1. Introduction to Trauma & PTSD
Presented January 26, 2012 as part of the Grant per Diem educational training series for staff
Introduction to Trauma & PTSD
Karen Krinsley, Ph.D.
PTSD Section Chief,
VA Boston Healthcare System
& PTSD Consultant,
National Center for PTSD

2. Outline of Talk Recognizing PTSD How common is it?
Who is most at risk?
What treatments are effective?
How the PTSD Consultation Program can help

3. The technical diagnosis of PTSD — And why it is important
Misdiagnosis is common
Misunderstandings are common
Great reason not to focus on other issues
Serious but treatable when it is present
Typically NOT present alone

4. PTSD (DSM IV-TR): A Cluster of Symptoms
Trauma (The “Stressor”)
Reexperiencing / Intrusions
Avoidance/Numbing
Increased Arousal
More than one month of symptoms
Causes functional problems
#120
rates of PTSD are 5% and 10% (men / women) [kessler, 1996]
women more likely to develop ptsd is exposed to trauma
ptsd can be chronic, lasting for decades

5. PTSD Criterion A Stressor
Exposure to a traumatic event in which:
The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror.

6. Important to Remember
PTSD ≠ TRAUMA
and
TRAUMA ≠ ANYTHING bad

7. PTSD ≠ Trauma ≠ Anything bad
Traumas do not always lead to PTSD
Traumas may lead to PTSD, but then the person recovers
And, many bad things happen to people, affecting them deeply, that are not “trauma”

8. Criterion B: Reexperiencing/Intrusions
Recurrent recollections of the event
Recurrent distressing dreams of the event
Feeling as if the traumatic event were recurring
Intense distress at exposure to cues that resemble an aspect of the event
Physiologic reactivity upon exposure to cues that resemble an aspect of the traumatic event
EXAMPLES: Nightmares, Flashbacks, Shaking, Sweating

9. Criterion C: Avoidance/Numbing
Efforts to avoid thoughts about the trauma
Efforts to avoid things that remind one about the trauma
Inability to recall an important aspect of the trauma
Markedly reduced interest in significant activities
Feeling of detachment from others
Restricted range of affect (e.g., unable to have loving feelings)
Sense of foreshortened future
EXAMPLES: Avoiding the news, movies, crowded stores but also drinking and drug use

10. Criterion D: Increased Arousal
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
EXAMPLES: Keeping guns, checking locks, aggression, insomnia

11. PTSD Criterion E and F Duration: At least one month
Functional Impairment: “clinically significant”

12. Do you see the overlaps? Depression Substance Use Disorder
Mild Traumatic Brain Injury
Pain Symptoms

13. Likelihood of getting PTSD after Experiencing a Trauma
It depends on the event and the person
Men experience more traumatic events
Women are more likely to develop PTSD
After a traumatic event, who gets PTSD?
20% of women
8% of men get PTSD
Kessler et al., 1995
New work from Boston is showing similar rates in men and women in the current conflicts.

14. Likelihood of PTSD…. Rape Men 65% Women 45% Combat Men almost 40%
Physical Abuse
Almost 50% of women
20%+ men
Why no women in combat? Dawn Vogt’s new data….

15. What puts you at risk for PTSD?
Being female
Being poor
Less education
Bad childhood
Previous psychological problems

16. What puts you at risk for PTSD?
*Strength or severity of the stressor
Characteristics of the trauma:
Greater perceived life threat
Feeling helpless
Unpredictable, uncontrollable

17. Risk for PTSD: After the Trauma
Degree of Social Support
Degree of Life Stress

18. How common is PTSD? 3.5% general population, current
1.8% men
5.2% women
Lifetime: 6.8% % men, 9.7% women
(U.S. National Comorbidity Survey Replication )
Vietnam theater veterans:
15.2% of men
8.1% of women
(National Vietnam Veterans Readjustment Study )
In veterans
In combat veterans
In women veterans (who may be combat veterans!)

19. How common is PTSD? Gulf War (I): 10% OEF/OIF Population-based studies
13.8 (current)
Population-based studies
(RAND Corporation, Center for Military Health Policy Research, 2008)
Conclusions: PTSD is not unusual, although not the majority

20. What about MST?

21. How Common is MST. Margret Bell, Ph. D
How Common is MST? Margret Bell, Ph.D. Resource Development & Utilization Coordinator, MST Support Team – (national resource for VA MST teams)
Data Source
Time frame
Men
Women
Sexual harassment
Sexual assault
DoD 2002 Survey
(active duty sample)
Annual rates
23% 1%
54% 3%
Street et al., 2003
(reservist sample)
Anytime during service
27%
60%
Skinner et al., 2000
(users of VA healthcare) --
55%

22. Implications of PTSD Greater risk of other disorders
80% of people with PTSD another diagnosis
Depression, SUD, Anxiety Disorders
Greater unemployment
Relationships
Health problems
Violence
Generally, worse quality of life

23. What does PTSD look like?
No one clinical picture but not like it is shown on television/movies
Can’t stereotype, although it’s done
There are some “hallmarks”
Nightmares
Poor sleep
Anger
Numbness or sadness
Avoidance of groups

