American College of Physicians Internal Medicine 2012

William C. Menninger Memorial Award Lecture: PTSD and Other Trauma-Related Disorders
AL 003

Faculty
Robert J. Ursano, MD Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients. Clinical questions to be addressed: 1.What psychiatric and behavioral disorders follow traumatic events, disasters, and war? 2.What are predictors of these disorders? Who is at risk? 3.How to treat and care for post traumatic stress disorder and behavioral problems after the trauma.

Posted Date:March 23, 2012

2012 American College of Physicians. All rights reserved. Reproduction of Internal Medicine 2012 presentations, or print or electronic material associated with presentations, is prohibited without written permission from the ACP.

PTSD and Other Trauma Disorders

Robert J. Ursano, M.D. Ursano, Prof/Chair Dept of Psychiatry Uniformed Services University Director Center for the Study of Traumatic Stress

Trauma and Disasters

Human Made
Industrial Accident A id t Hurricane War Terrorism Epidemic

Natural

Psychiatric Responses to Trauma and War

Distress Responses
Change in Sleep Decrease in Feeling Safe Isolation (staying at home)

Anxiety PTSD Depression Resilience

Mental Health/ Illness

Health Risk Behaviors

(changed behavior)

Smoking Alcohol Over dedication Change in travel Separation anxiety

The Past One type of symptomatic behavior associated with depressions, either neurotic or psychotic in type, is suicide. Between July, 1940, and June 1946, there were 2,214 suicides in the Army, 300 of which occurred among officers.1 .these figures represent g g p a sharp drop during the war period from the peacetime suicide rate in the Army. 2 There was also a sharp drop in the number of suicides in the Army in World War

Menninger, K. Psychiatry in a Troubled World. Pp. 166-167, 1948

And we think we have answers

Suicides have always been of special interest to psychiatrists because they represent a symptom of serious maladjustment. It is not surprising that the rate would fall in the Army during the war. There are superficial though valid explanations that the individual makes a major change in his job and relationships, has a new outlook, enlists in a mission of great social importance and distinctions, and becomes identified with a group of like-minded public servants. It is possible that better psychiatric screening and better psychiatric treatment facilities were responsible in some degree for the lowered rate. Probably more important, the war gave many opportunities for the direct expression of aggressive.

Menninger, K. Psychiatry in a Troubled World. Pp. 166-167, 1948

140

Army News Service, http://www.army.mil/-news/2009/03/31/19022-army-vicechief-addresses-suicide-rate-across-army/, March 31, 2009 Jelinek, P., Army suicide rates at record high. Associated Press, 5/30/2008

Active Duty Suicide Rate 2003-2009

Army Health Promotion Risk Reduction Suicide Prevention Report, 2010

Suicide State of Knowledge and Need

Suicide is among the leading causes of death and disease burden around the world. Although there have been significant advances in suicide research as well as increases in the treatment of suicidal people, the rate of suicidal behaviors has not changed as a result

Nock M, et al WHO PLoS 2009

Suicide Ideation
WHO Study: 108,664 respondents from 21 countries

A wide range of mental disorders increased the odds of experiencing suicide ideation ideation.

Nock M, et al WHO PLoS 2009

Yes.. But.. Attempts?

59.2%75.3% of all suicide attempts are associated with prior DSM-IV disorder due largely to the prediction of suicide ideation (60.9%76.1%), much smaller for prediction of the onset of a suicide plan among ideators (0.0% 4.7%), planned attempts among ideators (5.5% 18.7%), unplanned attempts among ideators (10.2% 17.6%)

Nock M, et al WHO PLoS 2009

And who will attempt

After controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts but less than 10% associated these conditions
Nock M, et al WHO PLoS 2009

So it cant be true here? NCS-R (N=9282 US adults)

Depression predicts suicide ideation, but not suicide plans or attempts among those with ideation. Instead, disorders characterized by severe anxiety/agitation (for example, post-traumatic stress disorder) and poor impulse control (for example, conduct disorder, substance use disorders) predict which suicide ideators go on to make a plan or attempt.
Nock M, et al NCM-R Molec Psych 2009

Survival Bivariate models : number of temporally primary lifetime DSM-IV/CIDI disorders and the subsequent first occurrence of a suicide attempt Response variable: lifetime attempt among total sample (n = 5692)

Exactly 1 disorder Exactly 2 disorders E Exactly 3 di d tl disorders Exactly 4 disorders Exactly 5 disorders

