Agenda

9:00AM – Noon

•Showing of HBO Documentary “War Torn, 1861-2010”

•Panel Discussion

•Breakout Small Group Discussion

Noon- 12:50 Lunch will be provided

1:00PM – 4:00PM

•Colin A. Ross, M.D. – PTSD and Suicide in the Military

•Theodore F. Mauger, M.D. - Unique Ways Current War Injuries Alter

The Brain

•Chaplain COL Herman Keizer (ret.) - Worship that Addresses Needs of

Veterans with Moral Injury 

2015 The Hidden 2015 The Hidden Wounds of War ConferenceWounds of War Conference

The Hidden Wounds of War Conference is made possible by the generous The Hidden Wounds of War Conference is made possible by the generous support and contributions made by:support and contributions made by:

Group 9 Joseph MartinezRoom: 138 E

Group 8Elise MooreRoom: 136 E

Group 6Dr. Colin RossRoom: 119 E

Group 7Chaplain Herman KeizerRoom: 121 E

Group 5Dr. Theodore MaugerRoom: 117 E

Group 4 Dr. William BusbyRoom: 109 D

Group 3Elena BridgesRoom: Exhibition Hall

Group 1Dr. Michael RyanRoom: Auditorium Stage

Group 2Dr. Mark KaneRoom: 107 D

Breakout GroupsBreakout Groups

The Goal: Fluidity of Spirit

PTSD AND SUICIDE IN THE MILITARY

Colin A. Ross, M.D.Grand Rapids, Michigan

May 15, 2015

THE RELATIONSHIP BETWEEN TRAUMA

COLIN A. ROSS, M.D.

1701 Gateway, Suite 349

Richardson, Texas 75080

Phone: 972-918-9588

Fax: 972-918-9069

e-mail: rossinst@rossinst.com

www.rossinst.com

TRAUMA MODEL THERAPY

• The Problem of Attachment to the Perpetrator• The Locus of Control Shift• The Problem is Not the Problem• Just Say ‘No’ to Drugs• Addiction is the Opposite of Desensitization• The Victim-Rescuer-Perpetrator Triangle

THE PROBLEM OF ATTACHMENT TO THE PERPETRATOR

The Locus of Control Shift

Power

Control

Mastery

Badness

PerpetratorChild

The Problem is Not the Problem

Just Say ‘No’ to Drugs

Addiction is the Opposite of Desensitization

Victim - Rescuer - Perpetrator Triangle

Rescuer Perpetrator

Victim

SUICIDAL IDEATION AND SELF-BLAME AMONG COMBAT VETERANS

The Locus of Control Shift

Pre-Combat Trauma

Suicide as Murder of the Self

Placing Oneself on Death Row

The Euthanasia Model of Suicide

Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.American Journal of Psychotherapy,67, 309-322.

SUICIDAL IDEATION AND SELF-BLAME AMONG COMBAT VETERANS

Survivor Guilt

Self-Blame for Death of a Fellow Soldier

Self-Blame for Deaths of Civilians and for Atrocities

Self-Blame for Being Raped by a Fellow Soldier

Self-Blame for Failure to Protect Loved Ones Post-Deployment

Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.American Journal of Psychotherapy,67, 309-322.

COLIN A. ROSS, M.D.

1701 Gateway, Suite 349

Richardson, Texas 75080

Phone: 972-918-9588

Fax: 972-918-9069

e-mail: rossinst@rossinst.com

www.rossinst.com

Unique Ways Current War Unique Ways Current War Injuries Alter the BrainInjuries Alter the Brain

Blast Induced Neuro Trauma (BINT) andBlast Induced Neuro Trauma (BINT) and

Posttraumatic Stress Disorder (PTSD) Due to the BlastPosttraumatic Stress Disorder (PTSD) Due to the Blast

Theodore F. Mauger, M.D.Theodore F. Mauger, M.D.

May 15, 2015May 15, 2015U.S. Air Force Photo/Master Sgt. Scott Reed - C-17 Medevac mission, Balad AB, Iraq

Blast Injury TypesBlast Injury TypesA. Primary injury (compression and decompression)

1. Hollow organs receive direct impact i.e. ear with

tympanic rupture, lungs with collapse and air emboli.

2. Solid tissue suffers damage to the intracellular

architecture.

3. Blood over pressure associated with lung

compression with disruption of the vascular

architecture.

Blast WaveBlast Wave

Blast Injury TypesBlast Injury TypesA. Primary injury (compression and decompression) cont.

