All right , welcome back everyone . Uh We , we're gonna now begin our sixth and final session today , which is titled Promising Practices For the Treatment of post traumatic stress disorder , PTSD in veterans and service members . This will be presented by Doctor Lisa Anne Karroo . Dr Lisa Ann Karroo is a clinical psychologist at the National Center for Post traumatic Stress Disorder at the White River Junction Veterans Affairs Medical Center in White River Junction , Vermont . Please join me in welcoming Doctor Karla . Hi everyone . It is nice to be with you today . Um And thanks for the intro , uh a little bit about how I sort of got to you all today is first and foremost , this is PTSD Awareness Month . And so I am happy to be with such a large group of people interested in PT care and learning more about treating veterans and active duty service members and learning just generally more about PTSD . So , thank you so much for hanging with me . I know this has been a long day and I am likely your last hour or close to your last hour . So thanks for being with me if um you can use the chat , you know , at NC PTSD where I work , um we answer questions related to PTSD care . So as long as I have access to the chat , I can make sure every single question you all ask during my talk will get answered . As long as you put your email in there or a way for me to contact you , I will happily reach out and provide you any answers . So I'm gonna see how I can move . One more thing is that yeah , if I have access to move these slidess , which I don't think , I , I think if you'll just say next slide , the folks will be happy to move forward for you . Sure , that's great . So um I have no disclosures or anything to disclose , but I will say this , the information that I share and present is information and my opinions alone . Um They do not reflect the department of Defense , the US government , the VA um or the National Center for PTSD , like any um federal employee . When we're giving talks , this information is my own to share with you , you can go to the next slide . So my hope for us today is to be able to learn more about the diagnostics of PTSD . So learning about the symptom clusters as well as some symptoms of PTSD um to be able to summarize key points of the Clinical Practice Guideline . And I have good news in that um the newest Clinical Practice guideline was just officially signed . And so it isn't even , I would say hot off the presses , but it hasn't even gone to the presses yet . So , in some ways , I'll be able to give you some insight on our newest VA Dod Clinical Practice guideline for PTSD . And then also share with you National Center Resources and education products to help all of you when you are working with active duty or veteran populations um related to understanding PTSD or helping them understand PTSD as well as their loved ones and families . You can go to the next slide but a little bit about us at the National Center for PTSD , our job is to advance the clinical care and Social welfare of America's veterans and others who have experienced trauma or who suffer from PTSD . And we do that through research , education and training in the science , the diagnostics and the treatment of PTSD and other stress related disorders . Go to the next slide , but we don't do it alone at the VA . In fact , lots of veterans don't receive services at the VA or receive most of their services , their health care services at VA . And so at NC PTSD , we have lots of partners , whether that's our DOD partners , but also our community partners to help provide best care related to PTSD . Go to the next line because what we know is that trauma exposure is really common . In fact , most people you meet every day will have experienced what we identify as a criterion , a stressor or in just regular terms of trauma . So , about 60% of men and 50% of women will have met that experience of having a traumatic event . And so that's sort of step . One of ptsd is identifying that someone has had a trauma , a traumatic experience in their lives . And you can see that that is true of most people . You can go on to the next , but it's not just having a trauma . That is what makes PTSD a mental health disorder . Um There's lots of symptoms that go along with that . So what you'll be able to see in some of my slides is that I have embedded links to trainings um or web pages or even talks related to some of the topics that I am going to talk about with . The hope that you guys will , you all will be able to have some access to these or screen grab so that you can check out some of these resources you can go to the next slide . So when we talk about trauma , the F and PTSD , the first thing we have to think about is does a person have a criterion , a stresser ? So was this person who's sitting in front of us , were they exposed to actual or threatened death , serious injury or sexual violence through the following ways , whether that was a direct personal experience , whether they witnessed someone experiencing um that that experience or they learned about it happening to a close family member or friend and that has to be in a violent or accidental way or they have repeated exposure um or extreme exposure through their jobs like first responders or medics . Um And so first we have to identify , did someone have this experience ? And then you can go to the next slide . But what we know is that um here in modern day , we use the word trauma in our everyday lives . You know , I was just talking to a friend this week and she told me that she got a bad haircut and she was like the trauma of looking in the mirror and seeing the bad haircut and having to have the conversation with the hairstylist that her haircut was bad . And all I kept thinking was as a trauma psychologist , like that's not trauma . But what we know is that there are hassles in everyday life , things like your car breaking down or getting a bad haircut or paying bills and having money be tight . But there's also um major life events stressor that happen in our lives , like losing a job , getting divorced , buying a new home , getting married . These are things that are also might , might be happy things in your life , but it still