Psychiatry & Psychotherapy Podcast - The Unspeakable Mind: Stories of Trauma and Healing from the Frontline of PTSD Science

Episode Date: June 13, 2019

PTSD, or Post Traumatic Stress Disorder, occurs when someone experiences or subjectively experiences a near death or psychologically overwhelming event and then goes on to develop specific symptoms. Different types of trauma/stressors that can lead to PTSD include sexual violence, combat experience, medical conditions (e.g. myocardial infarction), and natural disasters (e.g. hurricane) (Chivers-Wilson, 2006; Edmondson et. al, 2012; Grieger et al., 2006; Hussain, Weisaeth & Heir, 2011). It is characterized by: Direct exposure or witnessing of trauma/stressor Presence of intrusive symptoms post-traumatic experience Avoidance of traumatic stimuli Negative changes in mood and cognition Hyperreactivity Hyperarousal (APA, 2013). Here are a few stats about PTSD: In 2017, over 47,000 Americans died by suicide (CDC, 2019). This number has been climbing about 1,000 new cases per year from 31,000 American deaths by suicide in 2000 (CDC, 2019). One contributor to this statistic are people with Post-traumatic stress disorder (PTSD), who are at increased risk of suicide (Wilcox, Storr & Breslau, 2009). The lifetime prevalence of PTSD in the general population of the US was found to be 6.1% in one national epidemiologic study with certain populations at higher risk for PTSD (e.g. female sex, low socioeconomic status, previously married status, experienced trauma at a young age, African Americans, Native Americans, refugees or immigrants from countries with conflicts) (Alegría et al., 2013; Brewin, Andrews & Valentine, 2000; Goldstein et al., 2017; Kisely et al., 2017; Marshall, Schell, Elliott, Berthold & Chun, 2005). By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel

Hello and welcome to the psychiatry and psychotherapy podcast with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental off field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. So welcome back to the podcast. I am here with Shelley Jane.

She is a psychiatrist who is a clinical associate professor affiliated with Stanford University School of Medicine. She is a PTSD specialist who works at the VA, and she has recently written a book called The Unspeakable Mind, Stories of Trauma, and Healing from the Frontiers of PTSD Science. So welcome to the podcast. Thanks so much for having me. It's my pleasure. Yeah, so I wanted to jump into the why first, why this is an important topic to discuss. And as I was reading your book, the chapter that really jumped out to me as like why it would be really important to talk about it is to talk about suicide prevention. And so tell me a little bit about how you think PTSD is related to the 30,000 Americans who die every year from suicide and specifically in the VA how it's related.

Okay, well, yeah, that's a great place to start. So I think the first point to make is that PTSD is a pressing public health concern all over America. You know, we tend to think, when we think of PTSD, we tend to think of the soldier back home war. But obviously, many traumas can cause PTSD. So when you think of sexual violence, family violence, you know, being forced to flee, being a refugee, escaping a natural disaster, there were so many traumas that can lead to PTSD.

And it turns out that we know from epidemiological data, that exposure to major traumas like this are actually really common in the United States, something like six out of ten men, five out of ten women will say that at some point in their life, they will experience a major trauma, and a subset will experience multiple traumas. Now, of course, not all of them will develop PTSD, but a substantial minority will, and that translates to huge numbers of people. So at any given moment in time, we have six million Americans who have active symptoms of PTSD, and who need treatment.

And then in addition to the six million, there are many, many millions more who have what we now know to be a syndrome called partial PTSD, which doesn't meet the textbook criteria, but is still significant and people still suffer. And then we have this massive problem that a lot of times people who have PTSD, they're hard to reach.

Integral to the nature of the disorder is that they are avoidant. They don't want to address the trauma. a lot of times they're mistrustful. So they're hard to reach. We're not even accessing these people. They're never making it into mental health care. So if you combine all of that, you can start to get a sense of the mental health burden of this condition.

And specifically with regards to what you were saying about suicide, you know, people who live with PTSD, a lot of times there's a lot of comorbidity. So depression, addiction, anxiety disorders. Oftentimes they go hand in hand with PTSD. And then all of them have a higher risk of death by suicide. So, you know, in my mind, one of the best ways we can prevent suicide, especially in high-income countries, is access to high-quality mental health care.

And by high-quality, I mean, you know, evidence-based. We know it works for the condition. And unfortunately, that's where we hit a roadblock because, A, access to mental health care is a massive problem across the whole country because of parity, because of stigma. be, you know, the way we offer care isn't always the most friendly, you know. I think re-engineering care to make it more acceptable, more available, more accessible for people is key. And that's what a lot of my research focuses on. And so, you know, so we're not accessing the people who need help.

