A biopsychosocial approach with traumatically hospitalized injured soldiers
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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 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


Slide2 l.jpg
PCLS Injured Soldiers

  • 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 Injured Soldiers

  • 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


Trauma stimuli l.jpg

Explosives Injured Soldiers

Gunshots

Blood

Immobility

Recognized body Losses

Comments of soldiers

Death-Bodies

Body parts

Observation-witness

Separation anxiety

Survivor guilt

Shooting or not?

Previous trauma’s

Inaccurate judgement

Medical Event

Trauma Stimuli


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Repsonses to Combat Injured Soldiers

  • Fear

  • Persistent Threats

  • Anxiety

  • Vigilance

  • Sleep deprivation

  • Sympathetic Discharge

  • Self Inflicted wounds -simulation


Responses to injury l.jpg

Fear Injured Soldiers

Worry-Existential

Disbelief

Prayer

Rage

Anticipation

Concerns about families

Need to maintain alertness

Dissociation

Regression

Denial

Anxiety

Cognitive Distortion

Grief

Anger

Responses to Injury


Stresses on injured and amputees l.jpg
Stresses On Injured And Amputees Injured Soldiers

  • 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


Amputees l.jpg
Amputees Injured Soldiers

  • 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


Individual soldier s responses l.jpg
Individual Soldier’s Responses Injured Soldiers

  • “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?


Bookmarks l.jpg
Bookmarks Chronic Disabling Psychiatric Stress Disorders Following Tauma?

  • 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


  • Preventive medical psychiatry pmp l.jpg
    Preventive Medical Psychiatry (PMP) Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    • 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 Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    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

    behavior

    < 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 Chronic Disabling Psychiatric Stress Disorders Following Tauma?


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

    Therapeutic Alliance conversational tone, empathy, Humor Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    Timing of Intervention

    Psychotherapy

    Mechanism of change

    Internalization

    Support

    Normalization

    Psychotherapy

    Cognitive Reframing

    Empathy-Genuiness

    Meet The patient…....

    Empathic Exposure

    Reinforce Assets

    Personality Style

    Healthy Defenses

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


    Tipps continued l.jpg
    TIPPS continued Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    • Hypnosis

    • Pharmacology

    • Management

    • Education

    • Families

    • Staff

    • Command

    • BioPsychoSocial Formulation


    Approaches that facilitate t i p p s l.jpg

    Flexibility is needed Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    Expect the unexpected

    Help anchor

    Keep listening

    Observe

    Be aware of transference issues

    Be aware of counter transference issues

    Think about their trauma

    Avoid pathologizing

    Normalize

    Stabilize

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


    Treatments l.jpg
    Treatments Chronic Disabling Psychiatric Stress Disorders Following Tauma?

    • Psychotherapy-Empathic Exposure-cognitive reframing-hypnotic

    • Hypnotic Techniques

    • Groups-patients-families

    • Pharmacotherapy

    • Follow ups

    • Numbers for prosthetists

    • Phone calls post discharge


    Themes in some groups l.jpg

    Families they left behind in Iraq-States

    Anger

    Boards

    Startle response

    Others’ perceptions

    Sexual concerns

    Vocational concerns

    Reserves-Nat Guard-Active Duty

    Prolonged hospitalization

    Frequent surgeries

    Pain-Sleep

    Changes, some warmer more responsive-critical

    Specialized treatments

    Pre morbid styles

    Hierarchy of patients

    Appreciation for treatments

    Themes in some groups


    Support for medical staff and patient families l.jpg

    Individual Approaches Iraq-States

    Groups for family

    Groups for spouses

    CAPS sees children

    Meetings with administrators and hospital leadership

    Case Conferences

    Grand Rounds

    Questions about friends and kids

    E-mail

    Change of shift grps

    Suggestions for coping

    Phone Numbers

    Support For Medical Staff and Patient Families


    Follow up and disposition l.jpg
    Follow up and Disposition Iraq-States

    • 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


    Pcls staff l.jpg

    H. Wain Ph.D, Chief Iraq-States

    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

    PCLS STAFF


    A key point from research l.jpg
    A Key Point From Research Iraq-States

    • 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)


    Conclusions l.jpg
    Conclusions Iraq-States

    • 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


    Conclusions continued l.jpg
    Conclusions Continued Iraq-States

    • 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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