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Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD): The impact of cartel related violence on the U.S./México border. Thom Taylor.

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Presentation on theme: "Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD): The impact of cartel related violence on the U.S./México border. Thom Taylor."— Presentation transcript:

1 Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD): The impact of cartel related violence on the U.S./México border. Thom Taylor

2 Agenda A brief background to traumatic stress – Post-Traumatic Stress Disorder (PTSD) – Ongoing Traumatic Stress (OTS) Preliminary study of OTS in population exposed to violence and insecurity in Ciudad Juárez Considerations for U.S./México Border Public Health and Safety communities

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7 TRAUMATIC STRESS BACKGROUND

8 Violence and Insecurity Extreme increase in cartel and community related violence in northern México – Cartel related murders (2000+ in past year) – Kidnappings – Car-jackings – Robberies/Extortion (Cuotas) – Constant threat U.S. not immune Cartel and army related violence (CARV) – Psycho-social costs to a community – Increases stress Caetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003

9 Extreme Stress Reactions Post-Traumatic Stress Disorder (& Probable PTSD) – Exposure to traumatic experience (s) – Feelings of fear, helplessness, and/or horror peri-event – Intrusive thoughts/Re-experiencing (1+ symptoms) – Avoidance/numbing to situations (3+ symptoms) – Hyper-arousal (2+ symptoms) – Psycho-social impairment Partial PTSD – Threshold for full PTSD may be too high – Impairment still seen (e.g., anger) American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997

10 Acute Event PTSD: Implicit Assumptions

11 Identified Traumatic Stress Trends Chronic PTSD (> 3 months) Acute PTSD (> 1 Month) Resistant Resilient APA, 2000; Bonnano, 2004; Norris et al., 2009

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17 Core Trauma Symptoms Avoidance / Numbing Re-experiencing / Intrusive Thoughts Hyper-Arousal

18 PERI Trauma (Immediate) Considerations Unpredictable and Un-controllable Subjective exposure – Fear – Helplessness – Horror Direct forms of Trauma (e.g., assault, terrorism) Indirect forms of Trauma (e.g., witnessing, media, trauma by proxy-such as family member) Subjective interpretation Breslau et al., 2004; Gray et al., 2004; Gabriel et al., 2007; Suvak et al., 2008; Collimore et al., 2008; Foa & Riggs, 1995; Weathers & Keane, 2007

19 PRE-Trauma Risk Factors Demographic risk factors (e.g., female gender) Exposure to multiple traumata (re-exposure) Anxiety disorders rarely present in pure form – Pre-existing anxiety disorders may worsen traumatic stress after exposure – Anxiety Sensitivity predisposes to traumatic stress after exposure Depression – Unclear if PRE or POST factor – Depression highly comorbid with TS post-event (correlation) – May worsen traumatic stress Brewin et al., 2000; Ozer et al., 2003; Norris et al., 2003b; Dunner, 2001; Goldenberg et al., 1996; Elwood et al., 2009; Gabriel et al., 2007; Jaycox et al., 2003; Collimore et al., 2008; Breslau et al., 1997; Breslau et al., 1991; Breslau et al, 2000

20 PRE-Trauma Sources of Coping Social support strongly buffers against traumatic stress Coping in uncontrollable situations – Problem focused (limited in uncontrollable situations) – Emotion-focused Active – Self distraction (+ or -) – Venting (+ or -) – Cognitive acceptance of situation/experience ( + or -) Avoidance based – Denial ( generally - ) – Giving up/feeling hopeless ( - ) – Self-blame ( - ) – Substance use ( - ) Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989

21 Unique Opportunity Virtually no empirical study of psycho-social impact of cartel related violence in the Americas Limited knowledge of real-time (daily) impact – Memory distortion after the fact (e.g., months, years, melding of traumas? Such as in VHA situation) – More refined understanding of impact of ongoing traumatic situations Nisbett & Wilson, 1977; Wolfer, 1999

22 Preliminary Study of Ongoing Traumatic Stress 1.Assess Ongoing Traumatic Stress (OTS) 2.Examine impact of factors commonly associated with PTSD in: 1.Ongoing (daily) Traumatic Stress 2.Ongoing (daily) Re-experiencing symptoms 3.Ongoing (daily) Avoidance symptoms 4.Ongoing (daily) Hyperarousal symptoms

