1. PTSD: Defining the Disorder Alyssa Rippy PhD. Program Coordinator PRRC Program Jack C. Montgomery VAMC outpatient clinic Feb. 27 th, 2014

3. Prevalence of Traumatic Stress Historically people viewed trauma very differently Currently, many people do not expect sudden catastrophic events to happen to them Many people live with daily stress or occasionally intense stress Serious trauma is unexpected and more rare

4. Prevalence of Traumatic Stress The majority of people do experience at least one traumatic stressor and a large number experience more than one Prevalence is the number of persons in a population who have been victimized, could be in a year or across the lifetime For every 1000 age 12 or older: 2 rapes 2 assaults with injury 5 robberies (US National Crime Victimization Survey 1995) 16,272 murders in US in 2008

5. Prevalence of PTSD Prevalence samples have focused on rates of PTSD among trauma exposed individuals Breslau et al., (1991) estimated a lifetime prevalence rate of 9% for PTSD (6% of men and 11% of women developed PTSD) Resnick et al., (1993) found 7% or trauma exposed sample had PTSD at some point Women are more likely than men to develop PTSD

6. Prevalence of PTSD The most likely traumatic events are the very events that result in less PTSD (>10%) Violent, personal trauma resulted in greater prevalence of PTSD with rape resulting in the single most likely to cause PTSD

7. Classifying Reactions to Stress and Trauma People exhibit a range of symptoms in response to stress that typically are temporary Chronic stress may result in negative beliefs about helplessness or about the cause of the situation May develop into depression, substance abuse or an anxiety disorder When stress decreases, so do the symptoms

8. Prevalence of Traumatic Stress from Kessler et. Al., (1995) TraumaMen %Women % Rape1**9** Molestation312* Physical Attack117* Combat6*0 Shock (trauma to another)1112 Threat with weapon197 Accident2514 Disaster1915 Witness3615 Neglect2*3 Physical Abuse3*5* Other Trauma23*

9. Some individuals are more likely to develop long-term problems under stress than others Coping skill and other resources are key Some individual characteristics that improve an individual’s ability to cope with stress Optimism Greater psychological control or mastery Increased self-esteem Good social support Genetic factors may also be at play Recent research links a particular form of the 5HTTLPR gene was linked to how likely people were to developing depression especially with two short forms of the gene May make us more “stress sensitive” Factors Predisposing a Person to Stress

10. What makes one stressor more serious than another? The severity of a stressor Its chronicity Its timing How closely it affects our own lives How controllable it is Stressors that involve the more important aspects of a person’s life tend to be highly stressful for people The longer a stressor operates, the more severe its effects Encountering a number of stressors at the same time also makes a difference Characteristics of Stress

11. Classifying Reactions to Stress and Trauma Exposure to trauma may create more dramatic stress responses Sudden, unexpected, threatening events Bodies are hard-wired for emergency Triggers biological, cognitive, and emotional responses Autonomic nervous system/fight or flight/freezing or disassociating In attempts to cope with symptoms people may try to shut off the images and feelings, too much avoidance can lead to prolonged reactions that can evolve into PTSD

12. Recovery and Chronicity Longitudinal studies have examined victims of crime and PTSD Very strong reactions initially with gradual recovery over the months that follow 3 months post crime 47% with PTSD Most improvement 3-9 months Women with more severe reaction and stopped improving after 1 month developed PTSD Rape victims had more severe reaction than assault victims sooner improvement with therapy

13. Posttraumatic Stress Disorder (According to new DSM-V) Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Directly experiencing the traumatic events Witnessing, in person, the event as it occurred to others Learning about the traumatic events occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse) NOTE: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related

14. Posttraumatic Stress Disorder Criterion B: Presence of 1 or more of the following intrusion symptoms associated with the traumatic event, beginning after the traumatic events occurred: 1.Recurrent, involuntary, and intrusive distressing memories of the trauma (in children older than 6, repetitive play which themes or aspects of the trauma are expressed) 2.Recurrent distressing dreams of the event 3.Dissociative reaction (flashbacks) in which the individual feels or acts as if the traumatic events were recurring. 4.Intense psychological distress at exposure to internal or external cues that resemble an aspect of the trauma 5.Psychological reactivity on exposure to internal or external cues that resemble an aspect of the trauma

15. Posttraumatic Stress Disorder Criterion C Persistent avoidance of stimuli associated with the traumatic events, beginning after the traumatic event occurred, as evidenced by one or both of the following: 1.Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events 2.Avoidance of or efforts to avoid external reminders (people, places, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the trauma

