Psychobiology of PTSD

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(No Transcript)
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Providing care to OIF/OEF veterans

• Steve McCutcheon, PhD
• Matthew Jakupcak, PhD
• VA Puget Sound Healthcare System, Seattle
• Department of Psychiatry and Behavioral Sciences,
• University of Washington School of Medicine

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Acknowledgments

• Miles McFall, PhD
• Director, Psychology Service
• Director, PTSD Patient Care Line
• VA Puget Sound Health Care System

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Workshop overview

• Basic epidemiology and patient characteristics
• A model of integrated care for OIF/OEF veterans
• Federal and State collaboration in Washington
  State
• An integrated model of primary stepped care at VA
  Puget Sound, Seattle
• Adapting evidence-based PTSD treatments in
  secondary prevention efforts for OIF/OEF veterans

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Faces of the war

• James
• Avoidance and withdrawal
• Gary
• Vigilance and control

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Facts about the war
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War in Southwest AsiaPopulation Statistics

• Over 1,000,000 military personnel deployed to
  Southwestern Theater of Operation
• 505,366 veterans have left active duty (as of
  12/31/05)
• 43 active duty troops
• 57 Reserve and National Guard
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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War in Southwest AsiaHuman Costs

• 2,513 Americans killed (2/7/06)
• 17,096 officially wounded (2/7/06)
• 50,000 250,000 civilians killed (Nov. 2004)

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Top 10 Causes of OIF Deaths 3/19/2003
11/30/2004
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Increasing Survival Rate of Injured Soldiers

• WWII 23 of injured combatants died
• Vietnam 17 of injured combatants died
• Iraq/Afghanistan 9 of injured combatants die
• As many US soldiers have been injured in combat
  thus far in Iraq/Afghanistan as were in the
  Revolutionary War, the War of 1812 or the first 5
  years of the Vietnam War
• Gawande A. Casualties of WarMilitary Care for
  the Wounded from Iraq and Afghanistan. NEJM
  351(24) 2471-2475.

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Combat Exposure for OIF SoldiersHoge et al.
(2004)
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Service utilization
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Perceived Barriers to Mental Health CarePositive
Screen Cases Hoge et al. (2004)
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Utilization of Mental Services Active Duty
Personnel

• Only 23 of positive screen active duty Army/USMC
  personnel sought mental health care in past year1
• 35 soldiers in a population-based study sought
  mental health services in first year after
  demobilization2
• 1Hoge et. Al. 2004
• 2Hoge et. Al. 2004

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Utilization of VA Services

• 29 (144,424) have sought VA care nationally
  (12/31/05)
• 32 of separated active duty
• 26 for reserve component
• Represents 3 of all vets seen in VA
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Utilization of VA ServicesCharacteristics of
Patients

• 87 male 13 female
• Age 20-29 53 age 30-39 23
• ARMY 66, USAF 13, USMC 11, USN 10
• Active duty 49, Reserve Component 51
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Clinical characteristics
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Medical Diagnoses (N 144,424)

• Musculoskeletal 40
• Mental disorders 32
• Digestive System 30
• Ill Defined Symptoms 30
• Nervous system 28
• Respiratory 17
• Injury/Poisoning 16
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Spectrum of Post-Deployment Mental Disorders (N
46,571)

• Disorder N
• PTSD 20,638 44
• Drug Abuse 17,768 38
• Depression 14,317 31
• Neurotic Disorders 11,481 25
• Affective Psychosis 7,460 16
• Alcohol Dependence 3,116 7
• Acute Stress Reaction 1,327 3
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Prevalence of Mental Disorders by War ZoneStrict
Diagnostic Criteria
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Outcomes for Symptom Screening (Iraq)Liberal
Criteria
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Health Risk Screening OutcomesDemobilization
Sites

• Alcohol 33
• Hostility 22.8
• Suicide ideation/risk 1.1 - 4.1
• Interpersonal Aggression/Domestic Violence 2.1
  - 2.2
• Tobacco Use 50 (25 - 44 want to quit)

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Health Risk BehaviorsVAPSHCS Clinic Sample (n
144)
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Post-Deployment Readjustment ReactionsFunctional
Limitations

• Unemployment
• Financial deficits (lacking money management
  skills)
• Homelessness
• Phobias about driving
• Reunion stress (over-controlling, detached,
  intimacy problems)
• Marital conflict, parenting concerns and family
  reintegration problems (including divorce, DV,
  and infidelity)

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Post-Deployment Readjustment ReactionsProminent
Arousal Symptoms

• Disturbed sleep and dreaming
• Easily startled
• Irritability and anger
• Hypervigilance (discomfort in crowds)

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Post-Deployment Readjustment ReactionsCommon
Themes and Concerns

• Addiction to CNN war coverage
• Worry about friends still deployed overseas
• Miss excitement of combat, urges to return
• Worries about re-deployment

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Traumatic Brain Injury

• cognitive problems (e.g., impaired memory,
  attention, or executive function)
• headaches
• sensitivity to light or noise
• dizziness or nausea
• irritability, impulsivity, poor frustration
  tolerance
• depression
• insomnia
• TBI can cause impaired or lost sensory function
  (e.g., eyesight), mobility, and ability to
  perform basic activities of daily living