1. 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
2. Map of Ohio Deployment
3. Health concerns of War and re-entry home
Every War has its own:
4. Vietnam SCI – establishment of SCI research
Agent Orange – Cancer, DM, Neuropathy, TBI?
Drugs of choice – Downers: Heroin; Marijuana; ETOH
5. Gulf War – ALS -
1. Incidence – 1.6 X general population.
2. Etiology – Sarin? Pesticides?
6. OIF/OEF – TBI/multiple amputations
1. ARMOR – more survive, but multiple amputations; severe burns
Drugs of choice – Uppers:
methamphetamine, caffeine, cocaine
National Council on Disability: March 2009
Established the HALLMARK pathologies of
Operation Iraqi Freedom
Operation Enduring Freedom
8. 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
TBI Incidence Disputed by HOGE – NEJM
9. 25% - Women Report Sexual Abuse
TRIAD: TBI, PTSD, PAIN
current rates highest in 2 decades
Note: National Guard; Reserves omitted
Every Day 18 6500/yr.
10. 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.
11. HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterations
b. Hyperacusis –
c. Sensory overload – ie., Meijer Syndrome
2. Loss of Mapping skills.
12. CAFFEINE CONTENT of DRINKS Adding 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
13. BONUS Drink Include: RED BULL - 80 mg/Phenylalanine
Red BULL - Germany – Cocaine
Long term increased ingestion of caffeine may deplete cortisol/adrenalin
14. Diagnosis of TBI
Listen to the Patient: He is telling you the diagnosis.
Sir William Osler
TBI Diagnosed by HISTORY.
15. Radiologic Studies: Timing/Technique
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;
ESR, Tox screen.
Do NOT miss Dx. Of hypopituitarism which mimics depression.
17. 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
18. Posttraumatic Stress Disorder
19. Formerly Called Traumatic War Neurosis
20. 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)
21. 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)
22. 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
23. 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
24. Two routes for processing danger (Pinel, 2000)
25. Advantages of subcortical method Quicker
Leap, then think
Ready for “flight or fight”
Looking for the enemy
26. Advantages of cortical method Slower
Time to think and process information
Decide that stimulus is not a risk
More suited to common life situations
27. 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)
28. 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)
29. 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
30. 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
31. Increased Arousal (Sympathetic Nervous Activation) Difficulty falling or staying asleep
Irritability or outbursts of anger
Exaggerated startle response
32. 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”)
Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
33. Comorbidities (DSM-IV) Major Depressive Disorder
Generalized Anxiety Disorder
Dysfunction in relationships, marriage, work, school
34. Suicide 2nd leading cause of death in military
Young, White, Unmarried Male Junior Enlisted Active Duty
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)
35. Suicide – Dr. Thomas Joiner – Why People Die By Suicide 2005
3. Feeling of burdensomeness.
36. A.C.E. Ask
37. “MUSH” Syndrome Hard to differentiate mild TBI from PTSD
Sometimes both present
Psychological factors may lead to maintenance of TBI symptoms and medical issues may lead to maintenance of psychological factors
38. Symptoms more consistent with PTSD Flashbacks
Exaggerated startle response
39. HALLMARKS of TBI – midbrain/frontal injuries 1. Sensory processing alterations?
b. Hyperacusis –
c. Sensory overload – ie., Meijer Syndrome?
2. Loss of Mapping skills.
40. PTSD Psychopharmacology
41. 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)
42. Prolonged Exposure In vivo exposure
Exposing oneself to fearful situations, people, places
Telling the story of the trauma in session and listening to the session on tape
Remove avoidance and symptoms will not be maintained (Foa, Hembree, & Rothbaum, 2007).
43. TREATMENT options for TBI:
Amantadine, Ritalin, Dexedrine- for processing
Inderal, Elavil – for post concussive
Electronic aides – Bushnell GPS, PDA, iPHONE
Setting modifications or organization
Memory strategies (chunking, acronyms, music)
Pain management as needed
44. Adjunctive Treatment Service
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
Adequate, restful sleep
45. TBI & PTSD Team Primary care physician/specialist
“We can’t all be heroes, because somebody has to sit on the curb and applaud when they go by.”
– Will Rogers
47. Health care providers to get involved -
2. Sliding fee schedule $5 - $10
3. Volunteer for Yellow Ribbon events
4. Be vigilant in your community
48. 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)
Military Family Life Consultant (614-336-7479 and 614-336-1413)
49. 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