Carly Godden: This podcast was made on the lands of the Wurundjeri people.
Carly Godden: The Woi-wurrung and the Bunurong. We would like to pay respects
Carly Godden: to their elders, past and present and emerging.
Carly Godden: From the Melbourne School of Psychological Sciences at the University
Carly Godden: of Melbourne. This is PsychTalks.
Cassie Hayward: Hi and welcome back to Psych Talks, a series that
Cassie Hayward: explores exciting new research in psychology and neuroscience. I'm Cassie Hayward,
Cassie Hayward: an Associate Professor here at the University of Melbourne's School
Cassie Hayward: of Psychological Sciences. Today I'm without my usual co-host professor
Cassie Hayward: Nick Haslam. But I am going to be joined by
Cassie Hayward: a fabulous guest, Professor Kim Felmingham. Kim is going to
Cassie Hayward: unpack for us her fascinating research into post-traumatic stress disorder,
Cassie Hayward: otherwise known as PTSD. We'll learn what kind of treatments
Cassie Hayward: are being used now and about promising new developments that
Cassie Hayward: might help those affected by this disorder. So stay tuned.
Cassie Hayward: Kim, welcome to PsychTalks.
Kim Felmingham: Thanks, Cassie. Thanks for having me.
Cassie Hayward: The main thing we're going to talk about today is PTSD,
Cassie Hayward: but I think it's one of those clinical terms that's
Cassie Hayward: kind of seeped into the vernacular of just casual language
Cassie Hayward: like anxiety or OCD. And I think when people use
Cassie Hayward: it in that everyday way, they are probably not using
Cassie Hayward: it in its proper clinical definition. So, I thought to
Cassie Hayward: set the scene today, you could set us straight with
Cassie Hayward: a proper clinical definition of PTSD.
Kim Felmingham: There is quite a stringent definition of PTSD the way
Kim Felmingham: that we define it, and there's been a lot of
Kim Felmingham: controversy over this over the years. First up is what
Kim Felmingham: is the nature of the trauma that you've experienced? Because
Kim Felmingham: uniquely amongst the psychological disorders, we actually know the aetiology
Kim Felmingham: of how it starts. It starts with a trauma experience,
Kim Felmingham: but the trauma experience actually has to be one where
Kim Felmingham: you are either witnessing or you're directly experiencing life threat
Kim Felmingham: to yourself or someone else or significant threat to your
Kim Felmingham: own physical integrity is what the core definition of is.
Kim Felmingham: We are recognising emotional abuse as part of that if
Kim Felmingham: it's repeated bullying and you've grown up in a really
Kim Felmingham: aversive environment, but often that goes along with physical abuse
Kim Felmingham: as well. The only exception to that is people who
Kim Felmingham: are observing traumatic incidents say they are first responders or
Kim Felmingham: they are looking at a lot of horrible graphic imagery,
Kim Felmingham: and it's a cumulative trauma. That's now also recognised as trauma. So,
Kim Felmingham: you need to experience that to actually qualify for the diagnosis.
Kim Felmingham: I think way that the word "trauma" is used has
Kim Felmingham: been overused. Increasingly, so people will say that their divorce
Kim Felmingham: is traumatic, and it is, it can be life shattering.
Kim Felmingham: But it's not the clinical definition we use of trauma
Kim Felmingham: for PTSD. And then, you know, we have a very
Kim Felmingham: clear set of symptoms, so we have re-experiencing symptoms. So,
Kim Felmingham: you either need to be having intrusive memories, nightmares, flashbacks
Kim Felmingham: or distress and physiologic reactivity to trauma reminders. So you're triggered.
Kim Felmingham: You need to have avoidance of those triggers and thoughts
Kim Felmingham: and memories. And then there's a whole range of negative
Kim Felmingham: cognitions and mood. A lot of those overlap with depression
Kim Felmingham: and generalised anxiety as well. But there are some that
Kim Felmingham: are quite unique to PTSD. So having emotional numbing, not
Kim Felmingham: being able to feel love or happiness, positive emotions is one.
Kim Felmingham: There's social withdrawal, negative thoughts about yourself and just feeling
Kim Felmingham: really intense negative emotion. And then we've got our hyperarousal symptoms,
Kim Felmingham: so they are often overlapping with other anxiety disorders. So
Kim Felmingham: sleep disturbance, irritability, concentration difficulties, but also more unique to
Kim Felmingham: PTSD is hypervigilance for danger. So, you're constantly looking around
Kim Felmingham: expecting something terrible is going to happen, scanning for threat
Kim Felmingham: and also an exaggerated startle response.
Cassie Hayward: But to meet the definition, they have to have something
Cassie Hayward: on the trauma side and something on the symptom side.
Kim Felmingham: Yes, you do.
