Understanding and Treating Chronic Post-Traumatic Stress Disorder

Understanding and Treating Chronic Post-Traumatic Stress Disorder

so good evening it’s my pleasure to
welcome you here tonight I’m Steve buck chair of the Department of Psychology
here at the University of Washington this is a very exciting time for us
tonight with the first lecture of the Allen Edwards public lecture series I
want to tell you a few words about Allen Edwards professor Edwards was affiliated
with the University of Washington department of psychology for half a
century from his arrival in Seattle in 1944 as an associate professor to his
death in 1994 Alan was an outstanding teacher researcher and writer who’s
credited with changing the way that modern psychological research was
conducted by introducing new statistical techniques to the science Allen also
fundamentally and permanently changed the intellectual climate of UW
psychology by endowing the Alan Edwards lectureship to bring nationally and
internationally renowned psychologist to campus for short visits to interact with
faculty and students since the inaugural Edwards lecture in 1999 we have hosted
an impressive list of distinguished speakers now the Allen Edwards psychology
public lecture series will be an annual event bringing the excitement of
psychological research and it’s tangible benefits through our fellow citizens and
serving as an ongoing reminder of Alan’s foresight and generosity tonight’s
program is brought to you in part by the college of Arts and Sciences and the UWM
Alumni Association we are grateful to both the topics in this series
illustrate how psychological research not only advances science but directly
serves members of our community the contributions of the faculty members
profiled here both from the University of Washington
and from other institutions around the world provide us with tools to improve
the lives of many tonight’s topics address the results of trauma with
speakers sharing the latest information and the treatment of chronic
post-traumatic stress disorder otherwise known as PTSD our first speaker is dr.
Richard Bryant a scientia professor in the School of Psychology at the
University of New South Wales he is also director of the PT PTSD unit at Westmead
Hospital in Australia his study of post-traumatic stress response has led
to the development of the first assessment measures of acute stress
disorder professor Bryant is published widely and
co-authored the leading text on acute stress disorders he has been awarded
over eight million dollars in research grants and clearly his service to
humanity is greatly appreciated please help me welcome Richard Beynon good
evening everybody and let me start by thanking the organizers for the
invitation and also thanking the Alan Edwards Fund for arranging this talk and
for inviting me but also I think for arranging a wonderful series I think the
talks that lie ahead do look varied and intriguing I’m sorry I can’t be back to
hear the rest of them but we have a doubleheader tonight we’re going to talk
about the psychological effects of trauma and the way we’re going to do it
is I’m going to talk about the acute reactions to trauma how do people react
in the initial days and weeks what do we think is going on in that period and how
can we try to help people who are affected by trauma in that initial
period Lori’s honor we’ll talk about more
chronic effects of trauma and PTSD let me start by just briefly describing what
post-traumatic stress disorder or PTSD is Lori will talk more about this later
but in essence it’s the primary disorder we see after somebody has been exposed
to something very threatening a rape or motor vehicle accident industrial
accident natural disaster it’s essentially an anxiety reaction that’s
comprised of three major clusters of symptoms
we have reacts perience in symptoms now what we mean by that is that once the
event is over I still am reliving it I’ll have nightmares I will have very
bad memories and it’s not just I’m thinking bad about something will happen
in the past because we all do that somebody with PTSD will actually relive
what they went through it’s a very emotionally evocative experience and
full a very strong perceptual detail now this course is so much distress most
people with PTSD will then go out of their way to avoid and this is the
second cluster of symptoms I will try to avoid reminders of it feelings about it
anything that’s going to trigger these reminders I’m going to go out of my way
to not be aware of them because if I can’t do that effectively it does lead
to the third group of symptoms which are the hyper arousal symptoms which is
really just extreme anxiety its insomnia I’m very jumpy
I’m very restless very distractible and I’m hyper vigilant to all potential
threats now PTSD is formally defined by a thing called DSM for now in the
psychiatric world the Diagnostic and Statistical Manual of Mental Disorders
is the Bible that prescribes the mental disorders and for people in clinical
psychology and psychiatry it’s what we follow in terms of trying to diagnose
people with various disorders now according to the DSM we only call
somebody having PTSD at least four weeks after they’ve gone through the event
traditionally we haven’t called anybody inside four weeks having a disorder
because we didn’t want to pathologize what could be a very understandable and
transient stress reaction it’s very important to understand that
the cause of PTSD does tend for most of us to adapt we know of a number of
prospective studies that the majority of people will be unhappy after they get
exposed to something nasty this is not pathology this is common sense and
understandable human nature so most of us will have an array of these PTSD
reactions in the initial weeks but importantly within about three months
after the event even though we haven’t received treatment most of us will adapt
for example his slides from a couple of studies of rape and non sexual assault
and down here we have weeks after trauma we can see that in the first week or two
for example with rape victims nearly everybody is meeting PTSD type reactions
but as we trap these people over time after 12 weeks later the rate drops by
more than a half and we see similar patterns in motor vehicle accidents we
saw a similar pattern in New York following 9/11 and overall really about
one in five people give or take may end up developing a chronic PTSD the rest of
us over time tend to adapt now this raises two important issues the first is
how do we identify these people in the acute phase who are not going to get
better but are going to have a longer term problem because they all look the
same but all having these stress reactions is
there any way we can target these people because if we could it then opens up
that second possibility which is how do we prevent PTSD in those who are at high
risk let me also add but there’s a third
point here and it means that because most of us are actually resilient and
most of us will cope what that means is the
don’t need to rush in and treat everybody and where the field is moved
to now despite what you may read in the popular media is trauma debriefing or
trauma counseling in the initial days after an event it does not do any good
it does not prevent PTSD from developing and what the prospective data tells us
is that there’s really no need to be jumping in with everybody anyway because
most of us are resilient but many people aren’t and it does raise these two
important questions now with the first question how do we identify the people
who are high-risk in the latest edition of the DSM which came out 12 years ago
now they brought in a new diagnosis that was meant to answer this issue it was
called a kid stress disorder and it had a number of goals but its primary goal
was to identify these minority of people who were not going to get better but are
going to have a longer term problem now what was significant about this disorder
it was based on the notion of dissociation now let me explain what
dissociation is dissociation is a notion that was actually popularized by people
like Jaco and janae the late 1800s in Paris and what this view put forward was
that if I get exposed to something that is too distressing that is so
psychologically uncomfortable but while I am going to cope without in the here
and now is to psychologically distance myself from it or the word that they
used was dissociation I’m going to dissociate my wareness from that rape or
that shooting or that war now that in the short term is going to minimize my
distress but according to John a there was a significant psychological cost to
doing that because it was dissociated it may
I can’t process that experience and it will lead to subsequent psychological
disorder now in the years following Rene in the twentieth century largely
Freudian influences and in this country behavioral influences became more
predominant but in the 1980s everybody discovered dissociation again
it became a very sexy topic in North American psychiatry and there was a very
strong push by many people in this country to say the pivotal psychological
response to trauma is dissociation in fact there was a very strong Lobby to
have PTSD recognized not as an anxiety disorder but as a dissociative disorder
