From Combat to Mass Shootings:Reinventing the

Treatment of PTSD

Deborah C. Beidel, Ph.D., ABPP

Trustee Chair and Pegasus Professor

UCF RESTORESUniversity of

Central Florida

Acknowledgements and Disclosure

This study was supported in part by the U.S. Army Medical Research & Materiel Command-Military Operational Medicine Research Program (USAMRMC-MOMRP; contract W81XWH-11-2-0038) to the first author. The study had both MRCM HRPO and local IRB approval and does not necessarily reflect the policy/position of the government.

The funding source had no involvement with the design, collection, analysis or interpretation of the data, or the construction of this presentation.

This study was also supported in part by Department of Justice Antiterrorism and Emergency Assistance Program (2017-RF-GX-0003).

The author has no conflicts of interest to disclose with respect to this research.

Diagnostic (DSM-5) criteria for PTSD• Symptoms Present More than 1 Month

• (1) Intrusion Symptoms

• Nightmares, distressing thoughts, flashbacks

• (2) Avoidance of Stimuli

• Avoidance of people, places, feelings

• (3) Negative Alterations in Cognition and Mood

• Numbing of interests and positive emotions

• (4) Marked Alterations in Arousal and Reactivity

• Sleep/concentration difficulties, anger outbursts, exaggerated startle response

PTSD Affects Families and Communities

• Results in• Anger/Alienation

• Guilt Remorse

• Leads to• Reckless driving

• Physical assaults

• Carrying unneeded weapons

• DUI

• Unnecessary health risks

Adler et al. (2011)

The Challenge of Combat-Related PTSD

• Prevalence is 9%; lifetime prevalence is 30%

• From 2004-2009

• VA spent $3.7 billion for all veterans health care

• $2.2 billion (60%) went for PTSD and TBI –but only 28% of vets getting care

• Patients with PTSD, TBI or both had health care costs 4-6 times as high as patients without those conditions.

UCF Psychology

Impact of PTSD on the Nation

• PTSD was the 3rd

most prevalent condition for VA disability compensation in 2012 (572,612 veterans) after hearing loss and tinnitus

Duggan (2017)

Barriers to Care

• Difficulty getting appointments

• Difficulty getting time off to attend appointments

• Perceived stigma

• Preference for treatment of issues such as sleep disruption, anger and stress

Hoge et al. (2014); Crawford et al. (2015)

What about

veterans who

make it past the

barriers?

• Statistically significant reduction in symptoms but 50-66% still meet diagnostic criteria after a full course of treatment

• High rates of treatment attrition

• 28% - 40% drop out - even from our most efficacious treatments

• Ongoing crisis in PTSD care

• There is considerable room for improving treatment efficacy, “particularly for interventions that enhance treatment engagement and retention” (Hoge et al., 2016)

• Do we need different treatments?

• Or should we be delivering established treatments differently?

Brief History - Trauma

Management Therapy for

OIF/OEF Veterans

• Oct, 2003: Awarded a grant (NIMH MH063721) to treat Vietnam veterans with chronic PTSD

• Jan, 2011: Awarded a grant (W81XWH-11-2-0038) from the Military Operational Medicine Research Program (MOMRP) USAMRMC to develop and evaluate a new treatment for combat-related PTSD in OIF/OEF veterans.

• Charged with developing a “faster” treatment for treating active duty personnel with combat-related PTSD

From Vietnam to

Iraq and Afghanistan:

Doing Treatment Differently

• Incorporating the use of virtual reality to enhance exposure therapy.

• Adding a simultaneous group treatment component to address depression, guilt, anger, sleep and social maladjustment.

• Providing treatment daily (several sessions per day) for an intensive period of time.

What is the Core Element of

Exposure Therapy?

• How do you get over your fear of a dog?

• You have to be around a dog

• But the dog has to look like the dog that caused the traumatic event.

Challenges for Exposure Therapy for OEF/OIF Veterans

• Typically, exposure therapy is conducted using either imaginal or in vivo methods.

• How do you recreate this?

