Jim Boehnlein, M.D.Jim Boehnlein, M.D.Associate Director for Education, VA Northwest Network Associate Director for Education, VA Northwest Network Mental Illness Research, Education, and Clinical Center Mental Illness Research, Education, and Clinical Center

(MIRECC)(MIRECC)

Professor of Psychiatry, Oregon Health and Science Professor of Psychiatry, Oregon Health and Science UniversityUniversity

OutlineOutlineOEF/OIF context PTSD throughout historyAssociated disordersPTSD symptoms and diagnosisComprehensive PTSD treatment

Afghanistan- Operation Enduring Freedom (OEF)Afghanistan- Operation Enduring Freedom (OEF)Iraq- Operation Iraqi Freedom (OIF)Iraq- Operation Iraqi Freedom (OIF)

1,800,000 OEF and OIF Veterans have left active duty and become eligible for VA health care since FY 2002

60% Active Duty troops 40% Reserve and National Guard 46% of total separated OEF/OIF Veterans

have obtained VA health care since FY 2002 (cumulative total)

Frequency of Possible Diagnoses among Frequency of Possible Diagnoses among OEF and OIF VeteransOEF and OIF Veterans

265,450 (52%) Diseases of Musculoskeletal System/Connective System 233,443 (46%) Symptoms, Signs and Ill Defined Conditions 243,685 (48%) Mental Disorders 202,298 (40%) Diseases of Nervous System/ Sense Organs

*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2009; Veterans can have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 508,152; percentages add up to greater than 100 for the same reason.

PTSD Through the Decades- PTSD Through the Decades- Labeling and PerceptionLabeling and Perception

Railway Spine SyndromeIrritable HeartShell ShockPost-concussion syndromeConcentration Camp Syndrome

Etiological Models of PTSDEtiological Models of PTSD

Biological

Cognitive

Sociocultural

Co-morbid Conditions and PTSD

Mood DisordersOther Anxiety DisordersSubstance Abuse DisordersTraumatic Brain Injury

Overlapping Symptoms of PTSD and TBIOverlapping Symptoms of PTSD and TBI

Impaired concentrationImpaired memoryIrritabilityDepressionAnxiety

Importance of Accurate DiagnosisImportance of Accurate Diagnosis

Relieve sufferingEffective treatmentPrognosisEmployment/EducationStigma- not pathologizingEducating patients/families

Common PTSD SymptomsCommon PTSD Symptoms

Intrusive thoughts Nightmares Irritability Startle reactions Avoidance Emotional detachment Social isolation Anniversary reactions

Current Stressors Can Reactivate Current Stressors Can Reactivate Memories of Prior TraumaMemories of Prior Trauma

Psychological and emotional stress

Physiological reactivity Exposure to symbolic cues

Barriers to Treatment-Barriers to Treatment-Beliefs and ValuesBeliefs and Values

AvoidancePride in self-relianceLoss of control/autonomyTreatment is for those who are weak, “crazy”Provider will not understand or believe

traumaSocietal rejection

PTSD TreatmentPTSD TreatmentEducationSymptomatic relief of comorbid

conditionsReduction of hyperarousal symptoms

with medicationPsychotherapyReduction of other stressesSocial and vocational

Questions After TraumaQuestions After Trauma

Unpredictability of life and deathLossMoral Complexities

Core Assumptions Altered by TraumaCore Assumptions Altered by Trauma

Belief in personal invulnerabilityPerception of an understandable

worldTrust in self and others

Healing After TraumaHealing After TraumaTrustSecurityAcceptanceMeaningIdentitySocial Connectedness

Psychotherapeutic ThemesPsychotherapeutic Themes Trust Self Worth Grief and Mourning Anger and Revenge Control Meaning

National Center for PTSD

http://www.ptsd.va.gov/professional/index.asp