This document discusses a meeting focused on best practices for collaboration between rural mental health providers and the VA to meet the mental health needs of returning veterans in Michigan. It provides an overview of PTSD and TBI, including history, DSM-V criteria, symptoms, comorbidity, assessment tools, and treatment approaches. The objectives are to review the history and diagnosis of PTSD/TBI, explain assessment and case management skills, and discuss networking to strengthen veterans' services in Michigan.

1.  Combat PTSD/TBI/DSM-V. Meeting the Mental Health needs of
returning Veterans in Michigan: Best Practices of collaboration
between rural Mental Health Service Providers and the V.A.
1

2. Breakfast and Learn
December 10, 2014
 PTSD/TBI 101 - A Short History, DSM-V Symptoms,
Treatments, and Current Assessment Tools
 Understand the governmental and non-governmental
networking to build strategies to strengthen services for
veterans in Michigan

3. Information during this presentation is
for educational purposes only—it is not
a substitute for informed medical advice
or training. You should not use this
information to diagnose or treat a
mental health problem without
consulting a qualified professional/
provider.
3

4. 4

5. 5
https://www.youtube.com/watch?v=TNwywbP5hIQ
Make the Connection

6. Objectives:
 Review the history of PTSD, cross-cultural nature of working with
combat troops/vets and their families.
 Review the new criteria of the DSM-V diagnosis for PTSD focusing
on adults including Military Sexual Trauma (MST), and Combat
Traumatic Brain Injury.
 Focus on tools for assessment, and “Best Practices” explaining how
good case management skills are needed to address bruxism, sleep
apnea, hormonal issues, self-medication, mood disorders and family
issues.

7.  Disability and health care for veterans of the Iraq and Afghanistan wars —
including treatment for post-traumatic stress disorder and traumatic brain injury
— will cost the United States billions of dollars for decades to come, according to
data from the Congressional Budget Office. The office ran two scenarios:
Scenario 1 reflects a quick withdrawal of forces to 30,000 active-duty personnel
by 2013, and Scenario 2 reflects a more gradual withdrawal to 60,000 personnel
by 2015. Scenario 2 resulted in costs on par with the interest America pays on its
national debt.
Source: American Psychological Association. (2011, November ). Treating veterans will cost at least
$5 billion by 2020, CBO says. Retrieved from http://www.apa.org/monitor/2011/11/veterans.aspx.

8. PTSD/TBI101
A short history, DSM-V symptoms, and treatments and current Assessment tools
8
Mark S. Kane, Ph.D. Licensed Psychologist
Fellow Michigan Psychological Association
Riverview Psychological Services, P.C.
drmskane@gmail.com 616-464-0811

9. National Center for Post Traumatic
Stress Disorder Statistics
7.8 % of Americans experience PTSD (Keane et al., 2006)
Women=2X risk
• MVA-related PTSD 25-33% or higher-comorbidity 48% major
depression (NIH, 2008)
• 30% of combat veterans experience PTSD
(Duke and Vasterling, 2005)
- Approximately 50% of Vietnam veterans experience symptoms
- Approximately 8% of Gulf War veterans have demonstrated
symptoms
• www.ncptsd.va.gov 9

10. “Best Practice Treatment” of Shell
Shock after WWI
10

11. A Short History of PTSD From
Homer to “Irritable Heart” Civil War
• In the “Odyssey” in the 8th Century B.C. Homer
described Odysseus as a veteran of the Trojan Wars who
was afflicted with flashbacks and survivor’s guilt. In 490
B.C. Herodotus documented an incident where a soldier
became blind due to witnessing the death of his
comrade.
11

