PTSD and TBI: What are the Treatment Options

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PTSD and TBI What are the Treatment Options

• Katherine Porter, Ph.D.
• VA Ann Arbor Healthcare System

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• Thank you to collaborators that helped me with
  this talk (Sheila Rauch, PhD Erin Smith, PhD,
  and Melody Powers, LMSW along with others).
• Some of the content and slides have been borrowed
  from previous talks they have given on this
  topic.

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Outline

• What is PTSD
• PTSD and the courts/criminal behavior
• Data on TBI and comorbity
• Treatment planning with court order patients
• Evidence based care for PTSD

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Response to Trauma and Stress

• Following trauma many problems may occur and
  interact

Substance Abuse
Anxiety Panic
Depression
PTSD
Physical Health Problems
Relationship Problems
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PTSD

• Requires
• Event that threatened or caused death, physical
  injury, threat to physical integrity.
• Responded with fear, helplessness, or horror
• Recently, this criteria has been removed, but is
  seen in most cases even if they dont use the
  words.
• Symptoms
• Reexperiencing of a specific event/s
• Avoidance
• Negative alterations in thoughts and mood
• Alterations in arousal and reactivity
• Must impair function for at least one month

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Normal Reaction vs. Pathology

• Most individuals exposed to traumatic situations,
  do not develop PTSD.
• The manifestation of some symptoms during the
  first 30-90 days after a traumatic experience is
  not uncommon and is generally part of the normal
  stress response.
• However, a pattern of symptoms that begin to
  interfere with work, home life or interpersonal
  relationships marks PTSD.
• Persistent symptoms that either do not improve or
  worsen, even if considered normal initially,
  become problematic when they do not remit over
  time.

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Criminal Behavior and PTSD

• Symptoms of PTSD and comorbid disorders may
  increase chance that a person may experience some
  legal problems.
• Anger and irritability
• Hyperarousal/ perception of threat and danger
• Startle
• Feelings of disconnection/ isolation and lack of
  support
• Intrusions, including flashbacks
• Majority of patients with PTSD do not have
  problems with the law and are not violent.

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Criminal Behavior and PTSD

• Data suggests that PTSD may be linked to violence
  and aggression (e.g., Kulka et al.,1988 Lasko et
  al., 1994 Orcutt et al., 2003).
• Substance use can increase risk
• Presence of PTSD does not suggest criminality and
  criminal behavior does not mean that symptoms are
  the cause of the behavior.

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Anger PTSD

• Elevated levels of anger often seen in trauma
  survivors and has been shown to be related to
  severity of PTSD (e.g., Riggs et al., 1992).
• Anger is central feature in survival response
• Relationship between anger and PTSD stronger in
  military samples, but not specific to it (e.g.,
  Orth Wieland, 2006)
• Anger levels decrease with treatment of PTSD even
  if it is not directly targeted (Cahill et al.,
  2003 Stapleton et al., 2006)

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Substance Use Disorders and PTSD

• Why the link between PTSD and substance use?
• High Risk Hypothesis
• Susceptibility Hypothesis
• Self-medication Hypothesis (most support)
• Often conceptualized as avoidance in trauma
  focused therapy
• Data on prevalence varies, but it is estimated
  that
• 20 seeking help for PTSD have a substance use
  disorder http//www.ptsd.va.gov/public/pages/ptsd_
  substance_abuse_veterans.asp
• 33 of veterans seeking help for SUD have PTSD.
  http//www.ptsd.va.gov/public/pages/ptsd_substance
  _abuse_veterans.asp
• 3059 of women with SUD have PTSD
  (Najavits,Weiss, Shaw, 1997)

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Traumatic Brain Injury (TBI)

• 1.7 million people sustain a TBI annually
• Vast majority dont require hospitalization
• CDC (2010). Traumatic Brain Injury in the United
  States Emergency Department Visits,
  Hospitalizations, and Deaths.
• Symptoms and course can vary significantly
• Can include irritability, changes in mood,
  behavioral changes
• Many symptoms overlap with PTSD

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Rates of mTBI and PTSD among OIF/OEF Veterans

• Reported rates of both PTSD and mTBI vary
  according to the study and may be underreported
• TBI rates estimated at approaching 20 (Sayer et
  al., 2009)
• The majority of these cases are in the mild range
  of severity
• Evidence indicates that the majority of these
  cases resolve within weeks or months

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PTSD and TBI

• Studies looking at rates of PTSD following TBI
  vary considerably
• Depending on methods for diagnosing PTSD rates
  reported between 3-30 with interview and
  18-59 with self-report (Gill et al., 2014).
• PTSD maybe less likely in cases with longer
  periods of unconsciousness (Glaesser et al.,
  2004).