now that got knocked on the head but to keep that group happy if you like or to
recognize the notion of dissociation acute stress disorder was recognized and
inert was given the primary role of dissociation and the argument was that
if I too have dissociative reactions at the time or after a trauma then it means
I’m not able to access those memories are not able to access those emotions
and by definition that will lead to subsequent disorder so we have this new
disorder are recognized in 1994 it’s similar to PTSD except for a couple of
differences similar to PTSD I need to experience or witness a threat but
distinct from PTSD it requires that I have dissociative reactions now these
might be I can’t remember it I’m a music of what happened it may be that I just
have reduced awareness of my surroundings it may be I have
depersonalization which is a detached view of myself so the rape victim may
tell you I can see the assault happening but I’m looking at it from the other
side of the room from a detached point of view now these
responses the common theme across them theoretically is that I am dissociating
myself from the reality and the immediacy of this nasty experience but
similar to PTSD we also need we experiencing avoidance and arousal now
when this disorder came in we had no evidence for it we didn’t know whether
it worked or not but since that time there have now been
a large series of studies done where people have assessed adults within the
first month after trauma a system for acute stress disorder and then followed
them up at various points of time down the track and a system for PTSD now if
we look at those studies and we ask the question what proportion of people who
initially have acute stress disorder go on to develop PTSD we can see that if we
look at these top studies here the hit rate is pretty good remember how most
prospective studies tell us that most people are adapting in this time and
they’re getting better these studies up here are actually telling us that at
least three-quarters of people who have this diagnosis aren’t getting better
they’re still grabbing PTSD but if we look at these same studies and we asked
a different question what proportion of people in these studies who ended up
getting PTSD initially had a kid stress disorder note the different question the
number of people who ended up having the disorder what proportion of those
initially had acute stress disorder we can see what the rates are actually a
lot more modest across the studies only about a half of the people who ended up
getting PTSD initially had a cured stress disorder why well the main reason
is that many people in this first month after trauma will not have dissociation
but they can still develop PTSD and it seems that by requiring that we
all have this dissociative response is actually limiting the predictive ability
of acute stress disorder and really saying that you’re high risk and you
might need treatment but you must have dissociation what that’s really doing is
not identifying many people who are at high risk and we would miss many people
who actually may benefit from early intervention now what does this mean in
terms of dissociation well one of the models that’s being put forward as the
diathesis-stress model and this essentially argues that there might be a
number of proportion of people who do respond to a trauma with dissociative
responses such as amnesia and dissociation depersonalization etc
simply because they have a cognitive style that is dissociative they have a
predisposition towards it now it was very we thought how do we measure this
well one way obviously would be to assess their dissociation before the
trauma that’s a difficult thing to do the other way was we tried to measure
them measure these people their dissociative tendencies with a state
measure and one proxy for that is hypnotizability broth is not a perfect
proxy for dissociation it is strongly correlated with dissociation and it is a
trait that meant that we all have to varying degrees in fact if you look at a
person’s hypnotizability that is their capacity to respond to hypnotic
suggestion we have test-retest data two people over 25 years that tells us that
it actually stays quite stable across the lifespan so we’ve got a number of
people with acute stress disorder a number of people with subclinical acute
stress disorder now this is a group that’s got the same acute stress
reactions as the asd group but they don’t have any dissociative responses
and a bunch of people who are fine and what we did is we gave them a very
standard hypnotic test where you actually hypnotized them and give
a number of hypnotic items and what we found was that the people who actually
did have acute stress disorder they were very very hypnotizable much more
hypnotizable than this group now these two groups are matched in terms of their
acute stress reactions and they were both equally likely to develop PTSD the
only difference is these people also had dissociative responses and really what
this is saying is that just because you have a dissociative response doesn’t
mean you’re more likely to have a problem it’s just your cognitive style
and so you will react to a trauma in that particular way and it raises this
whole issue about dissociation what function is it serving we’ve got a
number of studies looking at different groups and here’s just some data from a
group we’ve been looking at novice skydivers people who go up in a plane
14,000 feet and jumped out for the first time it’s a rather distressing
experience for these people but importantly these people don’t develop
PTSD they not developing a mental disorder it’d probably be crazy because
they’re jumping out of an aeroplane so I don’t have ten eliza boluses but if we
look at these people here compared to assault survivors two weeks after an
assault we can see that the dissociative responses are in the same ballpark which
is just a highlight that when any of us go through a very stressful highly
arousing experience we will have the so called dissociative responses it’s
normal it doesn’t necessarily mean that it’s pathological so what do we do with
this acute stress disorder diagnosis at the moment the next edition of DSM is
now getting planned it’s probably going to come out in 2011 probably and so now
people are jostling to work out what diagnosis we’re going to keep in which
ones we’re going to throw out I’m arguing that we actually ditch this
diagnosis because it’s really failing in its goal to try to
identify people who are going to develop PTSD the idea that we’re putting all our
money on dissociation that was an ideologically driven step taken ten
years ago that wasn’t based on data but now it actually has stimulated a lot of
research that actually has challenged that data and tells us it’s not the
villain that we initially thought it was and then in fact probably trying to find
a predictor of PTSD in a diagnosis itself is probably misguided and where
the field is moving at the moment is trying to understand are there more
refined sensitive ways by which we can measure high risk people by looking at
the factors that mediate pathological responding and is that a better way to
predict who’s high risk rather than getting bogged down to a diagnostic
entity now the two ways people are really looking at now are both cognitive
and biological models and what I would like to do now is take a few moments and
just walk you through what they are and what the evidence for them is the
cognitive models can be complex but in essence what they’re really arguing is
that how I respond to a traumatic experience is going to be very strongly
influenced by how I appraise it that is how I interpret it and what this model
essentially argue is that if I could testifies about this experience and
about my response to this experience but that’s going to make the experience
worse and I’m more likely to think that the future is a bleak one so are more
likely to develop a disorder and in fact a number of prospective studies have now
been conducted with both adults and with children that tell us that if I could
catastrophic ly appraise the experience or my future in the first weeks after
the exposure it is very strongly predictive of me having PTSD further
down the track and a very strong predictor is actually
how I appraise my symptoms so for example I may be a woman who’s been
raped and I may make an appraisal about my response and I make this is a common
experience in people who are raped I might think the course during that rape
I felt slightly sexually aroused I make misattributions
about that was wrong and somehow I may have been enjoying this experience which
leads to great shame and guilt in some women following a rape in contrast that
is often an incorrect appraisal because just a mechanical reasons many women
will feel aroused during a rape even though they 100% don’t want the
experience and protoss the experience as much as they possibly can now if a woman
makes a poor appraisal about that response that can lead to serious
problems down the track whereas if they make a correct appraisal then it
actually can alleviate a lot of shame and guilt that they might otherwise
experience and we have a lot of data now telling us that – simply how I interpret
