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“I’ve got the PTSD”PRESENTED BY DANIELLE MURRAY, PHD
Objectives
1. Recognize signs and symptoms of PTSD and understand the diagnostic criteria
2. Understand the association of PTSD with substance abuse and concussions/mTBI
3. Identify barriers to seeking help
4. Identify evidence based treatment options and challenges
5. Understand the role of the PA in the treatment plan
History of Post-Traumatic Stress Disorder (PTSD)
The impact of psychological stress has probably always been around Ex. Saber tooth tiger attack
Its presence well documented in literary works included Shakespeare (Henry IV) and Homer (the Illiad)
First captured by the Diagnostic Statistical Manual Version III in 1980 (APA,
1980). Not usually an “ordinary stressor” (break-up, financial stress, etc) Unusual, catastrophic event outside the usual human experience rape, torture, genocide, and severe war zone stress are experienced as
traumatic events by nearly everyone
I got the “PTSD”…
Not permanent
Can wax and wane, even “delayed expression”
Can resolve
Problem with recovery
Google says PTSD is…
Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.
- NIMH, National Institute of Health
Google says…
Posttraumatic stress disorder (PTSD), once called shell shock or battle fatigue syndrome, is a serious condition that can develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened. PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster.
– WebMD
Media
Media has villainized the term PTSD and lay person may associate with the notion that The person is violent
The person is unpredictable or likely to “blow up” on others
The individual is going to shoot or kill someone
That PTSD is more severe than OTHER disorders such as depression
100 people see an event…
Trauma is how one experiences an event
One may experience difficultly in recovery while most may initially have some sx that natural resolve with time and they are never diagnosed with PTSD
About 7-8% of population has PTSD
How does PTSD present?
What do you think?
Diagnosing PTSD
Major changes to PTSD dx in DSM-5
PTSD is not just a fear-based anxiety disorder (as written in the DSM-III and DSM-IV), DSM-5 includes anhedonic/dysphoric presentations, which are most prominent marked by negative cognitions and mood states as well as disruptive (e.g.
angry, impulsive, reckless and self-destructive) behavioral symptoms
PTSD is now classified as a Trauma- and Stressor-Related Disorder, in which the onset of every disorder has been preceded by exposure to a traumatic or otherwise adverse environmental event
Criteria A: Stressor
Exposed to a catastrophic event involving actual or threatened death or injury (attempted murder, rape, combat event) or a threat to the physical integrity of him/herself or others (such as sexual violence). Indirect exposure includes learning about the violent or accidental death or perpetration of sexual violence to a loved one
Criteria B: Intrusive Recollections
Flashbacks (dissociative events), intrusive daytime memories, traumatic nightmares
a dominating psychological experience that retains its power to evoke mental, emotional, physical reactions such as panic, terror, dread, grief, or despair
trauma-related stimuli that trigger recollections of the original event have the power to evoke mental images, emotional responses, and physiological reactions associated with the trauma
Criteria C: Avoidance
Behavioral strategies PTSD patients use in an attempt to reduce the likelihood that they will expose themselves to trauma-related stimuli or minimize the impact of the stimuli
Criteria D: Negative cognitions and mood criterion
Erroneous cognitions about the causes or consequences of the traumatic event which leads them to blame themselves or others Ex: "nobody can be trusted," "the world is entirely dangerous“
Ex: Mass shootings are highly likely
Anger, guilt, or shame
Constricted affect makes it difficult to sustain a close marital or otherwise meaningful interpersonal relationship
Criteria E: Alterations in arousal or reactivity criterion
Includes panic, insomnia, irritability (outbursts), hypervigilance and startle easily (jumpy), cognitive impairments (mTBI complaints), reckless and self-destructive behavior such as impulsive acts, unsafe sex, reckless driving and suicidal behavior
Can appear like paranoia
Criteria F: Duration
Symptoms must persist for at least one month before PTSD may be diagnosed Otherwise: Acute Stress Disorder or Combat Stress
Criteria G: Functional Significance
Survivor must experience significant social, occupational, or other distress as a result of these symptoms
Criteria H: Exclusion
Symptoms are not due to medication, substance use, or other illness.
