References

1. Stahl SM, Psychosis and Schizophrenia, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 247–3262. Stahl SM, Antipsychotic Agents, in Stahl’s Essential Psychopharmacology, Cambridge University Press, New York, 2008, pp 327–4523. deKoning MB, Bloemen OJN, va Amelsvoort TAMH et al. Early intervention in patients at ultra high risk of psychosis: benefits and risks. Acta Psychiatrica Scand 2009; 119: 426–424. Stahl SM, Prophylactic antipsychotics: do they keep you from catching schizophrenia? J Clin Psychiat 2004; 65: 1445–65. McGorry PD, Nelson B, Amminger GP et al. Intervention in individuals at ultra high risk for psychosis: a review and future directions. J Clin Psychiatry 2009; 70: 1206–126. Cornblatt BA, Lencz T, Smith CW et al. Can antidepressants be used to treat the schizophrenia prodrome? Results of a prospective-naturalistic treatment study of adolescents. J Clin Psychiatry 2007; 68: 546–577. McGlashan TH, Zipursky RB, Perkins D et al. Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis. Am J Psychiatry 2006; 163: 790–98. Seidman LJ, Guiliano AJ, Meyer EC et al. Neuropsychology of the prodrome to psychosis in the NAPLS consortium. Arch Gen Psychiatr 2010; 67: 578–889. Lencz T, Smith CW, McLaughlin D et al. Generalized and specific neurocognitive deficits in prodromal schizophrenia. Biol Psychiatr 2006; 59: 863–7110. Howes OK, Montgomery AJ, Asselin MC et al. Elevated striatal dopamine function linked to prodromal signs of schizophrenia. Arch Gen Psychiat 2009; 66: 13–2011. Stahl SM, Mood Disorders, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, chapter 11, pp 453–51012. Stahl SM, Clozapine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 113–813. Stahl SM, Escitalopram, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 171–514. Stahl SM, Valproate, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 569–74

Patient FileThe Case: The soldier who thinks he is a “slacker” broken beyond all repair after 3 deployments to Iraq

The Question: Are his back injury and PTSD going to end his military career?

The Dilemma: Is polypharmacy with 14 medications including multiple opiates, tranquilizers and psychotropics the right way to head him towards symptomatic remission?

Pretest Self Assessment Question(answer at the end of the case) What proportion of deployed soldiers and marines return from Iraq/Afghanistan with a psychiatric disorder (depression, PTSD and/or substance abuse)?

A. 5%

B. 10%

C. 15%

D. 20%

Patient Intake 39-year-old army sergeant

Complains of:– Dizziness– Frequent severe headaches– Memory loss– Nervousness– Habitual stammering– Flashbacks and recurrences of images from the war– Being emotionally distant from others– Nighttime awakenings from nightmares– Bilateral knee pain– Low back pain

Social and Personal History Married 7 years, 2 children

Smokes cigarettes: one pack a day

Was a party drinker 5 years ago prior to deployments, no drinks available in Iraq

Now is binge drinking when angry or when out with buddies one to three times a week

No other drugs except prescription drugs given to him by medical professionals

Medical History None except for current injuries

Mild allergies

Family History No known psychiatric illnesses in first degree relatives

Psychiatric History: Initial Primary Care, Orthopedic and Psychiatric Evaluations Soldier served 3 tours of duty in Iraq, 42 out of 60 consecutive months, prior to returning home for the third time 12 months ago

No medical or mental health contacts between previous tours

No mental health contacts in combat theater overseas

Saw a primary care provider for bilateral knee injuries and lower back pain once he returned 12 months ago

Noted by primary care provider then to have orthopedic injuries but also appeared with a flat facial affect and numerous emotional symptoms as noted above

Additional history is that he is married and has 2 children ages 6 years and 8 months, the first one born just before his first deployment and the second one born during his third deployment

Doesn’t feel he knows his children or has any real connection with them yet

Initially referred to orthopedics and started physical therapy

After several weeks, began drinking heavily

Arguing with spouse, verbally threatening

After a few months back in the US, referred to psychiatrist who assigns him a few months later to the Warrior Transition Unit (WTU) for wounded soldiers on his base; thus he avoids his fourth deployment back to Iraq

This new assignment makes him feel like a loser who is broken beyond all repair and that his combat buddies will just think he is a “slacker” too weak to “man up” and get on with his life

Will stay in the WTU with the only assignment being “to heal” for several months while the army decides what to do with him

Now has a primary care provider, a nurse case manager and a fellow soldier (member of the “cadre”) all assigned to his case in the WTU

Sees an orthopedic specialist occasionally

Has numerous counselors/therapists

Has been in this unit now for 8 weeks

Goal is to return to duty in 6 months or to be medically discharged if not fit for duty by then

