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PTSD IN CHILDREN

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PTSD IN CHILDREN Powered By Docstoc
					PROJECT
PRACTICAL FRONT LINE ASSISTANCE & SUPPORT FOR HEALING

FUNDED AND SUPPORTED BY…

INTRODUCTIONS
Please introduce yourself to the group

What are the clinical issues you face?
What are your clinical needs? What do you want to learn today?

MAJOR SECTIONS OF PRESENTATION
SECTION 1:

Mental health assessment
SECTION 2:

Triage and treatment
YOUR ISSUES

Culture, boundaries, burnout

SECTION 1
MENTAL HEALTH ASSESSMENT
What we know
- to provide informed direction

Progression of decisions

DISASTER TRAUMA IS UNIQUE
Individual characteristics determine personal risk for exposure to most traumatic events
- Mental health outcomes of events can be difficult to separate from pre-existing personal characteristics that put people at risk for events

Disasters are "equal opportunity" events
- They tend to select people randomly, without regard for pre-existing characteristics

CAUSALITY AND RELATIONSHIPS
 Association does not necessarily imply

causation or causal directionality

pre-existing INAPPROPRIATE ASSUMPTION OF CAUSATION personal FROM MERE ASSOCIATION factors

C

"…after the fact,mental health event therefore because of the fact…" outcome

A

B

DISASTER TRAUMA IS UNIQUE

Some of what is known about PTSD in other settings does not apply to disaster

LIFETIME PREVALENCE OF PSYCHIATRIC DISORDERS: NATIONAL COMORBIDITY STUDY
Adapted from Kessler et al. 1994, 1995
25 20 % of population 15

SUBSTANCE USE DISORDERS

MOOD DISORDERS

10
5 0

ANXIETY DISORDERS

COMPREHENSIVE MODEL OF CATASTROPHIC EVENTS
EVENT OUTCOME Acute………..long term Psychiatric effects CAUSAL AGENT CHARACTERISTICS Type: symptoms/diagnosis:  natural  PTSD  technological accident  willful human act (terrorism)  major depression Severity:  anxiety disorders  scope & intensity (deaths, injuries, damage)  terror/horror  substance abuse  abruptness (sudden, unexpected, unprepared) Growth/restabilization  duration (acute, chronic) Lifestyle changes Subjective assessment
CAUSAL AGENT CHARACTERISTICS Type:  natural  technological accident  willful human act (terrorism) Severity:  scope & intensity (deaths, injuries, damage)  terror/horror  abruptness (sudden, unexpected, unprepared)  duration (acute, chronic) POST-TRAUMATIC COGNITIVE PROCESSING Intrusion vs. avoidance (recall) (numbing) Active vs. passive Making meaning Coping techniques COMMUNITY FACTORS Social networks, community cohesion Resources & outreach Demographics Attitudes:  dissensus & conflict  ambiguous & confusing definitions  attribution of blame Societal preparedness & experience SECONDARY SEQUELAE Bereavement Displacement Injury/illness Loss of job Marital/social conflict Loss of social support Financial loss Legal sequelae Loss of time INDIVIDUAL CHARACTERISTICS Degree of exposure:  direct/indirect, duration Demographic:  sex  age  ethnicity  marital  education, SES Personal:  interpersonal support  experience, other life events  resources & utilization Psychiatric:  psychiatric history  personality

EVENT OUTCOME Acute………..long term Psychiatric effects symptoms/diagnosis:  PTSD  major depression  anxiety disorders  substance abuse Growth/restabilization Lifestyle changes Subjective assessment

GATEKEEPER: PERCEPTION

KEY

direct effects confounders & interactions

PART 1: MENTAL HEALTH ASSESSMENT

Assessment is necessary before treatment can begin. This is because…
ONE SIZE DOES NOT FIT ALL. Do NOT attempt treatment until you know what you are dealing with.

STEP 1: ASSESS FOR PTSD WHY?  PTSD is the most common post-disaster
disorder, and most people dealing with any disorder are dealing with PTSD When asked why he robbed banks, the notorious bank robber Willie Sutton replied: Because that's where the money is! Optimize your efficiency: screen for the most likely disorder first

HOW DO YOU DIAGNOSE PTSD?
Not with a questionnaire, but the old fashioned way…by taking a history to determine if DSM-IV-TR diagnostic criteria are met (see checklist in handouts)

NEED TO MEET ALL 6 CRITERIA: A, B, C, D, E, AND F

DSM-IV-TR CRITERIA FOR PTSD
(adapted from American Psychiatric Association's DSM-IV criteria, 1994)

