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Outline

• Howdopeoplerespondtonaturaldisasters?

• WhatisPTSD?

• WhattodoandwhatnottodototreatPTSDeffec>vely

How do people respond to natural disasters?

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Witness

Accident

Threat(w

eapon)

NaturalDisaster

PhysicalAJack

Combat

Abuse/N

eglect

Molesta>on

Rape

Men

Women

Kessler et al., 1995

ExposuretoTrauma>cEventsinU.S.

NormalorUnexpected?

• Akeyissueisunderstandingthoseresponsesthatarenormalversusthosethatrequireinterven>on

•  Thereareseveralbarrierstoeffec>veiden>fica>onofpeoplewhoneedinterven>onfollowingadisaster

BarrierstoEffec>veIden>fica>on

•  Inadultsandchildren,lackofknowledgeabouttypicalandatypicalreac>onshampersiden>fica>on

•  Foradults,public,self,orstructurals>gmasurroundingaboutmentalhealthcanleadtolyingaboutsymptoms

• Mayalsoleadtopeoplenotevenknowingthatwhattheyareexperiencingisindica>veofproblems

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BarrierstoEffec>veIden>fica>on

• Astrongresponsetoadisasterortraumaisnormalandexpected

• Upto90%ofchildrenandadultsshowpsychologicalreac>onsimmediatelya_eradisaster,20-50%showreac>onsuptoayearlater

• Majorityofthesewillnotneedservicesotherthancareandsupportfromfamily,friends,andschool/work

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ack

Threat

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Disaster

Accident

SexualAssua

lt

Comb

atRap

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Men

Women

PTSD as a Func>on of Type of Trauma

Kessleretal.,1995,1999

BarriersinChildren

•  Therearetwomythsaboutchildrenwhohaveexperienceddisasters:

1.  Childrenareinnatelyresilientandwillquicklyrecover,evenfromextremetrauma

2.  Childrenarenotdisturbedbydisastersunlesstheirparentshavestrongresponses

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BarriersinChildren

•  Teachersandparentsmaymisinterpretproblema>cbehaviorasjustbeingwillful

• Adultsmaynotwishtoberemindedoftheirownreac>ons,andthusignoreorminimizeachild’sreac>on

• Mostchildrenrespondappropriatelytoadisaster,whichleadssometothinkthatallthechildrenaredoingso

HowWeReact

•  Threephasesofaperson’sreac>ontoadisaster:

1.  Duringthedisaster2.  Immediatelyfollowingthedisaster3.  Long-termreac>onstothedisaster

•  Certaintypesofreac>onsarenormalduringeachphase

DuringtheDisaster

• Whenconfrontedwithatrauma,weallhavethe“fightorflight”responseduetoautonomicnervoussystemac>va>on:

• Musclestense,heartpounds• Nervesareonhighalert•  Intenseanxietyorfear•  Shock,senseofunreality,notunderstandingwhatishappening

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ImmediatelyFollowing

•  Intheweeksa_eratrauma,upto90%ofpeoplemayexperience:

• Heightenedphysiologicalarousal• Diffuseanxiety•  Survivorguilt•  Emo>onallability

•  Theseareallnormalreac>onsandshouldbemetwithunderstandingandsupport

Long-Term

• By1-2yearspost-disaster,themajorityofpeoplewillshowfewproblema>csymptoms

• A>metowatchoutfor,however,istheanniversaryofthedisaster

•  Thoses>lldisplayingthefollowingdifficul>es3-4monthsa_erthedisastermayneedfurtherassessment

SymptomsofConcern

•  Inchildrenbelowage6,thesemayindicateproblema>cadjustmenttothedisaster

Ø Generalizedanxietyaboutsepara>on,strangers,orsleepproblems

Ø Avoidanceofcertainsitua>onsØ Preoccupa>onwithcertainsymbols/wordsØ Limitedemo>onalexpressionorplayac>vi>esØ Lossofpreviouslyacquiredskills

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SymptomsofConcern•  Forolderchildren,warningsignsofproblema>cadjustmentare

