Transcript COMBAT PTSD Recognition and Treatment

COMBAT PTSD
Recognition and Treatment
Harry Croft, M.D.
Texas Association of Osteopathic Physicians
San Antonio,
June, 2012
Research and Speaking Honoraria
Astra Zeneca
Boehringer-Ingelheim
BMS
Eli Lilly
Forest Pharmaceuticals
GSK
Otsuka
Pfizer
Takeda
Learning Objectives
1. Learn usual presenting symptoms to civilian pcp of combat
related PTSD.
2. Understand the importance of treating combat related ptsd in
addition to relieving obvious presenting symptoms.
3. Become familiar with common misconceptions as well as facts
regarding ptsd.
4. Know current evidence based treatments for ptsd.
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WWW.MYBACKTOTHEWALL.COM
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RECOGNIZING When PTSD is in Your Life
EDUCATING Yourself About PTSD
CONNECTING Biology With Your Psychology
ORGANIZING a Comprehensive Care Plan
VIEWING Your Issues in a New Light
EMPOWERING Yourself Through Strong
Systems of Support
• REDEFINING the Meaning of Your lIfe: Post
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Why Civilian Physicians Should Care
• PTSD in general population
• Returning Veterans
– 20% of 5+ million
• Vietnam
• Middle East
• But what about the VA?
– Don’t THEY take care of vets
• Not eligible
• No desire to go
Recognition of PTSD
Problems for Patients and Families
• Failure to Recognize Symptoms for what they
Are
• Incorrectly Ascribe Cause
• Myths and Misconception About PTSD
• Stigma Surrounding PTSD
Myths and Misconceptions about PTSD
• 1. Only a soldier’s problem
• 2. Only a man’s problem (men acting badly)
• 3. A Psychiatric condition (denoting cowardice
or “craziness” or weakness
• 4. Only affects those in direct combat
• 5. Almost everyone deployed to combat zone
comes back with PTSD
• PTSD is an “all or none” disorder
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PTSD IS.....
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Not just caused by Combat Related Trauma
Not Just a Man’s Problem
Not Just Psychiatric Disorder
Not all deployed to combat area
Not “all or none”
A Psycho-neuro-immunological problem
Problems for Physicians
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• Patient reports only certain symptoms
• Failure to report traumatic experience/ vet
• Visit by patient not self motivated
Risks to Military Members
More than Just Combat
• Combat
• Non-predictable Threats - to even “noncombatants”
• Repeated Deployments
• Repeated Separations
• Dwell time
• Unemployment / finances
Impacts Many Life Areas
• Relationships
•Marital, Family, Friends
•EMPLOYMENT/ EDUCATION
•Legal Problems
•Physical Health
•Risk Taking
•DESPAIR / SUICIDE
DIAGNOSIS
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STRESSOR
RE-EXPERIENCING
AVOIDANCE
AROUSAL
EMOTIONAL DISTRESS OR LIFE INTERFERENCE
DSM IV
Assessment of PTSD
• PC-PTSD Primary Care PTSD Screen
– 4 items (2 or more diagnostic)
• PCL PTSD Checklist (C & M)
– 19 items (0-4) cutoff = >50
CO-OCCURRING CONDITIONS
• DEPRESSION
• ANXIETY DISORDERS
– Generalized, Panic, Social Phobia
• SUBSTANCE ABUSE DISORDERS
• OCD VARIANTS
Foundations of Treatment
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Recognition of Need for Treatment
Decision to Get Help
Finding a Place – even if…..
Trust and Rapport
– Someone who understands
– Someone who will not judge
– Someone who will not be horrified
– BUT RAPPORT ALONE IS NOT ENOUGH
PSYCHOTHERAPY
• COGNITIVE-BEHAVIORAL THERAPY
– Prolonged Exposure
– Cognitive Processing Therapy
• SUPPORTIVE
• EMDR
• OTHER
MEDICATIONS
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ANTI-ADRENERGIC
SSRI and SNRI
MEDS TO AID WITH SLEEP
Other antidepressants
ATYPICAL Antipsychotics
ANTI-EPILEPTICS
• **Avoid BENZODIAZEPINES IF POSSIBLE
NEW MEDICATIONS
• CRF Antagonists
• Neuropeptide Y Agonists
• Antiadrenergic Drugs
• Selective Opiod agents
• Substance P Antagonists
• D-Cycloserine
• NMDA
• Anticonvulsants
• BDNF promoters
PTSD.VA.GOV
PTSD 101
OTHER THERAPIES
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Meditation
Exercise
Yoga
Accupuncture
Animal Therapy
Art and Writing
SUPPORT SYSTEMS
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FAMILY
FRIENDS
OTHER VETERANS
ORGANIZATIONS
HELPING OTHERS
SPIRITUALITY
VIEWING ISSUES IN NEW LIGHT
• Viewing TRIGGERS as Manageable Events
• Need for “Speed” and other Risky Behaviors
• Viewing Relationships in a New Light
– Intimacy
– Children
REDEFINING LIFE AFTER PTSD
POST PTSD GROWTH
• Recognizing how others survive
• Who you are vs. what you do..or did
• Importance of lifelong growth and learning
Co-occurring Disorders
• Treat both disorders
– Assumption that dealing with one “cures” the
other is not valid
• Need for support in sobriety
• “One day at a time…”
• Medications
Suicide Risk Factors
• Person sees no way out and fears things will get
worse
• Predominant emotions are hopelessness and
helplessness
• Person is anxious, agitated and has insomnia
• Thinking is constricted with a tendency to persieve
situation as all bad
• Judgement is impaired by use of alcohol or other
substances
• Lack of future orientation
• Weapons are easily accessible
FOR MORE INFORMATION
• www.va.ptsd.gov
• www.medscape.com
• www.ptsd.va.gov/professional/pages/assessments/ncptsdinstrument-request-form.asp
– TO DOWNLOAD PCL-M AND PCP PCL
• www.mybacktothewall.com
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