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Does This Patient Have Posttraumatic Stress Disorder? Interview With Dr Michele R. Spoont
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Does This Patient Have Posttraumatic Stress Disorder? Interview With Dr Michele R. Spoont
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>> I'm Ed Livingston, Deputy Editor of Clinical Reviews and Education at JAMA. In today's JAMAevidence podcast we're going to discuss PTSD or post-traumatic syndrome, a chapter covered in the Rational Clinical Examination. I'm speaking with the chapter's author Dr. Michelle Spoont who is with the U.S. Department of Veterans Affairs National Center for Post-Traumatic Disorder and the Minneapolis Veterans Affairs Healthcare System in Minneapolis, Minnesota. I also spoke with Maria M. Steenkamp who is with the Steven and Alexandra Cohen Veterans Center for Post-Traumatic Stress and Traumatic Brain Injury at the New York University Langone School of Medicine in New York.
I caution listeners that the descriptions of what this soldier experienced are graphic and disturbing. >> In northern Kuwait this was also a day to clean up, clear away the grisly reminders of war. Bulldozers moved in on the highway from Kuwait City to Bosra, the only way out for Saddam Hussein's army as it made a desperate last minute retreat. The highway became the scene for one of the last and bloodiest battles of the war. Thousands of Iraqi soldiers died as coalition forces cut them off on land and in the air, the so-called highway of death.
[ Music ] >> It was a like major city at the highway during rush hour and all the vehicles at a standstill with bodies still in the vehicles and bodies trying to exit the vehicles -- some bodies, you know, trying to exit the vehicles. And everyone was dead and body parts everywhere. And we had to roll -- you know, driving over these dead bodies.
And we did this for days. This was real. Iraqi soldiers in vehicles, no heads, no arms, no torso, upper torso. It was awful. I saw our scouts -- I was driving my company commander, and we saw the scouts get ambushed by some Iraqi, an Iraqi unit. And I couldn't get that out of my mind, you know, listening to it on the radio and then watching them.
We had three radios in our Humvee. I'm listening to it and I'm watching it, and they getting ambushed. And, you know, the guys getting hit it's like a movie, but you're watching it in real life and you're hearing it, the rounds hitting off the vehicles and the sounds of soldiers, you know, making them, "I'm hit, I'm hit." And, "My weapon's jammed," and stuff like that. And, you know, it's just -- you dream about this stuff. And then I dreamed we came under mortar fire one afternoon, and our convoy had stopped and mortars start, you know, shells started raining in on our position.
I dream about the Iraqi soldiers that were giving up, that were crawling down the road that had no legs and no arms, and they're buddies wouldn't pick them up. And they were just crawling down the road, they were surrendering. I dream about -- I dream about the guy who was trying to get out the vehicle, and he didn't make it out of his vehicle. And there was a hole in his windshield, he had no head, and just like spaghetti coming out his neck. >> You cannot experience things like this and not be affected by them. These events are seared into one's memory.
Oftentimes the sights, sounds and smells are linked together so that long after the traumatic event, an unrelated trigger might bring back the entire memory. For example, a sharp noise like that of a window slamming shut may sound like gunfire to an ex-soldier and bring back a visual memory of the battlefield scene. It is only since about the 1980s that post-traumatic stress disorder, or PTSD, was recognized as a problem for soldiers returning home from wartime experiences. Even though PTSD is commonly associated with war, oftentimes it occurs in civilians.
PTSD is experienced in about 13 percent of soldiers returning from the most recent wars. But PTSD is also present in about 10 percent of the general population who have never been to war. Horrific experiences such as rape, motor vehicle accidents, witnessing the death of a loved one are very shocking and can result in PTSD. So knowing what to look for and establishing the diagnosis of PTSD is important for all clinicians, not just those taking care of veterans. The meta-analysis performed for the Rational Clinical Examination chapter yielded two very simple instruments that enable primary care clinicians to identify PTSD in their patients.
One is a 17 item PTSD Checklist. Although it's long, the advantage of this checklist is that it touches upon all the DSM-5 criteria for making a diagnosis of PTSD. Knowing which of the various symptoms a patient has facilitates counseling and the appropriate referral for treatment. Equally effective in identifying PTSD in the general population is the 4 item Primary Care PTSD Screening Instrument. This instrument touches upon each of the major domains that are associated with PTSD making the screening instruments very simple to administer but very accurate in identifying patients who have PTSD.
