1. DX and RX of TBI and PTSD in OIF/OEF Veterans
Chrisanne Gordon, M.D.
Jeremy D. Kaufman, Psy.D.
Director of Psychological Health, Ohio National Guard

2. Map of Ohio Deployment

3. Health concerns of War and re-entry home
Every War has its own:
1. Injuries
2. Illnesses
3. Drugs
4. Technologies
5. Personalities

4. Vietnam SCI – establishment of SCI research
Agent Orange – Cancer, DM, Neuropathy, TBI?
Drugs of choice – Downers: Heroin; Marijuana; ETOH

5. Gulf War – ALS - 1. Incidence – 1.6 X general population.
2. Etiology – Sarin? Pesticides?
Pyridostigmine BR?

6. OIF/OEF – TBI/multiple amputations
1. ARMOR – more survive, but multiple amputations; severe burns
TBI/PTSD/“MUSH” syndrome.
Drugs of choice – Uppers:
methamphetamine, caffeine, cocaine

7. National Council on Disability: March 2009
Established the HALLMARK pathologies of
OIF/OEF:
Operation Iraqi Freedom
Operation Enduring Freedom

8. 20%- 25% TBI 1. BLAST INJURY – IED; RPG; Motar
2. VEHICULAR ACCIDENTS -MRAP
3. FALLS- Terrain
4. OTHER- Hits on head during night drills
TBI incidence supported by HOGE –NEJM
July 2004
TBI Incidence Disputed by HOGE – NEJM
January 2008

9. 25% - Women Report Sexual Abuse
TRIAD: TBI, PTSD, PAIN
Suicide:
current rates highest in 2 decades
Note: National Guard; Reserves omitted
Every Day /yr.
GSW; MVA;

10. Discussion of BRAIN SYNDROME-
TBI vs. Concussion
- TBI – insult to the brain from
external mechanical force.
- Concussion – injury due to shaking, spinning, or blow.
- Playing field injury is NOT a battlefield injury.

11. HALLMARKS of TBI – midbrain/frontal injuries
1. Sensory processing alterations
a. Photophobia
b. Hyperacusis –
c. Sensory overload – ie., Meijer Syndrome
2. Loss of Mapping skills.
Pituitary Dysfunction.
Chronic Headaches.

12. CAFFEINE 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

13. BONUS Drink Include: RED BULL - 80 mg/Phenylalanine
Red BULL - Germany – Cocaine
Long term increased ingestion of caffeine may deplete cortisol/adrenalin

14. Diagnosis of TBI
Listen to the Patient: He is telling you the diagnosis.
Sir William Osler
TBI Diagnosed by HISTORY.

15. Radiologic Studies: Timing/Technique
CT/MRI – Notoriously Negative – VA standard
2. Diffusion Tensor Imaging – Gold Standard
Lipton et al. Radiology Aug (DAI)
3. PET- SPECT Hovda UCLA -2007
4. fMRI –brain mapping
Most veterans tested 1-4 yrs. after last TBI

16. Blood work – pituitary profile- GH; TSH;
LH; ACTH
ESR, Tox screen.
Do NOT miss Dx. Of hypopituitarism which mimics depression.

17. Neuropsychological Testing
May not find unequivocal results
Most with mild TBI won’t show memory deficits
Lack of baseline
Helpful in more significant injuries
ImPACT, COGSTAT, ANAM, Headminder may be useful

18. Posttraumatic Stress Disorder

19. Formerly Called Traumatic War Neurosis Shell Shock Railway Spine
Stress Syndrome
Battle Fatigue
Soldiers’ Heart
Traumataphobia

20. What 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 others
Response involved intense fear, horror, or helplessness (DSM-IV)

21. Statistics of Trauma
About 60 percent of men and 50 percent of women have at least one traumatic event in their lives
8 percent of men and 20 percent of women eventually develop PTSD
Common to have trauma and subsequent adjustment difficulties, but most do not develop PTSD (Kessler, 1995 from CDP)

22. Military 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

23. Flight or Fight Response
Evolutionary instinct or response
Very adaptive in unsafe environments
Not adaptive at home in an everyday, safe environment
Two routes—fast and slow processing
One cortical and one subcortical
Engages sympathetic nervous system
Blood to limbs
Increase in breathing and heart rate
Pupils dilate
Reflexes sharpen

24. Two routes for processing danger (Pinel, 2000)

25. Advantages of subcortical method
Quicker
Leap, then think
Ready for “flight or fight”
Looking for the enemy

26. Advantages of cortical method
Slower
Time to think and process information
Not reactionary
Decide that stimulus is not a risk
More suited to common life situations

27. Avoidance
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted 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)

28. Behavioral Model of PTSD
Mowrer’s (1947) two-factor theory
Both classical and operant conditioning
Unconditioned 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 response
Negative reinforcement is avoidance of the aversive triggers (CS) which leads to increase in the behavior (fear)

29. DSM-IV Symptoms of PTSD
The person has been exposed to a traumatic event
Can 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

