Complex Trauma in Veterans Brian L. Meyer, Ph.D. Interim Associate Chief, Mental Health Services McGuire VA Medical Center Richmond, VA September 12, 2014

Complex TraumaComplex Traumain Veterans in Veterans

Brian L. Meyer, Ph.D.Brian L. Meyer, Ph.D.

Interim Associate Chief, Interim Associate Chief,

Mental Health ServicesMental Health Services

McGuire VA Medical CenterMcGuire VA Medical Center

Richmond, VARichmond, VA

September 12, 2014September 12, 2014

DisclaimerDisclaimer

The views expressed in this The views expressed in this presentation are solely those of presentation are solely those of the presenter and do not the presenter and do not represent those of the Veterans represent those of the Veterans Health Administration, the Health Administration, the Department of Defense, or the Department of Defense, or the United States government.United States government.

Trauma and PTSDTrauma and PTSD

LIFE-THREATENING EVENTS

IMPERSONAL

PERSONAL

TRAUMATIC

Prevalence of PTSDPrevalence of PTSD

More men (61%) More men (61%) than women (51%) than women (51%) experience a trauma experience a trauma at some point in at some point in their lives, but their lives, but women experience women experience PTSD at twice the PTSD at twice the rate of men (10% vs. rate of men (10% vs. 5%) 5%) (Kessler et al., 1995; Tolin (Kessler et al., 1995; Tolin and Foa, 2006)and Foa, 2006)

Trauma and PTSDTrauma and PTSD

Not all trauma leads to PTSDNot all trauma leads to PTSD

Depending on the study, the type of Depending on the study, the type of trauma, and the group studied, 3%-trauma, and the group studied, 3%-58% get PTSD 58% get PTSD

Not all abuse leads to PTSDNot all abuse leads to PTSD

Who Gets PTSD?Who Gets PTSD? It depends on:It depends on:

SeveritySeverityDurationDurationProximityProximity

PTSD is mitigated or worsened by:PTSD is mitigated or worsened by:Childhood experienceChildhood experiencePersonality characteristicsPersonality characteristicsFamily historyFamily historySocial supportSocial support

Other Common Psychiatric Other Common Psychiatric Diagnoses in People Diagnoses in People

Exposed to Traumatic Exposed to Traumatic EventsEvents

Dysthymic DisorderDysthymic Disorder Major Depressive DisorderMajor Depressive Disorder Mood Disorder NOSMood Disorder NOS Bipolar DisorderBipolar Disorder Generalized Anxiety DisorderGeneralized Anxiety Disorder Phobic DisorderPhobic Disorder Panic DisorderPanic Disorder

More Common Psychiatric More Common Psychiatric Diagnoses in People Diagnoses in People

Exposed to Traumatic Exposed to Traumatic EventsEvents

ADHDADHD Oppositional Defiant DisorderOppositional Defiant Disorder Conduct DisorderConduct Disorder Reactive Attachment DisorderReactive Attachment Disorder Borderline Personality DisorderBorderline Personality Disorder Antisocial Personality DisorderAntisocial Personality Disorder Narcissistic Personality DisorderNarcissistic Personality Disorder

Complex TraumaComplex Trauma

What is Complex What is Complex Trauma?Trauma?

Complex psychological trauma results Complex psychological trauma results from “exposure to severe stressors from “exposure to severe stressors that (1) are repetitive or prolonged, that (1) are repetitive or prolonged, (2) involve harm or abandonment by (2) involve harm or abandonment by caregivers or other ostensibly caregivers or other ostensibly responsible adults, and (3) occur at responsible adults, and (3) occur at developmentally vulnerable times in developmentally vulnerable times in the victim’s life.” the victim’s life.” Ford and Courtois, 2009Ford and Courtois, 2009


The psychological effects of chronic and The psychological effects of chronic and cumulative traumas cumulative traumas

Results from interpersonal victimization, Results from interpersonal victimization, multiple traumatic events, and/or multiple traumatic events, and/or traumatic exposure of prolonged duration traumatic exposure of prolonged duration – Sexual and physical abuseSexual and physical abuse– Domestic violenceDomestic violence– Ethnic cleansingEthnic cleansing– Prisoners of warPrisoners of war– TortureTorture– Being held hostageBeing held hostage


Complex trauma is often relationalComplex trauma is often relational Trauma creates vulnerability to Trauma creates vulnerability to

further trauma: adults who are further trauma: adults who are traumatized may have been traumatized may have been traumatized previously as childrentraumatized previously as children

What Are Complex What Are Complex Traumatic Stress Disorders?Traumatic Stress Disorders?

The sequelae of complex traumaThe sequelae of complex trauma Also known as Complex PTSD, or C-Also known as Complex PTSD, or C-

PTSDPTSD

Rates of PTSD for Rates of PTSD for Simple vs. Complex TraumaSimple vs. Complex Trauma

SimpleSimple ComplexComplex

10-20%10-20% 33-75%33-75%

Copeland et al., 2007; Kessler et al., 1995Copeland et al., 2007; Kessler et al., 1995

People at Risk of Developing People at Risk of Developing Complex Traumatic Stress DisordersComplex Traumatic Stress Disorders

Economically impoverished inner city minoritiesEconomically impoverished inner city minorities Incarcerated individualsIncarcerated individuals Homeless personsHomeless persons Sexually and physically revictimized children or Sexually and physically revictimized children or

adultsadults Victims of genocide or tortureVictims of genocide or torture Developmentally, intellectually, or psychiatrically Developmentally, intellectually, or psychiatrically

challenged personschallenged persons Civilian workers and Civilian workers and soldiers harassed on the job soldiers harassed on the job

or in the ranksor in the ranks Emergency respondersEmergency responders

Vogt et al., 2007Vogt et al., 2007

Core Problems Core Problems in Complex Trauma in Complex Trauma

Affect dysregulation Affect dysregulation DissociationDissociation Somatic dysregulationSomatic dysregulation Impaired self-conceptImpaired self-concept Disorganized attachment patternsDisorganized attachment patternsIn addition toIn addition to symptoms of PTSD symptoms of PTSD andand

other comorbid disordersother comorbid disorders

Ford and Courtois, 2009Ford and Courtois, 2009

Disorders of Extreme Stress Disorders of Extreme Stress Not Otherwise Specified Not Otherwise Specified

