Combat Related Stress Disorders

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Combat Related Stress Disorders

• Differential Diagnosis of PTSD and Treatment
  Options
• Feb. 20, 2008
• Paul Rentz, Ph.D.

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PTSD Frequent at VA (DoseResponse)
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Adverse Psychological Outcomes of War ?? PTSD ??
Depression ?? Substance Abuse ?? Marital Problems
(Divorce rate reported high) ?? Temper/Anger ??
Psychoses ?? Head Injuries ?? Neurotox
Exposures ?? Physical Injuries Pain
Rehabilitation Efforts Health Promotion
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Whats Normal and Whats Not?

• BehaviorF (Person, Environment)
• Normal Readjustment
• Most will go through some difficulties the first
  few months upon return
• Spouse/Significant other/Kids
• Readjust to garrison work / Change in
  responsibilities
• General malaise or decrease in motivation
• Dont expect the credit you think you deserve
• Everyone adjusts differently at their own pace
  flexibility is advised
• Although there will be some difficulties, serious
  problems will not necessarily occur

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Whats Normal and Whats Not?

• Operational Fatigue
• Upon return, service member may experience some
  of these normal responses to operational stress
• Sense of restlessness or boredom arousal or
  sensation seeking behavior
• Some decreases in motivation, avoidance of some
  responsibilities, mildly depressed mood, mission
  letdown
• Irritability or less frustration tolerance
• Sleep disruption for a period effects
  mood-outlook
• General medical complaints (fatigue, soreness,
  GI)
• Startle responses re-acclimatizing or
  re-learning

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Problematic Stress Responses KEY SHIFTS

• O1 X O2 Model of Causality
• Mental
• Poor concentration (forgetful, dissociating,
  vacant stare)
• Apathy (verbalized or seen through
  self-neglect)
• Declining performance (change from baseline,
  poor judgments)
• Indecision / Mental Paralysis (slowed
  thinking, less expressive)
• Emotional
• Irritability (out of place rage,
  hyper-vigilance, jumpiness)
• Depression (guilt, apathy, hopelessness,
  emotional numbing)
• Isolating Self / Detachment (no one else can
  understand)
• Loss of Confidence (in self, unit, mission)
• Prolonged Anxiety/Vulnerability

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Whats Normal and Whats Not?

• Problematic Stress Responses Are Treated as
  Misconduct
• Reckless driving / excessive speeding / DUIs
• Misuse or abuse of alcohol and substances
• Domestic Violence or abuse of family members
• Sexual misconduct
• Unauthorized Absence
• Malingering

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Why Dont More Soldiers Seek Help?

• Stigma
• I would be seen as weak 66
• Leadership would treat me differently 57
• My unit will have less confidence in me 59
• It would harm my career 47
• My leaders discourage the use of mental health
  19
• Access Problems noted (Mental Health/Command
  USMC)

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Exposure Based Risk Factors (pre-morbid,
post-event risks) ?? Life threatening
danger/physical harm ?? Grotesque death and
dismemberment ?? Extreme violence and
destruction ?? Malevolent environment ?? Duration
of exposure ?? Loss of home, neighborhood,
community King, King, Fairbank, Keane, Foy (1999)
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Basic Stress of Deployment
Warzone Stress PTSD Hoge, et al. (2004)
NEJM Examined MH in Army and Marines OEF and
OIF Active Duty Military 9 MH Prior to War
Exposure 11-18 MH DX Post Deployment PTSD
increased as Firefight Exposure Increased
(doseresponse) fire fights 4.5, 9.3,
12.7, 19.3
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Post Deployment Health ?? Population based study
of Army Marines ?? OEF16,318 OIF220,620
Other64,967 ?? PTSD, Depression, Other,
Utilization Rates ?? May 2003-April 2004. ??
Results OIF 19.1 OEF 11.3 Other 8.5 ?? 35
used Mental Health Services 2006 still have Vietnam era vets trickling
in for first complaint of PTSD
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Needs in MH Delivery Systems ?? Integration of
VA-DOD Medical Care (NG Reserve) ?? Further
Development of Shared Guidelines ?? Increased
Focus on Families/Couples ?? Focus on Work and
Rehabilitation ?? MH Focus in Primary Care ??
Internet Based Treatments ?? Widespread Adoption
of Telehealth
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Some Component Areas of Assessment (Ruzek)

• Identification of triggers
• What stimuli set off the problem emotions and
  behaviors?
• Description of response
• What exactly does the person do and experience?
• Including cognitive, behavior, physiological
  response channels
• Identification of consequences
• What happens after the symptoms and behaviors?
• What is happening with other people in the
  situation?

