VA Medical CenterAlbany, NY

Assessment, Diagnosis and Treatment of Posttraumatic

Stress Disorder

NADE National Training Conference

September 14, 2010

Posttraumatic Stress Disorder Program

Charles R. Kennedy, PhD

PTSD Program Director

Karen S. Voss, LCSW, BCD

Jennifer A. Courtney, LCSW

Loretta S. Malta, PhD

Jason B. Gallo, PhD

Jonathan Shay, MD, PhD Department of Veterans Affairs, Boston MAFrom Achilles in Vietnam 1994

“I shall argue throughout this book that healingfrom trauma depends upon communalization of thetrauma- being able safely to tell the story to someonewho is listening and who can be trusted to retell ittruthfully to others in the community. So beforeanalyzing, before classifying, before thinking, before trying to do anything- we should listen.”

History of Posttraumatic Stress Disorder

PTSD is an anxiety disorder that can occur after experiencing orwitnessing a traumatic event.

The person experienced, witnessed or was confronted by an eventor events that involved actual or threatened death or serious injury or threat to physical integrity of self or others.

The person’s response involved intense fear, helplessness orhorror.

Most survivors of trauma return to pre-trauma functioning over time.

Introduction to PTSD

Traumatic events have been a part of the humanexperience since the beginning of time.

Accounts of traumatic stressgo back at least as far asAncient Greece, whose authors wrote a great deal about betrayal, grief, combat and tragedy.

http://www.sfu.ca/classics/myth/images/fagles.jpg

Historical Terms for PTSD

Military Trauma

Nostalgia

Soldier’s Heart

Shell Shock

Combat Fatigue

War Neurosis

Civilian Trauma

Railway Spine

Survivor Syndrome

1980

The American Psychiatric Association 3rd edition of the Diagnostic and StatisticalManual of Mental Disorders used the termPosttraumatic Stress Disorder for the first time. PTSD became established as a diagnosis, with the stressor criterion that people had to have been exposed to a “recognizable stressor thatwould evoke significant symptoms of distress inalmost anyone.”

PTSD Prevalence Rates

Combat exposure is one of the traumas, along with sexual assault, most commonly associated with the development of PTSD

The estimated lifetime prevalence of PTSD for the general population is approximately 8%

It is estimated that 15.2% of male Vietnam combat veterans currently suffer from PTSD and the lifetime prevalence for this population is estimated at 30.9%

PTSD Prevalence Rates

60.7% of men and 51.2% of women are exposed totrauma

5% males and 10% of females are diagnosed withPTSD

Some people have stress reactions that do not goaway or get worse over time

These individuals may develop PTSD

OEF/OIF Veterans

Invisible Wounds of War

Approximately 1.65 million U.S. troops have deployed as part of Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) since October 2001

Editors Terri Tanielian and Lisa H. Jaycoxwww.rand.org

PTSD Prevalence Rates

19% of four surveyed U.S. combat infantry units met criteria for a diagnosis of combat-related PTSD following deployment to Iraq

1.6 million people have served in the Iraq and Afghanistan, 750,000 have left the military

Approximately 49% of those 750,000 who have left the military report mental health symptoms.

Approximately 60,000 of the 750,000 who have been discharged are currently seeking mental health services

TRAP: The Symptoms of PTSD

Trauma: the person experienced, witnessed, or was confronted by an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness or horror.

Reexperiencing Symptoms – intrusive recollections, traumatic dreaming, flashbacks

Avoidant Symptoms – of others, stimuli connected to trauma

Physiological Symptoms – exaggerated startle response, hypervigilance

Trauma

PTSD is an anxiety disorder that can occur afterexperiencing or witnessing a traumatic event. The person experienced, witnessed or wasconfronted by an event or events that involvedactual or threatened death or serious injury orthreat to physical integrity of self or others.

The person’s response involved intense fear,helplessness or horror.

Reexperiencing Symptoms

Recurrent, Persistent and Intrusive Thoughts

Vietnam veterans with PTSD and non-PTSD veterans were exposed to scents in minute proportions under ability toname. Veterans with PTSD showed intense polygraphreactions to odors (burning hair, jet fuel) associated withtrauma. 100% of veterans with PTSD called upon traumaticmemories during the study procedures. McCaffrey et al. (1993)

Nightmares and Dreams Flashback and Hallucinations

Avoidance

Efforts to avoid thoughts and feelings about the trauma

Avoidance of activities and situations which stimulate recollection of the trauma

Numbing / Emotional Avoidance

Psychogenic amnesia

Diminished interest in usual activities

Feelings of detachment or estrangement from others

Restricted range of affect

Detachment from the future

Physiological Arousal

Sleep disturbance

Increased irritability, lowered threshold for anger

Impaired concentration

Hypervigilance

Exaggerated startle response

Physiological reactivity to trauma reminders

Increase in measure of vital signs: breathing, muscle tension, heart rate and blood pressure, fear of “going crazy” or dying

