Psychological Reactions to Combat;
12+ Years into the Long War
COL (Ret) Elspeth Cameron Ritchie, MD, MPH
Chief Clinical Officer
Department of Behavioral Health
Washington DC
Elspeth.Ritchie@dc.gov
Elspeth.Ritchie@us.army.mil
Slide 1
OUTLINE
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Background and History
9/11 at the Pentagon
Post-Traumatic Stress Disorder
Suicide in the Army
Complementary and Alternative
Medicine for PTSD
1.
Including dogs!
6. Veterans and the Public Mental
Health System
7. Way Ahead
Slide 2
A Brief History of Psychological
Reactions to War
• World War I--“shell shock”, over evacuation led to chronic
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psychiatric conditions
World War II--ineffective pre-screening, “battle fatigue”,
lessons relearned, 3 hots and a cot
The Korean War---initial high rates of psychiatric casualties,
then dramatic decrease
Principles of “PIES” (proximity, immediacy, expectancy,
simplicity)
Vietnam
– Drug and alcohol use, misconduct
– Post Traumatic Stress Disorder identified later
Desert Storm/Shield
– “Persian Gulf illnesses”, medically unexplained physical
symptoms
Operations Other than War (OOTW)
– Combat and Operational Stress Control, routine front line
mental health treatment
Slide 3
9/11 in Washington DC
• Beautiful clear fall day
• New York attack
• Pentagon burning
• Reports of bombs elsewhere
• Are We at War?
Combat Stress Control Principles Applied
• Proximity, Immediacy, Expectancy. Simplicity
• DiLorenzo Clinic at the Pentagon
– Army, Air Force, Navy personnel operations for medical and
mental health services
• -Groups
– People more open to talk in workplace or at ‘coffee rounds”
Development of A Sustained
Response
• Family Assistance Center
• Operation Solace
The Pentagon Family Assistance
Center
• Tended to families of all victims
• The Sheraton in Crystal City
– Extended family, children
– Most lived there for up to a month
• Services
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Informational briefings
Red Cross
Department of Justice, FBI
Counseling
Childcare
• recreation
– Medical care
– DNA collection
The Pentagon Memorial at the Dedication
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Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New
Dawn
• Numerous stressors
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– Multiple and extended deployments
– Battlefield stressors
• IEDs, ambushes, severe sleep deprivation,
– Medical
• Severely wounded Soldiers, injured children,
detainees
Changing sense of mission
Strong support of American people for Soldiers
Major Focus of senior Army Staff
Numerous new programs developed to support Soldiers and
Families
Slide 9
The Army since 9/11
• Volunteer Army
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– Know they are going to war
– Seasoned, fatigued
– Large Reserve Component
– Reserve, National Guard
Elevated suicide rate
Wounded Soldiers
Effects on Families
– Continuous deployments
– Families of deceased
– Families of wounded
• Difficult Economy
– Recruiting now easier
Slide 10
Range of Deployment-Related Stress Reactions
• Mild to moderate
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Combat Stress and Operational Stress Reactions (Acute)
Post-traumatic stress (PTS) or disorder (PTSD)
Symptoms such as irritability, bad dreams, sleeplessness
Family / Relationship / Behavioral difficulties
Alcohol abuse
“Compassion fatigue” or provider fatigue
Suicidal behaviors
• Moderate to severe
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Increased risk taking behavior leading to accidents
Depression
Alcohol dependence
Completed suicides
Slide 11
PTSD DSM IV Diagnostic Concept
• Traumatic experience leads to:
• Threat of death/serious injury
• Intense fear, helplessness or horror
• Symptoms (3 main types)
• Reexperiencing the trauma (flashbacks, intrusive thoughts)
• Numbing & avoidance (social isolation)
• Physiologic arousal (“fight or flight”)
• Which may cause impairment in
• Social or occupational functioning
• Persistence of symptoms
mTBI may be associated with PTSD, especially in the context of
Blast or other weapons injury
Slide 12
DSM 5 Definition of PTSD
• Removes Criterion A-2
• Additional criteria
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Somatic reactions
Sleep
Depressive symptoms
Anger and irritability
Slide 13
Evidence Based Approaches for PTSD
• Psychotherapy
– Cognitive behavioral therapy
• Cognitive processing therapy
– Prolonged exposure
• Pharmacotherapy
– SSRIs
Slide 14
New and
Innovative Approaches
• Other Pharmacotherapies
– 2nd Generation Antipsychotics
• Integrative therapies
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Acupuncture
Stellate ganglion block
Yoga
Canine therapy
– Technology
• Virtual reality
Slide 15
Suicide Rates from 1990-2009
Army rate projected to
Exceed U.S.