Medication History Gets his pain medications from his primary care provider

Gets his headache medications from a private doctor off base

He also sees an army psychiatrist on base for psychotropic medications:– Piroxicam (Feldene) 20 mg per day– Fexofenidine (Allegra) 180 mg per day– Midrin (Isometheptene Mucate 65 mg, a sympathomimetic amine; Dichloralphenazone 100 mg, a mild sedative and Acetaminophen 325 mg, an analgesic) for his headaches– Valproate 500 mg at night– Seroquel 125–150 mg at night and 25 mg every 6 hours as needed for irritability– Clonazepam 0.5 mg three times a day as needed– Bupropion SR 150 mg per day

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, 7 Months Post Intake to the Warrior Transition Unit Current Treatment Plan:– Physical therapy twice weekly– PTSD group counseling weekly– Anger management class weekly– Psychologist counseling weekly– Social worker counseling weekly– Occupational therapy visits twice, and then as needed– Weekly nurse case manager meetings– Daily contact with cadre– Primary care physician visits as needed– Psychiatry med checks monthly– TENS (Transcutaneous Electrical Nerve Stimulation) unit for low back pain– Medical board process to determine discharge status initiated

Current Medications Fexofenidine (Allegra) 180 mg per day for allergies from off base private physician

Citirizine (Zyrtec) 10 mg at night to help with sleep from army primary care physician

Piroxicam (Feldene) 20 mg per day for knee and back pain from army orthopedist

Cyclobenzaprine (Flexeril) for low back pain and spasm from army orthopedist

Ergotamine (Cafergot) for headaches from off base private physician

Oxycodone for pain from headaches, knee pain and back pain from army primary care physician

Vicodin for pain from headaches, knee pain and back pain from off base private physician

Topiramate (Topamax) for headaches from army psychiatrist

Venlafaxine (EffexorXR) 75 mg for PTSD from army psychiatrist

Bupropion (Wellbutrin SR) 150 mg per day for depression from army psychiatrist

Prazocin (Minipress) 2 mg twice a day for PTSD from army psychiatrist

Valproate 500 mg at night for headaches from off base private physician

Clonazepam 0.5–1.0 mg three times a day for PTSD from army psychiatrist

Seroquel 125–150 mg at night and 25 mg every 6 hours as needed for irritability and PTSD from army psychiatrist

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued Had received neuropsychological testing, with results consistent with PTSD

Continues intermittent abuse of alcohol

Sometimes takes more opiates than prescribed and sometimes takes opiates when he binges on alcohol

Calls cadre liaison two-to-three times a week complaining of fighting with spouse

Withdrawn and feels no emotional attachment to family

Attends his therapy sessions

Appears to be compliant with his medications

Rates his back and knee pain as 6/10 (10 worst)

Continues having frequent nightmares but can now sleep through them

Working in a gun department of a sporting goods shop off post

Risk status upgraded 2 weeks ago by psychiatrist

Based on just what you have been told so far about this patient’s history and symptoms, what do you think will be his likely outcome?

Rejoin his unit for a fourth deployment

Continue his military career in another capacity

Be “boarded” out of the army

Be given access to veterans medical benefits

Be given a military medical disability pension

High risk of suicide

High risk of divorce

High risk of alcohol dependence/substance abuse

Find satisfactory civilian employment back in his home town

Have a smooth transition back to civilian life if boarded out of the army

Other

Case Debrief Combat and repeated deployments have taken a heavy toll on this soldier

It is not known what his outcome was, but probably was discharged from the army and not certain if he will receive military benefits

Has PTSD and chronic pain, and remains a high risk patient

Needs coordination of his therapy and medications once he leaves the army with fewer medications and alcoholism treatment with cautious or no use of opiates

Prognosis for full recovery would seem to be guarded

Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case – Military and PTSD

– Psychotherapy and medications for PTSD

Table 1: Military Personnel: A population at psychological risk Separation from family

Combat and threat to life

Witnessing destruction and death

Access to weapons

Adjustment to deployment and then to re entry

One in five with a mental illness post deployment (PTSD, depression and/or substance abuse)

Record rates of suicides

Barriers to mental health care

Insufficient numbers of mental health professionals in the army

Stigma for getting care

Most of the cadre in Warrior Transition Units think that most of the soldiers with PTSD are faking or exaggerating

PTSD likely to present with a number of physical symptoms, especially pain– Abdominal, muscle, joint, head pain– TMJ (temporomandibular joint) pain– CWP (chronic widespread pain)

Figure 1: More combat exposure increases the risk of PTSD. Risk for PTSD may increase with greater exposure to combat (i.e., being shot at, knowing someone who was killed, killing another individual). In fact, a linear “dose response” relationship exists between number of firefights a soldier or marine has been in, and the prevalence of PTSD

Figure 2: Psychotherapy options for PTSD. Numerous psychotherapies are being studied in PTSD, with exposure therapy the best documented to have the most robust results, in some cases with effect sizes bigger than medications

Table 2: Exposure therapy for PTSD Involves exposing the patient to feared stimuli associated with the traumatic event for repeated and prolonged periods of time.

