Terrance J. Goodell, MA, NCC Readjustment Counseling Therapist

Cedar Rapids Vet Center4250 River Center Court NE

Cedar Rapids, IA 52402(319) 378-0016

NOT ALL WOUNDS ARE VISIBLE• Post Traumatic Stress Disorder and Combat

Veterans: Assessment, Diagnosis, and Treatment

Over There…

On Campus…

Transitions Veterans Face• Airman, Marine, Sailor, or Soldier to civilian• Danger to safety• Discomfort to comfort• Camaraderie to solitude• Mistrust to trust• Chaos to order

Attributes Highly Valued in Combat• Heightened arousal.• Being on constant alert for danger.• Narrowed attention and focus.• A hostile appraisal of events.• Not trusting people.• Making quick, unilateral decisions.• Having a “mission first” mentality.• Expecting others to obey directives without question.• Reacting quickly and asking questions later.• Ability to shut down emotions.

Post Traumatic Stress Disorder(PTSD)

• An Anxiety Disorder caused by exposure to traumatic events.

• Trauma: Threats to life/limb, or witnessing of same. These experiences lead to intense feelings of fear, horror, terror, or helplessness.

Reexperiencing

• 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

• 2. Recurrent distressing dreams of the event.• 3. Acting or feeling as if the traumatic event

were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including

• those that occur on awakening or when intoxicated.

• 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the trauma.

• 5. Physiological reactivity on exposure to internal or external cues…

Avoidance

• 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

• 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.

• 3. Inability to recall important aspects of the trauma.

• 4. Markedly diminished interest or participation

Avoidance (continued)

• in significant activities.• 5. Feelings of detachment or estrangement

from others.• 6. Restricted range of affect (e.g., unable to

have loving feelings).• 7. Sense of foreshortened future (e.g., does

not expect to have a career, marriage…etc.).

Increased arousal

• 1. Difficulty falling or staying asleep.• 2. Irritability or outbursts of anger.• 3. Difficulty concentrating.• 4. Hypervigilance.• 5. Exaggerated startle response.

Additional Specifications

• Need at least 1 reexperiencing symptom.• Need at least 3 avoidance symptoms.• Need at least 2 arousal symptoms.• Duration of disturbance is more than 1 month.• The disturbance causes clinically significant

distress or impairment in social, occupational, or other important areas of functioning.

• Acute if duration of symptoms is less than 3 months.

• Chronic if duration is 3 months or more.• Delayed onset if onset of symptoms is at least

6 months after the stressor.

A Brief History

• Civil War– Soldier’s Heart /

Nostalgia– Railroad Spine

• WWI– Shell Shock

WWII/Korea/Vietnam• Battle Fatigue/Combat Exhaustion• Gross Stress Reaction• Post-Vietnam Syndrome

Other Trauma Syndromes• Rape Trauma• Police Officers Shooting Trauma• Battered Woman Syndrome

Statistics Please!• National Vietnam Veterans Readjustment

Study(1990):– 15.2 % of all male Vietnam theater veterans have

PTSD(479,000 vets)– Current estimates run as high as 30.6 % for males

(960,000) and 26.9 % for females (1900+)• New England Journal of Medicine Study on Army and

Marine infantryman in Iraq and Afghanistan:– 15.6 % – 17.1 % (Iraq)– 11.2 % (Afghanistan)– 23% of all OIF vets (2007)

• Studies on Gulf War vets range from 2 % - 10 %

ASSESSMENT

• Structured Clinical Interview• PTSD Checklist – Military Version (PCL-M)• Beck’s Depression Inventory – II (BDI-II)• Clinician Administered PTSD Scale (CAPS)

Biological Aspects• Opioid System Disregulation– a. Decreased pain threshold at rest– b. Stress-induced analgesia– c. Decreased endorphin levels

Triggers• Anniversary Dates• Environmental Cues• 5 Senses– Sounds– Smells– Sights– Taste– Touch

