PTSD: a guide for first responders and veterans

1. PTSD: a guide for first responders and veterans A presentation by Diane Adams Taylor, M.Ed. and Al Bender, M.A., LIMHC

2. You are not alone.

3. What is post-traumatic stress disorder (PTSD)? • Post-traumatic stress disorder is a severe condition that may develop after a person has experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury. It may also occur after a threat to the physical integrity of self or others. The person’s response involves intense fear, helplessness or horror. • The traumatic event is persistently re-experienced through one or more of the following: • Recurrent, intrusive and distressing recollections of the event • Recurrent distressing dreams of the event • Acting or feeling as if the traumatic event was recurring • Intense psychological distress or physiological distress at exposure to internal or external cues which resemble the traumatic event.

4. PTSD definition continued • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness with at least three of the following: • Efforts to avoid thoughts, feelings or conversations associated with the trauma • Efforts to avoid activities, places or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feelings of detachment or estrangement from others • Restricted range of affect (e.g. unable to have loving feelings) • Sense of foreshortened future (e.g. does not expect to have a career, marriage, children or even a long life span).

5. Symptoms of PTSD • Persistent symptoms of increased arousal (not present before the trauma) as indicated by two or more of the following: • Difficulty falling asleep or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hyper vigilance • Exaggerated startle response • Duration of these symptoms is more than one month. • The disturbance causes significant distress or impairment in social, occupational or other important areas of functioning. Definitions taken from the DSM IV

6. Real world definition of PTSD • You spend too much time surrounded by people who want to kill you. • You see your buddies killed or wounded. • You see too many dead bodies. • You have to help clean up dead bodies. • You spend your time in a place where dying is a continual possibility. • You have to kill one or more combatants. • You have to rescue those who are in life threatening danger which may include babies and young children. • You generally have to clean up after stupid people.

7. Symptoms of PTSD (in plain language) • Persistent nightmares about combat or other first responder situations. • Losing your temper over little things – things that did not use to matter. • Not being able to react to other people’s emotions (your wife is crying and you just stare at her). • Hating to go into crowded or unfamiliar situations. • Having flashbacks – suddenly you are back in combat in your head –for example, seeing a woman in a burka sets Al off. • Feeling threatened by everything. • Automatically ducking for cover when a loud noise occurs. • Not enjoying, not being happy, or looking forward to anything. • Not feeling close to anyone. • Not being able to fall asleep or if you do, not being able to stay asleep. • Not being able to stand “stupid” people (anyone who does not do things exactly the way you think they should be done).

8. PTSD Occurrence • Suburban Police = 13% of the population • Firefighters = 18% of the population • Military Veterans = 30% of the population • Veterans with Service-Related PTSD • Vietnam Veterans (initial estimate) = 830,000 • Gulf War Veterans = 56,000 • Iraq/Afghanistan Veterans (estimate through 2010) = 330,000 • Source – United States Department of Veterans Affairs

9. 12 Steps of PTSD • Activating event (the event that causes distress) • Pain (emotional, spiritual and physical pain) • Confusion (trying to remember, can I trust my memory?) • Guilt (feeling guilty, how responsible am I for what happened?) • Shame (filled with shame, who else knows?) • Self-worth dissipating (feelings of being worthless increase) • Anxiety (symptoms begin to develop) • Fear (PTSD is becoming more a part of your life) • Anger (Flight or fight is developing) • Resentment (Distrust of others more noticeable) • Depression (Self-esteem in a downward spiral) • Acute Anxiety (episodes of panic/anxiety) • From Randy J. Hartman, Ph.D.

10. Accepting you have a problem • Being a first responder means that you have been trained to refuse to accept any perceived weakness, emotional turmoil or pain in yourself. • You have avoided any thoughts on the experiences which lead to you and the diagnosis of PTSD, managing to put all of these thoughts on a shelf in your brain and shutting them out completely (or at least thinking they are shut away). • Active first responders do not want to demonstrate any form of “weakness” which may impact their job. Veterans do not want the stigma of the label of PTSD so they do not want to talk about their experiences. • Civilians do not get it. They do not understand the stresses which accompany these jobs. • Seeking help is not a weakness.

11. How does PTSD impact your thinking and beliefs? • Sensory information in the form of sight, sound, smell, taste and touch can all be distorted so that the person believes they have returned to the event which caused the trauma. The sight of a woman in a burka, the sound of a truck back firing, the smell of diesel fuel on a hot day, the feel of a certain fabric, as well as the taste of sweat can trigger an episode or a flashback. • Time can also be distorted so that a person with PTSD can be transported back in time many years with very little stimulus to trigger that event.

12. Distorted automatic thoughts • “No one but me is to blame for this trauma.” • “I should have known better [and I could have saved my friends]”. • “I should never have let my friend go out on this mission.” • “I should have prevented the trauma [I am stronger than this].” • “I should not allow this to affect me so long after the trauma.” • “People don’t care about my feelings.” • “My family does not understand what I am going through.” • “I will not share my experiences with others because they will think I am a monster (or crazy).”

13. Blaming yourself • Blame becomes a major issue for first responders and especially for combat soldiers suffering from PTSD. They have the distorted belief that they can keep every other soldier/police officer/fire fighter/rescue unit member safe from harm. • When this does not happen and they fail in this attempt to keep all others safe, it nearly destroys them.