4. Air emboli and abrupt pressure changes primarily damage white matter/limbic

system which then affects personality - religion, intimacy and politics.

a) The hippocampus - new learning and orientation

b) The thalamus - emotional valence

Blast Injury TypesBlast Injury Types

B. Secondary Injury - being struck by objects with diffuse effects - penetrating (especially bomb or improvised explosive device shrapnel).

C. Tertiary Injury - acceleration-deceleration with diffuse axonal injury from being thrown

D. Quaternary Injury - burns/toxic fumes (metabolic)

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

A. Post Concussion Syndrome/encephalopathy (blast, dAI, anoxic and toxic injuries)

1. Affective Labilitya. Restlessnessb. Irritabilityc. Depressiond. Anxietye. Decreased impulse control

2. Somatic Disturbancesa. Headacheb. Dizziness/vertigoc. Broken sleepd. Fatigue

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

3. Personality Changes Toward Cluster B Personality Typesa. Histrionic

b. Narcissistic

c. Borderline

d. Sociopathic

4. Fluctuating Level of Cognitive Deficitsa. Memory problems, especially problems with access to information

b. Concentration and attention deficits - ADD/ADHD pattern

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

B. Frontal Lobe Syndrome

1. Disinhibited type (medial)a. Impulse control problems

b. Social disinhibition - no filter

c. Poor judgment

d. Lack of insight

2. Amotivational type (lateral)a. Abulia

b. Negativism

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

C. Temporolimbic Syndrome (sphenoid cutting)

1. Ictal and non-ictal variant (based on EEG)

2. Kindling (the great mimicker) - rise in symptoms with sudden discharge:

a. Poor impulse control

b. Affective lability

c. +/- sensory changes (paresthesias)

d. +/- motor changes (tics)

e. Experiential phenomena (very common)

f. +/- mini psychotic episodes

g. Any DSM V diagnosis

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

D. Affective (Mood) Disorder signs are common secondary to decrease in neurotransmitter producing neurons. This is separate from mood symptoms

1. Middle insomnia

2. Early morning awakening

3. Non-restorative sleep

4. Diurnal mood variation

5. Appetite disturbance

6. Psychomotor retardation

7. Anhedonia

E. Psychosis is rare, often late onset, and can be very problematic

1. Usually with the ictal variant of the temporolimbic syndrome

2. Schizoaffective presentation

F. Violence and aggression1. Intermittent explosive type

2. Part of disinhibition syndrome

3. Misinterpretation of cues

4. Similar to catastrophic reaction (fight/flight)

Brain Injury Brain Injury Symptom PatternsSymptom Patterns

PTSD - NeuroanatomyPTSD - Neuroanatomy

1. Amygdala - the primary mediator of fear

2. Ventro-medial prefrontal cortex (vmPFC), the primary mediator of calm, positive mood

PTSD Treatment ConsiderationsPTSD Treatment Considerations

“It is more important to know what sort of a patient has a disease than what sort of a

disease a patient has”. - William Osler

“The fish with a hook in its mouth looks crazy to the other fish who don’t have that hook in their

mouth” - Carl Menninger

PTSD Treatment ConsiderationsPTSD Treatment Considerations3. Some experiences are PTSD inducers (even without the

full syndrome):a. Being shot at - bullet, rocket, mortar

b. Being ambushed

c. Shooting another human being

d. Have seen others dying and dead, especially a friend

e. Having a history of MST (military sexual trauma) or other emotional

f. trauma

g. Various biases regarding disability by self and others

h. Work expectations

i. (Role expectations

PTSD Treatment PTSD Treatment ConsiderationsConsiderations

4. PTSD symptom triggers - sounds, sights, touch, and odors may lead to:

a. Reliving trauma experience i.e. through nightmares, flashbacksb. Avoidancec. Numbnessd. Hyperarousal

5. Common complications - especially prevalent without treatment

a. Substance abuse with drugs, alcohol

b. Psychiatric illness, i.e. depression

c. Relationship problems leading to divorce, loss of employment, etc.d. Failures to meet expectations lead to feelings of hopelessness or sense

of incompetence

PTSD Treatment PTSD Treatment ConsiderationsConsiderations

6. Flashbacks - during a flashback event, the amygdala takes control. Has been called an amygdala hijacking. Typically a 3 to 4 hour process to restore equilibrium.

a. Acute behavioral strategies

1. Withdraw from the environment

2. Oxygenate brain by slow, deep breathing

3. Avoid fleeing or fighting

4. Refocus on islands of health (positive memories)

5. Write down feelings and later, process the journaling

PTSD Treatment PTSD Treatment ConsiderationsConsiderations

7. Dual diagnosis (PTSD & alcoholism)

a. There is a deep sense of alienation with dual diagnosis.

