Tag Archives: ACE score

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Update on PTSD 2017: hope!

I have just spent a week in San Antonio, Texas at the AAFP FMX: American Academy of Family Physicians Family Medicine Experience.

Whew. Long acronym.

However, I attended two programs on PTSD. One was a three hour offsite one put on by the U. of Texas Health Sciences Department of Family Medicine. The other was a one hour program about active duty military and PTSD.

The biggest message for me is HOPE. Hope for treatment, hope for diagnosis, hope for destigmatization, hope for remission. I am not sure if we should call it a “cure”. Once a diabetic, always a diabetic, even if you lose 100 pounds.

In medical school 1989-1993 I learned that PTSD existed but that was about it. There was no discussion of medicines, treatment, diagnosis or cure.

Ditto residency. I learned much more about psychiatry reading about addiction and alcoholism and Claudia Black’s books then I did in residency.

Fast forward to 2010, when I opened my own clinic. I worked as a temp doc at Madigan Army Hospital for three months.

The military was aggressively pursuing treatment and diagnosis of depression, anxiety, PTSD and traumatic brain injury. I worked in the walk in clinic from 6:30 to 8:00 four days a week. Every walk in had to fill out a screen for depression. They were trying to stem the suicides, the damage, the return to civilian life problems and addiction too. They were embedding a behavioral health specialist in every section of the military. I was amazed at how hard the military was working on behavioral health.

In 2010 I took the buprenorphine course, which is really a crash course in addiction medicine, at the University of Washington Med School. I took it because it was free (I had just opened a clinic) and I thought we were as a nation prescribing WAY too many damned opioids. Yes! I found my tribe!

This gave me a second DEA number, to prescribe buprenorphine for opiate overuse, but also hooked me up with the University of Washington Telemedicine. I presented about 30 opiate overuse problem patients (anonymously, there is a form) to the team via telemedicine over the next year. The team includes a pain specialist, addiction specialist, psychiatrist and physiatrist. They do a 30 minute teaching session and then discuss 1-2 cases. They often do not agree with each other. They reach consensus and fax recommendations to me. The Friday addiction one was shut down and now I present to the Wednesday chronic pain one.

But, you say, PTSD? Well, chronic pain patients and opiate overuse patients have a very high rate of comorbid psychiatric diagnoses. It’s often hard to sort out. Are they self medicating because they have been traumatized or were they addicted first and then are depressed/traumatized and anxious? And what do you treat first?

There was an ADHD program at this conference that said we should deal with the ADHD first. One of the PTSD courses said deal with the PTSD first. The thing is, you really have to address BOTH AT ONCE.

Tools? PHQ-9, GAD-7, PCLC and there is an ADHD one too. These are short screening tools. I don’t diagnose with them. I use them to help guide therapy along with the invaluable urine drug screen. Love your patients but verify. That is, the chronic pain patient and the addiction patient tell me the same thing: but one is lying. I don’t take it personally because they are lying to themselves. Also, studies have shown that many patients lie, about their hypertension medicine or whatever. If they have to choose between food and medicine…. I think food may come first.

The San Antonio program has a behavioral health person embedded in their clinic (like a diamond) and if a PTSD screen is positive, the doctor or provider can walk them over and introduce them and get them set up. This is more likely to get the person to follow up, because there is still stigma and confusion for ALL mental health diagnoses and people often won’t call the counselor or psychologist or god forbid, psychiatrist.

They have a protocol for a short term four week treatment. Four weeks? You can’t treat PTSD in four weeks! Well, sometimes you can. But if you are making no progress, the person is referred on if they will go. I have the handouts. I do not have an embedded behavioral health person. I wish I did. I am thinking of setting a trap for one or luring them in to my clinic somehow, or asking if the AAFP would have one as a door prize next year, but…. meanwhile, I may do a trial of DIY. No! you say, you are not a shrink! Well, half of family medicine is actually sneaky behavioral health and I have the advantage of being set up to have more time with patients. Time being key. Also I have seven years of work with the telemedicine and access to that psychiatrist. Invaluable.

So what is the most common cause of civilian PTSD? Motor vehicle accidents. I didn’t know that. I would have said assault/rape. But no, it’s MVAs. Assault and rape are up there though, with a much higher PTSD rate if it is someone the victim knows or thought loved them. Rates in the US general population is currently listed at 1%, but at 12% of patients in primary care clinics. What? One in ten? Yes, because they show up with all sorts of chronic physical symptoms.

