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

2.TBI/PTSD/“MUSH” syndrome.

3.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 alterationsa. Photophobiab. Hyperacusis –c. Sensory overload – ie., Meijer

Syndrome2. Loss of Mapping skills.3. Pituitary Dysfunction.4. Chronic Headaches.

CAFFEINE CONTENT of DRINKSAdding 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/Technique1. 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• Suicidality• 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. Photophobiab. Hyperacusis –c. Sensory overload – ie., Meijer

Syndrome?2. Loss of Mapping skills.3. Pituitary Dysfunction.4. 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– 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).(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