Practical Review of Post Traumatic Stress Disorder (PTSD) and the ...

The Returning Veteran
and
A Practical Review of
Posttraumatic Stress Disorder
Matthew J. Barry, DO
Lead Psychiatrist
Rochester VA Outpatient Clinic
19 JAN 2011

Agenda
• The Returning Veteran
– The experience
– Treatment services
– Transition from DoD to VA health care
• Posttraumatic Stress Disorder
– Neurobiology
– Treatment
• Therapy
• Medications
• Questions

Components of the US Military
• Army
• Navy
• Air Force
• Marine Corps
• Coast Guard

Classifications of the US Military
• Active Duty
• Reserve Forces
• National Guard
• Individual Ready Reserve (IRR)

Active Component
• Federal Service
• Currently 1,454,515
• Deployments NOW no longer than 12 months in
most cases (may work 24/7)
• Deployed Worldwide
– CONUS
– OCONUS in Afghanistan, Germany, Japan, Korea, Africa…

Reserve Component
• Federal Service
• Part‐time Job
• Currently 355,000
• Monthly Battle Assembly
• Transitions from Reserve Status to Active Duty
• Deployed During Times of War, Peace‐keeping and
Federal Need

National Guard Component
• State Service
• Part‐time Job
• Currently 459,300
• Deployed During Times of War, Peace‐keeping and
Disaster Relief

Troops
Component Military Enlisted Officer Female Civilian
Army 569,000 456,651 88,093 73,902 243,172
Navy 331,768 276,276 51,093 50,008 182,845
Marine 201,031 180,443 20,588 12,290
Air Force 329,980 261,193 64,370 64,137 154,032
Coast Guard 42,583
Reserves &
National
Guard
847,000

Numbers ‐ Army
1. Total number of Soldiers in Afghanistan
2. Percent of these Soldiers on psychiatric meds
3. Number of these Soldiers who will have
symptoms, or actual diagnosis of PTSD

Mental Health Status of Soldiers
and Marines
• Data relatively consistent from OIF I to OIF 05‐07.
• Findings from the WRAIR Land Combat Study
indicate that these rates may increase further at 6
and 12 months post‐deployment
Percent Screening Positive
35
30
25
20
15
10
5
0
OIF I Soldiers
OIF 04-06 Soldiers
OIF 05-07 Soldiers OIF 05-07 Marines
16
20 20
17
17
14 14 15
Acute Stress (PTSD scale)
Any Mental Health Problem
(anxiety, depression, or acute
stress)

Soldier Multiple Deployments
• Findings from the WRAIR Land Combat Study indicate
that Soldiers’ mental health status does not “re‐set”
prior to deploying to Iraq a second time.
• Soldiers deployed to Iraq more than once were more
likely to screen positive for a mental health problem
than first‐time deployers.
Percent Screening Positive
50
40
30
20
10
15
OIF 05-07 First time Deployers
OIF 05-07 Multiple Deployers
24 27
17
0
Acute Stress (PTSD scale)
Any Mental Health Problem

Stigma Toward Mental Health Care
• Stigma among Soldiers towards using behavioral health care is relatively
stable over time.
Stigma prevents Soldiers
from Using Mental Health
13% of ALL Soldiers and 7% of
ALL Marines reported being
interested in receiving help for
a stress, emotional, alcohol or
family problem.
Only 42% of Soldiers who
screened positive for a mental
health problem sought help
from a behavioral health
provider, primary care provider
or chaplain.
My unit leadership might
treat me differently
I would be seen as
weak
Members of my unit
might have less
confidence in me
It would harm my
career
38
36
31
35
36
57
53
59
48
54
48
55
48
54
54
47
OIF I
Soldiers
0 20 40 60 80 100
Percent Agree or Strongly Agree
OIF 04-06
Soldiers
OIF 05-07
Soldiers
OIF 05-07
Marines

Relationship / Family Problems
• About 15% of married Soldiers reported serious relationship concerns.
• 2% reported engaging in severe spouse abuse within the past month.
• Of 1,883 Soldiers who deployed, 26% reported that the process of reunion/ reintegration
with their family was very stressful.
• Most children are adjusting well. However, 29% of Soldiers report their children are
having significant behavioral problems, including fighting, depression, and threats of selfharm
20
Percent Reporting "Yes"
15
10
5
9.7
9.1
3.9
2.0
0
Infidelity a Problem
Planning
Divorce/Separation
Spouse Abuse -
Moderate
Spouse Abuse -
Severe

