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 | Science in the Cinema 2008 Transcript: Reign Over Me |
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National Institutes of Health
Science in the Cinema 2008 — “Reign Over Me”
Post-Film Discussion — Dr. Meena Vythilingam
Dr. Fuchs: Welcome everyone. Our speaker tonight is Dr. Meena Vythilingam. We are welcoming her back to Science in the Cinema. She was our guest speaker for the film "Fearless" in 2002.
She is a psychiatrist with expertise in post-traumatic stress disorder (PTSD) and currently conducts clinical research in the Mood and Anxiety Disorders Program at the National Institute of Mental Health (NIMH) at the NIH. She completed her medical training in Chennai, India, and then did a residency in psychiatry at the National Institute of Mental Health and Neuroscience in Bangalore, India. She did another residency in Psychiatry at Yale, and after a clinical fellowship, she joined the Yale faculty as an assistant professor. As the associate director of the Yale trauma research program, she was actively involved in the teaching of residents and medical students in addition to conducting research and treating patients.
Dr. Vythilingam came to the NIH in 2001. She is currently investigating hormonal and brain changes in women and men with post-traumatic stress disorder following the exposure to severe traumatic experiences such as sexual or physical abuse and combat trauma. She was the recipient of several honors awarded by the Yale Department of Psychiatry in recognition of her professional achievements, her dedication, and her scholarship. She has authored over 70 publications. Please help me welcome tonight's guest, Dr. Vythilingam.
Dr. Vythilingam: Thank you so much for having me this evening. I enjoy doing these talks because it comes with a free movie.
Movies are a great way to educate people who do not work in the field about mental illnesses because I think it tells the story from a patient's point of view. As a psychiatrist, we see patients in the office, but we don't really live their lives. We hear about it second hand. To see what it's like to live with a disorder and how it affects your relationships and gives you a three-dimensional view, is very difficult to get from a lecture or from sitting in an office and hearing a story. The challenge with learning from movies is to separate the symptoms and signs of an illness from a Hollywood moment. That's the tricky part and that’s what I'm going to try and do today.
What I'm going to do is go back to some of the scenes from the movie, point out Charlie Fineman’s symptoms, and try to give you a flavor for how we come up with a diagnosis and what the diagnosis is. It would have been great to project the specific scene that I'm referring to, but that won’t be possible due to technical limitations. I’m going to remind you of the specific scenes that reflect certain symptoms.
What I'm going to do is comment on the treatment that he pursued in the movie and talk about currently available treatment options for someone with post-traumatic stress disorder. In the first half of the movie, Charlie is really having fun. He's living in the 70s and riding around New York City on a scooter. He's got this terrific collection of vinyl. He's playing computer games. His dentist friend is almost envious of his freedom. And it’s difficult to figure out Charlie’s suffering. From a conversation with his friend the dentist, we hear that Charlie has lost his whole family. He’s lost his wife, his three kids, and their pet.
One scene that really brings the degree of his suffering to the forefront is when we realize, my God, he's running from someone. He’s running from this elderly couple who are his in-laws. He’s running like he’s scared of them. He flees from his in-laws and nearly gets run over by a bus. That’s the degree of his fear. We are shocked to realize that they are just his in-laws.
Over the course of the movie, it becomes clear that he's really putting a lot of effort into avoiding anything or anybody that reminds him of his family. Some examples are that there are absolutely no photographs in his apartment. That is in stark contrast to Alan Johnson's apartment, which is full of pictures.
He avoids his best friend, Sugarman. He avoids his in-laws. When Alan Johnson says his father just died, he says, “Let’s go get something to eat.” He just doesn't know how to deal with death. There’s a lot of avoidance. He avoids conversations about the topic, and he changes the topic whenever someone brings up his family. He's very socially withdrawn. Alan is his first connection with people after a long period of isolation.
