A Biopsychosocial Approach With Traumatically Hospitalized Injured Soldiers

1. A Biopsychosocial Approach With Traumatically Hospitalized Injured Soldiers H. J. Wain Ph.D Chief, Psychiatry Consultation Liaison Service Department of Psychiatry, WRAMC Professor in Dept. of Psychiatry, USUHS

2. PCLS • Mission • Military- prepare hospital staff and trainees for wartime scenarios/casualties • Consultation- evaluation, diagnosis, treatment of mental illness in medical-surgical patients • Liaison- education of non-psychiatric peers in psychological issues of their patients and wards • Research- add to literature in primary and tertiary care re psychiatric issues in med-surgical patients • GME- psychiatric and non-psychiatric

3. Immediate Results of Trauma • Nearly all survivors exposed to traumatic events briefly exhibit one or more stress related symptoms. In many instances these symptoms dissipate within a reasonable period of time. Morgan, et.al, 2003 • 20-40% of patients followed 1 year after trauma had a psychiatric disorder. O Donnel et.al. 2004

4. Explosives Gunshots Blood Immobility Recognized body Losses Comments of soldiers Death-Bodies Body parts Observation-witness Separation anxiety Survivor guilt Shooting or not? Previous trauma’s Inaccurate judgement Medical Event Trauma Stimuli

5. Repsonses to Combat • Fear • Persistent Threats • Anxiety • Vigilance • Sleep deprivation • Sympathetic Discharge • Self Inflicted wounds -simulation

6. Fear Worry-Existential Disbelief Prayer Rage Anticipation Concerns about families Need to maintain alertness Dissociation Regression Denial Anxiety Cognitive Distortion Grief Anger Responses to Injury

7. Stresses On Injured And Amputees • Surgical revisions of infected stumps • Painful stumps-Phantom Limb • Poor locomotion and balance • Dexterity • Acceptance-Rejection • Body Image • Sexual ability • Finances-Vocation • Family Issues • Educational Opportunities

8. Amputees • Physical Limitations • Altered body image • Lowered self esteem • Alterations of personal experiences • Social Stigma • Meaning of Loss • Severity of disability varies BKA<AKA<Hand<ARM<HID

10. Individual Soldier’s Responses • “I only felt flesh” • “I don’t want to bleed to death in this hum vee” • “I felt no leg so I picked it up and held it together to my bone” • “I couldn’t believe my arm was gone I was just holding something” • “Are they Still there?” • “My Sgt. brought me here and he was standing with the medic and he just fell over. Damn them they missed it.” • “I thought I was going to bleed to death”. • “I thanked G-D over and over again that he spared me especially when I see the others just trying to breathe to live, I can live without the leg”

12. What Have We Learned To Attempt To Prevent or Decrease Chronic Disabling Psychiatric Stress Disorders Following Tauma?

13. Bookmarks • Lessons learned from Vietnam, Somalia, Kenya • Blackhawk down • Gulf war operations • Traditional debriefing not effective with medical surgical hospitalized injuries • Arlington Hospital Center Washington Hospital Center-WRAMC • Willingness to talk with psychiatry • Sense of relief after visits • Follow-up • Empathic Exposure to Trauma< later occurrences • Relationships with patient helpful while going through crises and in follow up

14. Preventive Medical Psychiatry (PMP) • In order to avoid the stigma associated with a psychiatric evaluation PCLS developed a new designation for intervention with OEF and OIF, we became PMP • Patients are routinely seen without a formal consult • Notes are written under PMP

15. Foster acceptance of MH Decrease stigmatization Some duplicity always looking for dx,symp.tx Use biopsychosocial app Develop Relationship with patients Utilize TIPPS approach Meet The Pt. Where They are: - Facilitate medical tx Advocate for pt. needs Flexible eval. and tx. Re enforce pts adaptive behavior < of disabling PTSD-chronic somatization and other psychiatric dx Liaison with and educate medical staff Support staff and families All patients, are seen as early as possible Sedated and ventilated patients see families - Educate pts. and staff . Research Role of PCLS (PMP)

