UNDERSTANDING PTSD IN
VETERANS:
CRISIS MANAGEMENT WITH
WOUNDED WARRIORS
John Mundt, Ph.D.
drjohnmundt@hotmail.com
www.drjohnmundt.com
AGENDA
I. Who are the New Veterans? (demographics, prevalence of
mental health problems)
II. The Deployment and Homecoming Cycle (implications for
mental health in both vets and families)
III. Special challenges: Traumatic Brain Injury, Substance Abuse,
Suicide, Violence/Aggression
IV. Understanding Trauma and PTSD
V. Combat Vets: Points of Contact with Law Enforcement
VI. Intervention with a Veteran in Crisis (including accessing the
VA and veterans' resources)
“VETERAN”
 “Combat” or “non-combat” distinction
 Character of military discharge
 Active duty vs Reservist vs National Guard
 “Disabled vet”
DEFINITIONS:
“OEF/ OIF”
 OEF: “Operation Enduring Freedom”
 OIF: “Operation Iraqi Freedom”
 OND: “Operation New Dawn”
 GWOT: “Global War on Terror”
OEF/OIF Historical Timeline
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1991: Operation Desert Storm
1991-2001: Enforcement of “No Fly Zones”
9/11/2001: Terrorist attacks on US
10/7/2001: Operation Enduring Freedom (OEF)
(ground combat troops increase in 2002)
3/20/2003: Operation Iraqi Freedom (OIF)
8/31/2010: End of combat operations in Iraq
(Operation New Dawn - OND)
12/2011: Withdrawal of “last U.S. troops” (Iraq)
9/2012: Draw-down in US troops in Afghanistan
2014: “Islamic State” in Iraq & Syria
1/1/2015: Operation Resolute Support in
Afghanistan
Basic statistics
 2.8 million troops deployed to Iraq or
Afghanistan as of 2015
 4495 US military killed in Iraq as of 12/31/2016
 2378 US military killed in Afghanistan as of
12/31/2016
 50,000+ US military wounded as of 6/20/2014
 Iraqi war dead: estimates range from 110,000
to more than one million
 1% of US population is directly touched by
military service
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DEMOGRAPHICS:
Who are the OEF/OIF veterans?
 All-volunteer military
 Many did not expect deployment
 Multiple deployments the norm
 All service branches
 Both genders
 Wide range of ages
 Reservists & National Guard
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PTSD in Warzone Veterans
COMBAT
PTSD
Prevalence of mental health problems
 Problems with estimating: PTSD is a
“moving target”
 PTSD manifests months/years after trauma
 Diagnostic “fuzziness”: PTSD vs. other
psychiatric disorders
 Addiction as mask
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Prevalence of mental health problems
National Center for PTSD ( www.ptsd.va.gov )
• 48% of VA care-seekers between 20022009 were diagnosed with a mental health
problem
• Overall, studies suggest that 15% of OEF/OIF
veterans have PTSD
• 25% of OEF/OIF veterans who utilize VA have
PTSD
• Percentage is higher when considering “subclinical PTSD” and other mental health conditions
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DEPLOYMENT
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Deployment
Servicemember’s experience in Iraq & Afghanistan
• Most vets have been in a firefight
• Most have seen friends/buddies wounded or killed violently
• Most have handled human remains
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Deployment
Pervasiveness: relentless threat/ need for readiness
-no “rear” (contrast with Vietnam)
-helmets on all the time
-may alternate with periods of boredom
Persistent hyperarousal, sleep deprivation
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Deployment
 Fear/
Terror
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Deployment
Indirect threats: as opposed to direct assault/attack
-IEDs, car bombs
- RPGs, snipers
-suicide bombings
Deployment
“Crowd control”: Ambiguity and uncertainty
Deployment
Powerlessness: threat is indiscriminate
-not dependent upon skill or mastery
(relationship between loss of control and PTSD)
Deployment
Ambient factors: IRAQ
 Desert climate: temperature
 Sand, grit, dust
Wildlife
Deployment
Ambient stressors: AFGHANISTAN
o Terrain: mountainous, rugged, caves
o Weather: cold, snow, mud
o“Culture shock”
Deployment
This generation’s war:
•1st “Internet War” (Vietnam was TV war)
•Blogs, email, cell phones (cameras), 24hr news sites
•New versions of “Dear John” letter
•Home trouble as a leading stressor
•Reservists: repeated, unpredictable separations from
family/job
Other Military Experiences & PTSD
MILITARY SEXUAL TRAUMA (MST)
May be compounded by combat trauma
 Frequently unreported:
 trauma occurs in context of where the
servicemember lives/works
military culture emphasizes cohesion
occurs in civilian contractors as well as military
 Male victims as well as female;
female perpetrators as well as male
 Heavily male environment in VA
Other Military Experiences & PTSD
Non-combat PTSD in military populations:
• Relief and “peacekeeping” operations
• Military training experiences
• Aircraft carriers
Homecoming
Concept of HOMECOMING:
 Can be end of deployment AND end of
military career (serviceperson becomes a “veteran”)
 Can be emotionally confusing
and psychologically complex
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Homecoming
Onset of psychological symptoms: anxiety,
panic attacks, “flashbacks”
HYPERVIGILANCE: well-learned and
engrained
Grief & Bereavement

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Homecoming
 Feelings of alienation
 Surreal nature of return to civilian
society
 ANGER!!
