PTSD AND THE COURTPTSD AND THE COURTA PRESENTATION BY HARVEY DONDERSHINE, MD, JDA PRESENTATION BY HARVEY DONDERSHINE, MD, JD

““THE PAST ISN’T DEAD, THE PAST ISN’T DEAD, IT ISN’T EVEN PAST”IT ISN’T EVEN PAST”

William William FaulknerFaulkner

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SENSE OF SELF

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TOPICSTOPICS OVERVIEWOVERVIEW CAUSE AND COURSE OF PTSDCAUSE AND COURSE OF PTSD NEUROSCIENCE of TRAUMANEUROSCIENCE of TRAUMA DIAGNOSIS OF PTSD / CO-MORBID CONDITIONSDIAGNOSIS OF PTSD / CO-MORBID CONDITIONS TREATMENT & REHABILITATIONTREATMENT & REHABILITATION THE PTSD DEFENDANT THE PTSD DEFENDANT CONNECTION BETWEEN PTSD AND CRIME CONNECTION BETWEEN PTSD AND CRIME DE-LINKING BETWEEN PTSD AND CRIMEDE-LINKING BETWEEN PTSD AND CRIME REVIEW OF MAIN POINTSREVIEW OF MAIN POINTS

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OVERVIEWOVERVIEW

PTSDPTSD PTSD AND COURTPTSD AND COURT ATTORNEY AND THE PTSD CLIENTATTORNEY AND THE PTSD CLIENT WAR ON TERROR: “LOOMING NATIONAL DISASTER”WAR ON TERROR: “LOOMING NATIONAL DISASTER”

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PTSD DATAPTSD DATA

3.6% OF POPULATION CURRENTLY HAS PTSD3.6% OF POPULATION CURRENTLY HAS PTSD PTSD OVER-REPRESENTED IN JAILS AND PRISONSPTSD OVER-REPRESENTED IN JAILS AND PRISONS 200,000 VETS UNDER LEGAL SUPERVISION200,000 VETS UNDER LEGAL SUPERVISION WHAT’S “LOOMING”WHAT’S “LOOMING”

2 MILLION SOLDIERS DEPLOYED 2 MILLION SOLDIERS DEPLOYED 25% RETURNED WITH PTSD25% RETURNED WITH PTSD 10-15% WILL STILL HAVE PTSD IN 203010-15% WILL STILL HAVE PTSD IN 2030 50% WILL NEVER RECEIVE TREATMENT50% WILL NEVER RECEIVE TREATMENT MANY WILL BE IN COURT SOON AND FOR DECADESMANY WILL BE IN COURT SOON AND FOR DECADES

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PENAL CODE SEC. 1170.9PENAL CODE SEC. 1170.9

A VET ALLEGES OFFENSE RESULT OF SERVICE IN COMBAT THEATER OF OPERATIONS

COURT SHALL CONDUCT HEARING IF EVIDENCE CONFIRMS AND VET ELIGIBLE FOR

PROBATION, COURT MAY ORDER TREATMENT FOR PTSD, SUBSTANCE ABUSE, OTHER SERVICE-RELATED PSYCHOLOGICAL DISORDERS

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ATTORNEY AND THE PTSD CLIENTATTORNEY AND THE PTSD CLIENT

PTSD IMPACTS ATTORNEY-CLIENT RELATIONSHIPPTSD IMPACTS ATTORNEY-CLIENT RELATIONSHIP DISTRUST, ANGER, SPECIAL SENSITIVITIESDISTRUST, ANGER, SPECIAL SENSITIVITIES ““LEGAL” RETRAUMTIZATION AND REACTIONS TO ITLEGAL” RETRAUMTIZATION AND REACTIONS TO IT

ATTORNEY ROLEATTORNEY ROLE NEED TO SEE THROUGH THE FAÇADENEED TO SEE THROUGH THE FAÇADE ATTORNEY AS “FIRST-RESPONDER”ATTORNEY AS “FIRST-RESPONDER” DO BRIEF SCREENDO BRIEF SCREEN EMPOWER CLIENTEMPOWER CLIENT

