Presentation on theme: "Understanding Military Posttraumatic Stress Disorder (PTSD)"— Presentation transcript:
1Understanding Military Posttraumatic Stress Disorder (PTSD) 22 June 2013We, in the National Guard, are your family, friends and neighbors, it is therefore important that we understand Posttraumatic Stress Disorder especially as it relates to military members and their families. PTSD is significant to all of us here because there are nearly half a million members of the National Guard, both Air and Army, along with their families and 485,000 children, spread out across our nation, including here in our community of Northern Indiana.Guard members have been part of the total force for this last 2 decades of war. And make no mistake, a “low intensity, urban conflict” is not low intensity to those who are experiencing it. Since 2001 our communities have supported more than 675,000 Guard mobilizations for domestic and overseas missions. And since 9/11 over 700 Guard members have died in combat operations. We also mourn those Guardsmen last month who perished fighting forest fires, saving their fellow citizens and their property. Preserving our nation is a dangerous, stressful calling.
2Armed Forces Health Surveillance Center & by Col William W. Pond, MDIndiana State Air Surgeon(& Baghdad, & Balad & Kuwait & Qatar, etcWith thanks to Maj Gen Kirk Martin &Armed Forces Health Surveillance Center &Association of Military SurgeonsGood afternoon. I am Colonel William Pond, State Air Surgeon for the Indiana Air National Guard, discussing Post Traumatic Stress Disorder also known as PTSD. I have personally known friends and families affected by it. I was commander of the Indiana Medical Response to Hurricane Katrina, and for first 3 days wading through the swamp going door to door (when we could find a door that is); we set up our first clinic on a picnic table in a baseball field. We helped over 14,000 Mississippi citizens, saying, “I’m sorry this happened to you, what can I do to help?”I was also commander of the Air Force EMEDS hospital in Baghdad during the “surge” in 2007 and I have other deployments throughout SW Asia. I would like to thank Major General Kirk Martin, Air National Guard Assistant to the Surgeon General of the Air Force and Director, Office of the Joint Surgeon, National Guard Bureau, for sharing his thoughts, some of which have been incorporated into this lecture. I also recognize the Armed Force Health Surveillance Center for current and accurate data.
3PTSD Crisis ? Nicholas Horner, Iraq April 6, 2009 Altoona, PAAfter return from SW Asia, quiet, did not leave homeSlept poorly, found crying in basement by motherPanic attacks, doors always lockedExplosive moods, argument with wife in morningAfternoon drinking 2 pitchers of beer.Walked to Subway back door, cut electrical wires, shot out utility boxShot 2 inside and apologized, “Sorry, I didn’t wanna have to do that to you.”Shot another while trying to steal a carRage, insomnia, emotional numbness do not qualify as insanityConvicted of murder, PTSD “not an excuse for murder”Posttraumatic Stress DisorderCol William Pond, IN SAS
4Compare: Chistopher “Stone Cold” Mountjoy March 31, 2012, Fort CarsonSin City Disciples Motorcycle Club enforcerStreet barricaded, crouched behind trash binAmbushed cars of victimVictim previously beaten and was allegedly returning to retrieve wallet5 associates charged with murderMountjoy, an active duty soldier, served as sergeant-at0-arms for local Sin City disciplesMountjoy deployed to Afghanistan in 2011PTSD claimed as defense to actionsPosttraumatic Stress DisorderCol William Pond, IN SAS
5Posttraumatic Stress Disorder The topics of Psychological Health and Traumatic Brain Injury are high interest items with Association of Military Surgeons of the United States with the August 2012 issue dedicated to the topic. What I present to you today reflects our best and current thinking.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
6Posttraumatic Stress Disorder Congratulations, Ken, you have just purchased your very own low mileage HummerLower left, C-130 transport for moving patients, troops and supplies.Upper right Dave Cox, Critical Care Air Transport Nurse, later a patient with PTSD.Lower right, a little levity, which, with bonding helps to normalize thinking and decrease PTSD.Posttraumatic Stress DisorderCol William Pond, IN SAS
7Aeromedical Evacuation (A little humor on the slide while talking about the USAF, Guard and deployments before launching into the next slides)I thought that you would appreciate a little air humor—the irony of the sign that says, “Beware of low flying aircraft,” clipped off ostensibly by a low flying airplane.Last year at home, we responded to 14 natural disasters that each caused at least $1 billion dollars damage—dealing with fires in multiple states, flooding and storms, recovery support, and here in Indiana help and assistance within hours, for those who were struck by tornadoes last spring. Although missions may be important and in some respects fulfilling, they also take a toll. For some, the toll is physical with the loss of a leg or sight, but for others, it may be psychological with the loss of a friend or a debilitating mental disorder.25 September 2012Aeromedical EvacuationCol William Pond, IN SAS
