Wednesday, September 30, 2015

"Trigger Warnings"

After writing my last post, on PTSD, I started thinking about the current controversy over "Trigger Warnings," labels that are being placed on some class materials by some college professors. This term misappropriates a concept from mental health treatment. A content warning label is not a "trigger warning."The so-called "trigger warnings" are not really trigger warnings at all, as I will explain:

The concept of a "trigger" that incites symptoms has been used for some time in the study of PTSD (post traumatic stress disorder). For example, it has been observed for many decades that some combat veterans are triggered by the sound of explosions to re-experience combat experiences in a dissociative state. People who have been raped and who have PTSD as a result may experience a triggering of symptoms by a wide variety of stimuli: Some may experience anxiety when alone with a man, during sex, or when exposed to something only tangentially related to the rape--this could be anything from a song that was playing while they were being raped to a particular smell. Clinicians who work with people with PTSD, and researchers who study PTSD, know that a traumatized individual may have very individual, specific, triggers. Thus, it's impossible to predict in advance what might trigger PTSD symptoms in a person with PTSD without knowing that person.

Content warning labels have been used for a long time for movies, and more recently, for record albums. All movies are given a rating for content, the purpose of which is to alert parents that some content might not be appropriate for children. Warning labels on music, which began in the 1980s, perform a similar function. Content warning labels were not designed to help people with PTSD, but to provide information for the general public, especially parents.  Are such warning labels appropriate for college reading materials? College students aren't children and college reading assignments aren't entertainment, but may in fact be designed to provoke or challenge.

A college professor doesn't know individual students at the start of the semester, and can't possibly know whether the class will include students with PTSD, and in any case, what their triggers would be. Many students with PTSD can often figure out, by looking at synopses of books, films or other material that they will have to view for class, whether the materials might contain triggering material. But depending on the individual's triggers, it might also be impossible to predict. What is absolutely certain, however, is that it would be impossible for the professor to predict what material might be triggering to any particular student. And even if it was possible for the professor to know in advance that particular material would be triggering to a particular student, is it the professor's responsibility to warn the student? This puts the professor in the role of mental health clinician, a role most college professors are not qualified or licensed to fulfill.

From a clinical perspective, this type of discussion might be beside the point. Therapists don't counsel PTSD patients to avoid triggers. We don't tell rape survivors to avoid men, or tell Iraq combat veterans to avoid driving so that they won't think about roadside bombs. We help people develop coping skills, tell them that their symptoms are likely to subside over time, and encourage them to NOT avoid triggers, because to do so can increase the fear and create a phobia. This is precisely why the area of PTSD triggers is best left to mental health clinicians and not college professors from unrelated fields. I read a comment from a philosophy professor, in The New York Times, that she gives "trigger warnings" so that students with PTSD can meditate or take medication before exposing themselves to difficult material. As a therapist, I encourage meditation for people who can benefit, but I would never counsel anyone to take an anti-anxiety medication prior to reading a book. This could set the stage for a bad habit. This is not the purpose for which anti-anxiety medication is prescribed.

If a college student had such severe PTSD that she or he was unable to read or view triggering material without experiencing disabling symptoms for hours or without having a suicidal, homicidal or psychotic episode, that person should not be in college at all. College is a stressful environment and persons who are severely psychiatrically ill do not belong in college. However, few PTSD sufferers fall into this category. For most students with PTSD, attending therapy to improve coping skills and process the trauma in a safe environment is enough to be able to attend classes and complete all assignments. There is also the fact that some people with PTSD may have to  acknowledge that for the rest of their lives, they are going to experience some discomfort from certain stimuli that would have no affect on most people. Many people learn to live with symptoms from medical or psychiatric problems, because treatment often doesn't mean a 100 percent cure.

