Transcript The DX. And RX. Of TBI/PTSD in OIF/OEF Veterans

DX and RX of TBI and PTSD in
OIF/OEF Veterans
Chrisanne Gordon, M.D.
Jeremy D. Kaufman, Psy.D.
Director of Psychological Health, Ohio
National Guard
Map of Ohio Deployment
Health concerns of War and
re-entry home
Every War has its own:
1. Injuries
2. Illnesses
3. Drugs
4. Technologies
5. Personalities
Vietnam
• SCI – establishment of SCI research
• Agent Orange – Cancer, DM, Neuropathy,
TBI?
• Drugs of choice – Downers:
Heroin; Marijuana; ETOH
Gulf War – ALS 1. Incidence – 1.6 X general population.
2. Etiology – Sarin? Pesticides?
Pyridostigmine BR?
OIF/OEF –
TBI/multiple amputations
1.ARMOR – more survive, but multiple
amputations; severe burns
2.TBI/PTSD/“MUSH” syndrome.
3.Drugs of choice – Uppers:
methamphetamine, caffeine, cocaine
National Council on Disability: March 2009
Established the HALLMARK pathologies of
OIF/OEF:
Operation Iraqi Freedom
Operation Enduring Freedom
20%- 25% TBI
1. BLAST INJURY – IED; RPG; Motar
2. VEHICULAR ACCIDENTS -MRAP
3. FALLS- Terrain
4. OTHER- Hits on head during night drills
TBI incidence supported by HOGE –NEJM
July 2004
TBI Incidence Disputed by HOGE – NEJM
January 2008
• 25% - Women Report Sexual Abuse
• TRIAD: TBI, PTSD, PAIN
• Suicide:
current rates highest in 2 decades
Note: National Guard; Reserves omitted
Every Day 18 6500/yr.
GSW; MVA;
Discussion of BRAIN
SYNDROME• TBI vs. Concussion
- TBI – insult to the brain from
external mechanical force.
- Concussion – injury due to shaking,
spinning, or blow.
- Playing field injury is NOT a
battlefield injury.
HALLMARKS of TBI –
midbrain/frontal injuries
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Sensory processing alterations
a. Photophobia
b. Hyperacusis –
c. Sensory overload – ie., Meijer
Syndrome
Loss of Mapping skills.
Pituitary Dysfunction.
Chronic Headaches.
CAFFEINE CONTENT of DRINKS
Adding to Brain Insults
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Coffee
Cola
Mt. Dew
Rockstar
RAGE/WYD
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100 mg.
35-45 mg.
120 mg.
160 mg.
200 mg.
Caffeine impairs Brain glucose utilization –
up to 20 drinks/day ingested in Iraq
BONUS Drink Include:
• RED BULL
• Red BULL
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80 mg/Phenylalanine
Germany – Cocaine
Long term increased ingestion of caffeine
may deplete cortisol/adrenalin
Diagnosis of TBI
Listen to the Patient: He is telling you the
diagnosis.
Sir William Osler
TBI Diagnosed by HISTORY.
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Radiologic Studies: Timing/Technique
1. CT/MRI – Notoriously Negative – VA standard
2. Diffusion Tensor Imaging – Gold
Standard
Lipton et al. Radiology Aug. 2009 (DAI)
3. PET- SPECT - Hovda UCLA -2007
4. fMRI –brain mapping
Most veterans tested 1-4 yrs. after last TBI
Blood work – pituitary profile- GH; TSH;
LH; ACTH
ESR, Tox screen.
Do NOT miss Dx. Of hypopituitarism which
mimics depression.
Neuropsychological Testing
• May not find unequivocal results
• Most with mild TBI won’t show memory
deficits
• Lack of baseline
• Helpful in more significant injuries
• ImPACT, COGSTAT, ANAM, Headminder
may be useful
Posttraumatic Stress
Disorder
Formerly Called
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Traumatic War Neurosis
Shell Shock
Railway Spine
Stress Syndrome
Battle Fatigue
Soldiers’ Heart
Traumataphobia
What is a trauma?