8PTSD is one of several mental disorder diagnoses Although the men and women of the military are select, both mentally and physically, they are nonetheless subject to disorders that affect the population as a whole. When considering mental disorder diagnoses among all US Armed Forces, PTSD is but one of several mental disorder diagnoses. When looking at the rate of mental disorder diagnoses per 100,000 active US Armed Forces, there are adjustment disorders, depression, anxiety, alcohol abuse and PTSD among others.Various studies have looked at the rate of PTSD, with a Rand report finding that 19% of the service members deployed to Iraq or Afghanistan suffered from Traumatic Brain Injury and 25% have been diagnosed or have had symptoms of PTSD.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
9Acute 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 ASDReactions to stress are expected and exhibit a wide spectrum of psychological responses, both in magnitude and duration. Many experience Acute Stress Disorder which is defined as symptoms that last less than 30 days. Soldiers should be assured that reactions to stress are common, in fact studies of National Guard Troops returning from deployment have shown rates of positive screens for psychological health conditions as high as 40%.But a positive screen does not necessarily mean disease, any more than a positive tuberculosis skin test means that the member has tuberculosis--but it does mean that the issue warrants further investigation. Multiple deployments increase the likelihood of PTSD, major depression and alcohol abuse. Deployments also affect families when children may show increased sadness, anxiety, elevated stress levels, behavioral problems, feelings of uncertainty and academic problems. For example, a child “acting out” in school may be a manifestation of concern for his mother’s safety in Afghanistan or a father’s insomnia may reflect his anxiety for a daughter in Iraq. My mother-in-law still becomes teary-eyed when thinking of her brother, lost in the South Pacific 60 years ago.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
10PTSD—What is it and how is it defined? Traumatic eventPatient must feel seriously threatened to self or othersMust have intense negative emotional responsePersistent re-experiencingFlashback memories, bad dreams, re-experiencing the event—all evoke intense negative response to events that remind patientFor purposes of this discussion and to lend uniformity to the treating community, there are several elements that must be considered when discussing PTSD.First, there must first be a triggering traumatic event. The patient must feel seriously threatened, either to himself/herself or to another one close.This event must also have an intense negative emotional response.There must also be persistent re-experiencing of the event—after all, if the event happens and there is no reliving, then there is no effect on function. The re-experiencing may take the form of flashback memories, bad dreams, re-experiencing the actual event or similar ones—but in all cases these are associated with intense negative feelings usually accompanied by physiologic responses such as fast heart rate and sweating.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
11Posttraumatic Stress Disorder PTSD—More signsAvoidance and emotional numbingAvoiding stimuli associated with event such as thoughts or talking about itAvoiding places, or people who remindInability to recall major parts of eventDecreased ability to feel emotionsExpectation of short future or doomAdditional signs include avoidance and emotional numbing. Specifically, a patient may avoid stimuli associated with the event, for example, unexpected loud noises which may be a potent trigger.The patient may try to avoid talking about the event or even thinking about it, but to no avail, because the thoughts always creep in. The patient may also avoid places or people who remind of the event.He may cope by keeping his back to a wall in a public place.Symptoms may also include the inability to recall parts of the event which is as perplexing as it is real.Decreased ability to feel emotions may be reported by the wife, who anticipates a joyous reunion, but is instead met by a flat fish affect of the returning husband.There may also be an unexplainable expectation of a short future or of a feeling of impending doom. Although he or she can elucidate no reason, there may nonetheless be a true overwhelming feeling.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
12PTSD Arousal Disturbances Anger poorly controlled, “flies of the handle” easilyDifficulty falling or staying asleepHypervigilence or hyperalertOther signs include poorly controlled anger and difficulty in falling asleep or staying asleep—signs that may be reported by the spouse.The patient may be hyper-vigilant and hyper-alert—”on edge.” In a wartime situation these traits may be adaptive or even protective, but they are inappropriate in the home setting. And these reactions may be deep rooted in the subconscious.In June of 2007, I had just returned as being commander of the EMEDS hospital during the “surge.” during which time I had made several interesting night time helicopter MEDEVAC missions. At 6:00 am on a Friday morning here at home, I remember walking up from the parking garage adjacent to the helipad--the sound of the helicopter rotors, the smell of the fuel, the flashing lights—and suddenly, reflexively, without thinking, I dove behind the concrete wall. And just as quickly, I realized where I was, I looked around to see if anyone else had seen my actions, I sheepishly dusted myself off and walked into the hospital… a tangible event demonstrating that these subconscious reactions are real.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
