Podcast: Understanding Trauma and Trauma-Related Disorders
Jeff talks to Dr. Matthew A. Robinson about PTSD, DID, and other trauma-related disorders. Dr. Robinson also debunks common myths about these conditions and covers the evidence-based treatment methods to ensure that people are able to manage their symptoms and live rewarding lives.
Matthew A. Robinson, PhD, is co-director of McLean’s Outpatient Trauma Clinic, provides individual, group, and couples treatment for trauma and dissociative disorders, is also an instructor in psychology in the Department of Psychiatry at Harvard Medical School, and is an investigator on grant-funded, cutting-edge research.
Jenn: Welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for this episode of our educational webinar series.
Our focus today, Trauma and Trauma-Related Disorders. And our goal is to share with you what you should know about PTSD and related conditions.
Over the next hour, we’ll talk about how to recognize the symptoms of these challenges and how to find effective treatment. We’ll also explore how to understand if you have experienced a traumatic event. Our guest is someone with a lot of experience in this field.
Dr. Matthew A. Robinson is Co-Director of McLean’s Outpatient Trauma Clinic and provides individual group and couples treatment for trauma and dissociative disorders. As a member of the Dissociative Disorders and Trauma Research program, Dr. Robinson is an investigator on grant-funded, cutting-edge research. Matt, thanks so much for joining us today.
Matt: Thanks for having me. Happy to be here.
Jeff: We’re glad you’re with us and we’re going to be covering a lot of complex topics in our discussion today. And because of that, I think it’s especially important to start with some definitions and distinctions.
For example, can you help us understand the differences between trauma, traumatic events, and trauma-related disorders?
Matt: Sure. So, trauma is a term that has become increasingly used in households. It’s a term that, in part because of the good work at the VA, Veterans Administration Hospital on PTSD, that’s become very familiar to many of us. And it gets used in a variety of ways.
And so, when I talk about trauma today, throughout the presentation, I’m typically referring to the definition that is in the Diagnostic and Statistical Manual that’s put out by the American Psychiatric Association, their definition of trauma.
And that definition is any event that a person experiences directly or witnesses that is in some way, life or body threatening, including things like physical violence, accidents, sexual assault or sexual violence, and childhood abuse. So, that’s typically what I mean when saying the word trauma.
Traumatic is a word that people use, and it’s the subjective term. So, what a person experiences as traumatic really kind of depends on that person. And so, the distinction is important because a person’s experience of something as traumatic may not meet our diagnostic definition of trauma in all cases. We can talk more about that if there are questions as we go.
Jeff: Great, and then the whole concept of trauma-related disorders, is there a particular threshold that is crossed that takes somebody from having experienced a trauma to being faced with the challenge of an actual diagnosable disorder?
Matt: Yeah, there are a handful of problems or diagnoses that people might, problems they might face and diagnoses they might get, depending on the nature of the event that they’ve experienced and then their reaction to it.
Another key language thing that I’ll mention as an aside is sometimes, we’ll say things like treatment for trauma or getting trauma treatment. If you think about it, you can’t really treat trauma. Trauma is an event that a person experiences, a terrible event, in most cases.
Their reactions to that event or how they respond to it is what we are treating. So, when we say trauma-related treatment or trauma treatment, that’s what we’re referring to are the person’s symptoms or reactions to a traumatic event.
Jeff: And Matt, from your perspective, as somebody who works in this field, why is it that language matters so much?
Matt: Yeah, in terms of research and treatment, precise language is really important because it helps us guide accurate diagnosis, which then informs appropriate treatment planning.
We are finding more and more that people are coming to us identifying as having PTSD or complex PTSD, and using that language when they may or may not actually meet the criteria for PTSD and may or may not be a good candidate for the very well-researched and supported treatments we have for PTSD.
So, especially as clinicians and researchers, using precise language to communicate with colleagues, asking questions of people who are referred to us or seeking treatment to really clarify what they mean by the terms they’re using, is important to get people connected to appropriate care and on the path to recovery more quickly.
Jeff: Let me throw one more term by you, Matt, potentially traumatic events, we sometimes hear them referred to as PTEs. What are we getting at with that term?
