CARING FOR VETERANS WITH “INVISIBLE”

WOUNDS: PTSD,TBI & EARLY-ONSET DEMENTIA

Adam E. Perrin, M.D.

Gatekeeper National Conference May 14, 2015

OBJECTIVES

Reveal current toll of PTSD/TBI

Define PTSD: history in combat, the LFI story

Discuss TBI and its link to dementia

Discuss PTSD and its link to dementia

Review recent trends in treatment

Promote post-deployment care

Discuss how to claim Vet Dementia Benefits

Review best available resources

PREVALENCE OF PTSD: FAR MORE COMMON

THAN PHYSICAL WOUNDS

Studies demonstrate that roughly 20% of Iraq and Afghanistan veterans have PTSD and/or Depression (# higher when combined with TBI)

PTSD distribution between services for OEF, OIF/OND: Army 67% of cases, Marines 13%, Navy 11%, Air Force 9%

50% of those with PTSD do not seek treatment

Out of the half that seek treatment, only half of them get “minimally adequate” treatment

PREVALENCE

19% of veterans may have TBI

7% of veterans have both PTSD and TBI

Rates of PTSD are greater for current wars than

prior conflicts

Recent sample of 600 veterans from Iraq and

Afghanistan found:

14% PTSD

39% alcohol abuse

PRESENT TOLL OF PTSD

Without treatment PTSD can lead to:

ALCOHOL & DRUG ABUSE

HEART ATTACKS

DEPRESSION

DEMENTIA

SUICIDE

PTSD AND SUICIDE

Vets make up 7% of the US population, but they

account for 20% of its suicides

A veteran dies by suicide every 80 minutes

In 2012, more US Soldiers, Seamen, Airmen

and Marines died by their own hands than in

combat

Suicide is currently the #1 cause of death

among US Troops

LETTER FROM ITALY 1944

PTSD: A BRIEF HISTORY

Though referred to by a number of different names, PTSD has been with us for as long as wars have been fought

Herodotus, writing of the battle of Marathon in 490 BC, mentions an Athenian warrior who went blind when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body”

Steven Bentley, “A Short History of PTSD: From Thermopylae to Hue, Soldiers Have Always Had A Disturbing Reaction To War”, March/April 2005

PTSD: A BRIEF HISTORY

1678 Swiss military physician Johannes Hofer coins the term “nostalgia” to describe symptoms seen in Swiss Troops

Symptoms of “Nostalgia”

melancholy

incessant thinking of home

disturbed sleep or insomnia

loss of appetite

anxiety

cardiac palpitations

-> First to identify and name constellation of

behaviors that make up what we now know as PTSD

PTSD: A BRIEF HISTORY

The Civil War: Union Army

2,600 cases of insanity

5,200 cases of nostalgia.

In addition many “insane” soldiers were simply

discharged and left to find their own way home.

In 1864 the War Department ordered that such

soldiers be transferred to the Government Hospital

until their families could retrieve them. Franklin D. Jones, M.D., F.A.P.A, “Psychiatric Lessons of War in War Psychiatry, The Textbooks of

Military Medicine, ed. Brigadier General Russ Zajtchuk, M.C., (Washington, DC: Office of The

Surgeon General, Department of the Army, 1995),

PTSD: A BRIEF HISTORY

World War I: “Shell Shock”

Symptoms of Shell Shock

Staring eyes

Violent tremors

Blue, cold extremities.

Unexplained deafness, blindness, or paralysis

F. C. Hitchcock. Stand To: A Diary of the Trenches 1915–1918. London: Hurst & Blackett,

1937; report, Heath field, England: The Naval & Military Press, Ltd., 2001.

