Posttraumatic Stress Disorder in Women Veterans

1
Posttraumatic Stress Disorder in Women Veterans

• Kathleen M. Chard, PhD
• Director, PTSD and Anxiety Disorders Division
• Cincinnati VA Medical Center
• Associate Professor of Clinical Psychiatry
• University of Cincinnati

2
Women in the Military

• Women account for 1.7 million of the nation's
  veterans
• Approximately 350,000 women (almost 15 percent)
  are actively serving in the U.S. military
• 400,000 women served in World War II, 50,000
  served in Korea, 265,000 served in Vietnam and
  33,000 served in the Gulf War
• One in every seven troops in Iraq is a woman
• Female veteran population is projected to
  increase an additional 72,000 between 2000 and
  2020

3
Stress and Trauma

• Many women experience psychological distress
  during and after their service time.
• Females report experiencing PTSD at higher rates
  then men, and there is a higher prevalence of
  sexual assault and harassment experiences in
  women veterans
• Active duty women report higher levels of sexual
  assault than comparable civilian samples of
  women.
• Unfortunately, women use their earned benefits at
  far lower rates than their male counterparts

4
PTSD

• National study of American civilians conducted in
  1995 estimated lifetime prevalence of PTSD was 5
  men and 10 women.
• Most people who are exposed to a traumatic event
  experience symptoms in the days/weeks following
  exposure.
• Data suggest that about 8 men and 20 women
  develop PTSD, and roughly 30 of these develop a
  chronic disorder.
• About 20-30 percent of the men/women who have
  spent time in combat experience PTSD
• 7.8 percent of Americans will experience PTSD at
  some point in their lives

5
PTSD DSM IV Diagnosis

• What is the DSM?
• Common language for health care providers
• List of symptoms
• do not have to have ALL symptoms
• Anxiety Disorders Family
• PTSD
• Generalized Anxiety Disorder
• Panic Disorder
• Phobic Disorders

6
PTSD

• a traumatic event was conceptualized as a
  catastrophic stressor that was outside the range
  of usual human experience

• Emotional reaction
• Helplessness
• Horror
• Intense fear
• Shock

7
PTSD - Trauma

• the person has experienced, witnessed, or been
  confronted with an event or events that are
  outside the range of usual human experience and
  involve

• Actual or Threatened
• death or serious injury, or a
• threat to the physical integrity
• of oneself or others.

8
People can get PTSD from

• Combat
• Violent personal assault rape, mugging, physical
  assault
• Kidnapping
• POW and Concentration Camp survivors

• Terrorist Attacks
• Airplane Crashes
• Severe Auto Accidents
• Torture
• Natural Disaster
• Fires
• Hostage situations etc.

9
Lets start with the current criteria for PTSD

• A Stressor Criterion
• B Reexperiencing
• C Avoidance
• D Arousal
• E Time Criterion
• F Functional Impairment or Distress

9
10
Current criteria for PTSD
Avoidance
Reexperiencing
Flashbacks
Distressing recollections
Dreams
Physiological reactivity
1
3
Psychological distress w/ reminders
PTSD
2
P T S D
ost
raumatic
Sleep difficulties
Hypervigilance
tress
Irritability anger
Startle
isorder
Arousal
Concentration
11
PTSD is not a Static Process
12
In those who develop pathology, strong negative
affect leads to escape or avoidance
aggression self-harm behaviors substance
abuse binging cognitive avoidance behavioral
avoidance dissociation anhedonia/numbing social
withdrawal behavioral inhibition
Intrusions
Negative Affect/ Hyperarousal
Cognitions
Escape/ Avoidance
13
Treatment of PTSD
aggression self-harm behaviors substance
abuse binging cognitive avoidance behavioral
avoidance dissociation anhedonia/numbing social
withdrawal behavioral inhibition
Intrusions
Negative Affect/ Hyperarousal
Cognitions
Escape/ Avoidance
Core Symptom Clusters
14
1. Prevent Avoidance
aggression self-harm behaviors substance
abuse binging cognitive avoidance behavioral
avoidance dissociation anhedonia/numbing social
withdrawal behavioral inhibition
Intrusions
Negative Affect/ Hyperarousal
Cognitions
Core Symptom Clusters
Escape/Avoidance
15
2. Intervene with one or more of core symptom
clusters
MEDs
aggression self-harm behaviors substance
abuse binging cognitive avoidance behavioral
avoidance dissociation anhedonia/numbing social
withdrawal behavioral inhibition
NR
PE
Intrusions
Negative Affect/ Hyperarousal
Cognitions
Escape/ Avoidance
CT
CPT
16
Treatment Options for PTSD
17
Practice Guidelines for the Treatment of PTSD

• Expert Consensus Guideline Series (JCP, 1999)
• APA Practice Guideline
• Practice Guidelines from ISTSS
• United Kingdoms National Center of Clinical
  Excellence (NICE)
• VA/DoD Clinical Practice Guidelines
• Institute of Medicine Report

18
Evidenced Based Treatments

• VA/DoD Clinical Practice Guidelines for
  Behavioral Interventions
• Exposure Therapy, Cognitive Therapy -1st line
• EMDR, Stress Inoculation Training
• Imagery Rehearsal Therapy, Psychodynamic Therapy,
  Seeking Safety
• PTSD Psychoeducation
• Adjunctive Treatments
• Dialectical Behavior Therapy (DBT)