Matt: Yeah, that gets back to what I was mentioning before about the distinction between trauma and traumatic. Two people faced with the same situation will have vastly different experiences of that situation.
So, for example, if I were in a car accident and you were in a similar type of car accident, that would be considered a potentially traumatic event.
And depending on how each of us responded, you may have found the car accident to be scary and stressful, but not particularly traumatic, and I may subjectively have experienced it as very scary and traumatic, and having a number of aftereffects for me.
And so, when we say potentially traumatic, to acknowledge that not every person responds in a way that is negative or problematic in the face of stressful or traumatic events.
Jeff: And we’ll talk a little bit more about why some people do develop a disorder from these events and some do not, which is a fascinating topic in and of itself, but I do want to ask you about some perspective here, or ask you for some perspective here.
How common are PTEs? Will most of us experience one in the course of our lifetime?
Matt: Worldwide, the number is at around 70% of people at some point in their life will experience a potentially traumatic event, and close to 30% or more will experience four or more of those events in their lifetime.
So, it’s incredibly common that people are exposed to trauma, even more so these days with world events, ongoing conflict of war, the COVID-19 pandemic made exposure to trauma more widespread, so it’s very common.
Jeff: Do you find that most people recognize if they are in fact going through some kind of a potentially traumatic event or have been through one?
Matt: I think it varies. There are some interesting cultural, gender, and other differences between how people think about and respond to traumatic events.
I will hear from, for example, some male survivors of childhood trauma that they don’t conceptualize or think about what happened to them as traumatic and that in their mind, a trauma is really only something related to combat or something maybe related to physical violence. Other people may over-identify with things as being traumatic and affecting them.
So, I think it happens in both directions. And then culturally, there are people across the world who may grow up in situations and settings where violence is more common and prevalent and may not have the same threshold for what they consider to be traumatic and stressful and may not report, therefore, certain types of experiences in a healthcare setting.
Jeff: Let’s paint the broad picture, if you would, for what trauma-related disorders look like. Can you walk us through kind of the spectrum of what’s out there?
Matt: Sure. So, within the DSM-5 category of trauma and stressor related-disorders, there are a handful of reactions that people might have.
The first are called the adjustment disorders. These are typically reactions to stressful events that don’t rise to the level of a trauma, but still cause significant distress or a problem for the person in terms of functioning. A person with an adjustment disorder can have depression and anxiety along with their sort of stress reaction.
Some common ways we see this are major stressful life events like divorce, job loss, things that would commonly cause stress, understandably, but that that stress and difficulty adjusting lasts longer in duration than you would expect, typically. So, adjustment disorders are sort of one of the common reactions that people might have to a trauma or stressor.
The next is acute stress disorder. This is when someone does experience a trauma by the definition I mentioned before, and has a number of symptoms of PTSD, but hasn’t had them for long enough to meet full criteria for PTSD.
And so, for the first 30 days after a traumatic event, we expect people to have a certain number of symptoms, reactions to a traumatic event. If those symptoms don’t improve by the 30-day mark and still meet a certain threshold or level, then the person would go on to be diagnosed with PTSD or post-traumatic stress disorder.
And then, one recent addition is prolonged grief disorder. And so, this is the difficulty in adjusting to the loss of a loved one that extends beyond a year and causes significant distress or problems for the person.
Jeff: So, Matt, we’re going to circle back later and talk about dissociative identity disorder or DID. Does that fall under the same umbrella or is there another spectrum as well that we should know about?
Matt: Yeah, in the DSM-5, DID is in its own category of dissociative disorders. Importantly though, many of us consider DID to be a trauma-related disorder given that one of the criteria or one of the etiological reasons for developing DID includes significant and profound childhood abuse.
Jeff: Let’s zero in on PTSD for a little bit. There are a lot of misconceptions about PTSD, and I think the most common misconception, if you will, is that a lot of people associate it exclusively with military service or the horrors of war. Can you speak to that?
Matt: Yeah, I think that, in part, is because of, again, all the attention that PTSD has gotten related to the VA and wars. And a lot of the research we have on treatment it comes from the VA, but trauma and PTSD can develop from any number of events that are, again, life-threatening or body-threatening.
