Barbara Rothbaum, Ph.D., Discusses Post-Traumatic Stress Disorder (PTSD) and COVID-19

Barbara Rothbaum: Thank you for joining us today. I'm Dr. Barbara Rothbaum. I'm proud to be an NIMH-funded researcher as well as a professor of psychiatry and associate vice chair of clinical research at the Emory University School of Medicine's Department of Psychiatry and Behavioral Sciences. I'm the executive director of the Emory Health Care Benefits Program and the Trauma and Anxiety Recovery Program. June is Post-Traumatic Stress Disorder Awareness Month, or PTSD for short. During the next half hour, I'll try to provide an overview of the signs and symptoms, diagnosis, and treatments for PTSD. I'll discuss the latest research on PTSD and some of the challenges that the coronavirus of COVID-19 outbreak has presented for individuals with PTSD. If there's still time at the end, and I plan for it to be, I'll take some of your questions. So please ask them in the comments under this video feed on Facebook or tweet NIMH on Twitter. It's important to note that I can't provide specific medical advice or referrals. Please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. I'll be speaking about PTSD and some of its causes, so it's possible that people with PTSD may be triggered. If you need help finding a provider, please visit www.nimh.nih.gov/findhelp. If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK or 8255. You can also ask for help in the comment section of this feed, and someone from NIMH will assist you. All of the websites and phone numbers I just mentioned will be posted in the comments section of this feed so you can easily access them.

Barbara Rothbaum: So let's talk about PTSD and what PTSD is and isn't. A lot of people think of PTSD as the war veterans' disease, and it is certainly a huge problem in the war veteran population. But unfortunately, estimates are about 70% of us will undergo a traumatic or potentially traumatic event in our lifetimes, so it really is a public health concern. Now, that doesn't mean that 70% of us will end up with PTSD, but actually too many of us do. So let's talk about what is the diagnosis, what are some of the signs and symptoms of PTSD. It's the only anxiety or anxiety and fear disorder in which an external event, the trauma is part of the criteria. And the definition of a trauma is, loosely, if you felt that you or someone you care about could be killed or seriously injured. In general, the way I see PTSD is that someone is haunted by something that happened to them in their past, and the haunting nature of it comes out in the reexperiencing symptoms of PTSD. People can be having a nice time with their family, a work function, and all of a sudden, unwanted memories of the traumatic event intrude, and it knocks some off kilter. People can have nightmares. I remember one young woman I worked with who hated her nightmares so much that she would try to stay away all night long and finally fall asleep exhausted about 6:00 AM, not a good way to be very functional in the rest of her life.

Barbara Rothbaum: Flashbacks, I remember one combat veteran I worked with. He was in traffic on the highway, and he said it basically played out on his windshield like it was happening again. When people are reminded of it, they feel emotionally upset, and they often and usually feel it in their bodies. They feel physically on edge. In general, PTSD is a disorder of avoidance. People don't want to talk about it, they don't want to think about it, and they don't want to be around anything that reminds them of it. Sometimes people can have difficulty recalling important parts of the traumatic event. Now, everybody can't remember some things, but these are important parts. Very often their emotions and thoughts and assumptions are negative about themselves and the world. Very often they will blame themselves or have an exaggerated blame of others. It's not uncommon, for example, in post- 9/11 veterans who served in Iraq or Afghanistan will often hear a story that starts something like, "I'm driving, and we hit an IED, and then someone is hurt seriously or killed. And it's my fault since I was driving." So this exaggerated sense of blame. A lot of negative emotions and difficulty experiencing positive emotions. A lot of people will tell us, "I know I love my family. I love my kids. But it's hard to feel it. It's hard to feel that joy." A lot of times an analogy I use is like that emotions hose is kinked. Because people don't want to experience the negative emotions, they kink that hose, but it means the positive emotions don't come out as well.

