Recognizing Posttraumatic Stress Disorder Awareness Month

Unfortunately, mental struggles are often given scant attention in the media. Many people are surprised to learn that others struggle with the same difficulties. Although posttraumatic stress disorder (PTSD) has been getting more media attention lately because of the recent wars in Afghanistan and Iraq, I was pleased to learn that the secretary for Department of Health and Human Services (HHS) released a statement  recognizing Posttraumatic Stress Disorder Awareness Month. She writes:

During PTSD Awareness Month and on PTSD Awareness Day, June 27, 2012, we focus national attention on this debilitating condition and renew our commitment to support research, education, and treatment for those living with PTSD, as well as for their friends and families.

National recognition and focus on this often debilitating yet treatable problem is a wonderful step in helping people access needed services. I encourage you to read Ms. Sebelius’ statement yourself, and to pass it on to others.

Exposure Therapy on TV – “My Extreme Animal Phobia”

Not long ago my girlfriend stumbled across a YouTube video from Animal Planet’s show “My Extreme Animal Phobia.” It features a segment from the show involving a tough-looking, heavily tattooed man who is terrified of pit bulls. The fear is so intense the man breaks down in tears when a psychologist takes him to a park and confronts him with a pit bull puppy.

Since then, I continue to see the video pop up in unexpected places and thought I’d comment on it.

What Kind of Therapy is THAT?!

The man’s name is Marvin. He’s 47 years old, and according to his interview, he’s been terrified of pit bulls since he was a young child and he watched a neighbor friend viciously attacked.

The man in the video received some form of what’s called exposure therapy. Exposure therapy has been around for several decades and is one of the most effective treatments out there, particularly for fear and anxiety-related problems. For someone interested in getting over an extreme fear of dogs, some form of exposure therapy is the best bet.

However, I was little concerned by how the exposure therapy comes across in this segment. My concern: although I think it’s great that a well-researched, effective treatment such as exposure therapy is getting press, I worry that the way it is dramatized on TV may scare people away from it.

Full disclosure: I turned down an offer once—for many reasons—to  conduct on-camera exposure therapy for a TV show about people who claim to have experienced some sort of supernatural or paranormal experience.

The Therapist

According to her website, the therapist Robin Zasio, Psy.D. is a licensed clinical psychologist and licensed clinical social worker. Dr. Zasio appears to have reasonable credentials and seems to specialize in exposure-based treatments.

Exposure Therapy is Usually Conducted in Graduated Steps

When conducting exposure therapy, it’s common for the therapist to come up with a list of feared situations or experiences–commonly called a “fear hierarchy”–and rank them. Collaboratively, they then choose exposure sessions of increasing difficulty.

In the video, as they enter the park, Dr. Zasio says something really striking: “You don’t go to parks, do you?” Marvin says he stays away because “they’re dog friendly.” It’s quite likely Dr. Zasio already knew this, and that her question was for the audience—Marvin mentions in another part of the segment that he doesn’t go to parks with his family because of his fear. Regardless, if I were working with this person, going to the park would be an exposure exercise in itself. Given Marvin’s fear of parks, I think that most exposure therapists would discuss with him to possibility of having him visit the park several times as an exposure exercise in itself. The goal might be to eventually have going to the park be an enjoyable activity for him and his family.

However, this isn’t how it plays out on the show. Instead, while Marvin is seen reeling from being at a park, someone suddenly comes up with a pit bull puppy on a leash. The segment is obviously edited down, so it’s unclear how much time it takes for the puppy to get to Marvin. Dr. Zasio comforts Marvin as he reacts with fear and cries.

It’s a little stagey, but okay. Then Dr. Zasio says something that disturbs me. She tells Marvin, “I know you’re going to be scared but you’re going to have to touch the dog before you leave, I’m sorry.”

Excuse me? He’s going to “have to touch the dog?” I still tense up as I write this.

