Understanding and Treating Posttraumatic Stress Disorder
in Veterans
Patrick L. Kerr, Ph.D.West Virginia University School of Medicine
September 11, 2015
About the Presenter
Licensed Clinical Psychologist
Associate Professor and at West Virginia University School of Medicine-Charleston Division
Conflicts of Interest Statement
I have no financial conflicts of interest associated with this presentation, or any material presented.
Learning Objectives
1. Communicate and describe research on the diagnosis, risk factors for, and treatment of PTSD in veterans
2. Describe an evidence-based treatment (Prolonged Exposure Therapy) for PTSD in veterans
3. Describe ethical considerations in treating PTSD
My Informal AgendaInstill hope that veterans with PTSD can recover
Empower you with critical knowledge to assist veterans with PTSD
Inspire you to
The Diagnosis of Posttraumatic Stress Disorder
Why focus on veterans and service members?Active duty and veteran
service members are at high risk for multiple
forms of trauma…Combat
MVANatural Disasters
Sexual assault
Why focus on veterans and service members?
The concept of PTSD started with the military.
History of the PTSD Diagnosis:Terminology
• Recording of symptoms in response to intense duress dates back to at least the US Civil War
• “War Neurosis”
• “Shell Shock”
• “Battle Fatigue”
• Posttraumatic Stress Disorder1
Source: 1. American Psychiatric Association (1980)
Trauma vs. Traumatic Stress• Trauma through a psychological lens– An intense experience that induces stress
• Traumatic Stress– Traumatic stress is a common adaptive response
to intense, overwhelming experiences. – Not all traumatic stress becomes posttraumatic
stress disorder.
Posttraumatic Stress Disorder
Criterion B:Intrusion symptoms
Traumatic event is re-experienced via
involuntary/intrusive memories, nightmares, dissociation, prolonged
distress
Criterion D: Negative
alterations in
cognitions and mood
Criterion E: Trauma-related
alterations in arousal and
reactivity
Criterion F: Duration of symptoms for more than one
month
Criterion G: Significant symptom-
related distress or functional
impairment
Criterion H: Symptoms are
not due to medication, or other illness.
Criterion C: Avoidance
Persistent avoidance of distressing trauma-related stimuli after
the event via maladaptive behaviors
Criterion A: Traumatic Stressor
Person was exposed to death, threatened
death, actual or threatened serious injury, or violence
When diagnosing PTSD, think TRAUMATraumatic experience: intense, life-threatening, or
terrifying/horrifying experienceRe-experiencing: flashbacks, nightmares, intrusive
thoughts/memoriesAvoidance: emotional numbing, substance abuse,
isolationUnable to function: symptoms cause significant distress
and impairment in psychosocial functioningMonth: symptoms last one month or moreArousal: increased autonomic reactivity and
physiological hyperarousal
Source: Khouzam (2001)
7-8%
PTSD in the General Population
PTSD
4-5%PTSD in Men
PTSD by the Numbers
10%
PTSD in Women
Boys: 3-4%
Girls: 6-7%
11-
20%
PTSD in OIF/OEF Veterans
PTSD
15%
PTSD in Vietnam Vet-erans
12%
PTSD in Gulf War Veterans
PTSD by the Numbers
Universal Responses to Danger
Fight Flight Freeze
Neurobiology of Fear
Neocortex: Responsible for high level cognitive functioning
Limbic System (amygdala and hippocampus): Responsible for processing emotions and memory
Reptilian Complex (Cerebellum and Brain Stem): regulates vital physiological functions, e.g., breathing, heart rate
PTSD Complications:Suicide Risk
• PTSD independently increases risk for suicide attempts and suicidal ideations1
–Mediated by comorbid psychiatric disorders• 80-90% of people with PTSD also have 1 or more
comorbid psychiatric disorders2
• OIF/OEF Veterans with PTSD are 4 times more likely to report suicidal ideations than non-PTSD service members3
Source: 1. Krysinska & Leser (2010); 2. O’Donnell et al. (2004); 3. Jackupak et al. (2009)
2015 Meta-Analysis of PTSD Risk Factors in Military Service Members and Veterans
Source: Xue, Ge, Tang, Liu, Kang, Wang, & Zhang (2015)
Non-Office
r
Army (
vs others)
Combat exp
osure
Discharged w
eapon
Seeing so
meone wounded or k
illed
Deployment r
elated stresso
r
Seve
re trauma
Comorbid psychologica
l problems
0
1
2
3
4
5
2.18 2.3 2.1
4.3
3.122.69 2.91 2.83
Odd
s Ra
tios
K= 32 Studies
How do we help veterans with PTSD?