(DESNOS)(DESNOS) A. Alterations in regulating affect arousalA. Alterations in regulating affect arousal

– Persistent dysphoriaPersistent dysphoria– Difficulty modulating angerDifficulty modulating anger– Self-injurious behaviorSelf-injurious behavior– Suicidal preoccupationSuicidal preoccupation– Difficulty modulating sexual involvementDifficulty modulating sexual involvement– Addictive behaviorAddictive behavior

B. Alterations in attention and consciousnessB. Alterations in attention and consciousness– AmnesiaAmnesia– Dissociation Dissociation – Depersonalization/derealizationDepersonalization/derealization

Herman, 1992, and Courtois, 2004Herman, 1992, and Courtois, 2004


(DESNOS)(DESNOS) C. Alterations in self-perception C. Alterations in self-perception

– Chronic guilt, intense shame, and self-blameChronic guilt, intense shame, and self-blame– HelplessnessHelplessness– Sense of defilementSense of defilement– Sense of being completely different from othersSense of being completely different from others

D. Alterations in perception of perpetratorD. Alterations in perception of perpetrator– Preoccupation with relationship with perpetratorPreoccupation with relationship with perpetrator– Unrealistic attribution of total power to Unrealistic attribution of total power to

perpetrator perpetrator – Idealization or gratitude Idealization or gratitude – Sense of special relationshipSense of special relationship– Acceptance of belief system of perpetratorAcceptance of belief system of perpetrator



(DESNOS)(DESNOS) E.E. Alterations in relationships with othersAlterations in relationships with others

– Isolation and withdrawalIsolation and withdrawal– Inability to trust othersInability to trust others– Inability to feel intimate Inability to feel intimate – Repeated search for rescuerRepeated search for rescuer– Repeated failures of self-protectionRepeated failures of self-protection

F. Somatic and/or medical conditionsF. Somatic and/or medical conditions– Involving all major body systemsInvolving all major body systems– Chronic painChronic pain



(DESNOS)(DESNOS) G. Alterations in systems of meaningG. Alterations in systems of meaning

– Loss of sustaining faithLoss of sustaining faith– Sense of hopelessness and despair Sense of hopelessness and despair

Note: While these symptoms were not Note: While these symptoms were not included in DSM IV as symptoms of PTSD, included in DSM IV as symptoms of PTSD, some of these were included in DSM 5 as some of these were included in DSM 5 as symptoms of PTSDsymptoms of PTSD


Experiencing Complex Experiencing Complex TraumaTrauma

Emotional instabilityEmotional instability Overwhelming feelings of Overwhelming feelings of

rage, guilt, shame, despair, rage, guilt, shame, despair, ineffectiveness and/or ineffectiveness and/or hopelessnesshopelessness

Tension reduction activities Tension reduction activities such as self-mutilation, such as self-mutilation, compulsive sexual compulsive sexual behavior, and bulimiabehavior, and bulimia

Suicidal or violent behaviorSuicidal or violent behavior DissociationDissociation

Experiencing Complex Experiencing Complex TraumaTrauma

Loss of a sense of trust, safety, and self-worthLoss of a sense of trust, safety, and self-worth Loss of a coherent sense of selfLoss of a coherent sense of self Belief of being bad or unlovableBelief of being bad or unlovable Insecure attachments/damaged interpersonal Insecure attachments/damaged interpersonal

relationshipsrelationships Difficulty functioning in social settings, including workDifficulty functioning in social settings, including work Enduring personality changesEnduring personality changes Loss of faithLoss of faith

Complex Trauma: Complex Trauma: A Case ExampleA Case Example

Mr. M.: Vietnam veteran, physically Mr. M.: Vietnam veteran, physically and emotionally abused by mother and and emotionally abused by mother and stepfather, went to war to “kill”, 5 stepfather, went to war to “kill”, 5 divorces, polysubstance abuse, lost divorces, polysubstance abuse, lost career and imprisoned, dissociated career and imprisoned, dissociated experience of killing children in war, experience of killing children in war, remembered “I murdered children”, remembered “I murdered children”, became suicidal, referred for became suicidal, referred for treatmenttreatment

Complex PTSD May be Complex PTSD May be Confused With:Confused With:

PTSDPTSD ADHDADHD Other anxiety disordersOther anxiety disorders Bipolar DisorderBipolar Disorder Mood Disorder NOSMood Disorder NOS Psychotic Disorder NOSPsychotic Disorder NOS Reactive Attachment DisorderReactive Attachment Disorder

Complex PTSD Often Complex PTSD Often Appears as or Co-Occurs Appears as or Co-Occurs

with:with: PTSD PTSD Other Anxiety DisordersOther Anxiety Disorders Mood Disorders Mood Disorders Behavior Disorders, Behavior Disorders,

especially ADHDespecially ADHD Substance Use DisordersSubstance Use Disorders

Co-morbidity is the ruleCo-morbidity is the rule

PTSD and Complex PTSD PTSD and Complex PTSD Are Conceptually Related Are Conceptually Related

to:to: Anxiety DisordersAnxiety Disorders Dissociative DisordersDissociative Disorders Somatization DisordersSomatization Disorders Personality DisordersPersonality Disorders

That is why DSM 5 places trauma in a That is why DSM 5 places trauma in a new category entitled Trauma- and new category entitled Trauma- and Stressor-Related DisordersStressor-Related Disorders

Complex PTSD Is Much Complex PTSD Is Much More Than Simple PTSDMore Than Simple PTSD

Loss of a coherent sense of self Loss of a coherent sense of self Problems in self-regulationProblems in self-regulation Tendency to be revictimizedTendency to be revictimized Other mental health disordersOther mental health disorders Substance use disordersSubstance use disorders Health problemsHealth problems Relationship problemsRelationship problems Changes in systems of belief and Changes in systems of belief and

meaningmeaning

Changes to PTSD Changes to PTSD Diagnosis in DSM 5Diagnosis in DSM 5

Trauma and Stressor-Related Trauma and Stressor-Related Disorders are placed in their own Disorders are placed in their own categorycategory

