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Posttraumatic Stress
Disorder: What First
Responders Should
Know
Kathleen M. Chard, PhD
Director, PTSD and Anxiety
Disorders Division
Cincinnati VA Medical Center
Associate Professor of Clinical
Psychiatry
University of Cincinnati
There is no conflict of interest and I am not receiving any form of payment for this presentation- Kathleen Chard, PhD
PTSD
• 1995 Study of civilians -lifetime prevalence of
PTSD was 5% men and 10% women.
• Most people exposed to a traumatic event
experience symptoms in the days/weeks
following- disorder of non-recovery.
• Data suggest that about 8% men and 20%
women develop PTSD, and roughly 30% of these
develop a chronic disorder.
• About 20-30 percent of the men/women who have
spent time in combat experience PTSD.
• 7.8 percent of Americans will experience PTSD at
some point in their lives
People can get PTSD from:
• Combat
• Violent personal
assault: rape,
mugging, physical
assault
• Kidnapping
• POW and
Concentration Camp
survivors
• Terrorist Attacks
• Airplane Crashes
• Severe Auto
Accidents
• Torture
• Natural Disaster
• Fires
• Hostage
situations etc.
Stressor Criterion A:
A: Exposure to a traumatic event in
which
-the person experienced, witnessed,
or was confronted with an event or
events that involved actual or
threatened death, serious injury,
or threat to physical integrity to
self or others
AND
- The persons response involved
intense fear, helplessness or
horror. NOTE: in children may be
expressed instead by disorganized
or agitated behavior.
Criteria B-D
B: Re-experiencing (1 needed)
– Dissociative states, Flashbacks, Intrusive emotions
and memories, Nightmares and night terrors
C: Avoidant (3 needed)
– Avoiding emotions, Avoiding relationships, Avoiding
responsibility for others, Avoiding situations that are
reminiscent of the traumatic event
D: Hyperarousal (2 needed)
– Exaggerated startle reaction, Explosive outbursts,
Extreme vigilance, Irritability, Panic symptoms, Sleep
disturbance
Criteria E & F
E: Symptoms must endure for more than 1 month
F. The disturbance must cause a clinically significant
level of stress or impairment in social,
occupational and other important areas of
functioning
Acute<3 months Chronic>3months
Delayed Onset > 6 months after the stressor
Subthreshold PTSD: 1 criterion down on C or D
Comorbid disorders
• 40-70%% of all people with PTSD
typically meet criteria for a depressive
disorder as well
• Men more likely to have Substance Use
Disorder, women more likely to have
Depression
• Assess for anxiety, substance abuse,
panic, depression, personality disorders,
coping skills, TBI/cognitive skills, sleep
disorders, social support, etc…
Biology
behind
PTSD
Limbic System
Well-modulated emergency
response
PFC
Amygdala
Amygdala
Brain stem
Threat (UCS)
Resick and Rasmusson, 2010
10
PTSD Response
PFC
Amygdala
Bremner et
al 1999b;
Milad, et al.
2009; Rauch
et al 1998,
2000; Shin,
et al. 2001
Brain stem
Trauma Triggers
(CS)
Resick and Rasmusson, 2010
11
HPA axis Dysregulated
Associated Disorders
HPA axis dysregulation is also associated with
• Attention-deficit hyperactivity disorder,
• Sleep and memory disorders
• Pain control
• Cardiovascular disease
• Food intake regulation
• Substance use/abuse
– Tobacco, Alcohol, Marijuana, & Benzodiazepine
Treatment
Options for
PTSD
Practice Guidelines for the
Treatment of PTSD
•
•
•
•
Expert Consensus Guideline Series (JCP, 1999)
APA Practice Guideline
Practice Guidelines from ISTSS
United Kingdom’s National Center of Clinical
Excellence (NICE)
• VA/DoD Clinical Practice Guidelines
• Institute of Medicine Report
Evidenced Based Treatments
• VA/DoD Clinical Practice Guidelines for Behavioral
Interventions
• Exposure Therapy, Cognitive Therapy -1st
line
• EMDR, Stress Inoculation Training
• Imagery Rehearsal Therapy, Psychodynamic
Therapy, Seeking Safety
• PTSD Psychoeducation
• Adjunctive Treatments
• Dialectical Behavior Therapy (DBT)
An Overview of the Revised
VA/DoD Clinical Practice Guideline
for Post Traumatic Stress
Matthew J. Friedman, M.D., Ph.D.