doesn't mean it doesn't cause us stress and then there are serious traumatic events . There are things like war zone exposure , physical or sexual assaults , childhood , physical abuse or sexual abuse , serious accidents , national disasters , natural disasters or torture . These are things that we would consider a criterion a a stressor or a serious traumatic event , you can click again . So these are those things are gonna be the things that we're talking about when we think about criterion A . But aside from criterion add , we also are looking at other symptom clusters of PTSD and there are four others . So one is re experiencing symptoms , the other would be um avoidance symptoms , negative alterations in cognition and mood and hyperarousal . Now , in PTSD , these clusters provide you sort of a buffet of symptoms and you don't have to have every symptom in that cluster . In fact , in re experiencing , you only need one but in al negative alterations in cognition and mood , you need two . So when we go to the next slide and you can go to the next one , you can see that there's lots of opportunities to meet the minimum criteria for each cluster , right ? But you can also see as you read some of these symptoms , diagnostics and PTSD are not easy . How do we , right ? Look at intrusive and distressing recollections as well as things like what is a psychological um a psychological distress related to a reminder , right ? Those are very nuanced differentials . And it is important when we're thinking about PTSD to be really thoughtful about how we're asking questions , follow up questions to be able to parse A parse apart what these symptoms are and how do we not , as my colleague calls it double zip into anyone's symptom . Um maybe accounting for more than one in any cluster . But as you can see , um in each cluster , there are multiple ways to be able to meet the criteria . What's important to acknowledge too is that some of these symptoms are not unique to PTSD while some are right . And so when you look at negative alterations in cognition and mood and arousal , you'll find that these symptoms probably look really familiar to you if you know anything about depression or other anxiety disorders . Um these are um symptoms that are pretty present while if you look at things like avoidance and intrusion , many of these seem very consistent and very linked to their trauma experience , you can go to the next slide . But if we know that a lot of people have criterion a experiences , right , that 60% of men and 50% of women , well , what do we know about how common ptsd is ? If we know that having criterion , a stressor is pretty common . And what we know is that many people after about a month after their cri Q and A event or that trauma , they're symptoms of PTSD start to dissipate or go down . And that's the typical reaction . While there are other people who can recover for a few months , their symptoms may be high and then they can have either you know , a natural recovery or recovery with the help of treatment . But if some people might have chronic ptsd , whether that's , they don't move forward with treatment or their symptoms persist , um , that those people will typically have a high level of PTSD symptoms . Now , what we know is that it's a , a small percentage of people who actually have PTSD , even though the percentage of people who have a criterion , a stressor is high , you could move to the next slide . But there are some things that we can do to help influence um the adoption of PTSD in people's lives . There's some things that we can't . So there's some personal factors that are not mutable and if we could change the traumatic event , we probably would do that , right ? And we wouldn't have people experience a traumatic event . But the recovery environment , we may have some ability to change or provide more support . So what we know is that people who have low self , low social support as well as other stressful life events or even more traumas are more likely to develop PTSD . And this makes sense when someone's baseline stress level is high , um it can make them have a predisposition to having PTSD . So you can go to the next line . And what we know is that that group of people who do get PTSD , right ? They often have one or more mental health problem . Most typically , among them being things like depression , anxiety disorders or substance use disorders . And actually a very small percentage , 20% of the people who have PTSD have no other mental health problem . And this is particularly notable if you are a mental health provider or you work very closely with mental health providers . When we talk about the complexity of PTSD patients , what we know is that there are many factors moving in and out of the clinical picture that can influence how well people do in PTSD treatment and of and oftentimes also how consistent or compliant they can be in the utilization of that treatment . You can go to the next slide . Thank you . And that often people with PTSD have other coo occurring problems . So those coo occurring problems can be like higher unemployment rates , reduced quality of life and increased risk , risk for suicide attempts , relationship , difficulties and difficulties at home or work . And that makes sense , right ? If we , if we think about that list of symptoms we just saw before , right , those 20 symptoms of PTSD and those four clusters , we know some of them were things like um anger problems with concentration , difficulty in connection and relationship with others , right ? Being on guard or keyed up . Those are things that influence your quality of life , your ability to work and maybe even difficulties in relationships . So we know that the symptoms of PTSD can often cause these coo occurring many social problems as well as having an increased risk for suicide attempts . You can go to the next slide . Thank you . Um But here is the good news is that um in the PTSD world , we have fairly good treatments for PTSD . And this is something that's sort of the good news or silver lining story . And I look forward to talking more about these treatments because it is the thing that I like to talk about most . And also it is the thing that makes