Understanding Military Posttraumatic Stress Disorder (PTSD)

1. Understanding Military Posttraumatic Stress Disorder (PTSD) 22 June 2013

2. With thanks to Maj Gen Kirk Martin & Armed Forces Health Surveillance Center & Association of Military Surgeons by Col William W. Pond, MD Indiana State Air Surgeon (& Baghdad, & Balad & Kuwait & Qatar, etc

3. 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” Posttraumatic Stress Disorder Col William Pond, IN SAS

4. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

5. Posttraumatic Stress Disorder Col William Pond, IN SAS

6. Congratulations, Ken, you have just purchased your very own low mileage Hummer Posttraumatic Stress Disorder Col William Pond, IN SAS

7. Aeromedical Evacuation Col William Pond, IN SAS

8. PTSD is one of several mental disorder diagnoses Posttraumatic Stress Disorder Col William Pond, IN SAS

9. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

10. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

11. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

12. PTSD Arousal Disturbances • Anger poorly controlled, “flies of the handle” easily • Difficulty falling or staying asleep • Hypervigilence or hyperalert Posttraumatic Stress Disorder Col William Pond, IN SAS

13. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

14. Physiologic changes accompanying PTSD Fight or Flight response • Fast Heart rate • Hyperventilation, breathing deep and fast • Quivering or shaking • Easily startled with loud noises Posttraumatic Stress Disorder Col William Pond, IN SAS

15. PTSD may co-exist and be synergistic with Traumatic Brain Injury (TBI) Posttraumatic Stress Disorder Col William Pond, IN SAS

16. 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. Posttraumatic Stress Disorder Col William Pond, IN SAS

17. Previous diagnoses of what is now PTSD • Railway Spine • Stress Syndrome • Shell Shock • Battle Fatigue • Traumatic War Neurosis • PTSD since 1980s Posttraumatic Stress Disorder Col William Pond, IN SAS

18. 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? Posttraumatic Stress Disorder Col William Pond, IN SAS

19. Incidence rate decreases with age. Posttraumatic Stress Disorder Col William Pond, IN SAS

20. Predisposing factors • Associated life stresses, e.g. marital problems • Pre-existing psychological problems Posttraumatic Stress Disorder Col William Pond, IN SAS

21. Chronic lack of sleep is a real stressor

22. So is heat Posttraumatic Stress Disorder Col William Pond, IN SAS

23. Severity Posttraumatic Stress Disorder Col William Pond, IN SAS

24. Amputations as a marker of permanent severe injury Posttraumatic Stress Disorder Col William Pond, IN SAS

25. Proximity Posttraumatic Stress Disorder Col William Pond, IN SAS

26. And length of exposure • Civilian exposures are often single events whereas military may be multiple Posttraumatic Stress Disorder Col William Pond, IN SAS

27. After 35 days of uninterrupted combat, 98% of soldiers exhibited psychiatric disturbances of varying degrees Posttraumatic Stress Disorder Col William Pond, IN SAS

28. Posttraumatic Stress Disorder Col William Pond, IN SAS

29. Posttraumatic Stress Disorder Col William Pond, IN SAS

30. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

31. The VA has PTSD Inpatient Resourcesin the community • PTSD Intensive Inpatient Programs • Day Hospitals • Evaluation and Brief Treatment Units • Residential Rehabilitation • PTSD Domiciliary Posttraumatic Stress Disorder Col William Pond, IN SAS

32. The VA has PTSD Specialistsin the community • Vet Centers • By Veterans, records confidential Posttraumatic Stress Disorder Col William Pond, IN SAS

33. You, our community, are important Posttraumatic Stress Disorder Col William Pond, IN SAS

34. 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) Posttraumatic Stress Disorder Col William Pond, IN SAS

35. Your support is invaluable, and therapeutic, like the children’s notes of support on the concrete wall Posttraumatic Stress Disorder Col William Pond, IN SAS

36. Are Our Warriors Seeking Care? 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

37. 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

38. 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

39. 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. Posttraumatic Stress Disorder Col William Pond, IN SAS

40. Pastoral Care is invaluable Posttraumatic Stress Disorder Col William Pond, IN SAS

41. 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) Posttraumatic Stress Disorder Col William Pond, IN SAS

42. 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. Posttraumatic Stress Disorder Col William Pond, IN SAS

43. Posttraumatic Stress Disorder Col William Pond, IN SAS

44. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

45. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS

46. 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. Posttraumatic Stress Disorder Col William Pond, IN SAS

47. 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 Posttraumatic Stress Disorder Col William Pond, IN SAS