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Jan 20 2016

How PTSD Can Block Successful, Effective Outcomes in Life Part 2 – Activation of the Nervous System

PTSD sabotaged my efforts to get dental treatment for 8 years. This article goes a little bit into the story of my struggles finding a dentist and covers how experiencing activation of the nervous system was such an impediment to achieving my goal of having all my dental issues resolved.

PTSD, The Dentist and Me

An old quarry, silent dirt steps receding into a brown chasm, passed under us. Many square red roofs slipped by in the soft sunshine. Houses crowded narrow streets in the midst of expansive light and dark green fields. Overgrown small yards. A sense of abundant moisture and growing things. A sprawling barn with gray metal sheets covering it, surprisingly haphazard.

As the plane made its descent into the San Jose, Costa Rica airport, I realized most of the roofs were made of red corrugated metal even though they seemed like terra cotta at first. I turned off my tablet; my boyfriend and I had been listening to the “Fun Easy Learn Espanol” Ap, learning to say “El Mango” and “Carne Blanca” and “La Sandia” until the words began to swim together in our heads and fall out our ears.

As the plane hit the ground and rumbled loudly along the sunny, pale concrete, I began to cry. Just a little. I was finally going to be able to get all my teeth fixed. I had not been able to see a dentist for 8 years due to PTSD, and I had finally found my “angel” dentist, someone who was actually willing to accommodate my unusual requests that would help me feel safe (and that no other dentist had been willing to accommodate).

Finding him was a miracle. This was a dentist I trusted enough, that was open minded enough, communicative enough and flexible enough to ease the way to treatment of someone with PTSD. A dentist who was willing to go out of his way to do things I’m sure no client has ever requested or ever will request of him again. For the first time, I was not afraid on the way to see a dentist.  Simply by his willingness to communicate and be accommodating he actually calmed the terrors of a person who gets terribly triggered by medical and dental procedures. I felt like I had left the bowels of hell, where every dentist was some kind of devil in disguise, and was inexplicably being granted entrance into heaven.

Fluffy clouds passed by in the light blue sky through large glass panes as we approached customs. We walked hurriedly, breathlessly through the long maze; my hand shook until I almost could not form actual letters on the customs slip. I was dead with fatigue but the long journey was almost over.

Aerial photo of houses and fields near San Jose taken by CAPRA Technical Assistance Project

Aerial photo of houses and fields near San Jose, Costa Rica taken by CAPRA Technical Assistance Project

***

PTSD contributed to my developing some serious tooth decay. The over-activation of the reptilian brain coupled with repressed rage and pain caused nighttime clenching which I was unaware of for 5 years (2007-2012). I woke up one night in 2012 and realized I had just been holding my jaw closed in a vice grip that seemed like it would crack all my teeth and all their roots with no mercy.

Many things can cause bruxism, such as an incorrect bite and diet, but in my case when I tune into the layers of rock hard tension in my jaw muscles I always sense that, on some level I am usually unaware of, the muscles are full of fear (terror, panic) and rage. I believe that the emotional, muscular, chemical, nervous system and hormonal stresses caused by PTSD – the chronically hyped-up state – is what contributed the most to the clenching, grinding and “tongue thrusting” damaging my teeth at night. (And actually, despite trying many night guards, I have been unable to figure out how to stop it yet – clenching has damaged my teeth for 8 years total and still damages my teeth nightly as I clench on the night guards. 🙁 )

The resulting structural damage ultimately caused decay in 21 teeth. I developed decay near the gums, likely due to the teeth being pushed side to side creating mini cracks on the sides of the teeth. I also developed something I never knew existed: internal decay, in which the decay ate out big holes on the inside of my teeth but was invisible from the outside (only a hint of brown color showed, like a slight stain on the tooth, so I had no idea anything was wrong). I didn’t understand this at the time but even though I obsessively cleaned my teeth, it’s impossible to prevent decay from nightly structural damage (the tiny cracks on the sides and inside the teeth) by cleaning, and it’s also impossible to clean internal decay because it’s internal so you can’t access it.

