Realities of Combat and Treatment, Combat Stress & Treatment of PTSD in Veterans Returning Home

This product is supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.

Total Veterans and Military in Florida —  Ranks 3rd in U.S. in number of Veterans – 1,683,899 —  Family Members estimated – 1,852,288 —  Percent of Population – 18.8% —  Military (Active, Guard, Reserves) – 109,390 —  Adding families estimated – 120,329 —  Total est. of Military/Veterans and family members

is 3,765,906 (20% of FL pop.)

—  Florida Population – 18,800,000

War Time Data - 2001-20?? —  2.3 million deployed to combat zone

in Iraq and Afghanistan since 2001

—  35,591 Wounded, as of 3 June 13 —  6,676 Killed (hostile and non-hostile) 3 June 13 —  20 % or 300,000 of returning service members

report symptoms of PTSD or major depression ¡  Only 53% have sought treatment (stigma impact) ¡  19 % report possible TBI and 7% report both TBI and PTSD

Trauma – Treatment – Resources —  Military Trauma is complicated by the culture —  Treatment is available, yet stigma is greater —  Mission vs. Treatment —  Multiple Tours —  Constant wartime tempo —  Consequences of Combat —  Military Mental Health, VA Mental Health,

and Civilian Mental Health

Providing Veteran-Informed Services 1. Culture ¡ 

Military & Veteran Training ÷  Experiences ÷  History ÷ 

3. Resources ¡  ¡  ¡  ¡  ¡ 

2. Trauma ¡  ¡  ¡  ¡ 

Combat Trauma Traumatic Brain Injury (TBI) Military Sexual Trauma (MST) Service Hazards

Military and Contract Agencies Veterans Administration (VA) Washington State Department of Veterans Affairs (WDVA) King County Private agencies

Military Culture? —  Culture is the way of life for a society.

As such, it includes codes of manners, dress, language, religion, rituals, norms of behavior such as law and morality, and systems of belief, as well as the arts and gastronomy. —  Cultural Competence refers to an ability to interact effectively

with people of different cultures. —  Developing cultural competence results in an ability to understand,

communicate with, and effectively interact with people across cultures.

Culture = History+Training+Experiences

Service Slang Army:

Aren’t Ready for Marines Yet Air Force Rejected Me Yesterday

Navy:

Never Again Volunteer Yourself

Marines:

Muscles Are Required, Intelligence Not Essential

Air Force: Air Farce or Chair Force Coast Guard: Shallow Navy

U.S. Military Operations and Wars —  U.S. Army ¡ 

14 June 1775

—  U.S. Navy ¡ 

13October 1775

—  U.S. Marine Corp ¡ 

10 November 1775

—  U.S. Air Force ¡ 

8 September 1947

—  U.S. Coast Guard ¡ 

4 August 1790

—  U.S. National Guard ¡  ¡ 

Army Guard Air Guard

1)  2)  3)  4)  5)  6)  7)  8)  9)  10)  11)  12)  13)  14) 

American Revolution War of 1812 U.S. Civil War World War I World War II Korean War Vietnam War Lebanon Operation Just Cause Desert Shield and Storm Restore Hope Allied Force Enduring Freedom Iraqi Freedom

Oath —  I, Scott Swaim, do solemnly swear that I will support and

defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; and that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations and the Uniform Code of Military Justice. So help me God. —  Oath initiated 14 June 1775

Food - MRE

Ranks and Titles —  There are three general categories of rank/rate: ¡  ¡  ¡ 

Enlisted personnel (E1-E9) and Non-Commissioned Officers Warrant Officers (WO1-CW5) Commissioned Officers (O1-O9)

—  All commissioned officers "out-rank" all warrant officers and enlisted

members. All warrant officers "outrank" all enlisted members.

—  There are some operational anomalies:

A brand-new commissioned officer in the grade of O-1, would "outrank" an E-9, Army Sergeant Major. However, any 2nd lieutenant (Butter Bar) stupid enough to unnecessarily "pull rank" on an E-9 would quickly find him/herself having a talk with his/her own boss.

