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Presentation for Veteran’s Affairs . Spring 2014 Dr. Jeffrey Ennis. Victoria Cross Recipients. There have been 1351 VC’s given with 96 going to Canadians. Ties to the Military. Argyll and Sutherland Highlanders of Canada. Lieutenant Alexander Roberts Dunn.

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presentation for veteran s affairs

Presentation for Veteran’s Affairs

Spring 2014

Dr. Jeffrey Ennis

victoria cross recipients
Victoria Cross Recipients

There have been 1351 VC’s given with 96 going to Canadians

lieutenant alexander roberts dunn
Lieutenant Alexander Roberts Dunn
  • 1st recipient of the VC in Canada
  • Was in the ‘Charge of the Light Brigade’ in the Crimean War, October 25, 1854
  • For having in the Light Cavalry charge on the 25th October, 1854, saved the life of Serjeant Bentley, 11th Hussars, by cutting down two or three Russian Lancers who were attacking him from the rear, and afterwards cutting down a Russian Hussar, who was attacking Private Levett, 11th Hussars.”
  • - Victoria Cross citation, The London Gazette, February 24, 1857.
my physician qualifications
My Physician Qualifications
  • Masters in Social Work
  • MD (McMaster University)
  • FRCP(C) Psychiatry (McMaster University)
  • Two Years additional training (working under supervision) in the management of chronic noncancer pain
my patient qualifications
My Patient Qualifications
  • Guillain-BarréSyndrome
  • Chronic IdeopathicPolyradiculoneuropathy
  • Connective Tissue Disorder
  • Ehler-Danlos Syndrome
    • 18 Musculoskeletal surgeries
    • 6 to the back including 2 fusions
    • 6 to the knee
    • 6 to the hands
chronic pain epidemiology
Chronic Pain-Epidemiology
  • 38% of institutionalized elderly have chronic noncancer pain (CNCP) compared to 27% who live independently
  • OA affects 1:3 Canadians or 3 million people
  • 8.2% or 1 million Canadians have neuropathic pain
  • Telephone research finds about 25% of the population reports chronic pain (poor response rates)
  • In the US, 15% have LBP on most days for at least a month (no Canadian studies)
  • UK reports 46.5%
impact of cncp
Impact of CNCP
  • Physiologic changes
    • Sleep
    • Cognitive function
    • Sexual function
    • Mood
    • Cardiovascular function
  • Quality of Life
    • Loss of work capacity
    • Loss of role function as parent/spouse/friend
    • Loss of social/recreational activities

Fine PG.. Long-term consequences of chronic pain: mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Med. 2011 Jul;12(7):996-1004.

cncp co morbidities
  • Addiction
    • About 10% will abuse opioids
    • Alcohol
    • About 12% overlap between patients using opioids and ETOH abuse
  • Psychiatric Issues
    • Mood disorder (4 x more prevalent)
    • Anxiety disorders
    • Somaform Disorders
the military experience
The Military Experience
  • Now a Less than 10 % died from wound rate
  • Increase in survival
  • Significant increase in wounded with chronic pain
hampden zane churchill cockburn
Hampden Zane Churchill Cockburn

Born in Toronto, Cockburn served with the Royal Canadian Dragoons in South Africa during the Boer War.

Lieutenant Cockburn, with a handful of men, at a most critical moment held off the Boers to allow the guns to get away; to do so he had to sacrifice himself and his party, all of whom were killed, wounded, or taken prisoners, he himself being slightly wounded.

(London Gazette, no.27307, 23 April 1901)

  • Manage Pain
    • Surgery
    • Intervention
    • Analgesics
    • Other Medication
      • TCA, Anticonvulsant, Gabapentinoids
    • Other Strategies
      • Acupuncture
      • Marijuana
      • Herbal
  • Manage Coping
    • Multidisciplinary Programs
    • Individual Therapy
    • Pharmacotherapy
  • Manage Function
    • Occupational Therapy
    • Multidisciplinary Pain Program
    • Individual Therapy
reduce pain when possible
Reduce Pain When Possible
  • A good physical assessment as well as psychiatric assessment are required
  • Based on assessment, determine what physical treatments can lead to pain reduction
    • Disease management
    • Surgery
    • Medication management
    • Intervention
    • Other modalities
      • acupuncture

