PTSD in Vets and CIT

1
PTSD in Vets and CIT

• Lt Col (Ret) David N Lombard, PhD
• Psychologist
• Center for Applied Behavioral Studies
• David_at_davidlombard.com

2
Outline

• A brief history
• Definition of PTSD
• PTSD in Soldiers and veterans
• Suicide
• Suicide in Soldiers and veterans
• Suicides by police (suicide by cop)
• Therapies
• Response and De-escalation

3
A Brief History of Psychological Reactions to
War

• World War I--shell shock, over evacuation led
  to chronic psychiatric conditions
• World War II--ineffective pre-screening, battle
  fatigue, lessons relearned, 3 hots and a cot
• The Korean War---initial high rates of
  psychiatric casualties, then dramatic decrease
• Principles of PIES (proximity, immediacy,
  expectancy, simplicity)
• Vietnam
• Drug and alcohol use, misconduct
• Post Traumatic Stress Disorder identified later
• Desert Storm/Shield
• Persian Gulf illnesses, medically unexplained
  physical symptoms
• Operations Other than War (OOTW)
• Combat and Operational Stress Control, routine
  front line mental health treatment

4
Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn

• Numerous stressors
• Multiple and extended deployments
• Battlefield stressors
• IEDs, ambushes, severe sleep deprivation,
• Medical
• Severely wounded Soldiers, injured children,
  detainees
• Changing sense of mission
• Strong support of American people for Soldiers
• Major Focus of senior Army Staff
• Numerous new programs developed to support
  Soldiers and Families

5
The Military since 9/11

• Volunteer Military
• Know they are going to war
• Seasoned, fatigued
• Large Reserve Component
• Reserve, National Guard
• Elevated suicide rate
• Wounded Soldiers
• Effects on Families
• Continuous deployments
• Families of deceased
• Families of wounded
• Difficult Economy

6
Range of Deployment-Related Stress Reactions

• Mild to moderate
• Combat Stress and Operational Stress Reactions
  (Acute)
• Post-traumatic stress (PTS) or disorder (PTSD)
• Symptoms such as irritability, bad dreams,
  sleeplessness
• Family / Relationship / Behavioral difficulties
• Alcohol abuse
• Compassion fatigue or provider fatigue
• Suicidal behaviors
• Moderate to severe
• Increased risk taking behavior leading to
  accidents
• Depression
• Alcohol dependence
• Completed suicides

7
PTSD DSM IV Diagnostic Concept

• Traumatic experience leads to
• Threat of death/serious injury
• Intense fear, helplessness or horror
• Symptoms (3 main types)
• Reexperiencing the trauma (flashbacks, intrusive
  thoughts)
• Numbing avoidance (social isolation)
• Physiologic arousal (fight or flight)
• Which may cause impairment in
• Social or occupational functioning
• Persistence of symptoms

mTBI may be associated with PTSD, especially in
the context of Blast or other weapons injury
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DSM 5 Definition of PTSD

• Removes Criterion A-2
• Additional criteria
• Somatic reactions
• Sleep
• Depressive symptoms
• Anger and irritability

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National Center for Post Traumatic Stress
Disorder Statistics

• 7.8 of Americans experience PTSD
• (
• Women 2X risk
• 30 of combat veterans experience PTSD
• Approximately 50 of Vietnam veterans experience
  symptoms
• Approximately 8 of Gulf War veterans have
  demonstrated symptoms

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PTSD Stressors

• Violent human assault
• Natural catastrophes
• Accidents
• Deliberate man-made disasters

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Symptoms of PTSD

• Recurrent thoughts of the event
• Flashbacks/bad dreams
• Emotional numbness (it dont matter) reduced
  interest or involvement in work our outside
  activities
• Intense guilt or worry/anxiety
• Angry outbursts and irritability
• Feeling on edge, hyperarousal/ hyper-alertness
• Avoidance of thoughts/situations that remind
  person of the trauma

