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2013 Continuing Medical

Education Conferences:
Bangkok, Orlando, Dakar

Understanding
Post-Trauma Reactions
Priscilla M. Schulz, LCSW-C
Peace Corps Headquarters
Counseling and Outreach Unit
Washington, DC

Acute traumatic stress


reactions

Unwanted
upsetting
memories

Darkness in mood
and thoughts
Trauma
Reactions

Agitation,
watchfulness,
irritability

Avoidance of
trauma reminders

Most rape victims recover on their own


PTSD Symptom Scores (PCL)

57
52

What does this mean


for people whose job is
to support rape
victims?

47
44

42
37
32
27

Likely PTSD

22
17
1

Months since the rape

PTSD Symptom Scores (PCL)

Those who dont recover


start out more distressed
80
70

What can this mean


for people who support
rape victims?

60
50
40
30
20
10
0
1

Months since the rape

23% have
persistent
distress
77% recover
on their own

Trauma reactions: summary


Immediate, strong reactions are normal
Most recover within about 3 months
Persistent distress may indicate a need for help
Escaping or avoiding memories, reminders,
thoughts and feelings may get in the way of posttrauma recovery

How do these ideas


affect supporting
rape victims?

Best practices for immediate


care of trauma survivors
1. Provide concrete help

How might these


Food, water, shelter, physical comfort, safety

activities fit with


2. Soothe
your roles as
SARLs
and SSCs?
Find out from the PCV, and help him/her
do those
things that

are calming and increase a sense of control.

3. Help the survivor understand and cope


Let them know strong, even strange, reactions can be normal,
reactions should decrease w/time, & PC has trauma experts
who can help; Give educational brochures if available.
US Dept HHS, AHRQ, Comparative Effectiveness Review # 109, April 2013;
VHA, VA/DoD Clinical Practice Guidelines, 2004/2010

THE SCIENCE OF PTSD

How science makes sense of


post-trauma problems

When stress chemicals in the brain are unusually high or


low, the brain doesnt work right. This can happen
during, or when remembering a trauma. It can cause
speechless horror, make feelings feel out of control,
make ideas irrational, and memories mixed up.
When the brain doesnt work right, and memories are mixed up,
ideas about why or how a trauma happened are mixed up too.
When survivors avoid thinking about a trauma because its too
upsetting, memories and thoughts stay mixed up.
Basic human nature is if two things happen at the same time, we
think theyre connected. This is why survivors are jumpy around
places or things that remind them of a trauma.
When survivors avoid facing things and places that remind
them of a trauma, those things and places stay scary even
10
when theyre not dangerous.

PTSD BIOLOGY

Thinking
brain
(vmPFC)

Optimal brain
response to
threat
Fight/Flight
Amygdala
brain
(Amygdala)
Motor
brain

Threat

Fight/flight vs. thinking brain


view of threat
1st response: Overcalls
dangerousnessit gets a
How
fight/flight
threat
person
readybrain
for sees
anything.
Next responses: Sorts, plans,
& recalls training as it
manages
the
threat.
How thinking brain sees threat
Conceptualization courtesy of Ann Rasmusson, MD, Yale University & Boston VA Healthcare System

The thinking brain


oversees & manages
the fight/flight
response

Frontal lobe

Draws on past experience,


training etc to respond and
survive life threat

Hippocampus

(-)

Notices & remembers


what matters

Fight/flight
(-) (-)
Milad et al. (2009); Rauch et al. (2006); Shin et al. (2005); Southwick et al. (2005)

Immediate traumatic
stress response,
and PTSD

What does this suggest about


Thinking
Fight/flight
what
youll
see when working
brain
(vmPFC)
with a rape Brain
victim in the first
(Amygdala)
hours or days post-assault?

Trauma Triggers

Motor
brain

PTSD THINKING

Traumatic stress affects thinking


When the brains not working
right, memories & thoughts.

Ignore context
Are automatic impressions,
NOT fair assessments of experiences
Are like snapshots of the experience

Support prior-held beliefs AND


Ignore contradictions
Favor some details over others
View the future in extreme & catastrophic terms
Dunmore et al., 2001Ehlers & Clark, 2000; Hackmann
et al., 2004; Halligan et al., 2003; Speckens et al., 2007

Disorganized trauma memories are like


SNAPSHOTS OF EXPERIENCE

How do thinking problems


affect your work with trauma
survivors?
How can you help the survivor
understand and cope with this?

Farras Abdelnour, artist

Common thinking errors voiced by


trauma survivors

The world is unpredictably dangerous


People are untrustworthy
No place is safe

Its my fault (Im bad)

Outcomes reflect preparations. The outcome was bad, so its my fault.


I should have/could have done something to prevent it
If you do the right thing, things go okay; If you do the wrong thingits
your fault what happens

I am unable to cope (Im incompetent)

PTSD symptoms are a sign of weakness


Other people would get over it quickly
I didnt prevent it; I cant cope when bad things happen
Dunmore et al., 2001; Ehlers & Clark (2000)

PTSD AND
LEARNING BY ASSOCIATION

THE LEARNING MODEL OF PTSD:

Fear of non-threat stimuli is learned automatically.

Have you seen some


Fight/flighafraid of non-threatening
survivors
things
things
acquire the ability to trigger
t
brain
that really arent dangerous?
the full defensive response.
What things?
Learned
association
How can a SARLs or SSC
help survivors understand
Unconditioned
and Conditioned
cope with this?
Stimulus
Stimulus

PTSD Treatment
When symptoms of traumatic stress linger more than a
month, involving mental health providers can help

Treatments for PTSD available through COU are among


the effective treatments recommended worldwide
GUIDELINE AUTHORITY

A-LEVEL TREATMENTS

US Departments of VHA & DoD:


2004/10

CT, ET, SIT, EMDR

ISTSS: 2000/09

ET, CPT, CT, SIT

Amer. Psychiatric Association 2004

Trauma-Focused CBT (TF-CBT)

Institute of Medicine 2007

ET (includes CPT)

UK-Natl Institute for Clinical


Excellence 2005

TF-CBT, EMDR

Australia National Health & Medical


Research Council 2007

TF-CBT, EMDR w/in-vivo EX

Forbes et al., (2010). JTS.

PTSD Symptom Severity (CAPS)

CPT and PE provide lasting improvement in PTSD

Therapist ratings

Resick et al. 2011, N = 171

PTSD Symptom Checklist (PCL)

PCV/patients self-report of PTSD symptoms


pre-to-post CPT treatment
80

Pre-Tx

70

Post-Tx

60
50
40
30
20
10
0
Patient 1
MedEvac
ET: safety

Patient 2
MedEvac
RTC

Patient 3 Patient 4
MedEvac Phone
RTC
COS

Patient 5 Patient 6 Patient 7


MedEvac Phone
MedEvac
ET: choice COS
RTC

26

The end.

Thank you!