Welcome to the Psychofarm podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
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Morning, Dr. Malbert.
Good morning. It's not quite morning, though. We're meeting a little later today, aren't we?
Yeah, it's Joe. Are you afraid?
Afraid of?
Today's topic.
A little bit. We're going to talk about trauma, right? That's what's on the agenda, and we'll see how it goes.
Yeah, well, don't be afraid. Avoid avoidance. Don't forget.
Fear is the enemy.
Though it's a little much easier said than done.
Well, I mean... Maybe to make me a little bit less afraid, why don't you tell me what is trauma, how you define it and how you think about it?
I think that everyone is pretty sure they know what trauma is in a common language. Oh, I disagree.
Oh, well, I mean, you say in common language, it's just that to me, it's like a word like depression where it's like this gigantic bucket of stuff. And there's big T trauma, little T trauma, war trauma, sexual trauma, traumas of every day. So it's such a hard concept to grasp when we're talking about something specific.
Yeah, totally. You know, it's everyone thinks they know. Well, okay. I don't want to say anything to know. Everyone does know what they mean when they say trauma. It's a common word. People know what it means when they feel traumatized. Now, does that mean the same thing that we should mean as clinicians and researchers when we talk about trauma? I don't think so. The big T, little t trauma is helpful when...
We make that distinction. But I think what's more helpful is to ask, why does anyone make a distinction between big T and little t trauma at all? And I would say that there is a utility and there's a legal Clinical Reality to Preserving and Utilizing the DSM Model for Post Traumatic Stress Disorder. Being very specific with that criteria is useful because it sort of ties you to a well-researched and fairly well-constructed syndrome that is unique and not everyone is That undergoes traumas gets PTSD as defined in the DSM.
Well, I'm going to give you, because I'm trying to listen to what you're saying in a different ear. Can you help define little T trauma, big T trauma, and PTSD? And what's the difference between all three?
Well, I think that most people... Would essentially define trauma almost in a circular fashion. It's anything that they found traumatic. You know, extremely upsetting. Emotionally, physically, or personally threatening in a very scary or shocking way. That's traumatic. So when we talk about little t traumas, that can be anything from what laypeople refer to to what some clinicians will consider traumatic. And you can cover a lot of categories that can be emotional abuse, right?
That can be adverse childhood experiences like with the ACE study. It's just not very well defined and it goes from mild to more severe. Now, big T trauma. I think that most people, when they refer to that, they're talking about DSM criterion A trauma and trauma. At least in the fifth edition, what we're thinking about, what we're considering meets that is going to be direct threats to life, serious injury, or for sexual assault to the person witnessing that or learning about Either of those trauma types happening to someone very close to you.
I like to add in a manner that shocked or scared you, and I know that's a little bit more like DSM-IV, but I think that that's helpful to make that distinction, even though I understand it's not strictly in the DSM criteria. This is for clinical purposes. And then there's one more category that no one really talks about very much, but it sort of counts. Sorry, it doesn't sort of count.
It does count under DSM rules. But if you encounter traumatic material in an electronic format through your work as part of your work, that counts. It's a little carve out for people who, for example, work with child abuse cases.
Okay. So, I mean, I guess, as you mentioned, what you're using is the criterion A of PTSD to define what trauma is. And we're calling trauma actual or threatened death, serious injury, or some sort of sexual violence. Is that correct?
Yes, that's correct. And it's kind of funny because actual or threatened doesn't, to my knowledge, actually specify whether that's objective test or a subjective test. You know, I think that the text of the DSN-5 seems to imply that it's supposed to be objective. It's supposed to be objectively threatening in some fashion.
To me, that's surprising because I think subjective is so much more important.
Yeah. Personally, I think clinically, why do we even define big T traumas? Why do we define a criterion A trauma? It's because we are aware that there is a syndrome that we call PTSD. And how does that syndrome develop? It's a subjective experience. So I do think that while we need something reasonably objective, there still needs to be that subjective experience to match that thing that's reasonably objective.
You know, I've got a friend, he's a neurologist, so this question will not surprise you. But he likes to question and tease. He says, if somebody feels actual or threatened death upon the sight of seeing a cockroach, is that going to be trauma? Is that traumatic? Well, I guess it doesn't matter because for the most part, we do not encounter situations where people have the genuine fear response upon encountering something that would not ordinarily cause a genuine severe fear response in most human beings.
There is a little exception, though, and I think there have been cases documented where this has happened. I've seen one personally. Can you guess what the exception is? A situation where a trauma is not objectively threatening, yet the subject can develop PTSD.
Yeah, I would be thinking, I'm trying to read your mind here, but I would think if you were talking about like manic or psychotic patients.
You got it. That's right. If you encounter it because of a delusion, right, a hallucination, it's technically not objectively threatening. But I would say that that's a situation where most people encountering that and unable to tell apart from reality would be objectively threatened. And there's one more weird one that you only see in forensics. People can develop PTSD from being essentially the assailant, the murderer. Interesting, isn't it?
