Posttraumatic Stress Disorder in Women Veterans

1. Posttraumatic Stress Disorder in Women Veterans Kathleen M. Chard, PhD Director, PTSD and Anxiety Disorders Division Cincinnati VA Medical Center Associate Professor of Clinical Psychiatry University of Cincinnati

2. Women in the Military Women account for 1.7 million of the nation's veterans Approximately 350,000 women (almost 15 percent) are actively serving in the U.S. military 400,000 women served in World War II, 50,000+ served in Korea, 265,000 served in Vietnam and 33,000 served in the Gulf War One in every seven troops in Iraq is a woman Female veteran population is projected to increase an additional 72,000 between 2000 and 2020

3. Stress and Trauma Many women experience psychological distress during and after their service time. Females report experiencing�PTSD at higher rates then men, and there is a higher prevalence of sexual assault and harassment experiences in women veterans Active duty women report higher levels of sexual assault than comparable civilian samples of women. Unfortunately, women use their earned benefits at far lower rates than their male counterparts

4. PTSD National study of American civilians conducted in 1995 estimated lifetime prevalence of PTSD was 5% men and 10% women. Most people who are exposed to a traumatic event experience symptoms in the days/weeks following exposure. Data suggest that about 8% men and 20% women develop PTSD, and roughly 30% of these develop a chronic disorder. About 20-30 percent of the men/women who have spent time in combat experience PTSD 7.8 percent of Americans will experience PTSD at some point in their lives

5. PTSD DSM IV Diagnosis What is the DSM? Common language for health care providers List of symptoms do not have to have ALL symptoms Anxiety Disorders Family PTSD Generalized Anxiety Disorder Panic Disorder Phobic Disorders

6. PTSD � a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience� Emotional reaction: Helplessness Horror Intense fear Shock

7. PTSD - Trauma the person has experienced, witnessed, or been confronted with an event or events that are outside the range of usual human experience and involve: Actual or Threatened : death or serious injury, or a threat to the physical integrity of oneself or others.

8. People can get PTSD from: Combat Violent personal assault: rape, mugging, physical assault Kidnapping POW and Concentration Camp survivors Terrorist Attacks Airplane Crashes Severe Auto Accidents Torture Natural Disaster Fires Hostage situations etc.

9. Let�s start with the current criteria for PTSD A: Stressor Criterion B: Reexperiencing C: Avoidance D: Arousal E: Time Criterion F: Functional Impairment or Distress Let�s start with the current criteria for PTSD: Remember that it is an event accompanied by fear, helplessness or horror, not just fear. Need 1. Focus on flashbacks and nightmares. Ruminating about the event is not the same thing as an intrusive recollection. Need 3. We will talk a lot over the next two days about the thousands of ways that patients with PTSD avoid. Effortful avoidance and numbing appear to be quite different. Need 2. Symptoms need to be co-occurring for at least a month.Let�s start with the current criteria for PTSD: Remember that it is an event accompanied by fear, helplessness or horror, not just fear. Need 1. Focus on flashbacks and nightmares. Ruminating about the event is not the same thing as an intrusive recollection. Need 3. We will talk a lot over the next two days about the thousands of ways that patients with PTSD avoid. Effortful avoidance and numbing appear to be quite different. Need 2. Symptoms need to be co-occurring for at least a month.

