UNCLASSIFIED

1. Combat RelatedPost Traumatic Stress Disorder And Mild Traumatic Brain Injury: Assessment and Treatment Challenges for Family Advocacy Cases COL Derrick F. K. Arincorayan, PhD, LCSW, BCD Chief, Department of Social Work Services Tripler Army Medical Center Social Work Consultant, Pacific Regional Medical Command UNCLASSIFIED

2. Learning Objectives • Summarize PTSD and mTBI challenges • Identify high risk factors for PTSD • Identify screening methods for the assessment of PTSD and mTBI • Summarize PTSD treatment methods • Summarize Family Advocacy Treatment and policy Implications

3. BRIEFING OUTLINE PURPOSE: Provide information to Family Advocacy Social Workers and Behavioral Health providers in order to assist in the assessment and treatment challenges of PTSD and mTBI identified in Family Advocacy cases • Brief definition PTSD and TBI • Assessment Challenges • Treatment Challenges • Family Advocacy Policy/Treatment Implications • Conclusion

4. References References: - Family Advocacy Program, Army Regulation 608-18 (2008) - Rosen, (2007) NCPTSD module-Assessment - American Psychological Association, (2004), DSM IV-R, - Adler et al., (2003) The Effects of Psychological Debriefing on Soldiers Deployed on a Peacekeeping Mission or Combat Mission.” • Resick, P. (2007) Cognitive Processing Therapy, • Arincorayan, D. (Dissertation,2000), Leadership, Coping and Group Cohesion in relation to Deployment Stress, • Hill, J. (2004), Hungarian Conference Presentation • Department of Army Field Manual 4.02-55, COSC (2006).

5. Post Traumatic Stress Disorder Defined • Traumatic experience • Threat of death/serious injury • Intense fear, helplessness or horror • Symptoms (3 main types) • Re experiencing the trauma • Numbing & avoidance • Physiologic arousal • Impairment • Social or occupational functioning

6. Mild Traumatic Brain Injury Signs • Difficulty organizing daily tasks • Blurred vision or eyes tire easily • Headaches or ringing in the ears • Feeling sad, anxious or listless • Easily irritated or angered • Feeling tired all the time • Feeling light-headed or dizzy • Trouble with memory, attention or concentration • More sensitive to sounds, lights or distractions • Impaired decision making or problem solving • Difficulty inhibiting behavior –impulsive • Slowed thinking, moving speaking or reading • Easily confused, feeling easily overwhelmed • Change in sexual interest or behavior

7. Assessment Challenges

8. Starting with Soldiers Agenda: Why Are You here • To assist in sleep and have fewer nightmares • To get reassurance that I’m not crazy • So I don’t kill myself • To have a better relationship with my spouse • To get a handle on my anger

9. Psychosocial History • Distinguish between PTSD symptom and past history of violence • Gathered through intake and collateral sources (e.g., Other providers, spouse, buddy, sqd ldr, and cdr) • Performance before, during and after deployment • Chronological Life line • Coping patterns over time

10. PTSD Risk Factors

11. Assessment Domains Life Context: Risk & Resilience Factors Comorbid Dx PTSD

12. StrategyPTSD Symptom Questionnaires • PTSD Checklist (PCL; Weathers et al., 1993) • Impact Events Scale-Revised (Weiss& Marmar, 1997) • Posttraumatic Diagnostic Scale (FOA et al., 1997)

13. Handout #3 Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 INTRUSION need 1 or more PCL Repeated, disturbing memories, thoughts, or images of a stressful experience? Repeated, disturbed dreams of a stressful experience from the past? Suddenly acting or feeling as if a stressful experience were happening again? Feeling very upset when something reminded you of a stressful experience? Having physical reactions (e.g. heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?

14. Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 AVOIDANCE &/or NUMBING (need 3 or more) 6. Avoid thinking or talking about a stressful experience or avoid having feelings related to it? 7. Avoid activities or situations because they remind you of a stressful experience? 8. Trouble remembering important parts of a stressful experience? 9. Loss of interest in things you used to enjoy? 10. Feeling distant or cut off from other people? 11. Feeling emotionally numb or being unable to have loving feelings for those close to you? 12. Feeling as if your future will somehow be cut short?

15. Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 AROUSAL (need 2 or more) 13. Trouble falling or staying asleep? 14. Feeling irritable or angry outbursts? 15. Having difficulty concentrating? 16. Being “super alert” or watchful on guard? 17. Feeling jumpy or easily startled?

16. Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 PCL SCORING THE FORM 13. Trouble falling or staying asleep? 14. Feeling irritable or angry outbursts? 15. Having difficulty concentrating? 16. Being “super alert” or watchful on guard? 17. Feeling jumpy or easily startled? Subtotals:a x 1 b x 2 c x 3 d x 4 e x 5 TOTAL:A + B + C + D + E

17. Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 13. Trouble falling or staying asleep? 14. Feeling irritable or angry outbursts? 15. Having difficulty concentrating? 16. Being “super alert” or watchful on guard? 17. Feeling jumpy or easily startled? Subtotals:6 x 1 2 x 2 0 x 3 3 x 4 6 x 5 TOTAL:6 + 4 + 0 + 12 + 30= 52 SCORING THE FORM

18. Treatment Challenges

19. Treatment of PTSD aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Intrusions Emotions/ Arousal Cognitions Escape/ Avoidance Core Symptom Clusters

20. Prevent Avoidance aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Intrusions Emotions/ Arousal Cognitions Core Symptom Clusters Escape/Avoidance

21. Intervene into one or more of core symptom clusters MEDs aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Prolonged Exposure Intrusions Emotions/ Arousal Cognitions Cognitive Therapy Cog Processing Therapy Escape/ Avoidance

22. Treatment Challenges • Therapeutic relationship difficult to develop once soldier is identified as FAP referral • Stove piped behavioral health system doesn’t allow for a synergistic and comprehensive approach to address co- morbidity i.e., ASAP, FAP and Psychological Health issues, etc) • Medication can interrupt therapeutic process • WT soldiers non-compliance with treatment plan • Integrating Family into PTSD and FAP treatment plan • Secondary gain to keep PTSD diagnosis means benefits

23. Lessons Learned • Identify comprehensive approach • Follow up with Soldiers and Family via phone contact or email • Participate in memorial exercises • Utilize sandbox or digital picture technique • Include volunteer work in maintenance plan • Develop roster with email and phone numbers for support outside of group sessions • Keep command involved on progress • Reframe recovery from PTSD in resiliency terms • Family and Marital therapy must be integrated in treatment

24. PTSD Model (Resick Modified) • PCL administered in first session for baseline • PCL given every session • Booster support sessions • Modified modules to work with in Hospital setting • Exposure initiated after explanation of symptoms

25. PTSD Model (Resick Modified) • PCL administered in first session for baseline • Modified modules to fit Warrior Transition Unit (WTU) and Non WTU populations • Some Soldiers followed for over 1 year and a half. Lost criteria but other issues arose

26. Lessons Learned • Case #1 Combat Soldier diagnosed PTSD, and mild Traumatic Brain Injury w/back pain. After one year lost diagnosis but continued with chronic pain.

27. Lessons Learned • Case #2 2nd tour , air evac’d out mid tour, depression and anger control.

28. ‘Family Advocacy Policy Implications • Recommend comprehensive/integrative plan through Case Review Committee (e.g., ASAP, Psychiatry and FAP, etc) • Develop Family Advocacy treatment plan IAW Army Forces Generation process i.e., Reset, Ready/Train and Available phases • Include Brigade Combat Team BH officer in Case Review Committee • Include Brigade Combat Team BH officer in treatment of BH issues including PTSD

29. Conclusion • Establish habitual working relationships with Bn/Bde Surgeons, Bn/Bde Chaplains and supported commands • Treat soldiers upon identification and monitor throughout ARFORGEN model • Become “One Team” • Keep Soldiers and Family members mentally and physically fit to endure the ARFORGEN process Ph: 808-433-6606 derrick.arincorayan@us.army.mil