The Neurobiological Alterations of PTSD


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The Neurobiological Alterations of PTSD

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