COMBAT PTSDCOMBAT PTSD

Milton Lasoski, PhDMilton Lasoski, PhD

New Mexico Veterans Affairs New Mexico Veterans Affairs

Health Care SystemHealth Care System

Various ReactionsVarious ReactionsPTSD is only a Possible PathPTSD is only a Possible Path

• DepressionDepression• AnxietyAnxiety• PhobiasPhobias• Substance AbuseSubstance Abuse• AggressionAggression

• AdjustmentAdjustment

Acknowledgements for use of Acknowledgements for use of SlidesSlides

• Gregory A. Leskin, Ph.D. National Center Gregory A. Leskin, Ph.D. National Center for PTSDfor PTSD

• APA Sub-Committee on Resiliency and APA Sub-Committee on Resiliency and TerrorismTerrorism

• Jose Canive, MD New Mexico VAHCSJose Canive, MD New Mexico VAHCS

• Matthew Friedman PTSD 101 Course Matthew Friedman PTSD 101 Course ncptsd@va.gov

PTSD PTSD

A.A. Traumatic event experienced with fear, Traumatic event experienced with fear, helplessness, horror, extreme distresshelplessness, horror, extreme distress

B.B. Re-experiencing (Intrusion) Re-experiencing (Intrusion)C. AvoidanceC. AvoidanceD. Hyperarousal D. Hyperarousal E. E. Symptoms present for 1 month or moreSymptoms present for 1 month or moreF. Distress social/occupational functionF. Distress social/occupational function

Acute Stress Disorder (ASD): Acute Stress Disorder (ASD): CriterionCriterion

• ThreeThree dissociative symptoms dissociative symptoms– DerealizationDerealization– Numbing or detachmentNumbing or detachment– Reduced awareness of surroundingsReduced awareness of surroundings– DepersonalizationDepersonalization– Dissociative amnesiaDissociative amnesia

Acute Stress Disorder (ASD): Acute Stress Disorder (ASD): How predictive is it?How predictive is it?

• Prospective studies find that a high Prospective studies find that a high proportion of those diagnosed with ASD proportion of those diagnosed with ASD develop PTSD.develop PTSD.

• However, in terms of people who However, in terms of people who eventually developed PTSD, about half of eventually developed PTSD, about half of those met criteria for ASD.those met criteria for ASD.

B: Re-experiencing SXS (1) B: Re-experiencing SXS (1) neededneeded

• Distressing intrusive recollectionsDistressing intrusive recollections• Distressing Dreams of the eventDistressing Dreams of the event• Reliving the experience (flashbacks)Reliving the experience (flashbacks)• Distress at exposure to remindersDistress at exposure to reminders• Physiological reactivity at exposure to trauma Physiological reactivity at exposure to trauma

remindersreminders

C: Avoidance/Numbing SXS C: Avoidance/Numbing SXS (3) needed (3) needed

• Avoid thoughts/feelings that remindAvoid thoughts/feelings that remind• Avoid activities/situations that remindAvoid activities/situations that remind• Inability to recall aspects of the traumaInability to recall aspects of the trauma• Diminished interest in activitiesDiminished interest in activities• Detachment/Estrangement from othersDetachment/Estrangement from others• Restricted range of affectRestricted range of affect• Sense of foreshortened futureSense of foreshortened future

D: Hyperarousal SymptomsD: Hyperarousal Symptoms (2) needed (2) needed

• Difficulty falling/staying asleepDifficulty falling/staying asleep

• Irritability or outbursts of angerIrritability or outbursts of anger

• Difficulty concentratingDifficulty concentrating

• HypervigilanceHypervigilance

• Exaggerated startleExaggerated startle

Active Duty Self Report (Hoge,etal)Active Duty Self Report (Hoge,etal) PTSD/ GAD/ Depression PTSD/ GAD/ Depression

• Pre-DeploymentPre-Deployment

• OEF Post-OEF Post-DeploymentDeployment

• OIF Post-OIF Post-DeploymentDeployment

• 9%9%

• 11%11%

• 15—17%15—17%

Active Duty Self Report (Hoge,etal)Active Duty Self Report (Hoge,etal) ETOH Abuse ETOH Abuse

