Understanding PTSD: Impact, Diagnosis, and Treatment Options

1. Presented January 26, 2012 as part of the Grant per Diem educational training series for staff Introduction to Trauma & PTSD Karen Krinsley, Ph.D. PTSD Section Chief, VA Boston Healthcare System & PTSD Consultant, National Center for PTSD

2. Outline of Talk • Recognizing PTSD • How common is it? • Who is most at risk? • What treatments are effective? • How the PTSD Consultation Program can help

3. The technical diagnosis of PTSD —And why it is important • Misdiagnosis is common • Misunderstandings are common • Great reason not to focus on other issues • Serious but treatable when it is present • Typically NOT present alone

4. PTSD (DSM IV-TR): A Cluster of Symptoms • Trauma (The “Stressor”) • Reexperiencing / Intrusions • Avoidance/Numbing • Increased Arousal • More than one month of symptoms • Causes functional problems

5. PTSD Criterion A Stressor Exposure to a traumatic event in which: • The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. • The person's response involved intense fear, helplessness, or horror.

6. Important to Remember PTSD ≠ TRAUMA and TRAUMA ≠ ANYTHING bad

7. PTSD ≠ Trauma ≠ Anything bad • Traumas do not always lead to PTSD • Traumas may lead to PTSD, but then the person recovers • And, many bad things happen to people, affecting them deeply, that are not “trauma”

8. Criterion B: Reexperiencing/Intrusions • Recurrent recollections of the event • Recurrent distressing dreams of the event • Feeling as if the traumatic event were recurring • Intense distress at exposure to cues that resemble an aspect of the event • Physiologic reactivity upon exposure to cues that resemble an aspect of the traumatic event • EXAMPLES: Nightmares, Flashbacks, Shaking, Sweating

9. Criterion C:Avoidance/Numbing • Efforts to avoid thoughts about the trauma • Efforts to avoid things that remind one about the trauma • Inability to recall an important aspect of the trauma • Markedly reduced interest in significant activities • Feeling of detachment from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of foreshortened future • EXAMPLES: Avoiding the news, movies, crowded stores but also drinking and drug use

10. Criterion D: Increased Arousal • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hyper-vigilance • Exaggerated startle response • EXAMPLES: Keeping guns, checking locks, aggression, insomnia

11. PTSD Criterion E and F • Duration: At least one month • Functional Impairment: “clinically significant”

12. Do you see the overlaps? • Depression • Substance Use Disorder • Mild Traumatic Brain Injury • Pain Symptoms

13. Likelihood of getting PTSDafter Experiencing a Trauma • It depends on the event and the person • Men experience more traumatic events • Women are more likely to develop PTSD • After a traumatic event, who gets PTSD? • 20% of women • 8% of men get PTSD Kessler et al., 1995

14. Likelihood of PTSD…. • Rape • Men 65% • Women 45% • Combat • Men almost 40% • Physical Abuse • Almost 50% of women • 20%+ men

15. What puts you at risk for PTSD? • Being female • Being poor • Less education • Bad childhood • Previous psychological problems

16. What puts you at risk for PTSD? • *Strength or severity of the stressor • Characteristics of the trauma: • Greater perceived life threat • Feeling helpless • Unpredictable, uncontrollable

17. Risk for PTSD: After the Trauma • Degree of Social Support • Degree of Life Stress

18. How common is PTSD? • 3.5% general population, current • 1.8% men • 5.2% women • Lifetime: 6.8% -- 3.6% men, 9.7% women (U.S. National Comorbidity Survey Replication 2001-03) • Vietnam theater veterans: • 15.2% of men • 8.1% of women (National Vietnam Veterans Readjustment Study 1986-88) • In veterans • In combat veterans • In women veterans (who may be combat veterans!)

19. How common is PTSD? • Gulf War (I): 10% • OEF/OIF • 13.8 (current) • Population-based studies (RAND Corporation, Center for Military Health Policy Research, 2008) • Conclusions: PTSD is not unusual, although not the majority

20. What about MST?

21. How Common is MST?Margret Bell, Ph.D.Resource Development & Utilization Coordinator,MST Support Team – (national resource for VA MST teams)

22. Implications of PTSD • Greater risk of other disorders • 80% of people with PTSD another diagnosis • Depression, SUD, Anxiety Disorders • Greater unemployment • Relationships • Health problems • Violence • Generally, worse quality of life

23. What does PTSD look like? • No one clinical picture but not like it is shown on television/movies • Can’t stereotype, although it’s done • There are some “hallmarks” • Nightmares • Poor sleep • Anger • Numbness or sadness • Avoidance of groups

24. How can you help? • Be supportive but don’t allow PTSD to be used as an excuse • Do ask if they want to talk and acknowledge their military service • Don’t say “I understand” • Be alert for risk issues