Even with a graduated approach, exposure therapy is often very intense for people. It’s part of the therapist’s job to gently guide the client through it. The details of it are agreed upon in advance (e.g., “For 30 minutes, you’ll stand within 5 feet of the snake”). It’s possible that Dr. Zasio and Marvin agreed in advance that Marvin would pet the dog. It’s not implied in her command, but it’s quite possible. The way she phrases it though—“you have to”—veers dangerously close to bullying, in my opinion. Marvin doesn’t “have to” do anything. He may choose to. He may even have agreed to. But he doesn’t have to.

Concluding Thoughts

I realize that it makes for better TV for fewer to watch an intensely distraught Marvin get over his fears by petting a pit bull puppy in the park. I get it. It doesn’t make for good therapy, though. My concern is that viewers watching don’t get a sense of how gradual and collaborative exposure therapy should be. Ideally, the therapist and Marvin would plan out steps in advance while gradually working up to Marvin petting a pit bull. There would be no surprises and nothing would be planned without Marvin’s explicit consent. As I mentioned, it’s quite possible that this all happened and was left on the cutting room floor.

Exposure therapy can be very intense for people. No doubt about it. At the very least, I hope the show is able to humanize how painful these sorts of experiences can be for people like Marvin. (Sadly, from comments I’ve read, some people find the juxtaposition of a tough-looking guy brought to tears by a puppy amusing—which is really unfortunate.) For these reasons, it’s important that exposure be conducted in a safe and collaborative fashion—with no surprises.

What I hope people take from this is: 1) yes, exposure is a remarkably effective treatment for a range of fear and anxiety-based problems and 2) exposure should always be conducted safely and collaboratively.

Anxiety Treatment at Portland Psychotherapy

 Not long ago my girlfriend stumbled across a YouTube video from Animal Planet’s show “My Extreme Animal Phobia.” It features a segment from the show involving a tough-looking, heavily tattooed man who is terrified of pit bulls. The fear is so intense the man breaks down in tears when a psychologist takes him to a park and confronts him with a pit bull puppy.

Since then, I continue to see the video pop up in unexpected places and thought I’d comment on it.

What Kind of Therapy is THAT?!

The man’s name is Marvin. He’s 47 years old, and according to his interview, he’s been terrified of pit bulls since he was a young child and he watched a neighbor friend viciously attacked.

The man in the video received some form of what’s called exposure therapy. Exposure therapy has been around for several decades and is one of the most effective treatments out there, particularly for fear and anxiety-related problems. For someone interested in getting over an extreme fear of dogs, some form of exposure therapy is the best bet.

However, I was little concerned by how the exposure therapy comes across in this segment. My concern: although I think it’s great that a well-researched, effective treatment such as exposure therapy is getting press, I worry that the way it is dramatized on TV may scare people away from it.

Full disclosure: I turned down an offer once—for many reasons—to  conduct on-camera exposure therapy for a TV show about people who claim to have experienced some sort of supernatural or paranormal experience.

The Therapist

According to her website, the therapist Robin Zasio, Psy.D. is a licensed clinical psychologist and licensed clinical social worker. Dr. Zasio appears to have reasonable credentials and seems to specialize in exposure-based treatments.

Exposure Therapy is Usually Conducted in Graduated Steps

When conducting exposure therapy, it’s common for the therapist to come up with a list of feared situations or experiences–commonly called a “fear hierarchy”–and rank them. Collaboratively, they then choose exposure sessions of increasing difficulty.

In the video, as they enter the park, Dr. Zasio says something really striking: “You don’t go to parks, do you?” Marvin says he stays away because “they’re dog friendly.” It’s quite likely Dr. Zasio already knew this, and that her question was for the audience—Marvin mentions in another part of the segment that he doesn’t go to parks with his family because of his fear. Regardless, if I were working with this person, going to the park would be an exposure exercise in itself. Given Marvin’s fear of parks, I think that most exposure therapists would discuss with him to possibility of having him visit the park several times as an exposure exercise in itself. The goal might be to eventually have going to the park be an enjoyable activity for him and his family.

