Hello, Dr. Floyd.
Hi there. We're not going to say good morning?
It's not morning.
Dr. Malsberg, I don't know if I trust your judgment here. I feel like it's the morning for me.
It's all relative though, right?
Exactly.
Because it's not the morning for me.
Yeah. You're not going to convince me it's not the morning though. And I think that brings us to our topic today.
That is correct. But before we jump to our topic, I have a question. Do you like jazz? I do. Who do you like in jazz?
Bill Evans, mostly. I'm not too picky. I mostly just listen to people who strike my fancy.
Very nice. I ask because, especially with complex topics, I notice that there's a lot of teachers who teach in what I call jazz teaching, where they just, they ski bop from one topic to the next. And it's hard to, it's almost like they're playing jazz with their ideas. And it's really hard to pin them down.
Yeah, and Dr. Malsberg, I think, is bringing this up because that's me. I do have that problem, and I rely on the good ship Malsberg to set the course correctly.
And I'm not necessarily saying you have that problem. I think anyone who's really well-read is just at risk of ski-bopping from one...
There's no need to be gentle. I self-identify as having that problem. I know I do.
You identify as a jazz teacher?
Oh, yeah. That's right. I mean, I never heard that term until you brought it up, but yeah, definitely.
Yeah. Yeah, because I just remember in residency, there'd be some teachers that you couldn't hold them down to anything. And any sort of question, you'd get just this crazy jazz symphony. And then it'd be like, do you remember what my question was?
Yeah, yeah. When I staff, I try to now just keep it to one teaching point. But obviously, that doesn't happen most of the time.
So yeah, my goal today is to hold you down like a slippery fish. Let's try it. So today we're talking about treatment of PTSD because last time we talked a little bit about the concept of PTSD.
Right. And that's why I was talking about trust and the fact that I believe something differently from you, right? Because trust is sort of the fundamental thing that you need to establish first, really for any treatment, but especially in the treatment of trauma. And understanding that people have different perspectives that can be very resistant to integrating, especially between the clinician and the patient, is pretty much huge.
Now, before we jump to trusts, I think we should do a super brief overview of medications. And let's not get into the nitty gritty.
Let's kind of just talk about... Okay, we're going to go behind the curtain. You keep saying that. You were saying that before we start recording, and I disagree. We're going to get into the medications. All right. But I guess... It's a preview for later. We're going to get slightly more detailed into the Genet three-stage model for trauma treatment. Medications, in my opinion, are huge for stage one, which is stabilization, trust, safety.
yeah now you know in regards to treatment goals for ptsd and we talked about that a little bit in the last one maintain safety is a huge one reducing symptoms of distress related to intrusive re-experiencing talking about nightmares flashbacks unwanted thoughts all that good stuff reducing hyper arousal yeah reducing avoidant behaviors lessening risk of anxiety related to fear of recurrence and then a big one is addressing comorbidities and then of course overall which is just true of nearly every diagnosis improving adaptive and psychosocial functioning
Yeah. And medications can and do play a very nice role with that. Now we shouldn't overstate it. I tell every patient, this medication is not going to solve your problems. This medication is not going to take over, take over, take away the fact that you had these traumas, but it'll help. It's going to help reduce how bad it is. Hopefully it'll help you sleep and it'll help you move forward with the treatment that you really need to be doing, which is the psychotherapy and the lifestyle changes.
Yeah, and that's a great way. That's how I frame it, too, in that the medications allow you to stabilize to a point where you can really engage in therapy that will address your PTSD.
Now, the awkward area, of course, is that we don't really have a lot of good evidence for medications when it comes to treating PTSD. Nonetheless, there is this dizzying array of choices that you can use anyway off-label. You know, there are only how many medications approved by the FDA? There are two FDA-approved medications.
For PTSD. And they are sertraline and paroxetine.
Right, yeah. I do like to use sertraline. I try to avoid Paxil because I don't like to give people weight gain, as you know, with medications. But there's a lot more than that. So, I mean, what are you trying to do with medications, I think?
Before we jump into that, because I feel like it's almost, for a lot of guidelines and stuff, it's assumed that this is always known. But I always like to hammer it in because a lot of practitioners don't practice that way. First line is trauma-focused psychotherapy. Medications are an alternative if a patient truly does not want therapy but shouldn't be viewed as therapy or medication. It should be a patient who doesn't or isn't ready to engage in therapy.
The medications are an alternative. Mm-hmm. I just think it's so important because I see so many people who are only throwing medications at a problem and not seeing why it's changing.
Yeah, yeah. I don't like that, certainly, for trauma treatment. I will say I don't necessarily see the medications as optional in moderate to severe cases. What do I mean by that? I think if you're seeing enough disruption of work functioning clear-cut or just a really disrupted sleep, I think it's actually pretty important to medicate alongside the trauma treatment. I think it's going to be hard for them to do trauma treatment through psychotherapy or lifestyle changes if you don't stabilize them a little bit.
Absolutely. And I like how you said in that point, the medications are stabilizing you to engage in therapy. It's not medications or therapy, I guess. But yeah, I agree entirely with your point.
