Civilian vs. Military Trauma

1. Civilian vs. Military Trauma Brian L. Meyer, Ph.D. Interim Associate Chief, Mental Health Clinical Services McGuire VA Medical Center Richmond, VA May 26, 2015

2. Disclaimer The views expressed in this presentation are solely those of the presenter and do not represent those of the Veterans Health Administration, the Department of Defense, or the United States government.

3. The author has no conflicts of interest to disclose.

4. Trauma and PTSD

5. Trauma and PTSD • Not all trauma leads to PTSD Depending on the study, the type of trauma, and the group studied, 3%-58% get PTSD • Not all abuse leads to PTSD

7. Women May Be More Vulnerable to Stress Disorders Than Men • More men (61%) than women (51%) experience a trauma at some point in their lives, but women experience PTSD at twice the rate of men (10% vs. 5%) (Kessler et al., 1995; Tolin and Foa, 2006) • Females may be more sensitive to Corticotropin releasing factor (CRF) than males (Bangasser et al., 2010)

8. Trauma and Gender • Men are most likely to develop PTSD from combat exposure, rape, childhood neglect, and childhood physical abuse • Women are most likely to develop PTSD from rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (Kessler et al., National Comorbidity Survey, 1995)

9. Life-Threatening Events PERSONAL IMPERSONAL TRAUMATIC

10. Many Types of Trauma • Combat and war-zone trauma • Rape • Child physical abuse • Child sexual abuse • Domestic violence • Environmental trauma • Torture • Being held hostage • Genocide • Cultural trauma • Accidents • Natural disasters • Fires

11. PTSD: An Example of Torture Mr. E: Army; guarded Tomb of the Unknown Soldier; engaged; apartment broken into; tortured; fiancée raped; fear of sleeping at night; triggered by sports games; became hypersexual; seven children by four women; became dependent on PCP; drove while high, arrested, and jailed for nine months

12. Post-Traumatic Responses Occur on a Continuum None Moderate Mild Severe

13. Who Gets PTSD? • It depends on: Genetics Severity Duration Proximity • PTSD is mitigated or worsened by: Childhood experience Personality characteristics Family history Social support

14. PTSD and the Brain Amygdala – Emotional reactions, fight or flight alarm system Hippocampus – Relay station for sorting memories Prefrontal cortex – logic, reasoning, planning, impulse control, organizing (Overactive) (Underactive) (Smaller volume)

16. Changes in the DSM 5 Definition of PTSD

17. Changes to PTSD Diagnosis in DSM 5 • Trauma and Stressor-Related Disorders are placed in their own category • Loss of loved one must be traumatic or accidental • Elimination of B criterion of reaction of horror, terror, or helplessness • Military and first responders do their job

18. Changes to PTSD Diagnosis in DSM 5 • Addition of new criteria involving negative cognitions (negative beliefs about the world, blame of self or others for the trauma) and mood (depression, anger, guilt) • Addition of a new arousal criterion: self-destructive or reckless behavior • These changes result in approximately the same number of people who will meet criteria for a diagnosis of PTSD

19. Post-Traumatic Stress Disorder in DSM 5 PTSD is characterized by: • Exposure to a severe life-threatening event • Repetitive re-experiencing of the event • Avoidance of stimuli associated with trauma • Negative moods and cognitions • Increased arousal

20. PTSD: Exposure to a Life-Threatening Event A. Exposure to a traumatic event • Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence

21. PTSD: Intrusion Symptoms B. Re-experiencing symptoms: • Recurrent, involuntary and intrusive recollections • Traumatic nightmares • Dissociative reactions (e.g., flashbacks) • Intense or prolonged distress after exposure to traumatic reminders • Marked physiological reactivity to trauma-related stimuli

22. PTSD: Avoidance of Stimuli Associated with Traumatic Event C. Persistent effortful avoidance of distressing trauma-related stimuli after the event: • Trauma-related thoughts and feelings • Trauma-related external reminders

23. PTSD: Negative Cognitions and Mood D. Negative alterations in cognitions and mood that began or worsened after the traumatic event: • Inability to recall key features of the traumatic event • Persistent negative beliefs and expectations about self or world • Persistent distorted blame of self or others for causing the event or the resulting consequences

24. PTSD: Negative Cognitions and Mood • Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame) • Markedly diminished interest in significant activities • Feeling alienated from others • Constricted affect: persistent inability to experience positive emotions

25. PTSD: Increased Arousal E. Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: • Irritable or aggressive behavior • Self-destructive or reckless behavior • Hypervigilance • Exaggerated startle response • Problems in concentration • Sleep disturbance

26. PTSD: A New Subtype Dissociative Subtype of PTSD: • Meets criteria for a diagnosis of PTSD • Experiences high levels of depersonalization or derealization • Dissociative symptoms are not related to substance abuse or other medical condition

27. Further Symptoms Associated with PTSD

28. Implications of Changes to PTSD Diagnosis in DSM 5 • Angry, guilty, and anxious affects now apply • This is a rejoinder to the fear-based model of the past, recognizing greater complexity • There are probably four phenotypes of PTSD here: • Anxious/fearful • Angry • Guilty/shameful • Dissociative • Do they each need their own assessments and treatments?

29. Implications of Changes to PTSD Diagnosis in DSM 5 The existence of a dissociative subtype, combined with the new affective criteria and the new arousal criterion of self-destructive behavior, moves the description closer to that of Complex Trauma Some of the research on PTSD may no longer apply

30. Implications of Changes to PTSD Diagnosis in DSM 5 • Assessment instruments must change • Different treatments may be needed for different phenotypes of PTSD (anxiety, anger, depression/guilt, dissociation) • This may decrease the use of certain treatments, particularly Prolonged Exposure, which is fear-based

31. What Does It Feel Like to Have PTSD?

32. Inside the Skin of PTSD • Nerves on edge • Jumpy • Can’t sleep • Nightmares • Irritable all the time • Explosive outbursts • Wants to be left alone • Depressed • Can’t stand crowds • Heart races/sweats

33. Inside the Skin of PTSD • Hates New Year’s Eve and July 4th • Secretive • Distrusts others • Sees world as dangerous • Constantly watching for danger • Hates lines • Overwhelmed by stimulation • Feels responsible for trauma

34. Inside the Skin of PTSD Copes by: • Cutting off relationships • Isolating • Taking risks • Self-harming behaviors • Using drugs and alcohol

35. Faces of PTSD

36. Some Consequences of PTSD • Damaged relationships • Strain on families • Domestic violence • Multiple marriages • Problems in parenting • Children develop problems

37. More Consequences of PTSD • Lost productivity • Poverty • Homelessness • Legal problems • Reduced quality of life

38. THE CATALYZING EFFECT OF TRAUMA Health Problems Substance Abuse Problems Traumatic Experiences Mental Health Problems Criminal Behavior Relationship Problems Employment Problems

40. Civilian Trauma and PTSD

41. Environmental and Accident Traumas

42. Types of Disasters • Hurricanes • Earthquakes • Tsunamis • Tornadoes • Volcanoes • Nuclear plant meltdown • Airplane crashes • Boat sinkings • Etc.

43. Disasters: Hurricane Katrina • 1,833 deaths • $108 billion damage • Looting and violence • New Orleans population: • July, 2005: 440,000 • January, 2006: 158,000 • December, 2014: 384,000 • Grief, loss, devastation, family breakups

44. Disasters: Hurricane Katrina