A sudden, unexpected traumatic event: 1. With threat to life or limb 2. Evoking fear, helplessness, or horror Qualifying exposures: 1. Direct exposure 2. Indirect through a loved one's exposure 3. Witnessing from a safe distance

A. "STRESSOR A CRITERION"

DSM-IV-TR CRITERIA FOR PTSD
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

1 or more of the following related to the event:  Intrusive memories of event  Dreams / nightmares of event  Flashbacks to event  Upset by reminders of event  Physiologic reactivity to reminders of event
(racing heart, tremors, sweating)

B. INTRUSIVE RE-EXPERIENCE

DSM-IV-TR CRITERIA FOR PTSD
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

C. AVOIDANCE AND NUMBING
3 or more of the following NEW symptoms post-event:  Avoids thoughts / feelings  Avoids reminders  Event amnesia  Loss of interest  Detachment / estrangement  Restricted range of affect  Sense of foreshortened future

DSM-IV-TR CRITERIA FOR PTSD
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

D. HYPERAROUSAL
2 or more of the following NEW symptoms post-event:  Insomnia B, C, & D symptoms must be new after the event to  Irritability / anger qualify; existing symptoms  Poor concentration such as sleep problems in the population are not  Hypervigilance counted & will yield inflated estimates of PTSD  Exaggerated startle
rates

DSM-IV-TR CRITERIA FOR PTSD
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

ADDITIONAL CRITERIA
E. Duration more than one month F. Clinically significant distress - or impaired functioning
Note: Delayed onset > 6 months Chronic > 3 months

DSM-IV-TR CRITERIA FOR PTSD
NOTE
Most popular questionnaires do not:  consider the Stressor A criterion  separate new from pre-existing symptoms  require the one month duration  assess for clinically significant distress or impaired functioning These omissions all contribute to inflation of the diagnosis of PTSD.

PTSD PREVALENCE
POST-DISASTER ASSESSMENTS USING CONSISTENT METHODS
50

% with PTSD

40 30
20 10 0

WHAT ABOUT THE FIRST MONTH?
(BEFORE YOU CAN DIAGNOSE PTSD)
Acute stress disorder - questionable validity - clinical utility: diagnostic code to bill for services
Group C symptoms - avoidance & numbing - marker / identifier for PTSD

ASSESSMENT FLOW CHART
STEP 1: ASSESS FOR PTSD
 Avoids reminders DSM-IV-TR (+) 3 or more: PTSD / feelings  Avoids thoughts

Traumatic event

 Event amnesia  Loss SCREEN Diagnose of interest  Detached / isolated PTSD Group C?  Restricted affect DSM-IV-TR (-)  Sense of short future

EVIDENCE???

NO

no PTSD

TEMPLATE:
THE OKLAHOMA CITY BOMBING… LOOKING FORWARD FROM PAST EXPERIENCE

Interviews of 182 directly exposed bombing survivors at 6 months and a year later
North et al, JAMA 282:755-62, 1999

APPARENT DIFFERENCES

Scope & magnitude
Fatalities, bereavement Injuries

Nation's nerve center

National symbols

Act of war Continuing threats

ALTHOUGH OKLAHOMA CITY IS NOT NEW YORK CITY,

AND THERE ARE IMPORTANT DIFFERENCES,
USEFUL PRINCIPLES HAVE EMERGED FROM THIS WORK.

RELEVANCE OF THE OKC BOMBING
 Prior to September 11, 2001, the Oklahoma City bombing
was the largest act of terrorism ever on American soil

 The OKC bombing study provided new insights and

direction for assessment and management of PTSD and other psychiatric disorders. Extensive follow-up data validated the findings of the baseline study

 The OKC bombing experience provides a clinical road map
for future disasters like 9/11 or elsewhere…although the findings may need amendment with future experience

PREDICTORS OF PSYCHIATRIC PROBLEMS
 Female: twice the rates of PTSD & depression as males  Male: much higher rates of alcohol & drug use disorders  Greater exposure (proximity, injuries, losses)  Other negative life events  Pre-existing characteristics - Pre-existing psychopathology - risk for PTSD & depression - Prior trauma - confounded with other pre-event variables
(family background, pre-existing substance abuse & mental illness, socioeconomic status)

MENTAL HEALTH EFFECTS BY EXPOSURE LEVEL IN POPULATIONS
 The most severe mental health responses occur in the most highly exposed groups
- ripple effects fade with travel outward from epicenter

 Pre-existing psychopathology predicts PTSD particularly in the less exposed groups
 In the most highly exposed groups, the intensity of the exposure overwhelms the effects of pre-existing psychopathology

