Posttraumatic Stress Disorder. Casey Taft, Ph.D. National Center for PTSD, VA Boston Healthcare System Boston University School of Medicine

Transcription

1 Posttraumatic Stress Disorder Casey Taft, Ph.D. National Center for PTSD, VA Boston Healthcare System Boston University School of Medicine

2 Overview PTSD Overview Neurobiology of PTSD PTSD and Relationship Functioning PTSD and Partner Violence Strength at Home Program

3 6 Criteria for PTSD Diagnosis 1. Stressor- A threatening event accompanied by fear, helplessness, or horror 2. Reexperiencing 3. Avoidance 4. Arousal 5. Duration (> 1 month) 6. Distress or Impairment

4 Reexperiencing Avoidance P T S D ost raumatic tress isorder Flashbacks Intrusive memories Dreams Psychological distress w/ reminders Physiological reactivity 1 3 PTSD 2 Thoughts & feelings Activities/Places/People Amnesia Loss of interest Detachment Restricted affect Foreshortened future Sleep difficulties Hypervigilance Irritability & anger Startle Concentration Arousal

5 Think of PTSD as a failure to recover from a traumatic event If the event is severe enough, nearly everyone will have symptoms reflective of PTSD

6 Identifying Biomarkers of PTSD Gray Matter Volumetry Functional Brain Changes [fmri]

7 Fear Circuitry Brain Structures Amygdala Threat detection and fear conditioning Exaggerated activation in response to trauma-related memories Exaggerated activation for non trauma-related stimuli Activation positively related to PTSD symptom severity Medial Prefrontal Cortex Extinction (learn stimuli no longer aversive) Anterior Cingulate Cortex (racc): Diminished activation in PTSD Dorsal Anterior Cingulate Cortex (dacc) : Exaggerated activation Hippocampus Memory encoding (e.g., context during fear conditioning) Diminished activation in PTSD and lower hippocampal volumes

8 PTSD participants viewing fearful facial expressions during fmri R amygdala PTSD>Control, Fear vs. Happy Shin et al., 2005 Arch Gen Psychiatry

9 Bryant et al., 2008 Psychological Medicine Imaging of Treatment

10 How well do treatments work? Results from Meta-Analysis Effect Size (d) Prolonged Exposure Other Exposure Other CBT Stress Inoculation EMDR Group therapy SSRIs TCAs Other Antidepressants Alpha blockers MAO-Is Atypical Antipsychotics Benzodiazepines Note. Effect sizes are computed from the difference between groups in individual studies at posttreatment Psychotherapies shown in green Drugs shown in yellow Cognitivebehavioral therapy is most effective Watts et al., 2007

11 PTSD and General Relationship Functioning

12 Relationship Quantity National Comorbidity Study (Kessler et al., 1998) Nationally representative population survey 1.6 greater odds of divorce for PTSD.9 odds ratio for Social and Specific Phobias 3.2 odds ratio for Manic Episode 1.7 odds ratio for MDD Higher than all substance use disorders

13 Relationship Quantity National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990) Combat veterans with PTSD compared with those without PTSD were: Less likely to marry 2X more likely to divorce (70% vs 34.9%) 3X more likely to have multiple divorces (22% vs 8%)

14 PTSD and Relationship Quality In veterans, PTSD associated with: More relationship distress Less cohesion Less emotional expressiveness and engagement More intimacy difficulties More areas of relationship conflict Domestic violence and problems with anger

15 PTSD and Relationship Satisfaction Reexperiencing Avoidance/ Numbing Hyperarousal Emotional Numbing Effortful Avoidance

16 Other Mechanisms Secondary traumatization Caregiver burden Changes in family roles

17 PTSD and Partner Violence

18 Partner Violence Rates Yearly: 13% to 32% Heyman and Neidig (1999) Military vs. civilian rates adjusting for demographics Military sample more severe violence Rates of moderate violence more comparable Foran et al. (2011) Higher rates in Air Force women (15.1% vs. 12.9%) Higher clinically significant abuse in men (4.7% vs. 3.5%)

19 Deployment and Interpersonal Conflict Iraq Active and Reserve Soldiers (Milliken, Auchterlonie, & Hoge, 2007) Initial mental health screening (PDHA) and 3-6 month follow-up (PDHRA) Concerns about interpersonal conflict increased 4-fold The largest increase of any mental health concern 3.5% to 14% in Active Duty 4.2% to 21.1% in Reserves

20 PTSD and Partner Violence Military service members not more violent than civilians in absence of significant stress and/or PTSD (Bradley, 2007) Rates in the National Vietnam Veterans Readjustment Study (Kulka et al., 1990) Veterans with PTSD = 33% Veterans without PTSD = 13.5% Meta-analytic results (Taft et al., 2011) PTSD and physical aggression: r =.42 PTSD and psychological aggression: r =.36

