Post-Traumatic Stress DisorderThe Increase in Violence by Soldiers

Wendy Seiber

http://www.youtube.com/watch?v=TN3MR18uCoU

http://www.mentalhealthscreening.org/military/index.aspx

Many Names for One Problem

Civil War› Soldier’s Heart

WW1› Shell Shock

WW2› Battle Fatigue

Korean War› Gross Stress Reaction

Formally diagnosed as a disorder (PTSD) in 1980

Posttraumatic Stress Disorder Anxiety disorder that can occur after a

person experiences or witnesses a violent or frightening event.

Not everyone who experiences trauma develops PTSD.

The essential feature of PTSD is the development of characteristic symptoms following exposure to traumatic events that arouse “intense fear, helplessness, or horror” (APA).

Current Trends Number of reported cases up 50% from

2006-2007 Nearly 40,000 from Iraq/Afghanistan from

2003-2007 diagnosed› Army-28,365 Marine-5,581› Navy and Air Force < 1000

Up to 30% of deployed soldiers experience PTSD symptoms

Roughly 50% don’t get treatment b/c fear of embarrassment or hurting career

Trends cont. Self Reports - a study completed by

› 2,275 Operation Iraqi Freedom soldiers› 1,814 Operation Enduring Freedom soldiers

44% clinically significant levels of depression and/or PTSD (LaPierre, 2007)

Experts Estimate › 15% of Vietnam Vets currently, several years after war› 8-10% of Desert Storm› 6-11% of Enduring Freedom› 12-20% of Iraqi Freedom

Problems? 7-9% of general public suffers from PTSD (5.2 million 18-54) 30% of combat veterans develop PTSD

Strong link between PTSD and violence but violence alone does not cause PTSD (APA)

Violent Behaviors 121 Veterans have committed murder since their return to the

States› Most victims were their spouses or children

1/3 were spouses, girlfriends, children or other relatives› Trauma and stress of deployment along with alcohol abuse, family

discord and other problems set the stage› 75% were still in military when killed relative› 50% involved guns

Rest were stabbings, beatings, strangulation, and bathtub drownings› 25 face homicide charges for fatal crashes from drunken, reckless, or

suicidal driving (Sontag, 2008) Felony El Paso county jail bookings for service members jumped

from 295 in 2005 to 471 in 2006 Reports of theft and domestic violence for soldiers increased in

2006 Crime ring in Ft. Carson of Iraqi War Veterans were responsible

for the deaths of two GIs

Etiology May occur soon after trauma or can be delayed

for more than 6 months after› When occurs right after trauma, usually gets better

after 3 months› Some may have long term PTSD which can last for

many years› Approximately 50% of cases remit within 1 year

Psychological, genetic, physical and social factors involved but no exact cause› Changes the body’s response to stress› There may be a personal predisposition necessary for

symptoms to develop after trauma

General Risk Factors Being female Having learning disability Physical and/or sexual abuse Existence of mental disorder prior to event Low education levels and poor SES Some ethnic differences due to how pain and anxiety are

expressed (Hispanics, African Americans, Native Americans) Duration of traumatic event* Traumatic events inflicted by a person* Violence associated with trauma* Negative life events*

› *most likely to effect soldiers*

Protective Factors Disaster Preparedness training

› Firefighters, police and paramedics receive this Strong support systems

› Positive paternal relationship› Social support

Positive life events Stress management training Psychological preparedness Older age at entry to war Higher level of education Higher SES

Assessment Currently no tests to diagnose PTSD

› The diagnosis is made based on a certain set of symptoms that continue after the trauma has occurred.

