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

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Presentation on theme: "Understanding Military Posttraumatic Stress Disorder (PTSD) 22 June 2013."— Presentation transcript:

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

2 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

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 3

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 4

5 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 5

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

7 25 September 2012 Aeromedical Evacuation Col William Pond, IN SAS 7

8 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 8 PTSD is one of several mental disorder diagnoses

9 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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 9

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 10

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 11

12 PTSD Arousal Disturbances Anger poorly controlled, “flies of the handle” easily Difficulty falling or staying asleep Hypervigilence or hyperalert 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 12

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 13

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 14

15 PTSD may co-exist and be synergistic with Traumatic Brain Injury (TBI) 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 15

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 Posttraumatic Stress Disorder Col William Pond, IN SAS 16

17 Previous diagnoses of what is now PTSD Railway Spine Stress Syndrome Shell Shock Battle Fatigue Traumatic War Neurosis PTSD since 1980s 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 17

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 18

19 Incidence rate decreases with age. 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 19

20 Predisposing factors Associated life stresses, e.g. marital problems Pre-existing psychological problems 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 20

21 Chronic lack of sleep is a real stressor

22 So is heat September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 22

23 Severity 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 23

24 Amputations as a marker of permanent severe injury 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 24

25 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 25 Proximity

26 And length of exposure Civilian exposures are often single events whereas military may be multiple 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 26

27 After 35 days of uninterrupted combat, 98% of soldiers exhibited psychiatric disturbances of varying degrees 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 27

28 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 28

29 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 29

30 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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 30

31 The VA has PTSD Inpatient Resources in the community PTSD Intensive Inpatient Programs Day Hospitals Evaluation and Brief Treatment Units Residential Rehabilitation PTSD Domiciliary 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 31

32 The VA has PTSD Specialists in the community Vet Centers By Veterans, records confidential 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 32

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

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) 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 34

35 Your support is invaluable, and therapeutic, like the children’s notes of support on the concrete wall 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 35

36 36 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?

37 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 38 Army BATTLEMIND Program stresses 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. 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 39

40 Pastoral Care is invaluable 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 40

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) 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 41

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 42

43 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 43

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 44

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 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 45

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. 25 September 2012 Posttraumatic Stress Disorder Col William Pond, IN SAS 46

47 25 September 2012 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


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