Barbara Rothbaum: Very often people will describe not being interested in normal activities and feeling very isolated. And a lot of times, they add to that of isolation with the avoidance. I remember one veteran telling me he moved a mini-fridge into his room, and now he doesn't have to even leave his room to eat. As hard as it is living with PTSD, it can be hard to live with someone with PTSD. They can be irritable and even sometimes aggressive. And it's important to note I never excuse aggression or hurting someone in the name of PTSD. People with PTSD can engage in risky or disruptive behavior-- destructive, sorry. We will hear in Atlanta - we've got interstates - and we'll hear, for example, of some of our veterans driving their motorcycles down the interstate over 100 miles an hour. People with PTSD experience a lot of hypervigilance and exaggerated startle reaction. And the way I think about this is you just don't go through the types of events that lead to PTSD and walk through life quite as calmly as you did before. People will describe difficulty concentrating, and I always think of this kid. I went to Texas A&M University six years ago after the bonfire collapse to try to help. And one of the students there was also an EMT responder, and he said before the bonfire collapse, he had a 3.5 GPA. After the bonfire collapse, he had a 0.6 GPA. He described his difficulty concentrating. He would try to read his assignments, and he said they were just words on a page. He couldn't even put them together to make sense.

Barbara Rothbaum: A lot of people with PTSD have difficulty sleeping, and there are a lot of reasons for that. So we mentioned the nightmares. PTSD is an anxiety and fear disorder. And if you're scared, nighttime can be a really scary time. The house is quiet. It's dark outside. Everyone's asleep. It's very easy to misinterpret those noises and think, "Oh my gosh, is that someone breaking in?" And go into defensive reactions. Again, not a good way to relax and get the sleep. About half of the people with PTSD also have depression, and there are often a lot of sleep problems and depression. And some people I've seen who are functioning pretty well with PTSD, I think one way they do it is they stay very busy all day long. So at night, when they're laying down, and all of these distractions that have been holding these thoughts at bay are cleared away, the thoughts start flooding back and make it difficult to get to sleep. In general, in the United States, about 10% of the population have PTSD at any one point. And some of the hard stuff about PTSD, it's a hard disorder to live with, but it has a lot of other, we call it comorbidity, problems that often go with it. And in fact, most of the people with PTSD have at least one and usually two or three other problems that go with it. I mentioned depression. There are other anxiety disorders. A lot of times people use drugs and alcohol to self-medicate to try to numb, to try not to think about it. A lot of sleep problems.

Barbara Rothbaum: In general, the symptoms we just talked about of PTSD, that's part of the normal reaction to trauma. We did a study in female sexual assault survivors and met with them right after the assault, everyone within one week of the assault, and we were surprised to see that 94% of them met the symptomatic criteria for PTSD. So, again, what that says to me is that's the normal response to trauma. Three months later, about half met the full criteria for PTSD. So then we went back and tried to figure out-- it seems like everybody comes down the lot in the first month after the traumatic event. After that, people who don't end up with PTSD, they continue to improve steadily across time. But people who end up with PTSD, after about a month, they didn't change. They didn't get worse, but they didn't get better. And so this has led some of us to think of PTSD as a disorder of extinction. So what I mean by that, fear and anxiety is a normal response to trauma. For most people, that fear will extinguish over time. For example, if a common, potentially traumatic event that many people have experienced is a motor vehicle crash. So right afterwards, you're going to be thinking about it. You'll probably be crying about it if it was serious. It may be scary to get back into the car. After a month or so, after several weeks, if you've been driving, if nothing bad happened, that fear will extinguish. For a significant minority, though, it won't, and it can end up in PTSD or some other problems.

Barbara Rothbaum: Part of what we do to treat PTSD is in cognitive behavioral therapy called exposure therapy. And what we do with exposure therapy is we help people confront what they're scared of but in a therapeutic manner so that it changes. I'll give you an example unrelated to this. Say a child gets bitten by a dog and develops a dog phobia so severe that that child doesn't want to leave the house for fear of encountering the dog. If you just put that child in the room with a dog, and they ran out crying, that's an exposure, but it's not a therapeutic exposure. Nothing changed. What we would want to do is, for example, start with a cute little puppy and let that child stay with that puppy long enough to learn, in their body and in their brains, that, "This animal poses no threat to me." And then you might increase the size of the dog or the type of the dog to help that learning. I love a quote from Mr. Rogers, from Fred Rogers, "Anything that's human is mentionable, and anything that is mentionable can be more manageable." When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. And that is exactly what we do in prolonged imaginal exposure therapy for PTSD or PE for short. In general, I think of an emotional processing theory behind it, and the idea behind that is when something important happens to us in life, we need to emotionally process it and make a lot of analogies to the grief process. When we lose someone we love, there's no way to the other side of the pain except through it.

