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The Neurobiological Alterations of PTSD
 

The Neurobiological Alterations of PTSD

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    The Neurobiological Alterations of PTSD The Neurobiological Alterations of PTSD Presentation Transcript

    • VA Medical CenterAlbany, NY
    • Assessment, Diagnosis and Treatment of Posttraumatic Stress Disorder
      NADE National Training Conference
      September 14, 2010
    • Posttraumatic Stress Disorder Program
      Charles R. Kennedy, PhD
      PTSD Program Director
      Karen S. Voss, LCSW, BCD
      Jennifer A. Courtney, LCSW
      Loretta S. Malta, PhD
      Jason B. Gallo, PhD
    • Jonathan Shay, MD, PhDDepartment of Veterans Affairs, Boston MAFrom Achilles in Vietnam 1994
      “I shall argue throughout this book that healing
      from trauma depends upon communalization of the
      trauma- being able safely to tell the story to someone
      who is listening and who can be trusted to retell it
      truthfully to others in the community. So before
      analyzing, before classifying, before thinking,
      before trying to do anything- we should listen.”
    • History of Posttraumatic Stress Disorder
      PTSD is an anxiety disorder that can occur after experiencing or
      witnessing a traumatic event.
      The person experienced, witnessed or was confronted by an event
      or events that involved actual or threatened death or serious injury
      or threat to physical integrity of self or others.
      The person’s response involved intense fear, helplessness or
      horror.
      Most survivors of trauma return to pre-trauma functioning over time.
    • Introduction to PTSD
      Traumatic events have been a part of the human
      experience since the beginning of time.
      Accounts of traumatic stress
      go back at least as far as
      Ancient Greece, whose authors
      wrote a great deal about
      betrayal, grief, combat and
      tragedy. http://www.sfu.ca/classics/myth/images/fagles.jpg
    • Historical Terms for PTSD
      Military Trauma
      Nostalgia
      Soldier’s Heart
      Shell Shock
      Combat Fatigue
      War Neurosis
      Civilian Trauma
      Railway Spine
      Survivor Syndrome
    • 1980
      The American Psychiatric Association
      3rd edition of the Diagnostic and Statistical
      Manual of Mental Disorders used the term
      Posttraumatic Stress Disorder for the first time.
      PTSD became established as a diagnosis, with
      the stressor criterion that people had to have
      been exposed to a “recognizable stressor that
      would evoke significant symptoms of distress in
      almost anyone.”
    • PTSD Prevalence Rates
      Combat exposure is one of the traumas, along with sexual assault, most commonly associated with the development of PTSD
      The estimated lifetime prevalence of PTSD for the general population is approximately 8%
      It is estimated that 15.2% of male Vietnam combat veterans currently suffer from PTSD and the lifetime prevalence for this population is estimated at 30.9%
    • PTSD Prevalence Rates
      60.7% of men and 51.2% of women are exposed to
      trauma
      5% males and 10% of females are diagnosed with
      PTSD
      Some people have stress reactions that do not go
      away or get worse over time
      These individuals may develop PTSD
    • OEF/OIF Veterans
      Invisible Wounds of War
      Approximately 1.65 million U.S. troops have deployed as part of
      Operation Enduring Freedom
      (Afghanistan) and
      Operation Iraqi Freedom (Iraq)
      since October 2001
      Editors Terri Tanielian and Lisa H. Jaycox
      www.rand.org
    • PTSD Prevalence Rates
      19% of four surveyed U.S. combat infantry units met criteria for a diagnosis of combat-related PTSD following deployment to Iraq
      1.6 million people have served in the Iraq and Afghanistan, 750,000 have left the military
      Approximately 49% of those 750,000 who have left the military report mental health symptoms.
      Approximately 60,000 of the 750,000 who have been discharged are currently seeking mental health services
    • TRAP: The Symptoms of PTSD
      Trauma: the person experienced, witnessed, or was confronted by an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness or horror.