12. In those who develop pathology, strong negative affect leads to escape or avoidance

13. Treatment of PTSD

14. 1. Prevent Avoidance

15. 2. Intervene with one or more of core symptom clusters

16. Treatment Options for PTSD

17. Practice Guidelines for the Treatment of PTSD Expert Consensus Guideline Series (JCP, 1999) APA Practice Guideline Practice Guidelines from ISTSS United Kingdom�s National Center of Clinical Excellence (NICE) VA/DoD Clinical Practice Guidelines Institute of Medicine Report Currently there are a number of practice guidelines for PTSD treatment ISTSS was the first to recognize the need for clinical practice guideline and initiated the process in the last 1990s. Chaired by Edna Foa, Terence Keane and Matthew Friedman and published in 2000. Published information was graded with respect to the strength of the evidence, with randomized clinical trials receiving the highest grade ISTSS cast the �widest net�, 12 work groups, one for each of the identified treatments, no clinical algorithm was developed APA, small group of psychiatrists collectively reviewed entire empirical lit on PTSD, place much greater emphasis on randomized clinical trials and other experimental data Institute of Medicine Exposure Therapies, including CPT only have enough evidence -Problems with design and grouping of treatments -EMDR, Cognitive Restructing, Coping Skills Training, and Group formats not enough evidenceCurrently there are a number of practice guidelines for PTSD treatment ISTSS was the first to recognize the need for clinical practice guideline and initiated the process in the last 1990s. Chaired by Edna Foa, Terence Keane and Matthew Friedman and published in 2000. Published information was graded with respect to the strength of the evidence, with randomized clinical trials receiving the highest grade ISTSS cast the �widest net�, 12 work groups, one for each of the identified treatments, no clinical algorithm was developed APA, small group of psychiatrists collectively reviewed entire empirical lit on PTSD, place much greater emphasis on randomized clinical trials and other experimental data Institute of Medicine Exposure Therapies, including CPT only have enough evidence -Problems with design and grouping of treatments -EMDR, Cognitive Restructing, Coping Skills Training, and Group formats not enough evidence

18. Evidenced Based Treatments VA/DoD Clinical Practice Guidelines for Behavioral Interventions Exposure Therapy, Cognitive Therapy -1st line EMDR, Stress Inoculation Training Imagery Rehearsal Therapy, Psychodynamic Therapy, Seeking Safety PTSD Psychoeducation Adjunctive Treatments Dialectical Behavior Therapy (DBT) A=Always indicated and useful B=intervention may be useful C=may be considered D=Not useful or harmful I=insufficient evidence Behavioral Interventions First 4 are As, IR and Psychodynamic are Bs, education is IA=Always indicated and useful B=intervention may be useful C=may be considered D=Not useful or harmful I=insufficient evidence Behavioral Interventions First 4 are As, IR and Psychodynamic are Bs, education is I

19. Medication Studies have also shown that medications help ease associated symptoms of depression and anxiety and help with sleep. The most widely used drug treatments for PTSD are the selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Zoloft, which are approved by the FDA for PTSD. At present, cognitive-behavioral therapy appears to be somewhat more effective than drug therapy. However, it would be premature to conclude that drug therapy is less effective overall since drug trials for PTSD are at a very early stage. Drug therapy appears to be highly effective for some individuals and is helpful for many more. In addition, the recent findings on the biological changes associated with PTSD have spurred new research into drugs that target these biological changes. www.ncptsd.va.gov

20. Benzodiazapines The use of benzodiazepines shows no significant improvement when compared to no pharmacotherapy. While benzodiazepines are theorized to inhibit memory acquisition, the effect is anterograde. After trauma, benzodiazepines have been shown to interfere with adaptation, reappraisal and learning which could be helpful in recovery. The research suggests that some patients may feel relief with a short course of benzodiazepines but ongoing use is not supported. www.ncptsd.va.gov Gelpin, et al (1996). "Treatment of recent trauma survivors with benzodiazepines: a prospective study," J Clin Psych 57.

21. Research on CPT/PE There have been many randomized clinical trials of PE and CPT and several effectiveness studies. See the manuals for the exact references. The treatments have been shown to be effective with child abuse, rape, combat, and assault. So how well does CPT, the therapy we are teaching here, work with PTSD? There have been four randomized clinical trials that have included all the components needed (independent reliable assessors, random assignment to groups, trained and supervised therapists whose taped sessions are checked for adherence and competence, etc.). There have also been several effectiveness studies (application of the therapy in clinical settings) that we are not going to review here.So how well does CPT, the therapy we are teaching here, work with PTSD? There have been four randomized clinical trials that have included all the components needed (independent reliable assessors, random assignment to groups, trained and supervised therapists whose taped sessions are checked for adherence and competence, etc.). There have also been several effectiveness studies (application of the therapy in clinical settings) that we are not going to review here.