INDIVIDUAL PTSD SYMPTOMS
Oklahoma City Bombing (N=182) North et al 1999
Intrusive memories Dreams/nightmares Flashbacks Upset by reminders Avoidance of thoughts and feelings Avoidance of reminders Psychogenic amnesia Loss of interest Detachment/estrangement Restricted range of affect Sense of foreshortened future Insomnia Irritability/anger Difficulty concentrating Hypervigilance Jumpy/easily startled Physiologic reactivity to stimulus

Group B
(intrusive re-experience)

Group C
(avoidance/numbing)

Group D
(hyperarousal)

0

10

20

30 40 50 60 70 80 % of subjects reporting symptom

90

100

PTSD SYMPTOM GROUPS
Oklahoma City Bombing (N=182) North et al 1999
Group B Intrusive re-experience Group C Avoidance/numbing Group D Hyperarousal 36%

79%

94%
34% 0 10 20 30 40 50 60 70 80

82%

Groups B, C, and D

PTSD

90

100

% of subjects meeting criteria

INDICATORS OF ILLNESS BY PTSD SYMPTOM GROUPS OKC BOMBING (N=182)
Group B
without Group C

Group C
Avoidance & numbing

Group D
without Group C

Intrusive re-experience

Hypervigilance

Pre-disaster diagnosis Comorbid post-disaster diagnosis Received treatment Took medication Drank alcohol to cope Symptoms interfered with activities Work performance problems
(self report)

-

+ + + + + + + +

+/-

AVOIDANCE & NUMBING (GROUP C PROFILE) Indicator of illness:
Identifier / marker for PTSD (virtually defines it) Improvement in C symptoms parallels recovery Groups B & D without C are common, nonpathological responses

CASE VIGNETTES

Janel, a 27 year old receptionist in a law firm across the street
from the World Trade Center site, was referred to you by her family doctor two weeks post-9/11. As she was evacuating the area a police officer had told her, "Just keep walking and don't look back." Concerned, she turned around to see what he was talking about. She saw what she thought was debris falling until she was able to make out that it was not just debris, but also people falling. She now becomes panicky whenever she hears planes overhead and begins to sweat, shake, and look for things to hide under. Sirens upset her, reminding her of September 11. Even sounds that aren't all that loud make her jumpy. She can't sleep for more than an hour at a time before she wakes up in a sweat. She has never felt like this before.

Carmen is a 38-year-old copywriter at an advertising
agency who is 6 months pregnant, now referred to you by her obstetrician after she requested medication for sleep and for nerves. At the time of the attacks three months ago, she was employed on the 46th floor of the South tower. She escaped the building with only minor cuts and abrasions and did not lose anyone personally close to her. She did, however, witness several people jumping from the burning towers and saw both buildings collapse, memories that continue to bother her intensely. She has lost interest in all her old hobbies and can't concentrate on her work.

STEP 2: ASSESS FOR COMORBIDITY

WHY?  comorbidity with PTSD is more

likely than not  cormorbid disorders may be at least as important as PTSD for treatment and outcome

Remember to assess pre-existing disorders as well as post-event cormorbidity

ASSESSMENT FLOW CHART
STEP 2: ASSESS FOR OTHER DISORDERS
PTSD
DSM-IV-TR (+)

Other diagnosis?

PTSD "plus"
PTSD only

Traumatic SCREEN Diagnose event Group C? PTSD
NO

DSM-IV-TR (-)

EVIDENCE???

no PTSD

POST-DISASTER PSYCHIATRIC DIAGNOSES
Oklahoma City Bombing (N=182)
Non-PTSD diagnosis only 9% North et al 1999 No diagnosis 55%

PTSD 36%

POST-DISASTER PSYCHIATRIC DIAGNOSES
Oklahoma City Bombing (N=182)
Non-PTSD diagnosis only 9% North et al 1999 No diagnosis 55%

Bombing-specific PTSD 34%

Other PTSD 2%

POST-DISASTER PSYCHIATRIC DIAGNOSES
Oklahoma City Bombing (N=182)
Non-PTSD diagnosis only 9% North et al 1999

No diagnosis 55%

PTSD and comorbid disorder 21%

Other PTSD 2%

Bombing-specific PTSD only 13%

DON'T STOP WITH PTSD!
 Post-disaster comorbidity is typical & important
 In Oklahoma City, of those with PTSD, other post-disaster

diagnoses were also present (whether or not they pre-existed): Major depression 55% Personality disorder 33% Panic or generalized anxiety disorder 29% Alcohol abuse/dependence 13%

Note: personality disorder begins early in life and probably existed before the event. If one has a borderline client in the post-disaster setting, then one can conclude that one now has a (newly traumatized) borderline client.

