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

Map of Ohio Deployment

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

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

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

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

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

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

25% - Women Report Sexual Abuse TRIAD: TBI, PTSD, PAIN Suicide: current rates highest in 2 decades Note: National Guard; Reserves omitted Every Day 18 6500/yr. GSW; MVA;

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.

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.

CAFFEINE CONTENT of DRINKS Adding to Brain Insults Coffee - 100 mg. Cola - 35-45 mg. Mt. Dew - 120 mg. Rockstar - 160 mg. RAGE/WYD - 200 mg. Caffeine impairs Brain glucose utilization –up to 20 drinks/day ingested in Iraq

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

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

Radiologic Studies: Timing/Technique CT/MRI – Notoriously Negative – VA standard 2. Diffusion Tensor Imaging – Gold Standard Lipton et al. Radiology Aug. 2009 (DAI) 3. PET- SPECT - Hovda UCLA -2007 4. fMRI –brain mapping Most veterans tested 1-4 yrs. after last TBI

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

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

Posttraumatic Stress Disorder

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

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)

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)

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

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

Two routes for processing danger (Pinel, 2000)

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

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

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)

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)

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

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

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

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)

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

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)

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

A.C.E. Ask Care Escort

“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

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

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.

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

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)

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).

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

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

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

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

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

Resources Military One Source www.militaryonesource.com (800-342-9647) OHIOCARES (800-761-0868) www.ohiocares.ohio.gov National Suicide Hotline (800-273-TALK) Director of Psychological Health (614-336-7246) Chaplain (614-208-2325) Military Family Life Consultant (614-336-7479 and 614-336-1413)

More resources Defense Centers of Excellence www.dcoe.health.mil Department of Veterans Affairs www.va.gov Center for Deployment Psychology www.deploymentpsych.org National Alliance on Mental Illness www.nami.org American Academy of Physical Medicine & Rehabilitation www.aapmr.org Brain Injury Association of Ohio www.biaoh.org Ohio Psychological Association www.ohpsych.org Ohio Psychiatric Association www.ohiopsych.org Ohio Department of Mental Health www.odmh.ohio.gov Ohio Department of Alcohol and Drug Addiction Services www.odadas.ohio.gov Ohio Department of Veteran Services www.dvs.ohio.gov