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Duration of PTSD

• - To meet criteria for PTSD, symptom
  duration must be at least one month
• Acute PTSD duration of symptoms is less than 3
  months
• Chronic PTSD duration of symptoms is 3 months
  or more
• - Often, the disorder is more severe and lasts
  longer when the stress is of human design (i.e.,
  war-related trauma)

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Potential Consequences of PTSD

• Social and Interpersonal
• Problems
• - Relationship issues
• - Low self-esteem
• - Alcohol and substance abuse
• - Employment problems
• - Homelessness
• - Trouble with the law
• - Isolation

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Comorbid/Coexisting Problems

• Veterans with PTSD are also at risk for
• Depression and Anxiety
• Substance abuse
• Spectrum of severe mental illnesses
• Aggressive behavior problems
• Sleep problems like nightmares, insomnia or
  irregular sleep schedules
• Acquired Brain Injury
• - Traumatic Brain Injury
• It can be difficult for healthcare providers to
  prioritize target treatment areas given the range
  of symptoms and difficulties seen among veterans

15
TBI Comorbidity

• Head injury is damage to any part of the head
• TBI is damage to the brain triggered by
  externally acting forces (i.e., direct
  penetration, sustained forces, etc.)
• A significant portion of soldiers from OEF/OIF
  have sustained a brain injury
• ? Blast injuries are the leading cause of
  injury in the current conflict (DVBIC, 2005)

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Blast injuries

• Blast injuries are injuries that result from the
  complex pressure wave generated by an explosion
• Ears, lungs, and GI tract, brain and spine are
  especially susceptible to primary blast injury
• Those closest to the explosion suffer from the
  greatest risk of injury
• Additional means of impact Being thrown, debris,
  burns

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Why blast injuries are of interest

• Armed forces are sustaining attacks by
  rocket-propelled grenades, improvised explosive
  devices, and land mines almost daily in Iraq and
  Afghanistan
• Injured soldiers require specialized care
  acutely and over time

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TBI can result in

• Motor and sensory deficits
• Thinking, memory and learning difficulties
• Behavioral issues
• Higher rates of suicidal behaviors
• Psychiatric problems

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PTSD and TBI symptom overlap

• Emotional lability
• Difficulty with attention and concentration
• Amnesia for the event
• Irritability and anger
• Difficulty with over-stimulation
• Social isolation/difficulty in social situations

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TBI ? PTSD

• Research shows that among TBI patients who have
  a memory for the event, they were more likely to
  develop PTSD than those with no memory

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• Among TBI patients, greater risk for PTSD if
• History of ASD
• Memory of trauma that resulted in TBI
• Co-morbid psychiatric disorders
• Avoidant coping style

22
PTSD in Service Members

• Often accompanied by
• Irritability
• Anger
• Pain
• Substance abuse (usually alcohol)
• Traumatic brain injury
• Impulsivity
• Other physical disabilities

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UNCLASSIFIED//FOUO
POST TRAUMATIC STRESS DISORDER Number of Newly
Identified Cases, Army Deployed (OIF/OEF
Soldiers) and Non Deployed
NUMBER OF ARMY SOLDIERS WITH IDENTIFIED PTSD
We expect the number of new cases to be related
to the number of exposed troops, the number of
deployments and the overall exposure to combat.
UNCLASSIFIED//FOUO
Last updated 20 January 2010
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Assistance

• Psychotherapy
• Medication
• Employee Assistance Program (EAP)
• Non-traditional support (complementary and
  alternative medicine)
• Acupuncture
• Therapy dogs
• Resiliency
• Unit morale

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Evidence Based Approaches for PTSD

• Psychotherapy
• Cognitive behavioral therapy
• Cognitive processing therapy
• Prolonged exposure
• Pharmacotherapy
• SSRIs

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New and Innovative Approaches

