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Transcript of Understanding and Treating Posttraumatic Stress Disorder in Veterans Patrick L. Kerr, Ph.D. West...
![Page 1: Understanding and Treating Posttraumatic Stress Disorder in Veterans Patrick L. Kerr, Ph.D. West Virginia University School of Medicine September 11, 2015.](https://reader035.fdocuments.net/reader035/viewer/2022070413/5697bfd61a28abf838cade4d/html5/thumbnails/1.jpg)
Understanding and Treating Posttraumatic Stress Disorder
in Veterans
Patrick L. Kerr, Ph.D.West Virginia University School of Medicine
September 11, 2015
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About the Presenter
Licensed Clinical Psychologist
Associate Professor and at West Virginia University School of Medicine-Charleston Division
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Conflicts of Interest Statement
I have no financial conflicts of interest associated with this presentation, or any material presented.
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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
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My Informal AgendaInstill hope that veterans with PTSD can recover
Empower you with critical knowledge to assist veterans with PTSD
Inspire you to
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The Diagnosis of Posttraumatic Stress Disorder
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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
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Why focus on veterans and service members?
The concept of PTSD started with the military.
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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)
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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.
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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
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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)
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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%
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11-
20%
PTSD in OIF/OEF Veterans
PTSD
15%
PTSD in Vietnam Vet-erans
12%
PTSD in Gulf War Veterans
PTSD by the Numbers
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Universal Responses to Danger
Fight Flight Freeze
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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
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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)
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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
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How do we help veterans with PTSD?
First, we must understand it!
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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
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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)
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The Evidence in the Evidence Base: Prolonged Exposure Therapy
Outcomes Research
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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
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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)
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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)
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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)
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Prolonged Exposure from30,000 feet
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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…”
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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
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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?
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Prolonged Exposure Therapy: Session 1• Psychoeducation about PTSD
• Orientation to treatment
• Teach patient relaxation skills, including muscle relaxation and diaphragmatic breathing
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• 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
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• 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
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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
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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
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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
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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
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Prolonged Exposure:Session 3 and Beyond
• Homework– Listen to session recording daily– Complete at least one step from hierarchy
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Treating PTSD inthe Brave New World of mHealth:
Adjunctive Smartphone Applications
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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)
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The Brave New World of mHealth:PTSD Coach
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Prolonged Exposure:The Brave New World of mHealth
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Risks for Clinicians Treating Traumatized Patients
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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)
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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)
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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
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Presentation can be downloaded at the following web address:http://medicine.hsc.wvu.edu/media/21325/kerrcamctraumasymp2015-holder.pptx