1. James J. Lickel, Ph.D. & Richard Machotka William S. Middleton Memorial Veterans Hospital.

2.  Cluster of symptoms that follow exposure to a potentially traumatic event  Marked by clear cognitive, behavioral, and physiologic changes  Can be chronic if untreated and greatly affect quality of life  NOT a sign of weakness, lack of resiliency, or lack of preparation

3.  At least 50% of population will experience “trauma” in their lifetime, most more than once  Most will experience symptoms of PTSD initially, but won’t go on to develop PTSD  There are gender, racial, and ethnic differences in exposure to trauma and development of PTSD

4. Hoge, et al, 2004, NEJM

5. Event and PTSD Risk 5 Breslau et al., 1999

6.  Re-experiencing: Intrusive thoughts or memories about the trauma Nightmares Flashback Distress when reminded of the event (5 senses) Physiological reactions

8.  Avoidance Avoidance of trauma-related thoughts, feelings, or conversations Avoidance of trauma-related places, people, or activities

10.  Arousal Symptoms Impaired sleep Irritability or outbursts of anger Difficulty concentrating/focusing Hypervigilance Feeling jumpy or easily startled

12.  Negative alterations in thoughts and mood Difficulty remembering aspects of event Exaggerated beliefs or expectations about self, others, or the world (“No one can be trusted”) Loss of interest in past enjoyable experiences Feeling detached or cut-off from others Emotional numbness

14. Associated Problems PTSD Depression Physical Health Problems Relationship Problems Anxiety Panic Substance Abuse

15. Psychological Theory of the Development and Maintenance of PTSD Symptoms

17. Common Reactions to Trauma Re-experiencing Intrusive thoughts Strong emotions when triggered by reminder Avoidance Of stimuli present at time of trauma Hyperarousal Increased vigilance Anger Adaptive Function Easily accessed memories that warn of danger Reduces likelihood of repeated exposure to threat Increased attention to threat & Display of preparedness

18. Psychological Processes Involved in Development of Symptoms of PTSD Dust in the air Debris Group of kids Ethnic dress Child’s laughter Military gearDensity of housing Knee pain Sound of gravel Associative Learning Smell of trash

19. Psychological Processes Involved in Development of Symptoms of PTSD “IEDs can be planted anywhere.” “I must have done something to ask for this.” “I trusted this man, it is my fault.” “He died on my watch.” “Markets and crowds are unsafe.” “You can never let your guard down.” Cognitive Change

20. “Natural Recovery” vs. PTSD Time PTSD Symptoms Demographics Social Support Etc. Avoidance Negative Beliefs (Dunmore, Clark, & Ehlers, 2001 )

21. Psychological Processes Involved in Maintenance of Symptoms of PTSD Dust in the air Debris Group of kids Ethnic dress Child’s laughter Military gearDensity of housing Knee pain Sound of gravel Avoidance Smell of trash

23. Psychological Processes Involved in Maintenance of Symptoms of PTSD “I missed the IED.” “I am incompetent.” “I asked for this.” “I am a trash.” Generalization of Beliefs

25.  Current research suggests a number of physiological differences found in people diagnosed with PTSD ◦ Hormonal differences:  Abnormalities in stress response hormone levels (glutamate, GABA, Norepinephirne, CRF.  Responsible for preparing our bodies to respond to threat - > constant state of readiness ◦ Brain differences:  Smaller hippocampus (Inhibition of HPA axis and processing of memories)  Over-reactive amygdala (decreased threshold for “firing”)  Under-reactive prefrontal cortex (inhibits amygdala and interferes with working memory)

27. Clinical Practice Guidelines Psychotherapy va/dod cpg Significant Benefit Cognitive Processing Therapy (VA has trained 1,200 LIPs) Prolonged Exposure Therapy (VA has trained 1,500 LIPs) Stress Inoculation Training Eye Movement Desensitization and Reprocessing (EMDR) Some Benefit Imagery Rehearsal Therapy (IRT) Brief Psychodynamic Therapy Pharmacotherapy ISTSS cpg First-line pharmacologic Tx: SSRIs: (Sertraline / Paroxetine / Fluoxetinte) SNRI: (Venlafaxine) Other 2 nd Generation Antidepressants: (Mirtazapine) Antiadrenergic: (Prazosin; Propranolol. Note about relative efficacy and increased risk of return of symptoms following stop of medication.