Now, I don't know if you've seen the chart of medications from the VA about what can be used in PTSD and accompanying evidence base, but it's pretty much, I don't know, something like 20 different types of medications of maybe four to five classes. All of them are poor evidence. Okay. Yeah. So we want to start out with that, I think, when we're talking about medications and the treatment of PTSD that we have low evidence.
It's all pretty much off-label except we're certainly in Paxil. And, you know, we're kind of shooting in the dark. So the following things that I'm going to talk about, that's my favorites. This is in my experience treating a lot of community-based trauma.
Yeah, so I'll start with the, like, super simplified guidelines, and then we can help hammer in the specifics and what people actually see. Sounds good. So starting with, like, this is, like, the most basic, you know, like, if you were to make a flow chart, what it would look like, and then we can actually give it color. The basics are super duper simple. It's start with an SSRI.
If that doesn't work, switch to another SSRI. And I'm talking about without any nuance involved in these, you know, like your clean cut patients. SSRI, if that doesn't work, switch to another SSRI. If that doesn't work, you can add a second-gen antipsychotic. Prazosin is also considered for patients with significant sleep disturbance, most typically nightmares. Other medications largely have minimal evidence. There's a combo of Brexpiprazole and sertraline.
That is considered like a novel treatment. But there's still not enough evidence to kind of push it in front of other ones, in my opinion. We should be avoiding benzodiazepines. And that's because there's an absence of clear benefit. It could worsen the PTSD. And the big problem is it impairs learning in therapy. So it's going to diminish the effectiveness of exposure therapy, which is part and parcel of treatment.
Yeah, that's one I really want to emphasize, you know, and I totally agree with that one. You got to remember that something like a benzodiazepine is going to slow down recovery, right? Yes, you're suppressing the symptoms, but that one really does kind of match the anti-psychiatry accusations that we're just suppressing symptoms instead of bringing people progress along their treatments. So please don't use the benzos.
So I feel like that's really the crux of it. SSRI, then SSRI, then second-gen antipsychotic, avoid benzos, and then everything else. I think we're getting into the more colorful stuff.
Now, I'm going to acknowledge that that's a mainstream, quote, evidence-based algorithm. I do not like that algorithm. I think it's suffering just like the sleep algorithm that we have out from the sleep societies from what's essentially research and publication bias. The absence of evidence is not the evidence of absence of efficacy. Right. And there's just limited studies on alternative agents because most of the agents that I think are helpful in PTSD are off patent.
Nobody is going to want to try to get a new indication for this. You know what's new and sexy? Psilocybin. Okay. Magic mushrooms are sexy. They're researching that. They're going to research ketamine and all that. But here's how I approach things in the community. I would say that probably if somebody has PTSD and they're coming in to see the psychiatrist and they're not just either remitting on their own slowly or working through it with a counselor or a psychotherapist, it's because the sleep is severely disrupted.
And you do see this pretty often in PTSD. Even if it's just simple occasional nightmares or it can be a full blown fear of sleep cycle that develops because what's happening every night they are being automatically assailed by the trauma memories or at least nightmares that are very similar to it. So that's pretty bad. If you're not getting your sleep, you're not going to be able to function very well during the daytime.
Everything else is going to get worse. Now, if you start surgery, in most people, that's actually going to be enough. you will find that the nightmare frequency will at least decrease. Sometimes the sleep will regulate itself if you simply start an SSRI. Now, I also find that in moderate to severe cases, that's slower and does not necessarily get people there as quickly either. So I try to give a sleep agent.
Yeah. And, you know, that reminds me of, you know, you mentioned you're a sleep first psychiatrist, which I really like in that it's such a huge aspect of so many disorders and has a nice feedback loop that, you know, the disorder makes the sleep worse and then the worsening sleep makes the disorder worse. So if you get that on track, a lot of times you'll see just downstream improvements.
So, yeah, let's talk about the specifics of how you address sleep in PTSD.
Yeah, and you can go back to the sleep podcast episode that we did a while back if you want details. But it's a very similar approach that I do for depression. Basically, I give some kind of a medication. It's usually trazodone or gabapentin. Hydroxyzine is just fine, too. I avoid anticholinerotics like Benadryl, if I can help it. And if those aren't options for whatever reason, you can even consider things that regulate blood pressure.
The one that I use most is a beta blocker like propranolol. People obviously like to use prazosin. Don't forget that how much prazosin you're supposed to use depends a lot. on the individual, right? When they did the study on male veterans, mostly male veterans, I believe they were going up to seven or eight milligrams, pretty high. Everyone's a little different. Same thing for clonidine. And you could even think of something like Topamax.
That may have some efficacy as well. for reducing nightmares but essentially anything that can reduce the nightmare or even if it's not nightmares the panic fear threat response that happens automatically during the sleep cycle that can help you out and in my opinion really augment the speed of the SRI treatment.
Now, just to clarify to see if I'm hearing you correctly, so you mentioned at the start you consider gabapentin, trazodone, hydroxyzine. Now, you don't consider something like clonidine or prazosin above those things for sleep in these patients? Yeah.
