Introduction to Trauma & PTSD

Karen Krinsley, Ph.D.

PTSD Section Chief,
VA Boston Healthcare System
& PTSD Consultant,
National Center for PTSD

Presented January 26, 2012 as part of the Grant per Diem educational training series
for staff

Outline of Talk
Recognizing PTSD
How common is it?
Who is most at risk?
What treatments are effective?
How the PTSD Consultation Program
can help

The technical diagnosis of
PTSD
And why it is important

Misdiagnosis is common
Misunderstandings are common
Great reason not to focus on other
issues
Serious but treatable when it is present
Typically NOT present alone

PTSD (DSM IV-TR):
A Cluster of Symptoms
A Trauma (The Stressor)
B Reexperiencing / Intrusions
C Avoidance/Numbing
D Increased Arousal
E More than one month of symptoms
F Causes functional problems
PTSD Criterion A Stressor

Exposure to a traumatic event in which:
1. The person has experienced,
witnessed, or been confronted with an
event or events that involve actual or
threatened death or serious injury, or a
threat to the physical integrity of
oneself or others.
2. The person's response involved
intense fear, helplessness, or horror.


Important to Remember
PTSD TRAUMA
and
TRAUMA ANYTHING bad
PTSD Trauma Anything bad
Traumas do not always lead to PTSD
Traumas may lead to PTSD, but then
the person recovers
And, many bad things happen to
people, affecting them deeply, that are
not trauma

Criterion B:
Reexperiencing/Intrusions
Recurrent recollections of the event
Recurrent distressing dreams of the event
Feeling as if the traumatic event were recurring
Intense distress at exposure to cues that resemble an
aspect of the event
Physiologic reactivity upon exposure to cues that
resemble an aspect of the traumatic event
EXAMPLES: Nightmares, Flashbacks, Shaking,
Sweating

Criterion C:
Avoidance/Numbing
Efforts to avoid thoughts about the trauma
Efforts to avoid things that remind one about the
trauma
Inability to recall an important aspect of the trauma
Markedly reduced interest in significant activities
Feeling of detachment from others
Restricted range of affect (e.g., unable to have loving
feelings)
Sense of foreshortened future
EXAMPLES: Avoiding the news, movies, crowded
stores but also drinking and drug use

Criterion D:
Increased Arousal
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
EXAMPLES: Keeping guns, checking
locks, aggression, insomnia

PTSD Criterion E and F
Duration: At least one month
Functional Impairment: clinically
significant
Do you see the overlaps?
Depression
Substance Use Disorder
Mild Traumatic Brain Injury
Pain Symptoms


Likelihood of getting PTSD
after Experiencing a Trauma
It depends on the event and the person
Men experience more traumatic events
Women are more likely to develop PTSD
After a traumatic event, who gets PTSD?
20% of women
8% of men get PTSD

Kessler et al., 1995


Likelihood of PTSD.
Rape
Men 65%
Women 45%
Combat
Men almost 40%
Physical Abuse
Almost 50% of women
20%+ men

What puts you at risk for
PTSD?
Being female
Being poor
Less education
Bad childhood
Previous psychological problems
What puts you at risk for
PTSD?
*Strength or severity of the stressor
Characteristics of the trauma:
Greater perceived life threat
Feeling helpless
Unpredictable, uncontrollable
Risk for PTSD:
After the Trauma
Degree of Social Support
Degree of Life Stress
How common is PTSD?
3.5% general population, current
1.8% men
5.2% women
Lifetime: 6.8% -- 3.6% men, 9.7% women
(U.S. National Comorbidity Survey Replication 2001-03)

Vietnam theater veterans:
15.2% of men
8.1% of women
(National Vietnam Veterans Readjustment Study 1986-88)





In veterans
In combat veterans
In women veterans (who may be
combat veterans!)
How common is PTSD?
Gulf War (I): 10%
OEF/OIF
13.8 (current)
Population-based studies
(RAND Corporation, Center for Military Health Policy Research, 2008)
Conclusions: PTSD is not unusual,
although not the majority
What about MST?
How Common is MST?
Margret Bell, Ph.D.
Resource Development & Utilization Coordinator,
MST Support Team (national resource for VA MST teams)

Data Source Time
frame
Men Women
Sexual
harassment
Sexual
assault
Sexual
harassment
Sexual
assault
DoD 2002 Survey
(active duty
sample)
Annual
rates
23% 1%

54% 3%
Street et al., 2003
(reservist sample)

Anytime
during
service
27% 3% 60% 23%
Skinner et al., 2000
(users of VA
healthcare)
Anytime
during
service
-- -- 55% 23%
Implications of PTSD
Greater risk of other disorders
80% of people with PTSD another diagnosis
Depression, SUD, Anxiety Disorders
Greater unemployment
Relationships
Health problems
Violence
Generally, worse quality of life
What does PTSD look like?
No one clinical picture but not like it is
shown on television/movies
Cant stereotype, although its done
There are some hallmarks
Nightmares
Poor sleep
Anger
Numbness or sadness
Avoidance of groups