13PTSD Criteria--Impairment PTSD not present unless significant impairmentSocial 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 detailThe PTSD definition also requires significant functional impairment.Such impairment may be in social relationships with parents, spouse or coworkers. It is they who may be the first to notice.Impairment may also show in the ability to do ones job; he may be late to work, she may lack attention to detail or conversely she may have excessive attention to detail.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
14Physiologic changes accompanying PTSD Fight or Flight responseFast Heart rateHyperventilation, breathing deep and fastQuivering or shakingEasily startled with loud noisesThere may be associated physiologic responses.The fight or flight response may occur.There may be hyperventilation, fast heart rate, quivering, shaking or easily startling with loud noises.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
15PTSD may co-exist and be synergistic with Traumatic Brain Injury (TBI) This slide is to remind us that PTSD may also coexist with other conditions such as Traumatic Brain Injury or major depression.(These were fortunate Brits that were treated in our Baghdad ER complaining of disorientation, headaches and earaches. Several had ruptured ear drums. A rocket propelled grenade may take 3-15 meters to arm which is required prior to detonation. Fortunately for them, it struck the bulletproof glass and bounced up before arming and then exploding. So they had good reason for PTSD symptoms from a near death experience, but they also experienced a concussive traumatic brain injury.)25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
16Is PTSD a new disease, newly recognized or newly recategorized? First report 490 BC Herodotus noted soldier blind after Battle of Marathon1800s military doctors noted “exhaustion” with mental shutdown.During WWII 10% of American soldiers were hospitalized for mental disturbances between 1942 and 1945.Is PTSD a new disease or maybe a newly understood, recognized or re-categorized one? The psychological effects of war have been known since the beginning of war; in fact, the first report of a psychological disease with physical manifestations was reported by Herodotus of a soldier who experienced psychosomatic blindness after the Battle of Marathon.In the 1800s military physicians diagnosed a condition of “exhaustion” with mental shutdown. During WWII, 10% of American soldiers who were hospitalized were admitted for mental disturbances.Posttraumatic Stress DisorderCol William Pond, IN SAS
17Previous diagnoses of what is now PTSD Railway SpineStress SyndromeShell ShockBattle FatigueTraumatic War NeurosisPTSD since 1980sIt has also been noted as “Railway Spine, Stress Syndrome, Shell Shock, Battle Fatigue, Traumatic War Neurosis, and PTSD since the 1980s.”25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
18PTSD Risk and Protective Factors 50-90% of the American population experienced a traumatic event, but only 8% develop PTSD70-90% of deployed military members experience a traumatic event, but only 15% develop PTSDWhy not everyone?So 50-90% of Americans undergo traumatic stressful events, but only 8% develop PTSD. A similar percentage of military members may also experience a significant traumatic event, and still only 15% develop PTSD. So why not everyone? What might make one more resilient?Posttraumatic Stress DisorderCol William Pond, IN SAS
19Incidence rate decreases with age. It appears that many mental disorders decrease with age. A note of caution is in order regarding mental disorder diagnoses in the US military; there may be a certain selection bias because adjustment disorders and personality disorders may end one’s military service; whereas the traumatic event for PTSD occurs during one’s service.Nonetheless, the process of life experiences produces a resilience. If so, is there perhaps a way to transfer this protective effect learned from life lessons? We will address this more fully later in our talk.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
20Posttraumatic Stress Disorder Predisposing factorsAssociated life stresses, e.g. marital problemsPre-existing psychological problemsAssociated life stresses may predispose to developing PTSD; these include financial and marital problems and pre-existing psychological conditions. Perhaps for those who are already stressed and on the edge of adequate function, it does not take much additional stress to push them over the edge.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
21Chronic lack of sleep is a real stressor While night operations may be beneficial to the mission by decreasing heat stress or enhancing security, such interruption of normal daily sleep patterns can compound other stressors.
