Introduction to Trauma

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Presented January 26, 2012 as part of the Grant
per Diem educational training series for staff
Introduction to Trauma PTSD
Karen Krinsley, Ph.D. PTSD Section Chief, VA
Boston Healthcare System PTSD Consultant,
National Center for PTSD
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Outline of Talk

• Recognizing PTSD
• How common is it?
• Who is most at risk?
• What treatments are effective?
• How the PTSD Consultation Program can help

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The technical diagnosis of PTSD And why it is
important

• Misdiagnosis is common
• Misunderstandings are common
• Great reason not to focus on other issues
• Serious but treatable when it is present
• Typically NOT present alone

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PTSD (DSM IV-TR) A Cluster of Symptoms

• Trauma (The Stressor)
• Reexperiencing / Intrusions
• Avoidance/Numbing
• Increased Arousal
• More than one month of symptoms
• Causes functional problems

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PTSD Criterion A Stressor

• Exposure to a traumatic event in which
• The person has experienced, witnessed, or been
  confronted with an event or events that involve
  actual or threatened death or serious injury, or
  a threat to the physical integrity of oneself or
  others.
• The person's response involved intense fear,
  helplessness, or horror.

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Important to Remember

• PTSD ? TRAUMA
• and
• TRAUMA ? ANYTHING bad

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PTSD ? Trauma ? Anything bad

• Traumas do not always lead to PTSD
• Traumas may lead to PTSD, but then the person
  recovers
• And, many bad things happen to people, affecting
  them deeply, that are not trauma

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Criterion B Reexperiencing/Intrusions

• Recurrent recollections of the event
• Recurrent distressing dreams of the event
• Feeling as if the traumatic event were recurring
• Intense distress at exposure to cues that
  resemble an aspect of the event
• Physiologic reactivity upon exposure to cues that
  resemble an aspect of the traumatic event
• EXAMPLES Nightmares, Flashbacks, Shaking,
  Sweating

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Criterion CAvoidance/Numbing

• Efforts to avoid thoughts about the trauma
• Efforts to avoid things that remind one about the
  trauma
• Inability to recall an important aspect of the
  trauma
• Markedly reduced interest in significant
  activities
• Feeling of detachment from others
• Restricted range of affect (e.g., unable to have
  loving feelings)
• Sense of foreshortened future
• EXAMPLES Avoiding the news, movies, crowded
  stores but also drinking and drug use

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Criterion D Increased Arousal

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hyper-vigilance
• Exaggerated startle response
• EXAMPLES Keeping guns, checking locks,
  aggression, insomnia

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PTSD Criterion E and F

• Duration At least one month
• Functional Impairment clinically significant

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Do you see the overlaps?

• Depression
• Substance Use Disorder
• Mild Traumatic Brain Injury
• Pain Symptoms

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Likelihood of getting PTSDafter Experiencing a
Trauma

• It depends on the event and the person
• Men experience more traumatic events
• Women are more likely to develop PTSD
• After a traumatic event, who gets PTSD?
• 20 of women
• 8 of men get PTSD
• Kessler et al., 1995

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Likelihood of PTSD.

• Rape
• Men 65
• Women 45
• Combat
• Men almost 40
• Physical Abuse
• Almost 50 of women
• 20 men

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What puts you at risk for PTSD?

• Being female
• Being poor
• Less education
• Bad childhood
• Previous psychological problems

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What puts you at risk for PTSD?

• Strength or severity of the stressor
• Characteristics of the trauma
• Greater perceived life threat
• Feeling helpless
• Unpredictable, uncontrollable

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Risk for PTSD After the Trauma

• Degree of Social Support
• Degree of Life Stress

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How common is PTSD?

• 3.5 general population, current
• 1.8 men
• 5.2 women
• Lifetime 6.8 -- 3.6 men, 9.7 women
• (U.S. National Comorbidity Survey Replication
  2001-03)
• Vietnam theater veterans
• 15.2 of men
• 8.1 of women
• (National Vietnam Veterans Readjustment Study
  1986-88)
• In veterans
• In combat veterans
• In women veterans (who may be combat veterans!)

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How common is PTSD?

• Gulf War (I) 10
• OEF/OIF
• 13.8 (current)
• Population-based studies
• (RAND Corporation, Center for Military Health
  Policy Research, 2008)
• Conclusions PTSD is not unusual, although not
  the majority

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What about MST?
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How Common is MST? Margret Bell, Ph.D.Resource
Development Utilization Coordinator,MST
Support Team (national resource for VA MST
teams)
Data Source Time frame Men Men Women Women
Sexual harassment Sexual assault Sexual harassment Sexual assault
DoD 2002 Survey (active duty sample) Annual rates 23 1 54 3
Street et al., 2003 (reservist sample) Anytime during service 27 3 60 23
Skinner et al., 2000 (users of VA healthcare) Anytime during service -- -- 55 23
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Implications of PTSD

• Greater risk of other disorders
• 80 of people with PTSD another diagnosis
• Depression, SUD, Anxiety Disorders
• Greater unemployment
• Relationships
• Health problems
• Violence
• Generally, worse quality of life

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What does PTSD look like?

• No one clinical picture but not like it is shown
  on television/movies
• Cant stereotype, although its done
• There are some hallmarks
• Nightmares
• Poor sleep
• Anger
• Numbness or sadness
• Avoidance of groups

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How can you help?