25. How can you help? • Sleeping / Nightmares: No touching • No “fooling around”: Don’t sneak up on someone, don’t make sudden noises behind them • Understand the impact of TV • Consider special requests: Light, Noise, Large Groups

26. A few tips for Managing Anger • Confrontation probably NOT helpful • Try to understand the cause, both to help manage and to help yourself stay calm • Prepare ahead of time with the veteran if possible • Allow “escape”

27. Trauma-Informed Milieu • Structured but not authoritative or punishing • Everyone treated with respect and listened to • Setting is kept safe • Staff aware that residents may be traumatized

28. Professional Help • Know when to refer • Be knowledgeable about PTSD treatments and aware that they work • Encourage keeping appointments • Acknowledge that it will be HARD but it is worth it • Ask what the alternative is • Be wary of splitting

29. Effective PTSD Treatments • State of the art treatment • Empirically validated treatments • Staged, stepped model of care • Safety • Trauma focus • Reconnection • Interdisciplinary • PTSD ≠ chronic mental illness

30. Treatment for PTSD • Cognitive Behavioral Treatments most effective psychotherapy treatments • Medication can be an effective treatment • Most evidence for Cognitive Processing Therapy and Prolonged Exposure • Most evidence for antidepressants

31. Stepwise Treatment Model:Stage 1 Safety • Suicide and Homicide prevention • Harm reduction for risky behaviors • Teach positive coping tools • Teach the role of avoidance • Group focus when possible, including: Seeking Safety, Understanding and coping with PTSD, Relaxation & Stress Mgmt, ACT, DBT modules & Anger Management, Wellness, & more

32. Stepwise Treatment Model:Stage 2 Trauma Focus • Core of PTSD treatment • Empirically validated treatments include Cognitive Processing Therapy and Prolonged Exposure • It works! Recovery is possible.

33. Trauma Focus Therapy • Many types • Core common elements • Exposure to the trauma in some form • Processing of the trauma • Results: Decreased avoidance, increased tolerance of distress, and ultimately decreased distress

34. CPT AND PE Comparison Study(Resick et al., 2002) CPT, N= 83 55 50 41 63 PE, N= 88 55 51 39 64

35. CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT AND LONG TERM (Resick et al., 2002)

36. Stepwise Treatment Model:Stage 3 Reconnection • Focus is on relationships • Reconnection with friends, family • Support groups, process groups, marriage and family work and more • Also may include Reparation

37. Special issues with new veterans of Iraq and Afghanistan • National Guard OR Reserve OR Regular Military • Trauma is more acute or “raw” • Anger and aggression are common • Binge drinking or casual drug use • May be working and need different hours for treatment • Often have families and children, and may want or need them involved in treatment • May not want traditional treatments such as group therapy

38. PTSD Consultation Program • One-on-one PTSD consultation for any VHA provider OR contractor • Free of charge • Speak directly with “expert” PTSD clinicians • Response usually within 24 hours • Easy to contact us: Call, email, or complete an online form

39. Consultation Program Staff Karen Krinsley, PhD Consultant & VISN 1 PTSD Mentor PTSD Section Chief, VA Boston Nancy Bernardy, PhD PTSD Mentoring & Consultation Program Manager VA National Center for PTSD Matt Friedman, MD, PhD Executive Director, NCPTSD And associated experts from around the country

40. PTSD Consultation Program Ask questions regarding: • Assessment • Treatment • Therapy of all kinds • Medication • Clinical management • Programmatic issues • Resources for treatment • Ways to improve care • Any problem at all

41. Eligibility • We can’t say this enough: • ANY VHA Clinician • ANY Contractor • ANY Question • ABOUT ANY Veteran or Group of Veterans

42. For Whom and How We Have Been Useful • Experienced clinicians who want a second opinion • Relatively inexperienced clinicians who would rather not “bother” local colleagues that particular day • New staff who are overwhelmed • Staff without a lot of local folks for support

43. For Whom and How We Have Been Useful • Staff from programs outside PTSD with no connections to their PTSD programs • Staff who have hit a roadblock or a wall • Diagnostic and treatment challenges • Referrals to residential programs

44. Consultation Program Contact Information Contact us: • Call 1 (866) 948-7880 • Online Form at: vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp • Send e-mail to ptsdconsult@va.gov

46. A Few Things to Remember • Consultation provides an opportunity for problem solving and discussion with the treating clinician • Ultimate decision and authority for implementing consultation recommendations lie with the treating clinician and the local chain of command • Not for acute emergencies

47. More Information:National Center for PTSD Website • www.ptsd.va.gov • All types of information, for • Providers • Veterans • Families • General Public • Has online courses such as “Understanding PTSD” and much more