Transcript Document

VA National Center for
PTSD
Congressional Mandate:
PL 98-528
• “carry out and promote the training of health care
and related personnel in, and research into, the
causes and diagnosis of PTSD and the treatment of
veterans for PTSD”
• “serve as a resource center for, and promote and
seek to coordinate the exchange of information
regarding all research and training activities carried
out by the Veterans’ Administration, and by other
Federal and non-Federal entities, with respect to
PTSD”
• Reiterated in PLs 101-297, 102-902, and SR 105-53
Mission and Vision
• Mission: To promote the best clinical care and
functional status of veterans through research,
education, and training related to the etiology,
diagnosis, and treatment of PTSD and stressrelated disorders
• Vision: To be the foremost leader in information
on PTSD and trauma
Our Strategy
• Build a consortium around established centers
of excellence
• Sites have unique but complementary areas
of expertise
• Create an Executive Division to provide
leadership
• Directs overall operation
• Carries our program planning
• Guides sites to work as a unified whole
Hub-and-Spoke
• The “hub-and-spoke” model provides the basis for
the Center’s overall organization
• Model is also used for Center projects, with a given
site functioning as the hub for participating sites
• Education Division is leading the Prolonged
Exposure Rollout
• Clinical Neurosciences Division is leading CSP
#504
• Communication structures overseen by the Executive
Division promote information sharing and
coordination of these activities
Past Multi-Site Center Projects
• 3 VA Cooperative Studies to evaluate the
assessment or treatment of PTSD in veterans
• Development of widely-used assessment
instruments, e.g., CAPS, PC-PTSD Screen, PTSD
Checklist, Deployment Risk & Resilience Inventory
• The Iraq War Clinician Guide (w/DoD)
• PTSD 101, a comprehensive online curriculum on
trauma and PTSD
• The Matsunaga Study of PTSD among American
Indians, Native Hawaiians, and Americans of
Japanese Ancestry
Current Multi-Site Center Projects
• National rollout to disseminate PE for VA clinicians
• National program to provide training and ongoing
mentoring to VA PTSD program administrators
• CSP #504 to evaluate risperidone for augmenting
treatment of PTSD with SSRIs
• Development of a scale to measure resilience to the
adverse effects of traumatic stress
• Evaluation of VA MST screening and treatment
• The Clinician’s Trauma Update—Online newsletter
• Development of VAMSTA, an assessment tool for
monitoring outpatient PTSD treatment
NCPTSD Products and Services
Knowledge:
Center research plus world-wide resources
Educational
Materials
Consultation
Program
Evaluation
Tools
Training
Products aim to promote the best clinical care and functional
status of veterans
NCPTSD Customers
Within VA
Outside VA
•
•
•
•
• VSOs
• US military
• Disaster mental health
officials
• Congress & federal
departments
• UN, other govt’s
• Media, lay public,
academics, trainees
Clinicians
Researchers
Educators
Facility and VISN
Directors
• Program directors &
policymakers
• Veterans & families
Goals and Objectives
1. Promote improved assessment and treatment of
PTSD
2. Advance the scientific understanding of PTSD
3. Promote PTSD education for clinicians,
researchers, and veterans by developing and
disseminating information
4. Support GWOT through collaborations with
Department of Defense
5. Promote VA’s emergency medical response
capability
6. Provide consultation to VA’s top management
Accomplishments (17 years)
• Extramural funding: $172 million (~450 grants)
• 2,100 articles, chapters, & books; 3,600 scientific or
educational presentations
• 33,000+ publications cataloged in PILOTS database
• Developed key assessment and treatment materials
• Educated ~1,200 mental health practitioners in the
on-site week-long Clinical Training Program
• Trained >5,300 participants in disaster mental health
at 16 VA Facilities (>500 participants via
teleconference)
Normal & Pathological
Readjustment among Returning
Troops
Matthew J. Friedman, M.D., Ph.D.