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How Coping?
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Differential Diagnosis

• ACUTE STRESS DISORDER
• PTSD 1 month
• ADJUSTMENT DISORDER
• BRIEF REACTIVE PSYCHOSIS
• ALCOHOL, SEX, GAMBLING, ETC.
• PREMORBID CONDITIONS

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Prominent Symptoms of PTSD ?? Anxiety ??
Depression ?? Anger Hostility ?? Memory,
Concentration Attention ?? Sleep
Difficulties ?? Interpersonal Difficulties
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The current criteria for PTSD

• A Stressor Criterion ( Q.- Worse event?)
• B Reexperiencing
• C Avoidance
• D Arousal
• E Time Criterion 1 month
• F Functional Impairment or Distress 3 areas

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Components of PTSD
Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Anhedonia/Numbing Social
withdrawal Behavioral inhibition
Intrusions
Emotions/ Arousal
Cognitions
Escape/Avoidance
Core Symptom Clusters
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Symptom Criteria for PTSD
Flashbacks
Avoidance
Reexperiencing
Thoughts, feelings conversations
Distressing recollections
Activities/Places/People
Dreams
Amnesia
Physiological reactivity
Detachment
Loss of interest
1
3
Psychological distress w/ reminders
Restricted affect
PTSD
Foreshortened future
2
P T S D
ost
raumatic
Sleep difficulties
Hypervigilance
tress
Irritability anger
Startle
isorder
Arousal
Concentration
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Think of PTSD as a failure to recover from a
traumatic event.
If the event is severe enough, nearly everyone
will have symptoms reflective of PTSD. (Normal
Reaction to Abnormal Event) BF(P,E).

• Lets start with the most homogeneous
• severe event
• rape

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Normal Recovery
2
2
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Rothbaum et al
Resick et al.
Riggs et al.
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PTSD Among Rape Victims
Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock,
T. Walsh, W. (1992). A prospective examination
of posttraumatic stress disorder in rape victims.
Journal of Traumatic Stress, 5, 455-475.
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1. Intrusive Images and Sensations
Sensory memories
Intrusions
Images
Nightmares
Flashbacks
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2. Cognitions and Cognitive Processes
Cognitions
Intrusions
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3. Negative Affect and Hyperarousal
Intrusions
Fear
Sadness
Emotions/Arousal
disgust
Anger
Cognitions
Hyperarousal
Startle
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In normal recovery, intrusions and emotions
decrease over time and no longer trigger each
other
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However, in those who dont recover, strong
negative affect leads to escape avoidance
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4. Avoidance

• Research supports association of a range of
  behaviors with affect/tension reduction
  (short-term)
• Substance abuse (Kilpatrick et al. 1997 Nishith
  et al. 2001)
• Binging (Agras Telch, 1998 Cools et al. 1992
  Polivy et al. 1994)
• Self-injury (Briere Gil, 1998 Favazza
  Conterio, 1989)
• Dissociation (Bonanno et al. 2003 Feeney et al.
  2000)
• Social withdrawal (Riggs et al. 1998 Ruscio et
  al. 2002)

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Avoidance Criterion

• This list is not exhaustive
• Any behavior that functions to escape/avoid
  negative trauma-related emotion meets the
  criterion

Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Emotional
suppression Social withdrawal Behavioral
inhibition Somatic complaints
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Very Successful Avoidance Chronic Subthreshold
PTSD
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Mediators and Moderators
E V E N T
Nature Nurture Demos Events
Intrusions
Emotions/ Arousal
Escape/Avoidance
Cognitions
Post trauma environmental factors Social support
(/-) Resource strain/loss Externally imposed
inhibition of processing
Pretrauma
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Simple Versus Complex PTSD
Externalizing
Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Anhedonia/Numbing Social
Withdrawal Behavioral Inhibition
Intrusions
Emotions/ Arousal
Simple
Cognitions
Internalizing
Core Reactions
Escape/Avoidance
Simple vs Complex PTSD
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Developing Axis I and Axis II Comorbid Disorders
SUD Cluster B Bulimia ADHD
Externalizing
Intrusions
Fear Anxiety Disorders, Avoidant-PD
Emotions/ Arousal
Avoidance
Simple
Cognitions
Anxious Misery MDD GAD Schizoid Somatization
Internalizing
Core Reactions
Escape/Avoidance
Simple vs Complex PTSD
Comorbid Axis 1 or Axis 2 Disorders
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Two examples

• and why they look so different
• Jim was physically abused by his father as a
  child. He tended to blame other people for his
  problems and began drinking with friends in
  adolescence.
• Jen had an episode of depression in her early
  20s. She grew up thinking that when things went
  wrong, it must have been her fault.
• Both of them were victims of MST.

