1. War may be hell… but home ain’t exactly heaven, either. When a Soldier comes home from war, he finds it hard…

2. …to listen to his son whine about being bored.

3. …to keep a straight face when people complain about potholes.

4. …to be tolerant of people who complain about the hassle of getting ready for work

5. …to be understanding when a co- worker complains about a bad night’s sleep

6. …to control his panic when his wife tells him he needs to drive slower

7. …to be grateful that he fights for the freedom of speech.

8. …to be silent when people pray to God for a new car.

9. …to be compassionate when a businessman expresses a fear of flying.

10. …to not laugh when anxious parents say they’re afraid to send their kids off to summer camp.

11. …to not ridicule someone who complains about hot weather.

12. …to control his rage when a colleague gripes about his coffee being cold.

13. …to remain calm when his daughter complains about having to walk the dog.

14. …to be civil to people who complain about their jobs.

15. …to just walk away when someone says they only get two weeks of vacation a year.

16. …to be happy for a friend’s new hot tub

17. …to be forgiving when someone says how hard it is to have a new baby in the house.

18. …to not punch a wall when someone says we should pull out immediately.

19. The only thing harder than being a Soldier… By: Danielle “A Proud Army Wife”

20. is loving one.

21. A gentle reminder to keep your life in perspective. And when you meet one of our returning Soldiers, please remember what he’s been through and show him compassion and tolerance. Thank you. CPT Alison L. Crane, RN, MS Mental Health Nurse Observer-Trainer 7302 nd Medical Training Support Battalion

22. POST TRAUMATIC STRESS DISORDER (PTSD) Beth Jeffries, PhD PCT Supervisor Jack C Montgomery Veterans Hospital Muskogee, OK

23. What We’ll Cover Post Traumatic Stress Disorder (PTSD) Traumatic Brain Injury (TBI) Social Implications Academic Implications Occupational Implications

24. PTSD

25. Brief Overview Experience of being exposed to an extreme traumatic stressor falling outside of the typical human experience or expectation Response to this event involves intense fear, helplessness or horror Evidence of persistent re-experiencing of the event Evidence of persistent avoidance behaviors related to the trauma and generalized numbing of responsiveness Increased arousal These symptoms must be present for more than 1 month Create dysfunction in social, occupational, and other important areas of functioning

26. Extreme Stressors Some examples… Military combat Violent personal assault Terrorist attack Kidnapping Natural or Manmade disasters Diagnosed with life threatening illness or injury

27. Personal Response How the person responds is important… Amount of control the person feels in the situation appears to be very important for outcome Social support, or lack of, impacts symptoms Avoidance is NOT helpful…

28. Symptoms of PTSD Associated with Re-experiencing… Intrusive thoughts of the event Nightmares and sleep disturbance Flashbacks Intense psychological and physiological distress when reminded of the event

29. Symptoms continued… Associated with Avoidance and Numbing… Efforts to avoid reminders Inability to recall important aspects of the event Withdrawal from favored activities and interests Strong feelings of detachment and/or estrangement from others Restricted range of affect (poker face)

30. Symptoms continued… Associated with Arousal… Irritability and outbursts of anger Difficulty concentrating/often confused with memory loss Hypervigilance Exaggerated startle response

31. Suicide Feelings of hopelessness Feelings of isolation/detachment Depression and Loss Guilt Substance Abuse/Excessive Use Coming home to family changes such as divorce, loss of money, or deaths in the family Physical changes/disabilities resulting from wartime experience

32. Suicide What to look for Isolation Substance abuse/excessive use Depression Giving possessions away Threats of suicide/past attempts Talking about lack of future/hopelessness Family history should be considered Lack of social support

33. Suicide National Hotline It Takes the Courage and Strength of a Warrior to Ask For Help 1-800-273-TALK (8255) Press 1 for Veterans www.suicidepreventiononlifeline.org

34. PTSD Prevalence and Etiology Estimated that 8% of total population meets criteria as set forth by the Diagnostic and Statistical Manual-IV (DSM-IV) Research indicates 30-40% of persons exposed to trauma go on to develop PTSD Number may be higher in “real world”

35. Prevalence and Etiology cont… No one group impacted more than another Childhood traumas may “prime” individuals to develop PTSD after subsequent traumas Not considered an illness, but rather a stress reaction Long term, adrenal system impacted and other physiological problems

36. Symptom Presentation Withdrawal from family and friends Inability to “get along” with others Alcohol and substance abuse Poor performance in home activities, school and work “Personality” changes, behavior changes

37. Prognosis Typically considered chronic, but recovery/management realistic goal Up and down pattern of symptoms likely over a lifetime Anxiety and depression features are medication responsive Early, intense cognitive behavioral therapies are effective

38. Medications SSRIs TCAs Sometimes, anti psychotics Alpha blockers Discourage use of sleep agents and benzos consistently found to be ineffective, at best, and possibly, more harmful

39. Behavioral Treatments Group Therapy – Therapy of Choice Individual Therapy Supportive Therapy Cognitive Behavioral Therapy (CBT) Cognitive Processing Therapy (CPT) Prolonged Exposure Therapy (PET) Family/Marriage Counseling Support and Peer Groups

40. Evidence Based Psychotherapy Cognitive Processing Therapy (CPT) Prolonged Exposure (PE) Cognitive Behavioral Therapy (CBT)

41. PHYSICAL INJURIES Traumatic Brain Injury

42. Significant Issues Physical Injuries Loss of eyesight Loss of limbs Burns Traumatic Brain Injury (TBI) Soldiers are surviving injuries on the battlefield that would have been fatal in the past!

