PTSD: The Shadow of Combat

An Anxiety Disorder. 3-6% of adults in the United States. Twice as common in women as in men. Rates as high as 58% in heavy combat 1-14% non combat Torture/POW 50-75% Natural Disaster victims 4-16% PTSD

Exposure to a traumatic event in which the person Experienced, witnessed, or was confronted by death or serious injury to self or others AND Responded with intense fear, helplessness, or horror Features Appear in 3 clusters: re-experiencing, avoidance/numbing, hyperarousal Last for > 1 month Cause clinically significant distress or impairment in functioning DSM-IV diagnostic criteria for PTSD

Spontaneous re-experiencing of the trauma Startle responses Irritability Depression and Guilt Phobias Multiple physical complaints Numbing Impaired concentration and memory Disturbed sleep and distressing dreams History

Fright Neurosis Combat/War Neurosis Shell Shock Survivor Syndrome Operational Fatigue Compensation Neurosis Labels

Stats 1.6 million troops deployed to OEF/OIF to date 1.6 million troops deployed to OEF/OIF to date Approximately 40% have accessed VA care Approximately 40% have accessed VA care Three most common presenting problems: Musculoskeletal Ailments Three most common presenting problems: Musculoskeletal Ailments Mental Disorders (PTSD, SA/D, Depressive) “Symptoms, Signs, and Ill Defined Cond.” “Symptoms, Signs, and Ill Defined Cond.”

VA Healthcare Utilization among GWOT Veterans 868,717 OEF/OIF who have left active duty since February ,717 OEF/OIF who have left active duty since February ,873 Former Active Duty 430,844 Reserve and NG 40% (347,750) have accessed VA care since FY 2002 (96% outpatient)

Demographic Characteristics of OEF and OIF Veterans Utilizing VA Health Care % OEF/OIF Veterans % OEF/OIF Veterans (n = 347,750) (n = 347,750)Gender Male 88 % Male 88 % Female 12 Female 12 Age Group <20 7 < ≥40 18 ≥40 18Branch Air Force 12 Air Force 12 Army 64 Marine 13 Marine 13 Navy 11 Navy 11 Unit Type Active 52 Active 52 Reserve/Guard 48 Reserve/Guard 48Rank Enlisted 92 Enlisted 92 Officer 8 Officer 8

Frequency of Possible Diagnoses Among OEF and OIF Veterans Diagnosis (n = 347,750) (Broad ICD-9 Categories) Frequency * % Infectious and Parasitic Diseases ( ) 40, Malignant Neoplasms ( ) 3, Benign Neoplasms ( ) 13, Diseases of Endocrine/Nutritional/ Metabolic Systems ( ) 75, Diseases of Blood and Blood Forming Organs ( ) 7, Mental Disorders ( ) 147, Diseases of Nervous System/ Sense Organs ( ) 121, Diseases of Circulatory System ( ) 56, Disease of Respiratory System ( ) 71, Disease of Digestive System ( ) 110, Diseases of Genitourinary System ( ) 37, Diseases of Skin ( ) 55, Diseases of Musculoskeletal System/Connective System ( ) 165, Symptoms, Signs and Ill Defined Conditions ( ) 138, Injury/Poisonings ( ) 73, *These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 347,750.

Frequency of Possible Mental Disorders Among OEF/OIF Veterans since 2002 Disease Category (ICD code) Total Number of GWOT Veterans PTSD (ICD-9CM ) 75,719 Depressive Disorders (311) 50,732 Neurotic Disorders (300) 40,157 Affective Psychoses (296) 28,734 Nondependent Abuse of Drugs (ICD 305) 21,201 Alcohol Dependence Syndrome (303) 12,780 Special Symptoms, Not Elsewhere Classified (307) 7,685 Sexual Deviations and Disorders (302) 7,076 Drug Dependence (304) 5,764 Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310) 4,654 *

Three Different Types of Stress Injuries Combat/Operational Stress Stress Adaptations Stress Injuries Positive Behaviors Negative Behaviors Traumatic Stress Operational Fatigue Grief Due to a terrifying or horrible event Due to the wear and tear of deployment Due to the loss of friends and leaders

Multi-casualty incidents (SVBIEDs, ambushes) Friendly fire Death or maiming of children and women Seeing gruesome scenes of carnage Handling dead bodies and body parts “Avoidable” casualties and losses Witnessed or committed atrocities Witnessed death/injury of a close friend or leader Killing unarmed or defenseless enemy Being helpless to defend or counterattack Injuries or near misses Killing someone up close Traumatic Events in OEF/OIF

Belief in one’s basic safety Belief in being the master of oneself and one’s environment Belief in “what’s right” — moral order Belief that our cause is honourable Belief that every troop is valued Belief in the basic goodness of people (especially oneself) Beliefs That Can Be Damaged By Traumatic Stress

Causes of Shame or Guilt In Traumatic Stress Injuries Surviving when others did not Failing to save or protect others Killing or injuring others Helplessness Failing to act Loss of control Even just having stress symptoms of any kind

RAND Study (2008) 1965 service members from 24 communities 1965 service members from 24 communities 50%+ reported a friend seriously wounded or killed 50%+ reported a friend seriously wounded or killed 45% saw dead or wounded noncombatants 45% saw dead or wounded noncombatants 10% reported injuries requiring hospitalization 10% reported injuries requiring hospitalization 18.5% met criteria for PTSD or depression 18.5% met criteria for PTSD or depression 19.5% reported mTBI during deployment of which 1/3 reported concurrent PTSD or depression 19.5% reported mTBI during deployment of which 1/3 reported concurrent PTSD or depression

