Transcript Posttraumatic Stress Disorder and Military Veterans

By
Nealy Jenkins, LMSW
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Symptoms of Posttraumatic Stress Disorder
388.81
Rules of Engagement
Statistical Data of Veterans with PTSD
Neurotransmitters
Psychopharmacology and Side Effects
Treatment Models
1.
Reliving the Event
 Memories of the trauma that come back at any time such as
nightmares or going through it again like a flashbacks.
2.
Avoiding situations that remind you of the Event
 Client may try to avoid situations or people that bring back
memories of the event
3.
Feeling Numb
 Client may find it hard to express their feelings and difficulty
remembering or talking about parts of the trauma.
4.
Feeling Keyed Up
 Client may be jittery and on the lookout for danger.
 Client might suddenly become angry or irritable.
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Rules of Engagement (ROE)
1.) The military is a world of constant transition.
2.) Clinician must educate themselves two frequent
transitions: Deployment and Family Separation.
3.) Understand Hierarchical Military Structure.
4.) Important dynamic of the military culture is that
family must do nothing that will negatively impact the
service member’s career.
5.) The stigma is that service members are trained to be
self-reliant and capable; anything else would be to defy
their military training.
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Rules of Engagement Cont.
6.) The military has a mission to accomplish.
Understanding that families are seen as furthering that
mission is of utmost importance.
7.) It helps to know why a service member joins the
military. The reasons for joining may determine
commitment to the military and shed light on family
issues.
8.) Every military family is different. Having a working
knowledge of family transitions, remarried-coupled
issues, and stepfamily issues can be extremely helpful
in working with military families.
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11-20% of Veterans of Iraq and Afghanistan
suffer from PTSD
228, 361 Veterans diagnosed with PTSD
10% of Veterans of Gulf War suffer from PTSD
30% of Vietnam Veterans suffer from PTSD
23% of women reported sexual assault while
serving in military
34% of Veterans reported having been exposed
to dead, dying, or wounded.
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Since initiation of Global War On Terror
(GWOT), 54% of veterans use VA benefits.
 52% is used for Mental Health issues
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The Neuron is the basic functional unit of the
nervous system with primary purpose to receive,
conduct, and transmit signals to the other cells.
Neuronal signals that are transmitted from cell to
cell at specialized sites for contact are called
Synapses.
Within the brain, messages can be transmitted in
two ways: Electrically and Chemically.
A Neurotransmitter is synthesized within the
neuron out of precursors that are brought into the
neuron by outside cells.
Precursors within neuron are broken down to form
the Neurochemical.
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Step 1: Synthesis- Precursors present in the
transmitter site are activated by an enzyme and
become a neurotransmitter.
Step 2: Storage- Once created, neurotransmitters
are stored in vesicles, to be released when
signaled.
Step 3: Release- Neurotransmitters are released
into the synaptic gap.
Step 4: Termination- Transmitters are cleared from
synaptic gaps in three ways:
 Reuptake
 Enzymatic Degradation
 Diffusion
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10 Types of Neurotransmitters
 Dopamine--Psychosis
 Norepinephrine--Depression
 Serotonin—Depression
 Acetylcholine—Dementia (Alzheimer’s Disease and Parkinson’s
Disease)
 GABA—Anxiety
 Glutamate– Dementia (Alzheimer’s Disease and Central
Nervous System)
 Glycine– Depression, Dementia, and Schizophrenia
 Enkephalin– Addictive disorders and Depression
 Beta-endorphin– Addictive disorders
 Dynorphin– Depression and Addictive disorders
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75-90% of general neurotransmitters are Gammaaminobutyric Acid (GABA), Glutamate (Dementia),
and Glycine (Depression).
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Coyle and Enna (1998) stated many
professionals agree that GABA plays a large
part in mental health reaction and has been
identified as essential in exciting reactions and
initiating many of the brain’s chemical
transmissions.
GABA slows down transmissions of nerves
and many of the activities of the brain.
Benzodiazepines enhance the effects of GABA,
in which they reduce activity in the brain and
promote sleep.
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Medication Half-Life is the amount of time it
takes for one half of a drug’s peak plasma level
to be metabolized and excreted from the body.
Medication Potency refers to the relative dose
needed to achieve a certain effect.
Therapeutic Index of a drug is computed by
determining the ratio of the toxic dose of the
drug to its therapeutic dose (Example: Lithium
for Bipolar toxic levels needs be assessed b/c
toxic levels are so close to the therapeutic
levels).
