What we’ve said about PTSD

“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”

“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”

“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”

“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”

“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”

“the crux of the psychology of PTSD is that a patient develops cognitive and behavioral avoidance strategies to avoid distressing emotional reactions”

“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”

“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”

“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”

“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”

“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”

“I think there's some question about validity of post-traumatic stress disorder, whether it's as valid as something like schizophrenia. I forgot obsessive compulsive disorder. That's highly valid. Classic autism. Which is a bit different than Autism Spectrum Disorder. Addiction”

“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”

“Criterion A being that the person had a trauma. Then the trauma comes back to that person, so they have re-experiencing. Then the person avoids that trauma, so they have avoidance”

“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”

“while we need something reasonably objective, there still needs to be that subjective experience to match that thing that's reasonably objective”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“my approach is simply is there ptsd or not if there's ptsd that's ptsd to me and we're going to subsume most of those problems under ptsd”

“PTSD as defined by the DSM-5 is different than PTSD that is defined by the ICD-11. Baseline PTSD in the DSM-5 essentially more or less covers what is actually called complex PTSD in the ICD-11”

“What I'm not going to do is I'm not going to say that someone has complex PTSD or when they simply have a bunch of little t traumas in their history”

“it's fright, exposure, avoidance, and re-experiencing. And then CPTSD is bad fear. So that adds betrayal, affect regulation, and developmental impact”

“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”

“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”

“if it's depression alone, it's unlikely to see a large amount of nightmares, fear response, Startle, Irritability, Anger Outbursts, and Fearful Avoidance”

“PTSD is like the great imitator for psychiatry. And you do see patients all the time that it's so confusing because what you're seeing in front of you feels like a mania or hypomania”

“in PTSD, the problems of concentration is a core diagnostic criteria. It is part of the symptom set. You see it all the time. And again, the body and the mind in trauma disorder is at a high level of threat”

“a lot of people come in with like TikTok phrases of like, I have rejection, sensitivity, dysphoria, I can't concentrate. And if you walk through, if you pull up the DSM criteria, The way they word it matches the experience a lot more than the ADHD criteria”

“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”

“i recommend that we as a field we stop using terms delusions, hallucinations, negative symptoms, disorganized behaviors or speech. I think we should stop using those unless we can attribute them to a primary quote-unquote psychotic disorder”

“They say, if this patient has a generally high degree of anxiety, they have generalized anxiety disorder. Not true, folks, not true”

“major depression plus PTSD with an agitated state, major depression plus generalized anxiety disorder with an anxious state, major depression with attention deficit disorder with irritable phases, major depression with borderline personality disorder with phases of variety of symptoms”

“having true PTSD in terms of the physiologic reactivity and the burden of re-exposure and all that that goes with true PTSD is not that common when you look at people who've had a traumatic experience. It's only a subset who get the PTSD symptoms that go with it”

“plenty of people do. i find that for uncomplicated personality type cases the most common axis one issues are ptsd naturally trauma being important for much of the etiology of borderline conditions and maybe a dysthymic disorder”

“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”

“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”

“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”

“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 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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“anything that is a named and specific psychotherapy for trauma, I would generally recommend. That includes the IP, you know, the CPTs, right? the CBT traumas, even EMDR”

“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”

“trauma disorders respond better to trauma therapy. And that personality problems or developmental interpersonal problems respond better to changes and exercises in how you conduct your relationships and with who”

“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”

“the number one thing is I want them to identify for themselves something that is objectively safe, that they trust effectively. The people to be at least basically not aggressive and basically OK to spend time with”

“I'm going to give it an asterisk because mindfulness on its own can actually be harmful to the patient. It really depends on the particular patient”

“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”

“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”

“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”

“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”

“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”

“its efficacy, it works quickly, you know, and it's a Sleeper on top of being an antidepressant class medication. You get a lot of bang for your buck there. All in one tablet. Easy to dose. There's a long-acting form and a short-acting form”

“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”

“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”

“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”

“You can get away with buspar, forgot to mention. In some patients, it's adequately sedating at a high dose”

“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”

“Not SSRIs, you know, not necessarily serotonin-based medications primary because of the risk of agitating bipolar disorders because in undifferentiated patient, we don't know which is which, but just smaller things, you know. your gabapentin hydroxyzine your uh buspirone uh propranolol”

“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”

“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”

“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”

“I give some kind of a medication. It's usually trazodone or gabapentin. Hydroxyzine is just fine, too. I avoid anticholinergics like Benadryl, if I can help it”

“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”

“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”

“image rehearsal therapy for nightmares can be helpful too, which is a non-pharmacological add-on that can help”

“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”

“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”

“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”

“I do recommend that medication management actually take place separately from psychotherapy, even if you're capable of doing both”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“I pull up the criteria. And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma”

“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”