Several forms of exposure therapy:– Imaginal, which involves repeatedly recounting traumatic memories– In vivo, which is exposure to feared stimuli in real life– Interoceptive, which involves experiencing feared physical sensations.

Combining multiple types of exposure therapy is generally most effective.

Exposure therapy can target– Reexperiencing symptoms (by reducing fear associated with thinking about the trauma)– Avoidance behaviors (by reducing fear associated with confronting trauma-related stimuli that are not actually dangerous)– Reduction of general hyperarousal.

In addition, by increasing the patient’s perceived control over fear, this can facilitate processing of the traumatic memory (help patients “make sense” of it)

Table 3: Cognitive behavioral therapy for PTSD A structured form of psychotherapy that includes– Behavioral modification strategies– Cognitive therapies.– Involves exposing the patient to feared stimuli associated with the traumatic event for repeated and prolonged periods of time.– Intended to help patients learn new responses to life situations

Most if not all patients with PTSD should have CBT as part of their treatment regimen

Table 4: Cognitive restructuring therapy for PTSD Patients learn to evaluate and modify inaccurate and unhelpful thoughts (e.g., “It was my fault”)

Adjusting how one thinks about a traumatic event can presumably alter one’s emotional response to it

Particularly seems to help address emotions such as shame and guilt

Can be used alone but is often used as an adjunct to exposure therapy

Six main steps of cognitive restructuring:– Identify a distressing event/thought– Identify and rate (0–100) emotions related to the event/thought– I dentify automatic thoughts associated with the emotions, rate the degree to which one believes them, and select one to challenge– Identify evidence in support of and against the thought– Generate a response to the thought using the evidence for/against (even though evidence for, in fact is less than evidence against) and rate the degree of belief in the response– Re-rate emotion related to the event/thought

Table 5: Stress innoculation training for PTSD An anxiety management approach in which patients learn:– Relaxation– Assertive communication skills– Thought stopping (distracting oneself from distressing thoughts)– Guided self-dialogue (replacing irrational negative internal dialogue with rational thoughts)

Table 6: Eye movement desensitization and reprocessing (EMDR) for PTSD Patients recount traumatic experiences while focusing on a moving object (e.g., the therapist’s finger)

With the intention that this facilitates the processing of the traumatic memory

Empirical support for this approach, though not as much as for exposure therapy and cognitive restructuring

Table 7: Acceptance and commitment therapy (ACT) for PTSD Involves acceptance of thoughts and anxiety as experiences that a person can have while still living a life in accordance with one’s values

Table 8: Seeking safety therapy for PTSD A technique specifically developed for individuals with substance abuse and trauma histories

An integrated treatment approach in which both PTSD and substance abuse are addressed simultaneously

Main goal being to help patients attain safety in their lives (in terms of relationships, thought processes, behaviors, and emotions)

Offers 25 treatment topics based on four content areas: cognitive, behavioral, interpersonal,and case management

Can be customized for each individual patient, using whatever combination of treatment topics that best suits the patient’s needs

A clinician guide and client handouts are available for each treatment topic

Table 9: Motivational interviewing for PTSD Patient-focused counseling with the direct goal of enhancing one’s motivation to change by helping explore and resolve ambivalence (e.g., “I want to stop smoking, but I’m afraid I’ll gain weight’)

Originally developed to help individuals with problem drinking but can be used in the treatment of patients with other forms of substance abuse and dependence

The clinician is a facilitator, helping the patient identify, articulate, and resolve his or her own ambivalence without direct persuasion, confrontation, or coercion.

Figure 3: Psychopharmacologic options for PTSD First line medications include SSRIs and SNRIs with only paroxetine and sertraline specifically approved by the FDA for PTSD

Limited evidence for any other medications as monotherapy for PTSD and most medications leave patients with residual symptoms

Second line treatments include the anticonvulsants gabapentin, pregabalin, benzodiazepines (to be used with caution because of possible substance abuse), TCAs (tricyclic antidepressants) and MAOI (monoamine oxidase inhibitors). Adjunctive treatments include naltrexone and acamprosate for concomitant alcohol abuse and dependency; mirtazapine, hypnotics, atypical antipsychotics (SDAs are serotonin dopamine antagonists and DPAs are dopamine partial agonists), lamotrigine, topiramate, the alpha1 antagonist prazosin for nightmares, trazodone and doxepin.

Posttest Self Assessment Question: Answer What proportion of deployed soldiers and marines return from Iraq/Afghanistan with a psychiatric disorder (depression, PTSD and/or substance abuse)?

5%

10%

15%

20%

Answer: D