Comorbidity Rates. Comorbidity Rates. Males: Females:

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1 Comorbidity Rates Males: Any Diagnosis: 88% Alcoholism 52% Depression 48% Conduct Disorder 43% Drug Abuse 35% Phobia 31% Kessler, et al. (1995) Comorbidity Rates Females: Any Diagnosis 78% Depression 49% Alcoholism 30% Phobia 29% Drug Abuse 27% Conduct Disorder 15% Kessler, et al. (1995) 1

2 Understanding PTSD Comorbidity Disorder Precedes Trauma and is Risk Factor Disorder Accompanies PTSD at Onset PTSD Leads to Other Disorders over Time PTSD Leads to One that Leads to Another Disorder Leads to PTSD that Leads to Another Functioning & QOL SF-36 from MOS. WHO s Disability Tools Adopt for population Consider modifications for physically disabled. Utility for Polytrauma Injuries Incorporate TBI survivors. Distinguish QOL from Disability & Functioning Ongoing Scale Development (e.g., Marx, et al.) Inventory of Psychosocial Functioning (IPF; Marx et al.) The Inventory of Psychosocial Functioning (IPF): 80-item self-report measure to assess functioning in PTSD Respondents rate domains over the past 30 days Items are rated on a 7-point scale. The IPF yields a total score and scores for seven subscales: Romantic Relationships, Family, Parenting, Friendships, Work, Education, and Self- Care. Higher scores indicate greater impairment 2

3 Comparing veterans diagnosed with PTSD and veterans without PTSD on the IPF PTSD No PTSD IPF Scale n M SD n M SD t df IPF Total ** 273 Romantic * 136 Family ** 212 Work ** 91 Friendships ** 221 Parenting * 113 Education Self-Care ** 267 * p <.05; ** p <.01 Issues in Developing Screening Adaptation to trauma over time (Bonanno, 2004) 3

4 Screening Questions When do we screen? How often do we screen? For what do we screen? How do we respond to screening results? What treatment options are available? Who do we screen? Response to Screens What will you do with a positive screen? What will you do with a negative screen? What will you do with ambiguous results? What confidence will you have in data? Sensitivity Specificity Predictive Power of a Positive Test Predictive Power of a Negative Test. FDNY Objectives Establish system for all 15,000 Screen during annual physical exam. Cast broad symptom net. Set second tier confirmatory interview. Use established behavioral services. Increase treatment options in community. 4

5 FDNY System PTSD Depression Alcohol Abuse Domestic Violence Children s Behavior Marital Functioning Sexual Functioning Exercise Routines Smoking Headaches & Pain Chronic Fatigue Cognitive/Memory Spiritual Life SF-36 Lessons From 9/11 for Mental Health Event was Massive in Scope Coordination among County, City, State, Federal Agencies Needed. Best Practice Methods Not Established. Mental Health Workforce Not Trained. Best Methods to Deliver Interventions Not Clear. Are there effective treatments for PTSD? 5

6 Historical Roots of PTSD Treatment Fenichel (1945) Quiet the High Levels of Anxiety and Reactivity to the Event Reconstruct the Details of the Event with Emotional Reactions to Promote Mastery. Historical Roots of PTSD Treatment Logotherapy (Victor Frankl) In Franklian psychotherapy, the PTSD client is helped to remember the details of their trauma experiences to identify the meaning opportunities embedded in the memories of the trauma and to make use of such meaning for giving to the world. Lantz (1992) Historical Roots of PTSD Treatment Hypnotherapy (Pierre Janet) Therapeutic advances from (pathological grief and PTSD) make it clear that the trauma per se must be accessed before mourning can proceed. van der Hart et al. (1990) 6

7 Behavioral Conceptualization Keane & Kaloupek (1982) Conditioning and Instrumental Learning Model Avoidance Model of Psychopathology Rescorla & Solomon: Two Factor Theory CS: Environmental Concomitants with Exposure UCS: Traumatic Event Symptoms: Manifestations of Effortful Avoidance Objective Measures of Outcomes Keane & Kaloupek (1982) 7

8 Foa, Keane, Friedman, Cohen (2009) Best Practices for Treatment Psychosocial Exposure therapy Cognitive therapy Anxiety management Desensitization EMDR Pharmacological TCAs MAOIs SSRIs Mood stabilizers Anti-anxiety agents Common PTSD Treatment Elements Direct therapeutic exposure to events. Countering avoidance strategies. Education about trauma & PTSD. Cognitive restructuring on key distortions. Skills for Anxiety Management. Keane (2008) Vietnam Veterans With PTSD CBT Treatment of PTSD Prolonged Exposure v. Anxiety Management v. Wait List Control 6-Month Follow-up Keane, Fairbank, Caddell, & Zimering (1989) 8

9 PTSD Symptoms (PSS-I) PTSD Symptom Checklist Scores in Combat Veterans Score Pre Post Follow-up 0 Prolonged Exposure Conditions Wait List Control Prolonged Exposure (PE) Therapy, Stress Inoculation Training (SIT) and Their Combination for Female Assault Victims with PTSD (9 Sessions) Wait-list control PE/SIT SIT 10 PE 5 0 Week 0 Week 5 3 Months 6 Months PSS-I = Post Traumatic Stress Disorder Symptom Scale Interview; Foa et al, 1999b Mastering Traumatic Experiences You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing you think you cannot do. Eleanor Roosevelt 9

10 PTSD: A Cognitive Behavioral Approach Emotional & Behavioral Stabilization Trauma Education Anxiety Management Trauma Focus Work (e.g., Exposure) Relapse Prevention Ongoing Supportive Aftercare Keane et al. (1992) What Constitutes Exposure? Imagery Based Methods In Vivo Assisted Exposure Narrative Therapy Communication Skills Training Writing/Diaries Audio-Assisted Methods Any direct intervention working on the memory to facilitate emotional processing of the experience What Constitutes Anxiety Management? Trauma Education Relaxation Therapy Breathing Retraining to Affect Panic Anger Control Skills Self Control Strategies to Limit Stressors Specified Time for Processing Event Sleep Hygiene/Diet/Exercise Limiting Alcohol/Drug Usage Communication Skills Training 10

11 Cognitive Therapy Components Identifying Distorted Beliefs Identifying Catastrophic Thoughts Overgeneralization Fallacy of Invulnerability Fallacy of Control The Should Trap Righteous Anger & Blaming Functional Analysis of Patient What are this patient s strengths, assets, advantages? What is the patient s priority to change? What is the hierarchy of needs? What are structural changes in environment needed? What are the interpersonal problems? What are the emotional reactions needing change? Keane, et al. (1985) What are the psychopharm treatments? 11

12 PTSD Pharmacotherapy There are many more pharmacological options in Depression than PTSD Only two FDA approved medications for PTSD both SSRIs Many more approved medications in depression: SSRIs Venlafaxine - SNRIs Mirtazepine - NE/5HT modulator Buproprion - DA/NE reuptake inhibitor Tricyclic Antidepressants MAO Inhibitors Pharmacological Strategies for Non-responders Depression lithium thyroid hormone anticonvulsants psychostimulants ECT PTSD prazosin Atypical antipsychotics anticonvulsants 12