PTSD Presentation

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PTSD Presentation

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  • I am the Associate Director of the Tri-service Integrator of Outpatient Programming Systems (TrIOPS) and work with military programs throughout the country that provide behavioral health treatment for combat related stress conditions (i.e., PTSD, depression, anxiety, etc..). Please feel free to contact me if you have information or experiences you would like to share regarding this area of treatment. There is a much good work taking place with much more work to be done. I am dedicated to learning as much as I can about the system in which care is provided so that resources, products, and services can be developed and utilized by treatment programs working with our Warriors.
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PTSD Presentation

  1. 1. Understanding Post Deployment Issues
  2. 2. AS THE DISORDER IS DEFINED TODAY, IT INVOLVES THREE KINDS OF SYMPTOMS. 1. HYPERAROUSAL.  INDIVIDUALS WITH PTSD ARE IRRITABLE, EASILY STARTLED, AND CONSTANTLY ON GUARD. THEY SLEEP POORLY AND HAVE DIFFICULTY CONCENTRATING. 2. RE-EXPERIENCING OR INTRUSION.  THEY RECALL THE TRAUMATIC EVENT INVOLUNTARILY IN THE FORM OF VIVID MEMORIES, NIGHTMARES, AND FLASHBACKS. THEY MAY FEEL OR EVEN ACT AS THOUGH IT IS HAPPENING AGAIN. ANY OBJECT, SITUATION, OR FEELING THAT REMIND THEM OF THE TRAUMA MAY CAUSE INTENSE DISTRESS. 3. AVOIDANCE AND EMOTIONAL NUMBING.  THEY AVOID FEELINGS, THOUGHTS, PERSONS, PLACES, AND SITUATIONS THAT EVOKE MEMORIES OF THE TRAUMA. THEY LOSE INTEREST IN THEIR USUAL ACTIVITIES. THEY FEEL ESTRANGED FROM OTHER PEOPLE AND EVEN FROM THEIR OWN FEELINGS. THESE THREE SETS OF SYMPTOMS HAVE A COMMON THEME ---FIXATION ON THE TRAUMA.WITH EXPOSURE TO CONSTANT DAILY TRAUMA ,SUSTAINED OVER LONG PERIODS OF TIME, WITH MULTI DEPLOYMENTS , THEPTSD WOUND IS INEVITABLE.
  3. 3. (C)DESTINATION FOR SUCCESS -OPERATION OUTREACH 2007 3
  4. 4. The body and brain contain a highly attuned,primitive system that can sense danger, whichtriggers a body-wide response. The job of the amygdala The biochemical cascade: hypothalamus is triggered, pituitary and adrenal glands flood the blood stream with stress hormones (epinephrine, norepinephrine, cortisol) Release of norepinephrine increases alertness, focus, short term memory, pupil dilation, increased muscle tone (fight or flight response) The impact of the meaning of the situation as dangerous and life threatening. The impact on the hippocampus (memory) and the orbitofrontal cortex (problem solving and planning).OPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 4
  5. 5.  Increased blood pressure Increased heart rate Constriction of blood vessels Increased activation of lungs and quickened breathing Increased perspiration Liver excretes extra doses of glucoseOPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 5
  6. 6. Stress hormones activate immediate shut down of any bodily system not needed for immediate survival including:  Digestion  Hunger  Sleep  Sex  Digestion (C)DESTINATION FOR SUCCESS -OPERATION OUTREACH 2007 6
  7. 7.  Hypervigilance Trouble falling asleep or staying asleep Generalized anxiety (inability to relax) Exaggerated startle response (to sudden noises, touch, or memory cues associated with the trauma) Headaches, back aches, general malaise Unintentional weight loss or gainOPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 7
  8. 8. Once external conditions havereturned to normal, the body remainson high alert, reacting to neutral cuesas if they were a warning.Once chronic PTSD sets in, a myriad ofhealth conditions may occur in differentparts of the body: Cardiac Arterial Lower gastrointestinal tract Musculoskeletal Dermatological AutoimmuneOPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 8
  9. 9.  Chronic Fatigue Syndrome Fybromyalgia Irritable Bowel Syndrome Alopecia Lower back pain Multiple chemical sensitivity Interstitial cystitis Unexplained aches, pains, and problems that may be related to stress reactions.OPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 9
