The Neurobiological Alterations of PTSD
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  • 1. VA Medical CenterAlbany, NY
  • 2. Assessment, Diagnosis and Treatment of Posttraumatic Stress Disorder
    NADE National Training Conference
    September 14, 2010
  • 3. 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
  • 4. 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.”
  • 5. 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.
  • 6. 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
  • 7. Historical Terms for PTSD
    Military Trauma
    Nostalgia
    Soldier’s Heart
    Shell Shock
    Combat Fatigue
    War Neurosis
    Civilian Trauma
    Railway Spine
    Survivor Syndrome
  • 8. 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.”
  • 9. 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%
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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.
  • 15. 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
  • 16. Avoidance
    Efforts to avoid thoughts and feelings about the trauma
    Avoidance of activities and situations which stimulate recollection of the trauma
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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. 
  • 30. 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.
  • 31. Common Polytrauma Conditions
  • 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.
  • 38. Dedicated Levels of Care
    • Polytrauma Rehabilitation Centers provide acute, comprehensive, inpatient rehabilitation. 
    • 39. 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.
    • 40. 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
  • Polytrauma Network Sites
  • 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.
  • 60. 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)
  • 61. 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
  • 62. 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.
  • 63. 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.
  • 64. 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.
  • 65. 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.
  • 66. 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.
  • 67. 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.
  • 68. 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