Experiencing the loss of a loved Experiencing the loss of a loved one is no longer considered a one is no longer considered a traumatic stressor unless it is traumatic stressor unless it is violent or accidentalviolent or accidental

Elimination of B criterion of reaction Elimination of B criterion of reaction of horror, terror, or helplessnessof horror, terror, or helplessness– Military and first responders do Military and first responders do

their jobtheir job

Changes to PTSD Changes to PTSD Diagnosis in DSM 5Diagnosis in DSM 5

Addition of new criteria involving Addition of new criteria involving negative cognitions (negative negative cognitions (negative beliefs about the world, blame of beliefs about the world, blame of self or others for the trauma) and self or others for the trauma) and mood (depression, anger, guilt)mood (depression, anger, guilt)

Addition of a new arousal criterion: Addition of a new arousal criterion: self-destructive or reckless behaviorself-destructive or reckless behavior

These changes result in These changes result in approximately the same number of approximately the same number of people who will meet criteria for a people who will meet criteria for a diagnosis of PTSDdiagnosis of PTSD

Implications of Implications of Changes to PTSD Changes to PTSD

Diagnosis in DSM 5Diagnosis in DSM 5 Angry, depressive, and anxious affects now Angry, depressive, and anxious affects now

applyapply– This is a rejoinder to the fear-based model of the This is a rejoinder to the fear-based model of the

past, recognizing greater complexitypast, recognizing greater complexity The existence of a dissociative subtype, The existence of a dissociative subtype,

combined with the new affective criteria and the combined with the new affective criteria and the new arousal criterion of self-destructive new arousal criterion of self-destructive behavior, moves the description closer to behavior, moves the description closer to Complex TraumaComplex Trauma

Implications of Implications of Changes to PTSD Changes to PTSD

Diagnosis in DSM 5Diagnosis in DSM 5 Some of the research on PTSD may no longer applySome of the research on PTSD may no longer apply Assessment instruments must changeAssessment instruments must change

– A new version of the PTSD Checklist, the PCL 5 A new version of the PTSD Checklist, the PCL 5 – The Clinician-Assisted PTSD Scale, the “gold The Clinician-Assisted PTSD Scale, the “gold

standard” of PTSD assessment, is also being revisedstandard” of PTSD assessment, is also being revised Different treatments may be needed for different Different treatments may be needed for different

phenotypes of PTSD (anger, depression, anxiety, phenotypes of PTSD (anger, depression, anxiety, dissociation)dissociation)– This may decrease the use of certain treatments, This may decrease the use of certain treatments,

particularly Prolonged Exposure, which is fear-basedparticularly Prolonged Exposure, which is fear-based

Complex Trauma and Complex Trauma and Health: The Adverse Health: The Adverse

Childhood Childhood Events StudyEvents Study

17,421 adult patients of Kaiser 17,421 adult patients of Kaiser PermanentePermanente

Came out of an obesity program: many Came out of an obesity program: many dropouts who lost weight believed that it dropouts who lost weight believed that it protected them (against further sexual protected them (against further sexual abuse, against violence from prisoners)abuse, against violence from prisoners)

Eight categories of events in the home: Eight categories of events in the home: physical abuse, emotional abuse, sexual physical abuse, emotional abuse, sexual abuse, someone imprisoned, domestic abuse, someone imprisoned, domestic violence, substance abuse, chronic mental violence, substance abuse, chronic mental illness, and loss of parentillness, and loss of parent

Felitti, Anda, et al., 1998Felitti, Anda, et al., 1998

Complex Trauma and Complex Trauma and Health: The ACE StudyHealth: The ACE Study

Results more than 50 years later: Results more than 50 years later: More than 1/2 of population experienced More than 1/2 of population experienced

one or more ACEs; 1/4 had two or more one or more ACEs; 1/4 had two or more Exposure to one category increases Exposure to one category increases

likelihood of exposure to another by 80%likelihood of exposure to another by 80% The higher the ACE score, the worse the The higher the ACE score, the worse the

health problemshealth problems



Results: Results: Greater likelihood of health problems: Greater likelihood of health problems:

– Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease– Sexually transmitted diseasesSexually transmitted diseases– HepatitisHepatitis– ObesityObesity– Heart diseaseHeart disease– FracturesFractures– DiabetesDiabetes– Unintended pregnanciesUnintended pregnancies


Complex Trauma and Complex Trauma and Behavioral Health: The ACE Behavioral Health: The ACE

StudyStudyResults: Results: Greater likelihood Greater likelihood

of behavioral of behavioral health problems: health problems: – SmokingSmoking– Intravenous drug Intravenous drug

abuseabuse– DepressionDepression– Attempted suicideAttempted suicide– AlcoholismAlcoholism


The ACE Study: The ACE Study: A Dose-Response CurveA Dose-Response Curve


Results: Results: Greater likelihood of occupational Greater likelihood of occupational

problems: problems: – Occupational healthOccupational health– Poor job performancePoor job performance


RelationshipProblems

Substance AbuseProblems

Mental HealthProblems

CriminalBehavior

HealthProblems

Employment Problems

TraumaticExperiences

The Catalyzing Effects of Complex The Catalyzing Effects of Complex TraumaTrauma

Military Trauma Military Trauma and Complex Traumaand Complex Trauma

ACEs, Combat, and PTSDACEs, Combat, and PTSD Two or more adverse childhood Two or more adverse childhood

experiences (ACEs) are associated experiences (ACEs) are associated with increased risk of PTSD and with increased risk of PTSD and depression, beyond combat exposuredepression, beyond combat exposure

Cabrera et Cabrera et al., 2007al., 2007

High Prevalence of Prior High Prevalence of Prior Child Maltreatment in Child Maltreatment in

SoldiersSoldiersStudies of Army soldiers: Studies of Army soldiers:

Rosen & Martin, 1996: Rosen & Martin, 1996: –17% of males and 51% of females reported childhood 17% of males and 51% of females reported childhood sexual abusesexual abuse–50% of males and 48% of females reported physical abuse50% of males and 48% of females reported physical abuse–11% of males and 34% of females experienced both11% of males and 34% of females experienced both