12. • O, my good lord, why are you thus alone?
• For what offense have I this fortnight been
A banish’d woman from my Harry’s bed?
• Tell me, sweet lord, what is’t that takes from
thee – Thy stomach, pleasure
• And they golden sleep?
• Why dost thou bend thine eyes upon the
earth
• And start so often when thou sit’st alone?
• Why hast thou lost the fresh blood in they
checks,
• And given my treasures and my rights of
thee - To thick-eyed musing and cursed
melancholy?
• Social withdrawal and isolation
• Random, unwarranted rage at family, sexual
dysfunction, no capacity for intimacy
• Somatic disturbances, loss of ability to
experience pleasure
• Insomnia
• Depression
• Hyperactive startle reaction
• Peripheral vasoconstriction, autonomic
hyperactivity
• Sense of the dead being more real than the
living, depression
12
In 1597, William Shakespeare's Henry IV had Lady
Percy describe her husbands PTSD symptoms
Jonathan Shay, M. P. (2014). In Achilles in Vietnam Combat Trauma and the Undoing of Character (pp. 165-166). New York: Scribner

13. • In thy faint slumbers I by thee have watch’d
• And heard thee murmur tales of iron wars,
Speak terms of manage to they bounding
steed,
Cry “Courage! To the field!” And thou hast
talk’d
Of sallies and retires, of trenches, tents,
Of palisadoes, frontiers, parapets,
Of prisoner’s ransom, and of soldiers slain,
And all the currents of a heady fight.
They spirit within thee hath been so at war
And thus hath so bestirr’d thee in thy sleep,
That beads of sweat have stood upon they
brow,
Like bubbles in a late-disturbed stream;
• Fragmented, vigilant sleep
• Traumatic dreams, reliving episodes of
combat fragmented sleep
• Night sweats, autonomic hyperactivity
13
Continued…
In 1597, William Shakespeare's Henry IV had Lady
Percy describe her husbands PTSD symptoms
Jonathan Shay, M. P. (2014). In Achilles in Vietnam Combat Trauma and the Undoing of Character (pp. 165-166). New York: Scribner

14. History of PTSD: “Shell Shock”
World War I
14

15. PTSD first used in 1980 in DSM-III
Current Definition PTSD DSM V
• Was an anxiety disorder in DSM-IV but is now in a new Chapter:
• Trauma and Stressor-Related Disorders: Diagnostic criteria for
PTSD include a history of exposure to a traumatic event that
meets specific stipulations and symptoms from each of four
symptom clusters: intrusion, avoidance, negative alterations in
cognitions and mood, and alterations in arousal and reactivity.
The sixth criterion concerns duration of symptoms; the seventh
assesses functioning; and, the eighth criterion clarifies
symptoms as not attributable to a substance or co-occurring
medical condition. Two specifications are noted including
delayed expression and a dissociative subtype of PTSD, the
latter of which is new to DSM-5. In both specifications, the full
diagnostic criteria for PTSD must be met for application to be
warranted.
15

16. PTSD Stressors
• Violent human assault
• Natural catastrophes
• Accidents
• Deliberate “man”-made disasters
16
U.S. Department of Defense Images: http://www.defense.gov/DODCMSShare/NewsStoryPhoto/2001-
09/hrs_200109205g_hr.jpg

17. Combat Fatigue
Immediate psychological and functional impairment that
occurs in war or during other severe stressors during combat
Caused by stress hormones
- Features of the stress reaction include:
• +Restlessness
• +psychomotor deficiencies
• +withdrawal
• +Stuttering
• +Confusion
• +Nausea
• +Vomiting
• +Severe suspiciousness and distrust
APA, 1994
17

18. Symptoms of PTSD
18
• Recurrent thoughts of the event
• Flash backs (visual, sound, smell, taste, pressure etc…/bad
dreams)
• Emotional numbness (“it don’t matter”); reduced interest
or involvement in work or outside activities
• Intense guilty or worry/anxiety including survivor guilt
• Angry Outbursts and irritability
• Feeling “on edge,” hyper-arousal/hyper-alertness
• Avoidance of thoughts/situations that remind person of
the trauma

19. DSM – V Criteria
• Re-experiencing symptoms (nightmares, intrusive
thoughts)
• Avoidance of trauma cues and
Numbing/detachment from others
• Hyper-arousal (i.e. increased startle, hyper-vigilance)
19