Cassie Hayward: So, you could have people who experience- are a first
Cassie Hayward: responder or who experience something but don't end up having
Cassie Hayward: those symptoms.
Kim Felmingham: Absolutely.
Cassie Hayward: And some people who have those symptoms but haven't had
Cassie Hayward: the trauma to set it off.
Kim Felmingham: So, I think something that's missed a lot of the
Kim Felmingham: time is having a trauma experience doesn't equal PTSD. In fact,
Kim Felmingham: only about 10 to 15% of people who have a
Kim Felmingham: trauma develop PTSD. So, really, the story is one of
Kim Felmingham: resilience and recovery. But there's some traumas that are associated
Kim Felmingham: with higher rates of PTSD, so sexual abuse, combat experience,
Kim Felmingham: refugee experience and interpersonal violence far more. And if you've
Kim Felmingham: had childhood or cumulative trauma, you've got a higher risk
Kim Felmingham: as well. But what's fascinating is about 70 or 80%
Kim Felmingham: of us, probably 70% is more realistic, will experience these
Kim Felmingham: types of traumas, Criterion A trauma, but only 10 or 15%
Kim Felmingham: of us actually develop PTSD, and we don't really have
Kim Felmingham: a good answer as to why. What's the difference? What
Kim Felmingham: are the differentiating factors? We've got a range of risk factors,
Kim Felmingham: but we don't have a definitive answer yet. I wish
Kim Felmingham: we did.
Cassie Hayward: And of that definition, when we think of the clinical definition,
Cassie Hayward: what proportion of the population would meet that clinical definition
Cassie Hayward: in Australia?
Kim Felmingham: So, it's around 7%. So it's actually one of the
Kim Felmingham: more common psychological conditions and the real issue with PTSD.
Kim Felmingham: Once it gets going, it doesn't resolve by itself, so
Kim Felmingham: it can last for decades, and it can really impact
Kim Felmingham: on people's functioning terribly. It can really decimate their relationships,
Kim Felmingham: their occupational functioning, their social functioning, their sense of identity
Kim Felmingham: and self. It's really highly comorbid with depression, significant suicidality,
Kim Felmingham: substance abuse. So, you know, people really need to be able to
Kim Felmingham: access evidence-based treatments. It typically doesn't get better on its own.
Cassie Hayward: And I guess with some of those scenarios you mentioned: combat,
Cassie Hayward: there might be a stigma around seeking support, sexual assault.
Cassie Hayward: There might be shame associated. So I guess one of
Cassie Hayward: the challenges is convincing those people that they do need
Cassie Hayward: the treatment.
Kim Felmingham: Yes, really interesting. There's a lot of stigma, especially in
Kim Felmingham: first responder and combat veterans around. You know, there's some
Kim Felmingham: ideas of PTSD reflecting weakness. It actually isn't. It's a
Kim Felmingham: completely understandable response to the level of the trauma you've
Kim Felmingham: experienced or the cumulative nature of that trauma. One of
Kim Felmingham: the biggest predictors of developing PTSD is having cumulative exposure
Kim Felmingham: ahead of time. So, yes, it is a real challenge.
Kim Felmingham: But there are really effective treatments out there. So the
Kim Felmingham: hardest thing for me as a clinician is getting someone
Kim Felmingham: walking in the door, and they are 60 they've had
Kim Felmingham: these symptoms nightly nightmares for 40 years, you know? And
Kim Felmingham: I did. I treated a veteran who was 72 and
Kim Felmingham: he'd had symptoms for 48 years or 42 years. And
Kim Felmingham: within 10 weeks he didn't have any PTSD symptoms with treatment,
Kim Felmingham: but he just didn't have the access to the treatment.
Cassie Hayward: Was it access? Or was it a lack of kind
Cassie Hayward: of wanting to seek treatment?
Kim Felmingham: Good question. So what really happened for him was that
Kim Felmingham: he withdrew, and he was able to actually withdraw. He
Kim Felmingham: lived on a farm out in a rural setting. The
Kim Felmingham: work he did didn't involve interacting with anyone. And so
Kim Felmingham: he managed to create a world which felt safe for him.
Kim Felmingham: But he was still suffering from the symptoms. There was
Kim Felmingham: a lot of shame and stigma around it as well.
Kim Felmingham: And what really broke it for him was when he retired,
Kim Felmingham: the symptoms actually got worse. And he then went to
Kim Felmingham: a veterans' self-help group and a few Men's Sheds. And
Kim Felmingham: then he discovered that other men were also having these symptoms,
Kim Felmingham: and that undercut a bit of the shame and stigma
Kim Felmingham: and that then fed his way through to actually getting
Kim Felmingham: into seeing psychologists and getting some effective help.
