Combat PTSD: Team-Based Approach to Care of the Individual and Family

1. Combat PTSD: Team-Based Approach to Care of the Individual and Family Session # G3a Van Dyke Friday, October 11, 2013 Anne Van Dyke, Ph.D, ABPP Amber Gruber, D.O. Captain Michael Gruber Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • To increase awareness of the prevalence and impact of Combat PTSD on the individual & family • To understand the scope of specialized medical and mental health services needed for returning war veterans & their families • To increase the ability of health care providers to effectively diagnose & treat Combat PTSD from a biopsychosocial model

4. Learning Assessment Audience Question & Answer

5. Take Home Point • Diagnosis of Combat PTSD can be a hopeful one • Concept of “Posttraumatic Growth” in combat veterans involves 3 growth processes: • Strength through suffering • confidence to face future struggles • Existential reevaluation • gaining of wisdom, life satisfaction, new purpose in life • Psychological preparedness • Rebuilding core beliefs about oneself and one’s life

6. Background • Past 10 yrs~ 3 million U.S. military veterans in Operation Iraqi Freedom & Operation Enduring Freedom • Up to 19% of returning veterans report problems of depression, anxiety &/or PTSD • Veterans w/ PTSD report poorer health, more days off work, somatic complaints, depression, substance abuse & interpersonal difficulties

7. Background cont’d • Improvements in combat armor, vehicles and evacuation systems -> “survivable” injuries • Most common injuries = PTSD and TBI • More systemic diseases being seen in veterans due to prolonged & unrelenting stress – elevated cholesterol, triglycerides, HTN, DM

8. Evolution of term Combat PTSD • George Washington era: “nostalgia” • Civil War days: “Soldier’s Heart” • WWI: “Shell Shock” • WWII & Vietnam: “Battle Fatigue” • PTSD formally recognized and named 10 yrs after leaving Vietnam • ...it is now the 50th anniversary of Vietnam War “POST TRAUMATIC STRESS INJURY” currently under consideration to reduce stigma

9. SORT: Key Recommendation for Practice Clinical Recommendation Evidence Rating Returning service members who were in life C threatening situations or those where serious injury could occur should be screened for PTSD Quinlan et al. Care of the returning veteran. Am Fam Physician Jul 1; 82(1):43-49, 2010.

10. PTSD Co-Morbidities • Substance abuse to help control “biphasic” trauma response of emotional dysregulation • Hypervigilance, agitation, obsessive thinking vs. lethargy, depression, dissociation • Depression and Anxiety • Social & interpersonal difficulties • Increased suicide risk without proper treatment

11. Paradox • What are adaptive and potentially life-saving behaviors in combat become “symptoms” in civilian life • Hypervigilance • Hyperarousal • Channeling of anger • Shutting off emotion (numbing) • Replay/rehearse responses to danger • Limited sleep • Reversed sleep pattern

12. Scope of Those Affected • Important not to dismiss PTSD possibility in those not directly involved on the battlefield • ‘System at War’ involves non-combat oriented Military Operations Specialty such as security detail, medics & food service

13. Evidenced Based Treatment Intervention • IOM: PTSD tx with sufficient empirical evidence • Prolonged Exposure Therapy – in vivo, imaginal, Cognitive Processing Therapy – psychoeducation, narration, reframing negative thoughts and outcome • 12 sessions 60 to 90 minutes each • EMDR effective trauma intervention • National Competency Based Staff Training from the VA … only 10% of mental health providers report providing manualized PTSD tx

14. Neurochemistry of PTSD Evolving area of research Changes in hypothalamus-pituitary-adrenal axis Alteration in serotonergic and noradrenergic neurotransmitter systems Ultimately compromising memory processing, emotional reactivity, learning & behavioral responses

15. SSRI • Currently Paroxetine (Paxil) and Sertraline (zoloft) are the ONLY Medications approved for the treatment of PTSD • 18 RCTs to date • Short term treatment of PTSD • 29.4% remission rate with paxil alone at 12 weeks • No difference in 20 mg vs 40 mg of paxil • No difference in remission rate if comorbid depression

16. Evidence Based Pharmacotherapy • Unknown how long to treat. • 1 year based on expert opinion • High risk of relapse • SSRI: paroxetine (Paxil), sertraline (Zoloft) (LOE A) • *SNRI: venlafaxine (Effexor) (LOE A) • *Mirtazapine (Remeron) (LOE B) • *Alpha-blocker: prazosin (minipress) for refractory patients who cannot sleep (LOE B) • *Anti-psychotic agents if psychotic symptoms • *Add olanzapine if refractory to 12 weeks of SSRI alone

