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primary care management of the returning veteran with PTSD
- 1. Primary Care Management of the Returning Veteran with PTSD Bill Swann D.O. PCM WTU KACC
- 2. Objectives • a) Develop an understanding of the special considerations necessary in the Primary Care Management of the Returning Veteran of with PTSD b) Develop a better ability to recognize PTSD c) Develop a better understanding of how the management of • Common Primary Care Issues in the Returning Veteran may differ from our civilian population d) Develop a better understanding of the Role of Osteopathy and role of Adjunctive Health Care Providers ,in the management of issues particular to the Returning Veteran with PTSD e) Develop a better understanding of the when to refer and when to get help for your patients who are veterans with PTSD
- 3. Overview • • • • Objectives & Topic Review The Issue , Scope & Impact The Pathophysiology and Recognition of PTSD PTSD’s impact in common medical problems and issues Recognition of PTSD • Effect of PTSD on the Veteran’s Family • Role of an Osteopathic perspective and Adjunctive Interventions • Resources for PTSD management
- 4. Regional Map of Middle East
- 5. The Issue • Since October 2001, over 1.6 million U.S. troops have deployed to the wars in Iraq and Afghanistan, with many exposed to prolonged periods of combatrelated stress or traumatic events • As of May 2010 there are approximately 180,000 US troops in Iraq and Afghanistan • Researchers estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment -- an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more high-quality treatment could save close to $2 billion within two years • . The eventual cost of providing lifetime medical benefits, lifetime disability benefits, and lifetime social security benefits for veterans of the current Gulf War could easily reach $700 billion or more, close to the total overall cost of the first five years of the war.
- 6. Historical PTSD • The first documented case of psychological distress was reported in 1900 BCE, by an Egyptian physician who described a hysterical reaction to trauma. • PTSD may be one of the 1st recognized Psychological Disorders. • After the Battle of Gettysburg, ~28,000 rifles were recovered, • ~25,000 of them hadn’t been fired. Thru history & until the Vietnam conflict the, % of soldiers who fired their weapons, was~ 50% • During and after Vietnam that ratio increased, approaching 99%. • Many encounters are very face to face. Our Soldiers may be trained to aim, fire and hit, but training on how to deal with the psychological sequelae of those actions is sparse, as seen with over 25% of our Veterans suffering from some degree of PTSD.
- 7. The Issue , The Dollar Cost
- 8. Why do we get PTSD? What is the Pathophysiology of PTSD? PTSD is a normal reaction to undue and deadly stress. Our patients develop PTSD because they are Human. Despite what we see in the movies, we are not “wired” to Kill nor deal with pain, fear ,death and destruction on an on going basis.. One action our mind uses is to protect the brain through dissociation. This is a normal and usually temporary and benign response. The dissociated brain stops the horror of the event before it becomes a full real-time impossible reality. It “walls off” the event, and in extreme cases induces amnesia. It is a very healthy survival technique. Survival technique, in that our brain is now able to focus on survival rather than perseverate on the horrible issues at hand.
- 9. Cortisol Response to Stress
- 10. Hippocampal Pituitary Adrenal (HPA Axis) Dysfunctions in PTSD vs. Depression PTSD Cortisol Levels Low Glucocorticoid Receptors Increased Dexamethasone StimTest Hypersuppression Depression High Decreased Nonsuppression Negative Feedback Stronger Weaker CSF CRF Levels Increased Increased
- 11. The Neurophysiology of PTSD Cortex PFC Sensory Thalamus Amygdala
- 12. Limbic System & PTSD The High & the Low Roads
- 13. "Reduced" nerve activity e.g. as in depression: HOW SSRI ANTIDEPRESSANTS PROBABLY "WORK "
- 14. HOW SSRI ANTIDEPRESSANTS PROBABLY "WORK“ Reduced" nerve activity but with recycling blocked, and increased messages passes:
- 15. The High & Low Roads of Neuro Processing in PTSD & the Flight or Flight response • Low Road • Conveys a fast, rough impression of the situation, because it is a sub-cortical pathway in which no cognition is involved. This activates the amygdala which, through its central nucleus, generates emotional responses before any perceptual integration has even occurred and before the mind can form a complete representation of the stimuli • The High Road • Information that has travelled via the high road and has been processed in the cortex reaches the amygdala and tells it whether or not the stimulus represents a real threat.
