Introduction to Trauma & PTSD

Karen Krinsley, Ph.D.PTSD Section Chief,

VA Boston Healthcare System& PTSD Consultant,

National Center for PTSD

Presented January 26, 2012 as part of the Grant per Diem educational training series for staff

Outline of Talk

• Recognizing PTSD

• How common is it?

• Who is most at risk?

• What treatments are effective?

• How the PTSD Consultation Program can help

The technical diagnosis of PTSD —

And why it is important

• Misdiagnosis is common

• Misunderstandings are common

• Great reason not to focus on other issues

• Serious but treatable when it is present

• Typically NOT present alone

PTSD (DSM IV-TR): A Cluster of Symptoms

A Trauma (The “Stressor”)

B Reexperiencing / Intrusions

C Avoidance/Numbing

D Increased Arousal

E More than one month of symptoms

F Causes functional problems

PTSD Criterion A Stressor Exposure to a traumatic event in which:

1.The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

2.The person's response involved intense fear, helplessness, or horror.

Important to Remember

PTSD ≠ TRAUMA and

TRAUMA ≠ ANYTHING bad

PTSD ≠ Trauma ≠ Anything bad

• Traumas do not always lead to PTSD

• Traumas may lead to PTSD, but then the person recovers

• And, many bad things happen to people, affecting them deeply, that are not “trauma”

Criterion B: Reexperiencing/Intrusions

• Recurrent recollections of the event• Recurrent distressing dreams of the event• Feeling as if the traumatic event were recurring • Intense distress at exposure to cues that resemble an

aspect of the event • Physiologic reactivity upon exposure to cues that

resemble an aspect of the traumatic event • EXAMPLES: Nightmares, Flashbacks, Shaking,

Sweating

Criterion C:Avoidance/Numbing

• Efforts to avoid thoughts about the trauma • Efforts to avoid things that remind one about the

trauma • Inability to recall an important aspect of the trauma • Markedly reduced interest in significant activities • Feeling of detachment from others • Restricted range of affect (e.g., unable to have loving

feelings) • Sense of foreshortened future• EXAMPLES: Avoiding the news, movies, crowded

stores but also drinking and drug use

Criterion D: Increased Arousal

• Difficulty falling or staying asleep

• Irritability or outbursts of anger

• Difficulty concentrating

• Hyper-vigilance

• Exaggerated startle response

• EXAMPLES: Keeping guns, checking locks, aggression, insomnia

PTSD Criterion E and F

• Duration: At least one month

• Functional Impairment: “clinically significant”

Do you see the overlaps?

• Depression

• Substance Use Disorder

• Mild Traumatic Brain Injury

• Pain Symptoms

Likelihood of getting PTSDafter Experiencing a Trauma

• It depends on the event and the person• Men experience more traumatic events• Women are more likely to develop PTSD• After a traumatic event, who gets PTSD?

• 20% of women • 8% of men get PTSD

Kessler et al., 1995

Likelihood of PTSD….

• Rape• Men 65%• Women 45%

• Combat• Men almost 40%

• Physical Abuse• Almost 50% of women• 20%+ men

What puts you at risk for PTSD?

• Being female

• Being poor

• Less education

• Bad childhood

• Previous psychological problems

What puts you at risk for PTSD?

• *Strength or severity of the stressor

• Characteristics of the trauma:• Greater perceived life threat• Feeling helpless• Unpredictable, uncontrollable

Risk for PTSD: After the Trauma

• Degree of Social Support

• Degree of Life Stress

How common is PTSD?• 3.5% general population, current

• 1.8% men• 5.2% women• Lifetime: 6.8% -- 3.6% men, 9.7% women

(U.S. National Comorbidity Survey Replication 2001-03)

• Vietnam theater veterans: • 15.2% of men• 8.1% of women(National Vietnam Veterans Readjustment Study 1986-88)

• In veterans• In combat veterans• In women veterans (who may be combat veterans!)

How common is PTSD?

• Gulf War (I): 10%

• OEF/OIF• 13.8 (current)

• Population-based studies(RAND Corporation, Center for Military Health Policy Research, 2008)

• Conclusions: PTSD is not unusual, although not the majority

What about MST?

How Common is MST? Margret Bell, Ph.D.

Resource Development & Utilization Coordinator,

MST Support Team – (national resource for VA MST teams)

Data SourceData Source Time Time frameframe

MenMen WomenWomen

Sexual Sexual harassmeharassme

ntnt

SexuSexual al

assauassaultlt

Sexual Sexual harassmharassm

entent

SexuSexual al

assauassaultlt

DoD 2002 DoD 2002 SurveySurvey

(active duty (active duty sample)sample)

Annual Annual ratesrates

23%23% 1%1% 54%54% 3%3%

Street et al., Street et al., 20032003

(reservist (reservist sample)sample)

AnytimAnytime e

during during serviceservice

27%27% 3%3% 60%60% 23%23%

Skinner et al., Skinner et al., 20002000

(users of VA (users of VA healthcare)healthcare)

AnytimAnytime e

during during serviceservice

---- ---- 55%55% 23%23%

Implications of PTSD• Greater risk of other disorders

• 80% of people with PTSD another diagnosis• Depression, SUD, Anxiety Disorders

• Greater unemployment• Relationships• Health problems• Violence• Generally, worse quality of life

What does PTSD look like?