22Posttraumatic Stress Disorder So is heatSimply changing to a day work cycle may solve the stress of night work, but this may cause stress due to heat as we experienced in a normal summer day in Qatar—this shows 120 degrees in the shade and 135 degrees in the sun.Heat, dehydration and exhaustion further decrease one’s psychological reserve.12 25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
23Posttraumatic Stress Disorder SeveritySeverity of injury affects one’s perception and stress.The injuries of combat are up close and personal. For those not accustomed to bodily injuries, these injuries can produce nightmares of monstrous proportions.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
24Amputations as a marker of permanent severe injury In fact, catastrophic extremity injuries due to Improvised Explosive Devices (IEDs) and Rocket Propelled Grenades (RPGs) are the signature of injury of current conflicts.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
25Posttraumatic Stress Disorder ProximityProximity of the person to the traumatic event is also important.Feeling the heat, smelling the explosive, seeing the flash, being crushed by the blast—all these blend to form a multi sensory experience that imprints deep into the mind.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
26Posttraumatic Stress Disorder And length of exposureCivilian exposures are often single events whereas military may be multipleOur troops never know if the civilian is an unarmed non-combatant or a suicide bomber or an IED around the next corner. Day after day, the continued stresses ingrain the edginess. In the military, the duration, severity, proximity, length, repetition, and variety of exposure may further ingrain and predispose more than is seen in the civilian realm.(This is the AK 47 round from our last patient in Bagdad, by the growth plate on the bones, you could see it is a child about the same age as my granddaughter.)25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
27Posttraumatic Stress Disorder After 35 days of uninterrupted combat, 98% of soldiers exhibited psychiatric disturbances of varying degreesAlthough there are predisposing risk factors and protective factors, all are at risk. After 35 days of interrupted combat, 98% of soldiers exhibited psychiatric disturbances to varying degrees. (Depending upon time and audience interest, tell story of Dave Cox, CCATT Nurse, now an articulate spokesman for the Wounded Warrior Project.)25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
28Posttraumatic Stress Disorder How do we diagnose PTSD for military members in the civilian community? We first use a screening tool that determines appropriateness of referral to a professional for further diagnosis and treatmentThe gold standard for diagnosis is the professionally administered Semi-structured Diagnostic Interview where questions and answers can be clarified and explored using such tools as Clinical Administered PTSD Scale (CAPS) that explore frequency and intensity of symptoms. PTSD diagnosis is given if symptoms include the following: a re-experiencing event, three avoidance behaviors and two hyper-arousal symptoms.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
29Posttraumatic Stress Disorder In our community resources are available at the VA, Vet Centers, State Director of Psychological Health. If you need to refer someone, the information is located on the bottom of the PTSD Screening Tool, which is included in the handout materials.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
30The VA has PTSD Specialists in the community PTSD Outpatient clinicsPTSD Clinical TeamsSubstance use combined with PTSD treatmentWomen’s Stress Disorder Treatment TeamsPTSD specialistsEvery VA Medical Center has providers that have been trained to offer PTSD treatment. Please be aware that even if your VA Medical Center does not have one of the special PTSD programs described below, you can still get effective PTSD treatment. Ask your doctor to refer you to a mental health provider who is a PTSD specialist. Below you will also find information about other options for getting PTSD treatment within VA.Specialized Outpatient PTSD Programs (SOPPs)In addition to regular outpatient PTSD care provided by a specialist or in some form of outpatient PTSD program, SOPPs include three basic types of clinics. At these outpatient (not live-in) clinics, you can meet with a provider on a regular basis.PTSD Clinical Teams (PCTs) provide group and one-to-one treatment.Substance Use PTSD Teams (SUPTs) treat the combined problems of PTSD and substance abuse.Women's Stress Disorder Treatment Teams (WSDTTs) provide women Veterans both one-to-one and group treatment.Specialized Intensive PTSD Programs (SIPPs)SIPPs provide PTSD treatment services within a "therapeutic community." Many programs are residential (live-in). Activities offered are social, recreational (relax), and vocational (work), as well as counseling.PTSD Day Hospitals (DH) are outpatient. They provide one-to-one and group treatment for 4-8 hours each visit. Patients come in daily or several times a week.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
