COMBAT PTSD Recognition and Treatment. Harry Croft, M.D. TOMA San Antonio, June, 2012

Transcription

1 COMBAT PTSD Recognition and Treatment Harry Croft, M.D. TOMA San Antonio, June, 2012

2 Research and Speaking Honoraria Astra Zeneca Boehringer Ingelheim BMS Eli Lilly Forest Pharmaceuticals GSK Otsuka Pfizer Takeda

3 Learning Objectives 1. Learn usual presenting symptoms to civilian pcp of combat related PTSD. 2. Understand the importance of treating combat related ptsd in addition to relieving obvious presenting symptoms. 3. Become familiar with common misconceptions as well as facts regarding ptsd. 4. Know current evidence based treatments for ptsd. 3

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5 RECOGNIZING When PTSD is in Your Life EDUCATING Yourself About PTSD CONNECTING Biology With Your Psychology ORGANIZING a Comprehensive Care Plan VIEWING Your Issues in a New Light EMPOWERING Yourself Through Strong Systems of Support REDEFINING the Meaning of Your life: Post Traumatic Growth 5

6 Why Civilian Physicians Should Care PTSD in general population Returning Veterans 20% of approximately 5 million Vietnam Middle East But what about the VA? Don t THEY take care of vets Not eligible No desire to go

7 Recognition of PTSD Problems for Patients and Families Failure to Recognize Symptoms Incorrectly Ascribe Cause Myths and Misconception About PTSD Stigma Surrounding PTSD

8 Myths and Misconceptions about PTSD 1. Only a soldier s problem 2. Only a man s problem (men acting badly) 3. A psychiatric condition (denoting cowardice or craziness or weakness) 4. Only affecting those in direct combat 5. Almost everyone deployed to combat zone comes back with PTSD PTSD is an all or none disorder 8

9 PTSD IS... Not just caused by Combat Related Trauma Not Just a Man s Problem Not all deployed to combat area Not all or none Not Just Psychiatric Disorder A Psyco neuro endocrine disorder A Psycho neuro endocrinological problem

10 Problems for Physicians Pr Patient reports only certain symptoms Insomnia, Irritability, Nightmares, Isolation, Sexual Dysfunction, GI distress, Lack of concentration, Alcohol related problems Failure to report traumatic experience/ vet Visit by patient not self motivated

11 Risks to Military Members More than Just Combat Combat Non predictable Threats to even noncombatants Repeated Deployments Repeated Separations Dwell time Unemployment / finances

12 Impacts Many Life Areas Relationships Marital, Family, Friends EMPLOYMENT/ EDUCATION Legal Problems Physical Health Risk Taking DESPAIR / SUICIDE

13 DIAGNOSIS STRESSOR RE EXPERIENCING AVOIDANCE AROUSAL EMOTIONAL DISTRESS OR LIFE INTERFERENCE

14 DIAGNOSTIC CRITERIA FOR PTSD DSM IV and proposed DSM 5 STRESSOR CRITERIA EXPOSURE TO TRAUMATIC EVENT Experience, witness, or be confronted with actual or threatened death or serious injury or threat to physical integrety of self or others EXPOSURE TO ACTUAL OR THREATENED EVENT EXPERIENCE, WITNESS EVENT TO OTHERS, LEARNING OF EVENT OCCURRING TO FRIENDS OR RELATIVES, EXPERIENCING EXTREME EXPOSURE TO DETAILS... INTENSE FEAR, HELPLESSNESS, HORROR None 14

15 REEXPERIENCING AVOIDANCE AROUSAL DSM IV PTSD CRITERIA > ONE MONTH DISTRESS OR IMPAIRMENT INTRUSIVE SYMPTOMS AVOIDANCE I/E REMINDERS 15

16 Assessment of PTSD PC PTSD Primary Care PTSD Screen 4 items (2 or more diagnostic) PCL PTSD Checklist (C & M) 19 items (0 4) cutoff = >50

17 CO OCCURRING CONDITIONS DEPRESSION ANXIETY DISORDERS Generalized, Panic, Social Phobia SUBSTANCE ABUSE DISORDERS OCD VARIANTS

18 Foundations of Effective Treatment Recognition of Need for Treatment Decision to Get Help Finding a Place even if.. Trust and Rapport Someone who understands Someone who will not judge Someone who will not be horrified BUT RAPPORT ALONE IS NOT ENOUGH

19 PSYCHOTHERAPY COGNITIVE BEHAVIORAL THERAPY Prolonged Exposure Cognitive Processing Therapy Experiential SUPPORTIVE EMDR OTHER

20 MEDICATIONS ANTI ADRENERGIC SSRI and SNRI MEDS TO AID WITH SLEEP Other antidepressants ATYPICAL ANTIPSYCHOTICS ANTI EPILEPTICS **Avoid BENZODIAZEPINES IF POSSIBLE

21 NEW MEDICATIONS CRF Antagonists Neuropeptide Y Agonists Anti adrenergic Drugs Selective Opioid Agents Substance P Antagonists D Cycloserine NMDA Antagonist (Ketamine) Anticonvulsants BDNF Promoters PTSD.VA.GOV PTSD 101

22 OTHER THERAPIES Meditation Exercise Yoga Acupuncture Animal Therapy Art and Writing Others

23 SUPPORT SYSTEMS FAMILY FRIENDS OTHER VETERANS ORGANIZATIONS HELPING OTHERS SPIRITUALITY

24 VIEWING ISSUES IN NEW LIGHT Viewing TRIGGERS as Manageable Events Redirecting Need for Speed and other Risky Behaviors Viewing Relationships in a New Light Intimacy Children

25 REDEFINING LIFE AFTER PTSD POST PTSD GROWTH Recognizing how others survive Who you are vs. what you do..or did Importance of lifelong growth and learning

26 Co occurring Disorders Treat both disorders Assumption that dealing with one cures the other is not valid Need for support in sobriety One day at a time Medications

27 Suicide Risk Factors Person sees no way out and fears things will get worse Predominant emotions are hopelessness and helplessness Person is anxious, agitated and has insomnia Thinking is constricted with a tendency to persieve situation as all bad Judgement is impaired by use of alcohol or other substances Lack of future orientation Weapons are easily accessible

28 Suicide Prevention Strategies Check for suicidal thinking... Recheck for suicidal thinking Enlist aid of support system Encourage use of VA Suicide Prevention hotline Refer if you are uncomfortable, or want help 28

29 FOR MORE INFORMATION request form.asp TO DOWNLOAD PCL M AND PCP PCL 29