War and Mental Health

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War and Mental Health

• Evan Kanter, MD, PhD
• Staff Psychiatrist, PTSD Outpatient Clinic,
• VA Puget Sound Health Care System
• Assistant Professor, Dept. of Psychiatry
• and Behavioral Sciences, Univ. of Washington
• President, Physicians for Social Responsibility

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Health Consequences of War

• More death and disability than many major
  diseases combined
• Destroys families and communities
• Diverts resources from health services
• Destroys infrastructure that supports health
• Destroys environment

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Source www.childinfo.org
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The role of physicians and other health workers
in the preservation and promotion of peace is the
most significant factor for the attainment of
health for all.World Health Assembly Resolution
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PTSD Assessment and Epidemiology
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Evolution of a Diagnosis

• Civil War soldiers heart
• WW I shell shock
• WW II combat neurosis
• Vietnam posttraumatic stress disorder

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PTSD Diagnosis

• Well established diagnosis valid and useful
• Differentiated from other psychiatric disorders
  by biochemistry, neurophysiology, and
  phenomenology
• PTSD is not the only psychiatric response to
  trauma
• Significant distress or functional impairment
• Duration longer than 1 month
• Acute Stress Disorder questionable validity and
  utility

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Other Traumatic Stress Syndromes

• Mood Disorders
• Other Anxiety Disorders
• Dissociative Disorders
• Somatization Disorders
• Fibromyalgia and Chronic Fatigue
• Disorders of Extreme Stress

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Dissociation

• Defense mechanism employed in response to
  psychological trauma. Splitting or
  compartmentalization of consciousness in order to
  manage overwhelming memories, sensations,
  thoughts or emotions.
• Examples
• Depersonalization out-of-body experience
• Derealization sense of world not being real
• Dissociative amnesia inability to recall
  traumatic event
• Psychogenic fugue
• Dissociative identity disorder multiple
  personality

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Traumatic Event Exposure

• Actual/threatened death or serious injury
  
  threat to physical integrity
  of self or others
• Intense fear, helplessness, or horror

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Reexperiencing (1 or more)

• Intrusive memories
• Nightmares
• Flashbacks
• Triggered psychological distress
• Triggered physiological reactivity

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Reexperiencing
I was still mentally and nervously organized for
War. Shells used to come bursting on my bed at
midnight, even though Nancy shared it with me
strangers in the daytime would assume the faces
of friends who had been killed.
Poet Robert Graves after World War I
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Marine Cpl. James Lis, 21 years old, is worried
that for the rest of his life hell be haunted by
the image A clean-shaven, twentysomething Iraqi
in a white shirt, lying wounded in an alleyway
and reaching for his rifle just as Cpl. Lis
pumped two shots into his head. Every time I
close my eyes I see that guys brains pop out of
that guys headthats a picture in my head that
I will never be able to get rid of.
Wall Street Journal April 11, 2003
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Nothing fixes a thing so intensely in the memory
as the wish to forget it.
Michel de Montaigne
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Nightmares
I havent spent a complete night in bed with my
wife for at least ten years. I always end up on
the sofa. Its safer for herI once threw her out
of bed so hard it broke her shoulder. I thought
there was a grenade come in on us. Another time
I thought she was a Gook, and I had my hands
around her throat before I woke up.
Vietnam veteran in therapy (Jonathan Shay, MD)
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Long have they passd, faces and trenches and
fields, Where through the carnage I moved with a
callous composure, or away from the
fallen, Onward I sped at the time but now of
their forms at night, I dream, I dream, I
dream.
Walt Whitman (served as a medic in the Civil War)
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Dream Bubbles of Smoke and Blood Ray-Paul
Nielsen
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Avoidance/Numbing (3 or more)

• Avoidance of thoughts, feelings, or conversations
• Avoidance of activities places, or people
• Difficulty remembering important aspect of trauma
• Anhedonia
• Detachment or estrangement from others
• Restricted range of affect
• Sense of foreshortened future

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Hyperarousal (2 or more)

• Insomnia
• Irritability or anger outbursts
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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Hypervigilance
I havent really slept for twenty years. I lie
down, but I dont sleep. Im always watching the
door, the window, then back to the door. I get up
at least five times to walk my perimeter,
sometimes its ten or fifteen times. Theres
always something within reach, maybe a baseball
bat or a knife, at every door. I used to sleep
with a gun under my pillow, another under my
mattress, and another in the drawer next to my
bed.
Vietnam veteran in therapy (Jonathan Shay, MD)
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Primary Care PTSD Screen

• In your life, have you ever had any experience
  that was so frightening, horrible, or upsetting
  that, in the past month, you
• 1. Have had nightmares about it or thought about
  it when you did not want to?
• 2. Tried hard not to think about it or went out
  of your way to avoid situations that reminded you
  of it?
• 3. Were constantly on guard, watchful, or easily
  startled?
• 4. Felt numb or detached from others, activities,
  or your surroundings?