And I think the sad thing is if you look at the suicide statistics, we have a lot of data in the VA because we track it really carefully. a lot of people, a lot of those who die by suicide, they don't even make it in to a hospital. They don't even show up for help. So in my mind, access is a massive issue, diagnosing it, treating it early intervention. I think that's really key. Yeah, you talked about moral injury as like part of the picture of suicide prevention. Tell me a little bit about like when you think moral injury, how do you define it and then how does that relate? So moral injury is a kind of construct or a term that is being investigated and

studied probably I think in the last 10, 15 years and a lot of it obviously started with, it started in research with military personnel. And in essence, the argument goes this way, that the patients kind of distress, psychological distress and the kind of symptoms that they're having is related to their experiences that whilst they were serving, that whilst they were serving whilst they were in active military, whilst they were in combat, if they were exposed to situations, either they witnessed something or they were required to do something that really conflicted with the sense of who they are as a person morally, ethically, philosophically, you know, it could be that it was antagonistic to their kind of religious or spiritual beliefs.

That is the injury that is causing the distress. So it's been put forward as a separate construct to PTSD. And I think issues like guilt and shableness. shame play a huge role in moral injury. And we know those are really, in the context of PTSD, those emotions of guilt and shame are really integral to the pathology of PTSD. And shame has been called this soul-eating emotion. And we really get concerned about the connection with suicidality when there's a lot of guilt and shame, you know, survivor guilt or shame about something that happened. So it's right now, it's kind of like a construct. It's kind of an idea, is it a diagnosis? No. Like, is it a formal diagnosis? No. But it's really useful

to think of moral injury when you're talking to trauma survivors who, you know, maybe had to leave people behind. You know, loved ones died or people they cared about died or they, you know, so where guilt would be an issue or where their trauma involves something that they felt was shameful or something that they carry with a lot of regret or remorse. And I think recognition. their spiritual beliefs with that injury, then is the key to start healing. Yeah, that's really good. As I've worked with people with trauma, it's often the stories that they will not tell because they feel that moral injury or they did something that went against their conscience

that they feel a lot of guilt and shame about, it's sometimes that is what is causing a lot of the trauma but it's so hard to get to that is there do you have some common experiences with the patients you treat where it's like maybe at first you don't really even hear that story you know yeah absolutely i mean i've been a doctor for 20 years now thousands and thousands of people admit have got trauma histories regardless of whether or not they have PTSD often as mental health professionals you're meeting people who have got heavy trauma histories, you know. And here's the key.

And this is part of the reason why I really wanted to write the book, because here's a key. A lot of times when people survive a trauma, it really cuts to the heart of what they hold to be sacred, what they hold to be true. And the event simply becomes too terrible to utter aloud. It's literally unspeakable. And sometimes the survivor wants to speak up, right?

But the wider society isn't ready to listen to them, isn't ready to bear witness. so they're kind of forced into this silence. The problem is PTSD thrives under such conditions. You know, when these memories remain unspeakable, when these thoughts remain unthinkable, they become these stuck points in the brain's process of reintegration and healing. They become these stuck points that prevent that.

So making the unspeakable permanently speakable is such an important part of treatment. Most oftentimes that's what you need to get to. Now, what does that mean in real life practice? I think what it means is you spend a lot of time just gaining the trust of your patients, right? Creating an environment where they can come forward and speak. Yeah, I love one of the quotes from your book, Time-honored tradition and medicine, the power of a strong relationship with my patients

and the importance of creating an environment in which they feel they can say whatever is on their mind. And it really does echo throughout your book, the importance of the therapeutic alliance, the importance of creating that very person-to-person connection. And I like how you also talk about how technology can sort of insert its way back into and, you know, sort of keep us from that. Absolutely. I mean, I feel like part of the reason this theme of therapeutic alliance does come through in the book so much is because I do feel it's under-attract. attack. You know, like I said, I've been in practice for a while now, but there is something about 21st century medicine that has just taken a really undesirable turn in some ways. It really has. And I feel like probably the main issue for me that I'm grappling with right

now is screens, computer screens, electronic medical records, which have become, you know, something 20 years ago, I loved. I remember. when I came across my first electronic medical record in the VA when I was an intern. And I thought it was the best thing, you know, but now 20 years later, I feel like we're all sucked into the screens more than we are. And there's definitely this issue about these databases becoming, you know, requiring a lot of data entries. And I think a lot of times it's frontline clinicians who are doing the data entry. And that's a massive problem because our patients are going to suffer and our alliance with our patients suffers.