Yeah, that's a personal quirk. I know many psychiatrists do that and they get a lot of good efficacy. I personally try to avoid messing around with the blood pressure right away because I've found in my experience I don't need to. The gabapentin and the terazin is usually enough, even at low doses for most cases. I don't have to... do something that adjusts blood pressure. Obviously, the blood pressure, the alpha, beta mechanisms definitely work, it seems like, in conditions where the fear, anxiety, threat response is out of whack.
But I still don't have to go there. But if you are a practitioner who's comfortable with those, those are perfectly good options for sleep support at the start. Okay.
So, yeah, I guess to recap, you have a super low threshold to comorbidly treat the sleep at the same time that you're throwing on the SSRI. Now, I also, you know, just to add something aside from medications, which, you know, image rehearsal therapy for nightmares can be helpful too, which is a non-pharmacological add-on that can help. I have a little packet that I made in terms of like going through the steps for the patient.
I can link that in our show notes. All right. So you have SSRI. You treat sleep very low, super low threshold to treat sleep. What else are the important? Keep painting those pictures.
Well, I think what else is important to note is that at least I have a strong suspicion that the signal that is seen for Risperdal is more because of the alpha action and the sedative quality, the antihistamine. So I don't reach for the antipsychotic right away. Where I have found the antipsychotic to be very helpful is when the PTSD is of such severity and is accompanied by some kind of a true major depressive or even bipolar type mood, disorder, that they have that alongside it, a real comorbidity, not just PTSD looking like that.
You see things like the neurovegetative symptoms. They get it in this persistent episode differently from standard alone PTSD. In those cases, I definitely reach for the antipsychotic augmentation because they're very debilitated and you can get some good response pretty quickly.
And now from my understanding, and we kind of talked about, you know, the differential of psychotic symptoms in trauma, if there are psychotic symptoms within the context of PTSD, an antipsychotic still is what's typically recommended. Like you mentioned, either Rizponol at relatively low doses or quetiapine.
Yeah, that's right. Seroquel, Risperdal, even Zyprexa, I believe have been used in the literature. In my experience, if you see something that looks like MDV with psychotic features alongside the PTSD, don't be afraid to consider the agents for bipolar depression efficacy as well. Not that the patient is bipolar, but there is some reason to believe there is a little more efficacy for depression treatment. Abilify. That's not bipolar depression, but it seems to work.
Brexpiprazole, as you mentioned, lurasidone, cariprazine, etc. Now, I have some special experience with PTSD with secondary psychotic features, as it's called in the literature. Kind of a rare thing that's been talked about and studied. I started out with the mainstream. If you are getting reports of voices, these kinds of things that seem like they're psychotic in origin, treat with antipsychotic. I... over time found that for most cases, you don't need the antipsychotic.
What you need is the sleep support. So you can get away with the gabapentin. You can get away with the trazodone. You can get away with buspar, forgot to mention. In some patients, it's adequately sedating at a high dose. Even buspar, which has antipsychotic properties without the dopamine blockade, can be helpful. Not everyone responds. Some do need the antipsychotic. I come to a point where I feel like a lot of the time, the experiences of hearing apparent voices, noises, or seeing things, even flits of shadows going past that you see in the severe PTSD is a dissociative process and not properly with psychotic features process.
And that people need more of a full-on mood episode co-occurring with the PTSD to have the with psychotic features that warrants the classical added antipsychotic approach.
Got it. So I guess to repeat what you're saying is that because sleep medications are a lower risk treatment option, it makes sense to start with that because there's a decent chance it hits on the symptoms rather than going straight to the antipsychotics, which have more risks and more downsides.
Yeah, but I wouldn't hesitate if you're evaluating the patient and Their presentation, mental status exam, and history is pretty consistent with either major depression, with psychotic features, or especially something that seems more like mania or hypomania. But we also run into a wrench in the works here. I find that severe PTSD can be reported as something that really sounds like mania or hypomania. Some patients will talk about being awake for days.
I wonder if it's something somewhat similar to a paradoxical insomnia that is being induced by severe hypervigilance. Or I wonder if there are just some people who don't have a bipolar disorder, but constitutionally, if they're traumatized enough, they literally will be awake for days. But it's not... Mania or hypomania, unless, in my opinion, you see the accompanying features as described in the DSM or some kind of a family and life course history of the mood that shows you it's bipolar.
You don't need the antipsychotic. Again, you need sleep support and they need to be treated appropriately for the trauma.
Now, what are other core aspects of treatment? You know, let's not get into the like severe symptoms or like, you know, in terms of like moderate PTSD. Any other like core medications that you consider aside from, you know, SSRIs, second gen antipsychotics and sleep support?
They've talked about using mood stabilizers. I have not found that to be terribly helpful. Only the non-traditional mood stabilizers, not really mood stabilizers, Topamax and Gabapentin, I think, are more usable. I don't think there's much really left to say except for don't neglect the SSRI. There will be patients who really like the sleep support and then just kind of stick to that and they don't like the SSRI as much.
