Evidence Based Practices for PTSD: Mind-Body Interventions

In this segment, we're going to be talking about evidence based practices for ptsd. We're going to explore physical, affective and cognitive evidence based practices. So we'll start out with the most obvious medications in terms of treating ptsd. There are a lot of medications out there. The use of benzodiazepines following trauma was not beneficial and was found to actually increase the risk in some people of developing ptsd. They're not exactly sure why, but they have found that benzodiazepines administered in the immediate aftermath of the trauma sometimes increase the risk of developing it. Hypothesis. And, and I'm open to any hypotheses you may have for why that might be. Remember, benzodiazepines increase gaba, increase a sense of relaxation, which can be great, but during the acute stress phase, that actually may cause people to think that they're feeling better than they are and prohibit them from actually processing the trauma. Now, I'm hypothesizing here. There was no information in the articles that I read that really discussed why that was. But it is something that's important to recognize because a lot of people after a trauma do want a benzo. You know, the first thing they say is I want Valium or Xanax or, you know, know something else. And if we can help them explore alternatives, then that might be helpful. So let's talk about those alternatives. The use of the beta blocker pro propanol has shown conflicting results, but one randomized control treatment did show significant decrease in the severity of PTSD symptoms and lower likelihood of developing significant subsequent ptsd. Beta blockers are used to basically block the communication of the autonomic nervous system to a certain extent. And I am not super up on my beta blockers, but I know it is one of those thing medications they give to people who have tachycardia. For example, SSRIs may be helpful for addressing anxiety and depressive symptoms related to PTSD. Okay, true, we know that SSRIs can be helpful in addressing mood disorders. We need to balance that with the effects if it starts having a negative impact on their sleep quality and if that starts causing problems. CBD cannabidiol may offer therapeutic benefits as an adjunct to psychological therapy for disorders related to inappropriate responses to traumatic memories and aversive memory processing. It is being investigated quite extensively for use with ptsd. We, we talked yesterday about the fact that CBD is not available as a medication, as a prescription medication for, for anything except for a particular type of epilepsy. So the Availability of this is still somewhat limited, but in trials it is showing promise. What do we use for sleep problems in PTSD? Since we know that 70 to 90 some percent of people with PTSD do have sleep problems. Prazosin is an Alpha1 blocker which is a medication they use for high blood pressure that has been shown to be helpful. Lunesta has also been shown to be helpful. Anecdotal reports from clients that I've worked with that have been on Lunesta have indicated that it is pretty intense and for some people with PTSD it may be too intense and, or it may make them feel out of control and more vulnerable when they go to sleep because they know that they are going to be so out of it. Risperdone and Olan, which are atypical antipsychotics, have, and I believe olanzapine is Zyprexa have also been shown to be really effective for sleep disorders in ptsd. We're not prescribers. However, if our clients are struggling with some of these issues, we do want to let them know that there are medications that can help them. If they're given a beta blocker, for example, and they don't understand why they were given a beta blocker for their PTSD symptoms, you know, we might be able to, to explain to them or help them understand that the beta blocker helps re regulate the HPA axis. That's, you know, the basics of it. And we also want to educate them if they're taking a benzo, about how it can potentially cause the development of PTSD in some people. Obviously it's going to be up to them if they want to take it, but I know there are a lot of people who take benzos that aren't prescribed for them or the benzo was prescribed PRN two years ago and they just had it laying around and they started taking it. So we do want to ask about those things. Nutrition changes in diet with an emphasis on an anti inflammatory protocol that contains Omega 3s, a full complement of vitamins and minerals and amino acids may influence psychiatric disorders through direct effects on mood via the gut microbiome and nutrient availability. If we're giving the body all of the building blocks it needs to make the, the serotonin, the norepinephrine, the cortisol, the testosterone, all that stuff, then the system, the body factory, is going to be able to run more efficiently which can directly influence mood. Additionally, when the gut microbiome is imbalanced for that person, it is communicating through the vagus Nerve to the brain that hey, all things are a go. So it's important that we, we recognize that there are multiple systems at work here and we're just starting to learn