• Pre-DeploymentPre-Deployment

• OEF Post-OEF Post-DeploymentDeployment

• OIF Post-DeploymentOIF Post-Deployment

• 17%17%

• 24%24%

• 35%35%

Active Duty Self Report (Hoge,etal)Active Duty Self Report (Hoge,etal) PTSD and Reported Firefights PTSD and Reported Firefights

• NO firefightsNO firefights

• 1-2 firefights 1-2 firefights

• 5 or more firefights5 or more firefights

• 4.5%4.5%

• 8.2-9.3%8.2-9.3%

• 18.9-19.3%18.9-19.3%

PD Health Assessment and PD Health Assessment and MH Sxs Utilization (Hoge, et al)MH Sxs Utilization (Hoge, et al)

• Peace Keeping Peace Keeping DeploymentDeployment

• OEF Post-DeploymentOEF Post-Deployment

• OIF Post-DeploymentOIF Post-Deployment

• 8.5%8.5%

• 11.3%11.3%

• 19.1%19.1%

PD Health Assessment and PD Health Assessment and MH Sxs Utilization (Hoge, et al)MH Sxs Utilization (Hoge, et al)

• Active MilitaryActive Military• National GuardNational Guard• WomenWomen• MenMen

• 18.4%18.4%• 21%21%• 23.6%23.6%• 18.6%18.6%

PTSD SELF Report (Hoge, et al)PTSD SELF Report (Hoge, et al)

• Peace Keeping Peace Keeping DeploymentDeployment

• OEF Post-DeploymentOEF Post-Deployment

• OIF Post-DeploymentOIF Post-Deployment

• 2.1%2.1%

• 4.7%4.7%

• 9.8%9.8%

PTSD SELF Report (Hoge, et al)PTSD SELF Report (Hoge, et al)

• Screened Positive and Screened Positive and witnessed Casualtieswitnessed Casualties

• Screened Negative and Screened Negative and witnessed Casualties witnessed Casualties

• 80%80%

• 48%48%

PTSD SELF Report (Hoge, et al)PTSD SELF Report (Hoge, et al)

• OIF Vets who accessed OIF Vets who accessed MH SVS at least one MH SVS at least one timetime

• Screened Positive for Screened Positive for Mental Health Problems Mental Health Problems and accessed MH SVS and accessed MH SVS

• 1/31/3

• 60%60%

Anxiety depression and PTSD four months after trauma

3

PTSD37

16 (43.8%)

12

4

5

MDD30

11 (36.7%)

None(n=141)(67%)

ANX31

19 (61%)

PTSD Prevalence in US AdultsPTSD Prevalence in US Adults

• National Comorbidity Survey NCS-Replication (2005)– Large national probability samples (Ns > 5000)– Benchmark for prevalence of mental disorders in US

• Lifetime PTSD prevalence = 6.8% (NCS-R)– 9.7% women– 3.6% men

• Current PTSD prevalence = 3.6% (NCS-R)– 5.2% women– 1.8% men

0

10

20

30

40

50

Witness Accident Threat Attack Molestation Combat* Child Abuse Rape

Prevalence of Trauma

Prevalence of PTSD inexposed

Prevalence Of Trauma And PTSDPrevalence Of Trauma And PTSD

Kessler et al., 1999

More Than 60% Experience A Traumatic Event In Their LifeMore Than 25% Experience Multiple Traumatic Events

Combat Exposure in the NCSCombat Exposure in the NCS

• Lifetime prevalence of PTSD = 39% among combat veterans

• Male combat vs. all other male trauma– Higher lifetime PTSD prevalence– Greater likelihood of delayed onset– Greater likelihood of unresolved symptoms

Men WomenEvent PTSD Event PTSD

Natural Disaster 18.9 3.7 15.2 5.4

Criminal Assault 11.1 1.8 6.9 21.3

Combat 6.4 38.8 0.0 -

Rape 0.7 65.0 9.2 49.5

Any trauma 60.7 8.1 51.2 20.4

Kessler et al (1995)

Lifetime prevalence rates of trauma Lifetime prevalence rates of trauma and their association with PTSD (%)and their association with PTSD (%)

