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17-Mar-22

Obsessive Compulsive Disorder and PTSD Considerations for Screening and Treatment

Obsessive compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) rank among the most debilitating, distressing, difficult and expensive-to-treat mental health conditions. While the two conditions were once considered to be unrelated, accumulating evidence indicates they often co-occur.   Estimated rates of PTSD and OCD co-occurrence range from 24 to 41 percent. PTSD patients with symptoms of OCD appear to exhibit more severe PTSD than those without OCD. Co-morbid OCD and PTSD is particularly challenging to treat. OCD and PTSD commonly occur in people with trauma history. Although the association between the co-occurrence of the two disorders is unclear, some researchers have speculated that obsessive-compulsive behavior may be used to cope with, reduce, and avoid trauma-related stimuli. Assessment Screening and treatment for PTSD are routine in DOD and VA health care systems, however, OCD often goes unrecognized and untreated, or is inadequately treated. A recent study showed that less than half of VA providers could identify exposure and response prevention (ERP) as the frontline treatment for OCD, and less than 25 percent had training in OCD treatment. OCD and PTSD share some symptoms: Feelings of disgust or guilt Recurrent, intrusive memories or thoughts that induce distress Behaviors and actions that reduce or neutralize distress (e.g., rituals, isolation, avoidance) Disentangling the symptoms of OCD and PTSD can be tricky. A clinician may recognize and treat PTSD symptoms but may not identify and address co-occurring OCD. It can further complicate OCD diagnosis that some patients do not exhibit behavioral compulsions such as checking but instead engage in less observable mental rituals. Use of OCD screening and assessment tools among PTSD patients, coupled with availability of training for evidence-based OCD treatment, is essential. Treatment When addressing PTSD it is important for providers to be aware of a potential co-occurrence of OCD and how it may influence treatment. If only one disorder is identified and treated, the failure to consider the other may greatly intensify patient distress. And when both disorders are co-occurring, treatments targeted separately for each can sometimes be counterproductive. ERP treatment is the psychotherapeutic treatment of choice for OCD, while cognitive behavioral therapies (CBTs) such as prolonged exposure and cognitive processing therapy are recommended by VA/DoD clinical practice guidelines for PTSD. However, ERP treatment for OCD has been shown in some cases to be adversely influenced by co-occurring PTSD. Clinicians should assess for both PTSD and OCD in trauma patients to better direct the appropriate combinations of treatments and ensure the overall quality of care. Neglecting to do so can significantly reduce treatment efficacy and contribute to patient distress.  Additional resources The International OCD Foundation is a donor-supported nonprofit organization that provides resources and training for clinicians as well as links to resources for OCD sufferers and their families, including support groups and teletherapy. Although there is no VA/DOD clinical practice guideline for the treatment of OCD or co-occurring OCD and PTSD, you can consult the VA/DOD guideline for PTSD and other relevant links for PTSD treatment. The VA’s South Central Mental Illness Research Education and Clinical Center provides a fact sheet on Examining the Differential Diagnosis Between OCD and PTSD.     Dr. Skopp is a research psychologist at the Psychological Health Center of Excellence West at Joint Base Lewis McChord in Tacoma, WA and an affiliate associate professor at the University of Washington Department of Psychiatry and Behavioral Sciences. Her expertise is in military psychological health research.

