Tag Archives: military

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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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Go on

I must go on without you
the Beloved opens the path before me
let the past fall behind, the clear parts
and the murky, we alter each memory when we
pull the file in our brain and refile it,
I have duty you see, though I will miss you
terribly and keep inviting you along
as our paths diverge by millimeters
I wonder if you mind perhaps you are relieved
or perhaps you refuse to feel whether you mind
or not, we walk in parallel for now and can still
touch fingertips across the gap, more than
fingertips actually, but not for much longer.
I am still small compared to you yet when I said
to the Beloved that I don’t see how to
carry all of this, my back was infinitely broad and strong
for a period, as if a dream. Kiss me and leave, then,
if you must and I will love you always.

The picture is of early morning fog clearing 1/10/16.

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Adverse Childhood Experiences 7 : Revisiting Erikson

Welcome back, to Adverse Childhood Experiences, and I have been thinking about Erikson’s Eight Stages of Psychosocial Development.

These were mentioned in medical school and in residency. I was in medical school from 1989 to 1993 and in Family Practice Residency from 1993 to 1996. Family Practice is at least half psychiatry, if you have time. We are losing the time with patients in order to achieve “production”. I complained about the 20 minutes I was allotted per patient and was told that I should spend 8 minutes with the patient and 12 minutes doing paperwork and labs and calling specialists. This is why I now have my own practice. A new patient under 65 gets 45 minutes and over 65 gets an hour and my “short” visits are 25 minutes. I am a happy doctor. And on the Boards last year I scored highest in psychiatry….

So, back to Erikson. The first stage, at birth to one year is Basic Trust vs Mistrust. “From warm, responsive care infants gain trust or confidence that the world is good.”

I was taught that people would have to “redo” the stage if they “failed”. Let’s look at that a little more closely.

Take an infant in a meth house. No, really, there are babies and small toddlers that have addict parents, alcohol, opiates, methamphetamines. We do not like to think about this.

A social worker told me that the toddlers from a meth house were really difficult to deal with. They do not trust adults. The first thing they do in foster care is hide food.

Hide food? Well, adults on meth are not hungry, sometimes for 24 hours or more, and they are high. So they may not feed the child.

Now, should this child trust the adult? No. No, no, no. This child is adaptable and would like to survive. So even under three they will learn to hide food. In more than one place. This is upsetting to foster care parents, but perfectly understandable from the perspective of the child.

So has the child “failed” the first stage? Well, I would say absolutely not. The child looked at the situation, decided not to starve and learned not to trust adults and hid food. Very sensible. Adaptive.

Is the child “damaged”? That is a very interesting question. After 25 years of family practice medicine I would say that no, the child is not damaged. However, the child has started out with a “crisis” brain. The brain is plastic, all our life, and so this child did what was needed to survive.

Is the child “sick”? Again, I would argue no, though our society often treats the child as sick. We think everyone should be “nice” and “warm” and “why isn’t he/she friendly?” Well, if you started in an addiction household or a crazy household or a war zone, it would not be a good adaptation to be warm and fuzzy to everyone.

How do we treat the adult? In a warm fuzzy nice world the child would have a foster parent who adored them, was patient with them, healed them and they would be a nice adult. I have a friend who said that foster care was so bad that he chose to live in an abandoned car his senior year rather than stay in foster care. He couldn’t play football because he had to get back to the car and under the layer of newspapers before it got too cold. I am sure that most foster parents are total wonders and angels. But some aren’t.

I have a person who says that he lived on the streets from age 8. He did get picked up and put into foster care. He kept running away. “The miliary loved me because I could go from zero to 60 in 60 seconds.” That is, he has crisis wiring. He is great in a crisis. The military is a sort of a safe place, because it has rules and a hierarchy and stands in for the failed parenting. Expect that then you get blown up by an AED in Afganistan and hello, that makes the crisis wiring worse.

How DO we treat the adult? We treat them horribly. We say why can’t this person be nice. We diagnose them we drug them we shun them we isolate them we as a society discriminate against them deny them and we are a horror.

I get so angry when I see the Facebook posts where people say “surround yourself with only nice people”. Ok, how dare you judge someone? You don’t know that person’s history. You don’t know what they grew up with. How dare they say that everyone should be NICE.

I am a Veteran’s Choice provider. I have 6 new veterans in the last 3 months. I suspect I will get more. They are not “NICE”. They come in suspicious, hurt, wary, cadgy. And I don’t care, because I am not “NICE” either. We get along just fine.

When I run into someone who isn’t “NICE”, I think, oh, what has happened to this person? What happened to them when they were little? What happened to them as an adult? How have they been hurt?

Pema Chodron writes about sending love: to your loved ones, to a friend, to an acquaintance, to a stranger, to a difficult person and to an “enemy”.

Send love. And do something about it. Help at your local school, help families on the edge, help single parents, sponsor a child to a sport if their parents can’t afford it, pay for musical instrument lessons, do Big Brother/Big Sister, become a “grandparent” to a child at risk, be a good foster parent, donate to addiction care….

The photo is from 2007, when my children and I visited their father in Colorado. A stranger in the parking lot took it at our request…..