EP24: The Final Puzzle Piece

00:00:00 Erin: We're going to spend some time today wrapping up the past criteria that we've covered over the last five-ish months.

00:00:10 Cinnamon: One of the most common things I experience as walking somebody through it is it's not, accessible language just in and of itself. There has to be some kind of explanation or examples provided for that translation to happen from the clinical side to the everyday person side. If we've got folks who are listening to us and have struggled with different things, we can break that down and they can say, wait a minute, I didn't know that that's what that was, but that makes sense. When we talk about change, have you or other people noticed change in you that is making doing life a little harder?

00:00:55 Erin: We hope you enjoyed the PTSD series and all that it had to offer. We will continue to bring you knowledge and resources as we progress. But for this one, that's a wrap.

00:01:12 Cinnamon: It's the first responder, the first to get the call, the first on scene, greeted by God knows what, pushed beyond the limits that they don't even set. Then what happens? You're listening to After the Tones Drop. We're your hosts. I'm Cinnamon, a first responder trauma therapist who founded our practice after seeing the need for specialized care following a local line of duty death.

00:01:39 Erin: And I'm Erin. I'm a first responder integration coach.

00:01:43 Cinnamon: We help first responders receive transformational training, therapy, and coaching.

00:01:49 Erin: Now we come to you to explore, demystify, and destigmatize mental health and wellness for first responders.

00:01:57 Cinnamon: Our show brings you stories from real first responders, the tools they've learned, the changes they've made, and the lives they now get to live.

00:02:10 Erin: [It's the fun]. I don't know if that's, like, the right song to lead into.

00:02:23 [Cinnamon]: I know. 

00:02:23 Erin: Like, I feel like we need to have a song that's, like, about wrap up, wrap up. Maybe we should just write a rap about wrapping up the PT– 

00:02:29 Cinnamon: No, that is not what we should do.

00:02:32 Erin: Cinnamon never lets me sing or rap. It's like, come on.

00:02:35 Cinnamon: Because I've heard you sing and rap. 

00:02:40 Erin: I can barely hear you. 

00:02:41 Cinnamon: Oh, I'm trying to be polite because what I'm saying is, because I've heard you sing and rap, is why I am holding you back.

00:02:48 Erin: She just can't handle my skills, my master skills. You still need to put your mic closer, though, I think or some– 

00:02:55 [Cinnamon]: Hold me closer, tiny dancer. 

00:02:57 [Erin]: It might need to be adjusted in your thingamajigger.

00:02:59 Cinnamon: In my thingamajigger? Like this? Is that better?

00:03:03 Erin: Yeah. Yeah, that's better. All right. Now that we can hear you loud and clear, which is what we really, really want.

00:03:10 Cinnamon: Loud and clear. 

00:03:12 Erin: Loud and clear. We're going to spend some time today wrapping up the past five criteria that we've covered over, what, the last five-ish months, four months? I don't know. 

00:03:25 Cinnamon: I lost track. 

00:03:26 Erin: I can't even keep track anymore. I did too.

00:03:27 Cinnamon: And just as long as you remember the wrap up part, like there will be no rapping, just wrapping up.

00:03:35 Erin: Wrap up. 

00:03:35 Cinnamon: Yes.  There's a W there.

00:03:38 Eric: So unfair, so unfair.

00:03:39 Cinnamon: Yeah, kind of like how when people say whole, they don't always know to put the W at the beginning when they talk about, whole house. That's fine. 

00:03:46 Erin: Yeah, man, we got a whole nother kind of house. 

00:03:47 Cinnamon: Right. 

00:03:48 Erin: So move on, back to being appropriate and talking about PTSD criteria wrap up. Cinnamon, why do you feel like it's important that we did this breakdown of the PTSD criteria for our listeners?

00:04:07 Cinnamon: I mean, I get to look at this criteria every day. And I have heard a million answers to these, you know, questions of if you're experiencing it. And I think one of the most common things I experience is walking somebody through it is it's not, accessible language just in and of itself. There has to be some kind of explanation or examples provided for that translation to happen from the clinical side to the everyday person, what does that mean, side? And if we've got folks who are listening to us and have, you know, struggled with different things and we can break that down and they can say, wait a minute, I didn't know that that's what that was. But that makes sense now that I have an example or it's not fuzzy to me because it's, you know, using clinical language like negative alteration and mood and cognition or negative alteration and arousal and reactivity. Like, I wouldn't expect anybody to know what that means right off the bat.

00:05:22 Erin: No, I wouldn't either. And also, we don't really talk like that in session necessarily. I mean, we might refer to that like, this means this, but not everybody has a clinician that they're going to that can give them the layman terms of what this means of, what the different breakdown is for the PTSD symptoms or criteria. And because obviously this is a term and we've talked about it before that gets thrown around a lot is the PTSD in the first responder world. It felt very important for us to break it down like, okay, well, what does this to you.

