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By Nealy Jenkins, LMSW Symptoms of Posttraumatic Stress Disorder 388.81 Rules of Engagement Statistical Data of Veterans with PTSD Neurotransmitters Psychopharmacology and Side Effects Treatment Models 1. Reliving the Event Memories of the trauma that come back at any time such as nightmares or going through it again like a flashbacks. 2. Avoiding situations that remind you of the Event Client may try to avoid situations or people that bring back memories of the event 3. Feeling Numb Client may find it hard to express their feelings and difficulty remembering or talking about parts of the trauma. 4. Feeling Keyed Up Client may be jittery and on the lookout for danger. Client might suddenly become angry or irritable. Rules of Engagement (ROE) 1.) The military is a world of constant transition. 2.) Clinician must educate themselves two frequent transitions: Deployment and Family Separation. 3.) Understand Hierarchical Military Structure. 4.) Important dynamic of the military culture is that family must do nothing that will negatively impact the service member’s career. 5.) The stigma is that service members are trained to be self-reliant and capable; anything else would be to defy their military training. Rules of Engagement Cont. 6.) The military has a mission to accomplish. Understanding that families are seen as furthering that mission is of utmost importance. 7.) It helps to know why a service member joins the military. The reasons for joining may determine commitment to the military and shed light on family issues. 8.) Every military family is different. Having a working knowledge of family transitions, remarried-coupled issues, and stepfamily issues can be extremely helpful in working with military families. 11-20% of Veterans of Iraq and Afghanistan suffer from PTSD 228, 361 Veterans diagnosed with PTSD 10% of Veterans of Gulf War suffer from PTSD 30% of Vietnam Veterans suffer from PTSD 23% of women reported sexual assault while serving in military 34% of Veterans reported having been exposed to dead, dying, or wounded. Since initiation of Global War On Terror (GWOT), 54% of veterans use VA benefits. 52% is used for Mental Health issues The Neuron is the basic functional unit of the nervous system with primary purpose to receive, conduct, and transmit signals to the other cells. Neuronal signals that are transmitted from cell to cell at specialized sites for contact are called Synapses. Within the brain, messages can be transmitted in two ways: Electrically and Chemically. A Neurotransmitter is synthesized within the neuron out of precursors that are brought into the neuron by outside cells. Precursors within neuron are broken down to form the Neurochemical. Step 1: Synthesis- Precursors present in the transmitter site are activated by an enzyme and become a neurotransmitter. Step 2: Storage- Once created, neurotransmitters are stored in vesicles, to be released when signaled. Step 3: Release- Neurotransmitters are released into the synaptic gap. Step 4: Termination- Transmitters are cleared from synaptic gaps in three ways: Reuptake Enzymatic Degradation Diffusion 10 Types of Neurotransmitters Dopamine--Psychosis Norepinephrine--Depression Serotonin—Depression Acetylcholine—Dementia (Alzheimer’s Disease and Parkinson’s Disease) GABA—Anxiety Glutamate– Dementia (Alzheimer’s Disease and Central Nervous System) Glycine– Depression, Dementia, and Schizophrenia Enkephalin– Addictive disorders and Depression Beta-endorphin– Addictive disorders Dynorphin– Depression and Addictive disorders 75-90% of general neurotransmitters are Gammaaminobutyric Acid (GABA), Glutamate (Dementia), and Glycine (Depression). Coyle and Enna (1998) stated many professionals agree that GABA plays a large part in mental health reaction and has been identified as essential in exciting reactions and initiating many of the brain’s chemical transmissions. GABA slows down transmissions of nerves and many of the activities of the brain. Benzodiazepines enhance the effects of GABA, in which they reduce activity in the brain and promote sleep. Medication Half-Life is the amount of time it takes for one half of a drug’s peak plasma level to be metabolized and excreted from the body. Medication Potency refers to the relative dose needed to achieve a certain effect. Therapeutic Index of a drug is computed by determining the ratio of the toxic dose of the drug to its therapeutic dose (Example: Lithium for Bipolar toxic levels needs be assessed b/c toxic levels are so close to the therapeutic levels). Xanax (Alprazolam) Rapidity of Effect is Intermediate Half-Life is Intermediate Usual Daily Dosage is 0.5-4mg Klonopin (Clonazepam) Rapidity of Effect is Intermediate Half-Life is Intermediate/Long Usual Daily Dosage is 0.5-3mg Valium (Diazepam) Rapidity of Effect is Rapid Half-Life is Long Usual Daily Dosage is 5-40mg Ativan (Lorazepam) Rapidity of Effect is Intermediate Half-Life is Intermediate Usual Daily