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Lucy Chen: [00:00:03] Hey there, podcast listeners, this is Lucy Chen. I'm a PGY4 for psychiatry resident at the University of Toronto. Today, I'm going to be hosting an episode on post-traumatic stress disorder. I'm here at Women's College Hospital with Dr. Dana Ross, who I had the pleasure of working with as a PGY2 psychiatry resident, and also attended some of her interesting trauma workshops. So maybe without further ado. Dr. Ross, maybe you can tell us a little bit about yourself and your work with trauma and treatment and diagnosis.
Dr. Dana Ross: [00:00:37] Absolutely. Thank you for having me. So my name is, as you said, Dr. Diana Ross, and most people call me Dana. And so you're most welcome to as well. I am working at Women's College Hospital in the trauma therapy program, which is an outpatient trauma therapy program, where we see people who have a history of childhood trauma and that can be all kinds of trauma. So sexual abuse, physical abuse, neglect, abandonment, psychological abuse, all of that kind of a thing. And we do a lot of group work and then we do some individual as well. And in terms of my background, I did my medical school at the University of Calgary and I came and did residency at Queen's University for my first year and then came to Toronto to finish my residency here.
Lucy Chen: [00:01:19] That sounds great. So maybe I'll right now cover some of the objectives that we're targeting for this episode. And Dr. Ross really kind of created some specific objectives, so it'll help us with guiding the episode. So the objectives are to cite the prevalence and incidence rates of post-traumatic stress disorder or PTSD. Recognise the clinical features of PTSD using DSM five diagnostic criteria. List five Common Risk Factors for the development of PTSD. Identify three neurophysiological mechanisms underlying PTSD. Differentiate the three stages of trauma therapy. Describe evidence-based pharmacological and psychological treatments for PTSD. So we're covering a lot. So we'll do our best. So, Dr. Ross, why don't we start with, like, I guess, like the prevalence rates or how common PTSD is, how common trauma is?
Dr. Dana Ross: [00:02:22] Absolutely. So when we talk about prevalence, there's a lot of different studies on there's sort of a wide range of figures. And we'll talk a little bit about why that is as well. So we know that although about 50 to 90% of the population may be exposed at some point in their life to traumatic events, most people don't actually go on to develop PTSD, which is an interesting thing to think about. And I think later we're going to circle back around to talk about some of the factors that actually contribute to developing PTSD. So what we do know is the lifetime prevalence of PTSD ranges from about 6.1 to 9.2% and national samples just in the general population in the United States and Canada. And within one year, the prevalence rate is around 3.5 to 4.7%. And as I was mentioning it, it can be difficult sometimes to get an accurate rate there. And one of the reasons for that is that people may have symptoms of PTSD for many years before they actually seek treatment or they may have sub-syndromal PTSD. So the prevalence rate of PTSD may actually be underreported. So we do know that the prevalence of PTSD is considerably higher among patients who seek general medical care and among persons who are exposed to anything like a sexual assault or mass casualties, including, of course, war, national natural disasters and in refugee populations. And of course, in the veteran community. Different studies show prevalence of PTSD is somewhere between 10 to 30%.
Lucy Chen: [00:03:50] Mm hmm.
Dr. Dana Ross: [00:03:51] We also know that the lifetime prevalence of PTSD is higher in women than in men, and it's higher in the presence of underlying vulnerabilities such as adverse childhood experiences. We'll talk a little bit more about what that exactly means down the road and if people have comorbid diagnoses as well. And I think one of the most important things we need to know is that it's extremely common for people in mental health settings to have a history of trauma which may or may not include a diagnosis of PTSD. And so when we're working with people in the health care field, in mental health, I think it's very helpful for us to be holding a sense of that prevalent.
Lucy Chen: [00:04:28] This also it makes me think about like what's considered a trauma or like how I suppose in DSM five, it's something very specific, but lots of people will say, Oh, that was so traumatic for me. Or, you know, we talk about PTSD in a sense that it kind of it's just general symptomatology in response to trauma. But maybe we can better define and clarify that understanding of what a trauma really is.
Dr. Dana Ross: [00:04:53] Absolutely. It's a great conversation in the field. I think what is trauma and also just in a wider society. It's a great conversation that's going on. And so certainly I don't have the the one and only definition of trauma, but let's break into it a little bit. So if we look at the definition of trauma in the DSM five, we can start with that criterion, A, which is that exposure to actual or threatened death, serious injury or sexual violence in one of the following ways. And they include directly experiencing, witnessing, learning about it happening to others or experiencing repeated extreme exposure to the details. So for example, police officers, officers and that kind of thing. And so that's sort of the formal definition. But if we talk and think a little bit about the the less formal definition of what is a trauma, it can be anything from a single experience to multiple experiences. And it's often something that just completely overwhelms the individual and their ability to cope, to integrate things like ideas and emotions that are involved around that experience. And it can take a really serious emotional toll on those who are involved, involved in that kind of a trauma. It can have an impact on things like a person's identity, their sense of self, and really result in negative effects in mind, body and soul and spirit. Really often there are four elements that are identified in trauma.
Dr. Dana Ross: [00:06:15] So one was sometimes it's often or often it was unexpected. The person was sometimes unprepared for the trauma. There was nothing that the person could do to stop it from happening. So that sense of helplessness or lack of control and again, just the traumatic events were beyond that person's control. So those are more not formal definitions, but often I find key components of traumatic experiences for people. But certainly the scope of trauma and what is or isn't trauma I think is a larger conversation for us as a again, as a society and for us within the field of trauma as well. But it encompasses a wide variety of experiences like physical abuse, sexual, emotional violence, abandonment, neglect, of course, domestic violence and trafficking, all kinds of things around significant invalidation neglect that can happen. Harassment, discrimination. We see a lot of things around class and race, sexual orientation, age, religion, disability, gender, things like, of course, war, refugee populations, economic stress, mental physical illnesses, natural disasters. And then I think it's important when we're thinking about trauma to that, we think about it broadly. So trauma can be an experience of the individual, but it can also really be propagated and experienced through organisations and institutions. It can be embedded in cultures and communities, take place with service providers and families as well.
