UNDERSTANDING COMPLEX PTSD Dr. Jim Peightel, MD, Psychiatrist

UNDERSTANDING COMPLEX PTSD Dr. Jim Peightel, MD, Psychiatrist

UNDERSTANDING COMPLEX PTSD Dr. Jim Peightel, MD, Psychiatrist Jen Collier, MSW, MOL, Womanspace Philadelphia Program Director Long term drug and alcohol treatment for homeless women Journey of Hope PABHH Division WOMANSPACE PHILADELPHIA 3c Level of Care

Chronic Homelessness Mental Health Conditions WOMANSPACE ADMISSION CRITERIA Therapeutic Community Group Treatment Evidence Based Practices Member Empowerment Milieu Treatment

Life Skill Development/ Habilitation Healthcare Navigation Psychiatric Consultation WOMANSPACE TREATMENT INGREDIENTS Adjusting to a unique setting Housing enticement/distraction Triggered and reactive to anger and rage

Quick to withdrawal/isolate Adjustment from homelessness survival strategies Early trauma history Family estrangement Substance use Poor self-image/ disassociation from body

Trouble managing interpersonal differences Mistrust Expectations from past psychiatric diagnosis and medications CHALLENGES DDAP requirements- seen within a week Continuity of medication Projections from residents about the role of a psychiatrist Expectations of diagnosis

Expectations of symptom relief PSYCHIATRIC CARE AT WOMANSPACE PROCESS of determining which disease, syndrome or condition explains a persons signs and symptoms INFORMATION comes from history, physical and diagnostic tests PURPOSE: find a common language, direct treatment, and inform prognosis DIAGNOSIS BPD CPTSD

PTSD Not part of this conversation Over-diagnosed DSM IV R- Rapid Cycling Ultra-rapid cycling not a diagnosis Focus on change in activity and mood Asymptomatic between episodes BIPOLAR DISORDER

First in DSM III in 1980, connected to Vietnam veterans Symptoms: avoidance and numbness, intensive memories, anxiety and emotions DSM 5 changes Negative impacts on thought patterns and mood are added Irritable or aggressive behavior Reckless and self-destructive behavior PTSD

A Personality Disorder Pervasive pattern of instability in interpersonal relationships, affect, and sense of self Diagnosis has stigma and has been avoided Has effective treatment-DBT, others BORDERLINE PERSONALITY DISORDER Can follow social and/or interpersonal trauma (including captivity and entrapment) Trauma over time, without escape

Reactions to sense of powerlessness- learned helplessness or learned hypervigilance Rage turned inward or outward Avoidance Low self-esteem Dissociation, but often intact core sense of self Less para-suicidal behavior COMPLEX PTSD

PTSD Complex PTSD One or few traumas Chronic inescapable traumas Nightmares Night terrors and chronic insomnia Avoidance of reminders

Hypervigilance Social isolation, avoidance of relationships Exaggerated startle reflex Hypervigilance, pre-occupation with abuser No filter, easily overwhelmed PTSD VERSUS COMPLEX PTSD Borderline Personality Disorder Complex PTSD

Avoidance of abandonment Withdrawal from relationships Chaotic affect Rage/ hyper-reactive affect Poorly defined sense of self Defended sense of self Para-suicidal behaviors

Distorted survival strategies BPD VERSUS COMPLEX PTSD Case FOR C-PTSD Studies suggest symptoms different enough Provides focus on sustained developmental trauma-different etiology 25% of BPD report no trauma history Case AGAINST C-PTSD Some studies suggest etiology not different enough

Conversation focused on etiology not symptoms 75% of people with BPD do have trauma history Studied and revisited in DSM 4 and 5 ICD II Symptom severity spectrum Treatment focus-affect regulation, self-esteem, anger-management, less on self-harm

Directs treatment setting and approach Lots of treatment overlap Managing angry outbursts Staff training on trauma-informed care Choice-based programming and interventions Focus on self-worth

Skill development, especially through DBT and Seeking Safety Interpersonal focus, use of SCT Case-consultations TAILORING TREATMENT AT WOMANSPACE Understanding substance use patterns (numbing vs. boredom) Understanding of Therapeutic Community Community integration

Lifestyle health and wellness Smoking cessation NEXT STEPS History: 1980, DSM 3 2013: DSM 5, RDoC BACK TO DIAGNOSIS Understanding of impact of sustained trauma on individuals We can impact prevalence (all 3 diagnosis) through public health preventive measures

City focus on social determinants of mental health GOOD NEWS Research Domain Criteria Social Determinants of Mental Health Negative Valence Systems Social Exclusion and Discrimination Adverse Early Life Experiences Positive Valance Systems

Poor Education Unemployment/ Underemployment Cognitive Systems Job insecurity Social Processes Income inequality

Poverty Arousal and Regulatory Systems Neighborhood Deprivation Food Insecurity Poor Housing/ Housing Instability Adverse Features of the Built Environment Poor Access to Mental Health Care GOOD NEWS

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