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CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Evidence-based Treatment and Special Considerations for Military-related PTSD Dr. Alexandra McIntyre-Smith,

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Presentation on theme: "CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Evidence-based Treatment and Special Considerations for Military-related PTSD Dr. Alexandra McIntyre-Smith,"— Presentation transcript:

1 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Evidence-based Treatment and Special Considerations for Military-related PTSD Dr. Alexandra McIntyre-Smith, C.Psych. & Dr. Maya Roth, C.Psych. Parkwood Operational Stress Injury Clinic OPA Conference February 20, 2015 Toronto, Ontario

2 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Overview Operational Stress Injury Clinic Network PTSD –Core symptoms –Military-related PTSD –Notable Features of Military-related PTSD BREAK Treatments –Prolonged Exposure Therapy –Cognitive Processing Therapy –Treatment Considerations Special Considerations –Moral Injury

3 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 OSI - Clinic Network 9 specialized out-patient clinics + 1 in-patient hospital in Canada –Established in 2002 –Centre of expertise on operational stress injuries Federally funded –Veterans Affairs Canada (VAC) –With collaboration of the Department of National Defence (DND) 9 of 10 clinics administered by provincial health care organizations

4 CARING FOR THE BODY, MIND & SPIRIT SINCE Network of Clinics Edmonton Capital Health Out patient & Residential Treatment Clinic

5 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Who Do We See? Veterans Actively serving members of the Canadian Forces –Still serving members Treatment Pension assessments –Transitioning members Royal Canadian Mounted Police (RCMP)  Eligibility: Service-related injury

6 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 OSI Clinic - Clinical Presentation N = 202

7 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Canadian Deployments Afghanistan: ˃ 40,000 deployed – Mean age = 36 years UN & NATO Peacekeeping: > 125,000 deployed –CF Veterans = 594,500; mean age = 55 Korean War ( ): 26,791 deployed –10,600 surviving, mean age = 80 World War II: 1 million (and Newfoundlanders) deployed –107,600 surviving, mean age = 88

8 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 PTSD - DSM-V Criteria Defined Traumatic Stressor Exposed to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation Learning that this occurred to a close relative or close friend Experiencing repeated or extreme exposure to aversive details of the event(s) Exposed to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation Learning that this occurred to a close relative or close friend Experiencing repeated or extreme exposure to aversive details of the event(s)

9 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Core Symptoms of PTSD NEED 1 NEED 1 Flashbacks Intrusive memories Nightmares Emotional distress at reminders Physiological reactivity Intrusions NEED 2 Amnesia Negative expectations Distorted blame of self/others Negative emotional state Loss of interest Detachment Emotional Numbing- restricted affect Negative cognitions & mood NEED 2 Irritability and anger Reckless or self-destructive behavior Hyper-vigilance Startle response Poor concentration Insomnia Arousal & reactivity NEED 1 Thoughts/feelings Activities/places/people Avoidance

10 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Percentage of Victims with PTSD Percentage 1 Wk 1 Month 2 Mos. 3 Mos. 6 Mos. 12 Mos. Assessment (Kessler et al., 1995)

11 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Rate of PTSD – Influenced by Nature of the Trauma Kessler et al., 1995 (Kessler et al., 1995)

12 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Risk Factors for Development of PTSD Pre-Trauma Factors: –Gender –Psychiatric history –Childhood abuse –Prior adverse events Peri-Trauma Factors: –Trauma severity Post-Trauma Factors: –Stress –Lack of Social Support Military-Specific Factors: –Number of deployments –Serious injury –Younger age (Richardson et al., 2009; Hoge et al., 2004; Richardson et al., 2010)

13 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Comorbidity PTSD Major depression Substance abuse Other anxiety disorder Psychotic symptoms mTBI & Physical injury Chronic pain Personality disorder/traits Other social dysfunctions Major depression Substance abuse Other anxiety disorder Psychotic symptoms mTBI & Physical injury Chronic pain Personality disorder/traits Other social dysfunctions Comorbidity – the rule rather than the exception Comorbidity – the rule rather than the exception