Cassie Hayward: When you do get someone in for treatment when they've
Cassie Hayward: admitted that they need some help and they've gotten over
Cassie Hayward: those barriers to get in, what is the typical therapy
Cassie Hayward: for PTSD at the moment? And how successful is it?
Kim Felmingham: Yes. So, look, we've got a range of evidence-based treatments now. Predominantly,
Kim Felmingham: they all involve some element of processing trauma memories, which
Kim Felmingham: we so we have one sort of gold standard treatment
Kim Felmingham: is called prolonged exposure. It's got about 100-over 100 randomised control
Kim Felmingham: trials of evidence of its efficacy. It involves imaginal exposure
Kim Felmingham: where you're actually, rather than pushing the memories out, because
Kim Felmingham: we think that's what maintains PTSD. The more you push
Kim Felmingham: them out, the more they come back in. And so
Kim Felmingham: it involves inviting the memories in and going through them
Kim Felmingham: in detail with the therapist and talking them through. The
Kim Felmingham: old idea was that the mechanism of that was that
Kim Felmingham: led to a habituation or reduction of arousal. But we
Kim Felmingham: now know that that's really not the case. It's more
Kim Felmingham: about you get corrective information as doing that, which actually
Kim Felmingham: can then correct some of the difficult beliefs. So a
Kim Felmingham: classic example is, say, someone who's been sexually assaulted and has
Kim Felmingham: a lot of shame and self-blame that they didn't fight
Kim Felmingham: back. In that, they may have blocked, or their memory is
Kim Felmingham: typically fragmented. So, as we go back through the memory,
Kim Felmingham: remembering just how powerless they were or that the person
Kim Felmingham: had a weapon, actually, can be incredibly helpful, or that
Kim Felmingham: they had a freeze response, which is just a survival
Kim Felmingham: reflex that they didn't choose, that actually can really help
Kim Felmingham: them undercut the shame and the self-blame. And so it's
Kim Felmingham: corrective in that sort of way. We also then do
Kim Felmingham: in vivo exposure, which is gradually overcoming your avoidance to
Kim Felmingham: triggers but doing it in a very gradual way. So
Kim Felmingham: say someone has had a car accident and they, you know,
Kim Felmingham: don't want to get back into a car. We'll start
Kim Felmingham: by just getting them to sit in the car in
Kim Felmingham: the driveway until their anxiety comes down. Nothing bad happens.
Kim Felmingham: It's an example of extinction learning or being able to
Kim Felmingham: learn to reduce your fear in that context. Then you
Kim Felmingham: might start getting them to just reverse their car up
Kim Felmingham: and down the driveway until they feel confident enough. And
Kim Felmingham: then it might be just driving around the local streets,
Kim Felmingham: quiet back roads at a really quiet time, and then
Kim Felmingham: you are progressing gradually up to them resuming driving.
Cassie Hayward: And how successful are those treatments?
Kim Felmingham: So those treatments we would have probably between 50 and 60%
Kim Felmingham: of people have a good response to that treatment, so
Kim Felmingham: they are no longer PTSD. But you know, that means
Kim Felmingham: we've got 40 or 50% of people who don't and again,
Kim Felmingham: if you've got childhood trauma or more complex PTSD, the
Kim Felmingham: response rate is less than that, but there's a lot
Kim Felmingham: of complexities involved there.
Cassie Hayward: How does that compare to treatment for, say, depression or
Cassie Hayward: generalised anxiety or other...?
Kim Felmingham: It's pretty much on a par actually. So you know
Kim Felmingham: most of our psychological treatments are actually within that ballpark.
Kim Felmingham: You know, pharmacotherapy will have an equivalent success rate as well.
Kim Felmingham: Except when you go off the pharmacotherapy, you typically can
Kim Felmingham: relapse more than more of these psychological CBT interventions. And look,
Kim Felmingham: PTSD is one of the harder conditions to treat. Given
Kim Felmingham: the complexity and severity of the disorder, it's, I think
Kim Felmingham: it's actually a pretty good response rate. But being a clinician,
Kim Felmingham: what keeps you up at night is the other 40
Kim Felmingham: or 50% what's going on there and how do we
Kim Felmingham: improve it? There are some other evidence based treatments, so
Kim Felmingham: EMDR is one that has got equivalent efficacy to our
Kim Felmingham: exposure treatments.
Cassie Hayward: Kim. When you say EMDR, can you just give us
Cassie Hayward: a little snapshot of what that is?
Kim Felmingham: So, it stands for Eye Movement Desensitisation Reprocessing and again,
Kim Felmingham: it's been an intervention that's been around for about 20
Kim Felmingham: or 30 years, and it was evolved from Francine Shapiro's work,
Kim Felmingham: and there was a lot of controversy about it initially.