When he's pushed, he comes up with a few statements in the movie like, “Look, I don't remember.” “I don't like to remember my family; it's too painful for me to remember my family.” In the first half of the movie, the other symptom that you sort of get an inkling about is that there's something more going on than just an older guy stuck in the 70s. He is unable to sleep. He's got a lot of insomnia. He runs around at night on a scooter. He tries to rope in his reconnected friend to go see movies and to go out to eat. He's really suffering. He's unable to sleep at night. The avoidance and the sleep difficulties affect him more than anything else. But the symptoms that really get him into trouble are the fights and his short fuse.
The first fight is in the bar. Alan says, “Oh, there are a lot of women here.” Charlie perceives that statement as a slight. He perceives the reference to his family as a slight. The second episode where he really loses it and trashes the dentist's office is when he feels that Johnson is trying to focus him. He feels that perhaps Alan has been sent by the Timplemans, Charlie’s in-laws. The third fight is in the context of when Alan sets Charlie up for an unplanned run-in at the record shop with the shrink. In some ways, these outbursts make him realize that, in fact, he does need help. What does he need help with? Charlie says that he has trouble with these painful thoughts and that he does not want to think about. That would be one of the main things he needs to feel better about in addition to his outbursts of anger.
The most important thing to remember is on the surface; it appears that he doesn't want to think about his family. He does not want to think about anything to do with them. He's running away from the Timplemans. From the Timplemans’ point of view, they believe that Charlie doesn’t even think about his family or them. But the fact of the matter is, Charlie is constantly thinking about them. In fact, he’s thinking about them to the degree that it's so painful. He has to work hard to avoid these memories. He says he sees his dead wife, kids, and poodle in crowds. When he sees a woman, it looks like his wife. He sees his children in the people on the street. He sees a German shepherd and thinks it’s a poodle. He's re-experiencing the horrific, traumatic loss every moment of his life. We would classify this as having flashbacks. In a flashback, you lose contact with reality and you're back in time.
The other indication of how painful these memories are is very well illustrated in the court scene where he sees a picture of his family and becomes so emotionally distressed and agitated that he starts singing loudly, acting inappropriately, and has to be taken out of the court. His distress is so intense on just seeing a cue, a reminder of his family.
What is Charlie's diagnosis? Based on these symptoms, it is likely that Charlie has PTSD. What is PTSD? It's an anxiety disorder that follows a traumatic event. The traumatic event can be a rape. It can be physical abuse. It can be combat trauma. It can be traumatic loss.
Charlie’s trauma is very different from the kind of trauma that Alan is having. I wouldn't even call it trauma. I would call it stress. Alan is having trouble at work. He has a patient who is almost threatening to sue him, and he is having marital issues. But that doesn't qualify for the kind of trauma that you need to go through to have PTSD. What Alan has is everyday stress. What Charlie has is trauma. Trauma is a prerequisite to a diagnosis of PTSD.
There are three clusters of symptoms that define PTSD. The first cluster of symptoms, which is not as evident in the first part of the movie, is called the re-experiencing cluster. Charlie is reliving the trauma again and again, years after the trauma is done and gone. It's as if it's happening today; as though his mind is a clock that's stuck at the time of trauma.
The traumatic memories are intruding into his consciousness. He's having flashbacks. The intrusive recollections come in the daytime. They're unwanted, they’re intrusive, and he can't control them. Some patients frequently highlighted in the media are combat veterans who continually have nightmares. In this film, you don't see him having nightmares, but you rarely see him sleeping.
The other hallmark he is experiencing is this intense distress when reminded of the trauma. The second big cluster of symptoms, which are the most prominent set of symptoms that Charlie has, is the avoidance cluster. He is literally in a battle. On the one hand, there are painful memories that intrude on Charlie's mind all the time, even many years after the trauma’s finished. On the other hand, the way his body and mind deal with his intrusive, painful memories is to avoid thinking about it, avoid feeling about it, avoid conversing to people about it, avoid reminders of the trauma, and avoid his in-laws. He becomes isolated because everything reminds him of his family. He's become emotionally restricted. He's sitting at home playing with his computer games until he reconnects with his friend, Alan. Alan has no knowledge of the trauma and has never met Charlie’s family. Alan is a safe person for Charlie to reconnect with.
