PTSD- A Clinician’s Perspective

Features, diagnostic criteria, intersection with TBI

Paul Harig, Ph.D.

Housekeeping:

Financial Disclosure: Nothing to disclose

Representation: The comments expressed are the presenter’s personal views and are not intended to represent the policies or positions of the United States Department of Veterans Affairs

What constitutes a traumatic experience?

How broadly or narrowly should trauma be defined?

• The meaning of trauma has changed over the years in text explaining diagnostic criteria:

• Statistically rare: (DSM-III) “a psychologically traumatic event that is generally outside the range of usual human experience.. would evoke significant symptoms of distress in most people.”

• The DSM-5 revision- preserves trauma as a logical basis for intrusion and avoidance symptoms and must involve direct exposure to actual or threatened death, serious injury or a threat to physical integrity. (Friedman et al. 2011) “ Traumatic experience is usually a watershed event that marks a major discontinuity in the life trajectories of individuals affected.”

Weathers and Keane, Journal of Traumatic Stress, April 2007

Core neuroscience themes relevant to PTSD

• Fear Conditioning & Avoidance of Conditioned Contexual Cues in a Dangerous Environment supports survival

• Dysregulated Circuits- Abnormalities in the regulation of the sympathetic nervous system and the HPA axis & regulatory imbalance between medial prefrontal cortex and amygdala

• Memory Reconsolidation- Updating at each recall means opportunity for reinforcement of prior beliefs and interpretations , including cognitive distortions around guilt, responsibility and self-blame

• Epigenetic Considerations- Early childhood trauma can program the stress system for susceptibility to more trauma

Ross et al. , JAMA Psychiatry, March 2017

Core: A conditioned defensive survival circuit that does not require consciousness

Cognitive appraisal: Fear learning circuitry biased toward generalization of fear associations

Attentional Bias: Overestimation of risk, exaggerated fear expression, impaired extinction

Coping strategies to intrusive cognitions: cognitive and experiential avoidance

Negative emotions (guilt, shame, mood disorders)

Dose response: Effects of prior and cumulative trauma on emotion regulation

PTSD as a multi-layered cognitive- behavioral system

Diagnostic Criteria for PTSD once a Trauma has been Established– DSM-5 (2013)

• Intrusion Symptoms (≧1 meets PTSD Criteria)

• Recurrent, involuntary, intrusive distressing memories of the traumatic event(s)• Do you find yourself thinking about the trauma even when you don’t want to? Can you push these thoughts out of

your mind?

• Recurrent distressing dreams related to the traumatic event(s)• Are you having bad dreams or nightmares about the trauma? If so, how often are you having them?

• Dissociative reactions (flashbacks)• Sometimes people who have had traumatic experiences can have brief periods when they feel that they are back in

that previous traumatic experience, as though they are reliving it, even though the actual event happened in the past. Has that happened to you?

• Marked or prolonged distress at exposure to triggers that resemble or symbolize the traumatic events

• Have you been getting emotionally upset when something reminds you of the trauma?

• Marked physiological reactions at exposure to triggers that resemble or symbolize the traumatic events

• When something reminds you of the trauma, do you have physical reactions (e.g. heart pounding, trouble breathing, or sweating)?

Spoont et al., JAMA , August 2015

Diagnostic Criteria for PTSD once a Trauma has been Established– DSM-5 (2013)

• Avoidance Symptoms (≧1 meets PTSD Criteria)

• Avoidance of distressing memories, thoughts, or feelings associated with the traumatic event(s).• Have you been trying to think about the trauma?

• Avoidance of external reminders of the traumatic event(s)• Have you tried to avoid people or things that remind you of the trauma?

Diagnostic Criteria for PTSD once a Trauma has been Established– DSM-5 (2013)

• Alterations in Cognition and Mood (≧2 meets PTSD Criteria)

• Inability to recall an important aspect of the traumatic event• Do you have trouble remembering some important part of the trauma?

• Persistent negative beliefs or expectations about oneself, others or the world• Are you having more negative thoughts about yourself, other people, or the world since the trauma?

• Persistent distorted cognitions about the causes or consequences of the traumatic event• Do you feel like the trauma is your fault? Why? Do you think iy is all someone else’s fault?

• Diminished interest• Have you been less interested in things you used to enjoy before the trauma?

• Feelings of detachment or estrangement from others• Have you been feeling distant from people or like you can’t connect with them? Does this include family?

• Persistent inability to experience positive emotions• Have you had trouble having good feelings (e.g. happiness or love) since the trauma? Do you feel emotionally numb?

Diagnostic Criteria for PTSD once a Trauma has been Established– DSM-5 (2013)

• Marked Alteration in Arousal and Reactivity (≧2 meets PTSD Criteria)

• Irritable behavior and angry outbursts• Have you been feeling more irritable or angry and acting on it? Do other people notice?

• Reckless or self-destructive behavior• Have you been more reckless, taking too many risks or bigger risks even though you could have been really

hurt? Have you injured yourself?

• Hypervigilance• Do you feel hyper alert, constantly looking over your shoulder even when you don’t really need to?

• Exaggerated startle response• Do you feel you are more jumpy and easily startled. More so than other people?

