Global Health Conference 2-1-14: Introduction to PTSD Simulation Exercise

1. Global Health Conference 2-1-14:Introduction to PTSD Simulation Exercise Martin Klapheke, MDProfessor of Psychiatry University of Central Florida College of Medicine

2. Overview: Each Block will last approximately 50 minutes. • 5-10 minute introduction, to define the interviewing students’ task. • 15 minute patient (SP) interview by 1 or 2 students. A “Time Out” can be called by the primary student interviewer to consult briefly with the secondary student interviewer. There will be preceptors available for questions outside the rooms but the students should try to function independently of them during the interviews. • 5-10 minute feedback from SP to students. • 15 minute debriefing, with students reflecting on their thoughts and feelings about the experience. Will include a mini-didactic handout on Trauma from Dr. Klapheke.

3. Goal for the Interviewing Student(s): The goal of this exercise is for the student to gain experience by performing a 15-minute focused interview of a refugee that has experienced severe trauma. The student is not necessarily expected to come up with a complete diagnostic formulation or treatment plan.

4. Student Task: 1. Obtain a focused (maximum 15 minutes) history from a refugee who has experienced trauma. • Include a brief assessment of the impact of culture on the patient’s presentation. • Include a brief assessment of the impact of being a refugee on the patient’s presentation. • At the end of the interview, you may briefly counsel the patient regarding their condition and plan of care. 2. Following the interview, complete the post-encounter review with the Standardized Patient before leaving the room. 3. Then proceed to the Debriefing Room.

5. Examples for questions regarding the impact of culture on perception of the cause of the presenting problems and current help-seeking (DSM-5) • “Why do you think this is happening to you?” • “What do others in your community think is causing your problems?” • “Sometimes people have various ways of dealing with problems like you are experiencing. What have you done on your own to cope with it?” • “Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for your problems?” • “What kind of help do you think would be most useful to you at this time?” • “Are there any kinds of support that make your problem better, such as support from family, friends, or others?” • “Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?” • “Sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about this and is there anything that we can do to provide you with the care you need?”

6. Examples for questions regarding the impact of Refugee status on the presenting problems and current help-seeking (DSM-5) • “Some people experience hardship, persecution, or even violence before leaving their country of origin. Has this been the case for you or members of your family? Can you tell me something about your experiences?” • “Of the persons important or close to you, who stayed behind?” • “Were there any challenges on your journey to the United States that you or your family found especially difficult?” • “Do you or your family miss anything about your way of life in Syria?” • “Do you have concerns about relatives that remain in your home country?” • “Are there any other challenges or problems you or others in your family are facing related to your resettlement here?” • “Has coming to the United States resulted in something positive for you or your family?” • “What hopes and plans do you have for you and your family in the coming years?”

7. Acute Stress Disorder DSM-5 Exposure to trauma (or learning about violent or accidental event involving someone close) involving threat of death, serious injury, or sexual violation, to self or others; can also occur with repeated extreme exposure to aversive details of the trauma. Leads to 9 or more of: • Intrusion symptoms: intrusive memories; distressing dreams; flashbacks (with most extreme being with complete loss of awareness of current surroundings); marked distress in response to external cues symbolizing the trauma. • Negative mood: inability to experience positive emotions. • Dissociative symptoms: altered sense of oneself or surroundings (e.g., “in a daze”; derealization; depersonalization); inability to recall an important aspect of the trauma. • Avoidanceof the distressing memories/feelings and/or of external reminders of the trauma. • Arousal: sleep disturbance; irritability/angry outbursts; poor concentration; hypervigilance; exaggerated startle response. Duration is 3 days to 1 month.

8. Acute Stress Disorder DSM-5 Prevalence varies with nature and context of the trauma: • Typically in < 20% of cases involving trauma without interpersonal assault (e.g., 13-21% following MVA) • Typically in 20-50% of cases involving interpersonal trauma (e.g., rape, mass shooting). Risk factors: prior trauma or prior mental disorder, greater perceived severity of the trauma, and an avoidant coping style; females at greater risk than men (?neurobiological differences, ?greater exposure to some forms of trauma).

9. Acute Stress Disorder (ASD) Black & Andreasen • ASD lasts 3 days to 1 month; PTSD lasts > 1 month and may have dissociative symptoms but these are usually not as prominent in PTSD. • Most patients with ASD do not go on to develop PTSD, but those whose ASD trauma involves brain injury may be somewhat more likely to develop PTSD (Bryant et. al. J Clin Psychiatry June 2008)

10. Early Interventions Following Trauma, and Treatment of Acute Stress Disorder (ASD) Black & Andreasen; Bisson et.al. Am J Psychiatry 2007;164:1016-1019; and 2012 AADPRT Brain Conference • PTSD develops in approximately 14% of those exposed to trauma; studies suggest marked human resilience in that most individuals do not develop psychological problems after trauma. • DO NO HARM. Some studies suggest “critical immediate stress debriefing” does NOT appear helpful and may actually worsen outcome.

11. Early Interventions Following Trauma, and Treatment of Acute Stress Disorder (ASD): Bisson et.al. Am J Psychiatry 2007;164:1016-1019 • Any intervention should be tailored to the individual’s needs. “People cope with stress in different ways, and no formal intervention should be mandated for all exposed to trauma”. • The efficacy of “Psychological first aid”—compassion and support to distress & facilitate access to further care if needed—needs further study. But for now Bisson et. al. recommend: • 1st step: empathically provide practical, pragmatic support, to complement social support. • Educate the person about the range of individual responses to trauma including people’s natural resilience, positive coping strategies, and how to access social support and, if needed, treatment (see below).