00:06:01 Cinnamon: Well, and I also think that, like, we get to acknowledge there's probably a majority of first responders out there who, if they are going to a therapist, they're not necessarily, like, a designated culturally competent first responder trauma therapist, right? Like, we take very specific niche cases but if my practice just takes everyone, so we see a little bit of anxiety, we see a little bit of depression. Every once in a while we do see somebody with PTSD. We, you know, may have personality disorders. Like when you see everything, then we don't spend as much time in one concentrated area figuring out how to do that best. And part of being able to, you know, be a trauma therapist specifically for this population is I spend all day, every day with this criteria, making it understandable.

00:07:02 Erin: Accurate. Okay, well, what do you say we kind of run through what we've already done so that folks know, one, where they can find the episodes we've already done and give a little synopsis of what each of those means so that when we finish this out with F, G, and H today, it makes sense. They have a lead-in for it. 

00:07:23 Cinnamon: Yeah. Sounds good.

00:07:24 Erin: You open to that? 

00:07:26 Cinnamon: Yeah. Definitely in lieu of [rapping].

00:07:28 Erin: In lieu of [rapping]. 

00:07:32 Cinnamon: We're just ping-ponging. 

00:07:32 Erin: Well then, our first episode was, that we did this on, our first, when we start, we're calling it an educational series, which we tried, we decided to scratch that because that wasn't exciting for anybody. 

00:07:47 Cinnamon: No. 

00:07:48 Erin: It was Episode 3 and it had a completely different name so that people wouldn't be turned away and I can actually tell you exactly what that name is as soon as I pull it up because I can't remember which is which. 

00:08:01 Cinnamon: Direct Exposure. 

00:08:02 Erin: Oh, Episode 3, is that what we ended up calling it? 

00:08:05 Cinnamon: I don't know. 

00:08:06 Erin: Direct Exposure. So it is Episode 3 and Cinnamon's correct, Direct Exposure is the title. 

00:08:13 Cinnamon: Oh, that was just a guess. 

00:08:15 Erin: I'm impressed. I mean, that's really impressive.

00:08:18 Cinnamon: Or you just use common sense to name it.

00:08:21 Erin: Well, also, yeah, because what is it about?

00:08:25 Cinnamon: It's about Direct Exposure, [Vanna]. And what does that mean?

00:08:31 Erin: Direct Exposure would consist of the fact that this person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence in the following ways. Of course, one is Direct Exposure. 

00:08:47 Cinnamon: Where it happens to you. 

00:08:50 Erin: Correct. Two, witnessing the trauma and I was waiting for you to say where it happens to someone else but you're witnessing it. Three, learning that a relative or close friend was exposed to a trauma and indirect exposure to adverse details of the trauma usually in the course of professional duties like first responders and medics. 

00:09:11 Cinnamon: Yes. So there is a very good chance that we're not only watching our folks have that Direct Exposure where it is something that happened to them, but they also can be experiencing, like secondary or vicarious trauma because they watch it happen to somebody else. And both of those things can result in post-traumatic stress. You know, so whether you're doing detective work on a case, and you're having to look at, you know, gruesome photos, or you're on scene of a shooting victim or, you know, a sexual assault or a pediatric death, or if somebody while you're working on them, like spits at you, and it ends up in your eye or your mouth or something like that, like, all of those things are happening simultaneously.

00:10:05 Erin: Yep. Very good explanation on what that means. So that we encourage you to, as we run through these is, don't stop right now if you don't want to. But there is a series of specific episodes that lead up, this one today. So that's Episode 3, Direct Exposure. And then later on, we moved on to Episode 7, which is understanding nightmares, memories and flashbacks or– 

00:10:33 Cinnamon: Intrusion symptoms.

00:10:35 Erin: Yeah. So what can you tell us about Intrusion symptoms then?

00:10:38 Cinnamon: And so we talk about Intrusion in the same way that we would think about like an intruder, like it's coming uninvited. You weren't anticipating it. You weren't expecting it. You didn't extend an invitation. It's just showing up regardless of your consent. We also talk about that in terms of re-experiencing. So when we use that word, it kind of focuses on not necessarily the fact that it's coming up in an unwanted way, but that the way that it comes up, it feels like it's happening again. 

00:11:15 Cinnamon: And we have a guest, and I'm not sure if that's gonna be before or after this one, but he talks about having a flashback, but in that flashback, he knows the ending. But he still feels the intensity of what it felt like in the moment before he knew how it was gonna end. So, we talk about them and it's listed in the DSM as Intrusion symptoms or Intrusive symptoms, but we also talk about it in terms of re-experiencing. And I think those two words together, you know, whether we're talking about the unwanted and upsetting memories, nightmares, flashbacks, or the emotional distress or the physiological reactivity after being exposed to a traumatic reminder, all of those can be explained using those two words, Intrusive and re-experiencing.

00:12:08 Erin: Absolutely. And she is referring to Episode 21 with [Michael Sugrue], who is the one that spoke into that. And that is the episode right before this one. So there you have it. There's the answer. If you want to check Michael's out, check his out anyways. 

