PTSD AND THE COURT A PRESENTATION BY HARVEY DONDERSHINE, MD, JD “THE PAST ISN’T DEAD,

1. PTSD AND THE COURT A PRESENTATION BY HARVEY DONDERSHINE, MD, JD “THE PAST ISN’T DEAD, IT ISN’T EVEN PAST” William Faulkner

2. SENSE OF SELF P1 P3 P2 PRE POST

3. TOPICS • OVERVIEW • CAUSE AND COURSE OF PTSD • NEUROSCIENCE of TRAUMA • DIAGNOSIS OF PTSD / CO-MORBID CONDITIONS • TREATMENT & REHABILITATION • THE PTSD DEFENDANT • CONNECTION BETWEEN PTSD AND CRIME • DE-LINKING BETWEEN PTSD AND CRIME • REVIEW OF MAIN POINTS

4. OVERVIEW • PTSD • PTSD AND COURT • ATTORNEY AND THE PTSD CLIENT • WAR ON TERROR: “LOOMING NATIONAL DISASTER”

5. PTSD DATA • 3.6% OF POPULATION CURRENTLY HAS PTSD • PTSD OVER-REPRESENTED IN JAILS AND PRISONS • 200,000 VETS UNDER LEGAL SUPERVISION • WHAT’S “LOOMING” • 2 MILLION SOLDIERS DEPLOYED • 25% RETURNED WITH PTSD • 10-15% WILL STILL HAVE PTSD IN 2030 • 50% WILL NEVER RECEIVE TREATMENT • MANY WILL BE IN COURT SOON AND FOR DECADES

6. Penal Code Sec. 1170.9 • A VET ALLEGES OFFENSE RESULT OF SERVICE IN COMBAT THEATER OF OPERATIONS • COURT SHALL CONDUCT HEARING • IF EVIDENCE CONFIRMS AND VET ELIGIBLE FOR PROBATION, COURT MAY ORDER TREATMENT FOR PTSD, SUBSTANCE ABUSE, OTHER SERVICE-RELATED PSYCHOLOGICAL DISORDERS

7. ATTORNEY AND THE PTSD CLIENT • PTSD IMPACTS ATTORNEY-CLIENT RELATIONSHIP • DISTRUST, ANGER, SPECIAL SENSITIVITIES • “LEGAL” RETRAUMTIZATION AND REACTIONS TO IT • ATTORNEY ROLE • NEED TO SEE THROUGH THE FAÇADE • ATTORNEY AS “FIRST-RESPONDER” • DO BRIEF SCREEN • EMPOWER CLIENT

8. BRIEF SCREEN YES TO Q #1 PLUS ANY 2 OTHER YES’s MEANS PROBABLE PTSD • HAVE YOU EVER HAD SOMETHING VERY UPSETTING HAPPEN TO YOU? IF YES, IN PAST MONTH, DID YOU HAVE: • BAD DREAMS or UNWANTED THOUGHTS OF IT? • AVOIDED OR TRIED NOT TO THINK OF IT? • FELT HYPER ALERT OR EASILY STARTLED? • FELT NUMB OR DETACHED?

10. CRIMINAL LAW • ACTUS REUS • MENS REA • GENERAL INTENT • SPECIFIC INTENT • DIMINSHED CAPACITY VS. DIMINISHED ACTUALITY • INSANITY • COMPETENCY TO STAND TRIAL • DUE PROCESS • EQUAL PROTECTION • DOWNWARD DEPARTURE • DANGEROUSNESS VS PREDICTIVE RISK DETERMINATION

11. PTSD • “BEFORE-AND-AFTER” DISORDER • BRAIN “BURN” FROM A “HOT” EVENT • OFTEN CHRONIC, RELAPSING • MAY HIDE IN PLAIN SIGHT • USUALLY DOES NOT TRAVEL ALONE • PAIN IS OFTEN AN ISSUE IN PTSD

12. PTSD SEQUENCE TRAUMATIC EVENT PSYCHOLOGICAL “OUTCRY” NEUROBIOLOGICAL CASCADE RESOLUTION AND RECOVERY INTERRUPTION IN RECOVERY SYMPTOMS APPEAR / FUNCTION DETERIORATES DEPRESSION / SUBSTANCE ABUSE MAY FOLLOW BELIEFS AND ATTITUDES (SELF & WORLD) CHANGE

13. CAUSE AND COURSE OF PTSD ATS RESOLUTION RECOVERY 70% 30 DAYS COMORBIDITIES RISK FACTORS TRAUMA 30% PROTECTIVE FACTORS ASD ACUTE PTSD CHRONIC PTSD 80% 50% TIME

