1. COMBAT PTSD Recognition and Treatment Harry Croft, M.D. Texas Association of Osteopathic Physicians San Antonio, June, 2012

2. Research and Speaking Honoraria Astra Zeneca Boehringer-Ingelheim BMS Eli Lilly Forest Pharmaceuticals GSK Otsuka Pfizer Takeda

3. 3 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. 3

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5. 5 WWW.MYBACKTOTHEWALL.COM R ECOGNIZING When PTSD is in Your Life E DUCATING Yourself About PTSD C ONNECTING Biology With Your Psychology O RGANIZING a Comprehensive Care Plan V IEWING Your Issues in a New Light E MPOWERING Yourself Through Strong Systems of Support R EDEFINING the Meaning of Your lIfe: Post – Traumatic Growth T 5

6. 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

7. Recognition of PTSD Problems for Patients and Families Failure to Recognize Symptoms for what they Are Incorrectly Ascribe Cause Myths and Misconception About PTSD Stigma Surrounding PTSD

8. 8 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

9. 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

10. Recognizing PTSD Problems for Physicians - Pr Patient reports only certain symptoms Failure to report traumatic experience/ vet Visit by patient not self motivated

11. Risks to Military Members More than Just Combat Combat Non-predictable Threats - to even “non- combatants” Repeated Deployments Repeated Separations Dwell time Unemployment / finances

12. Impacts Many Life Areas Relationships Marital, Family, Friends EMPLOYMENT/ EDUCATION Legal Problems Physical Health Risk Taking DESPAIR / SUICIDE

13. DIAGNOSIS STRESSOR RE-EXPERIENCING AVOIDANCE AROUSAL EMOTIONAL DISTRESS OR LIFE INTERFERENCE DSM IV

14. 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

15. CO-OCCURRING CONDITIONS DEPRESSION ANXIETY DISORDERS – Generalized, Panic, Social Phobia SUBSTANCE ABUSE DISORDERS OCD VARIANTS

16. 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

17. PSYCHOTHERAPY COGNITIVE-BEHAVIORAL THERAPY – Prolonged Exposure – Cognitive Processing Therapy SUPPORTIVE EMDR OTHER

18. MEDICATIONS ANTI-ADRENERGIC SSRI and SNRI MEDS TO AID WITH SLEEP Other antidepressants ATYPICAL Antipsychotics ANTI-EPILEPTICS **Avoid BENZODIAZEPINES IF POSSIBLE

19. 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

20. OTHER THERAPIES Meditation Exercise Yoga Accupuncture Animal Therapy Art and Writing

21. SUPPORT SYSTEMS FAMILY FRIENDS OTHER VETERANS ORGANIZATIONS HELPING OTHERS SPIRITUALITY

22. 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

23. REDEFINING LIFE AFTER PTSD POST PTSD GROWTH Recognizing how others survive Who you are vs. what you do..or did Importance of lifelong growth and learning

24. 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

25. 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

26. 26 FOR MORE INFORMATION www.va.ptsd.gov www.medscape.com www.ptsd.va.gov/professional/pages/assessments/ncptsd- instrument-request-form.asp www.ptsd.va.gov/professional/pages/assessments/ncptsd- instrument-request-form.asp – TO DOWNLOAD PCL-M AND PCP PCL TO DOWNLOAD PCL-M AND PCP PCL www.mybacktothewall.com