• Experienced, witnessed, or been
confronted with an event that involves
actual or threatened death or injury, or a
threat to the physical integrity of oneself or
others
• Response involved intense fear, horror, or
helplessness (DSM-IV)
Statistics of Trauma
• About 60 percent of men and 50 percent
of women have at least one traumatic
event in their lives
• 8 percent of men and 20 percent of
women eventually develop PTSD
• Common to have trauma and subsequent
adjustment difficulties, but most do not
develop PTSD (Kessler, 1995 from CDP)
Military Statistics on PTSD
• On assessments after OIF/OEF deployment 6 to
9 percent of active-duty and 6 to 14 percent of
NG/Reserve endorse PTSD symptoms on
questionnaires (Milliken, Aucherlonie, & Hoge,
2007, per CDP)
• 15 percent according to RAND study (2008, per
CDP)
• Large number of women with PTSD related to
military sexual assault
Flight or Fight Response
• Evolutionary instinct or response
• Very adaptive in unsafe environments
• Not adaptive at home in an everyday, safe
environment
• Two routes—fast and slow processing
• One cortical and one subcortical
• Engages sympathetic nervous system
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Blood to limbs
Increase in breathing and heart rate
Pupils dilate
Reflexes sharpen
Two routes for processing danger
(Pinel, 2000)
Advantages of subcortical method
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Quicker
Leap, then think
Ready for “flight or fight”
Looking for the enemy
Advantages of cortical method
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Slower
Time to think and process information
Not reactionary
Decide that stimulus is not a risk
More suited to common life situations
Avoidance
• 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
• Feeling 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 a normal life span)
Behavioral Model of PTSD
• Mowrer’s (1947) two-factor theory
• Both classical and operant conditioning
• Unconditioned stimulus (explosion) 
Unconditioned response (fear)
• Conditioned stimulus (sand, heat, people in
uniform, guns)  Conditioned response (fear)
• Attempt to avoid CS in order to avoid fear, which
but actually increases fear response
• Negative reinforcement is avoidance of the
aversive triggers (CS) which leads to increase in
the behavior (fear)
DSM-IV Symptoms of PTSD
• The person has been exposed to a
traumatic event
• Can be conceptualized into three separate
symptom categories: reexperiencing (one
symptoms in this area needed), avoidance
(three symptoms needed), and increased
arousal (two symptoms needed)
• Symptoms last more than one month
Reexperiencing
• Recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event were recurring
(includes a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes,
including those that occur on awakening or when
intoxicated
• Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
• Physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
Increased Arousal (Sympathetic
Nervous Activation)
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
DSM-IV Acute Stress Disorder
• Experienced a trauma
• Lasts less than one month
• In addition to three areas of PTSD, also includes
dissociative symptoms (three required):
– A subjective sense of numbing, detachment, or
absence of emotional responsiveness
– A reduction in awareness of his or her surroundings
(e.g., “being in a daze”)
– Derealization
– Depersonalization
– Dissociative amnesia (i.e., inability to recall an
important aspect of the trauma)
Comorbidities (DSM-IV)
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Major Depressive Disorder
Bipolar Disorder
Substance-Related Disorders
Panic Disorder
Agoraphobia
Obsessive-Compulsive Disorder
Generalized Anxiety Disorder
Social Phobia
Specific Phobia
Suicidality
TBI
Dysfunction in relationships, marriage, work, school
Suicidality
Malingering/Secondary Gain
Suicide
• 2nd leading cause of death in military
• Young, White, Unmarried Male Junior Enlisted Active
Duty
• Drugs/alcohol
• Firearm
• No psychiatric history (Washington Post, 2008, per CDP)
• 1.2% Army Post-Deployment survey had suicidal
ideation (Miliken et al., 2007 per CDP)
• Of completed suicides, most saw a healthcare provider
within one month before suicide (USUHS, 2009)
• 19% of patients with PTSD will attempt suicide (CDP,
2009)
Suicide – Dr. Thomas Joiner –
Why People Die By Suicide 2005
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Capability
Desirability
Feeling of burdensomeness.
A.C.E.
