Aaron Jacoby, PhDChief Psychologist

VA Maryland Health Care SystemOctober 22, 2016

VA staff including: Nancy Bernardy, PhD Erin Romero, PhD

Service members and Veterans VA PTSD Mentorship ProgramNational Center for PTSD

Etiology/Diagnosis of PTSD

Reintegration into the Workforce

Treatments for PTSD

Clinical Trials for PTSD

Case Examples

Review of Resources available to Veterans

Participants will be able to: identify the epidemiology of PTSD expand current knowledge of PTSD treatment

literature identify the evidence-based treatments available for

PTSD identify common challenges Veterans face related to

reintegration into the workforce explore resources available to Veterans

• Results from an event or series of events• Involves actual or perceived threat to integrity

(self or other)• Experienced or witnessed

War exposure (combat or civilian) Threatened or actual physical assault Threatened or actual sexual violence Being kidnapped/taken hostage Terrorist attacks Being a victim of torture or witnessing tortureNatural or human-made disasters Severe motor vehicle accidents

Emotional Reactions (e.g., shock, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, numbing)

Cognitive Reactions (e.g., confusion, disorientation, indecisiveness, poor concentration, memory loss, self-blame, & unwanted memories)

Physical Reactions (e.g., tension, fatigue, edginess, insomnia, startle reactions, racing heartbeat, nausea, decreased appetite, decreased sex drive)

Interpersonal Reactions (e.g., distrust, irritability, withdrawal, isolation, feeling rejected/abandoned, being distant, judgmental, or over-controlling)

4 clusters of symptoms occur in PTSD: Intrusion Avoidance Negative Alterations in Cognitions and Mood Alterations in Arousal and Reactivity

Intrusion symptoms (1 required) include: Recurrent, involuntary, and intrusive memories Traumatic nightmares Dissociative reactions (e.g., flashbacks) Intense or prolonged distress after exposure to

traumatic reminders Marked physiological reactivity after exposure to

trauma-related stimuli

Avoidance symptoms (1 required) include: Avoidance of or efforts to avoid: distressing memories, thoughts, or feelings about

or closely associated with the traumatic event(s) external reminders (e.g., people, places,

conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Negative alterations in cognitions and mood (2 required) include: Inability to recall key features of the traumatic event(s) Persistent negative beliefs and expectations about oneself or

the world Persistent distorted blame of self or others for causing the

traumatic event or for resulting consequences Persistent negative trauma-related emotions Markedly diminished interest in (pre-traumatic) significant

activities Feeling alienated from others Constricted affect: persistent inability to experience positive

emotions

Alterations in arousal and reactivity symptoms (2 required) include: Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance

With dissociative symptoms Depersonalization (i.e., experience of being an

observer of or detached from oneself) Derealization (i.e., experience of unreality, distance,

or distortion

With delayed expression Full diagnosis not met until at least 6 months after

the trauma

Lifetime prevalence of PTSD among adult Americans (National Comorbidity Survey Replication, 2001-2003): Overall = 6.8 % 9.7% in women 3.6% in men

Military combat personnel are at increased risk: Vietnam ~ 30.9% (men), 26.9% (women) Gulf War ~ 10.1% OEF/OIF ~ 13.8%

Childhood trauma/abuseFamily history of mental illnessPersonal history of mental illnessLower socioeconomic statusLower educationGreater intensity and duration of traumaRepeated exposure to traumaLow cortisol levelsParent with PTSDLow social supportSubstance abuse

Risk of developing PTSD varies with a number of individual vulnerability factors.

Typically research has examined factors at three different time points in relation to the traumatic event:

Pretraumatic Peritraumatic Posttraumatic

Bernardy, N (2016). Overview of PTSD Disorder Prevalence and Risk Factors. Presented at PTSD Today and Tomorrow Conference. Johns Hopkins University.

Bernardy, N (2016). Overview of PTSD Disorder Prevalence and Risk Factors. Presented at PTSD Today and Tomorrow Conference. Johns Hopkins University.

