Background photo by & © Duane M. Lawrence Operational Psychiatry for IDCs & GMOs Updated May 2013...

Background photo by & © Duane M. Lawrence

Operational Psychiatryfor IDCs & GMOs

Updated May 2013or…

Everything You Wanted to Know from a Psychiatrist but Were Afraid to Ask

Duane M. Lawrence, MD, MS

Lieutenant Commander

(Commander-Select)

Medical Corps (Surface Warfare Officer)

United States NavyDiplomate, American Board of Psychiatry & Neurology

Head, Operational Forces Mental Health Liaison

Directorate for Mental Health, Naval Medical Center Portsmouth, VA

UNCLASSIFIED FOR OFFICIAL USE ONLY


Disclosures• No financial disclosures/conflicts• Nothing in this presentation represents

specific endorsement of or support forany specific product(including generic or “Brand Name”)

• Opinions expressed are solely those of the presenter and not necessarily those of the Departments of Defense or the Navy


Overview:

Common Symptom Patterns

Substance Misuse

Commanding Officers & Mental Health Concerns


Common & Serious Psychiatric Symptom Clusters

Psychosis

ManiaPTSD

TBI


Anxiety

• Most common psychiatric sx cluster• “Unpleasant physical sensations accompanied by

overwhelming thoughts that something horrible is about to happen”

• Common dx’es:– Generalized Anxiety Disorder– Panic Disorder– PTSD & ASD– OCD– Social Phobia– Anxiety D/o NOS– Secondary to General Medical Condition– Substance-induced Anxiety D/o– Adjustment Disorder w/ Anxiety (+/- Depression)


Combat/Operational Stress

• Stress reactions:– Occur in a stressful environment which may

include combat, the threat of combat, high operational temp, body handling, etc…

– Have the potential to keep you alive or possibly shut down completely

• EVERYONE HAS SOME LEVEL OF REACTION: “Expectable Responses”


The “Seven C’s”


• Signs/symptoms:– Insomnia, nightmares– Shaking, problems with fine motor skills– Mind “going blank,” disorientation– Tunnel vision– Loss of hearing– Time distortion– Fear– Avoidance– Loss of bowel/bladder control

• Presence of S/Sx is expectable after trauma and initial adjustment after return and not necessarily pathologic!

Combat/Operational Stress


Diagnostic Criteria for PTSD

• Experiencing a traumatic event threatening the person’s life/limb/person, or directly witnessing such event happen to others

• Reaction of fear, horror, or helplessness• 30 days or more of:

– Re-experiencing aspects of the traumatic event– Avoidance– Increased arousal

• Useful screening and measurement tool:PTSD Checklist – Military Version (PCL-M)


Anxiety:Assessment &Treatment

• Biological– Labs: TSH&T4, CBC, BMP, UA, UDS, STDs, Frac. Metaneph.– Tests: May include EKG, echocardiogram, CXR– Initial Meds:

• For long-term anxiolysis:SSRIs, SNRIs, ATypANs [EXCEPT FOR BUPROPION (which may worsen anxiety)], buspirone (except for panic), TCAs, MAOIs with caution.Screen for manic symptoms first!

• For PTSD-spectrum hyperarousal: prazosin or clonidine• For acute anxiolysis: BZDs (but with CAUTION)

– Treat insomnia and substance issues! (more to follow)

• Psychological:Individual &/0r Group Psychotherapy

• Psycho-social-spiritual:Support groups, family support, pastoral care (Chaplain Corps)


TBI:Traumatic Brain Injury

• Can follow high-explosive blasts, such as:– IEDs, RPGs, Mortars, artillery fire, naval gunfire, etc.

• Mild, Moderate, or Severe• Can cause problems with coordination, decision-

making, task organization, etc.• The brain can be bruised, but it also can heal!• ANAM testing prior to deployment for baseline• “Work-up” might include:

neuroimaging, neuropsych testing, labs• Consults might include:

Neurology, Psychiatry &/or Psychology, OT


DEPRESSION

• “Unpleasant physical sensations with the overwhelming thought that something horrible already has happened”

• Prevalence of 16-25% of US population• Common specific conditions

– Major Depressive Disorder– Dysthymic Disorder

(Chronic Low-Intensity Depression)– Adjustment Disorder with Depressed Mood

(+/- Anxiety)– Secondary to General Medical Conditions– Depressive D/o Not Otherwise Specified

• E.g., Premenstrual Dysphoric Disorder,“Minor” Depression


Depression Mnemonic: “DSIGECAPS”

• Depressed Mood• Sleep problems• Interest (loss thereof/anhedonia)• Guilt (e.g., Survivor’s Guilt; can trigger

hopelessness &/or helplessness)• Energy (low or too much)• Concentration problems• Appetite changes• Psychomotor changes• Safety: Suicidal or Homicidal ideation


Depression:Assessment & Treatment

• Biological– Labs: TSH&T4, CBC, BMP, UA, UDS, STDs– Test: Sleep study, if indicated– Initial Meds:

• SSRIs, SNRIs, ATypANs, TCAs, MAOIs with caution. Please screen for manic symptoms first!

• Most of the above can take 3-8 weeks for the patient to notice benefits (pre-synaptic reuptake inhibition early vs post-synaptic receptor generation later)

– Treat insomnia and substance issues! (more to follow)

• Psychological:Individual &/0r Group Psychotherapy

• Psycho-social-spiritual:Support groups, family support, pastoral care (Chaplain Corps)


Insomnia• In general, sleep disturbance is a SYMPTOM• Treatment principles:

– 1) Identify underlying conditions and tx them– 2) Good sleep hygiene– 3) Good substance hx, including caffeine and supplements!