The first question in the Primary Care PTSD Screening Instrument asks if a patient has had some event so frightening, horrible, or upsetting that they've had nightmares in the past month about it, or that they thought about this traumatic event and didn't want to think about it. >> I couldn't sleep. I noticed that before I got out the military. And the reason why I didn't sleep because I was scared to sleep because I had nightmares. And I kept waking up in cold sweats.
And I couldn't get Iraq out of my mind. >> The second question asks if the patient has tried hard not to think about the experience or went out of their way to avoid situations that reminded them of that experience. >> I did try illegal drug use but that didn't last. And so I tried drinking, that didn't last. That wasn't a solution for me. >> The third question asks if the patient is constantly on guard, watchful or easily startled.
>> Well, I lived in Inglewood, one of the worst neighborhoods in the United States. Because of the gunfire, all the gunfire and loud noises, I felt like I was back in Iraq in war. It's taken me right back there again. It feels like -- you feel like you're a soldier 24 hours a day. It feels like you are on guard duty 24/7. You're always watching your back. You always want to look out. You can never let your guard down.
You can never relax. You can never turn it off. And, you know, I can't sleep, and I feel like I'm on guard duty 24/7. It's hard for me to relax. >> The last question asks if the patients felt detached from others, detached from any activities or detached from their surroundings. >> I didn't know what was wrong with me. Everybody, I was withdrawn. I came home and I go to a bar, everybody was patting me on the back and I was just, you know, there was just no response, no emotion.
>> PTSD is a very real syndrome. And by listening to this Veteran, it's easy to see that he fulfills all the criteria in the PTSD screen. One would think that having so many problems after being exposed to major trauma would be obvious to the person who's got them. But it's not. Dr. Michelle Spoont, author of the Rational Clinical Examination on PTSD explains this. >> In VA we have a number of patients who end up coming to us not because they themselves realize they have PTSD.
I mean oftentimes they come home, and they feel like they're different. Their spouse may say, "You're different than you used to be, you're not yourself anymore." And they may go on but not think anything about it because, of course, you can't go through life changing experiences without feeling different. And everyone expects after a trauma to have some kind of symptomatology. But what they don't expect is the reason why they might, you know, lose job after job or have trouble staying in a marriage. And so a lot of secondary problems can develop when PTSD is not treated.
And it's often not until they're in connection maybe with other veterans. I've heard a lot of stories of serendipitous connections. You know, I was in a bank, the person in front of me happened to be a veteran. I noticed from their hat or their shirt or something like that, and they struck up a conversation. Or they went to a reunion of their unit, and they found that a number of other people had similar experiences, and they said, "You have PTSD like we do." >> I wandered down to the VA at the Lakeside, VA here in Chicago, and I thought that I was losing my mind.
And I ran into -- I saw a psychiatrist, and then she said, she told me you have PTSD. >> It's not obvious to most patients who have PTSD that they have the disease. That's why screening instruments like the Primary Care PTSD Screen or the PTSD Checklist should be used by all clinicians who are providing care for patients who suffered from traumatic events and may be suffering from PTSD. Once the clinician suspects PTSD and refers the patient for treatment how good is that treatment?
That question was answered by Dr. Maria Steenkamp in her Review of Psychotherapy for Military-Related PTSD. She reviewed the major randomized control trials, and that paper also appears in the August 4, 2015 JAMA. Psychotherapy for PTSD is divided into two major categories. One focuses on the traumatic event itself, and another focuses on issues not directly related to the trauma. Treatments of focus on the traumatic event itself involve reliving the traumatic event in one way or another.
Reliving this traumatic event helps the patient cope with the trauma or make the memory of the trauma itself less stressful. Therapies that don't focus on the trauma itself are directed at helping patients cope with the manifestations of PTSD. In the review published in JAMA by Steenkamp, the therapies most effective for treating PTSD were assessed. An important element of this was how the response to treatment was measured. When evaluating these studies the effectiveness of PTSD interventions were assessed by determining the proportion of patients who obtained a clinically significant reduction in PTSD symptoms.
Or the study's outcomes were the mean of some PTSD symptom score. The studies might have looked at the complete loss of a PTSD diagnosis after treatment was completed. There's also PTSD scales that assess the degree to which symptom remission occurs following treatment. Dr. Steenkamp found that three trauma-related treatments stood out as being particularly effective. One of them was cognitive therapy. >> Cognitive therapy is a type of therapy that focuses on how a patient is thinking about the trauma.
