Transcript PTSD Simulation - UCF College of Medicine

Global Health Conference 2-1-14:
Introduction to PTSD Simulation Exercise
Martin Klapheke, MD
Professor of Psychiatry
University of Central Florida College of Medicine
Overview: Each Block will last approximately 50 minutes.
 5-10 minute introduction, to define the interviewing students’ task.
 15 minute patient (SP) interview by 1 or 2 students. A “Time Out”
can be called by the primary student interviewer to consult briefly
with the secondary student interviewer. There will be preceptors
available for questions outside the rooms but the students should try
to function independently of them during the interviews.
 5-10 minute feedback from SP to students.
 15 minute debriefing, with students reflecting on their thoughts and
feelings about the experience. Will include a mini-didactic handout
on Trauma from Dr. Klapheke.
Goal for the Interviewing Student(s):
The goal of this exercise is for the student to gain experience
by performing a 15-minute focused interview of a refugee
that has experienced severe trauma.
The student is not necessarily expected to come up with a
complete diagnostic formulation or treatment plan.
Student Task:
1. Obtain a focused (maximum 15 minutes) history from a
refugee who has experienced trauma.
• Include a brief assessment of the impact of culture on the
patient’s presentation.
• Include a brief assessment of the impact of being a refugee
on the patient’s presentation.
• At the end of the interview, you may briefly counsel the
patient regarding their condition and plan of care.
2. Following the interview, complete the post-encounter
review with the Standardized Patient before leaving the room.
3. Then proceed to the Debriefing Room.
Examples for questions regarding the impact of culture on perception of
the cause of the presenting problems and current help-seeking (DSM-5)
o “Why do you think this is happening to you?”
o “What do others in your community think is causing your
problems?”
o “Sometimes people have various ways of dealing with problems
like you are experiencing. What have you done on your own to
cope with it?”
o “Often, people look for help from many different sources,
including different kinds of doctors, helpers, or healers. In the
past, what kinds of treatment, help, advice, or healing have you
sought for your problems?”
o “What kind of help do you think would be most useful to you at
this time?”
o “Are there any kinds of support that make your problem better,
such as support from family, friends, or others?”
o “Are there other kinds of help that your family, friends, or other
people have suggested would be helpful for you now?”
o “Sometimes doctors and patients misunderstand each other
because they come from different backgrounds or have different
expectations. Have you been concerned about this and is there
anything that we can do to provide you with the care you need?”
Examples for questions regarding the impact of Refugee status on the
presenting problems and current help-seeking (DSM-5)
o “Some people experience hardship, persecution, or even
violence before leaving their country of origin. Has this
been the case for you or members of your family? Can you
tell me something about your experiences?”
o “Of the persons important or close to you, who stayed
behind?”
o “Were there any challenges on your journey to the United
States that you or your family found especially difficult?”
o “Do you or your family miss anything about your way of life
in Syria?”
o “Do you have concerns about relatives that remain in your
home country?”
o “Are there any other challenges or problems you or others
in your family are facing related to your resettlement
here?”
o “Has coming to the United States resulted in something
positive for you or your family?”
o “What hopes and plans do you have for you and your
family in the coming years?”
Exposure to trauma (or learning about violent or accidental
event involving someone close) involving threat of death, serious
injury, or sexual violation, to self or others; can also occur with
repeated extreme exposure to aversive details of the trauma.
Leads to 9 or more of:
 Intrusion symptoms: intrusive memories; distressing dreams;
flashbacks (with most extreme being with complete loss of
awareness of current surroundings); marked distress in
response to external cues symbolizing the trauma.
 Negative mood: inability to experience positive emotions.
 Dissociative symptoms: altered sense of oneself or
surroundings (e.g., “in a daze”; derealization;
depersonalization); inability to recall an important aspect of
the trauma.
 Avoidance of the distressing memories/feelings and/or of
external reminders of the trauma.
 Arousal: sleep disturbance; irritability/angry outbursts; poor
concentration; hypervigilance; exaggerated startle response.
Duration is 3 days to 1 month.
Prevalence varies with nature and context of the
trauma:
 Typically in < 20% of cases involving trauma
without interpersonal assault (e.g., 13-21%
following MVA)
 Typically in 20-50% of cases involving
interpersonal trauma (e.g., rape, mass shooting).
Risk factors: prior trauma or prior mental disorder,
greater perceived severity of the trauma, and an
avoidant coping style; females at greater risk than
men (?neurobiological differences, ?greater
exposure to some forms of trauma).
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ASD lasts 3 days to 1 month; PTSD lasts > 1
month and may have dissociative symptoms but
these are usually not as prominent in PTSD.
Most patients with ASD do not go on to develop
PTSD, but those whose ASD trauma involves
brain injury may be somewhat more likely to
develop PTSD (Bryant et. al. J Clin Psychiatry June 2008)

PTSD develops in approximately 14% of those
exposed to trauma; studies suggest marked
human resilience in that most individuals do not
develop psychological problems after trauma.