Ø Repe>>ousplayreenac>ngapartofthedisasterØ Preoccupa>onwithdangerorexpressedconcernsaboutsafety

Ø SleepdisturbancesandirritabilityØ AngeroutburstsoraggressivenessØ ExcessiveworryaboutfamilyorfriendsØ Schoolavoidance,par>cularlyinvolvingsoma>ccomplaintsØ Behaviorscharacteris>cofyoungerchildrenØ Changesinpersonality,withdrawal,andlossofinterestinac>vi>es

SymptomsofConcern

•  Inadults,watchoutforthefollowing:

Ø IncreaseinsubstanceuseØ AvoidanceofsupportnetworksØ Droppingoutofac>vi>esØ TroubleaccomplishingtasksatworkØ Increaseinconflictwithspouse/family

•  Oneormoreofthesemaybeindica>veofamaladap>veresponsetothedisaster–ofbeingavic>mratherthanasurvivor

Vic>mstoSurvivors

• Vic>msarethosewhofeeltheyhavenocontrolovertheircurrentsitua>on

•  Survivorsarethosewhohaveregainedasenseofcontrolandareabletomeetthedemandsofwhateverdifficultyconfrontsthem

• Vic>msarepassiveanddependentonothers,survivorsareac>veandinvolved

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What is PTSD?

TraumaandStressRelatedDisorders• Aninappropriatelysevereresponsetoatraumaacrossalongperiodof>me,resul>nginfunc>onalimpairment,canappearinmanyways

• Reac>veAJachmentDisorder• DisinhibitedSocialEngagementDisorder• PosJrauma>cStressDisorder• AcuteStressDisorder• AdjustmentDisorders

Major changes from DSM-IV to -5

• Pos0rauma2cStressDisorder•  Morespecificabouthoweventwasexperienced•  Subjec>vereac>oneliminated•  Fourmajorsymptomclustersratherthanthree•  Developmentallysensi>veforkidsages6oryounger

• Reac2veA0achmentDisordernowdividedintotwodis>nctdiagnoses•  Emo>onallywithdrawn/inhibited(RAD)•  Indiscriminatelysocial/disinhibited(DisinhibitedSocialEngagementDisorder)

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Common Features across TSRDs

•  IntrusiveMemories

• Avoidance

• Nega>vechangesinthinkingandmood

• Changesinemo>onalreac>ons

PTSDintheDSM-5CriterionA:ExposureThepersonwasexposedto:death,threateneddeath,actualorthreatenedseriousinjury,oractualorthreatenedsexualviolence,asfollows:

1.  Directexposure2.  Witnessing,inperson3.  Indirectly,bylearningthatacloserela>veorclosefriend

wasexposedtotrauma.Iftheeventinvolvedactualorthreateneddeath,itmusthavebeenviolentoraccidental.

4.  Repeatedorextremeindirectexposuretoaversivedetailsoftheevent(s),usuallyinthecourseofprofessionaldu>es(e.g.,firstresponders,collec>ngbodyparts;professionalsrepeatedlyexposedtodetailsofchildabuse)•  Thisdoesnotincludeindirectnon-professionalexposurethroughelectronicmedia,television,moviesorpictures

PTSDintheDSM-5CriterionB:Intrusionsymptoms(atleast1)

•  Spontaneousorcuedrecurrent,involuntary,andintrusivedistressingmemoriesoftheevent(s).

•  Recurrentdistressingdreamsinwhichthecontentand/oraffectofthedreamisrelatedtotheevent(s).

•  Dissocia>vereac>ons(e.g.,flashbacks)inwhichtheindividualfeelsoractsasiftheevent(s)wererecurring

•  Intenseorprolongedpsychologicaldistressatexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectoftheevent(s)

•  Markedphysiologicalreac>onstoremindersoftheevent(s)

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PTSDintheDSM-5

CriterionC:Persistentavoidanceofs>muliassociatedwiththetrauma(atleast1)

• Avoidsinternalreminders(thoughts,feelings,orphysicalsensa>ons)thatarouserecollec>onsofthetrauma>cevent(s)• Avoidsexternalreminders(people,places,conversa>ons,ac>vi>es,objects,situa>ons)thatarouserecollec>onsofthetrauma>cevent(s).

