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  1. PTSD Recovery Stories: Case examples with video, and discussion with former patients Irene Powch, Ph.D. Grand Rounds Oregon Health & Science University February 22, 2011

  2. Acknowledgements • Thanks to Dwayne Washington and Will Murphy of Medical Media at PVAMC for their help with video productions and to Doug Park, Ph.D., for leading the recovery focus at PVAMC and inspiring the idea for these recovery videos and this presentation. • And most of all, thanks to the courageous and inspiring veterans who have walked this path of recovery from PTSD and are willing to share their stories.

  3. Introduction • Recovery from PTSD? • The VA Story • 1980’s: intensive exploratory trauma focused residential treatment in company of peers • Mid 1990’s: Rosenheck—concluded above doesn’t work, closure of programs, PTSD viewed as chronic and untreatable, era of symptom management and maintenance, lost trauma focused treatments, session length drastically shortened • 2007 Schnurr et al JAMA, and Monson et al 2006 JCCP—concluded trauma processing more effective than present-centered therapy, PTSD viewed as treatable with recovery achievable, session length increased to 60-90 minutes • Massive dissemination of CPT and PE begin in 2008

  4. View From the Trenches: Real Veterans Recovery Stories Today’s Presentation: • Orientation to Terms • 3 minute case presentation of “Katie” • 5 min “Katie” speaks • 5 min “Katie” fields questions ***** • 3 min case presentation of “Mark” • 20-min Mark’s Recovery Video • 2-5 min “Mark” speaks • 5 min “Mark” fields questions ***** • 5 min conclusion and discussion

  5. Orientation to Terms • PE=Prolonged Exposure Therapy • Starts w/ beh change, bust avoidance  desensitization & perspective shifts spontaneously from within • CPT/C=Cognitive Processing Therapy • Starts w/ cog change, question trauma induced beliefs shift in perspective first; behavior change follows gradually • SUDS=Subjective Units of Distress • 0 to 100 • PCL=PTSD Clinical Checklist • >50 is positive screen for PTSD (military) • CAPS=Clinician Administered PTSD Scale for DSM-IV • >45 severity admit for PTSD tx (military)

  6. Case #1: “Katie” • “Katie” was a 59 yr old veteran when I first saw her on Feb 16, 2010 • She clearly met criteria for severe PTSD r/t a brutal rape in the military as well as body bagging and tragic loss in the military, and an extensive hx of childhood sexual and physical abuse. • She had previously received long-term supportive therapy for 5 years prior to moving to Portland, and a year of process/support group at the Portland Vet Center prior to seeking an EBT for PTSD. • Her most prominent sxs were extreme, viscerally experienced fear, helplessness, and avoidance to reminders of the MST. She had been using marijuana for years to manage anxiety. She had severe GI sxs.

  7. “Katie” continued • She was terrified of PE but believed strongly that facing the memory would help her, and was highly motivated to proceed. • March 18, 2010: First session of PE; second rape (MST) was identified as the index trauma. • May 14, 2010: Completed PE early due to surgery scheduled for the following day with several weeks of recovery time expected. • June 8 & 30: Follow-up booster sessions.

  8. “Katie” continued BEFORE SNAPSHOTS AFTER SNAPSHOTS • PCL = 58 PCL = 38 • Marijuana for anxiety Quit MJ—no need for it • Shaking in fetal position (T) Tells it as a matter of fact • Cd not be on porch at night Enjoys night air outside • Avoided looking in mirror Appreciates whole body • Paralyzed by assertives Is assertive • Over a half year after conclusion of treatment, gains are holding solid.

  9. “Katie” continued COURSE OF TX AND PIVOTAL MOMENTS • Session 2-3: She inadvertently doubled in vivo exposure (movie segment); good movement • Highpoint SUDS from 97 to 75; lowpoint to 30. • Sessions 3-4: Imaginal SUDS 100, never below 85 • Session 6: Gap addressed; remembered her body betrayed her. Psychoed and Socratic Q’s in debrief. Major shift in cognition (from “I’m disgusting” to “this is not about me, I did not ask for this”  acceptance of herself and her body, self-care, assertiveness.

