DX and RX of TBI and PTSD in OIF/OEF Veterans

1. 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

2. Map of Ohio Deployment

3. Health concerns of War and re-entry home Every War has its own: 1. Injuries 2. Illnesses 3. Drugs 4. Technologies 5. Personalities

4. Vietnam • SCI – establishment of SCI research • Agent Orange – Cancer, DM, Neuropathy, TBI? • Drugs of choice – Downers: Heroin; Marijuana; ETOH

5. Gulf War – ALS - 1. Incidence – 1.6 X general population. 2. Etiology – Sarin? Pesticides? Pyridostigmine BR?

6. OIF/OEF – TBI/multiple amputations 1. ARMOR – more survive, but multiple amputations; severe burns • TBI/PTSD/“MUSH” syndrome. • Drugs of choice – Uppers: methamphetamine, caffeine, cocaine

7. National Council on Disability: March 2009 Established the HALLMARK pathologies of OIF/OEF: Operation Iraqi Freedom Operation Enduring Freedom

8. 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

9. 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;

10. 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.

11. HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterations a. Photophobia b. Hyperacusis – c. Sensory overload – ie., Meijer Syndrome 2. Loss of Mapping skills. • Pituitary Dysfunction. • Chronic Headaches.

12. CAFFEINE CONTENT of DRINKSAdding to Brain Insults • Coffee - 100 mg. • Cola - 35-45 mg. • Mt. Dew - 120 mg. • Rockstar - 160 mg. • RAGE/WYD - 200 mg. Caffeine impairs Brain glucose utilization –up to 20 drinks/day ingested in Iraq

13. BONUS Drink Include: • RED BULL - 80 mg/Phenylalanine • Red BULL - Germany – Cocaine Long term increased ingestion of caffeine may deplete cortisol/adrenalin

14. Diagnosis of TBI Listen to the Patient: He is telling you the diagnosis. Sir William Osler TBI Diagnosed by HISTORY.

15. Radiologic Studies: Timing/Technique • 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

16. Blood work – pituitary profile- GH; TSH; LH; ACTH ESR, Tox screen. Do NOT miss Dx. Of hypopituitarism which mimics depression.

17. 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

18. Posttraumatic Stress Disorder

19. Formerly Called • Traumatic War Neurosis • Shell Shock • Railway Spine • Stress Syndrome • Battle Fatigue • Soldiers’ Heart • Traumataphobia

20. 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)

21. 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)

22. 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

23. 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 • Blood to limbs • Increase in breathing and heart rate • Pupils dilate • Reflexes sharpen

24. Two routes for processing danger (Pinel, 2000)

25. Advantages of subcortical method • Quicker • Leap, then think • Ready for “flight or fight” • Looking for the enemy

26. Advantages of cortical method • Slower • Time to think and process information • Not reactionary • Decide that stimulus is not a risk • More suited to common life situations

27. 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)

28. 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)

29. 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

30. 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

31. Increased Arousal (Sympathetic Nervous Activation) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

32. 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)

33. Comorbidities (DSM-IV) • 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

34. 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)

35. Suicide – Dr. Thomas Joiner – Why People Die By Suicide 2005 1. Capability 2. Desirability 3. Feeling of burdensomeness.

36. A.C.E. • Ask • Care • Escort

37. “MUSH” Syndrome • 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

38. Symptoms more consistent with PTSD • Flashbacks • Nightmares • Intrusive thoughts • Avoidance behaviors • Exaggerated startle response

39. HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterations? a. Photophobia b. Hyperacusis – c. Sensory overload – ie., Meijer Syndrome? 2. Loss of Mapping skills. Pituitary Dysfunction. Chronic Headaches.

40. 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

41. 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)

42. 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).

43. TREATMENT options for TBI: 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

44. Adjunctive Treatment • 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

45. TBI & PTSD Team • Primary care physician/specialist • Nurse/nurse practitioner • Psychiatrist • Psychologist/Neuropsychologist • Counselor • Social Worker • Physiatrist • Speech-Language Pathologist • Occupational Therapist • Physical Therapist

46. “We can’t all be heroes, because somebody has to sit on the curb and applaud when they go by.” – Will Rogers

47. Health care providers to get involved - 1. TRICARE 2. Sliding fee schedule $5 - $10 3. Volunteer for Yellow Ribbon events 4. Be vigilant in your community

48. 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)

49. More resources • 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