However, this isn’t how it plays out on the show. Instead, while Marvin is seen reeling from being at a park, someone suddenly comes up with a pit bull puppy on a leash. The segment is obviously edited down, so it’s unclear how much time it takes for the puppy to get to Marvin. Dr. Zasio comforts Marvin as he reacts with fear and cries.

It’s a little stagey, but okay. Then Dr. Zasio says something that disturbs me. She tells Marvin, “I know you’re going to be scared but you’re going to have to touch the dog before you leave, I’m sorry.”

Excuse me? He’s going to “have to touch the dog?” I still tense up as I write this.

Even with a graduated approach, exposure therapy is often very intense for people. It’s part of the therapist’s job to gently guide the client through it. The details of it are agreed upon in advance (e.g., “For 30 minutes, you’ll stand within 5 feet of the snake”). It’s possible that Dr. Zasio and Marvin agreed in advance that Marvin would pet the dog. It’s not implied in her command, but it’s quite possible. The way she phrases it though—“you have to”—veers dangerously close to bullying, in my opinion. Marvin doesn’t “have to” do anything. He may choose to. He may even have agreed to. But he doesn’t have to.

Concluding Thoughts

I realize that it makes for better TV for fewer to watch an intensely distraught Marvin get over his fears by petting a pit bull puppy in the park. I get it. It doesn’t make for good therapy, though. My concern is that viewers watching don’t get a sense of how gradual and collaborative exposure therapy should be. Ideally, the therapist and Marvin would plan out steps in advance while gradually working up to Marvin petting a pit bull. There would be no surprises and nothing would be planned without Marvin’s explicit consent. As I mentioned, it’s quite possible that this all happened and was left on the cutting room floor.

Exposure therapy can be very intense for people. No doubt about it. At the very least, I hope the show is able to humanize how painful these sorts of experiences can be for people like Marvin. (Sadly, from comments I’ve read, some people find the juxtaposition of a tough-looking guy brought to tears by a puppy amusing—which is really unfortunate.) For these reasons, it’s important that exposure be conducted in a safe and collaborative fashion—with no surprises.

What I hope people take from this is: 1) yes, exposure is a remarkably effective treatment for a range of fear and anxiety-based problems and 2) exposure should always be conducted safely and collaboratively.

Can Light in the Ears Cure the Winter Blues or Do You Need a Hole in Your Head?

Here in Portland, seasonal depression, commonly called the Winter Blues or Seasonal Affective Disorder, is relatively common. Up to 20% of the population in the rainy Pacific Northwest may be impacted. I’ve written more extensively in another blog about the Winter Blues and how light boxes are an effective treatment.

It’s not available in the U.S. yet, but a Finnish company is marketing a new device called “Valkee.” It looks like an iPod, except instead of digital music, the headphones shine light into your ear. Yes, that’s right, the Valkee has small ear buds that shine light into your ear.

Why would shining bright light in your ear help with seasonal depression? Here’s where things turn a little fuzzy.

Why Light Boxes Work

Perhaps we might start with light boxes, the treatment with the greatest research support for the Winter Blues. With light box therapy, people sit in front of specially-designed devices that give off light at a specific intensity or lux—10,000 lux is optimal for bright spectrum white light boxes.

Light serves as a signal to our brain that it’s daytime. The accepted pathway is through our eyes. When light hits our retina, it sends signal to our brains; specifically, the signals travel to an area called the suprachiasmatic nucleus (SCN). This area controls our circadian rhythms or internal clock.

The shorter days and dark mornings of the fall and winter months, particularly in northern latitudes such as Portland, can lead to a desynchronization between our internal clock and our actual day. Light box therapy is a way to fix this. Regular use of a light box before dawn can signal to the brain that it’s time to get up and start our day, even though it’s dark and cloudy out.

Here we have a well-researched pathway and mechanism of action: daylight in our eyes signals to the brain that it’s time to get up, cueing up our circadian rhythms (aka our internal clock). Why would shining a light in our ears be a more effective pathway? This is unclear to me. It’s not as if we spend our summers tilting our heads so that the sunlight can stream into our ears.

