Traumatic Stress Disorder (PTSD):
Guest: John Freedy – Family Medicine
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. John Freedy, Assistant
Professor of Family Medicine, here at MUSC, and an expert in PTSD. Dr. Freedy, I know that you were a
psychologist before you went into family medicine and that PTSD was an area of
specialty for you. Let’s address, now,
if we can, the treatment of PTSD. How do
you begin to think about that when a patient comes to you and says, gee, I’m
really having trouble coping?
John Freedy: As a physician, you have to
have it on your radar screen. You have
to realize that it is a distinct possibility in a treatment environment. Knowing that, you know a little bit how it
might present and a little bit about the questions that might be asked. Oftentimes, people know that they’re
struggling but they don’t particularly know why. They just know they don’t feel well. They’re not sleeping well. They can’t seem to get where they want to in
their personal relationships or on the job.
They don’t really have insight, at least completely, as to why, so you
may get a more vague presentation.
Linda Austin: So, what are some of the
questions, then, that you ask a patient if you suspect that there may be some PTSD? Or let’s imagine someone comes in, say, with
back pain due to a bad traffic accident, but you think that there may be more
to it than that.
John Freedy: Yeah. You will find a lot
of people in primary care complaining of somatic sorts of complaints,
headaches, backaches, abdominal problems, and so forth. One of the things I look for is the
chronicity of the problem. Is this a
chronic problem that doesn’t seem to have a physical, organic explanation that
makes sense? One of the terms they’ve now
used in research is MUPS, medically unexplained physical symptoms.
person comes in and you give them the standard treatment for, say, headaches,
but it just doesn’t get better. And yet
they come in and have a quality of wanting to talk to you, or somebody, about
it, so it’s sort of clue to poke around:
Well, why is this the case? You
can ask the person what they think the matter is: When did these problems start? And, a lot of times, it’s a matter of
trust. Occasionally, people will come in
and say such and such has happened to me and I’m very upset about it. But more often, it’s the person who’s
troubled emotionally, or with these vague physical complaints, that doesn’t
quite know why; they keep coming to the family doctor. So you have to suspect it could be a form of
depression; it could be a form of anxiety.
trust you, they may say, the tenth or twelfth time you see them, and it’s been
ten months since you’ve known them: By
the way, doctor, I never told you that.
And then you can fill in the blank, and they’ll tell you about childhood
sexual abuse, or they’ll tell you about being physically or sexually assaulted,
or something like that. You may have to
spontaneously simply ask them if they’ve had upsetting or traumatic events
happen to them in their life, and tell them why it is you’re asking. And the reason that I tell people why is that
these sorts of events don’t often happen, but when they do happen, they can be
extraordinarily important in understanding the emotional and physical
functioning and well being of a person.
And usually with a context like that, patients are just fine talking
about events, whether they’re recent or very distant. But I think trust and having it on your radar
screen are two very important factors.
Linda Austin: It’s so hard, I think, for
people to understand the unconscious.
But one way I sometimes explain it to my patients is, if you think
about, let’s say, public speaking anxiety, you don’t say to yourself, gee, I’m
really scared about talking to this group of people, but your brain just
triggers a response, very unconsciously, that you may not think that something
is really bothering you. And you may not
even logically think it should bother you but, nonetheless, unconsciously, it
really can trigger a response. Now, if a
patient, then, goes to a psychologist or a therapist, or a psychiatrist for
treatment of PTSD, what are some of the major approaches to treating this
John Freedy: Well, almost any approach
is going to start with education, the treatment provider saying, this is what I
think the diagnosis is, these are what the symptoms are, how they’ve affected
you, and here’s what we can offer to you for help. It’s important that you get an understanding
of what the condition is about and go from there.
are, by the way, a number of treatment guidelines that have been issued, that
are endorsed by various professional bodies.
You can treat with medications, very broadly speaking. You can treat with psychotherapy. And there is some thought and research
evidence to support that social support, and even spiritual practices, are
important in creating a healing context for the individual. While there is some debate about which
medications are the best, probably the strongest evidence exists for various
SSRIs, selective serotonin reuptake inhibitors.
Linda Austin: Such as?
John Freedy: Such as Prozac, Paxil,
Zoloft, these sorts of agents. That
said, the way I, and most people, look at PTSD is that it’s a chronic recurrent
mental health problem. What I tell
patients is, it’s not like, say, you have a fever and you take some
acetaminophen or ibuprofen and the fever can be expected to come down in an
hour or two. Really, you’re going to
take the medicine, you need to say on it for a period of time, and it may help
dampen some of the symptoms, not all of the symptoms. It may work better for some people than for
others. And we’re going to have to find
the combination of medications and psychotherapy, and personal supports, that’s
best for that individual.
Linda Austin: Let’s move, now, to the
psychological treatment of PTSD. What
sorts of approaches seem to work the best?
John Freedy: The best evidence exists
for cognitive behavioral approaches and another approach called EMDR (eye movement
desensitization and reprocessing), which has to do with rhythmic eye
movements. The theory is recalling
traumatic memories and being able to reprocess and reintegrate them. That said, it’s a theory. I don’t think even the people that are the
leading proponents of that quite understand why it works and what parts of the
eye movement desensitization and reprocessing are necessary. But those are the two things that have the
best research evidence. Now, that said,
in practice, there are probably a lot of things beyond that which are done, and
which are offered. My own attitude about
that is to try not to do harm. In other
words, if you’re doing something and you’re still highly symptomatic and highly
dysfunctional and you aren’t getting the first-line evidence based treatments,
then that’s a problem. On the other
hand, if you are doing a lot better, feeling a lot better, functioning a lot
better, the fact that you’re having one form of psychotherapy versus another,
if you’re doing better, I think that’s okay.
Austin: How about somebody who has been
traumatized and doesn’t seem to want therapy at all?
Dr. John Freedy: It’s an interesting dilemma. I go back to the idea that one size doesn’t
fit all. I go back to the idea of
trust. This is a chronic condition. In this day of technology and instant
messaging, sometimes we’re impatient with how long it takes to treat a
condition. It may be a lifelong effort,
and it may be knowing a patient for months, if not years, before they are
willing to let their guard down. After
all, avoidance and numbing symptoms are one of the major categories of PTSD
symptoms, and we think one of the things that people with PTSD may do at times
is avoid people, places, and situations.
And, certainly, emotional intimacy is a big trigger for a lot of people,
so they avoid that intimacy that is, necessarily, a part of psychotherapy,
letting another person close to you emotionally, letting them get to know you,
being vulnerable, in a sense.
Part of the education
about PTSD is if you’re not ready to deal with that, I want you to know that I
understand that, and I want you to understand that. And I want you to be in control of when and
if you come forward to talk to me, or somebody else, about this. It’s a more realistic and less shaming
message for the patient and it empowers them to, maybe, be able to come forward
at some point in time, but when they’re ready and think they have the tools to
control some of the symptoms that are keeping them from coming forward.
Austin: Dr. Freedy, thank you very much.
Dr. John Freedy: Thank you.
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