Mesdames et messieurs, thank you for giving me this opportunity today. It’s quite humbling, as I do not consider myself an expert in quinism. Instead, I’m an expert in operational stress injuries, or OSIs: those diagnoses that arise from the stress of military training and operations, including PTSD, depression, adjustment reactions, and any of the myriad other problems that arise as a result of being thrust into extremely demanding situations.
I’m very pleased that the committee will be hearing from the real experts on quinism. In particular, I have learned much from Dr. Remington Nevin, who has studied quinism extensively, and will be able to teach you much more than I can about the neurological damage that it causes.
I’m here today primarily because I have listened to Veterans. Through doing so, I have learned about the challenges associated with mefloquine, including the difficulty that diagnosing it can represent.
I have worked with Veterans for about 15 years now, and as part of my work, I have completed many psychological disability assessments. For most of these, the issues associated with quinism have not been on my radar. It’s simply not something there’s much awareness of in my field.
To diagnose an operational stress injury, I begin with a clinical interview. I need to understand the Veteran’s presenting symptoms, and I gather a history, so that I can understand how they were functioning before and after the exposure to the military.
I look at the operational history of the Veteran, including what tours they went on, and what traumatic events occurred. We look at physical injuries, including exposure to blasts, as well as any other physical issues which might arise from the rigors of training and deployment.
I review what documentation I might have available (which is often pretty scant), and I administer psychological tests. From these, I’m able to identify the Veteran’s symptoms, and in combination with the history, I can draw conclusions about the diagnosis, and its probable link to military service.
I’d like to take a moment to review the diagnostic criteria for PTSD. You may already be reasonably familiar with these, but please bear with me, as I think it’s worth reviewing them in this context.
The diagnosis of PTSD is rather unique among psychiatric diagnoses. That’s because diagnosis begins not with the symptoms presented by the patient, but with an examination of the event.
Criterion A is directly experiencing, or witnessing, actual or threatened death, serious injury, or violence.
In the course of their careers, many, if not most, Veterans will experience an event which meets Criterion A. However, they don’t all end up with PTSD. They must experience symptoms which arise following the event:
Criterion B requires one intrusion symptom:
• Intrusive memories of the event
• Recurring dreams in which the content or mood of the dream reflects the trauma
• Dissociative reactions, such as flashbacks in which the person feels or acts as if it’s happening
• Intense or prolonged psychological distress at exposure to reminders of the event
• Physiological reactions to reminders of the event
Criterion C requires one avoidance symptom:
• Efforts to avoid distressing memories, thoughts, or feelings associated with the event
• Efforts to avoid external reminders of the event, such as people, places, conversations, activities, or situations
Criterion D references two symptoms of negative alteration in cognition or mood:
• Inability to remember some aspect of the event
• Exaggerated negative beliefs about oneself, others, or the world: “I’m broken,” “No one can be trusted”
• Distorted beliefs about the cause of the event, leading to blame of self or others
• Persistent negative emotional state (fear, anger, guilt, shame)
• Withdrawal from activities
• Feeling detached or estranged from others
• Inability to experience positive emotions
Criterion E references two symptoms of alteration in arousal and reactivity
• Irritability or angry outbursts
• Reckless or self-destructive behaviour
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance
Criteria B through E represent the symptoms of PTSD, and in each case, there should be evidence that the symptom began or worsened following the trauma. In these symptoms, you’ll find the echoes of other OSIs, including depression, or anxiety disorders. Substance abuse can be used to self-medicate and mask many of these symptoms; those who have strong reactions to events that don’t meet Criterion A might be diagnosed as having an adjustment disorder. All of these are common OSIs.
For our purposes, there’s one more important criterion for PTSD: Criterion H says these symptoms must not be attributable to the physiological effects of a substance—such as mefloquine.
That final criterion is pretty close to universal in DSM-5, as it’s found in the diagnostic criteria for most disorders. It’s so common, it’s actually easily overlooked; when you’re dealing with psychological trauma, it’s rare to see someone in clinical practice whose symptoms can be attributable solely to the effects of a substance. In fact, before I’d heard of mefloquine, I was not aware of any substance which could mimic PTSD. And this substance was often prescribed in proximity to a traumatic event.
