Treating Traumatic Stress Injuries: An Overview

Tulane School of Social Work

Mark C. Russell, Ph.D., ABPP, CDR, USN (Ret.)

Antioch University Seattle Charles, R. Figley, Ph.D.

Tulane University

April 5 2013; 8:30am-5pm (6 CEUs)

Schedule Time

Subject (Objective) Who

9:00 Introductions (1) Both 9:45 Overview of Trauma and Trauma Resilience (1) Figley 10:30 Break 11:00 Overview of Traumatic Stress Injuries (2-3) Russell 11:45 Overview of Treatment Planning (3-4) Both Noon Lunch 1:00 Overview of EMDR (5) Both 1:45 Demonstration (5) Both 2:30 Break 2:45 Treatment Adaptations for the Spectrum Traumatic Stress Injuries (3-4 & 5) Russell

3:30 Applications to Combat Stress Injuries and the Military Contexts (6-7) Both

4:15 Q&A Both 4:45 Wrap Up

Workshop Objectives

1. Provide an overview of resilience, trauma, traumatic stress, and the traumatic stress injury

2. Identify the spectrum of traumatic stress injuries 3. Clarify the importance of mental health professionals

focusing on human development and injury prevention and rehabilitation rather than seeking mental illness treatment

4. Provide an overview of trauma treatment planning 5. Describe contemporary EMDR treatment protocols for

acute stress injuries 6. Discuss unique treatment considerations in working with

military populations 7. Know where to go on the web to review and understand

the research on EMDR treatment of war trauma

Introductions

Charles, R. Figley, Ph.D. Tulane University

Mark C. Russell, Ph.D., ABPP, Antioch University Seattle

Overview of Trauma and

Trauma Resilience

Overview of Traumatic Stress Injuries

Spectrum

Mark C. Russell, Ph.D.,

What Are Stress “Injuries” and are they REALLY Injuries?

Dictionary Definition: Stress- “a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation.” Injury- “an act that damages or hurts.”

Source. Merriam-Webster at http://www.m-w.com

Working Definition of Stress Injury

A severe maladaptive or prolonged stress reaction (e.g., ASR/COSR/CSR) lasting greater than five days causing substantial functional and/or structural neurophysiological alterations as evident by clinically significant changes in one’s mental/physical health, sense of well-being, and/or impaired level of functioning. Maybe Acute or Chronic. Three subtypes: Traumatic Stress Injury (TSI) (1) Acute TSI (2) Chronic TSI (Specific/Developmental/Combined) War (Combat) Stress Injury (WSI) (1) Acute WSI (2) Chronic WSI (Specific/Combined TSI) Compassion Stress Injury (CSI) (1) Acute CSI (2) Chronic CSI (Specific/Combined TSI) Ex. CSI is caused by the cumulative effects of severe or prolonged CSR due to excessive, unregulated empathic responses (e.g., emotional contagion) combined with chronic activation of the helper’s sympathetic stress response to primary and secondary compassion stressors which overwhelms the helper’s self-care and resilience capacity.

Human Stress Response

Universal, Unchanged, Adaptive Human Stress Response

Combat Exposure for OIF Soldiers Hoge et al. (2004)

Event Army (%) USMC (%)

Attacked/Ambushed 89 95

Being shot at/receiving fire 93/86 97/92

Shooting at enemy 77 87

Killing enemy combatant(s) 48 65

Handling human remains 50 57

Seeing injured women/children 69 83

Seeing dead/injured Americans 65 75

Killing non-combatant(s) 14 28

Being wounded 14 9

Normal Combat Reaction (Menninger, 1948)

• 50% - pounding heart • 45% - sinking stomach • 30% - cold sweats • 25% - nausea • 25% - shaking/tremors • 25% -muscle stiffness • 20% - vomiting • 20% - general weakness • 10% - involuntary bowel • 6% - involuntary urination

Perceptual Distortions in Combat (Grossman, 2007)

85% Diminished Sound 16% Intensified Sounds 80% Tunnel Vision 74% Automatic Pilot (scared speechless) 65% Slow Motion Time 7% Temporary Paralysis 51% Partial Event Amnesia

47% Partial Amnesia for Actions 40% Dissociation- detachment 26% Intrusive Distracting Thoughts 22% Memory Distortions 16% Fast Motion Time

The “Dosage Effect”

Walter B. Cannon: “Flight of Fight”

Can Stress Cause Actual Injury or Death?