  10. “Katie” continued Katie talks briefly about her life now and fields questions for 5 minutes.

  11. Case #2: “Mark” • “Mark” was a 28 yr old veteran of the Gulf War when I first saw him on July 30, 1999. • He clearly met criteria for PTSD r/t combat trauma in the Gulf. This included a friendly fire incident in which he witnessed his friend shot in the head an arm’s length away, and had to clean up and burn the remains. • When Mark first came to treatment he was unable to go to skills classes for several months because he would have panic attacks and vomit in his car in the parking garage and leave.

  12. “Mark” continued • From July 30, 1999 to November 16, 2006, Mark received continuous treatment on the PCT, focused on symptom management and supportive therapy. • Then he was told it is time to do an EBT. • Nov 20, 2006 to Jan 22, 2007 he completed In Vivo Group and committed to completing CPT. • March 28, 2007 he declared he is not ready for CPT but took the manual to prepare and completed CPT on his own. • May 4, 2007 he reported on significant cognitive restructuring he had completed over the past 2 months and asked for my support with voc rehab; he wanted to train to become an EMT and eventually a paramedic.

  13. “Mark” continued BEFORE SNAPSHOT AFTER SNAPSHOT CAPS = 100 CAPS = 4 Panic attack w/ vomiting No panic attacks Unable to attend group Field q’s for audience Unable stand at sch bus stop Completed EMT training Unable to talk about traumas EMT for burn victims Isolated Reconnected • Almost 2.5 years after creation of his “recovery video” (Jun 20, 2008), Mark’s recovery is still solid and growing.

  14. “Mark” continued PIVOTAL MOMENTS • Support Group “I don’t want to be stuck here” • ER after anxiety attack “You just have to calm down.” • Ultimatum “Time to do an EBT” • In Vivo and CPT: avoidance busting and change in perspective • Virginia Tech Mom  “I will not allow this moment to define my son’s life” “There’s a lot more to me than just that one year”

  15. “Mark” continued Mark’s Recovery Video, produced June 20, 2008.

  16. “Mark” continued Mark talks about LIFE AFTER PTSD and fields questions for 5 minutes.

  17. Concluding Comments • These are not isolated cases; they are the new norm with EBTs • Response to recent PCT poll: • # of sessions (PE): 7, 8, 8, 15, 8, 13, 12, 16, 11, 8, 7 • # of sessions (CPT): 12 (group of 6 veterans) • Functional changes: Back to school, no more PTSD tx, riding public transport, travelling, developing new relationships, enjoying retirement with wife, return to church, kids “hanging on him” vs. running to hide from him

  18. Concluding Comments PE CPTC (Group*) PrePost (change) PrePost (change) 62 38 (24) 61 27 (34) 72 32 (45) 81 63 (18)* 54 24 (30) 61  45 (16)* 55  26 (29) 40  23 (17)* 56 33 (23) 59  42 (17)* 80  40 (40) 68  52 (16)* 40 27 (13) 74  54 (20)* 65 45 (20) 63  44 (20) * 6/7 wom 60 42 (18) 70  25 (45) * group; full cohort(s) 42  19 (23) 60 32 (28) 64  59 (6)* 41/62 sx

  19. Discussion • Would these veterans’ responses to the EBTs have been the same had they not had those years of prior therapy? • What made these veterans great candidates for evidence based PTSD therapy? • What value do we place on 80 clinician hours of treatment that result in: • 4 to 6 veterans dropping symptoms by 28 points (recovered and no longer in need of treatment) • 36 veterans dropping symptoms by 6 points (managing symptoms better) • How can we maximize the greatest recovery for the greatest number of people who suffer from PTSD?