By August 2012 the decay had reached the nerve and I was experiencing a lot of pain. I had bouts of dental pain for 3 years as I emailed and called dentists trying to find one I could handle being treated by. I put a TON of effort into finding someone – it is almost unbelievable how hard I worked on finding a dentist and how despite that I got nowhere for so long. Because I was unable to see a dentist for the last 3 years, and I continued to clench and damage my teeth every night even with night guards, the decay worsened to a very serious state by the time I found myself on an airplane landing in Costa Rica.

In the few weeks before the trip, two teeth broke revealing giant caves of internal decay I had not even known was there. I had no idea teeth could DO that if they get clenched on for 8 years. Even the dentist was a bit perplexed by the presence of decay causing the insides of my teeth to turn to soup while remaining practically undetectable from the outside.

Mind you, I had ZERO problems with going to see the dentist regularly for treatment prior to when I got PTSD in 2007. Prior to PTSD, I did not become terrified to the point of feeling like I would be sick or faint if I began making plans to go to a dentist.

And I also NEVER had these bizarre decay issues like huge decay caves INSIDE my teeth before I got PTSD.

Why was it almost impossible for me to get treatment for so long, when it had been no big deal before I got PTSD?

Following is a discussion of #1-3, the ways activation of the nervous system blocked my attempts to get dental treatment.

(click on image and zoom in to see a larger version)

Th threat response as experienced in PTSD can impair decision making, for article How PTSD Can Block Successful, Effective Outcomes in Life Part 2 - Activation of the Nervous SystemActivation of the Nervous System

1. Stuck in Threat Response – Physiological Effects

Being triggered is a fearful state in which terror, stress and anxiety overwhelm the system, producing a wide variety of mental, emotional and physiological effects.

This state can be referred to as:

  • activation
  • hyperarousal of the autonomic nervous system
  • fight, flight, freeze response
  • stuck in the threat response cycle or sequence
  • being triggered

Imagine, if you will, that you are sitting in a bedroom in Staten Island, NY in the sweltering heat of August 2012 and you realize you have a cavity that is now hitting the tooth nerve and is in significant pain. Said pain shows no sign of abating. You think – I have to see a dentist right away! This is an emergency! But then suddenly something about 100 times more scary than the pain in your mouth looms up over the horizon. It’s the fact that the dentist is a dentist and does things that are medical in nature and in fact does some things that are IDENTICAL to things that almost destroyed your body and you still believe yourself to be dying from. Suddenly the tooth pain vanishes and the trigger takes over your entire body. You feel dizzy. You feel faint. You feel like you will throw up. You go online and discover that there are a ton of ways to get rid of dental pain. You do them, the pain goes away, and you then resolve to find a dentist ASAP, just not this exact minute.

I finally went to see an actual dentist for a checkup in June of 2014 (Yup that’s 2 years of dental pain down with one more to go since I wouldn’t let the dentist who did the checkup treat me for various reasons). I had 8 months of Somatic Experiencing therapy under my belt by then, and had spoken with numerous dentists and this one was particularly nice and communicative (in the beginning) so I went.

Due to being triggered, I was unable to sleep for probably half the night before the appointment and when I did sleep it was very fitful and shallow. The level of fear I was in all night and the next morning is almost indescribable. It was all-consuming. I was shivering, had shallow breathing. I was sure I would faint or throw up even before walking through the door to the dentist’s. I felt like crying. It’s very physiological – the body is convinced it’s going to be killed and it’s just reacting with the entire fight flight activation as its response.

This appointment was the first time I had to go face to face with the actual “killers” since I got PTSD. Triggers are like this: Imagine someone tried to murder you and injured you very, very badly. Now you are going to go back to see them and they will have the same weapons and will use them on you again in a similar (but not identical) way, and they have promised that their weapons will not drastically injure you this time. Will you be afraid?

