Post-Traumatic Stress Disorder The Increase in Violence by Soldiers

1. Post-Traumatic Stress DisorderThe Increase in Violence by Soldiers Wendy Seiber

2. http://www.youtube.com/watch?v=TN3MR18uCoU http://www.mentalhealthscreening.org/military/index.aspx

3. 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

4. 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).

5. 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

6. 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)

7. 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

8. 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

9. 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*

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. Impact on Families of Soldiers • Abuse • Tension • Marital strain • Violence • Secondary PTSD for wives

22. 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)

23. 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

24. Important • The National Center for PTSD • http://ncptsd.va.gov/ncmain/index.jsp • 802-296-6300 • PTSD Self Test • http://www.patss.com

25. 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

26. 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.