Matthew J. Reinhard, Psy.D. War Related Illness & Injury Study Center (WRIISC)

1. Psychological Effects of Combat Stress and Potential Problems in Transitioning Skills Learned in Combat after Returning Home Matthew J. Reinhard, Psy.D. War Related Illness & Injury Study Center (WRIISC) US Department of Veterans Affairs Office of Public Health and Environmental Hazards

2. Reactions to serving in a combat zone • Reactions to being in a combat zone usually decrease and normalize after return home • For some, these reactions persist even when there is no longer danger and they may interfere with employment, relationships, quality of life and physical health • Serving in a combat zone can change worldview • The world isn’t safe • Others want to harm me • I must be ready for danger at all times • I had a sense of purpose while working in a combat zone– now what?

3. Conditions Following A Traumatic Event (not Just PTSD) • PTSD • Depression (Highly co-morbid) • Substance abuse (usually ETOH) • Panic Disorder • Phobias • Adjustment Disorder • Dissociative Disorders • Somatic Symptoms

4. PTSD and Substance Abuse • Substance abuse can be used to: • Avoid • Aid with sleep • Block out memories • Help “fit in” • Help “have fun”

5. Continuous Assessment • Why the need for continuous assessment? • Mental health symptoms may not appear initially—they may appear with time. • Greiger, et.al. (American Journal of Psychiatry, 2006) • Veterans who were wounded or injured in the line of duty • PTSD • One month, 4.4% • Four months, 8.9% • Seven months, 9.3% • Depression • One month, 4.2% • Four months, 12.2%

6. Treatment at VA includes “Non-Traditional” Options • Non-Traditional” Treatment Options • Strategies that might help with stress reduction • Army 10 Miler • Outward Bound, Wilderness Adventures designed for OIF/OEF Veterans in Rocky Mountains • Team River Runners, kayaking • Yoga and Tai Chi • Acupuncture • WWII Veterans as “mentors”

7. Treatment(PTSD) • BATTLEMIND as example of PTSD treatment • Developed at Walter Reed Army Institute of Research • Combat skills and battle mindset let you survive in a war zone • This “Battlemind” may be hazardous to social and behavioral health back home if it is not transitioned • Battlemind video; www.battlemind.org

8. Post-Deployment Battlemind: Soldiers • Buddies (cohesion) vs. Withdrawal • Accountability vs. Controlling • Targeted Aggression vs. Inappropriate Aggression • Tactical Awareness vs. Hypervigilance • Lethally Armed vs. “Locked and Loaded” at Home • Emotional Control vs. Anger/Detachment • Mission Operational Security (OPSEC) vs. Secretiveness • Individual Responsibility vs. Guilt • Non-Defensive (combat) Driving vs. Aggressive Driving • Discipline and Ordering vs. Conflict

9. Treatment Battlemind: Soldiers • B Buddies (Cohesion) vs. Withdrawal • In combat: no one understands your experience except your buddies who were there with you. • At home: may prefer to be with battle buddies rather than with spouse family or other friends. May avoid speaking about yourself to friends and family. Have thoughts such as: others will die on me like my military friends, so why should I bother getting close? • Potential Concerns: feeling alone, isolation, not connecting with loved ones

10. Treatment Battlemind: Soldiers • A - Accountability vs. Control • In combat: maintaining control of weapon and gear is necessary for survival • At home: become angry when someone moves or messes with your stuff, even if insignificant. Nobody cares about doing things right except for you. • Potential Concerns: Overreacting to minor events? Still having trouble letting family and friends share in making decisions? Trying to control things that don’t really matter?

11. Treatment Battlemind: Soldiers • T - Targeted vs. Inappropriate Aggression • In combat: soldiers make split second decisions that are lethal in a highly ambiguous environment, which keeps you alert and alive • At home: overreactions to minor insults. Inappropriate aggressiveness, assault, spousal abuse, snapping at the kids or buddies • Potential Concerns: are you snapping at others? Getting into fights or heated arguments? Avoiding people?