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BRIEF SCREEN BRIEF SCREEN

YES TO Q #1 PLUS ANY 2 OTHER YES’s MEANS PROBABLE PTSDYES TO Q #1 PLUS ANY 2 OTHER YES’s MEANS PROBABLE PTSD

1.1. HAVE YOU EVER HAD SOMETHING VERY HAVE YOU EVER HAD SOMETHING VERY UPSETTING HAPPEN TO YOU? IF YES, IN PAST UPSETTING HAPPEN TO YOU? IF YES, IN PAST MONTH, DID YOU HAVE:MONTH, DID YOU HAVE:

2.2. BAD DREAMS or UNWANTED THOUGHTS OF IT?BAD DREAMS or UNWANTED THOUGHTS OF IT?3.3. AVOIDED OR TRIED NOT TO THINK OF IT?AVOIDED OR TRIED NOT TO THINK OF IT?4.4. FELT HYPER ALERT OR EASILY STARTLED?FELT HYPER ALERT OR EASILY STARTLED?5.5. FELT NUMB OR DETACHED?FELT NUMB OR DETACHED?

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CRIMINAL LAWCRIMINAL LAW ACTUS REUS MENS REA GENERAL INTENT SPECIFIC INTENT DIMINSHED CAPACITY VS. DIMINISHED ACTUALITY INSANITY COMPETENCY TO STAND TRIAL DUE PROCESS EQUAL PROTECTION DOWNWARD DEPARTURE DANGEROUSNESS VS PREDICTIVE RISK DETERMINATION

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PTSDPTSD

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“ “BEFORE-AND-AFTER” DISORDERBEFORE-AND-AFTER” DISORDER BRAIN “BURN” FROM A “HOT” EVENTBRAIN “BURN” FROM A “HOT” EVENT OFTEN CHRONIC, RELAPSINGOFTEN CHRONIC, RELAPSING MAY HIDE IN PLAIN SIGHTMAY HIDE IN PLAIN SIGHT USUALLY DOES NOT TRAVEL ALONEUSUALLY DOES NOT TRAVEL ALONE PAIN IS OFTEN AN ISSUE IN PTSDPAIN IS OFTEN AN ISSUE IN PTSD

PTSD SEQUENCEPTSD SEQUENCE

TRAUMATIC EVENTTRAUMATIC EVENT PSYCHOLOGICAL “OUTCRY”PSYCHOLOGICAL “OUTCRY” NEUROBIOLOGICAL CASCADENEUROBIOLOGICAL CASCADE RESOLUTION AND RECOVERYRESOLUTION AND RECOVERY INTERRUPTION IN RECOVERYINTERRUPTION IN RECOVERY SYMPTOMS APPEAR / FUNCTION DETERIORATESSYMPTOMS APPEAR / FUNCTION DETERIORATES DEPRESSION / SUBSTANCE ABUSE MAY FOLLOWDEPRESSION / SUBSTANCE ABUSE MAY FOLLOW BELIEFS AND ATTITUDES (SELF & WORLD) CHANGEBELIEFS AND ATTITUDES (SELF & WORLD) CHANGE