- 17. What is PTSD/Post Traumatic Stress Disorder? • There are sixteen types of mental disorders, one is the anxiety disorder class. PTSD is an anxiety disorder. The DSMIV diagnosis code for PTSD is 309.81. Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that's triggered by a traumatic event. You can develop post-traumatic stress disorder when you experience or witness an event that causes intense fear, helplessness or horror. (Mayo Clinic Definition) • • What started out as a "syndrome" turned into a "disorder". A "disorder" is an illness. PTSD changed from being part of a collective indicator to a singular illness, a significant medical distinction. PTSD is a term initiated ~1980. The initial definition of PTSD described a psychological condition experienced by a person who had faced a traumatic event which caused a catastrophic stressor outside the range of usual human experience (an event such as war, torture, rape, or natural disaster). This definition separated PTSD stressors from the "ordinary stressors" that were characterized in DSM-III as "Adjustment Disorders", such as divorce, failure, rejection and financial problems.
- 18. Definitions of PTSD The VA’s most recent stance and definition of PTSD is: • Post Traumatic Stress Disorder (PTSD) is a condition resulting from exposure to direct or indirect threat of death, serious injury or a physical threat. The events that can cause PTSD are called "stressors” and may include natural disasters, accidents or deliberate man-made events/disasters, including war. Symptoms of PTSD can include recurrent thoughts of a traumatic event, reduced involvement in work or outside interests, emotional numbing, hyper-alertness, anxiety and irritability. The disorder can be more severe and longer lasting when the stress is human initiated action (example: war, rape, terrorism). • American Psychiatric Definition , essentially utilizes the diagnostic criteria required to make a diagnosis of PTSD as it’s definition . Refer to that portion of the presentation.
- 19. Recognizing the possibility of a Diagnosis of PTSD • Per DSM-IV-TR the “Gate Keeper” Criterion to consider a diagnosis of PTSD • • "the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others." "the person's response involved intense fear, helplessness and horror.“ • • • • • The DSM-IV-TR specifies the pattern of symptoms that must occur in 3 categories or Criterion of PTSD symptoms: 1) re-experiencing, 2) avoidance/numbing, and 3) increased arousal. • • • • PTSD can only be diagnosed if there is: at least One symptom of re-experiencing, Three symptoms of avoidance/numbing, and Two symptoms of increased arousal are present • If a person has six symptoms, for example, but all are in the hyper-arousal category, the diagnostic criteria for PTSD have not been met. • Forensic Validity of a PTSD Diagnosis Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW
- 20. DSM-IV-TR Diagnostic criteria for PTSD .1) History of exposure to a traumatic event meeting two criteria of the symptoms from each of 3 symptom clusters: 2) Intrusive recollections 3) Avoidant/Numbing symptoms, and 4) Hyper-arousal symptoms 5) The fifth criterion concerns duration of symptoms and a 6) Sixth assesses functioning
- 22. Body Language Diagnosis of PTSD • Your meta-language (body language) conveys 90% of your message. Your words convey only 10% of your message. • This idea also extends to your observation of the patient. Suttle nuanced mannerisms, i.e., scanning the room, inappropriate startling, obvious internal dialogue, avoidance of personal discussions. • Abnormal VS, Resting tachycardia, hyperhidrosis, systolic hypertension • Is the patient the disease? Would we say to a patient ,You are an appendicitis! Thus we need to be considerate and careful with our own responses to our patients who happen to have a mental disorder. • Be considerate, Consider is a great word and invitation vs “you need to do this, ect. Attempt to recruit the patient into their own care plan. • The veteran appreciates and expects sincere respect.
- 23. Criterion A: stressor • . • Criterion A: stressor • The person has been exposed to a traumatic event in which both of the following have been present: • 1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. • 2. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.