› Psychiatric and physical exams performed to rule out other illnesses

› Usually must have at least one re-experiencing symptom for diagnosis

Mental Health Self-Assessment Program› Military personnel and their families› Online or over the phone test› Identify symptoms › Access assistance before problems becomes serious

Symptoms of PTSD Repeatedly “reliving” of the event, which disturbs day-to-

day activities› Flashbacks, recurring distressing memories› Repeated dreams› Physical reactions to situations that remind of event

Avoidance› Emotional numbing, feelings of detachment› Inability to remember important parts of trauma› Lack of interest in normal activities› Less expression of moods› Staying away from anything that is a reminder› Sense of having no future

Arousal› Difficulty concentrating, sleeping difficulties› Exaggerated response when startled› Hyper vigilance› Irritability or outbursts of anger

Current Research Charles W Hoge (2004) 4 US Combat Infantry Units

› 3 Army 1 Marine› Iraq-2530 Afghanistan-3671

Combat duty in Iraq and Afghanistan- Levels of PTSD› Before combat in Iraq 9.3%› After Iraq 15.6-17.1%› After Afghanistan 11.2%

Only 23-40% sought mental health care 2x as likely to report concern about possible

stigmatization and other barriers to seeking mental health care› Feared seeking treatment b/c would make them appear

weak or cause their peers to treat them differently

Domestic Violence Study Michelle D. Sherman (2006) Veterans with PTSD have higher rates

than the general population of abuse 17 couples seeking therapy were

studied › PTSD and depression diagnosed Veterans

perpetrated more violence Much higher than found in previous research

› 81% engaged in at least one act of violence toward their partner in a year > than 6x the general population

Recently….. Cynthia A Leardmann (2009) If baseline functional health status can

predict PTSD after combat› 5410 participants

Baseline and follow-up questionnaires 7.3% had new onset symptoms of PTSD Those whose baseline mental component

summary scores were below the 15th centile had 2-3x the risk of symptoms of PTSD by follow-up compared to those in the 15th-85th centile.

› Low mental or physical health prior to combat significantly increased risk of PTSD

Treatment Traditional Treatments (Last 3-6months up to 1-2yrs+)

› CBT Behavioral therapy can be used to treat avoidance symptoms

› Supportive patient education Support groups with people who had experienced similar

traumas› Psychopharmacology

Antidepressants (SSRIs) can be effective in treating PTSD Sedatives for sleep disturbances

Immersion Therapy Video Game› Simulates sights, sounds & smells of combat› Gradually re-enter a traumatic event› “Virtual Iraq”

Side Issues› May need to treat side symptoms such as depression and

alcohol/drug abuse before addressing the PTSD

Eye Movement Desensitization & Reprocessing

8 phases of treatment› 1: History taking and treatment plan› 2: Does client have adequate methods developing

good coping skills and dealing with emotional distress-self calming exercises

› 3-6: Client identifies most vivid memories from event, intensity of negative emotions and positive personal beliefs

› 7: Closure-client keeps a journal during the week to document any related material

› 8: Re-evaluation of the previous session After EMDR clients typically report that the

emotional distress related to the memories is significantly decreased or gone

Prevention Research into how to prevent PTSD is

currently ongoing Possibilities

› Trauma debriefing immediately after event› Early intervention› Injection of Cortisol shortly after exposure

(currently in animal testing phase) (Navert, 2008)

Watching for Signs Fort Carson Units

› Every soldier and hundreds of family members are trained to spot signs of PTSD and brain injury

› Every returning soldier is screened repeatedly and those who need help get it quickly since the earlier they find something, the easier it is to treat

Training program › Soldiers learn how to deal with people who have

PTSD issues › Use verbal judo to take person down so no harm is

caused

Impact on Soldiers Difficulty fitting into the society they

went to war to defend Hard to turn off some of the reactions

that saved life in combat› May lead to grief in bar

No drug addictions, alcoholism, or criminal behavior until after war

War assignments basically 14months of testosterone build-up

Impact on Families of Soldiers

Abuse Tension Marital strain Violence Secondary PTSD for wives

Cost on Society Increased crime rates Lost lives

› Risk of suicide and/or homicide High medical costs

› Costs of untreated trauma, related alcohol/drug abuse about $160 Billion/yr

Legal woes› Criminal Behavior

Poor work performance› Lost jobs-US loses $3 Billion every year due to work place

problems caused by PTSD Family troubles

(Kedem, 2007)