Yeah, and I'll talk about both of those things. As you're saying, to me, all that matters is a subjective experience of the thought that you're threatened in some way. So even if it's from a delusional source, you're still going to be experiencing the exact same things internally, even if externally it doesn't match up with reality, like if it's a cockroach or if it's a delusional belief. Mm-hmm.
Then what you were saying is that the perpetrator can traumatize themselves because they're witnessing such horrific events.
Yes, it is possible.
Now, the reason why I think I have a silly response to that is because we think of traumatized people as victims. And here we're talking about a perpetrator becoming traumatized with full agency.
Yeah. So that is something that touches upon sort of the cultural milieu that we have with PTSD these days, right? We, I mean, it's not strange. 99% of the time, if you've developed PTSD, it's because you've been victimized in some fashion, you know, whether that's by natural disaster, something by accident, or just some perpetrator. But that brings me to what is PTSD?
Before, I do want to just read off. You said this, but I kind of want to just hammer it in. You were saying in terms of the exposure, it can directly expose to the trauma. So you actually have the experience directly. Also includes if you're an eyewitness to other person exposed to trauma. Doesn't have to be eyewitness. It's just a witness. It's just a witness.
Learning of a lot of people in prison will hear people being sexually assaulted or killed or severely injured in another cell. Yeah. Yeah.
Number four, which you already talked about, repeated or extreme exposure to aversive details of traumatic events in person or via work-related media. I think that's showing the horrific consequences of people who have to watch childhood sexual abuse as a part of their job. Yeah.
Yeah. So where were we? We were talking about, oh, the actual syndrome of PTSD. So, you know, you can...
Oh, and before we jump to the syndrome, what is it that's going on that a traumatic event and like seeing it or just being exposed to it, what's going on internally that it leads to potential symptoms of the syndrome?
Well, I don't think we have a definitive answer for this, but basically we believe that it's a state of fight flight fear, right? It's a fear response. It's something so threatening to yourself or your, uh, Integrity of self for sexual assault. Though, of course, sexual assault often comes with a threat to life and limb as well, often does. Something so threatening that a whole psychological and physiological response occurs and then produces an ongoing issue.
So, I mean, that kind of goes completely neatly into how we should conceptualize PTSD. Anyone can experience traumas. Everyone does experience traumas, both big and little t. But not everyone who experiences a traumatic event, even of the big T variety, will go on to develop PTSD. And not everyone who develops PTSD will continue to have it. In fact, based on some research, you could say that the majority of people will go into remission without any treatment within a year, sometimes even less.
I don't know if most people know that. It's hard to imagine, I think, especially as a clinician when we're mostly seeing cases of moderate to severe persistent post-traumatic stress disorder.
Maybe to elaborate on some of the things and tell me if anything I say you don't feel like applies or I'm saying it incorrectly. I think of it as an event where someone's fight or flight goes off and for whatever reason they get trapped. And they can't escape from the situation. And it's usually an event that is so overwhelming to like a person's ideas of how the world works or their ideas of self or others.
And that this event, which is, they're inescapable. It almost like fragments ideas of safety and ideas of being able to have any sort of agency in a situation. I also like the, oh, were you saying anything?
No, go ahead.
Yeah, I was going to say, I think something that's maybe a little bit helpful is the learned helplessness model. In that situation, if you take dogs and you put a cage around them and shock them, and then you remove the cage, they're going to run as far as they can away from that shock situation. Now, if you put dogs in a cage and shock them, And you keep shocking them.
It's going to set off their fight or flight. They're going to want to escape. But if you keep shocking them to a point where they realize that there is no chance of escape, they're going to experience what's called learned helplessness. So they're going to sit down and they're going to essentially lose the idea And if it's done to such a degree that they experience learned helplessness, even when you remove the cage, if you continue to produce those shocks, they're not going to leave that situation because essentially their brain has learned there's nothing I can do to fix my situation and I'm basically stuck in this hell.
I think it's a good description of how PTSD can develop in a lot of people. I would take issue with the focus on learned helplessness. It's certainly one way that develops and certainly common. And the feeling of being trapped, that's also not necessary in the development of PTSD. Don't get me wrong. You see in a lot of cases, I do think the description you're giving with the whole Mm-hmm.
But you know, you don't need trauma to that severity to develop a PTSD, even the severe one, you know, it can be as simple as seeing, you know, a very complicated death of family members, you know, finding someone dead in your home. It can be simply a car accident in some vulnerable individuals. And so you described nicely how the kind of trapped learned helplessness element might be present in some cases.
I would say in many, many cases that you see, Especially for adult onset PTSD. The issue is more akin to a panic disorder issue, right? Think of a panic disorder. Panic disorder isn't having the panic attacks. It's having fear and avoidance of the panic attacks. I find that in many cases of persistent PTSD that persists with treatment or without treatment, it's that there's an avoidance of trauma memories.
Okay. So it kind of helps to go through just... Criteria A through E of PTSD and DSM-5 because it's in order almost and it sort of lays out the course of persistent PTSD.