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Assessment and Treatment with Court Ordered
Patients

• Important to consider history of symptoms and
  behaviors
• Helps to reduce impact of secondary gain
• Provides information about potential function of
  behaviors
• Treatment plans should be symptom/diagnosis based
  
• Trauma focused therapies can be effective, but
  are only therapeutic when patients are willing
• Education and rationale are provided to patient
  and they be strongly encouraged, but not forced.

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Assessment and Treatment with Court Ordered
Patients

• PTSD therapies are short-term and involve work
  outside of the therapy office
• Goal is to help person reconnect and engage in
  their life
• Important that they practice skills in their
  environment
• Consistent messages from team (treatment team and
  courts) is important to help combat avoidance

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PTSD TreatmentClinical practice guidelines

• Prolonged Exposure and Cognitive Processing
  Therapy have been supported as first line
  treatments for PTSD
• VA/DOD PTSD Treatment guideline (VA/DOD, 2004,
  2010)
• National Institute of Clinical Excellence (NICE,
  2005)
• International Society of Traumatic Stress Studies
  (ISTSS, 2009)
• Institute of Medicine (IOM, 2007)
• Selective Serotonin Reuptake Inhibitors(SSRIs)
  are also supported first-line treatment- Zoloft
  and Paxil

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Prolonged Exposure (PE)Treatment Procedures

• Psychoeducation Education about treatment and
  common reactions to trauma breathing training
• Repeated in vivo exposure
• Imaginal exposure
• Processing of the revisiting and in vivo exposure
  experiences

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PE Rationale

• Exposure
• Challenges belief that anxiety lasts forever
• Challenges belief that memories, people, places,
  and situations are dangerous
• Results in reduction of anxiety without engaging
  in habitual avoidance behaviors
• Helps process traumatic experience(s)
• Enhances sense of control

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Cognitive Processing Therapy (CPT)

• Psychoeducation
• Impact Statement
• Trauma Account
• Cognitive Challenge
• Identify stuck points
• Safety, trust, power/control, esteem, intimacy

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CPT Rationale

• Trauma events change ones perceptions about the
  world, themselves, and other people
• The world is dangerous
• Its all my fault
• Trauma victims with PTSD have a distorted sense
  of
• Safety, Trust, Intimacy, Power/Control,
  Self-Esteem
• These distortions keep people stuck in their PTSD
  symptoms and therefore must be modified to
  accurately fit the context/reality of situations

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Initial Data on Outcomes with PTSD/TBI

• Sripada et al., 2013
• Examined clinical sample from a VA clinic of PTSD
  patient who received PE and data from a pilot
  study
• Compared outcomes of participants with and w/out
  a history of mTBI
• Showed that PE was effective in reducing PTSD
  symptoms and mTBI status did not impact efficacy.
  

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The Good News

• PTSD can be a chronic disorder, but with the
  right treatment patients can get significantly
  better, including no longer meeting criteria for
  the disorder post-treatment.
• For example, Rauch et al. (2009) found that 80
  of veterans treated with Prolonged Exposure (PE)
  therapy achieved clinically significant
  reductions in their PTSD symptoms and 50 no
  longer met criteria for PTSD.
• Data from VA roll out training of PE demonstrated
  that the percentage of veterans screening
  positive dropped from 87.6to 46.2 (Eftekhari et
  al., 2013).

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The Good News

• Monson et al. (2006) found that 40 of a veteran
  sample receiving Cognitive Processing Therapy
  (CPT) did not meet criteria for PTSD compared to
  3 for a wait-list control group.
• 50 of the veterans receiving CPT had a
  significant reduction in their symptoms, compared
  to 10 of the wait-list control group.