Future Research Relationships of soldiers and prisoners

of war before and after combat experience

Ways to assess PTSD properly so it is not misdiagnosed

Studies of long term treatment effectiveness

Important The National Center for PTSD

› http://ncptsd.va.gov/ncmain/index.jsp› 802-296-6300

PTSD Self Test› http://www.patss.com

References  Anxiety/Stress News, (2008, May 29). Reported cases of PTSD in soldiers up 50%, according to defense officials . Retrieved June 15, 2009, from Medical

News Today: http://www.medicalnewstoday.com/articles/109094.php

APA, (2009). PTSD facts and statistics. Retrieved June 15, 2009, from APA help Center http://www.apa.org/topics/topicsptsd/html  Barrish, I.S. (2008). Military Veterans PTSD Reference Manual. Bryn Mawr, PA: Infinity.  Basoglo, M. (1997). Psychological preparedness for traumas a protective factor in survivors of torture. Psychological Medicine 27: 1421-1433  Goulston, Mark (2008). PTSD for Dummies. Hoboken, NJ: Wiley.  Hoge, C.W. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351: 13-22  LaPierre, C.B. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of

Traumatic Stress 20: 933-943   LeardMann, C. A. (2009). Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective

US military cohort study. BMJ 338: 1273-1273  Lilly, David (2000). Preventing PTSD. Retrieved June 15, 2009, from Sonnet Psychology

http://www.sonnetpsych.com/Sonnet_Psychological_Freeport_Maine_psychology_preventing_ptsd.htm  MHSAP, (2009). Mental Health self-assessment program. Retrieved June 15, 2009, from Screening for Mental Health

http://www.mentalhealthscreening.org/ military/ index.aspx

Navert, Rick (2008, Dec 2). New treatment may prevent PTSD. Retrieved June 15, 2009, from Psych Central http://psychcentral.com/news/2008/12/02/new-treatment-may- prevent-ptsd/3428.html

NCPTSD, (2007, Aug 2). PTSD Information Center. Retrieved June 15, 2009, from National Center for PTSD http://ncptsd.va.gov/ncmain/index.jsp

References cont…  Psychiatric Disorders, (2009). PTSD. Retrieved June 15, 2009, from MoreFocus Groups: http://www.psychiatric-

disorders.com/articles/ptsd/overview/common-ptsd-sufferers.php  Reeves, R. R. (2007). Diagnosis and Management of Posttraumatic Stress Disorder in Returning Veterans. Journal of the

American Osteopathic Association 107: 181-189

Ridder, K. (2007, December 25). War stresses linked to soldier's crimes . Retrieved June 15, 2009, from Military.com: http://www.military.com/NewsContent/0,13319, 158912,00.html

Rogge, T. A. (2008, May 21). PTSD Health. Retrieved June 15, 2009, from Healthline ADAM: http://www.healthline.com/adamcontent/post-traumatic-stress-disorder? utm_medium=ask&utm_source=smart&utm_campaign=article_toc&utm_term=Post-traumatic+stress+disorder+risk+factor

Shapiro, F (2004). A brief description of EMDR. Retrieved June 18, 2009, from EMDR Institute http://www.emdr.com/briefdes.htm

Sherman, M.D. (2006). Domestic Violence in veterans with PTSD who seek couples therapy. Journal of Marital and Family Therapy 32: 479-490

  Solomon, Zahava. (1990). Life events and combat related PTSD; the intervening role of locus of control and social support.

Military Psychology 2: 241-256  Solomon, Zahava. (1988). Negative life events, coping response and combat-related psychopathology: A prospective study.

Journal of Abnormal Psychology 97: 302-307  Sontag, Deborah (2008, Jan 13). Across America, Deadly echoes of foreign battles. New York Times, War Torn Part 1.