14. Maladaptive assumptions and dysfunctional thoughts • “Bad things will happen so control is only an illusion.” • “I must stay always in control because danger is always present.” • “I can’t think about what happened, it makes me feel bad.” • “Dying would be much better than having to re-live those events.” • “Life is pointless and meaningless.” • “I must be a bad person or this would not have happened.” • “The world is a terrible and dark place to live in now.” • “There is no future for me aside from suffering.” • “Catastrophe will strike and there is nothing I can do about it.”

15. Why does PTSD impact some first responders but not all? • Psychophysiological responses to trauma occur in that a signal is sent to the portion of the brain which impacts survival. This information prepares the body to take immediate action (the fight or flight response). The brain may be re-activated by these strong sensations when feelings of danger are once again felt. • Some memories are more variable than others due to the second pathway to the brain used for information processing. Associations can be made and memories stored while the brain can alter the original memory or even lower the survival response. • Under conditions of extreme stress, the brain also produces stress chemicals (cortisol and adrenalin) which can interfere with memory storage and the traumatic events can become fragmented. If these memories trace back to the original memory, the body automatically reverts back to survival mode. • Negative reinforcement occurs when something the individual perceives to be bad is removed and this removal of negative stimulus reinforces the avoidance/anxiety behaviors which have been established.

16. What are the treatment options? • Cognitive-Behavioral Treatments for PTSD- this type of therapy focuses on changing the way in which people evaluate and respond to situations, thoughts and feelings. It also addresses the unhealthy behaviors which stem from these thoughts and feelings. • Exposure Therapy (also known as desensitization)- this is a behavioral therapy for PTSD that aims to reduce a person’s fear, anxiety and avoidance behavior by having the person fully confront (by exposure) to thoughts, feelings or situations that are feared. • EMDR or eye movement desensitization and reprocessing – helps change how you react to memories of trauma through focusing on other stimuli (eye movement, hand taps and sounds). • Combination of medication and behavioral therapy. • Family therapy is also beneficial to help the family communicate better while working through relationship issues caused by the PTSD symptoms. • New treatments are currently under study at the Veteran’s Administration.

17. Focus of treatment • It is essential that the therapist establish safety when working with clients with PTSD. This is defined as three distinct levels – resolving environmental and physical danger issues, improving thought and behavior patterns which are self-destructive and changing the concept of being a “victim” to one of survivor through the continued use of life-affirming self-care skills. • After a sense of safety and security is established, treatment of the trauma issues can begin. • One of the important practices of trauma treatment is relaxation. This is essential to reduce both cognitive symptoms as well as physiological ones. Some of the common relaxation techniques often utilized are deep breathing, meditation, progressive relaxation, safe-place visualization, prayer and soothing music.

18. Why seek help for PTSD? • Early treatment is essential as symptoms of PTSD may get worse. Dealing with them as soon as you are diagnosed might alleviate long term issues with PTSD. • PTSD symptoms can impact family life. PTSD symptoms can get in the way of your family life. You may pull away from loved ones, you may not be able to get along with others or even get angry or violent. • PTSD can be related to other health problems. PTSD can make physical health problems worse. For examples, studies have shown a relationship between PTSD and heart trouble. By getting help for PTSD you could also improve your physical health. • In 2012, more U. S. soldiers, seamen, airmen and marines died by their own hands than in battle. Suicide was the number one cause of death among U. S. troops that year.

19. Self-help tips for PTSD • Reach out to others for support. PTSD can make you feel disconnected to the rest of the world. You may want to withdraw from social activities as well as your loved ones. Consider joining a support group for other first responders who also suffer from PTSD. • Avoid alcohol and drugs. These substances make PTSD much worse over time. • Do not suffer in silence. Get the help you need. • Challenge your sense of helplessness by learning about trauma and PTSD, join a support group, practice relaxation techniques, pursue outdoor activities, confide in someone you trust, spend time with positive people, avoid alcohol and drugs, exercise regularly and enjoy the peace/quiet of nature often.

20. Everyone suffers from PTSD. Even the children.

21. Helping a loved one with PTSD • Be patient and understanding as getting better takes time, even when the person is committed to treatment for PTSD. Allow them to talk about the traumatic event over and over again. This is part of the healing process so avoid telling your loved one to “get over it” and move on. • Try to anticipate and prepare for PTSD triggers. Some common triggers are anniversary dates; certain places or people associated with the trauma; certain sights, sounds or smells. If you are aware of what triggers an upsetting reaction, you will be better able to support the person. • Do not take the symptoms of PTSD personally. Common symptoms of PTSD include emotional numbness, anger and withdrawal. If your loved one seems distant, irritable or closed off, this may have nothing to do with you or your relationship. • Do not pressure your loved one into talking. It can be very difficult for people with PTSD to talk about their traumatic experiences and you may even make things worse. Never force them to open up but let them know that you are there if they would like to talk.

22. For more information: • Contact Al Bender, Mental Health Counselor at fltleadaab2@att.net or at the Biblical Counseling Center 941-729-6600 • United States Department of Veterans Affairs website • http://www.ptsd.va.gov/ • Your local VA hospital • http://www.mycombatptsd.com/threads/today-i-finally-accepted-that-i-have-ptsd.903/ = website on Combat PTSD - a community for Veterans only as well as other threads