Disclaimer

1
Disclaimer

• For the purpose of this briefing he and she
  are used interchangeably.

2
Vet Center

• Acute Combat Stress
• and
• Post Traumatic Stress
• Bob Nelson, MA
• 4201 Tudor Centre Drive
• Anchorage, Alaska

Robert.Nelson3_at_med.va.gov
3
First Thought

• Its hard to realize that someone may look
  normal,
• sound normal
• and usually act normal,
• but yet not be normal.

4
Before We Start

• It was a long time, but World War II and Korea
  Veterans now come see us.
• It took the Vietnam generation many years to seek
  help and they are still coming in.
• It has taken Desert Stormers over 10 years to
  realize they cant do it by themselves.
• And now we see the same thing happening with
• the veterans of Iraq and Afghanistan.

5
A New Reality

• Time has shown that there is no such thing as an
  un-wounded soldier in war.
• War keep its own score.
• The question is how long will it take you?

6
Facts

• 2003 survey of 756 soldiers serving in Iraq.
• First survey ever taken in a combat zone.

7
Facts

• Stress was found to be low in 77 of the
  soldiers.
• 52 reported low personal morale.
• 72 reported low unit morale.

8
Facts - OIF
Why?

• Constant Alertness Roadside bombs, car bombs
  at checkpoints and insurgent attacks are common
  and growing.
• Source Article, Shannon Hanson, Stress Hard
  to Combat in War published in VFW Magazine,
  June/July 2004

9
Facts - OIF
Why?

• Combat Roles The study found that 82 of the
  soldiers surveyed had engaged in combat. In a
  normal war, only about 15 would be in the
  combat arms.
• Source Article, Shannon Hanson, Stress Hard
  to Combat in War published in VFW Magazine,
  June/July 2004

10
Facts - OIF
Why?

• Peacekeeping stresses The troops were trained
  for combat, but much of their duty has been
  peacekeeping, including riot control and police
  training.
• Source Article, Shannon Hanson, Stress Hard
  to Combat in War published in VFW Magazine,
  June/July 2004

11
OIF Specific Stressors

• 86 received artillery fire.
• 95 reported seeing dead bodies or remains.
• 93 were shot at - small-arms fire
• 77 fired at the enemy.
• 89 being attacked or ambushed
• 86 knew a killed or injured soldier.
• 65 saw dead or injured Americans.
• 69 saw injured women and children and
• were unable to help.
• Source New England Journal of Medicine Study
• Conducted July 1, 2004

12
Facts - OIF

• I dont know if I will ever be able to live a
  normal life again. Its very hard not to be
  stressed out when soldiers are dying every day
  around you.
• Army Sergeant Janice Smith
• Source Article, Shannon Hanson, Stress Hard
  to Combat in War published in VFW Magazine,
  June/July 2004

13
The Culprit

Stress!!

14
All Stress is Not the Same

Eustress - Just enough stress to give you the
power to make changes, learn something new, but
no big deal.

15
All Stress is Not the Same

General - You feel pressure, but its from stuff
that happens regularly late for work, waiting
for a phone call, etc.

16
All Stress is Not the Same
Cumulative - Things are ganging up on you, life
is not fun right now, youre wearing down, whats
next?

17
All Stress is Not the Same
Traumatic - Your life is different, relationships
suffer, you loose sight of who you are, ambition
gone, no future this is a long list.

18
Post Traumatic Stress Disorder

• PTSD a modern day description
  of a very human response to the trauma of combat
  and violence.

19
Civil War
-- Soldiers Heart or Irritable Heart --

• Names describe stress reactions of feeling
  irritated and restless, inability to sleep, and
  fear of returning to combat.
• First time the term syndrome was used also
  called Da Costas Syndrome.

20
World War I
-- Shell Shock --

• Prevailing feelings were that Shell Shock was
  caused by external factors.
• Symptoms Shaking uncontrollably, paralysis,
  confusion, blindness, depression, startle
  reaction to noise, and battle dreams.

21
World War II
-- War Neuroses --

• Prevailing feelings changed it was now thought
  that War Neuroses was caused by internal reasons
  (thoughts). Mental health experts agreed that
  physical fatigue was a new factor.
• When a soldier reacted he was described as going
  psycho.

22
Korean War
-- Combat Fatigue --

• 1952 the first Diagnostic and Statistical
  Manual DSM 1 is issued.
• Post Traumatic Stress (PTS) symptoms were put
  under a class of disorders entitled
• Gross Stress Reactions.

23
Vietnam War
-- Redefined the definition --

• 1968 DSM 2 published, replaced the stress
  reactions with transient adjustment reactions of
  adult life.
• Combat related stress was talked about as adult
  adjustment reaction.
• Symptoms Fear associated with combat and
  manifested by trembling, running and hiding.

24
Post Vietnam
-- New Definition --

• 1976 DSM 3 was published.
• 1980 A new title for combat stress Post
  Traumatic Stress Disorder.
• More common definition a normal reaction to
  an abnormal event.