population rate**
**Comparable civilian rates were only available from 1990-2006
1
DoD Suicide Deaths/Rates Branch CY 2001-2010
350
Confirmed and Suspected Active Duty Military Suicides by Component, Branch, and
Year
January 1, 2001 - December 31, 2010 (as of 2/7/2011)
300
350
300
26
26
Total Deaths
250
200
32
150
27
26
15
145
24
146
158
250
233
200
196
41
25
34
187
171
284
148
150
268
100
100
1st Qtr
50
50
0
0
2001
2002
Regular
2003
2004
Reserve
2005
Navy
2006
2007
Marine Corps
2008
Air Force
2009
Army
2010
Risk Factors for Suicide in Army Personnel
• Major Psychiatric Illness Not a Significant Contributor
– Adjustment disorders, substance abuse common
• Relationships
• Legal/Occupational Problems
• Substance Abuse
• Pain/Disability
• Weapons
– 70% with firearm
• Recent Trends
– Older, higher rank, more females
Slide 19
Screening and Surveillance
Annual and Post Deployment Screens
• The Department of Defense has mandated annual and post-
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deployment screening for PTSD and depression
– Post-deployment Health Assessment (PDHA): Conducted within
30 days of service members returning from deployment (begun
1998, s/p first Gulf War)
– Post-deployment Health Re-assessment (PDHRA): Conducted
within 3-6 months for service members returning from
deployment (began 2005 in Army)
– Periodic Health Assessment (PHA): Conducted annually (2009)
Screening is based on an interview with a behavioral health care
provider using a standardized interview guide. Service members at
risk will received immediate intervention or a mental health referral.
Slide 20
Screening and Surveillance
The DoD Suicide Event Report
• The Department of Defense implemented the DoD Suicide Event Report
(DoDSER) based on the Army Suicide Event Report (ASER), which was
validated by the U.S. Army Medical Research and Materiel Command.
• DoDSERs are submitted for suicide behaviors that result in death,
hospitalization or evacuation from theater.
• Data collected from standardized records
(e.g., medical records, CID).
• Army DoDSERs due w/in 60–days.
• Objective, detailed, and standardized information
collected:
• Comprehensive data (method, location,
fatality)
– Extensive risk factor data
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Dispositional or personal
Historical or developmental
Contextual or situational
Clinical or symptom factors
Slide 21
Past Suicide Mitigation Approaches
• Analysis of Incident Suicides
– DOD Suicide Event Report (DODSER)
– Epidemiologic Consultations (EPICONS)
• Clinical interventions to identify and treat high risk individuals
• Training Soldiers, Leaders and Family Members to recognize and
respond
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ASSIST
ACE
Battlemind
Beyond the Front
Stand-Down Training
Slide 22
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Suicide Risk Assessment
Behavioral health care providers and key unit members play an
active role in the management and treatment of suicidal
Soldiers.
• Improve suicide assessment and evaluation (primary care,
behavioral health clinic, VA).
– Establish best clinical practices and standards of care
– Train behavioral health and medical care providers at all levels
– Conduct routine reviews and audits to ensure compliance
• Improve engagement and retention in behavioral health care
employing motivational interviewing techniques.
• Involve close family members and friends where ever possible.
• Inform and educate unit leaders as appropriate.
• Enhanced focus on postvention efforts (maintain vigilance post
crisis), including cases of completed suicides.