PREMORBIDITY
(AS OPPOSED TO COMORBIDITY)

 Look for pre-existing disorders
 Pre-existing major depression - high recurrence  Drug / alcohol disorders - pre-existing (not new)

RATES OF POST-DISASTER DISORDERS AND PRE-DISASTER HISTORY OF DISORDER
Oklahoma City Bombing (N=182)
50
45% Post-disaster Dx only (incident/new Dx)

40
34%

% with diagnosis

30
23%

No new (incident) cases

Pre-disaster Dx with post-disaster Dx (persistent/recurrent Dx)
30%

20
9% 7%

10
4%

2%

0

PTSD Major Panic GAD Alcohol use Drug use depression disorder disorder disorder

Non- Any Dx PTSD Dx

RESCUE WORKERS
181 OCFD workers assessed 1-3 years post-bombing*:

 Post-disaster: 13% PTSD 8% major depression

*North et al, 2002a, 2002b

 Alcohol abuse/dependence: 24% post-disaster virtually all pre-existing 46% lifetime  Compare with firefighters NOT disaster-exposed: Wagner et al (1998) - 19% current alcohol / drug abuse Boxer & Wild (1993) - 29% current alcohol abuse

HOW DO YOU DIAGNOSE MAJOR DEPRESSION?
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

Qualifying symptoms of depression must: occur daily or almost daily

last for at least 2 weeks (otherwise it's just a mood) represent a change from the person's usual state include either or both:
1. Depressed mood 2. Loss of interest or pleasure

DIAGNOSIS OF MAJOR DEPRESSION
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

Requires at least 5 of 9 symptoms below within a single episode:
1. Depressed mood most of the day 2. Loss of interest or pleasure in most activities 3. Significant gain (or loss) of weight or appetite 4. Sleeping too much or too little 5. Physical agitation or retardation 6. Fatigue / low energy 7. Feeling worthless or excessively guilty 8. Inability to concentrate or make decisions 9. Preoccupation with death or suicide

DIAGNOSIS OF MAJOR DEPRESSION
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

NOTE: To qualify, the symptoms must:

cause significant distress or loss of function NOT be due to:
 alcohol or drugs  medical problems  normal bereavement
(see checklist in handouts)

MAJOR DEPRESSION: RELEVANCE
 Especially high likelihood of recurrence of

pre-existing major depression after disasters
depression

 Suicide: 15% lifetime prevalence in major  No demonstrated increase in suicide after

disasters

(suicide occurs in 1 of 100 deaths in general population)

BEREAVEMENT AND TRAUMATIC GRIEF

 Bereavement is a normal process that may be a focus
of clinical attention; traumatic grief is complicated

 Bereavement may complicate recovery from traumatic
events, and traumatic circumstances may complicate the grief process share common features with, psychiatric disorders, most notably major depression and PTSD

 Bereavement and traumatic grief are distinct from, but

DIAGNOSIS OF ALCOHOL / DRUG ABUSE

Maladaptive pattern of alcohol / drug use

(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

 resulting in clinical distress or impairment  and any of the following within a 12-month period:

1) Recurrent failure of role obligations (work, school, home) 2) Recurrent use in physically hazardous situations

3) Recurrent substance-related legal problems 4) Continues despite persistent or severe consequences

DIAGNOSIS OF ALCOHOL / DRUG DEPENDENCE
(adapted from American Psychiatric Association's DSM-IV-TR criteria, 2000)

Maladaptive pattern of alcohol / drug use - resulting in clinical
 Tolerance (dose escalation; decreased effect)  Withdrawal (or using substance to prevent it)  Use in larger amounts or longer than intended  Repeated efforts to control or reduce use  Much time spent to obtain & use substance  Gives up important activities to use  Use continues despite awareness of serious
physical or psychological consequences

distress or impairment and 3 of the following within a 12-month period:

ASSESSMENT FLOW CHART
STEP 2: ASSESS FOR OTHER DISORDERS
Other diagnosis?

PTSD
DSM-IV-TR (+)

PTSD "plus"
PTSD only Non-PTSD disorder Subdiagnostic distress

Traumatic SCREEN event
NO

Diagnose PTSD Group C? DSM-IV-TR (-)

no PTSD

NON-PTSD DISORDERS ONLY
Non-PTSD diagnosis only 9%

No diagnosis 55%

Not common

PTSD and comorbid disorder 21%

PTSD only 13%

Other PTSD 2%

 9% of the OKC sample  but not to be overlooked

DISORDER VS. DISTRESS
Psychiatric diagnosis: not just a label
- Necessary for selecting appropriate interventions (parallel example: chest pain) - Identifies need for psychiatric evaluation/ treatment

Subdiagnostic distress:
- Important: deserves recognition and intervention (just because it's not PTSD doesn't mean it's not significant)

SUBDIAGNOSTIC DISTRESS
Virtually everyone has upset / distress
- especially with most severe events - more effects with more intense exposure
EVIDENCE:

Oklahoma City bombing - directly exposed survivors: 81% described themselves as "very upset" 96% acknowledged at least one PTSD symptom

NORMAL REACTIONS
Most people react: - >2/3 of the nation was symptomatic post-9/11 - Statistically normative (normal) Consider new language: "reactions" or "responses" rather than "symptoms" (–symptoms of what?)