14 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Notable Features of Military-Related PTSD May be repeated “Criterion A” traumatic events in a single deployment –Difficulties can be compounded within and across multiple deployments May occur in the context of prolonged “high alert,” sleep impairment, and physical discomfort Potential for traumatic bereavement High likelihood of the trauma involving “moral injury”

15 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Military-Specific Content Events experienced are often interpersonal in nature Can involve loss/injury of close friends with whom share formative bond –Often resulting from violent/gruesome acts Events take on greater meaning –Considered to be peak/most representative experiences of their career, outcomes are more significant than in daily life Reactions are influenced by developmental stage Complicated by transition to civilian life and loss of identity/purpose

16 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment

17 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Evidence for PTSD Treatments Overall Pharmacotherapy = 0.69 Overall Psychotherapy = 1.17 Hypnosis = 0.94 Comparing different approaches Which Psychotherapy is best? Cognitive Therapy = 1.63 Exposure Therapy = 1.08 EMDR = 1.01 Watts et al., 2013 Van Etten & Taylor, 1998

18 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Prolonged Exposure Therapy Cognitive Processing Therapy –Manualised, time-limited, CBT derived interventions –Involve outcome measurement –Involve between session homework –Initially developed to treat victims of sexual assault in the 1980s –Significant empirical support for civilian and veteran application What are the most Empirically Supported Treatments?

19 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Aim = confront and emotionally process trauma 8 – 12 ninety minute sessions Components of PE: –Psychoeducation to common reactions to trauma –Breathing retraining –In-vivo exposure –Prolonged imaginal exposure + PROCESSING Prolonged Exposure Therapy

20 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Prolonged Exposure Therapy Repeated In-vivo exposure: –Blocks negative reinforcement –Realization that: Avoided situations are safe Anxiety in feared situation does not last forever Repeated Imaginal exposure results in: –Processing and organization of the trauma –Thinking about trauma vs. re-encountering it –Engaging with trauma does not result in losing control Increased self-control and competency + habituation How does PE work?

21 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Prolonged Exposure Therapy 51 year old male Served as a submariner for 25 years Deployed to the Adriatic Seas in 1993 Diagnosed with PTSD, Chronic and MDD, Recurrent in 2009 –Chronic Pain and a number of psychosocial stressors Treatment: –Group treatment for Chronic Pain –Individual and group treatment for Depression –PE Case

22 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Prolonged Exposure Therapy Session 10 – Final Session

23 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Aim = Examine how made sense of trauma & feel emotions 12 sixty minute sessions Components of CPT: –Psychoeducation – Impact Statement –Processing the trauma – Written Account –Cognitive restructuring –Trauma themes – Safety, Trust, Power/Control, Esteem, and Intimacy CPT vs. CPT-CGroup Application Cognitive Processing Therapy

24 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Cognitive Processing Therapy Cognitive Theory –Organize and process information in order to understand, predict and control –e.g., Just World Belief –PTSD occur when trauma is incongruent with prior beliefs –It is maintained by how the memory of the trauma is integrated Challenging avoidance Identifying Stuck Points (about the past/trauma and about present/future) Challenging Stuck Points Identifying type of emotion and processing –Natural vs. manufactured How does CPT Work?

25 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Cognitive Processing Therapy 28 year old male Served within an Armoured Regiment for 5 years Deployed to Afghanistan in 2010 Diagnosed with PTSD, MDD, Alcohol Abuse in 2012 Treatment: –PE - Discontinued –CPT Case

26 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Cognitive Processing Therapy Stuck Points - Assimilation I am responsible for hitting the IED I should have responded more appropriately to the warning signs I was complacent I should have been able to function at my best regardless of the stress that I was under

27 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Cognitive Processing Therapy Progress in CPT Identify and experience natural emotions (fear, sadness, anger) and manufactured emotions (Blame, guilt, shame) Reading written trauma account (13 pages) Using A-B-C Worksheets Using Challenging Questions Worksheets Using Patterns of Problematic Thinking Worksheets

