Tag Archives: Suicide

WAS MARILYN MONROE MURDERED?

A1No movie star lived on after death like Marilyn Monroe. She was far more than a bleached-blonde bombshell with a voluptuous frame and a lusty voice—she intuitively knew her craft. Born in poverty as Norma Jean Mortenson (aka Baker) to a mentally unstable mother, Marilyn Monroe rose to Hollywood glamor, fame, and idolization beyond what few ever reached. Tragically, by the time she died at age thirty-six, her performing career had spiraled into the same abyss her personal relationships and head space were already in.

MM10Marilyn Monroe was found dead in her Beverly Hills bed at 3 a.m. on Sunday, August 5, 1962. The scene suggested nothing suspicious—no foul play, that is—and the toxicology results from her autopsy proved she’d succumbed to a lethal dose of prescription drugs. The coroner ruled her death as “probable suicide” but, like the deaths of other uber-celebrities, many mumbled murder. Monroe’s death was reinvestigated in 1992 by the Los Angeles District Attorney who came to the same conclusion—“probable suicide”.

In today’s coroner-speak, “probable” is not in the official vocabulary. Neither is “possibly”. Everywhere in the civilized world, coroners are mandated by legislation to rule a manner of death as being in one of five categories: natural, homicide, accidental, suicide, or undetermined. Now, fifty-four years later, an impartial look at Monroe’s case facts indicate her manner of death should not be ruled as a suicide.

But was Marilyn Munroe actually murdered?

A7On the day of her death, Marilyn Monroe was in the company of many people, none of who reported any immediately implied threat or perceived action from Monroe that suggested an imminent danger of suicide, nor any behavior that was outside of her already troubled mental state of manic highs and depressive lows. She’d a history of emotional instability that, today, would likely be classified as Bipolar II Disorder and she was under the continual care of a general physician and a psychiatrist. Monroe was no stranger to prescription pharmaceuticals, specifically anti-depressants and sleeping pills, but she was a relatively light alcohol drinker.

Marilyn Monroe had a difficult year in 1961. She worked very little due to health issues. Besides her emotional imbalance and substance dependency, she underwent surgery for endometriosis (uterus ailment) and a cholecystectomy (gall bladder removal), then suffered a painful attack of sinusitis. Her stress level soared from a lawsuit with 20th Century Fox where they sued Monroe for breach of contract—her erratic behavior led to delays in filming, disputes with cast and crew, then finally a stop of production.

A14On Saturday morning, August 4, Marilyn Monroe met with her official photographer and discussed an upcoming Playboy deal, then kept a massage appointment, a meeting with her publicist, talked with friends on the phone, and signed for deliveries for her house renovation. She was visited by her psychiatrist, Dr. Ralph Greenson, in the late afternoon for a scheduled therapy session. Greenson left around 7 p.m. and reported no alarming behavior, however he ensured that Monroe’s housekeeper, Eunice Murray, would be staying overnight.

Marilyn Monroe retired to her bedroom around 8 p.m. The last person to have contact with Monroe was actor Peter Lawford who invited her to a Hollywood party. He reported that in their phone conversation Monroe sounded tired—sleepy—as under the influence of drugs. After their call, Lawford became alarmed and phoned back to the house where he got Murray. She assured him everything was fine with Monroe.

A22At 3 a.m. on Sunday morning, Eunice Murray woke and noticed light coming from under Monroe’s bedroom door. Sensing something not right, Murray tapped on the door. There was no response so she tried the handle and found it locked, which she stated was unusual.

Now alarmed, Murray phoned Dr. Greenson who instructed her to go outside and look through the bedroom window. She did and observed Marilyn Monroe lying facedown on the bed, covered in a sheet, and clutching a telephone receiver in her right hand.

Greenson arrived at approximately 3:20 a.m., broke the window with a fireplace poker, and climbed in. Immediately he could tell Monroe had been dead for some time and it was pointless to call an ambulance or attempt resuscitation. Greenson phoned Monroe’s physician, Dr. Hyman Engelberg, who arrived at around 3:50 a.m. Engelberg examined Monroe by removing the phone receiver and rolling her over, officially pronouncing death. At 4:25 a.m. they notified the LAPD.