• Pharmacotherapy
• Second generation anti-psychotics
• Sleep medications
• Integrative therapies
• Acupuncture
• Stellate ganglion block
• Yoga
• Canine therapy
• other

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Selected Dog ProgramsSupplement Traditional
Rehabilitation/Therapy Programs

• Animal Assisted Activities
• Animal Assisted Therapy
• Specialized Facility Canines
• Military Therapy Dogs
• Combat Stress Units
• Warrior Transition Battalion Work
• and Education Programs
• Service dog training
• Warrior Canine Connection
• Dog behavior/obedience and care training
• Washington Humane Society

Canine Assisted Therapy and Army Medicine AMEDD
Journal April to June 2012
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How training service dogs address PTSD

• PTSD Symptom Clusters
• Re-experiencing (B)
• Avoidance and Numbing (C)
• Increased Arousal (D)

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Major Depression

• Depression is the most common serious mental
  condition
• Major Depression This includes having one or
  more episodes that last at least 2 weeks where
  there is a very sad mood or the loss of interest
  in regular activities or interests

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Major Depression SYMPTOMS

• Sad mood, feeling dark, down all the time
• Change in appetite
• Feeling tired, having low or no energy
• Feeling helpless, hopeless, or worthless
• Suicidal thoughts or actions
• Concentration problems

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Suicidal Thoughts or Intentions
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Suicide Rates from 1990-2009among Army Soldiers
Army rate projected to Exceed U.S. population
rate
Comparable civilian rates were only available
from 1990-2006
33
34
DoD Suicide Deaths/Rates Branch CY 2001-2010
1st Qtr
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Risk Factors Related to Suicidal Thoughts or
Intentions Civilian

• Making or changing a will
• Giving away prized possessions
• Putting personal or financial matters in order
• Conveying a sense of hopelessness about the
  future
• Threat or loss of primary therapist
• Rejection by family or significant other

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Risk Factors for Suicide in Army Personnel

• Usually young, white, male
• Major Psychiatric Illness Not a Significant
  Contributor
• Adjustment disorders, substance abuse common
• Relationships
• Legal/Occupational Problems
• Substance Abuse
• Pain/Disability
• Weapons
• 70 with firearm
• Recent Trends
• Older, higher rank, more females

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Suicide-by-police

• Also known as death by cop, blue suicide
• Most common scenario is pointing a firearm at a
  police officer or innocent person
• Other weapons or provocative gestures
• Some will fire and/or kill others
• Aftermath often traumatic for police officers
• Research
• Of 843 police shootings, 50 were victim
  precipitated homicide (Parent, 2004)
• Other data hard to obtain

38
Causal Factors for Violence Among Soldiers

• Multiple individual, unit, and community factors
  appear to have converged to shift the population
  risk to the right

• Facts
• Individual
• Criminality/Misconduct
• Alcohol / Drugs
• BH Issues (untreated/under-treated)
• Unit
• Turnover
• Leadership (Stigma)
• Training / Skills
• Environment
• Turbulence
• Family Stress / Deployment
• Community
• Stigma

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The Public Mental Health System and Veterans
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State Example Washington DC
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Homeless Veterans
Veterans are 12 of the adult homeless 2/3rds
are chronically homeless 30 have histories of
substance abuse 28 mental health conditions
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Exercise/Case Study Vet with a Rifle

• You receive a call from a man who is concerned
  about his son. The son returned six months ago
  from Afghanistan and was discharged from the
  Army. Since then he has not been able to find a
  job. According to his father, he is now holed up
  in the basement of the familys home with a
  rifle. He has a history of PTSD, mild traumatic
  brain injury and has been drinking heavily. What
  do you do?

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Verbal de-escalation?

