War Related Traumatic Reactions in Veterans and Their ... Related...1947), “combat exhaustion”...

War Related Traumatic Reactions in Veterans and Their Impact on Families

Irit Felsen, PhD [email protected]

http://www.iritfelsen.com

PRESENTATION AT LEADINGAGE NY DNS/DSW ANNUAL CONFERENCE.

November 20, 2014

mailto:[email protected]://www.iritfelsen.com/

Before 1980: Not A New Concept

• There is literature documenting psychiatric aspects of military service during WWI (For an extensive bibliography see Brown and Williams, 1918, 1976).

• Investigators who studied psychiatric casualties in WWII combat veterans labeled the

constellation of symptoms they saw as “traumatic war neurosis” (Kardiner & Spiegel, 1947), “combat exhaustion” (Swank, 1949), and “operational fatigue” (Grinker et al., 1946, I., II.).

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The Symptoms of the Condition • Regardless of labels, these investigators described

a condition much like what we now recognize as PTSD.

• For example, Kardiner and Spiegel described a chronic syndrome that included preoccupation with the traumatic stressor, nightmares, irritability,

• Increased startle responsiveness, a tendency to angry outbursts, and general impairment of functioning.

(PTSD and Combat-related Psychiatric Symptoms in Older Veterans, Schnurr, P., PTSD Research Quarterly, 1991, winter, vol 2(1).)


After 1980 : Formal Diagnosis PTSD

• After the formalization of PTSD as a diagnosis, isolated case studies began calling attention to the fact that some veterans of wars prior to Vietnam had PTSD (Van Dyke et al.,1985).

• Research activity on older combat veterans over the past decades rendered PTSD estimates that are tragically high.

• Particularly high rates of PTSD observed among POW’s (Rosen et al., 1989; see PTSD Research Quarterly, 1(1)).


Long-term Impact of Trauma

• A theme of chronicity began to emerge from follow-up of WWII veterans and Korean conflict veterans (Archibald & Tuddenham, 1965)

• Lifetime and current prevalence of PTSD in WWII veterans of the Dutch Resistance found to be 84% and 56%, respectively (Op den Velde and colleagues, see PTSD Research Quarterly, 1(3).)

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The Veteran’s Trauma Affects Others • Whether chronicity is the true course of the

disorder or only the consequence of a failure to recognize and treat the disorder is a question for longitudinal studies over the next decades.

• Adult’s exposure puts their children and other

non-exposed adults at risk for psychopathology.

• PTS and PTSD in both spouses compromises the family well being and children’s well being.

• High risk of psychopathology observed in children of exposed parents independently of the child’s own exposure


What Are Post-Trauma Stress Reactions

• Lifetime exposure to trauma is high: 60-90% (Breslau et al., 1998; Kessler et al, 1995).

• Research evidence showing that shocking events cause serious damage to physical and mental health in a large minority of those exposed (Norris, 2002; 2009 ).

• In the general population in the USA: 8% lifetime prevalence of PTSD (Breslau, 2009). Much higher rates observed in populations exposed to mass violence.

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Other Post-trauma reactions • PTSD is the most commonly studied reaction but

other psychiatric D/O’s (anxiety and depression) are frequently associated with exposure to a traumatic, are often co-morbid with PTSD (Hoven et al., 2009), or can appear alone.

• The symptoms of the disorder are not unique to PTSD or unusual, but their relationship to a specific event (index trauma) is the defining feature.

• Non-psychiatric medical and other aspects of problems in daily living are also common.

(Neria 2008).


PTSD Criteria in DSM- V 2013 • A- Exposure, direct, witnessing, secondary.

• B-Intrusive phenomena (2): thoughts, nightmares, dissociative reactions, distress and physiological reactions to triggers.

• C-Avoidance (1): of thoughts, feelings, external stimuli.

• D- Negative Alterations in Cognitions and Mood: amnesia, negative beliefs, alienation detachment from others, constricted affect

• E-Alteration in Arousal(2) : Irritability, self-destructive behavior, hypervigilance, startle, sleep disturbance, problems concentrating.


PTSD in DSM-V and ICD The inclusion in the DSM-V of enduring

personality changes following exposure to massive trauma as in ICD attempts to:

• Include those alterations that go beyond the symptoms of the disorder defined by previous DSM classification.

• Address features of PTSD following massive and prolonged trauma as opposed to PTSD following single traumatic events.

• Relevant also in sub-clinical presentations.


Individual Variability • Great individual variability in the response to

trauma; estimates vary between 10-40% in the first year after exposure to a disaster (Neria et al., 2008).

• Most people adapt effectively within 3 months, others are at risk (Blanchard et al, 1996).

• 1/3 of those who develop PTSD recover spontaneously, 1/3 show lasting post-traumatic effects (Kessler et al, 1995)


Rates of Diagnosis of PTSD

• Recognition of PTSD is low, as few as 4% of individuals with the disorder who present in academic and Mental Health community settings are recognized.

