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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