ptsd: the shadow of combat. an anxiety disorder. 3-6% of adults in the united states. twice as...
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PTSD: The Shadow of PTSD: The Shadow of CombatCombat
An Anxiety Disorder.An Anxiety Disorder.3-6% of adults in the United States.3-6% of adults in the United States.Twice as common in women as in Twice as common in women as in men.men.Rates as high as 58% in heavy Rates as high as 58% in heavy combatcombat1-14% non combat1-14% non combatTorture/POW 50-75%Torture/POW 50-75%Natural Disaster victims 4-16%Natural Disaster victims 4-16%
PTSDPTSD
Exposure to a traumatic event in which the person
Experienced, witnessed, or was confronted by death or serious injury to self or others
AND Responded with intense fear, helplessness,
or horrorFeatures
Appear in 3 clusters: re-experiencing, avoidance/numbing, hyperarousalLast for > 1 monthCause clinically significant distress or impairment in functioning
DSM-IV diagnostic criteria for DSM-IV diagnostic criteria for PTSDPTSD
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.
DSM-IV diagnostic criteria for PTSD Re-experiencing
Persistent re-experiencing of 1 of the following
Recurrent distressing recollections of event
Recurrent distressing dreams of event
Acting or feeling event was recurring
Psychological distress at cues resembling event
Physiological reactivity to cues resembling event
*Related to the traumaAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.
DSM-IV diagnostic criteria for PTSD Avoidance/Numbing
Avoidance of stimuli and numbing of general responsiveness indicated by 3 of following
Avoid thoughts, feelings, or conversations* Avoid activities, places, or people* Inability to recall part of trauma interest in activities Estrangement from others Restricted range of affect Sense of foreshortened future
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.
DSM-IV diagnostic criteria for PTSD Hyperarousal
Persistent features of increased arousal 2
Difficulty sleeping
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
HistoryHistory
U.S. Civil WarU.S. Civil War–– Soldier’s Heart (DaCosta, 1871)Soldier’s Heart (DaCosta, 1871)
1919thth & 20& 20thth CenturiesCenturies–– Railway DisastersRailway Disasters
–– World WarsWorld Wars
–– HolocaustHolocaust
–– Atomic Bombs on Hiroshima and Nagasaki Atomic Bombs on Hiroshima and Nagasaki (Kar Ray, no date)(Kar Ray, no date)
Spontaneous re-experiencing of the Spontaneous re-experiencing of the traumatraumaStartle responsesStartle responsesIrritabilityIrritabilityDepression and GuiltDepression and GuiltPhobias Phobias Multiple physical complaintsMultiple physical complaintsNumbingNumbingImpaired concentration and memoryImpaired concentration and memoryDisturbed sleep and distressing Disturbed sleep and distressing dreamsdreams
HistoryHistory
Fright NeurosisFright NeurosisCombat/War Combat/War NeurosisNeurosisShell ShockShell ShockSurvivor SyndromeSurvivor SyndromeOperational FatigueOperational FatigueCompensation Compensation NeurosisNeurosis
LabelsLabels
StatsStats
• 1.6 million troops deployed to OEF/OIF 1.6 million troops deployed to OEF/OIF to dateto date
• Approximately 40% have accessed VA Approximately 40% have accessed VA carecare
• Three most common presenting Three most common presenting problems:problems: Musculoskeletal AilmentsMusculoskeletal Ailments
Mental Disorders (PTSD, SA/D, Depressive)Mental Disorders (PTSD, SA/D, Depressive) “ “Symptoms, Signs, and Ill Defined Cond.”Symptoms, Signs, and Ill Defined Cond.”