Executive Director of the VA National Center for PTSD
Professor of Psychiatry and Pharmacology
Dartmouth Medical School
Differences from Vietnam War
1. All volunteer
2. Guard & Reserve
3. Role of women
4. Survival of wounded
5. Communication: Email/Cell phones
6. Societal support
7. Effective treatments
8. VA/DoD collaboration
Impact of Iraq War
47% saw someone wounded or killed, or saw a
dead body
14% had an experience that left them easily
startled
6% wanted help for stress, emotional, alcohol or
family problems
2% had thoughts of hurting someone or losing
control
1% had thoughts that they might be better off
dead or could hurt themselves
Source: 193,131 Defense Department Post-Deployment Health Assessments from January through August
The Stress of War
Among service members returning from the Iraq war:
45% felt they were in great danger of being killed during their
tour
19% were bothered by finding little interest or pleasure in
doing things
14% were bothered by feelings of depression or
hopelessness
9% had an experience that gave them nightmares or that they
thought about when they didn’t want to
3% worried about serious conflicts with their spouse, family or
close friends
Source: 538,232 Defense Department Post-Deployment Health Assessments of service members returning from the Iraq
war from April 2003 to August 2005.
Casualties
In Iraq as of April 1, 2008 Official US Casualties
Total:
4,000 Deaths
75,000 Wounded
Many more coalition and contractor casualties
300-600,000 Iraqi deaths
VA Data (May, 2008)
837,458 vets separated from military
50% Active Duty
50% Reserves/Guard
324,846 (39%) sought VA care
Top 2 reasons: Musculoskeletal & MH
133,633 (41.1%) sought MH care
50.5% PTSD problems
3.0% acute stress reactions
33.8% depression
Patients’ military experience may
vary considerably depending upon
the military component (e.g. active,
reserve or National Guard) to which
these service members are assigned
Guard and Reserve Members:
Special Considerations
 Deployment may result in loss of:
- Civilian employment
- Financial penalty
- Separation from family
 Members may be assigned or inserted into
units in which they know no personnel
 Guard and Reserve families do not live on
military bases
Phases of Traumatic Stress Response:
The clinical picture will vary over the
course of time:
Immediate Phase
Delayed Phase
Chronic Phase
Psychological Distress
During War
Psychological injury may occur as a product
of combat and a consequence of:
•
•
•
•
•
•
physical injury
disruption of the environment
fear
rage
helplessness
combination of these factors
After The Fog:
A film by Jay Craven
Immediate Phase:
During or immediately after traumatic event(s):
Strong emotions
Disbelief
Numbness
Fear
Confusion
Anxiety
Autonomic arousal
Delayed Phase:
Approximately one week after trauma,
or in the aftermath of combat:
Intrusive thoughts
Autonomic arousal
Somatic symptoms
Grief
Apathy
Social withdrawal
Chronic Phase:
Months to years after traumatic event(s):
Disappointment or resentment
Sadness
Persistent intrusive symptoms
Re-focus on new life events
Three Important Questions:
1. What are the features of the Iraq War that may
impact the quality of life, well-being, and
mental health of returning veterans?
2. What are important areas of functioning to
evaluate returning veterans?
3. What might be beneficial for veterans of the
Iraq War who request clinical services?
1. What are the features of the Iraq
war that may significantly
impact the quality of life, wellbeing, and mental health of
returning veterans?
Every War is unique in ways that
cannot be anticipated
War-Zone Stressors: Lessons from
the Persian Gulf War
Preparedness
Combat Exposure
Aftermath of battle
Perceived threat
Difficult living and working environment
War Zone Stressors (Continued)
 Life and family disruptions
 Sexual or gender harassment
 Ethnocultural Stressors
 Perceived radiological, biological, and chemical
weapons exposure
Physical Stressors
Soldiers are taxed physically and emotionally
in ways unprecedented for them
Stress Hormones
- norepinephrine, epinephrine, cortisol
Fighting Edge
- hypervigilance, narrowed attention span
The majority of soldiers who
initially display distress will
naturally adapt and recover
normal functioning in the
following months
After The Fog
Risks:
•
•
•
•
•
Acute stress Disorder
Posttraumatic Stress Disorder
Depression
Substance Abuse
Aggressive Behavior Problems
DSM-IV Diagnostic Criteria for PTSD
• Exposure to a traumatic event in which the person:
• experienced, witnessed, or was confronted by death or
serious injury to self or others
AND
• responded with intense fear, helplessness,
or horror
• Symptoms
• appear in 3 symptom clusters: re-experiencing,
avoidance/numbing, hyperarousal
• last for > 1 month
• cause clinically significant distress or impairment in
functioning
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.