00:12:24 Cinnamon: It's so good. 

00:12:24 Erin: Because it’s incredible show.

00:12:27 Cinnamon: And so, do we need to repeat what, it was Episode 7 where we did the Intrusion symptoms?

00:12:34 Erin: That's right. Yeah. So check out, and that's for Criterion B specifically. And then we moved on to Criterion C, which is Episode 11, The Only Way Out Is Through, where we talked about my favorite thing, the cows and the buffalo story.

00:12:55 Cinnamon: I don't know if we've had a moment that, on the show thus far, that was as poignant and conveyed as much wisdom as the buffalo and the cows. And I'm, I sound sarcastic, but I'm actually not trying to be sarcastic. I've used that a million times because you had just recently told me about the cows and the buffalo right before we did that episode. And you're like, oh, here I can use it. Yeah.

00:13:26 Erin: Yeah. It's a perfect example of Criterion C, which is Avoidance. And that's Avoidance of trauma related stimuli after the trauma in the following ways, which is trauma related thoughts or feelings and trauma related external reminders.

00:13:42 Cinnamon: And I think in Episode 11, we talked a little bit into the fact that, like, one kind of begets the other, right? So we're not necessarily just avoiding those external reminders for the purpose of avoiding the external reminders. We're doing that in an effort to avoid the thoughts and feelings that go with being reminded of the traumatic event. 

00:14:09 Erin: Yeah.

00:14:09 Cinnamon: So I could drive by an intersection if I, if it didn't make me think of something.

00:14:19 VO: Hey there, listener. If you could ask any question or freely talk about any challenge related to being on the job and no one would know, what would you say? We are excited to share about our confidential hotline that we created just for you. Through this confidential hotline, you can leave a message sharing a success, a struggle, or simply ask a question. We will spotlight calls and offer feedback and insight from a licensed therapist and a certified coach who work exclusively with first responders. You can access our hotline voicemail by visiting afterthetonesdrop.com and clicking the voicemail tab. Additionally, you can join our mailing list if you'd like or easily follow us on Facebook and Instagram for all the most recent updates. You know the drill. Telephone, tell a friend, tell a first responder.

00:15:26 Erin:  Yeah, you might, it might look like avoiding people, places, and things because you don't want that stimuli, that reminder of a particular event that causes these feelings, symptoms, emotions, all of that stuff. 

00:15:39 Cinnamon: Yeah. 

00:15:40 Erin: So that is where the key word Avoidance comes in with criterion C. So that one is, yes, again, Episode 11, The Only Way Out Is Through. And then we moved on to Episode 15, which is, Internal Storms. 

00:15:56 Cinnamon: You are so clever. 

00:15:57 Erin: Such a powerful title.

00:15:58 Cinnamon: I know. I felt moved right in here. 

00:16:01 Erin: So good. 

00:16:03 Cinnamon: Here, right there.

00:16:04 Erin: Right. In Internal Storms, Episode 15, we're covering Criterion D, which is the negative alterations in cognitions and mood.

00:16:13 Cinnamon: So this is one of those moments when I'm kind of like, yeah, if we were to use like real people, everyday language, it would say, when your thoughts and feelings turn sour, right? Like it's a negative change in how you think and how you feel.

00:16:31 Erin: Yeah. What are some examples of that that obviously these folks would directly get? Because to me, I'm like, "Oh, yeah, this is like, you know, the normal, everyday thing, but it's not a normal everyday thing for everybody." So how would they know if this was something they were experiencing?

00:16:47 Cinnamon: I think there's a couple ways that might be helpful. from hearing it from other people. And that might be that they chronically have a negative effect, where they're just not getting excited about the things they used to get excited about. They're having a difficult time getting that excited. The things that used to make them laugh or they had fun with, it's not landing the same and maybe they're showing up and going through the motions, but they know they're not feeling it the same way and the people that are with them are recognizing that it doesn't feel the same as it used to. I think a couple of the other really important ones are the exaggerated blame of self or others for causing what happened.

00:17:35 Cinnamon: So sometimes we say it's like all my fault or it's all their fault. When that may not be accurate, but their perspective is altered and they can't see, maybe that there's responsibility elsewhere. And then the last one that I think is important, at least to mention, is the overly negative thoughts and assumptions about yourself as well as the world and other people. We hear a lot of that people are stupid or people are idiots or this kind of person is this kind of thing or anybody who doesn't call 911 for a reason that they feel is sufficiently important and emergent that how we talk about those people aka frequent flyers or people that are abusing the system. You know, where it's just like you see it so much that you start categorizing. And I'm going to even throw out the word, like, discriminating against certain groups of people that do a certain kind of thing. So whether it be drug addicts, people who struggle with addiction, or elderly people or, you know, whatever it is, there's, we put them all in one group and we label them negatively.

00:18:59 Erin: Yeah. Zero tolerance. That's the first thing that I thought of when you said that. 