Dr. Jeff Ennis -September 2008

management of cncp
Management of CNCP
  • Management is the last option of treatment when sensory discriminative types of treatment have failed.
  • Patients who require rehabilitation have been failed by the medical model
  • Always treat co-morbid psychiatric issues

Dr. Jeff Ennis -September 2008

operant conditioning
Operant Conditioning
  • Classical conditioning forms an association between two stimuli.
  • Operant conditioning forms an association between a behavior and a consequence.
  • Operant conditioning is distinguished from classical conditioning in that operant conditioning deals with the modification of "voluntary behavior" or operant behavior rather than reflex behaviour.
  • Operant behavior "operates" on the environment and is maintained by its consequences

Dr. Jeff Ennis -September 2008

cognitive behavioural therapy cbt
Cognitive Behavioural Therapy (CBT)
  • CBT incorporates principles associated with operant conditioning, information processing and learning theories.
  • A basic assumption of CBT is the recognition that there is a reciprocal relationship between a patient’s cognitive processes, affect, physiology, and behaviour.
  • CBT emphasizes the importance of changing cognitions, affect and behaviors as a way of reducing symptoms and improving the functioning of the affected person.
  • The therapist and the client are active participants in the therapy. The treatment is not driven by an exploration of past events.

Dr. Jeff Ennis -September 2008

  • It is based on the assumption that people believe they cannot function because of their pain and they are helpless to improve their situation. They become depressed and they avoid activity.
    • It is much more than Hurt vs Harm
  • Treatment goals focus on:
    • Examining thoughts (cognitions) and challenging ‘faulty’ thinking
    • Learning alternative behavioural responses (eg relaxation)
    • Altering negative affect
    • Dealing with ‘helplessness’
    • Develop new skills (behaviours) to respond to one’s circumstances in a more adaptive way.

Can J Psych.2008;53(4):213-223

Dr. Jeff Ennis -September 2008

cbt in brief
CBT in Brief
  • A person behaves in a particular way because of what they think and how they feel.
  • A person feels a particular way, because of how they think and behave.
  • A person thinks in a particular way because of how they feel and behave.
  • Thinking, feeling and behaviour are intimately intertwined. By changing one of these variables, the others are affected.

Dr. Jeff Ennis -September 2008

the nuts and bolts
The Nuts and Bolts
  • Change the cognition (thinking)
    • restructuring
    • Identify the patient’s schema
    • Self monitoring
  • Change the affect
    • Medication management (severe mood disorder MUST be treated with medication-this is a standard of practice)
    • psychotherapy
  • Change the behaviour
    • Behavioural Experiments
      • Activation (exercise, socializing, hobbies)
    • Relaxation Skills (do not send patients home with a CD and assume they know how to ‘relax’
      • This changes everything

Dr. Jeff Ennis -September 2008

operant conditioning and cbt
Operant Conditioning and CBT
  • Examine the system for reinforcers of the ‘sick role’/illness behaviours/pain behaviours. Use and ABC chart.

Dr. Jeff Ennis -September 2008

thomas william holmes
Thomas William Holmes
  • Holmes was born in Montreal in 1897, dying in Toronto in 1950. he served with the 4th Canadian Mounted Rifles, Canadian Expeditionary Force.
  • For most conspicuous bravery and resource when the right flank of our attack was held up by heavy machine-gun and rifle fire from a ‘pill-box’ strong point. Heavy casualties were producing a critical situation when Pte. Holmes, on his own initiative and single-handed, ran forward and threw two bombs, killing and wounding the crews of two machine guns. He then returned to his comrades, secured another bomb, and again rushed forward alone under heavy fire and threw the bomb into the entrance of the ‘pill-box,’ causing the nineteen occupants to surrender.
  • By this act of valour at a very critical moment Pte. Holmes undoubtedly cleared the way for the advance of our troops and saved the lives of many of his comrades.”
  • (London Gazette, no.30471, 11 January 1918)
the four steps of cbt
The Four Steps of CBT
  • 1 Education
  • 2 Skill Acquisition
  • (3 Activation)
  • 4 Generalization
  • 5 Maintenance

Can J Psych.2008;53(4):213-223

Dr. Jeff Ennis -September 2008

  • Provide new information about pain and pain management. The hypothesis is that with new information, patients will change their thinking and therefore affect/behaviour.
    • The concept of ‘hurt versus harm’ is an oversimplification of a complex problem and most patients do not buy it. The usual response to this is ‘how would you know’.
    • Topics include:
      • The physiology of pain and chronic pain
      • Medication management
      • Sleep
      • Managing medications
      • Human sexuality
      • productivity

Dr. Jeff Ennis -September 2008

  • Relaxation training is the most common skill
  • Tai Chi
  • Acupressure
  • Self Monitoring and analysis-this is critical
  • Self Hypnosis
  • Remember relaxation skills are important because they provide the patient with an alternative response to pain that is more functional.

