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)

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Comorbid psychologica

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0

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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

Thanks!

Contact Information:pkerr@hsc.wvu.edu