PTSDintheDSM-5CriterionD:Nega>vealtera>onsincogni>onsandmoodthatareassociatedwiththetrauma>cevent(3ormore)•  Inabilitytorememberanimportantaspectofthetrauma>cevent(s)

•  Persistentandexaggeratednega>veexpecta>onsaboutone’sself,others,orthe

•  Persistentdistortedblameofselforothersaboutthecauseorconsequencesofthetrauma>cevent(s)

•  Pervasivenega>veemo>onalstate•  Markedlydiminishedinterestorpar>cipa>oninsignificantac>vi>es

•  Feelingofdetachmentorestrangementfromothers•  Persistentinabilitytoexperienceposi>veemo>ons

PTSDintheDSM-5

CriterionE.Altera>onsinarousalandreac>vitythatareassociatedwiththetrauma>cevent(3ormore)•  Irritableoraggressivebehavior• Recklessorself-destruc>vebehavior• Hypervigilance•  Exaggeratedstartleresponse• Problemswithconcentra>on•  Sleepdisturbance

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PTSDintheDSM-5

F.  Persistenceofsymptoms(inCriteriaB,C,DandE)formorethanonemonth

G.  Thesymptomscauseclinicallysignificantdistressorimpairmentinsocial,occupa>onal,orotherimportantareasoffunc>oning

H.  Notduetomedica>on,substanceorillness

DSM-5PTSD,PreschoolSubtype

•  Rela>vetobroaderdiagnosisforthoseover6years,severalchanges

•  CriterionsAandB–nochange

•  CriterionsCandD–onlyneed1symptomfromeitherone•  Ccluster–nochange•  Dcluster–4insteadof7symptoms

•  Doesnotincludeamnesia,foreshortenedfuture,persistentblameofselforothers

•  CriterionE–only2symptomsneeded•  Preschooldoesnotincludesymptomof“recklessbehavior”

PreschoolPTSDintheDSM-5CriterionA:ExposureThepersonwasexposedto:death,threateneddeath,actualorthreatenedseriousinjury,oractualorthreatenedsexualviolence,asfollows:

1.  Directexposure2.  Witnessing,inperson3.  Indirectly,bylearningthatacloserela>veorclosefriend

wasexposedtotrauma.Iftheeventinvolvedactualorthreateneddeath,itmusthavebeenviolentoraccidental.

4.  Repeatedorextremeindirectexposuretoaversivedetailsoftheevent(s),usuallyinthecourseofprofessionaldu>es(e.g.,firstresponders,collec>ngbodyparts;professionalsrepeatedlyexposedtodetailsofchildabuse)•  Thisdoesnotincludeindirectnon-professionalexposurethroughelectronicmedia,television,moviesorpictures

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PreschoolPTSDintheDSM-5CriterionB:Intrusionsymptoms(atleast1)

•  Spontaneousorcuedrecurrent,involuntary,andintrusivedistressingmemoriesoftheevent(s).

•  Recurrentdistressingdreamsinwhichthecontentand/oraffectofthedreamisrelatedtotheevent(s).

•  Dissocia>vereac>ons(e.g.,flashbacks)inwhichtheindividualfeelsoractsasiftheevent(s)wererecurring

•  Intenseorprolongedpsychologicaldistressatexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectoftheevent(s)

•  Markedphysiologicalreac>onstoremindersoftheevent(s)

PreschoolPTSDintheDSM-5

CriterionC:Persistentavoidanceofs>muliassociatedwiththetraumaorchangesincogni>onsandmood(atleast1)

• Avoidsinternalreminders(thoughts,feelings,orphysicalsensa>ons)thatarouserecollec>onsofthetrauma>cevent(s)• Avoidsexternalreminders(people,places,conversa>ons,ac>vi>es,objects,situa>ons)thatarouserecollec>onsofthetrauma>cevent(s).

