An Interview with Edna Foa, Ph.D. on the Nature and Treatment of Post-traumatic Stress Disorder (PTSD)
In this episode of the Wise Counsel Podcast, Dr. Van Nuys speaks with Psychologist Edna Foa, Ph.D. a world-famous (in academic clinical psychology circles) Anxiety researcher on the topic of treating Post-traumatic Stress Disorder, better known as PTSD.
Dr. Foa's involvement with PTSD research dates back 28 years to 1980. PTSD had just been added as a new diagnosis to the newly revised DSM-III published that year, and Dr. Foa decided to do trauma research to better understand how to treat this new diagnosis. She decided to work with rape victims, as they were less likely to be involved in lawsuits that might make them less suitable research subjects than accident victims. Her work on understanding the nature of PTSD and how best to treat it has been very influential, and she was later tapped to chair the committees that worked on the PTSD and Obsessive-Compulsive Disorder (OCD) chapters in DSM-IV.
Dr. Foa describes how the definition of what constitutes a traumatic event has changed over the years she has been involved with the diagnosis. At first traumatic events were defined as events that occurred outside the range of normal experience. Later, it was recognized that trauma is not actually outside the range of normal experience, as the majority of adults in the united states report experiencing at least one traumatic event in their lifetimes. The definition was changed so that trauma occurred when people experience or witness or learn about an event that involves injury or death, or the threat of injury or death which leads people to feel helpless or terrified. This definition, which is still current, also has problems. the "learned about" part of the definition has turned out to be over-broad. It was intended to cover cases where a parent becomes traumatized by learning of their child's death or serious injury; not to cover cases where strangers read about or watch on TV the death of strangers. It is also not broad enough to cover traumatization that occurs due to sexual abuse which does not involve death or injury, but instead a violation of bodily integrity. A third problem with the current definition is that sometimes, such as in combat situations, people do not experience terror or helplessness at the time they are exposed to a traumatic event, but instead those feels occur later on after the event is passed. the current definition does not allow for a delayed trauma reaction.
Dr. Foa relates the three primary classes of post trauma symptoms. The first class of symptoms are "reexperiencing" symptoms. These include unwanted memories and nightmares of the trauma event, flashbacks, and the experience of distress upon recall of the trauma event. The second class of symptoms are "avoidance and numbing" symptoms, which include efforts to avoid remembering the trauma, or things or reminders that might possibly be associated with the trauma, amnesia, and a blunting of positive emotions including loving and affectionate feelings, interest in activities that used to be rewarding and pleasant, a feeling of alienation and detachment from loved ones, and a sense of a foreshortened future. the final class of symptoms (not discussed until later in the interview) are arousal symptoms, which include irritability, anxiety, problems concentrating and sleeping, and startle.
PTSD research is still considered to be in its infancy. Though a lot of recent research has looked for biological correlates of PTSD, such as by studying neurotransmitter and hormone functions and brain scans of traumatized people, the results are not yet consistent from study to study. In Dr. Foa's opinion, though she is confident that a biological understanding of PTSD will ultimately emerge, it is premature to talk about consistent biological markers or changes that are always present in all trauma cases.
With regard to treatment, Dr. Foa notes that the best, most consistently useful way to help traumatized people is via a particular variety of psychotherapy known as Prolonged Exposure Therapy. Prolonged Exposure Therapy has been studied in many different countries using rigorous scientific methods and it is known to be both an effective and efficient treatment. Other forms of psychotherapy may be useful as adjuncts to Prolonged Exposure Therapy, such as the use of virtual reality to simulate traumatic conditions such as combat, but at present, their use as a primary therapy is not scientifically verified. Psychiatric medications, specifically antidepressant medications, are often prescribed for PTSD, and Dr. Foa notes that in some cases such medications can be helpful, but these medications do not work for all traumatized people.