Yeah, that'd be awesome. Would you be able to do that for us? Yeah, I mean, let's just go
through it. As an aside, by the way, I do think that a lot of people out there in the community have a habit of diagnosing post-traumatic stress disorder without Actually going through the criteria. They can identify that someone is in a persistent fear or mood problem and that they have a criteria in a trauma and they say, well, they've got that. I've got some of the symptoms.
Let's go. Let's go. Right. But no, it's a wholesale change. And what you mentioned, by the way, about kind of beliefs about the self and the world and the spirit. I don't know if you said spirit. I like to say spirit. I think that is fundamental to the process of correctly identifying, correctly identifying PTSD.
Yeah, let's go through it. I'm really excited to hear what you say about spirit because I haven't heard you talk about that. But yeah, let's go through the criteria and circle back to that.
Yeah. So let's just go through it. A, you got to have a qualifying trauma. Easy, right? B is that that trauma has to recur to you in some fashion. OK, it has to come back on its own. In a way that disturbs you, right? Intrusive. Yeah, intrusive symptoms, precisely. That can come in a lot of different ways for people. But let's go through the common ones. There's flashbacks, right?
There's vivid remembering. There's dissociative reactions where you feel like you're there again. There's nightmares. And I believe they also refer to dissociation of memory or dissociative responses in criterion B. Is that correct?
I'll just walk them through. So recurrent involuntary distressing trauma memories. So trauma memories, distressing trauma-related dreams, dissociative reactions slash flashbacks, intense or prolonged psychological distress, and marked physiological reactions to trauma reminders.
Yeah, it's confusing, isn't it, to have to read through it because each of the sub criteria actually refer to multiple different types of manifestations. But I think what I was missing there is actually the sort of recurrence of the fear response when encountering reminders.
Mm hmm.
Yeah. So that's another method of recurrence, which to me, in my mind, I packaged that as the reliving, re-experiencing flashback type thing, but they're slightly subtly different if you really get down to it. So that's B. First, you have to have been traumatized. Secondly, the trauma has to come back on you to disturb you in some fashion. And then the third step is to avoidance. You need to try to avoid reminders or the memories themselves in some way.
If you can tell me if I've missed something within the written word of the DSM.
So C is avoidance. And then the two that I mentioned are avoidance or efforts to avoid distressing internal trauma reminders, memories, thoughts, or feelings. And then the second part is avoidance or efforts to avoid distressing external trauma reminders, people, places, activities.
Okay. They don't put dissociative reactions in C for the DSM file, correct? Correct.
The associated reactions is in B, the intrusion part. Right.
And then, so what do you have? You have your trauma, you have the recurrence of trauma, then you have avoidance of trauma. And that process is accompanied by a general change in what I like to refer to as... I suppose the psychology, mood and spirit. Okay. There are large scale and persistent changes in how the person who has been traumatized in the PTSD syndrome feels and relates to themselves and others.
It's almost characterological, but you can see this happening in people who have not had character problems, personality problems throughout their lives until they've encountered these traumas. Don't get me wrong, in my opinion, I think there's also a heightened vulnerability to developing the PTSD syndrome. And people with character problems, with personality problems, but it can happen in people who are apparently absent of those issues.
I'm reminded that before it was called like the predecessor diagnosis to PTSD was called traumatic neuroses, which I think is going to make more sense once we kind of go into what you're about to go into.
Yeah. So, you know, how's this map? So you can see a lot of different things. You can see just a persistent negative state of emotion, stuck in negative emotions. You can be unable to feel positive emotions. And by the way, this is why I think that the primary mimic of PTSD, the thing that PTSD gets misdiagnosed as the most is persistent depression or major depression. And then there's the spiritual stuff.
There's blaming yourself in a way that just isn't. Objectively accurate for your traumas or what's going on with you. There's having persistent negative beliefs about yourself or the world. My whole body's ruined. I'm screwed. I can't get better. You can't trust anybody. The world is a dangerous place. Those are spiritual psychological issues that arise from trauma. Go on.
Yeah. And I, you know, I just want to, I think the negative self image, like you said, like I'm screwed there. A lot of it is like, I'm bad. I'm worthless. A lot of times it's, I deserve this. There's a lot of like really conflicted feelings, which, you know, from the outside, especially when you're For example, childhood abuse seems absurd, but it's just a common manifestation. We see that kids blame themselves.
They think it's because they're bad. A lot of times there's confusion. We should be more
clear about that because I think that's a very easy one for lay people to misunderstand. Children who are sexually abused are often groomed in some fashion or the abuser is a friend or a family member. So there's a lot of positive feelings and experiences that are associated with that person. And then those get mixed up and mixed in with the abuse experiences too.
Yeah, and how confusing it is to love or rely on someone or have someone that you need for dependence also be the perpetrator. So you have all these weird amalgamations of love, abuse, pain mixed in so that there's no way to have a coherent sense of who you are and who my protectors are, who my dependents are, when they're so intertwined with horrific things.