Military 101: Tango Yankee DOD – OEF – Provide Comfort – OIF – TRASH – IED PCS – Noble Eagle – LES – AT – LSA – BCG – DFAC TDY – Bag – 203 – MOS – Head – Speaker Monkey Difac – Ramp – BX – PX – NEX – FOB – HR – LLMF DOS – Cover – Short – 214 – GWOT – TOC Roach CIB – JDAM – B-2 – F-15 – Salad Suit – COP – MRAP Fobbit – Buddha – Fred – Grunt – DPP – Bravo Foxtrot DNIF – FIGMO – BOB – FIDO – 11Bravo – VBIED Digi World – Butter Bar – REMF – SH – ISAF – FNG

Warrior Ethos: The Honor Code “Some say that self-preservation is the strongest instinct of all, not only in humans but in all animal life. Fear of death. The imperative to survive. Nature has implanted this in all living creatures. The Warrior Ethos evolved to counter the instinct of self-preservation. Against this natural impulse to flee from danger.”

Warrior Ethos – Before, During, After —  Sense of purpose

—  Prevent asking for help

—  Identity

—  How does the Warrior

—  Morality —  Belonging —  Honor —  Sacrifice

become the Veteran

—  Suffer in Silence —  Pride in

“Embracing the Suck”

Experience

Djibouti?

In the last 3,421 years of recorded history, only 268 years have not seen war.

Vietnam

OEF/OIF

—  Average age: 58-61

—  Average age: 25-29

—  Out of military 35-45 years

—  Out of military 0-6 years

—  Empty nesters - grandparents

—  Not married or young families

—  Usually 1 combat tour

—  Going to school, work,

—  High risk in all of VN but fewer in —  —  —  —  —  —  —  —  —  — 

direct combat role Married/divorced++ Considering retirement or unemployed /disabled Agent Orange illnesses Severe physical illnesses Few still homelessness Seeking more VA benefits Illnesses & early death 68% have used VA Chronic PTSD Post WW II Generation

—  — 

—  —  —  —  —  — 

AND planning career Living with parents or roommates – homeless by definition More time in war zone, more direct combat participation per person – contractors in support Fewer soldiers = multiple deployments to war zone 45% of vets have used VA Higher wound survival rate High rate of suicide Acute PTSD Gen X and Gen Y

Mottos of Identity: Official and Not-So “That others may Live” “One Shot, One Kill” “Don’t run, you’ll only die tired” “Anytime, anywhere” for per diem “Semper Fidelis” “Uno ab alto” Air Force Identity Crisis “In God we trust; all others we monitor” “The only easy day was yesterday” “Peace is our mission; killing is just a hobby”

Improving your Cultural Competence —  Listen to the Veterans by inclusion and invitation —  Become and create advocates —  Know the resources —  Have a Veteran-friendly agency —  Know the difference between Memorial Day and Veterans Day —  Educate yourself about war/combat trauma —  Don’t be afraid of us —  Develop community partnerships —  Know who gets it!

Portalet at 150°

Now, After

Kyle Haussmann-Stokes, OIF Veteran

Military Trauma Combat Trauma

1.  ¡  ¡  ¡ 

Anxiety Disorder Depression Post-Traumatic Stress Disorder

2.  Traumatic Brain Injury ¡ 

Mild/Moderate/Severe

3.  Military Sexual Trauma ¡ 

Male/Female, Male/Male, Female/Female

4.  Military Service Hazards and Deployment

PTSD, MH, and War Related Issues Among OEF/OIF Since 2002 the number of GWOT Veterans diagnosed with these mental disorders (Nationwide VA) out of the 400,304 seen by the VA: (945,000 of 1,900,000 who have served in OEF/GWOT/OIF/New Dawn) •  •  •  •  •  •  • 

PTSD Depressive Disorders Neurotic Disorders Affective Psychoses Nondependent Sub Abuse Alcohol Dependence Syndrome Drug Dependence