3.7 (2.84.9)* 6.8 (4.89.7)* 12 1 (7 8 18 6)* 12.1 (7.818.6)* 16.4 (11.722.9)* 12.8 (7.422.1)*

Six or more disorders 29.0 (19.742.6)

Nock M, et al NCM-R Molec Psych 2009

Percent Screening Positive for PTSD by Number of Firefights

25 20 15 [%] 10 5 0 0 1 to 2 3 to 5 6 to 9 10+

Hoge, et. al., NEJM July 2004

PTSD and Depression in Battle Injured Soldiers (n=613)

Grieger et al 2005, APA mtg

U.S. Army Child Neglect Rates Age 1-2 year olds, 1989-2004
7 6 Rate per 1,000 5 4 3 2 1 0
1 to 2 Years

Treatment Across The Domains of Illness

PTSD Disorder The Glue Self Repair Symptoms Withdawal Nightmares Impairment Of Function Disability Marital Job Job phobic Co-Morbid Conditions Trajectory- Prev of Relapse/Chro Depression Subst Abuse Acute, Chronic, Delayed Recoverying Walker Job Couns. Lg Trm Plan and Asst Hypertension Hyper chol. Life Style Changes (smoking) Nitroglycerin MI ICU Mult.Scler Back Pain

19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04
Years
McCarroll J et al CSTS USU, 2005

Where people seek care

(each month)

Engel: Green et al. Ecology of medical care revisited. NEJM 2001; 344(26):2021-5

Genes and PTSD

1) Serotonin Transporter Gene and Stressful life Events including child abuse predicting risk for depression (Caspi, Sugden Moffitt et al Science 2003) 2) Serotonin Transporter Gene x severity of trauma x level of social support (Hurricane Exposure) predicting risk for PTSD (Kilpatrick, Koenen, Ruggiero et al AJP 2007) 3) FKBP5 x severity of child abuse predicting risk for adult PTSD (Binder, Bradley.. Nemeroff.. Ressler, JAMA 2008) Increased gene expression Decreases Glucocorticoid Receptors leading to increased plasma cortisol)

http://commonfund.nih.gov/epigenomics/

Zhang et al 2007 Ursano et al , Progress in Brain Research 167, 2008

Stein MB & McAllister TW. Am J Psychiatry 2009; 166:768-776

Clinicians Must Consider Both PTSD and TBI

PTSD Flashbacks Re-experiencing phenomenon Attention problems Depression
Irritability

TBI
Headache Nausea vomiting Dizziness

Anxiety

Jaffee et al DVBIC 2008; Chen et al Dep TBI Arch Gen Psych 2008

Barriers to Care and Mental Health Risk*

I would be seen as weak My unit leadership might treat me differently Members of my unit might have less confidence in me My leaders would blame me for the problem It would harm my career
0 10 20 50 24 20 30 40 50 60 70 80 65 31 63 33 59 31 51 Screen pos Screen neg

Agree or Strongly Agree, %

*Participants were asked to rate each of the possible concerns that might affect your decision to receive mental health counseling or services if you ever had a problem. Hoge CW, et al. N Engl J Med. 2004;351:13-22.

Is Stigma Unique to Military?

Lack of perceived need Perceived lack of effectiveness Want to solve on own Unsure where to go Fear of forced hospitalization Stigma
0 24 10 17 20 30 40 50 60 70 80 22 23 40 49 35 Men Women 40 54 68 66 60 66

Agree or Strongly Agree, %

Maybe Less Than One Might Think!

Kessler RC. J Clin Psychiatry. 2000;61(suppl 5):4-12.

Lifetime Probability of Treatment Contact (USA)

Patients Making Treat tment Contact, %

100 95% 90

7% contact within year of PTSD onset and 12-year median delay to first treatment contact
94% 90% 88% 86%

80

70

65%
Panic Disorder Dysthymic Disorder Bipolar Disorder Major Depression GAD PTSD

60

GAD, generalized anxiety disorder. Wang PS, et al. Arch Gen Psychiatry. 2005;62:603-613.

Controversies
or Please answer

1) Debriefing 2) EMDR? 3) CBT? 4) Benzodiazapines? 5) SSRIs? 6) We can prevent PTSD? 7) We should intervene early to prevent PTSD? 8) Psychodynamic Rx is irrelevent to PTSD? ***Prazosin, Virtual Real, DcycloS (alpha adrenergic antagonist)

No No/Yes/No Yes No Yes Yes Early? No

CSTS Books

Practice Guidelines: PTSD/ASD

10