An Overview Of Post-An Overview Of Post-Traumatic Stress Traumatic Stress

Disorder in the College Disorder in the College SettingSetting

Tracy A. Clemans, PsyD.Tracy A. Clemans, PsyD.

VISN 19 Eastern Colorado Healthcare VISN 19 Eastern Colorado Healthcare SystemSystem

Mental Illness Research, Education and Mental Illness Research, Education and Clinical CenterClinical Center

ObjectivesObjectives

General overview of PTSDGeneral overview of PTSD

Overlap between PTSD and TBIOverlap between PTSD and TBI

Overview of PTSD in College StudentsOverview of PTSD in College Students Overview of PTSD in Student VeteransOverview of PTSD in Student Veterans

Accommodating Students with PTSDAccommodating Students with PTSD

Resources- Colorado, Wyoming, Resources- Colorado, Wyoming, NationalNational

www.ncptsd.va.govwww.ncptsd.va.gov

How common is PTSD?How common is PTSD?

60% of men and 50% of women experience at least one lifetime traumatic event.

Approximately 8% of men and 20% of women will develop PTSD.

Women = 2 x riskWomen = 2 x risk

www.ncptsd.va.govwww.ncptsd.va.gov

Definition of PTSDDefinition of PTSD

An anxiety disorder An anxiety disorder resulting from exposure resulting from exposure to an experience to an experience involving direct or involving direct or indirect threat of indirect threat of serious harm or death; serious harm or death; may be experienced may be experienced alone (rape/assault) or alone (rape/assault) or in company of others in company of others (military combat)(military combat)

PTSD StressorsPTSD Stressors

Violent human assaultViolent human assault

Natural catastrophesNatural catastrophes

AccidentsAccidents

Deliberate man-made disastersDeliberate man-made disasters

APA, 1994APA, 1994

Symptoms of PTSD

Recurrent thoughts of the eventRecurrent thoughts of the event

Flashbacks/ NightmaresFlashbacks/ Nightmares

Emotional numbness (Emotional numbness (““it donit don’’t mattert matter””); reduced interest or ); reduced interest or involvement in work or outside activitiesinvolvement in work or outside activities

Intense guilt or worry/anxietyIntense guilt or worry/anxiety

Angry outbursts and irritabilityAngry outbursts and irritability

Feeling Feeling ““on edge,on edge,”” hyperarousal/ hyper-alertness hyperarousal/ hyper-alertness

Avoidance of thoughts/situations that remind person of the Avoidance of thoughts/situations that remind person of the traumatrauma

APA, 1994APA, 1994

Duration of PTSDDuration of PTSD

- To meet criteria for PTSD, symptom - To meet criteria for PTSD, symptom duration must be at least one month duration must be at least one month

AcuteAcute PTSD: duration of symptoms PTSD: duration of symptoms is less than 3 monthsis less than 3 months

ChronicChronic PTSD: duration of PTSD: duration of symptoms is 3 months or moresymptoms is 3 months or more

- Often, the disorder is more severe - Often, the disorder is more severe and lasts longer when the stress is of and lasts longer when the stress is of human design (i.e., war-related human design (i.e., war-related trauma)trauma)

PTSD is a failure to adaptPTSD is a failure to adapt It’s adaptive for people to have strong It’s adaptive for people to have strong

reactions to a traumatic event.reactions to a traumatic event. If you are being chased by a ferocious dog, If you are being chased by a ferocious dog,

it’s adaptive if you run away.it’s adaptive if you run away. It’s your body’s way of protecting you.It’s your body’s way of protecting you. Over time we want to see these behaviors Over time we want to see these behaviors

decrease. (avoidance)decrease. (avoidance) PTSD is a failure to adapt PTSD is a failure to adapt because extreme because extreme

reactions occur even when there is no reactions occur even when there is no threatthreat..

