Thom Taylor

1. Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD):The impact of cartel related violence on the U.S./México border. Thom Taylor

2. Agenda • A brief background to traumatic stress • Post-Traumatic Stress Disorder (PTSD) • Ongoing Traumatic Stress (OTS) • Preliminary study of OTS in population exposed to violence and insecurity in Ciudad Juárez • Considerations for U.S./México Border Public Health and Safety communities

7. Traumatic Stress Background

8. “Violence and Insecurity” • Extreme increase in cartel and community related violence in northern México • Cartel related murders (2000+ in past year) • Kidnappings • Car-jackings • Robberies/Extortion (“Cuotas”) • Constant threat • U.S. not immune • Cartel and army related violence (CARV) • Psycho-social costs to a community • Increases stress Caetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003

9. Extreme Stress Reactions • Post-Traumatic Stress Disorder (& Probable PTSD) • Exposure to traumatic experience (s) • Feelings of fear, helplessness, and/or horror peri-event • Intrusive thoughts/Re-experiencing (1+ symptoms) • Avoidance/numbing to situations (3+ symptoms) • Hyper-arousal (2+ symptoms) • Psycho-social impairment • Partial PTSD • Threshold for full PTSD may be too high • Impairment still seen (e.g., anger) American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997

10. Acute Event PTSD: Implicit Assumptions

11. Identified Traumatic Stress Trends • Chronic PTSD (> 3 months) • Acute PTSD (> 1 Month) • Resistant • Resilient APA, 2000; Bonnano, 2004; Norris et al., 2009

17. Hyper-Arousal Re-experiencing / Intrusive Thoughts Avoidance / Numbing Core Trauma Symptoms

18. PERI Trauma (Immediate) Considerations • Unpredictable and Un-controllable • Subjective exposure • Fear • Helplessness • Horror • Direct forms of Trauma (e.g., assault, terrorism) • Indirect forms of Trauma (e.g., witnessing, media, trauma by proxy-such as family member) • Subjective interpretation Breslau et al., 2004; Gray et al., 2004; Gabriel et al., 2007; Suvak et al., 2008; Collimore et al., 2008; Foa & Riggs, 1995; Weathers & Keane, 2007

19. PRE-Trauma Risk Factors • Demographic risk factors (e.g., female gender) • Exposure to multiple traumata (re-exposure) • Anxiety disorders rarely present in pure form • Pre-existing anxiety disorders may worsen traumatic stress after exposure • Anxiety Sensitivity predisposes to traumatic stress after exposure • Depression • Unclear if PRE or POST factor • Depression highly comorbid with TS post-event (correlation) • May worsen traumatic stress Brewin et al., 2000; Ozer et al., 2003; Norris et al., 2003b; Dunner, 2001; Goldenberg et al., 1996; Elwood et al., 2009; Gabriel et al., 2007; Jaycox et al., 2003; Collimore et al., 2008; Breslau et al., 1997; Breslau et al., 1991; Breslau et al, 2000

20. PRE-Trauma Sources of Coping • Social support strongly buffers against traumatic stress • Coping in uncontrollable situations • Problem focused (limited in uncontrollable situations) • Emotion-focused • Active • Self distraction (+ or -) • Venting (+ or -) • Cognitive acceptance of situation/experience ( + or -) • Avoidance based • Denial ( generally - ) • Giving up/feeling hopeless ( - ) • Self-blame ( - ) • Substance use ( - ) Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989

21. Unique Opportunity • Virtually no empirical study of psycho-social impact of cartel related violence in the Americas • Limited knowledge of real-time (daily) impact • Memory distortion after the fact (e.g., months, years, melding of traumas? Such as in VHA situation) • More refined understanding of impact of ongoing traumatic situations Nisbett & Wilson, 1977; Wolfer, 1999

22. Preliminary Study of Ongoing Traumatic Stress • Assess Ongoing Traumatic Stress (OTS) • Examine impact of factors commonly associated with PTSD in: • Ongoing (daily) Traumatic Stress • Ongoing (daily) Re-experiencing symptoms • Ongoing (daily) Avoidance symptoms • Ongoing (daily) Hyperarousal symptoms

