Post Traumatic Stress Disorder (PTSD): An Overview

1. Post Traumatic Stress Disorder (PTSD):An Overview James J. Lickel, Ph.D. & Richard Machotka William S. Middleton Memorial Veterans Hospital.

2. What is PTSD? • Cluster of symptoms that follow exposure to a potentially traumatic event • Marked by clear cognitive, behavioral, and physiologic changes • Can be chronic if untreated and greatly affect quality of life • NOT a sign of weakness, lack of resiliency, or lack of preparation

3. Exposure To Trauma • At least 50% of population will experience “trauma” in their lifetime, most more than once • Most will experience symptoms of PTSD initially, but won’t go on to develop PTSD • There are gender, racial, and ethnic differences in exposure to trauma and development of PTSD

4. Example: Combat Exposure in Iraq Hoge, et al, 2004, NEJM

5. Event and PTSD Risk Breslau et al., 1999

6. 4 Main Types of PTSD Symptoms • Re-experiencing: • Intrusive thoughts or memories about the trauma • Nightmares • Flashback • Distress when reminded of the event (5 senses) • Physiological reactions

7. In my own words

8. 4 Main Types of PTSD Symptoms • Avoidance • Avoidance of trauma-related thoughts, feelings, or conversations • Avoidance of trauma-related places, people, or activities

9. In my own words

10. 4 Main Types of PTSD Symptoms • Arousal Symptoms • Impaired sleep • Irritability or outbursts of anger • Difficulty concentrating/focusing • Hypervigilance • Feeling jumpy or easily startled

11. In my own words

12. 4 Main Types of PTSD Symptoms • Negative alterations in thoughts and mood • Difficulty remembering aspects of event • Exaggerated beliefs or expectations about self, others, or the world (“No one can be trusted”) • Loss of interest in past enjoyable experiences • Feeling detached or cut-off from others • Emotional numbness

13. In my own words

14. Associated Problems Substance Abuse Anxiety Panic Depression PTSD Physical Health Problems Relationship Problems

15. Psychological Theory of the Development and Maintenance of PTSD Symptoms

16. “PTSD is full of contradictions. Virtually every reaction that mental health professionals label a ‘symptom,’ and which indeed can cause havoc in your life after returning home from combat, is an essential survival skill in the war zone.”-Charles W. Hoge, MD, Colonel (Ret.), U.S. Army2010

17. Common Reactions to Trauma • Re-experiencing • Intrusive thoughts • Strong emotions when triggered by reminder • Avoidance • Of stimuli present at time of trauma • Hyperarousal • Increased vigilance • Anger Adaptive Function Easily accessed memories that warn of danger Reduces likelihood of repeated exposure to threat Increased attention to threat & Display of preparedness

18. Psychological Processes Involved in Development of Symptoms of PTSD Associative Learning Ethnic dress Dust in the air Group of kids Military gear Density of housing Child’s laughter Smell of trash Knee pain Sound of gravel Debris

19. Psychological Processes Involved in Development of Symptoms of PTSD Cognitive Change “IEDs can be planted anywhere.” “I must have done something to ask for this.” “I trusted this man, it is my fault.” “He died on my watch.” “Markets and crowds are unsafe.” “You can never let your guard down.”

20. “Natural Recovery” vs. PTSD Avoidance Negative Beliefs (Dunmore, Clark, & Ehlers, 2001) PTSD Symptoms Demographics Social Support Etc. Time

21. Psychological Processes Involved in Maintenance of Symptoms of PTSD Avoidance Ethnic dress Dust in the air Group of kids Military gear Density of housing Child’s laughter Smell of trash Knee pain Sound of gravel Debris

22. In my own words

23. Psychological Processes Involved in Maintenance of Symptoms of PTSD Generalization of Beliefs “I missed the IED.” “I am incompetent.” “I asked for this.” “I am a trash.”

24. In my own words

25. Biological Basis of PTSD • Current research suggests a number of physiological differences found in people diagnosed with PTSD • Hormonal differences: • Abnormalities in stress response hormone levels (glutamate, GABA, Norepinephirne, CRF. • Responsible for preparing our bodies to respond to threat -> constant state of readiness • Brain differences: • Smaller hippocampus (Inhibition of HPA axis and processing of memories) • Over-reactive amygdala (decreased threshold for “firing”) • Under-reactive prefrontal cortex (inhibits amygdala and interferes with working memory)