But Valkee Makes Some Pretty Unlikely Claims

The company cites results from research studies that suggest their device has some very impressive outcomes. Perhaps a bit too impressive. For example, one article claims that “92% of people with SAD achieved full remission” from depression. If you’re familiar with depression research, a 92% response—particularly with “full remission”—is an incredible claim. As a point of comparison, with light box therapy, the most well established treatment, about 60-70% of people respond—and here we’re talking about decreases in depressive symptoms, not necessarily full remission.

Let’s Take a Look at Valkee’s Research

The Valkee website has a tab for “Evidence,” listing research studies. If the device is as incredibly effective as the company suggests, you might expect to find citations in high-ranking peer-reviewed journals where other researcher could look over the results and study them. Respected scientific journals serve as a gateway for quality research.

Instead, the only citations for the device are from conference poster presentations. Curiously, the poster presentations are all from 2011. There’s nothing wrong with poster presentations, but you don’t need a high quality study for a conference to accept a poster presentation. In fact, it’s not uncommon for people to present posters at conferences for studies that they haven’t yet conducted (as a way to get feedback).

[UPDATE 03/2014: Someone at Valkee has since pointed out since I wrote my orginal post a few years ago that they have expanded the research section on their website. The research does not alter my overall opinion, but I wanted to note that there are more studies listed. ]

[UPDATE 9/2014: We have written another article on the Valkee in light of new information on the device since this article was written]

Normally with any scientific treatment, there is a period of testing and refinement before it’s made available to the public. With the Valkee, we have a slick-looking device that was released before any research has been published.

Should I Buy a Valkee?

From what I’ve seen, I’d hold off on exchanging your hard-earned dollars for euros and plunking down your hard-earned money (£185 or $240) for a Valkee. (It’s not available in the US yet.) The plausibility for the why it works is unclear, and the research supporting its effectiveness is very limited. I could wrong—perhaps future research will show that shining light in your ears is a more effective treatment for the Winter Blues than light boxes. However, the Valkee may be little more than an expensive flashlight. And it doesn’t even play MP3’s.

Should I Be Taking “Alternative” Supplements for Anxiety?

More and more, I have clients coming into see me who are taking over-the-counter “natural” or “alternative” products. Sometimes these are recommended by a specialist, sometimes by a friend. I was curious about these alternative products and did a little research about what they are—and whether there’s any evidence of their effectiveness. I came across a helpful 2010 review by Zoberi and Pollard, two researchers at the Saint Louis University School of Medicine, and supplemented their paper with some of my own investigations.

St John’s Wort

St John’s Wort (Hypericum perforatum) is derived from a plant species and more commonly known as an alternative treatment for depression. It’s available in natural food stores in capsule form, tinctures, and even tea. There’s some evidence that St. John’s Wort may be helpful for mild depression, but there’s no research to suggest it helps with anxiety.

Valerian

I first heard about Valerian (Valeriana officinalis) years ago when it was touted as a sleep aid and even tried it once for sleep (seemed okay). Valerian is a perennial flowering plant that blooms in the summer. It’s been used as a sedative, historically, which is probably why it’s being marketed as a possible supplement for anxiety. Like St John’s Wort, it can be found as capsules, teas, and tinctures.

A review by the Cochrane Collaboration, a non-profit organization aimed at providing the public with summaries of the best scientific medical research, examined available studies on Valerian. Only one study was considered of a high enough quality for the Cochrane authors to seriously consider it.
The Cochrane Review concluded that Valerian had no more of an impact on anxiety than a non-active placebo. Consequently, there’s no reason to believe at this time that Valerian is useful for treating anxiety.

Kava

Kava (Piper Methysticum) is a plant found among islands in the Pacific Ocean that many Polynesian cultures traditionally turned into a drink and used as a sedative or relaxant. People still make Kava into a drink, but pharmaceutical companies have also converted it into pill form.