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17-Mar-22

Dialectical Behavior Therapy: An Evidence-Based Treatment for Suicide Risk

Clinicians should utilize all helpful strategies at their disposal in order to assist service members at risk for suicide. Dialectical Behavior Therapy (DBT) is one approach to help service members keep themselves safe when they experience suicidal ideation. DBT is recommended in the VA/DOD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for SuicideAssessment and Management of Patients at Risk for Suicide (2019) as an evidence-based treatment for those with suicidal thoughts, attempts, and self-harm behaviors. DBT is a multifaceted approach that includes aspects of Cognitive Behavioral Therapy and teaches skills to address emotion regulation, distress tolerance, and interpersonal effectiveness.1   Since it was first presented in 1993 by Marsha Lineham2 as a treatment for individuals with borderline personality disorder, DBT was adapted for use with additional populations, including service members who are at risk for suicide. DBT teaches effective and accessible strategies for managing emotions and reducing risky behaviors. Once learned, many strategies can be easily practiced by service members.   Providers who are interested in adding to their clinical toolbox to help address suicide risk may seek training in DBT. The training, as well as the treatment regimen, can be time-consuming. Mindfulness is one strategy taught within DBT that is widely accepted by both providers and clients, and can be easily incorporated into clinical work.1 The use of individual interventions outside of the full DBT framework is not necessarily evidence-based and may have limited effectiveness. However, mindfulness-based interventions show promise and have documented benefits to those with suicidal ideation, including veterans.3,4,5   Mindfulness Mindfulness skills are foundational within DBT and facilitate increased awareness of thoughts and emotions.4 It is a form of meditation that is taught within DBT to help service members focus on the present, avoiding rumination of the past or worrying too much about the future.   In the context of suicide risk care, mindfulness can help service members observe their present suicidal thoughts and accompanying emotions without judgment. With guilt and shame so often accompanying and worsening suicidal ideation, the skill allows them to think and feel without further burdening themselves.   Mindfulness is not a practice easily reinforced in our fast-paced, multi-tasking world, and specifically in the daily lives of service members. Many beginners report difficulty remaining focused or getting easily distracted during their meditation practice. Because it may feel foreign at first, basic mindfulness skills should be taught and practiced in session. You can teach basic skills such as the one described below, and once mastered, progress to more advanced skills. Below are some instructions for a basic mindfulness exercise.   Beginner Mindfulness Practice   Instruct the service member to assume a comfortable seated position and take some slow and deep breaths. Have them choose an item object to focus their attention on (You may choose to have some specific items in your office for this purpose. If so, offer these to the service member to choose). Instruct them that as they complete this exercise, it is likely that their attention may wander, and encourage them that, as this happens, they are simply to bring their attention back to the object they are observing.   Instruct them to observe the object and note anything they observe about the item: the color(s), shape, angles, texture, and anything else about the object that makes it unique. You should ask them prompting questions about these and other aspects as a way to guide them through this exercise at first. They should silently note these and continue to do so for a period of time agreed upon by the two of you at the beginning of the exercise (around 5 minutes at first).   When first teaching this skill, be sure to instruct in session and then send the service member home with printed instructions to practice on their own. Try practicing this skill in session until the service member feels they have learned it well enough to use on their own when experiencing suicidal thoughts or feeling overwhelmed. They can use mindfulness to observe their suicidal thoughts without judgment and without acting on them. This strategy can help them to get through moments of heightened risk and set the stage for the use of additional coping skills when in crisis.   For more information:   For additional reading on the utility of DBT for treatment of suicide risk in service members, please review the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for SuicideAssessment and Management of Patients at Risk for Suicide (2019).   References: The Assessment and Management of Suicide Risk Work Group. (2019). VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide. Washington, DC: Department of Veterans Affairs and Department of Defense. https://www.healthquality.va.gov/guidelines/mh/srb/Assessment and Management of Patients at Risk for Suicide (2019) Lineham, M. (2015). DBT skills training manual (2nd ed.). New York, NY: The Guilford Press. Barnhofer, T., Crane, C., Brennan, K., Duggan, D. S., Crane, R. S., Eames, C., Radford, S., Silverton, S., Fennell, M. J. V., & Williams, J. M. G. (2015). Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. Journal of Consulting and Clinical Psychology, 83(6), 1013–1020. Interian, A., Chesin, M.S., Stanley, B., Latorre, M., St. Hill, L.M., Miller, R.B., King, A.R., Boschulte, D.R., Rodriguez, K.M., & Kline, A. (2021). Mindfulness-based cognitive therapy for preventing suicide in military veterans: A randomized clinical trial. The Journal of Consulting and Clinical Psychology, 83(6), 1939-2117. Kline, A., Chesin, M., Latorre, M., Miller, R., St. Hill, L., Shcherbakov, A., King, A., Stanley, B., Weiner, M.D., & Interian, A. (2016). Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans. Contemporary Clinical Trials, 50, 245-252. Dr. Bentley is a licensed professional clinical counselor and contracted subject matter expert at the Psychological Health Center of Excellence. She has worked with individuals experiencing chronic suicidality and has facilitated dialectical behavior therapy groups for women in residential treatment.