22. What does treatment entail? Assessment (CAPS/PCL) Group or individual Education/Coping Skills building Understanding the connection between thoughts, feelings and behavior Intensive (9-20 sessions) Challenging distorted cognitions Family therapy Follow-up assessment

23. Residential Treatment 10 bed women/12 bed men, 7 week program 10 bed mTBI/PTSD, 9 week program All Eras, traumas admitted, including CSA only Pain and methadone pts admitted Active participation is mandatory 12 sessions of individual and group w/in 7 weeks. More individual sessions for CSA or as needed. Groups: anger, communication, distress tolerance, life skills, interpersonal effectiveness, mindfulness, relaxation, sleep, etc (25 hours/week)

24. Issues faced when treating veterans with PTSD

25. General Issues A majority have substance abuse issues that are either current or in recovery Most have at least one other mental health condition Many smoke Veterans often facing medical problems as well, e.g. TBI, pain, injury

26. Updated Roster of OEF and OIF Veterans Who Have Left Active Duty 868,717 OEF and OIF veterans who have left active duty and become eligible for VA health care since FY 2002 50% (437,873) Former Active Duty troops 50% (430,844) Reserve and National Guard VHA Office of Public Health and Environmental HazardsAugust 2008

27. Demographic Characteristics of OEF and OIF Veterans Utilizing VA Health Care % OEF/OIF Veterans (n = 347,750) Sex Male 88 % Female 12 Age Group <20 7 20-29 51 30-39 23 =40 18 Branch Air Force 12 Army 64 Marine 13 Navy 11 Unit Type Active 52 Reserve/Guard 48 Rank Enlisted 92 Officer 8

28. Frequency of Possible Diagnoses Among OEF and OIF Veterans Diagnosis (n = 347,750) (Broad ICD-9 Categories) Frequency * % � Infectious and Parasitic Diseases (001-139) 40,956 11.8 Malignant Neoplasms (140-208) 3,248 0.9 Benign Neoplasms (210-239) 13,910 4.0 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 75,850 21.8 Diseases of Blood and Blood Forming Organs (280-289) 7,675 2.2 Mental Disorders (290-319) 147,744 42.5 Diseases of Nervous System/ Sense Organs (320-389) 121,473 34.9 Diseases of Circulatory System (390-459) 56,900 16.4 Disease of Respiratory System (460-519) 71,087 20.4 Disease of Digestive System (520-579) 110,449 31.8 Diseases of Genitourinary System (580-629) 37,118 10.7 Diseases of Skin (680-709) 55,797 16.0 Diseases of Musculoskeletal System/Connective System (710-739) 165,439 47.6 Symptoms, Signs and Ill Defined Conditions (780-799) 138,043 39.7 Injury/Poisonings (800-999) 73,767 21.2 � *These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 347,750.

29. OEF/OIF Veteran Issues Younger � do not feel understood by VA or other veterans Job/Family Responsibilities Motivated Self Medicating alcohol use Family responsibilities Prolonged Exposure, CT or CPT can all be options

30. The VA and PTSD today Congress created the National PTSD Centers with 5 sites across the US Research, education and treatment are the goals of the centers Efficacy-based/ACTIVE treatment is to be emphasized at all VA�s Assessment before and after treatment

31. Where do we go from here: PTSD? Implementation of efficacy-based treatments (CPT and PE) throughout VA Mentor Program Evidence Based Practice Coordinators Training clinicians in the armed forces as well to ease transition

32. Where do we go from here: Women? More �women only� groups and treatment programs More focus on each person as an individual with individualized treatment More staff training in MST and child abuse More d�cor that is �woman friendly� More education on �women�s issues�, e.g. parenting, health, relationships and communication