  10. 10. Hormonal flooding helps to fend off threats,but ensures that traumatic memories areimprinted deeply in the amygdala. Recurring intrusive thoughts Flashbacks Memory loss Difficulty with focus, concentration, & sustained attention Difficulty learning new information Misperception of facial cuesPioneer Psychiatrist Bessel Van derKolk observed that the content of nightmares of veterans with PTSD had remained the same for 15 years.OPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 10
  11. 11.  Time distortion * Either stretching or losing time, often associated with biochemistry of hyper-activation or numbing.  Distractedness * Difficulty with details * Misdiagnosed ADD or ADHD (Attention Deficit Disorders) * Short term memory loss  Obsessive Thinking * Rigid planning and organizing * Chronic anxiety * Difficulty with change, transitions, or interruption of schedule * Repetitive behaviors (to bind anxiety) * Dissociation (C)DESTINATION FOR SUCCESS -OPERATION OUTREACH 2007 11
  12. 12.  Sorrow, grief, despair, loneliness Loss of a reasonable, safe world, shattered dreams Yearning for normalcy, sense of safety Feeling out of control of one’s life; helplessness Sense of impending doom or death Unusual amounts of anger, resentment, irritation, rage Oscillation between intense feelings (biochemical surge) and emotional numbing (endogenous opioids) Guilt, shame, and humiliationOPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 12
  13. 13. Avoidance & Isolation: Normal activities and events may provoke anxiety, panic, or fear of becoming out of controlDamaged Relationships: Over controlling Avoidance of intimacy Over reacting to situations Inability to share feelings Mood swingsDangerous Behaviors: High risk behaviors, flirting with disaster Unconscious attraction to dangerous situations The traumatized brain creates an uncontrolled and unconscious addiction to the biochemicals released when one is feeling threatened (real or perceived).OPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 13
  14. 14. Substance Abuse & Addiction: May initially provide some relief to overwhelming feelings Ultimately create larger problems (increased risks, domestic abuse, problems at work, depression, etc.)Self Mutilation or Repetitive Self Injury: May help to regulate emotional states Either help centralize overwhelming feelings or provide a sense of feeling alive (if numbed out)Compulsive Busyness: Avoidance of internal emotional states Binding anxiety Avoidance of relationships or social events WorkaholicOPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 14
  15. 15.  Multi and Extended Deployments  Strain Relationships (Dear John/Jane Letters)  Money Problems  Occupational Problems 71% of Military Suicides Use Fire Arms 15% to 17% of Suicide Victims Have PTSD Service Members need to have a decompression period – a more gradual transition back to civilian life.OPERATION (C)DESTINATION FOR SUCCESS -OUTREACH 2007 15
  16. 16.  THE FIFTH EDITION OF THE AMERICAN PSYCHIATRIC ASSOCIATIONS DIAGNOSTIC MANUAL MAY PUT LESS EMPHASIS ON THE DIAGNOSIS OF PTSD AND MORE ON THE RANGE OF RESPONSES AND INDIVIDUAL VULNERABILITY. FOR NOW IT IS IMPORTANT TO REMEMBER THAT NOT ALL TRAUMAS ARE ALIKE, THAT ANY TRAUMA WILL AFFECT PEOPLE DIFFERENTLY. HOWEVER,WITH EXPOSURE TO CONSTANT DAILY TRAUMA ,SUSTAINED OVER LONG PERIODS OF TIME, WITH MULTI DEPLOYMENTS , PTSD IS INEVITABLE. (C)DESTINATION FOR SUCCESS -OPERATION OUTREACH 2007 16
  17. 17. (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 17
  18. 18. Acute phase of PTSD:  Exacerbated symptoms of re-experiencing (of trauma).  Avoidance & Arousal  Compromised basic psychosocial functioning Three main goals required at this stage:  Basic needs & safety  Trust-Positive therapeutic alliance  Assessment of current coping strategies-substance abuse, medication needs (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 18
  19. 19. Therapist needs to use common language (understandand use military jargon) with clients.Client learns about positive and negative symptoms ofPTSDPositiveNegative Intrusive thoughts Lack of pleasure Nightmares Numbing Flashbacks Alienation Symptoms of PTSD Common co-occurring conditions Effects of PTSD on the body Effects of PTSD on the psyche Effects of PTSD on others (ie: family, co-workers) (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 19