      Reexperiencing Symptoms – intrusive recollections, traumatic
      dreaming, flashbacks
      Avoidant Symptoms – of others, stimuli connected to trauma
      Physiological Symptoms – exaggerated startle response,
      hypervigilance
    • Trauma
      PTSD is an anxiety disorder that can occur after
      experiencing or witnessing a traumatic event.
      The person experienced, witnessed or was
      confronted by an event or events that involved
      actual or threatened death or serious injury or
      threat to physical integrity of self or others.
      The person’s response involved intense fear,
      helplessness or horror.
    • Reexperiencing Symptoms
      Recurrent, Persistent and Intrusive Thoughts
      Vietnam veterans with PTSD and non-PTSD veterans were
      exposed to scents in minute proportions under ability to
      name. Veterans with PTSD showed intense polygraph
      reactions to odors (burning hair, jet fuel) associated with
      trauma. 100% of veterans with PTSD called upon traumatic
      memories during the study procedures. McCaffrey et al. (1993)
      Nightmares and Dreams
      Flashback and Hallucinations
    • Avoidance
      Efforts to avoid thoughts and feelings about the trauma
      Avoidance of activities and situations which stimulate recollection of the trauma
    • Numbing / Emotional Avoidance
      Psychogenic amnesia
      Diminished interest in usual activities
      Feelings of detachment or estrangement from others
      Restricted range of affect
      Detachment from the future
    • Physiological Arousal
      Sleep disturbance
      Increased irritability, lowered threshold for anger
      Impaired concentration
      Hypervigilance
      Exaggerated startle response
      Physiological reactivity to trauma reminders
      Increase in measure of vital signs: breathing, muscle tension, heart rate and blood pressure, fear of “going crazy” or dying
    • Recovery from PTSD
      Some veterans experience an immediate onset of PTSD, symptoms that occur right after the traumatic experience
      For other veterans, symptoms begin many years after they thought they had put their military experiences behind them
      Life stressors, such as transition to civilian life, physical illness, birth of a child, divorce, death of a loved one, or retirement may trigger symptoms unexpectedly
    • Goals of PTSD Treatment
      Symptom reduction
      Integration thoughts and feelings
      Create new memories
      Disinhibit imagination
      Foster interpersonal connection
      Register other than traumatic material
      Create a narrative about the trauma, create meaning
      Bring the trauma to the present instead of person being pulled back to the past
      Promote chosen action, challenge the fixed action of fight, flight or freeze reaction
      Reconnect the neocortex and limbic system
      Fulfillment in living in the present
      Investment in the future
    • Evidence Based Practice
      Individual Therapy
      Prolonged Exposure
      Eye Movement Desensitization & Reprocessing
      Cognitive Processing Therapy
      Group Therapy
      Cognitive Processing Therapy
      Seeking Safety/Strength
      Dialectical Behavior Therapy
    • Pharmacotherapy
      Pharmacotherapy is empirically supported, generally cost
      effective and often addresses the co-morbid
      symptomotology that accompanies PTSD
      Many drugs are used in the treatment of PTSD
      Friedman et al. (2000) cite multiple studies in reporting
      that SSRIs, such as fluoxetine, sertraline, paroxetine and
      fluvoxamine, are the only agents with the capacity to
      reduce symptoms in all three PTSD symptom clusters
    • PTSD Program Levels of Care
      Group 1 Simple Trauma
      Group 2 Mild Complex Trauma
      Group 3 Moderate Complex Trauma
      Group 4 Severe Complex Trauma
      Group 5 Chronic Severe
    • Treatment Group 1
      Combat Veterans and Acute Illness (Simple PTSD)
      Estimated to be 10-20% ( Groups 1 & 2) of Veterans followed by PTSD specialists
      Minimal history of prior (childhood or pre-military) trauma
      High level of pre-trauma functioning
      Usually responsive to EBPs with minimal time spent on
      pre-treatment therapeutic engagement
      Sometimes may be sub-clinical PTSD or Adjustment Disorder
      Unlikely to have co-morbid disorders such as substance abuse, if so, sub-threshold
    • Treatment Group 2