So it's almost like every day I feel like I'm fighting. I'm fighting to preserve my therapeutic alliance because I know that nine times out of 10, that's what's going to help my patient. Yeah, yeah, actually, it's a big theme of this podcast. I do a whole series on therapeutic alliance. And as I was reading through your book, I was like, man, we agree upon a lot of things. That's a lot of fun. You know, I want to, before we jump into PTSD a little bit more,

I want to hear a little bit about your personal journey, your father's journey, and maybe what it was like to be raised in a family where it sounds like your father had some significant trauma. So, yeah, so I think the seeds for what I'm doing today in my day-to-day life as a PTSD specialist and trauma scientist and the seeds for writing this book actually started a really, really long time ago. We have a personal family history of tragedy in that in the 1947 partition of British India. my father was a young boy. He was just 10 years old. And India, British, India was under colonial rule at that time. And the British were getting ready to quit India in 1947. And before they left, they partitioned the country into two countries. There was the Republic of India with the Hindu majority and then Pakistan with a Muslim majority. Unfortunately, that plan was a really, really negligently orchestrated plan. It was very hurriedly executed. It led to total chaos on the ground. No one knew what was going on. Families were required to move in an instant. They were required to abandon their homes, their ancestral lands.

And the result was absolute horrific into communal violence. Millions of people were murdered. Many, many millions of more became refugees and had to live under deplorable conditions. Something like 75,000 women were raped and mutilated. And then during this violence, my paternal grandfather, was murdered in this violence. And as a result, my dad became an orphan. And he was living as a refugee in the newly independent India.

And because he was so financially destitute for a couple years, but he was also a child laborer. So many years on, like flash forward, like 20 years later, as an adult, he ended up moving to England. And that's where I was born and raised. So in many ways, I was really disconnected from a family history, you know, in time and geography. I was really disconnected, barely, you know, I've been to India three times in my life, no heirlooms, no photographs of my grandparents, no family heirlooms or anything to connect me to that history.

But even though I was separated, I can't remember a time when I was growing up where I did not palpably feel the kind of harrowing social dissent that he went through when his life changed in an instant. And so even though I was growing up, you know, 20, 30 years later in a different country, I felt like in a way the events of 1947 were right there in the room. And obviously as a kid, I didn't have the words to describe it. But I think that's what my career became, you know, a quest to find the words, to describe what I was feeling. And, you know, obviously I chose to go to medical school. I had no idea at the time.

I chose to become a psychiatrist. I had no idea that this, my mind. of being connected to this family history. And then it was only in 2007 when I went on a road trip with my dad to celebrate his 70th birthday. And he kind of really told this whole family story in a lot of detail. In essence, he was giving me testimony because by this time he was the sole surviving member of his family of origin that the penny dropped for me.

The, oh, okay, I get it. You know, these are my people. I'm from really traumatized people. And then that started this journey where we moved to California. I trained to become a research at the National Center for PTSD. And ever since that has been my kind of subspecialty. And that is the work that I do every day. And that is the research that I do.

Wow. You know, that is, that's quite the story. And so you're in this home. It's kind of a lot of it's unspeakable, right? And so that's that word that goes with your book. And one of the questions that's come through recently, actually, what some of my listeners have asked, like, to speak to what it's like to be raised in a family where, you know,

the parents have suffered PTSD. And like, how do you see that and navigate that and grow through that? Well, I really believe, you know, you've got to, we've got to name it to tame it, right? And I think sometimes what is unfathomable for a child who's being raised by somebody who's being traumatized is you just don't know how to make sense of it, you know? I mean, I feel, I mean, I'll talk about generational trauma a little bit and what exactly know about, we know about that and the whole kind of science of epigenetics. I think that is fascinating in of itself. I think what was really interesting and what I've come to the conclusion with after writing this book and kind of contemplation,

hiding the whole situation and obviously having to look at a lot of the personal dimensions in my life. I think what kind of saved my dad and what really stopped me from being really injured through this whole process of being in a family that has this major trauma history, is that he was doing what a lot of trauma survivors actually don't do. He, his whole life was trying to make the unspeakable speakable. He was trying to find a language to express what had happened to him. And when I was a kid, and this is classic for trauma narrative. When I was, and I didn't know it at the time, but I know this now,

TSP special. So when I was a kid, he would talk about it. He never hid it. He never denied it. He never avoided it. And I do think that's what was what saved him and me and our relationship in the end. But when I was a kid, the way he would talk about it, it was really weird. He would just drop in these little snippets of information, often at really inopportune times,

and often it was accompanied by his anger and his bitterness. So they came to represent these, like, really awkward intrusions. But over time, the story got smoother. And by the time we reached 2007, he was retired. He'd been going back home more to India. He'd been collecting pieces. And then it was a really smooth narrative. He'd let go of the anger and the bitterness.