25
Quick Fact

• More than half of all male Vietnam veterans and
  almost half of all female Vietnam veterans
  about 1,700,000 Vietnam veterans in all have
  experienced clinically serious stress reaction
  symptoms.
• Source VA Post-Traumatic Stress Disorder
  Implications for Primary Care

26
Characteristics of PTSD

• Intrusive Thoughts and Flashbacks
• Replaying military experiences in your mind,
  searching for alternative outcomes.
• The thoughts can come in flashbacks triggered by
  everyday experiences.

27
Characteristics

• Isolation
• Few friends, isolates family emotionally and
  sometimes geographically. Fantasizes about being
  alone (hermit), moving away from problems. No
  one understands me. (Leave me alone!)

28
Characteristics

• Emotional Numbing
• Cold, aloof, uncaring, detached. Constant fear
  of losing control I may never stop
  crying.

29
Characteristics

• Depression
• Helplessness, worthlessness, and dejection.
  Lacks self esteem suffers from insecurity.
  Feels undeserving of good feelings. Problems
  handling life when things are going well may
  sabotage. Feels better (more alive) in chaos
  (adrenalin).

30
Characteristics

• Anger
• Quiet, masked rage which is frightening to the
  vet and to those around them. Sublimating the
  rage against inanimate objects. Unable to handle
  or identify frustrations. Unexplainable,
  inappropriate anger.

31
Characteristics

• Substance Abuse
• Used primarily to numb the painful memories of
  past experiences. Heavy use of alcohol,
  nicotine, caffeine, and other drugs.
• The cure often becomes a bigger problem than
  the problem it was supposed to help dependency.

32
Characteristics

• Substance Abuse
• Ability to function as soldiers, spouses and
  parents is reduced.
• As the addiction progresses alcohol is no longer
  used to make us feel good, but to avoid feeling
  sad (withdrawal).

33
Characteristics

• Substance Abuse
• Signs that problems may be developing
• Drinking to relieve stress
• Drinking alone
• More than 2 drinks 3 times per week
• Losing count of how many drinks

34
Characteristics

• Substance Abuse
• Complaints about drinking from spouse,
  friends, co-workers or supervisors
• Medical problems pancretitis, liver
  disease
• Legal problems DWI, DV assault

35
Characteristics

• Substance Abuse
• Risky behavior driving, working, operating
  machinery, unprotected sex
• Loss of control of drinking
• Increased tolerance to alcohol

36
Characteristics

• Guilt/Suicidal Thoughts
• and Feelings
• Self-destructive behavior. Hopeless physical
  fights, single car accidents, compulsive blood
  donors. Self inflicted injuries to feel pain
  many accidents with power tools. High suicide
  rate.

37
Characteristics

• Guilt/Suicidal Thoughts and Feelings (more)
• Financial suicide. As soon as things are well
  off, doing something to lose it all, or walking
  away.

38
Characteristics

• Guilt/Suicidal Thoughts and Feelings (more)
• Survivors guilt when others have died around
  them. How is it that I survived when others
  more worthy than me died or were severely
  injured?

39
Characteristics

• Anxiety or Nervousness
• Uncomfortable when people walk close behind
  them or sit behind them. Can prefer to have back
  to wall watching the door. Conditioned
  suspicion, trusts no one, high startle response.

40
Characteristics

• Emotional Constriction
• Unresponsive to self - unresponsive to
  others. Unable to express or share feelings,
  cannot talk about personal emotions. Unable to
  achieve intimacy with family, partner, or friends.

41
Quick Fact

• Rates of PTSD will be higher if trauma exposure
  has been more severe. For example, between
  30-70 of POWs will have chronic PTSD.
• Source VA Post Traumatic Stress Disorder
• Implications for Primary Care

42
Relationships

• Wives, Families,
• and Close Friends

43
Main Topics of Concern

• Memories
• Isolation and Alienation
• Emotional Numbing
• Depression
• Anger and Related Emotions
• Over Responsibility
• Enabler/Time Pressure/Blame

44
Main Topics (continued)

• Guilt
• Emotional Explosions
• Denial

45
How About The Children
Darn! Daddy/mommys gone.
46
How About The Children
Darn! Daddy/mommys home.
47
Result

• Secondary Wounding

48
Quick Fact

• Traumatic events that cause PTSD are generally
  high magnitude events that occur suddenly (e.g.
  Improvised Explosive Devices IEDs Ambushes
  unfriendly friendlies) and overwhelm a person
  with fear and helplessness.
• Source VA Post Traumatic Stress Disorder
  Implications for Primary Care

49
What is PTSD

• Symptoms of PTSD can begin within three months
  of the event. For some, however, they dont
  begin until years later.
• (The severity varies with each person and the
  amount of trauma exposure.)