• Ask
• Care
• Escort
“MUSH” Syndrome
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Hard to differentiate mild TBI from PTSD
Sometimes both present
Holistic thinking
Psychological factors may lead to
maintenance of TBI symptoms and
medical issues may lead to maintenance
of psychological factors
Symptoms more consistent with
PTSD
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Flashbacks
Nightmares
Intrusive thoughts
Avoidance behaviors
Exaggerated startle response
HALLMARKS of TBI –
midbrain/frontal injuries
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Sensory processing alterations?
a. Photophobia
b. Hyperacusis –
c. Sensory overload – ie., Meijer
Syndrome?
Loss of Mapping skills.
Pituitary Dysfunction.
Chronic Headaches.
PTSD Psychopharmacology
•No medication has been found to be successful in fully eliminating
PTSD
•Can manage symptoms
•Many non-responders or still experiencing significant symptoms
•Not a long-term answer
•Symptoms may return when off medication
•Zoloft and Paxil are FDA approved
•SSRIs typically first line agent
•Be careful with Prozac or if agent leads to stimulation
•Benzodiazepines are contraindicated
•Patient never learns appropriate ways of handling anxiety and fear
•In other words benzodiazepines permit avoidance, which maintains
anxiety
•Hinders psychotherapy
PTSD Psychotherapy
• Psychotherapy, specifically Prolonged Exposure
Therapy (PE) and Cognitive Processing Therapy
(CPT), has been found to be successful and is
the gold standard for PTSD treatment—not
medication
• Stress Inoculation Training, Cognitive Therapy,
and Eye Movement Desensitization and
Reprocessing also effective although exposure
likely mechanism (Foa, Hembree, & Rothbaum,
2007)
Prolonged Exposure
• In vivo exposure
– Exposing oneself to fearful situations, people, places
• Imaginal exposure
– Telling the story of the trauma in session and listening
to the session on tape
• Breathing retraining
• Remove avoidance and symptoms will not be
maintained (Foa, Hembree, & Rothbaum, 2007).
TREATMENT options for TBI:
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Amantadine, Ritalin, Dexedrine- for processing
Inderal, Elavil – for post concussive
Electronic aides – Bushnell GPS, PDA, iPHONE
Setting modifications or organization
Routine/schedule
Memory strategies (chunking, acronyms, music)
Pain management as needed
Adjunctive Treatment
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Service
Education (GI-Bill)
Psychoeducation and support groups for self and family
Exercise (use caution with TBI) and pleasurable activity
scheduling
De-toxification from caffeine, stimulants, and alcohol
Solutions (action-oriented, specific goals)
Family or marital treatments
Advocate regarding employment or military problems
Stress management
Adequate, restful sleep
Nutrition
Relaxation/Rest
TBI & PTSD Team
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Primary care physician/specialist
Nurse/nurse practitioner
Psychiatrist
Psychologist/Neuropsychologist
Counselor
Social Worker
Physiatrist
Speech-Language Pathologist
Occupational Therapist
Physical Therapist
“We can’t all be heroes, because somebody
has to sit on the curb and applaud when
they go by.”
– Will Rogers
Health care providers to get
involved 1.
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TRICARE
Sliding fee schedule $5 - $10
Volunteer for Yellow Ribbon events
Be vigilant in your community
Resources
• Military One Source www.militaryonesource.com
(800-342-9647)
• OHIOCARES (800-761-0868)
www.ohiocares.ohio.gov
• National Suicide Hotline (800-273-TALK)
• Director of Psychological Health (614-336-7246)
• Chaplain (614-208-2325)
• Military Family Life Consultant (614-336-7479
and 614-336-1413)
More resources
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Defense Centers of Excellence www.dcoe.health.mil
Department of Veterans Affairs www.va.gov
Center for Deployment Psychology www.deploymentpsych.org
National Alliance on Mental Illness www.nami.org
American Academy of Physical Medicine & Rehabilitation
www.aapmr.org
Brain Injury Association of Ohio www.biaoh.org
Ohio Psychological Association www.ohpsych.org
Ohio Psychiatric Association www.ohiopsych.org
Ohio Department of Mental Health www.odmh.ohio.gov
Ohio Department of Alcohol and Drug Addiction Services
www.odadas.ohio.gov
Ohio Department of Veteran Services www.dvs.ohio.gov