“Garbage in… garbage out.”
It’s really that simple. The quality of care you receive for your PTSD is a function of just how willing and able your care provider is to take information that is specific to you and “plug it in” to your care plan for therapy and medication. Informational garbage IN results in garbage treatment OUT.
In my work as a pastoral psychotherapist and clinical traumatologist, on the one hand, and as a collaborator/consultant to physicians and surgeons, on the other, I stand in relatinship to both patients and their doctors. It has given me a vantage point from which to observe the process of diagnosis and treatment from both patient’s and doctors’ viewpoints. From this observational “perch” I see the way in which patients not only have insufficient information about their physical processes, but don’t know how or why they should communicate this to their providers. I also see how limited time and an overwhelming number of patients impacts physicians. These factors, operating on both sides of the healthcare equation, contribute to a “garbage in… garbage out” dynamic in PTSD treatment.
Through the lens of the patient, I hear their disquieting narratives of going through psychiatric “cattle calls” in large mental health clinics, in which they may be seen for as little as 5 or 10 minutes and emerge with ever-increasing prescriptions for mind and behavior altering medications (many of which carry significant side effects). These people are asking – WITH GOOD REASON – “How can I receive individualized care for this illness that affects ME and MY LIFE and MY BODY, uniquely? Aren’t I more than just a number?”
Through the lens of the physician, I can see that many doctors who function in clinic settings are often given no more than 8 minutes to devote to the entirety of a patient’s care, including diagnosis, charting, prescribing etc. Guess how much time the physician has to take in depth history about the patient? That would be virtually ZERO. It is little wonder that in these large treatment settings, it is becoming increasingly common for virtually every patient with PTSD to get handed the same clipboard, and walk out with the same “prescription cocktail”, whether those drugs are appropriate for each individual, or not. After all, with so little information to go on, how’s the doctor to even know what’s going on with, and within, the individual patient?
The point is, many DON’T know. This is not only laden with risk for the patient, but extremely frustrating to the many good doctors who would like to treat PTSD more personally, more professionally and more effectively. Most physicians involved in the care of PTSD are extremely conscientious, but strapped for time by large institutional systems. So, instead of treating the root causes of PTSD, they wind up treating almost nothing except the emotional and behavioral “stuff” that floats on the surface. They have time for nothing else.
Is that necessarily bad? Well yes, in many cases, in my opinion. You see, the typical drug therapies that are currently dispensed for PTSD address only the behaviors that manifest on the surface. Meanwhile, the root causes continue intensifying and festering underneath. This means that the problem is being masked “on top”, and never fixed. At minimum, it means that the patient will remain as a consumer of larger and larger assortments of drugs, usually for the duration of his or her life. These therapies are alot like a steel lid that one slams on a boiling pot… because the problem never goes away, you are ALWAYS forced to stand by the stove and keep the lid on the pot, to ensure it doesn’t boil over. My question is this: wouldn’t it make more sense to just turn the heat down underneath the pot? Then, instead of wasting useless effort trying to continually contain the boil over, you simply reduce or eliminate it, at the point of origin… which is UNDER the pot, not over it !
I am convinced that most physicians would genuinely like to provide something more effective for patients. So why don’t they? I believe that it is not for lack of the right intention or the right drugs, but for lack of time necessary to dispense those drugs. You see, physicians have known for decades how to manage the “stress response” (the root process in PTSD), with central-acting medications known as adrenergic agents and antihypertensives. But it is irresponsible for a physician to administer these medications (which can be extremely effective in PTSD management) without first obtaining both a baseline as well as some extended history on the patient. And that is something the doctor in a psyche clinic will NEVER get in an 8 minute visit. Time is the enemy.
And this is the typical result: If you are a physician, and you (the patient with PTSD) come in complaining of “panic” the physician is likely to assume that this is a “perceptual issue” (clinical talk for “it’s in her head”, or “its what the patient believes or emotionally feels to be so, but not necessarily what IS so). The physician cannot give you medication that will actually, physically affect your cardiovascular system if he thinks that you simply have an “emotional perception of panic” and rapid heart rate. Without access to information that tells the doctor otherwise, he will assume that your symptom is psychological and give you a “psyche” medication to help dispel what he assumes is psychological anxiety.
Now, consider the example of one of my patients. Over the course of seeing 10 doctors over 10 years, this woman repeatedly complained of the feeling of panic and a racing heart. And in every case, it was assumed that this was her “perception.” She was given increasing numbers of psychotropic drugs to “calm” her mind and “tranquilize” her behavior. Her drug list became so long, that it occupied half a sheet, single spaced. But her symptoms did not go away. Her PTSD symptoms were ignored, because doctors assumed they were psychological. In fact, they were not. Her PTSD symptoms of racing heartrate and accompanying high blood pressure were very real, very physical and VERY dangerous. I referred the patient to the cardiologist with whom I collaborate , who promptly verified my initial clinical assessment : he concluded that her condition placed her in the “stroke zone,” on a such a regular basis that she could easily have died or sustained severe cardiovascular disability, due to the effects of PTSD on her heartrate and blood pressure. I wish I could say that this patient was unique, but her profile has been duplicated in the cases of many individuals under my psychotherapeutic care. Instead of suffering a heart attack or a stroke which might have killed her, she has instead been doing extremely well for over a year, and her PTSD has improved greatly through the use of two simple, generic central acting medications which treat her root physical stress reactions.