Kim Felmingham: But look, now they've done randomised control trials, and they
Kim Felmingham: do show that it's got equivalent efficacy for relative to
Kim Felmingham: some of our exposure-based treatments. So I think clinicians prefer
Kim Felmingham: to use it, and many clients prefer to use it
Kim Felmingham: because you don't have to talk through the details of
Kim Felmingham: the trauma memory. But, the thing we don't know which
Kim Felmingham: really lit a lot of the controversy about EMDR is
Kim Felmingham: what is the mechanism of it we really don't understand.
Kim Felmingham: It's a really weird therapy to do. So, you get
Kim Felmingham: an image of the trauma memory in mind. And whilst
Kim Felmingham: you keep it in mind, the therapist either does some
Kim Felmingham: bilateral hand movements. So moves their fingers backwards and forwards.
Kim Felmingham: Or they might have hand stimulators that stimulate each hand bilaterally.
Kim Felmingham: Or you might do tapping. And the idea is that
Kim Felmingham: that is going to desensitise the memory. Now there's been
Kim Felmingham: so many hokumm theories, "Ooh you know it's the intrahemispheric alpha rhythms,
Kim Felmingham: and they link, you know they mimic REM sleep comes
Kim Felmingham: into play here," but, you know, I think there isn't any really convincing evidence.
Kim Felmingham: And in fact, some people have done randomised control trials
Kim Felmingham: with and without the eye movements and found equivalent efficacy. So,
Kim Felmingham: it's not necessarily per se about the eye movements or
Kim Felmingham: the interhemispheric element. The most cogent theory, perhaps, I've found,
Kim Felmingham: is it's about memory reconsolidation again. So, the idea is,
Kim Felmingham: if you bring any memory back to mind, it's labile,
Kim Felmingham: which means that whatever you do in a certain period
Kim Felmingham: of time, it can be changed. So the idea is,
Kim Felmingham: if you bring this image to mind of the memory,
Kim Felmingham: it's back in a labile state. And then, if you
Kim Felmingham: are actually doing finger waggling and tapping, it's a dual task,
Kim Felmingham: and our memory and our attentional systems are limited capacity processes.
Kim Felmingham: So therefore, you are using up cognitive resources to be
Kim Felmingham: tracking fingers or to be doing a dual task. And
Kim Felmingham: the theory is that that then means you've got less
Kim Felmingham: brain processes or resources to reconsolidate the memory. So it's
Kim Felmingham: laid back down less strongly is the theory, and we
Kim Felmingham: also have cognitive processing therapy, which has really good evidence
Kim Felmingham: that doesn't necessarily involve working with trauma memories. But it's
Kim Felmingham: much more about the cognitions and beliefs about self. So
Kim Felmingham: you'd use that for someone with a very shame based
Kim Felmingham: PTSD who don't have many reexperiencing symptoms, for example.
Cassie Hayward: One thing I hear about in the kind of less
Cassie Hayward: evidence-based space, I guess, in the health podcast space, this
Cassie Hayward: emerging use of drugs like MDMA for treating PTSD a
Cassie Hayward: lot of acronyms there but basically using a pharmacologically supervised
Cassie Hayward: dose of what has traditionally been a recreational drug. What
Cassie Hayward: does the research actually say about that as a treatment?
Kim Felmingham: So, in terms of MDMA that's probably got, it's progressed
Kim Felmingham: furthest along. So, they've done the phase three trials. But
Kim Felmingham: the issue with it is that they've only been done
Kim Felmingham: largely by the one group of researchers. So we need
Kim Felmingham: independent replications, and you know there isn't sufficient evidence. The
Kim Felmingham: TGA approved it too early. The FDA has knocked it
Kim Felmingham: back because they think there's insufficient evidence and there are
Kim Felmingham: some real challenges in doing randomised control trials. You can't
Kim Felmingham: blind a control condition, and that actually is quite concerning
Kim Felmingham: because some of those early trials did have major expectancy
Kim Felmingham: effects in the participants. So some participants were flying themselves
Kim Felmingham: self-funding themselves to fly across the US to engage in
Kim Felmingham: these trials. So, they already came in with an expectancy.
Kim Felmingham: It was going to save them. Many desperate people, desperate
Kim Felmingham: for a cure for PTSD, which is understandable. And so,
Kim Felmingham: those expectancies weren't measured adequately enough. So that's one real
Kim Felmingham: flaw with the designs. And we need those independent replications
Kim Felmingham: from independent groups and probably in people who've got even
Kim Felmingham: a bit of cynicism about it and measuring the expectancy effects.
