Behavioral/Mental Health Issues

1. Behavioral/Mental Health Issues Dr. Jodi R. Owen, Psy.D. Licensed Psychologist/Clinical Director Capital Area Counseling, Pierre Behavioral Health Officer (CPT), 730th ASMC August 14 2012

2. Briefly… • …who I am and what I do • …how I wind up seeing a Soldier • …what happens from there?

3. Some ???s a Provider might ask (from general to specific) • Have you served in the military? (“Thank you for your service”) • What branch/unit? • Are you currently serving?... full-time or? • What’s your job in the ________? • Have you ever been deployed? • What was that like for you? • Any ongoing issues about that? • What sorts of things do you struggle with? (Ask about sleep, mood, relationships, anger, alcohol use, etc.)

4. Behavioral Health issues…in no particular order… • Post-traumatic Stress (symptoms/disorder) • Depression • Suicidal Thoughts/Behavior • Traumatic Brain Injury • Military Sexual Trauma • Alcohol Use/Abuse • Adjustment/Readjustment Issues • Anger • Relationship Issues • Sleep Difficulties • Etc…

5. Post-Traumatic Stress (Disorder) • Audience assessment…

6. Post-traumatic Stress (Disorder?)(paraphrased from DSM-IV-TR) • A) Traumatic event • B) Reexperiencing • C) Avoidance • D) Arousal • E) Duration • F) Causes distress/impairment

7. A. Traumatic Event • 1) person experienced, witnessed, or was confronted with an event/events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND… • 2) person’s response involved intense fear, helplessness, or horror

8. B. Traumatic event is persistently reexperienced (one or more)… • 1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions • 2) recurrent distressing dreams of the event • 3) acting or feeling as if event were recurring (reliving, illusions, hallucinations, dissociative flashback episodes) • 4) intense psychological distress at exposure to internal or external cues that remind of the event • 5) physiological reactivity on exposure to cues

9. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (3 or more)… • 1) efforts to avoid thoughts, feelings, or conversations associated with the trauma • 2) efforts to avoid activities, places, or people that arouse recollections of the trauma • 3) inability to recall important aspect of the trauma • 4) diminished interest or participation in activities • 5) feeling of detachment/estrangement from others • 6) restricted range of affect (e.g., unable to have loving feelings) • 7) sense of foreshortened future (e.g., does not expect to have career, marriage, children, normal lifespan)

10. D. Persistent symptoms of increased arousal (2 or more…) • 1) difficulty falling or staying asleep • 2) irritability or outbursts of anger • 3) difficulty concentrating • 4) hypervigilance • 5) exaggerated startle response

11. E. Duration • Duration of the symptoms = greater than… • 1 month

12. F. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • ?? What does this mean ??

13. Some questions to ask… • (If deployed) Any events during deployment that were very upsetting or that you still struggle with? • (If not deployed) Any events in your history that were very upsetting and that you still struggle with?

14. More questions… • How’s your sleep? • How’s your mood (anger, sadness, etc?) • Any issues with thinking about or talking about ________(the traumatic event(s)? • How’s your social/recreational life? (Are they engaged/participating in life?) What do you do for fun?

15. Depression • Whether deployed or not, some of our soldiers struggle with depression • Younger soldiers deal with transitioning from adolescence to adulthood, relationship issues, schooling, career, financial, whether to stay in military, etc. • Older soldiers deal with medical, financial, “when to retire”, etc. • Readjustment after deployment

16. Suicidal Thoughts/Behavior • Suicide rate in the military is approaching general population • Not necessarily related to deployment; many have not • Some say deploying is a protective factor, builds resilience, etc

17. Some ???s • How would you describe your mood most of the time? • Do you find yourself feeling sad or down? Do you cry? • How’s your sleep/concentration/energy level? • Ever feel hopeless? • When it gets bad, how bad does it get? • Do you think about hurting yourself or taking your own life?

18. If they say “no”… • Ask “NEVER—EVER thought about it?” • (it’s not unusual for people to have at least thought about suicide at some point in life) • They may admit thoughts in the past, but nothing current or beyond “thought”….normalize this…offer support. • “A lot of people think about it at some point in their lives…I’m glad you’re finding better coping now”.

19. But do not be surprised… • …if your patient grudgingly says “yeah, sometimes—I’ve thought about it sometimes…” OR “I think about it sometimes…” • (this is not time, nor cause for panic—stay calm and supportive--this is an opportunity to ask more questions…and help your patient)

20. If they say “yes”, then ask… • You said “yeah, sometimes”…When was that? Are you having those thoughts lately? • What kinds of things were you/are you thinking about? • Have you talked to anyone about it, gotten some help with it? • How seriously have you been considering it? • Have you thought about how you would do it?