Seifert et al., 2011 Seifert et al., 2011 (combined males and females)(combined males and females)::–46% reported childhood physical abuse46% reported childhood physical abuse–25% reported both physical and sexual abuse25% reported both physical and sexual abuse–Soldiers with both reported more severe PTSD symptoms Soldiers with both reported more severe PTSD symptoms and more problem drinkingand more problem drinking

Prior Child Maltreatment Prior Child Maltreatment and PTSD in Veteransand PTSD in Veterans

Veterans with PTSD are more likely to have Veterans with PTSD are more likely to have been physically abused as children than been physically abused as children than those without PTSD those without PTSD (Bremner et al., 1993; Zaidi (Bremner et al., 1993; Zaidi and Foy, 1994)and Foy, 1994)

– Physical abuse as a child also associated Physical abuse as a child also associated with greater severity of PTSD with greater severity of PTSD (Zaidi and Foy, (Zaidi and Foy, 1994)1994)

Childhood physical abuse and combat-Childhood physical abuse and combat-related trauma related trauma both both increase later anxiety, increase later anxiety, depression, and PTSD depression, and PTSD (Fritch et al., 2010)(Fritch et al., 2010)

Prior Child Maltreatment Prior Child Maltreatment and PTSD in Veteransand PTSD in Veterans

Recent evidence indicates Recent evidence indicates that the Veterans most that the Veterans most likely to develop PTSD are likely to develop PTSD are those who experienced those who experienced childhood traumachildhood trauma– Danish veterans of Danish veterans of

Afghanistan Afghanistan (Berntsen et al., (Berntsen et al., 2012)2012)

– US veterans of Iraq and US veterans of Iraq and Afghanistan Afghanistan (Van Voorhees et (Van Voorhees et al., 2012)al., 2012)

Multiple and Repeated Types Multiple and Repeated Types of Trauma in the Militaryof Trauma in the Military

Combat and war-Combat and war-zone traumazone trauma

Traumatic grief/lossTraumatic grief/loss Military sexual Military sexual

traumatrauma AccidentsAccidents

Combat Exposure and PTSDCombat Exposure and PTSD

Combat exposure increases PTSD Combat exposure increases PTSD (Kulka et (Kulka et al., 1990; Prigerson et al., 2002)al., 1990; Prigerson et al., 2002)

High war zone stress associated with High war zone stress associated with greater levels of PTSD, both current and greater levels of PTSD, both current and lifetime, than low and moderate war zone lifetime, than low and moderate war zone stress in Vietnam era veterans stress in Vietnam era veterans (Jordan et al., (Jordan et al., NVVRS, 1991)NVVRS, 1991)

Up to 58% of soldiers in heavy combatUp to 58% of soldiers in heavy combat 50-75% of POWs and torture victims50-75% of POWs and torture victims

The Problem of Repeated The Problem of Repeated DeploymentsDeployments

This is now the longest war in American This is now the longest war in American history, with the most repeated deploymentshistory, with the most repeated deployments

Repeated deployments wear down resiliencyRepeated deployments wear down resiliency 36% of servicemen 36% of servicemen and women have been and women have been

deployed twice or more deployed twice or more (Department of Defense, (Department of Defense, 2008)2008)

More than 400,000 servicemen and women More than 400,000 servicemen and women have been deployed at least 3 times have been deployed at least 3 times (Rosenbloom, 2013)(Rosenbloom, 2013)

50,000 servicemen and women have had at 50,000 servicemen and women have had at least four deployments least four deployments (Army Secretary John (Army Secretary John McHugh, testifying before Congress, 3/21/12)McHugh, testifying before Congress, 3/21/12)

Repeated Deployments Repeated Deployments Increase PTSDIncrease PTSD

Mental health problems increase with Mental health problems increase with repeated deployments: 14.3% of those repeated deployments: 14.3% of those with one deployment, 21.8% of those with with one deployment, 21.8% of those with two, and 32.5% of those with three or two, and 32.5% of those with three or four four (Mental Health Advisory Team-VII, 2011) (Mental Health Advisory Team-VII, 2011)

Army soldiers deployed twice have 1.6 Army soldiers deployed twice have 1.6 times greater chance of developing PTSD times greater chance of developing PTSD than those deployed once than those deployed once (Reger et al., 2009)(Reger et al., 2009)

Active duty military with PTSD may be Active duty military with PTSD may be sent back into combatsent back into combat

Shorter dwell times increase risk of PTSD Shorter dwell times increase risk of PTSD (MacGregor et al., 2012)(MacGregor et al., 2012)

Complex Traumatic Stress Complex Traumatic Stress Disorders in Male VeteransDisorders in Male Veterans

DESNOS symptoms at highest levels DESNOS symptoms at highest levels in veterans:in veterans:

Affect dysregulationAffect dysregulation Anger problemsAnger problems Overwhelming distressOverwhelming distress Guilt and shameGuilt and shame Amnesia for important life eventsAmnesia for important life events Feeling of being permanently Feeling of being permanently

damageddamaged Belief that no one understandsBelief that no one understands Distrust of othersDistrust of others Relational conflict or avoidanceRelational conflict or avoidance Despair and hopelessnessDespair and hopelessness Loss of meaning in life Loss of meaning in life Newman, Orsillo et al., 1995; Ford, 1999Newman, Orsillo et al., 1995; Ford, 1999

Complex Traumatic Stress Complex Traumatic Stress Disorders in Male VeteransDisorders in Male Veterans Study of 84 veterans in a specialized Study of 84 veterans in a specialized

residential PTSD treatment programresidential PTSD treatment program 31% diagnosed with both PTSD and 31% diagnosed with both PTSD and

DESNOS, 29% PTSD only, 27% DESNOS DESNOS, 29% PTSD only, 27% DESNOS only, and 13% met criteria for neitheronly, and 13% met criteria for neither

These data suggest that DESNOS overlaps These data suggest that DESNOS overlaps with but is distinct from PTSDwith but is distinct from PTSD