20. Duration of PTSD
To meet criteria for PTSD, symptom duration must
be at least on month
• *Acute PTSD: duration of symptoms is less than 3 months
• *Chronic PTSD: duration of symptoms is 3 months or
more
• Often, the disorder is more Severe and lasts longer when
the stress is of human design(i.e., war-related trauma)
20

21. HPA Axis explained…
• .
21

22. Hormone /Hypothalamic,
pituitary, adrenal (HPA) axis
22

23. TBI Comorbidity
TBI is damage to the brain triggered by externally
acting forces (i.e., direct penetration, sustained
forces, etc.)
• A significant portion of falls, car accidents,
physical abuse, gun shot wounds and soldiers
from OEF/OIF have sustained a brain injury.
• Blast injuries are the leading cause of injury in
the current conflict.
23

24. Blast Injuries
Blast injuries are injuries that result from the
complex pressure wave generated by an explosion
• Ears, lungs, and GI tract, brain and spine are
especially susceptible to primary blast injury.
• Those closest to the explosion suffer from the
greatest risk of injury
• Additional means of impact:
• Being thrown, debris, burns, vehicle accidents. 24

25. Why Blast Injures are of Interest
Now?
Armed forces are sustaining attacks by rocket-propelled
grenades, improvised explosive devices, and land mines almost
daily in combat.
• Injured soldiers require specialized care acutely and over time.
Not all combat vets are treated by the VA. Many of them are
in the Reserve, National Guard, have TRICARE or private
insurances. They can and do show up in the ER’s and civilian
employer jobs.
25

26. New Technology Identifies Organicity
after TBI
Control CC
TBI CC
Wang et al, Arch Neurol. 2008 May;65(5):619-26.
26

27. PTSD and TBI symptoms
Overlap:
Emotional Liability-
• Difficulty with attention and concentration
• Amnesia for the event
• Irritability and anger
• Difficulty with over-stimulation
• Social isolation/difficulty in social situations
27

28. Identifying PTSD Consultants and
Specialist
• Expert therapists Psychiatrists (MD/DO)
• Clinical Psychologists (Ph.D./Psy.D.) Social worker
(LCSW/MSW) Psychiatric Nurse
• VA Medical Centers/VA PTSD programs/VA Vets
Centers/Community Bases Outpatient Clinics (CBOCs)
• Hospital/Medical Clinic Affiliations
28

29. Therapeutic Approaches &
Techniques
Prolonged Exposure Therapy (PE) – Prolonged Exposure
Therapy (PE) – Imaginal exposure: Repeated and prolonged
recounting of the traumatic experience
• In vivo exposure: Systematic confrontation of trauma-related
situations that are feared and avoided, despite being safe
• Goal: Increase emotional processing of the traumatic event,
so that memories or situations no longer result in:
• Anxious arousal to trauma
• Escape and avoidance behaviors
29

30. Therapeutic Approaches &
Techniques
Cognitive Processing Therapy (CPT) - Modify the
relationships between thoughts and feelings
• Identify and challenge inaccurate or extreme automatic
negative thoughts
• Develop alternative, more logical or helpful thoughts
• Goals:
• Help the individual recognize and adjust trauma-related
thoughts and beliefs
• Help the individual modify his/her appraisals of self
and the world
30

31. Therapeutic Approaches &
Techniques
Eye Movement Desensitization and Reprocessing (EMDR)
• Information processing therapy and uses an eight phase
approach to address the experiential contributors for a
wide range of pathologies with a strong body of research
to support its effectiveness with PTSD. It attends to the
past experiences that have set the groundwork for
pathology, the current situations that trigger
dysfunctional emotions, beliefs and sensations, and the
positive experience needed to enhance future adaptive
behaviors and mental health.
31

