in the alien terrain. Their caravan of trucks, tanks, and personnel carriers engaged the enemy in occasional gunfire, but was under orders to proceed as quickly as possible to maintain the supply chain to their forward troops. As they drove deeper into Iraq, resistance increased and the caravan encountered regular gunfire and rocket attacks. Trucks were hit, troops were killed and Warren's fear steadily increased as they pressed forward.

While Warren doesn't recall a great deal about the night he was hit, he does remember that they had gone off course and found themselves driving in circles near a desert town. They had just started to suspect that they were at risk of an ambush when the firing began. The next thing Warren remembered was waking up in a hospital room in Kuwait about to be transferred to another hospital in Germany. He learned later that his truck had been hit by a rocket and that the explosion had severed Warren's lower leg and knocked him unconscious. He came home a month later, was fitted for a prosthetic, and began physical therapy. He was young and strong and in good shape; he took well to using his new leg and foot. Warren didn’t recall any psychological effects of his experiences and was told by Army doctors that because he was knocked unconscious, he didn't have to worry about PTSD. As he finished telling me this story, his eyes widened in surprise. "Could this be PTSD,” he asked, "after all these years?" 

As we explored the events around his recent symptoms, he remembered the day of his first anxiety attack. He was driving from Los Angeles to Palm Springs for a business meeting. As he drove deeper into the desert, he missed the exit and had to circle around in a big arc to get to his destination. It was an important meeting, he was running late, and he grew increasingly anxious as he searched for the right streets. It was at this point that he found himself breathing heavily and feeling dizzy. He pulled over to the side of the road to calm down, making a note to himself to see a doctor and have a stress test. "I remembered the smell, that desert smell, the dry air and the dryness of my skin-that feeling was what I remember about driving through Iraq.” During his tour of duty, he had wondered how people survived the heat in the Middle East and remembered having that same thought as he drove through the desert outside of L.A. 

Despite the fact that for more than a decade Warren was without symptoms from his combat experiences, he was having them now. His anxiety, sleep disturbances, and panic strongly suggested that the primitive circuits of his brain did remember his earlier traumatic experiences, and his sensory experiences were triggering his subcortical fear circuitry. While Warren had a hard time believing that his symptoms were connected to events from long ago, they gradually subsided during treatment focused on consciously processing his combat experiences. The recent stress of moving, his new job, and the increasing demands on his time may have made him more vulnerable to the intrusion of these memories triggered by his return to the desert. 

We need to have the participation of our entire brains to fully process experience. When we are overwhelmed by traumatic experiences, our brains lose the ability to maintain neural integration across the various networks dedicated to behavior, emotion, sensation, and conscious awareness. When memories are stored in sensory and emotional networks but are dissociated from those that organize cognition, knowledge, and perspective, we become vulnerable to intrusions of past experiences that are triggered by environmental and internal cues. In the process of psychotherapy, we attempt to reintegrate these dissociated networks, allowing for traumatic memories to be consciously processed. This, in turn, allows the networks of conscious cortical processing to develop the ability to inhibit and control past traumatic memories.

The reactivation of trauma by seemingly random experiences or sensory cues from the external environment - even if we have protected ourselves with dissociation or amnesia - reflects the vulnerability of our brains to discontinuities of experience. All of the obvious associations between Warren’s past experiences and what he was experiencing in the present were lost on him prior to being guided to reflect on them. Through our therapeutic interactions, I was able to serve as an external neural circuit and auxiliary executive system that helped Warren to put the pieces of his experiences into a coherent and meaningful narrative. Once the narrative was in place and he could accept it, he no longer feared he was crazy. Rather, he was impressed with his brain's ability to store implicit emotional information and make it experientially accessible so many years later. The process of therapy brought continuity and integration back into Warren’s life.

This is an excerpt from Dr. Cozolino’s book The Neuroscience of Human Relationships.