International Association of Chiefs of Police, Orlando October 26, 2014

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1 International Association of Chiefs of Police, Orlando If I dodged the bullet, why am I bleeding?" Manifestations of exposure trauma in emergency responders who do not have Posttraumatic Stress Disorder Presented for the Police and Public Safety Psychology Section, International Chiefs of Police, Orlando Mark Zelig, Ph.D, ABPP Board Certified in Clinical Psychology, Forensic Psychology, and Police & Public Safety Psychology Independent Practice Union Park Center, Suite 550 Cottonwood Heights, Utah Laurel St, Suite 297 Anchorage, Alaska Disclosure No conflict of interest 2

2 International Association of Chiefs of Police, Orlando Overview DSM-IV and DSM-5 PTSD criteria miss most emergency responders who have been traumatized. Greater sensitivity to those traumatized without full PTSD will benefit emergency responders. 3 My Discovery of Partial PTSD Personal injury evaluations in civil disputes. Conversations with peers at retirement gatherings. 4

3 International Association of Chiefs of Police, Orlando Importance of identifying traumatized responders who do not meet full PTSD criteria While police officers have lower rates of PTSD compared with other occupational groups (e.g., Perrin 2007), at least three studies indicate they may also be more likely to experience partial PTSD (Carlier et al., 1997; Maia et al., 2007; Pietrzak et al., 2012). Grubaugh et al. (2005): Individuals with Subsyndromal PTSD are at risk for not being identified and treated. 5 Perrin (2007) PTSD at World Trade Center Police PTSD = 6.2% Firefighters, construction workers, volunteers PTSD range = 7.2% % 6

4 International Association of Chiefs of Police, Orlando Importance of identifying traumatized responders who do not meet full PTSD criteria While police officers have lower rates of PTSD compared with other occupational groups (e.g., Perrin 2007), at least three studies indicate they may also be more likely to experience partial PTSD (Carlier et al., 1997; Maia et al., 2007; Pietrzak et al., 2012). Grubaugh et al. (2005): Individuals with Subsyndromal PTSD are at risk for not being identified and treated. 7 How did DSM-5 change major psychiatric diagnoses? Major Depression, Personality Disorders, Anxiety Disorders -- No significant changes. PTSD underwent major revision. 8

5 International Association of Chiefs of Police, Orlando Major Changes for PTSD from DSM-IV to DSM-5 PTSD was moved from Anxiety Chapter and now resides in a chapter entitled Traumaand Stressor-Related Disorders. A Criteria (Qualifying stressor) changed: Removal of the required response of fear, hopelessness, or terror. Sexual victimization explicitly recognized as traumatic event. Additional provision for emergency responders who are repeatedly exposed to aversive events. 9 Major Changes for PTSD from DSM-IV to DSM-5 3 additional symptoms 8 of the original 17 symptoms were revised Criteria C (Avoidance) of DSM-IV was divided into: DSM-5 Criteria C: Avoidance, and DSM-5 Criteria D: Negative Alterations in Mood and Cognition Criteria D (Arousal) in DSM-4 is now Criteria E in DSM-5 10

6 International Association of Chiefs of Police, Orlando PTSD Criteria DSM-IV & DSM-5 Criteria DSM-IV DSM-5 A Exposure to qualifying traumatic event(s) B Re-experiencing the event via unwanted memories, dreams, flashbacks; distressed when reminded of incident C Avoidance of events that trigger memories/distress Avoidance of events that trigger memories/distress & Numbing of emotions D DSM-5 Negative alterations in cognition and mood associated with the traumatic event(s) D DSM-IV Hyperarousal EDSM-5 11 Major Changes for PTSD from DSM-IV to DSM-5 DSM-5 recognizes but does not elaborate about partial PTSD: [T]here is evidence that subthreshold presentations are more common than full PTSD in later life and that these symptoms are associated with substantial clinical impairment (APA, p. 277). The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria (or criteria for another mental disorder). (APA, p. 279) 12

7 International Association of Chiefs of Police, Orlando Obstacles for Full PTSD Diagnosis It is difficult to satisfy criteria for PTSD. Those with DSM-IV PTSD may not qualify for a DSM-5 diagnosis. There is relatively little consensus on the definition of partial PTSD. 13 PTSD DSM-IV Criteria A: Exposure to an event that involved threatened death or actual serious injury, and the person reacted with intense fear, hopelessness, or horror Criteria B: 1/5 Re-experiencing symptoms Criteria C: 3/7 Avoidance and/or numbing symptoms Criteria D: 2/5 Hyperarousal symptoms Must satisfy B, C, & D simultaneously for 1 month or longer. 14

8 International Association of Chiefs of Police, Orlando Obstacles for Full PTSD Diagnosis It is difficult to satisfy criteria for PTSD. Those with DSM-IV PTSD may not qualify for a DSM-5 diagnosis. There is relatively little consensus on the definition of partial PTSD. 15 Responders who meet DSM-IV criteria may not satisfy DSM-5. Example: Hoge et al. (2014) administered the DSM-IV and DSM-5 PCL checklists to 1822 soldiers: 280 Soldiers met both DSM-IV and DSM-5 criteria for PTSD. 126 (45%) met either DSM-IV or DSM-5 criteria, but not the other. 67 who met DSM-IV did not meet DSM who met DSM-5 did not meet DSM-IV (pp ). The main source of discordance was failure to satisfy the Avoidance criterioa in DSM-IV and DSM-5. No difference in comorbidity between DSM-IV and DSM-5. 16