He'd made sense of it. He'd made meaning out of it. And then he offered me this kind of beautiful testimony. So the fact that he kept his precious peritence alive, I think he realized he didn't have a choice. He couldn't avoid it. It would take him down. But the fact that he kept it alive actually, I think,

turned out to be the best thing. I think where family's struggle is when trauma is avoided and denied, because the side effects are still apparent. You know, just because you avoid or deny a trauma, that doesn't mean you don't see the symptoms. The symptoms come out in one way or another, whether it's someone's addicted to something because they are unable to deal with the trauma

or whether it's that they have mood, mood states, anger, impulsivity issues, control issues, it comes out. So I feel like the fact that he was determined to make sense of this trauma, make meaning of it, actually worked hugely in his favor. And it was a very important lesson for me to watch growing up. because I think in its essence that that was what ultimately made this experience healing and that as father and daughter we could kind of come full circle and the trauma didn't get the

better of us. But it's a different story when it's avoided or denied or when people want to talk about it, but it's kind of shut away. Yeah. Yeah. So it's like him having that voice slowly throughout your childhood and then kind of working through it slowly kind of created. created health, whereas you think denial, stuffing, not talking about it, can actually create

a lot more issues. Agreed. Okay, so jumping a little bit into your approach to PTSD, when you meet with someone, what questions do you ask to help you sort of delineate, is this PTSD or is this anxiety or is this depression or is this more like borderline personality disorder so how do you sort of differentiate and make the diagnosis so um with the system that i work in the the the a system the way we're set up is that every patient who comes in to see their primary care doctor they get an initial screen which is called a PCL5 and um the reason i mention that is um screens such as the PCL5 and there are

other screens too, but I'll take that as an example. They've really increased a scientific precision with which we detect PTSD. So I really encourage people to consider using screens. And these screens are widely available, publicly available. You don't have to, you know, you don't have to pay or anything for them. And then, but of course, the screens have a lot of false positive, right? And that's when the trained mental health clinician comes in to really kind of weed out what is a false positive versus the real thing. So, when people come to see me, oftentimes what I'm listening out for is obviously a history of exposure to a major trauma. More often than not, that kind of comes out in the history.

Sometimes it doesn't. Sometimes it takes a while for it to come out. But, you know, exposure to a major trauma. And typically what we talk about when we talk about trauma and PTSD is, you know, their life was threatened. They felt the sense of normalcy was totally shattered. they felt totally utterly helpless in the face of that event. So then once you hear that there is a trauma history, then we start to look at the impact of that.

So timing matters, you know, usually in that first four weeks after exposing the trauma, you really don't want to pathologize. There's a lot of symptoms that look like PTSD, but actually are not PTSD. So timing matters, you know, usually if it's been more than a month since that exposure, then we're listening out for things. I think the textbook symptoms that help me distinguish PTSD from anxiety disorders and depression. Textbook symptoms are the intrusion symptoms, you know,

so classic PTSD nightmares, flashbacks, intrusive memories, that type of thing. Those are the really hallmark features of PTSD that you want to be listening out for. Other symptoms, you know, like the hypervigilance, the arousal state. what's more subtle that I don't think we look for carefully enough is mood states like shame, guilt, anger, fear, horror. Those are very particular for PTSD. Avoidance, that's a tricky one because a lot of times people are really avoidant. They never show up to see people like us,

but avoidance is a core feature of PTSD. So often how that manifests is you kind of notice that the patient has a very restricted range of emotions when there is. in the room with you. They never show pure happiness. They never show pure anger. They never show pure sorrow. It's a very narrow range of affect. And if you look at their life, they live their life in a very narrow range too. They avoid a lot of places, people, memory, they kind of re-engineed their life to avoid the trauma. So avoidance is another one. You mentioned personality disorders. I definitely think that construct known as complex PTSD that was put forward by Judith Herman. the Harvard psychiatrist who's a pioneer in the field of PTSD has been invaluable for me as a clinician over the years to help distinguish between, you know, cluster B personality disorder with someone has problems with emotional regulation versus something like complex PTSD.

So I think that's a really helpful thing to be aware of. So those are some of the main things that I look for. So maybe you can, I'm curious how you differentiate complex trauma. versus borderline personality disorder because I kind of see so much overlap. I tend not to think of it as borderline personality disorder, but complex trauma and attachment trauma. But how do you see it? I'm curious. So again, kind of listening out for the trauma history, so I think integral to the complex trauma,

sorry, complex PTSD diagnosis is oftentimes it's people who have experienced chronic trauma, right? and typically how this manifests is, you know, like adults, I mean, I just see adults in my practice. So oftentimes the adults, they have a history of extensive childhood abuse, right? They don't remember a time when they weren't being abused. There's no before and after, you know, or take for example, somebody who's in a relationship where there's a lot of inter-partner violence, but it's a chronic situation. So in essence, what I feel is happening here is there's no before and after the trauma. They don't have that anchor.