00:19:04 Cinnamon: Yeah. Well, and it also looks like compassion fatigue, right? Like, I don't have compassion for this person in front of me because I see them as one of many people who I don't feel like I need to be there for.

00:19:21 Erin: Yeah. And that sounds familiar, I'm sure, to everybody, with that compassion fatigue, which we talk about.

00:19:28 Cinnamon:  I mean, can I just say one other thing? You know, as I'm describing that, I can even hear the hesitancy in my voice because I want to make sure like it doesn't come across like I'm judging people negatively for having these feelings or using buzzwords like discriminatory thoughts, like it's not that. This is me more of like acknowledging. This is the reality of what happens and that doesn't make anybody a bad person. It means that you've done this job so long and so hard. And to be able to survive that, you have to start changing the way that you think to be able to go on that next run or that next call. If you feel every single thing so intensely, every run, every house you respond to, that's going to cause exhaustion and compassion fatigue as well. So this is just the result. It's not about anyone's character.

00:20:32 Erin: Definitely. Thank you for adding that. It is important for folks to hear that. All right, and the final one, before we get into our wrap up, was the most recent one was Episode 20, which is called Hyperarousal and Reactivity, and that is covering Criterion E. And the title of the show basically explains exactly what the show is about, about what Criterion E covers, which is trauma-related arousal and reactivity that begin or worsened after the trauma. And these can look like situations in the following ways - irritability or aggression, risky and destructive behavior, hypervigilance, heightened startle reflex, the difficulty concentrating, and difficulty sleeping, which the last two we definitely hear about all the time.

00:21:20 Cinnamon: Yeah.

00:21:22 Erin: Yeah.

00:21:23 Cinnamon: And even that, like, sometimes it's not just the difficulty of sleeping because we hear people say, "Oh, like once I'm asleep, I'm fine. I just can't get to sleep till 2 AM." So it really is like that sleep disturbance where my seven to nine hour plan gets messed up. And that's the plan of a human, right? So even working third shift or working 24 hours, is going to cause a sleep disturbance from jump.

00:21:56 Erin: Yeah. Hard to re-regulate. All right. So again, that was Episode 20 covering Criterion E, which is Hyperarousal and Reactivity. So check those five episodes out. Get yourself some deeper knowledge and understanding of exactly what all of those criteria mean, leading up to this final stage, which is more or less kind of breaking down the rigmarole and semantics of, okay, those are all the symptoms that we've just kind of listed through. I can see and understand all of these symptoms, but then what? There's more to actually, I don't want to use the word qualify me for the diagnosis of– 

00:22:37 Cinnamon: But that's the right word. 

00:22:38 Erin: PTSD. But, okay, so you could have any amount of these, give or take, and that still doesn't mean that you would have a PTSD diagnosis because there's other specifics that would have to go into that in order for someone to say, yes, in fact, this is PTSD.

00:22:58 Cinnamon: These last few, I don't think we really talk about, we look at A through E, and that's where we stop. And we don't always talk to our clients about them, because we're listening. And we can decide without actually asking the client if they qualify under those three. So these are the ones that, like we don't ever really talk about with clients simply because we can figure that out by whatever narrative they're already providing. So, surprise, there's three extra criteria.

00:23:33 Erin: Yeah. Well, it's not even important to them. This is kind of like the clerical side of the symptoms and of what equates this particular diagnosis. It's like for us to know, but it's not necessarily as important, but it is important. You know, we don't have to like, go into, in detail during sessions, but it's important to understand that you might have many of these symptoms occurring and that doesn't necessarily mean that you have PTSD. 

00:24:01 Erin: Of course, post-traumatic stress can affect many of us, but that doesn't mean PTSD, which we have also talked about, but also in addition to having said symptoms, you would need to also have these particular things that we're going to share with you today leading into the criterion F, which is the Duration of the symptoms.

00:24:27 Cinnamon: Would you like me to talk about this?

00:24:28 Erin: I would love for you to talk about this.

00:24:31 Cinnamon: All right, so Criterion F is the Duration, like how long that you've been experiencing the symptoms. So Criterion F requires that symptoms last for more than one month. I will say, I think it's a vague number, right? Like [where] the way that we apparently decided 30 days is pretty ambiguous, but the idea that we expect somebody who goes through a difficult event is going to have a lot of these symptoms for at least 30 days until their body works through it. And we hear a lot of people say, you know, it upset me at first, but then I moved past it. And that's perfect. You're allowed to have a rough go at the beginning until you get re-regulated, until you're able to process what happened, et cetera. 

00:25:28 Cinnamon: But the challenge was, we came up with this diagnosis in the 80s. But right around the time that we start looking at what happens when we go to therapy, because even though we haven't hit that 30-day mark, we're still suffering and we'd prefer to stop the suffering as soon as possible, which I have absolutely done with clients. After a critical incident where we get them in, we get it taken care of, and we reduce the likelihood of longer-term impact. 