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Associated Features

• Depression, suicidal ideation
• Alcohol and drug abuse
• Guilt, shame (commission or omission, survivor)
• Unable to trust, overcontrolling
• Dissociation
• Somatization
• Anniversary Reactions

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Poor Occupational and Social Function

• Unemployment
• Divorce
• Domestic violence and child abuse
• Few or no close relationships
• Extreme isolation

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untreated PTSD can devastate life and
incapacitate its victims from participation in
the domestic, economic, and political life of the
nation. The painful paradox is that fighting for
ones country can render one unfit to be its
citizen.
Jonathan Shay, MD Achilles in Vietnam
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Psychiatric Comorbidity

• 80-100 in community samples, higher among
  treatment seeking
• Major Depression and Dysthymia
• Substance Use Disorders
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Personality Disorders

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Medical Comorbidity

• Typically multiple organ system involvement
  (back pain, headaches, pelvic pain, GERD,
  irritable bowel, cardiac, TMJ, skin, prostate,
  etc.)
• Combat exposure and PTSD associated with
  increased incidence of chronic medical illness
  (cardiovascular disease, arthritis, diabetes)

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Probability of Developing PTSD
Post-Trauma Factors
Pre-Trauma Factors
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Pre-Trauma Factors

• Genetic factors 30 of variance in PTSD symptoms
  in twin studies
• Gender
• Age at time of trauma
• Family/social pathology violence, substance
  abuse, chaotic environment
• Developmental trauma physical/sexual abuse,
  early parental loss/separation

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Nature of Trauma

• Unpredictability and Uncontrolability
• Severity (Intensity and Duration)
• Significant Object Loss
• Human Design vs. Accident
• Relationship of Perpetrator
• Use of Weapon, Physical Injury
• Atrocities, Civilian Casualties, Friendly Fire

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Post-Trauma Factors

• Response of social group stigmatizing,
  invalidating, rejecting, blaming, shaming
• Retraumatizing procedures medical, psychiatric,
  legal, detention
• Medical and psychiatric comorbidity
• Family/social pathologies unemployment, patient
  identity, legal problems
• Refugee displacement

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High Level of Trauma in US

• Trauma Exposure in Americans - 40-70 lifetime
  prevalence in various community samples
• PTSD is NOT a normal response to extreme stress.
  Most trauma-exposed individuals do NOT get PTSD.

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Clinical course of PTSD following rape
Data from Rothbaum and Foa 1993
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25 - 15
W
3M
9M
Years
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Current PTSD Military-Related Trauma

• Cambodian Refugees
  86
• Auschwitz Extermination Camp Survivors
  65
• WWII European Theater Ex-POWs
  20
  
• Israeli Veterans from Lebanon Conflict
  16
• Vietnam Veterans
  15
• Gulf War Veterans
  8
• Veterans stationed in Somalia
  8

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PTSD Prevalence Non-Military Trauma

• Rape
  49.0
• Shot or Stabbed
  15.4
• Mugged, Held up, Threatened with weapon
  8.0
• Badly beaten up 31.9
• Serious motor vehicle accident 2.3
• Fire, Flood, Earthquake, Other natural disaster
  3.8
• Witnessing someone killed or seriously injured
  7.3
  

Data from Breslau, 1998 Detroit Area Survey
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Military Sexual Trauma

• Up to 30 of women veterans report rape during
  military service in national surveys
• 60 of women with MST (includes rape) receiving
  care in VA system had PTSD
• Frequently told not to talk about it and treated
  as if events never occurred
• Number of cases of MST in men similar

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During World War IIAmericas armed forces
lost504,000 men from the fighting effort because
of psychiatric collapse enough to man fifty
divisions. At one pointpsychiatric casualties
were being discharged from the U. S. Army faster
than new recruits were being drafted in.
Lt. Col. David Grossman On Killing
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They were in a constant state of potential
panicchildlike anger and anxiety without reason
were provoked by anything too sudden or too
intense What impressed me most was the loss
in these men of a sense of identityit was as
if, subjectively, their lives no longer hung
together and never would again.
Erik Erikson Childhood and Society
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Iraq and Vietnam - Similarities

• Not knowing who the enemy is
• Feeling like you have been lied to
• Front line is everywhere
• Inadequate training or preparedness
• Civilian casualties
• Friendly fire

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Iraq and Vietnam - Differences

• Supportive homecoming
• Greatly improved understanding of readjustment
  problems and traumatic stress disorders
• Early recognition and effective treatment

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RAND Study

• Returning veterans from Iraq and Afghanistan
• 14 PTSD
• 14 Major Depression
• 19 Traumatic Brain Injury
• 1/3 had 1 of 3 conditions
• 5 had all 3
• gt1,600,000 deployed
• 300,000-400,000 psychiatric casualties

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Multiple Deployments

• gt500,000 with 2 or more deployments
• Most important risk factor is intensity and
  duration of trauma (dose response)
• Increased risk of PTSD and increased severity of
  symptoms