Recovery from PTSD

Some veterans experience an immediate onset of PTSD, symptoms that occur right after the traumatic experience

For other veterans, symptoms begin many years after they thought they had put their military experiences behind them

Life stressors, such as transition to civilian life, physical illness, birth of a child, divorce, death of a loved one, or retirement may trigger symptoms unexpectedly

Goals of PTSD Treatment

• Symptom reduction

• Integration thoughts and feelings

• Create new memories

• Disinhibit imagination

• Foster interpersonal connection

• Register other than traumatic material

• Create a narrative about the trauma, create meaning

• Bring the trauma to the present instead of person being pulled back to the past

• Promote chosen action, challenge the fixed action of fight, flight or freeze reaction

• Reconnect the neocortex and limbic system

• Fulfillment in living in the present

• Investment in the future

Evidence Based Practice

Individual TherapyProlonged ExposureEye Movement Desensitization & ReprocessingCognitive Processing Therapy

Group TherapyCognitive Processing TherapySeeking Safety/StrengthDialectical Behavior Therapy

Pharmacotherapy

Pharmacotherapy is empirically supported, generally costeffective and often addresses the co-morbidsymptomotology that accompanies PTSD

Many drugs are used in the treatment of PTSD

Friedman et al. (2000) cite multiple studies in reportingthat SSRIs, such as fluoxetine, sertraline, paroxetine andfluvoxamine, are the only agents with the capacity toreduce symptoms in all three PTSD symptom clusters

PTSD Program Levels of Care

Group 1 Simple Trauma

Group 2 Mild Complex Trauma

Group 3 Moderate Complex Trauma

Group 4 Severe Complex Trauma

Group 5 Chronic Severe

Treatment Group 1

• Combat Veterans and Acute Illness (Simple PTSD)• Estimated to be 10-20% ( Groups 1 & 2) of Veterans followed by

PTSD specialists• Minimal history of prior (childhood or pre-military) trauma• High level of pre-trauma functioning• Usually responsive to EBPs with minimal time spent on

pre-treatment therapeutic engagement• Sometimes may be sub-clinical PTSD or Adjustment Disorder• Unlikely to have co-morbid disorders such as substance abuse, if

so, sub-threshold

Treatment Group 2

• Minimal history of prior (childhood or pre-military) trauma, but may have experienced multiple traumas in combat

• May have co-morbid depression or substance abuse specifically related to the traumas, secondary

• May need time to engage in therapy prior to initiating EBP treatment

Treatment Group 3• Combat Veterans and Stable but Serious Disability (Temporarily Stable, but (recent

decline in pre-morbid functioning precipitated by psychosocial stressor) Impaired Baseline of Functioning)

• Estimated to be 33% ( in combination with Group 4) of population seen by PTSD specialists within VISN 2

• Pre-military trauma and/or childhood neglect• Co-morbidities may include Substance Abuse or Dependence, Depression, Anxiety,

Bipolar Disorder, Axis II Personality Disorders• Likely to have episodes of increased PTSD symptoms, interpersonal problems,

distress tolerance problems• Therapeutic alliance is important due to fragility and trust difficulties• Best managed by PTSD specialists due to the complexity of their symptoms and the

likelihood of frequent relapses• May be sustained with group or monthly individual sessions to maintain contact and

monitor for exacerbations

Treatment Group 4

• Combat Veterans and Acute Illness and Stable but Serious Disability (Temporarily unstable and Impaired Baseline of Functioning)

• Estimated to be 33% (in combination with Group 3)of population seen by PTSD specialists within VISN 2

• Pre-military trauma and/or childhood neglect• Co-morbidities may include Substance Abuse or Dependence, Depression,

Anxiety, Bipolar Disorder, Axis II Personality Disorders or traits • Currently experiencing an exacerbation of symptoms due to recent deployment,

external triggers such as loss of a job, loss of a family member, other life changes and in need of an episode of intensive stabilization or exposure therapy

• Therapeutic alliance is important due to fragility and trust difficulties• Best managed by PTSD specialists due to the complexity of their symptoms and

the likelihood of frequent relapses

Treatment Group 5

• Combat Veterans and Chronic Condition with Limited Reserves (Chronic and Stable PTSD)

• Estimated to be 33% of population seen by PTSD specialists within VISN 2

• Unlikely to benefit from or not interested in EBP or any therapy that directly challenges them to make change

• Seeking supportive therapy to help them maintain level of functioning• May fear losing service connection if therapy discontinued altogether• May be socially isolated and rely on therapy as a primary social support• Can be treated in any clinic, may do well in supportive therapy groups

Traumatic Brain Injury

Traumatic brain injuries - caused by

Improvised Explosive Devices, mortars,

vehicle accidents, grenades, bullets,

mines, falls and blast concussion –

May be the hallmark injury faced by

veterans of Iraq and Afghanistan. 

VA Polytrauma Programs

Polytrauma care is for veterans and returning service members with injuries to more than one physical region or organ system, one of which may be life threatening.