So, a person who experiences childhood abuse, physical, sexual, and in some cases, emotional abuse and neglect, might meet criteria for PTSD. Things like sexual assaults or physical violence in adulthood would meet criteria for PTSD. Accidents, natural disasters, work-related accidents or events may meet criteria as well.
So yes, a lot of people who serve in the military go on to develop PTSD, especially those that are deployed to combat zones, but it is not the only way people develop PTSD, and it’s actually probably not, in terms of numbers worldwide, not the most common.
Jeff: And we sometimes hear people suffering from post-traumatic stress, but not post-traumatic stress disorder. Can you talk about that distinction? Because I imagine that’s fairly key as well.
Matt: Yeah, so post-traumatic stress isn’t a term that’s in the DSM-5 or it’s not a diagnosis, but it’s a term or a way that I hear some people describing having a reaction to, a significant reaction, to a traumatic event.
To some extent, and this is important, by definition, traumatic events should be stressful and should cause a reaction. They’re out of the ordinary events that are terrifying, life-threatening, body-threatening. So, to have a stress reaction to a trauma makes total sense.
The stress reaction, though, should reduce and the person should recover over time in order to not develop PTSD. So, I think post-traumatic stress is just one way of describing, I’m having symptoms or a reaction to this traumatic event.
Though I may not have PTSD, it may not rise to a level, or it may not be the right combinations of symptoms to meet criteria for a specific PTSD diagnosis.
Jeff: And before we move on from symptoms, talk a little bit more about some flags, if you will, that loved ones can be watching for that their loved one might in fact be dealing with post-traumatic stress disorder.
Matt: Yeah, I mean, some of the hallmark symptoms, which we can talk more about in a minute, are a person experiencing significant distress related to reminders of a traumatic event. So intrusive thoughts, or memories, or images, becoming emotionally or physiologically distressed when reminded of an event.
Having nightmares is another common symptom. And then, a number of avoidance symptoms. So, I think family members should really watch out for people who start to avoid people, places, or situations that they would otherwise enjoy or take part in, engaging in avoidance behaviors like substance use or other distractions that are potentially unhealthy.
Those are sort of the two hallmark symptoms in addition to changes in mood and thinking, so extreme negative thoughts about the world, their sense of safety, expressing self-blame and guilt, losing interest in activities, symptoms that are similar to depression.
And then, also a host of symptoms that are hyperarousal symptoms. So, things like hypervigilance, being on guard, watchful, jumpy, easily startled, things like that.
Jeff: What about the timing of the appearance of these symptoms? Sometimes it can be decades after a traumatic exposure, can it not?
Matt: It can, it can. There’s a qualifier in the DSM-5 for delayed onset. What we see, in some cases, I used to work in a clinic treating first responders, police officers and the like, and they’re trained to deal with and confront traumatic events every day, so they may not develop full symptoms of PTSD because they are able to avoid or cope with them in some other way.
We hear a lot of those first responders say that work becomes a distraction or a way to avoid dealing with the impact of a traumatic event, but then they retire, and they lose that structure or that sense of identity, and at that point, they experience an influx of symptoms and then meet criteria for PTSD.
Jeff: You mentioned the occ- I’m sorry, please go ahead.
Matt: I was just going to say, that’s one example. Experiences of childhood abuse that later emerge or develop into PTSD in adulthood is another common way that we see a delayed onset.
Jeff: That leads to a question from an audience member, and we’re going to try to weave some of those in throughout the webinar today, Matt.
Can a person suffer trauma from continued childhood emotional abuse, or must it be a physical abuse situation to be considered trauma?
Matt: Yeah. So, childhood abuse is unique in that children can’t protect themselves or escape from situations the way that adults can. So, to some extent, a child may experience emotional abuse, certain types of emotional abuse as life-threatening.
And if that’s the case, then it may meet criteria for PTSD. It’s one of those situations where a clinician who’s experienced with assessing for PTSD would want to ask some specific questions to get a better sense of what the person experienced and how it has affected them.
But it’s not as clear cut as something like, we know that physical violence or sexual violence always meets criteria for that definition of trauma.
Jeff: You talked about some occupational risks, those who are on the front lines, nurses, and doctors, and firemen, and firefighters in general. What are some other at-risk groups that we should know about when it comes to PTSD?