When we look at the symptoms of quinism, we’re going to see that they mimic many of the symptoms of PTSD and other OSIs.
According to the work of Dr Nevin, the adverse effects of mefloquine can include the following psychiatric symptoms:
• Panic attacks
• Severe mood swings
• Mania (racing thoughts, irritability, paranoia, excessive goal-driven behaviour, euphoria)
• Dissociative symptoms such as derealization and depersonalization
• Sleep disturbance, including terrifying, intense nightmares, or sleep paralysis (an experience like being awake in a body that will not move, often with a terrifying hallucination)
With varying degrees of frequency, all of these symptoms can, and do, present as sequelae to exposure to psychological trauma.
I’m thinking of two Veterans I’ve worked with. Both meet Criterion A for PTSD. Both present with an unusual feature, which I rarely see in OSIs: Hallucinations. Only one was exposed to mefloquine, and he experienced the full prodromal reaction: nights of severe terror, punctuated with what seemed to be auditory hallucinations of animals screaming in the forest surrounding him. Today, he suffers from tinnitus and a persistent auditory hallucination, consisting of mumbling voices, along with other more typical symptoms such as irritability, anxiety, and mood disturbance.
It was years after his initial diagnosis of PTSD that the issue of mefloquine came up—and that was the first time I’d ever heard of the word. I only heard about it because he brought it to my attention.
As we’ve seen, PTSD should not be diagnosed when the symptoms can be explained by the impact of a substance, such as mefloquine. Does this mean that his diagnosis is not accurate? Frankly, it’s possible. But I think the question may be more complex than a simple “yes or no” answer.
One of the challenges in clarifying the diagnostic conundrum is that Veterans may not always be able to accurately reconstruct the order in which events occurred, particularly vague events such as the emergence of a symptom.
Let’s consider a possible timeline: A soldier is deployed overseas, on his first tour of duty; there are no prior exposures to traumas. To prevent malaria, the soldier receives a course of mefloquine; he and his buddies joke about how rough their Friday nights are, after they’ve received the weekly dose of the drug, but they’re either not aware of the risks of continuing to take it, or they dutifully push through. Almost immediately after treatment, the soldier is exposed to a war zone, with all the horrors that entails.
When the subsequent symptoms arise and persist, are they solely due to the mefloquine? Are they solely due to the exposure to trauma?
Soldiers are not always the greatest historians. After years of pushing their emotions to the side, and ignoring discomfort, it can be difficult for them to remember precisely when a symptom arose. In the midst of a war zone, it’s only natural to be anxious, vigilant, and irritable. Years may pass before the psychological injury is assessed. How are we to say whether the symptoms are due to quinism or trauma?
There are some symptoms, more neurological in nature, that might be helpful—things such as difficulty with balance, vision, vertigo, or tinnitus, which do not typically present solely as the result of PTSD. Again, though, these have their own confounding variables—including the impact of blast injuries and concussions.
And of course, if the mefloquine was taken not on the first tour, but after the soldier has already been exposed to chronic trauma, then exposure to mefloquine may or may not account for subsequent symptoms.
The interaction between quinism and OSI may prove to be quite complex. Consider, for example, research on how MDMA, or ecstasy, can help Veterans overcome traumatic memories—in a nutshell, a drug which induces feelings of warmth and compassion, when paired with a traumatic memory, helps to settle the anxiety provoked by that memory, with lasting effects.
Is it not likely that quinism does the opposite—a drug which provokes a chronic state of anxiety, when paired with a trauma, leads to a greater likelihood of PTSD?
In some tragic circumstances, there may be another source of trauma—actions taken while under the influence of the drug could lead to horrific moral injuries. I understand that soldiers in the Airborne Regiment in Somalia were given mefloquine. Imagine being such a soldier. You might find yourself asking how you came to violate your values and your duty by acting violently and illegally. Though it may not meet Criterion A, perhaps the reaction to the drug is a kind of trauma in itself—is there anything more traumatic than having your very self, including your values and your sense of reality, stripped away?