1. Nearly 50% fail effort testing!

2. Essentially none with only one of the syndromes

NeurotransmittersNeurotransmitters1. Serotonin - provides a sense of affective relatedness and

interpersonal

2. reward/punishment. Psychic anxiety when indequate supply.

3. Norepinephrine - alert

4. Dopamine - pleasure, reward, addictions, drive, emotional engagement (the thalamus provides emotional valence)

5. Glutamic Acid - excitatory, neurotoxic in excess

6. Gamma-Aminobutyric Acid - calm

7. Acetylcholine - semantic memory

Medication TreatmentsMedication TreatmentsGeneral Principles

1.Restoration of function takes precedence over symptom control.

a. Is your world getting bigger?

2.Regulate the sleep/wake cycle with focus on ‘wake’

a. Generally avoid long acting stimulants - caffeine

b. Modafinil, Armodafinil to promote wakefulness

c. Stimulants (methylphenidate, amphetamines, et.)

Medication TreatmentsMedication Treatments3. Medication classes to avoid

a. Benzodiazepines

b. Narcotics

c. Anticholinergic medications

d. Older antipsychotic medications (movement disorders)

Medication TreatmentsMedication Treatments4. Use medications which minimize alterations in brain

neurotransmitter function.

a. Omega 3 fatty acids

b. Vitamin D3 - target blood level

c. Antiepileptic medication

1) Gamma-Aminobutyric Acid enhancement - gabapentin and pregabalin

d. Memantine - glutamic acid inhibition (lamotrigine does this as well)

e. Amantadine

Questions? Questions?

Theodore F. Mauger, M.D.Theodore F. Mauger, M.D.

REFERENCESKetcham, Mark. Kilgore College Lecture - from youtube.comSilver, Jonathan, neuropsychiatristHammond, Richard - Invisible worlds from youtube.comGoh, S.H. Singapore Medical Journal 2009; 50 (i):101-106 Blast causality, triage, and injury management

Worship That Addresses Needs of Veterans with Moral Injury

Herman Keizer, Jr.

hkeizer@msn.com

1. Moral Injury--definition & causes

2. Recovery of Moral Identity After War

3. Importance of Congregations and Communities in Soul Repair

1. Moral InjuryDefinition and Causes

Moral InjuryAn Ancient Wound of War with a New Construct

“Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerrilla wars amplify these challenges….[T]he lasting impact of morally injurious experience in war remains chiefly unaddressed.”

Moral Injury is disruption in an individual’s confidence and expectations about his or her own moral behavior or others’ capacity to behave in a just and ethical manner.

From “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva, and S. Maguen, (Dec. 2009) Clinical Psychology Review, 29, 695-706.

PTSD and Moral Injury• PTSD is a fear-victim reaction to extreme conditions that

damage amygdala and hippocampus (limbic brain)

• Moral Injury requires a healthy prefrontal cortex where empathy and moral thinking occur.

PTSD Can Result from Many Kinds of Exposure to Trauma

Has a consistent symptom profile for traumatic experiences:

Nightmares Dissociative episodes Panic attacks Hypervigilance Lack of conscious memory or memory fragments

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Aspects of Moral Injury Formation

• Participation in events that challenge core beliefs or have no clear moral choices, including violating moral codes of training in a closed system.

• Use of personal agency that violates core moral beliefs.• Reflection on memories and extreme conditions of extremity• Agony of inner judgment against oneself. • Feelings of grief, anger, despair, guilt, shame, remorse, betrayal,

contrition, depression, isolation, and loss of will to live.• Collapse of moral identity and meaning system that supports it.

Disruption of Two Important Relationships

•PTSD disrupts relationship to world when it becomes unreliable

•Moral Injury disrupts relationship with self when inner moral core is doubted

Military Culture and Moral Injury

• Military culture fosters moral and ethical codes of conduct. In war, being violent and killing are normal. Troops expect and are prepared for violence and killing.

• Still, even prescribed killing or violence may have a lasting impact

• Most service members can assimilate what they see and do in war because they are trained for it.

