Post Traumatic Stress Disorder (PTSD): Treatment

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Post Traumatic Stress Disorder (PTSD):  Treatment




Guest:  John Freedy – Family Medicine

Host:  Dr. Linda Austin – Psychiatry


Dr. 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?


Dr. 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.


Dr. 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.


Dr. 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. 


The 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. 


As they 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.


Dr. 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 disorder?


Dr. 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. 


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.


Dr. Linda Austin:  Such as?


Dr. 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.


Dr. Linda Austin:  Let’s move, now, to the psychological treatment of PTSD.  What sorts of approaches seem to work the best?


Dr. 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.


Dr. Linda 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.


Dr. Linda Austin:  Dr. Freedy, thank you very much.


Dr. John Freedy:  Thank you.


 If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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