Slide 1

Civilian vs. Military Trauma Brian L. Meyer, Ph.D. Interim Associate Chief, Mental Health Clinical Services McGuire VA Medical Center Richmond, VA May 26, 2015

Slide 2

Disclaimer The views expressed in this presentation are solely those of the presenter and do not represent those of the Veterans Health Administration, the Department of Defense, or the United States government.

Slide 3

The author has no conflicts of interest to disclose.

Slide 4

Trauma and PTSD

Slide 5

Not all trauma leads to PTSDNot all trauma leads to PTSD Depending on the study, the type of trauma, and the group studied, 3%-58% get PTSD Not all abuse leads to PTSDNot all abuse leads to PTSD

Slide 6

Slide 7

Women May Be More Vulnerable to Stress Disorders Than Men More men (61%) than women (51%) experience a trauma at some point in their lives, but women experience PTSD at twice the rate of men (10% vs. 5%) (Kessler et al., 1995; Tolin and Foa, 2006)More men (61%) than women (51%) experience a trauma at some point in their lives, but women experience PTSD at twice the rate of men (10% vs. 5%) (Kessler et al., 1995; Tolin and Foa, 2006) Females may be more sensitive to Corticotropin releasing factor (CRF) than males (Bangasser et al., 2010)Females may be more sensitive to Corticotropin releasing factor (CRF) than males (Bangasser et al., 2010)

Slide 8

Trauma and Gender Men are most likely to develop PTSD from combat exposure, rape, childhood neglect, and childhood physical abuseMen are most likely to develop PTSD from combat exposure, rape, childhood neglect, and childhood physical abuse Women are most likely to develop PTSD from rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuseWomen are most likely to develop PTSD from rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (Kessler et al., National Comorbidity Survey, 1995)

Slide 9

Life-Threatening Events IMPERSONAL PERSONAL TRAUMATIC

Slide 10

Many Types of Trauma Combat and war-zone traumaCombat and war-zone trauma RapeRape Child physical abuseChild physical abuse Child sexual abuseChild sexual abuse Domestic violenceDomestic violence Environmental traumaEnvironmental trauma Torture Being held hostage Genocide Cultural trauma Accidents Natural disasters Fires

Slide 11

PTSD: An Example of Torture Mr. E: Army; guarded Tomb of the Unknown Soldier; engaged; apartment broken into; tortured; fiance raped; fear of sleeping at night; triggered by sports games; became hypersexual; seven children by four women; became dependent on PCP; drove while high, arrested, and jailed for nine months

Slide 12

Post-Traumatic Responses Occur on a Continuum None Mild Moderate Severe

Slide 13

Who Gets PTSD? It depends on:It depends on:GeneticsSeverityDurationProximity PTSD is mitigated or worsened by:PTSD is mitigated or worsened by: Childhood experience Personality characteristics Family history Social support

Slide 14

PTSD and the Brain (Overactive) (Smaller volume) (Underactive) Amygdala Emotional reactions, fight or flight alarm system Hippocampus Relay station for sorting memories Prefrontal cortex logic, reasoning, planning, impulse control, organizing

Slide 15

Slide 16

Changes in the DSM 5 Definition of PTSD

Slide 17

Changes to PTSD Diagnosis in DSM 5 Trauma and Stressor-Related Disorders are placed in their own categoryTrauma and Stressor-Related Disorders are placed in their own category Loss of loved one must be traumatic or accidentalLoss of loved one must be traumatic or accidental Elimination of B criterion of reaction of horror, terror, or helplessnessElimination of B criterion of reaction of horror, terror, or helplessness Military and first responders do their jobMilitary and first responders do their job

Slide 18

Changes to PTSD Diagnosis in DSM 5 Addition of new criteria involving negative cognitions (negative beliefs about the world, blame of self or others for the trauma) and mood (depression, anger, guilt)Addition of new criteria involving negative cognitions (negative beliefs about the world, blame of self or others for the trauma) and mood (depression, anger, guilt) Addition of a new arousal criterion: self-destructive or reckless behaviorAddition of a new arousal criterion: self-destructive or reckless behavior These changes result in approximately the same number of people who will meet criteria for a diagnosis of PTSDThese changes result in approximately the same number of people who will meet criteria for a diagnosis of PTSD

Slide 19

Post-Traumatic Stress Disorder in DSM 5 PTSD is characterized by: Exposure to a severe life-threatening eventExposure to a severe life-threatening event Repetitive re-experiencing of the eventRepetitive re-experiencing of the event Avoidance of stimuli associated with traumaAvoidance of stimuli associated with trauma Negative moods and cognitionsNegative moods and cognitions Increased arousalIncreased arousal

Slide 20

PTSD: Exposure to a Life- Threatening Event A. Exposure to a traumatic event Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violenceExposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence

Slide 21

PTSD: Intrusion Symptoms B. Re-experiencing symptoms: Recurrent, involuntary and intrusive recollectionsRecurrent, involuntary and intrusive recollections Traumatic nightmaresTraumatic nightmares Dissociative reactions (e.g., flashbacks)Dissociative reactions (e.g., flashbacks) Intense or prolonged distress after exposure to traumatic remindersIntense or prolonged distress after exposure to traumatic reminders Marked physiological reactivity to trauma- related stimuliMarked physiological reactivity to trauma- related stimuli

Slide 22

PTSD: Avoidance of Stimuli Associated with Traumatic Event C. Persistent effortful avoidance of distressing trauma- related stimuli after the event: Trauma-related thoughts and feelingsTrauma-related thoughts and feelings Trauma-related external remindersTrauma-related external reminders

