Stanford expert explains PTSD

Most of us are familiar with the term PTSD – Post-Traumatic Stress Disorder, but what many may not know is that a significant number of those affected with the condition have not sought help. Not only have they not reached out for help, but may be undermining their wellbeing by trying to self-medicate.

To discuss this subject, I am pleased to introduce Dr. Debra Kaysen, Professor of Psychiatry and Behavioral Sciences – public mental health and population sciences at Stanford University.

Kaysen is well-published and active in research in the areas of overlap between PTSD and alcohol use disorders, and accessible interventions for individuals suffering from mental health symptoms following traumatic events. Her research has taken place across a variety of populations, including sexual assault survivors, torture survivors, active duty military personnel, and more.

Dedicated to her work both at Stanford and clinically, Kaysen’s passion for her field is recognized with the utmost clarity. Throughout our conversation she reinforces, “I love providing therapies for people.”

“Part of why I do it is because you can see people make these tremendous changes and you can see that moment in therapy where someone has been carrying this burden and they put it down,” Kaysen said. “It is unbelievably rewarding.”

I personally know individuals who have served in the military, returned home and are experiencing PTSD.

My goal is to help all of us gain a better understanding of what PTSD is, what the determining factors are, the influence of outsiders’ reactions and responses, and the overall grasp of the reality of living with PTSD. It appears that its symptoms, limitations, and struggles need more awareness.

In gaining understanding, it is my hope that strides are made to improve the lives of individuals experiencing PTSD. This includes a shift in society’s perspective of mental health conditions.

PTSD is first and foremost a condition created by “hav[ing] gone through a traumatic event.”  Kaysen says it is important to understand that there is big “T” trauma and little “t” trauma.

As daily events occur in our lives, the term ‘trauma’ may be loosely used at times to describe various concerning, disturbing, or upsetting occurrences. In other words, “People can have all kinds of horrible things happen in their lives,” Kaysen said.

She helps us understand the differences between big “T” trauma and little “t” trauma:

Big “T” trauma: “Are more the types of events where there is a loss of life that’s sudden or unexpected, where there is a threat to someone’s bodily integrity. So you can think about more events like a very severe car accident, combat, a physical or sexual assault.”

One of the key aspects of the trauma is “something you need to have experienced yourself or witnessed.”

Kaysen said it’s unlikely to have PTSD from watching terrible videos online. The common exception is “for our military personnel, there are folks who, in the course of their job, may wind up watching lots of footage of horrific events and those people can develop PTSD from those kinds of events.”

Little “t” trauma: “You might lose a grandparent who was really sick for a long time. You might be having trouble paying your bills and be really stressed out about that. You may have had a really awful divorce.” While these examples can be awful, unsettling, stressful, and overwhelming – they are events less likely to lead to PTSD.

Now that she’s explained the variances in trauma, understanding the main hallmark symptoms of PTSD are important.

Individuals suffering from the condition experience “intrusive symptoms,” which “is kind of like your brain can’t let go of the event,” Kaysen said. These types of symptoms are “things like having nightmares about it, having those memories that just keep popping into your mind even though you don’t want to have them, [or] getting really upset if something reminds you of the traumatic event.”

Some also talk about experiencing flashbacks, yet Kaysen notes that is a more unusual symptom. The most common symptoms are “nightmares and those memories.”

What follows is “avoidance symptoms,” which “makes total sense,” she said.

With or without experiencing PTSD, many of us can relate to “avoidance.” When things are tough, emotionally, physically, mentally, we may have a tendency to avoid talking about it, avoid working through it. Many people find asking for help really, really tough. In turn, it can be quite isolating and all-consuming, impacting our health and lives on many levels.

Kaysen said there are a few ways in which avoidance manifests – from working multiple jobs, signing a child up for non-stop activities, or “It could be that whenever those memories come up, you have a drink.”

Avoidance is “Anything that you’re doing to keep those feelings at arm’s length,” she emphasized.

PTSD has many facets.

I found it eye-opening to learn from Kaysen that “PTSD changes our thoughts and our feelings… in a couple of different ways.”

First – “People may blame themselves or blame other people in ways that don’t quite match the reality of what happened.”

Second – “They may think something was their fault, where objectively there is nothing they could have done; or they may blame somebody else who really didn’t have control over the event.”

Third – “It also can make people see the world in a way that may be a little more harsh, or not accurate, or black and white,” she said. This may include thoughts, feelings and statements like “I used to trust people and I don’t trust anybody anymore. I used to think the world was really safe, now I’m scared to leave my house.”

PTSD also may bring a lot of negative emotions to the forefront or even cause a lack of emotions – “guilt, shame, anger, and disgust.” Those feelings can get really intense, “or they might feel really emotionally numb,” Kaysen said.

The last bracket of symptoms is hypervigilance. Kaysen explains that this is “kind of like your internal alarm system [normally a scale of 1 to 10] gets turned up to 11.”

“Being really jumpy, watchful and on guard, not being able to sleep, or not being able to concentrate” are notable symptoms worth seeking guidance and treatment for, Kaysen emphasized. “Those symptoms can really wear people down.”

The commonality of PTSD is staggering.

“The one year prevalence rate of PTSD in the United States is 4% and 11% of people seen in primary care have PTSD,” Kaysen reported.

A one year prevalence rate means that at some point during a year, that percentage of the population has identified having the disease.

PTSD “is associated with higher risk of death, increased risk of suicidal ideation and attempts, poorer physical health, more marital instability, and higher healthcare cost in civilians and in veterans,” she continued.

“The number of folks who actually have PTSD symptoms is much bigger than the number who reach out for help,” Kaysen explained. She said while research is being carried out (and research findings take significant time), that in a broad statement there is a gap between folks with PTSD (both among veterans and active duty) and those who seek treatment/services.