Matt: Well, I think any profession where you’re likely to encounter the things that I just mentioned, physical violence, sexual violence, whether you’re treating it or witnessing it, jobs where they are more dangerous and accident prone.
I think of certain utility workers, for example, who may have experienced physical injury or significant accidents at work, but honestly, trauma can happen anywhere.
These sorts of terrible events and accidents are not limited to just professions where people are encountering these specific types of events.
Jeff: You mentioned depression. How common is it for that to co-occur with PTSD?
Matt: Yeah, depression is the highest co-occurring comorbid diagnosis with PTSD. It’s quite common, and in fact, some of the symptoms that are part of the diagnostic criteria for PTSD really overlap closely with symptoms that you would use to diagnose major depression.
Things like loss of interest, like persistent negative mood, irritability, things like that that we see in both major depression and PTSD.
Jeff: We’re going to talk more specifically about treatment strategies a little bit later in the hour, but give us the broad strokes, if you will, about how PTSD is treated.
Matt: Yeah, so I’ve mentioned a number of times, there’s been a great deal of research done at the VA and elsewhere in developing evidence-based treatments for post-traumatic stress disorder.
Generally, the recommendations are cognitive behavioral-based therapy that address avoidance behaviors and the sort of psychological and emotional reactions to trauma.
So, one of those treatments is prolonged exposure. This is a treatment that specifically addresses a person’s avoidance of trauma-related thoughts, feelings, emotions, and external cues.
It’s typically done in a time-limited fashion, so, 14 to 16 sessions of individual therapy. Another approach is called cognitive processing therapy. This approach focuses more on how a person’s thinking has changed in response to a trauma and helping a person to sort of rebalance or find a more balanced way of thinking about themselves, the situation.
And similarly, it’s a time-limited, 12-session, typically, approach. And there are a number of other ones that people often ask about. EMDR or eye movement desensitization and reprocessing also has an exposure-based element to it where a person is discussing the traumatic event.
And then there are more general cognitive behavioral strategies for treating PTSD that are highly recommended.
Jeff: What extent are medications used as part of the process of treating PTSD?
Matt: Yeah, there are some interesting medication trials ongoing looking at how they treat PTSD directly, but to date, in general, medications are used to treat a variety of symptoms related to PTSD.
So, if someone has depression, a medication might be helpful for that. There are medications that help reduce the impact of nightmares, improve sleep, reduce anxiety and panic symptoms.
So really, medications are used to augment and help treat some of the interfering symptoms that co-occur with PTSD. And in many cases, are very helpful and an important part of the treatment plan.
Jeff: What about the distinction between inpatient and outpatient treatment for PTSD? What are some of the considerations that go into that decision itself?
Matt: So, treatment for PTSD involves multiple stages, and depending on the person’s presentation, may require an inpatient level of care, especially if there’s risk for suicide or self-harm. Typically, though, PTSD treatment is done on an outpatient basis over the course of a number of weeks.
Inpatient treatment is usually for stabilization to help a person get back to their outpatient treatment program. It’s not to say that that is not part of treating PTSD, but it’s not part of the sort of evidence-based treatment for PTSD.
It’s really about safety stabilization and helping a person get back to a place where they can work on their reaction to the traumatic event on an outpatient basis.
Jeff: Matt, we sometimes hear the term complex PTSD. What is that getting at? How is that diagnosis different from PTSD?
Matt: So complex PTSD is not a disorder in the DSM-5, but it is listed as a disorder in the International Classification or the ICD, and complex PTSD applies to someone who has all the symptoms of PTSD, that’s important.
So, they have to meet criteria for PTSD, but in addition to that, have difficulty with emotion regulation, interpersonal difficulty. It’s more common for people who have early childhood trauma to develop complex PTSD.
But the important part that I always like to make clear is that a person still has to have PTSD, it’s just PTSD plus these other kind of specific problems that go with it, like the emotion dysregulation, identity, difficulty with understanding one’s identity, things like that.
Jeff: In terms of a loved one’s ability to recognize signs and symptoms, are there distinctions between PTSD and complex PTSD that are visible, so to speak?
Matt: I think that’s a tricky one because presentations of PTSD in general can look very different. So, whether or not someone has complex PTSD versus PTSD is really a question for a professional who can do a more thorough assessment.
