aaron jacoby, phd chief psychologist va maryland health ... · risk of developing ptsd varies with...
TRANSCRIPT
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Aaron Jacoby, PhDChief Psychologist
VA Maryland Health Care SystemOctober 22, 2016
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VA staff including: Nancy Bernardy, PhD Erin Romero, PhD
Service members and Veterans VA PTSD Mentorship ProgramNational Center for PTSD
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Etiology/Diagnosis of PTSD
Reintegration into the Workforce
Treatments for PTSD
Clinical Trials for PTSD
Case Examples
Review of Resources available to Veterans
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Participants will be able to: identify the epidemiology of PTSD expand current knowledge of PTSD treatment
literature identify the evidence-based treatments available for
PTSD identify common challenges Veterans face related to
reintegration into the workforce explore resources available to Veterans
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• Results from an event or series of events• Involves actual or perceived threat to integrity
(self or other)• Experienced or witnessed
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War exposure (combat or civilian) Threatened or actual physical assault Threatened or actual sexual violence Being kidnapped/taken hostage Terrorist attacks Being a victim of torture or witnessing tortureNatural or human-made disasters Severe motor vehicle accidents
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Emotional Reactions (e.g., shock, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, numbing)
Cognitive Reactions (e.g., confusion, disorientation, indecisiveness, poor concentration, memory loss, self-blame, & unwanted memories)
Physical Reactions (e.g., tension, fatigue, edginess, insomnia, startle reactions, racing heartbeat, nausea, decreased appetite, decreased sex drive)
Interpersonal Reactions (e.g., distrust, irritability, withdrawal, isolation, feeling rejected/abandoned, being distant, judgmental, or over-controlling)
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4 clusters of symptoms occur in PTSD: Intrusion Avoidance Negative Alterations in Cognitions and Mood Alterations in Arousal and Reactivity
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Intrusion symptoms (1 required) include: Recurrent, involuntary, and intrusive memories Traumatic nightmares Dissociative reactions (e.g., flashbacks) Intense or prolonged distress after exposure to
traumatic reminders Marked physiological reactivity after exposure to
trauma-related stimuli
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Avoidance symptoms (1 required) include: Avoidance of or efforts to avoid: distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s) external reminders (e.g., people, places,
conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
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Negative alterations in cognitions and mood (2 required) include: Inability to recall key features of the traumatic event(s) Persistent negative beliefs and expectations about oneself or
the world Persistent distorted blame of self or others for causing the
traumatic event or for resulting consequences Persistent negative trauma-related emotions Markedly diminished interest in (pre-traumatic) significant
activities Feeling alienated from others Constricted affect: persistent inability to experience positive
emotions
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Alterations in arousal and reactivity symptoms (2 required) include: Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance
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With dissociative symptoms Depersonalization (i.e., experience of being an
observer of or detached from oneself) Derealization (i.e., experience of unreality, distance,
or distortion
With delayed expression Full diagnosis not met until at least 6 months after
the trauma
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Lifetime prevalence of PTSD among adult Americans (National Comorbidity Survey Replication, 2001-2003): Overall = 6.8 % 9.7% in women 3.6% in men
Military combat personnel are at increased risk: Vietnam ~ 30.9% (men), 26.9% (women) Gulf War ~ 10.1% OEF/OIF ~ 13.8%
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Childhood trauma/abuseFamily history of mental illnessPersonal history of mental illnessLower socioeconomic statusLower educationGreater intensity and duration of traumaRepeated exposure to traumaLow cortisol levelsParent with PTSDLow social supportSubstance abuse
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Risk of developing PTSD varies with a number of individual vulnerability factors.
Typically research has examined factors at three different time points in relation to the traumatic event:
Pretraumatic Peritraumatic Posttraumatic
Bernardy, N (2016). Overview of PTSD Disorder Prevalence and Risk Factors. Presented at PTSD Today and Tomorrow Conference. Johns Hopkins University.
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Bernardy, N (2016). Overview of PTSD Disorder Prevalence and Risk Factors. Presented at PTSD Today and Tomorrow Conference. Johns Hopkins University.