28.  Psychoeducation  Stress/arousal reduction techniques  Review of traumatic memories  Exposure to avoided situations  Modification of trauma-related beliefs

29.  9-15 sessions; averages 10 sessions  90 min sessions  1: Assessment, treatment overview, PTSD psychoeducation, breathing retraining  2: In Vivo Exposure (continue throughout)  3-5: Imaginal Exposure  6-9: “Hot Spot” exposure  10: Final Imaginal exposure, wrap-up

30. Exposure Hierarchy 1. Grocery store with partner, not busy30 2. Restaurant with partner, back to wall35 3. Grocery store alone, not busy45 4. Grocery store with partner, moderately busy50 5. In line, facing sideways, wall to back50 6. Restaurant, whole family, back to wall50 7. Restaurant with partner, back to tables60 8. Elevator,1 or 2 people60 9. Movie with friends60 10. In line, facing forward or no wall at back65 11. Grocery store with partner, crowded65 12. Grocery store alone, moderately busy65 13. Feeling hot/sweaty70 14. Elevator, many people75 15. Mall alone, moderately busy75 16. Gym80 17. Restaurant, whole family, back to tables80 18. Go to friend’s house80 19. Mall alone, crowded95 20. Grocery store alone, crowded100

31.  Anxiety increases  Avoidance  This situation is dangerous; I got out just in time; Something awful could have happened Anxiety Time Courtesy of Sally Moore, Ph.D.

32.  Stop avoidance  Anxiety decreases on its own  This situation was not as dangerous as it felt; I can tolerate anxiety; I don’t have to avoid to feel better. Anxiety Time Courtesy of Sally Moore, Ph.D.

33.  Psychoeducation  Trauma account (evidence of efficacy without)  Identification of “Stuck Points”  Cognitive restructuring

34.  Psychoeducation  Impact Statement  “Stuck Points” ◦ Those things trauma survivors say to themselves about the trauma/self/others/world. ◦ Examples  “It was my fault. I could have prevented it.”  “I am a monster for what I did during the war.”  “I should have been able to save everyone.”  “The world is an incredibly dangerous place.”

35.  It is how we THINK about the event, not the event itself, that often causes us lasting distress ◦ Ex: Friend passing by  A-B-C Model – core of CPT A = EventB = Belief/Thought C = Feeling Firefight resulting in casualty I let my friend die Guilty Sad

36.  Sessions 4 - 6: Write/Read Trauma Account  Sessions 6 - 7: Cognitive Work in depth  Sessions 8 – 12: Explore Themes of Safety, Trust, Power/Control, Esteem, and Intimacy  Continue to read account throughout course of treatment for purposes of exposure  Session 12: Review of 2 nd Impact Statement

38.  In general, trauma-focused therapies more effective than non-specific/supportive interventions and no treatment.  No consistent differences observed between trauma- focused therapies, though there is limited research regarding this.  Initial response rates of EBP for PTSD range between 40- 92%.  Regular therapy attendance and family support associated with more positive outcome  Initial severity of symptoms and benzodiazepine use associated with poorer outcome.

39. Outcomes for Veterans with PTSD Prolonged Exposure TherapyCognitive Processing Therapy (Schnurr et al., 2007) d = 1.58d = 0.50 (Monson et al., 2006) PCL

40. OEF/OIF Combat Veterans with PTSD Prolonged Exposure TherapyCognitive Processing Therapy (Tuerk et al., 2011)(Chard et al., 2010) PCL

41. PTSD Resources http://www.ptsd.va.gov/

42. PTSD Resources www.istss.org

43. PTSD Treatment Resources www.abct.org Find a Therapist http://locator.apa.org