Medically Unexplained Physical

Symptoms

Complaint Total Group

Combat Veterans

Noncombat Troops

Gastrointestinal 29.7% 85.4% 14.6%

Orthopedic 23.5% 88.5% 11.5%

Multiple symptoms 17.3% 84.3% 15.7%

Cardiovascular 15.9% 88.1% 11.9%

Headache 8.1% 86.6% 13.4%

Genitourinary 5.4% 80.0% 20.0%

Source: Menninger, 1948; p. 156

Evidence that Stress Causes Injury

Institute of Medicine (IOM; 2008): “In the brain, there is evidence of structural and functional changes resulting directly from chronic or severe stress. The changes are associated with alterations of the most profound functions of the brain: memory and decision-making” (p. 60) and “profound effects on multiple organ systems…the continuation of altered physiologic states over months and years contribute to the accumulation of adverse long-term health consequences” (p. 66).

The Spectrum: Scope of a Mental Health Crisis Neuropsychiatric Diagnosis Total Number of Active Military

Diagnosed by Military Providers (2000-2011)1

Total Veterans Diagnosed by VA Providers (1st Qtr FY 2002-3rd Qtr FY 2012)3

Behavioral Problem (V-Code)

361,489

Other Mental Health Diagnoses

318,827 32,268 (Special symptoms)

26,788 (Sexual Deviations & Disorders)

*Total Number of Active Military and Veterans Diagnosed *Not include est. 657,000 (23%) using private sector (NCCBH, 2012)

1,780,649 *Not include Mil. Comm. Counseling Centers, Chaplains, & MFLC contractors **Not include family members

444,505 *Not include data from 300 Vet Counseling Centers

Somatoform and Dissociative Disorder2

205,181 (Number outpatient visits in 2010- includes

anxiety diagnosis dissociation)

*Co-Morbidity (subtracted from above total)

459,430

Neuropsychiatric Diagnosis Total Number of Active MILITARY Diagnosed by Military Providers (2000-2011)1

Total Number of OEF/OIF/OND Veterans Diagnosed by VA Providers (1st Qtr FY 2002-3rd Qtr FY 2012)3

Adjustment Disorder

471,833 56,633

Post-traumatic Stress Disorder (PTSD)

102,549 239,094

Depressive Disorder Bipolar Disorder4

303,880 8,280

184,404

Anxiety Disorder (not PTSD) 187,918 161,510

Substance Use Disorder 306,248 118,438

Traumatic Brain Injury (TBI) 212,742 28,828

Psychotic Disorder (not Schizophrenia)

15,456 111,199 (Affective Psychosis)

li i d

Understanding & Preventing Stress Injury Predominant Features: • Emotional dysregulation (fear, depression, anxiety, anger)

– DSM/ICD diagnoses mood d/o; anxiety d/o; adjustment d/o; anger d/o; alexithymia; impaired love, joy, reflection, humility, & humor.

• Cognitive/perceptual dysregulation (attentional bias, beliefs, memory, perception, learning) – DSM/ICD diagnoses brief or atypical psychotic d/o; ASD/PTSD; dissociative d/o; ADD/LD;

impaired curiosity, flexibility, efficacy, & mindfulness. • Sleep dysregulation (e.g., parasomnias; nightmare d/o; REM d/o) – impaired sleep hygiene. • Somatic dysregulation (pain, fatigue, cardiovascular, gastrointestinal, neuro, etc.)

– DSM/ICD diagnoses somatoform d/o; medically unexplained physical symptoms; immunological d/o; impaired physical activity, diet, relaxation, & wellness behavior.

• Behavioral dysregulation (e.g., problems regulating behavior & lifestyle) – DSM/ICD diagnoses suicidal/self-injurious; substance abuse d/o; personality d/o; eating

d/o; adjustment d/o; impulse control; sexual d/o; ADHD/ODD/CD; impaired moderation, interests, work, hobbies, & creativity.

• Social dysregulation (e.g., interpersonal problems, conflict/violence, isolation) – DSM/ICD diagnoses RAD; adjustment d/o; relational V-codes; personality d/o; impaired

other-focused orientation, recreation, altruism, & community involvement. • Identity/moral dysregulation (e.g., moral injury; traumatic grief, survivor guilt; perpetrator

trauma; spiritual existential crisis; borderline PD; suicidal/homicidal; “beserking;” atrocity; misconduct stress behaviors; impaired sense of meaning, integrity, purpose & connection.

