PTSD in Veterans: CIT Training

1. PTSD in Veterans: CIT Training Norman I. Itkowitz, Psy.D. Clinical Psychologist VA Medical Center Memphis TN

2. Some Police Officers are Veterans • How many of you are veterans or are in the Guard or Reserve? • How many of you have a family member who is a veteran or in the military? • You have a vested interest in serving veterans!

3. Plan for Today • What is PTSD? • PTSD in offenders and veterans • PTSD in police officers • Coping with PTSD and other stress reactions in a law enforcement setting

4. What is Post Traumatic Stress Disorder? • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: • Directly experiencing the traumatic event(s). • Witnessing, in person, the event(s) as it occurred to others. • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. • Direct (self) experiencing of repeated or extreme exposure to aversive trauma. Examples: police officers repeated exposed to details of child abuse, veterans repeated exposure to death of others. American Psychiatric Association, 2013

5. What is a Traumatic Experience? What is PTSD? Not every trauma experience causes PTSD

6. Normal Reactions After Trauma • It is NORMAL to have some symptoms right after a trauma. Those symptoms may include: • Sleep difficulties including dreams about the trauma. • Strong emotions such as anger, sadness, or shame. • Feeling very keyed up and jumpy. • Being overly concerned about safety and control. • Physical difficulties such as stomach pains/tight shoulders.. • Some people have different reactions to the same trauma such as: • Relief at survival. • Grateful.

7. Common Potentially Traumatic Events • Combat/ war-zone exposure • Sexual assault • Physical assault • Child abuse • Natural disaster (fire, flood, earthquake, tornado) • Manmade disaster • Life-threatening accidents • Serious injury or threat of injury to self or others • Threat by weapons

8. Jobs with Risk of Trauma Exposure What is PTSD? • Police officers • Corrections employees • Firefighters • Military personnel • Emergency medical workers

9. Workplace Violence What is PTSD? • The number of workplace non-fatal violent incidents is higher for police officers than for any other profession. • And Fatal incidents are on the rise as well http: //www.ncjrs.gov/pdffiles1/nij/183474.pdf The Police Chief, vol. LXXVIII, no. 5, May 2011

10. Reactions During Trauma Vary • Some individuals experience, fear-based re-experiencing, emotional, and behavioral symptoms • Others experience, anhedonic or dysphoric mood states or negative cognitions may be most distressing. • Still in other individuals, arousal and reactive-externalizing symptoms are prominent • While in others, dissociative symptoms predominate • Finally, some individuals exhibit combinations of these symptom patterns.

11. After Exposure to Trauma What is PTSD? While most people recover naturally, some will develop difficulties. • Posttraumatic stress symptoms (ASD, PTSD) • Traumatic grief symptoms • Depression • Alcohol or substance abuse • Impaired functioning • Elevated risk of mood, other anxiety, and substance abuse disorders • Elevated risk of suicide attempts

12. Risk Factors • Most people exposed to a trauma do not develop PTSD: resilience • Age, gender, previous trauma history, psychiatric hx, education • Severity of trauma exposure • Peritraumatic and persistent dissociation/ distress • Social support after trauma

13. Prevalence of Trauma and PTSD> 60% Experience A Traumatic Event In Their Life> 25% Experience Multiple Traumatic Events Kessler et al., 1995, 1999

14. Mental Health Problems in Veterans ~ Hoge (2004)

15. Symptoms of PTSD: Intrusion Symptoms What is PTSD? • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

16. Symptoms of PTSD Persistent Avoidance What is PTSD? • Avoidance or Efforts to Avoid: • Distressing memories • Thoughts or feelings related to the event • External Reminders • People • Places • Conversations • Activities • Objects or situations

17. Symptoms of PTSD:Changes in your beliefs/thoughts • May experience negative thoughts that you didn’t use to have: • ‘I can’t stand being at this party/around people.’ • ‘The world is unsafe and anything can happen at any time, anywhere.’ • ‘I can’t stand to be close to other people (physically, emotionally).’ • ‘I don’t care about little things anymore; I can’t stand it when others care about little things that don’t matter.’ • ‘I don’t trust anyone anymore.’

18. Symptoms of PTSD Hyper arousal What is PTSD? • May be more amped up, more jittery or constantly on alert and on the lookout for danger. It can cause: • Sudden angry and aggression, constant irritability. • Have a hard time falling or staying asleep. • Trouble concentrating. • Engagement in risky behaviors. • Extreme concern for one’s safety and always feel on guard. • Exaggerated startle when surprised.

19. Duration of Difficulties and Impairment What is PTSD? • Disturbance lasts more than one month • Disturbance causes significant distress or impairment in important areas of functioning • Considered acute if < 3 month; chronic if > 3 months • Onset can be delayed (no symptoms until 6 months post-trauma)

20. Effective Treatments for PTSD • Cognitive-behavioral therapy • Education • Stress management • In some cases, medication

21. Stigma in Mental Health: The Military Responds • 1/5 of OEF/OIF returnees report PTSD or depression, and only ½ of those seek treatment (Rand, 2008) • Change in security clearance questions • DoD launches anti-stigma campaign • Navy: ready-reacting-injured-ill • PT daily, MT just as important

22. Stigma in Mental Health: The Military Responds • Negative career consequences for seeking MH services in Air Force: 3% of self-referred versus 39% commander-referred • APA recommends emphasis on building resilience • Real Warriors*Real Battles*Real Strength: www.realwarriors.net

23. PTSD in Police • Police service is widely recognized as one of the most dangerous and stressful occupations • Incidence of duty-related PTSD in police officers: 7-19% • Important factors in development of PTSD in police: distress/ dissociation at time of incident, social support, routine work stress (Marmar et al., 2006)

24. Prevalence in Police at 9/11 • Sample of rescue/ recovery workers at World Trade Center on 9/11 • Overall prevalence of PTSD: 12.4% • 6.2% for police • 21.2% for unaffiliated volunteers • Disaster preparedness training and shift rotations to enable shorter duration of service at the site may reduce PTSD among workers and volunteers.

25. Resilience to Traumatic Stressors Coping with PTSD and other stress reactions Recognize the signs: • Trauma memories coming back repeatedly • World no longer seems safe • People no longer seem trustworthy • You question yourself, your actions, and your self-worth National Center for PTSD

26. Resilience to Traumatic Stressors Coping with PTSD and other stress reactions Recognize coping strategies that are natural but don’t work: • Avoiding people, places, or thoughts that are reminders • Shutting off feelings or connections to other people • Being hypervigilant or on guard • Using alcohol to relax or unwind National Center for PTSD

27. Resilience to Traumatic Stressors Coping with PTSD and other stress reactions Use positive coping strategies: • Talk to another person for support. • Talk to a professional counselor, your doctor, or support group • Practice relaxation methods • Increase positive activities National Center for PTSD

28. Resilience to Routine Stressors Coping with PTSD and other stress reactions Manage stress by using: • Mental and physical relaxation • Positive thinking • Problem solving • Anger control • Time management • Exercise • Responsible assertiveness • Interpersonal communication National Center for PTSD

29. PTSD in Crisis Intervention Coping with PTSD and other stress reactions • Speak softly • Use de-escalation strategies • Orient to present • Ask if person is a veteran • Validate • Allow time • Offer help

30. Questions? Thank you for your attendance!