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

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PCLS

• 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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Trauma Stimuli

• Explosives
• Gunshots
• Blood
• Immobility
• Recognized body Losses
• Comments of soldiers
• Death-Bodies
• Body parts

• Observation-witness
• Separation anxiety
• Survivor guilt
• Shooting or not?
• Previous traumas
• Inaccurate judgement
• Medical Event

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Repsonses to Combat

• Fear
• Persistent Threats
• Anxiety
• Vigilance
• Sleep deprivation
• Sympathetic Discharge
• Self Inflicted wounds -simulation

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Responses to Injury

• Fear
• Worry-Existential
• Disbelief
• Prayer
• Rage
• Anticipation
• Concerns about families
• Need to maintain alertness

• Dissociation
• Regression
• Denial
• Anxiety
• Cognitive Distortion
• Grief
• Anger

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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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Amputees

• Physical Limitations
• Altered body image
• Lowered self esteem
• Alterations of personal experiences
• Social Stigma
• Meaning of Loss
• Severity of disability varies BKAltAKAltHandltARMltHID
  

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Individual Soldiers Responses

• I only felt flesh
• I dont 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 couldnt 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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Bookmarks

• 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 Traumalt 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

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Role of PCLS (PMP)

• Re enforce pts adaptive
• behavior
• lt 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

• 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.

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

• Psychotherapy
• Cognitive Reframing
• Empathy-Genuiness
• Meet The patient....
• Empathic Exposure
• Reinforce Assets
• Personality Style
• Healthy Defenses

• Therapeutic Alliance conversational tone,
  empathy, Humor
• Timing of Intervention
• Psychotherapy
• Mechanism of change
• Internalization
• Support
• Normalization

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TIPPS continued

• Hypnosis
• Pharmacology
• Management
• Education
• Families
• Staff
• Command
• BioPsychoSocial Formulation

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

• Flexibility is needed
• 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

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Treatments

• 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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Themes in some groups

• 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

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Support For Medical Staff and Patient Families

• 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
• E-mail
• Change of shift grps
• Suggestions for coping
• Phone Numbers

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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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PCLS STAFF

• 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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Conclusions

• 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