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Xanax (Alprazolam)
 Rapidity of Effect is Intermediate
 Half-Life is Intermediate
 Usual Daily Dosage is 0.5-4mg
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Klonopin (Clonazepam)
 Rapidity of Effect is Intermediate
 Half-Life is Intermediate/Long
 Usual Daily Dosage is 0.5-3mg
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Valium (Diazepam)
 Rapidity of Effect is Rapid
 Half-Life is Long
 Usual Daily Dosage is 5-40mg
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Ativan (Lorazepam)
 Rapidity of Effect is Intermediate
 Half-Life is Intermediate
 Usual Daily Dosage is 1-6mg
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Restoril (Temazepam)
 Rapidity of Effect is Intermediate
 Half-Life is Intermediate
 Usual Daily Dosage is 15-30mg
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Halcion (Triazolam)
 Rapidity of Effect is Intermediate
 Half-Life is Intermediate
 Usual Daily Dosage is 0.125-0.5mg
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Hypotension
Dry Mouth
Upset Stomach
Decreased appetite
Blurred Vision
Depression
Tremors
Irregular Heartbeat
Confusion
Severe skin rash
Fever
Difficulty passing urine
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BuSpar (Buspirone)
 Rapidity of Effect is Slow
 Half-Life is Intermediate
 Daily Dosage is 5-60mg
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Catapres (Clonidine)
 Rapidity of Effect is Rapid
 Half-Life is Long
 Daily Dosage is 0.1-0.4mg
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Tenex (Guanfacine)
 Rapidity of Effect is Slow
 Half-Life is Intermediate
 Daily Dosage is 1-3mg
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Slow pulse rate
Insomnia
Low blood pressure
Dizziness
Contraindication with MAOI medications
(Nardil)
Skin redness
Nausea
Headache
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Because many of these medication are
addictive, start the intervention with
behaviorally based contract for awareness that
the pill is only one facet of a multidimensional
approach to the treatment of his or her anxiety.
Recognize and plan for the potential for
addiction that exists when using these anxiety
medications.
Long-term use at low doses is most appropriate
for individuals who have a long history of
chronic anxiety.
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In clinical depression the client experiences a
lack of desire, coupled with an inability to
perform everyday social and occupational
tasks.
Two Types of Major Depression
1.) Endogenous is related directly to internal biological
factors such as neurotransmitter dysfunction.
2.) Exogenous linked to a precipitating event involving
psychosocial stressors such as divorce, unemployment, or
trauma.
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Prozac (Fluoxetine)
 Daily Dosage is 20-80mg
 It takes 4 weeks or more to get the full benefits of the
drug
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Zoloft (Sertraline)
 Daily Dosage is 5-200mg
 Can be used for anxiety disorders
 Half-Life is much less than Prozac
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Paxil (Paroxetine)
 Daily Dosage is 20-40mg
 Can be used for anxiety disorders
 Half-Life is 12-20 hours
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Celexa (Citalopram)
 Daily Dosage is 20-80mg
 Can be used for Schizophrenia and Dementia
 Can trigger Mania or Suicidal Ideation
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Wellbutrin (Bupropion)
 Daily Dosage is 300-450mg
 It works directly with Dopamine
 It suppresses the appetite
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Remeron (Mirtazapine)
 Daily Dosage is 15-60mg
 Increases Appetite
 Decreases Liver or Kidney function in elderly people
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Dry mouth
Constipation
Decreased appetite
Diarrhea
Insomnia
Fatigue
Runny nose
Dizziness
Loss in sexual ability
Nausea or Vomiting
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Haldol (Haloperidol)
 Daily Dosage is 1-40mg
 Moderately Sedating
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Thorazine (Chlorpromazine)
 Daily Dosage is 400-500mg
 Highly Sedating
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Prolixin (Fluphenazine)
 Daily Dosage is 2-40mg
 Minimal Sedation
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Extrapyramidal Symptoms (EPS), also referred to as
parkinsonism, are common side effects with typical
psychotic medications.
Parkinsonism is similar to the symptoms that are seen
in Parkinson’s disease but the major difference is the
tremors are slow, rhythmic, and rotational, whereas in
EPS in the hands, fingers, and wrists move faster as a
unit.
Three Types of EPS
1.) Dystonia is movement problems as grimacing and difficulty
with speech or swallowing
2.) Akathisia is a extreme form of motor restlessness and may be
mistaken for agitation
3.) Tardive Dyskinesia is involuntary movements to the face
(mouth and tongue), trunk, and limb movements.
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Seroquel (Quetiapine)
 Daily Dosage is 300-400mg
 Used to treat Schizophrenia and involves the action of two
neurotransmitters in the brain: Serotonin and Dopamine.
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Risperdal (Risperidone)
 Daily Dosage is 4-6mg
 It blocks the action of two neurotransmitters: Serotonin and
Dopamine
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Abilify (Aripiprazole)
 Daily Dosage is 10-30mg
 Causes little weight gain, sedation and effect on heart function
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Zyprexa (Olanzapine)
 Daily Dosage is 5-10mg
 Prevents the binding of Dopamine, Serotonin, and Histamine
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Weight gain
Persistent muscle spasms
Tremors
Restlessness
Anxiety
Rapid heart rate
Problems with Menstrual cycle
Urinary Retention
Decreased Sexual Interest
Drowsiness
Restlessness
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Fear is generally the body’s response to real
threat.
