Understanding Military Posttraumatic Stress

Disorder (PTSD)22 June 2013

by Col William W. Pond, MDIndiana State Air Surgeon

(& Baghdad, & Balad & Kuwait & Qatar, etc

With thanks to Maj Gen Kirk Martin &Armed Forces Health Surveillance Center &

Association of Military Surgeons

PTSD Crisis ?Nicholas Horner, Iraq• April 6, 2009 Altoona, PA• After return from SW Asia, quiet, did not leave home• Slept poorly, found crying in basement by mother• Panic attacks, doors always locked• Explosive moods, argument with wife in morning• Afternoon drinking 2 pitchers of beer.• Walked to Subway back door, cut electrical wires, shot out

utility box• Shot 2 inside and apologized, “Sorry, I didn’t wanna have to

do that to you.”• Shot another while trying to steal a car• Rage, insomnia, emotional numbness do not qualify as

insanity• Convicted of murder, PTSD “not an excuse for murder”

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Compare:Chistopher “Stone Cold” Mountjoy

• March 31, 2012, Fort Carson• Sin City Disciples Motorcycle Club enforcer• Street barricaded, crouched behind trash bin • Ambushed cars of victim• Victim previously beaten and was allegedly returning to

retrieve wallet• 5 associates charged with murder• Mountjoy, an active duty soldier, served as sergeant-

at0-arms for local Sin City disciples• Mountjoy deployed to Afghanistan in 2011• PTSD claimed as defense to actions

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Congratulations, Ken, you have just purchased your very own low

mileage Hummer

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PTSD is one of several mental disorder diagnoses

Acute Stress Disorder (ASD) orPosttraumatic Stress Disorder (PTSD)• Reaction to stress and subsequent

dysfuction is a temporal continuum.• Duration of symptoms less than 30 days

is ASD

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PTSD—What is it and how is it defined?

• Traumatic event• Patient must feel seriously threatened to

self or others• Must have intense negative emotional

response• Persistent re-experiencing

• Flashback memories, bad dreams, re-experiencing the event—all evoke intense negative response to events that remind patient

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PTSD—More signs

• Avoidance and emotional numbing• Avoiding stimuli associated with event such

as thoughts or talking about it• Avoiding places, or people who remind• Inability to recall major parts of event• Decreased ability to feel emotions• Expectation of short future or doom

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PTSD Arousal Disturbances

• Anger poorly controlled, “flies of the handle” easily

• Difficulty falling or staying asleep• Hypervigilence or hyperalert

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PTSD Criteria--Impairment

• PTSD not present unless significant impairment• Social relationship—spouse, children,

parents, and coworkers (the ones who may notice first)

• Occupation—job function changes, e.g. late to work, lack of attention to detail, or excessive attention to detail

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Physiologic changes accompanying PTSD

Fight or Flight response• Fast Heart rate• Hyperventilation, breathing deep

and fast• Quivering or shaking• Easily startled with loud noises

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PTSD may co-exist and be synergistic with Traumatic Brain Injury (TBI)

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Is PTSD a new disease, newly recognized or newly recategorized?• First report 490 BC Herodotus noted soldier

blind after Battle of Marathon • 1800s military doctors noted “exhaustion” with

mental shutdown.• During WWII 10% of American soldiers were

hospitalized for mental disturbances between 1942 and 1945.

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Previous diagnoses of what is now PTSD

• Railway Spine• Stress Syndrome• Shell Shock• Battle Fatigue• Traumatic War Neurosis• PTSD since 1980s

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PTSD Risk and Protective Factors

• 50-90% of the American population experienced a traumatic event, but only 8% develop PTSD

• 70-90% of deployed military members experience a traumatic event, but only 15% develop PTSD

• Why not everyone?

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Incidence rate decreases with age.