Smoking addiction Vet Center System = Dx PTSD

92,998 63,009 50,569 35,937 27,246 16,217 7,412

48,900 12,000

Reactions to Traumatic Events —  Survival —  Adaption (fight or flight) —  Anxiety and panic —  Depression —  Substance abuse —  Physical illness —  PTSD —  Psychotic reactions

History of Psychological War Trauma 46

Old Testament Biblical Accounts: King David’s search for the best warriors. PTSD-like behaviors. PTSD is very functional in combat. Homer: Iliad (The war trauma); Odyssey (The 10-year homecoming) Shakespeare: Henry IV Part I, iii Railroad Spine: Train wreck law suits in England, 1830-40s American Civil War, 1860s: Soldier’s Heart WW I 1917-1919: Shell Shock WW II & Korean War, 1940s-50s: Combat/War Neurosis Vietnam (1980): DSM–III PTSD

PTSD Criteria: DSM, IV, TR 48

A. Exposure to a “traumatic event” ” (war = many potential traumas) Fearful of actual or perceived threat to life B. Trauma is persistently re-experienced —  Psychological – dreams, memories, distressing recollections, dissociation, re-enactment, flashback, compulsion to repeat trauma —  Physiological – somatic complaints, vivid body memories, pains, when internal, external cues/triggers occur symbolizing trauma C. Persistently engages in avoidance of stimuli associated with the trauma – not present before trauma —  Avoids everything that could or is related to recall of the trauma: movies, crowds, emotions, or situations that might arouse memories, and emotion related to trauma. Restricted range of emotions in self and others. —  Styles of avoidance vary widely: overwork, thrill-seeking, emotional numbing, isolation, drinking, humor, pro-social activism, body building

PTSD Criteria: DSM, IV, TR, cont. 49

D. Persistent symptoms of arousal – not present before trauma Anger, loss of concentration, sleep disturbance, hyper-vigilance, exaggerated startle response E. Duration of at least one month and causing significant clinical distress — Acute type Duration noted for less than 3 months — Chronic type Duration of symptoms more than 3 months — With delayed onset If onset of symptoms is at least 6 months after stressor events

Combat Stress and PTSD

The PTSD Paradox 52

In combat, PTSD-like reactions save your life. —  If you do not learn to pair danger with effective response, you may not come home —  Aggression, overcoming danger, emotional numbing, guided anger, and denial of needs and pain are essential to friendships in combat unit and survival in war/military. These modes of action are not functional in civilian life. —  They are not the basis of civilian relationships, careers, etc. —  Years after coming home, veterans are troubled with trigger events| and complications —  Much of treatment is about triggers and new reactions to triggered responses, de-conditioning the learned behavior. —  Once home, the vet needs to turn off that pair bond S-R

The Second PTSD Paradox 53

PTSD has at least one other odd feature. —  Some vets and others become very good at avoidance of all feelings and painful memories —  With no emotions, trauma sufferers soon become bored, joyless, depressed, without pleasure The result: Sensation-seeking behavior, even re-enactment of original trauma —  Adrenaline-oriented activity and extreme sports —  Risk taking behavior: fast driving, fights, drugs —  Firearms and motorcycles are common for war vets from Laurence of Arabia to OIF/OEF veterans —  Transitional objects, the thrill and illusion of safety

Presenting Problems —  Social Isolation —  Emotional Numb —  Sleep problems: No sleep and/or nightmares/terrors —  Loss of focused motivation —  Forgetfulness, lost in thoughts, dissociated —  Anger, feeling irritable, anxious, “on edge” —  Adrenaline junkie activities —  Alcohol or drugs to sleep or relax —  Depression and Suicidal Ideation —  Loss of libido and emotional/sexual interest

Some PTSD Facts • 

Not everyone one who is deployed develops PTSD (15% - 32%)

• 

Although many (41% - 90%) have readjustment issues, these usually resolve with help within a relatively short time

•  • 

25 - 40% of those with PTSD recover within the first year after trauma exposure

• 

Intensity and frequency of traumatic stress exposure predicts likelihood of PTSD, as well as severity and duration