MM2The attending detective agreed with the two doctors that there was nothing to indicate foul play and the death was most likely a drug overdose. The detective photographed the scene and recorded the “pill count” of the pharmaceutical vials on Monroe’s nightstand. Dr. Engelberg noted a vial containing twenty-five capsules of the barbiturate Nembutal that he’d prescribed two days earlier was empty. Vials with other prescriptions appeared in order including one containing the sleeping sedative Chloral Hydrate.

Marilyn Monroe was autopsied on the morning of August 6 by pathologist Dr. Thomas Noguchi who would later be known as “Coroner To The Stars” for his many postmortem exams on celebrities. His original autopsy report is on the public record and can be downloaded. Click Here.

A20Noguchi is very clear in his report and many subsequent interviews that he found no evidence of physical trauma—specifically needle marks—on Monroe’s body. Based on his observations and those of Drs. Greenson and Engelberg regarding Monroe’s rigor, livor, algor, and palor mortis conditions, he felt reasonable to estimate her time of death between 8 and no later than 10 p.m. the previous night. Noguchi found no natural cause of death and waited for the toxicology report before forming his final conclusions.

The tox screen was done by the LA County Coroner’s laboratory and released on August 13. The results concluded  Monroe’s blood contained 4.5 milligrams (percent) of Nembutal and 8.0 milligrams (percent) of Chloral Hydrate. Her liver contained 13.0 milligrams (percent) of Pentobarbital. Blood ethanol (alcohol) was absent.

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Noguchi was satisfied the combination of Nembutal and Chloral Hydrate levels in Monroe was sufficiently high to cause her death through respiratory and central nervous system failure and he knew the Pentobarbital stored in her liver was simply indicative of someone who had long exposure to barbiturates and developed a “tolerance”. Noguchi certified the cause as “acute barbiturate poisoning due to ingestion of overdose” but he was reluctant to rule the classification as “suicide”. Though Noguchi was certain no evidence existed to suggest the death was an intentional homicide, he was uncomfortable with there being no clear evidence that Monroe intended to take her own life.

There were no immediate threats, no suicide note, no warning behavior, and not all the Chloral Hydrate pills were consumed, not like the Nembutal.

A23It might be an accidental OD, Noguchi thought, and he was troubled by the fact Monroe had been prescribed the amounts of Nembutal and Chloral Hydrate at the same time—her physician had to have known they’d be lethal if mixed a large quantity.

Noguchi was under pressure—political pressure, if you will—from the elected Chief Coroner of Los Angeles County to shut down media speculation that there might be more to Monroe’s death than a sad case of a despondent star intentionally extinguishing her light. The Chief and Noguchi reached a temporary compromise that they’d say Monroe’s death was a “probable” suicide.

A21Noguchi didn’t go so far as to insinuate negligence by Monroe’s caregivers might be the smoking gun, yet he requested a “psychological autopsy” to investigate Marilyn Monroe’s mental state leading to her death. Without clear evidence of an intentional suicide, the pattern of Monroe’s behavior was crucial in corroborating a suicide rule.

This statement was issued by LA County Chief Coroner Theodore J. Curphey. It’s an addendum to Noguchi’s final autopsy report:

“Following is the summary report by the Psychiatric Investigative Team which assisted me in collecting information in this case. The team was headed by Robert Litman, M.D., Norman Farberow. Ph. D., and Norman Tabachnick, M.D.:

‘Marilyn Monroe died on the night of August 4th or the early morning of August 5th, 1962. Examination by the toxicology laboratory indicates that death was due to a self-administered overdose of sedative drugs. We have been asked, as consultants, to examine the life situation of the deceased and to give an opinion of the intent of Miss Monroe when she ingested the sedative drugs which caused her death. From the data obtained, the following points are the most important and relevant:
Miss Monroe suffered from psychiatric disturbance for a long time. She experienced severe fears and frequent depressions. Mood changes were abrupt and unpredictable. Among symptoms of disorganization, sleep disturbance was prominent, for which she had been taking sedative drugs for many years. She was thus familiar with and experienced in the use of sedative drugs and well aware of their dangers.
Recently, one of the main objectives of her psychiatric treatment had been the reduction of her intake of drugs. This has been partly successful during the last two months. She was reported to be following doctor’s orders in her use of drugs; and the amount of drugs found in her home at the time of her death was not unusual.
In our investigation, we have learned that Miss Monroe had often expressed wishes to give up, to withdraw, and even to die. On more than one occasion in the past, when disappointed and depressed, she made a suicide attempt using sedative drugs. On these occasions, she had called for help and had been rescued.
From the information collected about the events on the evening of August 4th, it is our opinion that the same pattern was repeated except for the rescue. It has been our practice with similar information collected in other cases in the past to recommend a certification for such deaths as a probable suicide.
Additional clues for suicide provided by the physical evidence are:
(1) the high level of barbiturates and chloral hydrate in the blood, which, with other evidence from the autopsy, indicate the probable ingestion of a large amount of drugs in a short period of time;
(2) the completely empty bottle of Nembutal, the prescription for which was filled the day before the ingestion of drugs; and
(3) the locked door which was unusual.’