• In an Israeli sample, 9% of primary care patients in a national cohort met criteria but only 2% were recognized by their treating physician

• More than 70% of respondents with PTSD in the general population have used general medical services in the past 6 months and were not recognized (Davidson, 2001).


• Rates and severity of PTSD are much higher in victims of political and interpersonal violence than in disaster studies, despite being conducted some years after exposure to the violence.

• Human-perpetrated violence has the added distinctly different aspect of malevolent intent, shattering beliefs about the self and the world.


Malignant Trauma (LaMothe, 1999)

PTSD Rates in USA War Veterans

• 9%-15% of Vietnam Veterans with PTSD 15 years later (NVVR, 1990)

• 12.1% Gulf War veterans suffering from PTSD

• 19%-30% Operation Enduring Freedom/Operation Iraqi Freedom veterans suffering from PTSD or depression (Gradus, 2007).

• 24% Life long rates among WWII vets, Korean War and Vietnam (Rand Report, 2010)

• Many others suffer from sub-threshold symptoms which can severely compromise functioning (Spiro, Schnurr & Aldwin, 1994; Qureshi et al, 2010; Schnurr, 2014)


Scene from “Born on the Fourth of July”

http://www.youtube.com/watch?v=ZsRDr3miUyc


http://www.youtube.com/watch?v=ZsRDr3miUyc

Recently Returning Veterans • 19.1% Prevalence of Mental Health problems

in returning veterans (Sayers et al., 2009) • Goff et al., (2007) PTS predicted lower marital

satisfaction in recent returning veterans • Over 50% domestic violence among returning

veterans (Sayaers et al., 2009; Price and Stevens, 2014 )

• 40% “feeling like a guest” and 25% report children act afraid or act not warmly towards them.

• Avoidant, withdrawn and anxious symptoms related to difficulties regaining spousal and parental roles.


Disruption to Psychosocial Adjustment

• “Disasters and mass violence may affect social adjustment, as well as psychological and physical health.” (Norris et al, 2009)

• Both actual perceived social support and social embeddedness are affected following trauma. Mass violence disrupts actual social networks as well as subjective psychological beliefs and expectations regarding control and support.

• “Normals” perceived by the returning veteran as incapable of relating to their experience (Carr, 2011).


Critical Role of Social Support

• Loss of perceived psychosocial support most consistently raised likelihood of adverse outcomes following trauma in many studies.

• Current social support predicts MDD and PTSD better than trauma exposure.

• Lack of social support related to late-onset PTSD in Veterans after initial better adjustment

(Smid et al., 2012; Holowka et al., 2012)


Secondary Traumatization

• Living with a traumatized spouse constitutes a stressor, “compassion fatigue” (Figley, 1986;1995)

• Identification and internalization trauma imagery, lead to acting and feeling like the traumatized.

• In Holocaust survivors (Lev-Wiesel and Amir, 2001), 1/3 of spouses of H-S had symptoms of PTS.

• Wives of Israeali veterans with PTSD manifested more MH symptoms ( Waysman, Mikulincer, Solomon, & Weisenberg, 1993) and wives of American veterans with PTSD report more acute distress than wives of veterans without PTSD (Nelson and Wright, 1996).


Combat Veteran’s Family-Functioning • Evidence shows that combat trauma leads to

substantial long-term impact on family functioning (Solomon et al., 2009).

• NVVR (1988) : those with higher PTS had poorer family functioning and greater domestic violence than other veterans, more than a decade after the end of the war.

• More than 70% of veterans with PTSD - clinical levels of

relationship distress vs. 30% without PTSD (Riggs et al, 1998)

• PTSD in Israeli combat veterans was related to greater somatization, depression, anxiety, loneliness, hostility and impaired marital, family and social functioning in wives (Solomon et al.,1992; 2009; Waysman et al., 1993).


Couple Intimacy –the casualty

• As there are common trauma symptoms in individuals, there may be common trauma mechanism in the couple and family systems, resulting in similar interpersonal patterns.

• PTSD positive couples report more problems with intimacy and relationship distress than PTSD negative couples (Riggs et al., 1998).

• Impaired sexual functioning and reduced intimacy might be one, as it has been reported across various traumatic experiences ( Nelson et al., 2006).


Impact on Youth in the Family (Norris, 2002)

• Spouses’ severity of symptoms affected each other’s scores; parents’ symptom scores correlated with each other’s.

• Parental psychopathology predicted adverse outcomes in children.

• Children are highly sensitive to post-disaster distress and conflict in the family. Parental irritability and supportiveness influenced degree of psychopathology in their children.


America’s Hidden Heroes: Military Caregivers (The Rand Corporation, 2014)

• A study that examined the magnitude and the needs of the population of those who care for the veterans and support their recovery and re-integration(Thanielian et al., 2014).