Lifetime Prevalence (%)

Major Depressive Disorder 48 Dysthymic Disorder 22 Generalized Anxiety 16 Simple Phobia 30 Social Phobia 28 Panic Disorder 12.6 (women) 7.3 (men) Agoraphobia 22.4 (women) 16.1 (men) Alcohol Use Disorder 51.9 (men) 27.9 (women) Substance Use Disorder 34.5 (men) 26.9 (women)

REINTEGRATION INTO WORKFORCE

Anxiety, feeling “on edge” Vigilant to safety concerns Frequent reminders of military experiences Feeling disconnected from friends, family, general

civilian population Feeling emotionally numb Anger and irritability Problems with attention, concentration and memory Changes in sleep patterns Difficulty falling asleep Difficulty staying asleep, nightmares

Physical Reactions

•Existing health problemsworsen

•Trouble sleeping•Stomach upset•Trouble eating•Rapid heart beat•Experiencing shock,numb, unable to feel happy

Behavioral Reactions

•Trouble concentrating•Edgy, jumpy•Being on point•Avoidance

• Too much drinking, smoking, other drug use•Poor self-care•Aggressive driving

Emotional Reactions

•Bad dreams, nightmares•Intrusive memories•Anger•Feeling nervous,helpless, or fearful

•Guilt, shame,self-blame• Feeling sad/rejected/abandoned•Negativeoutlook

http://www.ptsd.va.gov/public/reintegration/guide-pdf/SMGuide.pdf

Going to drills on weekends Watching current news about the war Hearing about deaths of military service members Seeing vehicles that remind Veterans of those driven by

Iraqis or Afghanis Being around children that remind Veterans of kids in the

war zone Seeing or hearing helicopters Smelling oil or gas Certain types of weather and terrain Being scheduled for redeployment or being redeployed Seeing people who look of “Arab” descent

Armstrong, Best, Domenici (2006) Courage After Fire pg 17

Most symptoms resolve naturally over time

Majority of Veterans do NOT have PTSD or other mental health disorders

Engaging in structured activities, like school and work assists with readjustment

Self-stigmaMental health related illnessIncreased aggression Wounded or disabledLack necessary skills to be

academically or vocationally successful

PTSD Major Depression Alcohol Use Often beginning as an effort to sleep

Opiate Use Often beginning with pain medication for injuries

Military Sexual Trauma Suicide Job loss Family dissolution Homelessness Violence toward self and others Incarceration

Feel “lost” or “alone” (“no one understands”) Struggle with lack of structure or goals Miss the adrenaline rush associated with various

military experiences Become easily annoyed with civilians who take

things less seriously or are too “laid back” Have anger or resentment towards those who did

not serve or towards other military personnel Feel on edge or tense Feel that everything back home has changed Feel down or depressed soon after being

separated from service

Elements of Warrior Ethos Example (Army): BATTLEMIND

Selflessness Loyalty Stoicism Moral Code Excellence

B = Buddies (cohesion) vs. Withdrawal A = Accountability vs. Controlling T = Targeted Aggression vs. Inappropriate

Aggression T = Tactical Awareness vs. Hyper-

vigilance L = Lethally Armed vs. “Locked and

Loaded” at Home E = Emotional Control vs.

Anger/Detachment M = Mission Operational Security (OPSEC)

vs. Secretiveness I = Individual Responsibility vs. Guilt N = Non-Defensive (combat) Driving vs.

Aggressive Driving D = Discipline and Ordering vs. Conflict

Increased reports of suicide among service members and Veterans.

Historically, suicide rates in military personnel were lower than in civilian populations.

Although an upward trend in Veteran suicide rates was noted starting in 2009, the rate for active duty soldiers in 2013 was similar to civilian populations: 18.7 per 100,000 suicide rates among active duty

soldiers compared to 18.8 per 100,000 among nationally matched civilians

Rates for Reserve and National Guard were 23.4 and 28.9 per 100,000, respectively

Institute of Medicine. (2010). Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members and Their Families Military Times: http://www.militarytimes.com/story/military/pentagon/2015/01/16/defense-department-suicides-2013-report/21865977/

http://t2health.dcoe.mil/sites/default/files/DoDSER-2013-Jan-13-2015-Final.pdf

Bumiller, E. (2012, January 10). Active duty soldiers take their own lives at record rate. New York Times., pp A13.