32. Therapeutic Approaches &
Techniques
Medications: SSRI’s
• http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-
medications-for-ptsd.asp
• Connecting and Networking
• PTSD/ Stress Disorder Treatment Units inpatient within the
VA; Battle Creek VA, Saginaw VA, Ann Arbor VA and their
related CBOCs, ie Grand Rapids VA Outpatient, Private
Hospitals with insurance.
• Captain Lovell Federal Health Care Center. An integration of
the VA and DOD systems Approach for the 21st Century.
CARF and JCAHO accredited. All Medical and PTSD.
32

33. PTSD Coach
• Smart phone application
• Education
• Coping/Support
• Self-tracking of PTSD using
the PCL
• Not to be used as a stand
alone treatment
33

34. Assessment and
Diagnosis of PTSD with
the DSM-V
*Please see PTSD Assessment Handout
34

35. Learning Objectives
• Understand the importance of PTSD Assessment
• Be Familiar with the New Diagnostic Criteria
• Select and Use Appropriate Measures
• Promote Accurate Diagnosis: Best Practices/Challenges
• Next Steps
35

36. Multimethod Assessment
• Hx of Trauma
• PTSD Symptoms
• Co-Morbid Conditions
• Response Bias
• Supporting Documentation
• Denotation of medals or honors
• DD214
• Discharge papers
• Medical/Neurological/Neuropsychological Records
• Occupational Records
• Family Reports, other
36

37. MEASURES
Can be found on the PTSD: National Center for PTSD webpage
http://www.ptsd.va.gov/professional/assessment/ncptsd-instrument-
request-form.asp
*Please see PTSD Assessment Handout
37

38. Measures 1
• Aftermath of Battle Scale (DRRI-2 Section: E)
• Beck Anxiety Inventory - Primary Care (BAI-PC)
• Child Posttraumatic Stress Reaction Index (CPTS-RI)
• Child PTSD Symptom Scale (CPSS)
• Childhood Family Functioning Scale (DRRI-2 Section: B)
• Childhood PTSD Interview
• Children's Impact of Traumatic Events Scale-Revised (CITES-2)
• Children's PTSD Inventory (CPTSDI)
• Clinician-Administered PTSD Scale (CAPS)
• Clinician-Administered PTSD Scale for Children and Adolescents
(CAPS-CA)
• Combat Experiences Scale (DRRI-2 Section: D)
• Combat Exposure Scale (CES)
38

39. Measures 2
• Concerns about Life and Family Disruption Scale (DRRI-2 Section: L)
• Davidson Trauma Scale (DTS)
• Deployment Measures
• Deployment Risk and Resiliency Inventory (DRRI)
• Difficult Living and Working Environment Scale (DRRI-2 Section: C)
• Dimensions of Stressful Events Rating Scale (DOSE)
• Distressing Events Questionnaire (DEQ)
• Evaluation of Lifetime Stressors (ELS)
• Family Stressors Scale (DRRI-2 Section: M)
• General Harassment Scale (DRRI-2 Section: K-1)
• Impact of Event Scale - Revised (IES-R)
• Life Event Checklist (LEC) 39

40. Measures 3
• Life Stressor Checklist - Revised (LSC-R)
• Los Angeles Symptom Checklist (LASC)
• Mississippi Scale for Combat-Related PTSD (M-PTSD)
• Modified PTSD Symptom Scale (MPSS-SR)
• My Worst Experiences Survey
• Parent Report of Child's Reaction to Stress
• Penn Inventory for Posttraumatic Stress Disorder (Penn Inventory)
• Perceived Threat Scale (DRRI-2 Section: G)
• Postdeployment Family Functioning Scale (DRRI-2 Section: P)
• Postdeployment Social Support Scale (DRRI-2 Section: O)
• Postdeployment Stressors Scale (DRRI-2 Section: N)
• Posttraumatic Diagnostic Scale (PDS) 40

41. Measures 4
• Potential Stressful Events Interview (PSEI)
• The Primary Care PTSD Screen (PC-PTSD)
• Prior Stressors Scale (DRRI-2 Section: A)
• PTSD Checklist (PCL)
• PTSD Symptom Scale - Interview (PSS-I)
• Screen for Posttraumatic Stress Symptoms (SPTSS)
• Nuclear, Biological, and Chemical Exposures Scale
• Preparedness Scale (DRRI-2 Section: H)
• Sexual Harassment Scale (DRRI-2 Section: K-2)
• Short Form of the PTSD Checklist - Civilian Version
• Short Screening Scale for PTSD
• SPAN 41