POST 9/11 MENTAL HEALTH REPORTS
New York City:
first days-weeks Any symptoms 90%; “substantial” symptoms 44% Estimated PTSD 8-11% (not fully DSM-IV-TR adherent) Major depression 10% Increased use of cigarettes, alcohol, and marijuana - use does not translate into new disorders

Nationally:
PTSD in Washington, DC, 3%; other metro areas, 4% 2/3 had symptoms  decreased markedly with time

PEOPLE ARE RESILIENT
Most people do not develop psychiatric illness
POSITIVE OUTCOMES (easily overlooked):

 Grow, find meaning, gain new perspective
Disasters bring out the worst / best in people Most people describe some positive outcome of catastrophic events

TIMING OF DISASTER PTSD
How early?
PTSD starts quickly after traumatic events
- No delayed PTSD

…And how long?
PTSD tends to be chronic

EVIDENCE?…..

TIMING OF PTSD ONSET
Oklahoma City bombing (n=182)
100 90 80 Cumulative % 70 onset of PTSD 60 50 40

No delayed onset cases (subthreshold)

30
20 10

Day 1

3 mo 1 mo 1 wk 6 mo

17 mo

7 years

RECOVERY FROM PTSD
Oklahoma City bombing (n=74)
100 90 80 Cumulative % 70 recovered from PTSD 60 50 40

All cases chronic

30
20 10

Day 1

3 mo 1 mo 1 wk 6 mo

17 mo

7 years

TIMING OF DISASTER PTSD
 There's no "early" PTSD  There's no "delayed" PTSD

 …There's just PTSD
And many come to treatment late

TIMING OF DISASTER INTERVENTION
 This means interventions can start early  It means we need to be there for people

over the long haul as their need continues
 It also means that we should not automatically

label all PTSD presenting to treatment late as delayed PTSD (rather, it's delayed treatment)

REVIEW OF ASSESSMENT FLOW CHART
Other diagnosis?

PTSD
DSM-IV-TR (+) Traumatic SCREEN Diagnose PTSD event Group C? DSM-IV-TR (-)

PTSD "plus"

PTSD only
Non-PTSD disorder

NO

no PTSD

Subdiagnostic distress

QUESTIONS, ANSWERS, RELEVANCE

CASE VIGNETTE

Joy is a 23-year-old, divorced hot dog vendor who was working 1½
blocks from WTC on the morning of the attacks, referred to you for therapy 6 weeks post-9/11. She witnessed both planes hitting the towers, people falling to their deaths, the collapse of both towers. She emerged from the cloud of smoke and debris after the collapse of the first tower with some mild cuts and bruises. Although she lost no one close to her, several regular customers were killed in the attacks. Joy had suffered bouts of depression since her teens, and the last episode was so severe that she had to drop out of junior college and was working this job until she figured out what to do. She now feels so low in the mornings that she can't get herself out of bed. She cannot bear to return to her workplace because she can't face the memories. Previously an outgoing, talkative person, she has clammed up and won't even speak to her family about the attacks or how she feels.

Dean is a 34-year-old bicycle courier. He lost his partner of 7
years, Tony—an EMT—in the rescue operation of the 9/11 attacks. None of his coworkers know he is gay, fueling his distress since they are able to openly grieve the loss of their spouses but he is not. Dean had struggled with dark moods off and on for years before he met Tony. Since they had gotten together, the mood swings had dissipated, but now the moods are back in full force. It takes him hours to get to sleep and then he sleeps only fitfully. He doesn't care about food, and has lost enough weight that it accentuates his haggard appearance. He has no interest in reading or watching the news—activities he used to love—because he can‘t concentrate. (continued….)

.…Dean fears he may lose his courier job because he is unable to think clearly, making it impossible for him to navigate the city the way he did before the attacks. If that happened, he would have no health insurance, no income, and minimal savings, as his partner used to pay most of the bills.
Before 9/11, he was a daily user of marijuana and alcohol and would frequently get drunk at weekend parties. Since 9/11 he has been drinking beer at home on weekends and smoking marijuana every night. A pack-a-day smoker before 9/11, he now smokes almost two packs per day.