It is important to distinguish in some ways because the treatment course may look a little different. Someone with complex PTSD, we would typically recommend a stage-based approach where the first stage focuses on a period of stability, safety, and skill development followed by stage two, which is more trauma processing.
Someone with PTSD that’s not complex PTSD might jump right into doing trauma processing work with a shorter or less of a period of work on skills, safety, stabilization.
Jeff: A viewer asks, are there significant differences between BPD, which would be borderline personality disorder and complex PTSD, your thoughts?
Matt: There’s a lot of overlap. This is a topic that’s been discussed frequently. The key distinction is that a person with complex PTSD has all the symptoms of PTSD. Where that overlaps with BPD are the emotion dysregulation symptoms, interpersonal difficulty with identity.
So, in some cases, a person may have complex PTSD and be misdiagnosed as having BPD. In other cases, a person might have BPD and be misdiagnosed as having complex PTSD. The two can also co-occur, though, so a person could have both.
So again, it’s one of the situations where having someone who has experience with assessment and understanding both diagnoses can do a careful, thoughtful clinical interview and better assess for where a person might fall, but there’s definitely overlap between the two.
Jeff: Let’s talk a little bit about DID. We mentioned it at the top of the webinar, dissociative identity disorder. What exactly is that?
Matt: Yeah, so dissociative identity disorder is, again, it falls in the category of dissociative disorders in the DSM-5. It is a childhood onset reaction to severe childhood abuse, typically occurring during a certain developmental phase for children, usually starting before the age of six.
And it includes a number of symptoms including depersonalization, which is the sense that a person’s body is somehow disconnected from or different from what it actually is.
A person might describe sensing that parts of themselves are missing, or bigger, or smaller than they actually are. Sometimes, people feel like they’re watching themselves from an outside perspective.
It includes symptoms of derealization, which are things like sensing the world around you as strange or unfamiliar in some way. It includes amnesia, memory difficulty or difficulty remembering kind of daily events, more than would be accounted for by normal forgetting.
And then, identity confusion and identity alteration. And that’s the sense of having one or more distinct personalities or self states within one mind and one body.
Jeff: We used to hear the term, sometimes, multiple personality disorder. Is that the same thing as DID, and if so, why has there been a change in the terminology?
Matt: Yeah, multiple personality disorder, DID is what was once called multiple personality disorder. The change happened with the advent of the fourth revision of the DSM-5 in the early 90s.
And the change occurred because DID is really not a disorder of having multiple personalities. Some of my mentors and colleagues would say it’s really about not having enough of one personality.
And to identify it as multiple personality disorder sort of misses the crux of what the disorder is, which is a person’s, a child’s, desperate attempt to stay hidden and to sort of survive or cope with unthinkable trauma and abuse.
So, to do that, they sort of go retreat inward and develop their creative. They develop an internal world, that over time, may become elaborated and feel or seem as if there are distinct personalities or persons and in one’s own mind.
But it’s not a personality disorder and it’s not really about having multiple personalities, it’s about not ever developing enough of one because trauma interfered with that normal development.
Jeff: A viewer would like you to further explain what you mean by patients having difficulty with their identity.
Matt: In terms of complex PTSD?
Jeff: I don’t honestly know.
Matt: Okay. Yeah, so that’s one of the criteria for complex PTSD.
That sort of symptom is commonly described as questioning who one is, not having a sense of self, not having a firm sense of identity, feeling maybe confused about who one is, how one would like to be.
So, those sorts of symptoms are often part of complex PTSD.
Jeff: Let me get us back on DID for a moment here. Signs and symptoms that folks should be watching for, either in themselves or a loved one. What can you tell us about those?
Matt: Well, DID is a disorder of hiddenness. So, in many cases, people with DID will go unnoticed, and that’s really most common. For clinicians, people who are sort of assessing, commonly we will see people with multiple diagnoses over time.
Of note, on average it takes nine years after a person is first treated for an accurate diagnosis of DID to occur. So, people are often carrying diagnoses like bipolar disorder, borderline personality disorder, PTSD.
So that’s one of the things I would look out for in considering DID. A lot of people with DID don’t want to talk about trauma or what’s going on in their mind. They might feel afraid of sharing that, they might feel uncertain about what it means for them.