you feel really efficacious as a provider . And even as someone who will be a good ambassador for PTSD treatment to be able to tell people a little bit about those treatments and also how well they typically work . So you can go to the next slide . So , like I said previously , we have a VA Dod Clinical Practice guideline for the management of PTSD . And in fact , um this guideline truly just got signed off on . I mean , I think we could probably count it in hours and days . That's how um recent this has been . But something that's important to note from any guideline um in mental health is that we're here to support clinical decision making with evidence based recommendations . This is not to define va or dod standards of care or policy . So in fact , this is just to support clinician judgment , support clinicians as they help their patients , veterans , active duty members , um make choices about treatment as well as give a nice synopsis of the literature on treatment you know , what works best , you can go to the next page . So here's something that hasn't changed , which is the screening of PTSD . And this is something that , um is highly suggested whether that is in an initial meeting , whether they , someone is in primary care or has come in specifically for PTSD treatment . If someone's coming in in primary care , there's the primary care screener for PTSD , it's a five item self report and it screens for PTSD and primary care positive of three or more . Um Yes , responses might be an indicator that something's going on related to PTSD . And maybe a referral to mental health might be a good idea if the , if your veteran or , or service member is willing . Now , there is also the PC L five . Now , this is really the gold standard self report measure for PTSD . It is um after identifying what that criterion , a trauma is at the top of the measure , it's a 2020 item scale that corresponds with the 20 symptoms of PTSD . It takes about 5 to 10 minutes and it's a screener , but there is a cut-off of about 31 to 33 . And if you're reaching higher than that cut off , it's likely that something is going on related to that event . And so the person is likely having symptoms and we wanna acknowledge that maybe he is talking more about it , understanding a bit more about their symptoms and how it's presenting in their life is gonna be an important sort of assessment to move forward with . Now , also on here , you can see that there's a link to the clinician administered PTSD scale for DS M or the CS five . Now , this is a clinician administered measure and this is really the gold standard diagnostic clinical measure for PTSD . Now it takes some training to learn how to do . Um at NC PTSD , we have a suite of about three trainings to help people train up to do the , the um the measure as well as if you are a clinician , we can provide you the measure . We just need to know that you are a mental health provider who has the appropriate credentials to be able to provide the training that I mean the measure and you should be sad and we can provide you with a link to it . In addition , you can get the PC L five and the PC PTSD five from National , the National Center for PTSD . And a bit later when I talk about resources , I'll share with you how to get it . You can go to the next slide . So this is where there is some change and you , if you click one more time , I think like a red circle should show up . So there we go . So in the previous guideline um and this is one , this slide is about is our 2017 guideline . They recommend individual manual trauma focused psychotherapies as the first line treatment for PTSD . And in fact , that has changed a bit in this new Clinical Practice guideline , what has remained the same is that individual um individual psychotherapy remains first line , but it's no longer in that umbrella component of trauma focused psychotherapies . In this new Clinical Practice guideline , they actually named the psychotherapies that are first line . And in fact , those are the ones that are circled in red . So it just so happened that those who had the most empirical support at the last Clinical Practice guideline , really their empirical support only grew . And so it was very evident that these three treatments should be first line . And so those include prolonged exposure , cognitive processing therapy , and eye movement , desensitization and reprocessing . And so those three treatments are first line treatments for PTSD in our newest Clinical Practice guideline . So the great news is that although there has been some change in what falls under first line , the things that were previously under first line , the three with the most empirical support sort of remain the first line treatments , you can go to the next slide and these treatments are very effective if you do trauma focused psychotherapy . But really when we think about these three best supported psychotherapies , these of the people who receive these psychotherapies , 53 out of 100 will no longer meet the clinical criteria for PTSD after about three months of treatment . Now , if they just took medication alone and those medications are really , um , SSR I , so that is , um , a Xer Paxil and I can think of the other . I am not a psychiatrist but I can look up the other for you . But these are the things , these are the treatments if they're just taking medication , um , only 42 out of 100 will no longer have PTSD after about three months of treatment . Now , here's the difference between medication and psychotherapy . After about three months , you're no longer in psychotherapy . And as long as you're living in the spirit of the treatment , you will not , you'll no longer have the diagnosis of PTSD while medication is typically a very long um clinical process , if not a forever clinical process to remain on these medications over time . Now , if you do no treatment , um , only about nine out of 100 people will no longer have PTSD after about three months . So once you meet that clinical criteria of PTSD , and it has been longer than a sort of one monthly way that we showed on that graph , on the graph slide . Once you sort of go outside that one month , the option for just a natural recovery is pretty