43. Traumatic Brain Injury (TBI) Closed or Open Wound Loss of consciousness Dizzy Headache Memory loss Nausea Suicidal risk

44. TBI, cont. Can be difficult to distinguish from PTSD, many symptoms are similar Behavioral changes Attention deficits, Concentration problems Impulsive behaviors/Acting out “Nervous” energy Depression, withdrawal, suicidal ideations Not always visually apparent

45. TBI Treatment Psychological Testing from a trained Neuropsychologist is recommended Medical tests such as CAT scans and MRIs may be warranted Assessment of pre-morbid functioning is recommended

46. TBI, cont Head injuries may impede a person’s ability to function in all spheres, including academic Ability to concentrate Socialize appropriately Focus of attention Memory Retention “Personality” changes Impulsivity

47. HOW DO ALL THESE INJURIES IMPACT THE RETURNING SOLDIER IN HIS “LIFE” AND HOW DO THEY IMPACT THE “REST OF US”

48. Social Functioning

49. Big Changes Withdrawal / Isolation Impulsive Aggressive / Acting out Short Attention Span Self Focused / “Selfish” / Childlike Regression Angry Controlling

50. Family and Friends Isolates from others, even at home May be “uninvolved” May be “overly involved” Detachment “Clingy-ness” Routines are disrupted Roles are altered

51. What Might Help Give self and family time to adjust Create a routine Communicate, communicate, communicate Set aside “alone” time Set aside “family” time Monitor and minimize substance use Seek VA (or other) services to assist with adjustment issues Understand that both of you have changed in some ways

52. Academic

53. Big Changes Loss of Concentration / Distractable Inability to sit still “Speaks out” in class Disorganized Easily Frustrated / “Slow” to learn

54. What Might Help Set aside study times that are brief and consistent/daily Consider testing in separate room and/or extended time Use a study partner Practice going outside your comfort zone in simple, small ways to start

55. Occupational

56. Big Changes Not Dependable or Reliable Frustrates Easily Loss of Concentration Difficulty Getting Along with Supervisors and Co-workers Frequent Mistakes Over Controlling -or- Appears to “not care”

57. What Might Help Consider employment options carefully Practice going outside your comfort zone in small ways Use relaxation and visualization techniques Improve surroundings in small but meaningful ways

58. Where and How to Get Help

59. Veterans Administration (VA) Services DoD and VA collaboration to inform veterans about our services Orientations and PTSD Screen in Primary Care Easy access and flexible hours Outpatient/Inpatient/Crisis services

60. PTSD Clinical Team (PCT) Specialized team focused on treatment and care of veterans with PTSD Psychiatrists, psychologists, social workers and administrative personnel available for comprehensive, team approach

61. Group Therapy Treatment of Choice 3 Stage Program Core group – 3 months/education focus Action group – 3 month/process focus Maintenance group – 1 yr/support focus Intense focus groups CPT groups

62. Individual Therapy Supportive and Cognitive CPT PET Marriage/Crisis/Family Importance of family involvement is stressed

63. Who Needs a Referral? Identifying the need is the biggest step The individual may avoid the problem by Self medicating with substances Withdrawing from activities and “life” Using anger Performance may suffer

64. Who can and should be referred to VA? Any member of the National Guard or Reserves, or other affiliation with our Armed Forces Any veteran of our Armed Forces Of the above, anyone who requests a referral

65. Who Do I Call for Assistance? Contact the business office at Jack C Montgomery VA Hospital Muskogee, OK (918) 577-3000 / (888) 397-8387 Contact the Behavioral Medicine Clinic Muskogee 918-577-3699 Tulsa 918-610-2000 Beth Jeffries, PhD Program Director/Supervisor PCT 918-610-2000 Ernest C Childress VA Tulsa 918-577-3699 Jack C Montgomery VA Muskogee

66. Operation Enduring Freedom (OEF) Operation Iraqi Freedom (OIF) Nanette Waller, MSW OEF/OIF Program Director Jack C Montgomery VA Hospital Muskogee, OK 74401 918-577-4150

67. Oklahoma City Area VA For admissions in person, go to the 2 nd floor of Building 3 and request an information packet. For telephone information, or to have a packet sent to your home, please contact Cheryl Bays, LCSW at (405) 270-0501, extension 5367 ** A copy of your DD214 is required.

68. Operation Enduring Freedom (OEF) Operation Iraqi Freedom (OIF) Steven Scruggs, PhD OEF/OIF Program Director Veterans Administration Hospital Oklahoma City, OK (405) 270-0501

69. QUESTIONS???

70. THANK YOU