• Be supportive but dont allow PTSD to be used as
  an excuse
• Do ask if they want to talk and acknowledge their
  military service
• Dont say I understand
• Be alert for risk issues

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How can you help?

• Sleeping / Nightmares No touching
• No fooling around Dont sneak up on someone,
  dont make sudden noises behind them
• Understand the impact of TV
• Consider special requests Light, Noise, Large
  Groups

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A few tips for Managing Anger

• Confrontation probably NOT helpful
• Try to understand the cause, both to help manage
  and to help yourself stay calm
• Prepare ahead of time with the veteran if
  possible
• Allow escape

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Trauma-Informed Milieu

• Structured but not authoritative or punishing
• Everyone treated with respect and listened to
• Setting is kept safe
• Staff aware that residents may be traumatized

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Professional Help

• Know when to refer
• Be knowledgeable about PTSD treatments and aware
  that they work
• Encourage keeping appointments
• Acknowledge that it will be HARD but it is worth
  it
• Ask what the alternative is
• Be wary of splitting

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Effective PTSD Treatments

• State of the art treatment
• Empirically validated treatments
• Staged, stepped model of care
• Safety
• Trauma focus
• Reconnection
• Interdisciplinary
• PTSD ? chronic mental illness

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Treatment for PTSD

• Cognitive Behavioral Treatments most effective
  psychotherapy treatments
• Medication can be an effective treatment
• Most evidence for Cognitive Processing Therapy
  and Prolonged Exposure
• Most evidence for antidepressants

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Stepwise Treatment ModelStage 1 Safety

• Suicide and Homicide prevention
• Harm reduction for risky behaviors
• Teach positive coping tools
• Teach the role of avoidance
• Group focus when possible, including Seeking
  Safety, Understanding and coping with PTSD,
  Relaxation Stress Mgmt, ACT, DBT modules
  Anger Management, Wellness, more

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Stepwise Treatment ModelStage 2 Trauma Focus

• Core of PTSD treatment
• Empirically validated treatments include
  Cognitive Processing Therapy and Prolonged
  Exposure
• It works! Recovery is possible.

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Trauma Focus Therapy

• Many types
• Core common elements
• Exposure to the trauma in some form
• Processing of the trauma
• Results Decreased avoidance, increased tolerance
  of distress, and ultimately decreased distress

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CPT AND PE Comparison Study (Resick et al., 2002)
CPT, N 83 55 50
41 63 PE, N 88 55
51 39 64
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CPT PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT
AND LONG TERM (Resick et al., 2002)
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Stepwise Treatment ModelStage 3 Reconnection

• Focus is on relationships
• Reconnection with friends, family
• Support groups, process groups, marriage and
  family work and more
• Also may include Reparation

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Special issues with new veterans of Iraq and
Afghanistan

• National Guard OR Reserve OR Regular Military
• Trauma is more acute or raw
• Anger and aggression are common
• Binge drinking or casual drug use
• May be working and need different hours for
  treatment
• Often have families and children, and may want or
  need them involved in treatment
• May not want traditional treatments such as group
  therapy

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PTSD Consultation Program

• One-on-one PTSD consultation for any VHA provider
  OR contractor
• Free of charge
• Speak directly with expert PTSD clinicians
• Response usually within 24 hours
• Easy to contact us Call, email, or complete an
  online form

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Consultation Program Staff

• Karen Krinsley, PhD
• Consultant VISN 1 PTSD Mentor
• PTSD Section Chief, VA Boston
• Nancy Bernardy, PhD
• PTSD Mentoring Consultation Program Manager
• VA National Center for PTSD
• Matt Friedman, MD, PhD
• Executive Director, NCPTSD
• And associated experts from around the country

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PTSD Consultation Program

• Ask questions regarding
• Assessment
• Treatment
• Therapy of all kinds
• Medication
• Clinical management
• Programmatic issues
• Resources for treatment
• Ways to improve care
• Any problem at all

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Eligibility

• We cant say this enough
• ANY VHA Clinician
• ANY Contractor
• ANY Question
• ABOUT ANY Veteran or Group of Veterans

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For Whom and How We Have Been Useful

• Experienced clinicians who want a second opinion
• Relatively inexperienced clinicians who would
  rather not bother local colleagues that
  particular day
• New staff who are overwhelmed
• Staff without a lot of local folks for support

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For Whom and How We Have Been Useful

• Staff from programs outside PTSD with no
  connections to their PTSD programs
• Staff who have hit a roadblock or a wall
• Diagnostic and treatment challenges
• Referrals to residential programs

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Consultation Program Contact Information

• Contact us
• Call 1 [phone]
• Online Form at
• vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp
  
• Send e-mail to ptsdconsult_at_va.gov

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A Few Things to Remember

• Consultation provides an opportunity for problem
  solving and discussion with the treating
  clinician
• Ultimate decision and authority for implementing
  consultation recommendations lie with the
  treating clinician and the local chain of command
• Not for acute emergencies

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More InformationNational Center for PTSD
Website

• www.ptsd.va.gov
• All types of information, for
• Providers
• Veterans
• Families
• General Public
• Has online courses such as Understanding PTSD
  and much more