about the gut brain axis. Obesity is associated with changes in neurotransmitters, neuropepto neuropeptides and inflammatory factors that are present in both the gut and the brain and have effects on both mood and eating behaviors. Obesity increase in excess adipose tissue is associated with increases in inflammation and we've already talked about how inflammation is a bugaboo and throws the entire body factory out of, out of whack. So we do want to be aware of the fact that if we have clients who are experiencing difficulty with obesity and mood and, and those sorts of things, that there actually may be a connection. Progesterone and estrogen appear to influence fear processing and extinction and PTSD with differing vulnerabilities at different stages of the menstrual cycle. Obviously this is for women, so it is interesting to note that depending on what where they are in the, in the stage of their cycle, the, the ratio of progesterone to estrogen fear processing will be different. So what may be processed as extremely stressful and traumatic at one place, maybe less so. I mean it's not going to be a huge difference, but maybe less so at a different phase in the cycle. Exercise, therefore hormone management can also be helpful. Remember, estrogen is neuroprotective. So if people have adequate levels of estrogen and remember males as well as females have estrogen, it can be neuroprotective for them. Gonadal hormones are easily measured in blood work. So this is another area that we want to make sure that our clients are attending to in order to make sure that there's not some underlying physiological factor contributing to their distress, contributing to their symptoms, their sleep, their pain, their inflammation, their mood, etc, so hormone getting hormones tested, getting vitamin D levels tested, getting iron, thyroid hormones tested, all of those can be helpful. Liver function is also super helpful because if the liver is not functioning well, you've got some inflammation, some cirrhosis, some hepatitis, some cirrhosis going on. It can back up the toxins into the brain, which is leads to something called hepatic encephalopathy, which is associated with a dementia type state. Obviously that's a little bit different than ptsd, but if we're noticing cognitive issues, cognitive symptoms, we don't want to necessarily rule that out. Any normal blood panel is going to look at liver enzymes, so that's not even an extra test that needs to be done. Exercise. Potentially aerobic exercise can exert a positive impact in PTSD through exposure and desensitization to internal arousal cues. So as people exercise, their heart rate goes up, they start breathing harder. This is akin to what happened when they were experiencing the trauma. But in this situation, they're in total control of, you know, how hard they're working, how hard they're breathing. They can stop at any time. So they're. When they have a increase in their heart rate, they may become less sensitive to it. It may not automatically trigger a memory of the traumatic event. It also enhances cognitive function. There are a lot of reasons they hypothesize for this. The increase in oxygenation is not the only one. But exercise increase also increases dopamine. Dopamine is involved in cognition. So, you know, drum roll, please. Exercise induced neuroplasticity. Your brain actually is more flexible when you are exercising, when it's getting enough blood and nutrients and oxygen to normalizes HPA axis functioning. When you exercise, your body learns to, you know, go hard, respond to the stressor, and then when you stop, it learns to back off. One of the conditioning tests, if you will, or indications of conditioning, is how quickly your heart rate returns to baseline when you stop exercising. So they look at it in terms of how many seconds does it take for your body to drop, for your heart rate to drop 10 beats a minute. But as you become more physiologic, physically fit, that happens a lot faster. So it's normalizing that HPA axis. The HPA axis goes, oh, stressor's gone. I can check out for the day. And there are reductions, believe it or not, in inflammatory markers. When you exercise, it actually triggers some endocannabinoids to be secreted, dopamine to be secreted, endogenous endor, endorphins to be secreted, which are your endogenous opioids. So there's a lot of feelgood stuff going on that actually can contribute to a reduction in inflammation if you're exercising, you know, gently. If you're exercising and you're lifting weight until you can't move, you're creating micro tears, which obviously is going to contribute to inflammation. What we're really talking about here is easy aerobic exercise. Mindfulness based stretching and deep breathing exercises have been found to reduce the prevalence of PTSD like symptoms and normalize cortisol levels in individuals with subclinical levels of ptsd. This would also include yoga, you know, so mindfulness based stretching as well as yoga. Being aware in the moment of your body, your body position, how it feels, your breathing, being completely aware in the moment when you're stretching, you do it slowly. Yoga is generally done pretty slowly. So by virtue of that, your