PTSD Prevalence in Vietnam PTSD Prevalence in Vietnam VeteransVeterans

• National Vietnam Veterans Readjustment Study– Large, nationally-representative sample of theater and era veterans and

civilians (N >3000)

• Lifetime prevalence– 31% men, 26% women

• Current prevalence (1986-87)– 15% men, 8% women

Lifetime Prevalence:Lifetime Prevalence:Vietnam Veterans*Vietnam Veterans*

• SW American Indian SW American Indian 45%45%

• NP American Indian NP American Indian 57%57%

• HispanicHispanic 34%34%

• African AmericanAfrican American 35%35%

• WhiteWhite 20%20%

*NVVRS and Matsunaga: 8-year difference

Prevalence of PTSD from Other Prevalence of PTSD from Other WarsWars

• Gulf War veterans1: – Population sample of over 11,000 Gulf War veterans– Current PTSD prevalence = 10%

• Afghanistan2: – Army (N=1962)– Current PTSD prevalence = 6-11.5%

• Iraq2: – Army (N=894), current PTSD prevalence = 13-18%– Marine (N=815), current PTSD prevalence = 12-20%

11 Khan, Natelson, Mahan, Kyung, & Frances (2003). Amer. J. of Epidemiology2 Hoge, et al. (2004). New England Journal of Medicine

Military studiesMilitary studies

Risk FactorsRisk Factors Effect SizeEffect Size

Adverse ChildhoodAdverse Childhood .27.27

Trauma SeverityTrauma Severity .26 .26

Lack of social supportLack of social support .43 .43

PTSD Course in VeteransPTSD Course in Veterans

0

10

20

30

40

50

Yr 1 Yr 2 Yr 3 Yr 20

PTSD %

Shalev & Yehuda, 1999.

214 Israeli combat veterans– Assessed 1, 2, 3 & 20

years post-war

Delayed onset of PTSD at Yr 20:

No PTSD at Yr 1: 34.5%

No PTSD at Yr 3: 31.6%

No PTSD Yrs 1-3: 8.6%

Most People Who Develop PTSD Recover From It

Longitudinal Course Of PTSDLongitudinal Course Of PTSD

94%

47%

42%

25%-15%

3mW 9m Years

% w/PTSD symptoms

Shalev & Yehuda, 1999.

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PTSD and Comorbidity in the NCSPTSD and Comorbidity in the NCS

Odds Ratio (PTSD v. no PTSD)

1

2

3

4

5

6

MDD Dys-thymia

GAD Panic SocialPhobia

AlcoholAbuse

DrugAbuse

Men Women

PTSD elevated the odds of comorbidity in men & women

Social Support IssuesSocial Support IssuesTo disclose or not to disclose? To disclose or not to disclose?

(Bolton et al., 2003)(Bolton et al., 2003)

• Self-disclosure about events to significant Self-disclosure about events to significant others/ military personnel was related to lower others/ military personnel was related to lower levels of PTSD severity.  levels of PTSD severity.  

• The reactions to self-disclosure by The reactions to self-disclosure by partner/spouse, family, friends, and other partner/spouse, family, friends, and other military personnel were significantly associated military personnel were significantly associated with PTSD symptoms severity. In each instance, with PTSD symptoms severity. In each instance, more positive reactions were related to lower more positive reactions were related to lower levels of PTSD symptoms severity. levels of PTSD symptoms severity.

Social Support IssuesSocial Support IssuesTo disclose or not to disclose? To disclose or not to disclose?

(Bolton et al., 2003), Cont. (Bolton et al., 2003), Cont.

• No differences were detected in PTSD symptoms between veterans whose disclosures were met with an overall negative or nonvalidating response and those who did not disclose at all.

• This later finding suggests that negative or nonvalidating responses by other to self-disclosure may negate the potentially beneficial effects of discussing the experience.

• However, it may also indicate that there are equally negative effects of not disclosing when the alternative is disclosure followed by a negative response.

Most People Who Develop PTSD Recover From It

Longitudinal Course Of PTSDLongitudinal Course Of PTSD

94%

47%

42%

25%-15%

3mW 9m Years

% w/PTSD symptoms

Shalev & Yehuda, 1999.

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