• Currently 5.5 million military caregivers in the US. • 20% of them, 1.1 million, are caring for a post

9/11 veteran. • Time spent caregiving can lead to job loss,

income loss, and neglect of one’s own healthcare and exert a substantial physical and emotional toll.


How Many Care Recipient Veterans are Getting Older Currently


Who Is Taking Care of the Veteran


Relationship of caregivers to veteran


Mental Health Characteristics of Post 9/11 care recipients


Post 9/11 Caregivers

• Military caregivers experience worse health outcomes, greater strains in family relationships, and more workplace problems than non caregivers

• Post 9/11 caregivers fare worse than earlier cohorts.

• Military caregivers have a high risk of depression, resulting from time spent giving care and helping prevent behavioral problems.

• Post 9/11 experience lowest quality of relationships with their spouse (they are younger) and are at higher risk for divorce.


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Conferences


Conferences

Post-traumatic Reactions In Veteran as causes for caregiver’s Depression


Books for Returning Veterans and Family Members

• Matsakis, A. (2007). (Sidran Press, paperback, ISBN 1886968187). Back from the Front: Combat Trauma, Love, and the Family. Aphrodite Matsakis is a psychotherapist with a special interest in PTSD. Her book aims to help partners and Veterans understand the effects of combat trauma on relationships and family life. It also includes resources to help every member of the family.

• Slone, L.B. & Friedman, M.J. (2008) (Da Capo Press, paperback, ISBN 1600940544). After the War Zone: A Practical Guide for Returning Troops and Their Families. Laurie Slone and Matt Friedman are in the leadership of the National Center for PTSD. Their book is a guide to homecoming for returning Veterans and their families. The book suggests ways families can cope with the effects of trauma.


Recognition and Treatment of PTSD

• PTSD is reaching alarming proportions in US veterans and is associated with persistent disability and co-morbidity.

• Often presents in medical settings

• It is largely under-recognized

• It can be successfully treated in about 50% of those diagnosed and an additional significant fraction can achieve partial relief from symptoms (Friedman, 1996).


Left Untreated

• Without treatment, most of those who are going to get better will get better within one year. Others are at risk for chronic PTSD.

• Additional 40% will get better within another year or two.

• 10% will get better by 5 years

• After that time period, no change is likely to occur on its own (Kessler, 1995; Blanchard et al., 1996).


What are the Likely Disguises of PTSD?

• High rate of somatization disorders

• Muskoloskeletal, genito-urinary, dermatological, respiratory, panic, sleep related and appetite disturbances, irritable bowl syndrome commonly seen.

• Pain syndromes, due to “hypervigilance to symptoms”; PTSD should be considered when prominent pain or somatization cannot be otherwise explained.

• Routine questions about trauma should be part of any medical or mental health intake.


Brief Instruments for PTSD

• Brief instruments for formal diagnosis of PTSD might be warranted. Some examples are:

• Primary Care Evaluation of Mental Disorders (PRIME-MD)

• Mini-International Neuropsychiatric Interview

• PTSD check list

• Self-Rated startle Physiological Arousal, Anger and Numbness (SPAN) scale.


Overview of Psychotherapy for PTSD

Several Clinical practice guidelines offer recommendations for the treatment of PTSD from different agencies and countries.

• The VA/DoD PTSD Clinical Practice Guidelines, 2010.

• The Institute of Medicine (IOM) ,2007.

• Psychotherapy is prominent in the guidelines


Best Treatments for PTSD

• The various guidelines unanimously recommend Cognitive-Behavioral therapies as the most effective treatments for PTSD

• The majority of guidelines recommend also EMDR.

• SSRI’s are also recommended in conjunction or on their own.


Cognitive-Behavioral Therapy Typically includes a number of components: • Psychoeducation about PTSD • Anxiety Management (Breathing, relaxation,

grounding, mindfulness) • Exposure –repeated experiencing, in safety • Cognitive re-structuring of thoughts and beliefs

about the trauma

Exposure and cognitive restructuring are thought to be the most effective components driving change.


Exposure-based Treatments

• The greatest number of studies have been conducted on Prolonged Exposure (PE).

• Survivors repeatedly re-experience their traumatic event.

• PE includes both imaginal and in-vivo exposure to safe situations which have been avoided because they elicit traumatic reminders.


Cognitive Approaches

• Also widely supported treatments.

• Cognitive Processing (CPT) has a focus on challenging and modifying maladaptive beliefs related to the trauma but also includes a written exposure component.

• Dismantling study examined Cognitive Processing, written exposure, full protocol: All led to improvement in PTSD and depression, but cognitive therapy alone was fastest (Resick et al., 2008).


EMDR

• Patients engage in imaginal exposure to a specific trauma while simultaneously performing saccadic eye movements.

• Good evidence that EMDR is more effective than waitlist, not clear if better than PE.

• There is disagreement how much the eye movements add to the effectiveness of EMDR.

• Recent meta-analysis found support for eye movement effectiveness on self-reported distress more than on PTSD symptoms.


