Dr. Bessel van der Kolk's Interview with Dr. Martin L. Korn

From Medscape Mental Health

Trauma Related Disorders: Conversations with the Experts
Trauma and PTSD: Aftermaths of the WTC Disaster
An Interview With Bessel A. van der Kolk, MD

Martin L. Korn, MD

Dr. Martin Korn talks with Bessel A. van der Kolk, MD, clinician, researcher and teacher in the area of posttraumatic stress and related phenomena, about the tasks for psychiatry in light of the recent World Trade Center disaster.

Can you tell me how you see recent events, and how you see the role of Psychiatry?

My first observation is that it is a multidimensional event. The thing that people most talk about is the social/political aspect of it. How do people get back together? How do people get to function? How does the nation respond to it? How do communities respond to it? How do airlines respond to it? How do people in uptown Manhattan and Boston and everywhere else in the world respond to it? This is one dimension. I'd say the meaning dimension. The trauma dimension is a different one, and that is one of exposure. I think the two of them should not be confused. For most of us this was a terrible tragedy, not a trauma. The trauma is when your biology gets assaulted in such a way that you might not be able to reset yourself. I think the trauma is largely confined to people who live below 14th Street in Manhattan, and the closer you get to "Ground Zero," the higher the likelihood, that something will have permanent impact on your system.

For directives, we have to deal the meaning of it all, but when people talk, "it will never be the same," well, people are amazingly adaptable. Emotionally, this is not going to be a permanent, profound change. For the people who lost their relatives, some of the airline people, people right down there, the kids at NYU who saw people jump out, those people are really the people with posttraumatic stress disorder, PTSD. What I would be most concerned about in this past week is all the talk about retaliation, and that we will pay more attention to social/political aspects and will forget or have our attention deflected away from the care of the people who are right now still digging in the basement of the World Trade Center, who are at extremely high risk of developing PTSD.

What would you say is appropriate intervention at this point?

The dilemma is this: One, is that these guys are obsessed with finding their comrades doing well, so they need this group cohesion. But I think they are burning themselves out with 12 hours on and 12 hours off. The people I talk to and the second-hand reports I hear is that they are beginning to really shut themselves down. They get this numbing response, and the people who develop numbing responses are at extremely high risk of developing PTSD. I have some friends at NYU who were also very close to what happened. When I talk with them, I am astounded by how I don't recognize them. They are shutdown. The traditional thing about PTSD is a hyperresponse, but we have come to understand more in recent years, as people did a hundred years ago, that the worst thing that happens in trauma is that people shutdown and become like zombies. Then people really can lose their capacity to engage in and attend to their current environment. Their whole system gets shut down.

Do you feel we should be more proactive with the workers and victims at this point?

I think that taking people out from time to time, having new crews come in, really making use of many more people and really taking people out who get exposed for longer than 48 hours or so, and then being very gentle with them. Holding them, giving them massages, calming their bodies down is a critical issue. I am probably the minority among my colleagues in that I am much more focused on bodily state than on articulating what's going on. I think that words are not really the core issue here. It is the state of being, of tenseness, of arousal, and of numbing, and that people need to learn again to be safely in their bodies.

What about the families, the extended networks of the victims?

What you see happening is people basically doing all the right things. Natural instincts of people are coming in line. I have observed what happened this past week everywhere I go, people are thoughtful. They are hugging each other. They are singing. They are getting together. Doing the sort of things that human beings need to do to restore that sense of safety. Really allowing people the time to process, to be with people, to cry, but most of all, to hug. What I find interesting is that some of my colleagues are over-biologizing this whole thing by doing research or giving clonidine or giving some beta-blocker. They too often think only of a pharmacological solution for the natural need for people to calm their bodies down. In nature, people don't take beta-blockers. In nature they deal with this by comforting each other and by moving their bodies. So I think the premature psychiatric medical chasing of this process is troublesome.

At your particular institute in general, is that your approach in dealing with the traumatic events?

We have 29 people right now in downtown Manhattan working with a number of the agencies that were affected by the tragedy. What we do is get people together and get people to just talk, to be there. We don't do a lot of premature exposure so much as really having people be together. We also like to sing with people and do exercises with people. We like to do Yoga-type movements with people to get the body back into a state where it feels like it is in its own domain, and really work with overcoming tenseness.