The Cochrane Review also looked at the impact of Kava on anxiety. Their results were a little more promising than Valerian: the Cochrane Review concluded that there is some evidence that Kava may have a small impact on reducing anxiety.

The Cochrane Review didn’t feel the side effects of Kava were anything to worry about, but I have elsewhere read that Kava may cause liver damage. Not everyone has problems with Kava, but some people have required liver transplants because of it. The FDA issued a warning about these dangers in 2002, and my understanding is that government funding for studies of Kava were suspended (Zoberi & Pollard, 2010).

Consequently, it appears the potential benefits from Kava are a little iffy and don’t necessarily outweigh the potential dangers. (At the very least, I’m not comfortable recommending something that may cause liver damage.)

Some conclusions and reflections

It’s hard to sort through information on alternative products, as enthusiasm for them often outstrips the research. Perhaps some of you know people who swear by these products. An important point to consider is placebo.

We often think of placebo as something that doesn’t work, but this is only partially true. Many people respond to being given a pill or treatment—more so than they would have if they were not given the pill—even if there’s nothing active in the pill (i.e., sugar). This is a crucial point: believing that a pill or supplement will work can often result in short-term benefits, even if the product has no actual benefits. (If you’re interested, here’s a great short video on the power of the placebo effect.) Consequently, if you read the Cochrane Reviews that I linked to, you’ll notice that they focused on studies where people were blind to whether they were being given the alternative treatment or something inactive.

Another point is that, as Kava illustrates, a substance can be natural and still toxic. Too often I see people equate “natural” with “harmless.” Much of the time this is true, but it’s important to be careful.

At this point, I couldn’t recommend any alternative supplements for anxiety based on the research I’ve seen.

Anxiety Treatment at Portland Psychotherapy

What do people think is the best treatment for anxiety?

Here at Portland Psychotherapy, we spend a lot of time researching the most effective treatments for problems in living. Too often, though, there’s a disconnect between what the research says works and what is often used in practice. Not only is it difficult to educate the public but even mental health professionals can have difficulty keeping up.

For these reasons, I read this CureTogether post (now associated with 23andme.com) with great interest. CureTogether is a website that collects ratings of treatments. It appears to have an ongoing survey of anxiety treatments. Anyone can log in and rate what worked and didn’t work for them. May 13, 2013, the website posted the results from over 10,900 people who had participated in their survey of anxiety treatments.

What do people think works?

I’ll confess: because there’s so much misinformation out there, I was a little worried about what I’d find. I honestly expected to find evidence-practice lagging behind pop psychology. When I saw the actual rankings, however, I thought to myself, “Not bad.”

Cognitive behavior therapy (CBT)—which arguably has the most impressive research base for addressing anxiety disorders—was number 6. Given that CBT is not as “sexy” as other treatments, I was pleasantly surprised to see it in the top 10. Even Acceptance and Commitment Therapy (ACT), the specific branch of CBT offered at Portland Psychotherapy, was number 11. (This is amazing, actually, as ACT is still new to many professionals.) Even exposure therapy, which has the greatest research support but is especially unsexy, was listed at number 14.

More informal treatments such as exercise (#1), yoga (#3), and meditation (#5) also have some research support for being helpful to people. Not everyone needs to see a therapist for anxiety.

What was more concerning—although not surprising—was the prominence of a class of drugs collectively known as benzodiazepines. These include Xanax (#2), Ativan (#8), and Clonazepam (#9). I say “not surprising” because these are commonly prescribed drugs that calm you down within 20-30 minutes. I say “concerning” because, although they make people feel better in the short-term, benzodiazepines can actually maintain anxiety in the long-term: they are a short-term solution, can be addictive, and can lead to withdrawal effects with prolonged use and rebound anxiety when people stop taking it. Xanax, which is faster acting, is particularly dangerous.

What conclusions can we draw?

I should note that this isn’t an objective research study: it’s simply a summary of what people who filled out an online survey say they’ve tried and decided was helpful. That said, it’s an extremely useful snapshot of the real world treatment of anxiety.

Anxiety Treatment at Portland Psychotherapy