Our understanding of quinism is in its infancy. We have yet to grapple with its impact on the diagnosis, misdiagnosis, overlapping diagnosis, or exacerbation of Operational Stress Injuries, in part because too few of us are sufficiently aware of the need to screen for mefloquine exposure, and subsequent reactions to that exposure.
In our ignorance, we’re also at risk of creating Sanctuary Traumas. A Sanctuary Trauma occurs when someone expects to find help and support, but instead, experiences invalidation and rejection. Research shows that the experience of such injustice can have a severe impact on recovery from physical and psychological injuries.
Therefore, it’s imperative that the Veterans coming forward with stories of quinism have access to well informed case managers and clinicians; and that means we must disseminate what we know, and do the research necessary to learn more, so that we know best how to assess and treat this complex condition.
Certainly, we need to start asking the questions, both as clinicians and researchers. I am grateful that the Ministry is asking the questions that need to be asked. I hope I’ve been of some help to you in that quest. Thank you for your time. Merci.
--Dr Jonathan Douglas
The "RTW" process is a pretty individualized process for me. Question one is always about what the worker feels ready to do—it’s rare for me to be convinced the worker is ready when they don’t think so, and probably rarer still for a resistant worker to make a successful RTW. If the worker is resistant, it's important for the psychologist to understand why, and if appropriate, address the underlying issue. Getting the worker on board is very helpful, if it’s at all possible. RTW should be a cooperative process, and everyone involved needs to recognize that.
On the other hand, we have to struggle with the process of avoidance, and make sure that the worker isn’t giving into an avoidant strategy when they could and should take on more. I think this is a matter of testing the ground prior to RTW—you can get a lot of sense of their readiness from how they handle tasks outside of work, such as shopping, yard work, exercise, social interaction, etc. If I can’t get them going in the community, chances are they're not ready to get going at work. This will also let me know how they are handling any provoked symptoms, and give me a chance to help them to practice coping strategies.
Next we have to consider what they’re ready to take on in comparison to the job demands. A good understanding of what the job entails, and what accommodations are available, is necessary. Personally, I like to leave WSIB up to the task of interacting with the employer as much as I can—the RTW Specialist is a wonderful resource. Workers are often highly anxious around WSIB interaction, so getting the RTWS involved early is important. It can take an incredibly long time to move from “I think we’re ready” to the client walking through the door at work.
Finally, we need to consider restrictions vs. accommodations. A restriction should be that which the worker clearly cannot do. Physical safety to self and others is the top priority here. For example, someone with significant deficits in focus and concentration shouldn't be in a position where a momentary lapse can put someone in danger.
Psychological safety is a more nebulous concept (and more controversial—cf. the concept of “trigger warnings.” How much discomfort is reasonable as we navigate an unpredictable world? How much should the world adjust to our emotional distress? That's a whole other blog post!)
An accommodation is that which the client can do with modification to the task. We need to push workers to experience some discomfort—to the extent that they can handle it. There’s a lot of judgment in that. Some anxiety may be reasonable; a panic attack may cross the line. How is their impulse control when under stress? Will sleep be disrupted by anxiety, pain, or shiftwork, , and if so, how will that impact on their emotional regulation? Will the worker lash out verbally at coworkers or customers? Can adjustments to work demands or schedules be made to mitigate that risk while the worker re-adjusts and continues healing?
Then there's the issue of bias. Underlying the whole thing is the role of the health care professional in an economic system: As we push our client back to work, is that because getting referrals depends on returning workers to work quickly, or because (as I’ve seen) the referral letter specified an arbitrary, a priori expectation of a RTW date? Is it our job to treat our patients, or to ensure that insurers don’t lose money on a claim? Is it our job to get people back to work because work is best for them, or because work is best for the employer, the insurer, our reputations, and our economy? Do we resent those who have access to benefits while others have to work? Does the concept of “milking the system” whisper in our ears, poisoning our perceptions of the disabled worker? Are we just acting as the pawns of The System, believing we’re acting for our client’s best interests when in fact The System is so deeply entrenched we don't see how its influence affects us?