      Minimal history of prior (childhood or pre-military) trauma, but may have experienced multiple traumas in combat
      May have co-morbid depression or substance abuse specifically related to the traumas, secondary
      May need time to engage in therapy prior to initiating EBP treatment
    • Treatment Group 3
      Combat Veterans and Stable but Serious Disability (Temporarily Stable, but (recent decline in pre-morbid functioning precipitated by psychosocial stressor) Impaired Baseline of Functioning)
      Estimated to be 33% ( in combination with Group 4) of population seen by PTSD specialists within VISN 2
      Pre-military trauma and/or childhood neglect
      Co-morbidities may include Substance Abuse or Dependence, Depression, Anxiety, Bipolar Disorder, Axis II Personality Disorders
      Likely to have episodes of increased PTSD symptoms, interpersonal problems, distress tolerance problems
      Therapeutic alliance is important due to fragility and trust difficulties
      Best managed by PTSD specialists due to the complexity of their symptoms and the likelihood of frequent relapses
      May be sustained with group or monthly individual sessions to maintain contact and monitor for exacerbations
    • Treatment Group 4
      Combat Veterans and Acute Illness and Stable but Serious Disability (Temporarily unstable and Impaired Baseline of Functioning)
      Estimated to be 33% (in combination with Group 3)of population seen by PTSD specialists within VISN 2
      Pre-military trauma and/or childhood neglect
      Co-morbidities may include Substance Abuse or Dependence, Depression, Anxiety, Bipolar Disorder, Axis II Personality Disorders or traits
      Currently experiencing an exacerbation of symptoms due to recent deployment, external triggers such as loss of a job, loss of a family member, other life changes and in need of an episode of intensive stabilization or exposure therapy
      Therapeutic alliance is important due to fragility and trust difficulties
      Best managed by PTSD specialists due to the complexity of their symptoms and the likelihood of frequent relapses
    • Treatment Group 5
      Combat Veterans and Chronic Condition with Limited Reserves (Chronic and Stable PTSD)
      Estimated to be 33% of population seen by PTSD specialists within VISN 2
      Unlikely to benefit from or not interested in EBP or any therapy that directly challenges them to make change
      Seeking supportive therapy to help them maintain level of functioning
      May fear losing service connection if therapy discontinued altogether
      May be socially isolated and rely on therapy as a primary social support
      Can be treated in any clinic, may do well in supportive therapy groups
    • Traumatic Brain Injury
      Traumatic brain injuries - caused by Improvised Explosive Devices, mortars, vehicle accidents, grenades, bullets, mines, falls and blast concussion –
      May be the hallmark injury faced by veterans of Iraq and Afghanistan. 
    • VA Polytrauma Programs
      Polytrauma care is for veterans and returning service members with injuries to more than one physical region or organ system, one of which may be life threatening.
      These injuries result in physical, cognitive, psychological, or psychosocial impairments and functional disability.
    • Common Polytrauma Conditions
      • Traumatic Brain Injury
      • Hearing Loss
      • Amputations
      • Fractures
      • Burns
      • Visual Impairment
      • Posttraumatic Stress Disorder
    • VA Polytrauma System of Care
      VA has treated over 500 OEF/OIF service members in inpatient units.
      The vast majority of these patients have been on active duty at the time of admission.
      The major cause of injury has been trauma sustained in combat.
    • Dedicated Levels of Care
      • Polytrauma Rehabilitation Centers provide acute, comprehensive, inpatient rehabilitation. 
      • Polytrauma Network Sites provide specialized, post-acute rehabilitation in consultation with the Rehabilitation Centers in a setting appropriate to the needs of veterans, service members, and families.
    • Polytrauma Support Clinic TeamsVAMC Albany
      • Provider follow up services in consultation with regional and network specialists.
      • Assist in managing the long-term effects of Polytrauma through direct care and
      consultation.
      • Inpatients are monitored 24 hours a day at all of our facilities.