So, I think it’s hard for family members to look out for things. Certainly, if a person commonly experiences memory difficulty and there isn’t an organic or substance use-related reason for that, that might be a sign that they have a dissociative disorder, including DID.
But again, overt signs are typically not there. People are usually surprised to find out that a person has DID.
Jeff: Talk a little bit about treatment for DID.
Matt: Yeah, so treatment for DID, it tends to be sort of longer term. It’s typically an individual therapy over the course of years. It is also done in phases where a lot of time is spent on developing shared language, so a person’s kind of language to understand their mind and their symptoms of DID, but also safety, stability.
At some point, treatment may include talking about or coming to understand the impact of trauma, but the course is really kind of prolonged compared to treating PTSD or even complex PTSD.
Jeff: You’ve touched on this a couple of times, the role of family members in the treatment process and in supporting a loved one with some of these conditions that we’re talking about today.
Can you break that down a little bit more specifically for us? Prior to treatment, during treatment, post-treatment. What is the proper level of involvement, generally speaking, for a loved one?
Matt: Yeah, because obviously, it varies quite a lot depending on the family or the person who’s being supportive. I think pre or prior, it’s encouraging someone to seek out appropriate health. Keeping in mind that reactions to traumatic events are to be expected and to not discourage, shame.
So, really being encouraging of seeking appropriate help is one thing I would say. During treatment, you might expect to see a person feel worse for a while, or really vacillate between feeling a little better and much worse. And so, to be patient and really help people to stick to it.
We do find that because of the nature of treatment for PTSD, a lot of people drop out or discontinue before they’re able to reach the full benefit.
So, family members can be really helpful in supporting a person continuing or staying connected to treatment throughout the process.
Jeff: I’m going to tap back into our bag of questions, if you will, that is getting more and more crowded as we go here.
Matt: Well, that’s a good thing.
Jeff: Let me see if I can pull one up here. How can someone help a loved one with developmental disabilities who experienced childhood trauma?
Matt: So how can someone... I would say the same recommendation would be to seek appropriate help and assessment. PTSD treatments have been employed with people who have a variety of different cognitive abilities.
So, I’m not quite sure what specific developmental problem the person is asking about, but in general, you’re going to want to find someone who treats, understands whatever that developmental problem might be.
I would say, one of the questions or things we get asked often are how necessary is it to have someone who specializes in trauma treatment to really recover from or treat PTSD or trauma-related symptoms?
And I think it’s important, I don’t want to diminish the fact that trauma experts and clinicians have a skill and ability that is very important, but in general, most trained therapists and clinicians are going to be able to help a person navigate the most interfering and common problems related to a traumatic event or PTSD.
So having a solid therapeutic relationship where there’s trust and safety is usually the most important key ingredient to successful therapy.
So, I would encourage community clinicians, people who don’t specialize in treatment of PTSD to not sell themselves short and to really understand that the relationship and the therapeutic alliance and the good work that they’re doing already is often just as, if not more helpful, than a specialized trauma-focused treatment, maybe.
Jeff: So, we often have a lot of clinicians tuning in for these webinars, if you will, and I want to ask you about what they should know in terms of when it’s appropriate to refer to somebody else and also, what they might do to train themselves in these particular areas as well?
Matt: Yeah, well, in our clinic, we provide evidence-based, trauma-focused treatment in an injunctive fashion. So, we expect that someone’s going to have a primary therapist with a good relationship, and that our role is to really provide a time-limited, specialized, targeted treatment for a set number of symptoms related to PTSD.
So, one thing I would say is that for clinicians to continue doing the good work that they’re doing and addressing the symptoms that are presenting and refer out, or reach out, when it seems like things aren’t improving as expected or there are symptoms that they’re less familiar with, especially, certain PTSD symptoms.
There are a number of trainings. I often refer people to the National Center for PTSD website. There is a plethora of resources for family members, clinicians, people who have PTSD, there are self-assessment tools, there are videos, and short blurbs on various types of treatment.
So, for both clinicians and patients, I think that’s a great resource to start with if they’re ever wondering about what they might do next.
Jeff: Well, more specific questions. Is there any research linking childhood trauma with other mental health conditions such as bipolar disorder and depression?