How can you help?
Be supportive but dont allow PTSD to
be used as an excuse
Do ask if they want to talk and
acknowledge their military service
Dont say I understand
Be alert for risk issues
How can you help?
Sleeping / Nightmares: No touching
No fooling around: Dont sneak up on
someone, dont make sudden noises
behind them
Understand the impact of TV
Consider special requests: Light, Noise,
Large Groups

A few tips for Managing Anger

Confrontation probably NOT helpful
Try to understand the cause, both to help
manage and to help yourself stay calm
Prepare ahead of time with the veteran if
possible
Allow escape

Trauma-Informed Milieu
Structured but not authoritative or
punishing
Everyone treated with respect and
listened to
Setting is kept safe
Staff aware that residents may be
traumatized
Professional Help
Know when to refer
Be knowledgeable about PTSD
treatments and aware that they work
Encourage keeping appointments
Acknowledge that it will be HARD but it
is worth it
Ask what the alternative is
Be wary of splitting
Effective PTSD Treatments
State of the art treatment
Empirically validated treatments
Staged, stepped model of care
Safety
Trauma focus
Reconnection
Interdisciplinary
PTSD chronic mental illness
Treatment for PTSD
Cognitive Behavioral Treatments most
effective psychotherapy treatments
Medication can be an effective
treatment
Most evidence for Cognitive Processing
Therapy and Prolonged Exposure
Most evidence for antidepressants
Stepwise Treatment Model:
Stage 1 Safety
Suicide and Homicide prevention
Harm reduction for risky behaviors
Teach positive coping tools
Teach the role of avoidance
Group focus when possible, including:
Seeking Safety, Understanding and
coping with PTSD, Relaxation & Stress
Mgmt, ACT, DBT modules & Anger
Management, Wellness, & more
Stepwise Treatment Model:
Stage 2 Trauma Focus
Core of PTSD treatment
Empirically validated treatments include
Cognitive Processing Therapy and
Prolonged Exposure
It works! Recovery is possible.
Trauma Focus Therapy
Many types
Core common elements
Exposure to the trauma in some form
Processing of the trauma
Results: Decreased avoidance,
increased tolerance of distress, and
ultimately decreased distress
CPT AND PE Comparison Study
(Resick et al., 2002)
CPT, N= 83 55 50 41 63
PE, N= 88 55 51 39 64
CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-
TREATMENT AND LONG TERM (Resick et al., 2002)
Stepwise Treatment Model:
Stage 3 Reconnection
Focus is on relationships
Reconnection with friends, family
Support groups, process groups,
marriage and family work and more
Also may include Reparation
Special issues with new veterans
of Iraq and Afghanistan
National Guard OR Reserve OR Regular Military
Trauma is more acute or raw
Anger and aggression are common
Binge drinking or casual drug use
May be working and need different hours for
treatment
Often have families and children, and may want or
need them involved in treatment
May not want traditional treatments such as group
therapy
PTSD Consultation Program
One-on-one PTSD consultation for any
VHA provider OR contractor
Free of charge
Speak directly with expert PTSD
clinicians
Response usually within 24 hours
Easy to contact us: Call, email, or
complete an online form
Consultation Program Staff
Karen Krinsley, PhD
Consultant & VISN 1 PTSD Mentor
PTSD Section Chief, VA Boston

Nancy Bernardy, PhD
PTSD Mentoring & Consultation Program Manager
VA National Center for PTSD

Matt Friedman, MD, PhD
Executive Director, NCPTSD

And associated experts from around the country

PTSD Consultation Program
Ask questions regarding:
Assessment
Treatment
Therapy of all kinds
Medication
Clinical management
Programmatic issues
Resources for treatment
Ways to improve care
Any problem at all

Eligibility
We cant say this enough:
ANY VHA Clinician
ANY Contractor
ANY Question
ABOUT ANY Veteran or Group of Veterans
For Whom and How We Have
Been Useful
Experienced clinicians who want a
second opinion
Relatively inexperienced clinicians who
would rather not bother local
colleagues that particular day
New staff who are overwhelmed
Staff without a lot of local folks for
support

For Whom and How We Have
Been Useful
Staff from programs outside PTSD with
no connections to their PTSD programs
Staff who have hit a roadblock or a wall
Diagnostic and treatment challenges
Referrals to residential programs
Consultation Program
Contact Information
Contact us:
Call 1 (866) 948-7880
Online Form at:
vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp
Send e-mail to ptsdconsult@va.gov
A Few Things to Remember
Consultation provides an opportunity for
problem solving and discussion with the
treating clinician
Ultimate decision and authority for
implementing consultation
recommendations lie with the treating
clinician and the local chain of
command
Not for acute emergencies

More Information:
National Center for PTSD Website

www.ptsd.va.gov
All types of information, for
Providers
Veterans
Families
General Public
Has online courses such as
Understanding PTSD and much more