Posttraumatic Stress Disorder - An Interview With Rachel Yehuda, PhD

Martin L. Korn, MD

Disclosures

Introduction

Dr. Martin Korn, psychiatrist and frequent contributor to Medscape, interviews Dr. Rachel Yehuda, an expert on posttraumatic stress disorder (PTSD), for her thoughts on the World Trade Center disaster and the aftermaths of trauma and PTSD.

Dr. Yehuda, since you have worked extensively in the area of biological mechanisms in PTSD, how do you see these events reflected in the underlying neurobiology?

Well, at this time I'm responding to this trauma like many others. I'm waiting to see how big it is. It seems like it's affected many, many people here in New York, and I am, of course, here in New York. I'm not thinking that much about the biology of this disorder at this time.

If you wanted to ask me how advances in the biology of PTSD have set us up to help people now, then I could answer that question by saying that in the last few years we've really learned a lot about PTSD -- that is, what it is and what it isn't. Certainly our ability to understand what it is has directly helped us in thinking about how to treat the disorder. One of the things that biology has taught us is that PTSD represents a type of a response to trauma, but not the only type of response. It is a response that seems to be about the failure to consolidate a memory in such a way as to be able to be recalled without distress.

It is, again, too early to know how big of a problem this is going to be for New York. Although, just doing the math, even by the most conservative estimates of the prevalence of PTSD, we have so many people who were directly affected. By directly affected, I mean running from the scene of the World Trade Center as the buildings were collapsing. So, I don't mean watching it and witnessing it, which is in itself trauma, or feeling frightened by the implications, which is also traumatic, or losing loved ones which is also traumatic. Certainly, many people are involved in the rescue efforts, that's traumatic, and there are a lot of people that we don't hear about. We are all hearing about the fire fighters and the policemen and the rescue workers. There are scores of city workers that have just been thrown into this and are now being confronted with scenes and sights and devastation that they have not been prepared for. We didn't have a good way of planning for this event, so the number of people that are potentially going to be affected by this trauma is very very large. Now we have to watch and see what is the response going to be. We have an opportunity to watch the response unfold over time.

Are you treating people at your clinic who are coming because of the events at the World Trade Center?

We are getting numerous calls. They are just starting this week. We didn't have any last week, but now we are getting calls from precisely those I predicted we would hear from -- people that had already once called us in the past or had already been treated for trauma-related symptoms that either were or were not related to the disaster at the World Trade Center, but are feeling very affected by it. Mostly the calls we're getting are from people who are actually professionals who are probably less stigmatized or they probably have better knowledge that a little intervention now may prevent a longer response. Our own patients are showing a tremendous reaction to this. There is a lot of clinical activity in the first week. Last week while everybody was running in many directions, I urged my clinicians to stay put, anticipating a very strong mental health need among our patients. I'm glad I did because I actually think the clinicians in our program were busier than they have ever been clinically with dealing with reactions to trauma.

Most clinicians are not really trained for this. Do you have any suggestions?

Yes, I do. This is the time to admit that you need training in posttraumatic stress disorder. Even if someone comes to you and may not exactly meet the diagnostic criteria, the approaches that have been developed, tested, and validated in the last few years are going to be helpful. These are approaches that are manualized or if they are not directly manualized, these approaches are very clear conceptually. They are different from standard counseling or psychotherapy in that there are certain things that the therapist does or doesn't do that need to be learned. People shouldn't be afraid to come forward. There's no particular reason why somebody should know how to do these treatments if they were not trained.

I know there are some schools of thought that stress expressing emotions or details of the trauma in detail in an attempt to relive the traumatic events. Others put less emphasis on this.

I think talking about the trauma is really important. Not everybody wants to do it. I don't think people should be forced. I think there are ways to be helpful to people who don't want to talk about a trauma, but you may not be able to get rid of their PTSD, because that's really going to involve processing and not avoidance. So people who say they don't want to talk about this, they can't talk about this, need to be told that, "Well, your difficulty in discussing this is called avoidance, which is one of the hallmarks of posttraumatic stress disorder. However, since the problem here is that the reason why you don't want to talk about it is because the memory's so distressing, and memory's aren't erasable, we have to find a way to make that memory less distressing." For example, you may continue by saying, "Look, let's think back on something terrible that happened to you in your past. Tell me about it." Any they'll tell you about it. Chances are they won't be feeling the distress that they experienced then. They'll be able to make a distinction between, "Boy did that hurt or boy did that feel bad" and feeling bad in real time. So, the job of the therapist is really to bring a person to the point where they're ready to do specialized PTSD treatment, and then the specialized approaches can be used. The therapist has to feel confident. If a patient is crying in your office, saying, "I don't want to talk about it," very few therapists will sit there and say, "But no, but we have to." I mean, it's just not what most therapists would do.