Don't neglect pushing that SSRI to an adequate dose. You will see benefits from that. It's just a slower acting one, generally speaking, than getting someone sleeping right away. But there are patients, especially mild to moderate PTSD, where if you simply stabilize asleep, they will recover. And that's not surprising considering the natural course of most PTSD where there isn't a lot of multi-trauma or complexity. Most will go into remission on their own, even without treatment.
But we're kind of helping people along, getting them back on their feet faster with the medication.
And just we kind of hammer on everything. You mentioned Buspar, and you like it at higher doses than commonly used.
Well, it kind of depends on who you ask. Some people say that's not a higher dose. That's normal. But yes, I start minimum 15 milligrams in the morning, 15 milligrams at night. I'm not terribly opposed to loading most of the dose at night if it's tolerated. And I try to get relatively quickly after a couple of visits to the maximum if they're responding correctly. Gotcha. If they're responding and they still need more remission, that's what I mean.
Now, I'm curious, you know, I think after this, I do want to go into the deeper dive of terms of like, you know, treatment principles. But, you know, I think in the last podcast, we kind of actually started off with a joke of like avoid avoidance. Is there any other like psycho ed that you provide, you know, early in treatment in terms of like basic principles for for patients that help them to engage in avoiding avoidance?
Yeah. I try to make it fairly clear that this is something that has happened to them both because of the traumas that they've had and also because of the response. That it's a rational but also perpetuating response to keep avoiding danger. I also emphasize that they should not, under any circumstances, be putting themselves at risk or in new dangerous situations or even old dangerous situations. I emphasize that I want them to go as slowly or quickly as they feel comfortable and only when they feel able to.
That's sort of the first phase of the Genet treatment model, the stabilization, safety and trust. Right. And basically, I say, you know, because of what has happened to you, you've probably developed this pattern of trying to withdraw from the life that you're living before or from other people and your activities. Or because this has been happening to you for so long from such a young age, you haven't really learned what types of settings are safe or productive for you to spend time in.
So whenever you feel ready, as part of this treatment, I want you to get a little bit more active. Whatever you can do to leave the house for activities, whatever you can do to make contact with other people, but people that are safe and trustworthy. So I'm really focusing on the socialization and the activity aspect because you can see in the criterion C of PTSD and with any intelligent look at trauma disorders, there's a lot of avoidance.
There's a lot of withdrawal and distrust of the world and other people.
That's great. And then, you know, I guess to recap what you're saying, and I think you'll feel free to disagree that the crux of the psychology of PTSD is that a patient develops cognitive and behavioral avoidance strategies to avoid distressing emotional reactions. And then the avoidance responses interfere with the natural processing of negative emotions and with the fear extinction that occurs when you have exposure to reminders that other things are safe and that the traumatic event is not going to recur, essentially.
Yeah, exactly. And, you know, you can think about it from a sort of neurobiology model saying the same stuff with different language as well. For example, in predictive coding, the short version of this is that our prior experiences give us things that we predict are going to happen in certain situations. You could think of PTSD as one where the prediction network of the brain just expects threat.
endanger so much that's out of whack, just like someone hearing the fireworks, for example. That loud noise gets through this prediction network of threat and then the threatening fear response starts to happen to the body and the mind. The solution to an out of whack prediction network is new experiences that can help sort of morph or at least develop the prediction network of the brain in a specific way.
These are called errors in that neurobiological theory. And then by getting new experiences that don't fit the expectations of danger and threat, that is how you sort of recalibrate things so that you're not constantly expecting danger and threat. Great.
If you wouldn't mind, I'm going to tell a little anecdote that I think might be helpful in terms of my own experiences. We talked about it in an earlier podcast. The way I learn best is by putting my own experiences and making sense of them to better understand things. Yeah. When I was in the emergency room, the day that I actually quit the emergency room, I had a patient that I walked in with the nurse to medicate the patient.
We explained why they needed the medications and the patient said, yeah, that's totally fine and turned and accepted the medication to their arm. As the nurse went to go give the medication, he swung with his left hand and punched her in the head. And I was standing right there with security. So with security, we were able to hold him to prevent him from continuing to beat up on the nurse.
We were able to get the patient medicated. I guess I'll just continue the full story. He bit his lip because he had HIV and he started spitting at us to try to get us infected with the HIV. And we were able to get him medicated and he calmed down and the situation went away. But the nurse had to go to the ER. And after that day, I remember I was like kind of Shook.
Naturally. And I wasn't the one who got hit. I was still relatively safe in that.
It doesn't matter. It's a criteria in a trauma, isn't it?
And after I went home, I did not want to return to work. When I did, I had a few days off. I was dreading going in. On the subway, I remember any loud noise, I would jump like crazy. I remember when I did return to work, my threshold for... Kind of being on high alert and wanting to medicate patients was really, really high. Like I was super anxious.
And then after a few weeks, I was fine and kind of back to my normal self. Now, I remember I saw the nurse who did get hit in the face like a month later in the emergency room. And I was like really impressed. I was like, oh my, you're back already? And she's like, yeah, I knew if I didn't come back that I would never come back.