heart rate is remaining, you know, relatively low when you're doing a lot of these things. So it normalizes cortisol levels. HPA axis RE regulation. Suppression of the HPA axis in PTSD has been reported with less variability. There's fewer peaks and troughs because remember those locks, they're broken. So there's fewer peaks and troughs because less is getting through. But then when they're, is when stuff does get through, it's, it's a flood. It just kind of breaks down the doors. And it's interesting to note that this is true through throughout the normal cortisol cycle. Your cortisol cycle is supposed to peak in the morning. That helps you get out of bed and then de. Decrease throughout the day with some peaks and troughs throughout. That's expected. But people with ptsd, it tends to be a lot flatter. You know, you don't have the significant peak in the morning. It just kind of stays somewhat steady state and it doesn't decrease in the evening when it's supposed to. In order to trigger the creation of melatonin, rapid eye movement. Sleep supports a process of effective brain homeostasis, optimally preparing the organism for next day social and emotional functioning. So REM sleep, your dreaming sleep, actually does have a function. You know, we talked about deep sleep is when the oxidative stress and the adenosine and stuff is cleared out. But REM sleep is necessary too. Poor sleep is associated with increased anxiety, irritability, deficient coping and circadian rhythm disruption. Now, circadian rhythm disruption, if you weren't around for that class, your circadian rhythms are involved in everything. They are involved in your energy levels, they're involved in regulation of your gonadal hormones, which is why, you know, women's cycles tend to be at a certain period, you know, 28, 30 days, something like that, that's regulated by the circadian rhythms. If their circadian rhythms are out of whack, then their cycle is likely going to be a lot more erratic. Circadian rhythms are also involved in inflammatory processes, stress processing. You know, it was a really interesting class, I thought, when I put it together. So if you're interested in circadian rhythms, you can watch that video later. Investigators have found both hypo and hyperactivation of specific brain regions in individuals with PTSD neuro during sleep. So they even sleep differently. People with PTSD are at a much higher risk of developing obstructive sleep apnea. They hypothesize it may be as high as a 75% greater chance of developing obstructive sleep apnea independent of body weight. A lot of times obstructive sleep apnea is seen in people who are obese. However, people with PTSD body weight didn't seem to have that much of an effect because OSA was seen in people who were were of normal body weight, which I thought was fascinating in terms of affective and cognitive interventions. Meta analyses do not support the effectiveness of widespread use of psychological debriefing after trauma in preventing or reducing the intensity of PTSD symptoms. That's important because a lot of places I know, a lot of insurance companies still think that psychological debriefing is the way to go and it's actually been shown to not be the case. Meta analyses have demonstrated the benefit of brief trauma focused cognitive behavioral therapy for prevention and multi session trauma focused cognitive behavioral therapy in people with acute stress disorder or ptsd. So right after the trauma, trauma focused cognitive behavioral therapy can be extremely helpful in an individual or, you know, sometimes family situation because they're actually processing what happened and, you know, trying to integrate it into or simulate it into their schema. If they develop ASD or ptsd, then trauma focused CBT has been multi session has been found to be really effective. The University of South Carolina Medical School, I'm thinking, has an online class on trauma focused CBT which is really good. I can look that up at our at our next break. Exposure based and other CBT protocols, as well as mindful based mindfulness based cognitive therapy in group and individual formats have also been shown to be effective for ptsd. So so far we're still seeing a lot of mindfulness and cognitive behavioral. What do we want to accomplish with CBT in working with people with PTSD though, first or number one, Gwen, According to the research, the group debriefing teams not only do not work, but often cause more harm because they expose people to repeated reminders of the trauma and can be really intense. You know, maybe Jim Bob over here didn't see all this stuff over here that happened and when they're processing it together, people who weren't exposed to some things actually get exposed indirectly. When I was doing working with people after the tornadoes up here, because they still do do a lot of. Debriefing, we were doing individual debriefing but the reports that I was hearing were very, very different from people. Some people experienced and saw some things that were really graphic and horrific. Other people saw some things that were horrific in a different sort of way. But if they. They hadn't been exposed to the same exact experiences, and