A therapist may also say "we'll give you a medication." Whatever they'll do, it's going to take somebody who really understands why we do need to talk about it, and has the confidence of the training of exactly how to approach talking about it, and how the next session is going to show improvement over the previous one. It's hard to convince people that you want them to talk about their trauma now with the distress and the affect, that's the job. So, I feel that you never force patients, but you educate and convince, you cajole. You educate in a very supportive way, and then the patient comes to see that you are competent. You will help them. You understand their resistance. Believe me, they will then talk about it. When does therapy begin? Who begins the process? I mean, there are a lot of questions that have been raised by this. My own opinion, and I think I'm supported by the literature that shows that debriefing and similar kinds of grief counseling are more effective in people who seek out those services rather than in people who are asked to participate in them. However, the dilemma is that mental health treatment is still somewhat stigmatized in this country.

Do you see a need for being proactive in terms of meeting with groups of firemen or whoever was involved?

Firemen are busy right now, and I'm not sure that it is helpful to meet with them now to do anything more than tell them that you're here. I don't want to criticize people that are going out there and being proactive, however, I think that our job now is to educate the public, and help destigmatize.

When the trauma happens on this large of a scale, it's kind of an opportunity to capitalize on the collective grief and trauma that we all feel and destigmatize this. That's what I think is important. I don't want to send a message that we're all going to be a nation of mentally ill people. I don't believe that's true. I believe in our ability to cope. I believe in resilience. I think that people have extraordinary capacities to recover from trauma. They may need help to facilitate that process, and the message that one gives in the early stages is one of: "This is a normal reaction and you have the coping skills required to get through this. I'm going to teach you how to identify them and shore them up. We're going to work through this together." Normal, normal, normal.

Now if things persist for a long time and people just can't seem to get rid of the emotion and the distress associated with the memory. If they can't sleep, or are afraid to sleep, or are haunted by images, this indicates that there is a failure to recover. How are we going to tackle this? Now, members in the field believe that the treatments that would be "the big guns for later," can be used effectively earlier, and possibly prevent a longer-term response. So even though, conceptually, I believe that what is going on now from a biologic perspective is the normal stuff, I still think that PTSD treatments can be applied even though what's going on now may not really be this chronic, malignant posttraumatic stress disorder about failure to recover. So, I also think that it's really important for mental health practitioners to just stand back and listen. We've never been in this exact situation before. We just need to let people tell us what they need from us. Let's not run and tell them what they need. Or, impose our own need to help on people who may not require our services just yet.

How do you see this as extending beyond New York? In other words, do you think we're going to get a national response?

Yes. We are having a national response. We're in New York, but I'm hearing that this is true all over the country. I think that this activates a lot of stuff in a lot of people for a lot of reasons. First of all, there is the imminent possibility of war. I think people are frightened. People are afraid to travel. So, the terrorists have accomplished, in some measure, their goal -- we have been terrorized. We are terrorized. We are joining now many countries and people all over the world that are terrorized. We somehow felt as Americans who do the right thing and have the right values that we were somehow shielded from this. Now we're learning that we, too, have to learn how to cope with a world that is not fair.

Do you see, other than education, in terms of the wider sphere of affected individuals, a role for prevention outside of New York, perhaps a more specific mental health role?

Again, I think that we want to send a message that as mental health workers, physicians, we want to reassure people that it is normal to now feel frightened, that it is normal to feel like our innocence is lost. We're having normal responses, and another normal response is, ultimately, resilience and concreteness. I would hate to "pathologize" this or "over pathologize" this. I think that there is going to be an epidemic of PTSD in New York. There is really no getting around that, but I don't think we want to compound the problem or make it worse. Hopefully see the upcoming epidemic in the early stages before it becomes this malignant, intransigent, and difficult-to-treat illness. We're now dealing with people who were traumatized decades ago -- veterans, holocaust victims. One of the things that you hear over and over again is how people didn't provide the social supports when they were needed, which is right in the aftermath of the event. People were not giving the right message for recovery. So, maybe we will not fall into the pit of having rampant chronic posttraumatic stress disorder because we are giving a different message.

Do you see specific reactions among various individuals with differing psychiatric disorders or from differing clinical populations such as veterans?