Slide 23
Evidence-Based Treatments
Adapt evidence-based treatments for suicidality among Soldiers.
• Two generally accepted psychotherapeutic approaches for treating
suicidal patients:
– Cognitive behavioral therapy (based on social learning theory
that focuses on changing distorted beliefs and cognitions about
self and the world).
– Dialectical behavioral therapy (a cognitive behavioral approach
that includes social skills and problem solving).
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Treat the underlying behavioral health disorder.
Slide 24
Population-Based Strategies for Suicide
Mitigation
• The best evidence-based suicide mitigation strategies are
optimal identification of high-risk groups and treatment of
suicidal individuals
• “Gatekeeper” strategies, which identify high risk individuals,
may decrease suicides if identification leads to appropriate
clinical management or reduction of stress
• Recent literature suggests interventions which decrease riskfactors in the population may impact suicide rates
• Current Army suicide mitigation programs focus on
identification/treatment of high risk individuals, not groups.
• Incorporating strategies to mitigate risk-factors in the general
Army population and among specific high risk groups may
decrease risk for suicide in the population
Slide 25
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Causal Factors for Violence Among Soldiers
•Multiple individual, unit, and community factors appear to have converged to shift
the population risk to the right
Percentage of Population
Facts
Individual
• Criminality/Misconduct
• Alcohol / Drugs
• BH Issues (untreated/undertreated)
Individual, Unit, and
Environment Factors
Very Low
Risk
Lower
Risk
Average Risk
Higher
Risk
Number / Severity of Risk Factors
Very High
Risk
Unit
• Turnover
• Leadership (Stigma)
• Training / Skills
Environment
• Turbulence
• Family Stress / Deployment
• Community
• Stigma
Slide 26
Strategies to Decrease Violence
• While it is important to identify and help individual Soldiers, the biggest impact will
come from programs that shift the overall population risk back to the left
• Effective medical treatment can prevent individuals from increasing in risk or
decrease their risk, but it cannot shift overall population risk very much
Percentage of Population
Army Campaign Plan:
• Health Promotion, Risk Reduction, and
Suicide Prevention
• Increase Resiliency
• Decrease Alcohol/Drug Abuse
• Decrease Untreated/Undertreated BH
• Decrease Stigma to Seeking Care
• Decrease Relationship/Family Problems
• Decrease Legal/Financial Issues
Population Interventions
Very Low
Risk
Lower
Risk
Average Risk
Higher
Risk
Number / Severity of Risk Factors
Very High
Risk
Installation:
• Reintegration (Plus)
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Mobile Behavioral Health
Teams
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Mental Toughness Training
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Resiliency Training
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Military Family Life
Consultants
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Decompression Reintegration
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Warrior Adventure Quest
• Consistent Stigma Reduction themes
Slide 27
Selected Dog Programs
Supplement Traditional Rehabilitation/Therapy Programs
• Animal Assisted Activities
• Animal Assisted Therapy
• Specialized Facility Canines
• Military Therapy Dogs
– Combat Stress Units
• Walter Reed
• Warrior Transition Battalion Work
and Education Programs
– Service dog training
• Paws for Purple Hearts
– Dog behavior/obedience and care training
• Washington Humane Society
Canine Assisted Therapy and Army Medicine
AMEDD Journal April to June 2012
How training service dogs addresses PTSD
symptoms
PTSD Symptom Clusters
• Re-experiencing (B)
• Avoidance and Numbing (C)
• Increased Arousal (D)
Re-experiencing symptoms
*Grounding in the here and now*
• Train dog to have positive associations w/noises
etc.
• Dogs have the ability to redirect through touch
• Changing the context; “I didn’t have a dog in Iraq”
• Lower anxiety when triggered
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Avoidance and numbing
symptoms
Avoidance
• Need to socialize service dogs in the community
• Dogs serve as social lubricants. Isolation is not an option.