23 METHODS

24 Participants N = 121 (N days = 816) Inclusion Criteria – Travel/live in Cd. Juárez at least 3 days/week – Internet access at least every 24 hour period – Bilingual – UTEP student Comfort with online survey; anonymity/confidentiality Post-hoc advantage; could still recruit after UTEP travel ban Compensation : $40USD giftcard to Target OR 4 experimental credits

25 Measures: Main Outcome All measures professionally translated and back-translated with subsequent native Spanish speakers input on items Post-traumatic Stress Disorder Checklist (PCLS) – Specific event-adapted for CARV: …violencia relacionado con el narcotrafico u hostilidad y maltrato militar. – Past 30 day Acute PTSD (α =.89) Adapted version for daily traumatic stress for past 24 hours (PCLSD): α range = Brislin, 1970; Liu, 2002; Weathers et al., 1993 Ruggiero et al., 2003; Orlando & Marshall, 2002

26 Background Measures Life Events Checklist (LEC) documents 17 traumatic events often associated with PTSD Experienced Directly (direct) Witnessed (indirect) Learned of/Heard about (indirect) Depression, Anxiety, and Stress Scale (DASS) Depression (α =.86) Anxiety (α =.78) General Stress (α =.85) Gray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002

27 Background Measures Continued Multi-dimensional Scale of Social Support (MSPSS) Family (α =.89) Friends (α =.96) Significant Other (α =.92) Brief COPE coping measure (BCOPE); Carver encourages malleability given nuances of coping Problem Focused Coping (α =.78) Emotion Focused Active Coping (α =.73) Avoidance Coping (α =.76) Zimet et al., 1988; Carver et al., 1997, Schneider et al., 2007; Perczek et al., 2000

28 Daily Assessment Completed online >24 hours for 7 days PCLSD (daily traumatic stress) Time-varying explanatory covariates – Travel to CJ (# hours) – Reasons for being in CJ (family, friends, business, antro/club/bar) – Perceived degree of exposure to violence (fear, helplessness, horror)

29 Lemonade out of Lemons Drop out rarely positive outcome, but allows unique analysis in present study 20% did not return for follow-up Unique opportunity in trauma study – Avoidance unpleasantness drop-out? – Re-experiencing unpleasantness drop-out? – Hyper-arousal unpleasantness drop-out?

30 Informative Drop-Out Diggle-Kenward Selection Model (DKSM) – Single covariate entered due to estimation complexity: Past 30 day traumatic stress (PCLS) – Survival indicator from daily reports 3 to 4 constrained to be 0; no drop-out in interval – To allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scores Drop-out unassociated with traumatic stress, all Zs.52 Take Home Point: Preliminary support that asking about trauma on a daily basis does not make it worse for those assessed. Rubin, 1976; Molenberghs, Michiels, Kenward, & Diggle, 1998; Diggle & Kenward, 1994

31 Approach to Analysis: Multi-level modeling – Specified Expectation-Maximization in Maximum Likelihood; robust to MAR – Grand Mean centered variables – Standardized (N~0,1) covariates to give common scale to psychological factors OPTS dependent variable (PCLSD) – Condition on demographics, LEC, DASS, MSPSS factors, BCOPE sub-scales – Time varying covariates Presence in CJ (hours) Perceived exposure to violence occurring (fear, helplessness, and horror) Snijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009

32 PRELIMINARY STUDY RESULTS

33 Demographic Highlights

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35 Variable Possible RangeMeanSDMed.Min.Max. Days in Cd. Juárez, Chih per week0 to Days in El Paso, TX per week0 to Family who live in Cd. Juárez, Chih (%)0 to Friends who live in Cd. Juárez, Chih (%)0 to Age (years) PTSD Checklist Past 30 day Score (PTSD)17 to Sample Continuous Characteristics

36 Variable Possible RangeMeanSDMed.Min.Max. Days in Cd. Juárez, Chih per week0 to Days in El Paso, TX per week0 to Family who live in Cd. Juárez, Chih (%)0 to Friends who live in Cd. Juárez, Chih (%)0 to Age (years) PTSD Checklist Past 30 day Score (PTSD)17 to Sample Continuous Characteristics

37 Variable Possible RangeMeanSDMed.Min.Max. Days in Cd. Juárez, Chih per week0 to Days in El Paso, TX per week0 to Family who live in Cd. Juárez, Chih (%)0 to Friends who live in Cd. Juárez, Chih (%)0 to Age (years) PTSD Checklist Past 30 day Score (PTSD)17 to Sample Continuous Characteristics

