VA Medical Center Albany, NY

1. VA Medical CenterAlbany, NY

2. Assessment, Diagnosis and Treatment of Posttraumatic Stress Disorder NADE National Training Conference September 14, 2010

3. Posttraumatic Stress Disorder Program Charles R. Kennedy, PhD PTSD Program Director Karen S. Voss, LCSW, BCD Jennifer A. Courtney, LCSW Loretta S. Malta, PhD Jason B. Gallo, PhD

4. Jonathan Shay, MD, PhDDepartment of Veterans Affairs, Boston MAFrom Achilles in Vietnam 1994 “I shall argue throughout this book that healing from trauma depends upon communalization of the trauma- being able safely to tell the story to someone who is listening and who can be trusted to retell it truthfully to others in the community. So before analyzing, before classifying, before thinking, before trying to do anything- we should listen.”

5. History of Posttraumatic Stress Disorder PTSD is an anxiety disorder that can occur after experiencing or witnessing a traumatic event. The person experienced, witnessed or was confronted by an event or events that involved actual or threatened death or serious injury or threat to physical integrity of self or others. The person’s response involved intense fear, helplessness or horror. Most survivors of trauma return to pre-trauma functioning over time.

6. Introduction to PTSD Traumatic events have been a part of the human experience since the beginning of time. Accounts of traumatic stress go back at least as far as Ancient Greece, whose authors wrote a great deal about betrayal, grief, combat and tragedy. http://www.sfu.ca/classics/myth/images/fagles.jpg

7. Historical Terms for PTSD Military Trauma Nostalgia Soldier’s Heart Shell Shock Combat Fatigue War Neurosis Civilian Trauma Railway Spine Survivor Syndrome

8. 1980 The American Psychiatric Association 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders used the term Posttraumatic Stress Disorder for the first time. PTSD became established as a diagnosis, with the stressor criterion that people had to have been exposed to a “recognizable stressor that would evoke significant symptoms of distress in almost anyone.”

9. PTSD Prevalence Rates Combat exposure is one of the traumas, along with sexual assault, most commonly associated with the development of PTSD The estimated lifetime prevalence of PTSD for the general population is approximately 8% It is estimated that 15.2% of male Vietnam combat veterans currently suffer from PTSD and the lifetime prevalence for this population is estimated at 30.9%

10. PTSD Prevalence Rates 60.7% of men and 51.2% of women are exposed to trauma 5% males and 10% of females are diagnosed with PTSD Some people have stress reactions that do not go away or get worse over time These individuals may develop PTSD

11. OEF/OIF Veterans Approximately 1.65 million U.S. troops have deployed as part of Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) since October 2001 Editors Terri Tanielian and Lisa H. Jaycox www.rand.org Invisible Wounds of War

12. PTSD Prevalence Rates 19% of four surveyed U.S. combat infantry units met criteria for a diagnosis of combat-related PTSD following deployment to Iraq 1.6 million people have served in the Iraq and Afghanistan, 750,000 have left the military Approximately 49% of those 750,000 who have left the military report mental health symptoms. Approximately 60,000 of the 750,000 who have been discharged are currently seeking mental health services

13. TRAP: The Symptoms of PTSD Trauma: the person experienced, witnessed, or was confronted by an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness or horror. Reexperiencing Symptoms – intrusive recollections, traumatic dreaming, flashbacks Avoidant Symptoms – of others, stimuli connected to trauma Physiological Symptoms – exaggerated startle response, hypervigilance

14. Trauma PTSD is an anxiety disorder that can occur after experiencing or witnessing a traumatic event. The person experienced, witnessed or was confronted by an event or events that involved actual or threatened death or serious injury or threat to physical integrity of self or others. The person’s response involved intense fear, helplessness or horror.

15. Reexperiencing Symptoms Recurrent, Persistent and Intrusive Thoughts Vietnam veterans with PTSD and non-PTSD veterans were exposed to scents in minute proportions under ability to name. Veterans with PTSD showed intense polygraph reactions to odors (burning hair, jet fuel) associated with trauma. 100% of veterans with PTSD called upon traumatic memories during the study procedures. McCaffrey et al. (1993) Nightmares and Dreams Flashback and Hallucinations

16. Avoidance Efforts to avoid thoughts and feelings about the trauma Avoidance of activities and situations which stimulate recollection of the trauma

17. Numbing / Emotional Avoidance Psychogenic amnesia Diminished interest in usual activities Feelings of detachment or estrangement from others Restricted range of affect Detachment from the future

18. Physiological Arousal Sleep disturbance Increased irritability, lowered threshold for anger Impaired concentration Hypervigilance Exaggerated startle response Physiological reactivity to trauma reminders Increase in measure of vital signs: breathing, muscle tension, heart rate and blood pressure, fear of “going crazy” or dying

