3Health concerns of War and re-entry home Every War has its own:1. Injuries2. Illnesses3. Drugs4. Technologies5. Personalities
4Vietnam SCI – establishment of SCI research Agent Orange – Cancer, DM, Neuropathy, TBI?Drugs of choice – Downers: Heroin; Marijuana; ETOH
5Gulf War – ALS - 1. Incidence – 1.6 X general population. 2. Etiology – Sarin? Pesticides?Pyridostigmine BR?
6OIF/OEF – TBI/multiple amputations 1. ARMOR – more survive, but multiple amputations; severe burnsTBI/PTSD/“MUSH” syndrome.Drugs of choice – Uppers:methamphetamine, caffeine, cocaine
7National Council on Disability: March 2009 Established the HALLMARK pathologies ofOIF/OEF:Operation Iraqi FreedomOperation Enduring Freedom
820%- 25% TBI 1. BLAST INJURY – IED; RPG; Motar 2. VEHICULAR ACCIDENTS -MRAP3. FALLS- Terrain4. OTHER- Hits on head during night drillsTBI incidence supported by HOGE –NEJMJuly 2004TBI Incidence Disputed by HOGE – NEJMJanuary 2008
925% - Women Report Sexual Abuse TRIAD: TBI, PTSD, PAINSuicide:current rates highest in 2 decadesNote: National Guard; Reserves omittedEvery Day /yr.GSW; MVA;
10Discussion of BRAIN SYNDROME- TBI vs. Concussion- TBI – insult to the brain fromexternal mechanical force.- Concussion – injury due to shaking, spinning, or blow.- Playing field injury is NOT a battlefield injury.
11HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterationsa. Photophobiab. Hyperacusis –c. Sensory overload – ie., Meijer Syndrome2. Loss of Mapping skills.Pituitary Dysfunction.Chronic Headaches.
12CAFFEINE CONTENT of DRINKS Adding to Brain Insults Coffee mg.Cola mg.Mt. Dew mg.Rockstar mg.RAGE/WYD mg.Caffeine impairs Brain glucose utilization –up to 20 drinks/day ingested in Iraq
13BONUS Drink Include: RED BULL - 80 mg/Phenylalanine Red BULL - Germany – CocaineLong term increased ingestion of caffeine may deplete cortisol/adrenalin
14Diagnosis of TBIListen to the Patient: He is telling you the diagnosis.Sir William OslerTBI Diagnosed by HISTORY.
15Radiologic Studies: Timing/Technique CT/MRI – Notoriously Negative – VA standard2. Diffusion Tensor Imaging – Gold StandardLipton et al. Radiology Aug (DAI)3. PET- SPECT Hovda UCLA -20074. fMRI –brain mappingMost veterans tested 1-4 yrs. after last TBI
16Blood work – pituitary profile- GH; TSH; LH; ACTHESR, Tox screen.Do NOT miss Dx. Of hypopituitarism which mimics depression.
17Neuropsychological Testing May not find unequivocal resultsMost with mild TBI won’t show memory deficitsLack of baselineHelpful in more significant injuriesImPACT, COGSTAT, ANAM, Headminder may be useful
19Formerly Called Traumatic War Neurosis Shell Shock Railway Spine Stress SyndromeBattle FatigueSoldiers’ HeartTraumataphobia
20What is a trauma?Experienced, witnessed, or been confronted with an event that involves actual or threatened death or injury, or a threat to the physical integrity of oneself or othersResponse involved intense fear, horror, or helplessness (DSM-IV)
21Statistics of TraumaAbout 60 percent of men and 50 percent of women have at least one traumatic event in their lives8 percent of men and 20 percent of women eventually develop PTSDCommon to have trauma and subsequent adjustment difficulties, but most do not develop PTSD (Kessler, 1995 from CDP)
22Military Statistics on PTSD On assessments after OIF/OEF deployment 6 to 9 percent of active-duty and 6 to 14 percent of NG/Reserve endorse PTSD symptoms on questionnaires (Milliken, Aucherlonie, & Hoge, 2007, per CDP)15 percent according to RAND study (2008, per CDP)Large number of women with PTSD related to military sexual assault
23Flight or Fight Response Evolutionary instinct or responseVery adaptive in unsafe environmentsNot adaptive at home in an everyday, safe environmentTwo routes—fast and slow processingOne cortical and one subcorticalEngages sympathetic nervous systemBlood to limbsIncrease in breathing and heart ratePupils dilateReflexes sharpen
25Advantages of subcortical method QuickerLeap, then thinkReady for “flight or fight”Looking for the enemy
26Advantages of cortical method SlowerTime to think and process informationNot reactionaryDecide that stimulus is not a riskMore suited to common life situations
27AvoidanceEfforts to avoid thoughts, feelings, or conversations associated with the traumaEfforts to avoid activities, places, or people that arouse recollections of the traumaInability to recall an important aspect of the traumaMarkedly diminished interest or participation in significant activitiesFeeling of detachment or estrangement from othersRestricted range of affect (e.g., unable to have loving feelings)Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
28Behavioral Model of PTSD Mowrer’s (1947) two-factor theoryBoth classical and operant conditioningUnconditioned stimulus (explosion) Unconditioned response (fear)Conditioned stimulus (sand, heat, people in uniform, guns) Conditioned response (fear)Attempt to avoid CS in order to avoid fear, which but actually increases fear responseNegative reinforcement is avoidance of the aversive triggers (CS) which leads to increase in the behavior (fear)
29DSM-IV Symptoms of PTSD The person has been exposed to a traumatic eventCan be conceptualized into three separate symptom categories: reexperiencing (one symptoms in this area needed), avoidance (three symptoms needed), and increased arousal (two symptoms needed)Symptoms last more than one month
30ReexperiencingRecurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptionsRecurrent distressing dreams of the eventActing 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 on awakening or when intoxicatedIntense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic eventPhysiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
31Increased Arousal (Sympathetic Nervous Activation) Difficulty falling or staying asleepIrritability or outbursts of angerDifficulty concentratingHypervigilanceExaggerated startle response
32DSM-IV Acute Stress Disorder Experienced a traumaLasts less than one monthIn addition to three areas of PTSD, also includes dissociative symptoms (three required):A subjective sense of numbing, detachment, or absence of emotional responsivenessA reduction in awareness of his or her surroundings (e.g., “being in a daze”)DerealizationDepersonalizationDissociative amnesia (i.e., inability to recall an important aspect of the trauma)
33Comorbidities (DSM-IV) Major Depressive DisorderBipolar DisorderSubstance-Related DisordersPanic DisorderAgoraphobiaObsessive-Compulsive DisorderGeneralized Anxiety DisorderSocial PhobiaSpecific PhobiaSuicidalityTBIDysfunction in relationships, marriage, work, schoolMalingering/Secondary Gain
34Suicide 2nd leading cause of death in military Young, White, Unmarried Male Junior Enlisted Active DutyDrugs/alcoholFirearmNo psychiatric history (Washington Post, 2008, per CDP)1.2% Army Post-Deployment survey had suicidal ideation (Miliken et al., 2007 per CDP)Of completed suicides, most saw a healthcare provider within one month before suicide (USUHS, 2009)19% of patients with PTSD will attempt suicide (CDP, 2009)
35Suicide – Dr. Thomas Joiner – Why People Die By Suicide 2005 1. Capability2. Desirability3. Feeling of burdensomeness.
37“MUSH” Syndrome Hard to differentiate mild TBI from PTSD Sometimes both presentHolistic thinkingPsychological factors may lead to maintenance of TBI symptoms and medical issues may lead to maintenance of psychological factors
38Symptoms more consistent with PTSD FlashbacksNightmaresIntrusive thoughtsAvoidance behaviorsExaggerated startle response
39HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterations?a. Photophobiab. Hyperacusis –c. Sensory overload – ie., Meijer Syndrome?2. Loss of Mapping skills.Pituitary Dysfunction.Chronic Headaches.
40PTSD Psychopharmacology No medication has been found to be successful in fully eliminating PTSDCan manage symptomsMany non-responders or still experiencing significant symptomsNot a long-term answerSymptoms may return when off medicationZoloft and Paxil are FDA approvedSSRIs typically first line agentBe careful with Prozac or if agent leads to stimulationBenzodiazepines are contraindicatedPatient never learns appropriate ways of handling anxiety and fearIn other words benzodiazepines permit avoidance, which maintains anxietyHinders psychotherapy
41PTSD PsychotherapyPsychotherapy, specifically Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT), has been found to be successful and is the gold standard for PTSD treatment—not medicationStress Inoculation Training, Cognitive Therapy, and Eye Movement Desensitization and Reprocessing also effective although exposure likely mechanism (Foa, Hembree, & Rothbaum, 2007)
42Prolonged Exposure In vivo exposure Imaginal exposure Exposing oneself to fearful situations, people, placesImaginal exposureTelling the story of the trauma in session and listening to the session on tapeBreathing retrainingRemove avoidance and symptoms will not be maintained (Foa, Hembree, & Rothbaum, 2007).
43TREATMENT options for TBI: Amantadine, Ritalin, Dexedrine- for processingInderal, Elavil – for post concussiveElectronic aides – Bushnell GPS, PDA, iPHONESetting modifications or organizationRoutine/scheduleMemory strategies (chunking, acronyms, music)Pain management as needed
44Adjunctive Treatment Service Education (GI-Bill) Psychoeducation and support groups for self and familyExercise (use caution with TBI) and pleasurable activity schedulingDe-toxification from caffeine, stimulants, and alcoholSolutions (action-oriented, specific goals)Family or marital treatmentsAdvocate regarding employment or military problemsStress managementAdequate, restful sleepNutritionRelaxation/Rest
45TBI & PTSD Team Primary care physician/specialist Nurse/nurse practitionerPsychiatristPsychologist/NeuropsychologistCounselorSocial WorkerPhysiatristSpeech-Language PathologistOccupational TherapistPhysical Therapist
46“We can’t all be heroes, because somebody has to sit on the curb and applaud when they go by.” – Will Rogers
47Health care providers to get involved - 1. TRICARE2. Sliding fee schedule $5 - $103. Volunteer for Yellow Ribbon events4. Be vigilant in your community
48Resources Military One Source www.militaryonesource.com (800-342-9647) OHIOCARES ( )National Suicide Hotline ( TALK)Director of Psychological Health ( )Chaplain ( )Military Family Life Consultant ( and )
49More resources Defense Centers of Excellence www.dcoe.health.mil Department of Veterans AffairsCenter for Deployment PsychologyNational Alliance on Mental IllnessAmerican Academy of Physical Medicine & RehabilitationBrain Injury Association of OhioOhio Psychological AssociationOhio Psychiatric AssociationOhio Department of Mental HealthOhio Department of Alcohol and Drug Addiction ServicesOhio Department of Veteran Services