Yeah. And you know, the self-blaming, it'll look different and is different for adults too, right? You'll see people with unrealistic self-blame, like their parent was dying of cancer. They still feel like they could have done more somehow, even if they're there every minute of every day, taking them to every appointment. You know, it could be just being in some random car accident. There was something I should have done differently to prevent myself from being that car accident, even if there's just no realistic thing that can be found.
It's an irrational self-blame that they can be aware is irrational, yet they can believe almost 100%, even if they're cognitively aware that it's irrational.
Yeah, and you see that all the time in that they're able to say the right things and think the right things, but deep down there is an internal sense of worthlessness, of blame. I also want to say that it's interesting...
In this criterion, and what I mentioned, the mimic of major depression, I find that one of the more reliable, though of course it's not 100% reliable, ways to tell the difference is that people with PTSD, they show up, they tell you they're depressed, they tell you they're stuck in negative emotions. They tell you they're not doing the same things they used to do. They don't look depressed a lot of the time, okay?
They might look upset sometimes. They might look very anxious or unhappy, but they don't look major depressed, like a melancholic depression or psychomotor slowing. And just broad sadness. Okay. They're much more mood reactive, in my opinion, even if they can't enjoy their lives and they feel badly most of the time. I think that's a mental status exam pearl that you can use to help yourself differentiate a little bit.
And why is this important? I also think that a lot of people with PTSD get misdiagnosed as major depression because... In some cases, they can struggle to even consciously tell you about the traumas. They might be aware that they've been traumatized, but there in the visit with you, especially the first time, even if you go through a formal trauma screen, they might forget to tell you. I've had that happen multiple times in multiple cases.
It seems to be that part of the memory seems to be dissociated.
Yeah, and I think we'll be getting to that concept a lot more. Yeah, I do want to talk a little bit. Actually, I wanted you to clarify. So you say they don't look depressed. Could you rephrase what you meant by that in layman's terms? Because I think... Someone with a very...
Yeah, someone with a classical, more biological depression... You know, the kind that can happen to people in episodes lasting at least two weeks in a row. And even if their life is pretty much going OK. They look different. They move slow. They talk slow. They are despondent almost throughout the entire interview. OK, versus in PTSD, the day to day experience is still miserable for these people. OK, but.
Mm-hmm.
Thank you. I think that'd be helpful. Now, another thing I wanted to talk about in regards to this area is shame and how shame is just a major aspect of what patients with trauma experience. I think there's a lot of unacknowledged shame about the event, about the trauma. I think patients also get a deep sense of shame for... Because a lot of times with that negative cognition means that they're not enjoying positive events and they feel ashamed and feel like monsters for not enjoying the things that other people expect them to enjoy.
And it really becomes a dominant aspect of their life.
By the way, I think it's kind of interesting. There's a sort of reflection of the differences, I think. We're talking about the same entity, but I think we've had a little bit of difference in the patient population where we mostly see this. And also there's maybe a difference in the training. As you might expect, my training and experiences with post-traumatic stress disorder are very cognitive behavioral therapy, CBT and forensics.
I feel like you have a much more psychodynamic bent to it, even though I obviously am a psychodynamic practitioner in other ways. When it comes to trauma, I go less there. I suppose just because my clinical experiences are in the forensic and community mental health realm.
Yeah, I think it's interesting. I think I usually just have a slight psychodynamic bent to things.
Both relevant. I would say psychodynamic being more important for early onset traumas. I feel like that's an area where going pure CBT struggles. You know, there's actually a type of psychotherapy that seems to be more intended for people with multi-traumas. And I do think that building that narrative is a large part of being able to recover, at least to improve. We can get into that if we talk more in the future about the psychotherapy approach to trauma disorders.
Yeah, I guess let's just circle back. You were talking about the negative cognition and mood and the negative aspects to mood and spirit. Why don't you pick back up to where we're talking about that?
That's right. So, you know, that brings us to the final aspect, which I would consider the physiological response, the sort of biological element. So we have so far you get traumatized. The trauma comes back on you in some fashion that's disturbing. You begin to try to avoid that response. And then your spirit, your way of relating to people and yourself and your psychology changes. And finally, the threat system of your body seems to change as well.
Okay. The hypervigilance aspect, people seem to be just constantly on the elevated threat level. Okay. Difficult to relax, can't relax, but not in a generalized anxiety fashion, in a threat detection fashion, and not the paranoia of psychosis either, though it often can sound the same if you stay on the surface with these people. Exaggerated startle response. Okay. A surprise, a loud noise brings you back with this bang of fear, adrenaline in the body.
Naturally, being in this worked up state will mess up your ability to think. Sleep and pay attention. The concentration suffers. The most obvious manifestation of this aspect is, of course, dreams, sleep, okay? Nightmares and just general sleep interruptions, panic attacks, waking up from sleep, commonly seen. Interestingly, this is an aspect that I think more lay people and even maybe some clinicians conceptualize as psychological, but it's physiological.