PTSD: A BRIEF HISTORY

World War I: Treating Shell Shock

1917: U.S. Army Surgeon General’s office creates

comprehensive treatment program for shell shock

Placing psychiatrists in combat units

Treatment is centered on:

Proximity (treating the soldier as close to the battle as possible)

Immediacy (treating the soldier as soon as possible)

Simplicity (providing simple treatment such as rest, a warm shower and

food)

Expectancy (the expectation that the solider will return to fight after he

has been treated)

PTSD: A BRIEF HISTORY

World War II: “Combat Fatigue”

Unit cohesion recognized as a factor in “resilience” to

combat fatigue.

Understanding that intensity and duration of combat

exposure increased risk for combat fatigue

Concurrently it was noted that “replacement” troops were

more susceptible than “seasoned” Veterans – see unit

cohesion.

PTSD: A BRIEF HISTORY

Vietnam War:

Veterans treated for “Stress Response

Syndrome”

Informed that if their symptoms lasted more

than 6 months after their return from Vietnam

they had a "pre-existing" condition, making it a

"transient situational disorder", and the

problem was not considered service connected

DIAGNOSTIC & STATISTICAL MANUAL OF

MENTAL DISORDERS (DSM)

DSM-I 1952: what we now know as PTSD was called "stress response syndrome" and was caused by "gross stress reaction”

DSM-II 1968: Trauma-related disorders were lumped together in a category titled "situational disorders“

DSM-III 1980: Post-traumatic Stress Disorder first introduced as a diagnosis

Placed under a sub-category of anxiety disorders

DSM-III (1980)

PTSD Criteria:

Essential feature: Characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. The original stressor is usually experienced with intense fear, terror, and/or helplessness

The precipitating stressor must not be one which is usually well tolerated by most other members of the cultural group (e.g. death of a loved one, ordinary traffic accident)

DSM-IV (2000)

PTSD defined under classification of Anxiety

Disorders. Briefly defined:

Person exposed to traumatic event with both of

the following:

Experiencing or witnessing an event that involved

actual or threatened death or serious injury; or a

threat to physical integrity (or the integrity of others)

Response to the traumatic event involved fear,

helplessness or horror

DSM-IV DEFINITION PTSD

For a duration of at least 1 month, the individual experiences the following symptoms: Intrusive recollection: recurrent, distressing recollections or

dreams of event which cause heightened physiologic reactivity

Avoidance: persistent avoidance of stimuli associated with the event

Hyperarousal: persistent symptoms of increased arousal including difficulty sleeping, outbursts of anger, hypervigilance, exaggerated startle response

-> These persistent symptoms cause significant distress or impair social or occupational function

DSM-V (2013)

Major revisions to PTSD diagnosis:

Classification: moved from Anxiety Disorders to new class of “trauma & stressor-related disorders”

Diagnostic criteria: the 3 symptom clusters described in DSM-IV re-organized into 5 criterion

Exposure

Intrusive recollection

Avoidance (at least one avoidance symptom required)

Negative alterations in cognition and mood

Alterations in arousal and reactivity

ARGUMENT FOR NAME CHANGE

Military brass asked APA to modify name: “injury” to replace “disorder”

Pro: Calling the condition a “disorder” perpetuates a bias against mental illness and is a barrier to vets getting the care they need.

Con: Changing name could have unintended negative consequences in that it would confuse issue and set up diagnostic distinctions for which there is no scientific evidence.

THE “INVISIBLE WOUNDS”

Psychological injuries:

PTSD

Major Depression

Mild traumatic brain injury/concussion

Moderate to severe TBI is typically not “invisible”

Under-reported

-> Key: These are treatable conditions!