16. A BioPsychoSocial Approach

18. Therapeutic Alliance conversational tone, empathy, Humor Timing of Intervention Psychotherapy Mechanism of change Internalization Support Normalization Psychotherapy Cognitive Reframing Empathy-Genuiness Meet The patient….... Empathic Exposure Reinforce Assets Personality Style Healthy Defenses Components of Therapeutic Intervention and Prevention of Chronic Psychiatric Stress Disorders (TIPPS)

19. TIPPS continued • Hypnosis • Pharmacology • Management • Education • Families • Staff • Command • BioPsychoSocial Formulation

20. Flexibility is needed Expect the unexpected Help anchor Keep listening Observe Be aware of transference issues Be aware of counter transference issues Think about their trauma Avoid pathologizing Normalize Stabilize Approaches That Facilitate T.I.P.P.S.

22. Treatments • Psychotherapy-Empathic Exposure-cognitive reframing-hypnotic • Hypnotic Techniques • Groups-patients-families • Pharmacotherapy • Follow ups • Numbers for prosthetists • Phone calls post discharge

23. Families they left behind in Iraq-States Anger Boards Startle response Others’ perceptions Sexual concerns Vocational concerns Reserves-Nat Guard-Active Duty Prolonged hospitalization Frequent surgeries Pain-Sleep Changes, some warmer more responsive-critical Specialized treatments Pre morbid styles Hierarchy of patients Appreciation for treatments Themes in some groups

24. Individual Approaches Groups for family Groups for spouses CAPS sees children Meetings with administrators and hospital leadership Case Conferences Grand Rounds Questions about friends and kids E-mail Change of shift grps Suggestions for coping Phone Numbers Support For Medical Staff and Patient Families

25. Follow up and Disposition • PMP becomes advocate for Pts and families • Upon discharge each pt receives phone number to call when leaving hospital grounds • Patients are contacted 30, 90 and 180 days after leaving hospital • Families are given our phone numbers • Satisfaction • Referrals to Mental health resources within pts community • Crises management via telephone

26. H. Wain Ph.D, Chief G. Grammer MD Asst Ch. 5 Housestaff MD 1 Psychology Resident P. Martinez RN C. Miller MSW J. Stasinos MD## D. Cotter MD## E. McLaughlin RN ## M. Oleshansky MD I. Janke MD S. Moran MD R. Kogan MSW R. Ansong A. Arjona C. Deboer PCLS STAFF

27. A Key Point From Research • Preliminary results from PDHAT suggest that although psychiatric symptoms among these injured soldiers rose during the six month follow-up period, overall the rates remained lower than what has been documented in other studies (e.g. Hoge et al., NEJM, 2004)) • Injured soldiers usually have higher psychiatric symptoms than non-injured, “therefore these results are very encouraging and suggests that the preventive psychiatry program (TIPPS) at WRAMC may be effective in preventing or decreasing long term severity and chronicity in this high risk group” (Hogue)

28. Conclusions • First Mental Health Service To See Every Hospitalized Traumatically Injured Patient Without A Formal Consult • Approximately 1125 patients have been seen • Reduced need for emergency psychiatric intervention • Therapeutic Alliance emphasized • Empathic exposure repeated individually and in group • Normalization and Cognitive reframing used regularly • Hypnotic-relaxation techniques utilized

29. Conclusions Continued • Pharmacology used in conjunction with a variety of adjunctive treatments • Need for early involvement with trauma team • Contacts with Treatment team and nursing staff maintained • Contact with Command imperative • Use of PDHAT helps with follow up and screening • Over 1300 pt contacts per month • Need to measure what we have impacted • The Learning Never Stops • “Every Day Above Ground Is A Holiday”