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Now that the final toxicological report and that of the psychiatric consultants have been received and considered, it is my conclusion that the death of Marilyn Monroe was caused by a self-administered overdose of sedative drugs and that the mode of death is probable suicide.

– Theodore J. Curphey, M.D. Chief Medical Examiner-Coroner for the County of Los Angeles, August 13, 1962.”

There’s that word “probable” again.

A24In my time as a police officer and coroner, I’ve attended many drug overdose deaths. Some were clearly suicides, backed-up by threats and notes. Some were accidents by misadventure, usually mixed with alcohol. And some were undetermined—not shown to have a definite intent by the decedent to take their own life.

I’d say some of the undetermined deaths were probably suicides—if I could say it. But a coroner doesn’t have the legal option to say “probably”. There’s a long-held  court ruling called the Beckon Test that states a death can only be classified as a suicide if it can be determined that the individual knew the consequences of their actions would end in death and intentionally carried them out. There is a high standard of proof required for a finding of suicide as the ruling states:

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“In most legal cases the test to be satisfied is a balance of probability. But a determination of suicide can only be made where there is clear and convincing evidence. There is to be a presumption against suicide at the outset and one must be certain beyond a high degree of probability that the death was a suicide. Where one cannot be absolutely certain, the death must be classified as undetermined.”

Based on my death investigation experience, there are three points about Marilyn Monroe’s suicide ruling that bother me.

First, in all the polypharmacy overdoses I’ve seen where suicide was obvious, the deceased downed the whole darned stash.

A30In Monroe’s case, Dr. Engelberg prescribed her 50 caps of 500 mg Chloral Hydrate on July 31 as a refill for a previous Chloral Hydrate order on July 25. She was taking 10 per day. At her death scene, there were still 10 Chloral Hydrate caps left in her bedside vial. 40 were gone and, at a rate of 10 per day from July 31 till August 4, the pill count is right in order.

In the toxicology world, the effects of drugs are rated on a range scale of Therapeutic, Toxic, and Lethal. In the Lethal range, the substance is given a value called LD50 where it’s expected that 50 percent of the population would be expected to die from the drug’s effect at a certain point based upon the drug’s milligram blood content per the kilogram weight of the person.

MM17

Marilyn Monroe’s autopsy report recorded her weight at 117 pounds or 53.2 kilograms. The Chloral Hydrate level in her blood was determined to be 8.0 milligrams (percent) based on her weight or 80 parts per million (ppm). Looking at my toxicology scale from my coroner days, I see that Chloral Hydrate has a Therapeutic range to 30 ppm and an LD50 value at 100 ppm, so Monroe was 20% under the Chloral Hydrate lethal bar.

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Looking at her barbiturate blood content from the Nembutal, it’s recorded to be 4.5 mg (percent) or 45 ppm. My chart says the barbiturate Pentobarbital, which is what’s in Nembutal, has a Therapeutic range to 12 ppm and an LD50 at 40 ppm. So Monroe was only 12.5 % over the average barbiturate lethal threshold, not taking into account that she was a very “tolerant” user.

However, the combination of Chloral Hydrate and Nembutal was deadly and this had to be known by Dr. Engelberg when he ordered Monroe’s prescription. This brings me to my second point.

A29A physician has a professional duty of care to their patient, especially when prescribing medication to a person with Monroe’s mental history. I find it irresponsible, actually negligent, that Dr. Engelberg failed to ensure Monroe no longer had Chloral Hydrate in her possession when he issued her a prescription for 25, 1500 mg caps of Nembutal four days later, knowing her supply of Chloral Hydrate wasn’t exhausted based on her prescribed consumption.