The third cluster of symptoms is the hyperarousal cluster, which often gets people into trouble with the law. Sleep disturbances are something the person suffers with, but the outbursts of anger, the verbal outbursts, the physical outbursts, and the damage to property are things that can get people into trouble.
The key criterion for diagnosing this disorder is that the symptoms must have occurred for longer than one month. Charlie clearly meets this criterion. There has to be either impaired functioning or intense subjective distress. Clearly, he has both. He stopped practicing. The distress is pretty obvious under circumstances in which he is reminded of the trauma. It is not until midway through the film that Charlie acknowledges that he has a problem. He starts treatment, but the treatment doesn't go quite as well as one would hope.
When you go to a doctor for hypertension, your doctor may give you a prescription for the elevated blood pressure. You don't fight with the doctor, because you know he is competent and that the medicine is necessary. The tricky thing about PTSD is avoidance. Avoidance is one of the hallmark symptoms of PTSD, but in order to treat PTSD, you have to stop avoiding and talk about it. It's kind of a paradox.
Charlie goes to a psychiatrist for treatment after being pressured to do so by Alan. Once in the psychiatrist’s office, he listens to music, peruses kitchen catalogs, and makes comments about [the psychiatrist’s] body. He's not interested in treatment. He's not able to engage in therapy. Finally, the psychiatrist says, “Look. This may be a futile exercise, but you have to tell someone your story. It doesn't have to be me, but someone.” This is where I think it's a Hollywood moment. I would never say this to a patient.
Charlie runs into the waiting room and tells Alan everything. How does Alan respond? He's stunned. He doesn't know what to say. He says one or two words, but then becomes totally silent. How does it end? Charlie walks out of the office and says that he doesn’t want to think about it.
At this point, the movie turns. It becomes very clear that Charlie realizes his is alone. He is alone in the apartment. To some degree, he faces his loss and loneliness. For the first time in the movie, he goes out and drinks alcohol. Prior to this moment, he has been drinking root beer all along. You also see him having flashbacks of his family. He walks through the corridor, sees his kids, and then sees his wife in the bathroom. You start seeing signs of depression creeping in. Until that part of the movie, the depression symptoms are not obvious. After that, the depression symptoms become very obvious.
He finally gets admitted involuntarily to the hospital because he stages a suicide in the presence of the police. Once hospitalized, he becomes progressively disheveled and depressed. That is very common.
PTSD does not occur in isolation. More than 50 percent of patients with PTSD have associated depression. It can also go hand-in-hand with alcohol and drug abuse to dampen the intense emotions that the individual feels.
Charlie eventually gets discharged after a three-day evaluation. But the big debate is whether he should be left to find his own way or undergo more intensive treatment on an inpatient basis for one year. The in-laws decide to let him find his own way. Conveniently, there's a very attractive woman who wants to rescue him and mend his broken heart. We don't quite know how it all worked in the end. We don’t know if this attractive woman was able to persuade him to go back and see the psychiatrist. We don’t quite know how it all works. But it looks like he won’t be hospitalized for one year.
What are the possible treatment options for someone like Charlie, besides being rescued by a potential partner? I'm not recommending that as a treatment.
Well, actually, I should be careful. There are no double-blind controlled studies evaluating the efficacy of the partner’s role in treatment response. Has anybody seen "Minority Report" with Tom Cruise? That is a fantastic way to prevent PTSD. For people who have not seen “Minority Report,” Tom Cruise catches the bad guys before a bad crime happens. Essentially, it's called primary prevention of trauma. You get the bad guy and you prevent the traumatic event from happening. So if you prevent the event from happening, there's no one who gets traumatized and gets PTSD. Obviously, we're not at that stage in our lives. There are many events that cannot be prevented. An unfortunate few do undergo traumatic events, particularly in this climate where there is an active war going on. Currently, there is a high rate of PSTD in the returning soldiers. The most important question is, What kind of help can we offer to these individuals who are suffering?
