VA Medical Center Albany, NY

1. VA Medical CenterAlbany, NY

2. Posttraumatic Stress Disorder: Attachment Based Experiential Interventions May 16, 2013

3. Posttraumatic Stress Disorder Program Charles R. Kennedy, Ph.D., Gretchen Wilber, Psy.D.

4. History of Posttraumatic Stress Disorder PTSD is an anxiety disorder that can occur after experiencing or witnessing a traumatic event. The person experienced, witnessed or was confronted by an event or events that involved actual or threatened death or serious injury or threat to physical integrity of self or others. The person’s response involved intense fear, helplessness or horror.

5. Prediction of Imminent Danger What is the probability that you will face a life threatening event upon leaving today’s presentation?

6. PTSD Prevalence Rates Most survivors of trauma return to pre trauma functioning over time 60.7% of men and 51.2% of women are exposed to trauma 5% males and 10% of females are diagnosed with PTSD Some people have stress reactions that do not go away or get worse over time. These individuals may develop PTSD

7. PTSD Prevalence Rates Combat exposure is one of the traumas, along with sexual assault, most commonly associated with the development of PTSD (Kessler, Sonnega, Bromet, Hughes & Nelson, 1995). The estimated lifetime prevalence of PTSD for the general population is approximately 8% (Keane, Weathers & Foa, 2000). It is estimated that 15.2% of male Vietnam combat veterans currently suffer from PTSD and the lifetime prevalence for this population is estimated at 30.9% (Kulka et al., 1990).

8. PTSD Prevalence Rates More currently, Hoge et al. (2004) found that 19% of four surveyed U.S. combat infantry units met criteria for a diagnosis of combat-related PTSD following deployment to Iraq. 1.5 million people have served in the Iraq and Afghanistan Wars. 750,000 have left the military. Approximately 40% of those 750,000 who have left the military report mental health symptoms. At present, approximately 60,000 of the 750,000 who have been discharged are seeking mental health services at this time.

9. Military Trauma Terms used to describe responses to combat trauma before 1980 Nostalgia (Civil War) Soldier’s Heart Shell Shock Combat Fatigue War Neurosis

10. Civilian Trauma Terms used to describe responses to civilian trauma before 1980 Railway Spine Survivor Syndrome

11. 1980 The American Psychiatric Association’s 3rd edition of the Diagnostic and Statistical Manual used the term Posttraumatic Stress Disorder for the first time in 1980. PTSD became established as a diagnosis, with the stressor criterion that people had to have been exposed to a “recognizable stressor that would evoke significant symptoms of distress in almost anyone.”

12. Recovery from PTSD • Some veterans experience an immediate onset of PTSD, symptoms that occur right after the traumatic experience. • For other veterans, symptoms begin many years after they thought they had put their military experiences behind them. • Life stressors such as transition to civilian life, physical illness, birth of a child, divorce, death of a loved one, or retirement may trigger symptoms unexpectedly.

13. Symptoms of PTSD Trauma – exposure to a traumatic event that evoked intense fear, helplessness, horror Re-experiencing – intrusive recollections, traumatic dreaming, flashbacks Avoidance – of others, stimuli connected to trauma Physiological arousal – exaggerated startle response, hypervigilance

14. Reexperiencing • Recurrent, persistent, intrusive thoughts McCaffrey Study • Nightmares and dreams • Flashbacks and hallucination-like experiences Gerardi example

15. Avoidance • Efforts to avoid thoughts and feelings about the trauma • Avoidance of activities and situations which stimulate recollection of the trauma

16. NumbingEmotional Avoidance • Psychogenic amnesia • Diminished interest in usual activities • Feelings of detachment or estrangement from others • Restricted range of affect • Sense of foreshortened future; loss of ability to project self in time

