Selected Podcast
Post-Traumatic Stress Disorder (PTSD)
Dr. Nick Dewan discusses PTSD, who is at risk and the latest treatments that are used to treat this complex condition. Learn more about BayCare's behavioral health services.
Featured Speaker:
Nick Dewan, MD
Dr. Nick Dewan is a pioneer and an accomplished physician leader and sports psychiatrist with a nationally respected track record in health care value improvement and information technology. Currently, he serves as Chief Medical Officer for the Behavioral Health Division of the BayCare Health System. In 2015, he published his third book on information technology “Mental Health Practice in a Digital World: A Clinicians Guide”. His clinical experience includes work in emergency, hospital, outpatient, addiction medicine, and sports medicine settings. He is a sought after speaker and is interviewed by local and national media on behavioral health issues and sports performance topics. His work on clinical guidelines, performance bonuses for quality, efficient use of healthcare, best practice adoption, and patient empowerment and technology positions him as a leading expert in an era of accountable healthcare. Transcription:
Post-Traumatic Stress Disorder (PTSD)
Melanie Cole, MS (Host): If you’ve gone through a traumatic experience, it’s normal to feel lots of emotions. However, if those emotions effect your life and last more than a month, you may have post-traumatic stress disorder. My guest today is Dr. Nick Dewan. He’s the chief medical officer in the behavioral health division of BayCare Health System. Dr. Dewan, tell us about the current state of PTSD. What’s the prevalence and what do we know about it?
Nick Dewan, MD (Guest): Well, the post-traumatic stress disorder, as it’s called, has been around for a number of decades. Especially because of the research we’ve had in terms of what I would call the Veteran’s Administration and also the Department of Defense, we’ve learned a great deal more about what I would call the nature of PTSD, the symptoms associated with PTSD, and how one approaches this condition.
Now in terms of how much, there is a debate as to the, what I would call, the prevalence of PTSD in our community. In general, the prevalence can range from 3% to 10% related to what data you're looking at. For instance, the most recent study looked at in U.S adults the prevalence was around 3.5%. Now there are other studies that show it’s less than 1%, but I think the 3.5% number is appropriate. Historically when we look at lifetime risk, that’s when you get near the 10% and that data’s around 8.7%. So, in any given year, the data shows 3.5%. In any person’s lifetime, the data says 8.7%. So that’s the prevalence.
In terms of the other things related to PTSD, in terms of how we’ve changed our definition of this disorder, we have changed what we call the criteria that one uses to diagnose this disorder in the past five to ten years. There are two critical things people need to remember. Number one, and I think you had mentioned this earlier, is the duration of symptoms have to be at least one month long. If it’s less than one month, it’s called an acute stress disorder. So, point number one, it’s got to be more than a month.
The other thing that we sort of became more clear in terms of the definition, obviously when you look at the work post-traumatic, it’s obviously a traumatic event. That traumatic event is defined as any exposure to an actual or threatened death, serious injury, or sexual violence. That can mean directly experiencing the traumatic event, witnessing it, sometimes learning about it, and sometimes experience repeated, what I would call, extreme exposures to the event. So those are the two things. The event itself and the duration of what I would call the symptoms post-event.
Now those symptoms have been, what I would call, more clearly defined, for instance, recurrent, intrusive, distressing memories. Recurrent, intrusive, distressing dreams. Sometimes even, we call that in medical word dissociative reactions, but in what I would call the common terminology is flashbacks. Then there is what we would call intense distress associated with it. There’s also what’s called physiological. Some people’s heart will race, they’ll be sweaty. So, there’s physical things that happen and people tend to avoid situations, circumstances related to this. A lot of times people have what’s called mood and cognitive alterations. They also have what I would call this continued vigilance. They startle easily. So, it’s sort of like the adrenaline is sort of on hyperdrive.