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17-Mar-22

Let’s make people experts in their own mental health

Jessica, who experiences Schizoaffective Disorder, discusses her idea of creating distance learning courses for mental health conditions so that people can become experts in their own illnesses.   I have become an amateur sleuth, my investigation mainly centred around psychotic disorders and what we know about them so far. I trawl scientific journals when I have the energy to read (as the so-called negative symptoms of psychosis affect concentration and memory and make reading harder). I have a social media account where I ask other sufferers questions about my symptoms and we share knowledge and experiences like a group of detectives researching the crimes against them by mental illness. This helps equip me with the knowledge I need to have informed conversations with my mental health team. When I first went through psychosis, a condition where you interpret reality differently and experience symptoms such as delusions, hallucinations and disorganised thoughts and speech, I wanted to know everything there was to know about it. Once the delusions were more manageable, I took a Level 2 in Working With People With Mental Health Needs via distance learning at my local college. This course was free as long as I completed it but if I dropped out there was a fee.   It was one of the first steps in becoming an expert in my own illness This course enabled me to start to educate myself on mental health issues and better understand my own. This helps me better manage my psychotic illness and opened my eyes to the struggles of other people with mental health issues too. It was one of the first steps in becoming an expert in my own illness and identifying overlapping illness traits of mental health conditions such as Obsessive Compulsive Disorder (OCD) as well as neurodiverse conditions such as Attention Deficit Hyperactivity Disorder (ADHD). I’m autistic and dyslexic, so as well as having a psychotic disorder (at the moment I have a diagnosis of Schizoaffective Disorder) I am also neurodiverse, which means I have differences in the way I experience, interact with and interpret the world around me. Psychosis has become my autistic special interest.   We need to treat sufferers with respect and encourage people to become experts in their own mental illnesses and neurodiverse conditions. Neurodiverse conditions are highly relevant to mental health because neurodiverse people are often more susceptible to mental health issues.   Understanding your mental health condition can help make the unknown seem more manageable, it can be easier to fight a monster when it has a name and traits you can work to battle. Rather than the general course I took, it feels essential that we develop courses aimed at sufferers in particular, that cover what they will need to know for their meetings with mental health teams to help enhance their treatment. These courses should be easy-to-understand and relatable, perhaps with video interviews with other patients, rather than just clinical descriptions of conditions.   It can be easier to fight a monster when it has a name and traits you can work to battle. When it comes to conditions such as psychosis, there’s a whole world to immerse yourself in when you get diagnosed. From picking up the lingo, such as antipsychotic side-effects akathisia (a movement disorder that makes it hard for you to stay still) and tardive dyskinesia (what a mouthful!) which involves involuntary movements of the face and jaw. I think it’s important to give sufferers the language to help them explain their symptoms as well as a general knowledge of mental health so they can help identity traits from different co-occurring conditions which can be more common with certain mental health issues. There are statistics people might find it helpful to know too, outcomes for their condition and factors, such as substance abuse that make relapse more likely. I believe we need to arm sufferers with the knowledge to help them survive a lifetime alongside their illness.   It’s crucial for us to respect people’s autonomy when it comes to their illness and make them their own best advocate. This is not possible for everyone, and I know that during crisis this would not be possible as many people lack insight or are too unwell to learn about their illness. I also know that some people do not respond well to treatment and deteriorate over time, and are too unwell to be their own advocate, but for the people who retain their independence and are stable, we should trust and empower them to become their own best cheerleader.   Sometimes to get the best treatment, you and your friends and family have to prioritise your own care. These courses could also be useful for curious friends and family members who want to do their best to support sufferers with their illness.   A course like this would need to be developed with lived experience at its heart I believe we need to create courses for mental health issues and symptoms, from Major Depressive Disorder (MDD) to psychosis, which are aimed at educating suffers in their own illnesses and symptoms. A course like this would need to be developed with lived experience at its heart - a panel of people with mental illnesses who are at different stages of living with their illness and different levels of severity giving advice for what they wish they had known before they got ill.   These types of courses might even have positive effects, such as reduced hospital admissions because people would be educated about their illness and could help prevent relapse triggers and discuss medication compliance. They can also help people carve out additional meaning from their recovery journeys as they would have an active role within their own care.  

