Posttraumatic Stress Disorder, PTSD Diagnosis and Treatment

Online Conference Transcript

Dr. Darien Fenn, our guest, is an expert in trauma psychology. The discussion focused on the causes, symptoms, and treatment of PTSD (Posttraumatic Stress Disorder).

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Posttraumatic Stress Disorder, (PTSD)." Before I introduce our guest, here is some basic information on PTSD. You can also visit the HealthyPlace.com Abuse Issues Community.

Our guest is Dr. Darien Fenn, who is a clinical psychologist in private practice in Wilsonville, Oregon. He is also an assistant professor of psychiatry and a research psychologist with the Department of Psychiatry at the Oregon Health Sciences University in Portland. Dr. Fenn has written many articles on depression and suicide and is an expert in the field of trauma psychology.

Good evening, Dr. Fenn and welcome to HealthyPlace.com. We appreciate you being our guest tonight. I have read that many times PTSD is misunderstood or misdiagnosed. So, I'd like to start with you giving us a general overview of what PTSD is and is not?

Dr. Fenn: Hi, and thanks for the introduction. PTSD is one of a spectrum of anxiety disorders. Unlike most psychiatric diagnoses, PTSD is tied to a specific event. Although we usually think of the event as traumatic, it is not always that way. PTSD has been seen after assaults, disasters, witnessing a trauma, chronic stress, chronic illness, and even sometimes after learning of a severe illness. PTSD is closely related to Acute Stress Disorder (ASD). The main difference being that ASD is what you get if the trauma is recent (30 days or less), and PTSD is what you get if it goes longer. The disorder is characterized by four types of symptoms:

1. Re-experiencing - which can include the classic flashback symptom.
2. Avoidance - usually of places or reminders of the trauma, but sometimes also avoidance of the memories of the trauma.
3. Emotional numbing - when people's emotions seem to shut down.
4. Arousal - including jumpiness, difficulty concentrating, anger, and sleep problems.

David: What is it in the individual that leads to PTSD? To clarify, two people can suffer from a similar traumatic event, let's say sexual abuse, but one will develop PTSD, the other will not. Why is that?

Dr. Fenn: That's one of the most interesting things about the disorder, is that some people "don't" get it, even after terrible traumas, and sometimes side-by-side with someone that does get it. There are a number of factors that seem to matter.

1. First, there does seem to be "some" genetic predisposition, but this is not a big part of it.
2. More important seems to be psychological factors, such as whether the victim thinks they are going to die.
3. Also, people who have a past history of psychological problems are more vulnerable.
4. Depression also adds an increment of risk.
5. Post-Traumatic Stress Disorder seems to stem primarily from a hormonal response to the trauma. Hormones released into the brain can create a long-lasting chemical imbalance that is responsible for many of the symptoms. People who have more of this surge of stress hormones seem to be at more risk.
6. Also, trauma experiences are cumulative. If you have more than one, you are more and more sensitive, so they seem to be additive.

Then, there is a separate set of factors that relate to how the person reacts to the initial symptoms.

1. People who dissociate (space out the emotional reaction) are at risk for lingering PTSD,
2. people who ruminate over the incident (why me), are chronically angry about the experience,
3. or people that have some chronic reminder of the trauma, such as a lingering physical disability, or sometimes even involvement in the legal system itself.

David: So, what may be extremely stressful for one person experiencing an event, may be better psychologically handled by another. Is that what you are saying?

Dr. Fenn: Yes, and in truth, for the most part, we don't know why.

David: We have a lot of audience questions, Dr. Fenn. Let's get to a few, then we'll continue with the conversation:

angel905d: How long does PTSD last?

Dr. Fenn: Post-Traumatic Stress Disorder seems to have a natural course for healing on its own. Some studies done with auto accident victims show that about 60% of people who initially have PTSD get over it within the first six months. After that, however, things pretty much level off. There appear to be something upwards of 20% that go into a chronic course. In chronic PTSD, symptoms have been found to persist in concentration camp survivors (more than 50 years!). So, without treatment, the condition can become pretty persistent.

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rick1: Dr. Fenn, do you agree that PTSD is nothing more than old memories that are worked up?

Dr. Fenn: Old memories are what is most visible, but there is physiological alterations that result too. Changes have been documented in neurological structures in the brain, the neuroendocrine system, brain structures (there is sometimes atrophy of the amygdala for example), peripheral receptors (individual cell structures), immune systems function less well (perhaps due to sleep disturbance), and there are problems with attention and memory. The problem is that most symptoms are subjective, so it is harder to diagnose.

punklil: Thank you for coming tonight! My question is, can you have PTSD for more than one event?