- 24. Criterion B: intrusive recollection The traumatic event is persistently re-experienced in at least one of the following : 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. 3. 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 upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- 25. Criterion C: avoidant/numbing • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: • 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma • 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma • 3. Inability to recall an important aspect of the trauma • 4. Markedly diminished interest or participation in significant activities • 5. Feeling of detachment or estrangement from others • 6. Restricted range of affect (e.g., unable to have loving feelings) • 7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
- 26. Criterion D: hyper-arousal • Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: • • • • • 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyper-vigilance 5. Exaggerated startle response
- 27. Criterion E:Duration & F: Functional significance Criterion E: duration • Duration of the disturbance (symptoms in B, C, and D) is more than one month. • Criterion F: functional significance • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • • • • Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more Specify if: With or Without delay onset: Onset of symptoms at least six months after the stressor
- 28. Primary Care PTSD Screen (PC-PTSD) • The PC-PTSD is a 4-item screen that was designed for use in primary care • In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: • 1) Have had nightmares about it or thought about it when you did not want to? YES / NO • 2) Tried hard not to think about or went out of your way to avoid situations that reminded you of it? YES / NO • 3) Were constantly on guard, watchful, or easily startled? YES / NO • 4) Felt numb or detached from others, activities, or your surroundings? YES / NO • Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. • *** Primary Care PTSD Screen (PC-PTSD) Prins, Ouimette, Kimerling et al., 2003
- 30. Primary Care Issues and the Returning Veteran with PTSD • 1) Musculoskeletal Issues • 2) TBI Traumatic Brain Injury 3) Sleep Issues 4) Chronic Pain Management 5) Co Morbid Mental Health Issues & Suicide 6) Sexual Dysfunction 7) Metabolic & Core Primary Care Issues
- 31. The Effect of Hypocortisolism on Health
- 32. Standard of Care for PTSD • 1) Cognitive Behavioral Therapy CBT • 2) Virtual Exposure Therapy VET • 3) Individual & Group Counseling • 4) Psychotropic Medications • 5) Optimal Management of Underlying Medical Issues
- 33. Afghanistan
- 34. Weight of War
- 36. A Soldier’s Day
- 37. Chronic Pain • • • • • • So, is it Pain, or is it withdrawal from narcotics. ?? Is the Pain valid, Is it Musculoskeletal pain? Is it neuropathic Pain>? Is it diffuse or focal Rheumatologic pain? Is it psychogenic PTSD Modulates Pain via a number or pathways. • The Severity of the PTSD is often correlated with the severity of the reported pain. • Treating the PTSD is crucial to successfully treating the chronic pain a veteran suffers. • Often times the therapies are similar, CBT, VRT
- 38. Traumatic Brain Injury, Blast vs. CHI Blast Injury Closed Head Injury
- 39. Traumatic Brain Injury ( TBI) • Blast Injury and Traumatic Brain Injury • A TBI is caused by a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Exposure to blast events can affect the body in a number of ways; in addition, these different injury mechanisms can interact and result in more impairments or prolonged periods of recovery. • Primary blast injury is the result of exposure to the over-pressurization wave or the complex pressure wave that is generated by the blast itself. This blast over-pressurization wave travels at a high velocity and is affected by the surrounding environment; for example, the effects of the blast wave may be increased in a closed environment such as a vehicle. Air-filled organs such as the ear, lung, and gastrointestinal tract and organs surrounded by fluid-filled cavities such as the brain and spinal cord are especially susceptible to primary blast injury. The over-pressurization wave dissipates quickly, causing the greatest risk of injury to those closest to the explosion. –
- 40. TBI continued • • • TBI resulting from blast exposure can be much more complex compared to TBI from other causes. As such, it is challenging to differentiate blast related TBI and/or concussion from other conditions. Finally, it is also difficult to estimate the course of recovery in these cases, as it may vary widely depending on various types of blast injury and other injury variables, such as the size of the blast, distance from the blast, etc. Due to these issues, it may be difficult to assess blast related TBI and concussion in the same manner that other brain injuries are examined. A better approach may be to conduct an evaluation based on the mechanism (cause) of the injury; that is, screen all individual service members exposed to a blast for any symptoms which might be resulting from the effects of blast on the brain. Difficulties experienced as a result of a closed brain blast injury may include a range of physical, emotional, cognitive, and behavioral symptoms. Many of these symptoms are non-specific, however; that is they occur with other conditions such as depression or combat stress. It requires an experienced clinician who is familiar with the many variables involved in blast injury, and has an understanding of how these variables can affect recovery and ultimately impact return to everyday activities.
- 41. 1. Did you have any injury(ies) during your deployment from any of the following? (check all that apply): A. Fragment B. Bullet C. Vehicular (any type of vehicle, including airplane) D. Fall E. Blast (Improvised Explosive Device, RPG, Land mine, Grenade, etc.) F. Other specify: ________________________________ __________
- 42. 2. Did any injury received while you were deployed result in any of the following?(check all that apply): A. Being dazed, confused or “seeing stars” B. Not remembering the injury C. Losing consciousness (knocked out) for less than a minute D. Losing consciousness for 1-20 minutes E. Losing consciousness for longer than 20 minutes F. Having any symptoms of concussion afterward (such as headache, dizziness, irritability, et c.) G. Head Injury H. None of the above
- 43. 3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? (check all that apply): A. Headaches B. Dizziness C. Memory problems D. Balance problems E. Ringing in the ears F. Irritability G. Sleep problems H. Other specify:_____________________
- 45. Sleep Disorders in Veterans with PTSD • A substantial number of US Veterans are suffering from PTSD following deployment in recent military conflicts. • Sleep disturbances are a primary complaint of Veterans presenting to the VA with PTSD. Veterans with PTSD have more self-reported and physician-rated health problems, and health status is associated with PTSD symptom severity. Most Veterans meeting criteria for PTSD report difficulty initiating or maintaining sleep (70-91%), and increased PTSD severity is associated with increased sleep disturbance. • Even after receiving treatment for PTSD, Veterans continue to experience residual insomnia at a rate of about 50%, in spite of having achieved PTSD remission. The best available evidence from literature sources suggests the diagnosis of SA is still best accomplished with full PSG.