it could have been potentially a whole lot more traumatic being exposed to those cues. That is what the research says. So, yep. And yes, news reporting also can do this. And thank you for bringing that up. That is one of my pet peeves. News reporting is far too graphic and actually re. Traumatizes a lot of people by repeatedly bringing things up or if somebody had an experience. My stepfather, for example, lost his family in a fire many, many years ago. And seeing stories about house fires and seeing firemen run out of house, house fires with children in their arms is so triggering for him. You know, there's. There's some stuff that we really don't need all the details, in my opinion. But yes, news media, in their effort to be clickbait, and I know that's cynical, but a lot of times there. There's a lot more information or a lot more graphic than we may need. So exposure. Exposure therapies, whether it be through emdr, you know, when. When they're working through it and talking through what happened, or direct exposure, virtual reality exposure therapies are designed to encourage patients to face their fears, to encourage them to experience it, be able to sit with it for a second and, and recognize that they have the control. Patients learn corrective information through this experience. So instead of thinking, it's going to crush me, it's going to. This fear is going to obliterate me. They start learning that, hey, this is really. This is unpleasant, but I can do this. They also start learning corrective information about what happened. So, you know, as they go through the narrative, you know, they can check their impressions. They can also be prompted, not an emdr, but in processing and exposure therapy, they can be prompted to take a wider view of what happened. When we're in a trauma state, we have tunnel vision. So processing it helps us remove those blinders and look at, okay, what other factors might have been going on. And that's one of the key aspects of cognitive processing therapy. Extinction of fear occurs through repeated exposure to the situations. So, okay, people start to experience it. And when you've done something, when you haven't done any something before, it can be really scary. When you've done it once, it's like, okay, that wasn't so bad. When you've done it 20 times. It's old hat. Well, exposure works kind of in the same way. When you've been through the situation and it was traumatic and overwhelming, so, I. E. You struggled to cope, that was terrifying. But when you've been exposed to it multiple times and each time you've been able to cope with it a little bit more effectively, then it becomes less threatening, it becomes less scary to think about being being triggered. Successful coping enhances self efficacy. The second thing that you can accomplish with CBT is safety response inhibition. Patients restrict their usual anxiety reducing behaviors like their need to escape. Instead of going, I can't do that, I can't. I worked with somebody who had been exposed to a really bad traffic accident, and driving on the interstate was something that he couldn't do for a period of time. It was terrifying to even think about driving on the interstate. So this was a safety response inhibition. To stay safe, he was going to prevent being in a situation where it might trigger that fear response. Some people need reassurance. Some people, you know, they have different mechanisms for figuring out how to deal with the fear that comes with flashbacks, that comes with re experiencing. And we want them to ideally start developing the internal strategies to be able to do that and develop strategies that don't restrict their quality of life. It decreases negative reinforcement. So negative reinforcement is what happens when somebody gets rewarded by eliminating something. So if I eliminate driving on the interstate, then, you know, I don't feel stressed, so great. But that also means there's a lot of places I can't get to very quickly or at all if I'm not on the interstate. And it increases coping with anxiety without using anxiety reducing behaviors in order to enhance self efficacy, helping them recognize that, hey, you did this. You didn't have to rely on escape. You didn't have to rely on having somebody do it with you. You did it. And cognitive strategies. In cbt, we want to educate the person about the disorder and the treatment, help them understand what's the function of the PTSD symptoms, how do they make sense, and what can we do to help you integrate these so they're not, you know, impairing your, your quality of life. Cognitive restructuring, behavioral experiments targeting unhelpful thought patterns and beliefs, the all or nothing thinking, personalization, mind reading. You know, the standard list of cognitive distortions cognitive behavioral approaches can, can address. It provides corrective information regarding the level of threat. During the incident, the level of threat was high. But with cognitive behavioral strategies, we're helping people be able to more effectively Identify the current level of threat in the present context. So I'm getting on, we'll stay with that interstate. If the person's getting on the interstate, recognizing