Dr. David Van Nuys: Welcome to Wise Council, a podcast interview series sponsored by CenterSite, LLC covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
Dr. Van Nuys: On today's show, we'll be talking about treating post-traumatic stress disorder and other forms of anxiety with my guest, Dr. Edna B. Foa. Edna B. Foa, Ph.D., is a professor of clinical psychology and psychiatry at the University of Pennsylvania, and director of the Center for the Treatment and Study of Anxiety. She received her Ph.D. in clinical psychology and personality from the University of Missouri, Columbia in 1970.
Dr. Foa devoted her academic career to the study of the psychopathology and treatment of anxiety disorders, primarily obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia, and is currently one of the world's leading experts in these areas.
Dr. Foa was chair of the DSM-IV subcommittee for obsessive-compulsive disorder and co-chair of the DSM-IV subcommittee for post-traumatic stress syndrome. She's also been the chair for the treatment guidelines taskforce of the International Society for Traumatic Stress Disorders.
She's published several books and over 300 articles and book chapters, and has lectured extensively around the world. Her work has been recognized with numerous awards and honors.
By the way, the sound quality improves after the first three minutes or so. Dr. Foa was initially using a speakerphone, and once I figured that out and got her to switch to a regular handset, the quality got much better. So, please hang in there for the first few minutes. Now here's the interview.
Dr. Edna Foa, welcome to Wise Council.
Dr. Edna Foa: Thank you.
Dr. Van Nuys: Great to have you here. You're one of the world's top experts on the treatment of trauma. How did you get into this area?
Dr. Foa: Well, it was in 1980, when I went for a sabbatical to work with Dr. Blackman from the Institute of Psychiatry in London. At this point, both he and I were interested in understanding how people process negative information, and especially traumatic information.
And we discussed what kind of research can be done to answer this theoretical question. What are the mechanisms by which people who are going through a traumatic experience, or it doesn't have to be traumatic, but emotionally negative experience, how do they recover from this experience?
And as we discussed what kind of population should I do the research on, we thought that rape victims would be the best population, partially or mainly because at that time, nobody reimbursed them. So, if you take a population of people who were traumatized by traffic accidents, you would, you know, they would be in the middle of litigation, and maybe you won't get accurate information from them.
So, that's how I started. I started with theoretical interest on mechanisms for recovery.
Dr. Van Nuys: OK.
Dr. Foa: At that time, in 1980, it was the year that post-traumatic stress disorder entered the DSM-III, so this was the first time the diagnosis of PTSD was part of the official APA manual for mental disorders.
Dr. Van Nuys: OK. I have to ask, are you on speakerphone?
Dr. Foa: Let me see. Yeah.
Dr. Van Nuys: OK, so we've made a little bit of adjustment here in our telephonic arrangement, and I think the sound is going to be better.
I have the impression that you're originally from Israel. Is that true?
Dr. Foa: That's true.
Dr. Van Nuys: So, I was just wondering if that didn't play in there somewhere into your interests in trauma.
Dr. Foa: Well, you know, if it did, it was unconscious.
Dr. Van Nuys: OK.
Dr. Van Nuys: Well, as a psychologist, you're allowed to speculate on that possibility.
Dr. Foa: Right.
Dr. Van Nuys: So, maybe we should start off by defining trauma. Exactly how is trauma defined?
Dr. Foa: Well, trauma, the definition of trauma has changed since 1980 when it was introduced into the DSM-III. The original definition was an event that is outside the normal range of human experience. And that's kind of a normative definition.
It turned out, over the years, as we did more and more studies on post-traumatic stress disorder, we found that in the United States in 1995, 60 percent of men and 51 percent of women had gone through a traumatic experience. And so, it clearly, at least once in their life, so clearly a traumatic experience is not outside of normal range of human experience.
So, that kind of motivated us, and I was co-chair of the PTSD workgroup for the DSM-IV, and it motivated us, the group that worked on the definition of PTSD, including the definition of trauma, to change the definition. The definition now says that the person has to have gone through experiencing or witnessing or learned about an event that either involved injury or death, or threat of injury or death, and that during the event, the person felt terrified, horrified, or helpless. Yes.