Matt: There are, I would imagine. So, I’m not as familiar with the connection to bipolar disorder and childhood trauma, but I know there are studies that link prevalence of depression, or that those with childhood trauma are more likely to develop depression or depressive disorders later in life.
I couldn’t quote, or I’d have to go and look for the specific studies, but there is a strong link between adverse childhood events, childhood trauma, and a number of adulthood mental health problems, physical health problems. There’s actually a number of negative outcomes.
Jeff: Question about the role of exercise in the recovery of complex PTSD.
Matt: Well, I think in general, exercise is a helpful thing, regardless of mental health problem.
I don’t know of anything specifically looking at exercise for the treatment of complex PTSD, but I believe it would help in the same ways it helps with really any other approach in terms of improving well-being, physical health.
I’m certain there are benefits to cognition and things like that that we really would focus on in treatment of PTSD.
Jeff: One thing that’s always very helpful is if we can sort of walk through a hypothetical situation in terms of treatment.
If somebody came to you with PTSD challenges and was interested in starting a treatment protocol with you, can you walk us through a hypothetical situation and what that might look like? The duration of the treatment, what the outcomes might be, and so forth?
Matt: Yeah, so typically, if someone’s coming to me and saying that they’re having a hard time and they may have experienced a life-altering or significant event, the first step is to do kind of a thorough assessment, and that typically involves a clinical interview, I’ll often use the clinician administered PTSD scale or the CAPS to assess for symptoms.
With that information and depending on the person’s diagnosis, let’s say they are diagnosed with PTSD based on the CAPS, I’ll then talk with them about some of the most interfering symptoms they have and give them some information about the types of treatment that I’m able to provide, and make a decision together, at that point, about what approach.
And then, typically, it’s 12 to 16 sessions of individual therapy. And the approach, whether it’s prolonged exposure or cognitive processing therapy, both of those are treatments that I provide, each session sort of has specific tasks.
There’s between-session work that a person will do. Prolonged exposure, for example, involves talking through a traumatic memory in session, recording it, and then listening to it between sessions. The goal being to reduce the amount of distress a person experiences related to thinking about or hearing about the traumatic memory.
But again, it would be weekly sessions over the course of 12 to 16 weeks, typically.
Jeff: What kind of expectations can patients have for post-treatment recovery? What does that look like?
Matt: So, PTSD is, luckily, a disorder that people can recover from successfully. Treatment has been found to be very, research has shown it to be very effective. Some people, after PTSD treatment, don’t need additional support or therapy.
They actually feel like they’re able to get back to life and meaningful activities. Others will find that there are some lingering problems that they face, mood symptoms. Even as the PTSD gets better, they might still have anxiety or depression.
So, some people may have continuing treatment for those specific problems. It really depends, I would say, on how much support a person needs after treatment.
Jeff: Question about the link between being a child of an alcoholic and complex PTSD. Is it common for children of alcoholics to suffer from complex PTSD is the question?
Matt: Yeah, I think it’s another one of those it depends. I understand, from my own work and peers, that there is a common thread.
A lot of people who live in households where alcohol use disorders or problems are prevalent are also witnessing domestic violence, situations where maybe a parent or caregiver is unresponsive or not able to provide appropriate care.
And in those situations, those may meet criteria for trauma and childhood abuse or neglect. And so, there is a strong link, overlap, correlation between the two.
Jeff: Question about prolonged grief disorder, which I believe you mentioned earlier in our conversation today. Is there a book that you would recommend on the subject or perhaps other resources for learning more about it?
Matt: There is. I’d have to look up the title of it. There’s a recent book on prolonged grief disorder and treatment, and I’m blanking on the author.
Jeff: We can get that from you later, Matt, and link it up to our webinar page as well.
Matt: Perfect. But yes, there are some good resources on prolonged grief disorder.
Jeff: Is personality impacted by PTSD. And if so, how?
Matt: That’s a good question. Yes, I would say, especially in the case of childhood trauma. Personality development is occurring early in life. And so, anytime that a person experiences trauma during that developmental phase, their personality may be impacted or affected in some way.
But in general, in adulthood, personality tends to be a pretty stable factor. And I would say that how one copes with trauma or the type of PTSD that they develop may depend on their personality style more than the reverse, if that makes sense.