Or, alternatively, are we advocating for our assessment of our client's needs...or for our client’s preferences? Are we afraid of losing the relationship with the client if we push them outside of their comfort zone? Do our hearts bleed in the face of our client’s pain and distress, causing us to want to protect them—but keeping ourselves from pushing them to be all that they can be? (And is all that they can be just another cog in the machine? Aren't other ways of being in the world just as valuable as being a "productive worker"? Is it moral to return a worker, injured in a good job, to work which is less satsifying?)
There may not be a clear answer for many of these variables--the RTW process demands careful assessment, not only of the client, but of my own political and economic biases. The best I can do is communicate as openly and honestly as I can with my client, while standing up not for the client's preferences but for my assessment of their actual restrictions and need for accommodations, and working as co-operatively as I can with all the players--but always with the client's best interests at heart.
Dr Jonathan Douglas
It's so important in the face of these tragedies that we remember: The tragedy of the suicides hits us in the gut, leading to headlines and shock. And they get communicated, quickly and powerfully. This is good, because without the talk of suicide, it's likely that PTSD wouldn't be recognized for the serious injury that it is.
However, it's also true that suicide is still a comparatively rare outcome of PTSD. Far more people survive PTSD than succumb. Some people even grow through the experience of it, even if they're forever changed.
The stories of survival don't sock us in the gut the way the stories of suicide do, and they don't get shared as readily. And our brains aren't wired for statistics--they're wired for experience and narrative. So we tend to think that the thing we hear about more often is more common than it really is.
That can be dangerous, because we can develop a schema about PTSD that says "this diagnosis is fatal." And that can be a self-fulfilling prophesy.
We need to honour this life and mourn this loss, but we must never given in to fatalism. Suicide is the exception, not the rule. Far more people survive PTSD than die from it. And those stories of survival aren't so easy to find.
Take care of yourselves, and keep surviving until you're thriving.
There may be nothing quite so stigmatizing about PTSD as the belief that it's easily faked. People are routinely accused of "milking the system." They assume that faking PTSD is as simple as memorizing the symptoms and reporting them. So how easy is it, really?
I took one of our commonly used psychological tests. This is a measure I know very well. And I set out to fake PTSD, a disorder I know very well. I imagined that I'm trying to present as someone wanting time off work because of PTSD and depression. What would show that I'm really struggling? How would such a person present?
The test I used is designed to not only record people's reported symptoms, but to examine how they approached the test. Were they exaggerating, or minimizing? Do they view themselves especially negatively? How similar are their responses to those of people who are setting out to falsify their results?
I use this test at least once a week. Let's see if I know it well enough to beat the test.
PTSD is unique in psychological diagnosis. Usually when we diagnose somebody, that’s what we’re doing—diagnosing SOMEBODY. But Step One in assigning a diagnosis of PTSD isn’t about the person. We start with the event they were confronted with.
The current version of DSM, the diagnostic manual published by the American Psychiatric Association and most commonly used in North America, defines a traumatic event in this way:
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. directly experiencing the traumatic event
2. witnessing, in person, the event as it occurred to others
3. learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental
4. experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion 4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.
Does this mean that events that do not meet these criteria cannot produce posttraumatic reactions? Absolutely not. People have a wide variety of reactions, both to events that meet the criterion for what we might consider to be the “Big T” Traumas that meet the definition above, and to events that do not meet this definition – those things that I like to call “small t” traumas. However, for a person to be diagnosed with PTSD, the event to which they were exposed must meet this description.
It is important to realize, too, that PTSD is not the only psychological injury that can arise from trauma (whether Big T or small t). Mood disorders, anxiety disorders, adjustment disorders, substance use disorders, and even psychotic disorders can arise as a consequence of events. Where there is a diagnosable condition and significant impairment, which arose as a consequence of an event, we would consider this to be a psychological injury—and PTSD is only one example of such an injury.
Consider, for example, a reaction to the break up of a relationship. Maybe this breakup came suddenly, with no warning. You might respond with numerous reactions to that event, including disruption in sleep, withdrawal, depressed mood, irritability, and anxiety. I do not think anyone could blame you for describing it as a “traumatic” event in your life if, say, you came home to find your partner in bed with your best friend. However, this event would not meet the definition for PTSD. A more likely diagnosis would be an Adjustment Disorder, a reaction to an identifiable stressor which includes one or both of:
· a level of distress which is out of proportion to the severity of the stressor, or
· significant impairment in social, occupational, or other areas of functioning.