Dr. Van Nuys: OK. Interesting that heard about, that it's not just experienced or witnessed, but also learned about.
Dr. Foa: Yes. And the learned about really was not intended to include, you know, you read the newspaper and you hear about 9/11.
Dr. Van Nuys: Right.
Dr. Foa: And then, by reading about it, you get traumatized, or even by watching the news.
Dr. Van Nuys: Do you say that would be included or would not?
Dr. Foa: No, that was not the intent.
Dr. Van Nuys: OK.
Dr. Foa: The intent was that, let's say for example, a woman is mother of several children, is at home, and she gets a phone call from the police, and they say, "Is this Mrs. Smith?" and she says, "Yes." "Well, we just wanted to let you know that your son has been killed in a gang fight."
Dr. Van Nuys: Oh, OK. Yes.
Dr. Foa: And then, she didn't see, she didn't witness, it didn't happen to her, but this knowledge was a traumatic event for her.
Dr. Van Nuys: Yes. Yes, I can certainly see that.
Dr. Foa: Right. And we had cases like this.
Dr. Van Nuys: Yes.
Dr. Foa: I mean, this example was a real patient of ours.
Dr. Van Nuys: OK. Yes.
Dr. Foa: Right. There are some problems with its definition.
Dr. Van Nuys: Such as?
Dr. Foa: Well, there are traumatic events such as child sexual abuse, where there's no injury or threat of injury, or threat of death. In fact, you know, the opposite, if it's an incest, and the perpetrator is the child's father, let's say, what would happen often is that the father said, "You are my favorite little child, and I do it because I love you so much, but don't tell anybody because it's a secret between us."
Dr. Van Nuys: Yes.
Dr. Foa: And then, you know, would this be considered a traumatic event? And it isn't for save yes. And I'd say, for an event that imposes loss of bodily integrity, and then in the text, it gives a lot of examples of sexual abuse, child sexual abuse, so it's clear that child sexual abuse, no matter how much threat there is involved in it, it's going to be defined as a traumatic event by itself.
Dr. Van Nuys: Yes.
Dr. Foa: The other problem that we find now more with combat veterans is that often they say that they were not terrified or horrified and helpless during the trauma, which is during the combat, but as they thought about it afterwards, that's when they became horrified and terrified.
Dr. Van Nuys: That makes a lot of sense to me. I can understand that.
Dr. Foa: And so, I think, we need to take this into account, because if we just go by the very narrow definition, then combat often would not be a traumatic event, and well, it clearly is. Not every combat, not any war experience is a traumatic event, but many times it is.
Dr. Van Nuys: Yes, yes. And I think men are sort of trained to suppress their emotions, suppress their fear. In a situation like that, I could well imagine that they have so effectively suppressed that emotional response that it might not crop up until later.
Dr. Foa: And not actually just suppressing, not only men, but also women, if you are extremely busy defending yourself and others, you're just not free to feel, you know, your mind is very occupied with taking care of yourself.
Dr. Van Nuys: Yes, excellent point.
Dr. Foa: And you're just not afraid, in fact.
Dr. Van Nuys: Yes, yes.
Dr. Foa: There are other emotions that take precedent in a situation like this.
Dr. Van Nuys: Well, it is called Post traumatic stress syndrome, so what are the symptoms that crop up later? How might a person recognize that they're suffering from PTSD?
Dr. Foa: The official symptoms that define PTSD are 17.
Dr. Van Nuys: Wow, that's a lot.
Dr. Foa: You don't have to have all of them in order to meet criteria for PTSD. So, the 17 symptoms are divided into three clusters. The first cluster is called reexperiencing. It includes intrusive thoughts about the traumatic event, nightmares about the traumatic event, flashbacks, psychological distress upon reminder of the trauma, and physiological distress upon reminder of the trauma. And in order to meet criteria for PTSD, you need to have only one of those.
Dr. Van Nuys: Interesting.
Dr. Foa: And the second cluster is avoidance and numbing, and it includes effort to avoid thinking about the traumatic event, effort to avoid going to situations, confronting situations that are reminders of the traumatic event, then we have psychological amnesia, and then loss of interest in things that you used to be interested in, which is kind of also a depressive symptom. And then, restricted range of affect, inability to relate to people, feeling alienated from people, and forshortened sense of future.