Dr. Jeff Ennis -September 2008

  • Help patients develop skills to identify their cognitions (thoughts and beliefs-ABC charting)
  • Help them recognize the relationship between cognition/behaviour/affect/consequence.
  • Help them develop self-monitoring skills
  • Help patients examine their cognitions/develop alternative thoughts and responses

Dr. Jeff Ennis -September 2008

  • Self monitoring is a significant and most difficult skill for patients to develop in Goal attainment scaling. Often, it is their cognitions that are the barriers to goal attainment.

Dr. Jeff Ennis -September 2008

physical activation
Physical Activation
  • Fitness
    • Fitness can reduce deconditioning and pain from weakened muscles. There is no evidence that fitness is a method of pain reduction
    • Fitness is a behavioural experiment.
  • Activity Sessions
    • Cooking
    • Hardware Store
    • Aquatherapy
    • Tai Chi
    • Painting

Dr. Jeff Ennis -September 2008

physical activation1
Physical Activation
  • Pacing skills are an integral part of physical activation.
  • Pacing does not mean doing less
  • Pacing does not mean stopping when you have pain
  • Pacing is learning to make activity not contingent on pain (changing the consequences of pain)
    • Break up an activity into time dependent, do-able components with planned breaks.

Dr. Jeff Ennis -September 2008

physical activation2
Physical Activation
  • Gives patients the opportunity to identify limitations to activity other than pain and develop solutions to these limitations
  • Physical activity can be viewed as behavioural experiments
  • Physical activity provides an opportunity to practice pacing
  • The activity should be easily available and can be tailored to a specific patients capacity
  • Physical activity is gradually increased in a planned way while examining cognition, affect and consequences.

Dr. Jeff Ennis -September 2008

thomas ricketts
Thomas Ricketts

“For most conspicuous bravery and devotion to duty on the 14th October, 1918, during the advance from Ledeghem, when the attack was temporarily held up by heavy hostile fire and the platoon to which he belonged suffered severe casualties from the fire of a battery at point-blank range.

Pte. Ricketts at once volunteered to go forward with his section commander and a Lewis gun to attempt to outflank the battery. Advancing by short rushes under heavy fire from enemy machine guns with the hostile battery, their ammunition was exhausted when still 300 yards from the battery. The enemy, seeing an opportunity to get their field guns away, began to bring up their gun teams. Pte. Ricketts, at once realising the situation, doubled back 100 yards under the heaviest machine-gun fire, procured further ammunition, and dashed back again to the Lewis gun, and by very accurate fire drove the enemy and the gun teams into a farm.

His platoon then advanced without casualties, and captured the four field guns, four machine guns, and eight prisoners.

A fifth field gun was subsequently intercepted by fire and captured.

By his presence of mind in anticipating the enemy intention and his utter disregard of personal safety, Pte. Ricketts secured the further supply of ammunition which directly resulted in these important captures and undoubtedly saved many lives.”

(London Gazette, no.31108, 6 January 1919)

epidemiology of ptsd1
Epidemiology of PTSD
  • Global prevalence rate=1.3-37.4
  • Canadian Lifetime Prevalence Rate=9.2
  • The most common forms of trauma resulting in PTSD included unexpected death of a loved one, sexual assault, and seeing someone badly injured or killed
  • It is associated with high levels of impairment and co-morbidities.
    • Mood disorder
    • Substance abuse
    • Other anxiety disorders

Van Ameringen M1, Mancini C, Patterson B, Boyle MH.. Post-traumatic stress disorder in Canada. CNS NeurosciTher. 2008 Fall;14(3):171-81.

epidemiology of ptsd in the military
Epidemiology of PTSD in the Military
  • A total of approximately 30,000 Canadian service personnel were deployed to Afghanistan. Afghanistan the largest Canadian military operation since the Second World War. One hundred and fifty-eight soldiers and four civilians died, and by the end of 2010, a total of 1,859 military members had been wounded.
  • Serving soldiers have a similar rate of PTSD to the general population
  • The prevalence increases when a soldier enters a war zone
  • The rate among Veterans receiving services from Veterans Affairs is 42.5% (compared to the Canadian average of 9.2%)