Re the military, it’s about the same. BUT noncombatant is 5%. High intensity combat has a PTSD risk of 25%, which is huge. One in four. Not a happy thing. In 2004 less then half the military personnel who needed care received it. PTSD needs to be destigmatized, prevented, treated compassionately and cured.

The risk of suicidality: 20% of PTSD people per year attempt. One in five.

Men tend to have more aggressiveness, women more depression.

Back to that PCLC. A score of over 33 is positive, over 55 is severe. There is sub threshold PTSD and it does carry a suicide risk as well. In treatment, a score drop of 10 is great, 5-10 is good and under 5, augment the treatment. Remember, the PCLC is a screening tool, not a diagnosis. I often ask people to fill out the PCLC, the GAD7 and the PHQ9 to see which is highest, to help guide me with medicines or therapy. If I need a formal diagnostic label, off to psychiatry or one of my PhD psychologists or neuropsych testing. Meanwhile, I am happy to use an adjustment disorder label if I need a label. If the patient is a veteran and says he or she has PTSD, ok, will use that.

Untreated PTSD, the rate of remission is one third at a year, the average remission is 64 months.

Treated PTSD, the rate of remission is one half at a year, and the average duration is 36 months. So treatment is not perfect by any means.

Pharmacology: FDA approved medicines include paroxetine and fluoxetine, and both venlafaxine and one other SSRI help.

Benzodiazepines make it worse! Do not use them! They work at the same receptor as alcohol, remember? So alcohol makes it worse too. There is no evidence for marijuana, but marijuana increases anxiety disorders: so no, we think it’s a bad idea. Those evil sleep medicines, for “short term use” (2 weeks and 6 weeks), ambien and sonata, they are related to benzos so I would extrapolate to them, don’t use them, bad.

Prazosin helps with sleep for some people. It lowers blood pressure and helps with enlarged prostates, so the sleep thing is off label and don’t stop it suddenly or the person could get rebound hypertension (risk for stroke and heart attack). I have a Vietnam veteran who says he has not slept so well since before Vietnam.

Part of the treatment for the PTSD folks at the U. of Texas Medical Center is again, destigmatization, normalization, education, awareness and treatment tools.

Hooray for hope for PTSD and for more tools to work with to help people!

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Adverse Childhood Experiences 8: Social cues

I am thinking about social cues for people with high Adverse Childhood Experience scores. With crisis brain wiring the response to social cues may be very different than what is considered the acceptable “norm”.

I always miss the cue when someone says “see you later”. I think “When?” Then I realize it’s a social comment and they do not in fact plan to see me later. I have a moment of disappointment. I do the same thing when someone says, “Let’s get together for dinner.” or “Let’s have coffee some time!” or “I will call you back!” or “Why don’t you come to our cabin some day?” Yes, I think, when?

And then I think “Liar.”

So I fail social cues….. or do I? Maybe I am not responding to the “correct” or “conventional” or “nice” social cues.

My father drank too much and especially while I was in high school and college. And my mother would enable and cover up and pretend nothing was happening. Children in this situation, which is way too common, develop special skills.

My sister was three years younger. As adults we discussed the stages of drinking and which one we hated most. We would both walk in the house from school with trepidation. In the door and almost feeling the air: what is happening? Am I safe? Do I need to hide? How dangerous is it? How much will it hurt?

I walked in once during high school and missed the cue. I was thinking about something. I thought my father was asleep in the kitchen. I went in to get something. I was very quiet so as not to wake him. I made a cup of tea.

He was not asleep, or else he woke up. And it was the worst stage, or the one I hated most.
Not physical violence. But he started talking. One of things he said was “You can tell me anything.” Now, he meant it. But he was crying by then and I knew I did not want to tell him anything and all I wanted was desperately to leave the room. And neither my sister or my mother was home. Finally I was crying too, because I said “I just want to go read my book.” and he was more crushed and maudlin and emotional and crying. And I tore out of the room and up to my room, as my mother walked in.

I did not cry much. Ever.

I refused to talk to my mother about it.

The next day she said to me, “Your father told me that you were talking about Lamont.” Lamont Cranston was a very beloved cat, The Shadow, who was missing now. Dead, we thought.

I said nothing. Because we had not talked about Lamont. So either my father was lying or else he’d had a blackout, didn’t remember and was making shit up. And if I told my mother the truth, she would back him and deny what I said or make it into a joke.