The following therapies that I am going to speak about are not necessarily in their order of importance. They may all be important used in combination. The first component is medication. The second component is psychotherapy. Both medication and psychotherapy are important. The third component is family therapy and building on the patient’s social network. In Charlie’s case, building the association network comes much later in the hierarchy of importance. In Charlie’s case, he has very severe PTSD, associated depression, and suicidal thoughts. With these symptoms, medication will likely play a very important part in his recovery as well.
The medications that have been approved by the Food and Drug Administration (FDA) for PTSD belong to the class of drugs called selective serotonin reuptake inhibitors (SSRIs). Three SSRIs have been approved for PTSD: Sertraline, Fluvoxamine, and Paroxetine. The one problem with using SSRIs in the treatment of PTSD is that the benefits are modest. They may be effective only in about 60 to 70 percent of PTSD patients. In addition, drugs may have unwanted side effects, and patients may be reluctant to take them. In those cases, the patient may prefer talk therapy instead of medication. It doesn't look like Charlie is the kind of a guy who would want talk therapy. He seems like the kind of guy who would want drugs first and engaging in talk therapy later, once trust has been established. In the medical field, talk therapy is actually referred to as cognitive behavioral therapy. In the treatment of PTSD, a very specific type of cognitive behavioral therapy has been shown to be very effective. The type of therapy routinely used in PTSD patients is called “exposure therapy.”
The key question here is that if Charlie is really afraid of talking to his in-laws, of thinking about the traumatic event, and of looking at family photos, how can he overcome this?
Audience Member: By facing it.
Dr. Vythilingam: Yes. He must face his fears. That sounds like a nice mantra, but it may be a long and difficult process. For example, let's say it’s summer and you have decided to take your child to the beach. The child then plays in the water. All of a sudden, a huge wave comes in and engulfs the child, and he no longer wants to go back into the water again because he is afraid. How do you get that child to go back on the beach? You start by helping your child to gradually feel safe again in that context. You may start by spending the first day in the hotel room, looking out at the ocean. The next day, you may bring the child out to the beach, but not into the water. Later, you may be able to get the child to ride a float in the water while you are present, etc. Gradually, the child eventually faces what they are afraid of.
If you run away from something, then it becomes very scary. The more you try not to think about something, the more intrusive it becomes. Let's try something. I'm going to ask all of you to think of anything except a pink elephant with wings flying in the air. What image do people get in their heads? You see, the more you try not to think of it, the more it’s going to come back in your head. That's probably what's happening with Charlie. He's trying so hard not to think of his family. Is he succeeding? No, he is not. Avoidance is not a terrific way to cope with a painful experience. Facing your fears, as cliché as it sounds, is really the only way to make the traumatic memory less scary.
Exposure treatment helps an individual face their fears repeatedly until the memory of the trauma becomes less scary. This process is called habituation. By saying it repeatedly to a person you trust and have a connection with, you begin to process and digest the traumatic experience. Eventually you will have mastery of the trauma. That is exactly what happens to Charlie. In the end, he is back in the driver’s seat. The caveat here -- which is why I said it was a Hollywood moment — is that it needs to be done in a supportive, professional environment. Clearly, if it’s done with Alan, he didn't quite know how to respond when he heard this horrific trauma. The key is that it needs to be done under professional care because it's going to generate a lot of emotion. It is extremely distressing for the person, and there needs to be a wrap-up. There needs to be processing of this traumatic experience. The psychiatrist should not have let Charlie walk out of the office, as happened in the film. She should have invited him back. It was a short session, and he was still paying her.
In closing, I want to reiterate that there is help for patients with PTSD. People with PTSD and depression do not have to walk alone. There is help available in the medical community and support networks. I'm open for questions.