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Predisposing factors

• Associated life stresses, e.g. marital problems

• Pre-existing psychological problems

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Chronic lack of sleep is a real stressor

So is heat

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• Severity

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Amputations as a marker of permanent severe injury

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Proximity

• And length of exposure• Civilian exposures are

often single events whereas military may be multiple

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• After 35 days of uninterrupted combat, 98% of soldiers exhibited psychiatric disturbances of varying degrees

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The VA has PTSD Specialistsin the community

• PTSD Outpatient clinics• PTSD Clinical Teams• Substance use combined with PTSD treatment• Women’s Stress Disorder Treatment Teams

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The VA has PTSD Inpatient Resourcesin the community• PTSD Intensive Inpatient Programs

• Day Hospitals• Evaluation and Brief Treatment Units• Residential Rehabilitation• PTSD Domiciliary

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The VA has PTSD Specialistsin the community

• Vet Centers• By Veterans, records confidential

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You, our community, are important

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Prevention and treatment

• **Family, community, employers, ministers can be of invaluable assistance**

• By fostering recognition and early intervention

• By listening empathetically—do not give false assurances even if well intentioned, e.g. “It’ll be all right, I know how you feel.” (because you do not, unless you have been there)

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Your support is invaluable, and therapeutic, like the children’s notes of support on the concrete wall

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Less than 50%of our Warriors who meet the criteria for a behavioral health diagnosis report receiving care

Marriages, spouses and children are also impacted by war

Spouses have fewer stigma concerns and are more likely to pursue behavioral healthcare

Are Our Warriors Seeking Care?

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Battlemind Overview

• What is Battlemind?• A Warrior’s inner strength to face adversity, fear and

hardship during combat with confidence and courage; it’s the will to persevere and win

• Comparable to resiliency: • The ability to recover rapidly from misfortune

• Battlemind • also refers to the U.S. Army’s premiere psychological resiliency

building program and speaks to Warrior skills

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Army BATTLEMIND Programstresses positive factors, such as

• Buddies (cohesion) vs. Withdrawal• Accountability vs. Controlling• Targeted Aggression vs. Inappropriate Aggression• Tactical Awareness vs. Hypervigilance• Lethally-Armed vs. “Locked and Loaded” at Home• Emotional Control vs. Anger/Detachment• Mission Operational Security (OPSEC) vs. Secretiveness• Individual Responsibility vs. Guilt• Non-Defensive (combat) Driving vs. Aggressive Driving• Discipline and Ordering vs. Conflict

Taking care of the soldier’s mind is as important as taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

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Pastoral Care is invaluable

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Treatment

• Cognitive behavioral programs• Indentifying, challenging and modifying

biased or distorted thoughts and interpretations about the event and its meaning

• Confronting avoided situations, people or places in a graded and systematic manner (in vivo exposure)

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PTSD Treatment

• Addressing the traumatic memory in a controlled safe environment (imaginal exposure)

• EMDR (eye movement desensitization) probably most likely due to the re-engagement of the memory, cognitive reprocessing and coping.

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PTSD Medications(not the first line)

• Beta blockers – for decreasing the sympathetic fast heart rate, jittery, hyperarousal and sleep disturances.

• Benzodiazepines (Valium)—should be used with caution (relieve acute anxiety, but do not treat underlying cause of PTSD

• Prazosin—for nightmares• Topiramate—for flashbacks and nightmares.• SSRI Antidepressants

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PTSD Treatment

• Imperative to foster an expectation that member will recover with treatment and time, just as would occur in any other condition such as a broken arm or pneumonia.

• Important also to remove secondary gain—Member is not disabled, but duty limited.

• Return to normal work environment is therapeutic and should be accomplished with concessions as necessary

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PTSD Treatment Prognosis and Duration

• (Lost my crystal ball)—depends upon patient response, but in general,

• Many patients receive substantial relief from 8-12 ninety minute sessions.

• If there is no secondary gain and if treatment is appropriate and timely, symptoms can be expected to become manageable within 1-2 months.

• Goal is not to forget or to hide, but rather to maximize function.

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• A psychological reaction is not uncommon after a severe stressful situation.

• Recovery is expected with timely support and compassionate treatment.

• Home and camaraderie are integral to recovery.

• Family and community are invaluable in recognition, support and treatment.

• Your support means more than you will ever know

• We are grateful for it. • • Thank you