• Empathic dysregulation (e.g., CSI: CF, STS, VT, burnout) – impaired balance & self-care.

Other Aspects of Spectrum and Crises

Providers should also expect that 50 to 80% of patients with PTSD with comorbidity.

In 2007 military epidemiologists found a high frequency of somatic complaints in returning OEF/OIF personnel including over 75% reporting fatigue, 70% sleep difficulties, 42% headaches, 50% joint-pain and 23% gastrointestinal symptoms (Hoge, et., al., 2007).

According to the Government Accounting Office (GAO, 2008), DOD data from November 2001, through June 2007, revealed that 26,000 service members were separated for personality disorder.

During 2001-2010, a total of 25,357 active-duty service members engaged in suicidal or parasuicidal behaviors, including 1,939 completed suicides, 19,955 received inpatient or outpatient diagnosis of an intentionally self-inflicted injury or poisoning, and 3,463 were identified as “likely self-harm” after hospitalization for injury or poisoning with a concurrent mental health diagnosis (AFHSC, February, 2012).

56.1% of deployed Marines, and 48.4% Soldiers, reported killing combatants in 2010 (MHAT-VII, 2011, risk for moral injury; risk traumatic grief -86% knew a fellow service member shot or wounded (Hoge, et al., 2006).

Military children at risk intergenerational effects, increase mental health utilization in outpatient and inpatient visits since OEF/OIF (Gorman 2010; Mansfield et al, 2011); 46% spouses reported high stress w/ partner PTSD (Greentree et al., 2012).

48% of returning Marines threatened physical violence; 26% hit someone (Koffman, 2006);69% reported injuring a woman or child (Hoge, 2004).

Misconduct Stress Behaviors Misconduct stress behaviors are described by the U.S. Army (2006) as a range of maladaptive stress reactions from minor to serious violations of military or civilian law and the Law of Land Warfare including: • mutilating enemy dead • not taking prisoners • looting, rape, brutality • self-inflicted wounds • "fragging" (killing of one’s own military leaders) • desertion • torture and intentionally killing non-combatants. It is often assumed that misconduct stress behaviors are due to an underlying personality disorder or other character defect, as opposed to evidence of possible war stress injuries in that “even the good and heroic, under extreme stress may also

engage in misconduct" [Department of the Army (DOA), 2006; p. 1-6).

Overview of Treatment Planning

Mark C. Russell, Ph.D Charles, R. Figley, Ph.D.

Seven Considerations for Treatment Planning and Adaptation of EMDR to

Operational Settings (Russell, Cooke, & Rogers, in press)

– Referral Question – Strength of the Therapeutic Alliance – Client Treatment Goals – Timing and Environmental Constraints – Clinical Judgment Regarding Client Safety – Suitability for Standard Trauma-Focused EMDR

Reprocessing Protocol

– Utilization of Any Adjunctive Intervention and

Referral Need

Treatment Planning for TSI Spectrum: Training & Screening

Training is essential!

Spectrum screening: - History (risks & resilience) - Level of Exposure (single best predictor)-(e.g., CES) - Safety (self/other violence, psychosis)

- Physical health, Pain & TBI (e.g., WIA, exercise, diet, medical, recreation, PHQ-15, MACE)

- Sleep (e.g., sleep hygiene)

- Substance use (e.g., AUDIT, CAGE, Rx & stimulants)

- Social (e.g., level of perceived support, family, friends, work, recreation, conflict/violence, transitions)

- ASD/PTSD (e.g., PCL, IESR); Depression (e.g., BDI-II; Anxiety (e.g., STAI); Anger, Traumatic Grief, Moral Injury - Level of Functioning

Overview of EMDR

Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D.

What is EMDR?

EMDR integrates elements of psychotherapy into standardized set of procedures and clinical protocols Consists of two major unique components: • Dual-focused attention (internal and external

focus) and • Bilateral (rhythmic) stimulation (BLS) (visual,

auditory, kinesthetic).

VA/DoD (2010) PTSD Practice Guidelines

“The choice of a specific approach should be based on the severity of the symptoms, clinician expertise in one or more of these treatment methods and patient preference, and may include an exposure-based therapy (e.g., Prolonged Exposure), a cognitive-based therapy (e.g., Cognitive Processing Therapy), Stress management therapy (e.g., SIT) or Eye Movement Desensitization and Reprocessing (EMDR).” (pp. 117-118).

