Introduction to Trauma 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 #120 rates of PTSD are 5% and 10% (men / women) [kessler, 1996] women more likely to develop ptsd is exposed to trauma ptsd can be chronic, lasting for decades#120 rates of PTSD are 5% and 10% (men / women) [kessler, 1996] women more likely to develop ptsd is exposed to trauma ptsd can be chronic, lasting for decades

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 New work from Boston is showing similar rates in men and women in the current conflicts. New work from Boston is showing similar rates in men and women in the current conflicts.

14. Likelihood of PTSD…. Rape Men 65% Women 45% Combat Men almost 40% Physical Abuse Almost 50% of women 20%+ men Why no women in combat? Dawn Vogt’s new data….Why no women in combat? Dawn Vogt’s new data….

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) This graph shows all of the participants who were available at each data point. As you can see, the gains that were made during treatment appear to have been maintained over time. 47% had received no further psychotherapy (for anything) since receiving CPT or PE. 24% received six months or less of treatment for anything since tx. only 15% had been in therapy for 2 or more years At pretreatment, 41% were taking psychotropic medication (including sleep medications). At the long term follow-up 23% were taking medication.This graph shows all of the participants who were available at each data point. As you can see, the gains that were made during treatment appear to have been maintained over time. 47% had received no further psychotherapy (for anything) since receiving CPT or PE. 24% received six months or less of treatment for anything since tx. only 15% had been in therapy for 2 or more years At pretreatment, 41% were taking psychotropic medication (including sleep medications). At the long term follow-up 23% were taking medication.

35. CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT AND LONG TERM (Resick et al., 2002) Rather than severity, here are the diagnostics on the CAPS. As you can see, both CPT and PE had long lasting improvements in PTSD diagnosis. Rather than severity, here are the diagnostics on the CAPS. As you can see, both CPT and PE had long lasting improvements in PTSD diagnosis.

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 Highlight programmatic issues b/c they get these questions all the timeHighlight programmatic issues b/c they get these questions all the time

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