Question: Can you talk a little bit about the risk of retraumatization through what you’re calling exposure therapy and about some of the action-oriented therapies, such as psychodrama and art therapy, that help a person to more gently look at some of these issues? I heard one side of it. I didn't hear the other part of it.
Dr. Vythilingam: I think this is a very important question. If you are talking about this trauma, are you really opening up raw wounds? Are you unnecessarily making it more difficult and painful for that person? The key question is, is it worse to have people talk about their trauma, or is it better to cover it up and let the wound fester inside? If it were a shrapnel wound, would it be better to surgically open it up and get the shrapnel out? I'm being very concrete here. The best way is to go back and look at the data. There are several studies that have actually looked at what happens to PSTD symptoms when people talk about their traumatic experience. What happens to their stress hormone system? Does the stress hormone go up? Does the PTSD symptom severity go up? How do people feel at the beginning of the interview, the end of the interview, one week later, and two weeks later?
There's no evidence to show that people actually get worse after talking about their trauma in terms of objective ratings. They might feel that they are more distressed, but they also report that they are relieved after talking about it. They return and say that they are glad they were able to “get it out.” The ratings are either unchanged or improved, but not worse.
The other hallmark study on talk therapy and PTSD actually looked at stress hormone response. Researchers observed the level of stress hormones while patients talked about their traumatic event. There's no evidence to show that cortisol, which is a stress hormone, increases while talking about the trauma.
If you look at the data, there's no clear evidence to show there's retraumatization. On the other hand, if you look at the treatment studies that look at what happens to ratings over time, prolonged exposure treatment is one of the most effective treatments for PTSD. Nobody has done head-to-head comparisons between prolonged exposure versus drugs versus combination. But statistically, there's some evidence to show that talk therapy may be as effective, if not slightly more effective, than medicine. However, more detailed studies still need to be done.
In terms of the second question, what about other therapies, e.g., art therapy, drama therapy, meditation, and relaxation? I think these are extremely important adjunct strategies. There is also a study on the role of aerobic exercise. In terms of all of these strategies, there's drama, there's poetry therapy, there’s several therapies, and I think it's important to say that all these therapies probably have a particular role for certain kinds of patients. The kind of patient this could be effective for or whether it's going to be effective for a large group of patients has not been tested yet. The studies that have tested specific interventions (other than exposure therapy) are aerobic exercise and meditation. Aerobic exercise has been shown to reduce PTSD symptoms, and mindfulness-based and breathing meditation practices have been shown to reduce PTSD symptoms.
If a patient comes to me and says, “You know what? Art really relaxes me, and I feel like I'm in a much better place doing art in terms of my symptoms,” I would absolutely support the patient in doing so. I hope that answers your question.
Question: How should Alan have responded when Charlie talked about his trauma? Should he have said, “There, there, poor baby”? What would be the appropriate response in the context of their relationship?
Dr. Vythilingam: I think that's a very difficult question. Alan is a dentist. He's just being a good friend. He's being a supportive guy. There's been plenty of evidence throughout the movie that he's got a lot of trouble communicating. He can barely finish a sentence. He stutters and fumbles for words. He's disconnected from his wife and disconnected from his feelings. So he's being a friend and accompanying Charlie on his journey. If Alan was able to respond, then I definitely think that instead of letting Charlie leave the office in such a way, Alan could have brought him back and turned him over to the psychiatrist. He could have explained that he is still paying the psychiatrist for her time. He could also remind her that “Charlie had just spilled his guts to me” and that he doesn’t know what to do. He should have asked the psychiatrist to please help him.
The other way to deal with the situation would have been to sit with Charlie and let him talk until he gets calmer. As the film shows, by letting Charlie run off, he ended up back in his apartment, where he starting drinking alcohol and pulling out his gun. Alan should have sat with him long enough to get him back to his baseline or turn him over to a professional for help.
Question: You said earlier, in the first half of the movie, he seemed to be happy and doing okay. When he gets reacquainted with his friend, Alan, things start getting sticky. Is this a very dangerous period for the PTSD patient — going from a point where the patient is coping at some level and then they are asked to talk about the traumatic event and seek professional help?
