Transcript PTSD - Collaborative Family Healthcare Association

Session # G3a Van Dyke
Friday, October 11, 2013
Anne Van Dyke, Ph.D, ABPP
Amber Gruber, D.O.
Captain Michael Gruber
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
We have not had any relevant financial relationships
during the past 12 months.
 To
increase awareness of the prevalence and
impact of Combat PTSD on the individual &
family
 To
understand the scope of specialized medical
and mental health services needed for
returning war veterans & their families
 To
increase the ability of health care providers
to effectively diagnose & treat Combat PTSD
from a biopsychosocial model
Audience Question & Answer
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Diagnosis of Combat PTSD can be a hopeful one
Concept of “Posttraumatic Growth” in combat veterans
involves 3 growth processes:
• Strength through suffering
 confidence to face future struggles
• Existential reevaluation
 gaining of wisdom, life satisfaction, new purpose in
life
• Psychological preparedness
 Rebuilding core beliefs about oneself and one’s life
 Past
10 yrs ~ 3 million U.S. military veterans in
Operation Iraqi Freedom & Operation
Enduring Freedom
 Up
to 19% of returning veterans report
problems of depression, anxiety &/or PTSD
 Veterans
w/ PTSD report poorer health, more
days off work, somatic complaints, depression,
substance abuse & interpersonal difficulties
 Improvements
in combat armor, vehicles and
evacuation systems -> “survivable” injuries
 Most
 More
common injuries = PTSD and TBI
systemic diseases being seen in veterans
due to prolonged & unrelenting stress –
elevated cholesterol, triglycerides, HTN, DM
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George Washington era: “nostalgia”
Civil War days: “Soldier’s Heart”
WWI: “Shell Shock”
WWII & Vietnam: “Battle Fatigue”
PTSD formally recognized and named 10 yrs
after leaving Vietnam
...it is now the 50th anniversary of Vietnam War
“POST TRAUMATIC STRESS INJURY”
currently under consideration to reduce stigma
SORT: Key Recommendation for Practice
Clinical Recommendation
Rating
Evidence
Returning service members who were in life C
threatening situations or those where serious
injury could occur should be screened
for PTSD
Quinlan et al. Care of the returning veteran. Am Fam Physician Jul 1; 82(1):4349, 2010.
 Substance
abuse to help control “biphasic”
trauma response of emotional dysregulation
• Hypervigilance, agitation, obsessive thinking vs. lethargy,
depression, dissociation
 Depression
 Social
and Anxiety
& interpersonal difficulties
 Increased
treatment
suicide risk without proper
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What are adaptive and potentially life-saving behaviors
in combat become “symptoms” in civilian life
 Hypervigilance
 Hyperarousal
 Channeling of anger
 Shutting off emotion (numbing)
 Replay/rehearse responses to danger
 Limited sleep
 Reversed sleep pattern
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Important not to dismiss PTSD possibility in
those not directly involved on the battlefield
‘System at War’ involves non-combat oriented
Military Operations Specialty such as security
detail, medics & food service
 IOM: PTSD
tx with sufficient empirical evidence
• Prolonged Exposure Therapy – in vivo, imaginal,
Cognitive Processing Therapy – psychoeducation,
narration, reframing negative thoughts and outcome
• 12 sessions 60 to 90 minutes each
 EMDR
effective trauma intervention
 National
Competency Based Staff Training from
the VA … only 10% of mental health providers
report providing manualized PTSD tx
 Evolving
area of research
 Changes
in hypothalamus-pituitary-adrenal
axis
 Alteration in serotonergic and noradrenergic
neurotransmitter systems
 Ultimately compromising memory processing,
emotional reactivity, learning & behavioral
responses
 Currently
Paroxetine (Paxil) and Sertraline
(zoloft) are the ONLY Medications approved
for the treatment of PTSD
 18 RCTs to date
 Short term treatment of PTSD
 29.4% remission rate with paxil alone at 12
weeks
 No difference in 20 mg vs 40 mg of paxil
 No difference in remission rate if comorbid
depression
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Unknown how long to treat.