31The VA has PTSD Inpatient Resources in the community PTSD Intensive Inpatient ProgramsDay HospitalsEvaluation and Brief Treatment UnitsResidential RehabilitationPTSD DomiciliaryEvaluation and Brief Treatment of PTSD Units (EBTPUs) provide PTSD treatment for a brief time ranging from 14 to 28 days.PTSD Residential Rehabilitation Programs (PRRPs) provide PTSD treatment and case management. The goal is to help the trauma survivor return to healthy living in the community. Stays at a PRRP tend to be 28 to 90 days long.Specialized Inpatient PTSD Units (SIPUs) provide trauma-focused treatment. Hospital stays last from 28 to 90 days.PTSD Domiciliary (PTSD Dom) provides live-in treatment for a set period of time. The goal is to help the Veteran get better and move to outpatient mental health care.Women's Trauma Recovery Program (WTRP) was opened by the VA in Palo Alto, CA, in This live-in program focuses on war zone-related stress as well as Military Sexual Trauma (MST). In the program Veterans can work on skills needed to deal comfortably with other people. The program is 60 days long.Other optionsSome VA medical centers are now offering walk-in clinics. By walking into the primary care clinic, a Veteran can be seen that day by a mental health provider.Other VA treatment locations where a Veteran can get PTSD treatment include:Community Based Outpatient Clinics (CBOCs)Primary care programsProvide care in a local settingServices include mental health care (some locations)25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
32The VA has PTSD Specialists in the community Vet CentersBy Veterans, records confidentialVet Centers are operated by VA's Readjustment Counseling Service. Call toll free during normal business hours: (Eastern) , OR (Pacific)Located outside medical facilitiesMany workers are VeteransProvide a mix of counseling and help with accessing other programsNo information about your treatment will be given to any person or agency (including the VA) without your consent25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
33You, our community, are important Nearly 85% of Guard Members are traditional meaning that they are trained, ready and willing to serve when called. Most of the time they live with families in their communities, receiving care from their community, not the military. They have normal jobs, go to school and live normal, non military lives after they return. But these stresses are not limited to guardsmen deployed overseas, but also to those who respond to disasters here at home.Difficulties of an absent parent and uncertain finances stress all in the family. The family relies on community medical care and psychological support.Posttraumatic Stress DisorderCol William Pond, IN SAS
34Prevention and treatment **Family, community, employers, ministers can be of invaluable assistance**By fostering recognition and early interventionBy 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)Here is where each of us can make a difference, because recognition and willingness to be treated are the first steps. Family, community employers, ministers, and mental health professionals can play a pivotal role in fostering recognition and early intervention.Listening empathetically will start the process. But do not give well intended false assurances, like, “I know it’ll be all right, or I know how you feel.” No you don’t, and not unless you’ve been there. This is where the Vet centers shine, because they are staffed by veterans who have “been there.”25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
35Posttraumatic Stress Disorder Your support is invaluable, and therapeutic, like the children’s notes of support on the concrete wallYour support is invaluable and therapeutic, like the children’s notes taped to the blast wall. There are so many times that I have seen a troop stop to read, reflect and re-read these notes.These are small lifelines from home that bring grounding to the troops.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
36Are Our Warriors Seeking Care? Less than 50%of our Warriors who meet the criteria for a behavioral health diagnosis report receiving careMarriages, spouses and children are also impacted by warSpouses have fewer stigma concerns and are more likely to pursue behavioral healthcareUnfortunately, less than 50% of our warriors who meet the behavioral health problem criteria report that they have received care. In spite of the Post Deployment Health Assessment at the end of the deployment and the Reassessment 6 months later, many fail to report symptoms.The Guard has placed a Director of Psychological Health in each state and at each stateside Air Wing to further encourage assessment and treatment.
37Battlemind Overview What is Battlemind? Comparable to resiliency: A Warrior’s inner strength to face adversity, fear and hardship during combat with confidence and courage; it’s the will to persevere and winComparable to resiliency:The ability to recover rapidly from misfortuneBattlemindalso refers to the U.S. Army’s premiere psychological resiliency building program and speaks to Warrior skillsThe military has various programs to encourage “resiliency”—for the Army, it is a program called Battlemind which endeavors to strengthen the Warrior’s inner strength to face adversity, fear and hardship.
38Army BATTLEMIND Program stresses positive factors, such as Buddies (cohesion) vs. WithdrawalAccountability vs. ControllingTargeted Aggression vs. Inappropriate AggressionTactical Awareness vs. HypervigilanceLethally-Armed vs. “Locked and Loaded” at HomeEmotional Control vs. Anger/DetachmentMission Operational Security (OPSEC) vs. SecretivenessIndividual Responsibility vs. GuiltNon-Defensive (combat) Driving vs. Aggressive DrivingDiscipline and Ordering vs. ConflictThe Battlemind program stresses positive factors such as cohesion, instead of the isolation of withdrawal.It also differentiates between accountability versus controlling, targeted wartime aggression versus inappropriate aggression, tactical awareness for self preservation in theater versus hyper-vigilance at home, mission operational security versus unnecessary secretiveness, combat driving versus aggressive driving.
