The following article is part of conference coverage from the 2019 American Psychiatric Association Annual Meeting (APA 2019) in San Francisco, CA. Psychiatry Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in psychiatry. Check back for the latest news from APA 2019.
SAN FRANCISCO — Psychiatry Advisor sat down with Elspeth Cameron Ritchie, MD, a retired Army psychiatrist, and Keith A. Caruso, MD, PLC, a forensic psychiatrist in private practice in Tennessee, both experts on posttraumatic stress disorder (PTSD) and 2 of 3 co-presenters of a workshop at the American Psychiatric Association (APA) Annual Meeting, held May 18-22, 2019, in San Francisco, California.
Psychiatry Advisor: Dr Ritchie, can you tell us about your experience working in the Army?
Dr Ritchie: Working in the military, one comes across a lot of individuals with PTSD and traumatic brain injury (TBI) after almost 20 years of war. Some people think of PTSD and TBI as the signature wounds of the war. Others consider the blast to be a signature weapon of the war which can cause PTSD, TBI, but also genital or limb amputation, facial burns, hearing loss, and much more. We have learned a lot over the last 20 years on how to treat these conditions. An important question is how does one differentiate between TBI and PTSD for the purposes of disability evaluation, either in the military, in the Veterans Affairs system, or in the civilian world?
Psychiatry Advisor: Are there imaging findings associated with PTSD?
Dr Ritchie: There are imaging findings associated with severe TBI, but not in most cases of PTSD or mild TBI. These findings may be more relevant in research than in clinical practice. Symptoms, particularly for PTSD, are based on self-reports, which is part of the challenge when trying to figure out what is “real” from what is embellished or heightened, and what is outright malingered.
Dr Caruso: There are preliminary studies that have shown functional magnetic resonance imaging findings in the dorsolateral, prefrontal, orbitofrontal, media-frontal, and anterior cingulate cortices in both TBI and PTSD.
Psychiatry Advisor: Have you encountered issues for the insurance coverage of patients with PTSD or TBI?
Dr Caruso: The workshop we organized here at APA came out of my work as a consultant for a private disability insurer. Most policies have language that terminates benefits for patients after 24 months if they have only been diagnosed with a psychiatric disorder — what is called a “mental and nervous limitation,” whereas patients with a neurological disorder such as TBI would be compensated indefinitely. In an effort to be as fair as I can when reviewing these claims, I started to do some research on my own to figure out how to differentiate these. In the military and in the Veterans Affairs system, it is the opposite: PTSD is a much more compensable injury than are TBIs.
Psychiatry Advisor: What are the tools you use for diagnosis?
Dr Caruso: One of the tools one can use is neuropsychological testing that would help determine whether imaging findings are due to PTSD or TBI. Both disorders are associated with attentional deficits, and deficits in response inhibition and in verbal memory, although the cognitive deficits in PTSD are not as severe as in TBI. A decrement in intellectual quotient, and deficits in visual memory, processing speed, and executive function are more specific to TBI.
Psychiatry Advisor: What treatment options do you use?
Dr Ritchie: There has been a lot of discussion about treatment for PTSD. When I talk to patients, I talk about treatment as being in 3 “buckets.” Two buckets are medication, and therapy — the most widely used type being cognitive behavioral therapy or variants (ie, cognitive processing therapy or exposure therapy). The trouble with medication and therapy is that soldiers and young men and women in general often do not like these approaches. The third bucket includes yoga, meditation, acupuncture, and animal therapy. Some of the medications used for the treatment of PTSD have been approved by the Food and Drug Administration (eg, paroxetine, paxil, and citrullin), but there is a host of medications that are used off-label very effectively.
PTSD is often accompanied by other symptoms (eg, nightmares, hyperarousal, and a fear of getting out of the house). In these patients, treatment can target comorbid conditions using options from the last bucket (ie, yoga, meditation). These methods allow patients to self-regulate their own affect. Patients may be interested in leveraging a technique that they can control. For example, snipers presented with deep breathing as a way to calm themselves down, but also as a way to improve their ability to hit the target, may find this option attractive.
Dr Caruso: After a trauma, an individual may become hypervigilant, and an important goal of the treatment is to get the patient back to a place where they feel more in control over their environment.
For more coverage of APA 2019, click here.
Caruso K, Guina J, Ritchie E. Brain changers: Integration and differentiation of PTSD and TBI in clinical and disability evaluations. American Psychiatric Association Annual Meeting; May 18-22, 2019; San Francisco, CA.