and appraise both the experience and my response is a very big predictor the
other very important model which is more of a biological model is best described
under the heading of fear conditioning game now if air conditioning models
essentially emanate from animal studies about fear conditioning now let me just
go back – for many of you that may have been psyched one lectures and explained
the old notion of classical conditioning in a classical conditioning experiment
we would get a rap and we would put it in a chamber and we would administer an
electric shock to that rap at the same time as pairing it to say a light so the
light becomes associated in that learning experience with the aversive
experience of having a shock now the rock learns this so when we put
that rack back into that chamber the same chamber the next day we don’t shock
it but we do put the light on it responds with fear and it has many of
the fear responses that we see in people with PTSD
it has freezing freezing potentiated startle increased heart rate increased
blood pressure stress hormones get activated this is the generalized fear
reaction that we as humans have then we see it very much in in rats now really
what’s happening there is that the rat is learning that this life is dangerous if we translate that to the human the
trauma that I go through that is the unconditioned stimulus that is the same
as the electric shock that we give the route the fear that I have is the
unconditioned response which is the fear reaction of the rat face next time we
put the rat in the chamber and we show it the light that is the same as all the
reminders that the PTSD patient has for the rape victim it may be the smell of
aftershave the sight of men being in a dark place these are all reminders that
trigger we experiencing symptoms and that are they are the conditioned
stimuli and the conditioned response that is the rapp responding to the to
the light is simply the fear and the re experiencing that we have that is our
conditioned response now the important part of this equation too is what we
call extinction learning now from when we put the rack back in the chamber and
we don’t shock it anymore we’re just giving it the light what that rat learns
over time is that the lights not dangerous anymore it’s not signaling
that I’m going to get shocked and so there’s new learning going on the rat is
learning this light is okay that’s extension learning and that is
essentially what most of us do in the weeks
months after trauma initially we have a very strong unconditioned response but
for most of us we get back in the car we drive around and we find out that I’m
not having another accident and all the cues that are there that are initially
triggering a fear reaction that settling down because I am having successful
extinction learning I am learning that these things don’t hurt me anymore
and so what one this model argues is that essentially what PTSD can be
conceptualized as is failed extension learning now that’s too simplistic
obviously there’s a big difference between a wrap and a human or in most
cases there is but in terms of the simplicity of this model it’s a very
useful one because we can start to make comparisons between basic animal
neuroscience and also what we see in a clinical scenario of PTSD now what are
some of the evidence for this model well as we saw one of the indicators of
stronger conditioning can be elevated heart rate because that’s part of the
fear reaction so what a number of teams have done around the world is trying to
look at people initially after trauma exposure looked at their resting heart
rate and then followed them up months or years later to see whether they develop
PTSD according to the conditioning model if I’m going to go on and get PTSD I
should have a resting high resting heart rate just after the trauma because that
should be a marker of greater sympathetic activation and in fact
there’s been numerous studies like this they’ve come from Israel they’ve got
from this country we’ve done them and what many of them have shown not all
that many is that people who subsequently get PTSD six or twelve
months later will have a higher resting heart rate in ER than the people who
don’t get PTSD and that’s controlling for medical variables and injury
severity in the usual sorts of suspects which is consistent that conditioning
may be happening we even found that people who develop
PTSD after brain injury and that actually represents a large proportion
of people in car accidents and industrial accidents these people
actually don’t remember what happened to them because they have a severe brain
injury and they don’t remember but these people can still develop PTSD even in
those people we found that in the initial week after trauma their resting
heart rate was higher than the people who didn’t which again is consistent
with theories of conditioning I don’t need to have full awareness for
conditioning to occur and there’s also several studies with kids as well
same pattern children will also show this conditioning pattern in terms of
elevated heart rate seen in people who go on to develop PTSD compared to those
who don’t some more data skin conductance response which is a very
common measure of autonomic activity in essence another measure of arousal a
study we’ve done this group here is people with acute stress disorder much
more arousal than people with chronic PTSD and people who don’t have acute
stress disorder we’ve also looked at panic attacks panic attacks are very
unpleasant experiences where people feel like they’re choking they’re dying
they’re losing control it’s the most extreme anxiety state you can have we
find that nearly everybody with acute stress disorder actually has a panic
attack during the trauma itself so while I’m being raped or while I’m stuck in
the car or while the the bank robber has got a gun pointed at me I will often
panic now that’s consistent again with the fear conditioning model that there
is going to be extreme fear and arousal at the point of trauma but importantly
most of these people are going to be having ongoing panic attacks which is
consistent with this notion that very elevated arousal at and after the
traumatic experience is going to fuel much of the psychological distress that
I subsequently have one of the questions that always is
posed in this field which is a very good question though is why are only some
people developing this problem everybody gets exposed to the same traumatic event
and to be honest if the conditioning models were true and simplistic then we
should all be conditioned but obviously this is not happening the vast majority
of us are being very adaptive and resilient than we’re getting over it but
there’s this minority who isn’t why well much work has been done over the years
trying to look at these people but all of this work has been done after the
traumatic experience which is obviously a flawed methodology what people are
starting to do now though is assess people before they get exposed to trauma
now clearly that’s a very expensive task because you’re betting that that person
is going to get exposed to trauma otherwise you’ve got a sample an
enormous number of people what some people are doing including my team is
we’ve tried to look at people who are high risk for developing for being
exposed to trauma and assessing those people before they get exposed to the
event and then assessing them again after they’ve been exposed one study
that we’ve recently done is we looked at firefighters and we looked at 85
firefighters during their cadet training so these were young guys came in put up
the hands I want to be a firefighter and they go through a whole bunch of class
type exercises before they start getting put in fire houses we got them to come
in and we did a whole bunch of studies with them but then we had access to the
emergency database so we knew and everybody got sent to something nasty we
could pull them back to our lab and then we pull them back again 12 months later
which allowed us to actually see what is really happening before in those people
who do go on to develop a problem now this is an a useful paradigm because all
of these people by definition got exposed to something nasty one of the
questions we asked is to what extent do appraisals but I have
before I walk into a trauma to what extent is that going to predict my
stress response and we gave these guys measures of you know catastrophizing
generally and we found that the people who tended to catastrophize the more I
tended to do that that accounted for 16 percent of the variance of my
post-traumatic stress the extinction learning that I spoke about we put these
guys through a particular experimental paradigm that was identical to what we
put through the rats that is we had these firefighters and we gave them
electric shocks and the great thing about working with the fiber partners
the Commissioner says we don’t have an IRB or we don’t have an ethics committee
you can you can electrocute my guys that’s fine they’re tough they can take
them so we we shock the hell out of these guys whilst they got paired with
different stimuli so we actually were allowed to do very good conditioning
studies with them but then we showed them these stimuli when they weren’t
being shocked so then they went through extension learning and what we did was