slim and you can go to the next slide . But and also a really important part in thinking about great . Now , we know we have treatments that work and we know that we should be talking to our patients about treatments that work how do we actually do that ? And so some of this work is really borrowed from our colleagues , especially in oncology who are amazing at share decision making . And it is about how do we engage with our clients to help them make a decision about the treatments they want and about what effective treatment options are available . So first , it's about what are the options . And this might look different at different types of clinics and different types of locations with different types of providers . But what we should always be explaining to our patients is that there are treatments that work . This is what they are called , maybe they may be available , maybe some are only available where you are and some may mean that you have to change providers to get those treatments in order to have that availability . But we have to convey that choice exists and that they can choose to do none of those top three treatments or to choose medication or to choose another path . But we have to make them educated consumers within this process . So providing all of our information , reviewing all the treatment options , comparing effective treatments and talking about pros and cons and some of those pros and cons are real logistical things in our patients' lives . Those are things like , you know , I don't have child's care to be able to do an extensive amount of at home work outside of my session or I might have um really off hours at work . And so the time I have to be able to do work associated with this might be in the middle of the night . So anything that requires me to go to a store , to go out in the world might be really difficult for me to do . So , thinking about the pros and cons as they apply to the context that your patient is sort of living in and then support their deliberation , check their understanding and help them consider what matters most to them so that they can make a decision that honors the importance of all those things together , including the evidence about the treatments , but also the context in which our patients live . We go to the next slide . So to help with that , we have the PTST Decision Aid . So this is a place where you can learn about PTST treatments . You can go through the decision aid with patients , you can compare effective PTSD treatment options and sort of take the first steps to get started . Now sometimes if you're not working in mental health , um and you might be sort of the first face that someone sees when they say , I think I might have a problem or something is concerning to me . And I've been sort of ambivalent about treatment or debating about treatment . You can just give them this link . They don't have to go through it with a provider , but it is a way that a person can start initially looking . The reason I really love the decision . A is it has embedded videos , embedded fact sheets . So if someone is really just trying to soak up a lot of information , this is a great one stop shop for them and you can go to the next stage . But let's talk a little bit about what are the treatments that are in this decision aid and what are those treatments that we have persistently ? Time and time again said , have the most evidence . So , um first is prolonged exposure . Now , this is a treatment that is a specific type of cognitive behavioral therapy takes about three months , typically a little less . And it teaches our patients and our veterans , active duty member , active duty service members to gradually approach trauma related memories , feelings and situations that they've been avoiding since the trauma . So this is done through both an imaginal type of exposure as well as in vivo or real life exposures that's going to stores or going to places that are either an overestimation of danger or maybe our trauma reminders . And then in that imaginal exposure , they go through their trauma memory because what we know in prolonged exposure is that avoidance is typically the thing that keeps ptsd present in people's lives . So if avoidance is the thing that keeps PTSD present , we would want to attack that thing that keeps ptsd sort of persistent in people's lives . And part of that is instead of avoidance , we wanna approach and we do that through exposures and by confronting these challenges , you can decrease your PTSD symptoms and it has excellent results . Go to the next page . And so CPT is also one specific type of cognitive behavioral therapy . Now , anyone who um knows any information about traditional cognitive therapy or cognitive behavioral therapy , this is very consistent with traditional cognitive therapy . It teaches you how to evaluate and change the upsetting thoughts you have , you've had since the trauma and by changing these thoughts , you change your feelings . And so when you change how you feel , you then change how you act in the world and then knowing that because of a trauma , you can change the way you think about yourself about other people and the world , whether that was , you know , I thought I was a really capable person and that other people could be trusted and that the world was safe . I had this experience . And in fact , I don't feel capable , I don't feel like I can trust other people and the world is a dangerous place . So when we have these kinds of unhelpful thoughts , these are the things that keep people stuck in ptsd . Because if I think the world is not safe and I think the people around me can't be trusted , I'm not gonna be going out and doing a whole lot of things . And in fact , I'm gonna be avoiding a whole lot and because of that , they miss out on things in their lives , right ? But they also miss out on that corrective information that the world actually can be safe , that people can be trusted . And so CPT teaches you a new way to handle these upsetting thoughts by traditional C BT techniques and you can go to the next page . So E MD R also is um a type of trauma focused treatment that could help you process , upsetting memories , thoughts and feelings related