42. Measures 5
• SPRINT
• Stressful Life Events Screening Questionnaire (SLESQ)
• Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID
PTSD Module)
• Structured Interview for PTSD (SI-PTSD)
• Trauma Assessment for Adults--Self-report (TAA)
• Trauma History Questionnaire (THQ)
• Trauma History Screen (THS)
• Trauma Screening Questionnaire (TSQ)
• Trauma Symptom Checklist - 40 (TSC-40)
• Trauma Symptom Checklist for Children (TSCC)
• Trauma Symptom Checklist for Young Children (TSCYC) 42

43. Measures 6
• Trauma Symptom Inventory (TSI)
• Traumatic Events Questionnaire (TEQ)
• Traumatic Events Screening Inventory (TESI-C)
• Traumatic Life Events Questionnaire (TLEQ)
• Traumatic Stress Schedule (TSS)
• The UCLA PTSD Index for DSM-IV
• Unit Social Support Scale (DRRI-2 Section: J)
• When Bad Things Happen Scale (WBTH)
43

44. Choosing the “Right” Measure
• Goals
• Level of Training
• Time
• Cost
• Patient Characteristics
• Psychometric Properties of the Measure
44

45. Samples
• Primary Care PTSD Screen (PC-PTSD)
• Self-administered: PTSD Checklist (PCL-5)
• Interview: Clinician Administered PTSD Scale (CAPS)
45

46. Recommendation for Medical Practice:
Primary Care PTSD Screen (PC-PTSD)
• In your life, have you ever had any experience that was so frightening,
horrible, or upsetting that, in the past month, you:
• Have had nightmares about it or thought about it when you did not
want to?
YES NO
• Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it?
YES NO
• Were constantly on guard, watchful, or easily startled?
YES NO
• Felt numb or detached from others, activities, or your surroundings?
YES NO
• ¾ “yes” responses = positive screen.
• Positive screen warrants further investigation
• Positive screen warrants suicidal ideation screen
46

47. PCL-5
• 20-item self-report measure
• Likert Scale: 1-5 from “Not at All” to “Extremely”
• Follows DSM diagnostic Criteria
• 5-10 minutes to complete
• May assist with Diagnosis
• May be used to measure change over time
• Three versions: military, civilian, specific
47

48. Clinician Administered PTSD Scale
(CAPS)
• Gold Standard
• 45-60 minutes
• 30-item structured clinician-administered interview
• Follows DSM-5 criteria
• In conjunction with Life Events Checklist
• Severity, Frequency, Intensity on ≤ 3 traumatic
events
• Impact on social, occupational functioning
• Requires Significant Training
• In public domain, available from VA 48

49. CHALLENGES TO ACCURATE
DIAGNOSIS
Training, live skills, cross-cultural perspective, time, resources,
supervision and support from peers, historical data including pre-military,
military and medical, family input. Longitudinal data from
inpatient treatment and related outpatient treatment, strong
therapeutic alliance and a willingness to share what you do not
know and learn from the Vet.
49

50. Essential Considerations
• Suicide Risk
• Co-occurring Substance Abuse
• Co-occurring mTBI
• Insomnia
• Careful consideration of PTSD risks when
prescribing medications
• Family Support
50

51. SUMMARY
• Assessment is a Collaboration
• PC-PTSD: Great Screen
• PCL: Great Screen, Useful for dx & tracking 
• CAPS: “Gold Standard” Dx Interview
• Evidence Based Measures
• Assess for Safety
51