You know, a lot of patients who have like textbook PTSD. They had their life before and then they saw their life after the trauma. And the life before kind of acts of this anchor. You know, they know where they're headed. They know where they're going back to. But people with complex PTSD, they don't know any different. And I think it really manifests in the therapeutic relationship. you know, there's a lot of ups and downs in the therapeutic relationship.

There's a lot of mistrust. There's issues with emotion regulation. I mean, literally they can go from rageful to regretful within the space of one session, right? And then reenactment is something I look for too. I think reenactment is this really powerful phenomenon where throughout their life, despite trying not to do this, they get caught in these cycles of reenactment, where they're going back to reenacting the trauma that oftentimes they grew up in. So, you know, it acts out in their relationships, their personal relationships.

Sometimes it can act out in therapeutic relationship. So I think the chronic trauma history is huge for me, the reenactment phenomenon. I think with textbook borderline personality disorder, I think some of the identity issues, some of the self-injury issues, the chronic suicidality. Maybe that would push me more in a direction of borderline personality disorder. But I don't know. I'm biased because I'm a PTSD specialist, but the more and more I think about complex PTSD, I just feel like more and more that's actually what the vast majority of the patients who I once would have diagnosed this cost to be. It's actually complex PTSD. Yeah, yeah. I'm glad you, it's interesting how you've had a very different

experience from me, but we've had similar sort of conclusions and how we see things. So how would you describe dissociation? And when someone dissociates and telling you their story, how do you interact with that in your session? Or how do you help them in the midst of your session? So great question. The first part about dissociation, so, you know, as your listeners are probably aware in the latest iteration in the DSM-5, there's actually a dissociative subtype of PTSD now that occurs in 15 to 30 percent of PTSD sufferers. So we now actually have a subtype which has its own kind of biological footprint. And I think it's useful to think of that. And in essence, you know, there's feelings of kind of depersonalization, de-realization,

you know, feeling like you don't feel real, feeling like the world around you isn't real. Of course, all of us can have those symptoms sporadically from time to time when we're stressed, when we haven't slept much, when we're grieving. But for these sufferers, these patients who have this dissociative subtype, they experience de-realization, depersonization every day. It is frequent. And you can imagine how that starts to do that well your day because you're not living in the present. You're dissociating all the time.

And, you know, again, oftentimes in my experience, it's people who have these severe childhood abuse histories who end up having the dissociative subtype. And it's got a much poorer prognosis, the dissociative subtype. So it's important to recognize the dissociation. It answered to your question about what I do if I feel like someone is dissociating in treatment. my preference is to have them use a grounding technique. I don't feel comfortable when someone is dissociating that way. And I think my preference is for reintegration versus allowing that process to continue. So grounding techniques that the patient can use.

And typically you've talked about what those are before they talk about the trauma to get them back into the presence so they can disconnect from that emotional plane and get back in the present. Obviously, I don't do a lot of therapy myself, just my role, perhaps, that I wear, I end up oftentimes being put in that pigeonhole of the medication management. So that's what works for me in the type of setting and practice I have.

I'm sure people would have different approaches, but grounding techniques, anxiety management, breathing skills, that type of stuff, the basic 101 stuff can be invaluable in getting people back when they've been dissociating. Since psychopharm is kind of like that one of the things that you do, if someone is the PTSD with the heavy dissociation, what types of medications have helped you pull someone out of that dissociative experience?

Okay. Well, I feel like when it comes to meds for PTSD, first of all, meds is actually second line. I should say that second line treatment, you really want to focus on the trauma focus. of therapies in the talk of therapies first. There's just a lot better data for them than there are for meds. But obviously we end up using meds all the time for a variety of reasons, and certainly the cohort of people who end up coming to see me for various reasons, medications is a needed option. So I feel like my goal with medication management is to treat the underlying PTSD, and then my hope is all the PTSD symptoms, including the dissociation, will settle down.

And really my first go-to are the SSRIs, the SNRIs, just because we have the best data to support their use. Obviously, paroxetine and so trillin have actually got an FDA indication for PTSD. But in my mind, all the SSRIs, SNRIs, they all are pretty equivalent. It's just a matter of tailoring what might fit for that patient's particular history. So, for example, a lot of PTSD patients, they have a lot of chronic pain. and so then a vaccine might be a good choice. But it just varies depending on the patient's unique history. But I think that's been my approach, to tell the honest truth.