Dr. Fenn: Yes, as I said before, it is additive. Sometimes, a new event can bring up PTSD from an old event that had gotten better.

Jennifer_K: Dr. Fenn, you mentioned flashbacks; however, can you expound on night terrors, please?

Dr. Fenn: Be careful asking me to "expound" because I feel like I'm rambling as it is. But yes, nightmares are very common. Sometimes the dreams are about the trauma, sometimes they are just bad dreams about death, other accidents, or fearful situations. There are some theories of PTSD that suggest the dreams are part of the healing process. Your unconscious memories coming up so that they can be processed, made sense out of in some way.

David: Dr. Fenn, what about the treatment of PTSD?

Dr. Fenn: There are a number of treatment options. Some of the new SSRI antidepressant medications help control some symptoms. There are many that seem to help, but that differ from individual to individual, but the primary treatments are still psychological (therapy). Of those, many people have heard of EMDR (Eye Movement Desensitization and Reprocessing), which has some good supporting evidence, but also some detractors, as some studies have shown the eye movements don't appear to be necessary and there are several cognitive-behavioral approaches that have shown good success. Almost all approaches involve two things:

1. Control of the arousal symptoms.
2. Systematic re-exposure to the traumatic memories, most frequently done gradually and in a safe setting (don't try this at home).

In some cases, people's sense of the safety of the world, or of their basic worth, or competence, is damaged in the experience and those issues become an important part of the treatment focus.

David: The treatment phase sounds like it could take a long time, at least a year or more. Is that true?

Dr. Fenn: Yes. The shortest case I have had was about twelve weeks. Sometimes, especially if there are multiple traumas, if the traumas occurred a long time ago, or if people have developed an avoidance (or dissociative strategy for coping), the treatment may take several years.

David: Here are some more audience questions:

hope: Will CBT (Cognitive Behavioral Therapy) work with someone who has been diagnosed PTSD and bipolar, or is it a waste of time?

Dr. Fenn: Actually, almost all cases of PTSD involve some sort of companion problem (a co-morbid disorder, in the lingo). The treatment rule is that these issues need to be treated simultaneously. Certainly, it is possible for the stresses associated with Bipolar Disorder to produce PTSD, so that is likely to be a common presentation and a manageable one.

saharagirl: Sometimes, it seems that I am drawn to things that remind me of the trauma as opposed to avoiding it. What is going on here? It seems like intentional triggering.

Dr. Fenn: The leading theory of PTSD contends that there is a natural healing mechanism built into us for trauma. Since we know from treatment studies that the most important part of the treatment is frequently the exposure to the memories of the trauma, it would make perfect sense to find that people are unconsciously drawn to do exactly what you mention. The idea is that this exposure to the traumatic memories is necessary for sorting it all out.

Medic229thAHB: If a Vietnam Vet goes into a flashback, is that person in Vietnam or in the U.S.?

Dr. Fenn: I like the question. To an outside observer, the person is here. From the person's point of view, they are in Viet Nam. It really is re-experiencing, from the point of view of the person affected.

scarlet47: I developed PTSD after going through childhood abuse and abandonment. I am currently in therapy and want to know, when one is recovered, does PTSD return? I can't seem to ever get rid of the flashbacks. I can't ever imagine having a clear mind. I also suffer with anorexia and self-harming behavior. These disorders certainly seem to be very complex to understand and heal. Thank you.

Dr. Fenn: Not an easy question to answer, but I'll give it a shot. The reactions that characterize PTSD are a form of conditioned response, just like the conditioning that Pavlov described with his famous dogs.

What this means is that some of the reactions are recorded in the body at the level of the neurons. When a conditioned response "goes away," what is actually happening is that a new response is learned. That new response suppresses the old one. So the old response is still under there somewhere. What people experience, is that the PTSD can go away, but sometimes, things can trigger a return.

The good news is that the recurrence of the symptoms is usually very short-lived and not very strong. If the triggers are repeated, the responses also diminish each time. So it's not quite like getting over a cold, where the virus disappears. It's more like getting over a case of tennis elbow, where there may be lingering, if low-level, symptoms that gradually get better over a long time.

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Mucky: Can you talk about delayed onset?