SECTION 2
TREATMENT AND TRIAGE

What we know
- to provide informed direction

Logical progression of choices

INTERVENTION DECISION TREE
First: You have evaluated for psychiatric disorders  PTSD  Major depression  Alcohol & drug abuse / dependence  Other disorders as presentation suggests

INTERVENTION DECISION TREE
STEP 3: Choose the intervention that fits…
based on diagnostic status  Psychiatric disorders: - Specialized therapy programs - Medication - Counseling - Be vigilant for urgent triage indicators  Subdiagnostic distress: - Supportive counseling, debriefing, observe

For intervention, one size does NOT fit all

INTERVENTION DECISION TREE
FIRST: ASSESSMENT

PTSD "plus" PTSD only Another disorder Subdiagnostic distress

THEN: SELECT TREATMENT

Specialized therapies
Medication

Urgent triage

(comorbidity)

Counseling
Debriefing

(EMERGENCY ROOM )

SPECIALIZED THERAPY PROGRAMS
Not generic front-line interventions (not PFLASH):
 Cognitive Behavioral Therapy (CBT) - Beck  Stress Inoculation Training (SIT) - Michenbaum  Prolonged Exposure Therapy (PET)  Traumatic bereavement therapy  Psychodynamic psychotherapy  Critical Incident Stress Debriefing (CISD) - Mitchell  Eye Movement Desensitization and Reprocessing (EMDR) - Shapiro  Group therapy

 Family therapy

EVALUATION FOR MEDICATION
Diagnostic approach to PTSD medication:
 Requires consistent use  Antidepressant medications, esp. SSRIs (not addictive)  FDA-approved for PTSD: sertraline, paroxetine

 6-12 months or more, often 2+ years

EVALUATION FOR MEDICATION
Symptomatic approach to crisis medication:  Short term low-dose non-addictive sedatives for significant sleep symptoms:
- zolpidem, zaleplon, diphenhydramine, trazodone, mirtazepine

 Habit-forming drugs (addictive):
- benzodiazepines (such as alprazolam, diazepam, lorazepam) avoid if substance abuse or severe personality disorder - days to weeks, as needed only - avoid abuse / chronic use

SOME MEDICATIONS TRIED FOR PTSD
 Benzodiazepines / antianxiety:

alprazolam, buspirone

 SSRIs / novel: sertraline, paroxetine, venlafaxine, nefazodone  SSRIs / novel: sertraline, paroxetine, venlafaxine, nefazodone  TCAs: imipramine, amitriptyline, desipramine, nortriptyline  MAOIs: phenelzine
 Mood  5-HT2 antagonists: cyproheptadine

 Antidepressants

 lithium  valproate  topiramate  carbamazepine  lamotrigine
 Noradrenergic agents:

stabilizers / anticonvulsants

clonidine, propranolol, guanfacine

 Atypical antipsychotic agents:

olanzapine

URGENT TRIAGE
Danger to self or others:
 Suicide / self harm  Homicide / harm to others  Inability to care for self - psychosis - severe depression - dementia
.

Danger - assess:
 Thought  Intent  Plan  Lethal means

SUICIDALITY RISK FACTORS
Completed suicide: Older white male Major depression Drug or alcohol abuse Chronic health problems Recent major loss Lives alone Prior attempts or ideation
.

Repeated suicide attempts: Young female Borderline personality Impulsivity Intimate relationship disrupted Prior attempts or ideation

7-STEP PRACTICAL FRONT-LINE SKILLS

"DRIVING ON THE WRONG SIDE OF THE ROAD"  This intervention has elements not traditionally part of conventional therapy

 More directive than psychodynamic therapy
 Goal is not to fix pathological defenses but

rather return people to pre-disaster state

PRINCPLES OF FRONT-LINE COUNSELING
PRACTICAL, LOGICAL, SIMPLE
 NOT deep psychotherapy  Based on empirical data, not assumption of psychopathology  May contain elements common to established therapies  Goal = return people to daily functioning  Basic support and restoration - solve immediate problem

FRONT-LINE COUNSELING SKILLS
7 elements of front-line counseling:
1) Being there / Supportive listening 2) Education & reassurance 3) Coping / Stress management 4) Problem solving 5) Find meaning & perspective 6) Symptom management 7) Observation & reassessment (referral)

1) BEING THERE / SUPPORTIVE LISTENING
 Be an anchor: genuine caring, physical comfort

 Listen to the stories
 Invite thoughts - gently probe details with interest - don't push the psychological - don't force feelings; let them come (and prepare for intense emotions)  Respect personal styles (e.g., touch, disclosure)