Doing Treatment Differently: Virtual Reality (VR) to Augment EXP

• Allows presentation of relevant cues, overcoming reluctance to imagine these events

• Overcomes the inability to engage in imagery of sufficient detail and affective magnitude

Why Olfaction?• Olfactory cues, paired with aversive

stimuli, produce conditioned fearful behavior to both the odor and the context (Kroon et al., 2008).

• Patients with PTSD associate odors with traumatic events and describe specific olfactory cues as primary precipitants of flashbacks (Kline & Rausch, 1985; Vermetten & Bremner, 2003).

• This is particularly so for veterans of OIF/OEF who report memories of the novel smell of the desert, smells from IEDs, garbage and related smells such as Middle Eastern spices

Doing Treatment Differently- Trauma Management Therapy

• Multi-component intervention (all 5 days per week for 3 weeks)

• Imaginal or VR individual exposure

• In-vivo exposure

• Group treatment

Monday Tuesday Wednesday Thursday Friday

Week 1 BehavioralActivation

ImprovingSleep

Anger Management

SocialReintegration

Behavioral Activation

Week 2 Improving Sleep

Anger Management

Social Reintegration

Behavioral Activation

Improving Sleep Skills

Week 3 Anger Management – Guilt

Social Reintegration

Behavioral Activation

Integration Session

RelapsePrevention

TMT Results (comparison to 17 week program)

82.3

40.144.3

95.4

43.1 45

0

20

40

60

80

100

120

Pre TX Post TX 6 Month Follow up

Clinician Administered PTSD scale (considered the VA gold standard for determining the presence of

PTSD in combat veterans)

17 Week 3 week

• Drop out rate• 2% (3 week program)

vs. 28% (17 week program)

• Relapse rate • 1% (3 week program)

vs. 4.5% (17 week program)

16 Aug 201616

UCF RESTORES Trauma Management Therapy (TMT)

UCF TMT outcome vs. Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for Combat PTSD