So, all those criteria, a mixture of those for 30 days in duration, makes sort of what we would call the clinical criteria for post-traumatic stress disorder. It’s a very debilitating, very gut-wrenching sort of disorder that, like I said, in anybody’s lifetime the U.S data is about 8.7% for lifetime and 3.5% during any given year.
Host: Why do some people suffer post-traumatic stress disorder and other people might have the same traumatic experience and not suffer PTSD? Tell us a little bit about risk factors or if there’s a genetic component. Also, Dr. Dewan, do children react differently than adults to trauma?
Dr. Dewan: Boy those are some great questions you just asked me. So, let me try to address little bit little. Let’s talk about risk factors. Now when researchers study this issue, they divide, what I would call, risk factors into pre-traumatic factors, peritraumatic factors, or post-traumatic factors. So, when we look at pre-traumatic factors, there’s obviously the genetic. Now there is some research in terms of specific molecular or receptors in the brain that people are more vulnerable. We’re doing research on that. There are environmental issues. Actually, people who have less social support, more traumatic life experience tend to develop this disorder.
Then there’s also what I would call, the researchers will say temperamental kinds of pre-traumatic factors. Someone who has predisposing anxiety or predisposing OCD characteristics may have greater likelihood of developing the disorder. We know that monozygotic twins have higher rates that dizygotic twins. So, have we identified all the genes related to this that make people more vulnerable? No, we have not. But we do know it’s a mixture of three different pre-traumatic factors.
The, what’s called during the trauma, depending on the severity of it, the closer the person is to the trauma, the life threat or personal injury—especially if the violent event was “perpetrated” by someone you knew, that carries much more significance. Then post-trauma, there’s the environmental and, once again, what the research will call temperamental. Meaning what are people’s usual coping strategies. What’s their resilience capability and what happens post-event in terms of their psychosocial support systems?
Now children do experience, can experience it differently. They sometimes cannot communicate, they can't verbalize what it feels like. They can't verbalize their thoughts as well, their dreams. So, their manifestations are much more behavioral in nature. There might be more impulsivity. More acting out, more distressful behaviors in say adults. So that’s a little bit of the difference.
Host: Speak about treatments then. What’s the first form of treatment you might try? Do the symptoms ever go away with these treatments? Tell us about some of the treatments available?
Dr. Dewan: I think this is where, I think, we’ve made significant progress in the last two decades. We have a number of psychotherapies that have been researched in very large clinical trials. There’s a type of therapy that’s cognitive behavioral therapy that’s called cognitive processing therapy where someone is in a therapeutic relationship with a therapist, gets to discuss the nature of the traumatic event, gets to be able to share their story, and gets to understand the framework of that story in a way that they can know that it’s not their fault, know that it’s not happening again. The more exposure people have to talking about the story in a therapeutic framework and context, the less fear, the less avoidance, the less startle response, the less vigilance they feel.
There’s also been some great work in what’s called virtual reality therapy combined with cognitive processing therapy. This is where, I think, both the military research and the veteran’s research has been tremendously helpful where people sit with these—You’ve seen these game goggles that people have that they put on and you're in sort of this 3D world, well there’s been some software development where you get exposed to specific traumas. Let’s say its military trauma. You get exposed to this and you do it in a therapeutic way, and sometimes you get medicine while you’re experiencing that trauma to reduce the fear or the threat response during the reexperiencing of this trauma, so the pain is less. So, I think we’ve made some great strides in the area of the psychotherapy aspects.
Obviously, there’s obviously medical interventions. The most common treatment historically has been SSRIs. These have been around since the late ‘80s. There has been research done. SSRIs can give you 10 to 20 to 30% reduction in symptoms, similar to psychotherapy. When people have very, very significant extreme symptoms, usually the combination is much more beneficial. There’s also a high blood pressure pill, surprisingly, that people have been using for reducing nightmares. Now the specific high blood pressure pills given at night actually reduces nightmares and you get sometimes 30 to 50% response rate. So, I think we’ve come a long way from just anti-depressants, just mood stabilizers. Now we’re using things like high-blood pressure pills.