that we were trying to look at how well these guys engaged in extension learning
this is on an experimental task before they got exposed to trauma they then got
exposed to trauma and we assess them for their stress reactions and amazingly 32
percent of the variance of their stress reactions was accounted for by their
impaired extinction learning on that task which may be telling us that as an
individual if I have problems in engaging in new learning to inhibit fear
as a general capacity as a general skill that I have if I’m that sort of person
and then I have the bad luck to walk into a traumatic experience then I’m
most likely not going to adapt well I’m probably going to have post-traumatic
stress which is consistent with this fear conditioning model and it also
highlights that we can’t be thinking of these people as just responding to the
event but these people walk into that event
with a whole bunch of vulnerability factors that may be associated with
genetics may be associated with prior learning probably both
let me turn now to the issue of intervention if we can identify a group
of people who are high risk and acute stress disorder does allow us to do that
it’s limited because it also ignores a bunch of other people who are at high
risk but at least if we can focus on the people with acute stress disorder it’s
an acid test of an early intervention because we know across studies about
eighty percent of those people are not going to get better so it’s a useful
test useful group to test any early interventions on what we’ve been engaged
in over the last few years is asking the question can we prevent PTSD by
targeting these high risk people and jumping in early with intervention that
actually has been shown to work now later Laurie will actually go through
cognitive behavior therapy with chronic PTSD but essentially what we’ve done is
we’ve taken a very established treatment program we didn’t invent anything new
but we just took this program and abridged it abbreviated it and
administered it to people with acute stress disorder in essence cognate
behavior therapy is a very simple intervention where we give people a bit
of Education about normal trauma reactions we give them some anxiety
management techniques which is really is trying to reduce their arousal try to
reduce panic try to get them to breathe more slowly but the two critical
ingredients of the next two one is cognitive therapy which really speaks to
those cognitive models I spoke about earlier where in cognitive therapy we
are trying to help the person realize their catastrophic appraisals about the
experience and about their future and we teach them to think more realistically
in a praise this whole experience in a more realistic manner prolonged exposure
is probably the most controversial complaint of the treatment and here we
ask the person to essentially engage in extinction learning because we want
these people to get close to what’s scaring them and to learn that that
thing doesn’t hurt them anymore and we do that in two ways with PTSD we ask
people to think about their memories and we ask them to focus on them and we want
them to get us upset as humanely as possible and we want them to keep doing
this for about 40 or 50 minutes which sounds very counterintuitive to anybody
with PTSD and let me say I don’t love doing this but it is arguably the most
effective intervention because if we get a patient to do this what they learn
usually quite quickly is that there ain’t some anxiety does subside even
though they’re still thinking about this horrid memory and they learn to master
the memory and what this results in is fewer memories and when the memories to
occur less distress we typically combine this with what’s called in vivo exposure
where we ask the person to actually approach the things that they’re
avoiding so for the car accident survivor we ask them to get back in the
car and we do this gradually so again they’re going to abstention learning by
getting back to those reminders feeling upset but learning that their anxiety
subsides and they’re learning to inhibit the fear now in our first study a pilot
study with 24 people with a kids stress disorder we gave them five sessions of
that program I just described or they got randomly allocated to supportive
counseling now supportive counseling is a is a rather inert intervention where
they will also see a therapist for the same number of sessions and we do this
to try to control for the effects of just having a nice supportive therapist
who’s listening and not involved you know you’re talking and it sort of
separates the effects of actually active ingredients of CBT and in essence what
we found at follow-up well that whereas two-thirds of the
people who got the counseling still had PTSD only 20% of the people who got the
CBT had PTSD which is an encouraging finding we did a subsequent study a
larger one we repeated this group and this group from the first study behind a
third group where they just got exposure and cognitive therapy no anxiety
management and essentially we got the same finding two-thirds of the people
who got counseling still had PTSD both receiving two groups or equally well in
only 20% of PTSD we recently did a four year follow-up of everybody that went
through those first two studies and you can see the effects were holding whereas
25% of the people who got counseling still had PTSD four years later not many
of the people have got CBT did we did another study where we tried to increase
the benefits of CBT by adding hypnosis to it and the reason for that is that we
know these people are skilled in hypnotized ability and also there’s this
notion that because these people may have dissociative tendencies one of the
arguments is that these people when we’re doing exposure they can’t really
access their former memories very well because they do distance themselves from
them so we argued if we actually use hypnosis it may engage people more fully
in these memories and they may get a better treatment response well we didn’t
find it but we did replicate puttan from the previous studies we did another
study where we replicated our first study but this time we focused on people
with brain injury that is people who were knocked out so they only had
islands of memory we’re wondering if this technique would work with them and
then a nutshell it did this is now becoming a very repetitive story and the
study that we’ve just finished as we did a horse race between prolonged exposure
and cognitive therapy and exposure one cognitive therapy still be better than a
waitlist but exposure was certainly been in cognitive therapy so this certainly
tells us that these are effective interventions but let me throw in some
qualifications whilst these slides look impressive is probably fair to say only
a half of the people who put their hand up and come in for treatment are
benefiting from it now across psychological therapies that’s not a bad
hit rate but let’s not think we have a panacea here there’s a half of the
people are not responding or they’re dropping out of therapy we have a long
way to go in trying to work out what’s the best way to treat these people
there’s also this notion that many people think it’s very important that we
treat people early early intervention is always best if we don’t treat them early
we’re missing this wonderful window of opportunity I think our studies have
certainly said that’s wrong many people benefit from just support and just
having containment and allowing their social context to stabilize and often
they do better if we treat them six months or 12 months later the notion
that we must treat everybody early is really a hangover from the crisis
intervention days of several decades ago that the data doesn’t support that many
people will do just as well if we treat them later but some of the challenges
that are facing us at the moment with this early intervention aspect of PTSD
obviously since 9/11 and since the terrorist attacks around the world and
mass disasters such as Katrina how do we actually try to treat people when
there’s thousands of people or even hundreds of people affected a place like
New York City which is rather well resourced when it comes to mental health
still did not cope well with an early intervention it’s raised interesting
issues about if you have a whole city or a whole population affected is there
some way we can get the message of this intervention technique out to large
numbers of P one thing that people have been playing
with and we have as well is trying to deliver this through the web because if
you look at cognitive behavior therapy to be honest most of it is done by the
person themselves with encouragement by a therapist a lot of it is done nearly
in a self-help manner one study we recently finished with
collaborators from Boston and from the Pentagon we took some of our CBT
techniques and we put it into a web program and we tested it on people in
the Pentagon when it got attacked and to cut a long story short it worked and the
effect sizes of the people who actually completed this program which essentially
involved them logging on to a website the secure website filling out
assessments and then each time they logged on administering to themselves