My third point deals with the “rescue” issue.

This very much applies to the Beckon Test. Intentional overdoses as attention-getting devices are common and always rely on the person’s backup plan that someone will intervene. This was part of Monroe’s previous overdose episodes as noted in the “psychological autopsy” report. And they referenced Monroe’s locked door as being unusual.

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I think the locked door issue is completely negated by the fact that Monroe was found with her telephone receiver in hand. This was stated by Eunice Murray, Dr. Greenson, Dr. Engelberg, and corroborated by the investigating detective who verified they reported this to him and suggested she was phoning for rescue—which was her pattern—but was overcome.

If I were the coroner ruling on the manner of Marilyn Monroe’s death, I’d be legally bound to consider how the facts apply to the parameter of categories.

MM1A natural cause determination is completely eliminated by the autopsy and toxicology evidence. Monroe clearly died as the result of a drug overdose.

Despite kooky conspiracy theories that Bobby Kennedy snuck in and injected Marilyn Monroe to cover up her alleged affair with President Jack or that mobsters Jimmy Hoffa and Sam Giancana knocked her off to keep from ratting them out, no sensible person can make a case that Monroe was intentionally murdered. But a homicide ruling doesn’t just apply to murder. The definition of homicide is “the killing of a human being due to the act or omission of another”.

I believe Dr. Engelberg was professionally negligent in his duty of care to Marilyn Monroe. He had to know—certainly ought to have known—that he was treating an emotionally unstable patient with a history of suicide attempts through polypharmacy. By giving Monroe a potentially lethal amount of barbiturates and not ensuring her chloral hydrate was gone, Engelberg effectively signed her death warrant.

However negligent Engelberg may have been, though, my suspicion falls far short of the burden necessary for establishing a homicide conclusion.

A3That Monroe accidently died from a self-administered overdose is a distinct probability but, again, the Coroners Act and court precedents won’t allow me the liberty to rely on probabilities regarding suicide. I have to come to a clear conclusion based on facts.

Setting aside the locked door and phone receiver in hand—these two negate each other—I must defer to one other glaring fact. There were still 10 caps of Chloral Hydrate left in her pill vial. Marilyn Monroe was a very experienced and tolerant prescription pill user. She knew exactly what she was taking, what their effects were, and she failed to down her whole darned stash which is always proof of a polypharmacy overdose suicide.

A4So deferring to the Beckon Test, I have to presume against Marilyn Monroe’s suicide from the outset and must be satisfied beyond a high degree of probability that her death was a suicide—I must be certain—and I can’t—because no clear evidence exists that Monroe’s death was an intentional act to end her own life. It may well have been an unfortunate, unrescued accident.

Therefore, I find Marilyn Monroe’s manner of death as Undetermined.

THE CREEPY CASE OF THE FLOATING FEET

F17Since 2007, sixteen shoes containing severed human feet have washed up on the shores near the mouth of British Columbia’s Fraser River which supplies freshwater to the tidal Pacific Ocean at the Canadian Strait of Georgia and Washington State’s Puget Sound. Curiously, the majority of the found flotsam-footwear are large, men’s runners holding a disarticulated right foot.

The story quickly gained international attention and refuses to go away. Just last month (February 2016) two more New Balance sneakers with their feet ran aground at Botanical Beach on Vancouver Island. Public speculation has stepped-up—not surprisingly given that, historically, the Pacific Northwest has the largest number of prolific serial killers per capita in the world.

F19The Northwest Noir is home to Ted Bundy—the College Dorm Slayer, Gary Ridgway—the Green River Killer, Robert Pickton—the notorious Pig Farmer, Clifford Olson—the Beast of BC, Harvey Carignan—the Want-Ad Murderer, Robert Silveria—the Box-Car Killer, Gilbert Jordan—the Boozing Barber, and at least one currently active serial killer who’s terrorizing the Highway of Tears.

Could it be there’s another homicidal maniac on the loose—one with a fiendish foot-fetish? Someone who’s cutting off his victim’s feet and chucking them in the ocean? Possibly the Reebok Ripper at work?

Or is it more likely just as the authorities say—all the feet belong to suicide victims—jumpers from any one of more than thirty-two bridges in the Vancouver area?