I don't necessarily know how different it would be. The way that I view stress reactivity, or reacting to these kinds of events, is that if your system is already coping with something then having the additional burden of coping with something else is taxing the resources. So, I think it's really quite simple. On the other hand, some people can really mobilize a lot of constructive energy to help them with that. I know that our veterans are looking for ways to be helpful to others and are reaching out. This can be very therapeutic, reaching out to other people. We can all reach out to people. This is one of the things that is happening in New York that I think is really very moving, at least to me. People have a real sense of wanting to help their fellow man in whatever small or big way. There are a lot of humble, silent heroes in this that we don't hear about and we don't read about and we don't see. They are just invisible. Real heroes. To me, they are those silent people who are just sitting with people, getting them a glass of water.

That is very inspiring.

It's unbelievably moving, and sometimes these gestures of solidarity and support and just kindness decrease the stigma and the amount of shame.

In what way does shame play a role?

People who are exposed to trauma or who are victimized may experience a sense of shame, even if it was really not their fault. This also can generate a response of embarrassment for somebody's degradation. People, in general, are more inclined to not comfort a trauma survivor, to not talk about it. It's uncomfortable -- "So tell me about your rape." We don't do that. And in this trauma, we are not behaving that way. We are going great distances to remove the stigma and the shame that is associated with being victimized. I think that this is going to translate into a very good prognosis for recovery for many, many people. You know, I've been watching this for a week. I've been right in the eye of the storm and I feel like the response of the average New Yorker has been amazing and therapeutic. Now mental health workers in New York are going to be seeing, whatever kind of therapy they do, whatever kind of patients they've seen before, that they're going to have to add a few tricks up their sleeve. They're going to have to find ways to incorporate some of the very specific techniques that have been developed into their regular clinical practice if they use the manualized research grade version of these therapies.

Could you talk about your specific work in terms of the biology of PTSD?

Sure, I'd be happy to. I've been doing this since 1987; and since 1991, I have only been doing the biology of PTSD. I think we've learned a lot. We started out finding that cortisol levels were low. An implication of John Mason's finding something that I didn't quite believe when I first saw it because it wasn't obvious that the cortisol levels would be low, but look, you know, you replicate something, it's very powerful. You see it with you own eyes. Then the question became: "Why is cortisol low?" The bottom line of what we learned about cortisol was that it seemed that the glucocorticoid receptors were more sensitive. There was an enhanced negative feedback inhibition, which was opposite of what has been associated with depression. That was puzzling -- What's that about? Concurrently, we were finding that in the same people who had low cortisol there was increased norepinephrine. It was very puzzling to us. When we started to do our prospective studies, we thought for sure that this was an adaptation that occurred. We were studying people decades after the trauma, but certainly this couldn't be the case at the time of the trauma, right? Because everyone knows that cortisol levels are high during trauma. With the hippocampus-shrinkage theory, people were suggesting that it was caused by high cortisol levels.

Do you believe in this theory?

The hippocampus-shrinkage concept? No, I don't.

Other theories suggest that it was related to whole-brain shrinkage.

There is some suggestion that the original finding was not significant at the P < .5 level, but rather at the P < .6 level. There may also have been some methodologic problems. Although it was replicated, some of the studies may have not been done in a methodologically rigorous way, so, consequently, the studies that are now coming out are not always replicating it. However, there does seem to be something going on in the hippocampus. It just may not be a volume issue, but the point is that our work failed to find that anything was related to high cortisol, even close to the time of the trauma. That didn't seem to be there in people who were either at risk for developing PTSD or, who frankly, developed it. So, then I had to really think, "What's going on here?" The model that I came up with is a theory, it's a model. It could be wrong, who knows.

My theory is this: You walk into trauma a certain way. There may be risk factor, maybe prior trauma, and basically, you're walking in with a system that is more sensitive in that the negative feedback is more sensitive so that cortisol production is shutdown prematurely. Since we know that the role of cortisol in stress is to shut down the catecholamine system, if cortisol is shut down prematurely, then there may be more catecholamines around for longer than would be optimal, and this is what leads to the faulty memory consolidation, specifically the distress associated with the memory. Then you have a period of incubation. What happens during that period? Either people get more distress and the PTSD process continues or they take very drastic steps to remove their distress.

You have focused on the role of norepinephrine in the pathophysiology of the disorder, but the serotonergic drugs specifically, I think sertraline and paroxetine, have been shown to be effective therapeutic agents. What is the role of serotonin in the disorder?

Just because these drugs work doesn't mean serotonin is involved, they have a lot of nonspecific effects. In fact, since all the SSRIs don't work equally, then possibly what's related to efficacy is the slight differences in the effects of the other neurotransmitters. So, I think it's a fallacy to say that because a drug is effective, we now know that this neurotransmitter system must be involved.

Thank you so much for your time.

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