21. Decision time… • If they are seriously considering suicide and have a plan… • …and do not seem willing for immediate intervention… • Implement emergency procedures

22. However… • …If they are seriously considering suicide and have a plan… • …but say they want and will accept help…

23. You must decide… • 1) …to refer for immediate follow-up care with a MH professional (if available, depending on risk/risk-tolerance) • 2) …to implement emergency procedures • 3)…??

24. Traumatic Brain Injury • Injury to the brain by sudden force, concussive blast, or explosion. • Can be mild, moderate, or severe • Mild TBI (mTBI) is the most common, and may or may not be diagnosed.

25. TBI Prevalence • Veteran’s advocates believe that between 10 and 20% of Iraq veterans, or 150,000 and 300,000 service members have some level of TBI. • 30% of soldiers admitted to Walter Reed Army Medical Center have been diagnosed as having had a TBI

26. TBI symptoms • Persistent headache or neck pain • Sensitivity to light and noise • Loss of balance • Changes in sleep patterns • Feeling tired all the time, lacking energy • Ringing in the ears • Loss of sense of smell and taste • Slowness in thinking, acting, speaking or reading

27. TBI symptoms, cont’d • Symptoms that may appear to be mental health conditions • Sudden mood changes for little or no reason • Difficulty managing relationships • Chronic anxiety, depression, apathy • Sleep difficulty • Short term memory loss, disorganization, losing things • Getting lost or easily confused • Having more trouble than usual with • Paying attention or concentrating • Organizing daily tasks • Making decisions

28. Ask • Have you ever had a head injury (in sports, car accident, combat)?? • Were you “knocked out”? • How long? • Treatment? • Symptoms? What changes do you or others notice?

29. Military Sexual Trauma • "Military sexual trauma" or MST is the term used by the Department of Veterans Affairs to refer to experiences of sexual assault or repeated, threatening acts of sexual harassment. • VA screenings show reports by 1 in 5 females, 1 in 100 males • (see brochure)

30. MST continued… • …to be defined and treated as MST, must have occurred while on active duty, or active duty for training • Treated for free at VA, regardless of service-connection or other VA eligibility

31. 2 MST Coordinators in SD • Christi Kitzelman, VA Black Hills, 605-718-1095, ext. 3018 • Robin Carter-Visscher, Ph.D., Sioux Falls VA HCS, 605-336-3230, ext. 6923, robin.carter-visscher@va.gov

32. These next 8 slides came directly from Dr. Carter-Visscher, MST Coordinator

33. Responses to Disclosure Often, you may be the first person the survivor has ever told about his or her experiences. An empathic, supportive response has the power to be tremendously healing. Provide validation and empathy: “I’m sorry this happened to you while you were serving your country” Provide education and normalization: “Many Veterans have had experiences like yours and for some, it can continue to affect them even many years later. People can recover, however.” Assess current difficulties: “How much does this continue to affect your daily life today? In what ways?” Assess social support: “Have you ever been able to talk to anyone about this before?”

34. Responses to Disclosure (cont.) Assess implications for care: “How do you think this will affect our work together?” Offer other VA services: “Some of the Veterans I’ve met with have found it helpful to talk with someone about their experiences. The VA offers free counseling related to MST. Would it be okay if I asked this facility’s MST Coordinator to be in touch with you to tell you about the services available? After talking with him/her about your options, you could decide if you wanted to take it any further.” Not everyone needs counseling: “If you ever change your mind and want to speak to someone, just let me know.” Offer a way to learn more: MST brochure www.mentalhealth.va.gov

35. Adapt care when necessary • Patient-provider relationship can resemble some aspects of the victim-perpetrator relationship • Power differential • Being in physical pain • Physical exposure and touching of intimate body parts • Feeling a lack of control over the situation • Perpetrator may have been a healthcare provider

36. Signs That a Veteran May Be Having an MST-Related Reaction • Veteran is highly anxious, agitated, or “jumpy” • Appears tearful during exams, with no obvious cause • Physically withdraws, or becomes very quiet or “frozen” • Has difficulty concentrating, is very distractible, or seems disoriented • Minimizes symptoms that might require an intrusive exam • Cancels appointments or refuses needed care • Exhibits strong emotional reactions to relatively benign interactions (e.g., crying, panic, irritability, anger) • Experiences flashbacks or dissociates during appointments