As I thought about this topic, it occurred to me that perhaps what I'm saying here is obvious, and maybe I am missing the point: Maybe the point isn't to help PTSD sufferers at all. Maybe the point of these so-called "trigger warnings" is to alert students to the professor's opinion about the material. Maybe what these "trigger warnings" really do is alert students to the fact that the professor finds the material troubling, and to suggest that the students should also find it troubling. I hope this isn't what's really going on, because it would be a violation of the basic principle of a liberal arts education, which is to teach students independent critical thinking.

Wednesday, September 23, 2015

Taking a Closer Look at PTSD

I wrote a previous post about PTSD (post-traumatic stress disorder), but I decided the subject could use more elaboration. There seems to be  misinformation about PTSD floating around. In addition, there is some dispute in the mental health field about how to categorize PTSD patients who've had different experiences.

PTSD can result from a wide range of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders states that PTSD can result from exposure to "actual or threatened death, serious injury, or sexual violence." This covers many types of situations.

It's normal for people exposed to one of the above situations to have symptoms including fears, flashbacks and intrusive memories, for up to one month following the incident. If symptoms last only one month or less, the syndrome is called "Acute Stress Disorder," but in my opinion it is not a disorder at all, but a normal reaction. Most people who have witnessed an accident or a crime that involved serious injury or death to another person will have some of these symptoms. For example, I counseled someone who, while working at a bank, witnessed the bank's armed robbery. In another case, the patient witnessed the sudden death of a co-worker from natural causes. These individuals had some symptoms, but they were not serious.  These types of patients might not need long term treatment and may only need support. If the incident happened at a workplace, sometimes it is helpful for employees to meet as a group for support. I have facilitated some groups for this purpose.

The PTSD cases I've treated have been diverse. At least two patients I've seen had PTSD from terrible accidents. One case resulted from a construction accident in which one person was killed and another seriously injured. Another patient was a driver in a car accident that killed several people--his friends. These individuals had severe PTSD that included hallucinations. In these hallucinations, they saw their dead friends sitting next to them on the sofa and in some cases were able to "touch" the dead friend. The presence of such symptoms does not indicate a chronic psychotic disorder. In fact, visual hallucinations are not uncommon in PTSD, whereas chronic psychotic disorders such as schizophrenia are more likely to involve auditory hallucinations ("hearing voices"). Both patients got somewhat better over time with treatment, but unfortunately one of them developed a drug addiction, which complicated matters.

I've also worked with combat veterans from conflicts including Vietnam, Lebanon, Kosovo,  Iraq and Afghanistan. It is normal for any combat veteran to have some stress disorder symptoms. In some cases, however, symptoms persist long after the person leaves the combat zone. Why does this happen with some individuals and not others? There can be many factors, including the severity of combat experienced, and, as I mentioned in my previous post, guilt feelings.  The guilt can be either irrational or rational. Irrational guilt feelings can be treated in psychotherapy through examining the irrational thoughts and how they developed. Helping someone who feels guilty about doing something that was actually wrong is a bit more complicated. In those cases the treatment might involve helping the person to make amends in some way or helping the person to put  actions in a context. In some cases, when a person has voiced religious views, I have suggested that he speak with clergy from his denomination. I can't answer the question "am I going to Hell?" 

 Exposure to wartime combat may change views on life and prompt philosophical questions. In my opinion dealing with such issues can be an important part of therapy, but unfortunately, there is a trend in the field to emphasize behavioral approaches to PTSD that may be helpful in symptom management but ultimately fail to address the roots of the disorder. Many people who have been exposed to trauma suffer a loss of a previous, idealized view of the world that is common but also inaccurate. I believe that trauma survivors, far from being merely damaged individuals, often have  wisdom that should be appreciated.

About 20 years ago, a psychiatrist named Judith Lewis Herman proposed a new diagnosis called "Complex PTSD" for people who have survived long-term captivity in an abusive situation. This category includes survivors of childhood abuse, as children have no power to leave their abusive situations. This diagnosis has never been formally accepted by the American Psychiatric Association, which is a puzzle to me, because PTSD from long-term childhood abuse is going to result in a different symptom profile than PTSD from a one-time incident or even PTSD from wartime combat.  Long-term exposure to trauma, especially if it starts during childhood, can cause personality changes.

