From Combat to Mass Shootings: Reinventing the Treatment of …€¦ · Research & Materiel...
Transcript of From Combat to Mass Shootings: Reinventing the Treatment of …€¦ · Research & Materiel...
From Combat to Mass Shootings:Reinventing the
Treatment of PTSD
Deborah C. Beidel, Ph.D., ABPP
Trustee Chair and Pegasus Professor
UCF RESTORESUniversity of
Central Florida
Acknowledgements and Disclosure
This study was supported in part by the U.S. Army Medical Research & Materiel Command-Military Operational Medicine Research Program (USAMRMC-MOMRP; contract W81XWH-11-2-0038) to the first author. The study had both MRCM HRPO and local IRB approval and does not necessarily reflect the policy/position of the government.
The funding source had no involvement with the design, collection, analysis or interpretation of the data, or the construction of this presentation.
This study was also supported in part by Department of Justice Antiterrorism and Emergency Assistance Program (2017-RF-GX-0003).
The author has no conflicts of interest to disclose with respect to this research.
Diagnostic (DSM-5) criteria for PTSD• Symptoms Present More than 1 Month
• (1) Intrusion Symptoms
• Nightmares, distressing thoughts, flashbacks
• (2) Avoidance of Stimuli
• Avoidance of people, places, feelings
• (3) Negative Alterations in Cognition and Mood
• Numbing of interests and positive emotions
• (4) Marked Alterations in Arousal and Reactivity
• Sleep/concentration difficulties, anger outbursts, exaggerated startle response
PTSD Affects Families and Communities
• Results in• Anger/Alienation
• Guilt Remorse
• Leads to• Reckless driving
• Physical assaults
• Carrying unneeded weapons
• DUI
• Unnecessary health risks
Adler et al. (2011)
The Challenge of Combat-Related PTSD
• Prevalence is 9%; lifetime prevalence is 30%
• From 2004-2009
• VA spent $3.7 billion for all veterans health care
• $2.2 billion (60%) went for PTSD and TBI –but only 28% of vets getting care
• Patients with PTSD, TBI or both had health care costs 4-6 times as high as patients without those conditions.
UCF Psychology
Impact of PTSD on the Nation
• PTSD was the 3rd
most prevalent condition for VA disability compensation in 2012 (572,612 veterans) after hearing loss and tinnitus
Duggan (2017)
Barriers to Care
• Difficulty getting appointments
• Difficulty getting time off to attend appointments
• Perceived stigma
• Preference for treatment of issues such as sleep disruption, anger and stress
Hoge et al. (2014); Crawford et al. (2015)
What about
veterans who
make it past the
barriers?
• Statistically significant reduction in symptoms but 50-66% still meet diagnostic criteria after a full course of treatment
• High rates of treatment attrition
• 28% - 40% drop out - even from our most efficacious treatments
• Ongoing crisis in PTSD care
• There is considerable room for improving treatment efficacy, “particularly for interventions that enhance treatment engagement and retention” (Hoge et al., 2016)
• Do we need different treatments?
• Or should we be delivering established treatments differently?
Brief History - Trauma
Management Therapy for
OIF/OEF Veterans
• Oct, 2003: Awarded a grant (NIMH MH063721) to treat Vietnam veterans with chronic PTSD
• Jan, 2011: Awarded a grant (W81XWH-11-2-0038) from the Military Operational Medicine Research Program (MOMRP) USAMRMC to develop and evaluate a new treatment for combat-related PTSD in OIF/OEF veterans.
• Charged with developing a “faster” treatment for treating active duty personnel with combat-related PTSD
From Vietnam to
Iraq and Afghanistan:
Doing Treatment Differently
• Incorporating the use of virtual reality to enhance exposure therapy.
• Adding a simultaneous group treatment component to address depression, guilt, anger, sleep and social maladjustment.
• Providing treatment daily (several sessions per day) for an intensive period of time.
What is the Core Element of
Exposure Therapy?
• How do you get over your fear of a dog?
• You have to be around a dog
• But the dog has to look like the dog that caused the traumatic event.
Challenges for Exposure Therapy for OEF/OIF Veterans
• Typically, exposure therapy is conducted using either imaginal or in vivo methods.