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HOMECOMING:
Change of roles: boredom, loss of power,
“need for speed”
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Work and school: Cultural challenges
 “1 per-centers”, political discussions,
civilian griping
 standing out as a vet:
being thanked or
questioned
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Work and school:
Cultural challenges
 Challenge of hypervigilance:
seating, crowds, workplace, classroom
 TBI, tinnitus and hearing problems
 Balancing medical care with other obligations
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TRAUMATIC BRAIN INJURY (TBI)
“Signature Injury” of this war
• Explosions account for 3 of 4 combat-related injuries 1
• Other sources of TBI: penetrating wounds, toxic fumes,
MVA’s
• No uniform definition of TBI, no systematic
reporting method
• Improvements in warzone trauma treatment decrease
fatalities
• Soldiers return home with “polytrauma”
Zouris,J.M., Walker, G.J., Dye, J. & Galarnewau, M. (2006). Wounding patterns for U.S. Marines and sailors
during Operation Iraqi Freedom, major combat phase. Military Medicine, 171(3):246-52.
1
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TRAUMATIC BRAIN INJURY (TBI)
Source: Chart provided by Dr. Michael Carino, Army Office of the Surgeon General, December 13, 2012. Data
source is the Armed Forces Health Surveillance Center (AFHSC), Defense and Veterans Brain Injury Center,
http://www.dvbic.org/dod-worldwide-numbers-tbi.
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TRAUMATIC BRAIN INJURY (TBI)
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ADDICTION and SUBSTANCE ABUSE
Factors leading to substance abuse problems:
 Pre-existing problems
 “Self-medication” of depression, PTSD
 Chronic pain
 Boredom
 Affiliation/ peer pressure: culture
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“Self-medication”
Anxiety and hypervigilance
Insomnia
Depression
Anger and volatility
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CHRONIC PAIN
Intractable pain as a chronic stressor
Physical demands of military deployment: “Battle
rattle”
Headaches: PTSD versus TBI versus other medical
basis
Orthopedic, neurological, psychosomatic
Medication of “pain”: physical versus emotional
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SUICIDE
Literature: Both trauma exposure
and specific diagnosis of PTSD are linked
with suicidal behavior. Why?
Despair
 Impulsivity
Guilt / Grief
 “Misadventure”
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SUICIDE
High-profile suicides of OEF/OIF
veterans have led to changes in VA
policy/approach:
•Suicide hotline
(National Suicide Prevention
Lifeline: Call
1-800-273-TALK (8255),
and press “1” to be connected
to VA hotline)
•Suicide Prevention Coordinators
•Increased outreach and follow-up
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CHALLENGES TO TREATMENT :
SUICIDE
ASSESSING RISK: Patterson et al’s “SAD PERSONS” mnenomic:
S ex (male)
A ge (elderly or adolescent)
D epression
P revious suicide attempts (highest risk within 3 months of prior
attempt)
E thanol abuse (alcoholics’ rate of suicide is 50x that of non-alcoholics)
R ational thinking loss (psychosis)
S ocial supports lacking (subjective perception of lack)
O rganized plan to commit suicide (specific, lethal)
N o spouse (divorced > widowed > single)
S ickness (physical illness)
Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the
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SAD PERSONS scale. Psychosomatics 1983;24(4):343-9
SUICIDE
ASSESSING RISK: Suicide warning signs in veterans
CHANGE in behavior
o Calling friends, particularly vets, to say goodbye
o Cleaning weapons
o Visiting graveyards
o Stopping or hoarding medication, alcohol
o Spending sprees, buying gifts
o Obsession with media coverage of war
o Wearing uniform, combat gear
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SUICIDE
WEAPONS and OEF/OIF veterans
“Don’t leave home without it!”