Dosage is 1-6mg Restoril (Temazepam) Rapidity of Effect is Intermediate Half-Life is Intermediate Usual Daily Dosage is 15-30mg Halcion (Triazolam) Rapidity of Effect is Intermediate Half-Life is Intermediate Usual Daily Dosage is 0.125-0.5mg Hypotension Dry Mouth Upset Stomach Decreased appetite Blurred Vision Depression Tremors Irregular Heartbeat Confusion Severe skin rash Fever Difficulty passing urine BuSpar (Buspirone) Rapidity of Effect is Slow Half-Life is Intermediate Daily Dosage is 5-60mg Catapres (Clonidine) Rapidity of Effect is Rapid Half-Life is Long Daily Dosage is 0.1-0.4mg Tenex (Guanfacine) Rapidity of Effect is Slow Half-Life is Intermediate Daily Dosage is 1-3mg Slow pulse rate Insomnia Low blood pressure Dizziness Contraindication with MAOI medications (Nardil) Skin redness Nausea Headache Because many of these medication are addictive, start the intervention with behaviorally based contract for awareness that the pill is only one facet of a multidimensional approach to the treatment of his or her anxiety. Recognize and plan for the potential for addiction that exists when using these anxiety medications. Long-term use at low doses is most appropriate for individuals who have a long history of chronic anxiety. In clinical depression the client experiences a lack of desire, coupled with an inability to perform everyday social and occupational tasks. Two Types of Major Depression 1.) Endogenous is related directly to internal biological factors such as neurotransmitter dysfunction. 2.) Exogenous linked to a precipitating event involving psychosocial stressors such as divorce, unemployment, or trauma. Prozac (Fluoxetine) Daily Dosage is 20-80mg It takes 4 weeks or more to get the full benefits of the drug Zoloft (Sertraline) Daily Dosage is 5-200mg Can be used for anxiety disorders Half-Life is much less than Prozac Paxil (Paroxetine) Daily Dosage is 20-40mg Can be used for anxiety disorders Half-Life is 12-20 hours Celexa (Citalopram) Daily Dosage is 20-80mg Can be used for Schizophrenia and Dementia Can trigger Mania or Suicidal Ideation Wellbutrin (Bupropion) Daily Dosage is 300-450mg It works directly with Dopamine It suppresses the appetite Remeron (Mirtazapine) Daily Dosage is 15-60mg Increases Appetite Decreases Liver or Kidney function in elderly people Dry mouth Constipation Decreased appetite Diarrhea Insomnia Fatigue Runny nose Dizziness Loss in sexual ability Nausea or Vomiting Haldol (Haloperidol) Daily Dosage is 1-40mg Moderately Sedating Thorazine (Chlorpromazine) Daily Dosage is 400-500mg Highly Sedating Prolixin (Fluphenazine) Daily Dosage is 2-40mg Minimal Sedation Extrapyramidal Symptoms (EPS), also referred to as parkinsonism, are common side effects with typical psychotic medications. Parkinsonism is similar to the symptoms that are seen in Parkinson’s disease but the major difference is the tremors are slow, rhythmic, and rotational, whereas in EPS in the hands, fingers, and wrists move faster as a unit. Three Types of EPS 1.) Dystonia is movement problems as grimacing and difficulty with speech or swallowing 2.) Akathisia is a extreme form of motor restlessness and may be mistaken for agitation 3.) Tardive Dyskinesia is involuntary movements to the face (mouth and tongue), trunk, and limb movements. Seroquel (Quetiapine) Daily Dosage is 300-400mg Used to treat Schizophrenia and involves the action of two neurotransmitters in the brain: Serotonin and Dopamine. Risperdal (Risperidone) Daily Dosage is 4-6mg It blocks the action of two neurotransmitters: Serotonin and Dopamine Abilify (Aripiprazole) Daily Dosage is 10-30mg Causes little weight gain, sedation and effect on heart function Zyprexa (Olanzapine) Daily Dosage is 5-10mg Prevents the binding of Dopamine, Serotonin, and Histamine Weight gain Persistent muscle spasms Tremors Restlessness Anxiety Rapid heart rate Problems with Menstrual cycle Urinary Retention Decreased Sexual Interest Drowsiness Restlessness Fear is generally the body’s response to real threat. Anxiety is an exaggerated response to a threat that is unclear, unrealistic, or unknown. The negative aspect of Anxiety is most problematic when it begins to interfere with an individual’s ability to work, sleep, or concentrate. The person becomes either physically or psychologically exhausted by constantly preparing to face his or her unrealistic fears. Cognitive Processing Therapy (CPT) Theory Session Four Main Parts Prolonged Exposure Therapy (PET) Theory Session Four Main Parts Eye Movement Desensitization Reprocessing (EMDR) Theory Session Four Main Parts It’s based on Social Cognitive Theory that focuses on how the traumatic event is construed and coped with by the client who is trying to regain a sense of mastery and control in their life. The theory behind CPT conceptualizes PTSD as a disorder of "non-recovery" in which erroneous beliefs about the causes and consequences of traumatic events produce strong negative emotions and prevent accurate processing of the trauma