• No one clinical picture but not like it is shown on television/movies

• Can’t stereotype, although it’s done• There are some “hallmarks”

• Nightmares• Poor sleep• Anger• Numbness or sadness• Avoidance of groups

How can you help?

• Be supportive but don’t allow PTSD to be used as an excuse

• Do ask if they want to talk and acknowledge their military service

• Don’t say “I understand”

• Be alert for risk issues

How can you help?

• Sleeping / Nightmares: No touching

• No “fooling around”: Don’t sneak up on someone, don’t make sudden noises behind them

• Understand the impact of TV

• Consider special requests: Light, Noise, Large Groups

A few tips for Managing Anger

• Confrontation probably NOT helpful• Try to understand the cause, both to help

manage and to help yourself stay calm• Prepare ahead of time with the veteran if

possible• Allow “escape”

Trauma-Informed Milieu

• Structured but not authoritative or punishing

• Everyone treated with respect and listened to

• Setting is kept safe

• Staff aware that residents may be traumatized

Professional Help

• Know when to refer

• Be knowledgeable about PTSD treatments and aware that they work

• Encourage keeping appointments

• Acknowledge that it will be HARD but it is worth it

• Ask what the alternative is

• Be wary of splitting

Effective PTSD Treatments

• State of the art treatment• Empirically validated treatments

• Staged, stepped model of care• Safety• Trauma focus• Reconnection

• Interdisciplinary• PTSD ≠ chronic mental illness

Treatment for PTSD

• Cognitive Behavioral Treatments most effective psychotherapy treatments

• Medication can be an effective treatment

• Most evidence for Cognitive Processing Therapy and Prolonged Exposure

• Most evidence for antidepressants

Stepwise Treatment Model:Stage 1 Safety

• Suicide and Homicide prevention• Harm reduction for risky behaviors• Teach positive coping tools• Teach the role of avoidance• Group focus when possible, including:

Seeking Safety, Understanding and coping with PTSD, Relaxation & Stress Mgmt, ACT, DBT modules & Anger Management, Wellness, & more

Stepwise Treatment Model:Stage 2 Trauma Focus

• Core of PTSD treatment

• Empirically validated treatments include Cognitive Processing Therapy and Prolonged Exposure

• It works! Recovery is possible.

Trauma Focus Therapy

• Many types

• Core common elements• Exposure to the trauma in some form• Processing of the trauma• Results: Decreased avoidance,

increased tolerance of distress, and ultimately decreased distress

CPT AND PE Comparison Study (Resick et al., 2002)

CPT, N= 83 55 50 41 63 PE, N= 88 55 51 39 64

CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT AND LONG TERM (Resick et al., 2002)

Stepwise Treatment Model:Stage 3 Reconnection

• Focus is on relationships

• Reconnection with friends, family

• Support groups, process groups, marriage and family work and more

• Also may include Reparation

Special issues with new veterans of Iraq and Afghanistan

• National Guard OR Reserve OR Regular Military• Trauma is more acute or “raw”• Anger and aggression are common• Binge drinking or casual drug use• May be working and need different hours for

treatment• Often have families and children, and may want or

need them involved in treatment• May not want traditional treatments such as group

therapy

PTSD Consultation Program• One-on-one PTSD consultation for any

VHA provider OR contractor• Free of charge• Speak directly with “expert” PTSD

clinicians• Response usually within 24 hours• Easy to contact us: Call, email, or

complete an online form

Consultation Program Staff

Karen Krinsley, PhD

Consultant & VISN 1 PTSD Mentor

PTSD Section Chief, VA Boston

Nancy Bernardy, PhD

PTSD Mentoring & Consultation Program Manager

VA National Center for PTSD

Matt Friedman, MD, PhD

Executive Director, NCPTSD

And associated experts from around the country

PTSD Consultation ProgramAsk questions regarding:• Assessment• Treatment

• Therapy of all kinds• Medication

• Clinical management• Programmatic issues• Resources for treatment• Ways to improve care• Any problem at all

Eligibility

• We can’t say this enough:• ANY VHA Clinician• ANY Contractor• ANY Question• ABOUT ANY Veteran or Group of Veterans

For Whom and How We Have Been Useful

• Experienced clinicians who want a second opinion

• Relatively inexperienced clinicians who would rather not “bother” local colleagues that particular day

• New staff who are overwhelmed

• Staff without a lot of local folks for support

For Whom and How We Have Been Useful

• Staff from programs outside PTSD with no connections to their PTSD programs

• Staff who have hit a roadblock or a wall

• Diagnostic and treatment challenges

• Referrals to residential programs

Consultation Program Contact Information

Contact us:• Call 1 (866) 948-7880• Online Form at:vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp

• Send e-mail to ptsdconsult@va.gov

A Few Things to Remember• Consultation provides an opportunity for

problem solving and discussion with the treating clinician

• Ultimate decision and authority for implementing consultation recommendations lie with the treating clinician and the local chain of command

• Not for acute emergencies

More Information:National Center for PTSD Website

• www.ptsd.va.gov

• All types of information, for • Providers• Veterans• Families• General Public

• Has online courses such as “Understanding PTSD” and much more