- 49. Suicide • • There are about 30,00 suicides annually in the U.S., it is the 11 th most frequent cause of death .Veteran may make up to 20 % of all suicides. • Veterans of Iraq and Afghanistan conflicts who screened positive for PTSD were four times more likely to report suicide-related thoughts relative to veterans without the disorder. The research, published in the Journal of Traumatic Stress, establishes PTSD as a risk factor for thoughts of suicide in Iraq and Afghanistan war veterans. This holds true, even after accounting for other psychiatric disorder diagnoses, such as substance abuse and depression. Veterans who screened positive for PTSD and two or more comorbid mental disorders were significantly more likely to experience thoughts of suicide relative to veterans with PTSD alone. • As many as forty-six percent of veterans in the study experienced suicidal thoughts or behaviors in the month prior to seeking care, and of those veterans, three percent reported an actual attempt within four months prior to seeking the care. Suicide-related thoughts and behaviors discovered in a returning veteran who has been diagnosed with PTSD, especially in the presence of other mental disorders, may suggest an increased risk for suicide.
- 50. Suicide Prevention Hotline • The VA has also partnered with the Lifeline Program, a grantee of the Substance Abuse and Mental Health Services Administration (SAMHSA), of the Department of Health and Human Services (HHS), to develop a VA suicide prevention hotline. Those who call 1-800-273-TALK are asked to press “1” if they are a veteran, or are calling about a veteran.32 When they do so, they are connected directly to VA’s hotline call center, where they speak to a VA mental health professional with • real-time access to the veteran’s medical records. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response. In other cases, after providing support and counseling, the hotline transfers care to the suicide prevention coordinator at the nearest VAMC for follow-up care. From October 7 to November 10, 2007, 1,636 veterans and 311 family members or friends called the VA suicide prevention hotline. These calls led to 363 referrals to suicide prevention coordinators and 93 rescues involving emergency services. 1-800-273-TALK
- 53. Acupuncture for the treatment of PTSD, Pain and other Disorders • Researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment. COL Engel, of WRAMC • For more info go to: • http://www.pdhealth.mil/downloads/Evaluating_the_Efficacy_of _Acupuncture_as_a_Treatment_for_Posttraumatic_Stress_in_ Military_Personnel.pdf For a brief review of how Acupuncture works with emotional disorders: http://www.hiddenrhythmacupuncture.com/page11/files/acupuncture-foremotional-disorders-and-ptsd-a-presentation.pdf
- 54. Is their a role for Osteopathy in the care of the Veteran with PTSD 1)As far as the major tenet of Osteopathy is that of recruiting the “ Health” of the patient in developing a treatment plan for amelioration of suffering and in the healing of our patients, Yes there is a role. 2) Consider engaging the veteran and their family in the care, without a rigid agenda. 3) In utilization of manual medicine, have first developed a repoire, as not all veterans with PTSD are initially receptive to touching therapies 4) Care for the Caregiver “ Stay Grounded”
- 55. Links for more Info on PTSD • www.ptsdinfo.org/ http://www.ptsd.va.gov/professional/pages/trauma-ptsd-provider.asp • www.BrainLine.org/PTSD • www.nimh.nih.gov/health/publications/post-traumatic-stress-disorderptsd/index.shtml • helpguide.org/.../post_traumatic_stress_disorder_symptoms_treat ment.htm • www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp • http://www.ptsd.va.gov/professional/ptsd101/pages/iraq-neverleaves-us.asp
- 56. Some Books to Read on PTSD • On Killing: The Psychological Cost of Learning to Kill in War and Society Dave Grossman: • Moving A Nation to Care: Post-Traumatic Stress Disorder • • • (by Ilona Meagher, Robert Roerich • • Handbook of PTSD: Science and Practice by Matthew J. Friedman MD PhD, Terence M. Keane PhD • • • Night Falls Fast: Understanding Suicide • by Kay Redfield Jamison
- 59. Review of Topics Pertinent to Discussion • • 1) Objectives 2) The Issue 3) The Soldier 4) A Day Down Range 5) Coming Home B/ Veteran Specific Issues 6) PTSD 7) TBI 8) Musculoskeletal Injuries 9) Suicide 10) Sleep Disorders C/ Common Primary Care Issues and the Returning Veteran 11) Diabetes 12) Hypertension 13) Arthritis 14) Obesity 15) Depression 16) Headache Syndromes 17) Pain Management
- 60. D/ Role of Society and the Returning Veteran • 18) Family Issues 19) Occupational Issues 20) Veteran's Administration 21) Special Programs 22) Tricare E/ Special Considerations 23) Role of Osteopathy 24) Adjuctive Health Care Providers 25) What Not to Do 26) When to Refer and get Help 27) Resources 28) Review and Conclusion
Editor's Notes
- In the Military Health system we use an EMR,AHLTA where we can see All of a service members medical records and encounters. In the civilian sector that information may not be available to you. So that recognition of PTSD will be crucial for effective management of the medical problems of your Veteran Patient.