memory and natural emotions emanating from the event. Is an adaptation of the evidence-based therapy known as Cognitive Behavioral Therapy used by clinicians to help clients explore recovery from PTSD and related conditions. Consists of 12 sessions and has been shown to be effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. Learning about your PTSD symptoms and how treatment can help. Becoming aware of your thoughts and feelings. Learning skills to challenge your thoughts and feelings (cognitive restructuring). Understanding the common changes in beliefs that occur after going through trauma. Clinicians use Socratic Dialogue to discuss the details of the trauma, which helps patients gently challenge their thinking about their traumatic event and become increasingly able to consider the context in which the event occurred, with the goal of decreasing self-blame and guilt and increasing acceptance. Developed by Dr. Edna B. Poa Form of Behavioral Therapy and Cognitive Behavioral Therapy designed to treat PTSD characterized by re-experiencing the traumatic event through remembering it and engaging with, rather than avoiding, and reminders of the trauma. Theoretically-based and effective treatment for chronic PTSD or related depression, anxiety, and anger. Education to learn about their symptoms and how treatment can help. Breathing Retraining to help client to relax and manage distress. Real World Practice (Vivo Exposure) to reduce distress in safe situations that have been avoided. Talking through the Trauma (Imaginal Exposure) to get control of your thoughts and feelings about the trauma. Studies have shown symptom reduction rates of between 50%-80% Post-Treatment Follow-up studies report 75% of patients no longer meet diagnostic criteria for PTSD 6 months after treatment None of the patients meet the diagnostic criteria after 1 year Involves 8-15 sessions with therapist, plus practice assignments client will do own their own. In 1987, Dr. Francine Shapiro was walking in the park when she realized that eye movement appeared to decrease the negative emotion associated with her own distressing memories. Dr. Shapiro assumed that eye movement had a desensitizing effect, and when she experimented with this she found that others also had the same response to eye movements. Her theory of explaining EMDR is called “Adaptive Information Processing Model” because all humans possess an information processing system that processes experiences and stores these as memories in a way they are easily assessible and linked to a network of accompanying images, sensations, and emotions and beliefs. Identification of a target memory, image and belief about the trauma Desensitization and reprocessing by focusing on mental images while doing eye movements that the therapist has taught the client Installing positive thoughts and images, once the negative images are no longer distressing Body scan by focusing on tension or unusual sensations in the body, to identify additional issues you may need to address in later sessions A course of 4-16 session is common Dr. Shapiro conducted a controlled study where randomly assigned 22 individuals with traumatic memories to two conditions: half received EMD and half received the same therapeutic procedure with imagery and detailed description replacing the eye movement. Report showed that EMD resulted in significant decreases in ratings of subjective distress and significant increases in ratings of confidence in a positive belief. Participants in the EMD condition reported significantly larger changes than those in the imagery condition. Since the initial studies were published in 1989, hundreds of case studies have been published, and there have been numerous controlled outcome studies. These studies have demonstrated EMDR’s effectiveness in PTSD treatment and EMDR is now recognized as effective in the treatment of PTSD. VOLUNTEER FOR PRACTICE THERAPY SESSION. We can see them as sick, with all the stigma, neediness, and expense that entails, or we can recognize them as human beings, confronting the morality of what they’ve done in our name and what they’ve seen and come to know– even as they try to move on. Our challenge as a nation is to insure that our Warriors know of our concern, care and commitment to acknowledge, support, and help heal the invisible moral wounds of combat. Bamber, M. & McMahon, R. (2008). The role of maladaptive schemas at work. Clinical Psychology and Psychotherapy, 15, 96-112. Benda, B. (2002). 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Australian and New Zealand Journal of Psychiatry, 44, 4-19. Epidemiology Program Post-Deployment Health Group. (2012). Report on VA facility specific Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans coded with potential PTSD. Office of Public Health Veterans Health Administration Department of Veteran Affairs. http://www.publichealth.va.gov/epidemiolog y. Marks, A. (2012). Big boy rules: Surviving combat & mental health consequences.