Kim Felmingham: The other thing, I think with the psychedelics that's a
Kim Felmingham: real limitation is this is not going to be a
Kim Felmingham: panacea for treating people. It's not going to be widely
Kim Felmingham: disseminated because it's such an expensive therapy. The estimates at
Kim Felmingham: the moment are it will cost between 10 and $20,000
Kim Felmingham: for a treatment. And if you think about it, you've
Kim Felmingham: got double the clinician time as a standard treatment for PTSD.
Kim Felmingham: And the other thing is, we don't have head to
Kim Felmingham: head randomised control trials of how well does it work
Kim Felmingham: compared to prolonged exposure, for example? So why would you
Kim Felmingham: suggest people do psychedelic therapies or MDMA assisted therapies? if
Kim Felmingham: they might respond better to prolonged exposure, which is cheaper
Kim Felmingham: and can be done in 10 weeks. So I think
Kim Felmingham: we are at a very premature area or level. But look,
Kim Felmingham: the pharmacological adjuncts has been around for about 10 or
Kim Felmingham: 15 years, now. They've tried cortisol, yohimbine, oxytocin, MDMA. They've
Kim Felmingham: done D-cycloserine so they've done a whole range of them.
Kim Felmingham: And actually, when you look at the meta-analytic evidence, it's
Kim Felmingham: pretty uninspiring, and they haven't really found large effects. So
Kim Felmingham: I think there's a lot of fascination and interest. And
Kim Felmingham: certainly there's too much hype about MDMA and psychedelics. I'm
Kim Felmingham: sick of reading newspaper articles, and the damaging thing is
Kim Felmingham: that actually hurts vulnerable people because people with PTSD and
Kim Felmingham: trauma are incredibly vulnerable. They are living with a terrible condition,
Kim Felmingham: and then they are desperately seeking treatment. And then that
Kim Felmingham: compounds the expectancy bias, I think in the research.
Cassie Hayward: And so just to go back on something you said
Cassie Hayward: about they couldn't do blind trials. So you can't do
Cassie Hayward: a placebo with a hallucinogen or-
Kim Felmingham: No, it's impossible to have blind because of the effects
Kim Felmingham: of the MDMA because of the effects. If you're using
Kim Felmingham: psilocybin the person knows they've taken it and they're getting
Kim Felmingham: that active dose relative to a placebo. And the placebos
Kim Felmingham: they've trialled so far really aren't that effective. So in
Kim Felmingham: the maps trials that they've done, they used a very
Kim Felmingham: low dose of MDMA. But it was so low, it
Kim Felmingham: was really not.
Cassie Hayward: The person taking it would know they weren't getting the full dose?
Kim Felmingham: Yes, pretty much, pretty much. And look, you know, three
Kim Felmingham: of the MDMA papers have just been retracted. Actually, there
Kim Felmingham: have been really serious adverse events in those trials, like
Kim Felmingham: one patient was sexually assaulted, and they've included that data
Kim Felmingham: in some of those papers, so they've been retracted. But
Kim Felmingham: there's even now evidence coming out. They didn't measure serious
Kim Felmingham: adverse events well enough. So, there is reports of increased
Kim Felmingham: suicidal ideation and also people also saying they didn't want
Kim Felmingham: to report they had PTSD still, because they didn't want
Kim Felmingham: to threaten this new frontier of mental health treatment. So,
Kim Felmingham: there's these demand characteristics, so it's really inflating the effects.
Kim Felmingham: So I think we just need to do good critical science.
Kim Felmingham: You know, it's an exciting new potential. I'm all for
Kim Felmingham: getting new treatments for PTSD, but we need to do
Kim Felmingham: the science well.
Cassie Hayward: Yeah, I think it definitely highlights the need for that
Cassie Hayward: evidence-based research. And I know you've done some pretty groundbreaking
Cassie Hayward: work around other treatments for PTSD. Maybe around exercise therapy?
Cassie Hayward: Do you want to walk us through some of that research?
Kim Felmingham: Yeah, so look, the exercise stuff really came from my
Kim Felmingham: work in neuroscience, So I- there was some research coming out.
Kim Felmingham: There's a neurotrophin in the brain called BDNF: Brain Derived
Kim Felmingham: Neurotrophic Factor, and it enhances synaptic plasticity. It's critical for
Kim Felmingham: learning and memory. So, one of the theories about the
Kim Felmingham: exposure therapy is it involves this fear extinction process, which
Kim Felmingham: is unlearning your fear response that is being connected to
Kim Felmingham: stimuli or triggers in the environment. So, exposure therapy, you're
Kim Felmingham: bringing the memory into your mind, and you are in
Kim Felmingham: a safe therapy context and nothing bad happens, so you
Kim Felmingham: can learn to regulate your fear or extinguish it. So anyway,
Kim Felmingham: there was some evidence from animal work that BDNF actually
Kim Felmingham: enhanced fear extinction learning. And so we then took that
Kim Felmingham: into our human trials. So we- I do fear extinction research,
Kim Felmingham: giving people electric shocks, which is a bit mean, but
Kim Felmingham: why not? So, we found that people with BDNF, low
Kim Felmingham: levels of it had poorer extinction learning with PTSD and
Kim Felmingham: we were doing a clinical trial of prolonged exposure in
Kim Felmingham: PTSD patients. And again, we found those people who had
Kim Felmingham: lower levels of BDNF had poorer response to exposure therapy.