It's the irritability and anger outbursts. That's kind of from being on edge all the time and looking out for danger, being heightened and looking out for danger will make you irritable. And if there are surprises or people just set you off a little bit, you react with the fight response. Am I missing anything else?
No, I think I can read them off. So this is categorized as hyperarousal, irritability and anger outbursts with little or no provocation, reckless or self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, and sleep disturbances. Right. Yeah. And then, you know, in terms of how I think about this, you know, when a traumatic or, you know, something that's a scary event occurs, your amygdala lights up like crazy. It triggers a stress response.
So it spikes your cortisol, which spikes the noradrenaline system to get your body fight or flight, moving or doing something to get out of the situation. When trauma occurs, it's essentially as if your body just always... If trauma occurs and you have PTSD, your body kind of always has its stress response on. Like that hypervigilance, that lit up amygdala is just all the time and it gets provoked at the littlest things.
So someone who doesn't have PTSD, you know, you need to be... Maybe some violence picking up, something scary to have that stress response picked up. So with PTSD, the littlest or smallest potential threat or even perceived threat triggers that stress response as if your body thinks that the trauma is going on. Continuously. And when this amygdala is lit off, when you look at the brain, the Broca's area, which is the speech area, goes offline.
So there isn't verbal acknowledgement and a cognitive process that's occurring when you're getting these flashbacks or when you're experiencing a traumatic event.
Yeah. You know, and in the psychological fashion, you could describe that as a dissociation, right? Of language from the fear and threat experience.
Yeah. Dissociation plays a big role in my understanding of how trauma manifests because essentially, you know, in a normal memory, you have this integration of the sensations, the emotions, the thoughts that you were having. And it gets integrated into your idea of self and other. When you have a traumatic event, it's almost as if all these different parts don't get integrated into a holistic experience of an event that's able to be processed.
So you almost have these Like split apart aspects of the event so that when you have a flashback, it's not like you experience the event. Maybe just like a small smell that reminds you the event will bring up these horrific fractured memories of kind of what occurred.
Yeah. You know, we probably should have defined dissociation first. I think we should do that now. You know, the DSM talks about dissociation, I think, in a relatively constrained way within the PTSD criteria. They talk about, I think, dissociation, like feeling derealization, depersonalization, and maybe dissociation of memory. I can't quite recall. But broadly speaking, what is dissociation? I think the easiest way to conceptualize it, clinician, person, is to separate out the word.
It's disassociation. Any two parts of the mind can be associated. You can link them together. A memory can be linked to words, your ability to talk about it. A behavior can be linked to an emotion. But in disassociation, it's when any two parts of the mind that would or could be normally linked together, connected, become disassociated. And we seem to see that this happens with disassociation. Obviously traumas.
And when the normal process of developing the self and relationships gets messed up in some fashion during childhood, that seems to cause dissociation, dissociation.
Yeah, one way I've heard someone put it, you remember the N64 in the old days had that red cord, the yellow cord, and the white cord that you plugged into the TV? It's almost like with trauma that those cords kind of get taken out of the TV.
One of the cables, or basically they're not all created at the same time. Your audio, your visual, whatever inputs you have, X outputs,
they don't come together the way they normally do.
We want to hear about your most difficult, confusing, or challenging cases. Obviously, we can't give clinical supervision over a podcast, but especially when they're de-identified, we do think we can learn together with these cases and reviewing them in detail.
Yeah, definitely. If it's on the community forum, we'll definitely get it. That's just on the farm and then you hit the community. Or you can send an email. Just make sure wherever you post it, it's de-identified.
You know, of course, de-identified and for learning only, send us your most difficult cases. I'd like to hear about them.
Awesome. And I'll also just mention that this month we're doing a book club and we'll be having a discussion on it at the end of the month. I think this month we're doing the psychoeducation for bipolar disorder. So head on over to the forum and start participating. So where do you see dissociation play a role in PTSD?
Well, as I mentioned, dissociation of memory is very common. And as a result, especially in people with more moderate to severe cases or with other existing comorbidities and vulnerabilities, their ability to either tell you a organized story of what has happened to them and why they're suffering or even to tell you about the traumas having occurred at all can be quite impaired. Don't take this as an invitation, by the way, to get into the camp where you think you can uncover all these memories.
Be careful about that. If you look at the research of Elizabeth Loftus, you, the clinician, can absolutely endure. So I'll give you an example. I've had cases where I wouldn't have been able to meet the PTSD criteria with somebody's reported history, but I still noticed that they had a severe decline in function at a certain time. I didn't say... You must have been abused or traumatized during that time.
No, I said, you know, it's a little unusual. You told me about some traumas and you told me about a recovery from it. Yet, you know, three years ago, you started really declining and you didn't tell me about anything happening that year. What was stressing you out that year? What was causing the problems? And for example, they might say, oh, actually, I was seeing a lot of people in the emergency room.
I started working in the ER instead of the floors, and I saw several deaths that really disturbed me. Okay. That's something that I've seen before, where a healthcare worker, you know, someone who's otherwise high-functioning, organized, couldn't even report to me the more recent witnessed criterion-aid traumas when we had gone through a full trauma screen before. Mm-hmm.