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References

• Cahill, S. P., Rauch, S. A.,Hembree, E. A.,Foa,
  E. B. (2003). Effect of cognitive behavioral
  treatments for PTSD on anger. Journal of
  Cognitive Psychotherapy, 17, 113131.
• CDC (2010). Traumatic Brain Injury in the United
  States Emergency Department Visits,
  Hospitalizations, and Deaths. Retrieved from
  http//www.cdc.gov/traumaticbraininjury/pdf/blue_b
  ook.pdf
• Eftekhari, A., Ruzek, J. I., Crowley, J. J.,
  Rosen, C. S., Greenbaum, M. A., Karlin, B. E.
  (2013). Effectiveness of national implementation
  of prolonged exposure therapy in Veterans Affairs
  care. JAMA psychiatry, 70, 949-955.
• Glaesser, J., Neuner, F., Lütgehetmann, R.,
  Schmidt, R., Elbert, T. (2004). Posttraumatic
  Stress Disorder in patients with traumatic brain
  injury. BMC psychiatry, 4, 5.
• Gill, I. J., Mullin, S., Simpson, J. (2014).
  Psychosocial and psychological factors associated
  with post-traumatic stress disorder following
  traumatic brain injury in adult civilian
  populations A systematic review. Brain Injury,
  28, 1-14.
• Kulka, R. et al. (1988). National Vietnam
  Veterans Readjustment Study Contractual Report
  of Findings from the National Vietnam Veterans
  Readjustment Study, Volumes III (Veterans
  Administration Contract No. V101(93)P-1040).
  Research Triangle Park, NCResearch Triangle
  Institute.
• Lasko, N.B. et al. (1994). Aggression and its
  correlates in Vietnam veterans with and without
  chronic posttraumatic stress disorder.
  Comprehensive Psychiatry, 35, 373-381.
• Monson, C. M., Schnurr, P. P., Resick, P. A.,
  Friedman, M. J., Young-Xu, Y., Stevens, S. P.
  (2006). Cognitive processing therapy for veterans
  with military-related posttraumatic stress
  disorder. Journal of Consulting and clinical
  Psychology, 74, 898.

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References

• Najavits, L.M., Weiss, R.D. Shaw, S.R. (1997).
  The link between substance abuse and
  posttraumatic stress disorder in women A
  research review. The American Journal on
  Addictions, 6, 273-283.
• Orcutt, HK, et al., (2003). Male-perpetrated
  violence among Vietnam veteran couples
  Relationships with veterans early life
  characteristics, trauma history, and PTSD
  symptomatology. Journal of Traumatic Stress, 16,
  381 390.
• 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,
  698706.
• Rauch, S. A. M., Defever, E., Favorite, T.,
  Duroe, A., Garrity, C., Martis, B. and Liberzon,
  I. (2009), Prolonged exposure for PTSD in a
  Veterans Health Administration PTSD clinic.
  Journal of Traumatic Stress, 22 6064.
• Riggs, D. S., Dancu, C. V., Gershuny, B. S.,
  Greenberg, D., Foa, E. B.(1992). Anger and
  post-traumatic stress disorder in female crime
  victims.Journal of Traumatic Stress, 5, 613625.
• Sayer, N.A., Rettmann, N.A., Carlson, K. F.,
  Bernardy, N., Sigford, B. J., et al. (2009).
  Veterans with history of mild traumatic brain
  injury and posttraumatic stress disorder.
  Challenges from providers perspective. Journal of
  Rehabilitation Research Development, 46,
  703-716.
• Sripada, R. K., Rauch, S. A., Tuerk, P. W.,
  Smith, E., Defever, A. M., Mayer, R. A, et al.,
  (2013). Mild traumatic brain injury and treatment
  response in prolonged exposure for PTSD. Journal
  of traumatic stress, 26(3), 369-375.
• Stapleton JA, Taylor S, Asmundson GJ. (2006).
  Effects of three PTSD treatments on anger and
  guilt exposure therapy, eye movement
  desensitization and reprocessing, and relaxation
  training. Journal of Traumatic Stress 19,19-28.