- Where are these soldiers coming from, Iraq and Afghanistan. AFGHANISTAN FACTSPopulationof Afghanistan is 31,056,997 by the latest July,2006 estimate. The major part of the population consist of 88% Sunni Muslims ,11% Shia Muslims and the remaining 1% includes Zoroastrian, Jewish, Hindu, Baha'i and ChristianChild deaths under 5:257 per 1,000Life expectancy:42.5 yearsTotal health expenditure:$29/capita
- So, why is this pertinent? Anyway we as PCP can alleviate the suffering, assist with the successful integration of these veterans back into society, the work place, with their familiesMay have a significant impact on lowering this cost to our communities.
- Roman Soldiers, Bayonet cdharges, Fire and death ratr at gettysburg
- . The eventual cost of providing lifetime medical benefits, lifetime disability benefits, and lifetime social security benefits for veterans of the current Gulf War could easily reach $700 billion2 or more, close to the total overall cost of the first five years of the war
- This topic itself is a series of lectures in itself. PTSD may be maintainedby second-order conditioning where trauma-relevant cues cometo serve as unconditioned stimuli, thus generalizing enhancedemotional responses to many previously neutral cues and impedingextinction. This extinction deficit in PTSD underlines the need for therapies focusing onthe extinction of learned responses, such as behavioral treatment,with or without the addition of pharmacological substances thatenhance the extinction of a learned response.Chemical precursors are depleted in PTSD and thus reversal of excitation/fear states are pathologically diminished.The extinction deficit in PTSD
- MRI studies showed an 8% reduction of hippocampal volume in Vietnam vets and similar decreases are found in those of physically and sexually abused women.Twin Studies and Sibling Studies have implicated the finding that the Hippocampus of PTSD victims is smaller to begin with.
- Cortisol Levels Low HighGlucocorticoid Receptors Increased DecreasedDexamethasone StimTestHypersuppressionNonsuppressionNegative Feedback Stronger WeakerCSF CRF Levels Increased Increased
- The Limbic system controls the 4 F’s, Feeding, Fleeing, Fighting and Sexual Behavior.No wonder that damage to it from dysregulation of stress hormones is associated with inappropriate and / or diminished function of the above four processes.Recent Studies suggest that PTSD may be maintainedby second-order conditioning
- The extinction deficit in PTSD patients observedin this study underlines the need for therapies focusing onthe extinction of learned responses, such as behavioral treatment,with or without the addition of pharmacological substances thatenhance the extinction of a learned response.This may explain why SSRI’s are 1st line pharmacologic therapy for PTSD.
- The extinction deficit in PTSD patients observedin this study underlines the need for therapies focusing onthe extinction of learned responses, such as behavioral treatment,with or without the addition of pharmacological substances thatenhance the extinction of a learned response.This may explain why SSRI’s are 1st line pharmacologic therapy for PTSD.
- Where trauma-relevant cues cometo serve as unconditioned stimuli, thus generalizing enhancedemotional responses to many previously neutral cues and impedingextinction. PTSD may be maintainedby second-order conditioning where trauma-relevant cues cometo serve as unconditioned stimuli, thus generalizing enhancedemotional responses to many previously neutral cues and impedingextinction. The extinction deficit in PTSD patients underlines the need for therapies focusing onthe extinction of learned responses, such as behavioral treatment,with or without the addition of pharmacological substances thatenhance the extinction of a learned response. Chemical precursors are depleted in PTSD and thus reversal of excitation/fear states are pathologically diminished.
- So, Let’s take breath from all of that and put it some context of some clinical relevancy.
