The Transition of Returning Disabled Veterans: “Easy as apple pie?”

1. The Transition of Returning Disabled Veterans: “Easy as apple pie?”

2. Disclaimer The views expressed in this presentation are those of the author’s and do not reflect the official policy of the Department of the Navy, Department of Defense, U.S. Government or the University of Massachusetts, unless otherwise stated.

3. Workshop Overview • Discuss Iraq/Afghanistan veteran profile. • Review pathologies of combat: Post Traumatic Stress Disorder (PTSD) Traumatic Brain Injury (TBI) • Provide insight into dealing with academic challenges within the combat veteran population. • Apply practical learning techniques and solutions to common learning difficulties.

4. Iraq/Afghanistan Veteran Profile • Gender: 85% male; 15%female. • Military service: 40% of those deployed are National Guard/Reserve. • Age: “older population”. • Since October 2001 >1.5 million men and women deployed to Iraq and Afghanistan; 280,000 re-deployed. • 89%-95% reported being ambushed or attacked. • 93%-97% reported being shot at. • 86%-87% reported knowing someone who was seriously injured or killed. (NCPTSD Nov 2006)

5. Historical Notes: Post Traumatic Stress Disorder • Homer’s account of Trojan War tells of Achilles’ disintegration following the battlefield death of his best friend, Petroclus. • 1800’s Civil War soldiers suffered with “Nostalgia”, “Soldier’s Heart”. • WWI, WWII, Korean War “Shell shock”, “Combat Fatigue”. • 1970s misdiagnosed Vietnam veterans’ maladies ranged from alcoholism to schizophrenia; “Post-Vietnam Syndrome”. • 1980 Post Traumatic Stress Disorder listed as sub-category to anxiety disorder with APA. • 1987 Post Traumatic Stress Disorder recognized as a diagnosis, following National Vietnam Veterans Readjustment Study.

6. Incidence of Post Traumatic Stress Disease • One in six Iraq veterans have suffered from Post Traumatic Stress Disorder, (PTSD) major depression or generalized anxiety. • One in nine Afghanistan veterans have suffered from PTSD, major depression or generalized anxiety. • Many unreported cases due to stigma perceived. • General population: prevalence of PTSD is 4-6%; 10% will have clinically diagnosable PTSD sometime in their lives. (NCPTSD 2006)

7. It’s All in Their Head… • Post Traumatic Stress Disorder • Acute Stress Disorder • Traumatic Brain Injury • Depression/Suicide • Drug and alcohol abuse

8. What is Post Traumatic Stress Disorder? Post Traumatic Stress Disorder (PTSD) is a debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

9. “PTSD is the inability to flip the switch from combat soldier to every day citizen to stop reliving the war at so high a frequency that it interferes with the ability to function.” Betsy Streisand U.S. News & World Report, Oct. 2006

10. Signs and Symptoms of PTSD • Spontaneous re-experiencing or reliving of event (flashbacks), intrusive memories • Increased or hyper-vigilance • Hyper-arousal • Avoidance behavior (activities/situations/people/ conversations avoided which are associated with the trauma)

11. Signs and Symptoms of PTSD • Social impairment, detachment, loss of interest • Memory deficits • Concentration difficulty • Numbing, referred to as “a freezing of the heart” • Anger outbursts • Feelings of intense guilt • Recurrent dreams/nightmares/frightening thoughts • Sleep disorders

12. Physical Changes Found In PTSD • Elevated levels of stress hormones such as noradrenalin and adrenaline. • Hyperactive sympathetic nervous systems. Exaggerated increases in heart rate and blood pressure. • Reduction in the volume of the hippocampus and amygdale region of the brain (learning and memory). • Alteration in brain processes.

13. MRI View of Post Traumatic Stress Disorder

14. How prevalent is PTSD in Veteran population? • About 30% of men and women who have been in a war zone experience Post Traumatic Stress Disorder. • More than half of all male Vietnam veterans, and just under half of Vietnam female veterans have experienced clinically serious stress reaction symptoms. • Gulf War estimates are as high as 8%. (NCPTSD 2006)

15. Obstacles to Treatment Over forty percent of those experiencing mental health problems associated with combat refuse treatment due to fear that treatment will: - hurt their image - ruin their military careers/promotions - cause negative perception from peers and leadership

16. What is Traumatic Brain Injury (TBI)? A TBI is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Blasts are a leading cause of TBI for active duty military personnel in war zones. Closed head injury may be missed when more visible injuries require immediate attention. The severity of injury to the brain ranges from mild and undetected, to life threatening.

17. Blast Injury/TBI • Primary: Direct exposure • Secondary: Impact from blast energized debris • Tertiary: Displacement of the individual by the blast and impact

18. Mild Traumatic Brain Injury(MTBI) • Caused by external physical force to the head • In war zone caused by sudden explosion from Improvised Explosive Device (IED), Rocket-Propelled Grenade (RPG), land mines, bombs • “Shaken Soldier” Syndrome. • The “signature” injury/disability from current war. • Understanding the complexity of this injury is critical to helping our troops achieve optimal transition

19. Signs and Symptoms of mTBI Mild Traumatic Brain Injury Insomnia/sleep problems Impaired memory Poor concentration/attention Depression Anxiety Irritability/mood changes Headache Dizziness/Imbalance Excessive Fatigue: physical and mental Noise/light intolerance Ringing in the ears (tinnitus) Vision change: blurred or vision

20. Mild Traumatic Brain Injury Insomnia/sleep problems Impaired memory Poor concentration/attention Depression Anxiety Irritability/mood changes Headache Dizziness/Imbalance Excessive Fatigue: physical and mental Noise/light intolerance Ringing in the ears (tinnitus) Vision change: blurred or double Post Traumatic Stress Disorder Insomnia Impaired Memory Poor concentration/attention Depression Anxiety Irritability/mood changes Stress symptoms Emotional numbing Avoidance mTBI vs. PTSD:Overlapping Signs and Symptoms

21. mTBI • Diagnosis and treatment made through soldier’s verbal history and/or witnesses’ account. • Technological advances in battlefield gear, reduces deaths, increases severity of injuries to head and limbs. • Modern military medicine allows for life-saving trauma care in the war zone with immediate transport to definitive care and rehabilitation. • Incidence of MTBI in Iraq: 1 in 10 has sustained a concussion or more.

22. Cognitive Consequences of mTBI • Attention and concentration difficulty • Information processing (speed and efficiency) • Learning and memory difficulty • Abstract reasoning sluggish • Executive functions slowed - problem solving - planning - Insight/awareness - Set shifting - Sequencing

23. Classroom Challenges • Concentration Difficulties • Memory/Learning/Info retrieval • Time Management/Performing or Completing Tasks • Stress • Sleep Disturbance • Panic Attacks • Emotions