Posttraumatic Stress Disorder and Military Veterans

1. Posttraumatic Stress Disorder and Military Veterans By Nealy Jenkins, LMSW

2. Objective • Symptoms of Posttraumatic Stress Disorder 388.81 • Rules of Engagement • Statistical Data of Veterans with PTSD • Neurotransmitters • Psychopharmacology and Side Effects • Treatment Models

3. Symptoms of Posttraumatic Stress Disorder (PTSD) 388.81 • Reliving the Event • Memories of the trauma that come back at any time such as nightmares or going through it again like a flashbacks. • Avoiding situations that remind you of the Event • Client may try to avoid situations or people that bring back memories of the event • Feeling Numb • Client may find it hard to express their feelings and difficulty remembering or talking about parts of the trauma. • Feeling Keyed Up • Client may be jittery and on the lookout for danger. • Client might suddenly become angry or irritable.

4. Rules of Engagement (ROE) 1.) The military is a world of constant transition. 2.) Clinician must educate themselves two frequent transitions: Deployment and Family Separation. 3.) Understand Hierarchical Military Structure. 4.) Important dynamic of the military culture is that family must do nothing that will negatively impact the service member’s career. 5.) The stigma is that service members are trained to be self-reliant and capable; anything else would be to defy their military training.

5. Rules of Engagement Cont. 6.) The military has a mission to accomplish. Understanding that families are seen as furthering that mission is of utmost importance. 7.) It helps to know why a service member joins the military. The reasons for joining may determine commitment to the military and shed light on family issues. 8.) Every military family is different. Having a working knowledge of family transitions, remarried-coupled issues, and stepfamily issues can be extremely helpful in working with military families.

6. Statistical Data of Veterans with PSTD • 11-20% of Veterans of Iraq and Afghanistan suffer from PTSD • 228, 361 Veterans diagnosed with PTSD • 10% of Veterans of Gulf War suffer from PTSD • 30% of Vietnam Veterans suffer from PTSD • 23% of women reported sexual assault while serving in military • 34% of Veterans reported having been exposed to dead, dying, or wounded.

7. Statistical Data of Veterans with PSTD Cont. • Since initiation of Global War On Terror (GWOT), 54% of veterans use VA benefits. • 52% is used for Mental Health issues

8. Neurotransmitters • The Neuron is the basic functional unit of the nervous system with primary purpose to receive, conduct, and transmit signals to the other cells. • Neuronal signals that are transmitted from cell to cell at specialized sites for contact are called Synapses. • Within the brain, messages can be transmitted in two ways: Electrically and Chemically. • A Neurotransmitter is synthesized within the neuron out of precursors that are brought into the neuron by outside cells. • Precursors within neuron are broken down to form the Neurochemical.

9. Steps in the Synaptic Transmission • Step 1: Synthesis- Precursors present in the transmitter site are activated by an enzyme and become a neurotransmitter. • Step 2: Storage- Once created, neurotransmitters are stored in vesicles, to be released when signaled. • Step 3: Release- Neurotransmitters are released into the synaptic gap. • Step 4: Termination- Transmitters are cleared from synaptic gaps in three ways: • Reuptake • Enzymatic Degradation • Diffusion

10. Neurotransmitters Cont. • 10 Types of Neurotransmitters • Dopamine--Psychosis • Norepinephrine--Depression • Serotonin—Depression • Acetylcholine—Dementia (Alzheimer’s Disease and Parkinson’s Disease) • GABA—Anxiety • Glutamate– Dementia (Alzheimer’s Disease and Central Nervous System) • Glycine– Depression, Dementia, and Schizophrenia • Enkephalin– Addictive disorders and Depression • Beta-endorphin– Addictive disorders • Dynorphin– Depression and Addictive disorders • 75-90% of general neurotransmitters are Gamma-aminobutyric Acid (GABA), Glutamate (Dementia), and Glycine (Depression).

11. Neurotransmitters Cont. • Coyle and Enna (1998) stated many professionals agree that GABA plays a large part in mental health reaction and has been identified as essential in exciting reactions and initiating many of the brain’s chemical transmissions. • GABA slows down transmissions of nerves and many of the activities of the brain. • Benzodiazepines enhance the effects of GABA, in which they reduce activity in the brain and promote sleep.