First, we must understand it!
Emotional Processing Theory
Adapted from Foa & Rothbaum (1998)
TRAUMA
Fear
Return to physiological homeostasis
Adaptive integration of
trauma
Continued physiological hyperarousal
Return to functioning
Pathological fear associations
Avoidance-based coping- ETOH,
Isolation
Progressive dysfunction
Risk FactorsNeurobiological
PsychiatricSocial
Me=> HelplessExplosion=> Danger Vehicle=> Explosion
Vehicle=> DangerDriving=> Danger
Adaptive fear associations
Explosion=> DangerAssailant=> Explosion
Assailant=>DangerNegative
Reinforcement- Stress decreases
Acute stress responses:cognitive, emotional,
physiological
Emotional Processing Theory
The Basics of Emotional Processing Theory• Traumatic stress is related to fear responses.
• Fear can be either normative or pathological.
• Normative fear facilitates survival and leads to recovery post-trauma.
• Pathological fear leads to interference and degradation of functioning. Sources: Linehan (1993); Koerner & Dimeff (2007)
The Evidence in the Evidence Base: Prolonged Exposure Therapy
Outcomes Research
Prolonged Exposure Outcomes Research:Meta-Analyses
• Sherman (1998)– K=12 studies– PE > Supportive Counseling– PE = EMDR
• Benish et al.(2007)– K=15 studies– PE > Inactive Control (waitlist or placebo)– PE > Supportive Counseling– PE = EMDR, Stress Inoculation Training
• Powers et al (2010)– K=13 studies– PE > Inactive Control (waitlist or placebo) (ES=1.08)– PE = “active control” treatments, including Cognitive Processing Therapy,
EMDR, Stress Inoculation Training
Prolonged Exposure Outcomes Research:Longitudinal Data
• Long-term functioning (5-10 years): PE leads to sustained adjustment in psychosocial functioning- interpersonal, occupational, economic1
–PE = CPT at follow-up
Sources: 1. Wachen et al (2014)
Prolonged Exposure Outcomes Research
Cost of Mental Health Care Service for Veterans who receive evidence-based treatment for PTSD
34%
Source: Meyers et al. (2013)
Cautions for Prolonged Exposure• For Whom is Prolonged Exposure Inappropriate– Current psychosis– Imminent suicide risk– Imminent homicide risk– Non-suicidal self-injury– Current high risk of being traumatized– Insufficient memory of traumatic event
Source: Foa & Rothbaum (2007)
Prolonged Exposure from30,000 feet
Requirements for Prolonged Exposure• The person must have a cohesive trauma narrative
(or narratives), with a beginning, middle and end.– Video vs. Polaroid
• The person must have a clear memory of the trauma that permits a verbal description.– No exploration of, searching for, etc.– NO DEEP SEA DIVING EXPEDITIONS!– No “vague sense of…”, “some idea about…”, “was told
that…”
Prolonged Exposure:Pre-Treatment Assessment
• Pre-treatment assessment of appropriateness for prolonged exposure
• Assessment of PTSD symptoms– Structured interviews- e.g., ADIS IV, SCID– Self-report instruments- e.g., PCL-C
Prolonged Exposure:Pre-Treatment Assessment
• Assessment of traumatic event(s)– Obtain a thorough description within patient’s limits– Collect information on medical, social, and functional
consequences of the trauma
• Functional analysis– Conduct a functional analysis of avoidance and other trauma-
related behaviors • Identify antecedents/contexts for symptomatic behaviors• Identify consequences reinforcing symptomatic behaviors
– Collect data on history of symptoms- Have they gotten progressively worse? Do they seem to relapse and remit? Have they ever been less/more severe than they are right now?