At what point do you think medication is necessary?

I think medications are necessary if therapists have exhausted other techniques of calming people's bodies down. It is down the line. I think psychiatrists have increasingly become subject to pharmacological approaches. I think that if therapists know Yoga or if they know how to use exercise to help people get back in their bodies to get a sense of safety, they help people to learn the resources to cope without taking it away from them. That's the first approach. If after that, people are so hyper that they can't sleep at night, I think helping people sleep is critical, so you would want to give people clonidine or beta-blockers. A fascinating research finding of a student of mine was that burn children who get opiates right after their burns do not get PTSD. The opiates are probably the natural way that the system takes care of these things. We don't know how to activate induction of those opiates, but we need to look further into the need to calm the system down.

I'm sorry to focus so much on the medications at this point since you believe much is not pharmacologic, but there is a lot of interest in that, of course. You haven't mentioned the serotonergic drugs.

There is no evidence that serotonergic drugs are helpful acutely. There is a lot of evidence that the serotonergic drugs are useful once people have developed PTSD. I was the first person to show how the serotonergic drugs are helpful, but if you look at the overall treatment outcomes, a good psychological intervention like eye movement desensitization and reprocessing (EMDR) has an effect size of 2.2 compared with an SSRI having an effect size of 0.48. It is about 5 times as powerful.

How do you do EMDR? Could you be more specific?

What is so nice about it is that you can dose the exposure when people come up with something that seems to overwhelm them. As I see from MRI imaging, the frontal lobes are shut down and the limbic system takes over and people start sobbing and cannot talk anymore. They reach a state where the emotions overtake them. When you see that beginning to happen, you say "stay there, feel that in your body," and you see bilateral eye movements and when you do it, something takes place in many people that after a while the intensity of the emotion has decreased.

How do you understand that neurobiologically?

It is like a natural mechanism of treatment, but that is just a speculation. But what I like about it particularly, is that you don't rely on what I call the purity of language. So you don't force people to speak more than they can speak about the unspeakable. When people are in the state of distress they don't have to explain to you why they feel so upset, but you allow them to feel and you have a technique that is going to decrease the stress to that particular trigger. I love the relatively nonverbal part of the EMDR.

Do you use psychodynamic approaches much?

In the long-term trauma I do, and I think all of us in certain aspects of treatment track the details of what people experienced. You don't allow people to gloss over small details, but you really go over them and then people will defend themselves and circumvent the things that give them distress. They will create a narrative that basically tends to exclude the most traumatic part of the story. All of my cognitive behavior friends and therapists like myself will then look for the missing pieces of what people aren't talking about and very carefully check people's faces and body movements to see where in the story they seem to get upset. The natural thing for people to do is to move away from it, rationalize it, to change the subject to make the thing go away. As a therapist, psychodynamic or cognitive behavioral, you track those bodily states and the moment you see the people enter something, you want to go after that gently to help people feel that and process it.

In your book, one of the things you comment on is that the study of trauma has become the soul of psychiatry. It has some wonderful metaphors and descriptions that you are using to characterize PTSD. For example you state, "This has opened the door to the scientific investigation of the nature of human suffering." Could you talk about that philosophically? How you see the study of PTSD and its role in psychiatry?

When I was a psychopharmacology fellow, we were putting together the Feighner diagnostic criteria that predated the Diagnostic and Statistical Manual (DSM) system of the American Psychiatric Association. We really needed to agree on which patients should be involved in the study so we could determine who responded and who didn't. That whole thing got unified into what I think is a crazy DSM system where people believe that all these categories actually exist. All of these differentiations were conveniences by committees to say "okay let's more or less figure out, group these people together for now," and now all these things exist.