www.ncptsd.va.govwww.ncptsd.va.gov

Potential Consequences of Potential Consequences of PTSDPTSD

Physiological ConcernsPhysiological Concerns

Physical complaints are often treated Physical complaints are often treated symptomatically rather than as an symptomatically rather than as an indication of PTSDindication of PTSD

www.ncptsd.va.govwww.ncptsd.va.gov

Potential Consequences of Potential Consequences of PTSDPTSD

Social and InterpersonalSocial and Interpersonal

Problems:Problems:- - Relationship issuesRelationship issues

- Low self-esteem- Low self-esteem

- Alcohol and substance - Alcohol and substance abuse abuse

- Employment problems- Employment problems

- Homelessness- Homelessness

- Trouble with the law- Trouble with the law

- Isolation- Isolation

www.ncptsd.va.govwww.ncptsd.va.gov

Potential Consequences of Potential Consequences of PTSDPTSD

Self-Destructive & Dangerous Self-Destructive & Dangerous Behaviors:Behaviors:

- - Substance useSubstance use

- Suicidal attempts- Suicidal attempts

- Risky sexual behavior- Risky sexual behavior

- Reckless driving- Reckless driving

- Self-injury- Self-injury

APA, 1994APA, 1994

““Complex PTSDComplex PTSD””

Long-term, prolonged (months or years), Long-term, prolonged (months or years), repeated trauma or total physical or repeated trauma or total physical or emotional control by anotheremotional control by another

Concentration camps Prisoner of war

Prostitution brothels Childhood abuse

Long-term, severe domestic or physical abuse

www.ncptsd.va.govwww.ncptsd.va.gov

Comorbid/Coexisting Comorbid/Coexisting ProblemsProblems

Individuals with PTSD are also at risk for: Individuals with PTSD are also at risk for: Depression and AnxietyDepression and Anxiety Substance abuseSubstance abuse Spectrum of severe mental illnesses Spectrum of severe mental illnesses Aggressive behavior problemsAggressive behavior problems Sleep problems like nightmares, Sleep problems like nightmares,

insomnia or irregular sleep schedulesinsomnia or irregular sleep schedules Acquired Brain Injury Acquired Brain Injury

- Traumatic Brain InjuryTraumatic Brain Injury

PTSD and TBI PTSD and TBI Symptom OverlapSymptom Overlap

Emotional lability Emotional lability

Difficulty with attention and concentrationDifficulty with attention and concentration

Amnesia for the eventAmnesia for the event

Irritability and angerIrritability and anger

Difficulty with over-stimulation (e.g., lights, Difficulty with over-stimulation (e.g., lights, noises)noises)

Social isolation/difficulty in social situationsSocial isolation/difficulty in social situations

dvbic.orgdvbic.org

TBI TBI PTSD PTSD

Research shows that Research shows that among TBI patients among TBI patients who have a memory for who have a memory for the event, they were the event, they were more likely more likely to develop to develop PTSD than those with PTSD than those with no memoryno memory

Psychological Psychological problems with College problems with College

StudentsStudents 38% Depression38% Depression 40% Anxiety40% Anxiety 9% Non-suicidal self-injury9% Non-suicidal self-injury 11% Substance abuse/ dependence11% Substance abuse/ dependence 7% Eating disorders7% Eating disorders 15% Suicidal thoughts & behaviors15% Suicidal thoughts & behaviors(AUCCCD, 2011)(AUCCCD, 2011)

Trauma in Trauma in College StudentsCollege Students

Prevalence of traumatic events Prevalence of traumatic events 67%- 84%67%- 84%

Rates of current PTSD 6 – 17% Rates of current PTSD 6 – 17% This is a higher rate than the This is a higher rate than the

general populationgeneral population College women are at greatest risk College women are at greatest risk

for specific traumas such as sexual for specific traumas such as sexual & interpersonal violence & interpersonal violence (Smyth et al., 2008)(Smyth et al., 2008)

Read et al. Study Read et al. Study (2011)(2011)

66% students reported exposure 66% students reported exposure to traumato trauma; 9% had PTSD; 9% had PTSD

25% reported physical assault; 7% 25% reported physical assault; 7% reported sexual assault (11% reported sexual assault (11% women, 2% men)women, 2% men)

Most common traumas: Life-Most common traumas: Life-threatening illness & sudden/ threatening illness & sudden/ expected death of loved one (1/3 of expected death of loved one (1/3 of sample)sample)

Now to make things even Now to make things even more complicated…more complicated…