Now, prior to sending her to the cardiologist, I knew information that the woman’s former physician did not know, and that he had not investigated. I knew that this patient’s concerns were physical, and not simply perceptual. I knew that these cardiovascular symptoms reflected her PTSD reactions at their root of the stress response. I knew they were absolutely real, and therefore, that they were also absolutely manageable under a competent doctor’s care (such as the excellent doctor to whom I referred the woman.) This was not rocket science. I knew all of these things because, as a first step in her care, I had taken the simple step that I request of every one of my patients: I asked the patient to engage in the “BACK TO THE WALL SELF-ASSESSMENT SYSTEM FOR PTSD”. In fact, she spent two weeks completing the forms, at my request, and provided them to me when she appeared for her first visit. I, in turn, immediately provided them to her new doctor. Those forms probably saved the patient’s life, by providing her new doctor with the critical information required to (l) RECOGNIZE PHYSIOLOGICAL SYMPTOMS OF PTSD, and (2) PRESCRIBE APPROPRIATE MEDICATION TO MANAGE HER SYMPTOMS, RATHER THAN MASK THEM.
This Self Assessment System is available to you, the reader, on the www.mybacktothewall.com website (the home base for the SFI Portal). Simply click on the Icon that says “forms”. Download and print as many copies as you need. If you are one of our premium Portal members who has a copy of “I Always Sit With My Back To The Wall” on CD, you will also find the forms included on your disc, which you can likewise download and print. You will find the BTTW Self Assessment System discussed in detail in Chapter 4 of “I ALWAYS SIT WITH MY BACK TO THE WALL”. The forms provided to you on the website also contain complete explanations of HOW and WHY the forms should be used by all persons seeking treatment for PTSD.
There are, as you will see, several parts to the Self-Assessment Packet. I will discuss each of these parts in separate blogs. In this blog, I will focus on the part entitled “Vital Signs Record”.
The BTTW Self Assessment Vital Signs Record (VSR) is probably the single most important information you can give a doctor (of any type), or physician assistant from whom you are seeking treatment for PTSD. Here’s why:
1. WHAT IS THE VSR: The VSR tracks three of your four vital signs, 5 times daily, for periods of 1 week, 2 weeks, or 4 weeks. Just as an electrocardiogram tracks the function of your heart over a space of time and creates a “paper trail”, this simple form does something similar by tracking THREE vital functions for a period of days and creating a paper trail. Often, I will take the patient’s results and convert them to the form of a graph, so that the doctor can “see and read” them, much the way he would an EKG strip.
2. WHY IS IT IMPORTANT: Your PTSD is, at root, a chronic reoccurence of the stress response. This response is something that is “ordered” chemically, and then carried out physically, in the body of every person. It is trackable in several ways. One of the ways we can track the stress response is by tracking the vital signs of HEARTRATE, BLOOD PRESSURE AND TEMPERATURE.
3. WHY ARE THOSE IMPORTANT: Vital signs are prime indicators of HOW and WHEN and AT WHAT INTERVALS your body marshals a stress response. For example: Heartate measures how hard your heart is working to boost bloodflow to your muscles, to enable you to physically meet a threat. It is also an indicator of when your body is secreting norepinephrin, the neurochemical that governs cardiac output (how hard your heart pounds and how much blood it moves around). Blood pressure not only reflects whether increased bloodflow is pressing on the inner walls of your vessels, but also may indicate the extent to which you internalize stress, instead of venting it outward. Temperature may signal the presence of an inflammatory response that is prompted by certain stress hormones.
4. WHAT IF YOUR VITAL SIGNS VARY THROUGHOUT THE DAY: They not only WILL vary, but they are, in fact, supposed to vary ! This is why the taking of vital times several times a day, at roughly the same time every day, is so important. By tracking the highs and lows, and by comparing what each vital sign is doing relative to the others at various points in time a trained health care provider can tell alot about what kind of stress responses are going on inside the patient. We call this TRENDING your vitals.
5. WHAT DIFFERENCE DOES THIS MAKE TO A PERSON’S TREATMENT: This takes the patient’s responses out of the realm of “perception” and makes them concrete, physical and real to the physician. It gives the physician the kind of information he / she could never get in a short visit. On the basis of the information YOU provide, the doctor can make informed decisions about how to best medicate you physically, for stress responses that are, in fact, physical. When this occurs, your doctor is treating the problem at the root, instead of masking it.
You can find out more: By reading future blogs in this series, you can learn more about your vital signs, how to trend them, and the relationship between your vital signs and the types of PTSD responses that people manifest.
BY BECOMING KNOWLEDGEABLE ABOUT YOUR BODY’S INTERNAL PROCESSES…
BY GATHERING INFORMATION THE INFORMATION THE DOCTOR CANNOT GATHER…
BY INSISTING THAT YOUR DOCTOR REVIEW YOUR DATA AND DISCUSS IT WITH YOU…
YOU WILL HAVE BECOME A MORE EMPOWERED PARTNER IN YOUR OWN HEALTHCARE AND WILL BE MORE LIKELY TO RECEIVE PROPER PTSD TREATMENT IN THE SHORT TIME YOUR DOCTOR HAS FOR YOU.
More to come, in subsequent installments !
Rev. Dr. Chrys L. Parker
Co-Director of Spiritual Fitness Initiative and Back To The Wall Foundation; Co-Author, “I Always Sit With My Back To The Wall” (Croft & Parker, 2011).