Really good medication management, not just throwing a prescription at someone, really good, really careful medication management within SSRI, SNRI, a lot of handholding. I can't tell you how much handholding I have to do with patients. A lot of them are really mistrustful of meds and they're very ambivalent. but if we can get them through that and get them on a good therapeutic dose and then have them stay on it for a therapeutic amount of time, so at least six, eight, 12 weeks, then you start to see benefits across the board in all the symptom categories. Yeah.

So you talked about a study of 3,000 PTSD sufferers and you talked about how SSRIs reduced intrusions, emotional numbing, hypervigilance. anything you want to say about that specific study or? I think I'm not sure it was once that it was like pooled together. You know, if we look at all the RCTs that have been done for SSRIs, I think the total is about 3,000. And I think we can bring that up because, you know, we don't have great data for what meds might work in PTSD, but this is the best that we have got for whatever reasons.

Now, 60% of sufferers will get a better. benefit in terms of a reduction in symptoms. Now, some people might think that's really low. I actually think that's pretty good. And I think with really solid medication management, which speaks to what we were talking about earlier, the therapeutic alliance and how that is under attack in the 21st century way we practice psychiatry, with really good medication management and handholding and strong therapeutic alliance, I think that's a 50% goes off. I don't have a month or a week that goes by where I don't see someone have a life or transforming, effective starting an SSRI.

So I think a lot of it, it varies in how the medication is dispensed and managed and the relationship with the psychiatrist. But yeah, that's pretty much the best data we have for what works in terms of meds. And then you also mentioned sometimes you give metasapine for insomnia. Now, are you giving that at like low doses, like 7.5 or 15, or do you normally take that up and get the sort of anti-depressant anti-anxiety effect at the higher dose?

So my personal approach, you know, I tend to be really conservative when it comes to medication. I really avoid polypharmacy like the plague. So my personal preference is always try to start with one medication and see how we do. I start low and then a lot of times where I might use something like metazapine is if, if insomnia is the kind of primary or main complaint. And then I start low, hope that that helps with the insomnia. When people get two, three weeks of really good sleep, they start to look different.

And then what I do is I start advancing the dose so that it can touch some of the other symptoms too. Now, we're lucky here where I work. I was just giving a grand round at a different organization earlier this week. And it was really distressing. They don't have access to. therapists who provide things like CBTI, you know, I being for insomnia or image rehearsal therapy, which is a really great talk therapy for nightmares. Both of those, we can offer freely

here where I practice in the VA. Many of the therapists are trained in those. They're really good ways to address sleep, great evidence for their effectiveness and bypass a lot of those side effects that a lot of meds have. So for sleep, I really recommend those non-farmar approaches. And if I'm using meds for sleep, it's temporary. It's a short term, you know, just to help people get, you know, a couple weeks of consistent sleep so they can start to feel human again. But then the goal is I want to get rid of the sleep med as soon as possible and just leave it with one medication that's targeting the PTSD symptoms. Yeah, I think CBTI is fantastic. And I would definitely prefer that over medications just because long term, yeah, I think

it has better outcomes from the data. So with the mood stabilizers, you talk a little bit about carbamazepine, divalproix, lamotrogen, topiramate, anything you want to comment on those? Like, are those more of a rarity that you use or are you using those when the SSRIs don't work?

Yeah, so my general approach is, if I'm focusing on the med piece, start off with SSRI, SNRI, SNRI, like I said, therapeutic alliance max out the dose, max out the duration. Then if we're not making a dent or if this patient still have significant symptoms,

okay, then you've got to put your thinking cap on. The data for mood stabilizes is neither here nor there. There's some to support, there's some not to support. So really can we be gung-ho about recommending it? No. But at the same time, oftentimes the psychiatrist, you're the one who's in the, you know,

you're the last stop. people are coming to you because they're desperate and we have to think of something. So when people have pretty stubborn symptoms, when there's issues with aggression or hostility or issues of concerns of harm to self or others, then yes, yes, I would consider a mood stabilizer, maybe like a dihoborix or like you're saying, to pyramid, depending on the side effect profile and the patient's unique history. Second generation antipsychotics, there was that time when it was really, really popular to add low-dose SGA to the treatment of people with PTSD, especially, again,

those ones who had kind of aggression, hostility, impulsivity. There was a massive trial done. I think in 2012, it was published in JAMA. Study came out of Yale where they did a RCT comparing like respiratory for people who had severe PTSD. And unfortunately, it was not a good outcome. It showed no improvement. But of course, patients were exposed to these really horrible side effects. And the metabolic syndrome, is something I really worry about in our population. I mean, I think all clinicians have to worry about it because we have such an obesity problem in the country.