28 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Are they universally applicable? Empirically Supported Treatments

29 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Essential elements in the determination of a patient-centered treatment plan include careful and thorough assessment of : –The nature of the trauma –Past experiences in psychotherapy –Patient readiness –Patient ability to access internal cognitive and emotional processes –Patient preference for treatment Attention to individual differences The patient at the center of decision making Flexible application of evidence-based PTSD treatments

30 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Treatment Considerations Lack of skill in attending to internal mental events can sometimes complicate the treatment picture Perceived clinician credibility or competency is a key predictor of outcome in this population Competency is defined as: –Knowledge of military history –Knowledge of military nomenclature and structure –As well as expertise in treating military-related PTSD Process Considerations

31 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Moral Injury Cognitive/emotional reaction to perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs Such experiences create: –Mental dissonance or mental conflict that is extremely difficult to resolve –Conflict between the reality of the experience and the individual’s previous beliefs about their moral character, or their expectation about how other people can be expected to behave. The experience is often very difficult to contextualize or justify What is it?

32 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Moral Injury Highly motivated not to think about it (shame, guilt) Anticipate condemnation from valued others Event is likely not thought about or talked about in dispassionate detail that would allow realistic appraisals of personal responsibility, moral culpability, and so on Can strongly affect how view the self – unforgivable, immoral, deserving of punishment Through various processes, contributes to social withdrawal Traumas Involving Moral Injury are Virulent

33 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Moral Injury Moving a mass grave in Rwanda after the genocide – uncovering bodies of children Korean War – clearing a tunnel and hit a woman in labour and her mother Vehicle rollover in Bosnia where driver was killed – officer responsible questions his decision to leave at night not next day Killing a child solider in middle east and being congratulated by peers Case Examples

34 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Moral Injury Tank gunner in Afghanistan who killed adolescent among group of militants firing on convoy Engineer in Bosnia who inadvertently disturbed unmarked burial site Infantryman in Afghanistan who set up observation post in a position determined by chain of command resulting in death of 7 Witnessing/perpetrating harm to children/animals Case Examples

35 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Considerations: Moral Injury Specific break-out exercises when trauma involves traumatic loss, betrayal, perpetration, or sins of omission Experiential exercises e.g. imaginal dialogue with benevolent moral authority or person who was lost Exposure to corrective life experience e.g. behavioural experiments and exercises designed to help client move forward in accordance with core values, and to rebuild relationships/ reconnect with others; “entails increasing the accessibility of positive judgment about the self by doing good deeds and positive judgments about the world by seeing others do good deeds, as well as by giving and receiving care and love.” (Litz et al, 2009) Adaptive Disclosure Therapy (see Litz et al., 2009)

36 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 PE, CPT, and Moral Injury Approaches Emphasis on overcoming experiential avoidance – confronting rather than suppressing/ distracting from memories Examination of maladaptive (e.g., extreme, rigid, or inaccurate) beliefs about the meaning and implications of the traumatic events Incorporate assignments that encourage behavioural change (directed at overcoming situational/social avoidance) outside the therapy session Explicit teaching of the rationale: –Why do we expect this therapy to be effective? –How do you, as the client, use your understanding of the principles underlying treatment to continue recovery/ prevent relapse when therapy is complete? Common Themes

37 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Psychotherapy Adjuncts: IRT Short term, cost-effective cognitive-behavioural treatment for recurrent nightmares Originally developed to treat idiopathic nightmares (Krakow et al. in 1995) Recently been applied to the treatment of PTSD nightmares Involves formulation and rehearsal of a less distressing variant of a trauma-related nightmare (Krakow et al., 2001) Strong empirical support What is IRT?