to the trauma . And by processing these experiences , you can get relief from PTSD symptoms . Now , in E MD R , you pay attention to a back and forth movement or a sound while you recall in your mind , upsetting memories until a shift occurs in the way you experience these memories . Um And you have more information from the past about how to process this and how to think through this memory . Now , there's still some disagreement about how the mechanism of action works . It is trauma focused , but there's some disagreement related to the back and forth movement or the bilateral stimulation . So that's something to think about while you're having these conversations with patients . But it doesn't mean that the treatment doesn't work . It has great findings , you can go to the next page , but we also know that people may not be ready to come in and do trauma focused psychotherapy . They might not be their interest at this time or they might need to warm up a little bit to therapy . People might have lots of stigma related to mental health treatment and that feeling of like , I don't , I don't want people to know or I don't know if I really want to do this or even related to PTSD . And so part of this is to just think about how do we , how can we generally do some trauma informed care principles ? What does that look like and what are some things we can do in getting to know a patient or getting to know someone um to help them when we know they've experienced a trauma . So first , it's just to keep that in your awareness when you're doing , asking questions as well as doing things like asking permission . Um My life before working at NC PTSD is I was the military sexual trauma coordinator at the New Orleans VA . And while I was there , we talked a lot about how do you do trauma informed care in other areas of the hospital , in particular , um places that did physical examinations for MST , many of my patients were women , not all of them , but many of them were . And so in places like gynecology or primary care , how do we help those providers provide trauma awareness and trauma informed care in those medical rooms as well as , as my , my um psychology office and things like ensuring our patient's safety , things like being trustworthy . So asking for permission , um whether that's to do an exam to ask questions , to learn more or have follow up questions so that um our patients feel willing to share this information , providing lots of choice as well as collaboration to help get to a decision . And that sounds a lot like that shared decision making slide and then empower and recognize our patients strengths . And this is something that is really important in our PTSD patients because they have already experienced the worst event in their life , right ? That's their trauma and their criteria and a stressor . And so when we share with them , yes , you've experienced this and it has altered your life in the way you interact with the world . What it also shows me is you're especially strong , you're here at this appointment today , you're engaging in your life in lots of ways , whether that's with your family , your friends , for your good health , whether you're seeking out more help to try to get you a better life or a life that's more consistent with your values . These are all really important strengths . And so we want to acknowledge those because it is a really big deal for our patients and that there are cultural historical and gender issues that may be related to our person's trauma as well as their willingness to seek health care , especially mental health care . And we wanna acknowledge those , we wanna be very transparent about them and in acknowledging them , often times we dis we can disarm that a little bit and acknowledge that no history of anything is perfect . But when we bring it to the forefront , then we're willing to have a conversation about it . And when it in any way interferes or something related to these issues comes up in treatment , it's not taboo to talk about . In fact , it's something we should be talking about very readily go to the next page . So what we know is that um providing care to veterans and service members is not easy because context changes , right ? And context influences how people um come in and try to receive treatment of what is available to them . And so we have some information and resources um for particular groups and with professionals in mind , one is a community provider tool kit . So if you know that people are seeking treatment um in the community setting , this is one way where you can share information with that provider about ptsd care in the community and treating our veterans as well as our active duty service members in the community . And also what we know about rural health care and rural health care is um is a real passion of mine , even though today I live and , and I sit in Brooklyn , New York , which is home to me . Um I actually really love rural health . I and I have worked in rural health for many years in many different ways . And so we have a rural provider tool kit , which is also specifically talking about how do we get access , our patients , access to these treatments if they're living in pretty remote area areas ? You know , for you all , I think that's also interesting about , you know , how do we connect with , um , people who have made choices to live in more rural areas ? We know , like I just said , avoidance is sort of the fuel in the truck and not wanting to be around . People are thinking others in the world is dangerous . Those really add up to people , maybe making the choice to live further away from others and maybe outside the confines of the typical everyday life that other people have . And so thinking about that , um through our rural providers tool kit can be really helpful , you can go to the next page . So we also know that PTSD awareness can happen in any setting . Um We hope that everywhere there is the ability to acknowledge and be aware that um so many of the people that we treat may have had a trauma or may have PTSD . So this is a short video and Sibella is our associate Director of Education at NC PTSD . She is um so wise and she provides this sort of 15 minute video