Treatment in Theater
and Home Station
• Combat and Operational Stress Control
– Over 200 mental health providers in Afghanistan
• Prevention
• Treatment
• Restoration
• Medication
– Clarity of use of psychiatric medications for deployment
• Health Affairs Policy Nov 06
• Army guidelines Apr 07
– SSRIs
• Psychotherapy
– Cognitive‐behavioral therapy (CBT)
– Exposure therapy
• Resiliency Training
• Suicide Prevention
• Air Evacuation and Disposition from the military

Current Challenges:
Typical 12‐month Redeployment Cycle
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Return/
screenings
Block
Leave
Retrain
Re-Screen
JRTC/NTC
Block
Leave
Therapy

Operation Enduring Freedom/
Operation Iraqi Freedom
• Numerous stressors
– Multiple and extended deployments
– Battlefield stressors
• IEDs, bodies, killing
– Medical
• Severely wounded Soldiers, injured children, detainees
• More often you go, higher chances of difficulty
• Unit cohesion and morale are key to resilience
• Stigma is high in military population
• Increasing isolation of career Soldiers from society
• Difficult to provide evidence based care due to tempo

Transition

VA Services
(just a few of them!)
• Behavioral health clinic,
including PTSD specialty
clinic
• Vet Center
• Veterans Outreach
Center
• Vocational
rehabilitation
• Primary / specialty
health care
• Inpatient, Residential,
Domiciliary Services
• Intensive Case
Management
• Veterans Court
• GI Bill
• Family support
• Substance abuse
services

What Can You Do At Your Clinic
• Engage the patient:
– 6 questions to ask military veterans (Current Psychiatry, Sep 2008)
1) Did you experience traumatic events while deployed
2) What was your job in the military
3) Were you stop‐lossed
4) Did you receive mental health care downrange
5) How did you exit the military
6) Have you enrolled in the VA

What Can You Do At Your Clinic
• Encourage Veterans to get VA services
– Veterans Service Center, 585‐463‐2687
– Rochester Outpatient Clinic, 585‐463‐2668
– Vet Center, 585‐232‐5040
– Veteran Outreach Center, 585‐546‐1081
– National Health Care line, 1‐877‐222‐VETS (8387)
– Crisis line, 1‐800‐273‐8255
– http://t2health.org/mobile‐apps
– Afterdeployment.org
– www.ptsd.va.gov
– www.dcoe.health.mil

What Can You Do At Your Clinic
• Improve your knowledge base:
– National Center for PTSD
• www.ptsd.va.gov
– Center for Deployment Psychology
• www.dcoe.health.mil
– Veterans Mental Health Training Initiative
• NASW, 4/27/12
• www.naswnys.org/veterans_yr2.html

Agenda
• The Returning Veteran
– The experience
– Treatment services
– Transition from DoD to VA health care
• Posttraumatic Stress Disorder
– Neurobiology
– Treatment
• Therapy
• Medications
• Questions

Consistent Findings in the Literature
• Trauma exposure is extremely common
• PTSD is relatively rare
• Many people recover from PTSD, but a
minority develop chronic and persistent
symptoms
• Other psychiatric disorders may develop or
co‐occur with PTSD

Numbers ‐ VA
1. Number of Veterans who served in either
Iraq or Afghanistan
2. OEF/OIF Veterans eligible for VA healthcare
3. OEF/OIF eligible Veterans getting healthcare
at the VA
3. OEF/OIF Veterans diagnosed with PTSD

Neurobiology
Prefrontal Cortex
•“Executive function”
•Cognitive response
•Working memory
•Attention
•Carrying out tasks
•Suppresses amygdala

Neurobiology
Anterior Cingulate
Cortex
•Interprets emotional
stimuli and processes
responses
•Gating function in
modulating conditioned
fear response

Neurobiology
Hippocampus
•Contextual provider

Neurobiology
Amygdala
•Emotional processor

Neurobiology

Neurobiology
Norepinepherine
Adaptive
• Flight Response
• Fear
• Sympathetic Activation
• Conditioning
• Consolidation
Symptomatic
• Hypervigilance
• Autonomic Arousal
• Fear
• Exaggerated Startle
• Flashbacks
• Intrusive Memories

Neurobiology
Serotonin
Adaptive
• Fight Response
• Aggressive Retaliation
• Self Defense
• Rage
• Attenuation of Fear
Symptomatic
• Aggression
• Violence
• Suicide Attempts
• Impulsivity
• Depression
• Anxiety and Panic

