Transcript Document

Understanding Military
Posttraumatic Stress
Disorder (PTSD)
22 June 2013
by Col William W. Pond, MD
Indiana 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
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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
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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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Aeromedical Evacuation
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PTSD is one of several
mental disorder diagnoses
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Acute Stress Disorder (ASD) or
Posttraumatic 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, reexperiencing 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
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Fast Heart rate
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Hyperventilation, breathing deep
and fast
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Quivering or shaking
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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
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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
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• 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 Specialists
in 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
Resources
in 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 Specialists
in 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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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
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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 Program
stresses positive factors, such as
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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
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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.
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•Thank you
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