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CAUSE AND COURSE OF PTSDCAUSE AND COURSE OF PTSD

RISK FACTORS TRAUMA

ACUTE PTSD

CHRONIC PTSD

ATS RECOVERY RESOLUTION

COMORBIDITIES

TIME

50%

80%

30%

70%

30 DAYS

ASD

PROTECTIVE FACTORS

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EVENT VS. STRESSOR VS. TRAUMAEVENT VS. STRESSOR VS. TRAUMA

EVENT IS A HAPPENINGEVENT IS A HAPPENING STRESSOR IS A “SUPER HEATED” EVENT STRESSOR IS A “SUPER HEATED” EVENT

INTENSITY, DURATION INTENSITY, DURATION TRAUMA IS PERSONAL RELATIONSHIP BETWEEN TRAUMA IS PERSONAL RELATIONSHIP BETWEEN

STRESSOR & VICTIMSTRESSOR & VICTIM PERSONAL MEANINGPERSONAL MEANING

PRE-TRAUMA VULNERABILITY PRE-TRAUMA VULNERABILITY LACK OF SUPPORT LACK OF SUPPORT PRIOR TRAUMAPRIOR TRAUMA GENETIC POLYMORPHISMGENETIC POLYMORPHISM

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PTSD AND THE BRAINPTSD AND THE BRAIN

HIPPOCAMPUS

PITUITARY

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HYPOTHALAMUS

AMYGDALA

H-P-A ENDOCRINE RESPONSEH-P-A ENDOCRINE RESPONSE

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SENSORY IMPUT RECEIVED IN BRAINSENSORY IMPUT RECEIVED IN BRAIN HYPOTHALAMUS SECRETES CRF HYPOTHALAMUS SECRETES CRF CRF RELEASE PITUITARY ACTH AND CORTISOLCRF RELEASE PITUITARY ACTH AND CORTISOL

ACTH CAUSES ADRENAL RELEASE OF EPINEPHRINEACTH CAUSES ADRENAL RELEASE OF EPINEPHRINE CORTISOL TURNS OFF ACTHCORTISOL TURNS OFF ACTH

TRAUMA LEVELS OF CORTISOL TOXIC TO BRAINTRAUMA LEVELS OF CORTISOL TOXIC TO BRAIN CORTISOL THEN EXCITES - NOT TURNS OFF - CRF/ACTHCORTISOL THEN EXCITES - NOT TURNS OFF - CRF/ACTH PERSISTENT AROUSAL OF THREAT CENTERS IN BRAINPERSISTENT AROUSAL OF THREAT CENTERS IN BRAIN

HIPPOCAMPUSHIPPOCAMPUS

IMPAIRED BY TRAUMAIMPAIRED BY TRAUMANARRATIVENARRATIVE

INTEGRATIVEINTEGRATIVE

AMYGDALAAMYGDALA

SENSITIZED BY TRAUMASENSITIZED BY TRAUMATHREAT DETECTORTHREAT DETECTORSOMATOSENSORYSOMATOSENSORY

PRE-FRONTAL CORTEX PRE-FRONTAL CORTEX REGULATORY FUNCTIONREGULATORY FUNCTION

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OVERVIEW OF DSM V CRITERIAOVERVIEW OF DSM V CRITERIA

A.A. TRAUMATIC EVENT TRAUMATIC EVENT B.B. INTRUSIONSINTRUSIONSC.C. AVOIDANCE AVOIDANCE D.D. AROUSALAROUSALE.E. CHANGE IN COGNITION / EMOTIONCHANGE IN COGNITION / EMOTIONF.F. DURATION OF B, C, & D MORE THAN ONE MONTHDURATION OF B, C, & D MORE THAN ONE MONTHG.G. CLINICALLY SIGNIFICANT DISTRESS / IMPAIRMENTCLINICALLY SIGNIFICANT DISTRESS / IMPAIRMENT

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A. EXPOSED TO DEATH / THREATENED DEATH, A. EXPOSED TO DEATH / THREATENED DEATH, SERIOUS INJURY, SEXUAL VIOLATION; 1OR SERIOUS INJURY, SEXUAL VIOLATION; 1OR MORE OF FOLLOWING WAYS: MORE OF FOLLOWING WAYS:

1. PERSONALLY EXPERIENCED THE EVENT2. WITNESSED THE EVENT AS IT OCCURRED 3. LEARNED EVENT HAPPENDED TO CLOSE RELATIVE OR

FRIEND; VIOLENT OR ACCIDENTAL4. INTENSE EXPOSURE TO DETAILS; DOES NOT APPLY TO

EXPOSURE THROUGH MEDIA UNLESS EXPOSURE IS WORK RELATED.