These injuries result in physical, cognitive, psychological, or psychosocial impairments and functional disability.

Common Polytrauma Conditions

Traumatic Brain Injury Hearing Loss Amputations Fractures Burns Visual Impairment Posttraumatic Stress Disorder

VA Polytrauma System of Care

VA has treated over 500 OEF/OIF service members in inpatient units.

The vast majority of these patients have been on active duty at the time of admission.

The major cause of injury has been trauma sustained in combat.

Dedicated Levels of Care

Polytrauma Rehabilitation Centers provide acute, comprehensive, inpatient rehabilitation. 

Polytrauma Network Sites provide specialized, post-acute rehabilitation in consultation with the Rehabilitation Centers in a setting appropriate to the needs of veterans, service members, and families.

Polytrauma Support Clinic TeamsVAMC Albany

Provider follow up services in consultation with regional and network specialists.

Assist in managing the long-term effects of Polytrauma through direct care andconsultation.

Inpatients are monitored 24 hours a day at all of our facilities.

Polytrauma Rehabilitation Centers

Richmond, VA Tampa, FL Minneapolis, MN Palo Alto, CA

Polytrauma Network Sites

Syracuse, NYBronx, NY Boston, MA Lexington, KY Houston, TX Cleveland, OH Dallas, TX Indianapolis, IN Tucson, AZ

Philadelphia, PA Hines, IL Denver, CO Washington, DCSt. Louis, MO Seattle, WA Augusta, GA West Los Angeles, CA

Support for Veterans and Families

Logistic SupportClinical Support

Emotional Support

VA Polytrauma programs provide comprehensive, high

quality, inter-disciplinary care to patients.

Teams of clinicians from every relevant field plan and

administer an individually tailored rehabilitation plan to help

the veteran recover to their highest level of functioning.

Impact of Combat-Related PTSD on Primary Relationships and Family Functioning

Difficulties with self-disclosure, communication and problem solving (Carroll, Rueger, Foy & Donahoe, 1985; Nezu & Carnevale, 1987)

Elevated levels of spousal and familial verbal and physical aggression (Byrne & Riggs, 1996; Savarese, Suvak, King & King, 2001)

Greater somatization, depression, anxiety, loneliness and hostility among wives of veterans with combat-related PTSD (Solomon, Waysman, Avitzur & Enoch, 1991; Waysman, Mikulincer, Solomon & Weisenberg, 1993)

Parenting problems (Jordan et al., 1992)

Family members of veterans with combat-related PTSD report more problems with affect regulation and less affective responsiveness than do family members of non-PTSD veterans (Dansby & Marinelli, 1999; Davison & Mellor, 2001)

Important Others

The most significant protective and resiliencerecovery variables associated with PTSDseem to be those related to perceivedemotional sustenance, current social supportand attachment style.

Dieperink et al., 2001 King, Foy, Keane & Fairbank, 1999

What We Would Like Our Family and Friends to Know about Living with PTSD

Written by Combat VeteransStratton VA Medical Center, Albany, New York

• Sometimes I am moody and I don’t understand why, please give me some space until I am ready to be around people again.

• I am often uncomfortable and anxious in crowds orwith unfamiliar people because my experienceshave made it difficult for me to trust unknownpeople.

What We Would Like Others to Know

• Certain “triggers” e.g. loud noises, smells, objects in the road startle me, remind me of traumaticexperiences or cause me to behave in ways thatyou might not understand.

• Please know that these “triggers” signal danger for me.

• I am easily startled and I am always watchful fordanger in the environment.

What We Would Like Others to Know

• Please understand that not everything can beexplained.

• Please don’t take it personally if I cannot explaincertain things to you. I don’t always understandthem myself.

• Please don’t ask for a description or details of my traumatic experiences. Sometimes explaining things can increase my distress.

What We Would Like Others to Know

• Please know that certain days or anniversaries are important.

• Know that close relationships are often difficult and scary. We are often afraid of losing those we care about and engage in distancing behaviors as a way to protect ourselves from potential loss.

• Please “hang in there.” Be supportive but not intrusive.

What We Would Like Others to Know

• Please know that we often do things in a certain way to promote order and organization and to help balance the chaos we often feel internally and in other parts of our lives.

• Ultimately, we often do things in a certain way to feel safe.

• Many of our behaviors e.g. eating with back against the wall in restaurant or driving around an object in the road are automatic and have been conditioned to maintain safety.

What We Would Like Others to Know

• Please know that all of these behaviors are the result of our experiences and the mental and physical changes that are the result of trauma.

• These behaviors are ways that we protect and sustain ourselves.

• For us, these thoughts, feelings and behaviors are about life, death, survival and safety.

http://www.ncptsd.va.gov/ncmain/index.jsp

VA National Center for PTSD

http://www1.va.gov/VISNS/visn02/albany.cfm

VA Medical Center, Albany, NY

http://www.polytrauma.va.gov/

VA Polytrauma System of Care