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VIOLENCE in COMBAT VETS
Is violence impulsive/reactive (in
context of hyperarousal?
Dissociation?) (Affective violence)
Is violence planned/deliberate (starting
fights? “patrolling”?) (Predatory
violence)
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VIOLENCE in COMBAT VETERANS
 Domestic violence: affective (PTSD-related) vs.
predatory?
 Intoxication (disinhibition?)
 Traumatic Brain Injury (TBI)
(neuropsychological impairments)?
 Related to peer-group
 “Suicide by cop”
PREDICTING VIOLENCE
WEAPONS
PARANOIA
STIMULANTS
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Deployment, Homecoming &
the Family
What happens?
 Displacement of serviceman from prior role
 Family adapts in his/her absence
 Change in roles
 Change in lifestyle
 Change in family dynamics
 Homecoming: veteran returns
 Loss of roles
 Efforts to re-establish and/or create roles
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Deployment: Impact on Family
Spouse/partner
 “Where is the person I knew?”
 Has adapted/ changed
 Has unrealistic expectations
 Vicarious traumatization (“PTSD by proxy”)
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Deployment: Impact on Family
Spouse/partner (continued)
 separation/ divorce
 stalking
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PTSD negatively impacts relationships:
Separation and divorce
Family violence
Impaired parenting
Sexual/Intimacy problems
Caregiver burden
“The Bind That Ties” - Ned Broderick
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Deployment: Impact on Family
Children
“Who Is This?”
“This is scary.”
Regression
Exposure to trauma
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Deployment: Impact on Family
TEENAGERS
“Who are you to tell me what
to do?!?!?!”
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Deployment: Impact on Family
PARENTS
 “What happened to my son/daughter?”
 “Can’t you shake this off?”
 “This reminds me of my
own service…”
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Deployment: Impact on Family
PARENTS: “Empty Nesters”
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Deployment: Impact on Family
SPECIAL CASE OF MOTHERS:
Early separation from newborns
Problems reattaching
Change in roles
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 RESILIENCE is the norm
POST-TRAUMATIC GROWTH is
common
RECOVERY is possible
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Understanding “PTSD”:
 Intrusion and re-experiencing
 Avoidance of reminders
 Negative thoughts and emotions
 Alterations in arousal and reactivity
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PTSD Criteria from DSM-5:
A. Exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s),
2. Witnessing, in person, the event(s) as it occurred to
others,
3. Learning that the traumatic event(s) occurred to a close
family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s)
must have been violent and accidental.
4. Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s) (e.g., first responders
collecting human remains; police officers repeatedly
exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure to electronic
media, television, movies, or pictures, unless the exposure is
work related.
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PTSD Criteria from DSM-5:
B. Presence of one (or more) of the following intrusion symptoms associated
with the traumatic event(s), beginning after the traumatic event(s)
occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels
or acts as if the traumatic event(s) were recurring. (Such reactions
may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings).
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
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Understanding “TRIGGERS”

Think “full body” :
memories are laid down
in all sensory spheres
Terrain: desert, urban
Weather: heat, wind, humidity
Songs, sounds
Smells: olfactory memories
People: automatic responses to persons
who appear Middle Eastern; children
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Understanding CUES or “TRIGGERS”:
SITUATIONAL TRIGGERS:
-Mimic feelings of helplessness, danger
-Invasive medical procedures
-Seclusion or restraint
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Driving: “signature trigger” for OEF/OIF
veterans
 Nature of war in Iraq & Afghanistan
 Need for high speeds, evasive maneuvers
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PTSD Criteria from DSM-5:
C. Persistent avoidance of stimuli associated with the
traumatic event(s), beginning after the traumatic event(s)
occurred, as evidence by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic
event(s).