39Posttraumatic Stress Disorder 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.The unit cohesion and strong leadership have been shown to decrease PTSD and positively to affect outcomes. Taking care of a 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 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
40Pastoral Care is invaluable During Aeromedical Evacuation missions, I was always appreciative when a pastor accompanied us to provide care and comfort to the patients.Many troops have never had a previous relationship at home with a mental health professional and further wish to avoid the stigma of association. But the same solider may have had a lifelong relationship with a minister at home. So in times of combat stress, it is natural to reach out to pastoral care for support, guidance, and if necessary referral to a mental health provider.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
41Posttraumatic Stress Disorder TreatmentCognitive behavioral programsIndentifying, challenging and modifying biased or distorted thoughts and interpretations about the event and its meaningConfronting avoided situations, people or places in a graded and systematic manner (in vivo exposure)Avoidance does not work; it is comfortable initially, but it does not solve the underlying problem.Cognitive behavioral programs have been shown to be of benefit by identifying, challenging and modifying biased or distorted interpretations about the event. Gradual, graded exposure to the avoided situations gradually returns one to a normal response.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
42Posttraumatic Stress Disorder PTSD TreatmentAddressing 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.The traumatic memory may be addressed in a controlled safe environment (imaginal exposure)Eye movement desensitization is also effective, most likely again due to re-engagement of the memory, cognitive reprocessing and enhancing coping.Posttraumatic Stress DisorderCol William Pond, IN SAS
43Posttraumatic Stress Disorder And for the younger, techno savvy crowd, who seem do 98% of their communication via texting, perhaps they would feel a little more comfortable with this application: Reliable information on PTSD and treatments that work, tools for screening and tracking symptoms, convenient, easy-to-use skills to help handle stress symptoms, direct links to support and help, always available.To set it up, first select friends and professionals who can help when stressed, load relaxing and comforting pictures and songs.There are modules for education, self assessment, management of symptoms and finding support.I was favorably impressed by the 9 minute muscle relaxation module with music and instructions.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
44PTSD 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 PTSDPrazosin—for nightmaresTopiramate—for flashbacks and nightmares.SSRI AntidepressantsMedications may be adjuncts to treatment but are not the first line. Beta blockers can decrease the fast heart rate, jitteriness, hyper-arousal and sleep disturbances related to adrenaline release. It may be better to use relaxation techniques long term.Benzodizepines should be used with caution since they do no relieve the underlying cause of anxiety, but may mask the symptoms. They have a high abuse potential in this population.Prazosin may assist with nightmares.Topiramate may be useful for flashbacks and nightmares.SSRIs may be useful to treat concomitant depression.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
45Posttraumatic Stress Disorder PTSD TreatmentImperative 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 necessarySince more than 2/3 patients will be able to successfully treated, it is imperative to foster an expectation that the member will recover with treatment and time, just as would occur in any other injury such as a broken arm or pneumonia. But just as a pneumonia make take several doses of antibiotic to cure, PTSD may require several treatments to cure. Sometimes a different treatment is necessary for a given patient.Of parenthetic interest, evidence does not show that a single critical incident stress debriefing session helps prevent development of PTSD.As with any potentially disabling condition, secondary gain must be minimized while still providing comprehensive treatment. Return to gainful work is therapeutic.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
46PTSD 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.What is the prognosis and duration? In general many patients receive substantial relief from 8-12 ninety minute sessions. If there is no secondary gain and if treatment is timely and appropriate, symptoms can be expected to become manageable within 1-2 months.Of course, those with concurrent psychological issues, traumatic brain injury, ongoing life stresses or deeply ingrained PTSD, more aggressive and long term treatment may be required. Like patients with diabetes or hypertension, the goal is to manage symptoms and maximize function.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS
47Posttraumatic Stress Disorder 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 knowWe are grateful for it.Thank youThe take home message: a psychological reaction is not uncommon after a severe stressful experience. Recovery is expected with early, accurate diagnosis and comprehensive, compassionate treatment.Family, home, community, and camaraderie are integral to recognition and motivation for treatment. We are grateful for your support; it means more than you will ever know. And with your support, the Guard will continue to defend and care for America as we have done since 1636.25 September 2012Posttraumatic Stress DisorderCol William Pond, IN SAS