Dr. Van Nuys: OK.
Dr. Foa: And those really are kind of divided into what I would say phobic avoidance, which are the first two, because even if you are dog-phobic or elevator-phobic, you would try not to go in an elevator, and you're not going to make your appointments on the 30th floor. And also, you try not to think about elevators because it's distressing.
Dr. Van Nuys: Yes.
Dr. Foa: The remaining symptoms are more like the numbing symptoms, emotional numbing, where people are not feeling as much as they used to feel, so that in situations that call for emotions in normal people, they would feel numb and not emotional.
And a restricted range of affect is more like the positive affect is restricted, because people with PTSD have a lot of anger, many times. Certainly, they have anxiety, so they have negative emotions. What is restricted really are the positive emotions, they are like love, affection.
Dr. Van Nuys: Yes.
Dr. Foa: Where they don't feel as much affection, especially to people they used to like the family members, being kind of remote from them, that's part of the numbing.
Dr. Van Nuys: Right, right. Given the new imaging technologies, what do we know about the impact of trauma on the brain?
Dr. Foa: Well, you know, we don't know that much, and what we know is kind of one study finds it's true, one study finds that it's not true. So, I don't think that we have a reliable body of knowledge about the biology of PTSD.
In some studies, for example, the stress hormones, like cortisone, are suppressed. And in some studies, there is too much cortisone. In other studies, the level of cortisone is normal. So, that's kind of an example of how much we don't know about the biology.
Dr. Van Nuys: Yes. Yes, interesting. Interesting, because it seems to me I've heard assertions made, you know, about changes in the brain, but it sounds like they're maybe not as conclusive as was represented.
Dr. Foa: Right. Yeah. So, we are still searching. Clearly there will be some biological and brain changes.
Dr. Van Nuys: Yes. So, what's your approach to the treatment of trauma, then?
Dr. Foa: Well, you know, irrespective if we're talking about biological changes in the brain or not, the treatment that works the best now are the psychological treatments, and less so, the medication, although for some people, medications such as SSRIs, the antidepressant medications, do help, but not as much, and not as consistently as psychological treatment - and mainly, the treatments that include exposure to trauma reminders.
The Institute of Medicine was asked to come up with a literature review with recommendation, what works and what doesn't work. Last March, they came up with the recommendation and the conclusion, and what they say is that there is clear evidence that exposure therapy works for PTSD. And that's the only treatment that they found conclusive evidence for.
Dr. Van Nuys: Now, when you say exposure, would that, then, be exposure in fantasy and imagination of going back and reliving the experience?
Dr. Foa: There are two kinds of exposure. There is what we call medullar exposure, or what I call revisiting the traumatic event, and those are done, of course, in the imagination.
And what you are asking the patient to do is to close their eyes, most people can, if they can't close their eyes, they can stay with their eyes open, and recount the traumatic event repeatedly, with as many details as possible, including details on what happened, details of what they were thinking during the event, what they were feeling during the event, what sensations they had during the event, so kind of the complete memory of the event, not just the details of what happened.
And when you ask them to do it, and when they do it repeatedly, several things happen, actually. The story became a more complete story, rather than fragmented story. And secondly, they learned to distinguish between remembering and going back to the trauma, because people with PTSD, when they think about the trauma, it feels to them as if they are in the trauma again.
And that's why they are so anxious, and that's why they try to avoid thinking about the trauma, because it's really not dangerous to think about something happened to you 10 years ago, or even one year ago. They only feel anxious because it feels to them as if they are there.
Dr. Van Nuys: Yes.
Dr. Foa: And when you repeat your story, your traumatic story again and again and again, you kind of gain perspective of distinguishing between remembering, which happens in the present, and the trauma which happened in the past.
Dr. Van Nuys: Are you just having them recount the incident, or is it paired with relaxation?
Dr. Foa: No, it's not paired with relaxation at all. In fact, only on very, very rare occasions we pair it with techniques to induce anxiety. But, in fact, we want them to be able to tell the story without relaxation, because what we want them to learn is that they can tolerate the distress that is associated with getting engaged, emotionally and cognitively, with the traumatic experience, and that nothing bad happens to them. They don't fall apart, they don't go crazy, they don't die, they don't faint. In fact, they find out that they can tolerate it, and over time, not only they can tolerate it, over time the anxiety decreases. As they go through those repetitions again and again, they also get used to the story.
