1.Primary Care Management of the Returning Veteran with PTSD Bill Swann D.O. PCM WTU KACC

2. Objectives a) Develop an understanding of the special considerations necessary in the Primary Care Management of the Returning Veteran of with PTSD b) Develop a better ability to recognize PTSD c) Develop a better understanding of how the management of Common Primary Care Issues in the Returning Veteran may differ from our civilian population d) Develop a better understanding of the Role of Osteopathy and role of Adjunctive Health Care Providers ,in the management of issues particular to the Returning Veteran with PTSD e) Develop a better understanding of the when to refer and when to get help for your patients who are veterans with PTSD 3. Overview Objectives & Topic Review The Issue , Scope & Impact The Pathophysiology and Recognition of PTSD PTSDs impact in common medical problems and issues Recognition of PTSD Effect of PTSD on the Veterans Family Role of an Osteopathic perspective and Adjunctive Interventions Resources for PTSD management 4. Regional Map of Middle East 5. The Issue Since October 2001, over 1.6 million U.S. troops have deployed to the wars in Iraq and Afghanistan, with many exposed to prolonged periods of combatrelated stress or traumatic eventsAs of May 2010 there are approximately 180,000 US troops in Iraq and AfghanistanResearchers estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment -- an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more high-quality treatment could save close to $2 billion within two years. The eventual cost of providing lifetime medical benefits, lifetime disability benefits, and lifetime social security benefits for veterans of the current Gulf War could easily reach $700 billion or more, close to the total overall cost of the first five years of the war. 6. Historical PTSD The first documented case of psychological distress was reported in 1900 BCE, by an Egyptian physician who described a hysterical reaction to trauma. PTSD may be one of the 1st recognized Psychological Disorders. After the Battle of Gettysburg, ~28,000 rifles were recovered, ~25,000 of them hadnt been fired. Thru history & until the Vietnam conflict the, % of soldiers who fired their weapons, was~ 50% During and after Vietnam that ratio increased, approaching 99%. Many encounters are very face to face. Our Soldiers may be trained to aim, fire and hit, but training on how to deal with the psychological sequelae of those actions is sparse, as seen with over 25% of our Veterans suffering from some degree of PTSD. 7. The Issue , The Dollar Cost 8. Why do we get PTSD? What is the Pathophysiology of PTSD? PTSD is a normal reaction to undue and deadly stress. Our patients develop PTSD because they are Human. Despite what we see in the movies, we are not wired to Kill nor deal with pain, fear ,death and destruction on an on going basis.. One action our mind uses is to protect the brain through dissociation. This is a normal and usually temporary and benign response. The dissociated brain stops the horror of the event before it becomes a full real-time impossible reality. It walls off the event, and in extreme cases induces amnesia. It is a very healthy survival technique. Survival technique, in that our brain is now able to focus on survival rather than perseverate on the horrible issues at hand. 9. Cortisol Response to Stress 10. Hippocampal Pituitary Adrenal (HPA Axis) Dysfunctions in PTSD vs. Depression PTSD Cortisol LevelsLowGlucocorticoid ReceptorsIncreasedDexamethasone StimTestHypersuppressionDepression HighDecreasedNonsuppressionNegative FeedbackStrongerWeakerCSF CRF LevelsIncreasedIncreased 11. The Neurophysiology of PTSDCortex PFC Sensory ThalamusAmygdala 12. Limbic System & PTSD The High & the Low Roads 13. "Reduced" nerve activity e.g. as in depression:HOW SSRI ANTIDEPRESSANTS PROBABLY "WORK " 14. HOW SSRI ANTIDEPRESSANTS PROBABLY "WORK Reduced" nerve activity but with recycling blocked, and increased messages passes: 15. The High & Low Roads of Neuro Processing in PTSD & the Flight or Flight response Low Road Conveys a fast, rough impression of the situation, because it is a sub-cortical pathway in which no cognition is involved. This activates the amygdala which, through its central nucleus, generates emotional responses before any perceptual integration has even occurred and before the mind can form a complete representation of the stimuli The High Road Information that has travelled via the high road and has been processed in the cortex reaches the amygdala and tells it whether or not the stimulus represents a real threat. 16. What is PTSD/Post Traumatic Stress Disorder? There are sixteen types of mental disorders, one is the anxiety disorder class. PTSD is an anxiety disorder. The DSMIV diagnosis code for PTSD is 309.81.Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that's triggered by a traumatic event. You can develop post-traumatic stress disorder when you experience or witness an event that causes intense fear, helplessness or horror. (Mayo Clinic Definition)What started out as a "syndrome" turned into a "disorder". A "disorder" is an illness. PTSD changed from being part of a collective indicator to a singular illness, a significant medical distinction. PTSD is a term initiated ~1980. The initial definition of PTSD described a psychological condition experienced by a person who had faced a traumatic event which caused a catastrophic stressor outside the range of usual human experience (an event such as war, torture, rape, or natural disaster). This definition separated PTSD stressors from the "ordinary stressors" that were characterized in DSM-III as "Adjustment Disorders", such as divorce, failure, rejection and financial problems. 17. Definitions of PTSD The VAs most recent stance and definition of PTSD is: Post Traumatic Stress Disorder (PTSD) is a condition resulting from exposure to direct or indirect threat of death, serious injury or a physical threat. The events that can cause PTSD are called "stressors and may include natural disasters, accidents or deliberate man-made events/disasters, including war. Symptoms of PTSD can include recurrent thoughts of a traumatic event, reduced involvement in work or outside interests, emotional numbing, hyper-alertness, anxiety and irritability. The disorder can be more severe and longer lasting when the stress is human initiated action (example: war, rape, terrorism). American Psychiatric Definition , essentially utilizes the diagnostic criteria required to make a diagnosis of PTSD as its definition . Refer to that portion of the presentation. 18. Recognizing the possibility of a Diagnosis of PTSD Per DSM-IV-TR the Gate Keeper Criterion to consider a diagnosis of PTSD "the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others." "the person's response involved intense fear, helplessness and horror. The DSM-IV-TR specifies the pattern of symptoms that must occur in 3 categories or Criterion of PTSD symptoms: 1) re-experiencing, 2) avoidance/numbing, and 3) increased arousal. PTSD can only be diagnosed if there is: at least One symptom of re-experiencing, Three symptoms of avoidance/numbing, and Two symptoms of increased arousal are presentIf a person has six symptoms, for example, but all are in the hyper-arousal category, the diagnostic criteria for PTSD have not been met.Forensic Validity of a PTSD Diagnosis Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW 19. DSM-IV-TR Diagnostic criteria for PTSD .1) History of exposure to a traumatic event meeting twocriteria of the symptoms from each of 3 symptom clusters: 2) Intrusive recollections 3) Avoidant/Numbing symptoms, and 4) Hyper-arousal symptoms 5) The fifth criterion concerns duration of symptoms and a 6) Sixth assesses functioning 20. Body Language Diagnosis of PTSD Your meta-language (body language) conveys 90% of your message. Your words convey only 10% of your message. This idea also extends to your observation of the patient. Suttle nuanced mannerisms, i.e., scanning the room, inappropriate startling, obvious internal dialogue, avoidance of personal discussions. Abnormal VS, Resting tachycardia, hyperhidrosis, systolic hypertension Is the patient the disease? Would we say to a patient ,You are an appendicitis! Thus we need to be considerate and careful with our own responses to our patients who happen to have a mental disorder. Be considerate, Consider is a great word and invitation vs you need to do this, ect. Attempt to recruit the patient into their own care plan. The veteran appreciates and expects sincere respect. 21. Criterion A: stressor . Criterion A: stressor The person has been exposed to a traumatic event in which both of the following have been present: 1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. 2. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior. 22. Criterion B: intrusive recollection The traumatic event is persistently re-experienced in at least one of the following :1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. 3. 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 upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 23. Criterion C: avoidant/numbing Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: 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 an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feeling of detachment or 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 a career, marriage, children, or a normal life span) 24. Criterion D: hyper-arousal Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyper-vigilance 5. Exaggerated startle response 25. Criterion E:Duration & F: Functional significanceCriterion E: duration Duration of the disturbance (symptoms in B, C, and D) is more than one month. Criterion F: functional significance The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more Specify if: With or Without delay onset: Onset of symptoms at least six months after the stressor 26. Primary Care PTSD Screen (PC-PTSD) The PC-PTSD is a 4-item screen that was designed for use in primary careIn your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:1) Have had nightmares about it or thought about it when you did not want to? YES / NO2) Tried hard not to think about or went out of your way to avoid situations that reminded you of it? YES / NO3) Were constantly on guard, watchful, or easily startled? YES / NO4) Felt numb or detached from others, activities, or your surroundings? YES / NOCurrent research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items.