Without question, some of the criteria for diagnosing a Big T Trauma involves the use of judgement (for example, what constitutes a “serious” injury?), and lines that may be considered to be somewhat arbitrary: Repeated exposure to traumatic material can produce PTSD. Repeated exposure to traumatic material through electronic media cannot produce PTSD. Repeated exposure to traumatic material through electronic media which is part of a person’s work can produce PTSD.
One gets the impression that some of the lines that get drawn here are based not so much on what we know about people’s clinical reactions to traumatic material as on a concern for how the diagnosis of PTSD can have an impact on extraneous concerns such as employment law and compensation for injuries.
In fact, it’s often important that a trauma therapist be able to interact effectively with the legal system, as so often, psychological injuries end up before the courts or need to be adjudicated by some other third party. If you’re dealing with psychological trauma in the context of such a system, be sure your therapist is comfortable with writing reports, can defend the diagnosis, and will be able to provide convincing testimony in court.
It’s the time of year when our clients are told by their accountants that they should ask us about the Disability Tax Credit.
The concept of disability is easily misunderstood. There’s no universal definition of disability. You might be off on “disability” due to an inability to work; however, that does not mean that the definition of disability used by the DTC would apply.
Psychologists are commonly asked to rate the disability in the Mental Functions Necessary for Everyday Life category. This is defined in this way:
A person is considered markedly restricted in performing the mental functions necessary for everyday life (described below) if, even with appropriate therapy, medication, and devices (for example, memory aids and adaptive aids):
It is important to address what occurs at home or out in the community, not only what occurs in a work or school environment.
An “inordinate amount of time” is defined as taking three times longer than the typical individual to perform the task; and this would have to be true 90% of the time.
As an example, difficulties in memory and concentration, which are common in many of the conditions we treat, could meet the definition. However, most of the people we treat could not meet the definition of “markedly restricted” in spite of having difficulties with memory and concentration. Someone with such a marked restriction could probably not successfully follow through with appointment times and navigating to our office without substantial support from a third party.
Unless you are substantially unable to care for yourself, pose a risk to your own safety without supervision, or are unable to manage your own affairs, it is unlikely that you will meet the bar set by the Disability Tax Credit from a psychological perspective. These conditions must impair your functioning 90% of the time, and be expected to last 12 months or longer, to qualify.
Also, beware of companies that offer to help you receive the DTC. These companies make their money by taking a percentage of what you are awarded, while claiming to help your doctor complete the forms. In reality, such companies are often predatory, and in fact, their practices have forced the government to take a much harder line on the DTC. If you qualify, your health care practitioners can complete the form on your behalf without any input from such companies. You can read about such companies here.
--Dr Jonathan Douglas
Do you have concerns about your child’s learning or progress at school?
Is your child struggling with reading, writing, or math, despite efforts from parents and teachers to help?
Do you notice that your child is working hard but not achieving results at school?
Do you wonder whether your child has learning difficulties that are interfering?
Central Ontario Psychology has a team of psychologists who offer psycho-educational assessments for children and adolescents.
A psycho-educational assessment is an in-depth exploration of an individual’s thinking and learning. Information is gathered for a psycho-educational assessment through in-depth, interviews, consultation with teachers, a review of report cards and other documents, rating scales, one-on-one formal testing, and observations of the child and adolescent.
Using all of the information gathered, a formal report is prepared, documenting results, any diagnoses, and recommendations for home, school, and community. Psycho-educational assessments include a feedback meeting during which the psychologist will discuss the findings and recommendations with parents. This is an opportunity for discussion and questions about how your child or adolescent thinks and learns.
Psycho-educational assessments can be appropriate to understand how an individual thinks and learns at any stage of their school career. We see children in elementary school, high school, and even college and university for psycho-educational assessments.