31%

42%

66%

0%

10%

20%

30%

40%

50%

60%

70%

% withoutPTSD

% Without PTSD at posttreatment

CPT

PE

UCF TMT

17.5

27.1

52.8

0

10

20

30

40

50

60

Mean Decrease inCAPS Score

Decrease in CAPS score

CPT

PE

UCFTMT

56%66%

96%

0%

20%

40%

60%

80%

100%

120%

Percent with atleast a 10 pointdecrease on the

CAPS

Ten point decrease as clinically significant

CPT

PE

UCFTMT

Pulse Nightclub Shooting – June

12, 2016

• Latin night – 300 primarily Latino patrons

• 2:00am - officer reported shots fired

• Incident became a hostage situation

• 5:00am – SWAT teams breached the wall, rescued hostages and killed the gunman

Pulse Nightclub Shooting – June 12, 2016

Secondary Impact

Type

Secondary Impact # Persons

Extended Family

Multiplier

# at risk of Negative BH Consequences

EMS First Responders

75 2.76 207

Medical Examiner’s Office

20 2.76 55

Clinicians deployed by

OCHS and CFCHS 70 2.76 193

Law Enforcement First Responders

300 2.76 828

Subtotal 1,283

Department of Justice, 2017

SUICIDE AND FIRST RESPONDERS

93

129

103

140

0 20 40 60 80 100 120 140 160

Firefighter

Police Officer

First Responder Morbidity

Suicide Line of Duty

UCF RESTORES Treatment for First Responders

Responder Type Number1

Percentage

Fire/EMS 163 76%

Law Enforcement

43 20%

Dispatcher 8 4%

TOTAL 214 100%

PULSE RELATED

Yes 34 16%

No 177 83%

Left Blank 3 %1Since June12, 2016

Orlando Pulse Shooting

• Immediate Crisis Management

• Psychological First Aid

• Not forms of CISD that can exacerbate symptoms

• Symptom Monitoring

• Education about typical trauma responses and when to seek help

Problems Among First Responders Seeking Treatment at UCF RESTORES

Type PTSD Trauma AUD PDD MDD GAD Adjust Other No DX

Disp 0 1 0 0 1 0 1 3 2

FF/EMS

62 21 4 4 18 2 8 19 27

LE 21 6 0 0 1 0 0 6 9

Total 83 28 4 4 20 2 9 28 38

% 38% 13% 2% 2% 9% 1% 4% 13% 18%

22%

16%

13%

11%

10%

8%

7%

6%

5%

4%

3%

1%

Pediatric Calls

Pulse

Multiple Events

Death of Family Member or Friend

MVA w/ Death

Gorey/Graphic/Dramatic Death

Near Death Experiences

Shooting

Suicide Calls

Trauma not Related to Work

Trauma During Military Service

Sexual Assault

Trauma Index Percentages

Firefighter/Paramedic

Law Enforcement

Dispatcher

TMT for Pulse First Responders

• Intervention Example• Trauma Management

Therapy – adapted• Exposure to sounds

and smells

• In vivo exposure – to their uniforms, to driving the route to Pulse

• Group intervention to deal with anger and depression

“I had to keep telling those people that help was coming even when I knew it was not.”

“It was a war zone in there – no one ever saw anything like this.”

TMT for First Responders

35.4

45.1

11.4

4.4

0

5

10

15

20

25

30

35

40

45

50

CAPS 5 PCL 5

PTSD Symptoms

Pre-Tx Post-Tx

n=28; CAPS 5, p<.05; PCL 5, p<.01 n=28; All ps <.05

TMT Outcome:Firefighters and Law Enforcement Officers

34

43.8

37.8

50.4

10.2

4.4

11.3

16.4

0

10

20

30

40

50

60

CAPS 5 Firefighters PCL 5 Firefighters CAPS 5 LEO PCL 5 LEO

PTSD Symptoms

Pre Post

n=19 firefighters; n=8 law enforcement officers

Pulse Nightclub Shooting

• 2nd largest mass shooting

• Multiple “sets” of people impacted

• Victims, victims’ families

• First responders

• Employees of Pulse and surrounding businesses

• FBI Vetted:

• 850 (Families and survivors)

• Directly impacted at Pulse:

• 49 deceased

• 88 physically injured (gun wound, broken bones, etc.)

• 38 proximate (inside)

• 47 proximate employees (inside)

Pulse Nightclub Shooting – June 12, 2016

Primary Impact

Type

Primary Impact # Victims

Extended Family

Multiplier

# at risk of Negative BH

Consequences

Deaths 49 10 490

Wounded 53 6 318

Patrons and Staff

300 4 1,200

Subtotal 2,008

Department of Justice, 2017

Adapting TMT for

Pulse Survivors

• Need to move more slowly – initial sessions dedicated to managing extreme levels of anxiety

• Medical needs/treatment are ongoing for many –numerous surgeries, physical therapy limit time for therapy

• More emphasis on breaking patterns of avoidance/social isolation through in vivo exposure

• Sounds and smells are important triggers

• Spanish-speaking Moms group

Pulse Survivors at RESTORES

Demographics

Age 31 years

Sex 50% Male; 50% Females

Education 50% – Some College17% – Master’s degree33% – Not Reported

Race/Ethnicity 17% Black Hispanic50% White Hispanic17% Caucasian17% Not Reported

0

10

20

30

40

50

60

PCL-5 BDI-II

PTSD and Depression

Pre Tx Post Tx

Increased Community

Requests for

Continued Services

• Requests for clinic expansions from Brevard and Hillsborough Counties

• Request to incorporate our peer support program into the Federal Law Enforcement Training Center

• One Central Florida Police Department Chief – “get to RESTORES” for evaluation

• Central Florida fire departments and police departments now call RESTORES requesting psychological first aid after occupation-related deaths

• RESTORES now contacted regularly by other communities that have experienced mass-shooting events.

• Continued need for services for survivors of the Pulse nightclub shooting

New Partnerships: Extending Our Scope

• UCF RESTORES is now the exclusive mental health partner for the Florida Firefighters Safety and Health Collaborative.

• Redline Rescue

• UCF RESTORES is a member of the Advisory Board to the National Police Foundation’s Center for Mass Violence Response Studies

• Examining characteristics of averted vs completed school shootings to determine if there are ways to predict and/or intervene

How Do You Do What You Do?

Trauma Won’t Win

UCF RESTORES-Lives

-Families-Communities