Ford, 1999Ford, 1999

Complex Traumatic Stress Complex Traumatic Stress Disorders in Male VeteransDisorders in Male Veterans

Veterans diagnosed with DESNOS were more Veterans diagnosed with DESNOS were more likely to have diagnoses of major depressionlikely to have diagnoses of major depression

All veterans diagnosed with personality disorders All veterans diagnosed with personality disorders were diagnosed with DESNOSwere diagnosed with DESNOS

Veterans with DESNOS were more likely to be Veterans with DESNOS were more likely to be psychiatrically hospitalizedpsychiatrically hospitalized

Veterans with DESNOS had more extreme Veterans with DESNOS had more extreme intrusive reexperiencing symptoms and poorer intrusive reexperiencing symptoms and poorer object relationsobject relations

DESNOS-only veterans were more likely to have DESNOS-only veterans were more likely to have histories of childhood trauma, while PTSD-only histories of childhood trauma, while PTSD-only veterans were more likely to report severe veterans were more likely to report severe combat traumacombat trauma

DESNOS-only group were more likely to have DESNOS-only group were more likely to have participated in combat atrocitiesparticipated in combat atrocities

Ford, 1999Ford, 1999

Complex Traumatic Stress Complex Traumatic Stress Disorders in Male VeteransDisorders in Male Veterans Complex trauma may be more common in Complex trauma may be more common in

veterans with prior histories of traumatic veterans with prior histories of traumatic experiencesexperiences– 80% of sample in Newman et al. study80% of sample in Newman et al. study– Among veterans who seek treatment, many Among veterans who seek treatment, many

have histories of child abuse have histories of child abuse (Bremner et al., 1993)(Bremner et al., 1993)

– Can combat-only trauma result in complex Can combat-only trauma result in complex traumatic outcomes?traumatic outcomes?

– The necessity of taking a full traumatic The necessity of taking a full traumatic experiences historyexperiences history

Complex Traumatic Stress Complex Traumatic Stress Disorders in Male VeteransDisorders in Male Veterans Recognizing complex trauma in Recognizing complex trauma in

veterans allows therapists to:veterans allows therapists to:– Develop greater empathy and Develop greater empathy and

understandingunderstanding– Gain distance from difficult and Gain distance from difficult and

noncompliant behaviorsnoncompliant behaviors– Anticipate obstacles to building and Anticipate obstacles to building and

maintaining therapeutic alliancesmaintaining therapeutic alliances– Identify non-PTSD targets for Identify non-PTSD targets for

interventionintervention

Newman, Orsillo et al., 1995Newman, Orsillo et al., 1995

Premilitary Trauma Premilitary Trauma in Female Veteransin Female Veterans

Female service members and veterans report Female service members and veterans report more premilitary trauma than menmore premilitary trauma than men

Female service members report more Female service members report more premilitary trauma than female civilianspremilitary trauma than female civilians

More than half of female veterans experienced More than half of female veterans experienced premilitary physical or sexual abusepremilitary physical or sexual abuse

1/3 of female veterans report a history of 1/3 of female veterans report a history of childhood sexual abuse, compared to 17-22% childhood sexual abuse, compared to 17-22% of civilian womenof civilian women

1/3 of female veterans report a history of adult 1/3 of female veterans report a history of adult sexual assault, compared to 13-22% of civilian sexual assault, compared to 13-22% of civilian womenwomen

Zinzow et al., 2007; Merrill et al., 1999Zinzow et al., 2007; Merrill et al., 1999

Premilitary Trauma Premilitary Trauma in Female Veteransin Female Veterans

Female veterans report more Female veterans report more severe childhood abuse, severe childhood abuse, including sexual abuse by a including sexual abuse by a parent and greater duration parent and greater duration of sexual abuse, than civilian of sexual abuse, than civilian women women (Schultz et al., 2006)(Schultz et al., 2006)

Adult rape was 4 times more Adult rape was 4 times more likely among Navy likely among Navy servicewomen who servicewomen who experienced childhood sexual experienced childhood sexual abuse and 6 times more likely abuse and 6 times more likely if they experienced childhood if they experienced childhood physical and sexual abuse physical and sexual abuse (Merrill et al., 1999)(Merrill et al., 1999)

Military Sexual TraumaMilitary Sexual Trauma

Military Sexual Trauma is sexual assault Military Sexual Trauma is sexual assault or sexual harassment that is or sexual harassment that is threateningthreatening

Among active duty personnel:Among active duty personnel:– 3% of women and 1% of men reported attempted or 3% of women and 1% of men reported attempted or

completed sexual assault in the previous yearcompleted sexual assault in the previous year– 54% of women and 23% of men reported sexual 54% of women and 23% of men reported sexual

harassment in the previous yearharassment in the previous year Department of Defense, 2002Department of Defense, 2002

Among veterans using VA health care:Among veterans using VA health care:– 23% of women reported being sexually assaulted 23% of women reported being sexually assaulted

while in the militarywhile in the military– 55% of women and 38% of men reported sexual 55% of women and 38% of men reported sexual

harassmentharassment U.S. Dept. of Veterans Affairs, 2009U.S. Dept. of Veterans Affairs, 2009

Military Sexual TraumaMilitary Sexual Trauma 37% of women reporting MST had been 37% of women reporting MST had been

raped at least twice during military service raped at least twice during military service (Sadler et al., 2003)(Sadler et al., 2003)

Female veterans experience sexual Female veterans experience sexual assaults (30%), physical assaults (35%), or assaults (30%), physical assaults (35%), or both (16%) both (16%) (Sadler et al., 2000)(Sadler et al., 2000)

80% of sexual assaults in the military go 80% of sexual assaults in the military go unreported unreported (Department of Defense studies quoted by Whitley in (Department of Defense studies quoted by Whitley in testimony before Congress, 2010)testimony before Congress, 2010)

Female veterans with MST are more likely Female veterans with MST are more likely to develop PTSD than those who have to develop PTSD than those who have experienced other traumas (60% vs. 43%) experienced other traumas (60% vs. 43%) (Yaeger et al., 2006)(Yaeger et al., 2006)

Mental Health Problems Mental Health Problems Following Military Sexual Following Military Sexual