Slide 23

PTSD: Negative Cognitions and Mood D. Negative alterations in cognitions and mood that began or worsened after the traumatic event: Inability to recall key features of the traumatic event Inability to recall key features of the traumatic event Persistent negative beliefs and expectations about self or world Persistent negative beliefs and expectations about self or world Persistent distorted blame of self or others for causing the event or the resulting consequences Persistent distorted blame of self or others for causing the event or the resulting consequences

Slide 24

PTSD: Negative Cognitions and Mood Persistent negative trauma- related emotions (e.g., fear, horror, anger, guilt, or shame) Persistent negative trauma- related emotions (e.g., fear, horror, anger, guilt, or shame) Markedly diminished interest in significant activities Markedly diminished interest in significant activities Feeling alienated from others Feeling alienated from others Constricted affect: persistent inability to experience positive emotions Constricted affect: persistent inability to experience positive emotions

Slide 25

PTSD: Increased Arousal E. Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: Irritable or aggressive behavior Irritable or aggressive behavior Self-destructive or reckless behavior Self-destructive or reckless behavior Hypervigilance Hypervigilance Exaggerated startle response Exaggerated startle response Problems in concentration Problems in concentration Sleep disturbance Sleep disturbance

Slide 26

PTSD: A New Subtype Dissociative Subtype of PTSD: Meets criteria for a diagnosis of PTSDMeets criteria for a diagnosis of PTSD Experiences high levels of depersonalization or derealizationExperiences high levels of depersonalization or derealization Dissociative symptoms are not related to substance abuse or other medical conditionDissociative symptoms are not related to substance abuse or other medical condition

Slide 27

Further Symptoms Associated with PTSD

Slide 28

Implications of Changes to PTSD Diagnosis in DSM 5 Angry, guilty, and anxious affects now applyAngry, guilty, and anxious affects now apply This is a rejoinder to the fear-based model of the past, recognizing greater complexityThis is a rejoinder to the fear-based model of the past, recognizing greater complexity There are probably four phenotypes of PTSD here:There are probably four phenotypes of PTSD here: 1.Anxious/fearful 2.Angry 3.Guilty/shameful 4.Dissociative Do they each need their own assessments and treatments?Do they each need their own assessments and treatments?

Slide 29

Implications of Changes to PTSD Diagnosis in DSM 5 The existence of a dissociative subtype, combined with the new affective criteria and the new arousal criterion of self-destructive behavior, moves the description closer to that of Complex Trauma Some of the research on PTSD may no longer apply

Slide 30

Implications of Changes to PTSD Diagnosis in DSM 5 Assessment instruments must changeAssessment instruments must change Different treatments may be needed for different phenotypes of PTSD (anxiety, anger, depression/guilt, dissociation)Different treatments may be needed for different phenotypes of PTSD (anxiety, anger, depression/guilt, dissociation) This may decrease the use of certain treatments, particularly Prolonged Exposure, which is fear- basedThis may decrease the use of certain treatments, particularly Prolonged Exposure, which is fear- based

Slide 31

What Does It Feel Like to Have PTSD?

Slide 32

Inside the Skin of PTSD Nerves on edgeNerves on edge JumpyJumpy Cant sleepCant sleep NightmaresNightmares Irritable all the timeIrritable all the time Explosive outburstsExplosive outbursts Wants to be left aloneWants to be left alone DepressedDepressed Cant stand crowdsCant stand crowds Heart races/sweatsHeart races/sweats

Slide 33

Inside the Skin of PTSD Hates New Years Eve and July 4 thHates New Years Eve and July 4 th SecretiveSecretive Distrusts othersDistrusts others Sees world as dangerousSees world as dangerous Constantly watching for dangerConstantly watching for danger Hates linesHates lines Overwhelmed by stimulationOverwhelmed by stimulation Feels responsible for traumaFeels responsible for trauma

Slide 34

Inside the Skin of PTSD Copes by: Cutting off relationshipsCutting off relationships IsolatingIsolating Taking risksTaking risks Self-harming behaviorsSelf-harming behaviors Using drugs and alcoholUsing drugs and alcohol

Slide 35

Faces of PTSD

Slide 36

Some Consequences of PTSD Damaged relationshipsDamaged relationships Strain on familiesStrain on families Domestic violenceDomestic violence Multiple marriagesMultiple marriages Problems in parentingProblems in parenting Children develop problemsChildren develop problems

Slide 37

More Consequences of PTSD Lost productivityLost productivity PovertyPoverty HomelessnessHomelessness Legal problemsLegal problems Reduced quality of lifeReduced quality of life

Slide 38

Relationship Problems Substance Abuse Problems Mental Health Problems Criminal Behavior Health Problems Employment Problems Traumatic Experiences THE CATALYZING EFFECT OF TRAUMA

Slide 39

Slide 40

Civilian Trauma and PTSD

Slide 41

Environmental and Accident Traumas

Slide 42

Types of Disasters HurricanesHurricanes EarthquakesEarthquakes TsunamisTsunamis TornadoesTornadoes VolcanoesVolcanoes Nuclear plant meltdownNuclear plant meltdown Airplane crashesAirplane crashes Boat sinkingsBoat sinkings Etc.Etc.

Slide 43

Disasters: Hurricane Katrina 1,833 deaths1,833 deaths $108 billion damage$108 billion damage Looting and violenceLooting and violence New Orleans population:New Orleans population: July, 2005: 440,000July, 2005: 440,000 January, 2006: 158,000January, 2006: 158,000 December, 2014: 384,000December, 2014: 384,000 Grief, loss, devastation, family breakupsGrief, loss, devastation, family breakups

Slide 44

Disasters: Hurricane Katrina