*** Primary Care PTSD Screen (PC-PTSD) Prins, Ouimette, Kimerling et al., 2003 27. Primary Care Issues and the Returning Veteran with PTSD 1) Musculoskeletal Issues 2) TBI Traumatic Brain Injury 3) Sleep Issues 4) Chronic Pain Management 5) Co Morbid Mental Health Issues & Suicide 6) Sexual Dysfunction 7) Metabolic & Core Primary Care Issues 28. The Effect of Hypocortisolism on Health 29. Standard of Care for PTSD 1) Cognitive Behavioral Therapy CBT 2) Virtual Exposure Therapy VET 3) Individual & Group Counseling 4) Psychotropic Medications 5) Optimal Management of Underlying Medical Issues 30. Afghanistan 31. Weight of War 32. Afgan Mountain Range 33. A Soldiers Day 34. Chronic Pain So, is it Pain, or is it withdrawal from narcotics. ?? Is the Pain valid, Is it Musculoskeletal pain? Is it neuropathic Pain>? Is it diffuse or focal Rheumatologic pain? Is it psychogenic PTSD Modulates Pain via a number or pathways. The Severity of the PTSD is often correlated with the severity of the reported pain. Treating the PTSD is crucial to successfully treating the chronic pain a veteran suffers. Often times the therapies are similar, CBT, VRT 35. Traumatic Brain Injury, Blast vs. CHIBlast InjuryClosed Head Injury 36. Traumatic Brain Injury ( TBI) Blast Injury and Traumatic Brain InjuryA TBI is caused by a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Exposure to blast events can affect the body in a number of ways; in addition, these different injury mechanisms can interact and result in more impairments or prolonged periods of recovery.Primary blast injury is the result of exposure to the over-pressurization wave or the complex pressure wave that is generated by the blast itself. This blast over-pressurization wave travels at a high velocity and is affected by the surrounding environment; for example, the effects of the blast wave may be increased in a closed environment such as a vehicle. Air-filled organs such as the ear, lung, and gastrointestinal tract and organs surrounded by fluid-filled cavities such as the brain and spinal cord are especially susceptible to primary blast injury. The over-pressurization wave dissipates quickly, causing the greatest risk of injury to those closest to the explosion. 37. TBI continued TBI resulting from blast exposure can be much more complex compared to TBI from other causes. As such, it is challenging to differentiate blast related TBI and/or concussion from other conditions. Finally, it is also difficult to estimate the course of recovery in these cases, as it may vary widely depending on various types of blast injury and other injury variables, such as the size of the blast, distance from the blast, etc. Due to these issues, it may be difficult to assess blast related TBI and concussion in the same manner that other brain injuries are examined. A better approach may be to conduct an evaluation based on the mechanism (cause) of the injury; that is, screen all individual service members exposed to a blast for any symptoms which might be resulting from the effects of blast on the brain. Difficulties experienced as a result of a closed brain blast injury may include a range of physical, emotional, cognitive, and behavioral symptoms. Many of these symptoms are non-specific, however; that is they occur with other conditions such as depression or combat stress. It requires an experienced clinician who is familiar with the many variables involved in blast injury, and has an understanding of how these variables can affect recovery and ultimately impact return to everyday activities. 38. 1. Did you have any injury(ies) during your deployment from any of the following? (check all that apply): A. Fragment B. Bullet C. Vehicular (any type of vehicle, including airplane) D. Fall E. Blast (Improvised Explosive Device, RPG, Land mine, Grenade, etc.) F. Other specify: ________________________________ __________ 39. 2. Did any injury received while you were deployed result in any of the following?(check all that apply):A. Being dazed, confused or seeing stars B. Not remembering the injury C. Losing consciousness (knocked out) for less than a minute D. Losing consciousness for 1-20 minutes E. Losing consciousness for longer than 20 minutes F. Having any symptoms of concussion afterward (such as headache, dizziness, irritability, et c.) G. Head Injury H. None of the above 40. 