52. Take Home Points
Essential Features of PTSD
• Re-experiencing symptoms (nightmares, intrusive thoughts)
Avoidance of Trauma cues
• Numbing/detachment from others
• Hyperarousal (i.e. increased startle, hypervigilence)
• Dissociation in more complex PTSD
*A variety of factors including personal, cultural, and social
characteristics, coping abilities, experiences in war, and the post-deployment/
civilian environment all contribute to the level,
severity and duration of stress reactions.
*U Tube conference on Hidden Wounds of War: PTSD/TBI and
Moral Injury. April 2014 Grand Valley State University.
http://www.youtube.com/playlist?list=PLU9_N-RwLk9yLW2AShlCjWFrVEXTCXA05
52

53. Medicaid Expansion Benefits Veterans
and the Economy
• http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-
economy
53
1. Source: Michigan League for Public Policy. http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-economy

54. 54
VISN 11
Catchment Area Map

55. Medicaid Expansion Benefits Veterans
and the Economy
55
1. Source: Michigan League for Public Policy. http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-economy

56. Resources
1. VISN 11 Telehealth - Mr. Casey Thayer, Facility Telehealth Coordinator, Casey.Thayer2@va.gov,
269-966-5600 ext. 36234. Please call Casey regarding the specific about the program. VA
Telehealth Services uses health informatics, disease management and telehealth technologies
to target care and case management to improve access to care, improving the health of
veterans.
2. Community Provider Toolkit - VA has many resources available to support Veterans in many
areas of their lives. We encourage you and your client to work together to identify what
information could be most helpful to him or her. To do this, we have provided a brief Resource
Plan that you can complete with your client to assess potential needs and match resources. We
have included contact info on many of the services listed below on the resource plan itself so
that it can be used as a quick reference tool. - See more at:
http://www.mentalhealth.va.gov/communityproviders/partner_resources.asp#sthash.80oWNb
tn.dpuf
3. National Resource Directory for Veterans - https://www.ebenefits.va.gov/ebenefits/nrd We are
encouraging all Veteran Service Providers to register in the National Resource Directory
https://www.ebenefits.va.gov/ebenefits/nrd/suggest-resource
4. Veterans Crisis Line 1800-273-8255, http://veteranscrisisline.net/ The caring professionals at
the Veterans Crisis Line are specially trained and experienced in helping Veterans of all ages and
circumstances. Many of the responders are Veterans themselves and understand what Veterans
and their families and friends have been through and the challenges Veterans of all ages and
service eras face. Power of One!
56

57. “Courage is learning to ask for help”
57

58. Thank you!
Mark S. Kane, Ph.D. Licensed Psychologist
Fellow Michigan Psychological Association
Riverview Psychological Services, P.C.
drmskane@gmail.com 616-464-0811 58

59. No Wrong Door for Michigan Veterans

60. No Wrong Door for Michigan Veterans
Returning Veterans, and the current population of aging Veterans have
multifaceted needs in…
Education
Social services
Vocational rehabilitation
Health care
Employment and training
Independent living
assistance
Care giving
Housing
Family support
How to help?

61. Michigan Veterans Community Action Team – MiVCAT
“No-Wrong-Door” Approach to Serving Veterans
• The Michigan Veterans Community Action Team (MiVCAT) is a collaborative
community model created for the Michigan Veterans Affairs Agency by Altarum
Institute. The model is designed to provide a “no wrong door” approach to
enhance the delivery of services from public, private, and nonprofit
organizations to Veterans and their family members.
• MiVCAT establishes system of care for Veterans, characterized by a
comprehensive network of service providers, empowered with knowledge,
information, and tools to ensure all Veterans and family members are
connected to the appropriate service providers in a timely manner and are fully
served.
• 2014 MiVCAT – West Michigan Veterans Coalition (Region 4), Tri-County
(Wayne, Oakland, Macomb) VCAT.
• 2015 MiVCAT – Regions 5, 6, 7, & 9 will be developed within Michigan.
61

64. Integrated System of Care

65. Thank you.
Questions?
Elena Bridges
Veterans Services Community Coordinator,
Altarum Institute
Chairperson, West Michigan Veterans Coalition
Elena.bridges@altarum.org
616-401-2026