• Problems with concentration• Are you having a harder time focusing?

• Sleep Disturbance• Have you been having trouble sleeping? What kinds of problems are you having?

Recommended Psychometric Tools for Assessment of PTSD

Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)• Gold standard for diagnosis of PTSD• 30-item structured interview• In addition to assessing the 20 DSM-5 PTSD symptoms, questions target the

onset and duration of symptoms, subjective distress, impact of symptoms on social and occupational functioning, etc.

• Takes 45-60 minutes to administer

PTSD Checklist for DSM-5 (PCL-5)• 20 item self-report measure that addresses the 20 symptoms of PTSD• Sensitive and specific screening tool that can be used to support a provisional

diagnosis• Can be completed by patients in 5-10 minutes

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)• 5 item screen for use in primary care settings• Designed to identify respondents with probable PTSD• Those screening positive require further assessment, preferably with CAPS -5

IED Strikes Convoy on Patrol 1-40 CAV, 3rd ID, Task Force Marine Videographer SPC Jay Townsend https://www.youtube.com/watch?y=rNx3-R13FtA

How PTSD and TBI Can Occur Together

• mTBI without amnesia- conscious memories of whole traumatic event

• One or more ‘islands’ of memory during post-traumatic amnesia

• No conscious/explicit memory due to organic amnesia but trauma is re-experienced by a non-conscious/implicit fear response

• Little or no memory of the event but where imagined or reconstructed “pseudomemories” are generated based upon what patient believes has happened or was told what happened

King, Brain Injury, January 2008; 22(1)

Yurgil et al. Association between TBI and PTSD in 2600 Active Duty Marines

Longitudinal study 1 month before deployment and 3-6 months after deployment

57% of participants reported prior TBI; 20% reported sustaining TBI between assessments (most mTBI)

Deployment related TBIs nearly doubled the likelihood of postdeployment PTSD

“Even when accounting for predeployment symptoms, prior TBI and combat intensity, TBI during the most recent deployment is the strongest predictor of postdeployment PTSD symptoms.”

Yurgil et al., JAMA Psychiatry, 2014; 71(2)

Does PTSD mediate or confound the association between concussion and post-deployment health?

Hoge et al. (2008) – 2525 infantry soldiers 3-4 months after return from deployment :Of 5% who reported LOC – 44% met PTSD criteriaOf 10% who reported altered mental status – 27% met PTSD criteria

History of concussion/mTBI was associated with more postconcussive and somatic symptoms,poorer general health and more work days missed

However

After controlling for PTSD and depression, concussion/mTBI was no longer associated with these outcomes except for persistent headache

Hoge et al., New England Journal of Medicine, January 2008

Polusny et al. (2011) Longitudinal effects of mTBI & PTSD Comorbidity on Postdeployment Outcomes

Studied 2677 National Guard soldiers 1 month before return home and 1 year laterTime 1: 8% were PTSD+ and 9% self-reported mTBI/concussionTime 2: 14% were PTSD+ and 22% self-reported mTBI

Results suggest that a history of concussion/mTBI alone was not associated with postdeployment PCSs, depression, problematic drinking, somatic complaints, social adjustment, or quality of life.

“Regardless of whether soldiers reported sustaining mTBI at time 1, self-report of Time 2 post-concussive symptoms was common” When PTSD severity was controlled, there were no significant differences between mTBI and controls

Postdeployment memory problems, balance problems , difficulty concentrating, and irritability were more common in the PTSD-only group

Polusny et al., Archives of General Psychiatry, January 2011

Russo & Fingerhut Consistency of self-reported Symptoms from End of First Deployment to VA Comprehensive TBI Evaluation

Studied rates of neurocognitive, PTSD symptoms and concussive events in 140 VeteransParticipants averaged 4 years post deployment between assessments

The majority were deployed 1x and 68% endorsed combat experiencesStudy compared rates on DOD PDHRA and VA TBI Evaluation

378% increase in concentration impairment (9 TO 43)

600% increase in decision making impairment (5 to 35)

429% increase in memory impairmemt (24 to 127)

115% increase in reported headaches (59 to 127)

124% increase in reported sleep disturbance (58 to 130)

Russo and Fingerhut, Archives of Clinical Neuropsychology, 2017

Concussive events: blast, fall, MVA, wound above shoulders

Only 39% (20) reported the same events at both assessments; 73% (37) reported an event at DOD PDHRA, 98% (50) reported an event at VA Eval

133% increase in reported LOC (9 to 21)

169% increase in being dazed or seeing stars (16 to 43)

380% increase in post event amnesia (5 to 24)

Half of all subjects denied PTSD at PDHRA; 75% endorsed all symptoms at VA evaluation

155% increase in re-experiencing trauma (44 to 112)

231% increase in avoidance (35 to 116)

135% increase in watchfulness (51 to 120)

354% increase in numbing (26 to 118)

Russo & Fingerhut

“Finally, although the vast majority reported severe or very or very severe levels of current functional impairment, most also reported that they were working and/or attending college despite their professed levels of marked impairment.”

Russo & Fingerhut (2017):

Main finding is the marked lack of consistency of combat veteran self-report of trauma related events over time