Proposed Changes To PTSD Diagnosis in DSM

Psychotherapeutic Treatment of
Appalachian Combat Veterans
with PTSD
Myra Qualls Elder, Ph.D.
James H. Quillen Veterans Affairs
Medical Center, Mountain Home, TN
Post Traumatic Stress Disorder
• Trauma: Outside normal range of human
• Re-experiencing the trauma:
– Nightmares
– Intrusive memories
– Flashbacks
– Distress when faced with triggers
PTSD Symptoms: Avoidance
• Avoidance of thoughts, feelings, people,
places assoc. w/ the trauma
• Detachment/numbing/estrangement
• Some amnesia of trauma
• Foreshortened future
• Loss of interest in activities
PTSD Symptoms: Arousal
• Insomnia/broken sleep
• Irritability/anger
• Problems concentrating
• Hypervigilance
• Exaggerated startle response
Symptoms listed in DSM-IV-TR
Proposed Changes To PTSD
Diagnosis in DSM-V (2013)
• Event experienced by close relative/friend
• Do not need to feel
• Repeated exposure to distressing details
of events of others (police officer, for ex.)
• Criterion D: negative thoughts, moods, or
evaluations of self and/or world
• (Thanks to Dr. Tom Stoss for this information)
Appalachian Veteran-Specific
Diagnostic Questions
• When do you do your grocery shopping?
• Do you ever eat at a restaurant? Where
do you sit?
• Is there a gun in your bedroom? How
many guns are in your house?
• How many times a night do you check
your window/door locks?
• What do you do on July 4th?
PTSD Prevalence Data
• Community stats: current PTSD rates = 5-6%
men, 10-12% women
National Vietnam Veterans Readjustment Study
(mid-1980s): then-current PTSD rates = 15%
men, 8% women
Lifetime rates: 30% men, 25% women (cited in
Friedman, 2004)
PTSD Prevalence Data II
• Operation OIF/OEF: 2008 Rand Institute
Study: 18.5% diagnosed with PTSD
• 35% of Iraq war vets accessed MH svcs in
the year after returning home (Hoge, et al., 2006)
• 2001-2005, N = 103,788 OEF/OIF vets:
25% received MH dxs, 56% of those rec’d
2 MH dxs, skewed toward vets 18-24 (Seal, et
al., 2007)
National Center for PTSD Data
• 12% to 20% soldiers and Marines had
PTSD after serving in Iraq
• 7% to 15% had depression after serving
in Iraq or Afghanistan
• 1 in every 4 soldiers or Marines reported
using alcohol more than they meant to
• 1 of every 3 returning soldiers treated by
the VA for MH issues
Now what?
• Establish trust: necessary condition
• Must be present: minimize distraction,
pay attention, have two channels open
• Must be engaged: reflective is good,
responsive is better, avoid being reactive
• Patient must feel as safe as possible,
physically and emotionally (ex. windows,
pagers, intrusions)
Conditions Necessary for Tx
• Time: no substitute for this, need it for
trust to develop
• Maslow’s Triad: can it be taught?
• Culture/Context: military training,
masculinity, Appalachian (“Alvin York
• Military service an honorable way to
individuate from an enmeshed family
From Sebastian Junger’s 2010 book,
“War,” about the 173rd in Afghanistan
• “War is supposed to feel bad because
undeniably bad things happen in it, but for
a 19-y.o. at the working end of a .50 cal
during a firefight that everyone comes out
of okay, war is life multiplied by some
number that no one has ever heard of. In
some ways, 20min of combat is more life
than you could scrape together in a
lifetime of doing something else.”
Early Therapeutic Tasks
• Orientation to therapy
• Rationale for therapy: “crude oil to
gasoline” and reducing avoidance
• Possible negative and positive effects of
therapy (this is informed consent)
• Educate about PTSD & talk to spouse.
• Analogy of physical therapy: “frozen
The “A” Problems in PTSD
• Anger
• Alcohol
• Avoidance
Early and Mid-Tx Tasks
• Therapeutic deed, not just word
• Assessing and creating coping skills
FIRST: distraction, relaxation, music,
hobbies, social support, exercise
• Then, constructing the trauma narrative
• Hearing the hard stuff and staying present
• Dealing with current life stressors/issues
Middle and Later Therapy Tasks
• Decreasing affective reactivity: must learn
words for emotions (visual to verbal)
• Decreasing maladaptive behaviors
• Decreasing “stinking thinking:” with vets,
all-or-nothing thinking and paranoia very
• Increasing some integration into society
• Increasing self-efficacy: homework
PTSD is a chronic condition
• Balance instillation of hope with realistic
view: there will be exacerbations
• Current stress, medical problems, travel
away from home, media exposure to
ongoing war, substance use/abuse
• Anniversary reactions
• The body remembers
Potential Pitfalls
• Secondary traumatization
• Patient dropping out in middle of trauma
• Unrealistic expectations
• Acting out (patient, not therapist)
• Exhaustion (therapist and patient)
Psychologist Self-Care
• Balance case-load
• Peer supervision and/or occasional
therapy to “offload baggage”
• Stable and balanced life away from work
• Seeing work as meaningful
Does Therapy Work?
• 40 years of data on therapy: patient’s
rating of the alliance is the best predictor
of engagement and outcome
• All therapy models show that the most
change occurs early in the therapeutic
• Therapy accounts for 13% of variance for
change (Wampold, 2001, cited by Miller, 2007)
PTSD Therapy Outcome Data
• Limited data, focuses on:
• Exposure-based therapies
• Cognitive Behavioral Therapy
• Small-scale studies, different populations
(rape and accident victims, vets), modest
treatment gains/effect sizes
Difficult to Measure Prevented
• Who did not commit suicide?
• Who did not commit homicide?
• Who did not drink/use drugs?
• Who did not abuse family members?
• “Maybe the ultimate wound is the one that
makes you miss the war you got it in.”
- Sebastian Junger, “War”