DO NO HARM. Some studies suggest “critical
immediate stress debriefing” does NOT appear
helpful and may actually worsen outcome.
Any intervention should be tailored to the individual’s
needs. “People cope with stress in different ways, and no
formal intervention should be mandated for all exposed
to trauma”.
 The efficacy of “Psychological first aid”—compassion and
support to distress & facilitate access to further care if
needed—needs further study. But for now Bisson et. al.
recommend:
 1st step: empathically provide practical, pragmatic
support, to complement social support.
 Educate the person about the range of individual
responses to trauma including people’s natural
resilience, positive coping strategies, and how to access
social support and, if needed, treatment (see below).

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Do not push patient into treatment unless they
want it: match the intervention to the individual
patient.
Utilize support system: social connectedness can
buffer traumatic stress
Teach positive coping and resilience
If the patient has distressing symptoms:
 Prolonged Exposure therapy or Cognitive therapy
can effectively prevent chronic PTSD in patients
with full acute PTSD criteria (except for the 1-month duration

criterion; treatment began a mean of 5.7 days with SD 29.8 days after the trauma) (Shalev et. al.
Arch Gen Psychiatry 2012;69:166-176).
 Data
do NOT suggest benzodiazepines are
helpful (possible  in dissociation??).
 Post-trauma symptoms tend to subside if the
patient does not avoid thoughts & feelings about
the trauma, i.e. it is the avoidance that make us
ill.
Posttraumatic Stress Disorder (PTSD)
DSM-5
Exposure to trauma (or learning about violent or accidental event involving someone
close) involving threat of death, serious injury, or sexual violation, to self or others; can
also occur with repeated extreme exposure to aversive details of the trauma. Leads to:
• Intrusion symptoms: intrusive memories; distressing dreams; flashbacks (with most
extreme being with complete loss of awareness of current surroundings); marked
psychological—and/or physiological—distress in response to external cues
symbolizing the trauma.
• Avoidance of the distressing memories/feelings and/or of external reminders of the
trauma.
• Negative cognitions and mood: inability to recall an important aspect of the trauma;
exaggerated negative views of self, others, or the world; distorted blame of self or
others for the trauma; persistent negative emotional state (e.g., anger, shame);
marked decreased interest or participation in activities; detachment/estrangement
from others; inability to experience positive emotions.
• Arousal: sleep disturbance; irritability/angry outbursts; poor concentration;
hypervigilance; exaggerated startle response; reckless or self-destructive behavior.
Duration is > 1 month.
May have dissociative symptoms: derealization or depersonalization.
The criteria are modified for children 6 years old and younger.
Epidemiology & Features of PTSD Black & Andreasen; Kaplan & Sadock; DSM-5
• Lifetime prevalence: 7-8%. However, most persons exposed to
trauma do NOT develop PTSD.
• May be especially severe or long-lasting with interpersonal and
intentional trauma.
• Trauma, e.g., childhood abuse, increases suicide risk.
• May have paranoid ideation and auditory pseudo-hallucinations
(hearing one’s thoughts spoken in 1 or more different voices).
• For men, combat is the most frequent trauma; for women, it is
physical assault or rape. Can begin soon after the trauma or
months/years later.
• PTSD resolves within 3 months in about 50% of adults, but can be
chronic, with waxing/waning especially with stresses.
• Comorbidities: major depression, anxiety disorders, substance abuse,
TBI (48% co-occurrence of PTSD and mild TBI in recent combat
veterans).
Epidemiology & Features of PTSD Black & Andreasen; Kaplan & Sadock; DSM-5
• Risk factors:
 History of prior trauma or emotional problems
 Female gender (appears in part due to greater exposure to some forms
of trauma).
 severity of the trauma;
 Persistent dissociation symptoms;
 Acute Stress Disorder;
 Imaging: Hippocampal volume and metabolic activity in limbic
regions especially the amygdala
• Social support prior to trauma is PROTECTIVE, and
following trauma it moderates outcome
Education of patient, and Positive coping after trauma
2012 AADPRT Brain Conference
• Excellent resource for patients, families, professionals:
http://www.ptsd.va.gov/
• Free download of Mobile App: PTSD Coach to help manage
symptoms:
http://www.ptsd.va.gov/public/pages/ptsdcoach.asp
• Educate patient that it is “normal” to react strongly to
trauma; one need not fear intense affect, as it should
dissipate with time. However, if intense affect does not
begin to dissipate by 3 months, seek treatment (next slide).
• Positive coping: Mobilize social support; Exercise;
Relaxation; Pleasureable activities; Sleep hygiene
Treatment of PTSD
Black & Andreasen; and Treatment Guidelines from The Medical Letter 2006;4:39-40; and
2012 AADPRT Brain Conference
Psychotherapy:
• Cognitive Processing Therapy is effective: see website
http://cpt.musc.edu
• Prolonged Exposure therapy is effective
Pharmacotherapy:
• Generally treated with an SSRI (re-experiencing symptoms such as
nightmares & flashbacks, hyperarousal and improve sleep,
avoidance/numbing symptoms): Sertraline, Paroxetine
• Venlafaxine also appears effective
• TCAs, MAOIs
• Alpha 1-adrenergic antagonist prazosin may intractable nightmares,
reexperiencing & hyperarousal symptoms
• Use of benzodiazepines controversial due to possible dissociation
and potential for dependence
• May need adjunctive antipsychotic, but try to keep any such use
short-term.