Jim Boehnlein, M.D. Associate Director for Education, VA Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC)

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1 Jim Boehnlein, M.D. Associate Director for Education, VA Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC) Professor of Psychiatry, Oregon Health and Science University

2 Outline Definition and symptoms PTSD throughout history Associated disorders and differential diagnosis Treatment 175

3 Criterion A: stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) Direct exposure Witnessing, in person Indirectly, by learning that a close relative or friend was exposed to trauma; if the event involved actual or threatened death, it must have been violent or accidental Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders); does not include indirect non-professional exposure through electronic media, television, movies, or pictures

4 Criterion B: intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories Traumatic nightmares Dissociative reactions (e.g., flashbacks) Intense or prolonged distress after exposure to traumatic reminders Marked physiologic reactivity after exposure to trauma-related stimuli 478

5 Criterion C: avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) Trauma-related thoughts or feelings Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations)

6 Criterion D: nega9ve altera9ons in cogni9ons and mood Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs) Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous") Persistent distorted blame of self or others for causing the traumatic event Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame) Markedly diminished interest in (pre-traumatic) significant activities Feeling alienated from others (e.g., detachment or estrangement) Constricted affect: persistent inability to experience positive emotions

7 Criterion E: altera9ons in arousal and reac9vity: (two required) Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance

8 Symptoms must: Persist for more than one month Cause significant distress or social/occupational impairment Not be due to medication, substance use, or other illness

9 PTSD Through the Decades- Labeling and Percep9on Railway Spine Syndrome Irritable Heart Shell Shock PTSD Concentration Camp Syndrome Postconcussion Syndrome

10 Afghanistan- Opera9on Enduring Freedom (OEF) Iraq- Opera9on Iraqi Freedom (OIF) 1,950,000 OEF and OIF Veterans have left active duty and become eligible for VA health care since FY % Active Duty troops 40% Reserve and National Guard 61% of total separated OEF/OIF Veterans have used VA health care since FY 2002 (cumulative total)

11 Frequency of Diagnoses among OEF and OIF Veterans 735,582 (62%) Diseases of Musculoskeletal System/ Connective System 690,869 (58%) Symptoms, Signs and Ill Defined Conditions 685,540 (58%) Mental Disorders *September 2015 Epidemiology Program Post-Deployment Health Group Office of Public Health Veterans Health Administration Department of Veterans Affairs

12 Co-morbid Condi9ons and PTSD Mood Disorders Other Anxiety Disorders Substance Abuse Disorders 600 Traumatic Brain Injury Chronic Pain

13 Overlapping Symptoms of PTSD and Depression PTSD Insomnia Irritability Impaired Concentration Anxiety Withdrawal Depression 82

14 Overlapping Symptoms of PTSD and Trauma9c Brain Injury (TBI) PTSD Impaired Concentration Impaired Memory Irritability Depression Anxiety TBI 320

15 Unique Symptoms of TBI Dizziness Nausea Photophobia Headache Tinnitus 251

16 Importance of Accurate Diagnosis Prognosis Employment/Education Effective treatment Education of clients

17 E9ological Models of PTSD Biological Cognitive Sociocultural 623

18 Education PTSD Treatment Symptomatic relief of comorbid conditions Reduction of hyperarousal symptoms with medication Psychotherapy Reduction of other stresses Social and vocational

19 Barriers to Treatment- Beliefs and Values Avoidance Pride in self-reliance Loss of control/autonomy Treatment is for those who are weak, crazy Provider will not understand or believe trauma Societal rejection

20 Loss Ques9ons & Doubts AOer Trauma Unpredictability of life and death Belief in personal invulnerability Perception of an understandable world Moral Complexities Trust in self and others Sp

21 Healing & Psychotherapeu9c Themes Trust Self Worth Grief and Mourning Anger and Revenge Control Security Acceptance Meaning Identity Social Connectedness 645

22 Psychotherapy Cognitive Behavior (CBT) 550 Cognitive Processing (CPT) Dialectical Behavior (DBT) Prolonged Exposure (PE)

23 Clinician Reac9ons Sadness Anger Vulnerability Fatigue Intolerance of other patients Intolerance/avoidance of violence images Indifference vs. over involvement

24 Ethical Principles in Treatment Creation of trust, predictability Cause no harm Respect for personal boundaries Primacy of reducing suffering and promoting health Respect for patient autonomy, independence, and creativity Promotion of justice

25 Pharmacotherapy of PTSD First-line pharmacotherapy includes SSRIs and SNRIs Second-line agents have less evidence for usefulness and require further controlled trials Prazosin beneficial for nightmares Benzodiazepines and antipsychotics generally are not recommended Treating co-occurring disorders (major depression, traumatic brain injury, substance use, pain) is essential

26 Resources movingforward/

27

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