VA Healthcare Utilization among GWOT VA Healthcare Utilization among GWOT VeteransVeterans
• 868,717 OEF/OIF who have left active 868,717 OEF/OIF who have left active duty since February 2002duty since February 2002
437,873 Former Active Duty437,873 Former Active Duty
430,844 Reserve and NG430,844 Reserve and NG
40% (347,750) have accessed VA care 40% (347,750) have accessed VA care since FY 2002 (96% outpatient)since FY 2002 (96% outpatient)
Demographic Characteristics of Demographic Characteristics of OEFOEF and and OIF OIF Veterans Utilizing VA Health CareVeterans Utilizing VA Health Care
% OEF/OIF Veterans % OEF/OIF Veterans (n = 347,750)(n = 347,750)
GenderGender Male 88 %Male 88 % FemaleFemale 12 12 Age GroupAge Group <20<20 7 7 20-2920-29 51 51 30-3930-39 23 23 ≥≥4040 18 18 BranchBranch Air ForceAir Force 12 12
ArmyArmy 64 64
MarineMarine 13 13 NavyNavy 11 11Unit TypeUnit Type ActiveActive 52 52 Reserve/Guard 48 Reserve/Guard 48 RankRank EnlistedEnlisted 92 92 OfficerOfficer 8 8
Frequency of Frequency of Possible Possible Diagnoses Diagnoses Among Among OEF and OIFOEF and OIF Veterans Veterans
Diagnosis Diagnosis (n = 347,750) (n = 347,750) (Broad ICD-9 Categories)(Broad ICD-9 Categories) Frequency * % Frequency * % Infectious and Parasitic Diseases (001-139)Infectious and Parasitic Diseases (001-139) 40,956 11.8 40,956 11.8Malignant Neoplasms (140-208)Malignant Neoplasms (140-208) 3,248 3,248 0.9 0.9Benign Neoplasms (210-239)Benign Neoplasms (210-239) 13,910 13,910 4.0 4.0Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 75,850Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 75,850 21.8 21.8
Diseases of Blood and Blood Forming Organs (280-289) Diseases of Blood and Blood Forming Organs (280-289) 7,675 7,675 2.2 2.2Mental Disorders (290-319) Mental Disorders (290-319) 147,744 147,744 42.542.5Diseases of Nervous System/ Sense Organs (320-389) Diseases of Nervous System/ Sense Organs (320-389) 121,473 34.9 121,473 34.9Diseases of Circulatory System (390-459) 56,900 16.4Diseases of Circulatory System (390-459) 56,900 16.4Disease of Respiratory System (460-519) Disease of Respiratory System (460-519) 71,087 71,087 20.4 20.4Disease of Digestive System (520-579) Disease of Digestive System (520-579) 110,449 110,449 31.8 31.8Diseases of Genitourinary System (580-629) Diseases of Genitourinary System (580-629) 37,118 37,118 10.7 10.7Diseases of Skin (680-709) Diseases of Skin (680-709) 55,79755,797 16.0 16.0Diseases of Musculoskeletal System/Connective System (710-739) Diseases of Musculoskeletal System/Connective System (710-739) 165,439 165,439 47.647.6Symptoms, Signs and Ill Defined Conditions (780-799)Symptoms, Signs and Ill Defined Conditions (780-799) 138,043 138,043 39.739.7Injury/Poisonings (800-999)Injury/Poisonings (800-999) 73,76773,767 21.2 21.2
*These are cumulative data since FY 2002, with data on h*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; vospitalizations and outpatient visits as of March 31, 2008; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted eterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 347,750.only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 347,750.
Frequency of Possible Mental Disorders Frequency of Possible Mental Disorders Among Among OEF/OIFOEF/OIF Veterans since 2002 Veterans since 2002
Disease Category (ICD 290-319 code) Total Disease Category (ICD 290-319 code) Total Number of Number of GWOT Veterans GWOT Veterans
PTSD (ICD-9CM 309.81) 75,719PTSD (ICD-9CM 309.81) 75,719Depressive Disorders (311)Depressive Disorders (311) 50,732 50,732
Neurotic Disorders (300) Neurotic Disorders (300) 40,157 40,157 Affective Psychoses (296) Affective Psychoses (296) 28,73428,734 Nondependent Abuse of Drugs (ICD 305) 21,201Nondependent Abuse of Drugs (ICD 305) 21,201Alcohol Dependence Syndrome (303) Alcohol Dependence Syndrome (303) 12,780 12,780 Special Symptoms, Not Elsewhere Classified (307)Special Symptoms, Not Elsewhere Classified (307) 7,685 7,685Sexual Deviations and Disorders (302)Sexual Deviations and Disorders (302) 7,076 7,076Drug Dependence (304)Drug Dependence (304) 5,764 5,764 Specific Nonpsychotic Mental Disorder Specific Nonpsychotic Mental Disorder
due to Organic Brain Damage (310) due to Organic Brain Damage (310) 4,654 4,654
**
Three Different Types of Stress Three Different Types of Stress InjuriesInjuries
Combat/Operational Stress
Stress Adaptations
Stress Injuries
Positive Behaviors
Negative Behaviors
Traumatic Stress