So the underlying premise is that there's sort of a maladaptive or sort of, quote unquote, faulty type of thinking going on. And then what you try and do in the therapy is have the person modify those thoughts. In other words, you have them identify it, challenge it, and replace the thought with a better kind of cognition, a more adaptive cognition. >> So in practice how do you do that? >> It's several steps. It takes several weeks. You know, first off is, of course, they have to become more aware of the kinds of thoughts that they're having about the trauma.
So you will do something that we call thought monitoring. So this could involve, for example, using worksheets in which you ask the patient to start noticing the kinds of thoughts they have related to the trauma and kind of writing them down, and then bringing them into the next session so that you can look through them together. You know, there are sort of typical kinds of thinking traps, if you will, that people often fall into, certain kinds of expected ways of thinking about the trauma that are very common and typical. For example, lots of guilt, thoughts around guilt and shame.
And then you identify which ones continue to really cause a lot of distress and suffering. And then what you do is you teach them to weigh the evidence for and against these kinds of thoughts. You teach them how to challenge these thoughts if you will. And so, you know, is there another way of looking at this? And, you know, I understand that when you think about the trauma you think about it from this angle. But have you considered this other angle? You know, what about this piece of it?
And so often by talking about it at length with the therapist it opens up the patient's way of thinking about it and they broaden their perspective. And they come to more neutral, balanced ways of thinking about the trauma. And that changes their whole perception of it and can often improve their symptoms as a result. >> The second therapy found to be effective in treating PTSD was exposure therapy. >> So often when people talk about exposure therapy, they're talking about prolonged exposure therapy. And this is composed of several techniques that you deliver over roughly about 12 weeks or so.
This includes psychoeducation in which you educate the patient about PTSD. And you introduce the idea that PTSD symptoms are maintained through avoiding thinking and talking about the trauma. That's really one of the basic premises of PE, this idea that avoidance is at the heart of PTSD. And, therefore, to get better you have to stop avoiding thinking and talking about the trauma which really boils down to no longer kind of avoiding having feelings related to the trauma.
So one of the principle techniques of PE is something called imaginal exposure in which you ask the patient to recount in detail what happened during the trauma. And you ask them to do this over and over. Often what you'll do is you actually record that in session and then ask the person to go home and listen to that tape recording every day over and over. And the idea here is that you extinguish the trauma memory. So an analogy would be kind of imagining a really, really scary movie that you watched once and kind of remembering how scary it was the first time you watched it.
But if I asked you to watch that same movie 25 times over, usually by the 25th time it's not scary anymore. So it's the same kind of idea of extinction, habituation of that same memory. So that's one principle technique. There's also another very important technique that's called in vivo exposure. And in that you ask the patient to confront things in the real world that they usually avoid because it reminds them too much of the trauma. So, for example, if a veteran hasn't driven since being in an IED blast in Afghanistan, you would get them to start driving again.
And you do this in a very kind of specific step-by-step way. >> Eye movement desensitization reprocessing, or EMDR, was the third trauma-related therapy found to be effective for treating PTSD. >> EMDR asks patients to think about the trauma while focusing on an external stimulus. And usually this is the therapist's finger moving back and forth in front of their eyes. It can be different kinds of stimuli as well, though that traditionally it's the therapist's finger. It also involves identifying bodily sensations associated with the trauma.
And similar to cognitive therapy, it works to replace negative cognitions about the trauma with more positive cognitions as well. >> These three trauma-related therapies are about equally effective in managing PTSD. Non-traumatic PTSD treatments focus on helping patients cope with the ramifications of PTSD. Of those treatments only stress inoculation training was found to be effective. >> Stress inoculation training is an approach, again, sort of an umbrella approach that teaches anxiety management skills.
This is often things like relaxation training, breathing retraining, positive thinking, self-talk and assertiveness training. It can also optionally include trauma exposure components if that's desired by the therapist. So stress inoculation training is not used very widely anymore with the VA and DOD, at least not formally. And it comes from sort of the 1980s. There was a lot of studies around it at that time. Since then, it's largely been replaced by PE and CBT and, to a lesser extent, EMDR.
But it is still included in sort of the official practice guidelines simply because it was one of the first kinds of treatments on the scene and back in the day had received some good outcomes and efficacy in effectiveness trials. >> Although most emphasis is placed on therapies relating to addressing the traumatic event, built into these treatments is some element of coping skills and helping patients understand how to deal with their PTSD symptoms. However, about a quarter of patients enrolled in the PTSD studies dropped out.