Yeah, and just how, you know, we kind of talked about the cognition is necessarily like kind of not online here that the more extreme responses and the hyper arousal and the intrusive flashbacks, people commonly have no connection. Yeah. Yeah. Yeah.
I remember also making a difficult diagnosis of PTSD in a forensic case where the patient's perception, not patient, the evaluator's perception, and what she was told by clinicians up until that point was that she had a depressive disorder and anxiety. And if I just chased it based on her conscious ability to report mental health symptoms, that's all that we would have gotten. But... I had already detected that she had experienced some criterion traumas early in her childhood.
And so I simply asked, what kind of problems were you having at that time in the period leading up to the offense? And so I had her talk about her day and she talked about how she didn't put it in these words, but she basically gave a narrative description of intermittently freezing and not being able to respond throughout the day. And once we found that, I was able to explore the events in her life leading up to that point, and we uncovered some extra traumas that she didn't report the first time.
So I guess broadly speaking, keeping in mind the tendency Mm-hmm. Mm-hmm.
Yeah, and I think there's a huge spectrum of dissociation from, as you said, just a disconnected... Some small thing disconnected to experiencing someone in a full dissociative state where their mind goes... You can see their face goes blank. It's almost as if they're not present. I've seen some people where they... They feel like a small child. You'll get a very abrupt change in the feeling in the room and you feel like you're talking to a small scared child all of a sudden as a dissociative experience.
Yeah, it helps to have a strong attunement to what the patient is actually doing. You can call it attunement. You can call it being actively attended in your mental status exam. But some freezing and dissociation can be so subtle that some people might read it as hesitation or just kind of thinking to themselves for some period or not being interested in answering certain questions. You got to be pretty attentive sometimes to catch this kind of thing.
Yeah. And it's actually wild to hear people report back what happened and that there's a patient that I at first didn't know they were dissociating. And when I asked them, like, what did they just experience? They said, like, nothing. I wasn't really thinking about much at all. And it's like, what was different? It's nothing. I just like. And it was only later as we continued to work together that I realized they were completely blank.
And afterwards would make sense of it, but they were fully dissociated. And then afterwards, their brain would make up something to fill in the gaps to make sense of what had occurred.
Yeah, or it can be as simple as they don't appreciate how long they've been frozen or not responding, right? They might think it was just a moment, but it was longer than that. Obviously, the sense of time can be a bit difficult for people who are dissociating at the present.
Yeah, so I'm going to quickly wrap up the criteria. So duration greater than one month, distress is clinically significant and not accountable for another disorder. Now, you talked about something I want to dive into a little bit more. You talked about the importance of trust in this in terms of the patient. Can you talk a little bit more about trust and how that is involved in trauma, PTSD, treatment?
Yeah, but if it's okay, I actually want to touch on those last two criteria you mentioned. It's very important for diagnosis. So let's get to trust a little bit later. But duration is very important. Another very important thing you're going to see in every criteria is that these things that we just talked about, they have to have basically started and persisted after some trauma. You need to find a temporal relationship and a sequence between this syndrome and those traumas.
Why? Because as you can expect, after having gone through all of these criteria, these are all symptoms and impairments that are commonly seen in other conditions as well. And so the not better explained by another mental disorder is also a very important part of your work in making a proper PTSD diagnosis. You have to actually consider other causes and also roll out mimics. And almost anything can mimic it.
We've talked about depressive disorders mimicking it, right? Sometimes the severe agitation and problems of sleep that people with PTSD have can look like or sound like mania or hypomania. Obviously, anxiety and specific phobias can be easily confused with PTSD. Problems with concentration, focus, memory can be confused for neurodevelopmental or neurocognitive disorders. The list is extremely long in terms of what other conditions can sound like other conditions.
One very important one is also psychosis. This is rare, but in my opinion, a lot of people who might be identified by some clinicians as having some kind of an odd psychotic disorder are actually experiencing dissociative reactions. A lot of voice hearing is not the product of a schizophrenia spectrum disorder. A lot of voice hearing experience is the product of a cultural background, a personality trait or syndrome, or PTSD.
You can experience flashbacks, dissociations as apparent voices, even when it doesn't seem to be directly related to the incident trauma. So you have to consider all the different possibilities that can be creating a syndrome and ask yourself which one is best supported by the evidence.
Yeah. And I think, you know, we should almost do maybe doing a whole separate podcast on like the differential between auditory hallucinations, because there's so many people who hear auditory hallucinations and go psychosis. And it's so much richer than that.
Yeah. Hearing voices can do that as a podcast. That's good.
Yeah. You also mentioned the duration is greater than one month. I was curious if you were going to talk about acute stress disorder as a contrast.