TraumaTrauma Rates of PTSD for sexual assault are higher Rates of PTSD for sexual assault are higher

than those for combatthan those for combat– 65% of men and 46% of women who have been 65% of men and 46% of women who have been

sexually assaulted report PTSD symptoms, compared sexually assaulted report PTSD symptoms, compared to 39% of men following combatto 39% of men following combat

Almost 1/3 of those who have been sexually Almost 1/3 of those who have been sexually assaulted experience an episode of Major assaulted experience an episode of Major DepressionDepression

Sexual assault survivors are more likely to use Sexual assault survivors are more likely to use drugsdrugs– They are 3.4 times more likely to use marijuanaThey are 3.4 times more likely to use marijuana– They are 6 times more likely to use cocaineThey are 6 times more likely to use cocaine– They are 10 times more likely to use hard drugsThey are 10 times more likely to use hard drugs

(Department of Veterans Affairs, 2009) (Department of Veterans Affairs, 2009)

Characteristics of MST Characteristics of MST Are Similar to Complex Are Similar to Complex

TraumaTrauma May be repeatedMay be repeated Veteran experiences harm or neglect Veteran experiences harm or neglect

(ignoring, disbelief) by responsible adults(ignoring, disbelief) by responsible adults Occurs at a vulnerable time in lifeOccurs at a vulnerable time in life Victim remains exposed to perpetrator and Victim remains exposed to perpetrator and

may even depend on that person for his/her may even depend on that person for his/her life life

Sequelae of MST Sequelae of MST Are Similar to Complex Are Similar to Complex

TraumaTrauma Co-morbid mental health diagnoses such as Co-morbid mental health diagnoses such as

PTSD, depression, anxiety disorders, PTSD, depression, anxiety disorders, substance abuse, and personality disorders substance abuse, and personality disorders (Kimerling et al., 2007; Street et al., 2009)(Kimerling et al., 2007; Street et al., 2009)

Co-morbid medical problems involving Co-morbid medical problems involving gynecological, neurological, gastrointestinal, gynecological, neurological, gastrointestinal, pulmonary, and cardiovascular conditions pulmonary, and cardiovascular conditions (Frayne et al., 1999)(Frayne et al., 1999)

Other problems such as self-harm Other problems such as self-harm behaviors, obesity, and dissociation behaviors, obesity, and dissociation (Kimerling et al., (Kimerling et al., 2007)2007)

MST and Post-Military MST and Post-Military TraumaTrauma

Domestic violence and sexual Domestic violence and sexual revictimization revictimization (Cougle et al., 2009; Drause et al., 2007)(Cougle et al., 2009; Drause et al., 2007)

Homelessness Homelessness (Gamache et al, 2003)(Gamache et al, 2003)

PTSD and SUDs Following PTSD and SUDs Following Military Sexual TraumaMilitary Sexual Trauma

Rates of PTSD for sexual assault are higher Rates of PTSD for sexual assault are higher than those for combatthan those for combat– 65% of men and 46% of women who have been 65% of men and 46% of women who have been

sexually assaulted report PTSD symptoms, sexually assaulted report PTSD symptoms, compared to 39% of men following combatcompared to 39% of men following combat

Sexual assault survivors are more likely to Sexual assault survivors are more likely to use drugsuse drugs– They are 3.4 times more likely to use marijuanaThey are 3.4 times more likely to use marijuana– They are 6 times more likely to use cocaineThey are 6 times more likely to use cocaine– They are 10 times more likely to use hard drugsThey are 10 times more likely to use hard drugs

Increased domestic violence and sexual Increased domestic violence and sexual revictimization revictimization (Cougle et al., 2009; Drause et al., 2007)(Cougle et al., 2009; Drause et al., 2007)

Department of Veterans Affairs, 2009 Department of Veterans Affairs, 2009

Military Trauma in Military Trauma in WomenWomen

2/3 of female OIF veterans report at least 2/3 of female OIF veterans report at least one combat experience one combat experience (Milliken et al., 2007)(Milliken et al., 2007)

38% of OIF servicewomen are in firefights, 38% of OIF servicewomen are in firefights, and 7% report shooting at an enemy and 7% report shooting at an enemy (Hoge et (Hoge et al., 2007)al., 2007)

OIF servicewomen handle human remains OIF servicewomen handle human remains more often than servicemen: 38% vs. 29% more often than servicemen: 38% vs. 29% (Hoge et al., 2007)(Hoge et al., 2007)

21% of female veterans of Iraq and 21% of female veterans of Iraq and Afghanistan have been diagnosed with Afghanistan have been diagnosed with PTSD PTSD (VA, 2010)(VA, 2010)

Complicated Relationships between Complicated Relationships between Child Abuse, Military Service, PTSD, & Child Abuse, Military Service, PTSD, &

SUDsSUDs

Combat and War Zone Trauma

Childhood Abuse

MST

PTSD and SUDS Military

Service

Treatment of Treatment of

Complex TraumaticComplex Traumatic

Stress DisordersStress Disorders

Phases of Integrated Phases of Integrated TreatmentTreatment

After Herman, 1992After Herman, 1992

Stage I: Safety and Stage I: Safety and StabilizationStabilization

Alliance buildingAlliance building Psychoeducation about Psychoeducation about

multiple traumasmultiple traumas SafetySafety StabilizationStabilization Skills-building Skills-building

– Affective regulationAffective regulation– CognitiveCognitive– InterpersonalInterpersonal

Self-careSelf-care

Stage I: SafetyStage I: Safety Safety plansSafety plans Tension reduction activities (e.g., exercise)Tension reduction activities (e.g., exercise) Harm reduction and eliminationHarm reduction and elimination

- Self-harm and suicidal behaviors- Self-harm and suicidal behaviors - Gambling- Gambling - Driving- Driving - Fighting- Fighting - Eating- Eating - Sex- Sex - Medication- Medication - Breaking laws- Breaking laws

Stage I: StabilizationStage I: Stabilization Reduction and elimination of drug and Reduction and elimination of drug and

alcohol abusealcohol abuse HealthHealth Housing Housing - In a safe neighborhood- In a safe neighborhood IncomeIncome - Employment- Employment - Financial skills (budgeting, banking)- Financial skills (budgeting, banking) TransportationTransportation Setting and keeping a scheduleSetting and keeping a schedule

