1. PTSD in Veterans: CIT Training
Norman I. Itkowitz, Psy.D.
Clinical Psychologist
VA Medical Center
Memphis TN

2. Some Police Officers are Veterans
How many of you are veterans or are in the Guard or Reserve?
How many of you have a family member who is a veteran or in the military?
You have a vested interest in serving veterans!

3. Plan for Today What is PTSD? PTSD in offenders and veterans
PTSD in police officers
Coping with PTSD and other stress reactions in a law enforcement setting

4. What is Post Traumatic Stress Disorder?
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as it occurred to others.
Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
Direct (self) experiencing of repeated or extreme exposure to aversive trauma. Examples: police officers repeated exposed to details of child abuse, veterans repeated exposure to death of others.
American Psychiatric Association, 2013

5. What is a Traumatic Experience?
What is PTSD?
What is a Traumatic Experience?
Not every trauma experience causes PTSD

6. Normal Reactions After Trauma
It is NORMAL to have some symptoms right after a trauma. Those symptoms may include:
Sleep difficulties including dreams about the trauma.
Strong emotions such as anger, sadness, or shame.
Feeling very keyed up and jumpy.
Being overly concerned about safety and control.
Physical difficulties such as stomach pains/tight shoulders..
Some people have different reactions to the same trauma such as:
Relief at survival.
Grateful.

7. Common Potentially Traumatic Events
Combat/ war-zone exposure
Sexual assault
Physical assault
Child abuse
Natural disaster (fire, flood, earthquake, tornado)
Manmade disaster
Life-threatening accidents
Serious injury or threat of injury to self or others
Threat by weapons

8. Jobs with Risk of Trauma Exposure
What is PTSD?
Police officers
Corrections employees
Firefighters
Military personnel
Emergency medical workers

9. Workplace Violence
What is PTSD?
The number of workplace non-fatal violent incidents is higher for police officers than for any other profession.
And Fatal incidents are on the rise as well
http: //
The Police Chief, vol. LXXVIII, no. 5, May 2011

10. Reactions During Trauma Vary
Some individuals experience, fear-based re-experiencing, emotional, and behavioral symptoms
Others experience, anhedonic or dysphoric mood states or negative cognitions may be most distressing.
Still in other individuals, arousal and reactive-externalizing symptoms are prominent
While in others, dissociative symptoms predominate
Finally, some individuals exhibit combinations of these symptom patterns.

11. After Exposure to Trauma
What is PTSD?
While most people recover naturally, some will develop difficulties.
Posttraumatic stress symptoms (ASD, PTSD)
Traumatic grief symptoms
Depression
Alcohol or substance abuse
Impaired functioning
Elevated risk of mood, other anxiety, and substance abuse disorders
Elevated risk of suicide attempts

12. Risk Factors
Most people exposed to a trauma do not develop PTSD: resilience
Age, gender, previous trauma history, psychiatric hx, education
Severity of trauma exposure
Peritraumatic and persistent dissociation/ distress
Social support after trauma

13. Prevalence of Trauma and PTSD > 60% Experience A Traumatic Event In Their Life > 25% Experience Multiple Traumatic Events
Kessler et al., 1995, 1999

14. Mental Health Problems in Veterans
~ Hoge (2004)

15. Symptoms of PTSD: Intrusion Symptoms
What is PTSD?
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

16. Symptoms of PTSD Persistent Avoidance
What is PTSD?
Avoidance or Efforts to Avoid:
Distressing memories
Thoughts or feelings related to the event
External Reminders
People
Places
Conversations
Activities
Objects or situations

17. Symptoms of PTSD: Changes in your beliefs/thoughts
May experience negative thoughts that you didn’t use to have:
‘I can’t stand being at this party/around people.’
‘The world is unsafe and anything can happen at any time, anywhere.’
‘I can’t stand to be close to other people (physically, emotionally).’
‘I don’t care about little things anymore; I can’t stand it when others care about little things that don’t matter.’
‘I don’t trust anyone anymore.’