She said there are complicated reasons for this, one being “a leaky pipeline,” even when active duty and veterans are reaching out for help.

“Not everybody gets into treatment,” Kaysen said. “Not everybody who gets in to treatment stays to the point where they get a good dose [of therapy] – enough to get a benefit.”

“In a large national sample (the National Comorbidity Study Replication), only 34.4% of individuals with current PTSD received specialty mental health care (care by a psychologist or psychiatrist) during the course of a year,” Kaysen explained.

A Veterans Administration study of veterans who were involved in Afghanistan and/or Iraq conflicts and had been newly diagnosed with PTSD, concluded “only about one third received treatment from a PTSD mental health subspecialty clinic,” she said.

Staying in treatment to gain the benefit can be challenging. As Kaysen noted, “Less than 10% received the recommended exposure to PTSD treatment by attending 9 or more VA mental health treatment sessions in 15 weeks or less during the first year of PTSD diagnosis” (Seal et al., 2010).

The same goes for medication as “on average, approximately 30% of those prescribed medications for PTSD also drop out” (Ravindran & Stein, 2009).

Treatment options for PTSD can include medication, psychotherapy, or both.

Kaysen explained treatments involve between 8 and 15 sessions and are typically done at least once a week.

“Most effective treatments for PTSD involve focusing on the memory of the traumatic event or about the meaning of the event for you. Treatments may use a variety of strategies to help you do this. It could involve having you actively remember the event with your therapist in the room with you, or having you write about the event. It could involve having you write about the ways you made sense of how and why the event occurred. It could also involve having you go out and try doing things you’ve been avoiding since the trauma, in small approachable steps. Most of the effective therapies are structured and have ‘between session’ practice.”

While treatment consumes about 4 months of time, the results can be life-changing. Research is being done to conclude if treatments could be more intense/more frequent and just as effective. Kaysen said that the initial findings are “that you can actually make them more intensively dosed and they are just as effective.”

“Being able to have your PTSD symptoms better in 2 weeks – that’s like a miracle,” she said.

Between juggling family schedules, a deployment looming, or not feeling like there is time to start treatment due to other commitments, it can seem to some sufferers like it’s too hard to seek out professional help and stay in it long enough to see results.

Sage advice that Kaysen gave regarding seeking help for mental health issues is, “The best treatment is the treatment you’re going to do.”

“Medications in your medicine cabinet that you don’t take, don’t work,” Kaysen reinforced. The same thing goes for psychotherapy treatments and the required work on both the patient’s part and therapist’s part.

A key component is the provider / therapist the patient chooses to have treat them. Kaysen confirmed that can be the real game changer.

“[Doctors] work for you,” Kaysen emphasized. “I tell all my patients, first of all – that I work for them; and secondly, my goal is for them to either graduate from me or fire me.” It’s without doubt to me that she has her patients’ best interests at heart.

We should all be so fortunate in our lifetime to have a health provider like Kaysen.

Kaysen believes that “finding a provider you like and trust” is an important factor in therapy.

Look at it like interviewing your doctor. Kaysen explained, “Ask them what their experience is in treating PTSD? What treatments do they use? How do they know if somebody is getting better?”

In her practice, Kaysen assesses a measured PTSD level in each therapy session, therefore she knows the benchmarks as to which sessions patients should start feeling symptom relief.

“It’s not enough for your therapist to say ‘How is it going? How do you feel treatment is working?’” This can be applied in all aspects of your medical care.

If you find yourself in a doctor’s care where he or she is letting you guide the answers and solutions and not measuring where you are at (with PTSD, a heart issue, blood pressure, diabetes, migraine), then it may be time to take a hard look at the big picture and make a change.

Psychotherapies “can be incredibly powerful,” Kaysen said. But patients have to come in consistently (weekly) as well as do the prescribed at-home practice/homework.

The therapies have proven successful for PTSD patients. Kaysen revealed these statistics: “For sexual assault survivors, there was one study they found that 80% of people who did the therapy had at least a 50% reduction of symptoms.” Incredible. And on top of that, “These treatment effects lasted 10 years or more after they finished a brief psychotherapy.”

Touching on the “practice/homework” folks have outside of psychotherapy sessions, Kaysen makes a good point. “The way I think about it is when we are trying to learn something new, the best way to do that is to embed it in our day-to-day lives.”

Many individuals aren’t having active symptoms when they see her in her office at Stanford, however they are having them outside of session, in the middle of the night, at the grocery store, in their day-to-day lives. Psychotherapy provides the tools to work through the experiences on one’s own, whenever and wherever needed.

So the “best way to know how to handle PTSD when on your own is to practice it and get some help,” Kaysen said.

As with many therapies, it can be uncomfortable, painful, and the last thing a person wants to do that day – “but that is the way to get to full-functioning,” she said.

She feels at this time that treatment of PTSD in active military and veterans is “pretty successful.”

“We do have treatments that are effective for both [and] they work very well for some people, pretty well for some people, and there are some people that they don’t help at all,” she said.

Kaysen emphasized there is room for improvement.

“In one meta-analysis (a way of analyzing across studies to be able to combine their results) across all psychotherapies for PTSD, 67% of the patients who completed treatment no longer met criteria for PTSD after treatment,” Kaysen explained.

Based on the active research underway, I feel we can be confident that even more strides will be made to successfully allow individuals with PTSD to live more fulfilling and healthier lives.

“The good news is if you haven’t gotten treatment, try it, because there’s a good chance it’ll work,” Kaysen encouraged.

Coming next: PTSD and the impact alcohol/substance abuse has