Operational Fatigue
Grief
Due to a Due to a terrifying or terrifying or horrible eventhorrible event
Due to the Due to the wear and tear wear and tear of deploymentof deployment
Due to the Due to the loss of friends loss of friends and leadersand leaders
Multi-casualty incidents (SVBIEDs, ambushes)Multi-casualty incidents (SVBIEDs, ambushes)Friendly fireFriendly fireDeath or maiming of children and womenDeath or maiming of children and womenSeeing gruesome scenes of carnageSeeing gruesome scenes of carnageHandling dead bodies and body partsHandling dead bodies and body parts““Avoidable” casualties and lossesAvoidable” casualties and lossesWitnessed or committed atrocitiesWitnessed or committed atrocitiesWitnessed death/injury of a close friend or leaderWitnessed death/injury of a close friend or leaderKilling unarmed or defenseless enemyKilling unarmed or defenseless enemyBeing helpless to defend or counterattackBeing helpless to defend or counterattackInjuries or near missesInjuries or near missesKilling someone up closeKilling someone up close
Traumatic Events in OEF/OIF
Belief in one’s basic safetyBelief in being the master of oneself and one’s environmentBelief in “what’s right” — moral orderBelief that our cause is honourableBelief that every troop is valuedBelief in the basic goodness of people (especially oneself)
Beliefs That Can Be Damaged By Traumatic Stress
Causes of Shame or Guilt In Causes of Shame or Guilt In Traumatic Stress InjuriesTraumatic Stress Injuries
Surviving when others did notSurviving when others did notFailing to save or protect othersFailing to save or protect othersKilling or injuring othersKilling or injuring othersHelplessnessHelplessnessFailing to actFailing to actLoss of controlLoss of controlEven just having stress symptoms of Even just having stress symptoms of any kindany kind
RAND Study (2008)RAND Study (2008)
• 1965 service members from 24 communities1965 service members from 24 communities• 50%+ reported a friend seriously wounded or 50%+ reported a friend seriously wounded or
killedkilled• 45% saw dead or wounded noncombatants45% saw dead or wounded noncombatants• 10% reported injuries requiring hospitalization10% reported injuries requiring hospitalization• 18.5% met criteria for PTSD or depression18.5% met criteria for PTSD or depression• 19.5% reported mTBI during deployment of 19.5% reported mTBI during deployment of
which 1/3 reported concurrent PTSD or which 1/3 reported concurrent PTSD or depressiondepression
PTSD and Mild Traumatic Brain PTSD and Mild Traumatic Brain Injury (TBI)Injury (TBI)
• Slightly more than half of combat injuries Slightly more than half of combat injuries early in OIF came from explosionsearly in OIF came from explosions
• 29% evacuated from combat theater to 29% evacuated from combat theater to WRAMC had evidence of TBI (Jan 2003-Feb WRAMC had evidence of TBI (Jan 2003-Feb 2007)2007)
• Approximately 15% of all wounded vets Approximately 15% of all wounded vets have suffered TBI (4,471 cases diagnosed have suffered TBI (4,471 cases diagnosed between October 2001 and September between October 2001 and September 2007)2007)
TBITBI
• Physical damage by external blunt or penetrating Physical damage by external blunt or penetrating traumatrauma
• Acceleration-Deceleration Movement (whiplash) Acceleration-Deceleration Movement (whiplash) resulting in tearing or nerve fibers, resulting in tearing or nerve fibers, bruising/contusion of brainbruising/contusion of brain
• Scraping of brain across bony base of skull Scraping of brain across bony base of skull leading to olfactory, oculomotor, acoustic nerve leading to olfactory, oculomotor, acoustic nerve damage.damage.– Loss of sense of smell and reduction of taste Loss of sense of smell and reduction of taste
(anosmia), double and/or blurred vision, (anosmia), double and/or blurred vision, dizziness or vertigodizziness or vertigo
– Usually remit after several days or weeks Usually remit after several days or weeks (nerves recover or regenerate)(nerves recover or regenerate)
Levels of TBILevels of TBI
• MildMild– LOC for less then 30 minutes w/normal LOC for less then 30 minutes w/normal
CT and/or MRICT and/or MRI– Altered mental state: “dazed,” Altered mental state: “dazed,”
“confused,” “seeing stars”“confused,” “seeing stars”– PTA less then 24 hours (unable to store PTA less then 24 hours (unable to store
or retrieve new information)or retrieve new information)– Glasgow Coma Scale (GCS): 13-15Glasgow Coma Scale (GCS): 13-15