There's a group of patients who don't respond particularly well to the mainstream treatments for PTSD. For these patients there are some alternative approaches. >> Acupuncture has shown some large effect sizes. In one study there's also been some interest in mindful-based interventions, some more spiritual-type interventions like mantram repetition. And then more specific, more type interventions like attention bias modification. >> Primary care providers should be vigilant regarding PTSD. It's important to remember that the prevalence of PTSD in a nonmilitary civilian population is about the same as it is in the military.
Many traumatic experiences are common in the general population. These include motor vehicle accidents or death of a loved one. Unfortunately, in a civilian population, one of the most common causes of PTSD is rape. When a patient presents who has experienced some form of trauma, the primary care physician should look for symptoms of PTDS. These will include intrusion symptoms such as nightmares. Patients might have flashbacks or get very upset when they think about the traumatic event. They may try not to think about the event or not even talk about it.
They may have altered cognition or mood disorders as a consequence of the event. One characteristic symptom of PTSD is hyperarousal. When PTSD is suspected it's easy to use the four question Primary Care PTSD Screening Instrument. If positive, the patient should be referred for treatment knowing that the treatments will be effective for most patients. PTSD screening instruments are freely available on the web. To find the primary care PTSD screen, do a web search using the terms primary care PTSD screen.
The PTSD Checklist can be found by doing a web search using the key words PTSD Checklist. As we just heard from our patient, getting patients into treatment can be very helpful. So it's important to make the diagnosis of PTSD and refer patients to the appropriate mental healthcare provider who can help them. PTSD is a very real problem. Patients with PTSD have problems relating to people who have not been traumatized and can improve by interacting with people who have.
>> And being back out the Army no one spoke my language. No civilian spoke my language. I had no camaraderie no more. I wasn't around soldiers. When I was in the military after the war it was different, I was around soldiers. I had that camaraderie, and it was soldiers who had been there, had done that that were still in the military. But when I got out the military being around civilians, they didn't have a clue where I'd been, what I've done, what I've seen.
They didn't know what I was talking about. PTSD, a lot of guys don't want to talk about it. A lot of guys don't know they have it. And you have to kind of really look hard for it because they might be ashamed. There's guys still walking in that are part of my group that's been out here working since the Gulf War that didn't know they had it. They've been through two or three marriages and didn't know they had it. They have been to prison. They can't hold down a job.
>> Treatment works. As we heard, this patient got better by being around other people who had similar wartime experiences that he had. By confronting what he saw in the war he was better able to cope with the memory of it. To recap, three main treatments can help patients with PTSD. Prolonged exposure therapy involves repeated exposure to the memory of the traumatic event to the point where recalling what happened is no longer frightful. This is like watching a scary movie so many times that you're no longer surprised by it.
And the scenes that used to startle you no longer have an effect. Cognitive therapy involves talking to the patient about the traumatic event or have them write it down. By discussing what happened and how the patient feels about it, the therapist restructures how the patient interprets the traumatic memory. For example, if a veteran feels guilty that he remained alive when all of his buddies were killed, cognitive therapy will help him feel less guilty about his survival when he thinks about the battle.
The patient may be convinced to think about how his buddies would want him to live his life had they been able to tell him what they thought. EMDR, or eye movement desensitization and reprocessing, involves having the patient think about the traumatic event while focusing on some external stimulus, such as following the therapist's finger with one's eyes. This reduces anxiety when thinking about the traumatic event. Lastly, stress inoculation training does not focus on the trauma itself.
It emphasizes reducing the reactions of patient experiences when thinking about the traumatic event responsible for the PTSD. Thanks for listening to this episode of the JAMAevidence podcast. Today we focused on the post-traumatic stress disorder chapter from the Rational Clinical Examination book. We have an extended array of podcasts which can be found in the audio tab of jamaevidence.com or the multimedia tab of jama.com. JAMA podcasts are also found in the iTunes store at itunes.com/jamanetwork. Please go there and subscribe to the various podcast offerings that we have.
While you're there also provide reviews of our podcasts so that we can make then even better. All of our podcasts are also available in Stitcher. I welcome your questions, comments, and feedback. The best way to reach me is on Twitter. My Twitter handle is @ehljama. Once again, I'm Ed Livingston, Deputy Editor of Clinical Reviews and Education at JAMA, and I'll be back soon with another episode of JAMAevidence.