Posttraumatic Stress Disorder
(PTSD)
Risk factors:
History of psychiatric problems
Poor coping resources
Prior traumatization
Lack of supports
Genetic Factors
Suicide:
Complicated connection between
suicide and PTSD
 Combat-related risk (what we know from Iraq)
 PTSD and increased risk
 Other psychiatric conditions
 Highest relative suicide risk:
- wounded multiple times
- hospitalized for a wound
 Combat-related guilt
2. What are important areas of
functioning to evaluate in
returning veterans?
Assessment:









Work functioning
Interpersonal functioning
Recreation, self-care
Family functioning
Physical functioning
Psychological symptoms
Past distress, coping
Previous trauma
Deployment-related experiences
Stigma:
It is stigmatizing for soldiers to share fear
and doubt, and to reveal signs of reduced
capacity.
This is especially true for soldiers wishing to
advance their careers
It is entirely possible that some veterans will
have suffered silently and may still feel a
great need not to show vulnerability
because of shame
3. What might be beneficial
for veterans of the Iraq War who
request clinical services?
Context of Care:
Active Duty or Veteran
Active Duty:
 May not present to mental health
 Reluctant to acknowledge distress
 Culture of combat: Labeling counterproductive
Veteran:
 Diagnosis in medical record and impact on
career
Lessons from Vietnam Veterans
• Prevent family breakdown
• Prevent social withdrawal, isolation
• Prevent employment problems
• Prevent alcohol and substance abuse
Treatment
General considerations in care
•
•
•
•
•
•
•
Connect with the returning veteran
Connect veterans with each other
Offer practical help with specific problems
Attend to broad needs of the veteran
Involve Family
Consider Community
Educate about early treatment benefits
Methods of Care:
Education about PTSD reactions
Reduce fear and shame, normalize
experiences
Understanding of experience, recovery &
treatment
Affects a lot of people
Treatable
Methods of Care (Cont.)
Coping skills training & support
• Restoration of self-efficacy
• Anxiety management, emotional
grounding, anger management, and/or
communication
• Methods to support own recovery
Case Example - Background
38 year old National Guard soldier
Happily married, 2 children (10 & 12),
automobile salesman
12 month deployment
Extensive trauma exposure
heavily shelled, ambushed, IEDs,
witnessed death and injury
killed insurgents/possibly civilians
Case Example - Re-entry
Anxious, irritable, on edge most of the time
Pre-occupied with concerns about safety of self
and family
Keeps 9 mm pistol at all times (under pillow at
night)
Insomnia, nightmares, kicks wife
Emotionally distant from family
Subjectively numb or full of fear/panic/guilt/dispair
Dangerous behind wheel of car
Avoiding friends and family
Irritable and functioning poorly at work
Not suicidal but not sure he’s glad he survived
Case Example - Family
Wife assumed paternal responsibilities
- finances, family decisions, home
maintenance
- not eager to surrender checkbook/other
prerogatives
Children assumed responsibilities/more
independence
- not happy about his over-protectiveness
Case Example - Clinical
Assessment
Suicidal risk
Danger to others
Ongoing stressors
(home/work/social)
Risky behaviors
(alcohol/drug, impulsivity, potential exposure to
violence/trauma)
Personal characteristics
vulnerability/resilience, coping skills
Social Support
Comorbidity
Case Example - OIF Risk Factors
Stigma sensitivity
National Guard/reserve vs Active Duty
Military Sexual Trauma
Survival after serious injury
Concussive injury
Case Example - Treatment
CBT*
Pharmacotherapy
Family Therapy
*CBT option may be limited by availability of
skilled therapists
PTSD Treatment Options
Psychotherapy
Exposure therapy
Cognitive therapy
Anxiety management
Desensitization
EMDR
Pharmacotherapy
SSRIs
Other antidepressants
Mood stabilizers
Atypical antipsychotics
Anti-adrenergic agents
Meta-Analysis of PTSD Treatments
Psychotherapy
Pharmacotherapy
Controls
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Self-Rated PTSD
Clinician-Rated PTSD
Van Etten & Taylor, 1998
Meta-Analysis of PTSD Treatments
Effect Size (d)
0
0.5
1
1.5
Prolonged Exposure
Other Exposure
Other CBT
Stress Inoculation
EMDR
Group therapy
SSRIs
TCAs
Other Antidepressants
Psychotherapies
shown in green
Drugs shown in
light blue
Alpha blockers
MAO-Is
Atypical Antipsychotics
Benzodiazepines
Watts et al., 2007
VA/DoD Clinical Practice
Guidelines
First Line Treatments
• Cognitive-Behavioral Therapy
• Cognitive Processing Therapy
• Prolonged Exposure
• Eye Movement Desensitization and
Reprocessing (EMDR)
• Selective Serotonin Reuptake Inhibitors
(SSRIs)
Methods of Care (Cont.)