So then why would we add a medication that could make somebody predisposed to metabolic syndrome when we're really not sure of the benefits? So I don't mean to be a downer on it, but I think anyone who needs to prescribe these meds just got to be aware that the evidence isn't great. But whatever you do, only do it when other options have been used and then just use judiciously.

And then if you're going to use SGAs, obviously the ongoing monitoring for lipids and casting glucose, kind of doing that due diligence just to make sure the patient's not running into issues. That's key. And then the only thing that I feel like I definitely should mention when it comes to meds with PTSD is one thing we know that it's outright contraindicated or does not work, a benzodiazepines. We have a pretty robust sense now.

It used to be back in the day, all patients with PTSD were put on benzodiazepines. But guess what? it's a Band-Aid that does not work in the long term, in the long run, it makes the symptoms worse. And now we really know that the side effect profile of benzodiazepine, you know, especially in older adults, just not worth it. So that's one thing we tend to steer really clear of. And the only way I'll prescribe benzos for patients now who have PTSD is literally like a five-day supply that they keep in their medicine cabinet. You know, as an emergency supply, if they have some horrific flashback or horrific dissociation and they need something. They at least know they have it. But that's kind of my approach to benzos.

Yeah. And you cited that there's a 50% increased mortality with long-term use, which was huge. I also think about the cognitive side effects, especially as people get older. Now, if someone comes in on a benzodiazepine, you know, then there's that tricky sort of dance we get into about building a therapeutic alliance. They love their benzodiazepines. We want to reduce it. They don't want to reduce it. I don't know if you have any comment on that. Yeah, no, absolutely. We've all been there, right?

So I feel, I honestly feel I've had a lot of luck with literally just educating my patients. So that study you reference about the mortality, I think that came out, I think that just came out in like 2012. The British Medical Journal did this massive longitudinal study, right? Thousands and thousands of patients who were followed. And we came to know about the mortality this. the morbidity risk. When I share that data, you know, with patients and when I tell them that I'm coming from a position of just really caring about the long-term side effects of some of these meds.

And as you said, a lot of our patients, you know, 65 and above or 60 above, we worry about cognition and falls, you know, oftentimes I've got to say 75% of the time, when I have that conversation with them, they're like, oh, okay, well, I'm open. to trying other things. And I definitely don't yank them off. I don't think that's a good idea. We do the taper. We take it at their pace. A lot of times they want to be in control of the taper that is fine with me. As long as we are edging toward a mutually agreed upon goal, that's fine. And sometimes we take, you know, three steps backwards, two steps forward, but that's okay, as long as we have that. And, you know, of course, there's that percentage of

cases where the reaction is visceral and they don't want to come off it, that's a real dilemma because, you know, PTSD and addiction goes hand in hand. And unfortunately, some of these meds, as you know, the benzazepans can be really highly addictive. And then that just becomes a whole other issue that needs to be addressed. Like, you know, do they have a dependency? And do we have to address that in a different way? But yeah, the conversation, starting with education, I've had great results, just sharing what I know and asking them if they want to try something different. That's really good. How does that go, how does that conversation go for you when you're talking about their marijuana use? And I know a lot of patients believe that it's helpful for them.

I recently did a podcast episode on it, and I'm doing a second one on how it increases the risk of psychosis two to four times the what would be there otherwise. But as I was reading through, you talk about a 2016 Yale study of 13 studies they looked at with no evidence supporting the practice of giving. How is this in your sort of treatment with them? What are your pearls that you can give us? Yes. So I think we're all facing this very regularly, right? Definitely living in California. So, so I, again, I try and make sense of what I'm thinking in my own head. And then once I've made sense of it in my own head, what I believe about it, that's what I try and share with patients. So in essence, I'm really conflicted.

Okay. I'm not going to ignore all these stories that my patients are telling me about how helpful their medicinal marijuana or their recreational marijuana is for their PTSD symptoms, especially insomnia, especially nightmares. is I'm not going to ignore that. I'm a clinician at the end of the day. I'm trained to listen to what my patients are telling me. But beyond the hand, I'm conflicted, because if you actually look for the data, like you said, there is no data to support the use of marijuana in people with PTSD.