There’s some other novel treatments that are being researched, and I'm not ready to sort of talk about those right now because that might—I don’t want to talk about false expectations or there’s a miracle cure around the corner. I’d rather talk about things that we know have worked for the past decade.
Host: Then tell us what family and friends can do to help if they suspect that somebody is suffering from post-traumatic stress disorder. What would you like them to know about helping that loved one cope with the trauma? What about self-care for somebody who’s gone through a traumatic event?
Dr. Dewan: Alright. So, let’s talk about families and friends. First of all, what a family or friend can say is, “I know you're in pain. I've noticed you're getting more emotional or you're impulsive or you're backing off. You're not hanging out with us much more. It looks like you might be drinking a little bit more than you used to. I've noticed these and I want you to know that I'm here to be your support. I will go with you to the appointment. Let’s set this up together.”
I've looked at some recent research. People who suffer like this, if they have—Everybody these days has their social network, let’s say. Sometimes they have five people in their network, sometimes they have 500. What they really need is a social supported network. Meaning those people need to be identified as, “Hey if I'm in trouble, I need you to be available for me.” That’s what a friend of family can say to them. Say, “Here’s my phone number, here’s where you can call me. Whenever you need something or you're feeling down, you call me. I am here for you.” So those two things. Getting them to the proper treatment and saying, “I'm there for you and here’s my number. You tell me if you need me.” I think those are the two things that people can do, family and friends can do, to help their loved one.
One thing that people don’t realize is horrific trauma really impacts not only people’s emotions and sleep and energy levels, it actually impacts their ability to remember and think clearly. So, it really impacts everything to do with day to day life. I think the things that we take for granted in terms of take care of yourself, meditation, enjoy life, connect with others, there are—Now most organizations have websites that people can go to to practice mindfulness, to practice cognitive self-talk, support groups. I think there is a world out there that people can say you know what? There’s been a lot of research done these past two decades. There’s a lot of support out there. I'm going to take advantage of this. We are in the 21st century and we have more data and more research, and more capabilities now than we ever did before. I think people that can self-manage this illness a lot better if they just seek out these tools. So that would be my recommendation to folks.
Host: Thank you so much, Dr. Dewan. It’s a pleasure, as always, to have you on with such great information and you're such a great educator. Thank you for educating us today about post-traumatic stress disorder and the treatments that are available and the ways that family and friends can help their loved ones. You're listening to BayCare Healthchat. For more information, please visit baycare.org. That’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.
Post-Traumatic Stress Disorder (PTSD)
Melanie Cole, MS (Host): If you’ve gone through a traumatic experience, it’s normal to feel lots of emotions. However, if those emotions effect your life and last more than a month, you may have post-traumatic stress disorder. My guest today is Dr. Nick Dewan. He’s the chief medical officer in the behavioral health division of BayCare Health System. Dr. Dewan, tell us about the current state of PTSD. What’s the prevalence and what do we know about it?
Nick Dewan, MD (Guest): Well, the post-traumatic stress disorder, as it’s called, has been around for a number of decades. Especially because of the research we’ve had in terms of what I would call the Veteran’s Administration and also the Department of Defense, we’ve learned a great deal more about what I would call the nature of PTSD, the symptoms associated with PTSD, and how one approaches this condition.
Now in terms of how much, there is a debate as to the, what I would call, the prevalence of PTSD in our community. In general, the prevalence can range from 3% to 10% related to what data you're looking at. For instance, the most recent study looked at in U.S adults the prevalence was around 3.5%. Now there are other studies that show it’s less than 1%, but I think the 3.5% number is appropriate. Historically when we look at lifetime risk, that’s when you get near the 10% and that data’s around 8.7%. So, in any given year, the data shows 3.5%. In any person’s lifetime, the data says 8.7%. So that’s the prevalence.