  20. 20.  Recovery is facilitated by teaching effective coping strategies so clients can adaptively handle daily stressors.  The telling (and re-telling) of their experiences (both in individual and group therapy)  The gradual reestablishment of interpersonal relationships at home and work. Modalities:  Individual Therapy: Literature, videotapes  Psychoeducational Groups for veterans & their families (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 20
  21. 21. Purpose:  Reduction in stress response results in reduction of re-experiencing of trauma symptoms and memory activation  Reduction of avoidance behaviors results in as coping strategies improve  Reduction of avoidance behaviors results in opportunities for corrective information in various domains that may be associated with the trauma Strategies:  Relaxation through guided imagery  Deep breathing  Skills training (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 21
  22. 22. Direct Therapeutic Exposure (DTE) is the most systematic, efficient, and well studied DTE is utilized in many formats:  Systematic desensitization  Implosive Therapy  Flooding  Eye Movement Desensitization Reconstruction (EMDR)  Thought Field Therapy  Counting Method Note: Exposure therapy is contraindicated in some cases:  Inability to maintain stable, working therapeutic relationship  Continual relapses with substance abuse  Acute suicidal or homicidal ideation (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 22
  23. 23.  Therapist must be able to tolerate high levels of emotional upheaval from clients during exposure therapy.  Therapist must be aware of and in control of their own emotional responses/triggers to client reactivity.  Therapist must teach and prepare clients for unavoidable situations and conditions which may trigger trauma responses.  Therapist must have a solid historical understanding of the client and what he/she may have been exposed to prior to combat-related trauma (ie: domestic abuse, childhood abuse) (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 23
  24. 24. PTSD is increasingly being recognized as a phasicdisorder, with symptoms that wax and wane overtime. Prepare client for anniversary reactions Must be a proactive, collaborative problem solving approach to life’s stressors Relapse prevention is addressed throughout treatment Long term interpersonally oriented group therapy as necessary Aftercare planning for resolution of long term psychotherapy issues which may be related to prior trauma: (childhood abuse, sexual abuse, neglect.) (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS 24
  25. 25. A brief course in pharmacology (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS, LLC 25
  26. 26.  Provides something helpful/useful to the veteran  Does not lead to tolerance (of the medication)  Does not lead to abuse (of the medication)  Cannot be used to commit suicide (ie: Prozac)  Does not require blood testing  Does not cut a person off from the world or himself  Causes few, bearable side effects (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS, LLC 26
  27. 27.  Selective Serotonin Reuptake Inhibitors (SSRI’s): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.  Beta blockers: propranolol (Inderal), nadolol (Corgard), atenolol (Tenormin)  Buspirone (Buspar)  Low dose lithium Other drugs used for special circumstances:  Desyrel (Trazadone) for sleep  Quinine for nocturnal myoclonos  Low dose antipsychotics for violent urges and mood stability: thioridazine (Mellaril), mesoridazine (Serentil) (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS, LLC 27
  28. 28.  Benzodiazepines: diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan)  Caffeine  Alcohol  Yohimbine  ANY illegal drug Future Drugs: “Fear Pill” (Propranolol, Inderol) (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS, LLC 28
  29. 29.  A psychiatric condition controlled with proper medication should not automatically lead to non deployment.  Recommendation for deployability should rest with the clinical judgment of the treating clinician or physician.  Medications used safely together are SSRI’s and sleep medications.  Service members taking medications should not automatically be disqualified for any duty assignment.  Medications needed for serious or complex medical/psychiatric conditions are not usually suitable for extended deployments (C) 2007 - DESTINATION FOROPERATION OUTREACH SUCCESS, LLC 29

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