Lucy Chen: [00:07:46] This concept of like sub-syndromal PTSD, and I also think about invalidation or, you know, someone growing up with a really sensitive temperament to sort of parents that were a poor fit or and I wonder about like how that manifests. Like it's not sort of like a serious threat to their life, but they I guess I'm curious about this idea of like complex PTSD or like some of these other sort of manifestations of PTSD that are not clear cut, but they clearly are distressful. We clearly see it.
Dr. Dana Ross: [00:08:19] Absolutely. So in the DSM five, right now, we have PTSD, but we don't have complex PTSD. And so those who work in the field of trauma are pretty familiar with the idea of complex PTSD. However, because that, especially in my identity, is actually what I see. And so the diagnosis of diagnosis of complex PTSD is actually in the ICD 11, which is that international classification of diseases 11th revision, and it really defines it as arising after exposure to an event or a series of events of an extreme, extremely threatening, horrific nature. And what they really underscore there is that it can be prolonged. It's often about repetitive events that were difficult to escape or impossible to escape. It can cover a whole bunch of stuff like childhood abuse, repeated childhood sexual, physical abuse, torture, slavery, genocide, domestic violence, and all of the core symptoms that we find in PTSD are under that umbrella of complex PTSD. But it adds a few other things in there that I think are really important. And one of the things that we really see a lot with complex PTSD is really difficult abilities to regulate affect.
Dr. Dana Ross: [00:09:28] So moods are up and down and all over the place, and that can be really disruptive for people in their sense of who they are and their sense of their ability to function and their day to day life. It also encompasses a lot around sort of beliefs about oneself. A lot of people hold this idea in complex trauma of I'm worthless or I don't have value, and so it really hits those kind of core components of self. Other things that it touches. And I think this is one of the most important things we see as well here, is that it leads to a lot of difficulties in relationships, not just the relationships with self, which we've touched on, but also relationships with others, boundary issues, issues around trust. People can get into repetitive patterns of behaviours and relationships that are really rooted in past trauma. And so that's a lot of the work that we do here. And there's a whole bunch of stuff around dissociation, forgetting cognitive impacts. And again that kind of identity disturbance piece I think is a big one.
Lucy Chen: [00:10:30] Yeah. And I suppose it's naturally kind of leads into us into a discussion about like the DSM five criteria for PTSD, which I think covers spans like five pages or like really if you we have it like next to us right now, like it's kind of daunting sometimes when we kind of look through the criteria to be able to then make sort of a confident diagnosis of PTSD. So maybe you can give us some tips on how to navigate that.
Dr. Dana Ross: [00:11:01] Yeah, absolutely. I think the four symptom clusters are really important to just have a handle on the number one thing being avoidance. So avoidance of anything that reminds you of the trauma, that brings up emotions, feelings, people, places are avoided. And it's sort of the bedrock of trauma in some ways because on one hand, we're very happy that people have that ability to avoid because it allows people to live, to survive, to get through their day to day and not be completely overwhelmed and not functioning because of the experiences of trauma in their life. At the same time, avoidance really helps PTSD stay stuck because if you're not sitting with those emotions or body sensations or experiences, there's no chance to process them and to move through and past them as well. And so the other categories are that re-experiencing of past traumatic events like flashbacks, that kind of a thing. That's an important category as well. And then the other categories are negative changes on cognition and mood, which is a lot of people will say, you know, I have a lot of trouble holding on to positive emotions. I'm really stuck in those negative emotions, or sometimes I'm hardly feel any emotions at all because they're so shoved down, because they're so painful and so overwhelming.
Dr. Dana Ross: [00:12:22] And then the hyperarousal symptoms are probably something we see a lot of as well, which is holding that kind of tension and stress, being really concerned about safety, all of those kind of things. And so one of the mnemonics we can use is traumatic to remember some of these things. So the T is for trauma, which is reminds you about that criterion. A The R is for re-experiencing, the A is for avoidance. The U is for Unable to Function, which is a criteria for all of our disorders. The M is for the one month criteria. So for PTSD we want to have those symptoms lasting for more than a month. A is for arousal, Two is for two specifiers; so there's Depersonalisation and Derealisation of specifiers. And I think we'll talk about that in various ways over this podcast. And then I is for illness, so it's not due to an illness, substance or general medical condition and C changes in cognition and mood.
Lucy Chen: [00:13:23] So just to summarise, so there seems to be so there's four symptom clusters that we can organise PTSD into in terms of symptomatology. So one of them is intrusion symptoms, the other is avoidance, the other one is negative mood and cognition. And the fourth one is arousal and reactivity. And it sounds like dissociation symptoms. They can emerge in PTSD, but we sort of indicate the existence of them through specifiers.