And it is like if you saw a very scary movie. The first time, you're going to be very scared, obviously, scary movie. If you saw it 15 times, it is unlikely you're going to be anxious or scared anymore.
Dr. Van Nuys: Yeah. So, it sounds like the main thing is that you're confronting the avoidance and encouraging them to not avoid, but to revisit it over and over again in imagination.
Dr. Foa: That's right. And that gives them a sense of control over the traumatic memory. With PTSD patients, they feel the traumatic memory controls them. It tells them where to go and where not to go, it forces them to avoid a situation that they used to enjoy, so it dictates a lot of their life. And through the imaginary exposure, or revisiting the trauma and recounting it, they kind of gain control over the traumatic event, and they're being able to put it in long-term memory, and it becomes like any other memory. It will never be a very fun memory, it will always be a sad memory, but it's not going to be a memory that will create so much anxiety that it disturbs their ability to function.
And then, we also have another type of exposure, and that we call it in vivo exposure, which is a French name to say exposure in reality.
Dr. Van Nuys: Yes.
Dr. Foa: And what we do there is that we, together with the patient, create a list of situations or objects that the patients are avoiding either because the situation is similar enough in their mind to the original traumatic event that they are afraid that they are going to be injured again, or going to be traumatized again. So, they feel that those situations are not safe, and they avoid them because they want to protect themselves.
Or the situation reminds them of the traumatic event, and they don't want to remember the traumatic event because it's painful. So, they avoid confronting those situations, even though they know that the situations per se are not dangerous, like watching TV and being afraid that there will be stories about Iraq, and that will remind them of the traumatic event that they experienced while being in Iraq. And they don't want to remember it, although they know that the TV per se is not dangerous, and listening to those news are not dangerous per se, but they try to avoid the distress associated.
Dr. Van Nuys: Yes. You know, in line with the in vivo approach that you're talking about, I previously interviewed a Dr. Skip Rizzo at the University of Southern California. You might be familiar with his work, where he's trying to use virtual reality to put veterans in very realistic-feeling combat situations.
Dr. Foa: Right. And Barbara Rothbaum as well.
Dr. Van Nuys: OK. So, has your approach been implemented in any of the world's hotspots, you know, there're wars, floods, hurricanes, earthquakes.
Dr. Foa: Yes. I mean, prolonged exposure, it's the treatment that I was talking about; it's called prolonged exposure therapy.
Dr. Van Nuys: OK.
Dr. Foa: And it's usually treatment that lasts anywhere between eight and 15 sessions, so it's a very short treatment.
And it was studied around the world in many groups, Australia, England, Denmark, Sweden, and of course, here in the United States by several groups, including the treatment that we developed here with many grants from the National Institute of Mental Health. And so, it is the treatment that probably has the most evidence, not probably, it has the most evidence, empirical evidence, for its efficacy, and it's very effective.
Now, the treatment you were mentioning, virtual reality, is creating a virtual reality about, let's say situations of combat in Iraq, combat in Vietnam. And it is used as adjunct to prolonged exposure. So, we actually don't have very good evidence how it works on its own, and I think that the claim is that it may help people who have difficulty imagining the traumatic event, or difficulty in engaging emotionally with the memory of the traumatic event, because we do know that it's very, very important for the efficacy of prolonged exposure that the patient will be engaged emotionally when he's telling the story, not telling it as if it happened to somebody else or telling it as, you know, kind of telling a story to the police.
Dr. Van Nuys: Yes. It seems to me that there are sort of two intervention points. When PTSD crops up somewhere down the line, that's one situation. Another situation is, let's say you're in a hotspot, let's say, I live in Northern California, they tell us there's going to be an earthquake. I may find that I'm surrounded by traumatized people, if I'm not traumatized myself. What's the best thing that I can do immediately in a situation where somebody has just suffered a fresh trauma?
Dr. Foa: Right. When somebody was just traumatized, likelihood is that the person will have some of the symptoms that we talked about. By the way, I did not talk about the third cluster of symptoms that are called arousal symptoms. And there are five of those, and they include inability to concentrate, irritability, exaggerated startle response, general anxiety, difficulty sleeping, difficulty concentrating.