2) EDUCATION & REASSURANCE
A. For individuals without a psychiatric disorder Normalize the experience:
 Validate common emotional reactions  Disturbing feelings don't equal mental illness
- "normal responses to abnormal events"

 Most people don't develop mental illness - symptoms subside with time

EDUCATION & REASSURANCE
B. For individuals with a psychiatric disorder

Overcoming psychiatric stigma:
 Biological basis of persistent emotional changes and medication mechanisms  Many treatment options available - Treatment is effective

3) COPING & STRESS MANAGEMENT
 Lend permission to cry, feel bad, be nonproductive, focus on self for a period of time

 Regain control of some aspect; restore routine
 Utilize social supports  Positive self talk  Appropriate use of humor  Down time; relaxation; pleasurable activities  Self care (easy to neglect in crisis): sleep, meals, hygiene, exercise, habits, time off - balance

4) PROBLEM SOLVING
 Make a list; prioritize  Weigh advantages and disadvantages of potential choices

 Try new behaviors and develop new skills
 Try more than one approach; allows a backup if Plan A doesn't work  One step at a time - manageable units first  Keep sight of larger perspective and progress

5) FIND MEANING & PERSPECTIVE
 Natural part of the healing process
- Making meaning - Finding greater perspective in one's life

 Discover and respect personal values
- What is important to the individual - Be sensitive to "blaming the victim"

 Personal roles: victim, survivor
- Listen to the person's own language in self description

 Philosophy, spirituality

6) SYMPTOM MANAGEMENT TOOLS
B & D SYMPTOMS Intrusive memories Nightmares Flashbacks Insomnia Irritability / anger Hypervigilance Jumpy, easily startled MANAGEMENT TOOL Cognitive reframing, thought-stopping Systematic desensitization, lucid dreaming Cognitive reframing Sleep hygiene, systematic desensitization, relaxation, guided imagery Assertiveness training, relaxation Relaxation, cognitive reframing Relaxation, guided imagery

APPROACH TO THE C SYMPTOM PROFILE
Traumatic events challenge 3 basic life assumptions:

1. personal invulnerability
2. perception of the world as meaningful

3. view of the self as positive
C symptoms reflect inability to cope with shifts from these vital assumptions

PTSD = CHRONIC GROUP C SYMPTOMS
 People with only groups B & D symptoms recover early, leaving in chronic treatment mostly people with prominent C symptom profile (also usually accompanied by troublesome B & D symptoms)  Emotionally overwhelmed, cannot cope  "Checked out" emotionally - numb and distant  "Frozen" state  Not ready to re-encounter traumatic experience

 Therapies requiring them to face traumatic event before they are ready may retraumatize

APPROACH TO SYMPTOM MANAGEMENT - GROUP C
 For the group C profile, first consider antidepressant Rx - Reduces disabling C symptoms, permitting therapy

 For group C symptom profile, cognitive/behavioral procedures considered best therapy
- Do not focus on negative parts of avoidance (group C symptoms) directly - may retraumatize - Retrieve positive experiences in same specific content area as symptom (elicit polar opposite in same context)

APPROACH TO SYMPTOM MANAGEMENT - GROUP C
 Re-establish pre-disaster mental pathways to pleasant & positive memories
 Recover pleasant thoughts, feelings, & behaviors of past  3 domains for intervention: cognitive (think) emotional (feel) behavioral (act)  Task: recall pleasant memory of positive past experience

APPROACH TO SYMPTOM MANAGEMENT - GROUP C Principles of group C symptom profile management:
 Return a sense of mastery and sense of control to at least one
part of the individual's life

 Therapist and client/patient identify a target activity they agree
generates new or renewed self directedness.

 Goal: restore as much mastery and sense of control over
everyday existence as possible

 Only time will heal feelings of vulnerability and restore sense of
predictability of the world

SYMPTOM MANAGEMENT TOOLS - GROUP C
C SYMPTOM MANAGEMENT TOOL

Avoids thoughts Avoids reminders Event amnesia Loss of interest Detachment/ estrangement Restricted range of affect Sense of foreshortened future

Actively recall the most positive memories of pleasant times related to the context of the painful memories Seek out cues that evoke memories of good times and good feelings - focus on remembering minute details of these Recall positive, pleasant events that can be remembered Resume specific past favorite activities for specified durations Reconnect with an important person in your life (preferably outside of the disaster zone) Get in touch with feelings of happiness and sadness not related to the event Imagine or anticipate a happy or pleasant event beyond the time of the imagined end

7) OBSERVE & REASSESS
 Observe progression into…
- psychiatric disorders - healing and recovery

