COMBAT PTSDCOMBAT PTSDRecognition and TreatmentRecognition and Treatment

Harry Croft, M.D.Texas Association of Osteopathic Physicians

San Antonio,June, 2012

Research and Speaking Honoraria

Astra ZenecaBoehringer-IngelheimBMSEli LillyForest PharmaceuticalsGSKOtsukaPfizerTakeda

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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.

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• 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

• T5

Why Civilian Physicians Should Care

• PTSD in general population• Returning Veterans – 20% of 5+ million• Vietnam• Middle East

• But what about the VA?– Don’t THEY take care of vets• Not eligible• No desire to go

Recognition of PTSDProblems for Patients and

Families

• Failure to Recognize Symptoms for what they Are

• Incorrectly Ascribe Cause• Myths and Misconception About PTSD• Stigma Surrounding PTSD

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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 affects those in direct combat• 5. Almost everyone deployed to combat zone

comes back with PTSD• PTSD is an “all or none” disorder

PTSD IS.....

• Not just caused by Combat Related Trauma• Not Just a Man’s Problem• Not Just Psychiatric Disorder• Not all deployed to combat area• Not “all or none” • A Psycho-neuro-immunological problem

Recognizing PTSD Problems for Physicians

- Pr

• Patient reports only certain symptoms• Failure to report traumatic experience/ vet• Visit by patient not self motivated

Risks to Military Members More than Just Combat

• Combat• Non-predictable Threats - to even “non-

combatants”• Repeated Deployments• Repeated Separations • Dwell time• Unemployment / finances

Impacts Many Life Areas

• Relationships•Marital, Family, Friends

•EMPLOYMENT/ EDUCATION•Legal Problems•Physical Health•Risk Taking•DESPAIR / SUICIDE

DIAGNOSIS

• STRESSOR• RE-EXPERIENCING• AVOIDANCE• AROUSAL• EMOTIONAL DISTRESS OR LIFE INTERFERENCE

DSM IV

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

CO-OCCURRING CONDITIONS

• DEPRESSION

• ANXIETY DISORDERS– Generalized, Panic, Social Phobia

• SUBSTANCE ABUSE DISORDERS

• OCD VARIANTS

Foundations of 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

PSYCHOTHERAPY

• COGNITIVE-BEHAVIORAL THERAPY– Prolonged Exposure– Cognitive Processing Therapy

• SUPPORTIVE• EMDR• OTHER

MEDICATIONS• ANTI-ADRENERGIC• SSRI and SNRI• MEDS TO AID WITH SLEEP• Other antidepressants• ATYPICAL Antipsychotics• ANTI-EPILEPTICS

• **Avoid BENZODIAZEPINES IF POSSIBLE

NEW MEDICATIONS

• CRF Antagonists• Neuropeptide Y Agonists• Antiadrenergic Drugs• Selective Opiod agents• Substance P Antagonists• D-Cycloserine• NMDA • Anticonvulsants• BDNF promoters

PTSD.VA.GOV PTSD 101

OTHER THERAPIES

• Meditation• Exercise• Yoga• Accupuncture• Animal Therapy• Art and Writing

SUPPORT SYSTEMS

• FAMILY• FRIENDS• OTHER VETERANS• ORGANIZATIONS• HELPING OTHERS• SPIRITUALITY

VIEWING ISSUES IN NEW LIGHT

• Viewing TRIGGERS as Manageable Events• Need for “Speed” and other Risky Behaviors• Viewing Relationships in a New Light– Intimacy– Children

REDEFINING LIFE AFTER PTSDPOST PTSD GROWTH

• Recognizing how others survive• Who you are vs. what you do..or did• Importance of lifelong growth and learning

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

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

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FOR MORE INFORMATION

• www.va.ptsd.gov• www.medscape.com• www.ptsd.va.gov/professional/pages/assessments/ncptsd-

instrument-request-form.asp – TO DOWNLOAD PCL-M AND PCP PCL

• www.mybacktothewall.com