12. Early Interventions Following Trauma, and Treatment of Acute Stress Disorder (ASD) Black & Andreasen; Bisson et.al. Am J Psychiatry 2007;164:1016-1019; and 2012 AADPRT Brain Conference • Do not push patient into treatment unless they want it: match the intervention to the individual patient. • Utilize support system: social connectedness can buffer traumatic stress • Teach positive coping and resilience

13. Early Interventions Following Trauma, and Treatment of Acute Stress Disorder (ASD) Black & Andreasen; Bisson et.al. Am J Psychiatry 2007;164:1016-1019; and 2012 AADPRT Brain Conference • If the patient has distressing symptoms: • Prolonged Exposure therapy or Cognitive therapy can effectively prevent chronic PTSD in patients with full acute PTSD criteria (except for the 1-month duration criterion; treatment began a mean of 5.7 days with SD 29.8 days after the trauma) (Shalev et. al. Arch Gen Psychiatry 2012;69:166-176). • Data do NOT suggest benzodiazepines are helpful (possible  in dissociation??). • Post-trauma symptoms tend to subside if the patient does not avoid thoughts & feelings about the trauma, i.e. it is the avoidance that make us ill.

14. Posttraumatic Stress Disorder (PTSD) DSM-5 Exposure to trauma (or learning about violent or accidental event involving someone close) involving threat of death, serious injury, or sexual violation, to self or others; can also occur with repeated extreme exposure to aversive details of the trauma. Leads to: • Intrusion symptoms: intrusive memories; distressing dreams; flashbacks (with most extreme being with complete loss of awareness of current surroundings); marked psychological—and/or physiological—distress in response to external cues symbolizing the trauma. • Avoidance of the distressing memories/feelings and/or of external reminders of the trauma. • Negative cognitions and mood: inability to recall an important aspect of the trauma; exaggerated negative views of self, others, or the world; distorted blame of self or others for the trauma; persistent negative emotional state (e.g., anger, shame); marked decreased interest or participation in activities; detachment/estrangement from others; inability to experience positive emotions. • Arousal: sleep disturbance; irritability/angry outbursts; poor concentration; hypervigilance; exaggerated startle response; reckless or self-destructive behavior. Duration is > 1 month. May have dissociative symptoms: derealization or depersonalization. The criteria are modified for children 6 years old and younger.

15. Epidemiology & Features of PTSD Black & Andreasen; Kaplan & Sadock; DSM-5 • Lifetime prevalence: 7-8%. However, most persons exposed to trauma do NOT develop PTSD. • May be especially severe or long-lasting with interpersonal and intentional trauma. • Trauma, e.g., childhood abuse, increases suicide risk. • May have paranoid ideation and auditory pseudo-hallucinations (hearing one’s thoughts spoken in 1 or more different voices). • For men, combat is the most frequent trauma; for women, it is physical assault or rape. Can begin soon after the trauma or months/years later. • PTSD resolves within 3 months in about 50% of adults, but can be chronic, with waxing/waning especially with stresses. • Comorbidities: major depression, anxiety disorders, substance abuse, TBI (48% co-occurrence of PTSD and mild TBI in recent combat veterans).

16. Epidemiology & Features of PTSD Black & Andreasen; Kaplan & Sadock; DSM-5 • Risk factors: • History of prior trauma or emotional problems • Female gender (appears in part due to greater exposure to some forms of trauma). • severity of the trauma; • Persistent dissociation symptoms; • Acute Stress Disorder; • Imaging: Hippocampal volume and metabolic activity in limbic regions especially the amygdala • Social support prior to trauma is PROTECTIVE, and following trauma it moderates outcome

17. Education of patient, and Positive coping after trauma 2012 AADPRT Brain Conference • Excellent resource for patients, families, professionals: http://www.ptsd.va.gov/ • Free download of Mobile App: PTSD Coach to help manage symptoms: http://www.ptsd.va.gov/public/pages/ptsdcoach.asp • Educate patient that it is “normal” to react strongly to trauma; one need not fear intense affect, as it should dissipate with time. However, if intense affect does not begin to dissipate by 3 months, seek treatment (next slide). • Positive coping: Mobilize social support; Exercise; Relaxation; Pleasureable activities; Sleep hygiene

18. Treatment of PTSD Black & Andreasen; and Treatment Guidelines from The Medical Letter 2006;4:39-40; and 2012 AADPRT Brain Conference Psychotherapy: • Cognitive Processing Therapy is effective: see website http://cpt.musc.edu • Prolonged Exposure therapy is effective Pharmacotherapy: • Generally treated with an SSRI (re-experiencing symptoms such as nightmares & flashbacks, hyperarousal and improve sleep, avoidance/numbing symptoms): Sertraline, Paroxetine • Venlafaxine also appears effective • TCAs, MAOIs • Alpha 1-adrenergic antagonist prazosin may intractable nightmares, reexperiencing & hyperarousal symptoms • Use of benzodiazepines controversial due to possible dissociation and potential for dependence • May need adjunctive antipsychotic, but try to keep any such use short-term.