for just general medical center staff that can be the person who helps check our patients in , that could be the person who also may work in other jobs around the clinic , you know , whether that is in finance or other places , you know , whether they are part of our janitorial or maintenance staff , how do we help people just acknowledge that we can have PTSD awareness no matter what our position and work is . So , um so in some ways , I think this can be really helpful and it has a short facilitator guide next to it , to think about how can this be implemented where you work , You can go to the next slide . So I say buckle up because at NC PTSD , we have so many resources , we work very hard to try to provide as many as we can to um to not only those who treat veterans but active duty , but also the general population . What are ways that we can help you all provide best care and be good ambassadors of PTSD care . So you go to the next slide . So first and foremost , is our veterans crisis line . Um And I think you all have um are well aware of the suicide crisis line as well as any crisis that come up . They can call 24 hours , seven days a week and they will get a live person on the phone . And so please , if you are concerned , worried about anyone um related to suicidality , whether that I have a plan , intent or even a fleeting thought of hurting or killing themselves , hurting or killing someone else or they are just in crisis and need support they can feel free to call this line . Go to the next slide , please . Yeah . And yep , 988 . Absolutely is another option . Um , if you need to coach someone into care and this is especially can be true if , um , people are transitioning out of active duty or ambivalent and just sort of like want to take a flyer but aren't so connected with coming to the va for care . Um , or you get calls from family members of people you have previously treated or you previously have known and , and they're sort of ambivalent about getting into care . This is uh a place where you can call and get support to get them connected to the go to the next slide , please . So this is maybe my favorite NC PTSD resource and I will say this um wholeheartedly , I guess you're not supposed to have favorites , but I do . And here we are . Um , and so this is really a video library about , um , PT veterans sharing their story of having PTSD and FA families , sharing their stories about what it's like to be a family member with someone who has PTSD as well as providers , talking about what it's like to do evidence based treatments or PTSD and veterans are so generous to share their experience of going through these treatments . And in fact , we have just updated this site within the past like two or three weeks and we now also have specific pages for military , sexual trauma , as well as , um , racial trauma and any sort of de i related trauma . So , whether that's related to sexual orientation , um , how do we , um , really speak to veterans experiences who may have experienced trauma related to those issues and as well as how well those treatments have worked and what it was like to go through treatment . It is um , really humbling to acknowledge how hard it is to go through these treatments . And also on the other side , really celebrate with these veterans , the amazing gains they have made in their lives because they were willing to do that hard work and go through the treatment . And so I say , grab a Kleenex because you likely will be emotional going through it . But I also have to say , you know , I can talk about how treatments work and how well treatments work all day every day . But when our veterans and active duty service members hear it from one another , that treatments have worked and why it has worked and how it has changed them and how it has changed their families . They are our best endorsement for treatment . And so if you have someone who is a bit ambivalent about treatment or wants to learn more , but , you know , maybe is a bit suspicious of all of us as , as health care providers , um , this is a great resource to help them sort of move forward and think about how , how treatment might be helpful to them because they are very much like these veterans who have been so willing to share their story and go to the next page . We also have the ability to , um , send you all lots of PTSD materials for free . And so we have ones on understanding PTSD booklets as well as aging veterans and post traumatic stress . We have , um , all our booklets are also available in Spanish if you need that . But there's also other options to get um other pamphlets , posters for your office and more sort of like things like um magnets or other information . I can't call it swag . I have to call it promotional materials , but this is where you , if you go onto this website , you can be able to order and it will come to you free of charge . Um The only thing is that it does take some time to get to you . So , um just acknowledging that you can go to the next slide , we also have whiteboard videos . These are about 2 to 3 minute videos . Um And they're really about looking at certain aspects of engaging in PTSD care , whether that's learning about PTSD , learning about our first line treatments or just thinking about what is an evidence based treatment . What does that even mean ? How does something become evidence based or how do I make the decision between medication or talk therapy ? How can I make that choice ? And so , um , so these are some that might be really helpful . And if you only have a short amount of time with someone about three minutes is pretty easy to try to squeeze in versus some of our about face videos that can be up to 10 minutes . You can go to the next slide , you know , if you are a health care provider . Um I love this prescription for behavioral health plan pad which you can get on that um , link that I told you where you can get everything sent to you . Um And what this provides is a , is sort of a um , a prescription pad for all of our apps at the National Center for PTSD . And so you can see here , we have a nice cadre of apps that are all free and available via iphone or Android . You can see the little green like robot next