12. Terminology for Monitoring Medication • Medication Half-Life is the amount of time it takes for one half of a drug’s peak plasma level to be metabolized and excreted from the body. • Medication Potency refers to the relative dose needed to achieve a certain effect. • Therapeutic Index of a drug is computed by determining the ratio of the toxic dose of the drug to its therapeutic dose (Example: Lithium for Bipolar toxic levels needs be assessed b/c toxic levels are so close to the therapeutic levels).

13. Benzodiazepines: Typical Antianxiety Medications • Xanax (Alprazolam) • Rapidity of Effect is Intermediate • Half-Life is Intermediate • Usual Daily Dosage is 0.5-4mg • Klonopin (Clonazepam) • Rapidity of Effect is Intermediate • Half-Life is Intermediate/Long • Usual Daily Dosage is 0.5-3mg • Valium (Diazepam) • Rapidity of Effect is Rapid • Half-Life is Long • Usual Daily Dosage is 5-40mg

14. Benzodiazepines: Typical Antianxiety Medications Cont. • Ativan (Lorazepam) • Rapidity of Effect is Intermediate • Half-Life is Intermediate • Usual Daily Dosage is 1-6mg • Restoril (Temazepam) • Rapidity of Effect is Intermediate • Half-Life is Intermediate • Usual Daily Dosage is 15-30mg • Halcion (Triazolam) • Rapidity of Effect is Intermediate • Half-Life is Intermediate • Usual Daily Dosage is 0.125-0.5mg

15. Side-Effects of Typical Benzodiazepine Medications • Hypotension • Dry Mouth • Upset Stomach • Decreased appetite • Blurred Vision • Depression • Tremors • Irregular Heartbeat • Confusion • Severe skin rash • Fever • Difficulty passing urine

16. Benzodiazepines: Atypical Antianxiety Medications • BuSpar (Buspirone) • Rapidity of Effect is Slow • Half-Life is Intermediate • Daily Dosage is 5-60mg • Catapres (Clonidine) • Rapidity of Effect is Rapid • Half-Life is Long • Daily Dosage is 0.1-0.4mg • Tenex (Guanfacine) • Rapidity of Effect is Slow • Half-Life is Intermediate • Daily Dosage is 1-3mg

17. Side-Effects of Atypical Benzodiazepine Medications • Slow pulse rate • Insomnia • Low blood pressure • Dizziness • Contraindication with MAOI medications (Nardil) • Skin redness • Nausea • Headache

18. Beginning the Treatment Process • Because many of these medication are addictive, start the intervention with behaviorally based contract for awareness that the pill is only one facet of a multidimensional approach to the treatment of his or her anxiety. • Recognize and plan for the potential for addiction that exists when using these anxiety medications. • Long-term use at low doses is most appropriate for individuals who have a long history of chronic anxiety.

19. Veterans and Depression • In clinical depression the client experiences a lack of desire, coupled with an inability to perform everyday social and occupational tasks. • Two Types of Major Depression 1.) Endogenous is related directly to internal biological factors such as neurotransmitter dysfunction. 2.) Exogenous linked to a precipitating event involving psychosocial stressors such as divorce, unemployment, or trauma.

20. Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressant Medication • Prozac (Fluoxetine) • Daily Dosage is 20-80mg • It takes 4 weeks or more to get the full benefits of the drug • Zoloft (Sertraline) • Daily Dosage is 5-200mg • Can be used for anxiety disorders • Half-Life is much less than Prozac • Paxil (Paroxetine) • Daily Dosage is 20-40mg • Can be used for anxiety disorders • Half-Life is 12-20 hours

21. SSRI Antidepressant Medication Cont. • Celexa (Citalopram) • Daily Dosage is 20-80mg • Can be used for Schizophrenia and Dementia • Can trigger Mania or Suicidal Ideation • Wellbutrin (Bupropion) • Daily Dosage is 300-450mg • It works directly with Dopamine • It suppresses the appetite • Remeron (Mirtazapine) • Daily Dosage is 15-60mg • Increases Appetite • Decreases Liver or Kidney function in elderly people

22. Side Effects of SSRI Medication • Dry mouth • Constipation • Decreased appetite • Diarrhea • Insomnia • Fatigue • Runny nose • Dizziness • Loss in sexual ability • Nausea or Vomiting

23. Typical Psychotic Medication • Haldol (Haloperidol) • Daily Dosage is 1-40mg • Moderately Sedating • Thorazine (Chlorpromazine) • Daily Dosage is 400-500mg • Highly Sedating • Prolixin (Fluphenazine) • Daily Dosage is 2-40mg • Minimal Sedation

24. Side Effects of Typical Psychotic Medication • Extrapyramidal Symptoms (EPS), also referred to as parkinsonism, are common side effects with typical psychotic medications. • Parkinsonism is similar to the symptoms that are seen in Parkinson’s disease but the major difference is the tremors are slow, rhythmic, and rotational, whereas in EPS in the hands, fingers, and wrists move faster as a unit. • Three Types of EPS 1.) Dystonia is movement problems as grimacing and difficulty with speech or swallowing 2.) Akathisiais a extreme form of motor restlessness and may be mistaken for agitation 3.) Tardive Dyskinesia is involuntary movements to the face (mouth and tongue), trunk, and limb movements.