• How do you recreate this?
Doing Treatment Differently: Virtual Reality (VR) to Augment EXP
• Allows presentation of relevant cues, overcoming reluctance to imagine these events
• Overcomes the inability to engage in imagery of sufficient detail and affective magnitude
Why Olfaction?• Olfactory cues, paired with aversive
stimuli, produce conditioned fearful behavior to both the odor and the context (Kroon et al., 2008).
• Patients with PTSD associate odors with traumatic events and describe specific olfactory cues as primary precipitants of flashbacks (Kline & Rausch, 1985; Vermetten & Bremner, 2003).
• This is particularly so for veterans of OIF/OEF who report memories of the novel smell of the desert, smells from IEDs, garbage and related smells such as Middle Eastern spices
Doing Treatment Differently- Trauma Management Therapy
• Multi-component intervention (all 5 days per week for 3 weeks)
• Imaginal or VR individual exposure
• In-vivo exposure
• Group treatment
Monday Tuesday Wednesday Thursday Friday
Week 1 BehavioralActivation
ImprovingSleep
Anger Management
SocialReintegration
Behavioral Activation
Week 2 Improving Sleep
Anger Management
Social Reintegration
Behavioral Activation
Improving Sleep Skills
Week 3 Anger Management – Guilt
Social Reintegration
Behavioral Activation
Integration Session
RelapsePrevention
TMT Results (comparison to 17 week program)
82.3
40.144.3
95.4
43.1 45
0
20
40
60
80
100
120
Pre TX Post TX 6 Month Follow up
Clinician Administered PTSD scale (considered the VA gold standard for determining the presence of
PTSD in combat veterans)
17 Week 3 week
• Drop out rate• 2% (3 week program)
vs. 28% (17 week program)
• Relapse rate • 1% (3 week program)
vs. 4.5% (17 week program)
16 Aug 201616
UCF RESTORES Trauma Management Therapy (TMT)
UCF TMT outcome vs. Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for Combat PTSD
31%
42%
66%
0%
10%
20%
30%
40%
50%
60%
70%
% withoutPTSD
% Without PTSD at posttreatment
CPT
PE
UCF TMT
17.5
27.1
52.8
0
10
20
30
40
50
60
Mean Decrease inCAPS Score
Decrease in CAPS score
CPT
PE
UCFTMT
56%66%
96%
0%
20%
40%
60%
80%
100%
120%
Percent with atleast a 10 pointdecrease on the
CAPS
Ten point decrease as clinically significant
CPT
PE
UCFTMT
Pulse Nightclub Shooting – June
12, 2016
• Latin night – 300 primarily Latino patrons
• 2:00am - officer reported shots fired
• Incident became a hostage situation
• 5:00am – SWAT teams breached the wall, rescued hostages and killed the gunman
Pulse Nightclub Shooting – June 12, 2016
Secondary Impact
Type
Secondary Impact # Persons
Extended Family
Multiplier
# at risk of Negative BH Consequences
EMS First Responders
75 2.76 207
Medical Examiner’s Office
20 2.76 55
Clinicians deployed by
OCHS and CFCHS 70 2.76 193
Law Enforcement First Responders
300 2.76 828
Subtotal 1,283
Department of Justice, 2017
SUICIDE AND FIRST RESPONDERS
93
129
103
140
0 20 40 60 80 100 120 140 160
Firefighter
Police Officer
First Responder Morbidity
Suicide Line of Duty
UCF RESTORES Treatment for First Responders
Responder Type Number1
Percentage
Fire/EMS 163 76%
Law Enforcement
43 20%
Dispatcher 8 4%
TOTAL 214 100%
PULSE RELATED
Yes 34 16%
No 177 83%
Left Blank 3 %1Since June12, 2016
Orlando Pulse Shooting
• Immediate Crisis Management
• Psychological First Aid
• Not forms of CISD that can exacerbate symptoms
• Symptom Monitoring
• Education about typical trauma responses and when to seek help
Problems Among First Responders Seeking Treatment at UCF RESTORES
Type PTSD Trauma AUD PDD MDD GAD Adjust Other No DX
Disp 0 1 0 0 1 0 1 3 2
FF/EMS
62 21 4 4 18 2 8 19 27
LE 21 6 0 0 1 0 0 6 9
Total 83 28 4 4 20 2 9 28 38
% 38% 13% 2% 2% 9% 1% 4% 13% 18%
22%
16%
13%
11%
10%
8%
7%
6%
5%
4%
3%
1%
Pediatric Calls
Pulse
Multiple Events
Death of Family Member or Friend
MVA w/ Death
Gorey/Graphic/Dramatic Death
Near Death Experiences
Shooting
Suicide Calls
Trauma not Related to Work
Trauma During Military Service
Sexual Assault
Trauma Index Percentages
Firefighter/Paramedic
Law Enforcement
Dispatcher
TMT for Pulse First Responders
• Intervention Example• Trauma Management
Therapy – adapted• Exposure to sounds
and smells
• In vivo exposure – to their uniforms, to driving the route to Pulse
• Group intervention to deal with anger and depression
“I had to keep telling those people that help was coming even when I knew it was not.”