9 International Association of Chiefs of Police, Orlando Obstacles for Full PTSD Diagnosis It is difficult to satisfy criteria for PTSD. Those with DSM-IV PTSD may not qualify for a DSM-5 diagnosis. There is relatively little consensus on the terminology or definition of partial PTSD. 17 Terminology for people who have trauma symptoms but do not satisfy full PTSD criteria: Subsyndromal PTSD Partial PTSD Incomplete PTSD Subthreshold PTSD 18

10 International Association of Chiefs of Police, Orlando Definitions of Partial PTSD Abound! McLaughlin et al. (in press), reviewed various definitions of DSM-IV partial PTSD: Definition # 1: At least 1 symptom from B (reexperiencing), C (Avoidance), and D (Hyperarousal). Definition # 2: B + (C or D) Definition # 3: (B and D) + 1 symptom from C. Definition # 4: B or C or D satisfied. 19 Definitions of Partial PTSD Abound! McLaughlin et al. (in press) are the only group who have suggested a definition of partial PTSD with the DSM-5. Subthreshold DSM-5 PTSD is... defined as meeting two or three of the DSM-5 criteria sets: Criteria B (Re-experiencing) C (Avoidance), D (Negative Alterations in Mood) or E (Hyperarousal). 20

11 International Association of Chiefs of Police, Orlando What is the most common element apparent across the various definitions of Partial PTSD? 21 Frequency of Full and Partial PTSD in Police Responders to World Trade Center Pietrzak (2012) World Trade Center Police Officers (p. 837) Police officers assessed between.8 7 years post 9/11 Subsyndromal PTSD was defined as meeting Criterion B and either Criterion C or D; or if Criterion B was met and at least one symptom from both Criterion C and D were endorsed (p. 836). Full PTSD Partial PTSD Male officers 5.3% 15.3% Female officers 6% 15.7% 22

12 International Association of Chiefs of Police, Orlando Pietrzak et al. (2011): Full and Partial PTSD in Civilian Population Subjects participated in Wave 2 of the National Epidemiological Catchment Study (N = 34,653). Partial PTSD was defined as endorsement of at least 1 symptom within each of Criteria B, C, and D, lasting at least 1 month (Criterion E), after the worst event that involved intense fear, helplessness, or horror, or actual or threatened death, serious injury, or threat to the respondent s or someone else s physical integrity (p. 458) Partial PTSD Full PTSD Women 8.6% 8.6% Men 4.1% 4.5% 23 Comorbidity of Full and Partial PTSD Pietrzak (2012) World Trade Center Police Officers (p. 840). No Partial or Full PTSD Partial PTSD Full PTSD Depression 2% 13% 60% Panic Disorder 4% 18% 61% Alcohol abuse 3% 9% 19% Suicidal ideation 1% 2% 16% 24

13 International Association of Chiefs of Police, Orlando Suggestions Educate responders and administrators that only a minority of traumatized responders will have (full) PTSD. Responders with Partial PTSD may not have sufficient Avoidance symptoms to have full PTSD. Accordingly, exposure-based treatments, which target Avoidance, may not be helpful (e.g., Kornfield et al., 2012). Screen for comorbid conditions and consider symptom-targeted treatment. 25 The Toll of Partial PTSD "We thought we had managed all right, kept the awful things out of our minds, but, now that I am an old man they come out from where I hid them. Every night. Patsy Adam-Smith s chronicle of Australian military veterans (The Anzacs). 26

14 International Association of Chiefs of Police, Orlando References American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. Washington, DC: Author. Carlier I.V., Lamberts, R. D., Gersons, B. P. (1997). Risk factors for posttraumatic stress symptomatology in police officers: A prospective analysis. Journal of Nervous and Mental Disease,185, Grubaugh, A., Magruder, K., Waldrop, A., Elhai, J., Knapp, R., & Frueh, B. (2005). Subthreshold PTSD in primary care: Prevalence, psychiatric disorders, healthcare use, and functional status. Journal of Nervous and Mental Disease, 193, Hoge, C. W., Riviere, L. A., Wilk, J. E., Herrell, R. K., & Weathers, F. W. (2014). The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: A head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. The Lancet Psychiatry, 1, Kornfield, S. L., Klaus, J., McKay, C., Helstrom, A., & Oslin, D. (2012). Subsyndromal posttraumatic stress disorder symptomatology in primary care military veterans: Treatment implications. Psychological Services, 9, References Maia D.B., Marmar C.R., Metzler T., Nobrega A., Berger W., Mendlowicz M. V., et al. (2007). Posttraumatic stress symptoms in an elite unit of Brazilian police officers: Posttraumatic prevalence and impact on psychosocial functioning and on physical and mental health. Journal of Affective Disorders 97, McLaughlin, K. A., Koenen, K. C., Friedman, M. J., Ruscio, A. M., Karam, E. G., Shahly, V.,... & Kessler, R. C. (in press). Subthreshold posttraumatic stress disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry. Perrin M.A., DiGrande L., Wheeler K., Thorpe L., Farfel M., & Brackbill R. (2007). Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. American Journal of Psychiatry, 164, Pietrzak R.H., Goldstein R.B., Southwick S.M., & Grant, B.F. (2011). Prevalence Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and related conditions. Journal of Anxiety Disorders, 25, Pietrzak, R. H., Schechter, C. B., Bromet, E. J., Katz, C. L., Reissman, D. B., Ozbay, F.,... & Southwick, S. M. (2012). The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort. Journal of Psychiatric Research, 46,

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