23. Methods

24. Participants • N = 121 (N days = 816) • Inclusion Criteria • Travel/live in Cd. Juárez at least 3 days/week • Internet access at least every 24 hour period • Bilingual • UTEP student • Comfort with online survey; anonymity/confidentiality • Post-hoc advantage; could still recruit after UTEP travel ban • Compensation: $40USD giftcard to Target OR 4 experimental credits

25. Measures: Main Outcome • All measures professionally translated and back-translated with subsequent native Spanish speakers’ input on items • Post-traumatic Stress Disorder Checklist (PCLS) • Specific event-adapted for CARV: “…violenciarelacionado con el narcotrafico u hostilidad y maltratomilitar.” • Past 30 day Acute PTSD (α = .89) • Adapted version for daily traumatic stress for past 24 hours (PCLSD): αrange = .91 - .94 Brislin, 1970; Liu, 2002;Weatherset al., 1993 Ruggiero et al., 2003; Orlando & Marshall, 2002

26. Background Measures • Life Events Checklist (LEC) documents 17 traumatic events often associated with PTSD • Experienced Directly (direct) • Witnessed (indirect) • Learned of/Heard about (indirect) • Depression, Anxiety, and Stress Scale (DASS) • Depression (α = .86) • Anxiety (α = .78) • General Stress (α = .85) Gray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002

27. Background Measures Continued • Multi-dimensional Scale of Social Support (MSPSS) • Family (α = .89) • Friends (α = .96) • Significant Other (α = .92) • Brief COPE coping measure (BCOPE); Carver encourages malleability given nuances of coping • Problem Focused Coping (α = .78) • Emotion Focused Active Coping (α = .73) • Avoidance Coping (α = .76) Zimet et al., 1988; Carver et al., 1997, Schneider et al., 2007; Perczek et al., 2000

28. Daily Assessment • Completed online >24 hours for 7 days • PCLSD (daily traumatic stress) • Time-varying explanatory covariates • Travel to CJ (# hours) • Reasons for being in CJ (family, friends, business, antro/club/bar) • Perceived degree of exposure to violence (fear, helplessness, horror)

29. Lemonade out of Lemons • Drop out rarely positive outcome, but allows unique analysis in present study • 20% did not return for follow-up • Unique opportunity in trauma study • Avoidance unpleasantness  drop-out? • Re-experiencing  unpleasantness  drop-out? • Hyper-arousal  unpleasantness  drop-out?

30. Informative Drop-Out • Diggle-Kenward Selection Model (DKSM) • Single covariate entered due to estimation complexity: Past 30 day traumatic stress (PCLS) • Survival indicator from daily reports 3 to 4 constrained to be 0; no drop-out in interval • To allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scores • Drop-out unassociated with traumatic stress, all Zs < |.65|, all ps > .52 • Take Home Point: Preliminary support that asking about trauma on a daily basis does not make it worse for those assessed. Rubin, 1976; Molenberghs, Michiels, Kenward, & Diggle, 1998; Diggle & Kenward, 1994

31. Approach to Analysis: • Multi-level modeling • Specified Expectation-Maximization in Maximum Likelihood; robust to MAR • Grand Mean centered variables • Standardized (N~0,1) covariates to give common scale to psychological factors • OPTS dependent variable (PCLSD) • Condition on demographics, LEC, DASS, MSPSSfactors, BCOPE sub-scales • Time varying covariates • Presence in CJ (hours) • Perceived exposure to violence occurring (fear, helplessness, and horror) Snijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009

32. Preliminary Study Results

33. Demographic Highlights

35. Sample Continuous Characteristics

36. Sample Continuous Characteristics

37. Sample Continuous Characteristics

38. Sample Continuous Characteristics

39. Sample Daily Characteristics

40. Sample Daily Characteristics

41. Sample Daily Characteristics

42. Sample Daily Characteristics Cont.

43. Sample Daily Characteristics Cont.

44. Predicting Ongoing (Daily) Traumatic Stress Response Symptoms