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B. INTRUSIVE SYMPTOMS ASSOCIATED WITH B. INTRUSIVE SYMPTOMS ASSOCIATED WITH TRAUMATIC EVENT; 1 OR MORE OF TRAUMATIC EVENT; 1 OR MORE OF FOLLOWING: FOLLOWING: 1. INVOLUNTARY MEMORIES 2. DISTRESSING DREAMS RELATED TO EVENT 3. DISSOCIATION (E.G., FLASHBACKS)4. DISTRESS ON EXPOSURE TO CUES THAT SYMBOLIZE OR

RESEMBLE SOME ASPECT OF EVENT5. MARKED PHYSIOLOGICAL REACTION TO REMINDERS

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C. AVOIDANCE OF STIMULI ASSOCIATED WITH C. AVOIDANCE OF STIMULI ASSOCIATED WITH EVENT; 1 OR MORE OF FOLLOWINGEVENT; 1 OR MORE OF FOLLOWING: :

1.1. AVOIDS INTERNAL REMINDERS AVOIDS INTERNAL REMINDERS 2.2. AVOIDS EXTERNAL REMINDERSAVOIDS EXTERNAL REMINDERS

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D. NEGATIVE ALTERATIONS IN COGNITION OR D. NEGATIVE ALTERATIONS IN COGNITION OR MOOD; 3 OR MORE OF FOLLOWING: MOOD; 3 OR MORE OF FOLLOWING:

1. AMNESIA FOR IMPORTANT ASPECTS OF EVENT 2. NEGATIVE EXPECTATIONS SELF, OTHERS, OR WORLD3. BLAME SELF / OTHERS RE CAUSE OR CONSEQUENCES4. PERVASIVE FEAR, ANGER, GUILT, OR SHAME 5. DIMINISHED INTEREST /PARTICIPATION IN ACTIVITIES6. DETACHED OR ESTRANGED FROM SELF, OTHERS7. INABILITY TO EXPERIENCE POSITIVE EMOTIONS

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E. ALTERATIONS IN AROUSAL AND REACTIVITY; E. ALTERATIONS IN AROUSAL AND REACTIVITY; 3 OR MORE OF THE FOLLOWING: 3 OR MORE OF THE FOLLOWING:

1. IRRITABLE OR AGGRESSIVE BEHAVIOR 2. RECKLESS OR SELF-DESTRUCTIVE BEHAVIOR 3. PROBLEMS WITH CONCENTRATION4. SLEEP DISTURBANCE5. HYPERVIGILANCE6. EXAGGERATED STARTLE RESPONSE

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CO-MORBID CONDITIONSCO-MORBID CONDITIONS

DEPRESSIONDEPRESSION PANIC ATTACKSPANIC ATTACKS SUBSTANCE ABUSESUBSTANCE ABUSE (m-TBI)(m-TBI)

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PHASES OF TREATMENTPHASES OF TREATMENT

STABILIZESTABILIZE EDUCATEEDUCATE CONSENT PROCESSCONSENT PROCESS EMOTIONAL “SKILLS” TRAININGEMOTIONAL “SKILLS” TRAINING TREATMENT OF CO-OCCURRING DISORDERSTREATMENT OF CO-OCCURRING DISORDERS TRAUMA-FOCUSED THERAPY AND/OR MEDSTRAUMA-FOCUSED THERAPY AND/OR MEDS FOLLOW-UPFOLLOW-UP

REHABILITATE, REINTEGRATE, PREVENT RELAPSEREHABILITATE, REINTEGRATE, PREVENT RELAPSE

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SKILLS TRAININGSKILLS TRAINING

