Anne Van Dyke, Ph.D, ABPPAmber Gruber, D.O.
Captain Michael Gruber
Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.
Session # G3a Van DykeFriday, October 11, 2013
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
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 common injuries = PTSD and TBI
More systemic diseases being seen in veterans due to prolonged & unrelenting stress – elevated cholesterol, triglycerides, HTN, DM
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 EvidenceRating
Returning service members who were in life Cthreatening 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):43-49, 2010.
Substance abuse to help control “biphasic” trauma response of emotional dysregulation• Hypervigilance, agitation, obsessive thinking vs.
lethargy, depression, dissociation
Depression and Anxiety
Social & interpersonal difficulties
Increased suicide risk without proper treatment
What are adaptive and potentially life-saving behaviors in combat become “symptoms” in civilian life
HypervigilanceHyperarousalChanneling of angerShutting off emotion (numbing)Replay/rehearse responses to dangerLimited sleep Reversed sleep pattern
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
Unknown how long to treat. 1 year based on expert opinion High risk of relapse
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
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 material4 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 PTSDTraining in EB treatmentsTreating complicated patients
Veteran:Recognition of problemStigma associated with seeking helpAccessing services
Ruzek J, Hamblen J.(2012).Improving Care for Veterans with PTSD. National Center for PTSD
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
Down Time Maintenance
History doesn’t include “Coward” Increased awareness brings soldiers in for
Treatment
Causes
Symptoms
Obstacles
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.htm (link for physicians who want to learn more about using CBT in patient care)
http://www.ptsd.va.gov/professional/pages/fslistbiological.asp (U.S. Dept Veteran Affairs Nat’l Ctr for PTSD: Biology of PTSD
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 18:137-144, 2011
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 theevaluation form to the classroom
monitor before leaving this session.
Thank you!