I have another question about the woman who also sees the psychiatrist. She is clearly troubled and has gone through a bad divorce. She reaches out to Charlie. Is this normal for one patient to reach out to another? Does this infer some kind of codependency or something — a need to save someone she views as her soul mate?
One last thing, I heard a show recently where they were talking about using computer stimulations for troops coming home from Iraq. Do you think that might be helpful?
Dr. Vythilingam: In response to your first question about leaving Charlie alone, I think I've addressed that briefly. If Charlie was living as if he were still in the 1970s, if he had enough money to live on, if he was renovating the kitchen and not bothering anybody, if he was running away from the Timplemans and they understand it and accept it, if he's sleeping a-okay, and not getting into trouble, I agree with you that it's a dilemma. Everyone knows that he's deeply affected and he's isolating and he's in pain. But if he does not convey that he's in extreme distress and if he's functioning, he’s taking care of himself, he’s able to keep up with his bills and carry on with his life, then the question is, Do you treat him or do you let him find his own way? I think that's a very important question.
The reason I think Charlie would need treatment is because that's not the case. There are several incidences where he's actually gotten quite suspicious of Alan for innocuous statements. In the bar, he gets really upset when Alan makes the statement, “Hey, you’re single now.” Charlie lashes out saying, “Who sent you? Who told you?” He gets very suspicious and irritable and throws a drink on Alan. The second incident is when Charlie trashes the dentists’ office for a perceived statement that Alan could be trying to focus him. Those kinds of incidents make it much more likely that he's not a quiet avoider. That's a huge problem in terms of diagnosing PTSD. We get the reports from the Iraq and Afghanistan wars that the rates for PTSD are very high. We know the rate of occurrence is between 20 and 25 percent, but we don't know how many people avoid talking about it. Avoidance is an integral symptom of PTSD.
In Charlie's case, I think he would need treatment because of the specific incidents that I mentioned combined with the fact that he is not sleeping, is irritable, and has violent outbursts.
Your second question was about how to define trauma. I think it's a very important question. The female patient also seeing Charlie’s psychiatrist had a very horrible divorce. Her husband was cheating on her for many years in the marriage. The question is, Is that trauma? The way we think about trauma is that there are very specific criteria we follow. Specifically, the person has to experience, witness, or be confronted with actual or threatened death, severe physical injury, or threat to physical integrity.
Death and severe injury are pretty obvious. Threat to physical integrity, e.g., rape, also falls under this category. These are the three broad categories of the kinds of trauma that may qualify an individual as having an anxiety disorder, such as post-traumatic stress disorder. Divorce, as horrible as it is, does not fall under this category. Divorce would fall under the rubric of stress as part of everyday life. It would not fall under the rubric of trauma, unless physical or sexual abuse is involved.
In terms personality issues, the female psychiatric patient who reaches out to Charlie to try and rescue him thinks it's just a case of broken heart and that she can fix it. There's a certain vulnerability about Charlie, and there's a vulnerability about her. There are all sorts of reasons why people get together. I think those are things it might be hard to dissect from the movie. It was not clear that she had post-traumatic stress disorder. She was probably extremely depressed. The way she acted out in the dentist’s office suggests that she was acting out on some kind of sexual fantasy, but we don't know for sure. There is not enough information provided about her character in the film to determine if she was suffering from PTSD.
Your third question was about the role of computer-generated virtual-reality techniques in the treatment of PTSD. I completely agree with you. It is a wrinkle on exposure-based treatment. There's a study that came out in 2007 that looked at World Trade Center–related PTSD subjects and exposed them to a virtual-reality program that involved seeing clips from the World Trade Center events. They were exposed to the first plane, the second plane, and then people falling out of the towers. This is graded virtual reality, where the person is exposed to these pictures and has to relive this trauma with their own story. They found that it did indeed improve symptoms of PTSD after a few weeks.