certain strategies that taught them cognitive therapy exposure anxiety
management and the findings were encouraging and it’s certainly something
we’re now pursuing with groups coming back from Iraq and other high-risk
populations as well it probably will never be as good as face-to-face therapy
but if we’re actually trying to minimize the adverse acute effects of mass
violence or mass disaster the web is a good way to do it it doesn’t work though
in other cultures we’re doing a lot of work in tsunami affected countries and
one of the the programs we’re developing is in Thailand for instance where
thousands of people many thousands lost loved ones and were directly traumatized
by both at the waves now clearly that’s not a country where there’s a computer
in every house far from it one of the challenges again is taking
the basic change mechanisms that have that we think are operating in CBT and
saying can we take these basic change mechanisms and can we adapt them to a
non-western culture because one would assume that these basic mechanisms are
universal but how we conceptualize them and how we deliver them is
very culturally specific and it’s been fascinating sitting down with with
Buddhist monks and with and with people in Thailand trying to work out how can
we take this cognitive therapy or how can we take this thing that we call
exposure how would it fit into your culture and trying to teach them you
know to introduce those sorts of techniques in the aftermath of future
you know disastrous events so we have a long way to go but I think we’re on the
right track and I think it’s probably a good place to stop thank you our next speaker is laurie Zollner
associate professor of psychology here at the university of washington
laurie is the director of VW’s center for anxiety and traumatic stress and is
on the board of directors for the International Society for traumatic
stress studies Laurie researches the prevention and treatment of chronic PTSD
she is well recognized in the field of traumatic stress studies and has
published extensively on cognitive behavioral treatment of trauma survivors
she has given many national and international workshops for
practitioners on preventing and treating chronic PTSD please help me welcome
Laurie Zola before I get started I do need to make a
few acknowledgments most of the research that I’ll be talking about today has
been funded by a grant from the National Institute of Mental Health also a grant
from the anxiety disorders association of america and our medication supply for
our trials were actually funded by Pfizer and then finally as Richard also
hinted at research is done in groups and in teens and these are some of the
people who have worked hard on some of these projects and are really critical
to our efforts here so one of the things I wanted us to do it was how to censor a
feel of what it’s like for an individual to have PTSD and we have an ongoing
treatment study going on right now and a couple women who’ve participated in that
study graciously volunteered to help us out and to actually tell us a little bit
more about what their experience of PTSD is like and one of the things that I
want to put in here is one of our research associates at dr. FC Neff
dakari actually spent quite a bit of time putting together these clips for us
and you’ll actually hear her voice on it but as you’re listening and as you’re
watching what I want you to do is listen for these symptoms that we’ve been
talking about and take it away from kind of the theoretical or the academic into
what it translates into somebody’s real life what is PTSD like from your
hands-free well because of it happened I had a fear
of the dark I couldn’t go to sleep by myself I could go sleep in the dark like
a little light or can be above and I was afraid to sit with my back to a door or
laid my back to do so I wasn’t to turn around and all those on edge generally jelly afraid um and especially
from a personal walking toward me or walking down a hallway toward me
especially and we make a knot in my stomach and maybe really on edge to a
house ever you’re fast and have nightmares really all at once well
Brandon to the wedding no we don’t have lice but it was like
happening all over again okay and in what ways is continuous even in
California well in general it just hampered my life a lot there’s a lot of
great alive things so that I could do more things like my cousin’s house at
night I left something the clock going back out the car by myself it was
impossible I had to have them escort closely or going to a house alone going
in there day or night being by yourself and
unfamiliar place or trying to take a nap in a familiar place on a subway and do
it and also going then we would come up and hit me from behind
completely random times and so it’s sort of it’s sort of fully humanoid
so with that you could hear some of the classic symptoms that we’re talking
about you’re hearing the prevalence of that memory in her life I love her terms
and that the memory bullied her and and the just the pervasiveness and the
extensive extent to which the memory plays a prominent part in this woman’s
life the second clip that we’re going to listen to what I want you to hear here
is you’re hearing a little bit of a different flavored picture with her and
in what you’re hearing here is more of a depressogenic picture which comes in
you’re starting to see a very common comorbidity that we had in PTSD and that
we often see not only PTSD symptoms but we also see depression symptoms and so
with here with her er going to start hearing more of this picture coming out
you’re going to hear her loss of interest how difficult it was for her to
move forward in her life how difficult it was to to get out of the house what
was PTSD like for you and how did you experience it it was very difficult for
me it was hard to function I did not get enough sleep I was
constantly being like open up with nightmares now if I did try to sleep it
was never more than two hours or so I had a very hard time falling asleep and
I was constantly being triggered by events and things that would make me
really feel that the trauma all over again
and because of the trauma if I heard a baby cry or I saw someone playing with a
child or pushing a baby stroller it triggered so much pain and sadness and
anxiety I could not function well at all as just a normal human being I
constantly had migraines I constantly just was in this flight or flight
feeling where I just had no control and if someone was behind me and and it felt
like they were just sneaking up on me if I was out of where they were there I
would panic I would scream it was just a horrible horrible way of living and in
what ways has PTSD been common for you again just not being able to be normal
not being able to be myself to do the things that I really enjoy doing like
painting and poetry and the art and music
nothing was interesting anymore where there was just severe depression and
sadness it felt like it was a continuous cycle that I could not no matter what I
did get out of and even when there were some good things happening suddenly
something would trigger and I’d be right back into that pain and sorrow and I
could not get away away from it it made trouble for me for her in every way of
living just go to the grocery store going out in public going and just doing
things around the home everything was a burden was extreme
extremely difficult and I just felt like I was going crazy and that I could never
this would never end here you have your actually saying I feel like I’m going
crazy this notion of the cognitive component of feeling like these symptoms
mean that you’re going crazy is is very common that when we have somebody come
in they talk about how how they’re doing we we talk about what are normal common
reactions one of the first things that women often say is you mean I’m not
going crazy that this is actually pretty common and it’s it helpful to understand
that and to get a sense that that it feels like the person is going crazy
the other thing that that you hear her saying here which i think is really also
profound is is this feeling that her life was taken away from her but she
hasn’t been able to have the kind of life that she wants to have and it feels
like it’s taken away in some shape or some form so now what we’ve done is we
kind of first talked just conceptually about thinking about PTSD and and now
hopefully it’s feeling a little bit more real to you as you’re as you’re
listening and the next step is to really talk about what we can do to help people
and what do we have right now that’s out there for the treatment of chronic PTSD
and what I’m going to do is review a series of studies that tell you a little
bit about a flavor for where we’re at in the literature first to get us started I
want us to talk about how difficult it is for people with PTSD to actually come
in and seek treatment this is data from the National comorbidity survey
replication is probably one of the largest studies that’s been done on
mental disorder and on treatment seeking and I will do the the step back and
think about it for two seconds only 7.1 percent of people who have PTSD make
treatment contact within that first year that’s going a whole year without with
PTSD and not getting help and the median time to seek treatment