• An estimated 20 Veterans die by suicide every day

• Male Veterans are twice as likely as civilians to commit suicide

• 1000 suicides occur per year among Veterans receiving care at a VA Facility

• 5000 suicides among all Veterans

* Statistic from the www.dod.us.gov and www.va.gov

4 psychotherapies: Cognitive Therapy Exposure Therapy Stress Inoculation Therapy Eye Movement Desensitization

Reprocessing Therapy (EMDR)Pharmacotherapy: Selective Serotonin Reuptake Inhibitors

(SSRIs)

Treatment of PTSD: An Assessment of the Evidence

Published 2007 Reviewed all treatments included in VA/DOD

Practice Guidelines as well as other professional organization guidelines

Found the evidence for all but one psychotherapy (exposure therapy) inadequate to reach a conclusion regarding efficacy

Found the evidence for all pharmacological treatments inadequate to reach a conclusion regarding efficacy

MORE RESEARCH IS NEEDED!

During fiscal year 2014, NCPTSD investigators led 117 funded studies, ranging from small studies taking place at a single location to large multi-site projects.

NCPTSD continues to align its research support with the Operational Priorities identified in 2013 including research in the areas of: (1) Biomarkers, (2) DSM-5, (3) Treatment

efficiency, effectiveness, and engagement, (4) Care delivery, models of care, and system factors, and (5) Implementation

CTU-Online includes brief updates on the latest clinically relevant research.

Content on treatment and assessment is emphasized.

Publications on other topics are included if the content has significant clinical implications related to PTSD treatment.

Issues include an ID number so you can find the article in the PILOTS database and a link to the abstract/full article.

Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541e550.

The study sample consisted of 137 comparisons drawn from 112 randomized clinical trials of treatment for PTSD in adults.

The between-groups effect size (g) was 1.14 for psychotherapy, 1.25 for somatic treatment, and 0.42 for medication.

Watts, Schnurr et al., 2013

26 yo OEF/OIF veteran, Marine Corps Combat Engineer

Served 2 tours in Iraq 1st tour: initial invasion 2nd tour: year long, 2nd siege of Fallujah

History of previous TBI related to pre-combat car accident

Exposure to multiple blasts in 2nd tour of Iraq during house patrols and city sieges

Initially diagnosed with an adjustment disorder with mixed anxiety and depressed mood

Initially difficult to elicit trauma history due to memory problems

Role of alcohol abuse, disinhibition Intense emotional numbingAggression, bar fights, more head trauma? Paranoia

Impact on: memory cognition decision making concentration sense of smell mood regulation energy level

Due to PTSD? TBI? Both?

22 yo OEF/OIF Veteran, Army Infantry Served 12-month tour in AfghanistanOriginally trained with one unit, then

reassigned and deployed with new unitConsiderable detachment from deployed unitUpon return to U.S., Veteran was

disillusioned, unmotivated, and apathetic Therapy goals included life goal setting

Emotional numbing Lack of support network Veteran increased social supports, obtained

employment, and gained direction in life, being able to put into perspective his combat deployment

Veteran prescribed antidepressant and sleep medication

Veteran experienced mood improvement and social and professional life flourished

36 yo Persian Gulf Veteran, NavyHistory of Military Sexual Trauma (MST),

childhood trauma, and lifetime negative interpersonal relationships

Veteran seeking guidance on remaining in or leaving current long-term partner

Relationship Cost-Benefit analysis completed Explored role of past trauma on ability to

socially engage

Veteran craved more connection with boyfriend, who had been diagnosed with PTSD and post-TBI symptoms, but boyfriend struggles impeded connection

Use of cognitive behavioral interventions, targeting all-or-none thinking

Veteran now considering working on own trauma history to gain personal symptom reduction

64 yo Vietnam Veteran, Army Infantry Veteran completed treatment for PTSD, but

left with continued negative interpersonal relationship with wife of almost 40 years.

Veteran attempted to engage in couples treatment, initial success, but then wife discontinued both couples and individual therapy

Veteran experienced disillusionment, dysphoria

Veteran craves more connection with wife nowthat PTSD symptoms are better controlled

Wife also suffers from undiagnosed PTSD from childhood and early adulthood trauma

Therapeutic work included perspective takingand matching spousal needs with realistic expectations of possible change

Veteran is working to control ongoing disappointment, but gaining complacency from other social outlets