Successful therapy requires detailed client self-disclosure XX XX

Successful therapy requires client compliance with daily or

weekly homework assignments (24-48 hours total)

XX XX

Therapists frequently engage in extensive challenging of the

client’s cognitive distortions

X XX

Therapists teach coping skills in session that clients are

required to use in vivo outside of sessions

.5 XX XX

Requires clients to simultaneously pay attention to an internal

distressing stimuli and track alternating external stimulus (e.g.,

visually track therapist’s hand movements)

XX

Therapist takes an active, directive stance in implementing the

treatment protocol

XX XX

Theoretically regards client free associations not linked to

the target memory during exposure as a form of avoidance

that can derail therapy

XX

XX

Encourages the client to share as little or much of traumatic

material as they desire

XX

Same protocol is used to treat symptoms and/or diagnoses

related to depression, anger, guilt, grief, anxiety, pain, and

other medically unexplained physical symptoms

XX X X

Requires constant vigilance from the therapist to prevent

client avoidance behaviors

.5 XX XX

Four Acute Stress Injury Treatment Goals

For treatment planning purposes, assessing military client suitability for EMDR Standard reprocessing of acute stress injuries requires matching one of four treatment goals with the appropriate EMDR early intervention. Russell and Figley (2013) identified four treatment goals for utilizing EMDR as an early intervention for acute stress injuries: 1. Client stabilization 2. Primary symptom reduction 3. Comprehensive reprocessing, and 4. Prevention of compassion-stress injury

Treatment Goal 1: Client Stabilization

Purpose: In the immediate aftermath of a traumatic event, the majority of survivors experience normal ASR/COSR. However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, and erratic behavior. Signs of intense grief may be loud wailing, rage, or catatonia. Clients may develop severe, debilitating ASR/COSR that render them un-stable and/or unresponsive to medical or unit personnel. Such clients would present as being conscious and awake, however, in a state of acute peri-traumatic dissociation or “emotional shock” with limited or no responsiveness to verbal interchange. Therapists should attempt to quickly establish therapeutic rapport, ensure the survivor's safety, acknowledge and validate the survivor's experience, and offer empathy. After all basic safety needs have been taken care of and medical triage has been completed, medical/ nursing, unit or command, and/or other emergency personnel may request the therapist to assist with psychological stabilization in order to medically assess and/or transport to the next echelon of care.

Recommended EMDR Stabilization Interventions: (1) Emergency Response Procedure (ERP) (2) Eye Movement Desensitization (EMD) (3) Resource Development and Installation (RDI)

Emergency Response Procedure (ERP)

Script (Quinn, 2009) Purpose: Stabilization and triage of client by increasing orientation to present focus. Use in

the following situations: routine attempts to engage blankly staring clients are not successful; clients are suffering from acute stress reactions; clients are in “shock,” and/or unresponsive to verbal questions or commands (Quinn, 2009). 1. Calmly speak in the client’s ear to identify yourself, your role in the hospital/setting, and reassure the client of their safety in the hospital/setting. 2. Inform the client that you are going to tap them gently on the shoulder and remind them where they are, that they had survived the bombing (or any other incident), and they are now at a safe place. 3 .After brief periods of the bilateral taps, direct their attention to safety, so that clients can became responsive to outside stimuli, and be engaged verbally about their medical status and so on. (The total intervention time would be measured in minutes Quinn, 2009). 4. If stabilized, and deemed appropriate and consent is given, consider suitability for higher level of EMDR intervention (symptom reduction, comprehensive reprocessing, or resilience building).

Treatment Goal 2: Primary Symptom

Reduction Purpose: Limit reprocessing to a single, circumscribed event. A

variety of contexts arise that preclude comprehensive reprocessing for otherwise stable and suitable military clientele. Such variables include: time-sensitive constraints (e.g., impending client or therapist absence, impending client deployment, etc.), environmental demands (e.g., forward-deployed, operational settings), and client-stated treatment goals (e.g., expressed desire to not address earlier foundational experiences other than such as pre-military incidents), that may lead to the joint decision to deviate from the standard EMDR protocol after full-informed consent is provided.