- Is the patient the disease would we say to a patient ,You are an appendicitis! No, and thus we need to be considerate and careful with our own responses to our patients who happen to have a mental disorder. A significant issue many soldiers face “within” their selves, is a paradoxical feeling of shame, survivor guilt , inadequacy and a concern of being “stigmatized, when given a diagnosis of PTSD. It can be a disqualifying condition for military retention, a reason to possibly lose top secret clearances for possible government and security driven jobs, and a concern that they are being “Labeled:” as someone who could “Snap”, is weak, is unstable. It is an illness not unlike many other illnesses which require a strategy for management. Before that can occur we need to make a diagnosis and and recruit that veteran into and initiate a treatment plan.
- The most basic definition of PTSD is that it is an anxiety disorder with multiple effects on the body’s nervous and cardiovascular system, stemming from one, recurring or sequential experiences of one or more traumatic events so horrific that it causes intense fear, helplessness and horror, with symptoms lasting over 30days. PTSD is termed chronic if these symptoms last longer than 3 months.So, A Soldier is injured in an IED blast while driving a HumVee, He is badly,burned, this time, as it is his 3 deployment,two prior exposures to blasts were “near Misses”.The Medic who pulled him,out,saw his charred and dead comrades, It his 1stdepolyment, and he is in month 12 of 15 months of 15 hr,dasy,6 day a week, A soldier video’d the blast from100 meters, uploaded it to youtube, and on return to CONUS, cared for amputees at WRAMC. So,Who has PTSD?
- Well, your patient who is a veteran might not spew out the diagnostic criteria. A lot is had and seen via patient and if you are lucky their significant other’s body language.
- Body Language is important
- It here where the astute and experienced clinician will receive their cues and clues as to whether PTSD is a clinical consideration. To verify, refer ,if able all veterans without a treatment plan or behavioral health back up for a behavior health consultation and therapy.Remember, It is the Primary Care Physicans Task to Recognize the possiblity of PTSD, not make and / or confirm diagnosis. Having an established relationship ,if possible, or network ,to whom you can refer these veterans is the Key./
- Tread Lightly here. 1) “when you buy that ticket ,you got to ride the ride”. Inquiring too early, into topics that may reignite old memories is not without it’s consequences. SO, unless you have good behavior health accessibility or back up, leave these decisions& queries to BH. If however, your patient “drops the bomb”, you will be able to validate criteria A, in both emotional and vivid detail. Are you being played? After discharge, monetary issues are generally resolved, and unless there is a co morbid psychiatric disorder, your patient’s confiding to you and confidence in you is a good sign of trust.
- Case Study:So, you finish your evaluation and arrange treatment for a veteran you care for ,for routine care of his hyperlipidemia, hypertension, insomnia, and his chief complaint today, left shoulder pain. His wife and he are currently separated, you’ve only met this 32 year old former “infantry scout 11bravo 20”. He has gained 10 # since completing his recent Reserve contract and deployment and demobilization to Afghanistan 6 months ago , states he is taking all the medications he left the army with , but only knows them by their color, has deferred any referrals to behavioral health, thanks you for the Rx for Mobic and the ortho referral for what you believe is a possible labral tear of his left shoulder . As he gets ready to leave ,you ask him, if there is anything else you can do?, He pauses, then , can you help me not feel so numb?” Are feeling numbness down you arm, and pain/ you ask, and says No, I mean ,I just feel numb, everywhere, all the time.” “My wife says I have no feelings for people anymore, she is right, I could see he cut herself, and say, OH well, she’ll live” that is why she left me. So ,Doc, can you help me? And So, it goes.I am going to let you all sit with that scenario, for a bit, and we’ll move on.
- So, you stop, tell you front desk, you need a few a few more minutes before you can see your next patient. You note your veteran’s pulse is 102, despite being on Toprol XL 50 mg and lisinopril 10 with 12.hctz, he appears tired, and would rather stand than sit.You ask him, "How do you feel now”, he states he feels comfortable with you for some reason, but feels wired from the 2 red bulls he had to take to make it thru his night shift.You ask how many hours does he sleep, he says, about 3-4, but my wife says I am moving around all night, and once hit her in the face in my sleep. That is when she took the kids and went of her sisters. Hmmm . Well, you’ve bought that ticket, and you got to ride the ride.
- If the duration of dysfunction and symptoms exceed three months you are dealing with Chronic Post Traumatic Stress Disorder. You ask your patient, how long this has been going on, and he states, about a month before he demobilized from his 15 months tour in Afghanistan. You asked if he’d mentioned this to any other doctors, “he didn't', he said the guys who do, end up staying for months, some get boarded out, and he just wanted to go home.SO he kept quiet and just drank his self to sleep on most nights. So, about 7 months, you say, he replies ,about.