National Center for PTSD
White River Junction, VT
http://www.healthquality.va.gov/
Pharmacotherapy
• Pharmacotherapy: Monotherapy
– Strongly recommend SSRI’s (fluoxetine,
paroxetine or sertraline have strongest
support), or SNRI’s (venlafaxine has the
strongest support) for treatment of PTSD
[A]
– Recommend mirtazapine, nefazodone,
tricyclics, amitriptyline and imipramine,
and MAOIs, phenelzine, for treatment of
PTSD [B]
Pharmacotherapy (con’t)
• Pharmacotherapy: Monotherapy
– Insufficient evidence for the use of prazosin as
monotherapy for PTSD [I]
– Existing evidence does not support bupropion,
buspirone, trazodone, guanfacine,
anticonvulsants, or atypical antipsychotics as
monotherapy in the management of PTSD.
– Evidence is against use of benzodiazepines
PE & CPT:
Brief
Overview
Prolonged Exposure
 Prolonged Exposure (PE) was
developed by Edna Foa
 8-12, 90 minute individual
sessions
 Based on Emotional Processing
Therapy
 Exposure results in:
 habituation
 awareness of anxiety as
temporary
 improved confidence and
discrimination skills
 linear trauma memories
Prolonged Exposure
• PE has 4 main components
– Education about trauma and PTSD
(Session 1)
 Breathing retraining (Session 1)
 In-vivo exposure to situations that are
relatively safe but avoided (Session 2 final)
 Imaginal exposure via repeated
descriptions of the traumatic memory
(Session 3 – final)
Cognitive Processing Therapy
 A 12 session protocol, developed in 1988 by
Patricia Resick.
 Predominantly a cognitive therapy, with or
without written accounts of worst traumas
 Very specific session-by- session and teaches
the clients to challenge their own thoughts
 Can be implemented individually, in group or
a combined format
 Recovery-focused and based on collaboration
and informed choice
Cognitive Processing
Therapy
Sessions 1-4
• Education and Impact statement
• Client learns about connections between
events, thoughts, and feelings.
• Client writes detailed accounts of the
incident including sensory details,
thoughts, and feelings (if CPT-C then no
account).
23
Cognitive Processing
Therapy
Sessions 5-7: Cognitive therapy
• Challenging questions for a single belief
• Learning about patterns of faulty
thinking (Problematic Thinking
Patterns)
• Challenging Beliefs Worksheet
24
Cognitive Processing Therapy
Sessions 8-12: Over-accommodation
• Modules and worksheets challenging beliefs
regarding:
• Safety
• Trust
• Power / Control
• Esteem
• Intimacy
• Client rewrites impact statement
25
Research on CPT/PE
• There have been many randomized clinical trials of PE
and CPT and several effectiveness studies.
• The treatments have been shown to be effective with
child abuse, rape, combat, and assault.
CAPS SEVERITY PRE- AND POST-TREATMENT
(TREATMENT COMPLETERS)
27
BDI SEVERITY PRE- AND POST-TREATMENT
(TREATMENT COMPLETERS)
28
PTSD & Anxiety Disorders Division
• Outpatient clinic
– Group – education, aftercare,
supportive, DBT, anger
management
– Individual
– Couple/Family therapy
• 12 bed, 7 week men’s residential
• 10 bed, 7 week women’s residential
• 10 bed, 8 week TBI residential
TBI and PTSD
• TBI is the most common type of physical injury
sustained by Afghanistan and Iraq combatants (Stein &
McAllister, 2009)
•
Surveys of soldiers returning from Iraq show that being
wounded/injured is associated with increased prevalence
for PTSD (Hoge, et al., 2004)
• People with exposure to blasts have significantly higher
levels of PTSD (Kennedy et al., 2007; Vasterling et
al., 2009)
Mild TBI and PTSD: Overlapping
Symptoms and Diagnostic
Clarification
• Mild TBI
Insomnia
Impaired memory
Poor concentration
Depression
Anxiety
Irritability
Fatigue
Headache
Dizziness
Noise/Light intolerance
• PTSD
Insomnia
Impaired memory
Poor concentration
Depression
Anxiety
Irritability
Emotional Numbing
Flashbacks/Nightmares
Avoidance
Assessment/TX concerns
• Requires full work up to see where the damage had
occurred
• Neuropsychological tests may not be as effective for
multiple concussion patients
• Necessitates team approach
• Patients often will consolidate trauma memory instead of
challenging events – rehearsal of concepts is needed
• TBI treatment can integrate CBT techniques that bolster
PTSD treatment
Cincinnati TBI PTSD Program
• Integrated staff with mental health, PM&R, speech,
OT/PT
• Treatment was augmented by additional
psychoeducational groups including CogSmart, Distress
Tolerance, Anger management, Mindfulness, etc.