Post-traumatic Stress Disorder and the Mental Health of Military Personnel and Veterans. Parliament of Canada.

treatment individual therapy cbt
Treatment-Individual Therapy(CBT)
  • Good evidence to support CBT in the management of PTSD symptoms
    • Outcome is equal to that of exposure therapy
  • With treatment there appears to be no decay in results

Bradley R, Greene J, Russ E, Dutra L, Westen D. A Multidimensional Meta-Analysis of Psychotherapy for PTSD. Am J Psychiatry 2005;162:214-227.

Monson, Candice M.; Schnurr, Paula P.; Resick, Patricia A.; Friedman, Matthew J.; Young-Xu, Yinong; Stevens, Susan P. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, Vol 74(5), Oct 2006, 898-907

Sherman JJ. Effects of psychotherapeutic treatments for PTSD: A meta-analysis of controlled clinical trials. Journal of Traumatic Stress. 1998; 11(3): 413–435.

treatment marital therapy
Treatment-Marital Therapy
  • Secondary traumatization of family members
  • Veterans' numbing/arousal symptoms are predictive of family distress
  • Veterans' anger is also associated with troubled family relationships and secondary traumatization
  • Intervention should focus on two areas
    • Reducing the veteran’s symptoms and improving the family relationships
    • Improving the psychological wellbeing of family members
treatment marital con t
Treatment-Marital Con’t
  • When treating symptoms marital therapy should address the PTSD triad of reexperiencing, avoidance, and arousal
    • Examine the relationship consequences of each behaviour
  • Evidence for ‘Strategic Therapy’ (the Work of Haley and Madones)

Monson CM, Taft CT, Fredman SJ. Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clinical Psychology Review. 2009; 29(8):707-714.

Galovskia T. Psychological sequelae of combat violence: A review of the impact of PTSD on the veteran's family and possible interventions.

Sherman MD, Zanotti DK, Jones DE. Key Elements in Couples Therapy With Veterans With Combat-Related Posttraumatic Stress Disorder. Professional Psychology: Research and Practice. 2005;36(6):626-633.

Sautter F. et. al. A Couple-Based Approach to the Reduction of PTSD Avoidance Symptoms: Preliminary Findings. Journal of Marital and Family Therapy. 2009; 35(3): 343-349

treatment activation
  • Use of Model that is the basis of the pain program
  • Psychotherapy and maritial therapy are not enough
  • Significant gains reported
  • Maintained at 3 month follow-up

Jakupcak M. et. al. A pilot study of behavioral activation for veterans with posttraumatic stress disorder. 2006; 19(3): 387-391.

Jakupcak M. et. al. Behavioral activation as a primary care-based treatment for PTSD and depression among returning veterans. Journal of Traumatic Stress. 2010; 23(4): 491-495

Wagner Aw. et. al. Behavioral Activation as an Early Intervention for Posttraumatic Stress Disorder and Depression Among Physically Injured Trauma Survivors. • Cognitive and Behavioral Practice. 2007; 14(4): 341-349

treatment plan
Treatment Plan

Intake Assessment

-Medication Management




Activation Group




ian willoughby bazalgette
Ian Willoughby Bazalgette

August 4, 1944-Squadron Leader Bazalgette was "Master bomber" of a Pathfinder Squadron detailed to mark an important target for the main bomber force. When nearing the target his Lancaster was seriously damaged and set on fire by anti-aircraft fire; the bomb aimer was badly wounded. As the deputy "Master bomber" had already been shot down, the success of the attack depended on Squadron Leader Bazalgette who despite appalling conditions in his burning aircraft pressed on gallantly, bombed, and marked the target accurately. That the attack was successful was due to his magnificent effort. The condition of the aircraft had by now become so bad that Squadron Leader Bazalgette ordered his crew to leave the aircraft by parachute. He attempted the almost hopeless task of landing the crippled and blazing aircraft to save the wounded bomb aimer, and one air-gunner, who had been overcome by fumes. With superb skill and taking great care to avoid a French village, be brought the aircraft safely down. Unfortunately it then exploded and this gallant officer and his two comrades perished.