Stage I: Skill-buildingStage I: Skill-building

Affect Regulation SkillsAffect Regulation Skills- Anger Management- Anger Management- Relaxation (breathing, progressive - Relaxation (breathing, progressive muscle relaxation, Drop 3, etc.)muscle relaxation, Drop 3, etc.)- Emotional literacy- Emotional literacy- Distraction from intense emotion- Distraction from intense emotion- Self-soothing strategies- Self-soothing strategies- Behavioral activation - Behavioral activation - Changing facial expressions- Changing facial expressions- Self-talk- Self-talk- Opposite emotion- Opposite emotion

Stage I: Skill-buildingStage I: Skill-building Cognitive Regulation SkillsCognitive Regulation Skills

- Grounding- Grounding- Thought-stopping- Thought-stopping- Attending to one thing in the present - Attending to one thing in the present momentmoment- Re-thinking- Re-thinking- Noticing choices- Noticing choices- Seeing the whole picture- Seeing the whole picture- Problem-solving - Problem-solving - Examining the evidence- Examining the evidence

Empirically-Supported Empirically-Supported Treatments for Stage ITreatments for Stage I

Dialectical Behavior Therapy (DBT)Dialectical Behavior Therapy (DBT) Seeking SafetySeeking Safety Mindfulness-Based Stress ReductionMindfulness-Based Stress Reduction Therapies for specific problemsTherapies for specific problems

- Imagery Rehearsal Therapy- Imagery Rehearsal Therapy- Cognitive-Behavioral Therapy- Cognitive-Behavioral Therapy- CBT for Insomnia- CBT for Insomnia- Motivational Interviewing- Motivational Interviewing- SAMHSA’s Anger Management - SAMHSA’s Anger Management workbookworkbook

Stage II: Remembrance Stage II: Remembrance and Mourningand Mourning

Exposure and Exposure and desensitizationdesensitization

ProcessingProcessing GrievingGrieving Constructing a Constructing a

narrativenarrative Integration of the Integration of the

traumatrauma

Empirically-Supported Empirically-Supported Treatments for Stage IITreatments for Stage II

Cognitive Processing Therapy (CPT)Cognitive Processing Therapy (CPT) Prolonged Exposure (PE)Prolonged Exposure (PE) Eye Movement Desensitization and Eye Movement Desensitization and

Reprocessing (EMDR)Reprocessing (EMDR) Skills Training in Affective and Interpersonal Skills Training in Affective and Interpersonal

Regulation (STAIR) Narrative Therapy holds Regulation (STAIR) Narrative Therapy holds promise; it sequences Phase I and Phase II promise; it sequences Phase I and Phase II treatmenttreatment

Stage III: ReconnectionStage III: Reconnection

Gradually decrease isolationGradually decrease isolation Re-establishing estranged relationshipsRe-establishing estranged relationships Developing trusting relationshipsDeveloping trusting relationships Developing intimacyDeveloping intimacy Developing sexual intimacyDeveloping sexual intimacy ParentingParenting Community-based activitiesCommunity-based activities SpiritualitySpirituality


There are no Evidence-Based There are no Evidence-Based Psychotherapies for Phase III trauma Psychotherapies for Phase III trauma treatmenttreatment– but couples and/or family therapy may be but couples and/or family therapy may be

helpfulhelpful Cognitive-Behavioral Conjoint Therapy Cognitive-Behavioral Conjoint Therapy

for PTSD shows promise for PTSD shows promise (Monson and (Monson and Fredman, 2012)Fredman, 2012)


Giving back to the communityGiving back to the community Making amendsMaking amends AcceptanceAcceptance ReclaimingReclaiming CreativityCreativity Finding meaningFinding meaning Post-traumatic growthPost-traumatic growth

Treatment of TraumaTreatment of Trauma

There are no Evidence-Based There are no Evidence-Based

Psychotherapies for Phase III Psychotherapies for Phase III

trauma treatment*trauma treatment*

*but couples and/or family therapy may be *but couples and/or family therapy may be helpful, including Cognitive Behavioral helpful, including Cognitive Behavioral Conjoint Therapy for PTSD (Monson, 2012)Conjoint Therapy for PTSD (Monson, 2012)

Medical Treatment of Medical Treatment of Complex TraumaComplex Trauma

Medication for symptom management and Medication for symptom management and co-morbid disordersco-morbid disorders– AntidepressantsAntidepressants– Mood stabilizersMood stabilizers– AnticonvulsantsAnticonvulsants– Sleep aids, including Prazosin for nightmaresSleep aids, including Prazosin for nightmares– Atypical antipsychotics Atypical antipsychotics No longerNo longer– Anxiolytics Anxiolytics Not benzodiazepinesNot benzodiazepines

Only SSRIs are approved for treating PTSDOnly SSRIs are approved for treating PTSD There is no medication that specifically There is no medication that specifically

“cures” PTSD “cures” PTSD

Psychological Treatment Psychological Treatment of Complex PTSDof Complex PTSD

Evidence-based psychotherapies are Evidence-based psychotherapies are not, by themselves, enough, since not, by themselves, enough, since they are designed for specific they are designed for specific diagnoses; careful clinical attention diagnoses; careful clinical attention must be paid to the disruptions of must be paid to the disruptions of cognition, emotion, body, sense of cognition, emotion, body, sense of self, and interpersonal relationships self, and interpersonal relationships associated with complex traumaassociated with complex trauma

Ford and Courtois, 20Ford and Courtois, 200909

What Needs to Be DoneWhat Needs to Be Done

Provide Trauma-Specific Provide Trauma-Specific ServicesServices

Train court staff to understand the link Train court staff to understand the link between traumatic experiences and between traumatic experiences and negative outcomes negative outcomes

Screen all patients for a trauma historyScreen all patients for a trauma history Provide case management to expand Provide case management to expand

and link services (including housing, and link services (including housing, shelter, employment, family treatment, shelter, employment, family treatment, transportation, child care, health care, transportation, child care, health care, mental health and substance abuse mental health and substance abuse services, etc.)services, etc.)