• Weekly visits with speech therapist and other specialty
staff as needed on an individual basis
Pre-post Changes
Mild TBI (n = 28)
Pre
CAPS
75.14
PCL
61.82
BDI-II
32.64
Post
Mod/Severe TBI (n = 14)
Pre
Post
48.96
81.36
37.64
46.54
64.93
38.71
23.71 31.57
18.07
Note. CAPS = Clinician-administered PTSD Scale. PCL = PTSD
Checklist. BDI-II = Beck Depression Inventory-II.
Comparison to No-TBI
Res=140 Out pt=40, TBI=42
Information for First
Responders
PFA Manual Complete Guide
• Chapter 1 Introduction and Overview
• Chapter 2 Preparing to Deliver Psychological First Aid
Chapter 3 Core Actions –
• Topic 1 Contact and Engagement
• Topic 2 Safety and Comfort
• Topic 3 Stabilization
• Topic 4 Information Gathering: Current Needs and
Concerns
• Topic 5 Practical Assistance
• Topic 6 Connection with Social Supports
• Topic 7 Information on Coping
• Topic 8 Linkage with Collaborative Services
Working with Children
• For young children, sit or crouch at the child’s eye level.
• Help school-age children verbalize their feelings, concerns
and questions; provide simple labels for common
emotional reactions
• Do not use extreme words like “terrified” or “horrified”
because this may increase their distress.
• Listen carefully and check in with the child to make sure
you understand him/her.
• Be aware that children may show developmental
regression in their behavior and use of language.
• Talk to adolescents “adult-to-adult”
• Reinforce these techniques with the child’s
parents/caregivers to help them provide appropriate
support to their child.
Behaviors to Avoid
• Do not make assumptions.
• Do not assume that everyone exposed to a disaster will
be traumatized.
• Do not pathologize.
• Do not talk down to or patronize the survivor, or focus
on his/her helplessness, weaknesses, mistakes, or
disability.
• Focus instead on what the person has done that is
effective or may have contributed to helping others in
need, both during the disaster and in the present
setting.
Behaviors to Avoid cont’d
• Do not assume that all survivors want to talk or need to
talk to you. Often, being physically present in a
supportive and calm way helps affected people feel safer
and more able to cope.
• Do not “debrief” by asking for details of what happened.
• Do not speculate or offer possibly inaccurate
information. If you cannot answer a survivor’s question,
do your best to learn the facts.
Mobile App: PFA Mobile
• Following disasters or emergencies, the PFA Mobile app
can assist responders who provide Psychological First
Aid (PFA) to adults, families, and children. Materials in
PFA Mobile are adapted from the Psychological First Aid
Field Operations Guide (2nd Edition).
• The app allows responders to:
• Read summaries of the 8 core PFA actions.
• Match PFA interventions to specific stress reactions of
survivors.
• Get mentor tips for applying PFA in the field.
• Self-assess to determine their own readiness to conduct
PFA.
• Assess and track survivors' needs to simplify data
collection and referrals.
PTSD in First Responders
PTSD Rates in First
Responders
• 7-37% of firefighters
• 15-20% of EMS workers
• 4-19% of Police Officers
Risk Factors for PTSD
• Stressor magnitude and intensity,
unpredictability, uncontrollability, sexual
victimization, responsibility, betrayal
• Prior vulnerability factors such as genetics,
early age of onset and longer-lasting
childhood trauma, lack of positive social
support, and concurrent stressful life events
• Greater perceived threat or danger,
suffering, upset, terror, and horror or fear
• A social environment that produces shame,
guilt, stigmatization, or self-blame
Risk Factors for FP’s
•Being unmarried
•Holding a supervisory rank in the fire service
•Proximity to death during a traumatic event
•Experiencing feelings of fear and horror during a
traumatic event
•Experiencing another stressful event after a traumatic
event.
•Holding negative beliefs about oneself
•Feeling as though you have little control over your life
•Greater peritraumatic distress
•Greater peritraumatic dissociation
•Greater routinework environment stress
•Started as a firefighter at a younger age
Protective Factors
•
•
•
•
•
•
•
•
Genetics and biology – Long alleles
Temperament
Family environment
Coping skills
Supportive network
Supportive Leadership
Perceived “safe place”
Someone to talk to about the event(s)
Resources
• First Responder Support Network
– http://www.frsn.org/
• National Center for PTSD
– www.ncptsd.va.gov
Questions