Barbara Rothbaum: We may cry. We'll think about them. But gradually, over time, we'll always miss them, but it can become less painful. Maybe a year later, we can think about him without crying. It's less painful. But for various reasons, and what we think is maybe fear-- so, as I said, fear is a normal response to trauma. But, for example, if I get scared, if I drive after a motor vehicle crash, maybe I stop driving. If our society is not really very good about talking about negative events and certainly not the type of events that lead to PTSD. And sometimes people are given the message implicitly, and sometimes they're given the message explicitly, "Go on with your life. Forget about it. Put it behind you." In other words, "Stop talking about it. I don't want to hear it." And so all of this avoidance prohibits emotional processing. So it kind of festers. And this is how it haunts us. And we think for good emotional processing, what's required is you've got to activate the memory, you've got to bring it up, but you want to put it back differently. So if that kid runs out of the room screaming when they see a dog and they just put it back the same way, that that's no learning. We want new learning that, for example, that animal poses no threat. So we want to change it and change the memory. One of our main techniques, and we found that it's very good at activating the memory in most people, is imaginal exposure. So we asked people to close their eyes and go back in their mind's eye to the time of the traumatic event and recount it out loud in the present tense over and over and over. And we tape-record it and ask them to listen to that at home every day. And then we talk about the meaning. We talk about what came up in the exposure and if that's accurate.

Barbara Rothbaum: For example, of someone's blaming themselves, is that accurate that it was really their fault? Or how much was it their fault? And we'll work on that. We also do what's called in vivo exposure, and that just means in real life. So, for example, for motor vehicle crash survivor driving or driving that car, driving through that intersection, things that people are avoiding because they feel dangerous or they remind them of the traumatic event but that are realistically safe or safe enough to do. And then I'm going to talk a little bit about virtual reality exposure therapy. I'll add that we are working on an app now. And right now it's called Messy Memories. It's not quite ready yet, and then we're going to want to test it and do research on it. But we're working on an app to help people process these memories and take care of themselves. So hopefully, that'll be available soon. There are other evidence-based, trauma-focused treatments. So evidence based means that there has been research done on them and objective data and evidence that they work and they work for people with PTSD. One of the main ones is CPT, Cognitive Processing Therapy and EMDR. Many people have heard about Eye Movement Desensitization and Reprocessing.

Barbara Rothbaum: So getting to virtual reality exposure therapy, what VR is, people are wearing head-mounted display that's kind of a strappy helmet with two television screens in front of each eye, earphones, and a position tracker. So just as my view changes when my head moves, so it does in virtual reality. And what we do with virtual reality exposure therapy is imaginal exposure to the most traumatic memories. And we've done studies, for example, with Vietnam veterans and Iraq and Afghanistan veterans post-9/11. So for them, we'll ask them to recount it out loud in the present tense repeatedly. And now with their eyes open, and the therapist is matching in the virtual reality what the patient is describing. So, for example, if they're describing driving back to base, Smith next to him, Jones in the back seat, Garcia in the turret, they hit an IED on the right side, we can reproduce that. In the study that we did, the virtual reality exposure therapy was effective at decreasing their symptoms. And we also looked at more objective signs and symptoms of PTSD. We include psychophysiological monitoring of the startle response and heart rate and skin conductance, which is sweating. And we saw that these physical indices of anxiety decreased after treatment.

Barbara Rothbaum: And in our Emory Healthcare Veterans Program, we're doing these psychophysiological assessments before and after our two-week intensive outpatient program, and we're seeing these decreases in the body's physical response and reactivity to reminders. And that makes me really happy because I think part of what makes people with PTSD feel crazy is they can know they're not in a war zone and yet their bodies are feeling as if there's the same level of threat. So when their bodies are learning to become less reactive, I think that's wonderful. There are also pharmacological treatments for PTSD. In the United States, we have two FDA-approved medications for PTSD, sertraline or Zoloft and paroxetine or Paxil. It's been a long time since they were FDA approved over 20 years, so there's a lot of research going on into new medications. And one of them that there's been a lot of talk about lately is MDMA. So we'll only say it once, on the street, it's called ecstasy. But what's been tested in the research is not ecstasy because people don't know what's in ecstasy, it's not controlled, and don't try this at home. But in the MDMA studies, it is combined with specific psychotherapy that is meant to be combined with the MDMA, and it's been shown to be very successful. So there's a lot of excitement about that.