25. Atypical Psychotic Medication • Seroquel (Quetiapine) • Daily Dosage is 300-400mg • Used to treat Schizophrenia and involves the action of two neurotransmitters in the brain: Serotonin and Dopamine. • Risperdal (Risperidone) • Daily Dosage is 4-6mg • It blocks the action of two neurotransmitters: Serotonin and Dopamine • Abilify (Aripiprazole) • Daily Dosage is 10-30mg • Causes little weight gain, sedation and effect on heart function • Zyprexa (Olanzapine) • Daily Dosage is 5-10mg • Prevents the binding of Dopamine, Serotonin, and Histamine

26. Side Effects of Atypical Psychotic Medication • Weight gain • Persistent muscle spasms • Tremors • Restlessness • Anxiety • Rapid heart rate • Problems with Menstrual cycle • Urinary Retention • Decreased Sexual Interest • Drowsiness • Restlessness

27. Anxiety • Fear is generally the body’s response to real threat. • Anxiety is an exaggerated response to a threat that is unclear, unrealistic, or unknown. • The negative aspect of Anxiety is most problematic when it begins to interfere with an individual’s ability to work, sleep, or concentrate. • The person becomes either physically or psychologically exhausted by constantly preparing to face his or her unrealistic fears.

28. Treatment Models • Cognitive Processing Therapy (CPT) • Theory • Session • Four Main Parts • Prolonged Exposure Therapy (PET) • Theory • Session • Four Main Parts • Eye Movement Desensitization Reprocessing (EMDR) • Theory • Session • Four Main Parts

29. Cognitive Processing Therapy (CPT) • It’s based on Social Cognitive Theory that focuses on how the traumatic event is construed and coped with by the client who is trying to regain a sense of mastery and control in their life. • The theory behind CPT conceptualizes PTSD as a disorder of "non-recovery" in which erroneous beliefs about the causes and consequences of traumatic events produce strong negative emotions and prevent accurate processing of the trauma memory and natural emotions emanating from the event. • Is an adaptation of the evidence-based therapy known as Cognitive Behavioral Therapy used by clinicians to help clients explore recovery from PTSD and related conditions. • Consists of 12 sessions and has been shown to be effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees.

30. Four Main Parts of CPT • Learning about your PTSD symptoms and how treatment can help. • Becoming aware of your thoughts and feelings. • Learning skills to challenge your thoughts and feelings (cognitive restructuring). • Understanding the common changes in beliefs that occur after going through trauma. • Clinicians use Socratic Dialogue to discuss the details of the trauma, which helps patients gently challenge their thinking about their traumatic event and become increasingly able to consider the context in which the event occurred, with the goal of decreasing self-blame and guilt and increasing acceptance.

31. Prolonged Exposure Therapy (PET) • Developed by Dr. Edna B. Poa • Form of Behavioral Therapy and Cognitive Behavioral Therapy designed to treat PTSD characterized by re-experiencing the traumatic event through remembering it and engaging with, rather than avoiding, and reminders of the trauma. • Theoretically-based and effective treatment for chronic PTSD or related depression, anxiety, and anger.

32. Four Main Parts of PET • Educationto learn about their symptoms and how treatment can help. • Breathing Retraining to help client to relax and manage distress. • Real World Practice (Vivo Exposure) to reduce distress in safe situations that have been avoided. • Talking through the Trauma (Imaginal Exposure) to get control of your thoughts and feelings about the trauma.

33. Research on PET • Studies have shown symptom reduction rates of between 50%-80% Post-Treatment • Follow-up studies report 75% of patients no longer meet diagnostic criteria for PTSD 6 months after treatment • None of the patients meet the diagnostic criteria after 1 year • Involves 8-15 sessions with therapist, plus practice assignments client will do own their own.