 Exposure therapy
Confront trauma-related emotions &
memories
 Cognitive restructuring/CBT
Review and challenge distressing traumarelated beliefs
 Family/Couples counseling
May include: family education, workshops,
therapy, parenting classes, conflict
resolution training
Exposure Therapy
• A set of techniques designed to
promote confrontation with feared
objects, situations, memories and
images (e.g., systematic
desensitization, flooding)
Emotional Processing Theory
• Exposure therapy elicits trauma memories
and their overgeneralized associations with
fear networks
• The therapist provides corrective
information and experience that is
incompatible with trauma-related
appraisals
Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD. New York/London: Guilford
Press; 1998
Prolonged Exposure Therapy
• Education about common reactions to
trauma
• Breathing retraining
• Prolonged, repeated exposure to the
trauma memory (imaginal reliving)
• Repeated in vivo exposure to objectively
safe situations being avoided due to
trauma-related fear
CAPS PTSD Scores in Veteran and
Active Duty Women Treated With PE
Inte ntion to Treat Sample
Completer Sample
80
Overall d=.46*
70
50
50
40
40
s
on
th
6
M
3
m
on
t
en
t
m
tr
ea
t
Po
st
as
e
hs
60
lin
e
60
B
on
th
m
6
M
3
Prolonged Exposure
Present-Centered Therapy
*p<.05
70
s
hs
on
t
en
t
m
tr
ea
t
Po
st
B
as
e
lin
e
Overall d=.27*
80
Prolonged Exposure
Present-Centered Therapy
Schnurr et al., 2007
Odds of Good Clinical Outcomes
in PE vs. CPT
0
1
2
3
4
Among all patients:
All patients
Completers
Clinical response
*p<.05
*
*
41% of PE vs. 28%
of PCT no longer
met diagnostic
criteria
*
*
Loss of diagnosis
15% of PE vs. 7% of
PCT achieved total
remission
Total remission
Schnurr et al., 2007
PE vs. EMDR:
Good End-State Functioning*
% Good End-State Functioning
Better 6-month outcome in PE
EMDR
80%
PE
60%
WL
40%
20%
0%
*CAPS 50%  ; BDI < 10; STAI-S < 40
Postreatment
6 Month
Rothbaum et al., 2005
Cognitive Theory
Functioning in the world is guided by mental
constructs (schema). These develop within
predetermined parameters and are influenced
by both experience (learning) and traits
(temperament, personality, intelligence)
Erroneous Cognitions from OIF
Returnees
•
•
•
•
•
•
•
•
I am a failure because I was afraid
I will never have a normal life or normal relationships
I wasn’t strong enough
I didn’t do enough. I should have done more.
What happened proves that I cannot trust my
judgment
I am bad because I have killed
I should have been able to stop what was going on
around me
I have no control over my intrusive memories and
flashbacks
Erroneous Cognitions from OIF
Returnees
•
•
•
•
•
•
•
•
•
•
•
I can’t trust anyone anymore
This war has destroyed me
I am a coward
God abandoned me
I don’t deserve to feel happy
I have to cut off and distance myself from other
people
Even when I am safe, I feel like I am in danger
I have no control over my behavior
If I feel my emotions, that means I am weak
If I get close to someone I’ll hurt them
My family won’t accept the person I’ve become
Challenging Questions
1. What is the evidence for and against this idea?
2. Are you confusing a habit with a fact?
3. Are your interpretations of the situation too far
removed from reality to be accurate?
4. Are you thinking in all-or-none terms?
5. Are you using words or phrases that are extreme or
exaggerated? (e.g., always, forever, never, need,
should, must, can’t, and every time)
6. Are you taking selected examples out of context?
Challenging Questions
7. Are you making excuses? (e.g., I’m not afraid. I just
don’t want to go out. Other people expect me to be
perfect, or I don’t want to make the call because I
don’t have time.