Segment:0 .
>> I'm Ed Livingston, Deputy Editor of Clinical Reviews and Education at JAMA. In today's JAMAevidence podcast we're going to discuss PTSD or post-traumatic syndrome, a chapter covered in the Rational Clinical Examination. I'm speaking with the chapter's author Dr. Michelle Spoont who is with the U.S. Department of Veterans Affairs National Center for Post-Traumatic Disorder and the Minneapolis Veterans Affairs Healthcare System in Minneapolis, Minnesota. I also spoke with Maria M. Steenkamp who is with the Steven and Alexandra Cohen Veterans Center for Post-Traumatic Stress and Traumatic Brain Injury at the New York University Langone School of Medicine in New York.
I caution listeners that the descriptions of what this soldier experienced are graphic and disturbing. >> In northern Kuwait this was also a day to clean up, clear away the grisly reminders of war. Bulldozers moved in on the highway from Kuwait City to Bosra, the only way out for Saddam Hussein's army as it made a desperate last minute retreat. The highway became the scene for one of the last and bloodiest battles of the war. Thousands of Iraqi soldiers died as coalition forces cut them off on land and in the air, the so-called highway of death.
[ Music ] >> It was a like major city at the highway during rush hour and all the vehicles at a standstill with bodies still in the vehicles and bodies trying to exit the vehicles -- some bodies, you know, trying to exit the vehicles. And everyone was dead and body parts everywhere. And we had to roll -- you know, driving over these dead bodies.
And we did this for days. This was real. Iraqi soldiers in vehicles, no heads, no arms, no torso, upper torso. It was awful. I saw our scouts -- I was driving my company commander, and we saw the scouts get ambushed by some Iraqi, an Iraqi unit. And I couldn't get that out of my mind, you know, listening to it on the radio and then watching them.
We had three radios in our Humvee. I'm listening to it and I'm watching it, and they getting ambushed. And, you know, the guys getting hit it's like a movie, but you're watching it in real life and you're hearing it, the rounds hitting off the vehicles and the sounds of soldiers, you know, making them, "I'm hit, I'm hit." And, "My weapon's jammed," and stuff like that. And, you know, it's just -- you dream about this stuff. And then I dreamed we came under mortar fire one afternoon, and our convoy had stopped and mortars start, you know, shells started raining in on our position.
I dream about the Iraqi soldiers that were giving up, that were crawling down the road that had no legs and no arms, and they're buddies wouldn't pick them up. And they were just crawling down the road, they were surrendering. I dream about -- I dream about the guy who was trying to get out the vehicle, and he didn't make it out of his vehicle. And there was a hole in his windshield, he had no head, and just like spaghetti coming out his neck. >> You cannot experience things like this and not be affected by them. These events are seared into one's memory.
Oftentimes the sights, sounds and smells are linked together so that long after the traumatic event, an unrelated trigger might bring back the entire memory. For example, a sharp noise like that of a window slamming shut may sound like gunfire to an ex-soldier and bring back a visual memory of the battlefield scene. It is only since about the 1980s that post-traumatic stress disorder, or PTSD, was recognized as a problem for soldiers returning home from wartime experiences. Even though PTSD is commonly associated with war, oftentimes it occurs in civilians.
PTSD is experienced in about 13 percent of soldiers returning from the most recent wars. But PTSD is also present in about 10 percent of the general population who have never been to war. Horrific experiences such as rape, motor vehicle accidents, witnessing the death of a loved one are very shocking and can result in PTSD. So knowing what to look for and establishing the diagnosis of PTSD is important for all clinicians, not just those taking care of veterans. The meta-analysis performed for the Rational Clinical Examination chapter yielded two very simple instruments that enable primary care clinicians to identify PTSD in their patients.
One is a 17 item PTSD Checklist. Although it's long, the advantage of this checklist is that it touches upon all the DSM-5 criteria for making a diagnosis of PTSD. Knowing which of the various symptoms a patient has facilitates counseling and the appropriate referral for treatment. Equally effective in identifying PTSD in the general population is the 4 item Primary Care PTSD Screening Instrument. This instrument touches upon each of the major domains that are associated with PTSD making the screening instruments very simple to administer but very accurate in identifying patients who have PTSD.
