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!