to the ones that are Android as well as a computer for ones that are just um available via computer . And some of these are um companion apps , which means like um , co the one that is PE coach or CPT coach , those are used in conjunction with the treatment to sort of help keep all your paperwork in the same place and the ease of treatment . Now , there are others that are specifically about , but how do you build skills and those are things like um mindfulness coach or um , insomnia coach or PTSD family coach to help people build skills on their own , you can go to the next slide . So PTSD coach and this is one that I will just highlight for the sake of time is to acknowledge that like this is a sort of self driven um app about the education for PTSD . They can do some self assessment , they can learn some skills and they can get direct connection to crisis support . If that's important to them . It's used as just standalone education . It's not a companion app , but it might be the thing that helps people realize . Oh , wow , I'm doing these self assessments and I'm getting actually pretty high scores and this is might be a big deal . Maybe I should move forward in treatment and go to the next side as well as we have an online version . And so if you wanted to , um , you know , have someone who is maybe unwilling to put it on their phone for whatever reason , um , whether they have someone who's often in their phone like a child or someone like that , there's the ability to do , um , coach online , you can go to the next slide . We also have family coach app often times . Um , we have pro provide , we have patients , families reach out to us , they're looking for help , they're looking for support , even if their loved one isn't unwilling to get into treatment . At this point in time , this might be an option to be able to provide them some support and provide them with some skills right at their fingertips on their phone and go to the next slide . And so there's some veteran online training , things that might be applicable to your active duty service member . So that's like , how do we move forward ? What are some parenting skills , anger management , or even just a path to a better sleep ? I sort of came in on the tail end of the previous talk where we were talking about C BT I as the primary treatment for insomnia . And so a path to better sleep is not C BT I , but it , it does sort of elaborate on certain skills to help people develop healthy sleep habits . You can go to the next slide . We have over 50 hours of courses that are free ce us and so feel free to check out our continuing education um related to PTSD and PTSD care . Um And if you want to learn more about PTSD , this would be one of the first places that I would send . You , you can go to the next slide . And so at NC PTSD , we also have ways to stay connected whether that's to um the current research or clinical work that is coming through um new findings as well as things that are , um , that are often sort of like topic specific . So we'll have some topics that are things like anger or TB I . And then we'll have um , a research quarterly specifically related to those topics . So we encourage you to sign up and subscribe . It comes right to your email . And um oftentimes are great resources to keep you up to date on PTSD research and clinical work and go to the next slide . And so we have one hour consultations . Um These are a free one hour webinar that you can also get free ce us , these are a few that are coming up . One just happened yesterday that is on here . But if you want to learn more about um our new clinical practice guideline as well as new developments and prolonged exposure , which is one of those three treatments that is a primary or first line treatment for PTSD , encourage you to come to our consultations and you can sign up the link is above . You can go to the next slide . And so like I said before , June is PTSD Awareness . If you want information related to PTSD awareness . So we have a whole page on things you can do in your clinic , you can do in your personal life to help um raise awareness for PTSD . Feel free to please go to our page . We would love partners in PTSD Awareness Month to help raise awareness and and bring this to all different communities across the country . You go to the next slide . And so like I said before , there's national free ordering at the National Government printing office . So we can just go to the next slide and And again , these are some of the things that you can order there . So I hope some of the key takeaways of today are um you know , please screen or ask questions about PTSD . Know that there are effective treatment options , know a little bit about the symptoms of PTSD so that you can ask some good questions and just know that those of us at the National Center have lots of resources to help support you and your colleagues in this care and that we have a PTSD consultation program . So if you are treating a veteran at any point in the continuum of their health care and have questions related to PTSD , how do I ask this question to people who are coming into my office ? And I'm a nurse or a primary care doctor to how do I treat PTSD to ? I have this exceptionally complex patient . How can I get some help in consultation ? We answer all those questions at our consultation program . Go to the next slide and so here we are , here are some of my fabulous colleagues and our information for our consultation program . Please feel free to reach out . There's no question , too big or too small . You go to the next slide and then any questions from the group . I'm happy to answer . Thanks so much , Doctor Koo . That was a very impactful presentation . And we're excited that we were able to share all of those great resources with us today . I am getting just a little bit of an echo . So I don't know if maybe , oh , it seems to be gone now . That's great . All right . So , for our audience , um , now is the time if you haven't yet to start putting your questions in the chat , we do have a few minutes left to be able to help answer some of those . Let me just take a look and see , um , if I can clarify . So there's one question here , if treatment is