Dr. Dana Ross: [00:13:51] That's correct. And so that's a new one for DSM five. We didn't actually see that in DSM four. Tr And what they're talking about there is really there's a big prevalence of dissociation in people who've experienced trauma and dissociation in its most simple way of understanding it I think is about disconnection. So it's disconnection from your self, disconnection from others, disconnection from the world, and that can look like a lot of different things. But two of the really common ways that people dissociate are depersonalisation, which is that disconnection from yourself. And so when I'm talking to people about what that looks like and feels like, people will say, I actually feel sometimes like I'm floating above myself and just watching what's happening. Or they'll say, I feel like and actually I'm actually just a brain walking around. I don't even feel a sense of connection to my body or I don't feel anything below the neck or I feel just not real. That's something that's not to the point of being psychotic, but there's a sense of unreality to their being in. The world and then do you realisation is that disconnection from their surroundings, from the world? People describe that sometimes as it's like I'm watching a movie of my life but I'm not participating in it or people will say there's like a fog between me and the world or like a pane of glass. Everything is sort of happening. I can see it, but I'm not in that flow of life. There's no vitality in there for me.
Lucy Chen: [00:15:17] And so in PTSD, are all patients supposed to have like one of each symptom cluster. So what I have here is that it has to be one or more of those intrusion symptoms, one or more of those avoidant symptoms, and two or more of the negative mood and cognition symptoms and two or more of those arousal and reactivity symptoms.
Dr. Dana Ross: [00:15:43] Yeah, that sounds correct. And there's under those I think you'll go through the criteria in more detail. So there's it can look very different for different people because there are a number of symptoms that fall under the DSM five criteria. But I think those having something from those categories in the number that you said, I think that's fairly accurate to what we see.
Lucy Chen: [00:16:02] And just in terms of timing to I wonder about like the one month of of symptomatology compared to someone who would kind of maybe have some of these symptoms after a traumatic event only lasting, you know, a couple of days or a few weeks. And maybe this leads into this idea of a risk factors. But what makes someone predisposed to having these symptoms for longer and really turning in and manifesting us as this disorder?
Dr. Dana Ross: [00:16:30] Yeah. So we think about when we're less than a month, we think about acute stress disorder as a possible diagnosis, and then after a month, we're thinking more about that PTSD. So there are risk factors for developing PTSD and those are numerous, but there's different studies that show a little bit of slightly different things. But some of the things that come up are a female gender, the age of the trauma. So if people are younger age, they're more likely to go on to develop PTSD. Being separated, divorced, widowed, having previous trauma, of course, increases your risk of then developing PTSD as well. Having a lot of history of general childhood adversity, adversity, which we'll talk a little bit more again, having a personal or family psychiatric history, poor social supports. And I think there's probably a number of other things as well. But those are the things that kind of come to mind.
Lucy Chen: [00:17:25] We were sort of indicating that, you know, the five most common risk factors for the development of PTSD. So we talked about sort of childhood adverse events. I guess it's I guess like thinking about PTSD in the sense that it's so it's also it's so comorbid with multiple other DSM five sort of diagnoses. How to tease that out is sort of is MDD sort of a predisposition to PTSD? Does PTSD lead to more MDD? Are substances, I can imagine substances kind of perpetuating avoidance of certain traumatic events which can maybe lead to more PTSD. I suppose it's quite complex, but maybe if we can kind of maybe outline five particular common risk factors for the development of PTSD.
Dr. Dana Ross: [00:18:15] Sure. Do you want me to talk about comorbidity a little bit in there as well?
Lucy Chen: [00:18:18] Yeah, that'd be great.
Dr. Dana Ross: [00:18:20] Let me start there and then we'll we'll kind of see where we go. Yeah, I love talking about comorbidity, actually, because I think it's really the bedrock of psychiatry generally, and certainly it's the rule in PTSD rather than the exception. And so when we look at comorbidity comorbidity rates, we can see that in the National Comorbidity Survey. It suggests that 16% of people with PTSD have at least one existing psychiatric disorder, but actually 17% have two, and up to 50% have three or more comorbid psychiatric disorders when they have a diagnosis of PTSD. So again, when we're working with people who've experienced trauma, who have a diagnosis of PTSD, we really need to be thinking about what else might be complicating that picture, adding to either increasing the risk of developing PTSD or just being more morbid and making that more of a complex picture. So in terms of comorbidity, we know that substance abuse is really a high rate of comorbidity with PTSD up to like 60 to 80%, depending on what studies you're looking at. And that can be all kinds of different addictions, but substance abuse, alcohol, cocaine, whatever it is, we have to think about that as a way to modulate some of the symptoms of PTSD, some of the feelings, some of the body sensations and stuff like that as well. And so when we're asking about PTSD, we want to always be asking about substance abuse, depression as a huge one. Again, depending on the study, it can be up to 65% of people with PTSD who have comorbid depression and anxiety, social anxiety, panic disorder. Those are very common and I'd say clinically, a majority of people that I see who have trauma also have anxiety and depression both now and often throughout their lifetime. There's a whole bunch of other stuff too; brief psychosis, somatization disorder, eating disorders can be really aligned with that as well. Pain disorders, Dissociative disorders, of course, and personality disorders, including BPD, can be associated as well.
Lucy Chen: [00:20:30] You know, and it makes me think about these are all manifestations of how people end up coping with trauma like or maladaptive coping, rather. I can see how so many people there's such a diverse range of ways that people can end up sort of like maladaptive, trying to handle what they've experienced.
Dr. Dana Ross: [00:20:50] Absolutely. I often think about and I think there's a discussion in the field as well about even the title PTSD or post-traumatic stress disorder. Because when we see people and they've been through these horrific experiences in their life, the way that those symptoms are coming out and the behaviours that people have make complete and total sense given their history and their experiences and they make sense as a way to self protect, to cope, to be able to function. And so if we look at the disorder of PTSD through that lens, it really isn't in some ways a disorder. It's actually a very human, very understandable way of coping. But PTSD gives us a framework for understanding it. And of course, it can be very helpful to have a diagnosis, to do research and to lead treatment as well.