38 Variable Possible RangeMeanSDMed.Min.Max. Days in Cd. Juárez, Chih per week0 to Days in El Paso, TX per week0 to Family who live in Cd. Juárez, Chih (%)0 to Friends who live in Cd. Juárez, Chih (%)0 to Age (years) PTSD Checklist Past 30 day Score (PTSD)17 to Sample Continuous Characteristics

39 SD Continuous VariableRangeMeanOverallBetw.Within Hours each day in Cd. Juárez0 to Daily traumatic stress level17 to Peri-traumatic experiences Fear0 to Helplessness0 to Horror0 to Coping via substance use0 to Sample Daily Characteristics

40 SD Continuous VariableRangeMeanOverallBetw.Within Hours each day in Cd. Juárez0 to Daily traumatic stress level17 to Peri-traumatic experiences Fear0 to Helplessness0 to Horror0 to Coping via substance use0 to Sample Daily Characteristics

41 SD Continuous VariableRangeMeanOverallBetw.Within Hours each day in Cd. Juárez0 to Daily traumatic stress level17 to Peri-traumatic experiences Fear0 to Helplessness0 to Horror0 to Coping via substance use0 to Sample Daily Characteristics

42 Sample Daily Characteristics Cont. Categorical VariableOverall %Between %Within Avg. % Daily Traumatic Stress Risk Category Limited (PCL less than 34) Moderate (PCL of 34 to 43) Clinical (PCL greater than 44) Reasons for being in Cd. Juárez: Family No Yes Reason for being in Cd. Juárez: Friends No Yes Reason for being in Cd. Juárez: Business No Yes82630 Reason for being in Cd. Juárez: Antro/Bar No Yes51923

43 Sample Daily Characteristics Cont. Categorical VariableOverall %Between %Within Avg. % Daily Traumatic Stress Risk Category Limited (PCL less than 34) Moderate (PCL of 34 to 43) Clinical (PCL greater than 44) Reasons for being in Cd. Juárez: Family No Yes Reason for being in Cd. Juárez: Friends No Yes Reason for being in Cd. Juárez: Business No Yes82630 Reason for being in Cd. Juárez: Antro/Bar No Yes51923

44 PREDICTING ONGOING (DAILY) TRAUMATIC STRESS RESPONSE SYMPTOMS

45 Multi-Level Model Predicting Ongoing Traumatic Stress Time Invariant CovariatesB95% CIp Female U.S. Resident vs. citizen Income (ref. is Less than 15,000USD) 15,001 to 30,000USD ,001 to 45,000USD ,001USD to 60,000USD More than 60,000USD Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) Witnessed (Indirect) Directly experienced Psychological Symptoms (DASS-21) Depression Anxiety General Stress Social Support (MSPSS) Family Friends Significant Other <.05 Coping Problem focused Active emotion focused Avoidance based Acute Post-Traumatic Stress Disorder <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez Family <.05 Friends Business <.05 Club/Bar/Antro Peri-event exposure reactions Fear <.01 Helplessness <.01 Horror <.01

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47 Multi-Level Model Predicting Ongoing Re-Experiencing Symptoms Time Invariant CovariatesB95% CIp Female U.S. Resident vs. citizen Income (ref. is Less than 15,000USD) 15,001 to 30,000USD ,001 to 45,000USD ,001USD to 60,000USD More than 60,000USD Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) Witnessed (Indirect) Directly experienced Psychological Symptoms (DASS-21) Depression Anxiety General Stress Social Support (MSPSS) Family Friends Significant Other Coping Problem focused Active emotion focused Avoidance based Acute Post-Traumatic Stress Disorder <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez Family Friends Business Club/Bar/Antro Peri-event exposure reactions Fear Helplessness <.01 Horror <.01

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49 Multi-Level Model Predicting Ongoing Avoidance Symptoms Time Invariant CovariatesB95% CIp Female U.S. Resident vs. citizen Income (ref. is Less than 15,000USD) 15,001 to 30,000USD ,001 to 45,000USD ,001USD to 60,000USD More than 60,000USD Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) Witnessed (Indirect) Directly experienced Psychological Symptoms (DASS-21) Depression Anxiety General Stress Social Support (MSPSS) Family Friends Significant Other <.05 Coping Problem focused Active emotion focused Avoidance based Acute Post-Traumatic Stress Disorder <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez Family Friends Business <.01 Club/Bar/Antro Peri-event exposure reactions Fear <.01 Helplessness <.01 Horror