I mean, it feels kind of academic, but I think what's most important to note here is that you don't have to develop the PTSD right away. Okay. It's normal to have symptoms of PTSD without the full syndrome in that first month. It's called acute stress disorder. And The symptoms can even get better on their own and often do. But if you are noticing yourself stuck with the symptoms, suffering from the symptoms, they're causing you problems, that's a sign to seek treatment and diagnosis.
Yeah, and I, you know, in terms of kind of just reflecting on the different criteria, one thing that was helpful or helpful for conceptualization is that for certain patients, different criteria for PTSD take predominance over other ones. So you can see patients with like, you know, it's all hyperarousal and it's very, very apparent. For other patients, it's like the negative cognition and mood is really the predominant thing that you see with patients.
You know, like you really get different... There's a decent amount
of variation, even if they're all basically this physiological, psychospiritual avoidance and recurrence change after a trauma. That's the basic syndrome.
Now, I'm curious why you use the word spiritual.
Well, I just don't think that it captures enough how deep the feelings and problems are if we simply call it psychological problems. I don't think it's so simple. If you talk to people who are religious and spiritual, it can be felt almost as some kind of a loss of faith or a whole... Mm-hmm.
Yeah, I really like that. And it feels correct in terms of like there's a spiritual deficiency that there's something spiritual that's broken oftentimes.
And I'll also say this, by the way, I'm not advertising any particular spiritual But in the community setting where many patients either cannot, due to language barriers or willingness, engage with actual trauma psychotherapists. In fact, most of the time they don't have a trained trauma psychotherapist to work with. I have seen a lot of good clinical improvement from people who sought out traditional spiritual practices, engaging with the spiritual community, finding safe and trusting relationships and support in that method, which was free to them, brought them closer to recovery or more quickly to recovery than they were able to do through the limited community health system.
Okay. Can you help make sense of that to me? This can be as little as just going to the temple if you're a Buddhist, right, on a regular basis. Now, I personally think there's probably some benefit there also to the mindfulness practice that come with that tradition. But something like mindfulness is probably present in almost every religious experience that's practiced. So that's going to be beneficial, I think, to the treatment of PTSD.
And it's just a community that they can find themselves getting used to and exposing themselves to a Exposure response prevention model of the treatment of PTSD, right? They're able to encounter situations that they might anticipate are threatening because of the PTSD, but those situations are safe and reasonably loving and attentive. So that is sort of like a psychotherapy by proxy, right? And that does bring us back to what you were asking about for me to talk more about the trust issue, right?
When I say that trust is so important in the treatment, I don't mean that you, the clinician, trust everything the patient says. I mean that you need to demonstrate that the treatment and that you, the clinician, are trustworthy of the patient because after traumas, especially early traumas, the patients are primed to lack trust. They are primed to doubt that anything can be trustworthy, okay, themselves, the world, the That anything is safe.
So you're going to have to do a little extra work and groundwork, keeping a good frame and responding in an adequate way to make sure that they trust that it's worth going through this process with you of talking about these awful things and reliving them and also that they can continue to get better at all. I guess that's about the same thing. You need to inspire trust and hope in some fashion.
Yeah, I think we should do a whole thing on trust, but I wish this was taught earlier because with PTSD or patients who have had negative experiences with the medical system, they... I'm not trying to think of how to word this. They've learned that they can't trust people. They've learned that they can't trust doctors. It's really something that just because you have a white coat and a stethoscope, you do not deserve the trust of these patients.
And it really needs to be earned. It needs to be acknowledged that it's okay to not trust me. And I know you have to work for it.
I guess it's hard because clinicians are always going into it trying to be good, trying to give what the patient wants, treat them, make them better. And then if you say, well, you don't deserve to be trusted, that might sound a little bit mean. But I suppose we should dial back and we need to consider that the ability to trust at all is always earned in some fashion.
The patients who can come in and trust you right away, they do that because of the experiences that they've had with their prior physicians and doctors and with prior parents and caretakers, right? We get that for free because of the work that someone put into for it. And then for the person who didn't have those experiences or where those experiences have been fundamentally ruptured by the traumas, we need to lay the groundwork again to make it happen.
We have to earn that trust. So, you know, we've talked a lot. It's a really deep subject. It's a complicated area of treatment and a really important one because I don't know, depending on where you are, You may be feeling that trauma is underdiagnosed or overdiagnosed. I think that it's overreferenced. Everyone thinks everyone's got trauma and that's clinically relevant, but I don't think that enough people are identifying PTSD and giving the treatment recommendations specifically for PTSD.
Yeah. It's funny you say that because I feel like I saw a decent chunk of clinicians, therapists who think that everything is trauma. Depression is, oh, we need to get the trauma and get them up to speed on that trauma. Get it out and all the symptoms go away and substance use trauma, ADHD trauma. And then on the flip side, I saw a lot of PTSD patients or to me, their diagnosis of PTSD who carried the diagnosis of depression.
