First Responders and PTSD DR. KENNETH J. COOPER MD, MHSC, FRCPC DR. DION GOODLAND PHD OEMAC CONFERENCE ST. JOHN S NEWFOUNDLAND JUNE 13, 2017
Faculty/Presenter Disclosure Faculty: Dr. Dion Goodland Dr. Kenneth J. Cooper Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: Dr. Cooper: Calian Contractor work at CFB Halifax
Disclosure of Commercial Support This program has not received any financial support. This program has not received in-kind support. Potential for conflict(s) of interest: Dr. Goodland and Dr. Cooper have not received payment or funding from any organization.
Not applicable. Mitigating Potential Bias
PTSD What are we treating? Symptoms? Behaviours? What are treatment outcomes? Cure? Remission? Improved functioning?
PTSD What is the core problem? Is it what happened? (The Event) Is it the memory of what happened? Emotion and the Amygdala Sensory memories The psychological abscess The Psyche the present versus the past Association versus dissociation Lack of perspective
PTSD What is the role of: Avoidance? Emotional numbing? Negative alterations in cognition and mood? Waxing and waning: re-experiencing over time
PTSD DIAGNOSTIC CRITERIA (DSM-5): A. Traumatic event: (NECESSARY CRITERIA) Actual or threatened death/serious injury/sexual violence Directly experienced Witnessed Learning about close family member/close friend Must have been violent or accidental Repeated or Extreme exposure to adverse details First Responders Occupational exposure to details of events
PTSD TRAUMA PTSD Trauma is common, PTSD is not Most are OK after Trauma Trauma and Stress can be an opportunity and activate resilience and a sense of opportunity LIFE CHANGING (EVENTS) DISEASE Significant trauma is life changing, like many things in life Change could be: positive, negative or neutral but not singularly disease
After an adverse event Normalize Reactions Not to be distressed It s OK To be distressed When it is all over you may question yourself and this is normal If you find resolution - this is good If you keep ruminating - get help early Christiane Routhier, Ph.D. (2007)
Resiliency NOTE: 75 to 85% of those exposed to a traumatic event DO NOT develop PTSD
Natural Course of Symptoms Post-Trauma 6% recovered 53% recovered 58% recovered 15-25% UNRECOVERED Weeks 3 months 9 months YEARS Shalev & Yehuda, Psychological Trauma 1998
Core Symptoms of PTSD Flashbacks Intrusive memories Nightmares Emotional distress at reminders Physiological reactivity Thoughts/feelings Activities/places/people Amnesia Negative expectations Distorted blame of self/others Negative emotional state Loss of interest Detachment Emotional Numbing- restricted affect Irritability and anger Reckless or self-destructive behavior Hyper-vigilance Startle response Poor concentration Insomnia Intrusions Avoidance Negative cognitions & mood Arousal & reactivity NEED 1 NEED 1 NEED 2 NEED 2
PTSD Duration: Presence of B, C, D and E for greater than one month
Risk Factors for PTSD The reasons why one person develops PTSD, and another does not, are not fully understood Pre-trauma risk factors (previous adverse events, psychological vulnerability) Peri-trauma risk factors (severity of stressor, being injured) Post-trauma risk factors (the amount of support received afterwards, further traumatizing events) Which factors have most significance?
PTSD Changes from DSM-IV: 1. Removal of the emotional response as a requirement of the traumatic event ( A2 ) (Key for First Responders) Moved to section D (Negative cognitions/mood) 2. Expansion of the definition of a traumatic event more specific 3. Splitting of Avoidance into: Avoidance Negative alterations in cognitions/mood
PTSD Significance of no longer requiring an emotional response as part of the traumatic event KEY for First Responders!!! Can have PTSD without history of any strong adverse emotional response CONTEXT as a precipitant??? % of PTSD??? likely most still have emotional response
Predator/Prey (The Fear Response): the Classic PTSD Model
PTSD and First Responders How is PTSD different in First Responders: Not victims Lack of an emotional response Often NOT ONE particular traumatic event Numerous exposures
PTSD What does treatment mean? Medication? Psychotherapy? Cure requires processing = PSYCHOTHERAPY!! CBT/PE EMDR IPT Mindfulness Takes time 6/12 to 12/12 (or longer)
PTSD Role of medication: Not curative Symptomatic relief But patients can feel better in short term Stabilization Engagement in psychotherapy
PTSD Symptoms that respond well to medications: Within a week or two: Irritability Sleep latency/onset Reexperiencing (nightmares) Weeks to months: Mood, energy, interest, concentration Symptoms that respond less well: Reexperiencing (thoughts), Negative Cognitions, Avoidance?Startle?,?vigilance?
PTSD Medication targets (PTSD alone): Irritability: SSRIs, SNRI s, NDRIs +/- novel antipsychotics +/- mood stabilizers Sleep: Latency TCAs, Trazodone, Mirtazapine, Zopiclone Disruption (Nightmares) Prazosin (Level A on Ia evidence, Raskind et al, 2003 & 2013) Nabilone (Level A on Ib evidence, Jetly et al, 2015)
PTSD SLEEP: A key symptom to target!!!! In < 90%of cases If sleep improved: Decreased irritability (short term) Increased energy (short/medium term) Increased concentration (medium/long term) Improved mood (medium/long term)
Psychotherapy Talk therapy Tends to be very successful Requires a good assessment to understand the issues Therapeutic relationship is important Takes time to establish trust Frequency and Duration of sessions can vary greatly Required to help the person make sense of the trauma
Psychotherapy Many different kinds of psychotherapy exist Evidence-based Strategies used to treat PTSD: Exposure-based Therapies Cognitive-based Therapies Stress Inoculation Training Eye Movement Desensitization and Reprocessing (EMDR)
Other strategies to augment Psychotherapy Mindfulness-based psychotherapy Relaxation techniques Hypnosis Service dogs/equine therapy Yoga Medical Marijuana Hospitalization/Inpatient programs
Barriers to Treatment Denial Belief that Treatment does not work Fear of Job-related Consequences Financial concerns Access to treatment Stigma
Stigma mental illness stigma resulted in 10,200,000 hits on Google 60% or more of people with mental illnesses do not seek help primarily because of stigma Can come from within an individual or from society Examples: people with PTSD are dangerous or unstable, only weak people get PTSD Generally exists because people are uninformed/misinformed Often fear based Media and Entertainment industry
Stigma Ways to challenge stigma: Education Use the proper language
PTSD Questions????