James J. Lickel, Ph.D.
&
Richard Machotka
William S. Middleton Memorial Veterans Hospital.
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Cluster of symptoms that follow exposure to a
potentially traumatic event
Marked by clear cognitive, behavioral, and
physiologic changes
Can be chronic if untreated and greatly affect
quality of life
NOT a sign of weakness, lack of resiliency, or
lack of preparation
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At least 50% of population will experience
“trauma” in their lifetime, most more than
once
Most will experience symptoms of PTSD
initially, but won’t go on to develop PTSD
There are gender, racial, and ethnic
differences in exposure to trauma and
development of PTSD
Seeing Dead Bodies/Remains
Shot At/Receiving Small Arms Fire
Being Attacked/Ambushed
Receiving Artillery, Rocket, Mortar Fire
Knowing Someone Killed/Ser. Injured
Clearing/Searching Homes
Shooting/Directing Fire at Enemy
Ill/Injured Women/Child Couldn't Help
Seeing Dead/Serious Inj. Americans
Handling/Uncovering Human Remains
Resp. for Death of Enemy Combatant
Participating in Demining Ops
Buddy Shot/Hit Near You
Engaged in Hand-to-Hand Combat
Saved Soldier/Civilian Life
Being Wounded or Injured
Responsible for Noncombatant Death
Close Call/Hit but Saved by Gear
95%
93%
89%
86%
86%
80%
77%
69%
65%
50%
48%
38%
22%
22%
21%
14%
14%
8%
0%
Hoge, et al, 2004, NEJM
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Event and PTSD Risk
60
50
40
30
20
10
0
Torture
Rape
Breslau et al., 1999
Beating
Other SA
Accident
Sudden
Death
Child's
Illness
Witness
Natural
Disaster
5
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Re-experiencing:
• Intrusive thoughts or memories about the trauma
• Nightmares
• Flashback
• Distress when reminded of the event (5 senses)
• Physiological reactions
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Avoidance
• Avoidance of trauma-related thoughts, feelings, or
conversations
• Avoidance of trauma-related places, people, or
activities
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Arousal Symptoms
• Impaired sleep
• Irritability or outbursts of anger
• Difficulty concentrating/focusing
• Hypervigilance
• Feeling jumpy or easily startled
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Negative alterations in thoughts and mood
• Difficulty remembering aspects of event
• Exaggerated beliefs or expectations about self,
others, or the world (“No one can be trusted”)
• Loss of interest in past enjoyable experiences
• Feeling detached or cut-off from others
• Emotional numbness
Associated Problems
Substance
Abuse
Depression
PTSD
Physical
Health
Problems
Anxiety
Panic
Relationship
Problems
Psychological Theory of the
Development and Maintenance of
PTSD Symptoms
Common Reactions to Trauma
• Re-experiencing
• Intrusive thoughts
• Strong emotions when
triggered by reminder
Adaptive Function
Easily accessed memories that
warn of danger
• Avoidance
• Of stimuli present at time
of trauma
• Hyperarousal
• Increased vigilance
• Anger
Reduces likelihood of repeated
exposure to threat
Increased attention to threat
&
Display of preparedness
Psychological Processes Involved in Development of Symptoms
of PTSD
Associative Learning
Ethnic dress
Dust in the air
Group of kids
Military gear
Density of housing
Child’s laughter
Smell of trash
Knee pain
Sound of gravel
Debris
Psychological Processes Involved in Development of Symptoms
of PTSD
Cognitive Change
“IEDs can be planted
anywhere.”
“He died on my watch.”
“I must have done something to
ask for this.”
“Markets and crowds are unsafe.”
“I trusted this man, it is my
fault.”
“You can never let your guard down.”
“Natural Recovery” vs. PTSD
Avoidance
Negative Beliefs
PTSD Symptoms
(Dunmore, Clark, & Ehlers, 2001)
Demographics
Social Support
Etc.
Time
Psychological Processes Involved in Maintenance of Symptoms of
PTSD
Avoidance
Ethnic dress
Dust in the air
Group of kids
Military gear
Density of housing
Child’s laughter
Smell of trash
Knee pain
Sound of gravel
Debris
Psychological Processes Involved in Maintenance of Symptoms of
PTSD
Generalization of
Beliefs
“I missed the IED.”
“I asked for this.”
“I am incompetent.”
“I am a trash.”
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Current research suggests a number of
physiological differences found in people
diagnosed with PTSD
◦ Hormonal differences:
 Abnormalities in stress response hormone levels (glutamate,
GABA, Norepinephirne, CRF.