If you are concerned and want to understand more about your child’s thinking and learning, contact our office to ask questions or book a psycho-educational assessment.
When Kids Worry…
Worry can be a normal and healthy response that everyone experiences at some time or another. Concern or worry about something can help us to pay attention to it, can help kids grow and thrive (for example, the child who worries that she may not complete all her homework will make sure she sets aside enough time to get the work done). But, when kids experience worries and anxieties that are overwhelming and difficult to control, their functioning can be negatively impacted. For example, who struggle with overwhelming worries may withdraw socially, be afraid to try new activities, and cling to their parents. This is when worry becomes a problem and we need to think about how to provide support.
How Can Parents Help?
Some Helpful Resources for Parents:
I recently had the great pleasure of being interviewed by a real hero, @paramedicNat1 herself, Natalie Harris. Natalie is an Advanced Care Paramedic and mental health crusader. She's the author of "Save-My-Life School," about the ongoing process of her recovery. She's also an awesome human being.
I love magic feathers. I’m looking for them all the time. I collect them enthusiastically, and I sometimes incorporate them into my practice. I’m always looking for tricks, techniques, and short cuts that will help my clients keep themselves grounded, sleep better, control their rage and panic, and desensitize their traumatic memories. Hypnosis, eye movement, tapping, deep breathing, mindfulness---whether they’re harnessing dissociation, preventing dissociation, or modulating dissociation, these techniques are all helpful.
I buy devices for neurofeedback, biofeedback, cranial electrotherapy stimulation and even something called a Bio Acoustical Utilization Device. Whether they’re stimulating your brain, training your brain, or just confusing your brain, these devices are all helpful.
Then there’s the biological interventions—pharmaceuticals, neutraceuticals, medical marijuana, aromatherapy. Whether you sniff it, smoke it, or swallow it, these ingestibles are all helpful.
There’s a whole range of “therapeutic” experiences that aren’t traditional psychotherapy, but can be of enormous benefit: Service animals, equine therapy, art therapy, music therapy, outdoor adventures, peer support groups, yoga. Whether they put you in touch with animals, yourself, your body, others, or nature, these experiences are all helpful.
And then there’s a whole range of schools of psychotherapy: CBT, DBT, MI, humanistic, psychodynamic. All provide some guidance to treatment, all depend on a solid therapeutic relationship, and all of them are helpful.
And yet, as much as I love these magic feathers, there’s something I’ve learned:
There’s no magic feather.
Each one of these interventions are helpful. That is, they're enormously helpful for a few, somewhat beneficial for a lot. They're also useless to some, and unacceptable to others no matter how good they are. One person's magic is another person's useless or unacceptable.
Any one of these therapies might have a range of research supporting it, proving that it is an empirically validated technique; or any one of these might be an untested gem, so cutting edge that the research hasn’t caught up to it yet; or any one of these might be dependent almost entirely on placebo (which can be enormously helpful, by the way).
Research shines the light on which technique is going to be most helpful to most people. Research doesn’t shine the light on which technique is going to be the best fit for the person in my office. Research does suggest the most probable place to start. And research definitely informs my practice.
But there’s no magic feather.
And for the vast majority of my patients, overcoming trauma is a long, hard process. Cure really is possible for a few—typically, those with really good lives punctuated by one horrible event. For many others—for example, those with challenging childhoods, or multiple traumatic incidents across many years—change is possible, and sometimes tremendous change is possible, but it’s going to demand patience and hard work.
The vast majority of the work we do in therapy will be evidenced-based, though we might very well use a few magic feathers along the way. I collect as many as I can get my hands on. But as Dumbo learned while clutching his magic feather, he was really the one who learned how to fly all along.
And I don’t have a lot of faith in those who sell magic feathers. As Carl Sagan said, “Extraordinary claims demand extraordinary evidence.”
Treating trauma demands extensive training and knowledge. Anyone who claims that overcoming trauma is fast, easy, and guaranteed is a charlatan.
So keep an open mind about magic feathers…you never know what might prove helpful. But keep an eye on the research (and on your pocketbook), especially when the claims are extraordinary.
And never forget that you are your own magic feather.
--Dr Jonathan Douglas