A look at Student A look at Student VeteransVeterans

Impact on Impact on Colleges & UniversitiesColleges & Universities Between 1.8 – 2.1 million troops have Between 1.8 – 2.1 million troops have

deployed for Global War on Terrordeployed for Global War on Terror

900,000 OIF/ OEF Veterans have 900,000 OIF/ OEF Veterans have separated from active duty since the separated from active duty since the beginning of warbeginning of war

42% seeking care from Department 42% seeking care from Department of Veterans Affairsof Veterans Affairs

Student VeteransStudent Veterans

Veterans and military Service Veterans and military Service Members who are active duty or Members who are active duty or in the reserves who are enrolled in the reserves who are enrolled in postsecondary education.in postsecondary education.

Over 660,000 undergraduate Over 660,000 undergraduate students are Veterans-- 3% of all students are Veterans-- 3% of all undergraduates. undergraduates. (National Center for PTSD, 2012)(National Center for PTSD, 2012)

Student VeteransStudent Veterans 215,000 undergraduate students are active 215,000 undergraduate students are active

duty or in the reserves--1% of all duty or in the reserves--1% of all undergraduates.undergraduates.

Increasing number are using GI Increasing number are using GI (Government Issued) education benefits for (Government Issued) education benefits for postsecondary education.postsecondary education.

40% of military Service Members were using 40% of military Service Members were using Veteran education benefits in 2007-2008. Veteran education benefits in 2007-2008. (National Center for PTSD, 2012)(National Center for PTSD, 2012)

Characteristic ofCharacteristic ofStudent VeteransStudent Veterans

73% of student Veterans are 73% of student Veterans are male; 27% are female.male; 27% are female.

Only 15% are traditionally aged Only 15% are traditionally aged college students (18-23).college students (18-23).

31.4% are age 24 - 29.31.4% are age 24 - 29. 28.2% are between the ages of 28.2% are between the ages of

30 - 39.30 - 39. 24.9% are 40 or older. 24.9% are 40 or older. (National Center for (National Center for

PTSD, 2012)PTSD, 2012)

What will you see?What will you see?

““Signature Injuries” from GWT:Signature Injuries” from GWT:

1. Physical injuries from blasts (burns, 1. Physical injuries from blasts (burns, amputations, orthopedic injuries)amputations, orthopedic injuries)

2. Operational Stress Injuries/ Mental 2. Operational Stress Injuries/ Mental Health Injuries (PTSD)Health Injuries (PTSD)

3. Traumatic Brain Injury3. Traumatic Brain Injury

PTSD in VeteransPTSD in Veterans Of those receiving VA care, 45% Of those receiving VA care, 45%

have an initial diagnosis of PTSD. have an initial diagnosis of PTSD. (Kang, 2009)(Kang, 2009)

20% of recent Veterans experience 20% of recent Veterans experience PTSD and depression PTSD and depression (RAND Corporation, 2011)(RAND Corporation, 2011)

10 years of combat have resulted 10 years of combat have resulted in escalated rates of PTSD, in escalated rates of PTSD, substance abuse, depression, and substance abuse, depression, and suicide suicide

(U.S. Department of Defense, 2010).(U.S. Department of Defense, 2010).

DVBIC, 2005DVBIC, 2005

TBI due to Blast InjuriesTBI due to Blast Injuries

Armed forces are sustaining Armed forces are sustaining attacks by rocket-propelled attacks by rocket-propelled grenades, improvised explosive grenades, improvised explosive devices, and land mines almost devices, and land mines almost daily in Iraq and Afghanistandaily in Iraq and Afghanistan

Injured soldiers require specialized Injured soldiers require specialized care acutely and over timecare acutely and over time

National Center for National Center for Veterans Studies SurveyVeterans Studies Survey

11stst national survey for student national survey for student VeteransVeterans

Online survey (all but 4 states)Online survey (all but 4 states) 628 student Veterans participated628 student Veterans participated Exploration of their emotional Exploration of their emotional

adjustment, psychological adjustment, psychological symptoms, and suicide risksymptoms, and suicide risk

National Center for National Center for Veterans Studies SurveyVeterans Studies Survey

Results:Results:

34.6 % Severe Anxiety34.6 % Severe Anxiety

45.6% Significant symptoms of PTSD45.6% Significant symptoms of PTSD

23.7% Severe Depression23.7% Severe Depression

National Center for National Center for Veterans Studies Veterans Studies

SurveySurveyResults:Results:

46 % suicidal thoughts, 20 % suicidal 46 % suicidal thoughts, 20 % suicidal plan, 10.4% “thinking about suicide plan, 10.4% “thinking about suicide often or very often”often or very often”

7.7 % Suicide attempt in past7.7 % Suicide attempt in past

3.8 % Suicide attempt likely in future3.8 % Suicide attempt likely in future

Take Home messageTake Home message

Large numbers of student Large numbers of student Veterans are experiencing Veterans are experiencing significant psychiatric symptomssignificant psychiatric symptoms

Considerable number of Considerable number of student Veterans at student Veterans at heightened risk for Suicide!heightened risk for Suicide!

Working with students Working with students

with PTSD:with PTSD:

What is important What is important

to remember?to remember?

Remember…Remember…

Not every student with PTSD will Not every student with PTSD will require adjustments or require adjustments or accommodationsaccommodations

Others may only require a few Others may only require a few modifications modifications (Shea, 2010)(Shea, 2010)

Remember…Remember… Veterans with new injuries are justVeterans with new injuries are just

developing an understanding developing an understanding of how their disability is impacting of how their disability is impacting their learningtheir learning

Most do not identify with the term Most do not identify with the term “disabled”“disabled”

Mental health stigma- significant Mental health stigma- significant within Militarywithin Military

Acceptance of Acceptance of Disability StatusDisability Status

Asking for help and view of their Asking for help and view of their disability is often seen as a disability is often seen as a sign of sign of weaknessweakness

Psychological process for accepting Psychological process for accepting disability status may take timedisability status may take time

Student Veterans are also Student Veterans are also reintegrating into social and family reintegrating into social and family lives while going back to schoollives while going back to school

Remember…Remember… May not yet have a disability rating from May not yet have a disability rating from

the VA, and the VA, and they incorrectly assume they incorrectly assume this disqualifies them from receiving this disqualifies them from receiving services/ accommodations.services/ accommodations.

Bringing disability services, education, Bringing disability services, education,

and awareness to the attention of and awareness to the attention of student Veterans is student Veterans is critically critically importantimportant..

Factors impacting Factors impacting willingness to seek serviceswillingness to seek services

Non-combat injuries:Non-combat injuries:

Veterans who sustained non-Veterans who sustained non-combat injuries may be reluctant to combat injuries may be reluctant to discuss due to shamediscuss due to shame

““I don’t deserve help…my buddy I don’t deserve help…my buddy was hurt in combat and I wasn’t.”was hurt in combat and I wasn’t.”

Accommodations & Tips Accommodations & Tips for College Students for College Students

with PTSDwith PTSD

Accommodation Accommodation ConsiderationsConsiderations

Veteran integrating into Veteran integrating into care within VA care within VA

• It can take It can take monthsmonths for for Veterans to get Veterans to get appointments at VAappointments at VA

• Especially disability Especially disability evaluation and therapy evaluation and therapy appointmentsappointments

• Flexibility from Flexibility from professors due to these professors due to these reasons will reduce reasons will reduce stressstress

• These appointments are These appointments are important for their care!important for their care!

Accommodation Accommodation ConsiderationsConsiderations

Coping with Stress Coping with Stress

• Additional time for Additional time for assignmentsassignments

• Allow students to take a Allow students to take a short break short break (5-10 min) (5-10 min) during class sessionsduring class sessions

• Permit Permit flexibilityflexibility in in class session class session attendance schedules attendance schedules as long as absences do as long as absences do not conflict with core not conflict with core class requirementsclass requirements

Accommodation Considerations

Dealing with Emotions Dealing with Emotions

• Provide education about Provide education about college counseling college counseling services, VA services, and services, VA services, and Vet centers to students Vet centers to students

• Allow for a Allow for a support support animalanimal

• Allow telephone calls to Allow telephone calls to doctors, counselorsdoctors, counselors

• Encourage the student to Encourage the student to walk away & take a walk away & take a break break if an unhealthy if an unhealthy interaction is occurring interaction is occurring

Accommodation Considerations

Panic Attacks Panic Attacks

• Allow for a break or Allow for a break or place to go place to go to use to use relaxation relaxation techniques techniques or or contact a support contact a support personperson

• Identify and Identify and remove remove environmental environmental triggers triggers if possibleif possible

General Tips-for Flashbacks

EEncourage them to keep their eyes open. ncourage them to keep their eyes open. Have them look around the room and notice Have them look around the room and notice where they are.where they are.