For example, I am one of the people in the PTSD field who keeps saying that PTSD is an interesting diagnosis that captures some parts of what happens to traumatized people, but these are some very important pieces and may not be all that central for many traumatized people. For example, this weekend I was really impressed that the traumatized people that I see are primarily numb. The people who are at risk for PTSD and the data about PTSD started to come out right after the DSM outlined the disorder. We know that people who are upset and screaming are the people who are at risk for PTSD, but the people who shut down are as well. Not only is the concept that people shut down something that we haven't paid much attention to, but we also have a hard time treating it. We know very well what to do with people who scream loud and who yell; we can quiet them down with a wonderful medication. However, we don't know what to do very well with the people who can't feel, which is really the big bug-a-boo for traumatized people, and so the great danger for traumatized people is that the only thing that they can feel is their own trauma. So one thing that happened to me this past week is that I had arranged quite a while ago to be on a TV program for woman whose kids had been murdered. So in this program, the moderator said, "Okay, because of the event in New York, let's talk about the whole issue of trauma." The woman could not talk about anything but her own misery. So trauma can make people preoccupied with their own misery and they can stop being able to see the larger picture, and that may also explain some of the mind-sets of the perpetrators of this terrible disaster. The empathy goes away and the capacity to imagine what other people feel goes away, and so that whole connectiveness which is such an important part of the total picture. Traumatized people feel God-forsaken. They are all by themselves, they feel lonely and disconnected and they can't take new information in. That, to me, is what this trauma is about and the trauma treatment is to help the people open up for new experience.

Do you see this as a problem in verbalization?

I know it is a problem with verbalization. We saw that on our brain scans when the people get close to their trauma, the Broca's area shuts down. Freud said it very well in 1893 that the problem is one of association. That traumatized people cannot associate and integrate the information for, perhaps, the rest of their lives. It starts to lead a life all by itself, independently from anything else. Then he said it becomes like a 'parasite on the mind' and you can't let anything else in anymore because that takes over. We see that in neurophysiology studies, traumatized people have very low P300 on the EEG to neutral stimuli. So they have trouble concentrating on, taking in, and processing information, but they get hyperaroused to the old trauma. So the problem with trauma is that little new information can come in and so they can loop through the old misery.

What do you look for in the behavioral presentation of an individual?

Extremes of disconnection or false connections. I think that is the main thing. If there is no reserve in terms of coming into the office, people will either say, "Oh, you are going save my life, or "Are you going to be my last hope," or "You are the most wonderful person in the world." Or, they are deeply suspicions of you and think that you are the next traumatizer. So, the first thing that you see shows up in the relationship and how people position themselves in that relationship as not another person who is a partner in this enterprise, but as a person who is either totally submitted to the physician or the psychiatrist or who needs to protect himself against potential victimization.

Do you see psychological or neurobiological differences among individuals experiencing varying types of trauma?

Not much actually. I don't find much difference between people who have been tortured in a South African prison or people who have been in an airplane crash or people who have seen their child run over by a drunken driver. Some of the expression, of course, is culturally determined, but the core syndrome is very stable across situations. The big issue there is, of course, is whether there is a society that can hold or contain that particular trauma. In South Africa after Mandela was released, in the society embraced the survivors, so people could more or less talk about the trauma. The opposite of course is where there are incest survivors, where people make noises about how traumatized they have been and then people accuse them of having a "false memory syndrome." Comparatively, what happened in the World Trade Center is very positive psychologically, in that people can express their trauma openly. They say, "no wonder, look at the terrible thing that has happened to this person." There is much more empathy.

Would there be a higher incidence of PTSD in trauma that is difficult to talk about? For example, sexual trauma as opposed to something like this, where it is easier to talk about because it is overt?

I don't think you get more PTSD, but I think you have more secondary characteristics. You have more character pathology, from hiding and trying to cover over and trying to rationalize and trying to transform something because you cannot talk about it. So, I think my hunch would be that the more acceptable the trauma the more pure the PTSD.

Any other thoughts?

The big thought for me is help the body to be safe. It is not a cognitive issue, not a a frontal lobe issue. We are largely dealing with subcortical phenomena which can be expressed as people being very tense and very anxious, and so you cannot simply talk reasonably to people. We need to do techniques that reestablish their physical sense of safety. That is the big message.

Thank you very much.

Bessel A. van der Kolk, MD, is Professor of Psychiatry, Boston University Medical School, Clinical Director of the Trauma Center at JRI in Brookline, Massachusetts.

Martin L. Korn, MD, is Chief, Inpatient Unit, Department of Psychiatry, Mt. Vernon Hospital, Mt. Vernon, New York.

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