Subtypes
Dissociative symptoms Depersonalization –feeling detached from one’s own mind/body, as though in a
dream, unreality or slowed time
Derealization – unreality of surroundings, world around individual is unreal, dreamlike, distant/distorted
Specify if: With Delayed Expression – full criteria not met until 6 months post event
This is a change from delayed onset in DSM-IV since people often have at least some sxfollowing event but don’t meet full criteria until weeks, months, or years later
Course of PTSD diagnosis
People typically meet criteria for Acute Stress Disorder immediately following an event
For most, symptoms remit over the next few hours, days, and weeks and they go on to recover (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Nugent, Saunders, Williams, Hanson, Smith, & Fitzgerald, 2009; Orcutt, Erickson, & Wolfe, 2004).
Symptoms can wax and wane, be triggered weeks, months or years later
Triggers can include: reminders of event, ongoing life stress, or newly experienced traumatic event
Pre-trauma Factors that contribute to likelihood of development of PTSD
Childhood behavioral problems and previous mental health disorders
Lower SES, exposure to prior trauma, lower intelligence, minority racial/ethnic status, family psychiatric history
Female gender and younger the age at time of event
Social support serves as a protective factor (family, friends, etc)
Post-Traumatic factors
Negative appraisals, inappropriate coping styles (risky, drugs, avoidance)
Repeated exposure to upsetting reminders, subsequent life events (this is common in therapy), and financial or other trauma-related losses (such as loss of a friend or the suicide of a fellow service member)
Social support, again, a protective factors in how one copes following experiences a traumatic event
Cultural concerns
PTSD is a valid diagnosis cross-culturally, but expression of PTSD may differ culturally (Hinton & Lewis-Fernandez, 2011)
Concern by clinicians and researchers that diagnosis does not accurately reflect the clinical picture of traumatized individuals from non-Western traditional societies and cultures (Marsella, et. al, 1996)
Co-morbid Disorders
Substance Use Disorder
Individuals with PTSD 2 to 4 times more likely than those without PTSD to meet criteria for a Substance Use Disorder (NIH)
Estimated 46% of people with PTSD have a comorbid Substance Use Disorder Self-medicating coping mechanism
Helps fall asleep (not stay asleep)
Helps numb anxiety
Helps with avoidance
Alcohol significantly increases risk of suicide – lowers inhibitions and increases risk taking
Worsens withdrawal symptoms
PTSD and Substance
Use
Drugs suppress CNS
Drugs increase Dopamine
Dopamine lowers–
Low mood sets in
Painful Memories
Guilt/shame
Seeking Escape
Increased use of
substances
Repeated use =
harder for body to regulate
Stress lowers GABA
PTSD and Substance
Use
Increasing worry/anxiety
Release of EndorphinsEndorphins
subside
Painful Memories
Guilt/shame
Seeking Escape
Increased use of
substances
NumbPoor sleep,Isolation,
worsening relationships
Hyperarousal:fight/flight
Concussions and mTBI
Injury to head (LOC<30 min, GCS 13-15, PTA<24 hours) Blast exposure (IED, mortar fire, RPG, suicide bomber…) MVAs Falls
Hitting head on something (Humvee, luggage, etc) Etc
8 out of 10 people show symptoms improvement in the first days and weeks following injury with the majority making a full recovery to baseline within one year
Symptoms are a normal part of the recovery process – does not mean lasting injury – TBI is a historical event
Pts with mTBI are 2x as likely to develop PTSD or other anxiety disorders (Bryant, 2010)
Symptom Overlap
ConcussionMemory problems
Concentration problems
Fatigue
Sleep problems
Irritability
Anxiety
Depression
Apathy
Mood swings
Headaches
Dizziness
Anxiety/DepressionMemory problems
Concentration problems
Fatigue
Sleep problems
Irritability
Anxiety
Depression
Apathy
Mood swings
Headaches
Dizziness
Insomnia or painMemory problems
Concentration problems
Fatigue
Sleep problems
Irritability
Anxiety
Depression
Apathy
Mood swings
Headaches
Dizziness
Barriers to seeking help
Common Barriers
STIGMA
Concerns about career
Concerns about breaking down
Concerns about looking weak
Negative self-evaluations (“I am a monster”)
I don’t have time
They are going to hospitalize me
They are going to force me to take medication
Talking doesn’t help because it doesn’t change anything
Difficulty trusting others
Treatment Purpose
Process the event, feelings, memories and changes to belief system
Normalizing their symptoms and building confidence “You are a lean mean fighting machine!”