Neurobiology
Gaba
Adaptive
• Anxiolysis
• Hormonal Modulation
• Neurotransmission
Modulation
• Cognitive Functionality
• Decreases Release of CRF
Symptomatic
• Anxiety
• Reexperiencing
• Impulsivity
• Hyperarousal

CRF
Hypothalamus
Anterior
Pituitary
Posterior
Pituitary
Locus
Coeruleus
Adrenal
Kidney
ACTH
Cortisol
Norepinephrine

Neurobiology
Lateral Nucleus of Amygdala
++ glu ‐‐ gaba ++5HT
Central Nucleus
of Amygdala

“Battlemind”
• In a dangerous situation you don’t want to
sit around and think. You want to act
immediately using your amygdala and
bypassing your frontal lobe.
• In PTSD the brain acts like you are in a
dangerous situation all the time. The
amygdala is hyperactive and the frontal
lobe functions poorly.

Neurobiologic Alterations in PTSD
• Amygdala hyperactivity
• Prefrontal cortex is deficient
• Neurotransmission dysfunction
– Too much norepinepherine
– Too little serotonin
– Deficiency of gaba
• Stress hormone systems
• Thyroid
• Immune system
• Hippocampal volume loss
• Anterior cingulate

Neuroimaging in PTSD
• Amygdala – hyperactivity, responsivity is
associated with PTSD symptom
severity
• Frontal cortex –volume loss, responsivity
is inversely associated with PTSD
symptom severity
• Hippocampus –volume loss, decreased
neuronal and functional integrity

Salient Features of PTSD
• Hyperresponsiveness to stimuli that are
reminders of the trauma
Amygdalar hyperactivity
• Overgeneralization of stimuli
Hippocampal dysfunction
• Anger dyscontrol, failure of extinction
Medial prefrontal cortex dysfunction

Before You Initiate Treatment
• Normalize the situation
• De‐pathologize
• Explain everything
• It’s all about giving your patient a
sense of control

Treatment Pearls
• Prioritize crises or urgent conditions
• Remission is the goal
• Sensible sequencing
– Introduce one treatment at a time
– Conduct adequate trials, but d/c if ineffective
– Introduce a second treatment for partial
responders
– If response is adequate, try to d/c first treatment
– Re‐evaluate non‐responders

Treatment Options
• First‐line treatments:
– Cognitive Behavioral Therapy
• Cognitive Processing Therapy
• Prolonged Exposure
– Eye Movement Desentization and Reprocessing
– Pharmacotherapy
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Venlafaxine

Alternative Therapies
• Acceptance Commitment Therapy (ACT)
• Art therapy
• Somatic therapies/bodywork
• Acupuncture
• Yoga
• Tai Chi
• Religious/spiritual practices
• Virtual reality

Symptomatic Treatment
• Inventory all symptoms
• Identify target symptoms for a given
medication
• Focus initial therapy on one or two most
distressing symptoms
• Often significant resistance to improvement,
e.g. hypervigilance
• Treat comorbidity

Psychoeducation & Control Issues
• Give patient (and family) information
– handouts, internet
– spark of recognition
• Give the patient control
– titration decisions
– meds like trazodone, hydroxyzine useful in this
regard

Medication Specifics
• SSRIs
– Broad spectrum: improves all three clusters
• SNRI
– Venlafaxine
• Prazosin
– For core symptoms and traumatic nightmares
• Augmentation with atypical antipsychotic
– Risperidone and Olanzapine for partial responders

Medication Specifics
• Alpha‐2 Presynaptic Agonists
– Clonidine and guanfacine
– Mirtazapine (also a 5HT blocker)
• Anti‐adrenergic Beta Blockade
– Propranolol and atenolol
• Trazodone
– Weak action on PTSD, but good adjunct
• Anti‐histamine
– Diphenhydramine and hydroxyzine

Medication Specifics
• Not recommended for treatment of PTSD:
– Antiepileptic Medication
– Benzodiazepines
– Cyproheptadine
– Buspirone

Future Medications
• D‐Cycloserine
– Works at NMDA where learning takes place
– Extinction is new learning process
– New learning is mediated by NMDA receptors
– D‐cycloserine activates NMDA receptors
– So, if we combine can we accelerate learning
• CRF antagonists
• Neuropeptide Y agonists
• BDNF

Final Points
• There is no “off” switch in PTSD
• Psychotherapy is the best treatment option
• Research is moving beyond SSRIs and
considering medications that my improve
psychobiological abnormalities associated
with PTSD

Questions
Contact Information:
Matthew Barry
Rochester VA Outpatient Clinic
465 Westfall Road
Rochester, NY 14620
Matthew.barry@va.gov
(585)463-2776