• Dogs require a daily schedule, a reason to wake up
• Participate in a meaningful activity, pos. sense of purpose
Numbing
• Need to use positive emotions to reinforce behaviors
• Fake it until you make it
• Mindfulness, living in the moment, affective domain
• Learning effective communication skills, assertiveness
Symptoms of increased
arousal
• Concentrate on dog’s training, not self survival
• Practice emotional regulation w/ commands & praise
• Sleep comfort
• Opportunity to practice patience experientially
• Learn to synchronize with low aroused dogs
Training also impacts behaviors/symptoms that
are common for Warriors but may not be part of
diagnostic criteria.
•Parenting skills
•Pain management
•Trust issues
•Grief and loss issues
The Public Mental Health System and
Veterans
Slide 34
“State Example” Washington DC
Slide 35
WASHINGTON, DC
unique characteristics
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A Tale of Two Cities
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“City-State” - Collapsed Political Structure
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Federal and Local Governments Co-Exist
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Under the Thumb of Congress
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Geographically Condensed
– Home to Very High Income and Very Low Income
– Very Transient residents and multi-generational families
– State and local functions; Mayor is Governor, City Council is State
Legislature
– Relatively stable economy
– Small tax base (federal buildings, universities, hospitals, nonprofit
organizations)
– No vote in Congress, no 10th amendment protection
– No legislative or budget autonomy
– DC National Guard only activated by the President
– All urban, height restrictions on buildings
– 19 hospitals, 19 nursing homes, but no state prison
Slide 36
Washington, DC
a magnet
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Both home-grown and transient
consumers
Consumers come to DC for a variety of
reasons:
Some believe there are lots of jobs
Some believe there are better services
It’s easy to establish residency
“Right to shelter” - access to housing for
the homeless
“Someone put me on the bus to come
here”
Anger at government
Perceived access to the government
Monuments and free museums
In love with the First Lady
Slide 37
Slide 38
Homeless Veterans
Veterans are 12% of the adult homeless in
Wash DC
2/3rds are chronically homeless
30% have histories of substance abuse
28% mental health conditions
Slide 39
Relationship Between DBH, the VA and the
Military
Slide 40
Overall themes
• Disconnects between
Department of Veterans Affairs
system, military, academics and public mental health system
– At least in Washington DC
– Military residents rotate through CPEP (the Psych ER for DC)
– Residents from academic institutions rotate through VA
• Disconnects between programs and psychiatric societies
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and state mental system
SAMHSA Policy Academy attempting to improve
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Economic security
Health care
Homelessness
Education
Criminal justice
Slide 41
VA in Washington DC
• Hospital in Wash DC serves National Capital Region (NCR)
– Homeless outreach
– Supported employment
• Various residential/nursing facilities outside region
• “Central” VA in downtown DC
• Vet Centers
Slide 42
Military in and around Wash DC
Walter Reed Army Medical Center—closed
Slide 43
Walter Reed National Military Center—in
Bethesda
Slide 44
Pentagon
Slide 45
Other Military Facilities in the NCR
• Andrews Joint Base
• Bolling Joint Base
• Ft Belvoir with new community hospital
• Quantico Marine Base
• Ft Meade
• Defense Center of Excellence
• National Intrepid Center of Excellence
Slide 46
Current Efforts in Collaboration
• Getting patients into systems of care and supported
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employment
Combined homeless outreach meetings
Asking question at Access Help Line “Are you a veteran?”
Office of the Attorney General teaching VA on commitments,
involuntary hospitalization, etc.
Discussing with psychiatric societies
Training police on working with veterans
Slide 47
Veterans Courts
80 veterans courts
Slide 48
Schools and Veterans
Increasing number of
Veterans organizations
in schools
Slide 49
Future efforts
• Greater interaction of VA, military, public mental health,
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academic medicine
More organized community supports for returning veterans
More integrations for return home efforts
Slide 50
Questions/Discussion
Elspeth.Ritchie@us.army.mil
Elspeth.Ritchie@dc.gov
Combat and Operational
Behavioral Health
www.bordeninstitute.army.
mil
Slide 51