 1 year based on expert opinion
 High risk of relapse
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SSRI: paroxetine (Paxil), sertraline (Zoloft) (LOE A)
*SNRI: venlafaxine (Effexor) (LOE A)
*Mirtazapine (Remeron) (LOE B)
*Alpha-blocker: prazosin (minipress) for
refractory patients who cannot sleep (LOE B)
*Anti-psychotic agents if psychotic symptoms
*Add olanzapine if refractory to 12 weeks of SSRI
alone
 Acts
via serotonin system
 Alternative to SSRI and Venlafaxine
 Primary SE: sedation
 Sexual SE less than SSRI/SNRI
 Additional SE: weight gain
 NO
EVIDENCE for benzodiazepines!!
 May interfere with PE therapy because they
suppress fear extinction
BENZO
 Medical
management difficult
 Divalproex and respiradone have failed to
show efficacy
 Psychotherapy, behavioral interventions and
use of different first line agents more effective.
 PTSD
+ comorbid substance abuse
 Afghanistan/Iraq veterans with comorbid
Traumatic Brain Injuries (Prolonged Post
Concussive Syndrome)
 Tele-mental Health video conference
technology
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Insufficient evidence to support behavioral
family therapy or couples therapy
S.A.F.E. (Support And Family Education)
Multi-session group therapy for family
members of the mentally ill (PTSD, bipolar,
schizophrenic, MDD)
14 sessions with educational material
4 workshops to teach specific skills training to
minimize stressful home scenarios
 Hotline
to help family members of vets to get
access to their V.A. Benefits
 Local
vs. non-local spouses
 Seminar
 Call
list of other spouses
 Informal
gatherings organized by the most
senior officer’s spouse
 Depends
on military branch
 Pre-entry
phase
 Reunion “honeymoon”
 Disruption phase
 Communication
 New “normal”
Provider:
 Recognizing/diagnosing PTSD
 Training in EB treatments
 Treating complicated patients
Veteran:
 Recognition of problem
 Stigma associated with seeking help
 Accessing services
Ruzek J, Hamblen J.(2012).Improving Care for Veterans with PTSD. National Center for PTSD
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Fragmented military medical care
(deployment, changing assignments, discharge
schedules)
Stigma of weakness in military culture
Military care model: free, as needed, care
management coordination w/ employer, appts
part of work day
Civilian care model: can be overwhelming
initially and avoided
 Bio
 Disclaimer
 My
Experience
 Basic
Training to the Battle field to Going Back
Home.
 Generation PTSD?
 The patient’s perspective
 Obstacles to Care
 What works and what doesn’t work
 Resources
 Volunteer
 Location
 Family
 Education
 Race
Patrol
Maintenance
Down
Time
 History
doesn’t include “Coward”
 Increased awareness brings soldiers in for
Treatment
 Causes
 Symptoms
 Obstacles
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http://ptsdsurvivordaily.com/ (blog of Mike Piro,
Army combat veteran)
http://njms2.umdnj.edu/psyevnts/ptsd.html (U.S. Dept
Veteran Affairs Nat’l Ctr for PTSD: PTSD Resources
http://www.istss.org/ResourcesforProfesionals/1956.ht
m (link for physicians who want to learn more about
using CBT in patient care)
http://www.ptsd.va.gov/professional/pages/fslistbiolog
ical.asp (U.S. Dept Veteran Affairs Nat’l Ctr for
PTSD: Biology of PTSD
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Bulin T, Zawalski L. Biopsychosocial challenges
in primary care for the combat PTSD patient
from a social work and psychiatry perspective.
Osteopathic Family Physician 4:36-43, 2012
Perterson A, Luethcke C et al. Assessment and
treatment of combat-related PTSD in returning
war veterans. J Clin Psychol Med Setting
18:164-175, 2011
Tedeschi R. Posttraumatic Growth in Combat
Veterans. J Clin Psychol Med Settings 18:137144, 2011
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Hetrick, SE “ Combined pharmacotherapy and
psychological therapies for PTSD (Review), Cochrane
2010
Ipser, JC “Evidence-based pharmacotherapy of PTSD”
International Journal of Neuropsychopharmacology
(2012)
Jeffreys, M “Pharmacotherapy for PTSD: Review with
clinical applications” JRRD, vol 49, Number 5, 2012
Monson, CM “Couple/family therapy for PTSD: Review
to facilitate interpretation of VA/DOD Clinical Practice
Guideline” JRRD, vol 49 number 5, 2012
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!