- Take a Breath/ Introduce the 4 Question Screening Tool:Well, now that your overwhelmed, let’s make a bit easier for PC purposes and referral.So,now,you ask these four questions, and he answers to the affirmative for all four,.So, you consider the “Suicide Question”Being thorough, you ask the “would you harm yourself ?’ question. He states he has thought about it, but wouldn’t. his father a Vietnam vet ,killed shot his self in the head in their garage, when he was 12 . He does contract for safety. You spend about the next 20 minutes, with his permission, getting his wife involved, scheduling an appointment for them both, with you in 1 week, and a psychologist who has experience working with veterans, as you are concerned he has ptsd tomorrow. You add Prazosin 1 mg, with all the precautions, and add lunesta 3 mg to take before he sleeps , in the morning, and mention you might need to set him up to see a sleep Specialist. You give he and his wife the VA’s hotline #,1-800-273-TALK. Things appear wrapped up, your patient thanks you say your good byes, and you move on to catch-up .
- Well, I had to put a pic in of my grandson and our lab, Harvey. But, Now that we’ve reviewed the basic pathophysiology PTSD, understand the criteria for recognition and diagnosis, how does all this affect the primary care management of the veteran with PTSD.?/In this last case presentation, we see how all of his issues are linked.The care of the our returning veterans with PTSD is truly “Integrative Medicine in the Now”In the Now, like my grandson, and my Dog live in the Now,”Not a boutique form of medicine, not holistic or touchily feely, but a method to integrate the mind body spirit relationship and partnership on a moment to moment level in some cases.
- Introduce the 2nd portion of the talk.One could write a book ,at least a chapter on this topic . I will focus on only a few of the issues that the veteran with PTSD may have.We Focus on those issues that are clearly affected by diagnosis of PTSD.I do have limited time, and apologize for my brevity on these important issues.
- Reinterate and review the physiologic premise….Bring up the “Big & Small Rate Study”This what it mostly comes down to . In PTSD the patient is in an insufficient glucocorticoid state. This pathophysiologic situation has profound ramifications on the health and management of most all of the common disorders we see in primary care.This insufficient glucocorticoid state is associated with increased catecholaminergic and inflammatory responses. It is these pathologic responses in patients with PTSD that may be the reason these patients have demonstrate a exaggerated insulin resistance, proinflammatory cytokine production with its associated consequences, osteoporosis, disproportionate pain responses ,hypervigilance,agitation and depression. This hypothesis may also explain the success of antidepressants,especially the SSRI class.
- I am not going to a lot of time discussing the treatment, it is out of my scope of practice. Still research and find who does have this expertise. Contacting our local VA if available may help.CBT refer only to an experienced qualified therapistRefer only to a center with established history of good outcomes and trained personnelRefer only to Therapists with established experience in treating PTSDReview all medications with a Psychiatrist experienced in caring for patients with PTSDOptimize the care and management of TBI, <Sleep, HTN,Diabetes,Obesity,Addictions.
- The Afghanistan weather is marked by great variance in temperatures from region to region. It is accompanied by huge differences in day and night temperatures and summer and winter temperatures.
- Introduce the Video/Credits The US Army's Spc. Craig Brown talks about the weight of warfare and the amount of gear US soldiers must carry into battle in this video shot and produced by Justin Merriman, a staff photographer with the Pittsburgh Tribune-Review in Pittsburgh, PA. 90 #, at least 45 #, for 21 year old well trained and fit soldier, it may be doable.
- The drought-ridden regions of the southwestern plateau experience daytime temperatures of 35 C/95 F. Jalalabad is among the hottest places in the country recording the maximum temperature of 49 C/120 F in the month of July. January temperatures fall to -15°C / 5 F or below in regions situated at high altitudes in the mountains.
- Consider the consequences of carrying this load for a 33, 38,45 or 54 year old reservist or national guard soldier . They are literally bone breaking. Degenerative disc disease in the neck back, knee ,foot and ankle injuries ought to be assumed. Appropriate imaging,ortho,podiatry and neurosurgery consultations need to be considered.It is my anecdotal formula, that for every ‘downrange” deployment a veteran has completed, they age between 5 and 10 years . So consider that in your QA and timed considerations for wellness evaluations.
