Post Traumatic Stress Disorder (PTSD): An Overview

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Post Traumatic Stress Disorder (PTSD): An Overview




Guest:  Dr. John Freedy – Family Medicine

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m talking, today, with Dr. John Freedy, Assistant Professor of Family Medicine here at the Medical University of South Carolina.  Dr. Freedy, you’re an expert in the area of post traumatic stress disorder.  That’s a term that gets used very loosely and casually, I think maybe sometimes sloppily.  But, really, when you think about what is true PTSD, what are the causes of that disorder?


Dr. John Freedy:  Well, post traumatic stress disorder is an anxiety disorder and it has certain symptoms, and the symptoms have to be associated with difficulty in functioning, functioning in relationships, at work, at school.  And the causes have to do, both, with environmental factors and, we think, with the person themselves.  The environmental factors are particular types of traumatic events.  They could be something such as combat, sexual assault, even an auto accident.  And it tends to be events that the person perceives that they could be seriously injured or killed, or they are actually seriously injured, or somebody around them is killed.


The part that has to do with the person is, we think, that there may be certain vulnerabilities that people have that they’re more likely to develop an anxiety disorder, or a depressive disorder, in general.  And if they have an event, it may be that certain people, because of their genetics, are more likely to produce PTSD symptoms than another person with a similar type of event.


Dr. Linda Austin:  Now, I’ve heard people talk about events that might not be traumatic to anyone else, for example, my boss yells at me, or someone pushes my shoulder, shoves me, let’s say.  And to that person, it feels very traumatic and they may ascribe a lot of anxiety.  But, in your mind, would that meet the true diagnostic criteria for post traumatic stress disorder?


Dr. John Freedy:  Probably not.  But, it’s sort of like an iceberg.  There may be more than meets the eye.  In other words, say the person is yelled at or pushed from behind, it could be that the person, at an earlier time in their life, was physically assaulted in a very severe way, or was sexually assaulted, and there was something about that more recent event that served as a reminder, and if you didn’t know about the background, you would say they’re overreacting.


Dr. Linda Austin:  So, let’s imagine that there is a truly traumatic event, such as an auto accident, or a sexual assault, what is the time course in which you usually see symptoms arise following that?


Dr. John Freedy:  Almost everybody, after an extremely intense event like that, will be symptomatic.  Now, when I say symptomatic, they’ll have difficulty sleeping.  They’ll feel anxious.  They’ll feel jumpy.  They’ll feel tearful.  They may have nightmares.  And that’s going to go on for days, if not several weeks, for most people.  And we usually label that, acute stress disorder.  So, 90 percent, or more, of people, for example, after a sexual assault, will have those sorts of symptoms.  Gradually, over time, there’s a natural course of recovery so that the farther out you are from the event, the less likely and more unusual it is to have symptoms to persist.  Somewhere in the one to three-month range, it seems that people who are going to spontaneously recover, because the event wasn’t severe enough, because their constitution is such that it was less likely to produce an anxiety disorder, because they have good social support, particular coping skills, for whatever set of factors, people will recover. And once you are at about three months, the symptoms you have tend to persist across time, at a year, at two years, in some form or fashion.


Dr. Linda Austin:  What are some of the features of those who might be most vulnerable to developing an ongoing PTSD?


Dr. John Freedy:  Well, there are a lot of ways you can look at that.  A person who is traumatized early and/or traumatized repeatedly in their life tends to be a person that may be more likely to develop post traumatic stress disorder.  A person who has a family history of depression, anxiety, or alcohol abuse may be a person who is more likely to react to certain types of traumatic events with PTSD types of symptoms.  A person with poor social support, for example, may be a person who’s likely to react like this.  The event itself, as I mentioned, has to do with something that produced serious injury, produced deaths.  Or, and this is very important, it’s the person’s perception.


Clinically, the way we tease that out is we ask the person:  Did you believe that you might be killed or seriously harmed?  And if the person says, you know, I actually did, and as you look at them, you can tell that they’re shaking or their mouth is dry, or they seem to have the physical manifestations of anxiety, it tends to be a pretty good predictor that that person is at increased risk to have trouble across time.


Dr. Linda Austin:  During that initial one to three months, the acute stress time, do you recommend that folks seek professional help, or is it adequate to talk with family, friends, nonprofessional folks?


Dr. John Freedy:  It’s interesting.  The more you can do to support yourself, the better.  So, certainly, having family and friends to support you is important.  But an interesting phenomenon occurs which is that, oftentimes, people in the person’s life, at some point, think the person needs to get on with it.  So, at one, two, three months, they’re sort of tired of the person not sleeping well, not being able to function as they did before this event.  And oftentimes that’s where you see a person who’s almost driven, or compelled, into treatment, because they’re losing their social support and people are becoming frustrated and angry with them. 


I think it’s certainly helpful at any time, even if you would naturally recover, to come into counseling to get some education so you understand what’s going on, why it’s going on, what it is that you and the professional can do about it.  There has actually been some interesting research done.  When we try to use medication, such as antidepressants, antianxiety agents, sleep agents, they don’t tend to prevent acute stress disorder, that early emotional reaction that happens after a traumatic event from progressing to PTSD.  However, certain forms of psychotherapy, particularly cognitive behavioral psychotherapy, there has been at least one study that has found that people are less likely to progress to full-blown chronic post traumatic stress disorder if you get help early.


Dr. Linda Austin:  The typical thing, of course, if you’d had something traumatic, I would think, especially, say, an auto accident, would be to want to talk about it over and over again; that may be nature’s way.  If somebody has something traumatic happen, especially, I’m thinking of something shameful like, let’s say, a rape or, I’m seeing a lot of date rape situations now on college campuses, and the person isn’t talking about it early on, can that just be that person’s coping style, or do you think that might put them at greater risk for having problems later on?


Dr. John Freedy:  It’s a really interesting question.  The best we know from research is that the vast majority of women who are sexually assaulted do not talk to anybody about it.  Actually, over 80 percent do not talk to anybody, such as a physician, about it, don’t go to the emergency room, don’t report to the police.  There is sort of this culture of shame and perhaps even, some would say, blaming the victim.  I think that’s more the norm than the exception.  I would speculate that that may have to do with perpetuating negative feelings about self, feeling at fault, and that could be part of making you more vulnerable.  I don’t know of any research to report that, but my clinical sense is that probably is the case.


Dr. Linda Austin:  I would think it’s hard to sort out what’s causing what.  Is it the sense of shame that makes them not talk, which leads to symptoms later, or is the not talking and the not getting it out in anyway, not mastering it through talking about it that causes problems?


Dr. John Freedy:  Of course.  And if we think back to statistics about sexual abuse of children, we know that the rates of sexual abuse, of girls in particular, are fairly high.  And so, when you have a young woman, for example, who is raped, it may be that she had some experience in childhood that she feels ashamed about, and was even told by the perpetrator to keep this secret, nobody will believe you if you talk, and so forth, and so maybe primed to keep that secret to her own detriment, but understandably so given that sort of background.


Dr. Linda Austin:  I want to talk with you more, in another podcast, about the treatment of post traumatic stress disorder, but thank you very much for now.


Dr. John Freedy:  Thank you.


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