Kim Felmingham: So we had a really nice translation from animal science
Kim Felmingham: to human psychophysiology and neuroscience through to actual clinical trials.
Cassie Hayward: Which doesn't happen all the time.
Kim Felmingham: It's extremely rare and so we then went "Well, this
Kim Felmingham: is exciting. So how do we actually increase BDNF if
Kim Felmingham: we can increase BDNF before they go into the therapy session?
Kim Felmingham: Can we enhance the extinction learning?" And maybe that's going
Kim Felmingham: to enhance treatment outcomes for people. So, the best way
Kim Felmingham: to enhance BDNF is actually through aerobic exercise moderately intense
Kim Felmingham: to intense aerobic exercise. So that's how we devise this trial,
Kim Felmingham: which we've just randomised about 80 people and we are
Kim Felmingham: aiming to get about 110. It has taken five years
Kim Felmingham: off my life, but it's really exciting and worthwhile. So
Kim Felmingham: what we are basically doing is getting people to come in,
Kim Felmingham: and they do 20 minutes of moderate to intense exercise
Kim Felmingham: they are quite sweaty, and then they go into the
Kim Felmingham: therapy room and do standard prolonged exposure for 10 sessions. So,
Kim Felmingham: they do that across 10 weeks.
Cassie Hayward: And they do the exercise before each session?
Kim Felmingham: They do the exercise before every session. So the idea
Kim Felmingham: is that will enhance their BDNF and then their fear
Kim Felmingham: extinction learning will be better during the exposure, so we
Kim Felmingham: haven't unblinded it. We don't know what the results are
Kim Felmingham: as yet, but one thing that's really intriguing-
Cassie Hayward: So just, by unblinding you mean the clinician knows whether
Cassie Hayward: they've exercised or not?
Kim Felmingham: Yeah so it's fully, fully, and so we can't analyse
Kim Felmingham: the results. We really don't know until we get to
Kim Felmingham: the end of the trial. But what we have been
Kim Felmingham: tracking is people's dropout rates. And, you know, we've had-.
Kim Felmingham: Prolonged exposure, has fairly high about 25% dropout rates. Normally,
Kim Felmingham: we've actually been getting quite a complex childhood trauma group
Kim Felmingham: of people coming through. It wasn't by design. It's just
Kim Felmingham: who has come into the trial. So the dropout rates
Kim Felmingham: are even higher, which is to be expected. They are
Kim Felmingham: doing a very challenging therapy with really complex trauma. But
Kim Felmingham: the exercise group has got half of the dropout rates
Kim Felmingham: and that wasn't something we predicted, and I've got no
Kim Felmingham: idea why.
Cassie Hayward: Are they feeling- Is it because they are feeling more
Cassie Hayward: benefits from the therapy or we don't know yet?
Kim Felmingham: I don't know. Is it that they have another thing,
Kim Felmingham: that they'll get out of it as well as doing
Kim Felmingham: these challenging therapies? So that's what's keeping them going. Another
Kim Felmingham: theory might be that because they are doing the exercise,
Kim Felmingham: they are burning off some of the intensity of the
Kim Felmingham: anxiety before coming in so they can tolerate the exposure better.
Cassie Hayward: People who already exercise, who are runners or whatever who
Cassie Hayward: do this exercise. Will they have better effects of clinical therapy?
Kim Felmingham: Interestingly
Cassie Hayward: As a result of their BDNF?
Kim Felmingham: Interestingly, they have lower increases in BDNF than people who
Kim Felmingham: are less fit. So the less fit you are, if
Kim Felmingham: you do moderate exercise, you will have a higher rise
Kim Felmingham: of BDNF, which actually works for PTSD. Because many people
Kim Felmingham: with PTSD have metabolic syndrome, they tend towards more overweight
Kim Felmingham: and other health conditions, so it actually might be even
Kim Felmingham: of more benefit for people who-
Cassie Hayward: For those who don't, because I was wondering whether it was,
Cassie Hayward: you know, if you think about exercise as a stress
Cassie Hayward: on the body and you've trained your body to deal
Cassie Hayward: with that stress. And there was some translation from that.
Cassie Hayward: But it seems to be more about just that exercise
Cassie Hayward: before therapy increases this BDNF and they get a better outcome. Fascinating.