- Pain Management in a veteran with PTSD is difficult. If you are deciding to prescribe narcotics a “Contract” /Sole Provider program is essential. Referral to pain management specialist to assist ,review and “Bless “ your treatment plan, consider other non narcotic based therapies, interventional techniques, and other integrative medicine modalities such as acupuncture and qi qong should be considered.Chronic pain was characterized, and levels of PTSD and anxiety symptomatology were assessed by self-report questionnaires. Subjects with PTSD exhibited higher rates of chronic pain, more intense chronic pain and more painful body regions compared with the other two groups. PTSD severity correlated with chronic pain severity. Thresholds of subjects with PTSD were significantly higher than those of subjects with anxiety and healthy controls, but they perceived suprathreshold stimuli as being much more intense than the other two groups.These results suggest that subjects with PTSD exhibit an intense and widespread chronic pain and a unique sensory profile of hyposensitivity to pain accompanied by hyper-reactivity to suprathreshold noxious stimuli. These features may be attributed to the manner with which PTSD subjects emotionally interpret and respond to painful stimuli. Alternatively, but not mutually exclusive, the findings may reflect altered sensory processing among these subjects.
- In Summary, recognize possibility then refer to a center or VA specializing in TBI TXBlast induced TbI is different than CHI induced TBI
- I am spending time on this distinction, as the typical concussion we in primary care are used to evaluating, is just that, typical. However, suffering from blast exposure has a number of clinical ramifications, with some symptoms similar to PTSD. In TBI ,generally, most patients improve within a month, but what you see is what you get. A Patient does not TBI”. They can have a delayed response to stress, however, and develop PTSD .Persistent cognitveisses following a blast vs newly develop’d ones.With TBI “what you see,is what you get” With PTSD the onset is insidious.
- Again, with TBI what you see is what you get, in general. NeuroPsych testing to ferret out learning disabilities, cognitive dysfunction, are often appropriate. Trials of cognitive enhancing medications are Ok in the interim ,medications such as nuvigil, or Provigil. Withhold ADHS/ADD medications such as concerta until your patient has been tested and seen a specialist.
- NOTE: Endorsement of A-E meets criteria for positive TBI Screen
- Sleep disorders in the veteran like most of are population are predominantly related to underlying psychiatric disorders(with PTDS and Anxiety increasing this prevalence)medications ,substance disorders ,restless legs syndrome, pain and obstructive sleep apnea.
- If I could solve only one problem in my WTU soldiers, it would be to improve their sleep.I am not going review the treament,but mention, if at all possible avoid any medications with addiction potential.Treatment of Sleep Disorders in Veterans with PTSD is crucial, and often assist greatly in the abatement of PTSD symptomatologyTreating Co-Morbid Sleep Difficulties in Veterans With Posttraumatic Stress Disorder (PTSD): A Pilot Study
- Sexual Dysfunction, fear of Intimacy Fatigue, Shame, Anger, issues with intimacy, the dark, medications, sleep deprivation, numbing,pain.Viagra, Levitra, Cialis all work. And should be considered.as well as the consideration the SM has a dysfunctional hormal access aordefciency ,testosterone,thyroid,iron,Vit D.
- This is a Picture of the Mayon Volcanoe,from my wife’s backyard ,inthe Bicol area of the Philippines. It’s pertinence is, here we see aVolcanoe, but with the Veteran with PTSD, there is often, also, an internal Volcanoes ,that without the recognition of on e the most serious issues they face, that soldier will die, resulting in the catastrophic disruption of their core friends and families. That volcanoes is Suicide.
- Depression and other Co Morbid Psychiatric disorders only aggravate and potentiate the burden that the veteran with PTSD manages.There are about 30,00 suicides annually in the U.S., it is the 11 th most frequent cause of death .Veteran may make up to 20 % of all suicides.
- When to Refer for Specialized Psychiatric Care Medication failures or side effectsSuicidal or homicidal ideationComorbid psychiatric problems including substance abuseOther life stressors, limited social support
- The responders at the VA suicideprevention hotline have received American Association of Sociology (AAS)credentialing and certification.
- Well. We are on the Home stretch. Review Some Issues/PointsPhysiology4 question testRefer, referOther co morbid issues affectred by PTSD ortho,pain,sleep,sexualisses,metabolic,TBI,co morbid psych isses
- This my grandson HankSo what other modalities, what else can we offer, do ,seek to assist us in caring for our veterans.
- Taking care of your own self, is important. Your own sense of balance, groundedness is essential, especially if several of your patients are veterans with PTSD or other mental illnesses. Taking Jon Kabat Zinn’s course Mindfulness Based Stress Reduction for Health Professionals, Thru Omega .org
- This is what is all about, Coming Home to Loved ones, friends ,family, becoming Whole and at Ease, having done their duty in a most harsh environment, for their country and us. Questions.
- If you’d like this PP , need some links to the info, Email meswanndo52@yahoo.comwilliam.swann@AMEDD.army.mil240-409-3486Thanks/ Any QuestionsBill Swann D.O.PCM WTU KACC