okay the level of threat back then real high, the level of threat right now, you know, I'm driving, there's virtually no traffic. It is, you know, three o'clock in the afternoon. So there is virtually no threat in this environment. So it really helps them start becoming more grounded in where they're at. Recognizing in this context what is the level of threat and what parts of this do I have control over? Which helps them target self efficacy beliefs. Recognizing what, what do I have? What can I be effective in changing in this situation? You know, if traffic suddenly becomes really busy or if somebody starts driving erratically, I can get off the interstate or I can pull over, I can do that. So targeting those self efficacy beliefs, if I start feeling like I'm hyperventilating, I can do xyz. If I start experiencing a flashback or feeling like I'm going to experience a flashback, I can do this. And they've developed strategies that they've found that actually work so they don't feel like they are prisoner to their symptoms. And then arousal management, emotion regulation, distress tolerance skills can help the patient control increased anxiety levels. A lot of times we're not going to be able to help them completely eliminate and prevent all flashbacks and memories and arousal henceforth and forevermore. That's, that's not real realistic. So we want to make sure that they have the skills to deal with arousal when it happens instead of having distress intolerant thoughts like this is going to kill me, I can't stand this. Etc, helping them develop distress tolerance skills that this is unpleasant but I can make it through surrender of safety cues like their companion or lights. You know, maybe, maybe somebody sleeps with lights on in, in their bedroom because they were, um, it makes them feel safer. Well lights in the bedroom actually impair sleep. Even though it helps them get to sleep, it actually keeps them from getting quality sleep. So ideally they would get to the point where they could sleep in darkness. Um, but sometimes it takes people a while to get there but eventually that's one of those things that they may get to the point where they realize hey, I don't need this anymore. And then development of those adaptive self efficacy beliefs in general their ability to be empowered, their and their ability, their ability to keep themselves safe. EMDR is a really well studied technique now and I was apprehensive at first, you know what, 10 years ago or something when it kind of came on the scene. But I have done the reading and it's really a very, very helpful methodology. Interestingly, online EMDR has been demonstrated in early studies to be effective. I wouldn't have thought that, but evidently it is. So that's good because you know, that's kind of the wave of the future. EMDR therapy has been shown to reduce PTSD and other trauma related symptoms and has been shown to be more effective than other trauma treatments and shown to be effective even delivered with different cultures. With EMDR the therapist is helping the person process the trauma and recount the trauma. They're not trying to tell them what they should think or what the change their cognitions about it necessarily. They're processing that trauma in a way that's meaningful for them. So it's very empowering and very client led neuroimaging data, so they've even looked at neuroimaging show similar neurophysiological substrates for clinical improvement following following emdr as is as seen with trauma focused cognitive behavioral therapy involving changes in bilateral temporal pole connectivity. So the exact changes not super important to us. The important point here is that TF CBT has been shown to be really effective and they've shown that there's actually changes in the way the brain functions through, you know, imaging studies after emdr. So we know it's doing something. It's not just hokum or whatever you want to say. So there is evidence this is, this is a really effective practice. Exposure therapy and systematic desensitization have been proven to be highly effective with PTSD in reducing symptoms and comorbid symptoms associated with a variety of traumas. And finally, Emotional Freedom Technique is a tapping therapy that is being extensively used by the VA right now. And you can read more about that. It is still in its infancy. It is in many ways similar to emdr, but it has its differences. Obviously the data on it is still. It's not nearly as robust as the data for emdr. But I can tell you that I've have two people that I know, friends of mine, not clients who have used the emotional Freedom technique and found it to be ex. Both of them found it to be extraordinarily helpful. So for what it's worth, Cognitive behavioral therapy, emdr, Emotional freedom and exposure therapy are currently the most widely used approaches to address ptsd. Sleep quality can bidirectionally impact PTSD symptoms. Inadequate sleep can lead to the development of PTSD and PTSD can cause sleep problems. So we do want to screen for sleep problems in. In all of our clients, even if they don't have ptsd, because we know that it can make them more vulnerable to PTSD should they be exposed to a trauma.