Negative Beliefs Generated by Trauma• 1. Safety• 2. Trust• 3. Power (control)• 4. Esteem• 5. Intimacy

Comorbidity• Depression• Other Anxiety Disorders• Axis II Disorders• Dissociative Disorders

Substance Abuse• Comorbidity of PTSD and substance abuse is

common– “Self-medication Theory”– Studies vary on percentage of Vietnam combat vets

diagnosed with PTSD and comorbid substance abuse:• 22.2% (NVVRS, 1990) – alcohol/6.1% for other drugs• 35% (Brief, 1992)• 40% (Kovach, 1986)

– Complicates treatment– Must distinguish between abuse and dependence– Marijuana; not as “benign” as once believed

Treatment Approaches• 1. Individual psychotherapy• 2. Group psychotherapy• 3. Prolonged Exposure (PE)• 4. Specialized inpatient PTSD programs• 5. Pharmacotherapy• 6. EMDR• 7. Relaxation training/stress reduction• 8. Cognitive Processing Therapy (CPT)

Cognitive Behavioral Therapy• Focus on faulty beliefs• System of understanding• Creates less anxiety in treatment• Targets accessible cognitive processes• Recent research indicates that it is the most

effective form of psychotherapy

Group Therapy• Curative Factors in Groups

• Instillation of hope– “You’ll get through this”

• Universality– “You are not alone”

• Interpersonal learning– Learning from others

overcoming• Catharsis

– Release because it’s safe• Group cohesiveness

– “I belong”

Relaxation Training/Stress Reduction

• 3 count breathing• Tai Chi Breathing• Progressive muscle relaxation• Guided imagery• Audio/video tapes• Physical exercise• Avoid caffeine/other stimulants• Avoid alcohol/nicotine•

Symptom Management• Anxiety Containment• Anger Management• Mood/Affect Regulation

Grief Work• Verbalizing the loss.• Education about the grief process.• Talking through the loss.• Using guided imagery.• Saying goodbye.• Orienting toward the future.

Suicide• 2005 University of Georgia study found that

among Iraq veterans, suicide rates were twice that of non-veterans.

• 20-24 year-old veterans had 2-4 times higher rates than non-veteran peers.

• 1 800 273-TALK (8225)

Treatment Provider Issues• Vicarious traumatization• Compassion fatigue• Burnout

Welcome Them Home!

• Express appreciation for their service.• Understand that the transition home is a

process and will take time.• Support with patience and listening.

Topics to Avoid!• Do not pressure veterans about specifics

regarding their service that they do not want to share.

• Do not minimize the challenges a veteran may face.

• Do not make assumptions about any veteran’s political or foreign policy views.

• Do not single out a veteran without prior approval

Inappropriate Questions Did you kill anyone? Did you see anyone die? Are you glad that you’re back? Do you think we are winning over there? Is it worth it? Do you still support the war? What is your political affiliation?

???

Bibliography

• American Psychiatric Association (2000), Diagnostic and statistical manual of mental disorders (4th ed.; text rev.), Washington, D.C.

• Crosby, J.P. (2008), A mind frozen in time, Dog Ear Publishing, Indianapolis, IN.

• Herman, J. (1992), Trauma and recovery: The aftermath of violence – from domestic abuse to political terror, BasicBooks, New York, NY.

Bibliography

• Matsakis, A. (1994), Post-traumatic stress disorder: A complete treatment guide, New Harbinger, Oakland, CA.

• Schiraldi, G.R. (2000), The post-traumatic stress disorder sourcebook: A guide to healing, recovery, and growth, Lowell House, Los Angeles, CA.

• Taylor, S. (2006), Clinician’s guide to PTSD: A

• Cognitive-behavioral approach, The Guilford Press, New York, NY.

• Waites, E.A. (1993), Trauma and survival: Post-traumatic and dissociative disorders in women, Norton & Company, New York, NY.