• 

Duration of symptoms is shorter for survivors who obtain treatment (36 vs. 64+ months)

• 

Those needing treatment usually have many reasons for not obtaining help, usually out of fear of being seen as crazy or weak, or that the military will find out

30 - 50% of those with PTSD do not recover, even after many years

Changes in Cognition — Flashbacks

This symptom of PTSD involves an alteration of consciousness such that the individual believes that he or she is again experiencing the traumatic situation. When having a flashback, survivors with PTSD might commit an aggressive or criminal act while believing that they are in danger again. — Perceived Threat

Even without being in an altered state of consciousness, individuals with PTSD are more likely than those without PTSD to perceive threat toward themselves or others in their environment. Their worldview and belief systems are usually marked by themes of danger and mistrust (7). This manner of perceiving the environment and others may increase the likelihood of committing acts of aggression.

Changes in Cognition, cont. —  Beliefs about Justice

Individuals with PTSD may hold extreme beliefs about justice based on their trauma experiences. Examples of beliefs that might lead to criminal actions include: ¡ 

¡ 

Belief in the need for vigilantism or retribution in order to remedy perceived wrongdoings by others or institutions Disregard for authority or indifference for the law because of prior perceived and actual abuse by authority figures

Psychophysiological Arousal — Anger and irritability

Hyper arousal symptoms are a long-lasting and generalized product of the survival response to "fight" or "flee" when faced with situations perceived to be dangerous (8). Triggering of the "fight" instinct may mean that someone with PTSD is more likely to respond aggressively. — Hyper vigilance

Many individuals with PTSD are always "on guard." This hyper vigilance may be severe enough to represent paranoia, and may lead a person with PTSD to take defensive actions to protect him or herself or another person. — Exaggerated startle response

Individuals with PTSD may react instinctively or impulsively to threatening stimuli with behavioral responses that are exaggerated or extreme. For example, a person with PTSD may instinctively push back aggressively when accidentally jostled in a crowd.

Emotional Reactions — Psychological Distress

Upon exposure to a trauma reminder, individuals with PTSD have heightened distress, which is likely to influence their mental ability to make well-reasoned responses. — Heightened Emotions

Individuals with PTSD have generally high levels of emotions such as anxiety, fear, guilt, anger, shame, and depression. Negative emotions may lead those with PTSD to self-medicate with drugs and alcohol, which in turn can cloud judgment and cause disinhibition. Also, guilt may lead survivors to commit acts that will likely result in punishment, serious injury, or death.

Emotional Reactions, cont. —  Emotional Numbing

At the same time, another class of PTSD symptoms, emotional numbing, may contribute to wrongful or criminal behavior because the sufferer has: ¡  ¡  ¡ 

Diminished empathy for the victim Difficulty feeling remorse for the act Difficulty appreciating the severity and consequences of their behavior

Numbing could also lead some survivors to engage in sensation-seeking behavior in an attempt to experience some type of emotion.

Common Adjustments to Homecoming The following are normal reactions after being in a war zone Feeling emotionally dead or constricted Feeling detached or like you just don’t fit in with others Feeling as if in a daze Severe difficulty relating my experience to others and frustration with others not understanding me like my fellow soldiers did. Feelings of guilt Being irritable and feeling intensely angry Hyper awareness of your surroundings and other people Can’t get to sleep very easily and/or stay asleep Having nightmares and/or strange dreams Poor concentration and memory problems

Stigma “There is a perception among the troops that seeking mental health care means you're weak or a coward, and frankly, we in the military kind of foster that attitude. You're never going to have complete confidentiality in the military system. There is a big hole in the wall of confidentiality that will never close." – Col. Thomas Burke

Evidenced-Based Treatment for PTSD Cognitive Processing Therapy (CPT) Prolonged Exposure (PE) Eye Movement Desensitization and Reprocessing (EMDR)

Cognitive Processing Therapy (CPT) By using the skills learned in this therapy, you can learn why recovery from traumatic events has been hard for you. CPT helps you learn how going through a trauma changed the way you look at the world, yourself, and others. The way we think and look at things directly affects how we feel and act.