24. How can you help?
Be supportive but don’t allow PTSD to be used as an excuse
Do ask if they want to talk and acknowledge their military service
Don’t say “I understand”
Be alert for risk issues

25. How can you help? Sleeping / Nightmares: No touching
No “fooling around”: Don’t sneak up on someone, don’t make sudden noises behind them
Understand the impact of TV
Consider special requests: Light, Noise, Large Groups

26. A few tips for Managing Anger
Confrontation probably NOT helpful
Try to understand the cause, both to help manage and to help yourself stay calm
Prepare ahead of time with the veteran if possible
Allow “escape”

27. Trauma-Informed Milieu
Structured but not authoritative or punishing
Everyone treated with respect and listened to
Setting is kept safe
Staff aware that residents may be traumatized

28. Professional Help Know when to refer
Be knowledgeable about PTSD treatments and aware that they work
Encourage keeping appointments
Acknowledge that it will be HARD but it is worth it
Ask what the alternative is
Be wary of splitting

29. Effective PTSD Treatments
State of the art treatment
Empirically validated treatments
Staged, stepped model of care
Safety
Trauma focus
Reconnection
Interdisciplinary
PTSD ≠ chronic mental illness

30. Treatment for PTSD
Cognitive Behavioral Treatments most effective psychotherapy treatments
Medication can be an effective treatment
Most evidence for Cognitive Processing Therapy and Prolonged Exposure
Most evidence for antidepressants

31. Stepwise Treatment Model: Stage 1 Safety
Suicide and Homicide prevention
Harm reduction for risky behaviors
Teach positive coping tools
Teach the role of avoidance
Group focus when possible, including: Seeking Safety, Understanding and coping with PTSD, Relaxation & Stress Mgmt, ACT, DBT modules & Anger Management, Wellness, & more

32. Stepwise Treatment Model: Stage 2 Trauma Focus
Core of PTSD treatment
Empirically validated treatments include Cognitive Processing Therapy and Prolonged Exposure
It works! Recovery is possible.

33. Trauma Focus Therapy Many types Core common elements
Exposure to the trauma in some form
Processing of the trauma
Results: Decreased avoidance, increased tolerance of distress, and ultimately decreased distress

34. CPT AND PE Comparison Study (Resick et al., 2002)
This graph shows all of the participants who were available at each data point. As you can see, the gains that were made during treatment appear to have been maintained over time.
47% had received no further psychotherapy (for anything) since receiving CPT or PE.
24% received six months or less of treatment for anything since tx.
only 15% had been in therapy for 2 or more years
At pretreatment, 41% were taking psychotropic medication (including sleep medications). At the long term follow-up 23% were taking medication.
CPT, N=
PE, N= 34

35. CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT AND LONG TERM (Resick et al., 2002)
Rather than severity, here are the diagnostics on the CAPS. As you can see, both CPT and PE had long lasting improvements in PTSD diagnosis. 35

36. Stepwise Treatment Model: Stage 3 Reconnection
Focus is on relationships
Reconnection with friends, family
Support groups, process groups, marriage and family work and more
Also may include Reparation

37. Special issues with new veterans of Iraq and Afghanistan
National Guard OR Reserve OR Regular Military
Trauma is more acute or “raw”
Anger and aggression are common
Binge drinking or casual drug use
May be working and need different hours for treatment
Often have families and children, and may want or need them involved in treatment
May not want traditional treatments such as group therapy

38. PTSD Consultation Program
One-on-one PTSD consultation for any VHA provider OR contractor
Free of charge
Speak directly with “expert” PTSD clinicians
Response usually within 24 hours
Easy to contact us: Call, , or complete an online form

39. Consultation Program Staff
Karen Krinsley, PhD
Consultant & VISN 1 PTSD Mentor
PTSD Section Chief, VA Boston
Nancy Bernardy, PhD
PTSD Mentoring & Consultation Program Manager
VA National Center for PTSD
Matt Friedman, MD, PhD
Executive Director, NCPTSD
And associated experts from around the country

40. PTSD Consultation Program
Ask questions regarding:
Assessment
Treatment
Therapy of all kinds
Medication
Clinical management
Programmatic issues
Resources for treatment
Ways to improve care
Any problem at all
Highlight programmatic issues b/c they get these questions all the time

41. Eligibility We can’t say this enough: ANY VHA Clinician ANY Contractor
ANY Question
ABOUT ANY Veteran or Group of Veterans

42. For Whom and How We Have Been Useful
Experienced clinicians who want a second opinion
Relatively inexperienced clinicians who would rather not “bother” local colleagues that particular day
New staff who are overwhelmed
Staff without a lot of local folks for support

43. For Whom and How We Have Been Useful
Staff from programs outside PTSD with no connections to their PTSD programs
Staff who have hit a roadblock or a wall
Diagnostic and treatment challenges
Referrals to residential programs

44. Consultation Program Contact Information
Contact us:
Call 1 (866)
Online Form at:
vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp
Send to

46. A Few Things to Remember
Consultation provides an opportunity for problem solving and discussion with the treating clinician
Ultimate decision and authority for implementing consultation recommendations lie with the treating clinician and the local chain of command
Not for acute emergencies

47. More Information: National Center for PTSD Website
All types of information, for
Providers
Veterans
Families
General Public
Has online courses such as “Understanding PTSD” and much more