Not all PTSD is the same, and the difference decides the treatment [PODCAST]

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Some people process a terrible event over a week or two and move on. Others replay it for years, and their bodies never settle back down. Faust Ruggiero is a clinical psychologist who has treated post-traumatic stress in veterans, first responders, and others for years. This episode is based on his article “Understanding the types of PTSD and how to treat them,” published on KevinMD. You will hear how he distinguishes stress that follows a single event from stress built on years of ongoing harm, and why that distinction shapes the treatment plan he writes. He walks through the questions he tells primary care physicians to ask, from flashbacks and interrupted sleep to exaggerated startle, anger, and isolation. He explains when short-term medication is used to bring arousal down far enough for therapy to work. Press play for a plain account of what this condition does to the body and the mind, and why he tells patients it does not have to be permanent.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Faust Ruggiero. He’s a clinical psychologist. Today’s KevinMD article is “Understanding the types of PTSD and how to treat them.” Faust, welcome back to the show.

Faust Ruggiero: Ah, Kevin, so happy. I’m thrilled to be back with you.

Kevin Pho: All right. So tell us what this latest article is about for those who didn’t get a chance to read it.

Faust Ruggiero: Well, you know, I have been treating people with PTSD, veterans, first responders, and others, for years. So I finally put together the book to get it out there. My goal was to get to the point where people could understand, first of all, what this whole thing is: this progression. Someone is traumatized, or we have periods of lasting trauma through our lives, and then our bodies and our minds don’t reset, and then the PTSD sets in.

I want them to understand the progression and what it’s all about, how one feels, the symptoms, and all the things people experience. And then some of the things we can do, because there are some nice new therapies that are really efficient and really successful in treating this today. So I wanted to get that out there so people have a roadmap to do some things.

Kevin Pho: All right. So just to give us some context, give us a clinical definition of what PTSD is, and how would it typically present in the people that you see?

Faust Ruggiero: Yeah. You know, when you talk about PTSD and you look for a good clinical description, you talk about the body and the mind. You can’t separate those. For me, it is when the body does not physically reset and stays in a hyperstressed mode, and the mind has a difficult time letting go of the traumatic episode, replaying it over and over again. So when you have those two things together, that’s when PTSD thrives.

Kevin Pho: So give us a common example of the type of symptoms. If someone first presents to you and you’re suspecting PTSD, what does that look like in your office?

Faust Ruggiero: Yeah, you know, you have to look at what kind of PTSD we’re talking about. We have, you know, the simple PTSD: “I experienced a traumatic episode. I saw someone get killed. I was in the war,” what have you. Versus the ones that are more complex PTSD, where it’s ongoing, maybe bullying through the years, abuse at home, an abusive relationship, etc.

So when people come in, I’ll look for something that they’re not letting go. It may be, “I saw that, it shocked me, and when it shocked me, I couldn’t let go of it.” Or, “I’ve been in this thing for a long time. When I was a kid, they abused me. My father abused me when I got home. I’m in an abusive relationship right now, and I’m not doing anything that seems to change this.”

Kevin Pho: So in your article, you talk about the types of PTSD. Why don’t you outline the different forms PTSD can take?

Faust Ruggiero: You know, we talked about the simple form. Let’s look at that. You come into my office and you say, “Hey, I don’t know what’s going on. I’m having dreams. I’m having flashbacks of this thing, and I can’t let go of it.” OK, we’re talking basically about a simple form of PTSD. We want to look at the trauma. Why did it affect you the way it did? Sometimes it’s just the episode, and that’s all it is. Sometimes it attaches to other things that maybe we didn’t let go of, that we didn’t work through so well. Sometimes we compartmentalize things and we leave them back there. So it may attach.

Or there are the ones that are a little more difficult. You know, the kid who comes in. Sometimes I even have teenagers who come in with ten years’ worth of trauma and PTSD going on, and now they present with an ongoing thing. Sometimes it’s not only ongoing trauma of one type. Sometimes there are three or four different types of trauma: “I’ve been traumatized. I’ve been hurt. I’ve seen things happen. I’ve had recurring episodes all over my life.” So the first thing we do is determine which type they have, and that tells us how we’re going to treat it.

Kevin Pho: So give us an example of how defining the type of PTSD affects how you approach treatment.

Faust Ruggiero: It’s like anything else you do, Kevin. Someone comes into the office. It doesn’t matter what kind of practitioner we are, a medical person, a psychologist, whatever it may be. The first thing we want to do is get all the information. Sometimes they’re going to come in and be very clear: “This happened. I can’t let it go.” Or sometimes they come in and it’s an offshoot: “Oh, well, you know, my husband or my wife is doing this, the kids this, the guy at the job,” and they just can’t get to the point where they’ll let go of it. Sometimes it takes a simple form, or it’s just a lot of anxiety. Sometimes we get everything from personality changes to destructive behaviors.

So what I do is get that history, the biopsychosocial history, as we call it. I want to get all that information and put it in order. I want to see what’s going on. Then, at that point, we’re going to look at what they’re experiencing physically. We’re going to look at other things that happened in their lives, which may or may not be connected. We’re going to look at what they’re experiencing in the moment, because when we say PTSD, everybody thinks you go back to what happened before, but life is ongoing. So we’ve got to look at it within the context of what the person is living today. We want to put that in the picture as we’re defining the treatment plan.