F18Looking at the case facts that are readily available from the police and coroner websites, ten of the feet have been identified through DNA to individuals who were suspected of taking their own life. Six of the shoes belonged to three different people and eleven of the sixteen feet detached themselves from the right leg at the ankle.

The police and coroner departments are clear there are no striation marks on the bones to suggest any mechanical manipulation by way of severing the feet with a knife, ax, or saw. The forensic specialists assure the appendages appear entirely consistent with disarticulating, or pulling away, from a body that’s been submerged in water and undergoing a natural decomposition process that’s slowed due to the cold waters of the Fraser and the Pacific.

Nothing to see here, folks, they say.

Well, hang on a minute. I’m a curious old cop and coroner. This flotsam-foot thing is something you don’t see every day. Why is this foot phenomenon unique to the region? Why did it recently start to occur? And why are so many feet from the right? I decided to tread into this with an open mind—and the help of acquaintances from my forensic days.

Feet Map

 Foot Distribution Map

Dr. Gail Anderson is the Professor of Entomology at Vancouver’s Simon Fraser University. She pioneered a project to study decomposing pig carcasses 300 feet under the nearby Pacific and monitors the process via remote cameras to her laptop. She’s found that an entire adult hog can be left skeletonized within three weeks—being devoured by crabs, shrimp, and sea worms—as well as breaking down through a microbial process.

F20But, Gail says, getting at meat wrapped up in a rubber running shoe is a whole different challenge. And floating upside down on the ocean’s surface would prevent seabirds like gulls from attacking the foot from above.

Bill Inkster is a former dentist who now manages the identification unit for the B.C. Coroners Service. He takes the disarticulation and floatation process a step further.

They’re not severed, they’re disarticulated,” Bill explains. “As the body decomposes, the feet are separated from the rest of the body. Time was, the feet would have stayed underwater with the rest of the body. But Nike Air, and all the other high-buoyancy sneakers that followed, changed that with designs that featured little air pockets. These floating feet are enclosed in their own PFD’s (personal floatation devices) and just bob to the surface once freed.”

F7A little internet research into running shoe technology confirms that by 2005 the footwear industry profoundly changed materials in their products. Where the lightweight designs were first developed for the high-priced athletic market, the chemical advancement of switching from polyurethane (PU) mid-soles to ethylene-vinyl acetate (EVA) closed-cell blowing agents not only reduced the weight but drastically reduced manufacturing and shipping costs.

This allowed third-world makers of Nike, Adidas, New Balance, Reebok, Brooks, and other major sporting-shoe players to supply discount retailers like Walmart with cheap, yet decent runners.

F21Richard Thompson is a physical oceanographer with Vancouver Island’s Institute of Ocean Sciences. He shed light on why this was happening in the Fraser River region. Thompson explained the Fraser is a heavily-mudded waterway that carries silt from the province’s interior and deposits it in a vast delta extending miles out into the Pacific. The ever expanding bridge construction along the lower Fraser has created a series of dams due to their pilings that require continual dredging to maintain the shipping lanes.

It follows that victims who jump from one bridge may be carried along the bottom—pushed down by the weight of the silt—and become lodged in another piling dam. Dredging then shakes the body which has now decomposed to the point where the feet easily detach at the ankle and the high-buoyancy shoes sneak themselves to the surface where they drift on out to sea.

StraitofGeorgia_30_07_13Once the shoe-encased foot meets the tidal water, it enters what Thompson describes as a giant, endless spin cycle created by the freshwater outflow, the incoming currents, twice-daily tide action and, of course, the wind. The combination of these recirculation actions results in the wide—seemingly random—distribution of where the floating feet eventually beach themselves.

Once I objectively listened to the experts explaining the science behind decomposition, dredging, disarticulation and distribution of the sixteen severed feet, it made sense to me—except for one troubling fact.

Why are nearly three-quarters of the recovered runner-wraps from the right?

F16I got the answer from Professor Curtis Ebbesmeyer. He’s known as the rubber-duck man and the co-author of the fascinating book Flotsametrics and the Floating World: How One Man’s Obsession with Runaway Sneakers and Rubber Ducks Revolutionized Ocean Science. Ebbesmeyer spent his lifetime studying ocean currents, including the aftermath of a shipping accident involving thousands of Nike runners being discharged into the Pacific during a storm. The resulting locations where the shoes hit land was a landmark breakthrough in a better understanding of ocean drift.