Online Self Help Tools for dealing with various problem areas associated with

PTSD

• http://www.ptsd.va.gov/apps/ptsdcoachonline/default.htm

• http://www.ptsd.va.gov/apps/ptsdcoachonline/default.htm


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Including the Family in Treatment of Post traumatic Reactions

• Effective new treatments, as well as advances from brain research and the neurobiology of trauma, introduced progress in helping individuals overcome stigma attached to symptoms of PTSD, learn new thinking and self-regulation skill, and restore some sense of well-being and connection –

“at least while in the therapist’s office” (Barett, Psychotherapy Networker, 2014).

• Cognitive-Behavioral Couple Therapy (Monson et al., 2012) can help practicing change at home and outside of therapy.


Meeting the Aging Survivors of Trauma

• When do we meet the elderly trauma survivors? When illness and losses bring them to our care.

• At this point, it is not always possible to communicate with the elderly about their past traumatic experiences.

• It is therefore even more important that we are informed and sensitive to issues related with potential history of prior trauma in the elderly.


Presentation of Posttraumatic Symptoms in Old Age

• While trauma can occur at any time in life, its presentation is different in old age due to developmental processes and cohort effects.

• PTSD in the elderly can be disguised by health-related complaints, co-morbid health conditions, medication side effects, cognitive impairment

• Dissociative phenomena are less common in older adults

• Connection to index trauma might be lost


Course of PTSD

• The course of PTSD over the lifetime can be highly variable.

• Accumulation of evidence suggests late onset in old age in individuals exposed to traumatic events in earlier years, such as survivors of WWII bombardments, persecution, resistance movements and combat veterans

(Falk et al, 1994; Bramsen and van der Poeg, 1999; Aarts et al, 1996; Trappler et al.,2007;

Yehuda,2009; Lapp, Agbokou and Ferreri, 2011)


Types of PTSD

• Due to a recent trauma in old age

• Chronic course of fluctuations of symptoms

• Delayed onset after years of no symptoms or low symptoms

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• Chronic with enduring personality changes

• Chronic complex PTSD with multiple psychiatric disorders


Explanations for Delayed Onset

Decrease of physical and mental resilience- less able to “ward off”

Decrease of financial and social resources- less support

Interaction of trauma with normative processes of aging


Trauma and Normative Aging

• Ego Integrity versus Despair (Erikson, 1994)

• Life review: reminiscing, making meaning

• Continuity in the sense of self

• Coherence in the sense of self

• Accepting one’s unique path in life

• Awakening of earlier losses

• Longing for lost loved ones


PTSD is a Significant Issue for Older Adults

Elderly suffering full or sub-syndromal PTSD

show:

• Greater impairment in functioning in daily life

• Are less satisfied with their life

• Report older subjective age

• Receive less optimal care

( Lapp, Agbokou & Ferreri, 2011; Solomon, 2009;

van Zelst et al, 2006 ; Marshall, Olfson,

Helmann, Blanco, Guardino, Struening, 2001)


Sub-Threshold PTSD

• Large sample of community-dwelling, older survivors of WWII, including survivors of bombardments, persecution, resistance and combat who did not meet full criteria for PTSD were suffering long-term negative effects (Bramsen and van der Ploeg, 1999)

• Other studies of various trauma survivors render similar results, even 45, 50, and 60 years after the trauma (Falk et al, 1994; Trappler et al, 2007; Marshall et al, 2001)


Late Onset Stress Symptomatology“LOSS”

• Loss represents a broader construct than PTSD and encompasses a continuum of combat trauma-related phenomenology that specifically manifests within the context of normative late-life stressors (King, King et al, 2007)

• Agitation and upset are typical for LOSS, but don’t map into the PTSD clusters fully.

• Avoidance and emotional numbing are absent in LOSS


Treatment of PTSD in Elderly

• By 2010 40% of US Veterans reached age 65 or more (vetpop, 2000).

• The National Institute for Clinical Excellence does not specify detailed guidelines for treatment of PTSD in old age.

• However, particular challenges in the diagnostic process and age-specific cognitive changes and needs must be addressed in the provision of psychotherapy to older PTSD patients


Special Considerations with Elderly

• Trauma as a “Hidden Variable” :Forgetting, fear of stigmatization (cohort effects) and multiple temporally distinct traumatic events require a detailed and sensitive anamnesis at the start of treatment.

• Collaborate with family members and other healthcare providers to obtain information.

• Adapt: reduced short term memory and slower learning must be considered in therapeutic work, multimodal presentation of information and repetition of tasks is required.


Assessment of PTSD in Elderly • A full mental status exam, including cognitive screening

is recommended by the 2010 VA/DoD Clinical Guidelines for PTSD when assessing elderly patients.