In terms of the other things related to PTSD, in terms of how we’ve changed our definition of this disorder, we have changed what we call the criteria that one uses to diagnose this disorder in the past five to ten years. There are two critical things people need to remember. Number one, and I think you had mentioned this earlier, is the duration of symptoms have to be at least one month long. If it’s less than one month, it’s called an acute stress disorder. So, point number one, it’s got to be more than a month.
The other thing that we sort of became more clear in terms of the definition, obviously when you look at the work post-traumatic, it’s obviously a traumatic event. That traumatic event is defined as any exposure to an actual or threatened death, serious injury, or sexual violence. That can mean directly experiencing the traumatic event, witnessing it, sometimes learning about it, and sometimes experience repeated, what I would call, extreme exposures to the event. So those are the two things. The event itself and the duration of what I would call the symptoms post-event.
Now those symptoms have been, what I would call, more clearly defined, for instance, recurrent, intrusive, distressing memories. Recurrent, intrusive, distressing dreams. Sometimes even, we call that in medical word dissociative reactions, but in what I would call the common terminology is flashbacks. Then there is what we would call intense distress associated with it. There’s also what’s called physiological. Some people’s heart will race, they’ll be sweaty. So, there’s physical things that happen and people tend to avoid situations, circumstances related to this. A lot of times people have what’s called mood and cognitive alterations. They also have what I would call this continued vigilance. They startle easily. So, it’s sort of like the adrenaline is sort of on hyperdrive.
So, all those criteria, a mixture of those for 30 days in duration, makes sort of what we would call the clinical criteria for post-traumatic stress disorder. It’s a very debilitating, very gut-wrenching sort of disorder that, like I said, in anybody’s lifetime the U.S data is about 8.7% for lifetime and 3.5% during any given year.
Host: Why do some people suffer post-traumatic stress disorder and other people might have the same traumatic experience and not suffer PTSD? Tell us a little bit about risk factors or if there’s a genetic component. Also, Dr. Dewan, do children react differently than adults to trauma?
Dr. Dewan: Boy those are some great questions you just asked me. So, let me try to address little bit little. Let’s talk about risk factors. Now when researchers study this issue, they divide, what I would call, risk factors into pre-traumatic factors, peritraumatic factors, or post-traumatic factors. So, when we look at pre-traumatic factors, there’s obviously the genetic. Now there is some research in terms of specific molecular or receptors in the brain that people are more vulnerable. We’re doing research on that. There are environmental issues. Actually, people who have less social support, more traumatic life experience tend to develop this disorder.
Then there’s also what I would call, the researchers will say temperamental kinds of pre-traumatic factors. Someone who has predisposing anxiety or predisposing OCD characteristics may have greater likelihood of developing the disorder. We know that monozygotic twins have higher rates that dizygotic twins. So, have we identified all the genes related to this that make people more vulnerable? No, we have not. But we do know it’s a mixture of three different pre-traumatic factors.
The, what’s called during the trauma, depending on the severity of it, the closer the person is to the trauma, the life threat or personal injury—especially if the violent event was “perpetrated” by someone you knew, that carries much more significance. Then post-trauma, there’s the environmental and, once again, what the research will call temperamental. Meaning what are people’s usual coping strategies. What’s their resilience capability and what happens post-event in terms of their psychosocial support systems?
Now children do experience, can experience it differently. They sometimes cannot communicate, they can't verbalize what it feels like. They can't verbalize their thoughts as well, their dreams. So, their manifestations are much more behavioral in nature. There might be more impulsivity. More acting out, more distressful behaviors in say adults. So that’s a little bit of the difference.
Host: Speak about treatments then. What’s the first form of treatment you might try? Do the symptoms ever go away with these treatments? Tell us about some of the treatments available?
Dr. Dewan: I think this is where, I think, we’ve made significant progress in the last two decades. We have a number of psychotherapies that have been researched in very large clinical trials. There’s a type of therapy that’s cognitive behavioral therapy that’s called cognitive processing therapy where someone is in a therapeutic relationship with a therapist, gets to discuss the nature of the traumatic event, gets to be able to share their story, and gets to understand the framework of that story in a way that they can know that it’s not their fault, know that it’s not happening again. The more exposure people have to talking about the story in a therapeutic framework and context, the less fear, the less avoidance, the less startle response, the less vigilance they feel.