 Responsible for preparing our bodies to respond to threat > constant state of readiness
◦ Brain differences:
 Smaller hippocampus (Inhibition of HPA axis and processing
of memories)
 Over-reactive amygdala (decreased threshold for “firing”)
 Under-reactive prefrontal cortex (inhibits amygdala and
interferes with working memory)
Clinical Practice Guidelines
Psychotherapy
va/dod cpg
Pharmacotherapy
ISTSS cpg
Significant Benefit
• Cognitive Processing Therapy
(VA has trained 1,200 LIPs)
• Prolonged Exposure Therapy
(VA has trained 1,500 LIPs)
• Stress Inoculation Training
• Eye Movement Desensitization
and Reprocessing (EMDR)
First-line pharmacologic Tx:
Some Benefit
• Imagery Rehearsal Therapy
(IRT)
• Brief Psychodynamic Therapy
• Note about relative efficacy and
increased risk of return of
symptoms following stop of
medication.
• SSRIs: (Sertraline / Paroxetine /
Fluoxetinte)
• SNRI: (Venlafaxine)
• Other 2nd Generation
Antidepressants: (Mirtazapine)
• Antiadrenergic: (Prazosin;
Propranolol.
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Psychoeducation
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Stress/arousal reduction techniques
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Review of traumatic memories
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Exposure to avoided situations
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Modification of trauma-related beliefs
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9-15 sessions; averages 10 sessions
90 min sessions
1: Assessment, treatment overview, PTSD
psychoeducation, breathing retraining
2: In Vivo Exposure (continue throughout)
3-5: Imaginal Exposure
6-9: “Hot Spot” exposure
10: Final Imaginal exposure, wrap-up
Exposure Hierarchy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Grocery store with partner, not busy
Restaurant with partner, back to wall
Grocery store alone, not busy
Grocery store with partner, moderately busy
In line, facing sideways, wall to back
Restaurant, whole family, back to wall
Restaurant with partner, back to tables
Elevator,1 or 2 people
Movie with friends
In line, facing forward or no wall at back
Grocery store with partner, crowded
Grocery store alone, moderately busy
Feeling hot/sweaty
Elevator, many people
Mall alone, moderately busy
Gym
Restaurant, whole family, back to tables
Go to friend’s house
Mall alone, crowded
Grocery store alone, crowded
30
35
45
50
50
50
60
60
60
65
65
65
70
75
75
80
80
80
95
100
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Anxiety
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Anxiety
increases 
Avoidance
This situation is
dangerous; I got
out just in time;
Something awful
could have
happened
Time
Courtesy of Sally Moore, Ph.D.
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Anxiety
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Time
Stop avoidance
Anxiety
decreases on its
own
This situation
was not as
dangerous as it
felt; I can
tolerate anxiety;
I don’t have to
avoid to feel
better.
Courtesy of Sally Moore, Ph.D.
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Psychoeducation
Trauma account (evidence of efficacy
without)
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Identification of “Stuck Points”
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Cognitive restructuring
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Psychoeducation
Impact Statement
“Stuck Points”
◦ Those things trauma survivors say to themselves
about the trauma/self/others/world.
◦ Examples
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“It was my fault. I could have prevented it.”
“I am a monster for what I did during the war.”
“I should have been able to save everyone.”
“The world is an incredibly dangerous place.”
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It is how we THINK about the event, not the event
itself, that often causes us lasting distress
◦ Ex: Friend passing by
A-B-C Model – core of CPT
A = Event
B=
Belief/Thought
C = Feeling
Firefight
resulting in
casualty
I let my friend
die
Guilty
Sad
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Sessions 4 - 6: Write/Read Trauma Account
Sessions 6 - 7: Cognitive Work in depth
Sessions 8 – 12: Explore Themes of Safety,
Trust, Power/Control, Esteem, and Intimacy
Continue to read account throughout course
of treatment for purposes of exposure
Session 12: Review of 2nd Impact Statement
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In general, trauma-focused therapies more effective than
non-specific/supportive interventions and no treatment.
No consistent differences observed between traumafocused therapies, though there is limited research
regarding this.
Initial response rates of EBP for PTSD range between 4092%.
Regular therapy attendance and family support associated
with more positive outcome
Initial severity of symptoms and benzodiazepine use
associated with poorer outcome.
Outcomes for Veterans with PTSD
PCL
Prolonged Exposure Therapy
Cognitive Processing Therapy
70
70
60
60
50
50
40
40
30
30
20
d = 0.80
d = 0.43
20
10
10
0
0
PE
PCT
(Schnurr et al., 2007)
Pre
Post
d = 1.58
d = 0.50
CPT
WL
(Monson et al., 2006)
OEF/OIF Combat Veterans with PTSD
PCL
Prolonged Exposure Therapy
Cognitive Processing Therapy
70
70
60
60
50
50
40
40
30
30
20
d = 2.07
20
10
10
0
0
Pre
Post
(Tuerk et al., 2011)
Pre
Post
d = 1.46
Pre
Post
(Chard et al., 2010)
PTSD Resources
• http://www.ptsd.va.gov/
PTSD Resources
• www.istss.org
PTSD Treatment Resources
• www.abct.org
• Find a Therapist
• http://locator.apa.org