8. Is the source of information reliable?
9. Are you thinking in terms of certainties instead of
probabilities?
10. Are you confusing a low probability with a high
probability?
11. Are your judgments based on feelings rather than
facts?
12. Are you focusing on irrelevant factors?
CAPS PTSD Scores in Military
Veterans Treated with CPT
CPT
Wait list
90
80
70
60
50
40
Pretreatment
Midtreatment
Posttreatment
Monson et al., 2006
1 Month
Choice of CBT
Exposure Therapy: if it is more important to
extinguish intolerable fear-base memories and
avoidant behavior
Cognitive Therapy: if major clinical problem is a
disruption in core beliefs about the self or
others (eg: erroneous cognitions about
personal inadequacy, helplessness, guilt, etc.)
CAPS PTSD Scores in Women
Treated With PE vs. CPT
Comparable Effects of PE and CPT
80
60
40
20
CPT
PE
Minimal attention
0
Pretreatment
N = 171
Posttreatment
3 Months
9 Months
Resick et al., 2002
PTSD Diagnosis Before Treatment and
at 5+ Years in CPT and PE
% Meeting PTSD Diagnostic Criteria
(CAPS)
Long-term benefits in PE and CPT
100
)CPT (n=63
)PE (n=64
80
60
40
20
0
Before Treatment
5+ Years
Resick et al., 2002
VA Dissemination of PE and CPT
• Passive dissemination of guidelines (e.g.,
printing guidelines) is generally ineffective
• Two VA dissemination initiatives
• PE
• CPT
• OMHS leadership supports need to train
clinicians AND develop internal resources to
continue training over time
• Self-sustaining
First Line Medications for PTSD
SSRIs (Selective Serotonin Reuptake Inhibitors)
Sertraline (Zoloft)
Paroxetine (Paxil)
Fluoxetine (Prozac)
SNRIs (Serotonin/Norepinephrine Reuptake
Inhibitors)
Venlafaxine (Effexor)
Sertraline vs. Placebo
(N=187)
90
80
70
60
50
Placebo
40
Sertraline
30
20
10
0
0
2
4
6
8
10
12
Week
Brady et al, 2000
Adjusted Mean Change
from Baseline (ITT/LOCF)†
Paroxetine in PTSD
CAPS-2 Total Score
0
Placebo
Paroxetine 20 mg
Paroxetine 40 mg
-10
-20
*
-30
*
*
-40
*
*
0
4
*
8
Weeks
*p<0.001; †Adjusted for center and covariates; GlaxoSmithKline, 2000—Study 651 (Data on file)
12
PTSD Remission Analysis
% Remitters
(CAPS-2 of <20)
35
30
Paroxetine
Placebo
*
29.4%
25
20
16.5%
15
10
5
0
Week 12
*ITT/LOCF data set; Odds ratio = 2.29; *p=0.008; Tucker P et al. J Clin Psychiatry. 2001;62:860-868; Dose = 27.6 + 6.72 mg/day; N=323
90
80
70
CAPS-2 score
IES score
35
60
50
40
30
20
25
20
15
10
5
0
10
0
Week 0
12
20
28
36
Impact of Event Scale Score
CAPS-2 Total Score
Sertraline Continuation
Treatment in PTSD
Endpoint
Acute Phase Study Open-Label Continuation Study
Londborg et al. J Clin Psychiatry. 2001(May);62(5):325-331
Promising Psychopharmacological
Treatments for PTSD
Prazosin (Minipress)
Atypical Antipsychotics
Risperidone (Risperdol)
Olanzapine (Zyprexa)
Mood Stabilizers
Older Antidepressants
Ineffective Pharmacologcial
Treatments for PTSD
Anti-anxiety agents
Valium
Xanax
Special Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
Medical Casualty Evacuees
Traumatized Amputee
Implications for Primary Care
Caring for Clinicians
Military Sexual Trauma
Anger
Traumatic Grief
Substance Abuse
Impact of Deployment on the Family
For more information
Visit the National Center for PTSD
(NCPTSD) Website
www.ncptsd.va.gov
Download
Iraq War Clinicians Guide
Returning from the War Zone: A
Guide for Families
VT Yellow Book