Key moments, in order
Trust is the fundamental thing to establish first, in any treatment but especially trauma. That does not mean believing everything the patient says; it means demonstrating that you and the treatment are trustworthy, because early trauma teaches people that nothing is.
Medications are huge for stage one: stabilization, trust and safety.
Goals of treatment: maintain safety, reduce distress from intrusive re-experiencing (nightmares, flashbacks, unwanted thoughts), and reduce hyperarousal.
Tell every patient: this medication will not solve your problems or take away what happened, but it will help. It supports the primary treatment, which is the psychotherapy and what you do in your life.
Sertraline is preferred. Paroxetine is avoided by some for weight gain, though it works quickly and is a sleeper as well as an antidepressant, a lot of bang for the buck in one tablet.
First line is trauma-focused psychotherapy. Medication is an alternative for someone who truly does not want therapy, not a replacement for it.
In moderate to severe cases, with clear-cut disruption of work or really disrupted sleep, medication alongside trauma treatment is not optional.
The VA evidence chart lists something like 20 medications from four or five classes, all with poor evidence.
The plain algorithm for clean-cut patients: an SSRI, then another SSRI, then add a second-generation antipsychotic.
Avoid them in PTSD: there is no clear benefit, they could worsen it, and the big problem is that they impair learning in therapy.
It is basically a brain off switch. That is suppression, not treatment, though it can be useful in some situations. It slows recovery, and it is the one case that really does match the accusation that psychiatry only suppresses symptoms.
On day one, the first-line sleepers are the non-habit-forming ones that support deep, healthy sleep: trazodone and gabapentin, with hydroxyzine a fair choice too. These are broadly applicable for sleep in most to all disorders. Avoid anticholinergics like Benadryl if you can.
Imagery rehearsal therapy works well for nightmares, and DBT has a good nightmare protocol.
The mainstream PTSD algorithm is an SSRI, then another SSRI, then a second-generation antipsychotic. In our experience the antipsychotic helps most when severe PTSD comes with a true comorbid major depressive or bipolar-type mood disorder.
If you see what looks like major depression with psychotic features alongside PTSD, consider the agents with bipolar depression efficacy.
A lot of voice hearing is not a schizophrenia spectrum disorder but comes from cultural background, a personality trait or syndrome, or PTSD. In severe PTSD, apparent voices, noises or shadows flitting past are often a dissociative process, not psychotic features.
Traditional mood stabilizers have not been very helpful in PTSD. Topiramate and gabapentin, not really mood stabilizers, are more usable.
Make it clear that where they are now comes both from the traumas and from their response to them: avoiding danger is a rational response, but one that keeps the problem going.
In predictive terms, the brain's prediction network expects threat and danger far too much, like someone jolted by fireworks.
People with chronic PTSD are not brats who refuse to expose themselves, or weak people.
After some stability, roughly a year of remission (an arbitrary rule, with no data), you can at least peel off some of the medication.
Do not chase dissociative voices by pumping up the antipsychotic. It mostly does not work or just over-sedates. It is not dangerous: the target is not zero voices but less distress and better function.
For PTSD it may be one of the best choices, as long as appetite increase and weight gain are not a concern.
Incredibly sedating. Warn patients they will feel like a zombie: expect a hangover, usually three to four days of feeling a bit like a zombie the next day, which typically gets better after about a week. Do not start it the night before a big work meeting.
Its active metabolite, mCPP, can cause agitation and dysphoria, and some people get agitated even at low doses. If you see real agitation, do not keep adjusting it.
Advise against fighting it. Fighting seems to pull people into a generalized fear or anxiety response.
Many people fear they are completely out of control or almost unconscious during dissociation, which is not generally true. Tell them so.
Treatment starts with trust, safety and stabilization: the patient cannot be so dysregulated, or so on watch for danger, that they cannot think.
If a patient is chronically in a dangerous social situation, treatment will not go far, so use social work resources to make them safer first.
Trust is the first thing to build in any treatment, especially trauma. It comes from regularity and a solid, unwavering understanding of what you are there to do.
Saying you are trustworthy does not make it so. Be available as far as is realistic, be interested, investigate, help, and keep your promises.
Setting and keeping expectations is how you show the treatment is trustworthy. Much anxiety is just being untethered and not knowing what to expect.
The most important thing is to tell patients what to actually expect from a medication, adverse effects included. Say it plainly: this medication is not going to make you happy, and it is not going to solve all your problems.
Keep medication management separate from psychotherapy, even if you are capable of doing both.
When a patient will not accept a medically necessary treatment, your job is to keep counseling them toward it, and that does not mean simply repeating that they need it.
Do not try trauma processing in a medication visit. It is not appropriate, and you do not want to teach patients to be afraid of their trauma memories.
When a patient goes into therapy mode, thank them, and say you want to use the time to talk about what helps you decide about their medications.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.