MTBI/CONCUSSION

Much attention on this “hot topic” which is increasingly common in modern warfare with exposure to IEDs

All that we have learned from study of sports-related concussion can be readily applied to combat injury

Has now been demonstrated that repeat concussion injury can lead to Chronic Traumatic Encephalopathy (CTE), formerly known as “Dementia Pugilistica”, of which dementia is a primary symptom

TBI AND DEMENTIA

Multiple epidemiologic studies show that

experiencing a TBI in early or midlife is

associated with an increased risk of dementia

in late life

Best data indicate that moderate and severe

TBIs increased risk of dementia 2-4 fold

Becoming more evident that multiple mTBIs

may result in CTE and increased dementia risk

OVERLAP

mTBI and PTSD share key symptoms (mood changes, difficulty concentrating, sleep problems, fatigue) and can be hard to distinguish from one another, making focused treatment a challenge Depression also commonly associated with TBI

2008 study in NEJM suggested that infantry soldiers’ lasting symptoms like fatigue & dizziness could be attributed largely to PTSD and depression rather than TBI

7% of vets have both PTSD and TBI

TBI and PTSD may compound each other’s effects

PTSD AND DEMENTIA

Several recent publications, some studies

ongoing, all demonstrating a significant

association between PTSD and increased risk

of dementia in later life

Some have suggested that PTSD may

accelerate the aging process in general

PTSD AND DEMENTIA

Yaffe et al in Archives of General Psychiatry 2010: studied the incidence of dementia in a retrospective cohort of 183,000 veterans who did not have dementia at baseline enrollment (1997-2000) Mean age 69

PTSD diagnosed in 53,155 of the subjects

During follow-up period 2001-2007 the cumulative incidence of new-onset dementia (of all types) was 11% for those with PTSD, 7% for those without: a significant difference

PTSD AND DEMENTIA

Yaffe study (con’t):

Results did not change even when subjects with a history of TBI, substance abuse and depression were excluded

Recommendation generated for health care providers: critical to follow patients with PTSD and evaluate them early for dementia

Uncertain: nature of connection between PTSD and dementia

Further investigation needed to see whether successful treatment of PTSD may reduce risk of adverse health outcomes including dementia

PTSD AND DEMENTIA

Qureshi et al in Journal of American Geriatrics Society 2010 found results similar to Yaffe: roughly twofold increase in incidence and prevalence of dementia in vets with PTSD

Notes that it is unclear whether this is due to a common risk factor underlying PTSD and dementia or to PTSD being a risk factor for dementia

Study suggests that veterans with PTSD should be screened more closely for dementia, and because PTSD so common in vets, this association has important implications for long-term veteran care

PTSD AND DEMENTIA

Comments on these 2 studies from experts:

Causal event linking PTSD and dementia may well be physical: psychologically traumatic event in PTSD induces rewiring in brain areas that underlie emotion and memory

Result is increase in brain vulnerability to any degenerative or other dementing process

This further obscures the line between PTSD and TBI as distinct entities

MILITARY RISK FACTORS FOR ALZHEIMER’S

DISEASE

Very recent paper: Weiner et al in Alzheimer’s & Dementia journal 2013 reviews conclusions drawn from a meeting in May 2012 of experts from US military and academic medical centers

Discussed current evidence and hypotheses regarding the pathophysiologic mechanisms linking TBI, PTSD and Alzheimer’s disease

One possible mechanism considered: association of TBI and PTSD with “reduced cognitive reserve” and TBI early in life as risk factor for Alzheimer’s

TREATMENT

Realize not easy and that rarely treating just one entity. As can gather from talk, often concurrent problems: PTSD, TBI, depression

With some vets may be resistance to treatment: some do not wish to be labeled and by may have perception that by seeking treatment admit to weakness

Some may find it difficult to participate in time intensive therapy and will rely solely on their primary care provider

TREATMENT PTSD

Specialized treatment primarily involves

Cognitive Behavioral Therapy (CBT), which has

been empirically validated as the most effective

treatment

Mood stabilizer Rx: the SSRI class of drugs

Zoloft (sertraline) and Paxil (paroxetine) are two

SSRIs FDA-approved for treatment of PTSD

SSRIs found to be most effective when used in

combination with CBT

TREATMENT PTSD

Cognitive Behavior Therapy:

Exposure therapy or cognitive processing therapy, both of which involve repeatedly revisiting a single traumatic event in several extended sessions over several weeks