30. Reexperiencing
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
Recurrent distressing dreams of the event
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 on awakening or when intoxicated
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

31. Increased Arousal (Sympathetic Nervous Activation)
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response

32. DSM-IV Acute Stress Disorder
Experienced a trauma
Lasts less than one month
In addition to three areas of PTSD, also includes dissociative symptoms (three required):
A subjective sense of numbing, detachment, or absence of emotional responsiveness
A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
Derealization
Depersonalization
Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

33. Comorbidities (DSM-IV)
Major Depressive Disorder
Bipolar Disorder
Substance-Related Disorders
Panic Disorder
Agoraphobia
Obsessive-Compulsive Disorder
Generalized Anxiety Disorder
Social Phobia
Specific Phobia
Suicidality
TBI
Dysfunction in relationships, marriage, work, school
Malingering/Secondary Gain

34. Suicide 2nd leading cause of death in military
Young, White, Unmarried Male Junior Enlisted Active Duty
Drugs/alcohol
Firearm
No 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)

35. Suicide – Dr. Thomas Joiner – Why People Die By Suicide 2005
1. Capability
2. Desirability
3. Feeling of burdensomeness.

36. A.C.E.
Ask
Care
Escort

37. “MUSH” Syndrome Hard to differentiate mild TBI from PTSD
Sometimes both present
Holistic thinking
Psychological factors may lead to maintenance of TBI symptoms and medical issues may lead to maintenance of psychological factors

38. Symptoms more consistent with PTSD
Flashbacks
Nightmares
Intrusive thoughts
Avoidance behaviors
Exaggerated startle response

39. HALLMARKS of TBI – midbrain/frontal injuries
1. Sensory processing alterations?
a. Photophobia
b. Hyperacusis –
c. Sensory overload – ie., Meijer Syndrome?
2. Loss of Mapping skills.
Pituitary Dysfunction.
Chronic Headaches.

40. PTSD Psychopharmacology
No medication has been found to be successful in fully eliminating PTSD
Can manage symptoms
Many non-responders or still experiencing significant symptoms
Not a long-term answer
Symptoms may return when off medication
Zoloft and Paxil are FDA approved
SSRIs typically first line agent
Be careful with Prozac or if agent leads to stimulation
Benzodiazepines are contraindicated
Patient never learns appropriate ways of handling anxiety and fear
In other words benzodiazepines permit avoidance, which maintains anxiety
Hinders psychotherapy

41. PTSD Psychotherapy
Psychotherapy, 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 medication
Stress Inoculation Training, Cognitive Therapy, and Eye Movement Desensitization and Reprocessing also effective although exposure likely mechanism (Foa, Hembree, & Rothbaum, 2007)

42. Prolonged Exposure In vivo exposure Imaginal exposure
Exposing oneself to fearful situations, people, places
Imaginal exposure
Telling the story of the trauma in session and listening to the session on tape
Breathing retraining
Remove avoidance and symptoms will not be maintained (Foa, Hembree, & Rothbaum, 2007).

43. TREATMENT options for TBI:
Amantadine, Ritalin, Dexedrine- for processing
Inderal, Elavil – for post concussive
Electronic aides – Bushnell GPS, PDA, iPHONE
Setting modifications or organization
Routine/schedule
Memory strategies (chunking, acronyms, music)
Pain management as needed

44. Adjunctive Treatment Service Education (GI-Bill)
Psychoeducation and support groups for self and family
Exercise (use caution with TBI) and pleasurable activity scheduling
De-toxification from caffeine, stimulants, and alcohol
Solutions (action-oriented, specific goals)
Family or marital treatments
Advocate regarding employment or military problems
Stress management
Adequate, restful sleep
Nutrition
Relaxation/Rest

45. TBI & PTSD Team Primary care physician/specialist
Nurse/nurse practitioner
Psychiatrist
Psychologist/Neuropsychologist
Counselor
Social Worker
Physiatrist
Speech-Language Pathologist
Occupational Therapist
Physical Therapist

46. “We can’t all be heroes, because somebody has to sit on the curb and applaud when they go by.”
– Will Rogers

47. Health care providers to get involved -
1. TRICARE
2. Sliding fee schedule $5 - $10
3. Volunteer for Yellow Ribbon events
4. Be vigilant in your community

48. Resources Military One Source www.militaryonesource.com (800-342-9647)
OHIOCARES ( )
National Suicide Hotline ( TALK)
Director of Psychological Health ( )
Chaplain ( )
Military Family Life Consultant ( and )

49. More resources Defense Centers of Excellence www.dcoe.health.mil
Department of Veterans Affairs
Center for Deployment Psychology
National Alliance on Mental Illness
American Academy of Physical Medicine & Rehabilitation
Brain Injury Association of Ohio
Ohio Psychological Association
Ohio Psychiatric Association
Ohio Department of Mental Health
Ohio Department of Alcohol and Drug Addiction Services
Ohio Department of Veteran Services