• Routinely include questions about trauma-related experiences and behaviors

• Follow up on physiological and medical complaints with questions about changes in mood and activities

• Use brief measures of PTSD, geriatric depression inventory, and geriatric anxiety inventory (Mehta et al, 2003; Davidson, 2001; Blazer, 2009)

• Use lower cutoff scores to diagnose older adults on the various screening measures


Assessment of Suicidality in Elderly

• Assess for suicidality: Older Americans, and elderly veterans, are disproportionately likely to die by suicide

http://www.ptsd.va.gov/professional/pages/assessment_tx_older_adults.asp

NIMH Fact Sheet, http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-sheet/index.shtml)


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Prolonged Exposure with Older Veterans

• Conducting prolonged exposure with older veterans is possible and effective in reducing PTSD (Thorp et al, 2012) and anxiety (Swales et al, 1996.)

• One should be aware of cardiac and respiratory problems and consult with medical providers with such patients.

• In the presence of cognitive decline, provider might have to repeat material, present information in various ways and focus on one thing at a time, and engage caregivers to reinforce the learning outside sessions (Kaiser Press, Schuster et al, PTSD Research Quarterly,

2014).


Use of Virtual Reality (VERT) With PTSD Elderly War Veterans

• Use of virtual reality, 3-D computer visualization techniques as Virtual Reality Exposure Therapy, “VERT”.

• Hyper-realistic threatening stimuli provided by VERT as an alternative to In Vivo and Exposure in Imagination (EI)

• First session anamnesis and psycho-education for anxiety management techniques.

• Starting 2nd session, the EI group participated in traditional imagination therapy, while the VRET group was exposed to a virtual reality (VR) war scenario. Cues such as ambush, mortar blasting, and waiting for rescue were used in the VR.


Findings from VERT Study

• VERT found to be as effective as Exposure in Imagination. Results obtained in 12 sessions showed reduction in PTSD symptoms (CAPS) as well as in Psychopathological symptoms (SCL-90-R), in depression scores and in Anxiety (Gamito, Oliveira Ros, et al, 2010).

• There is a growing body that suggests that the use of VERT might be effective in reducing PTSD symptoms in war veterans (Wood, Wiederhold, Spira 2010) .


Life Review/ Testimonial Therapy

With Older Adults • Testimonial therapy has been effective with

middle-aged adults with PTSD (Cienfuegos and Monelli, 1983)

• Life-Review therapy observed to reduce PTSD symptoms in older adults (Maercker,2002) and depression(for a review-Bhomeijer et al,2003).

• ITT-specific for geriatric population, short term writing therapy incorporating imaginary exposure and cognitive restructuring with a strengths- focused life-review approach (Knaevelsrud et al, 2009; 2011).


Integrative Testimonial Therapy (ITT) Bottche, Kuwert and Knaevelsrud, 2011

• Adults 65 + who experienced war trauma in childhood and are currently showing PTSD symptoms associated with that trauma.

• ONLINE; two 45 minute writing assignments per week during 6 week period.

• Based on Erikson’s psychosocial phases Early childhood(1-4), childhood(5-12);

puberty(13-18), early adulthood( 19-30), adulthood( 31-50), late adulhood (51-65) and older age, (66 and older)

One essay dedicated to each phase.


Chronicity in War Children

• Post-traumatic symptoms have been observed in relation to WWII experiences 65 years later in:

• Finnish children displaced from home (Pesonen et al., 2007; Anderssen, 2011)

• German war children (Kuwert et al., 2007).

• English children (Foster et al., 2003)

• Jewish child survivors of the Holocaust (Shklarov, 2013; Barel et al., 2003)


Table from Barel et al., 2010


ITT: The Way It Works • Therapist and participants interact via the study

website.

• After each assignment, therapists provide individual feedback within 24 hours.

• Feedback is base on ITT manual but tailored individually to the participant’s needs

• Important aspect of the feedback: acknowledgment of the courage to disclose, reinforcement of independent work, feedback and encouragement to voice questions and doubts.


ITT Phase I: Moderate Exposure

• Before describing their life phases, participants were asked to describe their traumatic event in detail and encouraged to focus on the most painful images and thoughts.

• Write in the first person.

• Include all sensory details they had experienced during the traumatic event: olfactory, visual, auditory, tactile.


ITT Phase II: Cognitive Re-appraisal • The aim is to stimulate new perspective on the

traumatic event • Write a letter to a younger self from the current

perspective as a trauma survivor. • Instructed to reflect in the letter on the child’s

feelings of shame, guilt, and correct unrealistic assumptions.

• Summarize what happened to their young self, to reflect on childhood development and biography, on the therapeutic process they are undergoing and how they will cope with the event from now on.


• The focus is on resources, positive learning, skills and mastery experiences:

• Have you learned something specific that was important to you later in life?

• How did you manage to solve that problem?

• Was there anything in that phase of life that you are particularly proud of?

• Who was important to you during that specific time?

Examples of Specific Questions


Findings From ITT Study

• PTSD symptoms showed a significant reduction in overall score and for avoidance symptoms, which were maintained at follow up 3 months later.