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Lifetime Prevalence (%)
Major Depressive Disorder 48 Dysthymic Disorder 22 Generalized Anxiety 16 Simple Phobia 30 Social Phobia 28 Panic Disorder 12.6 (women) 7.3 (men) Agoraphobia 22.4 (women) 16.1 (men) Alcohol Use Disorder 51.9 (men) 27.9 (women) Substance Use Disorder 34.5 (men) 26.9 (women)
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REINTEGRATION INTO WORKFORCE
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Anxiety, feeling “on edge” Vigilant to safety concerns Frequent reminders of military experiences Feeling disconnected from friends, family, general
civilian population Feeling emotionally numb Anger and irritability Problems with attention, concentration and memory Changes in sleep patterns Difficulty falling asleep Difficulty staying asleep, nightmares
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Physical Reactions
•Existing health problemsworsen
•Trouble sleeping•Stomach upset•Trouble eating•Rapid heart beat•Experiencing shock,numb, unable to feel happy
Behavioral Reactions
•Trouble concentrating•Edgy, jumpy•Being on point•Avoidance
• Too much drinking, smoking, other drug use•Poor self-care•Aggressive driving
Emotional Reactions
•Bad dreams, nightmares•Intrusive memories•Anger•Feeling nervous,helpless, or fearful
•Guilt, shame,self-blame• Feeling sad/rejected/abandoned•Negativeoutlook
http://www.ptsd.va.gov/public/reintegration/guide-pdf/SMGuide.pdf
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Going to drills on weekends Watching current news about the war Hearing about deaths of military service members Seeing vehicles that remind Veterans of those driven by
Iraqis or Afghanis Being around children that remind Veterans of kids in the
war zone Seeing or hearing helicopters Smelling oil or gas Certain types of weather and terrain Being scheduled for redeployment or being redeployed Seeing people who look of “Arab” descent
Armstrong, Best, Domenici (2006) Courage After Fire pg 17
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Most symptoms resolve naturally over time
Majority of Veterans do NOT have PTSD or other mental health disorders
Engaging in structured activities, like school and work assists with readjustment
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Self-stigmaMental health related illnessIncreased aggression Wounded or disabledLack necessary skills to be
academically or vocationally successful
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PTSD Major Depression Alcohol Use Often beginning as an effort to sleep
Opiate Use Often beginning with pain medication for injuries
Military Sexual Trauma Suicide Job loss Family dissolution Homelessness Violence toward self and others Incarceration
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Feel “lost” or “alone” (“no one understands”) Struggle with lack of structure or goals Miss the adrenaline rush associated with various
military experiences Become easily annoyed with civilians who take
things less seriously or are too “laid back” Have anger or resentment towards those who did
not serve or towards other military personnel Feel on edge or tense Feel that everything back home has changed Feel down or depressed soon after being
separated from service
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Elements of Warrior Ethos Example (Army): BATTLEMIND
Selflessness Loyalty Stoicism Moral Code Excellence
B = Buddies (cohesion) vs. Withdrawal A = Accountability vs. Controlling T = Targeted Aggression vs. Inappropriate
Aggression T = Tactical Awareness vs. Hyper-
vigilance L = Lethally Armed vs. “Locked and
Loaded” at Home E = Emotional Control vs.
Anger/Detachment M = Mission Operational Security (OPSEC)
vs. Secretiveness I = Individual Responsibility vs. Guilt N = Non-Defensive (combat) Driving vs.
Aggressive Driving D = Discipline and Ordering vs. Conflict
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Increased reports of suicide among service members and Veterans.
Historically, suicide rates in military personnel were lower than in civilian populations.
Although an upward trend in Veteran suicide rates was noted starting in 2009, the rate for active duty soldiers in 2013 was similar to civilian populations: 18.7 per 100,000 suicide rates among active duty
soldiers compared to 18.8 per 100,000 among nationally matched civilians
Rates for Reserve and National Guard were 23.4 and 28.9 per 100,000, respectively
Institute of Medicine. (2010). Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members and Their Families Military Times: http://www.militarytimes.com/story/military/pentagon/2015/01/16/defense-department-suicides-2013-report/21865977/
http://t2health.dcoe.mil/sites/default/files/DoDSER-2013-Jan-13-2015-Final.pdf
Bumiller, E. (2012, January 10). Active duty soldiers take their own lives at record rate. New York Times., pp A13.