Education on cognitive response vs physiological response to trauma challenge thoughts / exposure to anxiety provoking stimuli
Replacing destructive coping skills with healthier coping skills
Treatment
Treatment Options
Individual Therapy Evidenced-based tx protocols (bolded = strongly recommended):
Prolonged Exposure (PE)
Cognitive Processing Therapy (CPT) typically 10-12 sessions 1-2x per week
Eye Movement Desensitization and Reprocessing (EMDR) or Accelerated Resolution Therapy (based on EMDR)
Brief Eclectic Psychotherapy (BEP)
Narrative Exposure Therapy (NET)
Psychotropic Medication Benzodiazepines remain “recommend against” and can worsen PTSD symptoms CHANGE: Prazosin for tx of nightmares from “fairly strong” recommendation “no
recommendation for or against” ONLY “strongly for” recommendation: fluoxetine, paroxetine, sertraline, and venlafaxine (APA
Clinical Practice Guideline for tx of PTSD, updated FEB 2017)
Treatment Options cont.
Group Therapy
Intensive Outpatient Treatment programs (2-6 weeks)
Inpatient Rehabilitation (2-4 weeks with possibility for extension; usually prioritizes treating substance abuse disorders before trauma tracks; some have dual programs)
Prolonged Exposure (PE)
Developed by Enda Foa, PhD 9-15 sessions 90 minute sessions preferred Session 1: Assessment, treatment overview (pitch and buy-in),
psychoeducation and breathing skills 2: In-vivo exposure 3-5: Imaginal exposure (talking, recording, listening) 6-9: “hot spot” exposure 10-15: Final exposure and completion of treatment
Cognitive Processing Therapy (CPT)
Developed by Drs: Patricia Resick, Candice Monson, and Kathleen Chard
Generally about 12 sessions
Session 1: Psychoeducation, introduction to CBT tools
2: Begin identifying unhelpful thoughts that interfere with recovery
3-4: Process event, continue to identify unhelpful thoughts, assist patients to challenge and modify unhelpful thoughts
4-12: Continue processing unhelpful thoughts with aim is to create new understanding of event and their conceptualization of the world; empower them to break self-detrimental cycle
Eye Movement Desensitization and Reprocessing Therapy (EMDR)
Initially developed in 1987 by Shapiro
Delivered 1-2 times per week for 6-12 sessions
Based on Adaptive Information Processing model that assumes symptoms of trauma and many other disorders result from past disturbing experiences that continue to cause distress because the memory was not adequately processed
Have Patient think of trauma memory while doing rhythmic bilateral movements (can be eyes, tapping, listening)
Process is intended to change the way that the memory is stored in the brain
Vividness and emotion of memory are reduced
EMDR structure
Phase 1: History-taking
Phase 2: Preparing the client
Phase 3: Assessing the target memory
Phases 4-7: Processing the memory to adaptive resolution
Phase 8: Evaluating treatment results
Brief Eclectic Psychotherapy (BEP)
Developed by 16 sessions lasting 45min to 1hour Focus is to change painful feeling about self and event and an emphasis on
the emotions of shame and guilt and the relationship between patient and therapist
1: Assessment and education 2-6: Talk about the event as though its occurring, possibly write letters to those
they feel are accountable 7: evaluate progress 8-15: Explore how event has impacted person and their view of world/beliefs 16: Relapse plan, review progress, “farewell ritual” performed
Narrative Exposure Therapy (NET)
Developed in 1970s/80s by Australian social worker Michael White and David Epston of New Zealand drawing from the work of Michel Foucault
Most frequently used in community settings and with individuals who experienced trauma as result of political, cultural or social forces (e.g. refugees)
Small Groups of 4-10 people, can be used individual basis
Pt creates chronological narrative of his or her life, concentrating mainly on their traumatic experiences, but also incorporating some positive events
develops a coherent autobiographical story and memory of a traumatic episode is refined and understood
Good for multiple traumas across lifespan and helps person acknowledge and to take back personal identity
Challenges to participation
Drop out avoidance
Limited availability for weekly appointments
Failure to generalize tools learned in session to life in the real world
Relying on psychotropic medication alone
Rapport with therapist is poor – don’t trust or feel Provider can understand
Other…
YOUR ROLE
Your role as medical provider
Identify symptoms – IMPORTANT – 1ST LINE Begin discussion Refer for treatment Medication evaluation for sx: know latest research on what is strongly
recommended vs. not recommended First introduction to behavioral health Breaking down stigma Following up on how someone is doing Continuing to encourage them to seek help if needed
Dr. Danielle Murray has no financial interests to disclose with regard to this subject or the contents of the presentation.