So if anyone knows how a sneaker sneaks about in the water, it’s Professor Ebbesmeyer.

He says that left and right shoes behave differently due to their curvature—lefts tend to drift in a clockwise pattern and rights will turn counter-clockwise. This contributes to a distribution pattern where the rights went to the closest land and the lefts possibly headed for the open ocean or perhaps to more deserted beaches.

F23Ebbesmeyer also pointed out an interesting and apparently verified fact—whether or not it bears weight on the floating feet. With ninety percent of the population being right-handed, most people tend to tie their right shoe tighter than the left and most people’s right foot is slightly larger than their left.

With maybe more slack in a left shoe, it’s possible more of the disarticulated left flesh and bone matter would fall out of its runner, then its shoe would go to a beach empty-handed and be ignored.

There’s one last factor in these recently-found, sixteen feet and that’s the Vicious Cycle effect. The floating-foot story is so widely known throughout the Pacific Northwest that by now nobody walks by a shoe on the shoreline without picking it up and checking inside.

Stefan Fonseca, my ex-colleague with the British Columbia Coroners Service, puts it well. “People will actually wade out to go look at a shoe. It’s creepy, but I guess that’s the fascination.”

POST-TRAUMATIC STRESS DISORDER IS A NASTY BITCH

PTSD1CLast month another police officer took his own life after a lengthy battle with Post-Traumatic Stress Disorder. I’ve handled lots of suicide cases over the years, but this one hit close to home –  I knew Corporal Ken Barker. We’d worked together prior to the events which brought on Ken’s PTSD.

Ken was one of the best-liked, most approachable Royal Canadian Mounted Police members I ever met. He certainly wasn’t the stereotype who’d you think would suffer a PTSD mental illness. Wait – there’s no such thing as a stereotype PTSD sufferer and, yes, PTSD is a mental illness.

PTSD2There’s a higher awareness of PTSD today than back in the 1990’s when I was posted with Ken. Personally, I’ve experienced events as a cop and a coroner which should have brought on PTSD in me, but didn’t. I was very aware of the disorder and knew to recognize the signs. Also, I wasn’t scared to talk about PTSD and I think that’s the best form of prevention and treatment.

Today, I watch with caution as my son’s career in the Canadian Army unfolds and the suicide deaths of soldiers pile up into a national crisis. There are more Canadian soldiers who died of PTSD related suicides than were killed in ten years of active combat in Afghanistan.

So who is this Post-Traumatic Stress Disorder bitch?

Clinically, PTSD is classified as a trauma and stress related disorder stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV. 

It’s simply summarized as:

1. Exposure to a traumatic event.

This includes both physical harm, or the risk of serious injury or death to self or others, and a response to the event that involved intense fear, horror, or helplessness. The traumatic event should be of a type that would cause significant symptoms of distress in almost anyone, and that the event was outside the range of usual human experience.

2. Persistent re-experiencing.

PTSD3One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any reminder of the traumatic event(s).

A. Persistent avoidance and emotional numbing.

PTSD4This involves a sufficient level of avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s) and avoidance of behaviours, places, or people that might lead to distressing memories as well as the disturbing memories, dreams, flashbacks, and intense psychological or physiological distress. It includes the inability to recall major parts of the trauma(s), or decreased involvement in significant life activities as well as a decreased capacity (down to complete inability) to feel certain feelings, and an expectation that one’s future will be somehow constrained in ways not normal to other people.

B. Persistent symptoms of increased arousal not present before.

These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hyper-vigilance. Additional symptoms include irritability, angry outbursts, increased startle response, and concentration or sleep problems.

C. Duration of symptoms for more than 1 month.

If all other criteria are present but 30 days have not elapsed, the individual is diagnosed with acute stress disorder. Anything longer would be considered chronic.

D. Significant impairment.

The symptoms reported must lead to clinically significant distress or impairment of major domains of life activity, such as social relations, occupational activities, or other important areas of functioning.

PTSD5Although most people with PTSD will develop symptoms within three months of the traumatic event, some people don’t notice any symptoms until years after. A major increase in stress, or exposure to a reminder of the trauma, can trigger symptoms to appear months or years later.

Who’s susceptible to PTSD?

Generally, at highest risk are those who experience traumatic events more frequently and for longer exposure. Combat personnel (soldiers, sailors, and airmen) are at the forefront, followed by emergency responders like police, firefighters, and medical professionals.