    • Polytrauma Rehabilitation Centers
      • Richmond, VA
      • Tampa, FL
      • Minneapolis, MN
      • Palo Alto, CA
    • Polytrauma Network Sites
      • Syracuse, NY
      • Bronx, NY
      • Boston, MA
      • Lexington, KY
      • Houston, TX
      • Cleveland, OH
      • Dallas, TX
      • Indianapolis, IN
      • Tucson, AZ
      • Philadelphia, PA
      • Hines, IL
      • Denver, CO
      • Washington, DC
      • St. Louis, MO
      • Seattle, WA
      • Augusta, GA
      • West Los Angeles, CA
    • Support for Veterans and Families
      Logistic Support
      Clinical Support
      Emotional Support
      VA Polytrauma programs provide comprehensive, high
      quality, inter-disciplinary care to patients.
      Teams of clinicians from every relevant field plan and
      administer an individually tailored rehabilitation plan to help
      the veteran recover to their highest level of functioning.
    • Impact of Combat-Related PTSD on Primary Relationships and Family Functioning
      Difficulties with self-disclosure, communication and problem solving(Carroll, Rueger, Foy & Donahoe, 1985; Nezu & Carnevale, 1987)
      Elevated levels of spousal and familial verbal and physical aggression(Byrne & Riggs, 1996; Savarese, Suvak, King & King, 2001)
      Greater somatization, depression, anxiety, loneliness and hostility among wives of veterans with combat-related PTSD(Solomon, Waysman, Avitzur & Enoch, 1991; Waysman, Mikulincer, Solomon & Weisenberg, 1993)
      Parenting problems(Jordan et al., 1992)
      Family members of veterans with combat-related PTSD report more problems with affect regulation and less affective responsiveness than do family members of non-PTSD veterans (Dansby & Marinelli, 1999; Davison & Mellor, 2001)
    • Important Others
      The most significant protective and resilience
      recovery variables associated with PTSD
      seem to be those related to perceived
      emotional sustenance, current social support
      and attachment style.
      Dieperink et al., 2001
      King, Foy, Keane & Fairbank, 1999
    • What We Would Like Our Family and Friends to Know about Living with PTSD
      Written by Combat Veterans
      Stratton VA Medical Center, Albany, New York
      Sometimes I am moody and I don’t understand why, please give me some space until I am ready to be around people again.
      I am often uncomfortable and anxious in crowds or
      with unfamiliar people because my experiences
      have made it difficult for me to trust unknown
      people.
    • What We Would Like Others to Know
      Certain “triggers” e.g. loud noises, smells, objects in the road startle me, remind me of traumatic
      experiences or cause me to behave in ways that
      you might not understand.
      Please know that these “triggers” signal danger for me.
      I am easily startled and I am always watchful for
      danger in the environment.
    • What We Would Like Others to Know
      Please understand that not everything can be
      explained.
      Please don’t take it personally if I cannot explain
      certain things to you. I don’t always understand
      them myself.
      Please don’t ask for a description or details of my traumatic experiences. Sometimes explaining things can increase my distress.
    • What We Would Like Others to Know
      Please know that certain days or anniversaries are important.
      Know that close relationships are often difficult and scary. We are often afraid of losing those we care about and engage in distancing behaviors as a way to protect ourselves from potential loss.
      Please “hang in there.” Be supportive but not intrusive.
    • What We Would Like Others to Know
      Please know that we often do things in a certain way to promote order and organization and to help balance the chaos we often feel internally and in other parts of our lives.
      Ultimately, we often do things in a certain way to feel safe.
      Many of our behaviors e.g. eating with back against the wall in restaurant or driving around an object in the road are automatic and have been conditioned to maintain safety.
    • What We Would Like Others to Know
      Please know that all of these behaviors are the result of our experiences and the mental and physical changes that are the result of trauma.
      These behaviors are ways that we protect and sustain ourselves.
      For us, these thoughts, feelings and behaviors are about life, death, survival and safety.
    • http://www.ncptsd.va.gov/ncmain/index.jsp
      VA National Center for PTSD
      http://www1.va.gov/VISNS/visn02/albany.cfm
      VA Medical Center, Albany, NY
      http://www.polytrauma.va.gov/
      VA Polytrauma System of Care