Dr. Van Nuys: What was the name of that third cluster?
Dr. Foa: Arousal.
Dr. Van Nuys: Arousal.
Dr. Foa: Yeah.
Dr. Van Nuys: OK.
Dr. Foa: So, people, after a traumatic event, especially severe traumatic event, because you know, you have milder or more severe traumatic events. After a rape, for example, we've found that 90 percent of the rape victims met symptom criteria for PTSD.
So, many people have symptoms of PTSD, it's quite normal to have those symptoms shortly after the traumatic event. And most people recover. In rape victims, the recovery rate is about 85 percent in the long run. Recovery means that the person goes back to function; they may have some symptoms, but they are not distressing enough and not causing them to be dysfunctional.
Dr. Van Nuys: So, you're talking about spontaneous recovery?
Dr. Foa: That's right.
Dr. Van Nuys: OK.
Dr. Foa: That's spontaneous recovery.
So, chronic PTSD is not normal. It's a psychopathology. That's why it's in the DSM. It's not a normal reaction to traumatic events. Most people are resilient, most people recover. Most of the recovery occurs within the first three months, and some recovery occurs within the first year. And from epidemiological studies we know that if the recovery does not occur within the first year after the traumatic event, it will become chronic.
So, the question is, when do you give treatment, and what treatment do you give?
Dr. Van Nuys: Yes.
Dr. Foa: So, when somebody comes to you within a week of the traumatic event, you want to give information about the symptoms so that they normalize them, and just put those symptoms within the perspective that most probably, they will decrease and the person will recover. So, not to be afraid of those symptoms, and not to be disturbed by them, they are normal, and they will go away.
And you tell the person, "Well, if in three or four weeks you don't see any improvement, come back. And in the meantime, get as much support from your natural environment, from, you know, the people that are around you, from your family, your friends."
The rate of recovery is very much up to the individual, and some people want to tell the story to everybody, and some people just don't want to tell the story, and that's OK within the first two weeks. After that, you want to encourage people not to avoid talking about the traumatic events, not to avoid thinking about them, because we do know that avoidance is one of the major factors that influence recovery or that impedes recovery, rather.
Dr. Van Nuys: Yes. I recently saw an interview with Condoleezza Rice on "Good Morning America," and she was discussing her efforts to have rape recognized as a weapon of war, and they talked a bit about your work with rape victims. Do you see, is the trauma that results from rape different from other forms of trauma, or is it all pretty much the same?
Dr. Foa: The symptoms are pretty much the same, except that the number of rape victims who have experienced PTSD sometime in their life is higher than any other trauma.
Dr. Van Nuys: Interesting.
Dr. Foa: So, the probability of developing PTSD, and especially chronic PTSD, changes from one trauma to another, but it also depends on the severity of the trauma, and many times the severity of rape is more than the severity of, let's say, traffic accidents in the perception of loss. Loss of dignity is greater in rape than in many other traumatic events.
Dr. Van Nuys: Yes.
Dr. Foa: So, if you look at statistics, you'll see that rape has the highest incident of PTSD, and that doesn't necessarily mean chronic PTSD, but PTSD at any time since the traumatic event. And after that, it's combat, and then next are disasters, which generate the least incident of PTSD.
Dr. Van Nuys: Well, that's very interesting. Now, you run a center on anxiety. Do you see PTSD as being part of a continuum with other forms of anxiety?
Dr. Foa: Well, PTSD, at this point PTSD is one of the seven anxiety disorders. So, it's not a continuum of anxiety, but as it is in the DSM-IV, we have several anxiety disorders. We have social anxiety disorder, we have obsessive-compulsive disorder, we have panic disorder, specific phobias, post-traumatic stress disorder, PTSD, and so we have various, various types of anxiety disorders. It may not be the case in the DSM-V; I don't know where it's going to go.
Dr. Van Nuys: OK. Will you be working on that committee as well?
Dr. Foa: No. Most of us that worked on the DSM-IV either were not asked or did not want to work on the DSM.
Dr. Foa: It's a new generation, and I think that it's really important to bring new blood into the process.
Dr. Van Nuys: Yes.