“It was a war zone in there – no one ever saw anything like this.”
TMT for First Responders
35.4
45.1
11.4
4.4
0
5
10
15
20
25
30
35
40
45
50
CAPS 5 PCL 5
PTSD Symptoms
Pre-Tx Post-Tx
n=28; CAPS 5, p<.05; PCL 5, p<.01 n=28; All ps <.05
TMT Outcome:Firefighters and Law Enforcement Officers
34
43.8
37.8
50.4
10.2
4.4
11.3
16.4
0
10
20
30
40
50
60
CAPS 5 Firefighters PCL 5 Firefighters CAPS 5 LEO PCL 5 LEO
PTSD Symptoms
Pre Post
n=19 firefighters; n=8 law enforcement officers
Pulse Nightclub Shooting
• 2nd largest mass shooting
• Multiple “sets” of people impacted
• Victims, victims’ families
• First responders
• Employees of Pulse and surrounding businesses
• FBI Vetted:
• 850 (Families and survivors)
• Directly impacted at Pulse:
• 49 deceased
• 88 physically injured (gun wound, broken bones, etc.)
• 38 proximate (inside)
• 47 proximate employees (inside)
Pulse Nightclub Shooting – June 12, 2016
Primary Impact
Type
Primary Impact # Victims
Extended Family
Multiplier
# at risk of Negative BH
Consequences
Deaths 49 10 490
Wounded 53 6 318
Patrons and Staff
300 4 1,200
Subtotal 2,008
Department of Justice, 2017
Adapting TMT for
Pulse Survivors
• Need to move more slowly – initial sessions dedicated to managing extreme levels of anxiety
• Medical needs/treatment are ongoing for many –numerous surgeries, physical therapy limit time for therapy
• More emphasis on breaking patterns of avoidance/social isolation through in vivo exposure
• Sounds and smells are important triggers
• Spanish-speaking Moms group
Pulse Survivors at RESTORES
Demographics
Age 31 years
Sex 50% Male; 50% Females
Education 50% – Some College17% – Master’s degree33% – Not Reported
Race/Ethnicity 17% Black Hispanic50% White Hispanic17% Caucasian17% Not Reported
0
10
20
30
40
50
60
PCL-5 BDI-II
PTSD and Depression
Pre Tx Post Tx
Increased Community
Requests for
Continued Services
• Requests for clinic expansions from Brevard and Hillsborough Counties
• Request to incorporate our peer support program into the Federal Law Enforcement Training Center
• One Central Florida Police Department Chief – “get to RESTORES” for evaluation
• Central Florida fire departments and police departments now call RESTORES requesting psychological first aid after occupation-related deaths
• RESTORES now contacted regularly by other communities that have experienced mass-shooting events.
• Continued need for services for survivors of the Pulse nightclub shooting
New Partnerships: Extending Our Scope
• UCF RESTORES is now the exclusive mental health partner for the Florida Firefighters Safety and Health Collaborative.
• Redline Rescue
• UCF RESTORES is a member of the Advisory Board to the National Police Foundation’s Center for Mass Violence Response Studies
• Examining characteristics of averted vs completed school shootings to determine if there are ways to predict and/or intervene
How Do You Do What You Do?
Trauma Won’t Win
UCF RESTORES-Lives
-Families-Communities