Remind the student where they are, what Remind the student where they are, what year it is, and that they are safe. year it is, and that they are safe.

Have them get up and move around if Have them get up and move around if necessary. necessary.

Have them get a drink of water and splash Have them get a drink of water and splash water on face.water on face.

General Tips-for Flashbacks

Display calmnessDisplay calmness

Provide reassuranceProvide reassurance

Orient to present (flashbacks will take a Orient to present (flashbacks will take a person to the “past”)person to the “past”)

Allow them to take a break, or call Allow them to take a break, or call someone as necessarysomeone as necessary

Can students recover from PTSD?

Keane, et.al., 2006Keane, et.al., 2006

Yes, therapy can work!Yes, therapy can work!

People CAN recover from PTSD.

Empirically Supported Trauma-Focused Therapies

Prolonged Exposure (PE)

Cognitive Processing Therapy (CPT)/ Cognitive Behavioral Therapy

Eye Movement Desensitization & Reprocessing (EMDR)

Identifying PTSD Identifying PTSD Treatment SpecialistsTreatment Specialists

Expert therapists

Psychiatrists (MD/DO)

Clinical Psychologists (PhD./PsyD.)

Social Workers (LCSW/MSW)

Psychiatric Nurse

They should have specialized experience in treating PTSD.

Resources for Students with PTSD

Encourage students to utilize their university Encourage students to utilize their university counseling center (often times free)counseling center (often times free)

Encourage students to contact their insurance Encourage students to contact their insurance provider for a list of therapists who specialize in PTSD provider for a list of therapists who specialize in PTSD treatmenttreatment

Try to find a therapist who specializes in: Cognitive Try to find a therapist who specializes in: Cognitive behavioral therapy (CBT); Cognitive Processing behavioral therapy (CBT); Cognitive Processing Therapy (CPT); Prolonged Exposure therapy (PE); or Therapy (CPT); Prolonged Exposure therapy (PE); or eye movement desensitization and reprocessing eye movement desensitization and reprocessing (EMDR).(EMDR).

Key PointsKey Points

PTSD is more common in college PTSD is more common in college students and student Veterans students and student Veterans compared to general populationcompared to general population

Suicide risk is increased with PTSDSuicide risk is increased with PTSD

Accommodations can help reduce Accommodations can help reduce stressors improving academic successstressors improving academic success

PTSD can be treated successfullyPTSD can be treated successfully

Resources for Student Veterans

• Veteran’s Affairs services: www.va.gov

• National Centers for PTSD www.ncptsd.va.gov or www.ncptsd.org

• VA Health Benefits Service Center 1.877.222.VETS or 1.800.827.1000

• Vet Centers’ national number 1.800.905.4675

• PTSD support groups can be located through VA, National Alliance for Mental Illness (NAMI), or About.com’s trauma resource page

• Department of Health Services- in the blue government pages of the phone book

National Resources for Student Veterans

• Veteran’s Affairs services: www.va.gov

• National Centers for PTSD www.ncptsd.va.gov or www.ncptsd.org

• VA Health Benefits Service Center 1.877.222.VETS or 1.800.827.1000

• Vet Centers’ national number 1.800.905.4675

• PTSD support groups can be located through VA, National Alliance for Mental Illness (NAMI), or About.com’s trauma resource page

• Department of Health Services- in the blue government pages of the phone book

PTSD Resources for Student Veterans in Wyoming

Cheyenne VA MedicalCheyenne VA Medical Phone: 307-778-7550 or 888-483-9127Phone: 307-778-7550 or 888-483-9127 PTSD Clinical Team (PCT) OutpatientPTSD Clinical Team (PCT) Outpatient Irena Danczik, MD  (307) 778-7650Irena Danczik, MD  (307) 778-7650