PreschoolPTSDintheDSM-5

•  Substan>allyincreasedfrequencyofnega>veemo>onalstates(e.g.,fear,guilt,sadness,shame,confusion)• Markedlydiminishedinterestedorpar>cipa>oninsignificantac>vi>es,includingconstric>onofplay•  Sociallywithdrawnbehavior• Persistentreduc>oninexpressionofposi>veemo>ons

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PreschoolPTSDintheDSM-5

CriterionD.Altera>onsinarousalandreac>vitythatareassociatedwiththetrauma>cevent(2ormore)•  Irritableoraggressivebehavior•  Hypervigilance•  Exaggeratedstartleresponse• Problemswithconcentra>on•  Sleepdisturbance

PreschoolPTSDintheDSM-5

E.  Persistenceofsymptoms(inCriteriaB,C,DandE)formorethanonemonth

F.  Thesymptomscauseclinicallysignificantdistressorimpairmentinsocial,occupa>onal,orotherimportantareasoffunc>oning

G.  Notduetomedica>on,substanceorillness

PTSDSpecifiers

• Withdissocia>vesymptoms•  Theindividual’ssymptomsmeetthecriteriaforPTSDandtheindividualexperiencespersistentorrecurrentsymptomsofeitherofthefollowing:

1.  Depersonaliza>on•  Persistentorrecurrentexperiencesoffeelingdetachedfrom,andasifonewereanoutsideobserverof,one’smentalprocessesorbody

•  Feelingasthoughonewereinadream,feelingasenseofunrealityofselforbodyorof>meslowlymoving

2.  Derealiza>on:Persistentorrecurrentexperiencesofunrealityofsurroundings•  Theworldaroundtheindividualisexperiencedasunreal,dreamlike,distant,ordisordered

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PTSDSpecifiers

• Withdelayedexpression•  Ifthefulldiagnos>ccriteriaisnotmetun>latleast6monthsa_ertheevent.

PTSDPrevalence

•  61%ofmenand51%ofwomenexperienceatraumaintheirlife>me

• Morethan25%experiencemul>pletraumas

•  Life>merate6.8%,currentrate3.6%

Kessler et al., (1995, 2005)

MostVulnerablePopula>ons

•  Thosewhoseexperiencewasespeciallyterrifyingorextreme

• Childrenbetween5-10yearsofage,especiallyifseparatedfromparents

•  Thosewithoutstrongsocialsupportnetworks

•  Thosewithapriorhistoryofanytypeoftrauma>cexperience

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PTSDisHigherinPopula>onswithMoreTrauma

DeJongetal.,2001

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35.00%

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Algeria

Cambodia

Ethiopia

Gaza

US

Life>mePTSDinfourpost-conflictseqngsandUS

PTSDRiskFactors

• Pretrauma>cevent:•  Femalegender•  Somegene>cfactors•  Childhoodtrauma•  Previouspsychiatricproblems•  Lowerlevelofeduca>on•  Lowersocioeconomicstatus•  Minorityrace

PTSDRiskFactors

• Pretrauma>cevent:•  Femalegender•  Somegene>cfactors•  Childhoodtrauma•  Previouspsychiatricproblems•  Lowerlevelofeduca>on•  Lowersocioeconomicstatus•  Minorityrace

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PTSDRiskFactors

• Peritrauma>cevent:•  Greaterperceivedthreatordanger,andhelplessnessincreasesrisk•  Unpredictabilityanduncontrollabilityoftrauma>ceventalsoincreasesrisk

• PosJrauma>cevent:•  Lackofsocialsupport,lifestress,aJribu>ons

GenderDifferences

• Muchhigherratesinfemalesincivilianpopula>ons

•  Equalratesseeninmilitarypopula>ons,althoughsomecontroversyoverthis

OklahomaandTornadoes

•  Oklahomaaverages54tornadoesyear,morepersquaremilethananywhereelseonEarth

•  ResearchhasshownveryhighlevelsofPTSDinOKchildren•  66%ofnon-exposedchildrenhadmoderateorhighlevelsofPTSSduringtornadoseason(Romero,1997)

•  41%metPTSDcriteriaoneyearlater(Evans&Oehler-S>nneJ,2006)

•  52%ofexposedchildrenhadmoderateorhigherlevelsofPTSSat18monthspost-tornado(Lack,2003)

•  HigherthaninothertornadosurvivorsoutsideofOklahoma(Lacketal.,2010)

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WhySuchHighRatesinOK?