And we're on their 30th trial of a new antidepressant. And, you know, they were substance use disorder and depression. It's like, no, this is a classic PTSD case. Yeah, I guess we're seeing the same
thing there. You know, basically it's kind of inadequate conceptualization to think that everything comes from trauma. Again, the majority of people who experience a criterion A trauma don't go on to develop PTSD. And then it's really necessary to both... Specifically recognize the PTSD syndrome and then give the psychoeducation and treatment recommendations that you need to get better from that. And I think time is a bit of an issue, so we should probably save the treatment approach for trauma for another episode.
Yeah, definitely.
I feel like it's too, too big for the time we've left.
Yeah. So what was the hardest thing about identifying or treating traumas? I feel like for me, the hardest thing was learning how to efficiently titrate my interview.
It's hard...
In a brief, it's relatively brief, even an hour and a half is brief for the first interview in psychiatry. That's just a reality we live in. I think it's really hard to, as we talked about, establish the frame and that trust and regulate the emotional state of the patient in a way that gets us all the objective historical information that we need. One thing that I want to emphasize also is that you should avoid dysregulating the patient in the interviews, right?
You're not doing a psychotherapy when you're doing a diagnosis. You're just trying to get information. And I will tell patients, listen, we're not here to get you sucked back into trauma memories. I'm trying to reach a medical diagnosis today, and so we will have to go over some difficult stuff. But tell me if you need a break, if we need to pause or stop, or if you're not ready to talk about something.
And when we do talk about traumas, I just want you to give me briefly just a fact. What happened and when. That's all.
Yeah, I think that's great because especially on an intake when trust hasn't been developed, you guys don't know each other. It's not the space yet to be unpacking these traumas, to be bringing them out. So it's helpful for patients to know what it is that you want to... We're in information gathering mode right now. Give me the sparse details that we can understand and learn about them later, learn the depth of them later.
Yeah, I can think of a case I had where on the intake, I wasn't doing a good job monitoring her state on the questions. And... After looking back, when I thought about what was going on, she was slightly getting more and more irritated by my questions because I think it was that they were triggering. And when I finally got to something that was really, really upsetting for her and because I wasn't doing a great job monitoring.
She got really emotional, she got angry at me, later apologized and we were able to repair that rupture. But it was because I wasn't doing a good job in the moment to moment monitoring And then when we got to relationships, it was distressing for her to a point where, yeah, like I should have been able with more and more experience, I'm being able to predict that and titrate her level of the patient's level of distress.
And it's advanced. In moments when I notice that these days, and I've made the same mistakes early on in my work, these days I stop and I sit back a bit. I say, hey, you know, I notice that as we're doing this, it seems like I'm... And I'll refrain. Nonetheless, the reason why I'm doing so is because I'm trying to help. And the best way I can help you is if I get a really clear picture of what's going on, because we won't know how to treat or what you should be doing in your life if we don't know that.
So when you're ready, I'd like to continue. And remember, if you don't feel comfortable or if you want to stop or if you want to talk about something else, we can put that aside for another day.
Yeah, I think that's a big part is giving them back the agency saying like, I acknowledge these questions are distressing. Any point you want to stop. And also not as a practitioner, like in residency, it's like I needed to gather these hundred questions and all the answers. It's not the truth. There's information packed in the fact that that information can't be gathered now and it can the black box can get filled in later.
Yeah. Yeah.
Tough area, tough place to be as the patient as well. But I do think that when it's accurately recognized and you actually tell people what's happening to them and how to solve that, people get better a lot faster and a lot better. It's that when you You kind of think that everything traumatic can cause mental issues or that you misidentify as these associated problems, as you mentioned, like mood, anxiety, substance use can be primary.
They can be at the same time of or they can be due to PTSD. But you find the PTSD syndrome, you tell the patient about it and they want to make those changes. People get better.
Now, I'm curious if you could give us a preview for treatment. If you were to do the one-sentence summary of what treatment is,
Well, I don't know if it motivates people to watch a future episode, but I actually cover a lot of it when we talked about, I think, the Treatment Alliance. My three pillars of treatment are really derived from treating trauma patients. I treat a lot of trauma patients. It's the nature of the community health center that I work at and just, you know, that patient population. And also I happen to be placed at a specific clinic that tends to see refugees.
Mm-hmm. Yeah, give us a taste. I'm not going to give you a taste. I think people should watch the other episode again
and also tune in next time.
All right. That works for me. Any closing remarks?
Don't be afraid.
Just telling people that is not going to convince them, right?
But be afraid and nonetheless act in the direction that will get you to where you want to be.
Yeah. There's that nice little picture of, I was watching Love on the Spectrum this weekend and the woman who teaches the autistic person who's going on a date, it's a circle of anxiety where you want to push your boundaries so that you experience the anxiety that's still tolerable.
Yeah. Optimal anxiety, optimal activation.
Yeah, yeah, fantastic.
All right, see you next time. Like, comment, subscribe, do everything. Doesn't work.
Tell people about this, whatever. No, you need to elicit emotion. We'll just buy
ads, you know? There's no emotions.
No, no. Say you're going to be crying all week if there's not comments.
No, I will no longer guilt trip the audience. Please share if you choose to, volitionally. All right. All right, that's three quotes next time.
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