The stages my sister and I identified were:
1. sober
2. a little bit
3. goofy/silly/makes no sense
4. crying
5. asleep

We were ok with 2 and 5. I don’t think we saw 1 for years. We disliked 3 intensely, especially in public and especially when our mother was doing a cover up dance. And 4 we hated.
And yet I loved my parents and mostly miss them now that they are gone. Except when I remember things like this.

So, what is the point?

I miss “social cues” because that is NOT what the crisis brain, the ACE score brain, pays attention to. I am paying attention to far more intuitive things: body language. Whether what the person is saying matches what I know about them and what they have done in the past. I am looking for whether this person is telling me the truth.

I don’t trust instantly. Why would I?

I said to a counselor once that reading the “cloud” around the person was terribly useful in medicine but made me a social misfit. “I don’t know how to turn it off.” I said. She grimaced and said, “Why do you think I went into counseling?” She said, “I can’t turn it off either but I have learned to ignore it during social situations.” I was in my forties before I realized that there are people who don’t sense this cloud, who trust people until the person is dishonest, who understand that it is just fine to say “Let’s get together.” and not mean it.

Because actually, when someone says “I’ll see you later.” and they don’t mean it, they are saying an untruth. They are not planning to see me later. They don’t mean it. And my brain automatically files that under evidence that this person is not trustworthy. To them it is a social cue that is polite. To some of us, it is clearly something that is not actually true. I pick up on a cloud of social cues, but not the ones that are acceptable or conventional. And I am not the only one.

my sister on the left and me on the right, in the 1960s

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Adverse Childhood Experiences 5: Love your brain

L for Love your brain, in the Blogging from A to Z Challenge.

I have just been to another conference and met a woman neurologist. She is studying traumatic brain injury patients. She is applying for a grant to study adverse childhood experience scores in traumatic brain injury patients because they have noted that the people with fairly awful or very awful childhoods tend to cope better than the people with a nice childhood. She wants to do a formal study to see if this observation holds up.

Why would people who have had major trauma during childhood do better after a traumatic brain injury than those with a good childhood?

The suspicion is that their brains are wired differently. The high ACE score people have “crisis” wiring. They have brain wiring for survival in difficult circumstances. They have already used this wiring in childhood and have survived something or survived many things. When they have a catastrophic injury, the wiring kicks right in: ah, back to this, well, I can survive.

The brain is especially plastic as a child. We want to see all children treated well and loved and cared for, but it may be necessary as a species to have a survival back up. What if there is a disaster or a tsunami or a war? How do we adapt? Who survives? What becomes necessary that was unthinkable previously? Children are still growing up in the midst of wars and disasters and the crisis wiring is put in place to help them survive.

Children growing to adults in difficult circumstances work hard to survive and continue to work hard as adults. Dr. Clarke, from the OHSU primary care review, says that the personality characteristics of responsibility and hard work described in my last essay “produce a strong positive response from the world. Over time (sometimes a long time) this tends to overcome the poor self-esteem and eventually produces a major shift in how a person views him or herself. This major shift can be summarized as “I DESERVE BETTER.”

a. Often the individual will decide that they deserve a better partner or a better work environment.

b. Often they will no longer tolerate being treated disrespectfully.

c. Often there is the idea that the individual deserved better treatment when they were children.

d. The first relationship with a supportive, respectful partner may occur at this time. This, too, can be stressful because it is such a change from the past.

e. Resentment or anger about how the individual was treated as a child may be generated at this time though it may not be consciously acknowledged. It is common for the anger to be suppressed because it is an unpleasant emotion, because childhood stress survivors spent years learning how to control emotion and because the anger is often directed at people about who there is still some caring. When there is enough of this anger present it can cause physical symptoms that can be mild or severe or anywhere in between. Many people are unaware of how much anger they have. Highly educated people often have the most difficulty comprehending their level of anger.

f. Imagination techniques to uncover anger: pretending that you are watching a child you care about endure the same environment you did; pretend you are overhearing a conversation between a child you don’t know who suffers as you did and the child’s parent.

g. Often it is during this time of significant change in self-image that physical illness occurs.”*

My hope is that as we learn more about how the brain is wired in childhood and how versatile and adaptable it is, we will also gain understanding of the differences among adults. That we will grow in tolerance and in ability to support growth and healing, rather than judging and rejecting.

*Dr. Clarke has kindly given me permission to quote from his work. This is from his handout at the 46th Annual OHSU Primary Care Review.

Further reading, that I am looking forward to:
They can’t find anything wrong!, by David Clarke, MD. See also http://www.stressillness.com/