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A Biopsychosocial Approach With Traumatically Hospitalized Injured Soldiers . H. J. Wain Ph.D Chief, Psychiatry Consultation Liaison Service Department of Psychiatry, WRAMC Professor in Dept. of Psychiatry, USUHS. PCLS. Mission

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A Biopsychosocial Approach With Traumatically Hospitalized Injured Soldiers

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A biopsychosocial approach with traumatically hospitalized injured soldiers l.jpg

A Biopsychosocial Approach With Traumatically Hospitalized Injured Soldiers

H. J. Wain Ph.D

Chief, Psychiatry Consultation Liaison Service

Department of Psychiatry, WRAMC

Professor in Dept. of Psychiatry, USUHS

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  • Mission

    • Military- prepare hospital staff and trainees for wartime scenarios/casualties

    • Consultation- evaluation, diagnosis, treatment of mental illness in medical-surgical patients

    • Liaison- education of non-psychiatric peers in psychological issues of their patients and wards

    • Research- add to literature in primary and tertiary care re psychiatric issues in med-surgical patients

    • GME- psychiatric and non-psychiatric

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Immediate Results of Trauma

  • Nearly all survivors exposed to traumatic events briefly exhibit one or more stress related symptoms. In many instances these symptoms dissipate within a reasonable period of time. Morgan, et.al, 2003

  • 20-40% of patients followed 1 year after trauma had a psychiatric disorder. O Donnel et.al. 2004

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Recognized body Losses

Comments of soldiers


Body parts


Separation anxiety

Survivor guilt

Shooting or not?

Previous trauma’s

Inaccurate judgement

Medical Event

Trauma Stimuli

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Repsonses to Combat

  • Fear

  • Persistent Threats

  • Anxiety

  • Vigilance

  • Sleep deprivation

  • Sympathetic Discharge

  • Self Inflicted wounds -simulation

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Concerns about families

Need to maintain alertness





Cognitive Distortion



Responses to Injury

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Stresses On Injured And Amputees

  • Surgical revisions of infected stumps

  • Painful stumps-Phantom Limb

  • Poor locomotion and balance

  • Dexterity

  • Acceptance-Rejection

  • Body Image

  • Sexual ability

  • Finances-Vocation

  • Family Issues

  • Educational Opportunities

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  • Physical Limitations

  • Altered body image

  • Lowered self esteem

  • Alterations of personal experiences

  • Social Stigma

  • Meaning of Loss

  • Severity of disability varies BKA<AKA<Hand<ARM<HID

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Individual Soldier’s Responses

  • “I only felt flesh”

  • “I don’t want to bleed to death in this hum vee”

  • “I felt no leg so I picked it up and held it together to my bone”

  • “I couldn’t believe my arm was gone I was just holding something”

  • “Are they Still there?”

  • “My Sgt. brought me here and he was standing with the medic and he just fell over. Damn them they missed it.”

  • “I thought I was going to bleed to death”.

  • “I thanked G-D over and over again that he spared me especially when I see the others just trying to breathe to live, I can live without the leg”

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What Have We Learned To Attempt To Prevent or Decrease Chronic Disabling Psychiatric Stress Disorders Following Tauma?

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  • Lessons learned from Vietnam, Somalia, Kenya

  • Blackhawk down

  • Gulf war operations

  • Traditional debriefing not effective with medical surgical hospitalized injuries

  • Arlington Hospital Center Washington Hospital Center-WRAMC

  • Willingness to talk with psychiatry

    • Sense of relief after visits

    • Follow-up

  • Empathic Exposure to Trauma< later occurrences

  • Relationships with patient helpful while going through crises and in follow up

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    Preventive Medical Psychiatry (PMP)

    • In order to avoid the stigma associated with a psychiatric evaluation PCLS developed a new designation for intervention with OEF and OIF, we became PMP

    • Patients are routinely seen without a formal consult

    • Notes are written under PMP

    Role of pcls pmp l.jpg

    Foster acceptance of MH

    Decrease stigmatization

    Some duplicity always looking for dx,symp.tx

    Use biopsychosocial app

    Develop Relationship with patients

    Utilize TIPPS approach

    Meet The Pt. Where They are:

    - Facilitate medical tx

    Advocate for pt. needs

    Flexible eval. and tx.