• Hyper-arousal and re-experiencing also showed significant reductions but only at follow up 3 months later.

• At post-treatment, 11.5% and at 3 months 29.9% of participants achieved a reduction.

• Self efficacy, quality of life, posttraumatic growth improved and satisfaction from treatment was high.


Testimonial Study with Holocaust Survivors Psychiatric patients, Strous et al., 2005

• The participants were chronically ill patients from two mental health institutions

• At least 3 years old at the time of persecution, victims of Nazi persecution

• Capable and willing to tell a story, even if only in fragments

• Exclusion criteria included cognitive impairment and severe psychotic dysorganization.

• Video testimony was taken in the participant’s preferred language


Results of the Testimonial Study with Holocaust Survivor Psychiatric Patients

• The study results indicate significant improvement in post-traumatic symptoms in chronically hospitalized psychiatrically ill Holocaust survivors after video testimony.

• No difference was noted in psychotic symptoms.

• A notable improvement of symptom severity was observed in all PTSD diagnostic clusters, particularly in severity of avoidance.


Trauma-specific Work with Elderly • The testimonial studies show decreases in

PTSD scores even after an interval of 60 years and more since the traumatic events occurred.

• Posttraumatic symptoms in older adults often present many decades after the events (Graziano, 2004; Kuwert et al., 2007; Trappler et al, 2007; Barel et al, 2010; Thorp and Blazer, 2012), and need to be addressed then.

• Elderly individuals with posttraumatic symptoms can benefit from evidence-based trauma-focused interventions.


Treatment Indications With Cognitively

Impaired Veterans with PTSD

• Treatments of choice for PTSD include CBT, prolonged exposure, EMDR, psychodynamic psychotherapy, supportive therapy. • Modified delivery of treatments according to cognitive capacity

• Assess competence for treatment of choice for PTSD, CBT ,modified.

• Assess for cardiac and respiratory problems if prolonged exposure is considered with elderly PTSD patients.

• Dementia does not need to be a barrier to implementation of Prolonged Exposure for PTSD ( Duax, Waldron-Perrine, Rauch and Adams, 2013).

• No evidence that older adults cannot benefit from it (Friedman, 2003).

• Supportive treatments develop coping skills for here-and-now stressors

• Assess need for pharmacologic treatment

• Engage caregivers in psychoeducation and therapy


Cognitive changes associated with PTSD

PTSD is associated with :

• Impairments in memory, attention and other executive functions (Moore, 2009).

• Altered stress hormone levels and altered brain structure (Yehuda, 2009)

• These are many of the features that characterize normative cognitive aging (Lupien et al, 2007) suggesting that PTSD is

associated with premature aging.


PTSD as Risk Factor for Dementia • Mild cognitive decline was associated with

delayed onset of PTSD in war veterans (Mitall,2001; Johnson, 2000) and in Holocaust

survivors (Grossman et al, 2004; Dasberg, 1989) • The odds for dementia diagnosis for patients with

PTSD are two times as high as for those without PTSD

• Regardless of combat-related trauma, co-morbid physical disorders and substance abuse (Qureshi et al, 2010).

• Bidirectional pathways: neurodegenerative decline can disinhibit trauma memories (Dallan, Mellman et al, 2011)


Frequency of Dementia in Elderly Veterans

• In 2004, the office of the Assistant Deputy Under Secretary of Health for Policy and Planning estimated that the total number of Veterans with dementia would be as high as 563,758 in 2010.

• Many are cared for at home. Due to the progressive nature of the illness and the intensity of care, caregivers (CG) may suffer psychological, physiological and emotional adverse consequences.


Caring for Elderly with Dementia

• Dementia is an irreversible disease resulting in cognitive deterioration and behavioral problems.

• Dementia affects 6.1% of those 65 and older.

• Once institutionalized, behavioral problems occur in 97% of individuals with dementia.


War Trauma Re-enactments in aging veterans with dementia

• Trauma re-enactments are not uncommon in older war veterans with dementia

• They occur in high frequency in those with previous diagnosis of PTSD (but can also appear in others)

• Episodes that appear dissociative can be dramatic.

• There is a predominance of sleep-related enactments (Dallan, Melman, Bhatnagar et al, 2011.)


Management of Behavioral Problems and Enhancing Well-Being of Elderly Residents • Snoezelen, developed in the Netherlands and

gaining popularity in Britain and the USA.

• An approach that actively stimulates the senses using light, sound, smell and taste.

• In house training of nursing assistants for 4 days ( total 16 hours) followed by incorporation of snoezelen into individual morning care of the residents was implemented for 18 months with demetia patients.


Training of Staff in Snoezelen • Training aimed at motivating team members to

improve their knowledge and practical skills with regard to resident-oriented care, and attitudes toward verbal and nonverbal communication:

• How to take a personal history, review specific behavior problems, observe sensory preferences, adapt care plans and apply sensory stimulation in daily care.