Dr. Foa: Especially if the idea is to kind of review the whole idea that is behind the DSM-IV, or even the DSM-III, DSM-IV.
Dr Van Nuys: Yes.
Dr. Foa: And so, most people are really new into the process.
And secondly, I could tell you that five years of my life, I was both the chair of the PTSD and of the OCD, the obsessive-compulsive disorder, and five years of my life was devoted, I think about one day a week to the DSM-IV.
Dr. Van Nuys: Oh, boy!
Dr. Foa: So, I think, it's good to do it once.
Dr. Van Nuys: It sounds like it might have been a traumatizing experience in itself.
Dr. Foa: No, it wasn't traumatizing. Well, interesting, and I think very important, but it's good for the younger generation to do it now.
Dr. Van Nuys: Yeah. Well, as we sort of begin to wind down here, I wonder if you have any recommendations for any listeners who think that they might be suffering from PTSD.
Dr. Foa: So, you kind of started to say, "When do you do the treatment?" and I say you don't really have to wait three months, after which PTSD becomes chronic. You can offer treatment to people, I would say two, three weeks after the traumatic event occurred, because at this point you already know who are the people with severe symptoms.
And those who have severe symptoms shortly after the trauma are likely to develop chronic PTSD - not, you know, saying likely, not everybody will. So, at the point of two or three weeks after the trauma, I think we offer treatment that is shorter, it's about five sessions of prolonged exposure. And that's sufficient usually.
But from three months and on, I think it justified to offer treatment, you know, prolonged exposure treatment or any treatment that includes some exposure component to it.
Dr. Van Nuys: OK. Is there anything else you'd like to say about either PTSD or the treatment of anxiety that you haven't had a chance to get out here?
Dr. Foa: Well, I just want to say that the treatment of anxiety disorders is pretty much similar across the anxiety disorders. Across the anxiety disorders we find that exposure therapy is very efficient and effective.
And with each of the disorders, like with PTSD, we pay a lot of attention to the imaginary exposure to give processing of the traumatic event, which is not necessary, for example, to do with a simple phobic, with people who are afraid of elevators. There, in vivo exposure is, most of the time, sufficient to reduce the symptoms of fear of elevators, of fear of dogs, or fear of cockroaches, or fear of blood.
So, there will be slight differences in the treatment of anxiety disorders, but you mostly, if you know how to do exposure therapy, you would know how to work with a variety of anxiety disorders, including PTSD.
Dr. Van Nuys: OK. Well, Dr. Edna Foa, thanks so much for being my guest today on Wise Council.
Dr. Foa: Thank you for inviting me. I enjoyed it.
Dr. Van Nuys: I hope you enjoyed this interview with Dr. Edna B. Foa at the University of Pennsylvania. I was discussing our interview with a friend, and she raised the counterexample of a friend of hers who talks about her trauma endlessly to everyone for years.
So, I fired off an email to Dr. Foa asking, "How does this fit with the idea that a repeated retelling of the traumatic event will eventually dissipate its energy and hold on the person? My friend's friend seems not to have gotten over it or let go of it despite years of retelling. Can you clarify this?" I asked Dr. Foa in my email to her.
And she replied, "Dear David, I enjoyed being interviewed by you very much. Indeed, there are people who are obsessed about their trauma endlessly by using repeated sentences such as, 'Why did it happen to me?' 'If only I did not go there,' et cetera, or they're focusing on certain details during the trauma. Such obsessing and ruminating prevents processing of the trauma."
"In contrast, we ask the patients to deliberately invite the entire memory, recount the traumatic event from the beginning to the end with details about what happened, what they were thinking, and what they were feeling several times during the sessions. Then, we discuss with them their perspective on the trauma, what they learned from recounting the trauma, and so on. We also tape their narrative and ask them to listen to their narrative at home every day. This method helps them digest the memory and organize it, as opposed to ruminating about a limited aspect of it. I hope this helps. Edna."
So, I thank her very much for that clarification, and I thought I would share it with you.
I noticed that Dr. Foa offers workshops on the treatment of PTSD. If you're interested in finding out more about these and/or more about her work, you can go to the Center for the Treatment and Study of Anxiety website at www.med.upenn.edu/ctsa.
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