Lucy Chen: [00:21:36] Yeah, that sounds like it'd be so helpful for someone encountering someone with PTSD, kind of having a trauma-informed approach, but understanding where those avoidance symptoms are coming from that it's really it's for it's for survival, it's for self maintenance. It's being able to to sort of navigate what they're going through and maybe being able to understand that and kind of communicate with the patient could be a window into better being able to relate with these patients.
Dr. Dana Ross: [00:22:01] Absolutely. I think a lot about when I'm sitting with somebody and they're telling me what they're struggling with, thinking about what are the advantages and disadvantages of the behaviour, the thought process, the way that they're dealing with emotions because there's something protective in there, there's something that makes sense and I think it's our job together to try and figure that out. And when you're taking away that kind of judgement or and you're sitting in that again, trauma-informed kind of way, which means really holding the idea and the knowledge about the prevalence of trauma, knowing how common it is in patient populations and holding that in mind when you're doing interviews, when you're designing spaces, all of those kind of things. But if we can sit with people from that kind of a lens, this work just becomes even more interesting, even more collaborative. And I think this I can't even think of another way to look at it at this point in my career.
Lucy Chen: [00:22:52] I suppose that's kind of also leads us into this idea of like how people manifest trauma in their body and like what's really happening in neuro physiologically. And I guess this idea of like hypervigilance and I think about the HPA axis, but there clearly is some underlying neurophysiological sort of understanding of PTSD.
Dr. Dana Ross: [00:23:16] I think that's a great question because what we're learning more and more in the field of trauma is exactly how much of trauma is really held in the body and experienced in the body. And so that can look like a lot of different things for people. A lot of people are really dealing with tension throughout their body and with pain that gets either brought up or exacerbated by all of that tension, by all that stress that people hold, a lot of people hold a lot of the abuse that they've experienced in their body. And so a lot of people are very also disconnected, not having sensations or feeling any kind of connection with their body. Of course, it impacts people sexually as well. If you have a difficult relationship with your body, especially if you have a history of childhood abuse, I actually forgot what your question was now.
Lucy Chen: [00:24:04] The sort of the underlying neurophysiological underpinnings, underlying PTSD.
Dr. Dana Ross: [00:24:09] Yeah, absolutely. So I think there's a couple of things to think about are a few things that we can think about when we're thinking about neurobiology. So there's kind of four areas of the brain that I tend to think about. I think about the hippocampus, the amygdala, the prefrontal cortex, and I also think about the brain stem. So what we know is that when we're really feeling threatened, the body releases stress hormones, including things like cortisol, adrenaline, and those are really going through the body and having a profound impact. And so what we know from research is that something like cortisol can actually damage cells in a part of the brain called the hippocampus that's really responsible for laying down and integrating memories. And so often when people are really struggling with memories and. Trauma. There's actually a way for us to kind of understand why that might be. We also know from research that people on imaging have had a smaller hippocampus, and that can also contribute to difficulties with learning and memory, because that's a big centre for those two important functions. But what we do know is that the more we're learning about the brain, the more we're learning about neuroplasticity, that we can make changes in the brain through medications and through psychotherapy. And there's a lot of hope in the field of trauma because of that. We also think about the amygdala a lot and we talk about the amygdala in psychoeducation when we're working with patients as well.
Dr. Dana Ross: [00:25:30] So we think often about in a very simplified way about the amygdala as a fire alarm in the brain. And so when people are triggered or stressed that amygdala is firing fire and firing and really taking over the show, and what it does is it kind of shuts down our frontal lobes, which is where we're thinking, planning like kind of more rational, logical kind of stuff. And when people are triggered, they often report, you know, I can remember what my skills were. I barely remembered my name. Sometimes I don't even know where I am. And I'm just completely overwhelmed by this emotional, physical response to being triggered. And the amygdala, when it's kind of taking over in the brain, can be largely responsible for that as well. And so what we're thinking about when we're thinking about learning skills, all of those kind of things, learning strategies and techniques to work with patients, we're thinking about how can we calm and soothe that amygdala, get that frontal lobe back online or those frontal lobes back online, and help that person be able to access both their emotions and their rational thought at the same time. And the other big area that we think about is the what we call the survival responses, which is like fight or flight freeze collapse. Most people are pretty familiar with fight-flight, which is that urge to either lean in the anger or the fight, or sometimes to run away. And sometimes we'll have people just get up in the middle of a group and kind of leave because it's such a strong urge.
Dr. Dana Ross: [00:26:58] And the freeze response is sometimes not as familiar to people. So that's a really high energy state along with the fight-flight, where people are really experiencing those high stress hormones, but they're feeling actually frozen. Sometimes it's literally they can't move and they're frozen. But inside it's this high energy, frightening, overwhelming kind of environment. Or sometimes people are actually you wouldn't even know they were in a freeze response. But inside they're feeling that experience. And then the collapse is a low energy kind of state where everything kind of goes into that collapse or feigned death kind of state. And those are four ways of being four reactions for survival responses that we see a lot when we're working with trauma. And so having even just a basic understanding of that allows us to organise our skills and some of the emotion regulation techniques and body techniques we use with people with trauma. And we can really be thinking very specialised for each individual. Are we working with a fight, the flight, the freeze collapse? Is the amygdala really taking over? How much is this person holding this trauma in their body versus are they in a more of an intellectual place? And so all of these kind of things and understanding bring in the neurophysiology helps us personalise the treatment. I think for people.