The authors of that study say that it could have a role in people with very high avoidance symptoms. They have such difficulty talking about the trauma, maybe they need a little sensory help. Maybe they need a little bit of prompting to enhance the emotional engagement. The jury is still out, there is a study going on right now in Iraq- — Operation Freedom and Operation Enduring Freedom. They are comparing how virtual-reality exposure therapy compares with prolonged exposure therapy. That's the exact question that needs to be addressed.
Question: I have more of a comment than a question. I want to go back to your Hollywood moment. You kind of contradicted yourself in saying that for the person suffering with PTSD, sometimes talk therapy is the best thing for them. From personal experience, you know, some people I know who have needed talk therapy have found that talking to friends is far more therapeutic for them and beneficial for them and makes them feel a whole lot more comfortable than talking to a therapist. Being a friend, you wouldn't want to disrespect that friendship by saying, “Okay, now let's go back to the doctor.” I don't think that I could do that. I also want to address another comment that you just made with that last question. You stated that you didn't think divorce could lead to PTSD. I've worked as a teacher for many years and I know many kids that are classic PTSD, having gone through very bitter divorces and custody cases.
Dr. Vythilingam: Okay. Let's talk about the first comment. I think it's a very important point you're raising. The question is, What is the role of friends and support in the recovery of someone with PTSD? I would not minimize the role of support and friends with PTSD, but there are no studies to show that supportive therapy alone can improve symptoms of PTSD. What you get from friends is a lot of support, comfort, and a certain trust. You can say things to family and friends that may take years to tell a therapist, although you're seeing them on a weekly basis. It's a very comfortable, supportive relationship.
There have been studies that looked at the “special ingredient” that makes people better. Is it talking to someone who's supportive? Therapies can also use supportive techniques. So if you go and see someone on a weekly basis and the person's job is to listen and to offer support, that's going to make the person feel good. You definitely walk out saying, “Wow, I have a confidant, I have someone I can talk to.” I think having a supportive network is priceless, but is that going to actually improve your PTSD symptoms? That is a different question. I would strongly encourage everybody to support their friends who are suffering. Part of being a supportive network is doing exactly what Alan did. He said, “Look, you need help. I’m here to support you as a friend. I will go out with you at night. I will ride on your scooter. I will play Colossus with you. I will play drums with you, but you need help.” I think it's very important to do both.
If Charlie was going to see the psychiatrist, Angela Oakhurst, and she was only seeing him on a supportive basis and not moving to the next phase, it's okay to start with supportive techniques. It's hard to start with exposure techniques right away. You've got to earn the trust. You've got to learn the logic of exposure-based treatment. It's okay to start with supportive, but it's also important to add additional techniques.
The second question, in terms of how divorce affects children, I did not address because the film was about an adult facing divorce because of her cheating husband. If children are involved in a divorce, it would be very important to get the whole story. Children do get affected. There is a lot of guilt. They feel they caused the divorce. Physical and sexual abuse may also be present.
Question: This is about the woman who proposed sexual advances toward the dentist. At the end of the film, it seemed to me that the dentist, the woman, and Charlie seemed to indicate by their looks to each other that there was going to be some future camaraderie. Do you think that would be beneficial? Also, if Charlie were to undergo therapy for several years, what do you think Charlie would look like as a human being?
Dr. Vythilingam: So the first question, unfortunately I'm not so gifted in differentiating between sexual arousal and camaraderie by looking at the movie. What's important to recognize is that she could become one of his important support networks. Charlie also has his friendship with Alan. Maybe his network will expand and slowly encourage him to move toward a more mainstream lifestyle.
In response to your second question, about two years of therapy of the kind and duration we're talking about for prolonged exposure, in reality, prolonged-exposure treatment that we conduct is 12-week sessions. This amount of prolonged exposure should improve PTSD symptoms significantly. Medications can take up to six weeks to work. Two years of therapy is ample time for improvement if he responded to medications, connected with his therapist, and was able to address some of the trauma issues. We would expect him to get back to his pre-trauma level of functioning.