12. Treatment Battlemind: Soldiers • Tactical Awareness vs. Hypervigilance • In Combat: survival depends on being aware at all time of your surrounding and reacting immediately to sudden changes • At Home: you may feel keyed up or anxious • Potential Concerns: jumping at loud noises… then staying revved up? Having trouble with sleep or nightmares? Drinking to calm down or to help you sleep?

13. Treatment Battlemind: Soldiers • L – Lethally Armed vs. Unarmed • In Combat: carrying your weapon at all times was mandatory and necessary • At Home: need to have weapons on you, in your home and or car at all times, believing that you and your loved ones are not safe without them. • Potential Concerns: Threatened someone with a weapon? Carry a loaded weapon in your car? Keep an unsecured, locked and loaded weapon at home?

14. Treatment Battlemind: Soldiers • E – Emotional Control Vs. Anger or Detachment • In Combat: controlling your emotions during combat is critical for mission success. • At Home: failing to display emotions, or only showing anger, around family and friends will hurt your relationships. You may be seen as detached or uncaring. • Potential Concerns: can you only show anger? Feeling numb? Friends and loved ones tell you that you have changed? Having relationship problems?

15. Treatment Battlemind: Soldiers • M – Mission & OPSEC vs. Secretiveness • In Combat: talk about mission only with those who need to know. Can only talk about combat experiences with unit members. In the chaos of war, you learned not to trust anything or anybody except your buddies (unsure who was the enemy and who was an ally) • At Home: soldiers may avoid sharing their deployment experiences with spouse or significant other. • Potential Concerns: Haven’t shared your deployment experiences with those closest to you? get angry when someone asks you about your deployment experiences? Can be a Win-win to share with your family – you feel heard and cared for and your loved ones feel needed

16. Treatment Battlemind: Soldiers • I – Individual Responsibility vs. Guilt • In Combat: your responsibility in combat is to survive and to keep your buddies alive • At Home: you may feel you have failed your buddies if they were killed or seriously injured. You may be bothered by memories of those wounded or killed. • Potential Concerns: Certain memories of the deployment keep bothering you? still feeling guilt about things that happened in combat? Recognize that guilt is a common reaction

17. Treatment Battlemind: Soldiers • N – Nondefensive (combat) driving vs. Aggressive Driving • In Combat: unpredictable, fast, rapid lane changes, straddling the middle line, keeping other vehicles at a distance. To survive convoy runs, had to drive as fast as possible and be alert to every pedestrian and car that could be a bomber. • At Home: aggressive driving leads to speeding tickets, accidents, fatalities. Today, slowing traffic produces anxiety • Potential Concerns: Chasing adrenalin highs by driving fast? Involved in driving accidents?

18. Treatment Battlemind: Soldiers • D- Discipline & Ordering Vs. Conflict • In Combat: Survival depends on discipline and obeying orders • At Home: inflexible interactions (ordering and demanding behaviors) with your spouse, children and friends often lead to conflict • Potential Concerns: Relationships aren’t going well? Ongoing conflicts over decisions? Does family say they feel as if “walking on eggshells?”

19. Mild TBI and PTSD have many smiliarities Postconcussion Syndrome (PCS) Post Traumatic Stress Disorder Insomnia Memory Problems Poor concentration Depression Anxiety Irritability Emotional numbing Avoidance Intrusive symptoms • Insomnia • Impaired Memory • Poor concentration • Depression • Anxiety • Irritability • Headache • Dizziness • Fatigue • Noise/Light intolerance

20. + PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Arousal Sensitive to noise Concentration Insomnia Irritability ? Mild TBI Residual Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness + Depression From presentation by R. Vanderploeg 2007

21. Moss, King, Blackman (2009). Phys. Review letters, 103 issue 10.

22. Moss, King, Blackman (2009). Phys. Review letters, 103 issue 10.

23. Questions?