00:25:58 Cinnamon: But in ‘94, they actually developed another diagnosis, the acute stress reaction or acute stress disorder. And the idea behind it was that, that would be indicative of who may actually have a higher likelihood of getting PTSD later. But all the research has indicated it's not actually that accurate. And we, again, want to kind of expect some of those. What I have found to be more accurate is it allows for insurance coverage, for those who are seeking treatment immediately after the event. Because if we only have the diagnostic code of PTSD, then we don't–

00:26:46 Erin: You have to wait 30 days. 

00:26:46 Cinnamon: We have to wait 30 days. And then if we want to use our insurance, we can't use that diagnosis. And then we have to have a diagnosis to be able to use your insurance and bill. And so they came up with the gap filler, which is– 

00:27:00 Erin: It's kind of like a holding, and a holding pattern. It's like a holding pattern. This is going to be the diagnosis while we evaluate, while we treat the current symptoms, because we're not going to leave people floundering for 30 days like, good luck. Obviously, what we've always said is that we're here to treat symptoms. We're not treating PTSD. We're treating the symptoms of PTSD or potentially of just post-traumatic stress in general. And so we want people to have that ease as promptly as possible and therefore the holding pattern is necessary so that people can begin to find relief. And then later down the road we might say, you know what, that's exactly what this is. But yeah, at least people can get to feeling a little bit better or get support prior to that.

00:27:51 Cinnamon: And I think that that comes up when we kind of mention the specifiers, which once we get through the rest of that criteria, we'll circle around and talk about, because what happens. So we know we've got acute stress disorder or acute stress reaction in those first 30 days. But what if it doesn't set in right after that? And we'll come back once we finish up our criterion.

00:28:20 Erin: Okay. Yeah, so that's pretty much the nuts and bolts of F is Duration. Has it been 30 days? Has it not been 30 days? And that is one of the deciding factors. And then we're looking at Criterion G, which is the Functional Significance. So symptoms create distress or functional impairment like social, occupational, et cetera. We have a huge list of the different functionings that could be included. And Cinnamon, I'm sure, to talk to you about those so that you all know what that means.

00:28:52 Cinnamon: I feel like you're putting me in a box by saying I'm the nerdy one.

00:28:56 Erin: Well, she's the nerdy one. And also, it's beautiful. She's just a wealth of knowledge. I mean, I definitely share them. I'm happy to do that.

00:29:07 Cinnamon: That is sweet. Thank you. 

00:29:10 Erin: [You're welcome]. 

00:29:12 Cinnamon: Okay, so Functional Significance, what we're really talking about is when we look at the domains of our lives. So like Erin mentioned, the social and the occupational, you know, we also are going to have like, if you're in school, there's academic functioning. We've got, you know, physical health, mental health domains. We have, you know, family and parenting domains. We have all of these, you know, areas of our life that kind of come together to make up our whole lives. And so when we start to notice, and sometimes it's not always us noticing. Sometimes it's the people around us, our loved ones, our friends, our co-workers that start to notice what we would call the functional impairment. And that's when things aren't going well in those areas and the difficulties are due to the PTS symptoms. 

00:30:08 Cinnamon: So it may look like, you know, I'm not being social anymore because I'm isolating. And I'm not having any fun when I go do those things. So I decide to stop doing those things. It can also look like I, you know, get too intoxicated when I'm out and my friends are like, "Wow, that's something that we've not seen out of you." It also, you know, can be that hypervigilance or even exaggerated startle reflex where, you know, I kind of mentioned on a previous episode about, like dropping to the floor when somebody jumped out and scared me. Yeah, that made that relationship a little bit awkward after that for a while. So it really is looking at how are these symptoms actually affecting our lives. And if our lives look peachy keen like they did before the event, great. But it's very challenging to have the appropriate amount of symptoms that you need to meet the requirement for the criterion and also not have any functional impairment.

00:31:14 Erin: I mean, unless, I don't know, superhuman? I just can't see it being an– 

00:31:18 Cinnamon: Denial? 

00:31:19 Erin: Okay, we'll call it denial. 

00:31:23 Cinnamon: Yeah. 

00:31:24 Erin: Superhuman sounds so much nicer, but yeah. I mean, it's true.

00:31:27 Cinnamon: We're both. I am a denying superhuman.

00:31:31 Erin: There you go. Now you can have both. Yeah. So it's, how does it, how are you showing up in the world and to others basically to kind of give it a little CliffsNotes version.

00:31:44 Cinnamon: When we talk about change, right? Like have you or other people noticed, change in you that is making doing life a little harder?

00:31:59 Erin: Yeah, and we've talked about it before. If a loved one, someone that's very familiar with your normal characteristics and how you show up in the world, is making comments like, something seems off, something's going on, there's an opportunity to perhaps hear them out and investigate that. So we definitely encourage, to listen to your loved ones because perhaps they know something that you don't or you're not ready to know. And then finally, we are to Criterion H, which is Exclusions. So this is basically saying like the symptoms are not due to any medication or substance use or other illnesses that we have to consider those things too.