Dr. Fenn: That is a really good question. Some people have PTSD that appears after the trauma, by many months or even up to a year, or eighteen months. However, it's not like it suddenly pops up out of nowhere. In all cases of delayed onset that I have seen studied, the person who later developed PTSD had some symptoms to start with. Just not enough of them to qualify under the official diagnosis.

There also seems to be an important characteristic common in these cases, and that is that delayed onset appears most often in people who dissociate a lot or who try to suppress their reactions, or who are extremely avoidant. It seems that these efforts at avoiding the traumatic memories or reactions are doomed to failure, but that people can keep it up for a good while.

The other important part of this is, that it points out a problem with the diagnostic system itself. There is now a lot of evidence that many people can have what is known as a sub-syndromal form of PTSD. That is they have some symptoms, but not enough to get diagnosed. It is clear that this form of the disorder is extremely debilitating for people. So even if you don't have the full disorder, you may have a problem that needs attention. I expect the diagnostic criteria to be revised on the next cycle of the code.

David: If a person experiences delayed onset of PTSD, is it that another smaller trauma, or stress, comes along to push them over the edge?

Dr. Fenn: It could be that way, but I think that the delayed onset really reflects a breakdown of a coping mechanism that tries to avoid the problem.

Medic229thAHB: What would the differences be in posttraumatic stress disorder from a war or a rape case? Would they have the same symptoms?

Dr. Fenn: Yes, they mostly would have the same symptoms. However, there is a difference, but it is probably due to the fact that most war-related cases of PTSD involve multiple and ongoing traumas, where rape is typically a more limited exposure.

David: Here are a few audience comments on what's been said so far tonight, then we'll continue on with the questions:

scarlet47: David, that is what happened to me. At age seventeen I was sexually abused, and at age forty-seven I was stripped by a doctor. That experience brought on flashbacks and PTSD thirty years later!

cbdimyon: But actually it's a collection of responses, that's why syndrome seems a more useful term than disorder.

A_BURDEN: I know all this stuff about PTSD. What I need to know is, how to overcome it. I have tried everything it seems.

Medic229thAHB: I have had PTSD for twenty-seven years. How come it hasn't healed yet?

David: Do some never recover?

Dr. Fenn: PTSD can get very difficult to treat if it has been around for a long time. It is hard to say whether or not there are cases that don't recover, because especially as people adapt to the problems, they entrench their behaviors and attitude. There are multiple issues to treat. So, it is hard to know what all the relevant factors are. I do not know exact statistics, but I recall that all the treatment studies I have seen have a success rate less than 100%.

Now, with that said, I would be very reluctant to say that there might be untreatable cases. It would depend on the nature of the original trauma, the other existing problems, current stressors, and importantly, the skill of the therapist. Most of what I have seen has been very optimistic with regard to treatment success. If people feel like they are not progressing in treatment, they should always consider changing treatments or providers or both. This would be true for any problem.

However, it is also important to note that there are some chemical and structural alterations inside the brain and body. It may be that for some people, there will be some lingering problems, just like when you hurt a knee, for example, it can continue to bother you some, even after it has mostly healed.

David: Here's the link to the HealthyPlace.com Abuse Issues Community. You can click on this link, sign up for the mail list at the top of the page so you can keep up with events like this. The Anxiety Community is here.

JeanneSoCal: Does the "size" of the trauma have anything to do with how long it lasts? For instance, Viet Nam vets seem to deal with this for many years afterward.

Dr. Fenn: The "size" doesn't seem to matter as much as you would think. Some Viet Nam vets have no symptoms. However, with Viet Nam, for many, it was a very prolonged stress. As I said before, whether you think you are going to die seems to be important, so I would also think that this might have been the case for many vets. So for those reasons, PTSD might be worse. However, PTSD can also occur in relatively minor traumas like being in a fender-bender.

NOWAYOUT: Can having PTSD make you hostile?

Dr. Fenn: Yes, absolutely. Anger is one of the seventeen symptoms that constitute the syndrome. It appears to be connected both, to the heightened arousal of the body and to psychological factors.

dekam20: How do you deal with reoccurring systems of PTSD?

Dr. Fenn: Depending on the particular symptom, people can learn specific containment strategies. The overall treatment of PTSD would probably be the same for long-term resolution of the disorder. Although a good therapist will tailor the treatment to your issues.

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efe: How does one differentiate this from other anxiety disorders? They seem so closely linked.

