Post Traumatic Stress Disorder Myths and Realties

West Virginia Offices of the Insurance Commissioner May 9, 2019

David A. Clayman, Ph.D. Clinical, Medical and Forensic Psychologist PTSD

• Long history – RELATED TO BATTLE – 480 B.C.: Spartan commander Leonidas dismissed emotionally and psychologically spent soldiers from battle. – 1678: Symptoms described by Swiss military physicians. • First officially identified as a “mental disorder” in 1980 in the DSM-III. – Included non-combat events Defining TRAUMA

• DSM-III: An event beyond the range of normal that would be distressing for anyone who experienced it (1980) • DSM-IV: An event that can cause serious injury, harm or death but not necessarily beyond the range of normal. (1994) • DSM-IV-TR: Redefined trauma to include events that cause intense fear, helplessness and horror. (2000) Acute Stress Disorder DSM-5 (2013) – The stressor criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. – Typically begin immediately after exposure to the trauma lasting for at least 3 days up to a month. – The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. PTSD DSM-5 (2013) Necessitates exposure to actual or threatened death, serious injury, or sexual violence in one or more defined ways. 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event (s) as it occurred to others. 3. Learning that the traumatic event(s)occurred to a close family member or). In cases of actual or threatened death of a family member or friend, the event(s) must’ve been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse.) PTSD DSM-5 (2013) Requires presence of symptoms from 4 different categories with symptoms starting after the index event:  Intrusive symptoms associated with the traumatic event(s) [≥1/5].  Persistence avoidance of stimuli associated with traumatic event(s) [≥1/2].  Negative alterations in cognitions and mood associated with the traumatic event(s) [≥2/7]  Marked alterations in arousal and reactivity associated with the traumatic event(s) [≥2/6] PTSD DSM-5 (2013)  Duration of the disturbance is more than one month.  May have delayed onset.  May include other qualifiers. *** Should be familiar with the cautionary statement for forensic use of the DSM-5. PTSD

• Scope has expanded to include non-combat stressors. • Consideration made of emotional-psychological presentations that do not meet the complete criteria. • Distinction being made between PTSD and Complex PTSD (prolonged, repeated trauma causing behavioral disturbance). • Lots of room for differing perspectives in spite of efforts to be explicit in defining criteria for diagnosis. • Diagnosis is necessary but not sufficient! Myths about PTSD

PTSD is a sign of mental weakness. Anything can be traumatic. You can get PTSD immediately after experiencing a trauma. People with PTSD are crazy and/or dangerous. People with PTSD cannot function in military or work environments. After a while, people with PTSD suggest be able to get over it. Myths about PTSD (cont.)