Barbara Rothbaum:We've also got some advances in the timing of when we deliver therapy. Since PTSD, as I mentioned, includes the definition of the trauma, an outside event-- and in most of the stories I hear about what happened to people, very often there is something that happens right after the traumatic event that can make it better or can make it worse. And obviously, we would want to make it better. So we have conducted some studies in the emergency room trying to deliver a modification of exposure therapy right after someone has experienced a traumatic event and then one week later and another week later for three sessions total. And in that study, three months later, we found that people who received the early intervention had half the rate of PTSD as people who didn't receive it. So that's where we're also hoping that if the app is effective, it might be effective early on. So there is not one person in the world that hasn't been affected by the COVID-19 pandemic. And unfortunately, people with PTSD, I think, have been hit doubly hard. As I mentioned, isolation is a problem with PTSD, and we've all been more isolated with COVID. Most of us, especially before the vaccinations, had a lot of fears about contracting it. What do we do? And that's just exacerbated in PTSD.

Barbara Rothbaum: Healthcare workers have really been-- a lot of people described it, i's like World War One combat soldiers. The front-line workers would go forward and get shot down, and then the next line would come in. It has felt like they have been in combat. The conditions have been so hard and what they've seen. So it really has been hard during the pandemic. I want to take just a minute and tell you briefly about the Emory Healthcare Veterans Program. We have regular outpatient therapy once a week. But the real innovation is what I mentioned, the intensive outpatient program in which we can see people. We fly in post-9/11 veterans from all around the United States, we put them up at the hotel across the street, and give them a lot of therapy every day for two weeks. Most people get more therapy in those two weeks than most people get in a year. And we were just able to show that by decreasing the PTSD, it decreases people's suicidal thoughts. And so that's wonderful. If you want to connect, you can connect on Facebook at Emory Veteran's Program or on the web, emoryhealthcare.org/veterans. And now we have, I think, a few minutes that I can take some questions. And it looks like they are, "What are self-help therapies for PTSD?" That's a great question. In general, what we recommend is talking about it because I think that's what most of us do. We think about it. We talk about it, We write about it.

Barbara Rothbaum: And actually, I'm not supposed to [inaudible] ourselves. We haven't written one yet, but we've got a contract to write a self-help book that will work like the app to help guide people. But it really is what people in common sense do. We talk about it. Think about it. We cry about it. And keep doing that until you don't need to talk about it anymore. "What should a family member do if they have PTSD and they're not diagnosed?" and I'm not sure if you're talking about the family member with PTSD or a family member of someone with PTSD. For example, in our veterans program, we have family therapy, and there are specific programs. For example, Focus is a specific evidence-based family therapy for PTSD to teach family members and the person with PTSD how to talk about it so people aren't just walking on eggshells, letting someone know that there is treatment available and treatment helps. A lot of people will tell us what's treatment going to do. You can't change what happened. And that's true. We can't change what happened. But usually, the problems that people are having right now are caused by PTSD, and treatment does help PTSD.

Barbara Rothbaum: I think that there are other questions and feel free to enter other questions. Here's one. "Many people around the globe are suffering from COVID-related PTSD. How can they be treated?" So the app is is primarily going to start off dealing with COVID-related PTSD and what we're calling people's messy memories. If their front-line healthcare workers or if they've had people be affected by COVID, the same thing that treats PTSD from any other kind of trauma should help. Talking about it, writing about it. My line in the sand is functioning. If it's interfering with your functioning, then I would contact a mental health professional and try to get an evidence-based treatment. And I think with that, our time is up. I want to thank you very much for joining us today and give you the message that treatment helps. I'm a believer in the resiliency of the human spirit, so please don't give up. Oh, and I've got a message. Sorry, we've reached the end of our discussion today on post-traumatic stress disorder. Thank you all for your questions for joining me today to learn more about PTSD. Please go to www.nimh.nih.gov/ptsd. Thank you and stay well.