12 years this is suffering for a huge block of time
seeking any type of mental health services the good news is though 65% or
so actually go in and finally get some type of service so just when we have
some good news it’s followed up by bad news again when we look at the type and
the quality of treatment that people are receiving only a third of folks are
actually being seen by mental health specialists a psychiatrist a
psychologist a third are being seen by a general mental medical practitioner this
would be a primary care doc in most cases and when we actually go in and
look across all mental disorders about what kind of care what standard of care
people are actually receiving the numbers are staggering that only about a
third are what we are getting even what we would call minimally adequate
treatment this is based on to what we consider evidence-based practice and
treatments that have strong evidence behind it so we have a picture of people
who take a long time to get into mental health services and once they get in
they’re not getting the type of care that we’d like to see them be able to
get so the question really is what can we do to facilitate getting good
treatment adequate treatment to individuals who need it so what I’m
going to start off with is is just talking about how we figure out what is
good adequate treatment and this is basic again psychology 101 type of
pieces but the gold standard in our field is this notion of a randomized
control trial and what you’re doing in a randomized control trial is comparing an
active treatment to some support some type of control condition oftentimes
you’ll actually see in the studies that that we’re doing that it’s typically a
waitlist condition of some shape or form when we look at the PTSD literature the
preponderance of what has actually been done has been on cognitive behavioral
therapies and also on serotonergic medications either selective serotonin
reuptake inhibitors or SSRIs and we really don’t have the good
randomized control trials in other areas so we know less about counseling
programs at community-based clinics and we know less about psychodynamic
psychotherapy for trauma survivors so when I’m talking I’m not going to be
talking about these things and I’m not saying that they don’t work all I’m
saying is that we haven’t had the gold standard randomized control trials in
this area to meet what we would call evidence-based practice at the current
time so when we think about psychosocial treatments Richard I talked before about
these cognitive behavioral therapies he mentioned exposure
prolonged exposure stress inoculation training is a form of anxiety management
that we’re going to talk about in a little bit cognitive restructuring which
Richard also mentioned and also EMDR eye movement desensitization and
reprocessing and what we’re going to do is we’re going to actually walk through
each of these trials and and look at the data for for these types of therapy and
what you’re going to find is that that at the current time these are what we
would consider the gold standard empirically supported treatments so
Richard also did a nice job of telling you a little bit about prolonged
exposure this has probably been the most studied of the PTSD interventions in the
field dating back into the 80s moving into the 90s when we think about
prolonged exposure it’s actually a treatment with multiple components
there’s education about common reactions following trauma there’s a relaxation
component of breathing retraining component repeated in vivo exposure to
situations that the person is avoiding because of trauma related reminders so
here you’re actually encouraging the person to take baby steps to move
forward in their lives into non dangerous situations that they’ve been
not able to engage in because of the traumatic event and then the last
component that Richard did a wonderful job in talking about as well is this
repeated re-experiencing or reliving of the traumatic memory and so
in therapy what you’re actually doing is having the person go back to the memory
and talk through it as a way as if it’s happening again you have them do it in a
repeated and prolonged type away for many minutes within a therapy session
and as Richard said I think this is one of the more controversial aspects of
this type of therapy because you’re asking somebody to go back to a memory
that’s been difficult and horrible and has been plaguing them for a block of
time but what I want to tell you a little bit more about with it is this
notion of engaging with a trauma memory is actually one when we think back to
common sense and common wisdom fits really well this is actually a quote
from Hemingway’s book for Whom the Bell Tolls and it’s an older woman who’s
giving advice to a man who has just began a relationship with a woman who
had been brutally raped and so this older woman is asking him giving him
advice about how to handle her and it reads she says I could tell thee of what
was done to me if I ever began to think of it again because thou art a good man
and already have understood it all but it were better never to speak of it
unless it came back on me as a black thing as it had before and then that
telling it to thee might rid me of it so she’s saying here that it isn’t
necessary for everybody to go back to the memory and deal with it but if it’s
coming back as that black thing that telling about it might actually be
really helpful and rid them of it and it’s common sense we think about the
notion that I need to talk about it you hear me talk about that that later that
it’s important to get it out important to deal with it I also want to point out
that this notion of engaging with the trauma memory has a very strong
historical psychiatric context as well this is a quote from Breuer and Freud
about handling trauma related symptoms since we found to our great surprise
that each individual symptom immediately and permanently disappeared when we had
succeeded in bringing clearly to light the memory of the event when the patient
had described the event in the greatest possible detail and had put the effect
into words this is almost a I guess it’s now about a hundred years ago and still
very powerful things that we think of as very clear active ingredients that we
want somebody to engage with the memory to engage with the feelings that they
have to experience some of that extinction learning that Richard was
talking about before the models when we think about the mechanism for this
treatment really do come very strong from from learning models of how we
think about extinction processes taking place
so another treatment that you’ll hear about is one called stress inoculation
training and this one is much more of an anxiety management type of treatment
here what you’re trying to do is teach coping skills to deal and to manage with
anxiety so you’re seeing a good amount of relaxation training a process called
thought stopping we are starting to get really negative distressing thoughts
actually closing yourself to stop guided self dialog kind of talking yourself
through things moving through things cognitive restructuring and covert
modeling and also role-playing so helping the person figure out how
they’re going to handle situations model that to them and roleplay how it might
might play out and one of the first trials that was actually done in the PE
literature was actually to compare this exposure based protocol to this anxiety
management protocol and this is a study that was was done by foe and colleagues
comparing prolonged exposure sit and the combination of adding both the anxiety
management component and adding the prolonged exposure component and over
here you’re going to see with all of these trials people start off with a
rate of PTSD diagnosis as a hundred percent everybody who’s coming into the
trial needs diagnostic criteria at post-treatment you’re seeing about
35% of those people with PTFE still having a PTSD diagnosis what you should
take from this is it looks like both sit and prolonged exposure are good
treatment options but also it doesn’t really look like adding the two together
really is getting any bang for our buck but teaching both anxiety management and
teaching prolonged exposure isn’t really helping out the other thing that I want
you to see here which is encouraging is that one year following treatment these
gains are maintained now you all could be thinking and sitting going well this
is PTSD symptoms what about the rest of their lives and one of the notions that
we have in our in our literature is that we need to be looking for what are
called clinically significant gains that we really are moving somebody from what
we would call a pathological distribution into a normal distribution
are there symptoms that kind of a normal functioning level and typically we call
this good end state functioning and we use measures of anxiety depression and
also PTSD symptoms so we want to see people moving down across all three
domains into lower anxiety lower depression and lower levels of PTL PTSD
and we want these to be comparable to what somebody would be just in the
regular population and here you see a little bit of a different picture
emerging you’re seeing much more that individuals in the PE condition are