Lucy Chen: [00:28:14] For sure.And for me just hearing this right now, it's helping me to kind of take me through the DSM five and really understand I give meaning to some of those symptom clusters, like the idea of the fight-flight freeze kind of maybe leading to some of those hyper arousal symptoms. The idea of sort of the amygdala sort of shutting off the frontal cortex, maybe leading to some of those cognitive symptoms or sort of the dissociation perhaps also as well.
Dr. Dana Ross: [00:28:39] I like that you brought in that cognitive piece because I actually think we don't talk enough in the field of trauma and working with PTSD about the impact of trauma on cognition. So when I'm actually seeing people for consultations, one of the most common things I'll hear is when I say and what I was. One of the main things that you're struggling with, people will say, I actually think I have Alzheimer's or I think I have dementia. It's such a profound impact on their cognition. So people will say, I can't remember words. My memory is just shot. I used to be able to read. I can't read anymore. I had a conversation with my friend on the phone yesterday and I didn't even remember what we talked about, all of those kind of things. So memory, recall, focus, attention is really negatively impacted as well. And you can imagine if you can't do all of those cognitive functioning skills, how difficult it is to go to work, have a job to do, any kind of activities, go to school, to just function at all in your day to day life. And so I think the profound impact that PTSD has, especially when it's also always, not always often associated with depression and anxiety and those co-morbid things like substance abuse and all of those other things we talked about. There are multifactorial reasons. Why people are really struggling with cognition when they've had experiences of trauma in their life.
Lucy Chen: [00:29:58] And do you see those symptoms reverse through trauma therapy?
Dr. Dana Ross: [00:30:02] Absolutely. And I think that is a really important message of hope for people. That's when that amygdala settled, when the body isn't going into that fight, flight freeze, collapse response automatically, when people are feeling more in control of their their body, their feelings, their emotions, that there's more room for that frontal lobe, again, to be present, more room to feel kind of in control, to have access to all the memory centres, to have access to thinking and planning and being focussed and all of those things. So I really see people progress through our program and absolutely see changes that are very positive in that arena of cognition.
Lucy Chen: [00:30:47] And this also it makes me sort of better understand why they're stages of trauma therapy and that the first stage really is about finding safety and then then kind of feeling safe enough to progress through through the rest. But maybe you can better sort of outline what the stages of trauma therapy really look like.
Dr. Dana Ross: [00:31:06] Absolutely. This is something we explain when we're working with patients. And it's also something that is really important for us to hold as clinicians and when we're doing education as well. So I'd say back in the day, going back in the 30 or 40 years ago when people were thinking about trauma, they often thought about we should jump into it, get into those memories, really tease all that apart in order to kind of have a cathartic experience and really discharge some of that emotion, some of that body sensation. But what they found in the field was that a lot of people, when that happened, they got worse, their symptoms got worse, they regressed. They were feeling much more triggered, actually weren't functioning as well. And so it was pretty obvious pretty quickly that that wasn't a great way to go. And so what happened in the field is this concept of three stages. And so the first stage, as you mentioned, is really about safety and stabilisation. And when people are doing that phase, which in my opinion is really the biggest piece of work that people do, is they're working on things around safety, around housing, around they're working on people if they're struggling with suicidal thoughts or self-harming behaviours, we're really working a lot around affect regulation in that stage. So we're doing a lot of skill-based work and really increasing people's toolboxes in terms of what they can do to self-manage as well. We're doing a lot of psychoeducation in that phase and we're doing a lot of alliance-building as well. A lot of people who are coming into therapy or treatments of any kind who have a history of trauma, have had negative experiences just interpersonally generally or in the health care system.
Dr. Dana Ross: [00:32:49] And so that's a period of time when we're really working on building trust, having people come in and feel safe in the environment, which is sometimes for some people, they've actually never had that experience of feeling safe in a space with another person in their entire life. So that's a really actually important and big piece of that work. And so the safety stabilisation is about building people's skill set and toolset and self-understanding, self-awareness. And what we see is people's symptoms really go down. People are starting to function a bit better and a lot of people actually don't have to go on to the other stages because they're functioning better, their life is looking better, their relationships are functioning better. And so we see a lot of people in our program who don't go on to the other stages. They're ready to go after stage one, which again, can be a varying amount of time for months to many years for people. It's a very big piece of work that that stage, stage two, we're looking at what we call remembrance and mourning, what we find with people who have histories of trauma, especially we work with people with complex trauma who have histories of child abuse is. That people have missed out on a lot of opportunities in their life because of their traumatic experiences and the symptoms that they've had. And so people do a lot of work around mourning and stage two, which is about opportunities lost, relationships lost. Who would I have been? Who could I have been if I didn't have this trauma in my life? And there's a lot of grief that has to be processed in that stage.
Dr. Dana Ross: [00:34:18] It's also can be about doing more memory work. And we're not ever digging for memories or looking for memories. We're working with whatever people come with. People can do profound pieces of work in trauma with very limited memories of the traumatic abuse itself. So we don't need to dig for those memories. But some people, when they finish stage one, really feel there's more work to do. There's some sticky pieces in there, and there's something for some people as well around having their story, their narrative witnessed by another human being, by having that validation and that empathy around that and by processing some of those details and some people need to do that work. And that can be very powerful, very important work for people as well. Stage three is about reintegration. So stage three people are starting to move out of trauma therapy. We're really focusing on your support system, getting back into life, redefining who you are. Sometimes when people start trauma therapy, they feel like they are their trauma and they've lost or never had a sense of self. So what we want to see over that course of trauma therapy is people really come in to a stronger sense of who they are, have a stronger foundation under their feet, be able to set boundaries and have healthy relationships and to go and pursue whatever it is that they want to pursue in their lives and be whoever they want to be.