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17-Mar-22

VETERAN MENTAL HEALTH BOOTCAMP: BEYOND PTSD AND TBI

How much do you really know about veteran mental health? Are you aware that it goes beyond just the common misconceptions that a majority of veterans struggle with Posttraumatic Stress Disorder and Traumatic Brain Injury? Over the past year, I’ve had many discussions with veterans, their family members, and those who serve veterans about this topic. One of the first questions I ask: what is the single biggest challenge that veterans face when it comes to mental health? While the answers vary, the majority of people consider PTSD, suicide, and military transition the largest problem that veterans face.   They’re not too far off base. The more combat veterans there are, the more likely those veterans have experienced a traumatic event. There is a greater chance of PTSD. And many in the veteran community are aware that suicide is an epidemic.   There are certainly struggles in military transition. In my experience, however, not all veterans I work with as a mental health professional are struggling with PTSD, and certainly not PTSD alone. And suicide is a symptom of an underlying problem, not a problem to be solved itself. It’s as if people said, “we must stop people from having a runny nose” or “we have to stop the headache problem.” I’m not minimizing the impact of suicide by trying to make it a trivial symptom, but it is an indicated of a deeper unresolved issue. And struggles in military transition are the result of unresolved problems not the problem itself.   I’ve written on the topic of looking beyond PTSD and TBI before. That series of posts was the genesis of this upcoming project. As I worked with veterans, I noticed that there were some things that they were experiencing that go beyond just PTSD and TBI. These included a lack of purpose and meaning, emotional dysregulation due to learned helplessness, moral injury, and frustration due to an inability to meet their needs after leaving the military. After writing this series of articles, and having discussions about them, I saw a greater need to explain more.   In March of 2017, I was invited to present the keynote address for the Military and Government Counseling Association. I talked about ethics and cultural competence when working with veterans. Essentially, the point was that, if a mental health professional is going to work with a veteran, they need to understand all aspects of the veteran’s mental health needs, not just PTSD and TBI. Similarly, if a veteran was going to address their concerns, they needed to know more about what they are experiencing.   Another point was that the mental health profession is uniquely qualified to help veterans across all of these concerns; yes, we have procedures and protocols to help treat and resolve PTSD. We have interventions to diagnose and support recovery from TBI. We also, however, have theories and interventions that address all of these concerns. If mental health professionals are not looking for them, we are going to use the wrong tool for the job.   Here is an overview of the conceptual framework that the series will cover. Each of the areas that are covered include the indicator of the problem, the problem itself, and the therapeutic intervention or theory that can help alleviate that problem. The internal and external pressures that keep a veteran from addressing these problems are also identified.   Veteran Mental Health Bootcamp In order to provide a deeper understanding of these concepts, I have been putting together a series of podcasts. This series will be released over the next two weeks, addressing each of these topics, and a little bit more. The series will be called Veteran Mental Health Bootcamp: Advanced Training for Your Brain. I have been having conversations with veterans and mental health professionals across the nation about each of these topics, and will be sharing these conversations with you.