• Re-exposuretoenvironmentalcues

•  Exposuretotrauma-relatedmedia

• Modelingoftrauma-responsebyadults

UniquelyOklahoman

•  Luckily,thedistressseemstobehighlyspecific,withnoevidenceofgeneralizeddistressorfunc>onalimpairmentsformostchildrenexposedtotornadoeswhohavePTSS(Lack,2003;Lack,2006)

•  Sucharesponsemaybemore“phobic”thanPTSDformanyOklahomans,giventhesefactors

ImpactofPTSD

•  Elevatedriskofmood,otheranxiety,andsubstanceabusedisorders

• Greaterfunc>onalimpairment

• Reducedqualityoflife

•  Elevatedriskofpoorphysicalhealth

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What to do and what not to do to treat PTSD

EBT for PTSD

•  Thereisahugeandverystrongevidencebasefortheuseofcogni>ve-behavioraltherapiestotreatPTSD•  Prolongedexposuretherapy•  Cogni>veprocessingtherapy•  Trauma-focusedCBT

• But,therearemanyproponentsofpseudoscien>fic,non-EBTtreatmentsaswell

CBT for PTSD

•  ThevariousformsofCBTaremuchmoreeffec>vethanmedica>onsinreducingPTSDsymptoms

• Medica>on,however,ismorereadilyavailableandcanusefulfortrea>ngcomorbidproblemsorloweringsymptomsenoughtobeabletoengageindoingCBT

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Meta-Analysis of PTSD Treatments

Van Etten & Taylor, 1998

Pharmacology for PTSD

•  SSRIsarethemostwellstudiedandmosto_enprescribed

•  Theyoutperformplacebossignificantly,inbothcivilianandmilitarypopula>ons

• Venlafaxine(Effexor)slightlyoutperformsSSRIsinbothpopula>ons

CBT for PTSD

• Prolongedexposure(PE),cogni>veprocessingtherapy(CPT),andtrauma-focusedCBT(TF-CBT)areconsistentlyshowntobeeffec>vetreatmentsforPTSD

• Generalcomponentssharedare•  Psycho-educa>on•  Anxietymanagement•  Exposure•  Cogni>verestructuring

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Prolonged Exposure (PE) 1.  Psycho-education: Patient learns about trauma

and PTSD

2.  Breathing skills: Learns to manage anxiety

3.  In vivo exposure: Confronts feared stimuli in real life

4.  Imaginal exposure: Involves mental exposure to trauma by repeated telling of memories

Cogni>ve Processing Therapy (CPT)

1.  Educa>onaboutPTSD,thoughtsandemo>ons

2.  Processingtrauma(withorwithoutaccount)

3.  Challengingthoughts

4.  Cogni>verestructuring

TF-CBT

•  Developedspecificallyforchildrenandadolescents

1.  Psychoeduca>on2.  Relaxa>onandstressmanagement3.  Affectexpressionandmodula>on4.  Cogni>vecoping5.  Traumanarra>on6.  Cogni>veprocessing7.  BehaviorManagementTraining8.  Parent-childsessions

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PEorCPTforAdults?

• Not a lot is known about treatment matching

• Most important is to use evidence-based therapy •  Dropout rates are similar •  Therapist comfort •  Patient preference

Pseudoscien>ficPTSDTherapies

• Cri>calincidentstressmanagement(CISM)

•  Eyemovementdesensi>za>onandretraining(EMDR)

•  Emo>onalfreedomtechnique(EFT)andthoughtfieldtherapy(TFT)

Conclusions

•  Experiencingtraumaisverycommon,butmostpeoplewillcomethroughwithoutmentalhealthproblems

•  Beonthelookoutforwarningsignsthatcanpredictlong-termdifficul>esadjus>ng

•  KnowhowPTSDpresentsdifferentlyinchildrenandadults

•  Useeffec>ve,evidence-basedtreatmentstohelpthosestruggling