RELAXATIONRELAXATION ANGER MANAGEMENTANGER MANAGEMENT TRIGGER CONTROLTRIGGER CONTROL COGNITIVE PSYCHOLOGYCOGNITIVE PSYCHOLOGY PROBLEM SOLVINGPROBLEM SOLVING COMMUNICATIONSCOMMUNICATIONS

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COGNITIVE PSYCHOLOGYCOGNITIVE PSYCHOLOGY

“…A WORD IS THE SKIN OF A LIVING THOUGHT…” “…A WORD IS THE SKIN OF A LIVING THOUGHT…” Oliver Wendell HolmesOliver Wendell Holmes

EVENT IS FACT. EVENT IS FACT. MEANING AND EMOTION DERIVE FROM THOUGHTMEANING AND EMOTION DERIVE FROM THOUGHT BOTH EMERGE FROM “INTERNAL RHETORIC”BOTH EMERGE FROM “INTERNAL RHETORIC” ADDRESS BY COUNTERING THIS RHETORICADDRESS BY COUNTERING THIS RHETORIC

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PHARMACOTHERAPYPHARMACOTHERAPY

11STST LINE – SSRI, SNRI LINE – SSRI, SNRI 22NDND LINE – EFFEXOR, REMERON, TCA, MAOI LINE – EFFEXOR, REMERON, TCA, MAOI ADD-ON DRUGS: RISPERDAL, PRAZOSIN, DESYRELADD-ON DRUGS: RISPERDAL, PRAZOSIN, DESYREL SOME DRUGS PROBABLY NOT EFFECTIVESOME DRUGS PROBABLY NOT EFFECTIVE

BUPROPION, DEPAKOTEBUPROPION, DEPAKOTE SOME DRUGS MIGHT BEST BE AVOIDEDSOME DRUGS MIGHT BEST BE AVOIDED

BENZODIAZEPINESBENZODIAZEPINES

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TRAUMA-FOCUSED PSYCHOTHERAPYTRAUMA-FOCUSED PSYCHOTHERAPY

EXPOSURE THERAPYEXPOSURE THERAPY TRAUMA FOCUSED COGNITIVE THERAPY TRAUMA FOCUSED COGNITIVE THERAPY COGNITIVE PROCESSING THERAPYCOGNITIVE PROCESSING THERAPY EMDREMDR STRESS INNOCULATION “TOOL BOX” TRAININGSTRESS INNOCULATION “TOOL BOX” TRAINING

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FOLLOW-UPFOLLOW-UP

FUNCTIONAL REHABILITATIONFUNCTIONAL REHABILITATION SOCIAL REINTEGRATIONSOCIAL REINTEGRATION MAINTENANCE OF SOBRIETYMAINTENANCE OF SOBRIETY PRIMARY HEALTH CAREPRIMARY HEALTH CARE

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BLOCKS TO RECOVERYBLOCKS TO RECOVERY SEVERITY OF DISORDERSEVERITY OF DISORDER INEFFECTIVE TREATMENT INEFFECTIVE TREATMENT LACK OF COMPLIANCELACK OF COMPLIANCE POVERTY POVERTY SOCIAL ISOLATIONSOCIAL ISOLATION CONTINUING SUBSTANCE ABUSECONTINUING SUBSTANCE ABUSE

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FORENSIC IMPLICATIONS FORENSIC IMPLICATIONS

TORTS – CAUSATION, DAMAGES CRIME – MORE ISSUES THAN MENS REA PTSD IMPACTS ALL PARTIES PTSD CRIMINAL DEFENDANTS CAN BE A CHALLENGE

THEY CAN “DEFEND” AGAINST OWN BEST INTERESTS PRE-EXISTING / SELF-INFLICTED TRAUMA CASE-RELATED RE-TRAUMATIZATION

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PTSD AND CRIMEPTSD AND CRIME

MANY DEFENDANTS HAVE PAST TRAUMAMANY DEFENDANTS HAVE PAST TRAUMA PAST TRAUMA IS LINKED TO PTSDPAST TRAUMA IS LINKED TO PTSD CRIME CAN BE CONSEQUENCE OF PTSD CRIME CAN BE CONSEQUENCE OF PTSD