Kim Felmingham: Originally in the trial, I was measuring blood so we
Kim Felmingham: could actually measure BDNF. And then COVID smashed that idea.
Kim Felmingham: And so, we had to progress to telehealth types of
Kim Felmingham: approaches instead so.
Cassie Hayward: And it must be exciting for you to, you know,
Cassie Hayward: be on this forefront of different treatments for PTSD.
Kim Felmingham: Yeah, well, I mean, that's why I do what I do, really.
Kim Felmingham: My drive isn't really about anything except improving outcomes for
Kim Felmingham: people with PTSD working on the coal face of it
Kim Felmingham: for nearly 30 years. 20 years? You are really- that's
Kim Felmingham: my burning passion is, you know, how can we actually
Kim Felmingham: enhance treatments and accessibility of treatments for people with PTSD? So.
Cassie Hayward: Other things that you hear in the kind of wellness
Cassie Hayward: podcast spaces around breathing exercises and yoga and those types of,
Cassie Hayward: kind of, I guess mind body exercise. Is any of
Cassie Hayward: your work looking at that?
Kim Felmingham: Not really. But a lot of other people are. So
Kim Felmingham: there are trauma informed yoga practices. People have looked at mindfulness,
Kim Felmingham: people have looked at breathing interventions. And look, you know,
Kim Felmingham: if you look at the randomised controlled trial evidence for that,
Kim Felmingham: the effect sizes aren't huge. They are probably about a
Kim Felmingham: third of what the effect sizes are for the trauma
Kim Felmingham: focused and exposure-based memory work. So EMDR and the exposure treatment.
Kim Felmingham: So it's not your first line treatment. Unfortunately, there's a
Kim Felmingham: lot of clinicians out there where it is the first
Kim Felmingham: line treatment for PTSD. But for me, ethically, if someone
Kim Felmingham: has really flagrant intrusions and nightmares and flashbacks, they really
Kim Felmingham: need trauma focused memory work. But it's not harmful, necessarily.
Kim Felmingham: It can be a nice adjunct, and I use it
Kim Felmingham: for people who say, are very dissociative, aren't connected into
Kim Felmingham: their body at all or can't recognise or connect with emotion.
Kim Felmingham: I might do that sort of work first, that sort
Kim Felmingham: of body-based work more to get that going for someone,
Kim Felmingham: because we really need that for the exposure therapy to work.
Kim Felmingham: So there's a little bit of a fallacy that the
Kim Felmingham: talk therapies, like exposure therapy, don't deal with the body.
Kim Felmingham: It's absolutely not true when we do this work and
Kim Felmingham: similar with EMDR. We actually focus on body, emotion and
Kim Felmingham: thought moment by moment through the narrative of the memory.
Kim Felmingham: So it's all integrated the mind-body stuff.
Cassie Hayward: And I guess the way that you integrate yoga or
Cassie Hayward: those other kind of breathing exercise in your clinical therapy
Cassie Hayward: is a great way of using it. But if someone
Cassie Hayward: is out there selling that as the therapy, then that's
Cassie Hayward: where it's dangerous.
Kim Felmingham: Beware anyone saying "This is a panacea. This will treat
Kim Felmingham: everyone and cure everyone with PTSD." because it's bunkum because
Kim Felmingham: PTSD in and of itself is an incredibly heterogeneous condition,
Kim Felmingham: so you'll have one person come in. They'll have one
Kim Felmingham: nightmare a month, but they'll have really corrosive shame and
Kim Felmingham: core beliefs that are shocking, and they will avoid social situations.
Kim Felmingham: They probably need more the cognitive based treatments, whereas someone
Kim Felmingham: who's got really intensive nightmares, flashbacks can still qualify for PTSD.
Kim Felmingham: Both of them do. They need trauma memory work, and
Kim Felmingham: that's where the field really needs to evolve, what works
Kim Felmingham: for who? Because we've got a range of different evidence-based treatments.
Kim Felmingham: But we really haven't got good clinical decision tools that
Kim Felmingham: will guide clinicians out there, so you do tend to
Kim Felmingham: find clinicians love mindfulness or they love EMDR. And so
Kim Felmingham: that's what they use for everyone. And we really need
Kim Felmingham: to be taking a case formulation approach. So not diagnostic.
Kim Felmingham: It's not a diagnosis equals treatment for every clinician we
Kim Felmingham: do an individualised case formulation to work out. What are
Kim Felmingham: your pattern of symptoms? What are your maintaining factors and
Kim Felmingham: what's then going to be the best treatment tailored to that?