Lucy Chen: [00:35:39] That's really interesting, this idea that most of the work or a foundational piece of the work is really stage one and that not everyone sort of progresses to stage two. And I find that sort of difficult sometimes when we were in this setting, when we're seeing patients in the emerge or sort of these one time encounters or these limited sort of the limited scope sometimes in which we're able to see patients. And I wonder how we can best help those patients or and figure out who who does progress to stage two and how we can better connect them to resources.
Dr. Dana Ross: [00:36:10] Absolutely. So one of the things I think we try to do here at U of T is really build more about trauma into the curriculum. And I think that's so important because I know when I did my training, I came and actually was at women's college during my residency and learned a lot of the stage one skills and the ideas and approaches and theories. And what I found was when I then went on call or was in the emergency department, I felt so much more equipped to work with people who are struggling from trauma, not just trauma, but just struggling in general, which is most people who come to the emerge. But I had models. I had tools that I could show and work with, with people who are coming in. And I felt like it was a much more effective approach for me as a resident because sometimes we're so busy, sometimes we can't give as much as we would like to give in terms of time. And so having tools and skills and handouts that you can give to people can be rewarding, I think not just for patients but for us in our work as well. Having said that, in terms of identity-identifying stage one and working with that, most people haven't had a lot of access to trauma work.
Dr. Dana Ross: [00:37:22] And I think there's a real lack of trauma treatment in the community. And we need to have more people who are trained in doing trauma work in stage two, trauma work in particular, and often people who have really complex histories of trauma and need longer term work, which is of course a problem in our system as we're working on access and and trying to hold all of those principles in mind. One of the biggest pieces that you can do, just based on what we talking about, is have that very basic understanding around the neurophysiology, which I often find when I explain to patients it can be actually transformative for people. A lot of people will say, I feel like I am just a black box of chaos inside. I'm a mess. Everything is. I'm clearly a terrible person. I can't control myself. All of these kind of self judgements that come up around that. When people start to have a real understanding, just the basics of neurophysiology, of trauma and stress, it can be a real shift in decreasing self-judgement and feeling validated and then understanding how and why we apply tools. Because some of, for example, a grounding tool might be to look around the room and name everything that's blue, and sometimes people will think, Well, that's a bit Mickey Mouse.
Dr. Dana Ross: [00:38:37] I'm kind of looking for a bit more than that. But when we have explained that background neurophysiology, we can say, Well, let's stop and think about that for a moment. If you're taking a moment stopping when you're feeling overwhelmed, looking around the room, you're actually moving your head, moving your eyeballs, you're searching out something that is blue. You have to think about what? Is that colour blue. And then you have to think of the name of the object. You have to say it out loud. There's multiple, multiple steps in that. And that is all about bringing the body back online, calming down from the bottom up, we would say, and top down using turning on that cortex and turning on those frontal lobes to be able to name things, to be able to see the colours, look around, interact. And so we really are using the full body to try and get people more regulated. And so I think when we know some of those really basic neurophysiology pieces, it's very helpful for us to then do some very basic grounding kind of skills with people, and that can be quite useful.
Lucy Chen: [00:39:34] Yeah. And I think about instances of, like, patients or even myself when I'm in a crisis sort of mode and I can't speak right. It's very hard to find language to represent how you feel or the state of mind that you feel. And it sounds like these are sort of strategies to reconnect with some of the language.
Dr. Dana Ross: [00:39:55] Yeah, a good point. So one of the big things that can happen with people with any kind of trauma is when you get overwhelmed by it or triggered by it, it takes you back into the past. It takes you out of the here and now. And so people are often in an internal state where they're not here, not present, not taking in the information. And so we are bringing people back into the present. Often people are in a nonverbal state or lost in emotions and feelings that don't have necessarily necessarily words and language that go with them. And so having some of these tools can be really helpful. So one, for example, tool I use a lot is I have people build just a little box at home by a box and put things in it like scented oils or photographs or letters or photos, pictures, that kind of a thing. So it's like a grounding box because when we're really overwhelmed, it's really hard for us to remember, to think about our skills, to remember the steps involved. But when we have kind of a grounding box, we can just grab it. We have it. We don't have to put a lot of thought into it. So it's good to have skills when you're really triggered that work and skills when you're less triggered and you might be able to do more cognitive kind of things.
Lucy Chen: [00:41:03] That's great. So we've covered a lot of ground in terms of describing stage one, which is safety and stabilization. Stage two, which is..
Dr. Dana Ross: [00:41:13] Remembrance and mourning.
Lucy Chen: [00:41:15] And processing a lot of the trauma that sort of residual work from after sort of finding for finding that sort of foundation and grounding and stage three, which is kind of reintegration back into society. So I'm curious now about sort of some of the pharmacological options in treatment of PTSD and then sort of, I suppose, like what's most evidence based.
Dr. Dana Ross: [00:41:39] Absolutely. So we don't have as much research as we would love to have in PTSD. And a lot of it, we have to really look at it like like everything. We have to look at the source of it. A lot of our research on PTSD is done in the military, in the States, and we're very happy and very grateful that that work is being done. But it doesn't always overlap and speak to the patient populations that we're working with. Having said that, there is a very strong research looking at first-line treatments that are pharmacological for PTSD. So what we want to start with and work with are first-line SSRI. So sertraline, fluoxetine and paroxetine are the recommended first-line agents and there's a first-line snris venlafaxine which is also first-line. And so those are really our go to medications when we're working with PTSD that have evidence behind them. There are other medications that we can use, but they're not as evidence-based as we would like. And so we're we might be using a second generation antipsychotic like quetiapine or risperidone. But again, the preliminary studies there are very entry-level. And I think if we're making decisions around what we're going to be doing pharmacologically, we want to really start with those first line four options.