Create a Safe, Supportive, Create a Safe, Supportive, Non-Threatening Non-Threatening

EnvironmentEnvironment Maximize choice and controlMaximize choice and control Avoid provocation and power assertionAvoid provocation and power assertion Model prosocial behavior and skillsModel prosocial behavior and skills Maintain clear and consistent Maintain clear and consistent

boundariesboundaries Show respectShow respect

National Child Traumatic National Child Traumatic Stress NetworkStress Network

Create a Safe, Supportive, Create a Safe, Supportive, Non-Threatening Non-Threatening

EnvironmentEnvironment Provide services in a respectful and Provide services in a respectful and

nonjudgmental mannernonjudgmental manner Provide a variety of treatments and Provide a variety of treatments and

groups on trauma: psychoeducation, groups on trauma: psychoeducation, skills training, processing, skills training, processing, reconnection, and ongoing supportreconnection, and ongoing support

Provide a range of culturally Provide a range of culturally competent servicescompetent services

Orient Clients Toward Orient Clients Toward Resilience Resilience

Teach and practice:Teach and practice: Affect regulation skillsAffect regulation skills Anger management strategiesAnger management strategies Problem-solving skillsProblem-solving skills Problem-focused coping strategiesProblem-focused coping strategies Communication skillsCommunication skills Stress management skillsStress management skills RelaxationRelaxation MindfulnessMindfulness

Resources Resources Trauma and RecoveryTrauma and Recovery (1992), Judy Herman (1992), Judy Herman Treating Complex Traumatic Stress DisordersTreating Complex Traumatic Stress Disorders

(2009), Christine Courtois and Julian Ford, eds. (2009), Christine Courtois and Julian Ford, eds. Treatment of Complex Trauma: A Sequenced, Treatment of Complex Trauma: A Sequenced,

Relationship-Based ApproachRelationship-Based Approach (2012), Christine (2012), Christine Courtois, Julian Ford, and John BriereCourtois, Julian Ford, and John Briere

Treating Survivors of Childhood Abuse: Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted LifePsychotherapy for the Interrupted Life (2006), (2006), Marylene Cloitre, Lisa Cohen, and Karestan Marylene Cloitre, Lisa Cohen, and Karestan KoenenKoenen

ResourcesResources The Trauma Recovery Group: A Guide for The Trauma Recovery Group: A Guide for

PractitionersPractitioners (2011), Michaela Mendelsohn, (2011), Michaela Mendelsohn, Judith Herman, Emily Schatzow, and Diya Judith Herman, Emily Schatzow, and Diya KallivayalilKallivayalil

Seeking SafetySeeking Safety (1998), Lisa Najavits (1998), Lisa Najavits Skills Training Manual for Borderline Skills Training Manual for Borderline

Personality DisorderPersonality Disorder (1993), Marsha Linehan (1993), Marsha Linehan Motivational Interviewing, 3Motivational Interviewing, 3rdrd Ed. Ed. (2012), (2012),

William Miller and Sam RollnickWilliam Miller and Sam Rollnick

Resources Resources Trauma Focused-Cognitive Behavioral Trauma Focused-Cognitive Behavioral

Therapy : Therapy : http://tfcbt.musc.edu EMDR: EMDR: http://www.emdr.com and and

http://emdria.org Seeking Safety: Seeking Safety:

http://www.seekingsafety.org Dialectical Behavior Therapy: Dialectical Behavior Therapy:

http://www.behavioraltech.com

Resources Resources

Acceptance and Commitment Acceptance and Commitment Therapy: Therapy: www.act-for-anxiety-disorders.com

International Society for Traumatic International Society for Traumatic Stress Studies: Stress Studies: http://www.istss.org

ResourcesResources

http://www.motivationalinterview.org/ http://www.motivationalinterview.org/

clinical/METDrugAbuse.PDF Motivational Enhancement Therapy Motivational Enhancement Therapy

ManualManual (1994) (1994),, NIH Pub. No. 94-3723. NIH Pub. No. 94-3723. Order from Order from http://pubs.niaaa.nih.gov/publications/ match.htm. .

http://mid-attc.org/accessed/mi.htmhttp://mid-attc.org/accessed/mi.htm

Online and Telephone Online and Telephone ResourcesResources

Online ResourcesOnline Resources

Self-assessment Mental Health screeningSelf-assessment Mental Health screeninghttp://www.militarymentalhealth.org/ Computer-based Problem-solving therapyComputer-based Problem-solving therapyhttp://startmovingforward.t2.health.mil/ Wellness resourcesWellness resourceshttp://afterdeployment.t2.health.mil/

Self-Help Mobile Self-Help Mobile ApplicationsApplications

http://www.t2health.org/mobile-apps http://www.t2health.org/mobile-apps – PTSD CoachPTSD Coach

– T2 MoodTrackerT2 MoodTracker

– Breathe 2 RelaxBreathe 2 Relax

– Tactical BreatherTactical Breather

– LifeArmor (includes family section)LifeArmor (includes family section)


http://www.t2health.org/mobile-apps http://www.t2health.org/mobile-apps mTBI Pocket GuidemTBI Pocket Guide

Concussion CoachConcussion Coach

BiofeedbackBiofeedback

Parenting2GoParenting2Go


Positive Activity JackpotPositive Activity Jackpot

http://www.militarymentalhealth.org/ articles/media/

Virtual Hope Box Virtual Hope Box

Provider Resilience Provider Resilience More to come!More to come!

Mobile Applications That Mobile Applications That Assist PsychotherapyAssist Psychotherapy

PE Coach PE Coach

CPT CoachCPT Coach

CBT-I Coach CBT-I Coach

Mindfulness CoachMindfulness Coach

ACT CoachACT Coach

Contact:Contact:

Brian L. Meyer, Ph.D.Brian L. Meyer, Ph.D.

[email protected]@va.gov

Documents

Complex Trauma in Veterans Brian L. Meyer, Ph.D. Interim Associate Chief, Mental Health Services McGuire VA Medical Center Richmond, VA September 12, 2014