• Verbal de-escalation is used during potentially
  dangerous, or threatening, situation in an
  attempt to prevent persons from causing harm to
  us, themselves, or others

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Goals of Verbal De-escalation

• Open up clear lines of communication
• Build trust and validate the consumers situation
• Get the consumer talking about his situation
• Gathering the necessary information make a good
  resolution

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What is De-Escalation

• De-escalation is less like a recipe or formula
  and more like a flexible set of options.
• No single set of de-escalation skills we have
  tried to put together a effective set of skills
  by borrowing from multiple approaches
• De-escalation will not always work

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Effective Communication

• 70 of communication misunderstood
• Effective communication is defined as passing
  information between one person and another that
  is mutually understood

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Effective Communication

• Communication becomes more difficult when the
  persons ability to understand what you are
  saying and/or their ability to express their own
  thoughts or needs are compromised by their
  symptoms.
• When they cant express their needs, they become
  more angry and frustrated more quickly and more
  frequently
• Your ability to engage a consumer in conversation
  and successfully resolve a conflict often depends
  as much on how you say the words you choose as
  much as the words themselves.

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Barriers to Effective Communication

• Barriers to communication are the things that
  keep the meaning of what is being said from being
  heard
• Pre-judging
• Not listening
• Criticizing
• Name-calling
• Engaging in power struggles
• Ordering
• Threatening
• Minimizing
• Arguing

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Non-Verbal

• It is very important to be able to identify
  exactly what you are communicating to others
  non-verbally
• You may be trying to de-escalate the situation by
  talking to the other person, but your body
  language may be saying something else. The
  consumer will react to want you are saying with
  your body language

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Personal Space

• Persons with mental illness often develop and
  altered sense of personal space. They require
  more space than usual to feel comfortable and
  feel intensely threatened when other people close
  in on them with no warning.
• Invasion or encroachment of personal space tends
  to heighten or escalate anxiety
• Personal space in American culture is about 3
  feet
• Do not touch a hostile person they might
  interpret that as an aggressive action
• Announce intention I need some space, so I am
  going to back up.

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Eyes

• One eyebrow raised sternness
• Eyes wide open surprise
• A hard stare threatening gesture
• Closing eyes longer than normal I am not
  listening

52
Body Posture

• Challenging postures that tend to threaten
  another person and escalate the situation
  include
• Finger pointing may seem accusing or threatening
• Shoulder shrugging may seem uncaring or unknowing
• Rigid walking may seem unyielding or challenging
• Use slow and deliberate movementsquick actions
  may surprise or scare the Vet

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Voice

• Tone - Usually unconscious
• Volume - A raised voice could create fear or
  challenges
• Rate of speech - Speak slowly This is usually
  interpreted as soothing
• Inflection of voice - I didnt say you were stupid

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Face

• Jaw set with clenched teeth shows that you are
  not open minded to listening to his or her side
  of the story
• A natural smile is good. A fake smile can
  aggravate the situation

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Vets typically will have one of 3 feelings

• Anger
• Fear
• Sadness/depression

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What you may be seeing . . .
Veterans Inner Experience
Hostility, evasion Fear
Risk-taking Elation
Self-destructive behavior Depression
Odd, dangerous behavior Confusion
Very odd behavior Psychosis
Attempts at self-treatment (e.g. drugs) Hopelessness, demoralization
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Engagement

• Be aware of your setting personal safety first
• Move to a safe place if necessary
• Allow plenty of space
• Persons with mental illnesses often can be
  expected to process information slowly and to
  have difficulty remembering things. This includes
  understanding and remembering instructions given
  by a police officer.

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Engagement

• Be aware that a uniform, gun, and handcuffs may
  increase anxiety in the veteran so reassure him
  that no harm is intended.
• Remain calm
• You will likely have contact with the Vet again
  how you treat him/her will be important for
  establishing trust

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Engagement

• Know when to act A person may be acting
  dangerously, but not directly threatening any
  other person or himself/herself. If possible,
  give the Vet time to calm down. This requires
  patience and continuous safety evaluation.
• Allow partner to de-escalate others on the scene
  as necessary

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Engagement

• It is the wise officer who can, at times,
  conceal his or her combat-ready status.
• -Lt. Michael Woody

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Avoid

• Maintaining continuous eye contact
• Crowding or cornering the Veteran
• Touching the Vet unless you ask first or it is
  essential for safety
• Letting others interact simultaneously with the
  Vet
• Negative thoughts (God, this is another one of
  those homeless Vets.)