3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? (check all that apply): A. Headaches B. Dizziness C. Memory problems D. Balance problems E. Ringing in the ears F. Irritability G. Sleep problems H. Other specify:_____________________ 41. Sleep Disorders in Veterans with PTSD A substantial number of US Veterans are suffering from PTSD following deployment in recent military conflicts. Sleep disturbances are a primary complaint of Veterans presenting to the VA with PTSD. Veterans with PTSD have more self-reported and physician-rated health problems, and health status is associated with PTSD symptom severity. Most Veterans meeting criteria for PTSD report difficulty initiating or maintaining sleep (70-91%), and increased PTSD severity is associated with increased sleep disturbance. Even after receiving treatment for PTSD, Veterans continue to experience residual insomnia at a rate of about 50%, in spite of having achieved PTSD remission.The best available evidence from literature sources suggests the diagnosis of SA is still best accomplished with full PSG. 42. Suicide There are about 30,00 suicides annually in the U.S., it is the 11 th most frequent cause of death .Veteran may make up to 20 % of all suicides.Veterans of Iraq and Afghanistan conflicts who screened positive for PTSD were four times more likely to report suicide-related thoughts relative to veterans without the disorder. The research, published in the Journal of Traumatic Stress, establishes PTSD as a risk factor for thoughts of suicide in Iraq and Afghanistan war veterans. This holds true, even after accounting for other psychiatric disorder diagnoses, such as substance abuse and depression. Veterans who screened positive for PTSD and two or more comorbid mental disorders were significantly more likely to experience thoughts of suicide relative to veterans with PTSD alone.As many as forty-six percent of veterans in the study experienced suicidal thoughts or behaviors in the month prior to seeking care, and of those veterans, three percent reported an actual attempt within four months prior to seeking the care. Suicide-related thoughts and behaviors discovered in a returning veteran who has been diagnosed with PTSD, especially in the presence of other mental disorders, may suggest an increased risk for suicide. 43. Suicide Prevention Hotline The VA has also partnered with the Lifeline Program, a grantee of the Substance Abuse and Mental Health Services Administration (SAMHSA), of the Department of Health and Human Services (HHS), to develop a VA suicide prevention hotline.Those who call 1-800-273-TALK are asked to press 1 if they are a veteran, or are calling about a veteran.32 When they do so, they are connected directly to VAs hotline call center, where they speak to a VA mental health professional with real-time access to the veterans medical records. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response. In other cases, after providing support and counseling, the hotline transfers care to the suicide prevention coordinator at the nearest VAMC for follow-up care. From October 7 to November 10, 2007, 1,636 veterans and 311 family members or friends called the VA suicide prevention hotline. These calls led to 363 referrals to suicide prevention coordinators and 93 rescues involving emergency services.1-800-273-TALK 44. Acupuncture for the treatment of PTSD, Pain and other Disorders Researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment. COL Engel, of WRAMC For more info go to: http://www.pdhealth.mil/downloads/Evaluating_the_Efficacy_of _Acupuncture_as_a_Treatment_for_Posttraumatic_Stress_in_ Military_Personnel.pdf For a brief review of how Acupuncture works with emotional disorders: http://www.hiddenrhythmacupuncture.com/page11/files/acupuncture-foremotional-disorders-and-ptsd-a-presentation.pdf 45. Is their a role for Osteopathy in the care of the Veteran with PTSD 1)As far as the major tenet of Osteopathy is that of recruiting the Health of the patient in developing a treatment plan for amelioration of suffering and in the healing of our patients, Yes there is a role. 2) Consider engaging the veteran and their family in the care, without a rigid agenda. 3) In utilization of manual medicine, have first developed a repoire, as not all veterans with PTSD are initially receptive to touching therapies 4) Care for the Caregiver Stay Grounded 46. Links for more Info on PTSD www.ptsdinfo.org/ http://www.ptsd.va.gov/professional/pages/trauma-ptsd-provider.asp www.BrainLine.org/PTSD www.nimh.nih.gov/health/publications/post-traumatic-stress-disorderptsd/index.shtml helpguide.org/.../post_traumatic_stress_disorder_symptoms_treat ment.htm www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp http://www.ptsd.va.gov/professional/ptsd101/pages/iraq-neverleaves-us.asp 47. Some Books to Read on PTSD On Killing: The Psychological Cost of Learning to Kill in War and SocietyDave Grossman: Moving A Nation to Care: Post-Traumatic Stress Disorder (by Ilona Meagher, Robert RoerichHandbook of PTSD: Science and Practiceby Matthew J. Friedman MD PhD, Terence M. Keane PhD Night Falls Fast: Understanding Suicideby Kay Redfield Jamison 48. Review of Topics Pertinent to Discussion 1) Objectives 2) The Issue 3) The Soldier 4) A Day Down Range 5) Coming Home B/ Veteran Specific Issues 6) PTSD 7) TBI 8) Musculoskeletal Injuries 9) Suicide 10) Sleep Disorders C/ Common Primary Care Issues and the Returning Veteran 11) Diabetes 12) Hypertension 13) Arthritis14) Obesity 15) Depression 16) Headache Syndromes 17) Pain Management 49. D/ Role of Society and the Returning Veteran 18) Family Issues 19) Occupational Issues 20) Veteran's Administration 21) Special Programs 22) Tricare E/ Special Considerations 23) Role of Osteopathy 24) Adjuctive Health Care Providers 25) What Not to Do 26) When to Refer and get Help 27) Resources 28) Review and Conclusion