1. PTSD and Veterans: Understanding and Accommodating Presented by: Cheryl Chesney-Walker, Executive Director for Health Careers/Education and Special Services for Students, VCU Medical Center, MCV Campus September 26, 2008 AHEAD Fall Conference

2. Background on PTSD Posttraumatic Stress Disorder Posttraumatic Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: The person has been exposed to a traumatic event in which both of the following were present: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior Source: DSM-IV-TR Source: DSM-IV-TR

3. PSTD Criteria The traumatic event is persistently re-experienced in one (or more) of the following ways: The traumatic event is persistently re-experienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external clues that symbolize or resemble and aspect of the traumatic event Physiological reactivity on exposure to internal or external clues that symbolize or resemble and aspect of the traumatic event Source: DSM-IV-TR Source: DSM-IV-TR

4. Symptoms and Behaviors of PSTD Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from other Feeling of detachment or estrangement from other Restricted range of affect (e.g., unable to have loving feelings) Restricted range of affect (e.g., unable to have loving feelings) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Source: DSM-IV-TR Source: DSM-IV-TR

5. Symptoms and Behaviors Continued Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: Difficulty falling or staying asleep Difficulty falling or staying asleep Irritability or outbursts of anger Irritability or outbursts of anger Difficulty concentrating Difficulty concentrating Hypervigilance Hypervigilance Exaggerated startle response Exaggerated startle response Source: DSM-IV-TR Source: DSM-IV-TR

6. Acute Stress Disorder The person has been exposed to traumatic event in which both of the following were presented: The person has been exposed to traumatic event in which both of the following were presented: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The person’s response involved intense fear, helplessness, or horror The person’s response involved intense fear, helplessness, or horror Source: DSM-IV-TR Source: DSM-IV-TR

7. Symptoms and Behaviors of Acute Stress Disorder Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: A subjective sense of numbing, detachment, or absence of emotional responsiveness A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of his or her surroundings (e.g., “begin in a daze”) A reduction in awareness of his or her surroundings (e.g., “begin in a daze”) Derealization Derealization Depersonalization Depersonalization Dissociative amnesia (i.e., inability to recall an important aspect of the trauma) Dissociative amnesia (i.e., inability to recall an important aspect of the trauma) Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, exaggerated startle response, motor restlessness). Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, exaggerated startle response, motor restlessness). Source: DSM-IV-TR Source: DSM-IV-TR

8. Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry. The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. Restlessness or feeling keyed up or on edge Restlessness or feeling keyed up or on edge Being easily fatigued Being easily fatigued Difficulty concentrating or mind going blank Difficulty concentrating or mind going blank Irritability Irritability Muscle tension Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Source: DSM-IV-TR Source: DSM-IV-TR

9. Combat Related Hearing Loss VA’s National Center for Rehabilitative Auditory Research recommends hearing protection for sounds louder than a lawn mover (90 decibels). Weapons and equipment used in the military often far exceed this level. VA’s National Center for Rehabilitative Auditory Research recommends hearing protection for sounds louder than a lawn mover (90 decibels). Weapons and equipment used in the military often far exceed this level.

10. Military Sound Levels Apache helicopter, pilot, Decibels: 104 Apache helicopter, pilot, Decibels: 104 9mm pistol, Shooter, Decibels: 157 9mm pistol, Shooter, Decibels: 157 Grenade, within 50 ft., Decibels:164 Grenade, within 50 ft., Decibels:164 105mm towed howitzer, Gunner, Decibels: 183 105mm towed howitzer, Gunner, Decibels: 183 MAAWS recoilless rifle, Gunner, Decibels: 190 MAAWS recoilless rifle, Gunner, Decibels: 190 Source: U.S. Army Center for Health Promotion and Preventive Medicine Source: U.S. Army Center for Health Promotion and Preventive Medicine

11. Symtomology of Hearing Loss for Veterans Depression Depression Lack of socialization caused by inability to understand others in conversations. Lack of socialization caused by inability to understand others in conversations. Mild to moderate brain damage from combat blast exposure. This is a new phenomenon with little research. Mild to moderate brain damage from combat blast exposure. This is a new phenomenon with little research. Isolated Isolated Paranoid Paranoid Emotionally unstable Emotionally unstable