As we get through the past, and what they’re dealing with in the present, and what they’re expecting, a lot of times it’s, “Well, this is going to happen in the near future.” We may want to factor that in. Now we’re going to start putting together a treatment plan to deal with all of that. So it sounds complicated, but once you have all the information, it really presents what you need to do next.

Kevin Pho: So how about in a primary care setting? If I’m talking to a patient who I suspect has components of PTSD, tell us the type of questions I should be thinking about to elucidate the different types, which may warrant referral to a psychologist like yourself and can perhaps affect how I treat that patient. What are the types of questions that you use, or that I should use, to distill the various forms of PTSD?

Faust Ruggiero: I always tell the docs I work with, because they ask me what to ask so they have an idea of what they’re treating. Sometimes it’s regarding where they’re going to refer them; sometimes it’s about the medicines they may want to prescribe. The first thing I tell them is, obviously, get the history, get the physical history, and have all of that in place first, so that we know what we’re dealing with.

Some people simply, neurologically, can shut things off. It happens. We process it. Maybe for a week or so it stays with us, but then it fades. For other people, the nervous system, the brain, just doesn’t let it go. It keeps on replaying it.

So I’ll ask them: Are they getting flashbacks? Are they thinking about this? Does it just pop into their mind so they can’t get rid of it during the day? Are they having dreams about it, or are they not able to shut their brains off at night? Do they find themselves at an accelerated pace, where you may be sitting and watching TV, maybe a door closes, and you’re jumping? Exaggerated responses to things? Is there more anger? Are they isolating? Are they increasing substance abuse? These are all things that people do when PTSD has taken over their bodies and their minds.

So I say, get all that information. If that’s the case, it may be suggestive of PTSD. Most of the time, when most of those are in the picture, that’s what we’re dealing with.

Kevin Pho: And in terms of potential pharmaceutical options, tell us your approach to when someone would need a medication versus cognitive behavioral therapy or other nonmedical treatments.

Faust Ruggiero: When those fail. I mean, for some people, if the hyperarousal is so significant, the doc may say, and I may agree with it, “Hey, let’s get them on an Ativan or a Xanax or something for a short period of time,” so we can then move into cognitive behavioral processing, where we can use the desensitization programs. We can use those things so the person can sit long enough to be able to do that.

Also, some of those drugs, again for a short period of time, give us the opportunity to calm that person down a little so they are receptive to what we’re saying. Because when we talk about a cognitive approach, what we’re looking to do is take the irrational part of PTSD, which has now blossomed into this huge emotional affair, and get it to a point where it’s factual, so we can have that person responding to facts. When you emote over the facts, it’s a whole different story than when you emote over the fear of the facts.

So sometimes we’ll see those medications prescribed. Sometimes they’ll get to me and the docs have already prescribed them, and I’m working with that part of it. But that’s usually either a precursor to those traditional methodologies, or it’s something that will be used during them, or because those are not working. In some cases, they’re going to go to the SSRIs with people, because people simply can’t get past anything and the mood disorders are presenting. So they may say, “Let’s do something. Let’s get them on a light SSRI. Let’s see what happens from that point.”

Kevin Pho: You also wrote that PTSD can be associated with other psychological and behavioral health conditions as well. What are some of the common ones that you see?

Faust Ruggiero: Typically, it’s anxiety and depression, but bipolar is there. It’s a big one where we see that. That’s another type of PTSD, if you will: when it is associated with a condition that already exists. Those people have a tendency to overreact to what’s going on and do two things. They don’t let it go, but it also kind of joins forces, if you will, with a condition they already have. So they will misperceive it to a more significant degree. They’ll react more strongly than they typically would. The treatment for those folks almost always includes pharmaceuticals and is longer-lasting.

Kevin Pho: So tell us some of the biggest misconceptions about PTSD that you would like to clear up.

Faust Ruggiero: You know, the first one is that you can’t treat it. People will surrender and say, “I can’t do this. This is me. It’s going to be there for the rest of my life.” That’s not the case, more so now than ever. That’s not the case. There are so many good people doing good work with this. So that’s the first thing.

The second thing is that it’s better if you don’t think about it and don’t talk about it. That’s horrible, because you’re keeping it inside, and you’re going to keep on replaying it, and it’s going to get bigger and bigger. So it’s very important to be able to get other people in the mix.

And the other thing is that this is going to replay forever and ever: Even if you get through it, your mind will stay in that PTSD mode, and when things happen, you’re going to overreact. Again, that’s not the case. We’re going to do things that will change the way you prepare yourself and the way your body receives information. We’re going to make some changes with that.

Kevin Pho: We’re talking to Faust Ruggiero. He’s a clinical psychologist, and today’s KevinMD article is “Understanding the types of PTSD and how to treat them.” Faust, we’ll always end with your take-home messages to the KevinMD audience.

Faust Ruggiero: You know what, Kevin? The best advice I love to give, and I used to give this just to the lighter cases I treat, but as I got older and got further into this, I tell people: You have the ability to make change. Please don’t think that your body remains stagnant. It’s a dynamic world. Your body can change, and your mind can change. We can address just about anything you can bring up. But be willing to take the time, make the commitment, and stick with what you’re doing, and good things happen.

Kevin Pho: Faust, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Faust Ruggiero: Ah, it’s always a pleasure. Thank you.

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