00:32:41 Erin: Before we get into the meat and potatoes, I want to make a request. How are you liking this show so far? Is it providing value in your life? Is it helping you understand yourself a little bit more? If so, nothing tells us more than a rate and review. So if you can take some time to provide some feedback by visiting the listening platform of your choice and giving us a rate and review about what your experience has been like and what value this has created in your life so that listeners know, hey, this is a nice tool to have, something to quite literally have in your pocket on your phone. We would greatly appreciate it and nothing tells us more that you're finding value out of this.

00:33:32 Cinnamon: So Category H is pretty common in the DSM for a lot of our diagnoses where it may say something, like symptoms are not better explained by another disorder because I think we've talked about this from the very beginning that all of our post-traumatic stress symptoms can, with, you know, just a handful that are exclusive to this particular diagnosis, can be pulled out and put into things like, you know, anxiety, depression, ADHD, bipolar, substance use disorder, right? Like we can see a lot of these criteria elsewhere. 

00:34:14 Cinnamon: So it is kind of important to make sure that if we're going to use the diagnosis of PTSD, that we're not missing another mental health issue or another illness that might better explain what's going on. And we just slap on the PTSD diagnosis simply because they had something bad happen, and now they're struggling. You know, because they simply may not meet that threshold. The other thing is, you know, we've seen medications that can cause some of these symptoms. We know that, I don't know. Do you remember, Erin, when that whole CHANTIX thing happened? When we were figuring out some people couldn't take it because– 

00:35:02 Erin: Because they're having crazy nightmares, like horrific nightmares from the CHANTIX. Yeah.

00:35:07 Cinnamon: Yeah. So that's kind of talking about things like that. Or we know that some of the psychotropics that folks take for depression or anxiety can cause suicidal ideation. Now we want to make sure that we feel confident that there's no other possibility or that we've done our due diligence to cross those other possibilities out.

00:35:35 Erin: Yeah, and some of those medications can also extremely affect sleep. Like either it'll keep you up, like you have no ability to sleep, or it'll make you sleep and only be tired. So all of those factors must be considered, which is why when you're filling out like 15 pages of paperwork before you go into basically any provider, whether it's therapy or primary care. They want to know what medications are you taking so we can be aware of not only what other medications we might prescribe, but could any of these medications be contributing to other ailments or issues that you might be having at that time.

00:36:16 Cinnamon: Right.

00:36:17 Erin: Correct, Mundo.

00:36:20 Cinnamon: And then let's talk a little bit about substance abuse.

00:36:25 Erin: Which can't, not talk about it.

00:36:28 Cinnamon: Right. This can kind of be one of those chicken-egg conversations. And so I want to make sure that we're not making any declarative statements that there's always exceptions to because we know among the first responders, especially alcohol misuse or misuse or using, as a coping mechanism, it can range from 20% to 30% or even higher among our first responders. It is a culturally accepted, widely used, both socially and in isolation substance that creates a, unwinding, numbing, checking out quality. 

00:37:10 Cinnamon: And so yeah, there are some people who may not necessarily have a substance abuse issue. Their drinking is part of, maladaptive coping mechanism to deal with the post-traumatic stress. And then we also know that some people might be predisposed to cross that line from a heavy drinker into a problem drinker. But we don't want to just assume that a behavior is because of the post-traumatic stress. And we don't look at the substance use piece because they may be meeting criteria for an alcohol use disorder diagnosis in addition to the PTS. And having a use disorder is not alcoholism. It's not, dependency. It's, are you misusing it in a mild, moderate, or severe way? But we also know we've seen addictions to painkillers. We've seen addictions to–

00:38:24 Erin: Stimulants. 

00:38:24 Cinnamon: I was going to say, how do I say like Adderall, cocaine, uppers, amphetamines, stimulants. That's it. Especially when there's sleep deprivation involved.

00:38:37 Erin: Yeah. So we can't ignore that. And if you or someone you know is struggling in general, it's always wise to be honest, especially with people like us who are just trying to help. And I understand that folks aren't always willing to be honest or actually don't really think that their way of using these substances is out of the ordinary or in excess, but the problem is, like, we're not going to just take your booze away, but we're going to talk about how this is affecting you in many different ways. And so I think people are like, if I tell the truth, they're going to take the one thing away that I believe is working for me, which is, you know, I understand it's a coping mechanism, it's a crutch, it's a safety net, but it also could be exasperating all of the issues.

00:39:31 Cinnamon: And we have, like, zero power to take anything away from anyone. 

00:39:33 Erin: Right. We're not going to come, like, sit on your– 

00:39:35 Cinnamon: I can't come to your house and, like, get into the fridge and take all your Coors Lights.

00:39:43 Erin: Coors Light. Yeah. Well, I mean, Cincinnati folks, I mean, you guys are so close to Kentucky. It's Bourbon. I hear about Bourbon all the time.