For me personally, the characteristics of experiencing hyperarousal due to being triggered can include:

  • Shortness of breath, shallow breathing
  • Shivering, shaking, buzzing
  • Discomfort in pit of stomach, stomach ache, difficulty digesting food
  • Dizziness, feel like I might faint, brain may be lacking oxygen
  • Nausea, feeling like I may throw up
  • Crying or feeling of wanting to cry
  • Sensations of heart pain, pain in chest, over laboring heart, rapid heartbeat
  • Dissociation
  • Loss of feeling in extremities; numb and tingling extremities
  • Lack of awareness of body state, such as pain or body temperature
  • Tension, stiffness, rigidity throughout body, especially in neck and back of head
  • Unaware of time
  • Stop doing normal routine, forget about life, stop eating
  • Feeling of trying to hold on but being engulfed /overwhelmed
  • Lack of energy, systemic exhaustion as all energy is being sucked out of body into fear state, heaviness, possible adrenal fatigue
  • Increased isolation and lack of ability to reach out if going more into the freeze response
  • Difficulty thinking, confusion
  • Difficulty communicating
  • Emotional numbness overall; leaden, shut down feeling
  • Motor control issues, uncoordinated, off-balance, drop things, bump into things
  • Inability to sleep, low quality sleep, fitful and shallow sleep, nightmares

As you can see, PTSD creates pure terror that manifests in the body in a wide variety of ways.

If you know something will bring up so much terror in your body that you will feel like you will pass out, dissociate, have shallow breathing, rapid heart, dizziness, nausea, and that will make it impossible for you to sleep the entire night before the appointment, you probably will be reluctant to do it and will keep putting it off.

On a conscious level I was committed to getting treatment, but I think that I knew subconsciously that I would have to go through this terror to see a dentist so I would find ways to put it off.

Having intense dental pain on and off for 3 years was like a mosquito bite in comparison to this terror that I would experience at the thought of going to a dentist. This is why it took 2 years from when the decay began hitting the tooth nerves to actually go in for a check-up, and 3 years and 4 months to actually let a dentist touch my teeth to treat the cavities.

2. Stuck in Threat Response – Effects on Perceptions

When I was stuck in the threat response my perception was fixated on danger. I perceived all dentists as dangerous and was absolutely unable to perceive safety. This narrow pinpointed perception exaggerated threat. It seemed like it was unshakable. I think that  this type of perception born out of such an overwhelming and impactful traumatic experience will not change until the threat response cycle reaches resolution in the body a number of times.

I wrote the following about being triggered a couple months ago when I was still struggling to find a dentist:

“It’s so hard to pick a dentist if you are convinced they are all dangerous. I have only recently had a glimpse, in therapy, of a perception that a dentist could actually be safe. That was a short-lived revelation. To me any medical person is truly dangerous. I have to put a lot of energy into proving they are safe (by talking to them a lot) in order to remove this perception even for a moment.

“My perception is extremely narrow. I’m pinpointing where the threat is and it can be the smallest, tiniest thing. It doesn’t matter if it’s small if it has any relationship at all with the previous traumas. My body really truly believes that a tiny thing that resembles the huge thing that damaged me will also damage me.

“It’s a challenge to try to shift this very targeted, narrow, needle-like perception of threat. I will have to create some mantras or some kind of mental/perceptional shifting technique to convince myself this threat at the dentist’s is very small and the trauma was very big. I will need to force my brain to perceive they are NOT the same.

“When the perception is stuck in a specific phase of the threat response, until it moves through the phases and out the other side, it will be seeking out danger and have a narrow, focused perception of only danger. This narrow, focused perception is essential when the body is assessing danger and responding to a threat. In PTSD, this pinpointed focus gets fixated on danger like a machine stuck on one setting. The body doesn’t seem to be able to break out of this “assessing danger” stage of the threat response.

“And this is no joke. I truly see the smaller procedure as equivalent in danger to the larger one and will NOT go anywhere near it until somehow I can argue with myself and convince myself it is actually different. It’s been a real problem. And sometimes arguing just doesn’t work and I simply can’t go through with it.

“To perceive safety my perception needs to relax and gradually become wider and more inclusive of more information, like really be able to take in the information that there are many patients that a dentist has seen who have been happy and completely unharmed. ”

This perceptual narrowing could be causing the following issues:

  • Risk Assessment, Risk-Benefit Analysis. No ability exists anymore to assess amount of risk using logic or rationality – risk is always 100%. An intellectual risk analysis has no effect until threat response within the body resolves enough times to be convincing.
  • Danger Scale. The “Danger Scale” has one setting – 100% Danger. Cannot see 10% or 50% Danger, for example, until after threat response resolves.
  • Inability to Perceive Safety. Sometimes when the intellect is given sufficient information about safety, the body does respond by calming down somewhat. Most of the time, however, it seems the body needs to be led to resolution to be able to fully process this type of information about safety in a complete way.
  • Perception of Big Picture, Inclusive Perception, Wide Perception, Balanced Perception – This kind of perception only really opens up after threat response resolves. Giving information about safety also helps a lot.