 May need reassessment
- if not recovering or new symptoms appear - if signs of potential urgency appear - if someone worries you

OBSERVE & REASSESS
(WHEN TO CONSULT, REFER, OR ADD)
When to consider for more specialized interventions?

 poor functioning, nonresponse, suffering

 For therapy:  For medication:

The individual requests a therapeutic intervention you don't do & front-line therapy seems insufficient The individual requests it A diagnosable disorder is likely (eg, PTSD) Prominent group C (avoidance/numbing) Unremitting anxiety, insomnia, or depression self, endangers others (eg, children)

 For urgent care: Suicidality, homicidality, inability to care for

QUESTIONS, ANSWERS, RELEVANCE

CASE VIGNETTES

Delaney is a 48-year-old construction foreman who was
working on a new building project in the WTC area at the time of the terrorist attacks. He injured his back lifting some fallen girders while evacuating. He was helped to safety by his assistant who went back for others, never returned, and was subsequently found dead. Delaney frequently has vivid and disturbing images of the event pop into his mind, and can‘t tolerate being in tall buildings now, which is a serious problem for his job, and loud noises make him jump. He has not been able to bring himself to return to work or even make contact with coworkers because the memories are too painful. He has even blocked out some of the memories and can't remember major details of the event. (continued….)

….Delaney can‘t get over his guilt: ―It should have been me and not my assistant who didn‘t come out, ‗cuz I‘m older, I‘m the supervisor, and I‘m the one who‘s supposed to be responsible for everybody‘s safety.‖ Delaney talks about how he can‘t stop thinking about his lost colleague and blaming himself. Over several months, Delaney increased his use of the prescription narcotic pain medication for his back so much that he got hooked on it. He‘s been seeing other doctors for additional prescriptions. His primary care doctor threatened to cut him off of his painkillers unless he saw a mental health professional. He‘s undecided about what to do.

Winston is a 55-year-old married auto mechanic who

was working 3 blocks from the World Trade Center on 9/11. He witnessed both towers falling and then he went home to his family in Brooklyn. Six weeks later, he complains of flashbacks of both towers falling, nightmares of being crushed under the towers, lying awake in bed for hours at a time, spells of sweating of trembling daily when he crosses the Brooklyn Bridge into Manhattan, inability to concentrate on his work, and dropping his tools when car engines backfire. He is very interested in his family and the news, he continues to attend his darts club, and he goes to Ground Zero every weekend to deliver sandwiches to the recovery workers.

YOUR ISSUES
AND

WRAP-UP

CULTURAL / ETHNIC / PERSONAL CONSIDERATIONS
 What

special qualities do you bring to work with PFLASH? family of origin / personal background religious / philosophical cultural / traditions ethnic / race

 Can we share these thoughts with each other?

BOUNDARIES, BURNOUT, BEING, & BUBBLES
Disaster and trauma work affect the helpers too
 Do

traditional therapist / patient (client) boundaries apply?

 How

do you know when it is time to take yourself out of direct care or supervisory activities?

 Has

your work changed you, your thoughts about yourself, family, friends, and the world?
you doing for yourself, to provide self care and revitalization?

 What positive things are

CASE VIGNETTE

Roger is a 36-year-old therapist working at a distance from the
World Trade Center. Since September 11, he has been dealing with a stream of traumatized clients, day in and day out, and it is wearing him down. He has been noticing with alarm that he is starting to "tune out" during sessions. His dreams have been invaded by the stories of his clients. He is becoming bothered by the lack of empathy that he has seemed to develop for his clients. In recent weeks, he has been irritable with his wife and children with little and sometimes no provocation. Noise bothers him, and he becomes infuriated at them if they do not turn off the television immediately during news reports of the terrorist attacks. He says, ―I am angry at the world and at the people who have changed me into this.‖ (continued….)

….Roger does not talk about his feelings with his family because he feels he needs to shield them from his experience and his feelings or with his colleagues because he is ashamed of his feelings. He has been able to talk with his priest, who has been somewhat supportive. (But now his priest is suffering from burnout and spent the rest of the session telling Roger about it.) Roger‘s moods and his persistent irritability make it more difficult for him to enjoy his job and to be as effective as he was before 9/11, but he still feels he is functioning reasonably well at home and at work, and that his personal relationships have not changed appreciably (denial?).

PAPER WORK

REVIEW OF PURPOSE AND GOALS
This program provided a mental health tool kit for practical, front-line post-disaster mental health : interventions following the 9/11 terrorist attacks:
 Differentiated normative and pathological responses

 Provided algorithms for evaluation, identification, & triage

of cases

 Imparted front-line disaster mental health management skills

Any Questions


				
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Description: PTSD IN CHILDREN