Charlie has the complicating factor of losing his wife and three children. For a parent, losing the child is the worst thing that can ever happen. To expect Charlie to totally forget the loss, put it behind him, and move on with his life like it never happened may not be realistic. Perhaps expecting him to practice medicine, consider new relationships, or even consider the possibility of reconnecting romantically with someone would be positive signs. You want that person to be able to balance their life, i.e., to love and work. If Charlie can love and work, sleep well, not be so irritable, have a social network, and have meaning in his life and not see the emptiness and no point in living, then I would say that would be a great outcome.
Question: To Alan's credit, I was pleased when he responded well to Charlie at the Chinese restaurant — when Charlie was talking about feeling very guilty about his last conversation with his wife. This brings me to my question. I work across the street on the Uniformed Services University of the Health Sciences campus. I am in the Center for Deployment Psychology. Since moving to this area, I have been surprised about the standard of care for trauma patients. Why do trauma specialists in this area seem to leave out important therapies such as cognitive processing therapy? In randomized controlled trials, cognitive processing therapy has been shown to work very well for things like guilt, guilt cognition, shame, and all those emotions that really don't fall under the picture of PTSD as described in the film. Could you please talk about that? I appreciate it. Thank you.
Dr. Vythilingam: You're referring to people who don't know what cognitive processing therapy (CPT) is. It's another school of treatment. CPT and exposure therapy both address some of the distorted-thinking patterns. For example, let’s say Charlie had gone to Disney World or somewhere else and shouldn't have gone to the cousin's wedding; “I could have avoided the whole accident.” So there are ways that therapists can work with the distortions and the feeling about their own contribution to the trauma and their view of the world.
You asked about CPT as an effective treatment for trauma in randomized, controlled clinical trials. Prolonged-exposure treatment has a cognitive processing component. Part of what happens with exposure therapy is that it includes a cognitive component of the prolonged exposure. I see them as complementary or synonymous, with two different labels.
Question: Is there a concept called habituation in therapy? I remember I heard that term.
Dr. Vythilingam: Habituation is one of the fundamental concepts of prolonged exposure. The concept behind habituation is that the more you talk about the trauma and you talk about the specific event, your fear of the memory becomes less. So you habituate to the fear of the traumatic memory. That's the whole logic with prolonged exposure or CPT.
Dr. Fuchs: Something that didn't come up is the link of alcohol and suicide. One of the things I like to forget about is that I had a dear friend in the ’70s who was a football quarterback. He was in a terrible car accident and was paralyzed. He became an alcoholic over time and eventually committed suicide. I'm wondering what is known about the link between alcohol and suicide. In the film, Charlie uses alcohol before a suicide attempt, although it was depicted in an acute way, not a chronic way. So what is known about the link?
Dr. Vythilingam: I think there are many links. One link is between PTSD and substance abuse. Patients with PTSD are much more likely to use drugs and alcohol. This has become a big problem with the returning veterans. Once alcohol is in the picture, it could act in multiple ways. It clearly is a depressant. It can change people's moods. It can depress, causing depressive symptoms. There can be mood symptoms related to alcohol. When you're coming off of alcohol, there can be withdrawal-related mood symptoms. Then there are mood changes with recurrent alcohol, cocaine, or other drug uses. Then your mood changes, your depression comes on board, and then there are suicidal thoughts, e.g., “There’s no point in living,” “I'm hopeless,” or “My life is not going to get better.”
There are many links between PTSD, drug and alcohol use, and suicide. That's one of the main reasons why it may not have been best for Charlie to find his own way. From the film, we cannot determine if he has a one-time drink or if he's going to go back to it. Maybe it gives him temporary relief, but if he gets addicted, that needs to be addressed. The mood symptoms also need to be addressed.
Dr. Fuchs: Thank you, Dr. Vythilingam. This ends our Science in the Cinema series for 2008. I would like to thank everyone who helped to make this year’s program a success. I hope you'll come back next summer. |
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