00:39:51 Cinnamon: It is Bourbon. Well, and now, was it Rhinegeist? Just put out a new beer called Cincy Light, I think, that is getting, like money is going to the university, and it's supposed to be like a Bud Light version. It's hilarious, like, how excited these people get for newly released, so.

00:40:15 Erin: And we're also not telling you that, Cincinnati folks, so you can run out and buy it. 

00:40:19 Cinnamon: No. No.

00:40:20 Erin: We're not advertising for that.

00:40:21 Cinnamon: It's just a little bit obnoxious. I mean, Cincinnati is a huge town for microbreweries. So there is constantly some alcohol, whether it's the beer from the breweries or the Bourbon from the trails, the Bourbon trail, or whiskey. It's so common that it does make it more difficult to recognize when it's a problem, when you look to your left and you look to your right and both people are drinking like you. So, Erin, what would be a measurement of if your drinking has exceeded what we consider healthy or normal?

00:41:08 Erin: What would be a measurement?

00:41:09 Cinnamon: Like how many drinks a day, how many times a week?

00:41:12 Erin: I mean, if you're drinking like a glass of wine at night at dinner, like, you know, okay. And for our folks, it's like they're, especially a lot of them are working 24, 48. Well, that isn't concerning, but it's when you're coming home and drinking in excess of six or more beverages in one sitting. And this is where it kind of gets like, this is where the rationalization comes in because we're looking at like a couple days a week, six plus beers, and that, that's a risky behavior.

00:41:40 Erin: And then folks can say, well, I can take down a case or I can take down a 12 pack. And for me, that's nothing. And then I'm like, Well, that's tolerance, you know, and so we're getting into a different kind of conversation. But you know, do you notice that when you have a, when you start drinking, you have a problem stopping? Like there isn't this ability to just say, okay, this is the last one. And now I'm walking out and I'm finished or are you noticing that you're forgetting on the whole entire night of experiences that have happened?

00:42:16 Cinnamon: Well, and if I only have three days off and I'm working for. Just easy math, and I'm drinking six or more drinks on the days that I'm off, would that be a problem? Because I'm not doing it every day because I'm at work. I'm only doing it on my days off.

00:42:36 Erin: Well, obviously, if you were doing it at work, you wouldn't have a job, first of all. 

00:42:40 Cinnamon: Okay. Yep. 

00:42:41 Erin: I'm being cautious of using the word a problem, okay? 

00:42:48 Cinnamon: Concerning. Worth examining.

00:42:51 Erin: Yeah, worth examining. I would ask more questions about that and what that looks like for you because that would definitely, to me, perk up my ear and say, hmm, that's interesting. So every day that you're not actually working, I'm here, what I'm hearing you say is that you are drinking six or maybe more alcoholic beverages at any given time. And then I also like to get specific by saying, how big are your pores? Are we talking like two fingers on a rocks glass of Bourbon or are we filling it to the top? You know, being mindful of, it's again, easy to rationalize, well, I'm only having a couple glasses of wine, but yeah, like getting those wine glasses, you can fit a whole bottle in?

00:43:30 Cinnamon:  Are they Margarita glasses? 

00:43:31 Erin: Right, so what are we working with? So obviously I understand that we want to protect the thing that makes us feel like we're, it feels like a safety net, but there, you know, it's not hard to go from, this using it as a coping mechanism, to it becoming dangerous and a significant risk-taking behavior that can be detrimental to mental and physical health.

00:44:03 Cinnamon: Well, and I think what makes it even trickier is that it works, right?

00:44:06 Erin: Isn't that annoying? 

00:44:07 Cinnamon: It does the job we want it to do. It does take the edge off. It does help us, you know, chill out from those intrusive thoughts or the rumination, whatever it is, like it works. And so then we get into a habit of what it feels like when it works. But when more things happen, we're also simultaneously building a tolerance. And so it's going to take more to get the same level of relief. And all of a sudden, we've just made this a habit that every single day off, I am drinking. And I'm drinking until I feel a certain way, but it's taking more and more to feel that certain way. 

00:44:51 Cinnamon: And we, you know, it's not like we have some timeline written on our wall where we know what it's looked like over the past six months, as we've increased that behavior. So it is sneaky and it's slippery. And even if, you know, we kind of joke about the word denial or, you know, minimizing or, you know, trying to protect that, like we don't always expect other people to see the problem that it's become because to them, it's the solution, not the problem. But when the solution becomes the problem, now we got another problem.

00:45:33 Erin: Exactly. And it's hard to resolve other problems when this is the overarching problem because everything else is masked. So, you know, often it's like we get to look at the alcohol first because it does many, many different things. It could also increase depression. It can increase all kinds of things. And so it's this interesting dichotomy of like what comes first. And we do have to take a hard look at the alcohol intake and substances.

00:46:04 Cinnamon: And you can't just check out on the stuff that's bothering you when you're using alcohol. When you're using a substance like that, you inadvertently are unavailable for all parts of your life.