16. Posttraumatic Stress Disorder Criterion D: Negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after the traumatic events occurred, as evidenced by two or more of the following: 1.Inability to remember an important aspect of the traumatic events 2.Persistent and exaggerated negative beliefs or expectations about oneself, other, the world 3.Persistent, distorted cognitions about the cause of consequences of the traumatic events that lead the individual to blame himself/herself or others 4.Persistent negative emotional state (anger, guilt, shame) 5.Markedly diminished interest or participation in significant activities 6.Feelings of detachment or estrangement from others 7.Persistent inability to experience happiness, satisfaction, or loving feelings

17. Posttraumatic Stress Disorder Criterion E: Marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after the traumatic events occurred, as evidenced by 2 or more of the following: 1.Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects 2.Reckless or self-destructive behavior 3.Hypervigilance 4.Exaggerated startle response 5.Problems with concentration 6.Sleep disturbance

18. Posttraumatic Stress Disorder Criterion F: Duration is more than 1 month Criterion G: The disturbance causes significantly significant distress or impairment in social, occupational, or other important areas of functioning

19. Adjustment Problems Following a trauma people may avoid situations they may have previously enjoyed Have strong emotional reactions Irritability that affects relationships Numbing down May become more violent with others Substance abuse (3/4 lifetime Veterans with PTSD) Work adjustment Divorce and parenting problems Unemployment Legal issues

20. Stress Related Illness PTSD = increased health care utilization More visits to primary care Association btw domestic violence, illness, and medical utilization (Veterans also) Hypertension Stress related medical issues

21. Comorbidity IN addition to PTSD, other disorders might develop due to maladaptive coping 88% of men and 79% of women had comorbid disorders Most common are depression (53-78%)and substance abuse (53- 84%), and anxiety disorders (30-56%)

22. PTSD can be a severe and chronic condition “Walking Disorder” Symptoms of PTSD can be delayed Survivor guilt and moral injury Comorbid disorders Substance abuse 80% Depression Anxiety disorders Traits that mimic personality disorder including Antisocial PD Psychotic symptoms including paranoia Long-term Effects of PTSD

23. Social Influences on Reactions and Recovery How people are treated after a trauma may well affect how they recover How others respond to one’s trauma can greatly influence how victims interpret the events and whether they continue to share their experiences and reactions or withdraw and isolate themselves Social support may reflect pre-existing influences as well as pot-trauma responses

24. Social Support Knowing you have people supportive of you that you can talk to or knowing there is no one close to you that you trust and you have to try to handle it alone

25. Life Survival Skills After returning from combat, many soldiers feel physically revved up and hyperalert after returning home They react to situations at home as if they are in a warzone High levels of anger

26. Returning Home The mind remembers skills that served to keep it alive Reflex actions/reactions Reacting to loud noises Crowds Traffic Not being able to communicate with someone Having things moved Using aggression to get things done Remaining armed and ready

27. How the Brain Reacts to Stress Anger Emotional control through numbing or detachment is necessary under extreme stress In combat soldiers learn to turn off emotions other than anger Anger helps a soldier to survive Anger is conditioned in basic training as a way of getting things done Wreaks havoc with family and loved ones once soldiers return home

28. How the Brain Reacts to Stress Cognitive Problems Veterans and deployed soldiers often complain of difficulty concentrating and paying attention One of the symptoms of PTSD but also is due to increased adrenaline and so can occur in those without PTSD Memory, attention, and concentration all become oriented toward survival, and this can make it difficult to stay focused on other things after returning home

29. How the Brain Reacts to Stress Control Control is an essential survival skill Survival in a combat zone depends on the ability to react instantaneously with the correct sequence of combat tasks under fire (remember the loading of guns in the civil war) If this fails the mission could fail and get someone killed This can cause difficulty with loved ones when they do not follow through with what they were going to do or move things unexpectedly

30. What can you do? Hoge gives some very basic and effective ways of reducing stress and anger Relaxation Journaling Acceptance Exercise Relaxation Healthy diet Sleep medication/medication for nightmares Staying away from alcohol and drugs Medications » Antidepressants (Trazodone) » Melatonin » BP meds » Antipsychotics (Seroquel) » Benzodiazepines (Xanax, Vlium, Ativan, Librium) » Zolpidem (Ambien)

31. Dealing with Stressful Situations Learning to deal with triggers is a big part of any treatment for PTSD Numerous things can trigger anxiety, fear, and anger or result in the sudden flooding of images and feelings Avoidance creeps in This can result in trouble with loved ones who want to go places or enjoy activities that are being avoided

32. How to Tell the Story and Who to Tell it To Individuals with PTSD have to find their own way to tell their story whether by writing it down or talking to someone Pastor, Psychologist, spouse, friend, battle buddy Warriors often want to protect those closest to them Important for families to know that they may not be able to share some stories with them Sharing with fellow warriors may be a problem especially where alcohol is involved, can result in the group getting ramped up Need to tell the story in a place that is free from judgment you emotions can be experienced freely