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.

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Breakfast and LearnDecember 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

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.

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https://www.youtube.com/watch?v=TNwywbP5hIQMake the Connection

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.

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.

PTSD/TBI101A short history, DSM-V symptoms, and treatments and current Assessment tools

8Mark S. Kane, Ph.D. Licensed PsychologistFellow Michigan Psychological AssociationRiverview Psychological Services, P.C.drmskane@gmail.com 616-464-0811

National Center for Post Traumatic Stress Disorder Statistics7.8 % 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

“Best Practice Treatment” of Shell Shock after WWI

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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.

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• 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

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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

• 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’dOf 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 warAnd 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 hyperactivity13

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

History of PTSD: “Shell Shock” World War I

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PTSD first used in 1980 in DSM-IIICurrent 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.

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PTSD Stressors

• Violent human assault

• Natural catastrophes

• Accidents

• Deliberate “man”-made disasters

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U.S. Department of Defense Images: http://www.defense.gov/DODCMSShare/NewsStoryPhoto/2001-09/hrs_200109205g_hr.jpg

Combat FatigueImmediate psychological and functional impairment that occurs in war or during other severe stressors during combatCaused by stress hormones- Features of the stress reaction include:

• +Restlessness

• +psychomotor deficiencies

• +withdrawal

• +Stuttering

• +Confusion

• +Nausea

• +Vomiting

• +Severe suspiciousness and distrustAPA, 1994

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Symptoms of PTSD

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• 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

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)

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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)

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HPA Axis explained…

• .

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Hormone /Hypothalamic, pituitary, adrenal (HPA) axis

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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.

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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

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.

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New Technology Identifies Organicity after TBI

Wang et al, Arch Neurol. 2008 May;65(5):619-26.

Control CC

TBI CC

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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

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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

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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

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Therapeutic Approaches & TechniquesCognitive 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

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Therapeutic Approaches & TechniquesEye 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.

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Therapeutic Approaches & TechniquesMedications: 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.

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PTSD Coach

• Smart phone application

• Education

• Coping/Support

• Self-tracking of PTSD using the PCL

• Not to be used as a stand alone treatment

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Assessment and Diagnosis of PTSD with

the DSM-V

*Please see PTSD Assessment Handout34

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

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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, other36

MEASURES

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

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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

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

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

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

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

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)

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Choosing the “Right” Measure

• Goals

• Level of Training

• Time

• Cost

• Patient Characteristics

• Psychometric Properties of the Measure

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Samples

• Primary Care PTSD Screen (PC-PTSD)

• Self-administered: PTSD Checklist (PCL-5)

• Interview: Clinician Administered PTSD Scale (CAPS)

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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

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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

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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

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.

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Essential Considerations

• Suicide Risk

• Co-occurring Substance Abuse

• Co-occurring mTBI

• Insomnia

• Careful consideration of PTSD risks when prescribing medications

• Family Support

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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

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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

Medicaid Expansion Benefits Veterans and the Economy

• http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-economy

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1. Source: Michigan League for Public Policy. http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-economy

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VISN 11 Catchment Area Map

Medicaid Expansion Benefits Veterans and the Economy

551. Source: Michigan League for Public Policy. http://www.mlpp.org/medicaid-expansion-benefits-veterans-and-the-economy

Resources1. 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.80oWNbtn.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!

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“Courage is learning to ask for help”

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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

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

No Wrong Door for Michigan Veterans

How to help?

• 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 fullyserved.

• 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.

Michigan Veterans Community Action Team – MiVCAT

“No-Wrong-Door” Approach to Serving Veterans

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Integrated System of Care

Thank you.

Questions?

Elena Bridges

Veterans Services Community Coordinator,

Altarum Institute

Chairperson, West Michigan Veterans Coalition

Elena.bridges@altarum.org

616-401-2026