The first question in the Primary Care PTSD Screening Instrument asks if a patient has had some event so frightening, horrible, or upsetting that they've had nightmares in the past month about it, or that they thought about this traumatic event and didn't want to think about it. >> I couldn't sleep. I noticed that before I got out the military. And the reason why I didn't sleep because I was scared to sleep because I had nightmares. And I kept waking up in cold sweats.
And I couldn't get Iraq out of my mind. >> The second question asks if the patient has tried hard not to think about the experience or went out of their way to avoid situations that reminded them of that experience. >> I did try illegal drug use but that didn't last. And so I tried drinking, that didn't last. That wasn't a solution for me. >> The third question asks if the patient is constantly on guard, watchful or easily startled.
>> Well, I lived in Inglewood, one of the worst neighborhoods in the United States. Because of the gunfire, all the gunfire and loud noises, I felt like I was back in Iraq in war. It's taken me right back there again. It feels like -- you feel like you're a soldier 24 hours a day. It feels like you are on guard duty 24/7. You're always watching your back. You always want to look out. You can never let your guard down.
You can never relax. You can never turn it off. And, you know, I can't sleep, and I feel like I'm on guard duty 24/7. It's hard for me to relax. >> The last question asks if the patients felt detached from others, detached from any activities or detached from their surroundings. >> I didn't know what was wrong with me. Everybody, I was withdrawn. I came home and I go to a bar, everybody was patting me on the back and I was just, you know, there was just no response, no emotion.
>> PTSD is a very real syndrome. And by listening to this Veteran, it's easy to see that he fulfills all the criteria in the PTSD screen. One would think that having so many problems after being exposed to major trauma would be obvious to the person who's got them. But it's not. Dr. Michelle Spoont, author of the Rational Clinical Examination on PTSD explains this. >> In VA we have a number of patients who end up coming to us not because they themselves realize they have PTSD.
I mean oftentimes they come home, and they feel like they're different. Their spouse may say, "You're different than you used to be, you're not yourself anymore." And they may go on but not think anything about it because, of course, you can't go through life changing experiences without feeling different. And everyone expects after a trauma to have some kind of symptomatology. But what they don't expect is the reason why they might, you know, lose job after job or have trouble staying in a marriage. And so a lot of secondary problems can develop when PTSD is not treated.
And it's often not until they're in connection maybe with other veterans. I've heard a lot of stories of serendipitous connections. You know, I was in a bank, the person in front of me happened to be a veteran. I noticed from their hat or their shirt or something like that, and they struck up a conversation. Or they went to a reunion of their unit, and they found that a number of other people had similar experiences, and they said, "You have PTSD like we do." >> I wandered down to the VA at the Lakeside, VA here in Chicago, and I thought that I was losing my mind.
And I ran into -- I saw a psychiatrist, and then she said, she told me you have PTSD. >> It's not obvious to most patients who have PTSD that they have the disease. That's why screening instruments like the Primary Care PTSD Screen or the PTSD Checklist should be used by all clinicians who are providing care for patients who suffered from traumatic events and may be suffering from PTSD. Once the clinician suspects PTSD and refers the patient for treatment how good is that treatment?
That question was answered by Dr. Maria Steenkamp in her Review of Psychotherapy for Military-Related PTSD. She reviewed the major randomized control trials, and that paper also appears in the August 4, 2015 JAMA. Psychotherapy for PTSD is divided into two major categories. One focuses on the traumatic event itself, and another focuses on issues not directly related to the trauma. Treatments of focus on the traumatic event itself involve reliving the traumatic event in one way or another.
Reliving this traumatic event helps the patient cope with the trauma or make the memory of the trauma itself less stressful. Therapies that don't focus on the trauma itself are directed at helping patients cope with the manifestations of PTSD. In the review published in JAMA by Steenkamp, the therapies most effective for treating PTSD were assessed. An important element of this was how the response to treatment was measured. When evaluating these studies the effectiveness of PTSD interventions were assessed by determining the proportion of patients who obtained a clinically significant reduction in PTSD symptoms.
Or the study's outcomes were the mean of some PTSD symptom score. The studies might have looked at the complete loss of a PTSD diagnosis after treatment was completed. There's also PTSD scales that assess the degree to which symptom remission occurs following treatment. Dr. Steenkamp found that three trauma-related treatments stood out as being particularly effective. One of them was cognitive therapy. >> Cognitive therapy is a type of therapy that focuses on how a patient is thinking about the trauma.