actually achieving higher rates of good and state function that they’re low in
anxiety low and depression and and low in PTSD symptoms and again you’re seeing
these gain Taine’s maintained through one-year follow-up and if anything as
well you’re seeing that more isn’t necessarily better in this picture that
again adding the combination of doing both the PE and the stress inoculation
training looks like it might actually be hurting a little bit it’s still
effective and still helpful but this notion that we have that if we add more
to our treatments sometimes we’ll get bigger bang for our
buck isn’t necessarily being evidenced here in this study so this shows you a
little bit about both prolonged exposure and sit the next type of therapy that I
want to talk about is cognitive processing therapy and what you’ll see
here is it’s tying into these notions that Richard talked about about
distressing cognitions and a way that people think about the world themselves
and other people and the goal here on the cognitive side is to really address
those type of cognitions so you’re focusing on event thoughts and emotions
particularly focusing on issues of safety Trust power control esteem and
intimacy but what you’ll also see here with the cognitive processing therapy is
is there is an added component of also engagement with the trauma memory so
you’re seeing in this therapy not just solely a cognitive based therapy but
also one that’s including some of these exposure components and engaging with it
with a traumatic event and this is a study by aunt patty music and colleagues
and what you see here basically is a pattern that that both CPT and PE look
relatively good and that active treatments are generally better than
weightless so if somebody’s not getting treatment they’re not getting better on
their own but this is encouraging results that both of these types of
therapy are providing good reductions in terms of PTSD symptoms note at nine nine
month follow-up we’re talking about eighty percent of folks being diagnosis
free and the pattern is also relatively encouraging when we look at good and
state functioning in in this part of the study you actually see some benefit at
post treatment for CPT that is getting people down into good levels on in this
study depression and PTSD and but we hit nine months that that advantaged for CPT
disappears but what it’s telling us is again we have another therapy in here
that’s also a good viable treatment option for chronic
TSD the last one in this series that I want us to talk about is EMDR and we’re
talking about EMDR we’re talking about again so you’re
seeing some of the same elements of these therapies coming across there’s an
accessing of the trauma memory and trauma related images again this
engagement with the memory kind of notion they also evaluate the aversive
qualities there’s a cognitive component that’s also there and a generating
alternative cognitive appraisals focusing on the alternative and then
what in EMDR they do is actually do sets of lateral eyes movements while focusing
on the response so you see in this therapy a combination of some of the
components that we’ve seen in some of the other therapies and this is a study
that just came out by Barbara Roth um and colleagues and in terms of comparing
prolonged exposure and EMDR we’re seeing again both of the active treatments
doing a lot better than wait lists and generally the gains being maintained at
follow-up the picture changes a little bit more when we actually move over and
look at these indices of good and state functioning and here what we actually
see is we see higher rates of good and state functioning with prolonged
exposure and that these differences actually are significant at the
follow-up period so in terms of kind of long-term functioning you’re seeing some
advantage for PE over EMDR at the 6-month follow-up period but again we’re
seeing another therapy that’s making good reasonable gains in terms of
reducing PTSD symptoms so when we move away from the psychosocial interventions
we then move over into the pharmacological interventions and we we
typically here think about both both as sertraline and paroxetine as being
viable treatment options there’s no studies that actually are published to
date that do a comparison between SSRIs and these psychosocial intervention
we we see that sertraline reduces PTSD symptoms significantly and similarly we
see in a say in a say by Davidson and colleagues that it also is doing well in
terms of reducing PTSD symptoms you do want to note that it’s just barely
beating placebo though so you kind of wonder and you kind of think well is
this the type of game that we’d like to see in terms of paroxetine we’re seeing
some advantage as well over placebo and here the doping is not making as much
difference that if you got 40 milligrams or if you got 20 milligrams the results
are relatively comparable one of the issues that comes up is that you’ll
notice with all of those trials that there weren’t any long term follow-up
there weren’t one year nine months six months type of follow-ups and one of the
things that we actually are now starting to be concerned about with with the
medications I think we’ve been concerned for a while but is this notion of
relapse when somebody’s pulled off of the medication and this trial basically
after somebody had responded to search early
we’re either randomized to search early in continuation or placebo and what you
see is that if they were on placebo their rates of exacerbation at six
months shot up dramatically so if you didn’t continue on the medication your
relapse rates went up considerably and when I talk to my psychiatry colleagues
about this they say this is probably one of stronger evidences that somebody
who’s on one of these serotonergic medications needs to stay on it for a
block of time and in our current treatment trial
we’re actually recommending that people who are responding actually stay on for
a year and that’s that’s to get past this potential for for relapse so what
we’ve seen very quickly is that we have some good psychosocial interventions and
we’ve also got some good pharmacological interventions and the questions are what
are our next steps what are our next directions Dilbert is always wonderful
at shining a a mirror on us as a society says it feels like everybody in the
world is lying to me Congress is lying about the budget
stock analysts are lying about the recommendations my boss is lying this
therapy stuff is scientifically proven to work right it’s a hundred percent
effective hopefully you’ve not heard me say that once here that we’re not at
100% and by far and the questions that move us for a future in in the field is
how do we increase our efficacy how do we boost the results that we’ve gotten
and how do we help more people actually do better with our therapies the other
thought that we’ve had besides trying to augment our therapies or do step care
with our therapies is this notion of treatment matching and really trying to
match attitudes and beliefs about treatment and patient characteristics
but the idea that decisions to seek treatment compliance and actual
treatment outcome may be very dependent on how people think about a treatment
and and their own personal characteristics and this is a question
that we’ve been asking extensively in our group with this we’ve done a series
of studies actually on this notion of treatment choice and we’ve we’ve looked
at how people have preferences in terms of either the prolonged exposure or the
serotonergic medication and you can start thinking about it that these are
really different treatment options one option is you’re going to engage with
the memory the thing that you’ve been avoiding that’s very scary and the other
is you’re going to talk to a psychiatrist for 15 minutes and take a
pill and come back very divergent type of treatment approaches and what we’ve
tried to do is we’ve created rationales that talk about these treatments and
we’ve tried to match them up as close as we can on other other aspects of it
and then we’ve asked people will what treatment would you like and we
initially thought that it was probably going to be about 50/50 that about 50
people would 50% would like the medication 50% would like the therapy
some people even told us there would be less people that would like the therapy
because it sounded hard when we first look at it within a actually University
of Washington College sample we weren’t we were shocked the rates of choice for
pee were incredibly high and it didn’t it matter too
if the person actually had PTSD or not and the rates of sertraline and no
treatment were relatively low we thought well that’s all well and good this is a
hypothetical choice with college students we then took and I’ll come back
to that we then took and and looked at a community sample of women who had all
been trauma exposed very similar types of rates in terms of preference for the
psychotherapy and when we asked people qualitatively why were you choosing this
therapy almost a good chunk of them always said I felt like I needed to talk
about it I needed to deal with it I needed to talk about it our last study
in this sequence was actually asking a question of does choice have any impact
