PTSD & Stress Responses After Individual and Mass Injury Trauma Douglas Zatzick, MD Professor Department of Psychiatry & Behavioral Sciences Research Faculty Harborview Injury Prevention & Research Center University of Washington School of Medicine Trauma Survivors Outcomes & Support (TSOS) Funding Sources NIMH PCORI NIAAA NIMHD CDC HRSA Maternal Child Health DOD City of Seattle/King County Strauz Foundation/Trust Trauma Survivors Outcomes & Support (TSOS) Collaborators Frederick Rivara MD MPH Tom Koepsell MD MPH Joan Russo, PhD Erik Van Eaton MD Stephen O Connor, PhD Jin Wang, PHD Amy Wagner, PhD Chris Dunn, PhD Wayne Katon, MD Gregory Jurkovich, MD 1
November 2012: Hurricane Sandy December 2012: Sandy Hook April 2013: Boston Marathon 2
September 2013: Washington DC Naval Yard Learning Objectives: PTSD and Other Stress Response Syndromes Overview of public health approaches to trauma recovery Stepped care approaches - Enhancing resilience - Treatment of persistent symptoms Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT Posttraumatic Concerns RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. EVIDENCE- BASED PTSD TX SYMPTOMS & FUNCTION Therapy &Meds TIME DAYS WEEKS MONTHS Post-Event 3
Learning Objectives Emphasis on clinical cases Emphasis on individual self-care When to seek professional help Learning Objectives Discussion & Questions are KEY!!! Harborview Trauma Center Seattle 4
California 1972 :San Fernando Valley Quake California 1989: Loma Prieta Earthquake Seattle February 2001 5
January 12 th 2010 Haitian Earthquake 200,000-300,000 killed Multiple ongoing stressors - Aftershocks - Tent encampments - Violence - Hurricane threats 6
University of Washington Haiti Earthquake Acute Response Interdisciplinary team assembled Team makes two visits to Haiti - February/March 2010 - July 12 th week 2010 Organizational trainings for UW/Haiti providers & staff delivered Clinical care and consultation also provided Ongoing telephone consultation Clinical ethnographic research 7
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Disaster Classification Natural disasters Technological accidents Human induced incidents (malice) 9
Public Health Approaches to Posttraumatic Reactions Crisis Enduring Disorder Acutely Symptomatic Exposed: Few Symptoms/ Asymptomatic At Risk Subgroups of Survivors Injured Life threat Bereaved Children Elderly Prior mental health vulnerabilities Spectrum of Trauma-related Disorders Posttraumatic Stress Disorder (PTSD) Acute stress disorder Other anxiety disorders Bereavement spectrum disorders Major depression Somatic symptom amplification Alcohol and drug use disorders Other risk behaviors (e.g., carrying a weapon) Organic disorders related to head injury, toxic exposure etc., Exacerbation of pre-existing chronic mental illness 10
Posttraumatic Stress Disorder (PTSD) A. Traumatic Event B. Intrusive Symptoms C. Avoidant Symptoms D. Arousal Symptoms PTSD Intrusive Symptoms Memories Nightmares Flashbacks Distress at reminders PTSD Avoidant Symptoms Avoiding reminders Amnesia Emotional numbing Social isolation Foreshortened future 11
PTSD Arousal Symptoms Insomnia Irritability Hypervigilance Startle Poor concentration The Biology of PTSD: Take Home Stress response biology and symptoms are part of being human 12
Video: Case Study Treating PTSD & Other Stress Response Syndromes: Stepped Care Individual Level Collaborative Care Interventions Combined disease management - Psychiatric (Depression, PTSD) - General Medical Settings Multidisciplinary teams - Care management (MSW, RN) - Mental health providers (PhD, MD) - Medical & surgical providers (MD) 13
Harborview Trauma Center Seattle Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT Posttraumatic Concerns RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. EVIDENCE- BASED PTSD TX SYMPTOMS & FUNCTION Therapy &Meds TIME DAYS WEEKS MONTHS Post-Event Harborview Trauma Center Seattle 14
Case Study: Violent Injury 15 y/o female Assaulted with knife to face Left VII cranial nerve injury Concerns followed post-injury Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT Posttraumatic Concerns RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. EVIDENCE- BASED PTSD TX SYMPTOMS & FUNCTION Therapy &Meds TIME DAYS WEEKS MONTHS Post-Event Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT TIME Posttraumatic Concerns DAYS WEEKS MONTHS Post-Event 15
Patient-Centered Evaluation: Posttraumatic Concerns Of all the things that have happened to you since you were injured, what concerns you the most? Inpatient Ward my smile might not be back no more and um my face might be scarred for life. 1 Month Post-injury my face being back the way it used to be I think they cut a nerve, so they said it takes 4 to 6 months for my smile to come back or not... 16
1 Month Post-injury I m kinda traumatized cause like, when it happened I thought I was going to die and stuff so I don t know, basically just hanging and stuff, it was just a total shock I guess. Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT TIME Posttraumatic Concerns DAYS WEEKS MONTHS Post-Event Step I: Posttraumatic Support Address primary needs & concerns Promote safety and calm Promote resilience based coping Do no harm Good communication and empathy Cultural sensitivity 17
Coping With Traumatic Events: Personal Care Caring for personal injury Restoration of biological rhythms Establishing safety Coping With Traumatic Events: Reconnection Making time with friends and family Spontaneous reflection on and discussion of reactions and feelings Coping With Traumatic Events: When to Seek Professional Help Overwhelming responses Extreme behaviors Persistent reactions 18
Case Study: Violent Injury 15 y/o female Assaulted with knife to face Left VII cranial nerve injury Concerns followed post-injury Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. Posttraumatic Concerns TIME DAYS WEEKS MONTHS Post-Event Motivational Interviewing Targeting Risk Behaviors Non-confrontational Weighing Pros and Cons Spontaneous discussions in Real World settings Enhancing individual capacity and motivation for behavior change 19
Adolescent Risk Behavior: Have You Carried a Weapon? 40 35 Intervention Control % Answering Yes 30 25 20 15 10 5 0 Baseline 0 2 4 6 8 10 12 Months After Injury p < 0.05 Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT Posttraumatic Concerns RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. EVIDENCE- BASED PTSD TX SYMPTOMS & FUNCTION Therapy &Meds TIME DAYS WEEKS MONTHS Post-Event Evidence-based PTSD Treatments Psychotherapy Medications 20
Evidence-based PTSD Psychotherapy Treatments Cognitive Behavioral Therapy (CBT) - Prolonged Exposure - Cognitive Restructuring - Behavioral Activation Others -EMDR - Psychodynamic Psychotherapy Evidence-based PTSD Medication Treatments Medication - Selective Serotonin Reuptake Inhibitor (SSRI): Fluoxetine, Paroxetine, Sertraline, Citalopram - SNRI: Venlafaxine, Duloxetine - Prazosin & Trazadone targeting insomnia Stepped Care POSTTRAUMA SUPPORT ENGAGEMENT Posttraumatic Concerns RISK BEHAVIORS TARGETED HARM REDUCTION Motivational Int. EVIDENCE- BASED PTSD TX SYMPTOMS & FUNCTION Therapy &Meds TIME DAYS WEEKS MONTHS Post-Event 21
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