Anxiety is an exaggerated response to a threat
that is unclear, unrealistic, or unknown.
The negative aspect of Anxiety is most
problematic when it begins to interfere with an
individual’s ability to work, sleep, or
concentrate.
The person becomes either physically or
psychologically exhausted by constantly
preparing to face his or her unrealistic fears.
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Cognitive Processing Therapy (CPT)
 Theory
 Session
 Four Main Parts
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Prolonged Exposure Therapy (PET)
 Theory
 Session
 Four Main Parts
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Eye Movement Desensitization Reprocessing
(EMDR)
 Theory
 Session
 Four Main Parts
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It’s based on Social Cognitive Theory that focuses on how
the traumatic event is construed and coped with by the
client who is trying to regain a sense of mastery and control
in their life.
The theory behind CPT conceptualizes PTSD as a disorder
of "non-recovery" in which erroneous beliefs about the
causes and consequences of traumatic events produce
strong negative emotions and prevent accurate processing
of the trauma memory and natural emotions emanating
from the event.
Is an adaptation of the evidence-based therapy known as
Cognitive Behavioral Therapy used by clinicians to help
clients explore recovery from PTSD and related conditions.
Consists of 12 sessions and has been shown to be effective in
treating PTSD across a variety of populations, including
combat veterans, sexual assault victims, and refugees.
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Learning about your PTSD symptoms and how
treatment can help.
Becoming aware of your thoughts and feelings.
Learning skills to challenge your thoughts and
feelings (cognitive restructuring).
Understanding the common changes in beliefs that
occur after going through trauma.
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Clinicians use Socratic Dialogue to discuss the details of
the trauma, which helps patients gently challenge their
thinking about their traumatic event and become
increasingly able to consider the context in which the
event occurred, with the goal of decreasing self-blame
and guilt and increasing acceptance.
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Developed by Dr. Edna B. Poa
Form of Behavioral Therapy and Cognitive
Behavioral Therapy designed to treat PTSD
characterized by re-experiencing the traumatic
event through remembering it and engaging
with, rather than avoiding, and reminders of
the trauma.
Theoretically-based and effective treatment for
chronic PTSD or related depression, anxiety,
and anger.
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Education to learn about their symptoms and
how treatment can help.
Breathing Retraining to help client to relax
and manage distress.
Real World Practice (Vivo Exposure) to reduce
distress in safe situations that have been
avoided.
Talking through the Trauma (Imaginal
Exposure) to get control of your thoughts and
feelings about the trauma.
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Studies have shown symptom reduction rates
of between 50%-80% Post-Treatment
Follow-up studies report 75% of patients no
longer meet diagnostic criteria for PTSD 6
months after treatment
None of the patients meet the diagnostic
criteria after 1 year
Involves 8-15 sessions with therapist, plus
practice assignments client will do own their
own.
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In 1987, Dr. Francine Shapiro was walking in the park
when she realized that eye movement appeared to
decrease the negative emotion associated with her own
distressing memories.
Dr. Shapiro assumed that eye movement had a
desensitizing effect, and when she experimented with
this she found that others also had the same response
to eye movements.
Her theory of explaining EMDR is called “Adaptive
Information Processing Model” because all humans
possess an information processing system that
processes experiences and stores these as memories in
a way they are easily assessible and linked to a
network of accompanying images, sensations, and
emotions and beliefs.
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Identification of a target memory, image and belief
about the trauma
Desensitization and reprocessing by focusing on
mental images while doing eye movements that
the therapist has taught the client
Installing positive thoughts and images, once the
negative images are no longer distressing
Body scan by focusing on tension or unusual
sensations in the body, to identify additional issues
you may need to address in later sessions
A course of 4-16 session is common
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Dr. Shapiro conducted a controlled study where randomly
assigned 22 individuals with traumatic memories to two
conditions: half received EMD and half received the same
therapeutic procedure with imagery and detailed
description replacing the eye movement.
Report showed that EMD resulted in significant decreases in
ratings of subjective distress and significant increases in
ratings of confidence in a positive belief.
Participants in the EMD condition reported significantly
larger changes than those in the imagery condition.
Since the initial studies were published in 1989, hundreds of
case studies have been published, and there have been
numerous controlled outcome studies.
These studies have demonstrated EMDR’s effectiveness in
PTSD treatment and EMDR is now recognized as effective in
the treatment of PTSD.
VOLUNTEER FOR PRACTICE
THERAPY SESSION.
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We can see them as sick, with all the stigma,
neediness, and expense that entails, or we can
recognize them as human beings, confronting
the morality of what they’ve done in our name
and what they’ve seen and come to know–
even as they try to move on.
Our challenge as a nation is to insure that our
Warriors know of our concern, care and
commitment to acknowledge, support, and
help heal the invisible moral wounds of
combat.
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Epidemiology Program Post-Deployment
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