Dr. Fenn: They are related. Differentiation depends on chronicity, the specific symptom profile, and on how people react to the anxiety. OCD, for example, is an anxiety disorder where the compulsive symptoms are attempts to control the anxiety. So the reaction defines the problem in that sense. The short answer to your question is, it depends on how the symptoms fit the diagnostic profiles that have been defined.

David: By the way, PTSD is classified as an anxiety disorder, isn't it?

Dr. Fenn: Yes.

PatriciaO: My husband is taking shock treatments for his Posttraumatic Stress Disorder. On this past Sunday, he told me he didn't want to live in my home anymore, and today he called and blamed it on the shock treatments and PTSD. Should I believe this?

David: I want to clarify here that shock treatments (ECT) are used to treat treatment-resistant depression, which may be one of the results of the trauma. But it's not a specific treatment for PTSD.

Dr. Fenn: I really couldn't say without knowing a lot more. Many times relationships fail due to PTSD because the symptoms can be hard for spouses to take. But I'm sorry, I really couldn't answer in your specific case.

kaj: I am getting married in fourteen days, and I am many miles away from my provider. I am afraid I will flashback to fifteen years ago to a very abusive marriage. I have kicked depression (although I am still on lithium). I am a bit scared of having flashbacks with a very kind, gentle, and understanding man. How do I shake the fear and avoid the flashback?

Dr. Fenn: Again, I can't offer advice specific to your case for ethical reasons. However, flashbacks are always a possibility after PTSD, especially if the issues have not been resolved completely. Some problems are better managed than solved. If you know you are likely to experience flashbacks or anxiety symptoms, it is a good idea to prepare for them. Especially if the people around you know where the symptoms come from, they can best be prepared to understand and offer support.

bukey38: How would one go about helping someone who has been sexually assaulted, and they refuse therapy, but exhibit classic symptoms of PTSD?

Dr. Fenn: Always a tough question. My recommendation is that we can offer concern but we can't insist. If we continue to be concerned, eventually, if there is trust, people begin to consider the possibility of getting help, and perhaps eventually get it. It may also help to provide information that help is available and effective. Sometimes, people can hear the message better from someone less involved, or someone with a similar experience in their past. So, arranging a meeting can sometimes help. Mostly, I think, just caring and worrying in a gentle way is the best way to get people out of resistance.

Lucybeary: To what extent might an ADD child, living in a very dysfunctional environment, develop PTSD?

Dr. Fenn: It could happen to non ADD children too. A possibility, but not in every case.

mothervictoria: My partner has PTSD, and is involved in a lengthy court case over the issue of assault and the splitting of their combined assets. Is it true that healing for her will not begin to take place until after the final hearing?

Dr. Fenn: Healing can begin, but it is unlikely to be completed until it is all over. The trauma is, in a way, still going on.

LBH: My therapist says I need to avoid triggers, however, your thoughts seem to go against that idea.

Dr. Fenn: My reading of the research evidence is that exposure to the trauma is essential and that avoidance is often harmful. However, in any particular case, there might be exceptions. For example, if someone completely dissociates when driving on the freeway (after an accident there), that is dangerous and that trigger should be avoided until the response can be brought under control.

David: Here are some more audience comments on what's been said tonight:

Lucybeary: When I'm a passenger in a car, it feels like I get triggered all the time and startle so easily. I've been doing EMDR therapy for a couple of years now.

cbdimyon: I am chronically angry, not about the incident, but the complete and chronic failure of fundamentally male legal and medical systems to respond appropriately to rape and sexual violence. My anger is just like being propelled by an explosion, just imploded with no control at all.

Dr. Fenn: The legal system frequently traumatizes rape victims as much as the rape.

Medic554: Shock treatments should be outlawed! They do more bad than good.

debmyster: I am a forty-two-year-old woman and have been diagnosed with PTSD for about fifteen years and it's still lingering.

shariohio: Hello, I have suffered from anxiety attacks for ten years and still have no relief. I am so tired of this. I can't go anywhere by myself and its frustrating.

Dr. Fenn: If you are not progressing, consider changing providers. The same goes for EMDR, the therapist is probably much more important than the technique.

David: Here are a few kind words for Dr. Fenn:

Mucky: This is the most useful conference I have been to. Dr. Fenn is a very good speaker. Thank you for having him, and thank you, Dr. Fenn for coming.

Dr. Fenn: Thanks to all.

David: If you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com.

Thank you, Dr. Fenn, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a large Abuse Issues and Anxiety Disorders communities here at HealthyPlace.com.

Thanks again, Dr. Fenn and good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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