PTSD Screening - An Interview with Dr. Brian Macobin

Q. For someone reading this who isn’t sure if they are suffering from PTSD, what suggestions do you have for them?

A. My first suggestion is to consider seeing a well-qualified and licensed therapist. Asking the question implies at a minimum that someone feels that something is wrong or bothering them. A good therapist can help them with that, regardless of the ultimate diagnosis. Second, please don’t ignore it. Whether or not the diagnosis is PTSD, there is help available. One of the most important factors in maintaining PTSD is avoidance of memories, thoughts, feelings, and external stimuli related to traumas. While this avoidance is understandable and maybe necessary sometimes (e.g., to focus on the next combat mission, to study for or take an exam, etc.), avoidance ultimately keeps someone from working through their traumas and healing. Third, please rely on your social supports. Quality of social support before, during and after experience of trauma(s) is robustly associated with resilience, recovery and healing.

Regarding the nature of the diagnosis, a licensed therapist will do an evaluation and determine a diagnosis. However, if someone has been exposed to “actual or threatened death, serious injury, or sexual violence” by direct experience, witnessing the event, learning about it happening to a close friend or loved one, and/or experiencing “repeated or extreme exposure to aversive details” of traumatic events, then someone has experienced the kind of event that can lead to PTSD.  PTSD has 20 symptoms in the latest edition of the DSM-5-TR; I won’t list them all here. These symptoms include: intrusive distressing memories of trauma(s); bad dreams with trauma-related themes and/or emotions; emotional upset when reminded of trauma(s); physiological fight/flight/freeze reactions to things that remind them of the trauma(s); avoidance of thoughts, feelings, memories, and/or external stimuli that remind them of the trauma(s); exaggerated blame of self and/or others for the trauma(s); negative beliefs about self, others, and/or the world; feelings of estrangement from others; emotional numbing; irritability; hypervigilance (being super alert for danger); exaggerated startle response; and insomnia. If someone has experienced a traumatic event(s) as defined above AND has some of the above symptoms related to one or more such events, they very well may meet criteria for PTSD. The good news is that there are good treatments and good therapists available to help.

Q. Following combat zones post-9/11, PTSD and its conditions have become widely understood. What is a major misconception associated with PTSD?

A.  One major misconception is that there is no cure for PTSD.  It’s not that I do or don’t believe in such a cure. I think that the concept of cure is an incorrect way to think about healing and recovery from PTSD. Traumatic memories will remain, and traumatic event(s) will always have happened. In this sense, there is no cure for the past; it does not need one. The meanings that one makes of traumas and one’s experiences of symptoms related to traumas can and do change --often markedly -- with successful therapy. Most people who complete an empirically validated, trauma-focused treatment such as the recommended first-line treatments in the VA/DoD Clinical Practice Guidelines, show at-least moderate improvements in symptoms, improvements in functioning, improvements in quality of life, and describe the treatment as helpful. About half of completers experience marked improvement in these areas. Further, as far as we can tell, these improvements continue for most people after treatment ends.

Q.  Treatments and therapies for PTSD patients have increased over the years. In your opinion, which remedies have proven to be the most effective?

A.  Wow. Books have been written on this topic, on the complexities and nuances of psychotherapy research, and on interpretation of said research. That said, treatments that both the therapist and patient both believe in tend to be most successful. Further, treatment that involves a close therapeutic alliance between the provider and patient tend to be most successful.

Regarding specific approaches and considering my clinical experience and interpretation of relevant research, Cognitive Processing Therapy (CPT), Prolonged Exposure therapy (PE), and Eye Movement Desensitization and Reprocessing (EMDR) have best combination of strength of outcomes and robustness of support (e.g., number of good studies, 30+ or so years over which research has been done). Brief Eclectic Therapy and Narrative Exposure Therapy also have very good evidential support. Further, Written Exposure Therapy is very good. It has very high completion rates (e.g., over 90% in some studies), is very brief (only five sessions), and has outcomes as strong as those of PE, CPT, or EMDR. It has comparatively fewer randomized controlled trials to support it, which is currently its primary weakness relative to the PE, CPT, and EMDR. However, it is a very promising and strong contender.

Q.  There are advocates for certain psychedelic mental health treatments who praise its efficacy over traditional treatments.

Where does the VA stand on the issue of psychedelic drugs for PTSD treatment?

A.  I don’t know where VA stands on this issue. Here is my stance: There is an incredibly promising and accumulating body of evidence that suggests that psychedelics (e.g., MDMA, psilocybin) --used appropriately and effectively -- could be a powerful therapeutic tool for treatment of people with PTSD. We need more research to conduct and interpret it well and to watch this area closely.

Q.  Many sufferers of PTSD use different forms of avoidance to bypass thoughts and feelings associated with a traumatic event. How should patients cope with various forms avoidance?

My first suggestion would be to see a licensed therapist: 1) who is a specialist in treatment of individuals with psychological trauma, and 2) whom you feel safe and click with. Prolonged Exposure therapy is designed particularly well to address avoidance; folks could consider pursuing that treatment. Further, patients can work to be more aware of how and when they avoid. This allows them to make conscious decisions about avoidance rather than being controlled by it. Sometimes it’s OK and/or even necessary to avoid because one must focus on something else. However, when it is done, it is best done with open eyes. Further, if they feel safe doing so, they can start to challenge their avoidance in different ways -- say by writing about their traumas, intentionally allowing themselves to feel their feelings related to traumas, talking with a trusted loved one, and/or doing things that they’ve been avoiding. These things are best done in work with a good therapist, so that’s the primary recommendation. 

Q.  PTSD is commonly associated with service in combat. However, sexual assault also produces an alarming number of PTSD patients. What should our Veterans know about trauma caused from sexual assault?  

A.  The trauma was not your fault. The trauma was not your fault. The trauma was not your fault.

Folks may be interested to know that sexual assault leads to PTSD more frequently than most other types of trauma (including combat exposure). Many variables appear to influence one’s probability of developing PTSD after a trauma, including the type of trauma(s) (e.g., motor vehicle accident, combat, sexual assault), the number of traumatic events a person has experienced; exposure to trauma, neglect, and other adverse events in childhood; one’s own genetics; and social support before, during, and after the trauma(s). However, sexual assault stands out as contributor to development of PTSD. 

Regardless, it’s treatable. With good treatment, healing and recovery are likely and within reach.  Please take care of your beautiful self and find a good trauma therapist!