14. EVENT VS. STRESSOR VS. TRAUMA • EVENT IS A HAPPENING • STRESSOR IS A “SUPER HEATED” EVENT • INTENSITY, DURATION • TRAUMA IS PERSONAL RELATIONSHIP BETWEEN STRESSOR & VICTIM • PERSONAL MEANING • PRE-TRAUMA VULNERABILITY • LACK OF SUPPORT • PRIOR TRAUMA • GENETIC POLYMORPHISM

15. PTSD AND THE BRAIN HIPPOCAMPUS AMYGDALA HYPOTHALAMUS PITUITARY

16. H-P-A ENDOCRINE RESPONSE • SENSORY IMPUT RECEIVED IN BRAIN • HYPOTHALAMUS SECRETES CRF • CRF RELEASE PITUITARY ACTH AND CORTISOL • ACTH CAUSES ADRENAL RELEASE OF EPINEPHRINE • CORTISOL TURNS OFF ACTH • TRAUMA LEVELS OF CORTISOL TOXIC TO BRAIN • CORTISOL THEN EXCITES - NOT TURNS OFF - CRF/ACTH • PERSISTENT AROUSAL OF THREAT CENTERS IN BRAIN

17. PRE-FRONTAL CORTEX REGULATORY FUNCTION • AMYGDALA SENSITIZED BY TRAUMA THREAT DETECTOR SOMATOSENSORY HIPPOCAMPUS IMPAIRED BY TRAUMA NARRATIVE INTEGRATIVE

19. OVERVIEW OF DSM V CRITERIA • TRAUMATIC EVENT • INTRUSIONS • AVOIDANCE • AROUSAL • CHANGE IN COGNITION / EMOTION • DURATION OF B, C, & D MORE THAN ONE MONTH • CLINICALLY SIGNIFICANT DISTRESS / IMPAIRMENT

20. A. EXPOSED TO DEATH / THREATENED DEATH, SERIOUS INJURY, SEXUAL VIOLATION; 1OR MORE OF FOLLOWING WAYS: PERSONALLY EXPERIENCED THE EVENT WITNESSED THE EVENT AS IT OCCURRED LEARNED EVENT HAPPENDED TO CLOSE RELATIVE OR FRIEND; VIOLENT OR ACCIDENTAL INTENSE EXPOSURE TO DETAILS; DOES NOT APPLY TO EXPOSURE THROUGH MEDIA UNLESS EXPOSURE IS WORK RELATED.

21. B. INTRUSIVE SYMPTOMS ASSOCIATED WITH TRAUMATIC EVENT; 1 OR MORE OF FOLLOWING: • INVOLUNTARY MEMORIES • DISTRESSING DREAMS RELATED TO EVENT • DISSOCIATION (E.G., FLASHBACKS) • DISTRESS ON EXPOSURE TO CUES THAT SYMBOLIZE OR RESEMBLE SOME ASPECT OF EVENT • MARKED PHYSIOLOGICAL REACTION TO REMINDERS

22. C. AVOIDANCE OF STIMULI ASSOCIATED WITH EVENT; 1 OR MORE OF FOLLOWING:   • AVOIDS INTERNAL REMINDERS • AVOIDS EXTERNAL REMINDERS

23. D. NEGATIVE ALTERATIONS IN COGNITION OR MOOD; 3 OR MORE OF FOLLOWING: • AMNESIA FOR IMPORTANT ASPECTS OF EVENT • NEGATIVE EXPECTATIONS SELF, OTHERS, OR WORLD • BLAME SELF / OTHERS RE CAUSE OR CONSEQUENCES • PERVASIVE FEAR, ANGER, GUILT, OR SHAME           • DIMINISHED INTEREST /PARTICIPATION IN ACTIVITIES • DETACHED OR ESTRANGED FROM SELF, OTHERS • INABILITY TO EXPERIENCE POSITIVE EMOTIONS

24. E. ALTERATIONS IN AROUSAL AND REACTIVITY; 3 OR MORE OF THE FOLLOWING: • IRRITABLE OR AGGRESSIVE BEHAVIOR • RECKLESS OR SELF-DESTRUCTIVE BEHAVIOR     • PROBLEMS WITH CONCENTRATION • SLEEP DISTURBANCE • HYPERVIGILANCE • EXAGGERATED STARTLE RESPONSE

25. CO-MORBID CONDITIONS • DEPRESSION • PANIC ATTACKS • SUBSTANCE ABUSE • (m-TBI)

27. PHASES OF TREATMENT • STABILIZE • EDUCATE • CONSENT PROCESS • EMOTIONAL “SKILLS” TRAINING • TREATMENT OF CO-OCCURRING DISORDERS • TRAUMA-FOCUSED THERAPY AND/OR MEDS • FOLLOW-UP • REHABILITATE, REINTEGRATE, PREVENT RELAPSE