17. Physiological Arousal • Sleep disturbance • Increased irritability, lowered threshold for anger • Impaired concentration • Hypervigilance • Exaggerated startle response • Physiological reactivity to trauma reminders • Increase in measure of vital signs: breathing, muscle tension, heart rate and blood pressure • Panic-like symptoms: hyperventilation, fear of 'going crazy' or dying

18. Evidence Based Practice Individual Trauma Processing Prolonged Exposure (Foa et al, 1991) EMDR (Shapiro, 1989) Cognitive Processing Therapy (Resick et al, 2007) Group Psychotherapy CPT (Resick et al, 2007) Seeking Safety (Najavits et al, 1998)

19. Goal of Treatment Integration of Thoughts & Feelings Symptom Reduction Fulfillment in Living in the Present Investment in the Future

20. Goals of PTSD Treatment • Create new memories • Disinhibit imagination • Foster interpersonal connection • Register other than traumatic material • Create a narrative about the trauma, create meaning • Bring the trauma to the present instead of person being pulled back to the past • Promote chosen action, challenge the fixed action of fight or flight

21. Case Example Mr. L. a veteran with PTSD Trauma: Motor Vehicle Accident

22. Jonathan Shay, MD, PhDDepartment of Veterans Affairs, Boston MAFrom Achilles in Vietnam 1994 “I shall argue throughout this book that healing from trauma depends upon communalization of the trauma- being able safely to tell the story to someone who is listening and who can be trusted to retell it truthfully to others in the community. So before analyzing, before classifying, before thinking, before trying to do anything- we should listen.”

23. Attachment and Trauma (Johnson, 2002; McFarlane & van der Kolk, 1996) “Emotional attachment is probably the primary protection against feelings of helplessness and meaninglessness.” McFarlane and van der Kolk (1996, p. 24)

24. Towards Attachment-Based Trauma-Focused Interventions Attachment theory is a “theory of love and its central place in human life.”

25. “It is the ability to derive comfort from another human being that ultimately determines the aftermath of trauma, not the history of the trauma itself”. (van der Kolk, Perry and Herman, 1991)

26. Interpersonal Traumas are More Likely to Result in PTSD(Charuvastra & Cloitre, 2008) • Human beings ascribe meaning to events. • Individuals who are exposed to human- generated trauma, such as war, will ascribe different meanings to their experiences than will individuals who are exposed to traumas of a non-personal nature.

27. The most significant protective and resilience-recovery variables associated with combat-related PTSD: Emotional Sustenance (Schnurr, Lunney & Sengupta, 2004) Attachment Style (Dieperink et al., 2001; Mikulincer, Horesh, Eilati & Kotler, 1999) Social Support (King, King, Fairbank, Keane & Adams, 1998; King, King, Foy, Keane & Fairbank, 1999)

28. Attachment Based Interventions in Trauma Treatment Emotionally Focused Therapy (Johnson, 1998) Couples therapy that helps partners reprocess their affective responses to one another and change their patterns of interaction to create trust and foster secure attachment. Family Workshop (VVRP/PTSD Program Albany VA) Psycho-educational workshop for partners and older children of veterans with PTSD. Provides family members a supportive, interactive and experiential opportunity to learn about PTSD and the impact on all family members. Strong Bonds (VVRP/PTSD Program Albany VA) This workshop was developed for the 99th Regional Readiness Command US Army Reserves, and presented to soldiers and their families throughout the Northeast.

29. Experiential Exercise Intrusive Recollections ‘The Whisperer’

30. A Letter From Veterans Dear Brothers and Sisters, The combat veterans in the Posttraumatic Stress Disorder Clinic at the Stratton VA Medical Center in Albany, New York are thinking of you and what you are going through. Our prayers and hopes go out to you. We hope that you seek out the help that you may need. We have confidence that you can go on and live the life you want to live and achieve your dreams. From our experience, drawing close to our loved ones is a necessary part of healing. We thank your family members and loved ones for their understanding, support and sacrifice. We send them strength. We salute you. Your Fellow Veterans