PTSD6There are other risk groups. Survivors of violent acts like sexual assault and attempted murder commonly experience post-traumatic stress. This extends to accident victims and witnesses of violent incidents.

What’s the medical reason for PTSD?

Three areas of the brain which control and administer PTSD have been identified. They’re the prefrontal cortex, the amygdala, and the medial prefrontal cortex.

Traumatic events cause an over-reactive adrenaline response, which creates deep neurological patterns in the brain.

PTSD7These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations. During traumatic experiences, the high levels of stress hormones secreted suppressed hypothalamic activity that may be a major factor toward the development of PTSD.

These biochemical changes in the brain and body differ from other psychiatric disorders such as major depression and bi-polar. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test than individuals diagnosed with clinical depressions.

PTSD8In addition, most people with PTSD also show a low secretion of cortisol and high secretion of catecholamines in urine with a norepinephrine / cortisol ratio consequently higher than comparable non-diagnosed individuals. This contrasts to the normal fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to stress.

Getting clinical – brain catecholamine levels are high and corticotropin concentrations are high. Together, these create an abnormality in the hypothalamic-pituitary-adrenal (HPA) axis.

The HPA axis is responsible for coordinating the hormonal response to stress. Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptors.

Translating this reaction to human conditions gives a patho-physiological explanation for PTSD by a maladaptive learning pathway to fear response through a hyper-sensitive, hyper-reactive, and hyper-responsive HPA axis.

PTSD9Low cortisol levels may also predispose individuals to PTSD and studies indicate that people that suffer from PTSD have chronically low levels of serotonin, which contributes to the commonly associated behavioral symptoms such as anxiety, ruminations, irritability, aggression, suicidality, and impulsivity. Serotonin also contributes to the stabilization of glucocorticoid production.

Insufficient dopamine levels in patients with PTSD can contribute to anhedonia, apathy, impaired attention and moto-skill defects. Increased levels of dopamine leads to psychosis, agitation, and restlessness.

Why are flashbacks so common in PTSD sufferers?

In a traumatic experience, the mind processes and stores the memory differently than it stores regular experiences.

Sensory information about the trauma – smells, sights, sounds, tastes, and the feel of things – is given high priority in the mind and is remembered as something threatening.

PTSD10Once this happens, whenever the sufferer is faced with a touch, a taste, a smell, a feel, or a sight that reminds them of the trauma, the memory (and the feeling of threat) comes back up and vivid memories or flashbacks about the trauma occur.

Getting all clinical again, a hyper-responsiveness in norepinephrine receptors in the prefrontal cortex is connected to the flashbacks. A decrease in other norepinephrine functions prevents the memory mechanisms in the brain from processing that the experience and emotions the person is experiencing during a flashback are not associated with the current environment. In other words, it takes them right back to the trauma time and it seems very, very real.

What can be done about it?

Many sufferers feel guilt or shame around PTSD because they’re often told they should just ‘suck-it-up’ to get over difficult experiences. Others feel embarrassed in talking with others. Some feel like it’s somehow their own fault.

Here’s the common treatments.

Counselling

PTSD11Cognitive-behavioural therapy (CBT) is effective. Very effective. CBT teaches how thoughts, feelings, and behaviours work together and how to deal with problems and stress. Relaxation techniques, such as meditation and hypnosis are used. This exposure therapy helps the sufferer talk about their experience and helps reduce avoidance.

In my experience, this stuff works. But the sufferer has to know the disorder before accepting the treatment.

Medication

A number of medications can prevent PTSD or reducing its incidence, especially when given in close proximity to a traumatic event. These include:

SSRIs (Selective Serotonin Reuptake Inhibitors)

SSRIs are considered to be a first-line drug treatment. They include citalopram, escitalopram, fluoxetine, paroxetine, and sertraline.

Tricyclic antidepressants 

Amitriptyline benefits distress and avoidance symptoms. Imipramine is effective for intrusive symptoms.

Alpha-adrenergic antagonists

In a study of combat veterans, prazosin shows substantial benefit in relieving or reducing nightmares. Clonidine helps with startle, hyper-arousal, and general autonomic hyper-excitability.