Uniqueness of Combat as Traumatic Stressor

• Involves multiple events over an extended period of time (7-12 months) with multiple deployments

• Creates a tightly closed system, so actions considered immoral in other contexts are sanctioned and even celebrated (e.g. killing) within rules of engagement

• Requires abrupt transition from one closed system (combat) to a second open system (civilian) with little or no process or support for transition

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Morally Disrupting Aspects of War

Reflexive Fire TrainingDehumanization of EnemyKillingSurvivor GuiltGriefEncountering and Handling human remains--major factorParticipation in torture or atrocitiesBetrayal by Authorities Doubt (uncertainty about goals or mission)

Losses in Returning to Civilian Life"War is the foyer to hell; coming home is hell."

--Tyler Boudreau, Packing Inferno: The Unmaking of a Marine • Loss of closest friends; isolation • Loss of unit and closed system• Loss or role / identity / career• Loss of home – relocate off base• Financial losses –• Loss of Weapon - security• Loss of family or capacity for intimacy– discord /

divorce• Loss of community of support – self /family• Loss of faith and meaning• Loss of reason to live

2. Recovery of Moral Identity After War

Individual/Social Dimensions of Recovery

Writing personal narratives; externalizing inner struggle and telling story

Integrating memory/story into larger picture Reconnection with estranged others; veteran

support systems; community service Long-term support and accountability

community

Moral Repair ProcessFrom B.T. Litz, et. al.

Dialogue with Benevolent Moral Authority

Reparation and Forgiveness Fostering Reconnection Long-Term Planning

Dialogue with Benevolent Moral Authority

Important to practice deep, nonjudgmental listening to experiences that precipitated

moral injury, and To offer benevolent understanding of moral struggle,

To affirm core moral beliefs that emerge,

To discuss how reparation might occur in the current context

To offer support for self-forgiveness or forgiveness from others.

Reparation and Forgiveness

Offer opportunities for service to others and ways to make a positive contribution to the lives of others.

Accompany veterans in finding decency and goodness in working for others

Model self-forgiveness and repair of harm—process of making amends

Fostering Reconnection

Encourage discussions of current relationships

• Forming deeper connections

• Strategies for greater openness and sharing of vulnerability and struggle

• Personal coping strategies for inevitable stress and conflicts

• Reflection on broken relationships that can be repaired in some form

Long-Term Planning• As making amends and self-forgiveness begin to take

hold, encourage reflection on the future

• What would they like to see for themselves?

• Who will continue to matter to them and how can those relationships be supported and enhanced?

• What values, beliefs, communities, etc. will continue to sustain them moving forward?

• How will they cope with the challenges, setbacks, and revisiting of war experiences that will come?

3. Importance of Congregations and Communities in Soul Repair

Spiritual Recovery Lamentation for losses

Forgiveness; amends

Transformation; renewal

Reconstruct moral core values and self-worth

Rituals of LossLiturgies for lamentation—dialogic in a monologic world; hold complex feelings; open doors to healing:

Complaint against God

Realization that conversation is with God

Remembrance of divine love and faithfulness

Restores God to soul

Support for Loss Amends

o Ex. Disaster Relief, Refugee Work

o Ex. Peace Missions

o Ex. Neighborhood Service Projects

Forgiveness and Discipleship

Absolution (letting go and moving on)

Transformation and Renewal Rhythms of the liturgical year bring renewal

Transformation via constant repetition of renewal

Vicarious reliving of baptismal rebirth

Sacramental structure of life

Dramatic reenactment of sacred stories of redemption here and now

Reconstruction

Recognition of existence of a moral order

System of meaning where personal life fits

Behavior and moral choices make sense

Joining not withdrawing

Participation in meaning-making in midst of moral ambiguity and difficult choices

Recommended ResourcesBooks:Letters from a Fort Lewis Brig, Sgt. Kevin BendermanPacking Inferno, Tyler BoudreauSoul Repair, Rita Nakashima Brock and Gabriella LettiniThe Unfinished War, Walter CappsLetters from Abu Ghraib, Joshua CasteelOn Killing, David GrossmanShade It Black, Jess Goodell and John HearnWhat It Is Like to go to War, Karl MarlantesRoad from Ar Ramadhi, Camilo Mejia Until Tuesday, Luis Carlos MontalvanThe Yellow Birds, Kevin Powers

Achilles in Vietnam, Jonathan ShayThe Untold War, Nancy ShermanThe Moral Treatment of Returning Warriors in Early and Modern Times, Bernard Vercamp

Websites:Hauenstein Center http://hauensteincenter.org www.conscienceinwar.orgwww.britesoulrepair.orgwww.ivaw.org/operation-recovery

Films:Soldiers of ConscienceThe Ground TruthThe Invisible WarLionessRestrepoStop-LossTaxi to the Dark Side