00:46:19 Erin: Yeah. Yeah. So we're not, like trying to go down this alcohol and substances rabbit hole. I obviously am, I'm a chemical dependency counselor. That's what I do with a lot of our folks, but it's such a prevalent and huge thing in this particular culture, you know, that it feels very important to kind of highlight that a little bit more than we would some other things. And so really, I know that there was something else, Cinnamon, that you wanted to kind of touch on that you said we would bounce back to. Do you recall what that was?

00:46:52 Cinnamon: Yeah. So in addition to all these criteria, we have something called specifiers and the diagnosis for PTSD has two. One is called the dissociative specification. And so in addition to meeting that criteria for the diagnosis, we're also seeing the individual experience high levels of either depersonalization or derealization. And I'm just going to very briefly give a definition of each one of those, their reactions to trauma-related stimuli. And depersonalization is the experience of being like an outside observer or detached from oneself. You hear a lot of people say, I felt like I was hovering above it. That would be depersonalization.

00:47:47 Cinnamon: And the other one is derealization. And that's the experience of, like an unreality or a distance or a distortion. It doesn't look real. I've had clients use the word cartoonish, right? So it just loses that realistic quality. And it's not necessarily, even that anything has to look different. It's just how we're experiencing it. So that's the two types of the dissociative specification. And because we haven't mentioned anything about dissociation in all of the criteria, and it is common to hear people say, I felt like I was floating above it. I wanted to make sure we at least acknowledge that, yes, that can be part of the post-traumatic stress experience. 

00:48:31 Cinnamon: The second specification is the delayed specification. And this is the one I was referring to earlier when we were talking about the onset or that you have to have had symptoms for 30 days or more. The interesting thing about the delayed specification and we see this happen probably more common than we even realize because we may have somebody come in and say that they're struggling. And we could easily assume they've been struggling for a while. And it's just gotten to the point where they're like, okay, now it's intolerable. 

00:49:07 Cinnamon: But the delayed specification is actually where that full diagnostic criteria isn't even met until at least six months after the trauma. So we're looking at, “I'm fine, I'm fine, I'm fine, I'm fine.” And then one day, all of a sudden, something happens. And now I'm having these symptoms. And we do see that where somebody is like, “I was fine with this.” And then it came up in a conversation. And now I can't stop thinking about it. And I'm having all these other things happen, like all these other symptoms. So I say that again, to, I don't want the folks out there who are like, this happened a while ago and I was fine. And now I'm having all of these shitty things happen and I'm experiencing these symptoms and these things are popping back into my mind. And it can't be PTSD because I didn't have like, it's been a while. Like it's, it looks on a timeline, very disconnected from the actual critical incident. So I want people to know that you can have a delayed onset, and that that is not terribly uncommon, where things are fine for at least six months, and then you start having those symptoms.

00:50:20 Erin: Yeah, that's a great key point. 

00:50:22 Cinnamon: Or it amps up, right? Like you could have like, at the beginning an onset, but you don't meet criteria, an onset of those symptoms, but you're not meeting the full criteria. But then after at least six months, then boom, all of a sudden you've got all the stuff that you need to meet criteria.

00:50:40 Erin: Absolutely. And I really think that it's important to say that just because you listen to all of these episodes and you might hear similarities, we don't want you diagnosing yourself and saying, that's me. I have PTSD. Please, this is not us diagnosing you by any means. This is us helping you understand the breakdown in layman's terms about what it looks like. And perhaps to pique your interest, perhaps to maybe, you know, support you in going, a direction of actually seeking professional support in whatever capacity that looks like for you. So I do want to caution anybody from listening to any of these episodes and then all of a sudden panicking or thinking that that might be them.

00:51:26 Cinnamon: Or being like, “Yeah, Cinnamon and Erin are my therapists.” 

00:51:27 Erin: Right.

00:51:27 Cinnamon: Well, why? Well, because I listen to the podcast. No, this is for educational purposes only. We highly recommend if any of this resonates with you, you go to a mental health professional who is able to diagnose appropriately.

00:51:47 Erin: Definitely. And there's a lot of culturally competent first responder clinicians across the country. So it's really at this point, is becoming a Google search away. And you can also look at our resource page at AfterTheTonesDrop.com and see if you can get some guidance in that direction as well. We hope you enjoyed the PTSD series and all that it had to offer. And so we will continue to bring you knowledge and resources as we progress. But for this one, that's a wrap.

00:52:20 VO: Thank you for joining us for today's episode of After the Tones Drop. Today's show has been brought to you by Whole House Counseling. As a note, After the Tones Drop is for informational purposes only and does not constitute for medical or psychological advice. It is not a substitute for professional health care advice, diagnosis or treatment. Please contact a local mental health professional in your area if you are in need of any assistance. You can also visit afterthetonesdrop.com and click on our resources tab for an abundance of helpful information. And we would like to give a very special thank you and shout out to Vens Adams, Yeti and Sanda for our show's music.