    Re enforce pts adaptive


    < of disabling PTSD-chronic somatization and other psychiatric dx

    Liaison with and educate medical staff

    Support staff and families

    All patients, are seen as early as possible

    Sedated and ventilated patients see families

    - Educate pts. and staff

    . Research

    Role of PCLS (PMP)

    A biopsychosocial approach l.jpg

    A BioPsychoSocial Approach

    Components of therapeutic intervention and prevention of chronic psychiatric stress disorders tipps l.jpg

    Therapeutic Alliance conversational tone, empathy, Humor

    Timing of Intervention


    Mechanism of change





    Cognitive Reframing


    Meet The patient…....

    Empathic Exposure

    Reinforce Assets

    Personality Style

    Healthy Defenses

    Components of Therapeutic Intervention and Prevention of Chronic Psychiatric Stress Disorders (TIPPS)

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    TIPPS continued

    • Hypnosis

    • Pharmacology

    • Management

    • Education

    • Families

    • Staff

    • Command

    • BioPsychoSocial Formulation

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    Flexibility is needed

    Expect the unexpected

    Help anchor

    Keep listening


    Be aware of transference issues

    Be aware of counter transference issues

    Think about their trauma

    Avoid pathologizing



    Approaches That Facilitate T.I.P.P.S.

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    • Psychotherapy-Empathic Exposure-cognitive reframing-hypnotic

    • Hypnotic Techniques

    • Groups-patients-families

    • Pharmacotherapy

    • Follow ups

    • Numbers for prosthetists

    • Phone calls post discharge

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    Families they left behind in Iraq-States



    Startle response

    Others’ perceptions

    Sexual concerns

    Vocational concerns

    Reserves-Nat Guard-Active Duty

    Prolonged hospitalization

    Frequent surgeries


    Changes, some warmer more responsive-critical

    Specialized treatments

    Pre morbid styles

    Hierarchy of patients

    Appreciation for treatments

    Themes in some groups

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    Individual Approaches

    Groups for family

    Groups for spouses

    CAPS sees children

    Meetings with administrators and hospital leadership

    Case Conferences

    Grand Rounds

    Questions about friends and kids


    Change of shift grps

    Suggestions for coping

    Phone Numbers

    Support For Medical Staff and Patient Families

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    Follow up and Disposition

    • PMP becomes advocate for Pts and families

    • Upon discharge each pt receives phone number to call when leaving hospital grounds

    • Patients are contacted 30, 90 and 180 days after leaving hospital

    • Families are given our phone numbers

    • Satisfaction

    • Referrals to Mental health resources within pts community

    • Crises management via telephone

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    H. Wain Ph.D, Chief

    G. Grammer MD Asst Ch.

    5 Housestaff MD

    1 Psychology Resident

    P. Martinez RN

    C. Miller MSW

    J. Stasinos MD##

    D. Cotter MD##

    E. McLaughlin RN ##

    M. Oleshansky MD

    I. Janke MD

    S. Moran MD

    R. Kogan MSW

    R. Ansong

    A. Arjona

    C. Deboer


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    A Key Point From Research

    • Preliminary results from PDHAT suggest that although psychiatric symptoms among these injured soldiers rose during the six month follow-up period, overall the rates remained lower than what has been documented in other studies (e.g. Hoge et al., NEJM, 2004))

    • Injured soldiers usually have higher psychiatric symptoms than non-injured,

      “therefore these results are very encouraging and suggests that the preventive psychiatry program (TIPPS) at WRAMC may be effective in preventing or decreasing long term severity and chronicity in this high risk group” (Hogue)

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    • First Mental Health Service To See Every Hospitalized Traumatically Injured Patient Without A Formal Consult

    • Approximately 1125 patients have been seen

    • Reduced need for emergency psychiatric intervention

    • Therapeutic Alliance emphasized

    • Empathic exposure repeated individually and in group

    • Normalization and Cognitive reframing used regularly

    • Hypnotic-relaxation techniques utilized

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    Conclusions Continued

    • Pharmacology used in conjunction with a variety of adjunctive treatments

    • Need for early involvement with trauma team

    • Contacts with Treatment team and nursing staff maintained

    • Contact with Command imperative

    • Use of PDHAT helps with follow up and screening

    • Over 1300 pt contacts per month

    • Need to measure what we have impacted

    • The Learning Never Stops

    • “Every Day Above Ground Is A Holiday”

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