Prolonged Exposure Therapy: Session 1• Psychoeducation about PTSD
• Orientation to treatment
• Teach patient relaxation skills, including muscle relaxation and diaphragmatic breathing
• Homework– Practice breathing control techniques for 10 minutes, 2-
3x/day– Read psychoeducational materials– If recorded, listen to recording of session
Prolonged Exposure Therapy: Session 1
• Review Common Reactions to Trauma– Provide psychoeducation about the physical, emotional,
and cognitive effects of traumatic experience
• Introduce In Vivo (real life) Exposure– Present rationale for in vivo exposure– Discuss procedures for in vivo exposure– Create a hierarchy of avoided situations to be used
during exposure– Introduce Subjective Units of Distress Scale (SUDS)
Prolonged Exposure Therapy: Session 2
Prolonged Exposure:Session 2
• Homework– Practice breathing control techniques for 10 minutes, 2-
3x/day– Read psychoeducational materials about common
responses to trauma – If recorded, listen to
recording of session– Complete at least one step
in hierarchy
Prolonged Exposure:Session 3 and Beyond
• Check-in: Review exposure homework (10-15 minutes); review self-monitoring form; problem-solve obstacles
• Agenda-setting: Review exposure plan for the session
• Recording: ensure that recording device/equipment is working, ready to be used
• Introduce and conduct imaginal exposure
Prolonged Exposure:Session 3 and Beyond
• Imaginal Exposure: Guide/coach patient through agreed upon, planned trauma narrative (45-60 minutes)– First person– Present tense– Eyes closed
• Monitor SUDS q5-10 min• Gentle prompts and
encouragement to continue the narrativeshould be given as needed
Prolonged Exposure:Session 3 and Beyond
• Exposure sessions: Post-exposure processing (15-20 minutes)– Patients are asked to describe their responses to the
narrative
– Patients are asked to describe any new insights or perspectives that occur to them during the narrative
Prolonged Exposure:Session 3 and Beyond
• Homework– Listen to session recording daily– Complete at least one step from hierarchy
Treating PTSD inthe Brave New World of mHealth:
Adjunctive Smartphone Applications
Do we really need an app for that(i.e. Why use mHealth devices/applications for PTSD treatment?)
Enhanced Access
Enhanced Support during Treatment
Service Members and Veterans are interested in them62-76% report an interest in using smartphone apps that can help with mastering and remembering skills learned
in prolonged exposure therapy (Erbes et al., 2014)
The Brave New World of mHealth:PTSD Coach
Prolonged Exposure:The Brave New World of mHealth
Risks for Clinicians Treating Traumatized Patients
It comes with the territory…
• Vicarious Traumatization: repeated exposure to the trauma of others can lead to: – Secondary traumatic stress– Changes in how you see yourself, the world, and
others– Burnout- with career/profession, life– Mood changes- especially depression– Anxiety disorders
Sources: McCann & Pearlman (1990); Pearlman & Saakvitne (1995)
None of us are immune, but we can be resilient!
• Protective Factors for Vicarious Traumatization– Perceived coping ability
– Supervision and consultation with colleagues who work in the field of trauma treatment
– Effective self-care• Adequate sleep• Adequate nutrition• Adequate exercise• Avoid drugs and alcohol as coping strategiesSources: Baird & Kracen (2006)
Summary• PTSD is a complex clinical phenomenon.
• Prolonged Exposure is an evidence-based treatment for PTSD.
• Working with veterans is both challenging and rewarding.
• Effective self-care prevents burnout and optimizes treatment outcomes for patients
Presentation can be downloaded at the following web address:http://medicine.hsc.wvu.edu/media/21325/kerrcamctraumasymp2015-holder.pptx
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