Anti-convulsants, mood stabilizers, and anti-aggression agents

PTSD12Carbamazepine reduces arousal symptoms involving noxious affect, as well as mood or aggression factors. Topiramate is effective in achieving major reductions in flashbacks and nightmares. Zolpidem proves useful in treating sleep disturbances. Lamotrigine reduces re-experiencing symptoms as well as avoidance and emotional numbing. Valproic acid reduces symptoms of irritability, aggression, impulsiveness, and reducing flashbacks. Similarly, lithium carbide works well to control mood and aggressions (but not anxiety) symptoms. Buspirone has an effect similar to lithium, with the additional benefit of reducing hyper-arousal symptoms.

Antipsychotics

Risperidone is the main medication for dissociation, mood issues, and aggression issues while cyproheptadine, a serotonin antagonist, helps with sleep disorders and nightmares.

Atypical antidepressants

Nefazodone works with sleep disturbance symptoms, secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone reduces or eliminates problems with anger, anxiety, and disturbed sleep.

Beta Blockers 

Propranolol has demonstrated possibilities in reducing hyper-arousal symptoms, including sleep disturbances – but the jury’s out.

Benzodiazepines

PTSD13These drugs are not recommended by clinical guidelines for the treatment of PTSD due to a lack of evidence of benefit. Nevertheless, some doctors use benzodiazepines with caution for short-term anxiety relief of hyper-arousal and sleep disturbance, and believe that the use of benzodiazepines is proper for acute stress, as this group of drugs promotes dissociation and ulterior revivals. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder.

Additionally, benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there’s some evidence that benzodiazepines contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a benzodiazepine dependence and withdrawal syndrome. Additionally, individuals with PTSD are at an increased risk of abusing benzodiazepines.

Glucocorticoids

High-dose corticosterone administration was recently found to reduce ‘PTSD-like’ behaviours in a rat models. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.

That’s great lab-rat stuff which I’m not going to try myself. However, the next stuff is something that I think ‘where’s there’s smoke – there’s fire”.

Cannabis

PTSD14There’s a study underway between a University and one of Canada’s largest producers of medicinal cannabis, suggesting that the active ingredients in marihuana – tetrahydrocannabinol and cannabinoids – may be very effective in reducing PTSD symptoms. Many PTSD sufferers self-medicate through black-market cannabis and swear by it. It’ll be interesting to see this clinical study’s results.

Support groups

PTSD15Support groups definitely help. Here people share experiences and learn from others. Connecting with people who understand what the sufferer goes through is probably the most effective form of treatment and this leads to identifying other forms of treatment such as medication and psychological intervention.

PTSD awareness is much greater in the twenty-first century, but the disorder is long known and buried. Historically they called it battle fatigue, shell-shock, and the thousand-yard stare. Soldiers were actually shot by their own command for perceived cowardness. I’ll bet the majority weren’t afraid – they were just suffering a nasty bitch of a disorder.

PTSD16On a personal note – looking back – I believe my dad suffered from PTSD. He was a gunner on a RCAF Lancaster bomber during World War II; the veteran of 113 operational runs. If that doesn’t do something to the psyche, I don’t know what would. I remember him sitting for long periods… on a big flat rock in our yard… in that thousand-yard stare… until his cigarette… burned down to his fingers… and snapped him back to reality.

After nearly six decades of life experience and being exposed to more traumatic life & death exposures than I can count, I can’t say that I’ve experienced PTSD.

Grief, yes. Compassion; in spades. Fear – I’ve been absolutely shit-scared, bewildered, and abhorred; being down on my belly under gunfire and questioning the existence and authority of Infinite Intelligence. But I’ve never experienced guilt and I don’t know much about it. Guilt seems like an evil, degenitive force who’s metaphysical purpose is to destruct. A lot more needs to be known about the psychological effects of guilt.

I think guilt is the nasty bitch in PTSD and I think that guilt walks hand-in-hand with shame.

Post-Traumatic Stress Disorder is a complex mix of psychological, physiological, and metaphysical workings and it’s nothing to be guilty about or ashamed of. It’s a naturally-occurring, mental illness. With proper support and effective treatment, PTSD sufferers can fully recover.

Remember, PTSD isn’t about what’s wrong. It’s about what’s happened.

Please leave your comments, ask questions, or tell about your experiences. It’s okay to talk about PTSD and raising awareness is the best form of treatment… and prevention.