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51 Multi-Level Model Predicting Ongoing Hyperarousal Symptoms Time Invariant CovariatesB95% CIp Female U.S. Resident vs. citizen Income (ref. is Less than 15,000USD) 15,001 to 30,000USD ,001 to 45,000USD ,001USD to 60,000USD More than 60,000USD Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) Witnessed (Indirect) <.05 Directly experienced Psychological Symptoms (DASS-21) Depression Anxiety General Stress <.05 Social Support (MSPSS) Family Friends Significant Other Coping Problem focused Active emotion focused Avoidance based <.05 Acute Post-Traumatic Stress Disorder <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez Family Friends Business Club/Bar/Antro Peri-event exposure reactions Fear Helplessness <.01 Horror <.01

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53 DISCUSSION

54 Ongoing Traumatic Stress Border significantly affected by OTS and PTSD – Present sample might objectively be considered of less risk (many protective factors/buffers) – Still, sample evidenced both PTSD and OTS scores warranting concern Assessing for PTSD can potentially help to reduce OTS Yet, common prior factors associated with long term traumatic stress (PTSD) less impactful at daily level more nuanced? Diamond et al., 2010; Mineka & Zinbarg, 2006; Ozer et al., 2008; Ursano et al., 2009

55 Evidence for Ongoing Traumatic Stress Objective exposure (i.e., less time in Cd. Juárez) does not reduce OTS Very strong subjective component – Strong peri-event subjective reactions to exposure observed – Assessment of real time reactions important Valid Anticipatory fears: the future as important as past – Unpredictability – Uncontrollability – Fear, helplessness, and horror on a daily basis – Reinforced avoidance and generalizing of fearful situations/psycho-social states Diamond et al., 2010; Hobfoll et al., 2009

56 What is not there that should be? Gender (female) unassociated with Ongoing Traumatic Stress in the present sample – Variability (model ICCs) HUGE – Other important factors to assess nested within gender Not only a Mexican problem – Socio-economic status not explanatory either – U.S. and Mexican citizens integrated in to both sides of border are significantly affected Kessler et al., 1995, Ozer et al., 2008

57 Past/Future Exposure Considerations Evidence for resilience from past traumata – Much exposure already in these young adults – Little impact on traumatic stress when accounting for other factors identified in traumatic stress literature Still, fear regulation strongly disrupted in traumatic stress; differentially to other anxiety disorders Long-term impact from short term OTS? Bonanno, 2004; deRoon-Cassini et al., 2010; Norris et al., 2009; Dutton & Greene, 2010; Etkin & Wager, 2007; Wilson & Freer, 2010; Ginzburg et al., 2010

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60 Other Factors to Consider: Psycho-Accumulation of Trauma? Re-exposure assumes a somewhat linear process Psycho-accumulation, potentially quadratic?

61 Depression, Anxiety, General Stress, and Traumatic Stress In ongoing traumatic stress, depression may or may not be present – Few depression symptoms overall (floor effect) – Still, depression assessment likely always warranted when assessing traumatic stress in general Sample applies for other anxiety disorders May meet criteria for multiple anxiety disorders (e.g., GAD) General stress may be one area where we can intervene for those exposed to OTS (more later) Breslau et al., 1991; Breslau et al, 2000; Collimore et al., 2008; Breslau et al., 1997

62 Coping with Ongoing Traumatic Stress Problem-focused coping difficult in uncontrollable/unpredictable situations – Adaptive routes/variation of routes to go somewhere in the city – Others examples from your perspective? Active/emotion-focused coping may not fully compensate for OTS Coping may be very diverse in OTS – Are some strategies helpful in one context of ongoing violence, while harmful in others? – Many of you see coping first-hand Riolli & Savicki, 2010; Bonanno, 2004; Lazarus, 2000; Bal et al., 2003; Ullman, Filipas, et al., 2007

63 Family, Familiarity, Stability Decision to move/stay in Cd. Juárez? – Separation from loved ones and familiarity – Family may still be exposed even if one individual family member is safe. – For better or worse… (the family unit) Resource loss worsens traumatic stress – Psycho-social resources (e.g., friends) Kids can do a little better herefrom research perspective Older adults can be vulnerable to effects of displacement – Physical resources/access Extortion (Cuotas) Example: IMSS Alim et al., 2008; Rivera et al., 2008; Hobfall et al., 2009; Wyshak, 1994; Fozdar, 2009