12. Statistics on Hearing Loss and PTSD for Iraq and Afghanistan Veterans Tinnitus (loud noise exposure is a very common cause of tinnitus, and it often damages hearing as well) is the No. 1 service connected health condition for Iraq and Afghanistan veterans, with nearly 70,000 diagnoses, according to the Veterans Benefits Administration. Tinnitus (loud noise exposure is a very common cause of tinnitus, and it often damages hearing as well) is the No. 1 service connected health condition for Iraq and Afghanistan veterans, with nearly 70,000 diagnoses, according to the Veterans Benefits Administration.loud noise exposureloud noise exposure Defective hearing is No. 3 with almost 60,000 cases. Defective hearing is No. 3 with almost 60,000 cases. PTSD is No. 4 with 38,000 cases. PTSD is No. 4 with 38,000 cases. Source: VFW September 2008 Source: VFW September 2008

13. What we do know. Many Iraq and Afghanistan veterans will be returning to postsecondary education to utilize the 2008 GI Bill. Many Iraq and Afghanistan veterans will be returning to postsecondary education to utilize the 2008 GI Bill. Many of the veterans will have disability needs that will need to be accommodated. Many of the veterans will have disability needs that will need to be accommodated. Veterans will need support in different aspects of postsecondary education life. Veterans will need support in different aspects of postsecondary education life. They may have difficulty adjusting to civilian life. They may have difficulty adjusting to civilian life. They may have interpersonal relationship difficulties at home and at school. They may have interpersonal relationship difficulties at home and at school. They may or may not know that they need disability support services and how to seek out such services. They may or may not know that they need disability support services and how to seek out such services.

14. What can we do? Create linkages and support networking with our university and college Veteran’s Affairs office. Create linkages and support networking with our university and college Veteran’s Affairs office. Create a referral system between DSS and Veteran’s Affairs office personnel. Create a referral system between DSS and Veteran’s Affairs office personnel. Provide information on both the DSS and Veteran’s websites on referrals, services, policies and procedures to seek out disability support services. Provide information on both the DSS and Veteran’s websites on referrals, services, policies and procedures to seek out disability support services. Provide informational “fact sheets” on disability services for your office to be disseminated to the Veteran’s prior to their enrollment in coursework. Provide informational “fact sheets” on disability services for your office to be disseminated to the Veteran’s prior to their enrollment in coursework. Be sensitive to their unique needs as a non-traditional student returning to postsecondary education. Be sensitive to their unique needs as a non-traditional student returning to postsecondary education. Provide other educational resources to the Veteran’s. I.e. University Counseling services, Vets Clubs (if they exist on your campus), financial aid services, etc. Provide other educational resources to the Veteran’s. I.e. University Counseling services, Vets Clubs (if they exist on your campus), financial aid services, etc.

15. What is your plan? Who needs to be involved? Who needs to be involved? How will your referral and support system work? How will your referral and support system work? How will you put it into motion? How will you put it into motion? How will you evaluate whether or not your plan is a good one? What if it doesn’t work well for the Veterans, DSS and Veteran’s Affairs office? How will you evaluate whether or not your plan is a good one? What if it doesn’t work well for the Veterans, DSS and Veteran’s Affairs office? How many people will be involved and how many more may be needed? How many people will be involved and how many more may be needed? What are some of the most common accommodations that you feel you will need to encounter with Veteran’s? Are you prepared to do so? If not, what steps need to be taken? What are some of the most common accommodations that you feel you will need to encounter with Veteran’s? Are you prepared to do so? If not, what steps need to be taken? Does anyone on campus need to be educated about returning Veterans to postsecondary education? Who and how will this happen? Does anyone on campus need to be educated about returning Veterans to postsecondary education? Who and how will this happen?

16. Conclusion: Questions and answers Questions and answers Resources: Resources: –Suicide Prevention: 1–800–273–TALK (8255) –Vocational Rehabilitation and Employment Program's http://www.vba.va.gov/bln/vre/index.htm http://www.vba.va.gov/bln/vre/index.htm –Regional VA Benefits Office: Roanoke Regional Office 210 Franklin Rd. SW Roanoke, VA 24011 1-800-827- 1000 –Regional VA Benefits Office: Roanoke Regional Office 210 Franklin Rd. SW Roanoke, VA 24011 1-800-827- 1000 Regional VA Benefits OfficeRoanoke Regional OfficeRegional VA Benefits OfficeRoanoke Regional Office –On-Line Resources for Veterans: http://www.vba.va.gov/bln/vre/resources.htm