That a person’s ability to cope with, recover from, think about trauma and PTSD is affected by personality, but that a traumatic event in adulthood is unlikely to completely shift a person’s personality.
Jeff: And as we mentioned at the beginning of the webinar, you are involved in some cutting-edge research, and I’m curious what you can share about that in terms of what the frontier for all of this is?
Matt: Yeah, so I’m a member of the Dissociative Disorders and Trauma Research Program, and there are a number of neurobiological and physiological research studies that are happening. The sort of cutting edge is really looking at fMRI data, actual brain scan information on differences between different types of PTSD.
Some of the research being done has identified sort of a fingerprint, if you will, of DID, DID with dissociation symptoms, and dissociative identity disorder. That’s one of the studies that’s being done in our lab.
So, that’s some of the cutting-edge research that I’m kind of adjacently involved in. We also are doing work on effectiveness of various treatments. I mentioned before that there are some good evidence-based approaches developed at the VA for treating PTSD, but some of those have been less effective for treating complex PTSD or PTSD with dissociation symptoms.
And so, we’re looking at different approaches to treating those kind of subcategories or different subtypes of PTSD by looking at people’s responses to different treatment approaches.
Jeff: Is there a trend line that we can look at in terms of numbers of people who are dealing with some of these issues, and if so, what direction is that trend line going?
I would imagine it’s a little difficult to answer that because of the awareness level now versus, say, 10 or 20 years ago as well. But what can you say on that front?
Matt: Yeah, well I can speak to sort of the trend that we’re seeing in terms of referrals and symptom severity in our various treatment programs.
We are also hearing the same pattern from colleagues across the country and around the world, in fact, that the number of people that are showing up, reporting having symptoms of PTSD or symptoms related to a traumatic event is increasing. And so, the trend line is sort of going up.
It’s not entirely clear if that’s because people are more exposed to trauma or if people are just more willing to seek treatment for trauma. That I don’t think we have firm data on yet, but the trend line is that people seeking treatment for trauma, trauma-related problems is going up.
Jeff: Let’s talk a little bit more about resources as we start to wind down the webinar here. You’ve mentioned a couple along the way.
Are there others you’d like to put out there for people that are looking for more information or perhaps even feeling a little overwhelmed by this topic and not knowing where to start doing further research for themselves or for a loved one?
Matt: Yeah, again, I would emphasize the National Center for PTSD, they have a clearing house of information. Very helpful.
The International Society for the Study of Trauma and Dissociation or ISSTD, has a number of good resources for people that may have more complex trauma presentations, dissociative disorders or problems. They have a find a clinician or find a provider resource and a number of other helpful resources.
The other places I would send people are SAMHSA, those are generally the online resources. I think reaching out to and seeking assessment from a provider is always a good idea if you really are concerned about it.
But in terms of online resources, the National Center for PTSD and ISSTD is where I typically send people.
Jeff: And finally, Matt, one of the things we’re trying to do with this series of educational webinars is provide hope to people who are dealing with these challenges or perhaps supporting somebody, a loved one who is.
What can you put out there in terms of the hope that is afforded through treatment and support for dealing with trauma and trauma-related disorders? What do you want people to know?
Matt: Recovery is entirely possible. And in fact, PTSD is sort of one of the most successfully treated mental health problems that a person might develop. I think it’s really wonderful that there’s been a great deal of de-stigmatization of PTSD and trauma reactions.
So, I would encourage people to, you know, seek help when appropriate, follow the guidance of providers and to know that people really do get better. It’s one of the reasons that I find our work, my work so meaningful, is that you get to see people improve in a relatively short period of time and return to meaningful life activities.
Jeff: Well, I want to thank you so much, Matt, for making some time to share some insights on a very complex range of topics here.
And I know that we’ve covered a lot of ground and you’ve shone a lot of light on a lot of important topics, so thank you so much for that. We appreciate it very much.
Matt: Thank you for having me.
Jeff: Matt Robinson, and to all of you who have joined us today on behalf of McLean Hospital, I want to thank you for your interest in our webinar series. Hope you’ll come back and watch more in the future, and we wish you a wonderful day.
Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.
Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.
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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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