Levels of TBILevels of TBI
• ModerateModerate– LOC less than six hours w/abnormal CT and/or LOC less than six hours w/abnormal CT and/or
MRIMRI– PTA less than seven daysPTA less than seven days– GCS: 9-12GCS: 9-12
• SevereSevere– LOC greater than six hours w/abnormal CT and/or LOC greater than six hours w/abnormal CT and/or
MRIMRI– PTA greater than seven daysPTA greater than seven days– GCS: 1-8GCS: 1-8
Post-Concussion Syndrome Post-Concussion Syndrome (PCS)(PCS)• Symptoms immediately post-injury may Symptoms immediately post-injury may
include:include:– Memory, attention, concentration deficitsMemory, attention, concentration deficits– Fatigues, poor sleep, dizziness, headachesFatigues, poor sleep, dizziness, headaches– Irritability, depressionIrritability, depression– AnxietyAnxiety
• Most common: free-floating anxiety, fearfulness, Most common: free-floating anxiety, fearfulness, intense worry, generalized uneasiness, social intense worry, generalized uneasiness, social withdrawal, heightened sensitivity, related dreamswithdrawal, heightened sensitivity, related dreams
• Recovery (mild TBI) expected within 4-12 Recovery (mild TBI) expected within 4-12 weeks; however, some symptoms may weeks; however, some symptoms may linger for months to yearslinger for months to years
AssessmentAssessment
• Post concussion Post concussion Syndrome (PCS)Syndrome (PCS)– InsomniaInsomnia– Memory DeficitsMemory Deficits– Poor ConcentrationPoor Concentration– Depressed MoodDepressed Mood– AnxietyAnxiety– IrritabilityIrritability– HeadacheHeadache– DizzinessDizziness– FatigueFatigue– Noise/Light IntoleranceNoise/Light Intolerance
• PTSDPTSD
– InsomniaInsomnia– Memory DeficitsMemory Deficits– Poor ConcentrationPoor Concentration– Depressed MoodDepressed Mood– AnxietyAnxiety– IrritabilityIrritability– Intrusive symptomsIntrusive symptoms– Emotional NumbingEmotional Numbing– HyperarousalHyperarousal– Avoidance behaviorAvoidance behavior
Mild TBI among OIF ReturneesMild TBI among OIF Returnees(Hoge et al., 2008)(Hoge et al., 2008)
• 2,525 soldiers included in study 2,525 soldiers included in study (assessed 3-4 months post-(assessed 3-4 months post-deployment)deployment)– 5% (124) reported injury with LOC (up to 5% (124) reported injury with LOC (up to
several minutes)several minutes)– 10% (260) reported injury with altered 10% (260) reported injury with altered
mental status w/out LOCmental status w/out LOC– Four soldiers reported LOC longer than 30 Four soldiers reported LOC longer than 30
minutesminutes– 17% (435) reported other injuries17% (435) reported other injuries
Of those who reported LOC, 44% Of those who reported LOC, 44% met criteria for PTSD, as compared met criteria for PTSD, as compared to:to:
-27% of those with altered -27% of those with altered mental state mental state -16% of those with other -16% of those with other
injuries injuries -9% of those with no injuries-9% of those with no injuries
TBI Among OIF Returnees TBI Among OIF Returnees (Hoge et al., 2008)(Hoge et al., 2008)
Blast InjuriesBlast Injuries
• Over 50% of combat injuries result from Over 50% of combat injuries result from bombs, grenades, land mines, missles, bombs, grenades, land mines, missles, mortar/artillery shellsmortar/artillery shells
• Account for majority of brain injury in theater Account for majority of brain injury in theater with GSWs, falls, and MVAs close behindwith GSWs, falls, and MVAs close behind
• TBI among service members as high as 22%TBI among service members as high as 22%– 2003-2008: over 6,600 TBI2003-2008: over 6,600 TBI– Four major polytrauma centers (MN, CA, FL, VA): Four major polytrauma centers (MN, CA, FL, VA):
923 OEF/OIF patients with TBI923 OEF/OIF patients with TBI
Blast InjuryBlast Injury
• Blast injuries results from pressure Blast injuries results from pressure generated from an explosion which generated from an explosion which causes in overpressurizationcauses in overpressurization
• Air-filled organs (ears, lung, GI tract) Air-filled organs (ears, lung, GI tract) and organs surrounded by fluid filled and organs surrounded by fluid filled cavities (brain, spinal cord) cavities (brain, spinal cord) susceptiblesusceptible
Hoge et al. (2006)Hoge et al. (2006)
• 01 May 2003 – 30 April 2004: 01 May 2003 – 30 April 2004: – OEF (Afghanistan)OEF (Afghanistan)– OIF (Iraq, Kuwait, Qatar)OIF (Iraq, Kuwait, Qatar)– Other (Bosnia, Kosovo, etc.)Other (Bosnia, Kosovo, etc.)