• An extensive manual of Snoezelen is available with specific instructions, observation form and examples of integrating snoezelen into 24 hour care.


Video of Snoezelen http://www.youtube.com/watch?v=ZbiVadI7VGk


http://www.youtube.com/watch?v=ZbiVadI7VGk

Video of Snoezelen • Some snoezelen rooms are like a Las Vegas palace

but other facilities have more modest versions:

http://www.youtube.com/watch?v=0muYVBIhWD8


http://www.youtube.com/watch?v=0muYVBIhWD8

A Study Examining Effects on Staff Van Weert, Janssen et al, 2006

• Nursing assistants were instructed by a snoezelen educator with nursing background.

• An individual snoezelen plan was developed for each resident based on lifestyle history interview with family and a stimulus preference screening.

• Findings for the experimental group indicate more changes in positive behavior of staff that were also maintained at 18 months.


Findings from Snoezelen Studies van Weert, Dulman et al, 2005

• In a study that examined the effects of snoezelen on behavioral problems and mood of residents with dementia, snoezelen influenced disturbing behaviors such as physical aggression and rebellion, and withdrawn behaviors such as apathy and depression, as well as “loss of decorum”.

• Significant effects were also seen in the dimensions tearful/sad, Happy/content, interactive/bored, negativism/complaining/reluctance.

• Effects were also seen on responding to speech, talking with longer sentences, relating better.

• Restlessness and verbal anger improved marginally.


Meet me At the MoMa

• The MoMa Alzheimer’s Project guide for museums

• A program intended for individuals with early and middle stages of the degenerative disease and their caregivers.

• At the museum, during non-public hours, groups and individual families engage with specially trained museum educators

• Can be adapted to assisted living facilities and nursing homes.


Pharmacologic Treatment of PTSD in the Elderly

• Pharmacologic treatment of PTSD in the elderly not sufficiently studied

• Clinical experience suggests up to 60 mg/day Fluoxetine or 200 mg/day Sertraline for optimal effect

• Trazadone may be effective but can cause sedation

• Mirtazapine/Venlafaxine/Duloxetine might be useful, but not enough studied in geriatric population for this indication

• Only modestly effective and have side effects

• (Jacobson et al, 2007)


Computer Games in Treatment of Depression in Elderly

• Executive functions (ED) deficits in geriatric depression (GD) are common and often persist despite remission of symptoms.

• A neuroplasticity-based computerized, cognitive remediation-geriatric depression treatment to target ED in GD.

• The assumption was that remediation of these deficits may modulate underlying brain network abnormalities shared by ED and GD.


Findings of Computer Games Study • The treatment group using the program was

compared to “gold standard” treatment with escitalopram 20mg per 12 weeks in 11 treatment-resistant older adults with MDD and 33 matched controls.

• 91% completed the program, which was as effective at reducing depression symptoms as escitalopram but did it in 4 weeks instead of 12.

• Treatment improved measures of ED more than escitalopram

(Morimoto, Wexler, Liu, Hu, Seirup and Alexopoulos, 2014.)


The Effects of Houseplants? Ellen Langer

• Langer gave houseplants to two groups of nursing-home residents. She told one group that they were responsible for keeping the plant alive and that they could also make choices about their schedules during the day. She told the other group that the staff would care for the plants, and they were not given any choice in their schedules. Eighteen months later, twice as many subjects in the plant-caring, decision-making group were still alive than in the control group.


Is Aging A Matter of A Mindset?

• Langer studies the relationship between psychological attitudes and their impact on the body’s capacity to deal with disease processes, aging, weight loss, and others.



Conferences

The “Counterclockwise Experiment”

• One day in the fall of 1981, eight men in their 70s stepped out of a van in front of a converted monastery in New Hampshire. They shuffled forward, a few of them arthritically stooped, a couple with canes. Then they passed through the door and entered a time warp. Perry Como crooned on a vintage radio. Ed Sullivan welcomed guests on a black-and-white TV. Everything inside — including the books on the shelves and the magazines lying around — were designed to conjure 1959. This was to be the men’s home for five days.


Don’t Act Your Age

• The men in the experimental group were told not merely to reminisce about this earlier era, but to inhabit it — to “make a psychological attempt to be the person they were 22 years ago”.

• 1950’s sports (Johnny Unitas and Wilt Chamberlain) or “current” events (the first U.S. satellite launch) or movies (“Anatomy of a Murder,” with Jimmy Stewart) were spoken about in the present tense.


Results of the Experiment

• At the end of their stay, the men were tested again. On several measures, they outperformed a control group that came earlier to the monastery but didn’t imagine themselves back into the skin of their younger selves, though they were encouraged to reminisce.

• They were suppler, showed greater manual dexterity and sat taller — just as Langer had guessed. Perhaps most improbable, their sight improved. Independent judges said they looked younger.