19. Recovery from PTSD Some veterans experience an immediate onset of PTSD, symptoms that occur right after the traumatic experience For other veterans, symptoms begin many years after they thought they had put their military experiences behind them Life stressors, such as transition to civilian life, physical illness, birth of a child, divorce, death of a loved one, or retirement may trigger symptoms unexpectedly

20. Goals of PTSD Treatment • Symptom reduction • Integration thoughts and feelings • Create new memories • Disinhibit imagination • Foster interpersonal connection • Register other than traumatic material • Create a narrative about the trauma, create meaning • Bring the trauma to the present instead of person being pulled back to the past • Promote chosen action, challenge the fixed action of fight, flight or freeze reaction • Reconnect the neocortex and limbic system • Fulfillment in living in the present • Investment in the future

21. Evidence Based Practice Individual Therapy Prolonged Exposure Eye Movement Desensitization & Reprocessing Cognitive Processing Therapy Group Therapy Cognitive Processing Therapy Seeking Safety/Strength Dialectical Behavior Therapy

22. Pharmacotherapy Pharmacotherapy is empirically supported, generally cost effective and often addresses the co-morbid symptomotology that accompanies PTSD Many drugs are used in the treatment of PTSD Friedman et al. (2000) cite multiple studies in reporting that SSRIs, such as fluoxetine, sertraline, paroxetine and fluvoxamine, are the only agents with the capacity to reduce symptoms in all three PTSD symptom clusters

23. PTSD Program Levels of Care Group 1 Simple Trauma Group 2 Mild Complex Trauma Group 3 Moderate Complex Trauma Group 4 Severe Complex Trauma Group 5 Chronic Severe

24. Treatment Group 1 Combat Veterans and Acute Illness (Simple PTSD) Estimated to be 10-20% ( Groups 1 & 2) of Veterans followed by PTSD specialists Minimal history of prior (childhood or pre-military) trauma High level of pre-trauma functioning Usually responsive to EBPs with minimal time spent on pre-treatment therapeutic engagement Sometimes may be sub-clinical PTSD or Adjustment Disorder Unlikely to have co-morbid disorders such as substance abuse, if so, sub-threshold

25. Treatment Group 2 Minimal history of prior (childhood or pre-military) trauma, but may have experienced multiple traumas in combat May have co-morbid depression or substance abuse specifically related to the traumas, secondary May need time to engage in therapy prior to initiating EBP treatment

26. Treatment Group 3 Combat Veterans and Stable but Serious Disability (Temporarily Stable, but (recent decline in pre-morbid functioning precipitated by psychosocial stressor) Impaired Baseline of Functioning) Estimated to be 33% ( in combination with Group 4) of population seen by PTSD specialists within VISN 2 Pre-military trauma and/or childhood neglect Co-morbidities may include Substance Abuse or Dependence, Depression, Anxiety, Bipolar Disorder, Axis II Personality Disorders Likely to have episodes of increased PTSD symptoms, interpersonal problems, distress tolerance problems Therapeutic alliance is important due to fragility and trust difficulties Best managed by PTSD specialists due to the complexity of their symptoms and the likelihood of frequent relapses May be sustained with group or monthly individual sessions to maintain contact and monitor for exacerbations

27. Treatment Group 4 Combat Veterans and Acute Illness and Stable but Serious Disability (Temporarily unstable and Impaired Baseline of Functioning) Estimated to be 33% (in combination with Group 3)of population seen by PTSD specialists within VISN 2 Pre-military trauma and/or childhood neglect Co-morbidities may include Substance Abuse or Dependence, Depression, Anxiety, Bipolar Disorder, Axis II Personality Disorders or traits Currently experiencing an exacerbation of symptoms due to recent deployment, external triggers such as loss of a job, loss of a family member, other life changes and in need of an episode of intensive stabilization or exposure therapy Therapeutic alliance is important due to fragility and trust difficulties Best managed by PTSD specialists due to the complexity of their symptoms and the likelihood of frequent relapses

28. Treatment Group 5 Combat Veterans and Chronic Condition with Limited Reserves (Chronic and Stable PTSD) Estimated to be 33% of population seen by PTSD specialists within VISN 2 Unlikely to benefit from or not interested in EBP or any therapy that directly challenges them to make change Seeking supportive therapy to help them maintain level of functioning May fear losing service connection if therapy discontinued altogether May be socially isolated and rely on therapy as a primary social support Can be treated in any clinic, may do well in supportive therapy groups

29. Traumatic Brain Injury Traumatic brain injuries - caused by Improvised Explosive Devices, mortars, vehicle accidents, grenades, bullets, mines, falls and blast concussion – May be the hallmark injury faced by veterans of Iraq and Afghanistan. 

30. VA Polytrauma Programs Polytrauma care is for veterans and returning service members with injuries to more than one physical region or organ system, one of which may be life threatening. These injuries result in physical, cognitive, psychological, or psychosocial impairments and functional disability.