effective is PTSD a lifelong diagnosis , if not , how does that affect veterans va ratings and claims so ? Great question . Oh , hi , Anthony . That is a tangled web . Um But I will answer the best I can , which is like I showed you on my slide , it's not a lifelong diagnosis . In fact , you can do a treatment like prolonged exposure , cognitive processing therapy and no longer meet criteria for PTSD . How that affects claims of veterans . Um That is really a veteran's benefit is so like the veteran , the VB A versus the VH A question , but I will do my best to answer a knowing that I am not a VB A employee , um which is that you would come in for a pen exam and at the time of the exam , they would do the evaluation for PTSD . And at that point , they would determine if you meet criteria for PTSD or not . Um In order for any claim to be decreased which is , I think what people feel most concerned about . Um that happens pretty rarely , I don't know the exact sort of percentage . But with that being said , even if it happens rarely , there are so many veterans who receive compensation and pension that um you know , it doesn't mean that it never happens . And so for any decrease , I would look to VB A for those numbers VA really focuses on the treatment of PTSD and the help of getting people to the life that they want . Super . Thank you so much for that . There is another question does having PTSD increase your risk factors for other conditions later in life ? Mhm So I think it depends on what conditions , right ? But we want to think about what is the course of PTSD look like for that person , right ? What we also said is that patients with PTSD typically have another mental health diagnosis and typically have other psychosocial stressors that happen in their life , like difficulty being able to maintain jobs or retain relationships . So what we know is that maybe if you can't maintain a job , health insurance is really hard , right ? And maybe you go to the doctor less or you know , you could be uh a person , a woman who had a military sexual trauma or any sexual trauma and going to the gynecologist is really triggering . And so you don't get medical treatment for certain things because of your ptsd and your trauma experience So , in some ways , it is very patient dependent on how it may influence you in the long term . But I would say typically , you know , when we talk about that 80% who have another co morbid mental health condition many times that is depression , substance use or an anxiety disorder . And so sometimes PTSD treatment can ameliorate those things and have those go down and sometimes it doesn't . And so you want to be good at assessing PTSD as well as being a good assessor of those other mental health disorders . Thanks for that . Absolutely . Uh One person asked , can you tell us more about getting trained to use the PC L five ? Mhm . So the PC L five is a self report measure . We have um ac eu related to how to utilize it and that is for sure . Um take up about one hour course , but because it's a self report measure for our patients . Um There isn't much besides recognizing the cut-off asking some really good questions related to their response style . But also I think there's the idea of the clinician administered PTSD scale or the caps , which is what you need . A little bit of training to learn how to do to administer to our patients . And there's three trainings on our NC PTSD website . Um And I am happy to send the link to those trainings . If you put your email in the um chat , I can just send it to you . I think that would be a great , a great link resource for probably everyone in our audience . If you want to put it in the chat as well later , I can try to do that for us . That'd be lovely . Yeah , let's see how well I am at multitasking , answering the questions and that's OK . Maybe the questions I'll put in there . Exactly . Answer the questions . Thank you so much . Um This is a good question that came through . I don't know if you're able to speak to it . Um , but it says knowing that exercise is as effective as sometimes medications for the treatment of PTSD has the VA considered reimbursement for gym . So here is what we know is that exercise is a great quality of life , um , intervention to help veterans with PTSD . But the data and the research on exercise as it compares to our first line treatments just is not there . And so I don't know about reimbursement for the gym . That is , um , N VA and I'm sure Dod World , there's the phrase that's way above my pay grade . Um , but so that's not , um , something I can comment on , but I can comment on the state of the research and it's just not there as compared to something like prolonged exposure or cognitive processing therapy , which have extensive amounts of randomized clinical trials . Great answer . I think that's lovely . And I think at least from my perspective in the world of lifestyle medicine . We encourage , um , individuals to find ways to move throughout their day , not just specifically at the gym because we recognize that not everybody has that access or financial ability . Yeah , I think about my rural veterans who might be driving through 30 40 minutes to , to get to something that maybe resembles a gym . Exactly . Uh , another person says , I love access to the consultation resource . Is it only available if working with veterans or can we access this support if working with foreign service members as well ? Yeah . So , um , we help support Dod or VA or anyone um , seeing veterans in the community . And in fact , sometimes we open our sort of like doors a bit wider in times of anything like during COVID-19 , we open to anyone who had any COVID-19 issues related to health care , providing health care or an assistance with PTSD , even if they weren't a veteran or active duty service member . Um , also during times of things like , um , mass shootings , unfortunately , things like wildfires , we open our doors to those sort of like nat natural disasters as well as manmade manmade disasters . That's perfect . All right . Well , I think we're just about at the end of our time block . So I did just want to say thank you again , Doctor Karla for that phenomenal presentation .