19
Medication

• Studies have also shown that medications help
  ease associated symptoms of depression and
  anxiety and help with sleep. The most widely used
  drug treatments for PTSD are the selective
  serotonin reuptake inhibitors (SSRIs), such as
  Prozac and Zoloft, which are approved by the FDA
  for PTSD. At present, cognitive-behavioral
  therapy appears to be somewhat more effective
  than drug therapy. However, it would be premature
  to conclude that drug therapy is less effective
  overall since drug trials for PTSD are at a very
  early stage. Drug therapy appears to be highly
  effective for some individuals and is helpful for
  many more. In addition, the recent findings on
  the biological changes associated with PTSD have
  spurred new research into drugs that target these
  biological changes.
• www.ncptsd.va.gov

20
Benzodiazapines

• The use of benzodiazepines shows no significant
  improvement when compared to no pharmacotherapy.
• While benzodiazepines are theorized to inhibit
  memory acquisition, the effect is anterograde.
  After trauma, benzodiazepines have been shown to
  interfere with adaptation, reappraisal and
  learning which could be helpful in recovery.
• The research suggests that some patients may feel
  relief with a short course of benzodiazepines but
  ongoing use is not supported.
• www.ncptsd.va.gov
• Gelpin, et al (1996). "Treatment of recent trauma
  survivors with benzodiazepines a prospective
  study," J Clin Psych 57.

21
Research on CPT/PE

• There have been many randomized clinical trials
  of PE and CPT and several effectiveness studies.
• See the manuals for the exact references.
• The treatments have been shown to be effective
  with child abuse, rape, combat, and assault.

22
What does treatment entail?

• Assessment (CAPS/PCL)
• Group or individual
• Education/Coping Skills building
• Understanding the connection between thoughts,
  feelings and behavior
• Intensive (9-20 sessions)
• Challenging distorted cognitions
• Family therapy
• Follow-up assessment

23
Residential Treatment

• 10 bed women/12 bed men, 7 week program
• 10 bed mTBI/PTSD, 9 week program
• All Eras, traumas admitted, including CSA only
• Pain and methadone pts admitted
• Active participation is mandatory
• 12 sessions of individual and group w/in 7 weeks.
  More individual sessions for CSA or as needed.
• Groups anger, communication, distress tolerance,
  life skills, interpersonal effectiveness,
  mindfulness, relaxation, sleep, etc (25
  hours/week)

24
Issues faced when treating veterans with PTSD
25
General Issues

• A majority have substance abuse issues that are
  either current or in recovery
• Most have at least one other mental health
  condition
• Many smoke
• Veterans often facing medical problems as well,
  e.g. TBI, pain, injury

26
Updated Roster of OEF and OIF Veterans Who Have
Left Active Duty

• 868,717 OEF and OIF veterans who have left
  active duty and become eligible for VA health
  care since FY 2002
• 50 (437,873) Former Active Duty troops
• 50 (430,844) Reserve and National Guard
  
• VHA Office of Public Health and Environmental
  HazardsAugust 2008

27
Demographic Characteristics of OEF and OIF
Veterans Utilizing VA Health Care

• OEF/OIF
  Veterans
• 
  (n 347,750)
• Sex
• Male
  88
• Female 12
  
• Age Group
• lt20 7
  
• 20-29 51
  
• 30-39 23
  
• 40 18
  
• Branch
• Air Force
  12
• Army 64
  
• Marine 13
  
• Navy
  11
• Unit Type
• Active 52
  
• Reserve/Guard 48
  
• Rank

28
Frequency of Possible Diagnoses Among OEF and OIF
Veterans

• Diagnosis (n 347,750)
• (Broad ICD-9 Categories)
  
  Frequency
•  
• Infectious and Parasitic Diseases (001-139)
  40,956 11.8
• Malignant Neoplasms (140-208)
  3,248 0.9
• Benign Neoplasms (210-239)
  13,910
  4.0
• Diseases of Endocrine/Nutritional/ Metabolic
  Systems (240-279)
  75,850 21.8
• Diseases of Blood and Blood Forming Organs
  (280-289) 7,675
  2.2
• Mental Disorders (290-319)
  
  147,744 42.5
• Diseases of Nervous System/ Sense Organs
  (320-389)
  121,473 34.9
• Diseases of Circulatory System (390-459)
  
  56,900 16.4
• Disease of Respiratory System (460-519)
  
  71,087 20.4
• Disease of Digestive System (520-579)
  
  110,449 31.8
• Diseases of Genitourinary System (580-629)
  
  37,118 10.7
• Diseases of Skin (680-709) 55,797
  16.0
• Diseases of Musculoskeletal System/Connective
  System (710-739) 165,439
  47.6
• Symptoms, Signs and Ill Defined Conditions
  (780-799)
  138,043 39.7
• Injury/Poisonings (800-999)
  
  73,767 21.2
•  

29
OEF/OIF Veteran Issues

• Younger do not feel understood by VA or other
  veterans
• Job/Family Responsibilities
• Motivated
• Self Medicating alcohol use
• Family responsibilities
• Prolonged Exposure, CT or CPT can all be options

30
The VA and PTSD today

• Congress created the National PTSD Centers with 5
  sites across the US
• Research, education and treatment are the goals
  of the centers
• Efficacy-based/ACTIVE treatment is to be
  emphasized at all VAs
• Assessment before and after treatment

31
Where do we go from here PTSD?

• Implementation of efficacy-based treatments (CPT
  and PE) throughout VA
• Mentor Program
• Evidence Based Practice Coordinators
• Training clinicians in the armed forces as well
  to ease transition

32
Where do we go from here Women?

• More women only groups and treatment programs
• More focus on each person as an individual with
  individualized treatment
• More staff training in MST and child abuse
• More décor that is woman friendly
• More education on womens issues, e.g.
  parenting, health, relationships and communication