18. Symptoms of PTSD Hyper arousal
What is PTSD?
May be more amped up, more jittery or constantly on alert and on the lookout for danger. It can cause:
Sudden angry and aggression, constant irritability.
Have a hard time falling or staying asleep.
Trouble concentrating.
Engagement in risky behaviors.
Extreme concern for one’s safety and always feel on guard.
Exaggerated startle when surprised.

19. Duration of Difficulties and Impairment
What is PTSD?
Disturbance lasts more than one month
Disturbance causes significant distress or impairment in important areas of functioning
Considered acute if < 3 month; chronic if > 3 months
Onset can be delayed (no symptoms until 6 months post-trauma)

20. Effective Treatments for PTSD
Cognitive-behavioral therapy
Education
Stress management
In some cases, medication

21. Stigma in Mental Health: The Military Responds
1/5 of OEF/OIF returnees report PTSD or depression, and only ½ of those seek treatment (Rand, 2008)
Change in security clearance questions
DoD launches anti-stigma campaign
Navy: ready-reacting-injured-ill
PT daily, MT just as important
APA Monitor article June 2009
Military security clearance questions were changed in 5/08 so that people who seek family counseling or mental health care for combat-related reasons do not have to report it
$2.7 million anti-stigma campaign by DoD that involves generals talking about their struggles with PTSD, ordinary service members will tell their stories of seeking help.
Navy has changed its system where service members were considered either ready or ill and unfit for duty, and psychologists were mostly responsible for labelling people as ill. The new system includes a broader continuum, and military leaders, psychologists, and chaplains can help people no matter where they lie on the continuum, meaning that even people in peak psychological shape can benefit from seeing counselors.

22. Stigma in Mental Health: The Military Responds
Negative career consequences for seeking MH services in Air Force: 3% of self-referred versus 39% commander-referred
APA recommends emphasis on building resilience
Real Warriors*Real Battles*Real Strength:
Seeking MH care doesn’t harm the career – it’s not being able to do the job because of personal issues that can harm the career
In police and firefighters, research has shown that public education campaigns with an approach based on building resilience is better received than the more traditional notion of treatment mental health problems
The Real Warriors Campaign is an initiative launched by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) to promote the processes of building resilience, facilitating recovery and supporting reintegration of returning service members, veterans and their families.

23. PTSD in Police
Police service is widely recognized as one of the most dangerous and stressful occupations
Incidence of duty-related PTSD in police officers: %
Important factors in development of PTSD in police: distress/ dissociation at time of incident, social support, routine work stress (Marmar et al., 2006)

24. Prevalence in Police at 9/11
Sample of rescue/ recovery workers
at World Trade Center on 9/11
Overall prevalence of PTSD: 12.4%
6.2% for police
21.2% for unaffiliated volunteers
Disaster preparedness training and shift rotations to enable shorter duration of service at the site may reduce PTSD among workers and volunteers.

25. Resilience to Traumatic Stressors
Coping with PTSD and other stress reactions
Recognize the signs:
Trauma memories coming back repeatedly
World no longer seems safe
People no longer seem trustworthy
You question yourself, your actions, and your self- worth
National Center for PTSD

26. Resilience to Traumatic Stressors
Coping with PTSD and other stress reactions
Recognize coping strategies that are natural but don’t work:
Avoiding people, places, or thoughts that are reminders
Shutting off feelings or connections to other people
Being hypervigilant or on guard
Using alcohol to relax or unwind
National Center for PTSD

27. Resilience to Traumatic Stressors
Coping with PTSD and other stress reactions
Use positive coping strategies:
Talk to another person for support.
Talk to a professional counselor, your doctor, or support group
Practice relaxation methods
Increase positive activities
National Center for PTSD

28. Resilience to Routine Stressors
Coping with PTSD and other stress reactions
Manage stress by using:
Mental and physical relaxation
Positive thinking
Problem solving
Anger control
Time management
Exercise
Responsible assertiveness
Interpersonal communication
National Center for PTSD

29. PTSD in Crisis Intervention
Coping with PTSD and other stress reactions
Speak softly
Use de-escalation strategies
Orient to present
Ask if person is a veteran
Validate
Allow time
Offer help

30. Thank you for your attendance!
Questions?
Thank you for your attendance!