Cassie Hayward: If any of our listeners are dealing with PTSD or
Cassie Hayward: have a loved one who is dealing with it, what's
Cassie Hayward: your advice to them? Maybe, first we start with those
Cassie Hayward: who might not be in treatment at the moment, but
Cassie Hayward: you know that you have it or you know that
Cassie Hayward: your loved one is possibly experiencing PTSD. What's a good
Cassie Hayward: way to encourage them to seek treatment?
Kim Felmingham: Look, you know there are really good online resources. Sometimes
Kim Felmingham: that can be a good place to start is to-
Kim Felmingham: Phoenix Australia has some really great resources. Beyond Blue has
Kim Felmingham: some good information as well, just so that you can
Kim Felmingham: start to read a little bit about it and read
Kim Felmingham: about the types of treatments that are available. I'd always
Kim Felmingham: encourage people to seek professional help and to try and
Kim Felmingham: see what is. It's really hard seeing a psychologist, you know,
Kim Felmingham: because there's some bad ones out there. You know, people
Kim Felmingham: will put up a sign "I'm a trauma expert" and
Kim Felmingham: what are their credentials? So, you know, we're going in
Kim Felmingham: and asking people what types of experiences they've had with
Kim Felmingham: delivering these different treatments. And what is the range of options?
Kim Felmingham: How many years? That's actually important stuff to know, to
Kim Felmingham: make decisions. But I think the other hard part is,
Kim Felmingham: you know, gee, the challenging step of going in to
Kim Felmingham: see a stranger and then talking about trauma, some of
Kim Felmingham: the most difficult stuff you might not have told anyone. So,
Kim Felmingham: there's trust. And so, it's also about finding someone who
Kim Felmingham: you really feel you can connect with and feel safe with. So,
Kim Felmingham: it might be starting by just telling a close friend
Kim Felmingham: and talking to a close friend, looking online at resources
Kim Felmingham: what is actually available and out there. And then, you know,
Kim Felmingham: hopefully going and seeking that support if you need it.
Cassie Hayward: And you've touched on this briefly. But what should they
Cassie Hayward: be looking out for in terms of credentials because we
Cassie Hayward: know anyone can call themselves a counsellor, and that doesn't
Cassie Hayward: mean they have the right training. But what what should
Cassie Hayward: people be looking for? If they've found someone who they
Cassie Hayward: think might be right, What should they be checking?
Kim Felmingham: Well, if they're practising EMDR, they should actually have done
Kim Felmingham: training with an accredited EMDR association, so you can ask
Kim Felmingham: them what kind of training they've done. So, there's the
Kim Felmingham: EMDR Association of Australia. People can actually get to be
Kim Felmingham: accredited EMDR therapists as well, which takes more training and supervision.
Cassie Hayward: And they would be a clinical psychologist to start with?
Cassie Hayward: And this would be-
Kim Felmingham: Not necessarily, you can be a psycologist and look social workers,
Kim Felmingham: mental health social workers can do EMDR. I would be
Kim Felmingham: looking at people who have they done CPT training. Have
Kim Felmingham: they done prolonged exposure training and ask people those questions? You,
Kim Felmingham: And if they haven't, then what is their experience?
Cassie Hayward: Kim. So what's next for you in terms of future
Cassie Hayward: research in this field?
Kim Felmingham: I have a lot of post academia fantasies, so I'd
Kim Felmingham: love to set up a trauma retreat service where it
Kim Felmingham: is holistic. It's got nature-based walking. It's got yoga because
Kim Felmingham: I used to be a yoga teacher, in yoga teacher
Kim Felmingham: training for about eight years, but then also doing delivering
Kim Felmingham: EMDR in our exposure-based treatments in a sort of secure,
Kim Felmingham: safe environment and doing intensive therapy because I think it
Kim Felmingham: actually is one of the better modalities if we can
Kim Felmingham: do it. Doing daily exposure therapy so you're really getting
Kim Felmingham: through the hardest part more quickly. It's getting the funding
Kim Felmingham: to do that. So, you know, it's whether I, you know,
Kim Felmingham: get Hollywood celebrities in and charge them a fortune, and
Kim Felmingham: then everyone else can do it for free for the rest.
Kim Felmingham: So these are elaborate fantasies that are probably going to
Kim Felmingham: go nowhere.
Cassie Hayward: Fascinating, Kim, thank you for joining us for PsychTalks today.
Kim Felmingham: No problem, my pleasure.
Cassie Hayward: You've been listening to PsychTalks with me, Cassie Hayward. I'd
Cassie Hayward: like to thank our guest for today, Professor Kim Felmingham.
Cassie Hayward: This episode was produced by Carly Godden with production assistance
Cassie Hayward: from Mairead Murray and Gemma Papprill. Our sound engineer was
Cassie Hayward: Jack Palmer. Thanks for tuning in to this great new
Cassie Hayward: series of PsychTalks. See you next time