• N = 303,905 Marines and Soldiers N = 303,905 Marines and Soldiers – OEF: 11.3% of 16,318OEF: 11.3% of 16,318– OIF: 19.1% of 222,620OIF: 19.1% of 222,620– Other: 8.5% of 64,967Other: 8.5% of 64,967
Hoge at al. (2006) Hoge at al. (2006)
• Combat Experiences:Combat Experiences:
OEFOEF OIF OIF OTHEROTHER
AnyAny 46.0% 65.1% 7.4% 46.0% 65.1% 7.4%
WitnessedWitnessed 38.1% 49.5% 5.3% 38.1% 49.5% 5.3%
DischargedDischarged 6.2% 17.8% 0.4% 6.2% 17.8% 0.4%
Felt in Danger 24.6% 50.3% 3.2%Felt in Danger 24.6% 50.3% 3.2%
Kessler R et al. Arch Gen Psychiatry 1999;56:617-626.
Suicidality and PTSD
PTSD patients are 6 times more likely to attempt suicide than the general population
PTSD has greater risk of increased number of suicide attempts than all other anxiety disorders
Therapeutic InterventionTeach patients that PTSD
Represent psychobiologic reaction to overwhelming stress
Not character flaw or sign of weakness Fear that will be seen as “damaged” or emotionally unstable
May lose right to carry weapon
May be viewed as unstable
Traumatized patients Notoriously reluctant to seek help
Particularly from mental health professionals
Therapeutic Intervention PTSD symptom relief
Usually requires specialized techniqueshelp patient confront fears and emotional responses to
trauma in more structured format Without becoming overwhelmed
Treatment involves Reducing level of distress associated with
memories of event
Quelling resultant physiological reactions
Focus on behavioral outcomes rather than biomedical indices
Therapeutic Intervention
Effective Exposure Therapy
Helping confront painful thoughts and feelings
Cognitive-Behavioral TherapyHelping process thoughts and feelings
Interpersonal therapiesUnderstanding ways in which traumatic event continues
to affect relationships and other aspects of their lives
Group Therapy May also help reduce isolation and stigma
Pharmacotherapy
In PTSD, randomized trials have shown effectiveness of SSRIs TCAs MAOIs
SSRIs 1st-line treatment safer and better tolerated
Only FDA-approved drugs Sertraline (Zoloft) Paroxetine (Paxil)
Pharmacotherapy
-blockers May reduce peripheral sympathetic tone
Perhaps, potential to worsen depression
Beneficial effects of drug therapy May not be evident for 8 weeks or more
Once drug a drug seems effective Continue for at least 12 months
Summary
Most people will gradually recover from psychological effects of traumatic event
PTSD will develop in a substantial portion of subjects exposed to trauma
PTSD Failure to recover from nearly universal set of emotions
and reactions
Typically manifested by Distressing memories or nightmares related to trauma
Attempts to avoid reminders of trauma
Heightened state of physiological arousal
Summary Biologic mechanisms of PTSD Changes in brain regions
Amygdala and hippocampusAssociated with fear and memory
Changes in systems involved in coordinating body’s response to stress Hormonal
Neurochemical
Physiological
Summary
Treatment Educate patient about nature of disorder
Provide safe and supportive environment Discuss trauma and impact
Relieve distress associated with Memories reminders of events
Treatment strategies with variable success Exposure therapy cognitive therapy
Pharmacotherapy
Summary Pharmacotherapy SSRIs
Effective and well tolerated
Many with PTSD do not respond to drugs Need to better study this subset
Pilot studies with propranolol Need confirmation
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