So like I just needed to kind of get back on the floor. I was so impressed by that because I had this like visceral response and this, you know, like my startle response was super high just having witnessed what she experienced. And then over time, I kind of returned to my normal self and I no longer was on hyper reactive to things. And it was an event I was able to process.
I had control over it. And then I said, I don't want to work in the emergency room anymore. And... I was fine. But I think that's a story in terms of what happens when you experience something that is emotionally intense and how over time you kind of learn more information that this is not going to happen to me all the time.
Yeah. I mean, thanks for sharing that. That's a very difficult and distressing situation that you went through and saw. And very nice demonstration, too, of that exposure can lead to treatment improvement and also some degree avoidance can also be healthy, right? Both of your choices were appropriate, I think. And the main difference is looking at the outcome and also that, at least for the nurse, this was something that she chose, right?
She had the control over it. She processed it the way that she felt was right. And hopefully there's a good outcome there. I'm really tempted, by the way, to have a completely unrelated aside about the safety and positioning of the patient during involuntary medication. Absolutely.
But too much.
We can't lay face down. Make lay face down, people should be in the protocol. OK, well, let's let's move on with that.
Yeah, but I guess that I can really see how if I didn't have a little time to process it, if I didn't have time to go back to work, if I let that fear... You can really see how these different patterns can develop as a result of the fear that develops from a traumatic response.
Yeah, and I want people to be understanding too, right? The people who... develop the chronic ptsd it's not because they you know are little brats who refuse to expose themselves or weak people or something like that right i would say that it's generally some combination of how much strength were they allowed to develop in their childhood and also how many traumas have they been able to live through That load and the lack of relative strength development for whatever reason will make their outcome different.
And, you know, I think we got to be understanding that we need people to get back onto the path of recovery or onto the path of development recovery they never had. But don't be overly judgmental. It's a difficult process.
Yeah, and I'm glad you bring that up because I didn't... Like, you know, the point wasn't that... The point was that, like, I very easily could have not returned. And, you know, I think by the grace of God, I was able to continue on. And, you know, I wasn't the one who had that terrible thing occur to me. I had tons of control. I had a lot of safety in it.
And still, I had a very visceral reaction. So I think this will get to... Well, I guess, you know, before we move on to the principles, do we any wrap ups that we want to do on the medication side?
Some patients will get very scared of bringing down the medications. Once they're stable, this is natural, especially if they were living with a PTSD for many years, they're going to feel or think that the medication is absolutely essential. If you have laid the appropriate treatment groundwork, that the medications were not the cause for recovery, but that they, their choices and their behaviors were the cause for recovery, assuming, by the way, that the PTSD was appropriately diagnosed, then they will feel more comfortable.
Yes, after some degree of stability, we don't have any data on this. I just do the arbitrary one year of remission thing. You can definitely at least peel off some of this medication. One more small thing. For the people with apparent voices, noises, and paranoia that may be more dissociative and trauma-based instead of actual with psychotic features psychosis, do not be surprised if they continue to have some degree of that for their whole lives.
OK, don't chase that by pumping up the antipsychotic. Most of the time doesn't work or you're just over sedating them so that they don't have that anymore. It's not dangerous. The treatment target is not zero voices, noises, experiences. The treatment target is those things don't bother me. That's the treatment target.
Yeah, that's great. And focusing on on functionality, not on, you know, reduction of the specific symptom. You know, I'm actually reminded of a patient that was on Serequel 600 for trauma voices. My goal was to get them off the circle because they'd been on for a long time to develop metabolic side effects. We got to 400. There was absolutely no decrease. We got to 300 and they started the distress of the voices was so much that it impacted her life.
So we went back to 400. So, you know, kind of talking to like we weren't I wasn't assessing voices or no voices. I was assessing the distress of the voices and how it impacted her functionality.
Oh, I guess I forgot to mention mirtazapine. It's a very good choice if you don't mind the appetite increase in weight gain. It may be, in my opinion, one of the best choices as long as there's no concern about weight gain, appetite increase.
What makes you say mirtazapine is better than the other sleepers you mentioned?
Well, it just seems to have a little bit more antihistamine action and the alpha action, all that stuff, dirtier drug. People just seem to respond better than, for example, Paxil. I would suspect, by the way, that any TCA would be good also. Any tetracyclic, anything like that. But, you know, I don't. go for those generally, again, because of the side effect profile.
With mirtazapine, just in terms of my clinical experience, it is really, really, really sedating. So I do like to warn patients that it can be like overwhelmingly sedating and that like you feel like a complete zombie the next day. That's expected to get better usually after a week. And it's supposed to get better every single day. I think it's worth warning patients because it can be like really, really overwhelming for patients because they'll be like, you completely zombified me.
Like this drug is the worst. But the truth is if that patient could tolerate it for a week, usually it will get better. But that said, I also take patients at their word that I've had patients on it for two weeks and they are a complete zombie and it just, they can't get through it. And we could try to lower the dose, but take that zombie feeling serious.
It's not like, I don't know, it can be really, really, really sedating.