“The Young Ones” - BBC broadcast, 2010

• A recreation, which Langer consulted on, with six aging former celebrities as guinea pigs.

• The stars were taken via period cars to a country house meticulously retrofitted to 1975, right down to the kitschy wall art.

• They emerged after a week as apparently rejuvenated as Langer’s septuagenarians in New Hampshire, showing marked improvement on the test measures.


Boomers re-defining aging AARP, Sept. 2014.

• Jane Seymour, 63-year old Emmy-winning actress, lovingly plays with one of her four grandchildren


Intergenerational Community for Injured Warriors

• Video : Bastion for wounded warriors

http://www.joinbastion.org/

• Living among others who share the culture and the pain, as well as the particular sources of pride, the activities, the memories and the camaraderie of the military can in many ways capture some of the benefits of the “counterclock” experiment in addition to many other advantages.



Intergenerational Community for Injured Warriors




Social Neuroscience • The new neuro-imaging technology allows

non-intrusive study of neural networks in the brain while individuals are engaged in various tasks.

• This allows inquiry of the function of the brain with regards to emotions, cognitions and social interactions.

• The findings from social neuropsychology have great relevance to clinical practice.

102 11/20/2014 Irit Felsen, PhD at LeadingAge DNS/DSW Conferences

“Less Human than Me” “People do not necessarily ascribe a fully

experiencing mind to the other and thus do not inevitably recognize that entity as fully human” (Fiske, 2009, pp. 31)

One of the most important determinants of the extent to which we attribute humanity to others is the perception of the other as possessing a working “mind”.

Infrahumanization is the denial of the capacity for higher order emotions and characteristics that are exclusively human, such as logic, reason and civility (Davivio and Fiske, 2013).


Emotional neurobiological biases

• Others who have been dehumanized elicit the negative basic emotion of disgust which is correlated with reduced mPFC activation (Harris and Fiske, 2006), the area in the brain that processes exclusively social cognitions.

• Others who are perceived as not possessing a fully human mind, or those who give rise to feelings of disgust in the perceiver, can be treated as not-quite-human according to both the neural responses and the behavioral responses in the perceiver (Haque and Wyatz, 2012.)


Dehumanization Can Be Reversed

• Emotional biases based on certain nonconscious neurobiological parameters by which the brain categorizes the other, cannot be changed by intellectual and educational effort alone.

• Intentionally focusing on the other’s mind, as in simple questions such as what might their food preferences have been, activates the mPFC and reverses the effects of dehumanization as seen by neurological correlates of such feelings.


Trailer for “Alive Inside”


PTSD at End of Life

• Virtually no research addresses PTSD at the end of life • Psychiatric symptoms highly prevalent in patients near

the end of life • 25% develop PTSD, often co-morbid with depression

and anxiety • Specific strategies of pharmacotherapy according to

the expected lifespan of the patient • Physicians might respond to the patient’s impending

death with their own avoidance and numbing. (Feldman and Periyakoil, 2006)


Additional Resources

– www.mindingourelders.com – www.theconversationproject.com

– National Center for PTSD Research, www.ptsd.va.gov

– Rand Corporation Reports on Recent Veterans

– Elders Share The Arts, NY

– Meet Me at the MoMa Alzheimer’s Project

Museum program and manual for adaptation to nursing homes


http://www.mindingourelders.com/http://www.theconversationproject.com/http://www.ptsd.va.gov/

Non Pharmacologic Mangement of Behavior Problems (Gitlin, Kales and Lyketsos, 2012)


Con’d (Gitlin, Kales and Lyketsos, 2012)


Coloring as De-stressor for Adults

• Coloring books for adults have made it to best-sellers list in Europe (Huffington Post, Oct. 13, 2014).

• The activity seems to be a good de-stressing strategy, possibly because it allows brain activity associated with stress reactions to subside while the brain is occupied with a structured, monotonous yet creative (colorful) activity, possibly remindful of positive childhood experiences.


Consensus Treatment for Depression in the Elderly

• Dan Blazer, 2003


Testimonies of Trauma Survivors

Irit Felsen, PhD at LeadingAge DNS/DSW Conferences

• http://www.youtube.com/watch?v=sCvQpS-pfb0

• http://www.youtube.com/watch?v=RKUvRZXOiqc

• http://www.youtube.com/watch?v=NHtRr7O9C_A

• http://www.youtube.com/watch?v=h9ldSEsECQU

• http://www.library.yale.edu/testimonies/

11/20/2014 114
http://www.youtube.com/watch?v=sCvQpS-pfb0http://www.youtube.com/watch?v=sCvQpS-pfb0http://www.youtube.com/watch?v=sCvQpS-pfb0http://www.youtube.com/watch?v=RKUvRZXOiqchttp://www.youtube.com/watch?v=NHtRr7O9C_Ahttp://www.youtube.com/watch?v=h9ldSEsECQUhttp://www.library.yale.edu/testimonies/

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