Yes, there are some anecdotal reports. There's some powerful testimony, but there's no data, like what we like to see, like the RCTs, the controlled trials, you know, that we hold our meds to standard. That's the standard that we hold our medications and our therapies to us. So I would want to hold Merida Carmarolana to the same standard. Now, the good news is that those trials are currently underway. So there's a trial going on in Arizona, a VA in Arizona,

where they are testing CBD in an RCT specifically for PTSD. So we are going to know, in the coming months and years, we are going to know if this is a thing and if this is a real treatment that we can ask for patients. Regardless, though, of what the data from that trial shows, there are three things I still worry about. Literally, I lose sleepover, and I'll tell my patients that, first of all, what about interactions between psych meds and marijuana? Like, what do we even know about that? Do we know much about that? It's rare for me to see someone who says, oh, yeah, I came off of all my psych meds and now all I need is marijuana. That's a rare story. It's that

they're doing both. So I worry about interactions and adverse interactions. The second thing I worry about is driving, right? I don't think people think about that with marijuana necessarily. Impaired driving. And then the third thing I really worry about is a regulation, sorry, it's an industry that still has very little oversight regulation. And what we've definitely seen, what I've heard, I don't know what your experience is, but in the last couple years, I've heard some really strange stories, people shung up in the ER with really idiosyncratic reactions. And oftentimes what it boiled down to, they were given something, a price of, product, but what was on the bottle didn't match what it actually was. And then people are having

just disturbing reactions. So I'm still going to worry about an industry that there's little oversight on. And if what my patient is ingesting is actually what they think they're taking. So that's kind of my spiel that I give to people. And again, my feeling is 70% of the time, reasonable people want to hear that. They're open to hearing that. And they may rethink what they're doing or how they go about doing it. And maybe sometimes I can't reach people with that. But then we have to find some kind of happy balance or I'd much rather them tell me they're using it than me get a surprise. And then we leave the lines of communication open. Okay, real quick, rapid fire. Ketamine and MDMA. Too early.

Too early. Too early to tell. Now there are some studies going on in the VA, though, right? Yep, yep, but we still got to see the data. And again, side effects. I always worry about side effects, especially addiction. Okay, I really want to leave off on something you talk about, like the search for meaning, the search for meaning in this.

So you want to speak to that, kind of end on sort of the idea of in the midst of the trauma, that people are searching for meaning and how helpful that is. I think the search for meaning, if you look at people who are resilient in the aftermath of trauma, there's a lot of science of resilience when it comes to PTSD, a lot of times what has helped them is they have made meaning of that trauma and they have used that meaning to kind of catapult their life into some direction where the trauma is kind of integrated into their life, you know? And so when we think of post-traumatic growth, when we think of resilience, that search for meaning is key.

Now, not everybody is fortunate that they're going to arrive at that place by themselves. But I think that's what the therapeutic process allows for, especially at talk therapies. If you think about what's being done in trauma-focused psychotherapies, you're reworking the trauma over and over and over again. You're adding new learning. You're re-evaluating core maladaptive beliefs. And I think when therapy's done right, that's essentially what happens, that the patient re-evaluates that trauma re-evaluate impact on their life. And then they can start to move forward with this kind of enhanced awareness

and integrate it into their life in a way rather than it kind of disabling and devailing their life. So I think search for meaning is key. And that's what adds a lot of richness to the work that we do with trauma survivors, right? That's what makes it all worthwhile. Okay, well, I wish we had another hour. I could pick your brain some more. I'm learning so much.

If people want to connect with you, learn more about your work, for sure they can get your book, The Unspeakable Mind, I will link that in the show notes. Where is the other best places to connect with you? Yeah, great. So the website, my name is the website, so ShelleyjaneMD.com. And there's a contact form through there. But otherwise, the email that I give you also, that's Stanford email. I don't mind getting queries from colleagues and professionals all the time at that stamp

for the email. That's fine too. And I saw you on Instagram there, so I'll post that as well. Great. I'm on Twitter and Facebook too. That's great. Yeah, been dragged into the same, whether I like it or not. Yeah, yeah.

No, it's where people have their attention. So that's important to bring the good stuff there, you know. Well, it's been a pleasure. I want to honor that you said we're going to be done at one, and it is now one. So it's been great having you on. And I hope we can continue to have this dialogue. And if there's new studies that come out that you think are really, really important that you want to get out there and talk about, I'd love to have you back on. Yeah, thanks so much, David.

It's been really nice to have a conversation where I know amongst colleagues and able to do the kind of deep dive and get into the ministry. And I really loved your questions, and I appreciate the careful read. I'd love to do a part two. This was a lot of fun. So yeah, hopefully in the future we can do a part too. Good, good. So I'll post this on my Instagram and people can ask questions. People always throw up comments. And I'll link you on that. And then if people have enough questions, we'll create a part two. Okay. Sounds great. Thanks so much, David. Have a good day. All right. Bye.