Sheridan VA Medical CenterSheridan VA Medical Center Phone: 307-672-3473 Or 307-672-3473Phone: 307-672-3473 Or 307-672-3473 PTSD Domiciliary (PTSD Dom) Intensive/InpatientPTSD Domiciliary (PTSD Dom) Intensive/Inpatient John Slaughter, LCSW  (307) 675-3638 John Slaughter, LCSW  (307) 675-3638

Brain Injury Alliance of Wyoming--Casper, WYBrain Injury Alliance of Wyoming--Casper, WY 307-473-1767 or 800-643-6457307-473-1767 or 800-643-6457

Easter Seals Wyoming--Acquired Brain Injury Easter Seals Wyoming--Acquired Brain Injury Program--Sheridan, WY Program--Sheridan, WY

307-674-1639307-674-1639

Wyoming Department of Health--Cheyenne, WY Wyoming Department of Health--Cheyenne, WY 307-777-7656, 866-571-0944307-777-7656, 866-571-0944

TBI Resources for Student Veterans in Wyoming

PTSD Resources for Student Veterans in Colorado

Colorado Springs ClinicColorado Springs Clinic Phone: 719-327-5660 Or 719-327-5660Phone: 719-327-5660 Or 719-327-5660   Women’s Stress Disorder Treatment Team (WSDTT) Women’s Stress Disorder Treatment Team (WSDTT)

OutpatientOutpatient Nancy Galbraith  (719) 667-4406Nancy Galbraith  (719) 667-4406

Grand Junction VA Medical CenterGrand Junction VA Medical Center Phone: 970-242-0731 Or 866-206-6415Phone: 970-242-0731 Or 866-206-6415 PTSD Clinical Team (PCT) OutpatientPTSD Clinical Team (PCT) Outpatient Heather Martinez  (970) 263-2824Heather Martinez  (970) 263-2824

Resources for Student Veterans in Colorado

VA Eastern Colorado Health Care VA Eastern Colorado Health Care System(ECHCS)System(ECHCS)

Phone: 303-399-8020Phone: 303-399-8020

   Women’s Stress Disorder Treatment Team (WSDTT) Women’s Stress Disorder Treatment Team (WSDTT)

OutpatientOutpatient David Kartchner  (303) 399-8020 X 3243David Kartchner  (303) 399-8020 X 3243

   PTSD Residential Rehabilitation Program (PRRP) PTSD Residential Rehabilitation Program (PRRP)

Intensive/InpatientIntensive/Inpatient Renee Labor, LCSW  (303) 399-8020 X 3890Renee Labor, LCSW  (303) 399-8020 X 3890

Internet Resources for Students with PTSD

Sidran Institute Help Desk- find therapists who specialize in Sidran Institute Help Desk- find therapists who specialize in trauma treatment (410) 825-8888trauma treatment (410) 825-8888

Anxiety and Depression Association of American- finds Anxiety and Depression Association of American- finds therapists by location and mental health disordertherapists by location and mental health disorder

EMDR International Association finds professionals who EMDR International Association finds professionals who provide EMDRprovide EMDR

Internet Resources for Students with PTSD

American Psychological Association (find a therapist)American Psychological Association (find a therapist)

Psychology Today (find a therapist)Psychology Today (find a therapist)

Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services Administration (SAMHSA) offers a mental health Administration (SAMHSA) offers a mental health services locator by location and type of facility services locator by location and type of facility (inpatient, outpatient, residential)(inpatient, outpatient, residential)

Hotline Resources forCollege Students

National Suicide Prevention LifelineNational Suicide Prevention Lifeline 1-800-273-TALK (1-800-273-8255)1-800-273-TALK (1-800-273-8255)

Treatment Referral Hotline (Substance Abuse)Treatment Referral Hotline (Substance Abuse) 1-800-662-HELP (1-800-662-4357)1-800-662-HELP (1-800-662-4357)

National Sexual Assault HotlineNational Sexual Assault Hotline 1-800-656-HOPE (1-800-656-4673)1-800-656-HOPE (1-800-656-4673)

Questions?

Thank You

Tracy.Clemans@va.gov