Resources
Trimble, M.D. (1985). Post-traumatic Stress Disorder: History of a concept. In C.R. Figley (Ed.), Trauma and its wake: The study and treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel. Revised from Encyclopedia of Psychology, R. Corsini, Ed. (New York: Wiley, 1984, 1994)
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, (3rd ed.). Washington, DC: Author.
De Jong, J., Komproe, T.V.M., Ivan, H., von Ommeren, M., El Masri, M., Araya, M., Khaled, N.,van de Put, W., & Somasundarem, D.J. (2001). Lifetime events and Posttraumatic Stress Disorder in 4 postconflict settings. Journal of the American Medical Association, 286, 555-562. doi: 10.1001/jama.286.5.555
Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28, 750-769. doi: 10.1002/da.20767
Hinton, D. E., & Lewis-Fernandez, R. (2011). The cross-cultural validity of Posttraumatic Stress Disorder: Implications for DSM-5. Depression and Anxiety, 28, 783-801. doi: 10.1002/da.20753
Marsella, A.J., Friedman, M.J., Gerrity, E. & Scurfield R.M. (Eds.). (1996). Ethnocultural aspects of Post-Traumatic Stress Disorders: Issues, research and applications. Washington, DC: American Psychological Association.
Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. & Walsh, W. (1992). A prospective examination of posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455-475.
Resources cont.
Orcutt, H. K., Erickson, D. J., & Wolfe, J. (2004). The course of PTSD symptoms among Gulf War veterans: A growth mixture modeling approach. Journal of Traumatic Stress,17(3), 195-202.
Nugent, N. R., Saunders, B. E., Williams, L. M., Hanson, R., Smith, D. W., & Fitzgerald, M. M. (2009). Posttraumatic stress symptom trajectories in children living in families reported for family violence. Journal of Traumatic Stress, 22(50), 460-466.
Gersons B. P. R. Patterns of posttraumatic stress disorder among police officers following shooting incidents: The two-dimensional model and some treatment implications. Journal of Traumatic Stress. 1989;2:247–257.
Shapiro F. Eye movement desensitization and reprocessing. New York: Guilford Press; 1995.
White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New Yord: W.W. Norton. ITSB 9780393700985
Raskind, M., Peskind, E., Chow, M., Harris, C., Davis-Karim, A., Holmes, H., Hart K., McFall, M., Mellman, T., Reist, C., Romesser, J., Rosenheck, r., Shih., M., Stein, M., Swift, R., Gleason, T., Lu, Y., and Huang, G.(2018). Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. New England Journal of Medicine, 378, 507-517. doi: 10.1056/NEJMoa1507598.
Byrant, R., O’Donnell, M., Creamer, M., McFarlane, A., Clark, C., and Silove, D. (2010). The Psychiatric Sequelae of Traumatic Injury. American Journal of Psychiatry, 167, 312-320.
