1. Not Just in the Military However…… PTSD

2. History of PTSD “Since the earliest of times there have been warriors returning to civilian life only to find that they have developed a behavior that is unacceptable in their old communities. After the Civil War in the US, the condition was called “soldier’s heart”; experiences in WWI produced “Shell Shock”; and that was carried over to the WWII era; and warriors in the Pacific called it “going Asian”. It was after the Vietnam War that it came to be known as “PTSD”, post traumatic stress disorder. www.gowarriorsproject.org

3. Diagnosis of PTSD Diagnosis of PTSD was controversial because of the role of outside stressors as the cause of the disorder. Psychiatry generally emphasized the internal weaknesses or deficiencies of the person as the source of the mental disorders. Prior to the 70’s, trauma survivors were blamed for their symptoms and regards as cowards, moral weaklings, or masochists. The high rate of psychiatric casualties among Vietnam vets led to studies conducted by the VA. These studies helped establish PTSD as a legitimate diagnostic entity with a complex set of causes. It was in the 1980’s that PTSD was added to the DSM list of diagnoses.

4. In PTSD patients, researchers found changes in the amygdala and the hippocampus – the parts of the brain that form links between fear and memory.

5. PET scans suggest that trauma affects the parts of the brain that govern speech and language. Societies that are highly authoritarian, glorify violence or sexualize violence have high rates of PTSD even among civilians. Occupations with work that expose workers to traumatic events or who treat trauma survivors may develop secondary PTSD (also known as compassion fatigue or burnout). Risk of PTSD is related to three factors, the amount and intensity of exposure to suffering, worker’s degree of empathy and sensitivity and unresolved issues from the worker’s personal history.

6. Causes of PTSD War Terrorist attacks Trauma - Physical or Emotional Rape Kidnapping Assault Sexual or physical abuse Elder abuse Childhood neglect Car or plane crashes Sudden death of a loved one Natural disasters Hurricanes, tornados, floods, fires

7. Classification of PTSD Acute Stress < 1 month Acute PTSD 1-3 months Chronic PTSD > 3 months

8. PTSD – Cycle of Symptoms High anxiety & stress + Loss of sleep Increased cognitive Impairment Reduced ability to cope

9. Symptoms Re-experiencing – flashbacks, pounding heart, rapid breathing, nausea Avoidance and numbing – selective amnesia, withdrawal, detachment, loss of interest Increased arousal – hypervigilance, decreased sleep, irritability, anger, startle reflex, loss of ability to concentrate Other symptoms – substance abuse, suicidal thoughts and feelings

10. A Few Statistics 65% of rape is associated with burglary 73% of attacks occur in victim’s homes 300,000 elder abuse cases in 1 year 9,000 were sexual assault There is a 13% incidence of PTSD in the elderly compared to 10% in the general population. This does NOT include the military. Higher rates of PTSD have been found to occur in African Americans, Hispanics and Native Americans compared to Caucasians.

11. Onset in the Elderly Onset in the elderly a. Neurological illness/depression b. Bereavement – loss of friends, family, spouse particularly if suddenly c. LOSS – Late Onset Stress Symptomatology – retired with more time to think about war, decreased physical condition, bad news of TV brings back memories, use of alcohol in past to cope and now have quit, normal to look back over your life as you age and re- experience it.

12. Don’t dismiss excessive worrying out of hand Sally had mid-stage Alzheimer’s disease and was living along in her own home, near her daughter June, who looked in 0n her and helped with groceries, cooking, transportation, etc. Sally wanted to remain in her own home and was able to manage well. Sally start complaining that the house next door had been invaded by aliens. Odd lights and noises disturbed her sleep and filled her with a feeling of dread.

13. Case Study Rebecca’s mother screamed frantically when the aides in the nursing home tried to give her a shower. Regardless of how kind, gentle or persuasive the caregiver was, she began yelling and sobbing hysterically when brought to the bright, white shower room, where the aide attempted to remove her clothes.