Yeah, it's just person to person, it seems like. And keep in mind that antihistamine-type drugs seem to be more sedating, especially during the day experience for Asians. That's kind of like a maybe thing, probably. Oh, little extra thing. Trazodone does have an active metabolite that can be agitating. So some people, for whatever reason, seem to respond to Trazodone even at lower doses of agitation. Don't try to play around further with it if you're getting actual agitation on Trazodone.
Just switch to med.
Yeah, I think so. Yeah, I guess it's a good point. There are patients who have like paradoxical responses to trazodone. Don't have them power through it. Yeah, it's not placebo.
There is an active metabolite that's agitating.
And yeah, the thing is mirtazapine has a really long half-life. So take them seriously if they're zonked during the day.
Yeah.
Um, all right. Should, well, yeah. And I, uh, I asked you this off, off the podcast and I, you know, in terms of patients with the dissociation symptoms, um, before we get into the principles, uh, how do you explain to patients the best, like, let's say, you know, Hey doc, like I dissociate, uh, whenever this happens, like, and then I fight against it. Like, what should I do with the dissociation?
Well, I probably advise against fighting it. Part of that fighting response seems to pull people into a generalized fear or anxiety response that might make things work. I would essentially tell them that, you know, this is just one of the ways that some people seem to respond to distress. And if it's not something that is causing you some extremely serious problem, I know it's kind of disturbing to have this, but I wouldn't worry about it too much.
I know that sounds silly that I'm telling you not to worry about it too much, but just try to let it come and go and focus on the appropriate treatment. Focus more on what you should be doing. Don't be too worried if that's happening to you. And then there are grounding techniques that you can teach people. I would generally recommend that you don't use the traditional kind of more mindfulness diffusion, still sitting kind of Grounding techniques.
Try to get people active if they're dissociating. Seems to be more of a freeze response. So make there are plenty of choices. You can review the literature of grounding techniques that are active in some fashion. Think of the DBT mindfulness module and the participate skills. OK, anything like that.
Yeah, that's great. And yeah, I do find providing the psycho-ed that fighting against it can be counterproductive. And in a sense, to me, I think the best starting place is acceptance and not reinforcing it. And yeah, teaching grounding techniques.
Yeah. I think a lot of people are also afraid that they're completely out of control. or can't do anything at all, or are almost unconscious during dissociation, which is not generally true. Obviously, extremely severe dissociation bordering on psychotic break. Yeah, that's a little different. But for most garden variety dissociative reactions, I think you can assure patients that they are going to be still capable of keeping themselves safe in most situations and reacting appropriately to what's happening around them.
Yeah. Great. Um, I'm going to put a timeout. Uh, we're at 40 minutes.
I know. I know. I think what we do is we basically, the fact is I think it actually takes less time to talk about the peers and anything and the three stages and it's stuff we had covered before. So I think we covered the right stuff today.
Um, wait, sorry. So, uh, should we go into the three stages? We say that for another one.
We're at 40 minutes, right? I think we can do it. I think let's try it. And then if it seems going a little too long, I think we can do like a 30 minute wrap up for the next one and do some like reader questions or something.
Okay. All right. So I think we covered the core medications. I'm looking at the timer a little bit more than I expected. Why don't we just kind of touch on the three-stage model and maybe we can go into the deeper principles another time.
Yeah. So if you don't know Pierre Genet, he was a clinician, I suppose. He's a psychologist. He was someone who was trying to treat trauma and hysteria using hypnosis as well. This is basically around the time of Freud. His model for trauma treatment is still pretty much the same model that everyone is using. in my opinion, for bona fide proper trauma treatment. So keep this in mind.
And you might even explain this to the patients as part of psychoeducation in terms of how you do a trauma treatment. I think it's applicable to medication management too, even though obviously this is more about psychological therapy. so the first stage of the treatment you need to start with trust safety and stabilization okay the patient can't be overly dysregulated okay they can't be so looking out for danger that they can't think okay because when you're in fight or flight you can't think you can't put thoughts together And you also need to make sure you're actually safe.
OK, if someone is just chronically in a social situation where they are in danger, your treatment is not going to go very far. OK, so you need to then start working socially with social work resources to try to get this person relatively safer. And then if you can't, well, you just have to have the knowledge that you're not going to be progressing in the treatment in the same way.
The second stage, once you've established that safety, they've got their grounding techniques, they're adequately managed medically, then that's the middle stage of the treatment. That's the trauma processing. Once the patient is actually ready, they will process the emotional and cognitive experiences of the traumas and what those have produced for them. And then finally, the final stage is integration. That's where the patient kind of takes in The parts of them that have been split off or that they're afraid of confronting and experiencing, they're less afraid of them.
They're able to make it part of their whole experience and then they grow for it. People can and do regularly grow in some fashion, learn something, change in a positive way, not just a negative from traumas and adverse experiences. And that's the direction that we want to take people. And it's not just an integration inside the mind for me. I think it's an integration back into society, back into a life worth living.
So that's the third stage.
This is great. I'm thinking of early on not recognizing the importance of the first stage in terms of safety and being a novice therapist trying to work on more serious stuff, not having established a strong therapeutic alliance and not having made sure the patient feels safe and steady to start working on that stuff and It's a grind for the patient and the therapist because, you know, the blueprint's not built before you're kind of moving on to the house.
