ptsd recovery stories: case examples with video, and discussion with former patients irene powch,...

PTSD Recovery Stories: Case PTSD Recovery Stories: Case examples with video, and examples with video, and

discussion with former patientsdiscussion with former patients

Irene Powch, Ph.D.Irene Powch, Ph.D.Grand RoundsGrand Rounds

Oregon Health & Science Oregon Health & Science UniversityUniversity

February 22, 2011February 22, 2011

AcknowledgementsAcknowledgements

Thanks to Dwayne Washington and Will Murphy of Thanks to Dwayne Washington and Will Murphy of Medical Media at PVAMC for their help with video Medical Media at PVAMC for their help with video productions and to Doug Park, Ph.D., for leading productions and to Doug Park, Ph.D., for leading the recovery focus at PVAMC and inspiring the the recovery focus at PVAMC and inspiring the idea for these recovery videos and this idea for these recovery videos and this presentation.presentation.

And most of all, thanks to the courageous and And most of all, thanks to the courageous and inspiring veterans who have walked this path of inspiring veterans who have walked this path of recovery from PTSD and are willing to share their recovery from PTSD and are willing to share their stories.stories.

IntroductionIntroductionRecovery from PTSD?Recovery from PTSD?

The VA Story The VA Story – 1980’s: intensive exploratory trauma focused residential treatment in 1980’s: intensive exploratory trauma focused residential treatment in

company of peerscompany of peers

– Mid 1990’s: Rosenheck—concluded above doesn’t work, closure of Mid 1990’s: Rosenheck—concluded above doesn’t work, closure of programs, PTSD viewed as chronic and untreatable, era of symptom programs, PTSD viewed as chronic and untreatable, era of symptom management and maintenance, lost trauma focused treatments, management and maintenance, lost trauma focused treatments, session length drastically shortenedsession length drastically shortened

– 2007 Schnurr et al JAMA, and Monson et al 2006 JCCP—concluded 2007 Schnurr et al JAMA, and Monson et al 2006 JCCP—concluded trauma processing more effective than present-centered therapy, trauma processing more effective than present-centered therapy, PTSD viewed as treatable with recovery achievable, session length PTSD viewed as treatable with recovery achievable, session length increased to 60-90 minutesincreased to 60-90 minutes

Massive dissemination of CPT and PE begin in 2008Massive dissemination of CPT and PE begin in 2008

View From the Trenches: Real View From the Trenches: Real Veterans Recovery StoriesVeterans Recovery Stories

Today’s Presentation:Today’s Presentation:Orientation to TermsOrientation to Terms

3 minute case presentation of “Katie”3 minute case presentation of “Katie”

5 min “Katie” speaks5 min “Katie” speaks

5 min “Katie” fields questions *****5 min “Katie” fields questions *****

3 min case presentation of “Mark”3 min case presentation of “Mark”

20-min Mark’s Recovery Video20-min Mark’s Recovery Video

2-5 min “Mark” speaks2-5 min “Mark” speaks

5 min “Mark” fields questions *****5 min “Mark” fields questions *****

5 min conclusion and discussion5 min conclusion and discussion

Orientation to TermsOrientation to TermsPE=Prolonged Exposure Therapy PE=Prolonged Exposure Therapy – Starts w/ beh change, bust avoidance Starts w/ beh change, bust avoidance desensitization & perspective shifts desensitization & perspective shifts

spontaneously from withinspontaneously from within

CPT/C=Cognitive Processing TherapyCPT/C=Cognitive Processing Therapy– Starts w/ cog change, question trauma induced beliefsStarts w/ cog change, question trauma induced beliefs shift in perspective first; shift in perspective first;

behavior change follows graduallybehavior change follows gradually

SUDS=Subjective Units of DistressSUDS=Subjective Units of Distress0 to 1000 to 100

PCL=PTSD Clinical ChecklistPCL=PTSD Clinical Checklist>50 is positive screen for PTSD (military)>50 is positive screen for PTSD (military)

CAPS=Clinician Administered PTSD Scale for DSM-IVCAPS=Clinician Administered PTSD Scale for DSM-IV>45 severity admit for PTSD tx (military)>45 severity admit for PTSD tx (military)

Case #1: “Katie”Case #1: “Katie”““Katie” was a 59 yr old veteran when I first saw herKatie” was a 59 yr old veteran when I first saw her

on Feb 16, 2010on Feb 16, 2010

She clearly met criteria for severe PTSD r/t a brutal rape in the She clearly met criteria for severe PTSD r/t a brutal rape in the military as well as body bagging and tragic loss in the military, military as well as body bagging and tragic loss in the military, and an extensive hx of childhood sexual and physical abuse.and an extensive hx of childhood sexual and physical abuse.

She had previously received long-term supportiveShe had previously received long-term supportivetherapy for 5 years prior to moving to Portland, and a year of therapy for 5 years prior to moving to Portland, and a year of process/support group at the Portland Vet Center prior to process/support group at the Portland Vet Center prior to seeking an EBT for PTSD.seeking an EBT for PTSD.