In short, there are many factors to consider when evaluating stress disorder symptoms. These include whether the trauma was a one-time incident or a prolonged series of incidents, whether or not the patient feels guilt about the trauma, and if so, is the guilt  rational or irrational, at what age was the trauma experienced and for how long, and also the identity of the perpetrator if there was one (or more than one). There are probably more factors that I can't think of at the moment. Treatment for PTSD in my opinion should involve a combination of insight-oriented and cognitive or behavioral interventions and in some cases medication may be necessary. Group therapy can sometimes be helpful, perhaps especially for combat veterans and for survivors of childhood sexual abuse. 

Tuesday, September 1, 2015

Diagnosis and Prognosis in the Information Age

Recently I read a quote from a celebrity, I think on Facebook, saying that he has been "struggling" with anxiety and depression for at least 7 years. I was puzzled by this, because there's no reason for anyone to struggle with anxiety or depression for that length of time. There are numerous treatments for depression and for anxiety disorders. Most people with depressive or anxiety disorders are able to resolve their symptoms or at least tolerate them, if they get the appropriate treatment.

 I wondered whether the celebrity had really been diagnosed with bipolar disorder or borderline personality disorder, but was afraid to say so, because these conditions are far more serious and he thought it would be too stigmatizing to admit he had them. It's also possible that his treatment professionals told him that he had "anxiety and depression" when in reality they had diagnosed him with borderline personality disorder or possibly even with bipolar disorder, without telling him. In other words, it's possible his treatment professionals lied to him, to avoid upsetting him (and potentially losing a high-paying patient). It's also possible the celebrity was misdiagnosed or was receiving inappropriate or inadequate treatment, or that he has been noncompliant with treatment. All I know is that something was missing from the picture.

This scenario and its possible behind-the-scenes factors illustrate some of the pitfalls of our "Information Age" in which people are inundated with "information" from the internet and especially from social media. It also may illustrate the continuing stigma relating to mental health conditions, as well as the general difficulties people may encounter getting correct diagnoses, information and treatment for their conditions.

I have learned that it is important to tell people what their diagnoses are. When I was in graduate school, some of my professors minimized this educative component of treatment. Many colleagues I've had believe that patients can fixate on diagnosis, or that diagnoses are controversial or often inaccurate. Although I agree with those colleagues that there are many potential problems involved in telling patients that they have a condition such as borderline personality disorder, antisocial personality disorder, or another stigmatizing condition, I now believe patients have a right to know and I feel comfortable making such diagnoses when I have the required evidence. 

I saw numerous comments on the actor's Facebook page from fans stating they too had been struggling with depression or anxiety and depression for years. I didn't see any comments from people speaking about how they recovered from their conditions. No one seemed to be questioning whether they had been given the correct diagnosis or the right treatment. This is sad. With only a couple of exceptions that I can think of, every patient I've worked with who had a depressive disorder or an anxiety disorder as their primary diagnosis got much better, sometimes with therapy alone and sometimes with a combination of therapy and medication. In the two cases that spring to mind in which the person did not get better, I strongly suspected the patients were not compliant with their medication and in one case, the person was using drugs. I also had one patient who didn't recover from severe depression until she had  treatment with a brain stimulation method that at the time was only available in Canada ( I believe it is now approved in the US). The medications she'd previously tried had been ineffective. It may take some time to find the correct treatment regimen for someone's condition. But there is no question that depression and anxiety can usually be resolved. The treatment of a condition such as borderline personality disorder is far more difficult and perhaps I'll discuss this in a later post. Bipolar disorder is incurable but can be managed with medication.

I commend public figures for speaking about their personal problems in an attempt to destigmatize those problems, but this is only useful if what they are saying is the truth. It's sad that both patients and their treatment professionals are still sometimes victims of the fear of stigmatization. Perhaps one day our society will acknowledge that there's no such thing as perfect mental health and that we all have problems.