Lucy Chen: [00:42:58] And we think about those options. Are we sort of targeting something specific? So I can see sort of for the anxiety, the depression sort of piece using the SSRIs or using the SNRI as well. But I think about is it also addressing the hyperarousal? I guess I'm trying to break it down by symptom clusters.
Dr. Dana Ross: [00:43:19] It's such an interesting idea to think about really, because as we already talked about, the coma, the rate of co-morbidity is so extensive that it's sort of hard for us to really be as precise as we would like to be. But if we're meeting with someone who has PTSD and by chance, you know, likely has some anxiety and depression, then it also is just very convenient that we have these SSRIs and that's an area to use as well. So I think what I see shift for people with PTSD who are using those first-line options is a decrease in the hyperarousal, which is a big, big component. And so sometimes. I can come with a bit of relaxation in the body as well and a little bit less focus on concern on safety and being aware of safety issues around you. So I would say it kind of takes down the stress level, the hypervigilance kind of stuff and also of course helps with the anxiety that goes with all of that and some of the low mood that goes with having experienced trauma. And that's just a high comorbid condition with that.
Lucy Chen: [00:44:23] And I suppose I'm wondering and I don't know if there's is there like in terms of antipsychotics and, you know, it's not first line, but treatment for dissociation or those two pieces.
Dr. Dana Ross: [00:44:38] We don't really have pharmacological treatment. That's good for dissociation. So that we're really targeting with with the psychotherapy component. In terms of the anxiety, we'll sometimes use benzo but very judiciously and we're really worried about again, we just talked about how high the comorbid rate of substance use disorders is. So we want to be holding that in mind. I find I will use a benzo maybe once or twice a week with somebody when they're experiencing a significant trigger, particularly at the more early stages of treatment. But that's not something that has a lot of evidence. And again, we want people, I think, not to be overly reliant on those because of the risk factors that go with them as well.
Lucy Chen: [00:45:21] Yeah, and I think that you kind of emphasize this, but yeah, the psychological treatments for really targeting specifically the dissociation with multiple aspects of PTSD. Is there sort of like categories of psychological approaches or ways to organise those psychological approaches to PTSD?
Dr. Dana Ross: [00:45:38] Absolutely. So we've got some evidence-based treatments that are in that arena. So we have things like prolonged exposure. We have EMDR, which is eye movement, desensitisation and reprocessing therapy if cognitive processing, therapy or CBT. There's also a lot of evidence around cognitive therapy or CBT and some evidence for narrative exposure therapy outside of those evidence-based interventions, which are all good and great to know. There's also some things like sensory motor psychotherapy, which really focuses on the body and how trauma is held in the body. I use a lot from DVT. A lot of the skills that you learn around there are just essential and basic, I think, for all of us to know. Psychodynamic psychotherapy really underscores and underlies, in my opinion, all of the therapeutic interventions. So that's also a good one to know. It's good to know a lot about or at least a little bit about the attachment theories because those are very prominent in a lot of the complex trauma as well, and art therapy, some of the creative therapies and there's a type of therapy called Seeking Safety in which looks at trauma and substance use specifically, and it's a group therapy and there's a manual for that. And so I've done that one before and I've found it to be really well thought out and effective.
Dr. Dana Ross: [00:46:56] When we're thinking about psychotherapy treatments, we really want to also be thinking about different cultures. We want to be knowledgeable and respectful of different cultures. We really want to be thinking about the cultural meaning of symptoms of illness, cultural values of the patient, the patient's family, and trying to hold in mind what is the cultural context in which the treatment occurs? How might that affect the treatment course, the development and expression of symptoms? And we also really want to be holding that. We know that there are higher rates of trauma in certain communities like the LGBTQ+ community with an indigenous communities, refugee populations and of course in other cultural, racial, minority communities. So we really want to be holding that lens and all of our treatment and interaction and psychiatry, but of course with PTSD and trauma as well. So I think those are the main ones we certainly in our program use. I would say we don't do a formal prolonged exposure, but that is built into much of what we do. A lot of us are trained in EMDR, CBT. We do a CBT. I do a cognitive therapy group here that I that I love. I think it's a great group and we do a lot of relational kind of work and body work as well.
Lucy Chen: [00:48:05] Maybe if you could take us through the perspective of a patient going through this program and what it would look like for them in terms of their schedule or kind of the progression through the program.
Dr. Dana Ross: [00:48:15] So in our program we're really working on, we just redeveloped it and we're really holding in mind access and equity in those kind of principles. And so what we have people go through now is kind of two pathways into the program. One is into our day treatment program, which is called Wrap or Women Recovering from Abuse Program, which is about eight weeks, Monday to Thursday, 9 to 1. And there are really working in all of those modalities during that intensive period. The other pathway is through our groups and that are more individual groups. So once a week, like an hour and 45 minutes, so people will come through the program, they'll do our foundational trauma group, which is eight weeks and we're really focusing on skills, on psychoeducation, on understanding models and theories of trauma, and we're really focussed on the here and now. So we're not talking about details of trauma at all in those groups. And that again, is that foundational. As people move through that, they can then stream into either focusing on healing through the arts, through the body, through the mind or through relationships. And so there's some choice to personalize and their pathway there. And then as they move on and through the program, eventually they can get to individual stage two therapy and or stage two groups as well. And when you're in stage two, you can talk a little bit more about the details of trauma. So people really need to be ready for that stage of work because like all therapy and like all trauma therapy, but particularly in stage two, it can be really harmful if people aren't quite ready to be in that stage. And that's why stage one is so important.