Can you talk to me how this plays out in medication management?
Well, I think a lot of this that... sort of is implicit and we don't do explicitly, we should do explicitly, is actually the treatment frame. A lot of treatment safety is not you giving the patient what they think they want or being very, very nice or understanding. That stuff is nice, right? It feels good. But how do you establish trust and safety in a treatment as a clinician?
It's about regularity and a really solid and unwavering understanding of what you're there to do. Right. You want to let patients know at the outset what your job is, what your job isn't and what you're going to do together when you're going to meet. OK, not just randomly. but how long and how long in total you expect to meet. The unpredictable nature of the world and life is already what has been a problem for patients who are traumatized.
You need to be extremely clear and draw good boundaries for the patient, for the good of the patient, so that it can feel, I know when I'm going to see you, I know what I'm supposed to do, I know what I'm supposed to do outside.
Can you help detail what you are going to do with the patient?
Well, it could be very simple. It could say, I'm the psychiatrist. My job at this clinic is to help you with medications. Medications are just to support you as you do XYZ, which is, of course, psychotherapy and lifestyle changes. I'm going to see you today for a certain amount of time. I'm going to try to get a diagnosis first. And once we're through with that, then I'm going to be checking out medications for you and how they're treating you.
We'll meet probably X amount of times or every X weeks. Just that kind, right? Anything like that. You don't have to be so concrete and upfront about it. Those are probably all elements that I cover scattered throughout the actual visit. But try not to leave it to be like, Call me anytime. Or, you know, let's just take care of you. We'll make sure things are okay. Those are things you can say, but, or thinking, saying like, oh, you can trust me.
You can say anything here. Okay. You can't just say these things. You have to just make them true. You have to be available to the extent that is realistic. You have to actually be interested, investigate, and help in some fashion. And you have to keep your promises. Right. Even if that promises we're meeting in three weeks. That's basically what I mean when I talk about the treatment frame.
We could go very long on this if we talk about from a psychotherapy standpoint. But I think it's important to medication, too.
Yeah, I mean, God, I wish I had known this when I had started throwing in a residency clinic full of patients I wasn't quite ready to treat. It's such an important aspect in regards to keeping the patient understanding what's expected to happen and the provider, I don't know. able to deal with challenges as they come up.
Yeah. I mean, a lot of anxiety for anyone is just being untethered, not knowing what to expect. Right. So if you can set and keep expectations, that is how you show that you and the treatment are trustworthy.
Now, I'm curious, what are some other expectations you see that you set with some regular frequency with patients? I think you tailor it to certain patients depending on diagnosis and what's going on, but what are ones that you commonly see yourself setting that are really productive and helpful?
You know, I think we already said it, but it's worth repeating. I think the most important one is to tell them what to actually expect from the medications. You mentioned some of that, right? It can be about adverse effects. This medication is not going to make you feel happy. This medication is not going to solve all your problems. What it's going to do is that the sleep will improve, hopefully a lot, but maybe just a little bit.
right or this medication is going to help you but it's well this medication is probably going to help you that's what i expect but you're going to have some side effects to begin with if we use this one you're probably going to feel real sleepy for a while you might not feel sleepy enough and if you have that problem i want you to tell me about it call me and leave me a message and we're going to talk about in detail the next formal visit for example It depends on how you're running your practice.
It depends on the resources, the amount of resources you can provide to the community or the population that you're working with. But you've just got to be clear and honest about what they can and should expect.
That's great. Any other common, I don't know, conversations that you have that you find are productive?
Yeah, it's unique to the way I conduct treatment, and I do recommend that medication management actually take place separately from psychotherapy, even if you're capable of doing both. I'm not talking about the E&M trick of billing for both at the same time with some supportive or something, okay? That's a billing thing. I'm talking about actual treatment. So I try to make it clear, you know, the time we spend together, what I'm going to be really focusing on is a medical assessment of sort of how you're doing energy, sleep, behaviors, activity, and how are the medications treating you.
What I want you to be doing, and what's more important than what we're doing, is the trauma psychotherapy that you're getting into when you work with your therapist. Or, I'll say, and it's really important that you find a therapist that is experienced and qualified to treat trauma with a trauma psychotherapy, and that's the real treat. And then, of course, I talk about that third pillar. So we've covered two of the pillars, medications and psychotherapy, the third pillar.
And that's not enough, too. That's our job. Our job is to give you these treatments, the psychotherapy, medication. And what you need to do, your responsibility is to come to the appointments and also to make sure that you're making changes in your day to day life to the extent that is possible for you.
Yeah. And this, this is great. And, um, you know, I think we've all, you know, the, the difference I've seen in terms of medication management, when a patient has a therapist that they're doing productive work on, uh, versus, um, not being in therapy is, is just night and day. The medications work better. The not work better. The, the, I think they work better.
Progress.