26. Treatment of PTSD

27. Clinical Practice Guidelines Psychotherapy va/dodcpg Pharmacotherapy ISTSS cpg First-line pharmacologic Tx: SSRIs: (Sertraline / Paroxetine / Fluoxetinte) SNRI: (Venlafaxine) Other 2nd Generation Antidepressants: (Mirtazapine) Antiadrenergic: (Prazosin; Propranolol. Note about relative efficacy and increased risk of return of symptoms following stop of medication. Significant Benefit • Cognitive Processing Therapy (VA has trained 1,200 LIPs) • Prolonged Exposure Therapy (VA has trained 1,500 LIPs) • Stress Inoculation Training • Eye Movement Desensitization and Reprocessing (EMDR) Some Benefit • Imagery Rehearsal Therapy (IRT) • Brief Psychodynamic Therapy

28. Active Elements in EBP for PTSD • Psychoeducation • Stress/arousal reduction techniques • Review of traumatic memories • Exposure to avoided situations • Modification of trauma-related beliefs

29. Prolonged Exposure Therapy • 9-15 sessions; averages 10 sessions • 90 min sessions • 1: Assessment, treatment overview, PTSD psychoeducation, breathing retraining • 2: In Vivo Exposure (continue throughout) • 3-5: Imaginal Exposure • 6-9: “Hot Spot” exposure • 10: Final Imaginal exposure, wrap-up

30. Exposure Hierarchy • Grocery store with partner, not busy 30 • Restaurant with partner, back to wall 35 • Grocery store alone, not busy 45 • Grocery store with partner, moderately busy 50 • In line, facing sideways, wall to back 50 • Restaurant, whole family, back to wall 50 • Restaurant with partner, back to tables 60 • Elevator,1 or 2 people 60 • Movie with friends 60 • In line, facing forward or no wall at back 65 • Grocery store with partner, crowded 65 • Grocery store alone, moderately busy 65 • Feeling hot/sweaty 70 • Elevator, many people 75 • Mall alone, moderately busy 75 • Gym 80 • Restaurant, whole family, back to tables 80 • Go to friend’s house 80 • Mall alone, crowded 95 • Grocery store alone, crowded 100

31. Habituation • Anxiety increases  Avoidance • This situation is dangerous; I got out just in time; Something awful could have happened Anxiety Time Courtesy of Sally Moore, Ph.D.

32. Habituation • Stop avoidance • Anxiety decreases on its own • This situation was not as dangerous as it felt; I can tolerate anxiety; I don’t have to avoid to feel better. Anxiety Time Courtesy of Sally Moore, Ph.D.

33. Cognitive Processing Therapy • Psychoeducation • Trauma account (evidence of efficacy without) • Identification of “Stuck Points” • Cognitive restructuring

34. CPT: Session 1 & 2 • Psychoeducation • Impact Statement • “Stuck Points” • Those things trauma survivors say to themselves about the trauma/self/others/world. • Examples • “It was my fault. I could have prevented it.” • “I am a monster for what I did during the war.” • “I should have been able to save everyone.” • “The world is an incredibly dangerous place.”

35. CPT Session 3:Events, Thoughts, and Emotions • It is how we THINK about the event, not the event itself, that often causes us lasting distress • Ex: Friend passing by • A-B-C Model – core of CPT

36. CPT Session Framework • Sessions 4 - 6: Write/Read Trauma Account • Sessions 6 - 7: Cognitive Work in depth • Sessions 8 – 12: Explore Themes of Safety, Trust, Power/Control, Esteem, and Intimacy • Continue to read account throughout course of treatment for purposes of exposure • Session 12: Review of 2nd Impact Statement

37. In my own words

38. Results of Evidence-Based Psychotherapy (EBP) • In general, trauma-focused therapies more effective than non-specific/supportive interventions and no treatment. • No consistent differences observed between trauma-focused therapies, though there is limited research regarding this. • Initial response rates of EBP for PTSD range between 40-92%. • Regular therapy attendance and family support associated with more positive outcome • Initial severity of symptoms and benzodiazepine use associated with poorer outcome.

39. Outcomes for Veterans with PTSD Prolonged Exposure Therapy Cognitive Processing Therapy PCL d = 1.58 d = 0.50 (Schnurr et al., 2007) (Monson et al., 2006)

40. OEF/OIF Combat Veterans with PTSD Prolonged Exposure Therapy Cognitive Processing Therapy PCL (Tuerk et al., 2011) (Chard et al., 2010)

41. PTSD Resources • http://www.ptsd.va.gov/

42. PTSD Resources • www.istss.org

43. PTSD Treatment Resources • www.abct.org • Find a Therapist • http://locator.apa.org