TCPR: To begin with, Dr. Friedman, I’d like to start with the diagnosis of PTSD. Given that patients sometimes come to us for disability evaluations and therefore have a secondary gain for getting the PTSD diagnosis, do you have any good tips for how we can be sure that we are making the proper diagnosis? Are there any unique ways of phrasing questions or interpreting answers that might make us feel more comfortable that they are genuinely experiencing these symptoms?
Dr. Friedman: At the VA we believe that a structured interview is best, and the gold standard that we have developed at the National Center is the CAPS (the Clinician Administered PTSD Scale). The CAPS has behavioral anchors for each of the severity measures in terms of intensity and frequency, so we think that it is better than an unstructured interview.
TCPR: How long does it take to administer?
Dr. Friedman: In the hands of an experienced person, it could generally be administered in 30 to 45 minutes. And then you would need to tack on additional time to rule out the other DSM disorders and to do the standard psychiatric history.
TCPR: How can we obtain a copy?
Dr. Friedman: It is in the public domain, although it is not available online. Clinicians who would like a copy of the CAPS should contact the National Center through its website (www.ptsd.va.gov).
TCPR: And are there any particular kinds of PTSD symptoms that clinicians fail to cover adequately?
Dr. Friedman: I think the symptom of a “foreshortened future” is a confusing thing to assess. It was originally interpreted in terms of life expectancy, but I think it is better understood as negative cognitions about the future—about what the future is going to bring, about what you could expect in terms of your life, not just in terms of your life span, but your life trajectory, your life goals, your life aims and what you hope or hoped to accomplish. A traumatic event can shatter your assumptions about yourself and the world you thought you knew. Patients may believe that things will never be the same because of what has happened to them.
TCPR: You and Laurie Sloane recently published the book “After the War Zone: A Practical Guide for Returning Troops and Their Families.” In it, you discuss something called “Battlemind” as an after effect of combat. Can you describe what this is?
Dr. Friedman: The concept of Battlemind was developed by Col. Carl Castro and colleagues at the Walter Reed Army Institute of Research. It is based on the recognition that when you have been in a war zone (specifically Iraq, for which this concept was developed) and you are on “high alert” 24/7 for a year or more, you develop behaviors that are adaptive in a war zone to keep you alive but that may be very maladaptive when you return to the home front. For example, driving your car very quickly, not stopping, and scanning the horizon for roadside bombs may be very adaptive in Iraq. It is not adaptive on I-95 or on city streets.
TCPR: Does Battlemind lead to the development of PTSD?
Dr. Friedman: Battlemind leads to problems adjusting to civilian life, but it is important to note that most of our returning troops are not going to exceed any clinical threshold for a DSM-IV diagnosis, whether it is PTSD, depression, substance abuse or other things. Approximately 20%-25% of troops will go on to develop a DSM-IV disorder that requires some form of treatment. The other 75% may have Battlemind-type readjustment problems but will never develop a psychiatric disorder.
TCPR: Regarding pharmacological treatment, what do you consider first-line treatments? In Great Britain, treatment guidelines relegate medications to second-line, after psychotherapy. Do you agree with this?
Dr. Friedman: I would not agree with that. I think that the SSRIs and venlafaxine are first-line treatments. They are very effective, and while they are not as effective as cognitive behavioral treatments, they are much more effective than no treatment or supportive therapy. Some of the negative results with SSRIs come from studies with patients in the VA who have chronic PTSD, often from Vietnam. These trials have therefore been conducted with the most chronic patients who have already failed to respond to many treatments over the years. If you look at some of the data with younger veterans, you get a different impression of these meds. For example, there was a big SSRI study done with UN peacekeepers, mostly European, and what they found was that combat exposure was a predictor of a positive response to SSRIs (Martenyi F et al., J Clin Psychiatry 2002;63:199-206).
TCPR: What kind of dosages should we use for PTSD, and does the response time differ from response times for depression?
Dr. Friedman: The dosages for SSRIs and other antidepressants are about the same as they are with depression. But the response time may be longer. In one study of sertraline, about 30% of PTSD patients had remission after 12 weeks, but after another six months, 55% had attained remission (Londborg PD et al., J Clin Psychiatry 2001;62:325-331).
TCPR: When a patient is only a partial responder, what would you recommend?
Dr. Friedman: I might add CBT if I could get it for them, or I might augment with other agents, such as prazosin (start with 1 mg QAM and 3 mg QHS, not to exceed 8 to 10 mg/day), or some of the antipsychotics, such as risperidone 3 to 16 mg/day or olanzapine 20 mg/day.
TCPR: And what about benzodiazepines? I think there has been some controversy about those in PTSD as well.
Dr. Friedman: I don’t like to prescribe benzodiazepines in PTSD, even though I know a lot of people do prescribe them. What the data show, and there are not a lot of good randomized trials, is that at the very least they don’t make the PTSD any better. In other words, they may help insomnia, they may help generalized anxiety, but not the core symptoms of PTSD.
TCPR:Well then, what do you like to prescribe for insomnia symptoms?
Dr. Friedman: I generally recommend using either trazodone or prazosin for insomnia and nightmares in PTSD.
TCPR: And what type of psychotherapy do you recommend for PTSD?
Dr. Friedman: The most effective techniques are prolonged exposure (PE) and Cognitive Processing Therapy (CPT).
TCPR: Can you explain how these techniques work?
Dr. Friedman: Prolonged exposure is essentially an extinction paradigm. In the safety of a therapist’s office, you expose the individual to traumatic reminders through his or her own narrative of the traumatic experience. The traumatic memory is never going to go away, but what we want to do is to disconnect the memory from its ability to trigger the aroused, emotional state associated with PTSD symptoms. In other words, PTSD patients are hostages of such memories because the memories have the capacity to make them feel, behave, and think quite differently than they otherwise would. In cognitive processing therapy, the focus is on distorted cognitions triggered by traumatic memories, such as “It’s all my fault,” or “I can never trust anyone again,” or “Nothing I can do will ever make a difference.” By successfully challenging such erroneous cognitions, the therapist enables the patient to disconnect such thoughts from the intolerable emotions that they can evoke.
TCPR: How robust is the evidence that cognitive behavioral treatments are effective?
Dr. Friedman: It is very robust. Every group that has looked at the evidence, including the Institute of Medicine, has concluded that these psychotherapies are very effective treatments for PTSD, likely more effective than medication treatment.
TCPR: Thank you very much for your time, Dr. Friedman. This information is sure to help us treat these challenging patients.