Yeah. Yeah. Yeah. Um, now what about patients who say, listen, doc, I'm not, I'm not doing therapy. Um,
Well, I say, you know, that's your choice. I think it's the wrong choice. It sounds like you want to accomplish X, Y, Z. You don't want to be feeling this way. I'm not sure how much you're going to improve without the psychotherapy. You're welcome to try, but that's what I'm recommending. I'll revisit it. You know, you can't necessarily get someone to agree with you or your recommendations on the first visit.
You just have to work with that. Same thing for any condition that we encounter.
Yeah, and it's funny because I see so many, you know, when I supervise different practitioners, you know, it's like the patient doesn't want to do therapy. Like, what's the next medication I should try? And it's like, you know, you have to appreciate what the patient's desires and values are. But that doesn't mean that reality changes in that, you know, like you can you can find a workaround to the treatment and find a medication that works for what they desire to work for just because they won't do the thing that will change what they want.
Yeah. When the patient won't accept the medically necessary treatment, your job as a clinician is to continue to counsel them on accepting the medically necessary treatment. And I don't mean just simply telling them over and over that's what they need to do. And if you need some guidance on how to best do this, the primary literature of motivational interviewing, I think, is most helpful. Forget what you know from the smoking cessation seminar of maybe one to two hours that you did several years ago.
Read the original books of motivational interviewing. And by the way, now that we've named a specific psychotherapy type, And we're kind of out of time. Maybe we can dangle the possibility. How about next time or some future time? We kind of do a little survey of trauma psychotherapy types or lifestyle changes that can be engaged in to help with trauma and maybe do some listener questions. Can listeners leave some questions about trauma?
Yeah, that would be awesome. I feel like usually we get one or two questions that I unfortunately ignore. Sorry, our faithful listeners out there. But yeah, I think in this one, if we get some great questions, we're going to be prepared to answer them.
Yeah, there is already many great questions, but I guess we just haven't really been doing breeder questions. I like them. I think about them. Also, in terms of shower crime behaviors, I'd love to see more Reddit comments. I like being on Reddit. It seems like people see it on Reddit, but they never comment. If you're listening to this and you're a Redditor, help me with my pathetic desires.
What do you think about the podcast? Give me your thoughts.
I guess what's funny is that it sounds like we're just trying to cheapishly get engagement.
Well, I sure am, but psychologically I'm also interested.
Yeah, I think you also just get a kick out of reading and responding more so than your desire to be the most world-famous psychiatrist,
Dr. Fu.
Yeah. All right. So, yeah, the three phases of treatment, safety, number one being safety, number two being trauma processing, three being integration. We expanded a little bit on one with regards to medication management. Is there anything, I don't know, specific about two and three that we can say about? And when I say medication management, I don't actually mean like the prescribing. I mean like the modality of, you know, 30-minute visits once a month more so than the prescribing medications.
Yeah. But is there anything more that you can say about two and three? Yeah,
I mean, I guess phases two and three have to be addressed with the other pillars of psychiatric treatment, not medication management, but psychotherapy and lifestyle changes. Those are the only way, really. Yeah. We don't have another good way. Even if you look at a one-off treatment like a psilocybin treatment, most likely what is happening is that there is some kind of a neurobiological change that has people go on to make those changes psychotherapeutically, intrapsychically, and within their life.
Now, I'm curious, is there any... aspects of like trauma processing that can occur through psychoeducation of the patient doing on their own without therapy.
I mean, that's speculative, right? How would we look into that? I wouldn't speculate too much. What I would say is don't try the trauma process when you're doing medication management. It's not appropriate. You don't want to teach patients to be afraid of the trauma memories. But on the other hand, you kind of don't need to. If they weren't afraid or distressed from trauma memories, they wouldn't have PTSD, basically.
Your job is not to abruptly process the trauma or bring it up beyond whatever you need to gather for medically necessary data. Ground the patients that they're dysregulating and get the minimum necessary data for the medication management only. The place for getting through the trauma memories is the psychotherapy. That is something I actively tell patients. I say, you know, what we're doing here, I don't want getting sucked back into trauma memories.
Okay, we're just going to talk about what we need to figure out how to help you with the medications. But you need a trauma psychotherapist where you can talk about that stuff when you feel safe and ready to do so.
Okay. Now, what about patients who bring that stuff up spontaneously? And, you know, I guess I see a lot of a lot of providers who think about how to word this patients who kind of go into therapy mode because they're used to seeing a therapist with their psychiatrist. What would you do with that patient?
I tell them. I tell them at the start and I remind them, hey, try to remember, not try to remember. Hey, remember, I'm trying to help you the most using medications right now. That's how we're doing this in our meetings. And I do need to, I'm sorry, I know this is very important stuff and I'm glad you're sharing with me. I appreciate that. At the same time, I want to use the time productively.
I want to talk about the things that help me figure out what to do with medications for you. And again, I love that you're trying to tell me about these things. I think it's very important. I want you to find a psychotherapist to talk about this with. Well, hopefully that was helpful and interesting. As always, like, comment, subscribe, share, , etc. Finesse the YouTube algorithm. And I guess I'll see you next time.
All right. We appreciate it. See you next time.
Bye.