50
What is PTSD

• Symptoms are often grouped into three main
  categories
• Re-living
• Avoiding
• Increased arousal

51
What is PTSD

• Re-living
• People with PTSD repeatedly re-live the ordeal
  through thoughts and memories of the trauma.
  They may also feel great distress when certain
  things remind them of the trauma such as the
  anniversary date of the event.

52
What is PTSD

• Avoiding
• The person may avoid people, places, or
  thoughts or situations that may remind them of
  the trauma. This can lead to feelings of
  detachment and isolation from family and friends,
  as well as a loss of interest in activities that
  they once enjoyed.

53
What is PTSD

• Increased Arousal
• These include excessive emotions problems
  relating to others, including feeling or showing
  affection difficulty falling or staying asleep
  irritability, outbursts of anger, and

54
What is PTSD

• Increased Arousal (more)
• difficulty concentrating, being jumpy or
  easily startled. The person may also suffer
  physical symptoms such as increased blood
  pressure and heart rate, rapid breathing, muscle
  tension, nausea and diarrhea.

Life is lived in a state of hyper-arousal!!
55
What is PTSD

• Hyper-Arousal - Survival

High highs Low lows
56
Quick Fact

• Despite limited American causalities, Operation
  Desert Storm included pockets of trauma
  with intense combat and death by friendly fire.
  
• Included were Scud attacks, the constant threat
  of deadly agents, Road of Death, etc.)
• Source VA Post Traumatic Stress
  DisorderImplications for Primary Care

57
Its Not Only About PTSD

• Major Depression
• Alcohol Abuse (sleep)
• Narcotic Addiction (pain)
• Military Sexual Trauma
• Suicide
• Job loss
• Family dissolution
• Violence towards self and others
• Incarceration

58
What Does This Mean

• WW II 1 out of 5 casualties were psychiatric
• Vietnam 1 out of 3 combat veterans have a
  history of PTSD the 40 factor
• Note Half of these still had PTSD over a
  decade later

59
What Does This Mean to Me

• Gulf War 1 of 10 combat veterans have PTSD (so
  far)
• 1 in 5 in heavy combat

60
OEF/OIF Early Findings

• 10 of soldiers evacuated through the military
  medical center at Landstuhl, Germany had mental
  health issues
• 4,500 OEF/OIF veterans have contacted Vet
  Centers as of March 2004.
• 12 reported symptoms consistent with
  psychological trauma

61
Early Findings

• The Armys Deployment Health Center at Walter
  Reed Army Medical Center reports
• At 3 month follow up, 40 of all casualties
  hospitalized at Walter Reed (including all
  medical and surgical casualties) reported
  symptoms consistent with PTSD

62
Early Findings

• The New England Journal of
• Medicine, July 2004
• Examined mental health problems among 3,671
  Soldiers and Marines 3-4 months after return
  from Afghanistan or Iraq (self reported).

63
Results

• Up to 17.1 screened positive for major
  depression, generalized anxiety or PTSD
• Of those who screened positive for a mental
  disorder, as few as 23 sought treatment

64
And That Means

• Those with a mental disorder
• were twice as likely to report
• concern about stigmatization
• should they report their problems to the
  military, leaving the question
• How many are really out there?

65
How About The
Chain of Command?

• If they report or refer a soldier is the
  soldier stigmatized?
• Does the system really want to help?
• Does the COC hurt the soldier while trying to
  help him?
• Do they lose the services of that soldier?

66
Questions for Soldiers

• 1. Have you had nightmares or thought about your
  wartime service when you didnt want to?
• 2. Have you tried not to think about it or went
  out of our way to avoid situations that reminded
  you of it?

67
Soldier Questions

• 3. Are you constantly on guard, watchful, or
  easily startled?
• 4. Do you feel numb or detached from others,
  from activities, or from your surroundings?

68
Fact

• Mental health professionals realize they are only
  seeing the proverbial tip of the iceberg. Just
  like Desert Stormers, the first crop of OIF/OEF
  veterans pop in for a quick visit and then
  create reasons not to return. After all they
  are young, bullet proof, are going to live
  forever and sure dont need to see a psych or
  deal with their chain of command.

69
Startling Future

• The official estimate is that fully 30 percent
  of current combat warriors are going to have
  mental health issues.
• Quick math thats 3 our of
  every 10.

70
Dont Try To Do This Alone

• Help is available

71
Treatment

• The goal of treatment is to reduce the emotional
  and physical symptoms associated with the PTSD,
  to improve daily functioning and to help the
  person cope with the event that triggered the
  disorder.
• Treatment may involve psychotherapy, medication,
  or both.

72
Treatment

• The magic of the 3Ts
• Time
• Talk
• Togetherness

73
Readjustment Counseling
Keeping the Promise
74
4201 Tudor Centre Drive (Adjacent to Alaska
Native Medical Center) 563-6966
Keeping the Promise
Robert.Nelson3_at_med.va.gov