Stress and anger management

Biofeedback

Interpersonal therapy

Group therapy

Music therapy

THE EPIDAURUS PROJECT

Led by Dr. Frederick Foote, retired Navy doctor

Project aims to enhance health of vet through:

Family-centered approaches

Multi-disciplinary care integration

Tools and practices that support wellness including

nutrition, exercise, mind-body medicine, CAM,

healing arts and spirituality

Evidence-based design of healing environments

TREATMENT TRENDS

Veterans with PTSD increased at a greater rate since 2005 compared with vets with other mental disorders

The number of visits per veteran with PTSD increased between 2006 and 2010

The rate of increase has been highest for Iraq and Afghanistan veterans

Trends coincide with enhanced screening & recognition of PTSD, increase in PTSD treatment funding and program expansion since 2005

TREATMENT: MEDICAL MARIJUANA

Word is still out but much buzz ensues

Review of evidence: 2012 paper out of University of Arizona School of Public Health Total 54 articles identified and reviewed

No study was found that focused specifically on the treatment effects of cannabis on those with PTSD

Conclusion: could not find any research that directly addressed the key questions of the benefits and harms of marijuana use for the treatment of PTSD. The most relevant literature was of low or very low quality and no definitive conclusions could be drawn. Most of articles reviewed recommended further research

TREATMENT: MEDICAL MARIJUANA

Mountain of anecdotal evidence that marijuana helps with PTSD by suppressing symptoms including flashbacks, insomnia & anxiety

However now one step closer to formal study: just days ago US Dept of HHS (FDA approved in 2011) gave approval to proceed with study as proposed out of Univ of Arizona. One final hurdle remains: approval from DEA before research can begin

In Connecticut PTSD is a qualifying condition to receive medical marijuana

www.veteransformedicalmarijuana.org

SCREENING

Because PTSD is so common among returning veterans, the Institute of Medicine in 2012 recommended screening for PTSD at least once a year

Also recommended that DOD and DVA conduct more research to determine how well various treatments for PTSD are working

Barely half of those diagnosed with PTSD actually get treatment, and when they do get care, they’re not tracked to determine which treatments are successful in the long term

NATIONAL RESEARCH ACTION PLAN

Responding to Executive Order, report issued

August 2013, product of coordinated effort

between DoD, DVA, DHHS, Dept of Education

Comprehensive report – focus on improving

access to mental health services for veterans,

service members and military families

Research biomarkers, mechanisms and

treatment, suicide prevention

POST DEPLOYMENT CARE

In general we, primary care physicians, don’t do it well

First and foremost MUST ASK THE QUESTION: “Have you ever served in the military?”

“Yes” answer should trigger a comprehensive process that:

May well elucidate a chronic condition

Get one plugged into specialty care

Determine if have service-connected condition that may allow for entitled benefits

ELIGIBILITY FOR BENEFITS

If have service-related condition and need

assistance in filing for compensation for

illness/injuries related to your service:

Call VBA at 1-800-827-1000

Gateway to veteran health benefits and services:

www.myhealth.va.gov

www.ebenefits.va.gov

1-877-222-8387

RESOURCES

National Center for PTSD, West Haven

www.ptsd.va.gov

US Dept Vet Affairs – War-related Illness &

Injury Study Center

www.warrelatedillness.va.gov

Mobile Apps

Self-help: PTSD Coach

Treatment companion: CBT-i Coach, PE Coach

NATIONAL CENTER FOR PTSD

Extraordinary site, very comprehensive

Among features: PTSD Coach Online

Public & Professional Sections

“About Face” feature: watch video of veterans

describing their struggles with PTSD and how

treatment turned their life around

Veterans Crisis Line: 800-273-8255 press 1

DEEP THOUGHTS

->“No one comes home from war unchanged”

“But always the absolute cure to the

eradication of symptoms of PTSD is to

eradicate their causes. We are disturbed by war

and justly so.”

Steve Bentley “A Short History of PTSD”

THANK YOU

Questions?

Comments?