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• An estimated 20 Veterans die by suicide every day
• Male Veterans are twice as likely as civilians to commit suicide
• 1000 suicides occur per year among Veterans receiving care at a VA Facility
• 5000 suicides among all Veterans
* Statistic from the www.dod.us.gov and www.va.gov
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4 psychotherapies: Cognitive Therapy Exposure Therapy Stress Inoculation Therapy Eye Movement Desensitization
Reprocessing Therapy (EMDR)Pharmacotherapy: Selective Serotonin Reuptake Inhibitors
(SSRIs)
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Treatment of PTSD: An Assessment of the Evidence
Published 2007 Reviewed all treatments included in VA/DOD
Practice Guidelines as well as other professional organization guidelines
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Found the evidence for all but one psychotherapy (exposure therapy) inadequate to reach a conclusion regarding efficacy
Found the evidence for all pharmacological treatments inadequate to reach a conclusion regarding efficacy
MORE RESEARCH IS NEEDED!
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During fiscal year 2014, NCPTSD investigators led 117 funded studies, ranging from small studies taking place at a single location to large multi-site projects.
NCPTSD continues to align its research support with the Operational Priorities identified in 2013 including research in the areas of: (1) Biomarkers, (2) DSM-5, (3) Treatment
efficiency, effectiveness, and engagement, (4) Care delivery, models of care, and system factors, and (5) Implementation
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CTU-Online includes brief updates on the latest clinically relevant research.
Content on treatment and assessment is emphasized.
Publications on other topics are included if the content has significant clinical implications related to PTSD treatment.
Issues include an ID number so you can find the article in the PILOTS database and a link to the abstract/full article.
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Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541e550.
The study sample consisted of 137 comparisons drawn from 112 randomized clinical trials of treatment for PTSD in adults.
The between-groups effect size (g) was 1.14 for psychotherapy, 1.25 for somatic treatment, and 0.42 for medication.
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Watts, Schnurr et al., 2013
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26 yo OEF/OIF veteran, Marine Corps Combat Engineer
Served 2 tours in Iraq 1st tour: initial invasion 2nd tour: year long, 2nd siege of Fallujah
History of previous TBI related to pre-combat car accident
Exposure to multiple blasts in 2nd tour of Iraq during house patrols and city sieges
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Initially diagnosed with an adjustment disorder with mixed anxiety and depressed mood
Initially difficult to elicit trauma history due to memory problems
Role of alcohol abuse, disinhibition Intense emotional numbingAggression, bar fights, more head trauma? Paranoia
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Impact on: memory cognition decision making concentration sense of smell mood regulation energy level
Due to PTSD? TBI? Both?
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22 yo OEF/OIF Veteran, Army Infantry Served 12-month tour in AfghanistanOriginally trained with one unit, then
reassigned and deployed with new unitConsiderable detachment from deployed unitUpon return to U.S., Veteran was
disillusioned, unmotivated, and apathetic Therapy goals included life goal setting
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Emotional numbing Lack of support network Veteran increased social supports, obtained
employment, and gained direction in life, being able to put into perspective his combat deployment
Veteran prescribed antidepressant and sleep medication
Veteran experienced mood improvement and social and professional life flourished
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36 yo Persian Gulf Veteran, NavyHistory of Military Sexual Trauma (MST),
childhood trauma, and lifetime negative interpersonal relationships
Veteran seeking guidance on remaining in or leaving current long-term partner
Relationship Cost-Benefit analysis completed Explored role of past trauma on ability to
socially engage
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Veteran craved more connection with boyfriend, who had been diagnosed with PTSD and post-TBI symptoms, but boyfriend struggles impeded connection
Use of cognitive behavioral interventions, targeting all-or-none thinking
Veteran now considering working on own trauma history to gain personal symptom reduction
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64 yo Vietnam Veteran, Army Infantry Veteran completed treatment for PTSD, but
left with continued negative interpersonal relationship with wife of almost 40 years.
Veteran attempted to engage in couples treatment, initial success, but then wife discontinued both couples and individual therapy
Veteran experienced disillusionment, dysphoria
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Veteran craves more connection with wife nowthat PTSD symptoms are better controlled
Wife also suffers from undiagnosed PTSD from childhood and early adulthood trauma
Therapeutic work included perspective takingand matching spousal needs with realistic expectations of possible change
Veteran is working to control ongoing disappointment, but gaining complacency from other social outlets
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