Prolonged Exposure Therapy for PTSD involves what is called imaginal exposure, which is exposure that happens in the imagination. Imaginal exposure can be contrasted to another kind of exposure called "in vivo" exposure which occurs out in the environment. Patients are asked to imagine their trauma experience in as much detail as possible and to talk about all the details out loud during the therapy session. All details about the trauma event are considered important including not only what happened, but also what patients were thinking and feeling and what sensations they experienced. Patients recount their trauma story in as complete form as they can manage repeatedly throughout the course of their therapy. They also record their trauma story and listen to it every day during their therapy. A full course of Prolonged Exposure Therapy takes place over 8 to 15 sessions. A short course might take 5 sessions.
The repetition of the trauma story tends to result in the following outcomes. First, the patient's memory for the traumatic events tends to move from an initially fragmented narrative to something richer and more unified. Second, where initially, trauma victims have difficulty distinguishing between the past trauma event and the present (it seems to them that they are re-experiencing the trauma event), over time they gain a better appreciation for what happened in the past and what is happening in the present. The third thing that happens is that patients learn that they can tolerate talking about their trauma and that they don't die or faint or fall apart, and over time their anxiety decreases even when they talk about their trauma.
It is not enough that patients simply talk about their traumatic experience; they must engage the story emotionally or the therapy won't work. If the patient remains detached during their therapy, they don't tend to get better. As a postscript to the podcast, Dr. Van Nuys communicates with Dr. Foa about how a friend of his raised up an example of another friend who was traumatized, and continually talks about that trauma and never seems to get over it. In Dr. Foa's answering email she notes that there are patients who become obsessed with little details of their trauma or with the injustice of their trauma, and that this obsession with aspects of the event serves to keep them from touching the entire event and feeling the feelings associated with that entire event. A therapist doing prolonged exposure therapy with such a patient would help that person to talk about the entire event including what they don't normally talk about, and this more complete retelling of the story will help the symptoms to abate.
Dr. Foa notes that immediately in the wake of a traumatic event, it is normal for people to experience PTSD like symptoms. For instance, 90% of rape victims will report PTSD like symptoms immediately after their rape. 80% of those victims will go on to experience a spontaneous remission of their symptoms within a few months (meaning that they will be able to function and continue on with their lives; not that the memory is ever a pleasant one). Most of the time people are resilient and these symptoms will go away after three or four weeks. So the therapy that is most useful immediately in the wake of a trauma is to simply inform people that what they are experiencing is normal; to talk about what the normal PTSD symptoms are; and to tell people that they can come back for help if they continue to be bothered by excessive symptoms after a few weeks have passed. After three or four weeks, a short course of Prolonged Exposure Therapy of about five sessions may be usefully experienced. The biggest part of trauma healing occurs within the first three months, and most of the remainder of healing occurs in the first year post-trauma. Trauma symptoms that have not resolved within one year tend to become chronic without treatment.
Links Relevant To This Podcast:
- The website for Dr. Foa's Center for The Treatment and Study of Anxiety is located at www.med.upenn.edu/ctsa
- Dr. Foa's Wikipedia article can be found here .
About Edna Foa, Ph.D.
Edna B. Foa, Ph.D. is a Professor of Clinical Psychology in 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 University of Missouri, Columbia, in 1970. Dr. Foa devoted her academic career to study the psychopathology and treatment of anxiety disorders, primarily obsessive-compulsive disorder (OCD), post traumatic stress disorder (PTSD), and social phobia and is currently one of the world leading experts in these areas. Dr. Foa was the chair of the DSM-IV Subcommittee for OCD and Co-Chairs the DSM-IV Subcommittee for PTSD. She has also been the chair for the Treatment Guidelines Task Force of the International Society for Traumatic Stress Disorders.
Dr. Foa has 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. Among them are: Distinguished Professor Award under the Fulbright Program for International Exchange of Scholars; Distinguished Scientist Award from the American Psychological Association, Society for a Science of Clinical Psychology; First Annual Outstanding Research Contribution Award presented by the Association for the Advancement of Behavior Therapy; Distinguished Scientific Contributions to Clinical Psychology Award from the American Psychological Association; Lifetime Achievement Award presented by the International Society for Traumatic Stress Studies; and the 2006 Senior Scholar Fulbright Award .