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Avoid

• Expressing anger, impatience or irritation
• Inflammatory language (You are acting crazy.)
• Feeling as though you have to rush or feeling
  like you are stuck if it takes time to get the
  consumer talking
• Intervening too quickly or trying too hard to
  control the interaction by interrupting or
  talking over the Veteran.

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Avoid

• Saying You need to calm down.
• Shouting or giving rapid commands
• Arguing with the Veteran
• Taking the words or actions of the Veteran
  personally (They are symptoms of mental illness.)
• Lying, tricking, deceiving, threatening the
  consumer to get her to comply

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Avoid

• Asking why questions.
• Why questions are logic-based. Persons in crisis
  are not logical. Typically, what ever has worked
  in the past is not working now. Why questions put
  the consumer on the defensive. Ask open-ended
  questions.
• Forcing discussion

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Avoid

• Minimizing the consumers situation as a way to
  elicit conversation (Things cant be that bad,
  can they?)
• Suggesting that things will get better they may
  not
• Making promises that you may not be able to keep

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Avoid

• Commands such as drop the knife, or Get down
  on the ground might seem to be straightforward
  and easy to understand. When dealing with
  Veterans who live with mental illness, however,
  officers need to take into account the types of
  barriers to effective communication that the
  brain disorder might create.
• Telling the consumer I know how you feel.

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Avoid

• Asking a lot of questions of the Veteran in the
  beginning.
• This is a natural tendency, however, this is
  generally not a good idea, especially early in
  the interaction. In de-escalation, encouraging
  the Veteran to continue talking is more effective
  than asking a lot of questions. It will help
  continue the dialogue and will provide the
  consumer with opportunities to give information
  that will help to resolve the crisis.

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DO

• Speak in a calm, slow, clear voice
• You may need to repeat the Veteran may be
  distracted or have TBI issues
• Be patient give the situation time time is on
  your side
• Try to reduce background noise and distractions
• Use and instead of but
• Obtain relevant information from informants

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DO

• Allow the Veteran to ventilate (Tell me some
  more about that.
• Use please and thank you often
• Remain friendly but firm
• Ask the Veteran if she needs something
• Offer a cigarette, nutrition bar, warm clothing
• Forecast Announce your actions and movements

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DO

• Accept the Veterans feelings, thoughts and
  behavioral
• acceptance is not easy when a Veteran is behaving
  in a bizarre or hostile manner
• Respect the dignity of the consumer without
  regard to sex, race, age, sexual orientation

71
Hot Buttons

• Veteran will sometimes push a hot button they
  are in battle mode
• We all have hot buttons know yours
• This is NOT the time to demand respect

72
The Logic of De-Escalation

• If you take a LESS authoritative, LESS
  controlling, LESS confrontational approach, you
  actually will have MORE control.
• You are trying to give the Veteran a sense that
  he or she is in control.
• Why? Because he or she is in a crisis, which by
  definition means the Vet is feeling out of
  control. The Vets normal coping measures are not
  working at this time.

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Listen

• Silent and listen are spelled with the same
  letters
• Listen twice as much as you talk thats why you
  have 2 ears and 1 mouth
• What is the difference between listening and
  hearing?

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Listen

• Listen for the total meaning
• Focus on what the Veteran is telling you
• Block out distractions

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Listen

• It is important understand and remember that what
  the Veteran is saying or believing may be real or
  imagined. Sometimes their thoughts are
  disconnected and youll hear this in their
  speech, which can be difficult to follow and make
  sense of
• Especially after a flashback

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Techniques that Show You Are Listening

• Minimal encouragers (Okay, Uh-huh, I see, I am
  listening)
• Reflecting
• Ask open-ended questions (Can you tell me more
  about that.)