17. Mirtazapine (Remeron) Acts via serotonin system Alternative to SSRI and Venlafaxine Primary SE: sedation Sexual SE less than SSRI/SNRI Additional SE: weight gain

18. BENZO NO EVIDENCE for benzodiazepines!! May interfere with PE therapy because they suppress fear extinction

19. Anger outbursts Medical management difficult Divalproex and respiradone have failed to show efficacy Psychotherapy, behavioral interventions and use of different first line agents more effective.

20. Upcoming Research PTSD + comorbid substance abuse Afghanistan/Iraq veterans with comorbid Traumatic Brain Injuries (Prolonged Post Concussive Syndrome) Tele-mental Health video conference technology

21. What about the Spouse? • Insufficient evidence to support behavioral family therapy or couples therapy • S.A.F.E. (Support And Family Education) • Multi-session group therapy for family members of the mentally ill (PTSD, bipolar, schizophrenic, MDD) • 14 sessions with educational material • 4 workshops to teach specific skills training to minimize stressful home scenarios

22. “Coaching into Care” Hotline to help family members of vets to get access to their V.A. Benefits

23. Pre-Deployment Preparation Local vs. non-local spouses Seminar Call list of other spouses Informal gatherings organized by the most senior officer’s spouse

24. Deployment Communication Depends on military branch

25. Reintegration Phases Pre-entry phase Reunion “honeymoon” Disruption phase Communication New “normal”

26. Challenges for Provider & Veteran Provider: • Recognizing/diagnosing PTSD • Training in EB treatments • Treating complicated patients Veteran: • Recognition of problem • Stigma associated with seeking help • Accessing services Ruzek J, Hamblen J.(2012).Improving Care for Veterans with PTSD. National Center for PTSD

27. Military vs. Civilian Medical Care • Fragmented military medical care (deployment, changing assignments, discharge schedules) • Stigma of weakness in military culture • Military care model: free, as needed, care management coordination w/ employer, appts part of work day • Civilian care model: can be overwhelming initially and avoided

28. Captain Michael Gruber Bio Disclaimer My Experience

29. An Inside View: Basic Training to the Battle field to Going Back Home. Generation PTSD? The patient’s perspective Obstacles to Care What works and what doesn’t work Resources

30. Who They Are Volunteer Location Family Education Race

31. Basic Training

32. Deployments Patrol Down Time Maintenance

33. Getting Out

34. Generation PTSD? History doesn’t include “Coward” Increased awareness brings soldiers in for Treatment

35. The Invisible Wounds of War Causes Symptoms Obstacles

36. What Works

37. What Doesn’t Work

38. Resources • http://ptsdsurvivordaily.com/ (blog of Mike Piro, Army combat veteran) • http://njms2.umdnj.edu/psyevnts/ptsd.html (U.S. Dept Veteran Affairs Nat’l Ctr for PTSD: PTSD Resources • http://www.istss.org/ResourcesforProfesionals/1956.htm (link for physicians who want to learn more about using CBT in patient care) • http://www.ptsd.va.gov/professional/pages/fslistbiological.asp (U.S. Dept Veteran Affairs Nat’l Ctr for PTSD: Biology of PTSD

39. References • Bulin T, Zawalski L. Biopsychosocial challenges in primary care for the combat PTSD patient from a social work and psychiatry perspective. Osteopathic Family Physician 4:36-43, 2012 • Perterson A, Luethcke C et al. Assessment and treatment of combat-related PTSD in returning war veterans. J Clin Psychol Med Setting 18:164-175, 2011 • Tedeschi R. Posttraumatic Growth in Combat Veterans. J Clin Psychol Med Settings 18:137-144, 2011

40. References • Hetrick, SE “ Combined pharmacotherapy and psychological therapies for PTSD (Review), Cochrane 2010 • Ipser, JC “Evidence-based pharmacotherapy of PTSD” International Journal of Neuropsychopharmacology (2012) • Jeffreys, M “Pharmacotherapy for PTSD: Review with clinical applications” JRRD, vol 49, Number 5, 2012 • Monson, CM “Couple/family therapy for PTSD: Review to facilitate interpretation of VA/DOD Clinical Practice Guideline” JRRD, vol 49 number 5, 2012

41. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!