Transcript The Neurobiological Alterations of PTSD

VA Medical Center
Albany, NY
Assessment, Diagnosis and
Treatment of Posttraumatic
Stress Disorder
NADE National Training Conference
September 14, 2010
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
Jonathan Shay, MD, PhD
Department of Veterans Affairs, Boston MA
From 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.”
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.
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
Historical Terms for PTSD
Military Trauma
Nostalgia
Soldier’s Heart
Shell Shock
Combat Fatigue
War Neurosis
Civilian Trauma
Railway Spine
Survivor Syndrome
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.”
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%
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
OEF/OIF Veterans
Invisible Wounds of War
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
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
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
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.
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
Avoidance
Efforts to avoid thoughts and feelings
about the trauma
Avoidance of activities and situations
which stimulate recollection of the trauma
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
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
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
Goals of PTSD Treatment
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Symptom reduction
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Integration thoughts and feelings
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Create new memories
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Disinhibit imagination
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Foster interpersonal connection
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Register other than traumatic material
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Create a narrative about the trauma, create meaning
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Bring the trauma to the present instead of person being pulled back to the past
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Promote chosen action, challenge the fixed action of fight, flight or freeze reaction
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Reconnect the neocortex and limbic system
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Fulfillment in living in the present
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Investment in the future
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
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
PTSD Program Levels of Care
Group 1
Group 2
Group 3
Group 4
Group 5
Simple Trauma
Mild Complex Trauma
Moderate Complex Trauma
Severe Complex Trauma
Chronic Severe
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
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
Treatment Group 3
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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
Treatment Group 4
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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
Treatment Group 5
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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
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.
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.
Common Polytrauma Conditions
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Traumatic Brain Injury
Hearing Loss
Amputations
Fractures
Burns
Visual Impairment
Posttraumatic Stress Disorder
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.
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.
Polytrauma Support Clinic Teams
VAMC 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.
Polytrauma Rehabilitation Centers
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Richmond, VA
Tampa, FL
Minneapolis, MN
Palo Alto, CA
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
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.
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 nonPTSD veterans (Dansby & Marinelli, 1999; Davison & Mellor, 2001)
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
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.
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.
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.
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.
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.
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.
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