So the underlying premise is that there's sort of a maladaptive or sort of, quote unquote, faulty type of thinking going on. And then what you try and do in the therapy is have the person modify those thoughts. In other words, you have them identify it, challenge it, and replace the thought with a better kind of cognition, a more adaptive cognition. >> So in practice how do you do that? >> It's several steps. It takes several weeks. You know, first off is, of course, they have to become more aware of the kinds of thoughts that they're having about the trauma.
So you will do something that we call thought monitoring. So this could involve, for example, using worksheets in which you ask the patient to start noticing the kinds of thoughts they have related to the trauma and kind of writing them down, and then bringing them into the next session so that you can look through them together. You know, there are sort of typical kinds of thinking traps, if you will, that people often fall into, certain kinds of expected ways of thinking about the trauma that are very common and typical. For example, lots of guilt, thoughts around guilt and shame.
And then you identify which ones continue to really cause a lot of distress and suffering. And then what you do is you teach them to weigh the evidence for and against these kinds of thoughts. You teach them how to challenge these thoughts if you will. And so, you know, is there another way of looking at this? And, you know, I understand that when you think about the trauma you think about it from this angle. But have you considered this other angle? You know, what about this piece of it?
And so often by talking about it at length with the therapist it opens up the patient's way of thinking about it and they broaden their perspective. And they come to more neutral, balanced ways of thinking about the trauma. And that changes their whole perception of it and can often improve their symptoms as a result. >> The second therapy found to be effective in treating PTSD was exposure therapy. >> So often when people talk about exposure therapy, they're talking about prolonged exposure therapy. And this is composed of several techniques that you deliver over roughly about 12 weeks or so.
This includes psychoeducation in which you educate the patient about PTSD. And you introduce the idea that PTSD symptoms are maintained through avoiding thinking and talking about the trauma. That's really one of the basic premises of PE, this idea that avoidance is at the heart of PTSD. And, therefore, to get better you have to stop avoiding thinking and talking about the trauma which really boils down to no longer kind of avoiding having feelings related to the trauma.
So one of the principle techniques of PE is something called imaginal exposure in which you ask the patient to recount in detail what happened during the trauma. And you ask them to do this over and over. Often what you'll do is you actually record that in session and then ask the person to go home and listen to that tape recording every day over and over. And the idea here is that you extinguish the trauma memory. So an analogy would be kind of imagining a really, really scary movie that you watched once and kind of remembering how scary it was the first time you watched it.
But if I asked you to watch that same movie 25 times over, usually by the 25th time it's not scary anymore. So it's the same kind of idea of extinction, habituation of that same memory. So that's one principle technique. There's also another very important technique that's called in vivo exposure. And in that you ask the patient to confront things in the real world that they usually avoid because it reminds them too much of the trauma. So, for example, if a veteran hasn't driven since being in an IED blast in Afghanistan, you would get them to start driving again.
And you do this in a very kind of specific step-by-step way. >> Eye movement desensitization reprocessing, or EMDR, was the third trauma-related therapy found to be effective for treating PTSD. >> EMDR asks patients to think about the trauma while focusing on an external stimulus. And usually this is the therapist's finger moving back and forth in front of their eyes. It can be different kinds of stimuli as well, though that traditionally it's the therapist's finger. It also involves identifying bodily sensations associated with the trauma.
And similar to cognitive therapy, it works to replace negative cognitions about the trauma with more positive cognitions as well. >> These three trauma-related therapies are about equally effective in managing PTSD. Non-traumatic PTSD treatments focus on helping patients cope with the ramifications of PTSD. Of those treatments only stress inoculation training was found to be effective. >> Stress inoculation training is an approach, again, sort of an umbrella approach that teaches anxiety management skills.
This is often things like relaxation training, breathing retraining, positive thinking, self-talk and assertiveness training. It can also optionally include trauma exposure components if that's desired by the therapist. So stress inoculation training is not used very widely anymore with the VA and DOD, at least not formally. And it comes from sort of the 1980s. There was a lot of studies around it at that time. Since then, it's largely been replaced by PE and CBT and, to a lesser extent, EMDR.
But it is still included in sort of the official practice guidelines simply because it was one of the first kinds of treatments on the scene and back in the day had received some good outcomes and efficacy in effectiveness trials. >> Although most emphasis is placed on therapies relating to addressing the traumatic event, built into these treatments is some element of coping skills and helping patients understand how to deal with their PTSD symptoms. However, about a quarter of patients enrolled in the PTSD studies dropped out.
