An Introduction to Posttraumatic Stress Disorder (PTSD)

1. An Introduction to Posttraumatic Stress Disorder (PTSD) Ann Muczynski, LCSW Erie VA Medical Center

2. Objectives • Define PTSD as a psychiatric disorder • Outline PTSD symptomatology • Discuss potential behavioral impacts especially related to law enforcement/ criminal activity • Brief look at overlap with Traumatic Brain Injury (TBI)

3. What is PTSD? • As defined by the American Psychiatric Association, PTSD is an anxiety disorder. • The essential feature is the development of characteristic symptoms following exposure to an extreme traumatic stressor in which the person experienced, witnessed, or was confronted with actual/threatened death or serious injury, or a threat to the physical integrity of self or others. • The response must involve fear, helplessness, or horror.

4. What is PTSD? • Some examples of traumatic events we see often with Veterans may include military combat, terrorist attacks, violent personal assaults (including physical and sexual), torture, incarceration as a POW, providing medical care to the seriously injured, and morgue duties. • Witnessed events common with Veterans include witnessing the violent death/injury of others and witnessing dead bodies or body parts.

5. PTSD Symptomatology • PTSD symptomatology falls into 3 clusters that include re-experiencing, avoidant behavior, and increased arousal. • Re-experiencing symptomatology (one or more): • Recurrent and intrusive recollections of the event • Recurrent distressing dreams • Acting/feeling as if the event were reoccurring (flashbacks) • Psychological distress on exposure to reminders • Physiological reactivity on exposure to reminders

6. PTSD Symptomatology • Avoidant behaviors (3 or more): • Avoid thoughts, feelings, & conversations associated with the trauma • Avoid activities, places, & people associated with the trauma • Inability to recall aspects of the trauma • Decreased interest in activities • Feeling detached from others • Restricted range of affect • Sense of a foreshortened future

7. PTSD Symptomatology • Increased arousal (2 or more): • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • Do you see some of these behaviors in the Veterans you encounter in the criminal justice system?

8. PTSD Symptomatology • Common associated features can include: • Depression • Paranoia/mistrust • Phobic avoidance • Emotional disinhibition • Self-destructive and impulsive behavior • Dissociative symptoms • Hopelessness • Loss of previously sustained beliefs • Hostility • Impaired relationships • Social withdrawal

9. Potential Legal Implications • In reviewing the symptomatology and common associated features, it becomes readily apparent that PTSD can lead to potential legal problems. • Over a number of years working with Veterans suffering from PTSD, common legal problems patients encountered have included: • Various MV violations: Speeding, reckless driving, accidents, road rage • Hostility-related violations: A&B, domestic violence, resisting arrest, malicious wounding, attempted murder, murder, destruction of property

10. Potential Legal Implications • Substance abuse-related violations: DUI, DIP, various drug-related violations • Dissociative-related violation: Breaking & entering, trespassing, fighting • Weapons-related violations

11. Potential Legal Implications • Thinking about PTSD symptomatology as the root cause: • Chronic insomnia/fatigue, decreased concentration, anxiety, recklessness, self-destructive behavior, and irritability/anger can all lead to MV violations. • OEF/OIF Veterans: exposure to road side bombs and IEDs can generalize to unusual driving behaviors. • Dissociation/flashbacks, emotional liability, paranoia, exaggerated startle/wired up, anger/irritability, and impaired interpersonal relationships can all lead to hostility-related violations.

12. Potential legal Implications • Substance abuse is unfortunately a very common way in which Veterans attempt to cope with the myriad of PTSD symptomatology, although a poor coping mechanism. Substance abuse can lead to many significant legal violations. • Dissociation/flashbacks can often lead to violations of ‘being in the wrong place’ such as breaking and entering, unlawful entry, trespassing. • PTSD usually impacts a Veteran’s view of the people and the world and often shakes the foundation of their belief systems…what is moral/ethical, right and wrong, and acceptable human behavior.

13. Potential Legal Implications • Suspiciousness and paranoia, as well as reckless behavior, often lead to weapons-related violations. • Survivor’s guilt, depression, emotional numbing, and ‘just not caring’ can be a recipe for illegal behavior, as well as suicide.

14. Additional Thoughts on TBI/PTSD • In recent survey indicates that of those who have experienced a TBI, from 37 to 44% also have overlapping PTSD or depression. • Unfortunately, many of our returning Iraq/Afghanistan Veterans are experiencing these co-morbidities. • Due to overlapping symptoms, legal issues associated with PTSD are also relevant for TBI.

15. TBI/PTSD • PTSD TBI Insomnia Insomnia Poor concentration Poor Concentration Depression Depression Anxiety Anxiety Irritability Irritability Emotional numbing Fatigue Flashbacks/nightmares Headache Hypervigilance Dizziness Avoidance Noise/light Intolerance

16. TBI/PTSD

17. PTSD/TBI Insomnia , poor concentration, irritability, anxiety/depression • What about the overlap? Think about associated legal problems.

18. Summary • PTSD can be a devastating illness affecting thought, emotions, and behaviors. • Veterans of the recent conflicts diagnosed with PTSD have a higher percentage of TBI, another debilitating disorder. • Left untreated, Veterans suffering from PTSD have a greater probability of becoming involved in the legal system secondary to their symptomology. • Fortunately, there are excellent treatments offered for this disorder if Veterans choose to engage.