on what you’re doing in treatment and so now I’m so just a theoretical choice we
actually asked people to make a real choice and for those people that chose
we then gave on 10 weeks of the therapy that they wanted this just tells you a
little bit about the sample and reiterate some of the points that we had
before nine point nine years since the traumatic event primarily sexual assault
three and a half other very significant traumatic events in these people’s lives
rates of choice again comparable strong preference for the psychotherapy and
then when we actually looked at who was making these choices and what factors
influence their choice education seemed to be a big one if you had a college
education everybody chose the psychotherapy but if you had more kind
of symptoms more PTSD more depression more anxiety much more likely to choose
the medication so there does seem to be real differences between the people who
would prefer one versus the people who prefer the other one being on education
the other being on symptom profile with the more severe people actually
preferred the medication when we looked at how they did with treatment we see
some advantage here in terms of prolonged exposure over the sertraline
and if you looked at and thought about the numbers that we had beforehand this
makes some sense and if you look at good end state functioning
same kind of picture much better rates of PTF of good and state functioning
with the PE condition what was really intriguing to us is we went back and
actually looked at depression and when we started looking at those people who
were depressed who had comorbid major depression the rates of choice flipped
dramatically that now we see very few people if you just had PTSD very few
preferring circling but if you had PTSD and depression the rates of choice for
about equal that actually if you’re seeing that comorbid picture people were
much more preferring to go on the medication than they were to going into
the psychotherapy but the bad news with it was these are what are called effect
sizes and when you look at an effect size you want the numbers to Bob viously
be bigger and these are Cohen’s D and so if you’re seeing a number of point 5.8
you’re moving into a large effects noise what you’re seeing here is for those
people with comorbid MDD you’d much rather be in the PE column than in a
circling column so what’s that saying is that your actual response to treatment
if you had comorbid depression is that you’d be a lot better being in the PE
condition even though you didn’t want it then the people who who chose the search
link addition this is really kind of an interesting dissociation between what
somebody wants and what actually might be helpful to them and this leads us to
where we’re going with our future research and really asking a question
about randomization and really testing this role of choice in terms of
treatment as we said before what you want is a randomized control trial of
some shape or form to really look at this role of choice and this is a study
that we’re doing right now and you actually see that individuals are
randomized to choosing their treatment or not choosing their treatment and this
just tells you a little bit about kind of the process and and how we’re moving
forward with it the other studies that we have going on with the studies we’re
looking at some biological mechanisms um and some at
narrative memory mechanisms that might tell us a little bit more about thinking
about treatment response who’s responding to a treatment and who isn’t
and if there’s a differential treatment response who’s responding to the
medication who isn’t responding to medication so dad to close us tonight I
wanted us to actually come back to these women these women that you met at the
beginning and as I said they were part of our our treatment study because we’re
an ongoing process I can’t tell you if they got to choose their treatment or
not and I can’t tell you which treatment they were in but I can tell you that
they’re doing better and I wanted you to hear from them and what ways are things
different since your completed treatment well for one thing I’m not afraid of
dark nearly as much like I have a lot more control over it I can go into a
dark house if no one else is in I can go into an unfamiliar room without all the
lights on I I can go out to the car at night without
feeling panicked I can sleep with my back to the door I can fall asleep on
myself when people walk toward me down the hall
and I hear that footsteps coming I made that panicky reaction in my
stomach get the knotted up heart beating fast let’s stay calm
stay a lot calmer in general and I’m nothing afraid of dark places or being
alone just a wrong with everything more calm and that’s really nice they’re bad
dreams are a lot less frequent they’re quite rare now rise the float away
every week the memory doesn’t come up and just sway me in the back of the head
like it used to out of nowhere for currently no reason set there’s a lot
better it doesn’t I don’t have to be anxious about that happening why did
that happen there are a lot of things that I used to avoid and I don’t have to
anymore I’ll have to feel upset or anxious when I run into those things and
I don’t have to try to maneuver around them or just like mix it up for comments
and back away from situations because not to do that anymore and so in general
I like this a lot less limited alright and the last woman and what ways are
things different since your completed treatment I no longer get the nightmares
that I got before um I may get them once or twice a month
nothing like every night or every other night I do not wake up in night tremors
and I’m not afraid to function and to go out and I’m not in that fight-or-flight
mode anymore are not the way I was I’m aware of my surroundings and I’m careful
but I’m not in fear that something’s going to happen to me at any moment and
if something does someone say just does come up behind me I I can handle it
better I feel more alive I can do the things that I’ve been wanting to do for
so long the painting that the drawing the poetry all of that there’s no fear
can you go to the library and things like that and go out in the evening and
it just feels good to have my life back and I’m able to handle when I do get
sometimes things still trigger the memories but their memories and not that
they’re forgotten but I’m not reliving them and I I’m able to handle that more
and understand that I’m no longer a victim I am a survivor and it’s very
important for me um so I still acknowledge what happened but
can also live and do the best I can with what I have here today and now and for
the future and it’s wonderful to have your life back so we do have a number of
good viable treatment options when we’re thinking about chronic PTSD both in
terms of the CBT treatments and also in terms of the serotonergic medications
and when we’re thinking about next steps we really are thinking about how how we
make our responses better how we prevent relapse with the medications poly
augment partial response to treatment and these notions of how we match
treatments to particular people are some of the next steps that we’re going to be
taking in this area and to kind of pull us back full circle I think one of the
important steps as well is now this dissemination of our evidence-based
treatments but we know that there is this preference for psychotherapy and
there’s a need for good psychotherapy to be out there for folks to be able to
access and to bring them into treatment so that concludes my talk I’d like to
thank again Professor Richard Bryant from the University of New South Wales
and Professor Lori Zollner from University of Washington and thank the
UW Alumni Association and the College of Arts and Sciences for their partnership
in presenting this lecture we hope to see you all over the next two Wednesday
evenings as well thank you


  1. @poeticpaul i am the same. We must keep letting them come and remembering it is our memories inside and not happened outside. We must get help. You can heal. But this way =what we are going through – is the way to healing. When we go insane oh year ago crap sorry

  2. I battled PTSD for five years (2004-2009) so this link was most needed to help educate people about this debilitating condition. I love how intellectual Dr. Bryant is and I hope others took a lot of learning from this lecture.

    I will say this…conquering PTSD is bar none the most liberating experience I've ever had in my life. I hope everyone who deals with it finds coping mechanisms to eventually defeat its suffocating impediments

  3. I disagree with trauma victims not needing talk right after the trauma.. I think when you get into people's belief's you'll find a lot of people don't believe they have a right to talk about the trauma as in them being victim in the situation, and these people will get anxiety disorder later on.. If we can convince them that they have that right, they don't suffer later..

  4. I am an avid #MentalHealthAwareness advocate and performer, and I love this so much. I travel the country trying to bring that awareness on stages, in classrooms, hospitals, and on my YouTube channel, so I get excited when I see other advocates. ?❤

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