Lucy Chen: [00:49:49] It sounds like a lot of stage two is exposure.
Dr. Dana Ross: [00:49:53] I think so. I think in some ways I think everything we do in psychotherapy is a form of exposure, right? When I'm thinking about working with trauma patients and groups and individually, I'm thinking about sitting with emotions that you're not comfortable sitting with. And how can we start to do that in bite-sized exposures that aren't overwhelming and that aren't going to make things worse? Right. But a lot of times people will come say they're really in a state of anger. I'm really thinking automatically, well, where is their sadness? Where's their grief? Or if someone's coming in a really collapsed state of depression, I want to know where their anger is. And so what we're doing through that is really sitting with and teasing apart people's ability to sit with their physical body, with their emotions, with their thoughts and with their sense of self, and through any of those kind of pathways of treatment or any of those modalities, I think we're very slowly exposing people to those things that they've been avoiding. And again, avoidance being one of those core components of trauma and PTSD. But we have to be thoughtful. We have to personalizing that to the person in front of us. But I think exposure therapy really underlies everything in some ways.
Lucy Chen: [00:51:01] Yeah. Well, thank you so much, Doctor Ross. I mean, I'm wondering if you have any sort of lasting sort or sort of anything, any tips or any ways that you suggest that we could be better, I guess, like health care providers in general in managing and treating patients who present with trauma.
Dr. Dana Ross: [00:51:23] So I think there are more and more training opportunities, both online and workshops. There's a lot more that's getting built into curriculums and medical school and in residencies as well, which is fabulous. There's usually a local resources where you can get more education or they might have good handouts and that kind of thing online a lot. There are so many organisations that have so many good infographics and stuff like that. Then when I go online and I just kind of pull them and we find them really helpful here as well. So basic grounding skills I think should be in the foundation of everybody's toolkit as a clinician, as a care provider, even if you're not doing therapy directly. And that would be around knowing kind of breathing skills, deep breathing, some basics around how to bring people back into the here and now if they're in either hyper that hypo arousal state. And then DVT is a good one. If you have that opportunity, mindfulness can be really helpful. Understanding some of those basic concepts like transference, counter-transference, reenactments, all of those kinds of things. We've talked about a little bit about the neurobiology of trauma. So again, I think that's a bedrock of the approach there as well. And then there's a lot out there about this concept of trauma-informed care, which is really care that is really rooted in principles around things like safety and trust, choice, collaboration, empowerment, having a respect for diversity and for our common humanity.
Dr. Dana Ross: [00:52:54] And I think those principles are things we're trying to really think about all the way through. From the moment we have contact with somebody through the moment, they walk through the door while they're in the program, while they're in the room with us, and while they're exiting the program as well. And so those are principles that we're always working on. We never reach a pinnacle of trauma informed care. We're always learning and seeing where our blind spots are and kind of moving forward. I think the best advice that I got in terms of how to learn more or when people are feeling really intimidated by working with trauma or asking about trauma, is from one of my mentors who said, you know, when in doubt, just be a human being. And in that moment we can just sit with people and just name what's in the room. So that was overwhelming. I can see that emotions coming up for you. Wow. That's an incredible amount of things that you've been through, all of those kind of things. And so a lot of just basic principles of being a human being, basic principles of psychotherapy. It can take us a long way.
Lucy Chen: [00:53:52] Thank you so much. Any sort of access to every sort of interview, but any lasting or sort of suggestions for young learners in navigating sort of their potential sort of interest in psychiatry or trauma therapy or PTSD or anything related to the field?
Dr. Dana Ross: [00:54:10] Sure. First of all, I'm just going to put a plug in for coming into trauma, coming into the PTSD field. I think if you're interested in the mind and the body and taking a real holistic lens to people, this is just a phenomenally interesting area to specialise in. And if you look at that, again, rates of comorbidity, you're going to be seeing everything, you're working with everything. So you're both a specialist and a generalist at the same time, which is very exciting. Everything is every patient is unique and diverse as they are in any area but in trauma and PTSD. With all of this comorbidity as well, you're really getting a lot of combinations of symptoms of people struggling with different things. And so I also find that in trauma, we have a lot of really effective treatments, a lot of really effective interventions and skills. And so it's also a very rewarding area to work on, to see people move through, get better and really be functioning in a way that they maybe didn't even think that they could. And so it's a very gratifying area to work in. And the people that we work with, the patients we work with, are just incredible human beings as well. I think if you're interested, there's definitely a lot of books that you can read and I can provide some a list of that. Maybe you can go on the website.
Lucy Chen: [00:55:22] On the show notes. That'd be great.
Dr. Dana Ross: [00:55:23] Great. And I'll provide a link to an article on how trauma impacts the brain that I wrote as well. That kind of summarises some of that neurobiology. But certainly, you know, reaching out and finding out what the opportunities are coming to workshops. There's two conferences I tend to be interested in and go to. One is called the through an organisation called the ISSTD or the International Society for the Study of Trauma and Dissociation. And the other one is ISTSS and it's sort of similar, but I'm not going to try and spell it right now. So those are two great opportunities to really network and to learn and get in on the ground floor as well.
Lucy Chen: [00:56:06] Thank you. Such a rich sort of episode to really understand the foundations of trauma and diagnosis and treatment. Thank you so much.
Dr. Dana Ross: [00:56:14] Thank you for having me.
Lucy Chen: [00:56:15] Thanks. Take care.
Jordan Bawks: [00:56:18] Psyched is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organisation. This episode was produced and hosted by Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by Olive Music. A special thanks to Dr. Dana Ross for serving as our expert this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you so much for listening. Catch you next time!