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Jim
SUD Cluster B Bulimia ADHD
Abuse
Externalizing
Aggresssion Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Numbing/Anhedonia Social
withdrawal Behavioral inhibition
Angry
Fear Anxiety Disorders, Avoidant-PD
Intrusions
Emotions/ Arousal
Simple
Others bad
Cognitions
Anxious Misery MDD GAD Schizoid Somatization
Internalizing
External-
Comorbid Axis 1 or Axis 2 Disorders
Escape/Avoidance
Simple vs Complex PTSD
Core Reactions
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Jen
SUD Cluster B Bulimia ADHD
Abuse
Sad, guilt
Externalizing
Aggresssion Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Numbing/Anhedonia Social
withdrawal Behavioral inhibition
Intrusions
Fear Anxiety Disorders, Avoidant-PD
Emotions/ Arousal
Im bad
Simple
Cognitions
Anxious Misery MDD GAD Schizoid Somatization
Internalizing
Internal-
Comorbid Axis 1 or Axis 2 Disorders
Core Reactions
Escape/Avoidance
Simple vs Complex PTSD
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PTSD as a Mediator
SUD Cluster B Bulimia ADHD
Externalizing
Health Social Family Work
Simple PTSD
Intrusions
Fear Anxiety Disorders, Avoidant-PD
Avoidance
Emotions/ Arousal
Cognitions
Anxious Misery MDD GAD Schizoid Somatization
Internalizing
Escape/Avoidance
Functional Outcomes
Simple vs. Complex PTSD
Core Reactions
Comorbid Axis 1 or Axis 2 Disorders
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Treatment of PTSD
Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Anhedonia/Numbing Social
withdrawal Behavioral inhibition
Intrusions
Emotions/ Arousal
Cognitions
Escape/Avoidance
Core Symptom Clusters
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1. Prevent Avoidance
Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Anhedonia/numbing Social
withdrawal Behavioral inhibition
Intrusions
Emotions/ Arousal
Cognitions
Core Symptom Clusters
Escape/Avoidance
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2. Intervene into One or More of Core Symptom
Clusters
Nightmare rescripting
MEDs
Aggression Self-harm behaviors Substance
abuse Binging Cognitive avoidance Behavioral
avoidance Dissociation Anhedonia/numbing Social
withdrawal Behavioral inhibition
PE
Intrusions
Emotions/ Arousal
Cognitions
CT
EMDR
CPT
Escape/Avoidance
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CAPS Diagnosis Pre- and Post-treatment (Treatment
Completers)
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Assimilation

• Traumatic event is remembered differently to
  preserve original beliefs and assumptions
• Modified memory of the traumatic event doesnt
  fit with emotions experienced
• Creates disconnect between the memories and the
  emotions

Original Belief RapeStranger
Traumatic Event Raped by friend
Assimilation Misunderstanding
Undoing and Self-Blame
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Over-accommodation

• Overall beliefs and assumptions about self and
  the world change too much following the traumatic
  event and are no longer accurate

Original Belief WorldSafe
Traumatic Event Assaulted
Over-accommodation WorldDangerous
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A-B-C Sheet
Date ___________
patient ______ Mr.A ACTIVATING EVENT
BELIEF CONSEQUENCE A B
C
Something happens I
tell myself something I feel
something  
  Is it reasonable to tell yourself B above?
_____________________ ____________________________
_________________________________________ What
can you tell yourself on such occasions in the
future? ___________________________ ______________
____________________________________
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A-B-C Sheet

Date ___________ patient ____ Mr.
B___ ACTIVATING EVENT BELIEF
CONSEQUENCE A B
C Something happens
I tell myself something
I feel something  
  Is it realistic to tell yourself B above?
_No. I did what I could to save her.____ What
can you tell yourself on such occasions in the
future? It wasnt my fault. I did the best I
could for her.
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Challenging Beliefs Worksheet
Jumping to conclusions Exaggerating or
minimizing Disregarding important aspects
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Shattered Assumptions

• Beliefs related to Self, Other, World
• Belief you can protect yourself from harm and
  have some control over events.
• Associated symptoms include anxiety, intrusive
  thoughts about danger, irritability, startle
  responses, intense fears about future dangers.

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Shattered Assumptions

• Beliefs related to Others
• Belief about dangerousness of other people and
  expectancies about the intent of others to cause
  harm, injury, or loss.
• Symptoms include avoidant or phobic responses,
  social withdrawal.

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Practical Skill Exercise Connecting with Self,
Peers Veterans

• Are you feeling _X___
• Because youre valued/needing __Y_?

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needs inventory
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Acceptance Commitment Theory (Hayes)
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CBT A Complex Tool
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WHEN TO REFER?

• WHEN IN DOUBT REFER
• Benefits of Prevention
• Inadequate Treatment Efforts in Past
• Permanent Disability Track
• Recovery ModelNew Paradigm of VA
• B.I.C.E.P.S. Model---Brevity, Immediacy,
  Centrality, Expectancy, Proximity, Success.

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Referral Resources

• Chaplain Ministry of Presence
• VA Hospital MHC
• CBOC
• Vets Center
• Tri-Care
• Community Mental Health Centers
• 12 Step groups
• Vet-to-Vet program