Recommended EMDR Primary Symptom Reduction Interventions: (1) Eye Movement Desensitization (EMD) (2) Modified EMD (Mod-EMD)

Eye Movement Desensitization (EMD)

(Russell, 2006) Purpose: Crisis intervention limited to the reduction of primary symptoms

associated with the precipitating event. In the immediate or near-immediate aftermath of exposure to a severe or potentially traumatic event, clients present with severe, debilitating ASR/COSR. Essentially an exposure therapy that adds BLS and does not reinforce free associations outside of either a single-incident target memory (e.g., primary presenting complaint), or a representative “worst” memory from a cluster of memories related to a circumscribed event (e.g., a recent deployment). Free associations reported outside the treatment parameters require the client to be returned to target memory whereby SUDS are re-accessed and BLS initiated. Clients may be returned to the target memory at any time by the therapist where SUDS are obtained to assess progress of desensitization effect. Repeat process until target memory has SUDS of “0” is obtained or “1” if ecologically valid. Installation, body scan, current triggers and future template are not included in EMD.

Potential Advantages of EMD

Allows more strictly controlled reprocessing by reducing chance for generalization to other memories, which might speed up symptom relief. When free associations outside of the target occur, the client is immediately returned to the target memory so that this may prevent client from in-depth exposure to other sources of emotionally intense material. May provide clients a mastery experience with EMDR that may open the door for comprehensive reprocessing with the Standard EMDR Protocol. Potentially more rapid relief of the most intense symptoms than either modified or standard EMDR. Primary symptom reduction may prevent escalation or exacerbation of stress injury and more readily improve client functioning at least in the short-term. May reassure military clients concerned about culture expectations that emphasize self-control and military readiness in the context of accessing earlier life events. Provides viable option for military clients who otherwise may refuse therapy.

Potential Disadvantages of EMD

Desensitization effects may not sustain due to unprocessed other past, current, and future contributors.

Reduction of primary symptoms may result in client termination without addressing other contributors. Increased possibility of stress injury may persist as sub-chronic, more prone to kindling and relapse, in response to future acute stress. Client will probably be exposed, even if fleetingly, to other negative associations in the maladaptive neural network – so needs thorough informed consent.

Modified-EMD (Mod-EMD) Script

(Russell, 2006) Purpose: Crisis intervention limited to the reduction of

primary symptoms associated with the precipitating event. In the immediate or near-immediate aftermath of exposure to a severe or potentially traumatic event, clients present with severe, debilitating ASR/COSR. *Note: See EMD Script with the following modifications: In Mod-EMD the client’s free associations are limited to either a single-incident target memory (i.e., the precipitating event), or within a cluster of memories related to a circumscribed event (e.g., specific operational mission, a certain deployment).

Treatment Goal 3: Comprehensive

Reprocessing The essential treatment plan for the eight-phased, Standard

EMDR Protocol has always consisted of what Shapiro (2001) refers to as the “Three-Pronged Protocol”: – Past traumatic events or other foundational emotionally

charged experiential contributors, or small t, as Shapiro puts it (2001), that are etiologic to the presenting complaints or psychopathological condition.

– Current internal or external triggers or antecedents that activate

the maladaptive neural (memory) network.

– Future template, of the client’s anticipatory anxiety, worries, or concerns, and/or needed coping skills or mastery achieved through imaginal or behavioral rehearsal, to prevent relapse, or reactivation of the maladaptive schema.

\ Treatment Goal 4: Prevention of

Compassion Stress Injury Purpose: Help process compression stress reactions (CSR) after intense

emotional or trauma-focused sessions. Therapists whose workload frequently exposes them to highly charged sessions, need to be particularly mindful of the insidious effects of compassion stress, and take proactive measures whenever possible to avoid cumulative wear-and-tear that may lead to compassion-stress injury (CSI). For therapists with CSI, treatment would be either mod-EMDR that restricts self-focus attention to particular client(s) or one’s clinical practice, or the Standard EMDR Protocol to address other past contributors that increase occupational risk. Recommended EMDR Compassion Stress Intervention: (1) Compassion Stress “Protocol” (for CSR) (2) Standard EMDR Protocol (for CSI)

Russell Compassion Stress “Protocol”

(Russell & Figley, 2013) In addition to traditional self-care (Figley, 2002). Every day

after work before heading home, or after intense session: 1. Put on Neurotek headphones 2. Initiate auditory BLS while recalling the daily events in mind 3. Image, thoughts, and visceral reactions are concentrated upon while listening to the BLS On average, approximately 5-10 minutes a day, or as needed.

Demonstration

Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D. • Emergency Response Protocol (ERP) • Eye Movement Desensitization (EMD) • Modified EMD (Mod-EMD) • Acute Compassion Stress Intervention

Treatment Adaptations for the Spectrum Traumatic Stress Injuries

Mark C. Russell, Ph.D.