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Specific Questions That You May Want You Ask,
When Appropriate

• Does the Veteran need something (e.g., hungry,
  thirsty)
• Is the Veteran receiving services
• Where is the Veteran receiving services
• Does the Veteran have a case manager
• Is the Veteran taking medication
• When did the Veteran last take his or her
  medication

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Medication

• Mentioning medication must be given careful
  thought.
• In some cases, the topic is best left to mental
  healthcare providers after the Veteran has calmed
  down.
• In other situations, the Veteran may want to talk
  about his or her medication.
• Also, many Veterans have had negative experiences
  with therapists and dont want to talk about it
  their counselor.

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Empathy

• Emotion labeling
• Paraphrasing

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Emotional Labeling Examples

• You seem to be . . . .
• It seems to me like you feel . . . .
• If I were in your situation, I think Id feel . .
  .

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Paraphrasing

• Builds rapport between officer and Veteran
• Helps the officer refine the assessment of the
  crisis
• Provides information that lays the groundwork for
  an eventual resolution of the crisis
• Communicates that you are listening and
  understanding

82
Paraphrasing Examples

• Veteran I dont know what I am going to do. My
  family doesnt want me here.
• CIT Officer Youre not sure where you can stay
  for awhile, but home doesnt seem like the best
  place right now.

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Paraphrasing Examples

• What I hear you saying is . . . .
• If I am hearing you right . . . .
• Let me see if I understand what you are saying .
  . .
• These types of statements also summarize what has
  been said in the communication.

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Resolution

• Can it be informally resolved?
• Is an evaluation needed?
• Are commitment criteria met?
• Was a crime committed?

85
What Ifs

• What if the Veteran asks you a long-term
  question?
• Say that you dont know the answer but that you
  and the Veteran can handle the immediate situation

86
What If

• The Veteran says that theres nothing you can do
  to help?
• Say that youre not sure what you can do, but
  that you want to work with the Veteran to figure
  out something

87
What If

• The Veteran will not engage problem-solving and
  is distracted?
• Say Stay with me, Ed. Lets work on this
  together. Id like for you to stop for a minute
  and take a deep breath with me. Like this. Thats
  good. Thank you, Ed.

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What If

• The Veteran moves too close you?
• Say I need some space, Jim, so I am going to
  back up.

89
What If

• The Veteran is talking so loudly it is
  disruptive?
• Drop the volume in your own voice and say, Jim,
  I am having a hard time understanding you because
  of how loud your voice is.

90
What If

• You think the Veteran might become aggressive?
• If possible, bring in another trained person.
• There is less chance of aggression if two people
  are talking to the Veteran but do not corner.

91
What If

• The Veteran will only respond non-verbally, like
  with a head nod
• Respond positively

92
What If

• The Veteran remains unresponsive?
• Simply validate the Veteran by stating what you
  observe about their situation
• You look really sad you must be really hurting
  right now.

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PTSD Flashbacks

• Veterans with post traumatic stress disorder
  experience flashbacks.
• During a flashback, the person is experiencing
  the traumatic event. So all the senses and
  thoughts are in the moment. It is really
  important to maintain personal space and avoid
  touch during a flashback.

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PTSD Flashbacks

• Orient and ground My name is . . . today is . .
  . you are (describe where), its our job to keep
  you safe
• Provide simple directives and reassurance softly
  and slowly

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Rapid Speech / Mania

• Some people talk rapidly when they are stressed
  or scared. People who are manic often talk very
  rapidly
• Encourage the person to slow down, take deep
  breathes.
• I want to understand what you are saying, but
  you are talking really fast. Lets take some deep
  breaths together.

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Thank YouDavid_at_davidlombard.com