21 Survival Mode Model Vigilance to threats in warzone leads combat veteran to enter into survival mode inappropriately when stateside Perceive unrealistic threats Exhibit hostile appraisal of events Overvalue aggressive responses to threats Exhibit lower threshold for responding to the threat Chemtob et al., 1997

22 Information Processing Model for Domestic Violence Violent men exhibit cognitive deficits (e.g., faulty attributions, irrational beliefs) that impact interpretation (decoding stage) Violent men have difficulty generating a variety of nonviolent responses (decision-making stage) Violent men lack the skills to enact a competent response (enactment stage) The process influenced by transitory factors such as alcohol use, traumatic brain injury, etc. Holtzworth-Munroe, 1992

23 PTSD and Aggression Reexperiencing Avoidance/ Numbing Hyperarousal e.g., Taft et al., 2007

24 Other Contributing Factors 1. Depression 2. Alcohol use problems 3. Traumatic brain injury

25 Core Themes 1. Shame and Self-Esteem 2. Trust and Intimacy 3. Power and Control

26 Shame and Self-Esteem Veterans may experience shame and unfairly blame selves for military traumas Low self-esteem leads to depression, insecurity in relationships, and abuse Shame and self-esteem thoughts She is trying to put me down She is trying to make me feel worthless She doesn t care about me She is going to leave me

27 Trust and Intimacy Trust in others disrupted by trauma Service member may feel they can t trust anyone or others will betray them Mistrust can carry over into relationships Hinders intimacy Leads to controlling behavior Trust and intimacy thoughts She is betraying me She is out to get me She is not on my side She is cheating on me

28 Power and Control Exposure to childhood and military trauma may contribute to a sense of powerlessness Feelings of powerlessness and military training emphasizing control contributes to power struggles Power and control thoughts She always has to have her way I will show her who she is dealing with I am going to get my way no matter what She is not respecting my authority

29 Strength at Home Men s Program

30 Men s Program Objectives Department of Defense Department of Veterans Affairs Primary goal is to end conflict and intimate partner violence in veterans of any era No prior randomized clinical trial has shown treatment effects in a military population (e.g., Dunford, 2000)

31 Structure and Format Veterans or active duty servicemen who have engaged in recent domestic violence Closed psycho-educational groups 12 weekly 2-hour sessions 3-5 veterans per group Male and female co-therapist

32 Strength at Home Stages Stage 3 Communication Stage 2 Conflict Management Stage 1 Introduction, Psychoeducation, Promotion of Insight

33 Strength at Home Stages Stage I (Sessions 1-2): Psychoeducation Pros/cons of abuse Forms of domestic abuse and impacts of trauma Goals for group

34 Strength at Home Stages Stage II (Sessions 3-6): Conflict Management Understanding anger Assertiveness Time Outs Survival mode thinking Core themes

35 Strength at Home Stages Stage III (Sessions 7-12): Communication Skills Roots of communication style Active listening Assertive messages Expressing feelings Communication traps Relaxation training

36 Overall Session Structure Check-out Assign Practice Practice Review 40 Introduce New Skill or Content 15 In-session Practice

37 Pilot Sample Characteristics 12 assessed 5 failed to attend after initial assessment 1 dropout 6 completed the intervention 6 completers 5 Caucasian, 1 African American Average age = 37.2 years 5 married and living together, 1 in a relationship, not living with partner 5 served in Iraq or Afghanistan, 1 in Vietnam

38 Conflict Tactics Scale -2 (CTS2): Physical Aggression- Variety Score Pre- Treatment 6-Month Followup CTS2 (Physical) M (SD) M (SD) t(5) p-level d Total 4.5 (2.0) 1.0 (0.6) Mild 2.8 (0.8) 0.8 (0.8) Severe 1.7 (1.4) 0.2 (0.4) Physical aggression variety mean scores and standard deviations are reported in their untransformed state for ease of understanding; analyses were performed on natural-log transformed data. M = Mean; SD = Standard Deviation

39 Conflict Tactics Scale -2 (CTS2): Psychological Aggression- Frequency Pre- Treatment 6-Month Follow-up CTS2 (Psychological) M (SD) M (SD) t(5) p-level d Total 92.8 (37.8) 43.2 (36.6) Mild 70.2 (29.9) 32.8 (27.3) Severe 22.7 (17.7) 10.3 (11.0) All reported data and analyses for psychological aggression frequencies use untransformed data. M = Mean; SD = Standard Deviation

40 MMEA Psychological Aggression- Frequency Pre- Treatment 6-Month Follow-up MMEA M (SD) M (SD) t(5) p-level d Total (81.6) 74.2 (56.5) Restrictive Engulfment 28.0 (35.6) 8.3 (9.9) Denigration 32.0 (21.7) 7.7 (10.2) Hostile Withdrawal 87.7 (46.8) 47.0 (52.1) Dominance 40.3 (27.1) 11.2 (8.1)

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