PTS(D): The Invisible Wound

Transcription

1 PTS(D): The Invisible Wound Julie Rake, MS, PA C Fellow, Integrative Medicine The intelligent combination of conventional and evidence based alternative medicine. It aims to restore the focus of medicine on health and healing and away from simply managing chronic disease. A deeper study of nutrition Understanding botanical/plant medicine Integrative approaches to all systems Mind body medicine Death and dying Spirituality in health care Chinese traditional medicine Ayurveda Other systems of medicine 1

2 The ability of our brain to change itself. How we adapt, learn new things, and develop new skills. The brain is always changing. 2

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4 A head full of fears has no spare room for dreams. 2 Main Types of Brain Injury 1 Traumatic Brain Injury (TBI) 2Psychological Trauma 4

5 PTSD has had numerous names throughout history Nostalgia Soldier s Heart or Irritable Heart Railway Spine DeCosta s Syndrome Shell Shock War Neurosis Battle Fatigue or Combat Stress Reaction (CSR) but the root pathology has remained the same. (U.S. Department of VA National Center for PTSD, 2016) PREDISPOSING VULNERABILITY Presence of childhood trauma Mental illness Inadequate family or support systems Being female Recent stressful life changes Drug and alcohol abuse RISK FACTORS FOR NON VETERANS Victims of violent crime Experiencing or witnessing an event involving death Childhood neglect and abuse Employed in occupations that expose them to violence (for example: soldiers and first responders) Victims of natural disasters Experiencing an event in which the individual felt intense fear, horror, or powerlessness. 5

6 RISK FACTORS FOR VETERANS Increasing number of deployments or cumulative combat experiences Intensity of combat Personal injury Witnessing others wounded or killed CLINICAL MANIFESTATIONS Recurrent thoughts about the event, flashbacks, or nightmares Hyperarousal (being keyed up) Avoiding reminders of the event Inability to trust others or even connect with others Disassociation (feeling of not being in reality) Anger or Aggression Reckless behavior Substance abuse (self medicating) Anxiety, depression Guilt and shame Memory problems, trouble concentrating Withdrawal and isolation Emotional numbness; and Multiple physical symptoms ASSESSMENT and DIAGNOSIS In 1980, the American Psychiatric Association (APA) added PTSD to the DSM 111. The DSM 5 now categorizes PTSD in a new category Trauma and stressor related disorders. A diagnosis of PTSD exists if four symptoms last for at least a month and cause significant distress or problems with day to day functioning. 1. Reliving the traumatic event(also called re experiencing or intrusion) 2. Avoiding situations that are reminders of the event 3. Negative changes in beliefs and feelings 4. Feeling keyed up (also called hyperarousal or over reactive to situations (U.S. Department of VA National Center for PTSD, 2016) 6

7 Primary Care PTSD Screen Have you had any experiences in the past month that were so frightening, horrible or upsetting that you: Have had nightmares about it or thought about it when you did not want to? Have you tried hard not to think about it or have you gone out of your way to avoided situation that reminded you of it? Have you been consistently on guard, watchful, or easily started? Have you felt numb or detached from others, activities, or your surroundings? ASSESSMENT and DIAGNOSIS (continued) The GOLD STANDARD for assessing PTSD is The Clinical Administered PTSD scale (CAPS). The PCL (PTSD checklist) is a self screening tool to help in the diagnosis of PTSD. The PCL has 4 different versions: 1. Diagnosis using DSM 5 2. For civilians 3. For military veterans or service personnel 4. For non military use for a VERY stressful event 7

8 AMYGDALA AMYGDALA ADVERSE EFFECT TO THE AMYGDALA 8

9 PRE-FRONTAL CORTEX In normal aging the hippocampus shows up to 25% shrinkage by the age of 80. The volume of the human brain and/or its weight declines at a rate of about 5% per decade after age 40. HIPPOCAMPUS 9

10 HIPPOCAMPUS How can I calm down after a stressful event? Beginner Tips: Ideally, sit with your back straight. Place the tip of your tongue against the ridge of tissue just behind your upper front teeth, and keep it there through the entire exercise. Exhale through your mouth around your tongue; try pursing your lips slightly if this seems awkward. Anyone can do it... Simple Quick No equipment needed Do it anywhere Signs that someone is having a flashback Sudden change in body posture Blanking out or becoming distracted Disorientation to time and place Sudden tension in muscles Sudden surge of anger or aggression Unusual verbalizations 10

11 Interventions for flashbacks Use calming and grounding techniques Use individual name, if possible Use time reference, if possible ( It s July ) Use place reference ( you are in Phoenix; you are at home. ) Show them your agency (shoulder patch or name tag) Ensure safety ( you are safe; we are here to help. ) Identify yourself ( My name is Officer Smith from the Phoenix Police Department. ) Ask what is scaring you? Are you afraid of something? TREATMENT OVERVIEW Treatment should be initiated immediately after diagnosis to facilitate optimal recovery and prevent further medical and psychiatric comorbidities. First assess symptoms requiring emergency intervention, such as suicidal or homicidal thoughts, acute psychotic symptoms or symptoms that severely interfere with psychosocial functioning. Assess, identify and address high risk behaviors, including tobacco, alcohol, or other drugs. TREATMENT OVERVIEW (continued) Pharmacologic Management SSRI s and SNRI s (first line) TCA s, Atypical Antidepressants (second line) Sympatholytic Prazosin (adjuvant therapy) AVOID Benzodiazepines due to their addictive nature Psychotherapy Cognitive Behavioral Therapy (CBT) Cognitive Processing Therapy (CPT) Prolonged Exposure Therapy (PE) Stress Inoculation Therapy (SIT) Eye Movement Desensitization and Reprocessing (EMDR) Group Therapy 11

12 INTEGRATIVE APPROACHES TO TREATMENT Acupuncture = limited evidence. Many studies conducted in China where this modality is mainstream. Yoga = evidence for decreased PTSD symptoms. Meditation = although more research studies are needed, there is robust evidence supporting positive brain changes resulting from various meditation techniques. My brain was recovering secondary to neuroplasticity. 12

13 AMYGDALA PRE-FRONTAL CORTEX Further, their hypothesis was supported when their results confirmed this area was thicker, had more gray matter and greater neural connectivity than non meditators. 13

14 While cultivating emotions like love, kindness and compassion during meditation (Done in METTA) neuroimaging reveals the left prefrontal cortex circuits light up. 14

15 Meditation techniques that involve focus on an emotion also activate interconnections between the frontal lobes and the limbic system. HIPPOCAMPUS Healthcare Provider Burnout Emotional exhaustion (feeling emotionally drained and exhausted by ones work). Apathy (negative or very detached feelings towards patients). Reduced personal accomplishment (evaluating oneself negatively and feeling unsatisfied with positive job performance and achievements). 15

16 SELF CARE Nutrition Exercise New learning Stay socially connected to family and friends Meditation and other contemplative practices Massage, nature, reading, art, golf, travel, hobbies, date nights, and retreat. 16