37. Strategies for Managing Reactions to Exams and Procedures • Anticipate and prepare • Explain that it is very common for MST survivors to have strong reactions to certain procedures • Describe the procedure and ask the patient what he or she anticipates will be the most difficult part • Brainstorm coping strategies with patient • Seeing procedure suite in advance • Having a chaperone or family member present • Sedation • Distraction (e.g., headphones, music, focused breathing, discussion of pleasant event) • Things that have worked in the past

38. Strategies for Managing Reactions to Exams and Procedures (cont.) • Ensure the Veteran feels in control • Ask permission before touching • Let the patient know you will stop if he/she asks you to • Keep a running commentary of exactly what you are doing and about to do • Check in with him/her periodically, to ask how he/she is doing • Respect reactions • Never ignore or dismiss a patient’s request or expression of distress

39. Simple changes can reduce your patient’s distress and strengthen the patient-provider relationship. Whenever possible, have conversations while the patient is fully dressed Sit at the same level as the patient, preferably without a desk between you. Make eye contact. Give the patient options and choices whenever possible. Be transparent; explain your reasoning for choosing certain courses of action. View the patient as an expert on his or her own body and functioning. Take complaints of pain or vague symptoms seriously. Privacy (exam rooms, bathrooms)

40. Handling Strong Reactions • It can be helpful to: • Listen empathically, acknowledging their distress. • Apologize, if appropriate. • Explain the reasoning behind your behavior. • Think about the reaction as likely due to feelings of helplessness, of vulnerability, or of being unsafe. • Avoid: • Touching the patient without his/her consent • Moving closer or “invading their space” • Making loud noises (e.g., hand clap, finger snapping)

41. Alcohol Abuse(from DSM-IV-TR) • A. A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: • (1) recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household) • (2) recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use)

42. Alcohol Abuse, cont’d… • (3) recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct) • (4) continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about consequences of Intoxication, physical fights) • B. The symptoms have never met the criteria for Alcohol Dependence.

43. Alcohol Dependence(DSM-IV-TR) • A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • (1) tolerance, as defined by either of the following: • (a) a need for markedly increased amounts of alcohol to achieve Intoxication or desired effect • (b) markedly diminished effect with continued use of the same amount of alcohol • (2) Withdrawal, as manifested by either of the following: • (a) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100), increased hand tremor, insomnia, nausea/vomiting, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizures • (b) alcohol (or a closely related drug such as valium) is used to relieve or avoid withdrawal symptoms

44. Alcohol Dependence cont’d… • (3) alcohol is often used in larger amounts or over a longer period than was intended • (4) there is a persistent desire or unsuccessful efforts to cut down or control alcohol use • (5) a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects • (6) important social, occupational, or recreational activities are given up or reduced because of alcohol use • (7) alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g. continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

45. Alcohol use and education • Some soldiers meet criteria for Abuse, smaller number for Dependence—referred for treatment (will discuss in referral segment) • More often, binge-drinking (often on drill weekends), that may meet one of the criteria for “abuse”, but does not cause “distress” • Self-medicating emotional or physical pain • Help with sleep • Educate about “safe use” versus “harmful use”. • Fewer than 2/day, 14 per week, 2% of Americans consume 98% of the alcohol • Discuss “normal” in their circles versus other circles

46. Ask • How much do you drink? • Any trouble at work, school, etc? • Do you drink and drive or do other things where you or others could get hurt? • Any legal issues related to drinking? (DUI, assault, etc) • Anyone saying they’re concerned about your drinking? • Does it take more now to get the same buzz than it used to? (tolerance) • Discuss “hang-overs” (withdrawal?)

47. Ask • Do you drink more than you meant to? • Ever tried to “cut down”? • Are you spending more time drinking than you meant to? (or recovering?) • Are you “not doing” things with friends or family and drinking instead? • Any physical or health problems related to drinking?

48. Additional BH issues • Adjustment/readjustment-family obligations, absence from work, renegotiating relationships • Anger, low frustration tolerance, short fuse • Relationship Issues—young families, domestic violence • Sleep (50+ to 90+% of Veterans who have deployed report sleep problems)

49. When Symptoms Overlap • Having TBI increases risk for Sleep Apnea, which puts one at risk for heart attack • Sleep difficulties are common with Depression, PTSD, TBI, alcohol abuse/dependence, and in Veterans who have none of the above, but have been deployed • Anger is common in PTSD, Depression, Alcoholism, or can stand alone • Lack of energy/interest happens in Depression, TBI, PTSD, or simple lack of sleep

50. Take-home Message • Rural providers are TREMENDOUSLY important as first-line screeners for Behavioral Health/Mental Health and Addiction Issues. • These issues can be complicated, complex, and confusing. • You are not expected to know everything!! • Utilize continuum of care and refer to specialists when need be