34. Eye Movement Desensitization Reprocessing (EMDR) • In 1987, Dr. Francine Shapiro was walking in the park when she realized that eye movement appeared to decrease the negative emotion associated with her own distressing memories. • Dr. Shapiro assumed that eye movement had a desensitizing effect, and when she experimented with this she found that others also had the same response to eye movements. • Her theory of explaining EMDR is called “Adaptive Information Processing Model” because all humans possess an information processing system that processes experiences and stores these as memories in a way they are easily assessible and linked to a network of accompanying images, sensations, and emotions and beliefs.

35. Four Main Parts of EMDR • Identification of a target memory, image and belief about the trauma • Desensitization and reprocessing by focusing on mental images while doing eye movements that the therapist has taught the client • Installing positive thoughts and images, once the negative images are no longer distressing • Body scan by focusing on tension or unusual sensations in the body, to identify additional issues you may need to address in later sessions • A course of 4-16 session is common

36. Research on EMDR • Dr. Shapiro conducted a controlled study where randomly assigned 22 individuals with traumatic memories to two conditions: half received EMD and half received the same therapeutic procedure with imagery and detailed description replacing the eye movement. • Report showed that EMD resulted in significant decreases in ratings of subjective distress and significant increases in ratings of confidence in a positive belief. • Participants in the EMD condition reported significantly larger changes than those in the imagery condition. • Since the initial studies were published in 1989, hundreds of case studies have been published, and there have been numerous controlled outcome studies. • These studies have demonstrated EMDR’s effectiveness in PTSD treatment and EMDR is now recognized as effective in the treatment of PTSD.

37. Demonstration of EMDR VOLUNTEER FOR PRACTICE THERAPY SESSION.

38. The Big Picture • We can see them as sick, with all the stigma, neediness, and expense that entails, or we can recognize them as human beings, confronting the morality of what they’ve done in our name and what they’ve seen and come to know– even as they try to move on. • Our challenge as a nation is to insure that our Warriors know of our concern, care and commitment to acknowledge, support, and help heal the invisible moral wounds of combat.

39. Questions

40. References • Bamber, M. & McMahon, R. (2008). The role of maladaptive schemas at work. Clinical Psychology and Psychotherapy, 15, 96-112. • Benda, B. (2002). Test of a structural equation model of comorbidity among homelessness and domiciled military veterans. Journal of Social Service Research, 29 (1), 1-35. • Creamer, M., & Forbes, D. (2003). The long term effects of traumatic stress. In G. Kearney, M. Creamer, & R. Marshall (Eds), The fire within: Stress and military performance-The experience of the Australian and Defence Force (pp. 175-186, 206-220). Melbourne, VIC, Australia: Melbourne University Press. • Dziegielewski, S. (2006). Psychopharmacology for the nonmedically trained. Norton & Company, Inc. • Jakupcak, M., Vannoy, S., Imel, Z., Cook, J., Fontana, A., Rosenheck, R., & McFall, M. (2010). Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan war veterans seeking mental health treatment? Depression and Anxiety, 27, 1001-1005.

41. References Cont. • Jordan, B.K., Schlenger, W.E., Hough, R.L., Kulka, R.A., Weiss, D.S., Fairbank, J.A., et al. (1991). Lifetime and current prevalence of specific psychiatric disorders among Vietnam Veterans and controls. Archives of General Psychiatry, 48, 207-215. • Kessler, R.C., Berglund, P., Demler, O., Jin, R., & Walters, E.E. (2005a). Lifetime prevalence of age-of-onset distributions of DSM-IV disorders in the National Comorbidity survey replication. Archives of General Psychiatry, 62, 593-602. • Koenen, K.C., Stellman, J.M., Stellman, S.D., & Sommer, J.F. (2003). Risk factors for course of posttraumatic stress disorder among Vietnam veterans: A 14-year follow-up of American Legionnaires. Journal of Consulting and Clinical Psychology, 71(6), 980-986. • Orth, U., & Wieland, E. (2006). Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: A meta-analysis. Journal of Consulting and Clinical Psychology, 74, 698-706. • Richardson, L.K., Fruch, B.C., & Acierno, R. (2010). Prevalance estimates of combat-related posttraumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.

42. References Cont. • Epidemiology Program Post-Deployment Health Group. (2012). Report on VA facility specific Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans coded with potential PTSD. Office of Public Health Veterans Health Administration Department of Veteran Affairs. http://www.publichealth.va.gov/epidemiology. • Marks, A. (2012). Big boy rules: Surviving combat & mental health consequences.