— Learning about your PTSD symptoms. — Becoming aware of thoughts and feelings. — Learning skills — Understanding changes in beliefs

Prolonged Exposure Therapy (PE) Exposure therapy is a type of therapy that helps you decrease distress about your trauma. This therapy works by helping you approach trauma-related thoughts, feelings, and situations that you have been avoiding due to the distress they cause. — Education. PE starts with education about the treatment. You will learn as well about common trauma

reactions and PTSD. Education allows you to learn more about your symptoms. It also helps you understand the goals of the treatment. This education provides the basis for the next sessions.

— Breathing. Breathing retraining is a skill that helps you relax. When people become anxious or scared,

their breathing often changes. Learning how to control your breathing can help in the short-term to manage immediate distress.

— Real world practice. Exposure practice with real-world situations is called in vivo exposure. You

practice approaching situations that are safe but which you may have been avoiding because they are related to the trauma.

— Talking through the trauma. Talking about your trauma memory over and over with your therapist is

called imaginal exposure. Talking through the trauma will help you get more control of your thoughts and feelings about the trauma.

Eye Movement Desensitization and Reprocessing (EMDR) EMDR therapy is an eight-phase treatment.  Eye movements (or other bilateral stimulation) are used during one part of the session.  After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist's hand as it moves back and forth across the client's field of vision. 

EMDR.com (EMDR Institute)

Traumatic Brain Injury (TBI) —  Not every blast results in a TBI —  Multiple deployments increase possibility of exposure —  Multiple concussions means longer recovery —  Treat expressed symptoms —  Educate patients about symptoms —  Collaborate with families —  Long-term care? —  PTSD or TBI or Both?

Consequences of TBI —  Physical ¡  ¡  ¡  ¡  ¡ 

Decreased stamina fatigue Headaches Dizziness Sensitivity to light and noise Weakness to paresis of limbs

—  Behavioral-Emotional ¡  ¡  ¡  ¡ 

Irritability Impulsivity Emotional deregulation

(apathy, agitation and aggression)

Depression

—  Cognitive ¡  ¡ 

¡  ¡ 

Slowed processing Impaired attention and concentration Less efficient learning and recall Executive functioning

(reasoning, problem solving, and planning)

—  Treatment ¡  ¡  ¡  ¡  ¡  ¡ 

Inpatient Outpatient Day Treatment Patient and family education Directed Work Compensatory therapies

Where Do I Go and Who Do I Trust?

—  VA

—  CMHC

—  Vet Center

—  Friends

—  Campus Counselor

—  Family

—  Private

—  Fellow Veterans

Resources —  Military and Contract Resources ¡ 

Active and Guard

—  Veterans Administration ¡ 

Veteran with DD 214 Discharge status

—  County Resources ¡ 

Varied by county

—  Service Organizations ¡ 

American Legion, VFW, DAV, Operation Home Front

Veterans Affairs: 1-800-827-1000 —  Disability Compensation —  Burial —  GI Bill —  Housing —  Physical Health Care —  Mental Health and Substance ¡  ¡  ¡  ¡  ¡ 

Inpatient Outpatient Post-Deployment Care Vet Center Counseling Fee for Service

County and Community Resources —  Each County has funds that they utilize for veterans ¡ 

In Florida most of these services are VSO

—  Each area has local service organizations ¡  ¡  ¡  ¡  ¡ 

Veterans of Foreign Wars American Legion Disabled American Veterans Operation Home Front Marine League

In memory of Senior Airman Mark Forester, a U.S. Air Force Combat Controller, who died serving in Afghanistan 29 Sept 10.

Readings and Websites —  After the War Zone, Slone & Friedman —  The Sandbox, G.B. Trudeau —  www.va.gov —  www.ncptsd.gov —  www.BattleMind.org —  www.MilitaryOneSource.com —  www.fdva.gov —  www.milspecvets.com

For More Information Scott R. Swaim, U.S.AFV, LMHC MilSpec Advisory Group, LLC Phone: 206-909-4745 Email: [email protected]