Her most prominent sxs were extreme, viscerally experienced Her most prominent sxs were extreme, viscerally experienced fear, helplessness, and avoidance to reminders of the MST. She fear, helplessness, and avoidance to reminders of the MST. She had been using marijuana for years to manage anxiety. She had been using marijuana for years to manage anxiety. She had severe GI sxs.had severe GI sxs.

“ “Katie” continuedKatie” continued

She was terrified of PE but believed strongly that facing She was terrified of PE but believed strongly that facing the memory would help her, and was highly motivated to the memory would help her, and was highly motivated to proceed.proceed.

March 18, 2010: First session of PE; second rape (MST) March 18, 2010: First session of PE; second rape (MST) was identified as the index trauma.was identified as the index trauma.

May 14, 2010: Completed PE early due to surgery May 14, 2010: Completed PE early due to surgery scheduled for the following day with several weeks of scheduled for the following day with several weeks of recovery time expected.recovery time expected.

June 8 & 30: Follow-up booster sessions.June 8 & 30: Follow-up booster sessions.


BEFORE SNAPSHOTSBEFORE SNAPSHOTS AFTER SNAPSHOTSAFTER SNAPSHOTS

PCL = 58PCL = 58 PCL = 38PCL = 38Marijuana for anxietyMarijuana for anxiety Quit MJ—no need for itQuit MJ—no need for itShaking in fetal position (T)Shaking in fetal position (T) Tells it as a matter of factTells it as a matter of factCd not be on porch at nightCd not be on porch at night Enjoys night air outsideEnjoys night air outsideAvoided looking in mirrorAvoided looking in mirror Appreciates whole bodyAppreciates whole bodyParalyzed by assertivesParalyzed by assertives Is assertiveIs assertive

Over a half year after conclusion of treatment, gains are holding Over a half year after conclusion of treatment, gains are holding solid.solid.


COURSE OF TX AND PIVOTAL MOMENTSCOURSE OF TX AND PIVOTAL MOMENTS

Session 2-3: She inadvertently doubled in vivo exposure (movie Session 2-3: She inadvertently doubled in vivo exposure (movie segment); good movementsegment); good movement– Highpoint SUDS from 97 to 75; lowpoint to 30.Highpoint SUDS from 97 to 75; lowpoint to 30.

Sessions 3-4: Imaginal SUDS 100, never below 85Sessions 3-4: Imaginal SUDS 100, never below 85

Session 6: Gap addressed; remembered her body betrayed her. Session 6: Gap addressed; remembered her body betrayed her. Psychoed and Socratic Q’s in debrief. Major shift in cognition (from Psychoed and Socratic Q’s in debrief. Major shift in cognition (from “I’m disgusting” to “this is not about me, I did not ask for this” “I’m disgusting” to “this is not about me, I did not ask for this” acceptance of herself and her body, self-care, assertiveness.acceptance of herself and her body, self-care, assertiveness.


Katie talks briefly about her life now Katie talks briefly about her life now and fields questions for 5 minutes.and fields questions for 5 minutes.

Case #2: “Mark”Case #2: “Mark”““Mark” was a 28 yr old veteran of the Gulf War when I first Mark” was a 28 yr old veteran of the Gulf War when I first

saw him on July 30, 1999.saw him on July 30, 1999.

He clearly met criteria for PTSD r/t combat He clearly met criteria for PTSD r/t combat trauma in the Gulf. This included a friendly fire incidenttrauma in the Gulf. This included a friendly fire incident in which he witnessed his friend shot in the head anin which he witnessed his friend shot in the head an arm’s length away, and had to clean up and burn thearm’s length away, and had to clean up and burn the remains.remains.

When Mark first came to treatment he was unable to go When Mark first came to treatment he was unable to go to skills classes for several months because he wouldto skills classes for several months because he would

have panic attacks and vomit in his car in the parking have panic attacks and vomit in his car in the parking garage and leave. garage and leave.

“ “Mark” continuedMark” continuedFrom July 30, 1999 to November 16, 2006, Mark received continuous From July 30, 1999 to November 16, 2006, Mark received continuous treatment on the PCT, focused on symptom management and supportive treatment on the PCT, focused on symptom management and supportive therapy. therapy.

Then he was told it is time to do an EBT.Then he was told it is time to do an EBT.

Nov 20, 2006 to Jan 22, 2007 he completed In Vivo Group and committed Nov 20, 2006 to Jan 22, 2007 he completed In Vivo Group and committed to completing CPT. to completing CPT.

March 28, 2007 he declared he is not ready for CPT but took the manual March 28, 2007 he declared he is not ready for CPT but took the manual to prepare and completed CPT on his own.to prepare and completed CPT on his own.

May 4, 2007 he reported on significant cognitive restructuring he had May 4, 2007 he reported on significant cognitive restructuring he had completed over the past 2 months and asked for my support with voc completed over the past 2 months and asked for my support with voc rehab; he wanted to train to become an EMT and eventually a paramedic.rehab; he wanted to train to become an EMT and eventually a paramedic.