There’s also been some great work in what’s called virtual reality therapy combined with cognitive processing therapy. This is where, I think, both the military research and the veteran’s research has been tremendously helpful where people sit with these—You’ve seen these game goggles that people have that they put on and you're in sort of this 3D world, well there’s been some software development where you get exposed to specific traumas. Let’s say its military trauma. You get exposed to this and you do it in a therapeutic way, and sometimes you get medicine while you’re experiencing that trauma to reduce the fear or the threat response during the reexperiencing of this trauma, so the pain is less. So, I think we’ve made some great strides in the area of the psychotherapy aspects.
Obviously, there’s obviously medical interventions. The most common treatment historically has been SSRIs. These have been around since the late ‘80s. There has been research done. SSRIs can give you 10 to 20 to 30% reduction in symptoms, similar to psychotherapy. When people have very, very significant extreme symptoms, usually the combination is much more beneficial. There’s also a high blood pressure pill, surprisingly, that people have been using for reducing nightmares. Now the specific high blood pressure pills given at night actually reduces nightmares and you get sometimes 30 to 50% response rate. So, I think we’ve come a long way from just anti-depressants, just mood stabilizers. Now we’re using things like high-blood pressure pills.
There’s some other novel treatments that are being researched, and I'm not ready to sort of talk about those right now because that might—I don’t want to talk about false expectations or there’s a miracle cure around the corner. I’d rather talk about things that we know have worked for the past decade.
Host: Then tell us what family and friends can do to help if they suspect that somebody is suffering from post-traumatic stress disorder. What would you like them to know about helping that loved one cope with the trauma? What about self-care for somebody who’s gone through a traumatic event?
Dr. Dewan: Alright. So, let’s talk about families and friends. First of all, what a family or friend can say is, “I know you're in pain. I've noticed you're getting more emotional or you're impulsive or you're backing off. You're not hanging out with us much more. It looks like you might be drinking a little bit more than you used to. I've noticed these and I want you to know that I'm here to be your support. I will go with you to the appointment. Let’s set this up together.”
I've looked at some recent research. People who suffer like this, if they have—Everybody these days has their social network, let’s say. Sometimes they have five people in their network, sometimes they have 500. What they really need is a social supported network. Meaning those people need to be identified as, “Hey if I'm in trouble, I need you to be available for me.” That’s what a friend of family can say to them. Say, “Here’s my phone number, here’s where you can call me. Whenever you need something or you're feeling down, you call me. I am here for you.” So those two things. Getting them to the proper treatment and saying, “I'm there for you and here’s my number. You tell me if you need me.” I think those are the two things that people can do, family and friends can do, to help their loved one.
One thing that people don’t realize is horrific trauma really impacts not only people’s emotions and sleep and energy levels, it actually impacts their ability to remember and think clearly. So, it really impacts everything to do with day to day life. I think the things that we take for granted in terms of take care of yourself, meditation, enjoy life, connect with others, there are—Now most organizations have websites that people can go to to practice mindfulness, to practice cognitive self-talk, support groups. I think there is a world out there that people can say you know what? There’s been a lot of research done these past two decades. There’s a lot of support out there. I'm going to take advantage of this. We are in the 21st century and we have more data and more research, and more capabilities now than we ever did before. I think people that can self-manage this illness a lot better if they just seek out these tools. So that would be my recommendation to folks.
Host: Thank you so much, Dr. Dewan. It’s a pleasure, as always, to have you on with such great information and you're such a great educator. Thank you for educating us today about post-traumatic stress disorder and the treatments that are available and the ways that family and friends can help their loved ones. You're listening to BayCare Healthchat. For more information, please visit baycare.org. That’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.