64 Social Support Strongest buffer to Post-Traumatic Stress – Applies to retrospective reports – Potentially more accessible when exposure is acute vs. ongoing May be more nuanced in Ongoing violence – Supporting others in uncontrollable and unpredictable ongoing stressors may be difficult – Larger families may have resources spread across many individuals Provider vs. receiver? Brewin et al, 2000b; Bradley et al., 2005; Kwak, 2003; Szapocznik & Kurtines, 1993; Monson et al., 2009

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69 Community Support Opportunity Regional attention to traumatic stress – A need (Cartel violence, Veterans of OEF/OIF) – An opportunity to be a Star community for helping those affected by traumatic stress Psychological/Psychiatry is important, but not the only answer: – Limit mental health stigma and shame – Promote autonomy: feeling in control – Potential nuances of exposure therapy Joseph, 2010; McCart et al., 2010; Jones, 2007; Diamond et al., 2010; Litz et al., 2002; Rose et al., 2002; Shalev et al., 2004; Milliken et al., 2007; Bradley et al., 2005

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73 Creative Community Support Promote predictability – May be limited in Cd. Juárez (ideas?) – El Paso/U.S. side of the border Educate on traumatic stress and the range of people affected-builds empathy Streamline policies/systems to accommodate range of victims needs Limit daily stressors: the daily grind – Wears down mental resources – Unprepared when crisis occurs Sutton, 2010; Hobfoll et al., 2007; Wei et al., 2010; Bryan, 2010

74 In a crisis, which battery do you want?

75 Preventing low power Address daily stressors of patients/clients/staff – Is a action/policy a barrier, a benefit, or both for the Patient/client? Staff? – Can the action/policy be adapted to reduce the daily grind? – Can benefit not just the individual patient/client, but also the system and staff Support the supporters – Remember, there is a hierarchy many systems – ____________ flows downhill. – You fill in the blank (can be positive or negative word) After presentation, I am interested in hearing your perspectives on how to prevent low power.

76 Focus on Small Wins Big changes are rare and when they do occur, there is sometimes a backlash Find ways to make small wins – Recognize small wins as wins none-the-less – Reinforces future action that can promote future small wins Promotes self-efficacy May promote community efficacy – Small wins add up. Bryan, 2010

77 Limitations and Strengths of Present Study Limitations – Threshold for impairment in PCLS may be different for this group Sensitivity and specificity Need for focus on psycho-social impairment criterion – Convenience/snowball sampling may limit generalizability of findings – Low statistical power due to large inter-individual variability Strengths – Daily level longitudinal assessment; not feasible in many cases – Professionally back-translated measures

78 Conclusions Moderate to high levels of ongoing traumatic stress a likely reality for many with close ties to Cd. Juárez Risk factors and buffers commonly associated with PTSD nuanced in Ongoing (Daily) Traumatic Stress Community can do a lot to indirectly help those affected by trauma – Small Wins – Creative opportunities for community support?

79 ONE FINAL NOTE

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81 The Future of Cartels When substance use revenues change, cartels may not disappear or even become weaker (VERY ADAPTIVE) – Example: 1920s-1930s Chicago – U.S. Gangs May move in to other activities that traumatize the population – Human/body trafficking (sex, labor, organs) – Consideration of (illegal) supply chains – Partnerships with other dangerous entities We need to consider the future of cartels to prevent future traumatization of our loved ones and friends.

82 Spanish Trauma Questionnaires National PTSD Center – Post-Traumatic Stress Disorder Checklist – Life Events Checklist – sments/assessment.asp sments/assessment.asp Contact me if you have questions on other scales:

83 Acknowledgements Dr. Cooper Dr. Byrd Dr. Cohn Dr. Eno Louden Dr. Morera Hispanic Health Disparities Research Center, Grant No. 1P20MD A Smoke Free Paso del Norte, Grant No Areli Guajardo and Ivan Torres Cisco Salgado and José Cabriales Prevention and Treatment in Clinical Health Lab Victoria A. Garcia and Richard Ford, Ph.D..

84 Thank you!

85 Time permitting, I would like Questions A discussion of problem focused coping from your eyes? To hear about possible Small wins in change/adaptation of activities and policies you think could help your organization to help those affected by trauma?


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