Chronic PTSD (Russell, Silver, Rogers, & Darnell, 2007)

Combat PTSD (n = 48) “Railway Spine” U.K. Client

0 20 40 60

IES-R

BDI-II

6 Mo. F/UPost-TxBaseline

Phantom Limb Pain

Medically-Unexplained Physical Symptoms (Russell, 2008)

Traumatic Grief Reaction

29 y.o., married, Hispanic male Presenting complaint: Paternal suicide while stationed overseas Second-hand exposure details imagined

Post-traumatic Anger

0

10

20

30

40

50

60

IES-R BDI-II DAR TGI

BaselineSession 3Post Tx2 Mo. F/U

25 y.o. single African American female Presenting complaint: Sexual assault (date rape) by co-worker after night of drinking Treatment course: 8 EMDR sessions w/ mid-tx assessment

Substance Abuse

19 y.o. single Asian male Presenting complaint: Body recovery off the Indonesian coast, referred w/ comorbid substance dependence dx Treatment course: 3 EMDR sessions

0 20 40 60 80

PCL

BDI-II

AUDIT

3 Mo. F/UPost-txBaseline

Applications to Combat Stress Injuries and the Military Contexts

Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D

Combat/Tactical Breathing Script (Grossman, 2007)

Therapist asks the client to sit in a chair and do the following: Say, “Breathe in through your nose with a slow count of four (two, three, four).” Therapist can have clients place their hand on their stomach to see if they are properly filling the diaphragm with air, as evident when their stomach and hand rise. Say, “Place your hand on your stomach, as you breathe in through your nose to the count of four and

notice your stomach and hand rise.” Say, “Hold your breath for a slow count of four (Hold, two, three, four).” Say, “Now, exhale through your mouth for a count of four until all the air is out (two, three, four).” Client’s hand should lower as their stomach lowers. Say, “Now, notice how your hand lowers as your stomach lowers.” Say, “Hold empty for a count of four (Hold, two, three, four).” **Repeat Cycle Three Times

Acute (Combat) Stress Injury (Russell, 2006)

Traumatic Grief Reaction (Wright & Russell, 2013)

Moral Injury 37 y.o., married African American male, combat decorated Marine Corps SSGT (E-6) with over 11 years of active-duty service, Presenting complaint: referred due to a positive post-deployment health rescreening for post-traumatic stress disorder (PTSD) and major depression disorder (MDD) symptoms. Treatment course: 3 EMDR sessions. Worst image was the initial sight of the elderly woman exiting the car with gaping wounds. Negative cognition (NC) “I killed her,” with ‘tightened’ sensations around his jaw and eyes, and stomach queasiness coinciding with the primary emotional response of “extreme guilt,” rated “10+” SUDS – “Reverse flow” 0

5

10

15

20

25

30

35

IES BDI-II BHS

Baseline

Post-TX

4-Mo. F/U

Moral Injury/Traumatic Grief/

38 y.o., married, Caucasian male Marine GySgt, OIF vet Presenting complaint: Accidental death of 6 year old son Treatment overview: 3 sessions, 1 EMDR

Comorbid Mild TBI

0 20 40 60 80

MACE

PCL

BDI-II

AUDIT

2 Mo. F/UPost-TxBaseline

23 y.o., married, Hispanic male, Marine, OIF/OEF vet x 3 Presenting complaint: Multiple IED attack and combat trauma, diagnosed w/ mild TBI 1 yr. ago Treatment course: Neg. MACE screen; 5 EMDR sessions

Web Resources VA/DoD Clinical Practice Guidelines (CPG) http://www.healthquality.va.gov/ American Psychiatric Association CPG http://www.psych.org/practice/clinical-practice-guidelines Defense and Veterans Brain Injury Center http://www.dvbic.org/ National Center for PTSD http://www.ptsd.va.gov/ EMDR Institute http://www.emdr.com/ Deployment Health Clinical Center http://www.pdhealth.mil/main.asp

Q&A and Wrap-up

Mark C. Russell, Ph.D. Antioch University Seattle

2326 Sixth Avenue Seattle, WA 98121-1814 Phone: (206) 268-4837 Fax: (206) 441-3307 Email: mrussell@antioch.edu

Institute of War Stress Injuries and Social Justice

www.antiochseattle.edu/institute-of-war-stress-injuries-social-justice/