“ “Mark” continuedMark” continued

BEFORE SNAPSHOTBEFORE SNAPSHOT AFTER SNAPSHOTAFTER SNAPSHOT

CAPS = 100CAPS = 100 CAPS = 4 CAPS = 4 Panic attack w/ vomitingPanic attack w/ vomiting No panic attacksNo panic attacksUnable to attend groupUnable to attend group Field q’s for audienceField q’s for audienceUnable stand at sch bus stopUnable stand at sch bus stop Completed EMT trainingCompleted EMT trainingUnable to talk about traumasUnable to talk about traumas EMT for burn victimsEMT for burn victimsIsolatedIsolated ReconnectedReconnected

Almost 2.5 years after creation of his “recovery video” (Jun 20, Almost 2.5 years after creation of his “recovery video” (Jun 20, 2008), Mark’s recovery is still solid and growing.2008), Mark’s recovery is still solid and growing.


PIVOTAL MOMENTSPIVOTAL MOMENTS

Support Group “I don’t want to be stuck here”Support Group “I don’t want to be stuck here”ER after anxiety attack “You just have to calm down.”ER after anxiety attack “You just have to calm down.”Ultimatum “Time to do an EBT”Ultimatum “Time to do an EBT”In Vivo and CPT: avoidance busting and change in perspectiveIn Vivo and CPT: avoidance busting and change in perspectiveVirginia Tech Mom Virginia Tech Mom “I will not allow this moment to define my “I will not allow this moment to define my son’s life”son’s life”

““There’s a lot more to me than just that one year”There’s a lot more to me than just that one year”

““Mark” continuedMark” continued

Mark’s Recovery Video, Mark’s Recovery Video,

produced June 20, 2008.produced June 20, 2008.


Mark talks about LIFE AFTER PTSD Mark talks about LIFE AFTER PTSD and fields questions for 5 minutes.and fields questions for 5 minutes.

Concluding CommentsConcluding Comments

These are not isolated cases; they are These are not isolated cases; they are the new norm with EBTsthe new norm with EBTs

Response to recent PCT poll:Response to recent PCT poll:

– # of sessions (PE): 7, 8, 8, 15, 8, 13, 12, 16, 11, 8, 7# of sessions (PE): 7, 8, 8, 15, 8, 13, 12, 16, 11, 8, 7– # of sessions (CPT): 12 (group of 6 veterans)# of sessions (CPT): 12 (group of 6 veterans)

– Functional changes: Back to school, no more PTSD tx, Functional changes: Back to school, no more PTSD tx, riding public transport, travelling, developing new riding public transport, travelling, developing new relationships, enjoying retirement with wife, return to relationships, enjoying retirement with wife, return to church, kids “hanging on him” vs. running to hide from church, kids “hanging on him” vs. running to hide from himhim

Concluding CommentsConcluding CommentsPEPE CPTC (Group*)CPTC (Group*)

PrePrePost (change)Post (change) PrePrePost (change)Post (change)

6262 38 (24) 38 (24) 6161 27 (34) 27 (34)

7272 32 (45) 32 (45) 8181 63 (18)* 63 (18)*

5454 24 (30) 24 (30) 61 61 45 (16)* 45 (16)*

55 55 26 (29) 26 (29) 40 40 23 (17)* 23 (17)*

5656 33 (23) 33 (23) 59 59 42 (17)* 42 (17)*

80 80 40 (40) 40 (40) 68 68 52 (16)* 52 (16)*

4040 27 (13) 27 (13) 74 74 54 (20)* 54 (20)*

6565 45 (20) 45 (20) 63 63 44 (20) * 6/7 wom 44 (20) * 6/7 wom

6060 42 (18) 42 (18)

70 70 25 (45) * group; full cohort(s) 25 (45) * group; full cohort(s)

42 42 19 (23) 19 (23)

6060 32 (28) 32 (28) 64 64 59 (6)* 41/62 sx 59 (6)* 41/62 sx

DiscussionDiscussionWould these veterans’ responses to the EBTs have been the Would these veterans’ responses to the EBTs have been the same had they not had those years of prior therapy?same had they not had those years of prior therapy?

What made these veterans great candidates for evidence based What made these veterans great candidates for evidence based PTSD therapy?PTSD therapy?

What value do we place on 80 clinician hours of treatment that What value do we place on 80 clinician hours of treatment that result in: result in: – 4 to 6 veterans dropping symptoms by 28 points (recovered and no 4 to 6 veterans dropping symptoms by 28 points (recovered and no

longer in need of treatment) longer in need of treatment)

– 36 veterans dropping symptoms by 6 points (managing symptoms 36 veterans dropping symptoms by 6 points (managing symptoms better)better)

How can we maximize the greatest recovery for the greatest How can we maximize the greatest recovery for the greatest number of people who suffer from PTSD?number of people who suffer from PTSD?

ptsd recovery stories: case examples with video, and discussion with former patients irene powch,...

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