• Meds:Approved– Non-anxiolytic BZD receptor agonists (zolpidem [Ambien] IR & CR),

eszopiclone [Lunesta], zalepon [Sonata])– BZDs (several approved, all are likely to work), but w/ CAUTION– Ramelteon (melatonin system)

Usually Off-label but MAY be helpful in some cases– Antihistamines (e.g., diphenhydramine)– Sedating antidepressants (trazodone, mirtazapine, TCAs)

Off-label and Used, but with VERY GREAT CAUTION– Sedating neuroleptics (e.g., quetiapine)


ManiaAbnormally & persistently elevated AND/OR irritable mood for

many days, a week, or perhaps more• Common Etiologies:

– Manic-Depression (Bipolar Disorder)• 2-8% prevalence• “1st break” commonly late teens-early 20s

– Substance-Induced– Due to GMC

• Same sx but less intense & less-impairing = “hypomania”– Component of Bipolar D/o, Type II

(Hypomanic-Depression)• Treating a person who is truly suffering from Bipolar illness

(even if presenting depressed) w/ an antidepressant alone runs the risk of “flipping” from depressed to manic!


Mnemonic for Mania:“DIG FAST”

• Distractibility• Insomnia (decreased need for sleep)• Grandiosity (e.g., professional, libidinous,

religious)• Flight of ideas• Activities (increase in goal-directed activities, “too

many irons in the fire”)• Speech is pressured (too fast/loud)• Thoughtless activities (reckless, harmful activities

like spending sprees, promiscuity, dangerous driving, etc.)


Psychosis

• Signs/symptoms:– Hallucinations (any of the senses)– Delusions (persisting false beliefs)– Disorganized speech– Disorganized behaviors

• Common Etiologies:– Schizophrenia/Schizophreniform Disorder/Schizoaffective

Disorder/Brief Psychotic Disorder– Severe manifestation of Mood or Anxiety Disorder– Substance-induced– Secondary to GMC

• Prevalence of Though D/o’s: 1-2% of pop’n• Age of onset of “1st break” of psychosis:

Often late teens-early 20s


Treatment forMania & Psychosis

• PLEASE seek Psych (& likely ED) assistance!• Top Priority: Maintain Safety!!!• Next Priority: Emergent/Urgent “Work-up”

• Labs & Tests: may includeNeuroimaging, UDS, UA, CBC, CMP, STDs, PPD, CXR, thyroid panel, hepatic panel, +/- LP

• Initial meds likely to be mood stabilizing antipsychotics

• LIMDU w/ cPEB referral likely to follow.


Personality Disorders

• Our personality describes the way we learn to interact with our environment, to deal with stress, to establish & maintain relationships.

• PDs hallmarked by firmly fixed and inflexible personality traits so maladaptive asmarkedly to interfere with daily functioning.

• Treatment MAINLY psychotherapeutic (meds may help with some symptoms)

• Can lead to ADMINISTRATIVE SEPARATION recommendation


Malingering• “DIAGNOSIS OF EXCLUSION”

– Very few people who present with a possible Mental Health problem are actually malingering

• If you DO suspect malingering, look at the reason WHY that person may be doing it– Good documentation & collateral information

from chain of command is very helpful

• Leave formal diagnosis of Malingering toMental Health specialists


Substance Misuse, Abuse& Dependence

Alcohol

Illegal Drugs

Caffeine

Nicotine

“Nutricuticals”, includingSupplements“Diet Pills”Body building/muscle enhancing OTCs

Over-the-counter medicines

Prescribed medicines


Substance Use Disorders:Treatment

AlcoholUnit DAPA (USN)/SACO (USMC)Substance Abuse Rehab. Program (SARP)

Illicits: SARP tx offered pre-separationNicotine

Counseling/support organic & @ MTFMeds: Nicotine replacement, bupropion, varenicline

Caffeine:gradual taper to avoid acute withdrawal sxLifestyle modifications/sleep hygiene


COMMANDING OFFICERS & MENTAL HEALTH INFORMATION


Mental Health Issues & Commanding Officers

• General Notification Issues• Command Directed Evaluations• Suicide-Related Events

– Notify CO of emergent referrals– PCR for attempts and completions– DODSER for attempts and completions

• Stigma & Privacy– Commanders strongly encouraged in

sensitivity of PHI and its appropriate handling


Command Notification

DoD Instruction 6490.08– Command Notification Requirements to Dispel

Stigma in Providing Mental Health Care to Service Members, August 17, 2011

– Intent: Promotion of a culture of support in the provision of mental health care and voluntarily sought substance abuse education

– MH Providers directed to follow presumption of non-notification unless overcome by risk of harm, mission-impact, admission, etc.



Command-Directed Mental Health Evaluations

• Governed by:DoD Directive 6490.04

SECNAVINST 6320.24A

Developed to protect both military and DoD civilian personnel from unwarranted referral to mental health with particular concern to prevent retaliation of “whistle blowing”



Fitness for Duty& Administrative Issues

• Small Arms Waiver: OPNAVINST 3591.1F • Limited Duty (LIMDU) versus

Administrative Separation (ADSEP) recommendations– Article18-2 MANMED (LIMDU)– MILPERSMAN 1910-120, -122 (ADSEPS)– Relevant MCOs/MARADMINS for USMC

• DoNCAF Evaluations (Security Clearance)• DoDSERs (Suicide Events)• DSM (IV-TR now, V coming after May 2013)



Questions?

“Hmmm, I know I remember that Psychiatrist said something about…”

• Office/VM: Commercial (from US): (757) 953-6922 DSN: (312) 377-6922

• Mobile (BB): Commercial (from US): (757) 582-6456• Pager: Commercial (from US): (757) 988-

5442• E-mail: [email protected]


Background photo by & © Duane M. Lawrence Operational Psychiatry for IDCs & GMOs Updated May 2013...

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