38 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Psychotherapy Adjuncts: Virtual Reality Virtual reality is a human-computer interaction medium that allows patients to be immersed in a virtual environment –Immersion in a digital replica enhances and increases vividness –Effectively elicits the fear structure targeted in exposure therapy Developed to: –Help patients engage emotionally in the exposure therapy process –Circumvents avoidance by delivering multisensory and context- relevant cues that evoke the memory of the traumatic event in question Growing empirical support Augmentation of Imaginal Exposure in PE

39 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Consideration: mTBI Overlapping Symptoms – PTSD and mTBI Stein et al., 2009

40 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Consideration: mTBI The risk of concussion is more common in Afghanistan than everyday life 10-20% of their combat troops experienced mTBI during deployment (US Data) Combat soldiers are more likely to be exposed to significant psychological stress at the time of concussion Comorbidities are more likely to develop or become exacerbated post mTBI Military Considerations

41 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Special Consideration: Somatic Complaints Chronic Pain PHQ-15 ItemBothered a lotBothered a littleNot bothered % (N) Stomach pain41.6 (121)39.9 (116)18.6 (54) Back pain16.2 (47)31.3 (91)52.6 (153) Pain in your arms, legs, or joints13.4 (39)31.3 (91)55.3 (161) Menstrual cramps or other problems with your period (women only)* 29.2 (7)41.6 (10)29.2 (7) Headaches62.2 (181)18.2 (53)19.6 (57) McIntyre-Smith & St. Cyr, 2013

42 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Other Complaints PHQ-15 ItemBothered a lotBothered a littleNot bothered % (N) Chest pain22.7 (66)51.9 (151)25.4 (74) Dizziness56.4 (164)35.1 (102)8.6 (25) Fainting spells44.0 (128)45.0 (131)11.0 (32) Feeling your heart pound or race87.6 (255)10.0 (29)2.4 (7) Shortness of breath25.1 (73)52.9 (154)22.0 (64) Pain or problems during sexual intercourse36.4 (106)45.0 (131)18.6 (54) Diarrhea, loose bowels, or constipation36.4 (106)39.5 (115)24.1 (70) Nausea, gas, or indigestion27.1 (79)43.0 (125)29.9 (87) Feeling tired or having low energy3.8 (11)16.8 (49)79.4 (231) Trouble sleeping4.1 (12)18.2 (53)77.7 (226) McIntyre-Smith & St. Cyr, 2013 Special Consideration: Somatic Complaints

43 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Perhaps even more than good medical care, veterans need individuals and communities who will commit to walk patiently alongside them, allowing them to tell their stories if and when they are ready to do so, even when these stories are distressing or complex or unbearably sad. Veterans need a civilian culture that refuses to distance itself from them either through reflexive condemnation… and above all, they need to be taken seriously as moral beings who have stood for us in hazy and complicated places and who now bear witness to what that commitment entails. W. Kinghorn (2012). USA Today. Closing Thought

44 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Questions/Comments

45 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Assessment Considerations Psychological factors influencing self-report –CF-related cultural conventions re: acknowledging emotion –Relies on ability to reflect on internal events (i.e., thoughts, feelings) and sometimes subtle behaviours (i.e., avoidance) –Avoidance is often a well-developed strategy Discourages reflection/observation of internal events Can impact diagnosis (i.e., reduced experience/awareness of re-experiencing and other symptoms) Working with Self-report as Primary Source of Data

46 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Assessment Considerations A positive assessment experience can set the stage –Destigmatizing, provide a way of understanding experiences, instill hope Utilize feedback to motivate for treatment –Often call on love/duty towards family, desire to return to work Utilize assessment as : –An opportunity to build mastery for coping with discussion of traumatic events –Highlight gains made and identify areas for growth Setting the Stage for Treatment

47 CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Assessment Considerations Secondary gain might increase the chance of malingering Always assess for: –Exaggeration of symptoms –Minimization or under-reporting of symptoms –Inconsistency of self-report Strategies: –Avoid yes or no questions –Ask for examples of what the client reports as a symptom –Meet with a family member to verify certain symptoms –Pay attention for possible contradictions –Consider what motivates patient Malingering


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