31. Common Polytrauma Conditions • Traumatic Brain Injury • Hearing Loss • Amputations • Fractures • Burns • Visual Impairment • Posttraumatic Stress Disorder

32. VA Polytrauma System of Care VA has treated over 500 OEF/OIF service members in inpatient units. The vast majority of these patients have been on active duty at the time of admission. The major cause of injury has been trauma sustained in combat.

33. Dedicated Levels of Care • Polytrauma Rehabilitation Centers provide acute, comprehensive, inpatient rehabilitation.  • Polytrauma Network Sites provide specialized, post-acute rehabilitation in consultation with the Rehabilitation Centers in a setting appropriate to the needs of veterans, service members, and families.

34. Polytrauma Support Clinic TeamsVAMC Albany • Provider follow up services in consultation with regional and network specialists. • Assist in managing the long-term effects of Polytrauma through direct care and consultation. • Inpatients are monitored 24 hours a day at all of our facilities.

35. Polytrauma Rehabilitation Centers • Richmond, VA • Tampa, FL • Minneapolis, MN • Palo Alto, CA

36. Polytrauma Network Sites • Syracuse, NY • Bronx, NY • Boston, MA • Lexington, KY • Houston, TX • Cleveland, OH • Dallas, TX • Indianapolis, IN • Tucson, AZ • Philadelphia, PA • Hines, IL • Denver, CO • Washington, DC • St. Louis, MO • Seattle, WA • Augusta, GA • West Los Angeles, CA

37. Support for Veterans and Families Logistic Support Clinical Support Emotional Support VA Polytrauma programs provide comprehensive, high quality, inter-disciplinary care to patients. Teams of clinicians from every relevant field plan and administer an individually tailored rehabilitation plan to help the veteran recover to their highest level of functioning.

38. Impact of Combat-Related PTSD on Primary Relationships and Family Functioning Difficulties with self-disclosure, communication and problem solving(Carroll, Rueger, Foy & Donahoe, 1985; Nezu & Carnevale, 1987) Elevated levels of spousal and familial verbal and physical aggression(Byrne & Riggs, 1996; Savarese, Suvak, King & King, 2001) Greater somatization, depression, anxiety, loneliness and hostility among wives of veterans with combat-related PTSD(Solomon, Waysman, Avitzur & Enoch, 1991; Waysman, Mikulincer, Solomon & Weisenberg, 1993) Parenting problems(Jordan et al., 1992) Family members of veterans with combat-related PTSD report more problems with affect regulation and less affective responsiveness than do family members of non-PTSD veterans (Dansby & Marinelli, 1999; Davison & Mellor, 2001)

39. Important Others The most significant protective and resilience recovery variables associated with PTSD seem to be those related to perceived emotional sustenance, current social support and attachment style. Dieperink et al., 2001 King, Foy, Keane & Fairbank, 1999

40. What We Would Like Our Family and Friends to Know about Living with PTSD Written by Combat Veterans Stratton VA Medical Center, Albany, New York • Sometimes I am moody and I don’t understand why, please give me some space until I am ready to be around people again. • I am often uncomfortable and anxious in crowds or with unfamiliar people because my experiences have made it difficult for me to trust unknown people.

41. What We Would Like Others to Know Certain “triggers” e.g. loud noises, smells, objects in the road startle me, remind me of traumatic experiences or cause me to behave in ways that you might not understand. Please know that these “triggers” signal danger for me. I am easily startled and I am always watchful for danger in the environment.

42. What We Would Like Others to Know Please understand that not everything can be explained. Please don’t take it personally if I cannot explain certain things to you. I don’t always understand them myself. Please don’t ask for a description or details of my traumatic experiences. Sometimes explaining things can increase my distress.

43. What We Would Like Others to Know Please know that certain days or anniversaries are important. Know that close relationships are often difficult and scary. We are often afraid of losing those we care about and engage in distancing behaviors as a way to protect ourselves from potential loss. Please “hang in there.” Be supportive but not intrusive.

44. What We Would Like Others to Know Please know that we often do things in a certain way to promote order and organization and to help balance the chaos we often feel internally and in other parts of our lives. Ultimately, we often do things in a certain way to feel safe. Many of our behaviors e.g. eating with back against the wall in restaurant or driving around an object in the road are automatic and have been conditioned to maintain safety.

45. What We Would Like Others to Know Please know that all of these behaviors are the result of our experiences and the mental and physical changes that are the result of trauma. These behaviors are ways that we protect and sustain ourselves. For us, these thoughts, feelings and behaviors are about life, death, survival and safety.

46. http://www.ncptsd.va.gov/ncmain/index.jsp VA National Center for PTSD http://www1.va.gov/VISNS/visn02/albany.cfm VA Medical Center, Albany, NY http://www.polytrauma.va.gov/ VA Polytrauma System of Care