There's a group of patients who don't respond particularly well to the mainstream treatments for PTSD. For these patients there are some alternative approaches. >> Acupuncture has shown some large effect sizes. In one study there's also been some interest in mindful-based interventions, some more spiritual-type interventions like mantram repetition. And then more specific, more type interventions like attention bias modification. >> Primary care providers should be vigilant regarding PTSD. It's important to remember that the prevalence of PTSD in a nonmilitary civilian population is about the same as it is in the military.
Many traumatic experiences are common in the general population. These include motor vehicle accidents or death of a loved one. Unfortunately, in a civilian population, one of the most common causes of PTSD is rape. When a patient presents who has experienced some form of trauma, the primary care physician should look for symptoms of PTDS. These will include intrusion symptoms such as nightmares. Patients might have flashbacks or get very upset when they think about the traumatic event. They may try not to think about the event or not even talk about it.
They may have altered cognition or mood disorders as a consequence of the event. One characteristic symptom of PTSD is hyperarousal. When PTSD is suspected it's easy to use the four question Primary Care PTSD Screening Instrument. If positive, the patient should be referred for treatment knowing that the treatments will be effective for most patients. PTSD screening instruments are freely available on the web. To find the primary care PTSD screen, do a web search using the terms primary care PTSD screen.
The PTSD Checklist can be found by doing a web search using the key words PTSD Checklist. As we just heard from our patient, getting patients into treatment can be very helpful. So it's important to make the diagnosis of PTSD and refer patients to the appropriate mental healthcare provider who can help them. PTSD is a very real problem. Patients with PTSD have problems relating to people who have not been traumatized and can improve by interacting with people who have.
>> And being back out the Army no one spoke my language. No civilian spoke my language. I had no camaraderie no more. I wasn't around soldiers. When I was in the military after the war it was different, I was around soldiers. I had that camaraderie, and it was soldiers who had been there, had done that that were still in the military. But when I got out the military being around civilians, they didn't have a clue where I'd been, what I've done, what I've seen.
They didn't know what I was talking about. PTSD, a lot of guys don't want to talk about it. A lot of guys don't know they have it. And you have to kind of really look hard for it because they might be ashamed. There's guys still walking in that are part of my group that's been out here working since the Gulf War that didn't know they had it. They've been through two or three marriages and didn't know they had it. They have been to prison. They can't hold down a job.
>> Treatment works. As we heard, this patient got better by being around other people who had similar wartime experiences that he had. By confronting what he saw in the war he was better able to cope with the memory of it. To recap, three main treatments can help patients with PTSD. Prolonged exposure therapy involves repeated exposure to the memory of the traumatic event to the point where recalling what happened is no longer frightful. This is like watching a scary movie so many times that you're no longer surprised by it.
And the scenes that used to startle you no longer have an effect. Cognitive therapy involves talking to the patient about the traumatic event or have them write it down. By discussing what happened and how the patient feels about it, the therapist restructures how the patient interprets the traumatic memory. For example, if a veteran feels guilty that he remained alive when all of his buddies were killed, cognitive therapy will help him feel less guilty about his survival when he thinks about the battle.
The patient may be convinced to think about how his buddies would want him to live his life had they been able to tell him what they thought. EMDR, or eye movement desensitization and reprocessing, involves having the patient think about the traumatic event while focusing on some external stimulus, such as following the therapist's finger with one's eyes. This reduces anxiety when thinking about the traumatic event. Lastly, stress inoculation training does not focus on the trauma itself.
It emphasizes reducing the reactions of patient experiences when thinking about the traumatic event responsible for the PTSD. Thanks for listening to this episode of the JAMAevidence podcast. Today we focused on the post-traumatic stress disorder chapter from the Rational Clinical Examination book. We have an extended array of podcasts which can be found in the audio tab of jamaevidence.com or the multimedia tab of jama.com. JAMA podcasts are also found in the iTunes store at itunes.com/jamanetwork. Please go there and subscribe to the various podcast offerings that we have.
While you're there also provide reviews of our podcasts so that we can make then even better. All of our podcasts are also available in Stitcher. I welcome your questions, comments, and feedback. The best way to reach me is on Twitter. My Twitter handle is @ehljama. Once again, I'm Ed Livingston, Deputy Editor of Clinical Reviews and Education at JAMA, and I'll be back soon with another episode of JAMAevidence.
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