14. Case Study A 90-year-old woman has been a patient of BA Care Center for several years. Chronic conditions are pernicious anemia, osteoarthritis and urinary incontinency. She is fully functional and fully independent. She provides care for her homebound husband who has severe COPD. They live in a row home specifically close to the hospital to ensure access to house calls for her husband. In September 2000, the husband dies due to respiratory arrest. Her only relative is a nephew who talks with her about once a month. In October 2002, her home is broken into and the patient is raped and robbed. She is taken to a local hospital specializing in rape. Here, she is distressed, delusional, and is reported to be very emotionally distraught. www.hopkinsmedicine.org/gec/studies/ptsd.html

15. Who and Why PTSD? Risk factors include: Previous traumatic experience Family history of PTSD or depression History of physical or sexual abuse History of substance abuse History of depression, anxiety or other mental illness High level of stress in everyday life Lack of support after the trauma Lack of coping skills

16. Who is less apt to have PTSD? Resilience factors include: Strong support system Counseling Feeling good about one’s actions Coping strategies Being able to act and respond effectively despite fear

17. Treatments Cognitive Therapy Relive the experience and reframe it Processing emotions and sensations will help restore a sense of control and reduce the hold that the memory has on your life Work through feelings of guilt, self blame and mistrust Exposure Therapy Virtual Reality EMDR – Eye Movement Desensitization & Reprocessing “unfreeze” the brain’s information processing system which is interrupted in times of extreme stress

18. Medications and Therapy Generalized Anxiety Disorder Benzodiazepines, buspirone, and tricyclics. Cognitive behavioral therapy, stress management and biofeedback. Panic AttacksSSRIs; benzos, tricyclics, MAO inhibitors. Cognitive behavioral therapy PhobiasBenzos, beta-blockers, SSRIs. Cognitive behavioral therapy (desensitization therapy, hypnosis. OCDSSRIs first; clomipramine ( a tricyclic); MAO inhibitors if non responsive to other drugs Cognitive behavioral therapy (exposure and response prevention) PTSDAntidepressants particularly SSRIs, clonidine Cognitive behavioral therapy

19. Alternative therapies Spiritual/religious counseling Yoga and various forms of bodywork Martial arts training Art therapy, journaling, dance therapy, and creative writing groups can offer safe outlets for the strong emotions that follow trauma.

20. Barriers to Treatment a.Non recognition of disease – denial by the provider that patient’s symptoms are PTSD b.Denial – by the patient that what they are feeling matches the symptoms of PTSD c.Medication Intolerance – inability to control anxiety and depression with usual meds. Takes many trials of meds to control symptoms

21. Prognosis CISD (critical incident stress debriefing) immediately after the event shows the best prognosis. Full-Blown PTSD can be treated with a combination of peer-groups meetings and individual psychotherapy and often be effective. May take several years with relapses experienced. PTSD can become a chronic mental disorder that can persist for decades, or the remainder of the patient’s life. These patients often have a cyclical history of symptom remissions and relapses. These have the poorest prognosis and some do not respond to any of the currently available treatments for PTSD.

22. New treatments?

23. Stellate Ganglion Blocks

24. A stellate ganglion block is an injection of local anesthetic into the sympathetic nerve tissues of the neck. They are found in front of the fifth and sixth cervical vertebrae A stellate ganglion block is typically done to: Diagnose the cause of pain in the face and head, arms and chest Manage pain in the head, neck, chest or arm caused by nerve injuries, the effects of an attack of shingles (herpes zoster) or angina that doesn't go away Reduce sweating in the face, head, arms and hands Treat reflex sympathetic dystrophy, sympathetic maintained pain or complex regional pain syndrome

25. References www.gowarriorsproject.org http://www.bioportfolio.com/resources/pmarticle/35449/Ptsd-In- Older-Bereaved-People.html Source: National Center for PTSD http://www.helpguide.org/mental/post_traumatic_stress_disorder_ symptoms_treatment.htm http://www.ptsd.va.gov/public/pages/ptsd-older-vets.asp http://www.helpguide.org/mental/post_traumatic_stress_disorder_ symptoms_treatment.htm http://www.aplaceformom.com/senior-care- resources/articles/elderly-anxiety-disorders http://health.nytimes.com/health/guides/disease/post-traumatic- stress-disorder.html http://www.minddisorders.com/Ob-Ps/Post-traumatic-stress- disorder.html

26. References (cont) http://www.army.mil/article/86211/Virtual_reality_therapy_may_hel p_PTSD_patients_recover.html http://www.hopkinsmedicine.org http://www.emdr.com/general-information/what-is-emdr.html http://www.cedars-sinai.edu/Patients/Programs-and-Services/Pain- Center/Head-and-Neck-Pain/Stellate-Ganglion-Blocks.aspx