PTSD and Mild Traumatic Brain Injury (TBI) Slightly more than half of combat injuries early in OIF came from explosions Slightly more than half of combat injuries early in OIF came from explosions 29% evacuated from combat theater to WRAMC had evidence of TBI (Jan 2003-Feb 2007) 29% evacuated from combat theater to WRAMC had evidence of TBI (Jan 2003-Feb 2007) Approximately 15% of all wounded vets have suffered TBI (4,471 cases diagnosed between October 2001 and September 2007) Approximately 15% of all wounded vets have suffered TBI (4,471 cases diagnosed between October 2001 and September 2007)

TBI Physical damage by external blunt or penetrating trauma Physical damage by external blunt or penetrating trauma Acceleration-Deceleration Movement (whiplash) resulting in tearing or nerve fibers, bruising/contusion of brain Acceleration-Deceleration Movement (whiplash) resulting in tearing or nerve fibers, bruising/contusion of brain Scraping of brain across bony base of skull leading to olfactory, oculomotor, acoustic nerve damage. Scraping of brain across bony base of skull leading to olfactory, oculomotor, acoustic nerve damage. –Loss of sense of smell and reduction of taste (anosmia), double and/or blurred vision, dizziness or vertigo –Usually remit after several days or weeks (nerves recover or regenerate)

Levels of TBI Mild Mild –LOC for less then 30 minutes w/normal CT and/or MRI –Altered mental state: “dazed,” “confused,” “seeing stars” –PTA less then 24 hours (unable to store or retrieve new information) –Glasgow Coma Scale (GCS): 13-15

Levels of TBI Moderate Moderate –LOC less than six hours w/abnormal CT and/or MRI –PTA less than seven days –GCS: 9-12 Severe Severe –LOC greater than six hours w/abnormal CT and/or MRI –PTA greater than seven days –GCS: 1-8

Post-Concussion Syndrome (PCS) Symptoms immediately post-injury may include: Symptoms immediately post-injury may include: –Memory, attention, concentration deficits –Fatigues, poor sleep, dizziness, headaches –Irritability, depression –Anxiety Most common: free-floating anxiety, fearfulness, intense worry, generalized uneasiness, social withdrawal, heightened sensitivity, related dreams Most common: free-floating anxiety, fearfulness, intense worry, generalized uneasiness, social withdrawal, heightened sensitivity, related dreams Recovery (mild TBI) expected within 4-12 weeks; however, some symptoms may linger for months to years Recovery (mild TBI) expected within 4-12 weeks; however, some symptoms may linger for months to years

Assessment Post concussion Syndrome (PCS) Post concussion Syndrome (PCS) –Insomnia –Memory Deficits –Poor Concentration –Depressed Mood –Anxiety –Irritability –Headache –Dizziness –Fatigue –Noise/Light Intolerance PTSD PTSD –Insomnia –Memory Deficits –Poor Concentration –Depressed Mood –Anxiety –Irritability –Intrusive symptoms –Emotional Numbing –Hyperarousal –Avoidance behavior

Mild TBI among OIF Returnees (Hoge et al., 2008) 2,525 soldiers included in study (assessed 3-4 months post-deployment) 2,525 soldiers included in study (assessed 3-4 months post-deployment) –5% (124) reported injury with LOC (up to several minutes) –10% (260) reported injury with altered mental status w/out LOC –Four soldiers reported LOC longer than 30 minutes –17% (435) reported other injuries

Of those who reported LOC, 44% met criteria for PTSD, as compared to: -27% of those with altered mental state -16% of those with other injuries -9% of those with no injuries TBI Among OIF Returnees (Hoge et al., 2008)

Blast Injuries Over 50% of combat injuries result from bombs, grenades, land mines, missles, mortar/artillery shells Over 50% of combat injuries result from bombs, grenades, land mines, missles, mortar/artillery shells Account for majority of brain injury in theater with GSWs, falls, and MVAs close behind Account for majority of brain injury in theater with GSWs, falls, and MVAs close behind TBI among service members as high as 22% TBI among service members as high as 22% – : over 6,600 TBI –Four major polytrauma centers (MN, CA, FL, VA): 923 OEF/OIF patients with TBI

Blast Injury Blast injuries results from pressure generated from an explosion which causes in overpressurization Blast injuries results from pressure generated from an explosion which causes in overpressurization Air-filled organs (ears, lung, GI tract) and organs surrounded by fluid filled cavities (brain, spinal cord) susceptible Air-filled organs (ears, lung, GI tract) and organs surrounded by fluid filled cavities (brain, spinal cord) susceptible

Hoge et al. (2006) 01 May 2003 – 30 April 2004: 01 May 2003 – 30 April 2004: –OEF (Afghanistan) –OIF (Iraq, Kuwait, Qatar) –Other (Bosnia, Kosovo, etc.) N = 303,905 Marines and Soldiers N = 303,905 Marines and Soldiers –OEF: 11.3% of 16,318 –OIF: 19.1% of 222,620 –Other: 8.5% of 64,967

Hoge at al. (2006) Combat Experiences: Combat Experiences: OEF OIF OTHER OEF OIF OTHER Any 46.0% 65.1% 7.4% Witnessed 38.1% 49.5% 5.3% Discharged 6.2% 17.8% 0.4% Felt in Danger 24.6% 50.3% 3.2%

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