Somatic Experiencing techniques gradually shift this because they are designed to lead you through the threat response and out the other side. When at the end, with the body in calm alert, it’s easier to open to perceptions of safety, and even more important, it’s easier to open to an experiential or embodied sense of safety.

Working on getting the body to experience calm alert via somatic therapy was important. Opening the mind to information about safety via cognitive therapy techniques was also helpful to move me forward. What I mean by cognitive techniques are things like – name the evidence for and against your belief, try to see the shades of gray and not in black and white. Also the persistent information gathering was very important – the more I learned about the dental procedures themselves the less activated I became as well. Doing both somatic and cognitive type work is helpful because a thought can stimulate the fight flight activation, but the fight flight activation can also stimulate thoughts. I found working on both ends to work pretty well.

Unfortunately, these processes can take months or years to work through. It was definitely slow going. Probably if I added some kind of body/movement like yoga it might have gone a bit faster.

Also, even when you get out the other side to a feeling of calm alert in the body during a session, it can be a challenge to maintain for any length of time after the session is over – and especially a challenge to maintain at a medical or dental appointment that is triggering.

I actually did fine in June 2014 at that first checkup; amazingly, I was able to calm myself down on the car ride to the dentist and during the appointment. I could not actually get treatment from this dentist though because there was a breakdown in communication shortly after this appointment.

By combining somatic and cognitive approaches, I was finally calm enough to actually go through with treatment last month (Dec. 2015).

It’s not 100% solved as I still fear dentists in general to some degree. I still don’t have a local dentist and I still need more dental work done, but at least I have had an experience of feeling trust in, and not being harmed by, a dentist. This should make it easier to find someone in the United States to go to.

3. Stuck in Threat Response – Problems With Being Able to Process Information

To make choices that lead to successful solutions to problems requires an ability to organize information in the mind. It’s necessary to balance many factors as to how they weigh, decide which are the biggest priorities and which don’t matter. Then compare two or three big piles of information (all properly weighted and prioritized within each pile) and decide – Yes! THAT pile is the best of all!

I’ve experienced a lot of mental “scatteredness” and chaos as a result of the body being overwhelmed with stress responses so frequently. Sometimes my mind is like a kaleidoscope, but one that’s been broken and shattered apart – images floating in and out in a random way. This is usually when I’m very stressed and my mind just can’t cope with the amount of stress it’s under. This brain scatter tendency makes it difficult to have organized thoughts that would lead to any particular decision.

Because dentists are activating for me, I always went into the threat response in relation to them. If you are being threatened by something there is no time for making complex intellectual analyses of things. There is very little mental organization – prioritization, categorization, comparison etc. – because the animal brain is being used. And Animal Brain doesn’t do categorization.

I think the body needs to experience safety and calm and security for a while in relation to a certain “threat” to allow the brain to understand that it’s OK to stop assessing for danger and know it is time to organize information again. Something about the dentists in Mexico and Costa Rica really helped me experience a deeper state of calm – I guess I feel a connection and appreciation for those cultures and it felt very comforting to connect with people there. So once I began focusing on Mexico and Costa Rica, my activation lowered and I was able to think things through a lot more effectively.

***

Activation of the nervous system was a huge impediment to getting the dental care I needed. It may seem like I should have “just calmed down already”, but it wasn’t that simple. My persistence with getting information, working on the issue in somatic experiencing therapy, and trying to shift my thinking helped me finally get the dental care I needed.

Got to PTSD Challenges – Perceiving and Experiencing Goodness (Part 3 of the series)

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Heidi Hanson is an artist and writer in Asheville, North Carolina currently working on an illustrated book chronicling her journey healing from Post Traumatic Stress Disorder.