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PTSD Criteria from DSM-5:
D. Negative alterations in cognitions and mood associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as head
injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., "I am bad," "no one can be trusted," "The world is
completely dangerous," "My whole nervous system is permanently ruined").
3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or
others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).
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GUILT:
 Concept of “moral injury”
 Rational or irrational
 Understanding
atrocities
 “survivor guilt”
 (also guilt for leaving,
for being “intact”)
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PTSD Criteria from DSM-5:
E. Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Irritable behavior and angry outbursts
(with little or no provocation) typically
expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty
falling or staying asleep or restless sleep).
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Duration of problems & DSM-5 criteria:
< 3 days: no diagnosis (military’s
“Combat Operational Stress”)
>3 days, <1 month: Acute Stress Disorder
>1 month: PTSD
> 6 months to meet full PTSD criteria:
delayed onset should be specified
Adjustment Disorder:
*Stressor not limited to Criterion A
*Response does meet all PTSD criteria
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Thinking outside the “DSM Box”:
What does PTSD feel like?
Sense of immediacy (“happening right now”)
Re-experiencing of original memories and
sensory impressions
Involuntary
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Thinking outside the “DSM Box”: Other “symptoms”
GRIEF:
 Multiple losses without
time to grieve
 Affective numbing,
anger/revenge
 Impact of pre-war losses, post-war losses
 Deaths of loved ones at home during deployment
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THINKING OUTSIDE THE “DSM Box”:
Other “symptoms”

Anger at Government
 Mistrust of Authority
 Desire to return to
warzone
 Damage to spirituality
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COMBAT VETERANS:
Points of Contact with Law
Enforcement
The VETERAN DEFENDANT:
?
PTSD or trauma as a factor?
(hypervigilance, dissociation, hyperstartle)
?
Military training/experience as a factor?
?
Just happens to be a veteran?
QUESTION: Does PTSD/trauma render
someone….
-disabled?
-incompetent?
-not responsible?
-an unfit parent?
-a violence risk?
-a suicide risk?
ANSWER:
.
.
.
.
…..Maybe.
Common criminal “points of contact”
 Substance abuse (DUI/DWI; intoxication)
 Aggression and violence (DV; workplace;
public fights)
 Suicidal behavior
 Driving offenses
 Weapons
 “disorderly”: crowds, authorities
Factors in criminal behavior

Unholy Triad:
PTSD, TBI, DUI
DUI (drugs or
alcohol OR
meds!)
TBI (side
effects,
impulsivity
PTSD (meds,
anger)
Common civil “points of contact”
 Divorce
 Child custody, visitation, parenting
 Child support
 Capacity to manage affairs, guardianship
 Disability benefits
 Landlord-tenant disputes & conflicts
Warzone PTSD: Challenges to Parenting
 Anger/impulse control problems
 “Medication”: licit & illicit
 Hypervigilance: over-control, security
 Depression, withdrawal, isolation
 Kids as “triggers”
“TIPS on WITNESSING”
handout
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Intervention with a vet in
crisis: “thinking PTSD”
 Intrusion and re-experiencing
 Avoidance of reminders
 Negative thoughts and emotions
 Alterations in arousal and reactivity
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Intrusion and re-experiencing
 What is a flashback? Dissociation?
 What are the triggers in a situation?
 Intervention: “grounding”, safety assurances
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Avoidance of reminders
 Agoraphobia/ “shut in”: feeling invaded
 Asking safe questions:
 SAFE: MOS, branch of service, deployments,
when separated
 UNSAFE: specific traumas, war experiences
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Negative thoughts and emotions:
 Thinking about depression: Loss or grief?
Guilt?
 Tough times of year:
 July 4th, Halloween, New Years Eve
 Memorial Day, Veterans Day
 “anniversaries”
 “The last straw”….
 Suicidal thinking: passive or active?
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Alterations in arousal and reactivity
 Hypervigilance: “affective violence” risk
 How is perimeter being secured?
(Home as “bunker”: booby traps, noisemakers, dogs,
etc)
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www.va.gov :
“locator”
*VA Medical Centers
*Community Based Outpatient
Clinics (CBOCs)
*Vet Centers
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www.drjohnmundt.com
drjohnmundt@hotmail.com