Veterans with PTSD are not “wounded.” Nothing can be done for those who have PTSD. Trauma and conditions like PTSD only impact people have had a near-death experience. Strong people can deal with trauma on their own and don’t need help. Realities about PTSD • An estimated 70 percent of adults in the United States have experienced a traumatic event at least once in their lives and up to 20 percent (14%) of these people go on to develop posttraumatic stress disorder, or PTSD. • An estimated 5 percent of Americans—more than 13 million people—have PTSD at any given time. • Approximately 8 percent of all adults—1 of 13 people in this country—will develop PTSD during their lifetime. • An estimated 1 out of 10 women will get PTSD at some time in their lives. Women are about twice as likely as men to develop PTSD. • Approximately 9% of car accident survivors develop PTSD. Workers’ Compensation and PTSD • West Virginia implicitly rejects the idea of a standalone claim for PTSD. • Physically injured individuals have made add- on claims for PTSD. • Often rely on statements by treating clinicians to determine whether an individual meets the diagnostic criteria for PTSD related to the claimant’s physical injury or even a standalone condition. Workers’ Compensation and PTSD Close but no Cigar • 2019 West Virginia Legislature SB 114. – allowing workers’ compensation benefits for first responders diagnosed with post-traumatic stress disorder resulting from an event that occurred during their employment. – Law Enforcement Officers (≈10%), Firefighters (≈ 20%)and Medical First Responders (≈10%) considered high risk careers. • LEO and EMT likely low estimates. • Higher in disaster response circumstances(15-30%). Health and Anxiety Disorders • The annual cost to society of anxiety disorders is estimated to be significantly over $42.3 billion, often due to misdiagnosis and under treatment. This includes psychiatric and non- psychiatric medical treatment costs, indirect workplace costs, mortality costs, and prescription drug costs. Diagnostic Issues • Changing criteria. • TRAUMA ≠ ANYTHING BAD/UPSETTING • Many bad things happen to people, affecting them deeply, that are not “trauma.” • Diagnosis often rendered by treating clinician who relies on subjective report of patient/client. • WC should rely on objective, qualified evaluators (forensically trained psychologists and psychiatrists). Identifying…Diagnosing…Treating • Misdiagnosis is common • Misunderstandings are common • Great reason not to focus on other issues • Serious but treatable when it is present • Typically NOT present alone – Substance Abuse – Depression Differential Diagnoses • Mental disorder secondary to GMC – (ex. head injury) • Substance-induced disorder • Dissociative disorders • Other anxiety disorders • Major depressive episode • Borderline personality disorder • Malingering • Litigation Points to Remember…not simple.

• If a patient has multiple complaints, think PTSD or personality disorder up front.

• Under-detected because we don’t ask the right questions.

• One of the few DSM disorders defined by it’s cause! Treatment: PTSD • Requires multiple modalities • Initial education, support and referrals important to establish trust • Pharmacotherapy • Psychotherapy • Relaxation Training • And more…. The Course of PTSD

• The symptoms and the relative predominance of re- experiencing, avoidance, and increased arousal symptoms may vary over time. • Duration of symptoms also varies: Complete recovery occurs within 3 months after the trauma in approximately half of the cases. Others can have persisting symptoms for longer than 12 months after the trauma. • Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events. The Course of PTSD (cont.)

• The severity, duration, and proximity of an individual’s exposure to a traumatic event are the most important factors affecting the likelihood of developing PTSD.

• Social supports, family history, childhood experiences, personality variables, and pre-existing mental disorders may influence the development of PTSD.

• PTSD can also develop in individuals without any predisposing conditions, particularly if the stressor is extreme.

• The disorder may be especially severe or long lasting when the stressor is of human design (torture, rape). References (Have used these numerous sources and combined information.) • https://psychcentral.com/disorders/ptsd/posttraumatic-stress-disorder- ptsd-facts/ • https://deserthopetreatment.com/ptsd-substance-abuse/high-risk- professions/ • https://www.betterhelp.com/advice/ptsd/the-facts-and-fictions-of-ptsd- statistics/ • https://www.nimh.nih.gov/health/statistics/post-traumatic-stress- disorder-ptsd.shtml • http://www.ptsdunited.org/ptsd-statistics-2/ • https://downtownlalaw.com/practice-areas/workplace-injury/post- traumatic-stress-disorder-workplace-injury/ • https://www.hartgrovehospital.com/five-myths-and-five-facts-about- ptsd/ • https://www.sidran.org/resources/for-survivors-and-loved-ones/post- traumatic-stress-disorder-fact-sheet-2/ Power Point Authors

• Karen Krinsley, Ph.D., PTSD Section Chief, VA Boston Healthcare System & PTSD Consultant, National Center for PTSD • Louise Burkhart, Jaime Hamm, Jessica Mungro & Erin Schultz • Anita S. Kablinger MD, Associate Professor, Departments of Psychiatry and Pharmacology, LSUHSC-Shreveport Thanks

David A. Clayman, Ph.D. Clayman & Associates, PLLC. 1097 Fledderjohn Road, Suite 3 Charleston, WV 25314 (p) 304.345.0880 (f) 304.345.1112 [email protected]