28. SKILLS TRAINING RELAXATION ANGER MANAGEMENT TRIGGER CONTROL COGNITIVE PSYCHOLOGY PROBLEM SOLVING COMMUNICATIONS

29. COGNITIVE PSYCHOLOGY“…A WORD IS THE SKIN OF A LIVING THOUGHT…” Oliver Wendell Holmes EVENT IS FACT. MEANING AND EMOTION DERIVE FROM THOUGHT BOTH EMERGE FROM “INTERNAL RHETORIC” ADDRESS BY COUNTERING THIS RHETORIC

30. PHARMACOTHERAPY • 1ST LINE – SSRI, SNRI • 2ND LINE – EFFEXOR, REMERON, TCA, MAOI • ADD-ON DRUGS: RISPERDAL, PRAZOSIN, DESYREL • SOME DRUGS PROBABLY NOT EFFECTIVE • BUPROPION, DEPAKOTE • SOME DRUGS MIGHT BEST BE AVOIDED • BENZODIAZEPINES

31. TRAUMA-FOCUSED PSYCHOTHERAPY EXPOSURE THERAPY TRAUMA FOCUSED COGNITIVE THERAPY COGNITIVE PROCESSING THERAPY EMDR STRESS INNOCULATION “TOOL BOX” TRAINING

32. FOLLOW-UP FUNCTIONAL REHABILITATION SOCIAL REINTEGRATION MAINTENANCE OF SOBRIETY PRIMARY HEALTH CARE

33. BLOCKS TO RECOVERY SEVERITY OF DISORDER INEFFECTIVE TREATMENT LACK OF COMPLIANCE POVERTY SOCIAL ISOLATION CONTINUING SUBSTANCE ABUSE

35. FORENSIC IMPLICATIONS • TORTS – CAUSATION, DAMAGES • CRIME – MORE ISSUES THAN MENS REA • PTSD IMPACTS ALL PARTIES • PTSD CRIMINAL DEFENDANTS CAN BE A CHALLENGE • THEY CAN “DEFEND” AGAINST OWN BEST INTERESTS • PRE-EXISTING / SELF-INFLICTED TRAUMA • CASE-RELATED RE-TRAUMATIZATION

36. PTSD AND CRIME • MANY DEFENDANTS HAVE PAST TRAUMA • PAST TRAUMA IS LINKED TO PTSD • CRIME CAN BE CONSEQUENCE OF PTSD • CORE SYMPTOMS • SECONDARY EFFECTS OF CORE SYMPTOMS • CO- MORBID CONDITIONS

37. SYMPTOMS LINKED TO CRIME • FLASHBACKS • DISSOCIATION • RECKLESS OR SENSATION-SEEKING BEHAVIOR • MISPERCEPTION OF THREAT • OVER-REACTION TO STARTLE • GUILT-DRIVEN BEHAVIOR • COMPLEX REENACTMENT BEHAVIORS • PSEUDO ANTISOCIAL ATTITUDES

38. DISSOCIATION • PERI-TRAUMATIC DISSOCIATION PART OF ASD • IS ALTERED STATE OF CONSCIOUSNESS • TRIGERRED BY SUDDEN EXTREME THREAT • RELEASES INSTINCTUAL “SURVIVAL” REACTION • ACTIONS NOT MEDIATED BY EXECUTIVE FUNCTIONS • ACTIONS INCONSISTENT WITH BASIC PERSONALITY • MEMORY IMPAIRED FOR DISSOCIATED BEHAVIOR

39. CRIMES ASSOCIATED WITH PTSD • UNDER THE INFLUENCE • DRUG POSSESSION / SALES & DISTRIBUTION • ASSAULT • DOMESTIC VIOLENCE • “REENACTMENT” CRIMES

40. DE-LINKING PTSD AND CRIME • PSYCHOEDUCATION • PROVIDE “SKILLS” TRAINING • DAMPEN CORE SYMPTOMS • MAINTAIN SOBRIETY • PROVIDE SOCIAL SUPPORT • MANAGE PAIN

41. REVIEW • PTSD IS A “BEFORE-AND-AFTER” DISORDER • MAY HIDE IN PLAIN SIGHT • ATTORNEY MAY NEED TO BE A “FIRST-RESPONDER” • ALL SIDES NEED TO SEE THROUGH THE FAÇADE • KNOW THE REHABILITATIVE OPTIONS • TREATMENT WORKS