CORE SYMPTOMSCORE SYMPTOMS SECONDARY EFFECTS OF CORE SYMPTOMSSECONDARY EFFECTS OF CORE SYMPTOMS CO- MORBID CONDITIONSCO- MORBID CONDITIONS

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SYMPTOMS LINKED TO CRIMESYMPTOMS LINKED TO CRIME

FLASHBACKSFLASHBACKS DISSOCIATIONDISSOCIATION RECKLESS OR SENSATION-SEEKING BEHAVIORRECKLESS OR SENSATION-SEEKING BEHAVIOR MISPERCEPTION OF THREATMISPERCEPTION OF THREAT OVER-REACTION TO STARTLEOVER-REACTION TO STARTLE GUILT-DRIVEN BEHAVIORGUILT-DRIVEN BEHAVIOR COMPLEX REENACTMENT BEHAVIORSCOMPLEX REENACTMENT BEHAVIORS PSEUDO ANTISOCIAL ATTITUDESPSEUDO ANTISOCIAL ATTITUDES

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DISSOCIATIONDISSOCIATION

PERI-TRAUMATIC DISSOCIATION PART OF ASDPERI-TRAUMATIC DISSOCIATION PART OF ASD IS ALTERED STATE OF CONSCIOUSNESSIS ALTERED STATE OF CONSCIOUSNESS TRIGERRED BY SUDDEN EXTREME THREATTRIGERRED BY SUDDEN EXTREME THREAT RELEASES INSTINCTUAL “SURVIVAL” REACTIONRELEASES INSTINCTUAL “SURVIVAL” REACTION ACTIONS NOT MEDIATED BY EXECUTIVE FUNCTIONSACTIONS NOT MEDIATED BY EXECUTIVE FUNCTIONS ACTIONS INCONSISTENT WITH BASIC PERSONALITYACTIONS INCONSISTENT WITH BASIC PERSONALITY MEMORY IMPAIRED FOR DISSOCIATED BEHAVIORMEMORY IMPAIRED FOR DISSOCIATED BEHAVIOR

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CRIMES ASSOCIATED WITH PTSDCRIMES ASSOCIATED WITH PTSD

UNDER THE INFLUENCEUNDER THE INFLUENCE DRUG POSSESSION / SALES & DISTRIBUTIONDRUG POSSESSION / SALES & DISTRIBUTION ASSAULT ASSAULT DOMESTIC VIOLENCEDOMESTIC VIOLENCE ““REENACTMENT” CRIMESREENACTMENT” CRIMES

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DE-LINKING PTSD AND CRIMEDE-LINKING PTSD AND CRIME

PSYCHOEDUCATIONPSYCHOEDUCATION PROVIDE “SKILLS” TRAININGPROVIDE “SKILLS” TRAINING DAMPEN CORE SYMPTOMSDAMPEN CORE SYMPTOMS MAINTAIN SOBRIETY MAINTAIN SOBRIETY PROVIDE SOCIAL SUPPORTPROVIDE SOCIAL SUPPORT MANAGE PAINMANAGE PAIN

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REVIEWREVIEW

PTSD IS A “BEFORE-AND-AFTER” DISORDERPTSD IS A “BEFORE-AND-AFTER” DISORDER MAY HIDE IN PLAIN SIGHTMAY HIDE IN PLAIN SIGHT ATTORNEY MAY NEED TO BE A “FIRST-RESPONDER”ATTORNEY MAY NEED TO BE A “FIRST-RESPONDER” ALL SIDES NEED TO SEE THROUGH THE FAÇADEALL SIDES NEED TO SEE THROUGH THE FAÇADE KNOW THE REHABILITATIVE OPTIONSKNOW THE REHABILITATIVE OPTIONS TREATMENT WORKSTREATMENT WORKS

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