PTSD: The Shadow of Combat
PTSD
An Anxiety Disorder.
3-6% of adults in the United States.
Twice as common in women as in men.
Rates as high as 58% in heavy combat
1-14% non combat
Torture/POW 50-75%
Natural Disaster victims 4-16%
DSM-IV diagnostic criteria for PTSD
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 horror
Features
Appear in 3 clusters: re-experiencing,
avoidance/numbing, hyperarousal
Last for > 1 month
Cause clinically significant distress or
impairment in functioning
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
American 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
*Related to the trauma
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
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.
History
Spontaneous re-experiencing of the
trauma
Startle responses
Irritability
Depression and Guilt
Phobias
Multiple physical complaints
Numbing
Impaired concentration and memory
Disturbed sleep and distressing dreams
Labels
Fright Neurosis
Combat/War Neurosis
Shell Shock
Survivor Syndrome
Operational Fatigue
Compensation Neurosis
Stats
• 1.6 million troops deployed to OEF/OIF to
date
• Approximately 40% have accessed VA
care
• Three most common presenting problems:
Musculoskeletal Ailments
Mental Disorders (PTSD, SA/D, Depressive)
“Symptoms, Signs, and Ill Defined Cond.”
VA Healthcare Utilization among GWOT Veterans
• 868,717 OEF/OIF who have left active
duty since February 2002
437,873 Former Active Duty
430,844 Reserve and NG
40% (347,750) have accessed VA care since
FY 2002 (96% outpatient)
Demographic Characteristics of OEF and
OIF Veterans Utilizing VA Health Care
% OEF/OIF Veterans
(n = 347,750)
Gender
Male
Female
Age Group
<20
20-29
30-39
≥40
Branch
Air Force
Army
Marine
Navy
Unit Type
Active
Reserve/Guard
Rank
Enlisted
Officer
88 %
12
7
51
23
18
12
64
13
11
52
48
92
8
Frequency of Possible Diagnoses
Among OEF and OIF Veterans
Diagnosis
(Broad ICD-9 Categories)
Infectious and Parasitic Diseases (001-139)
Malignant Neoplasms (140-208)
Benign Neoplasms (210-239)
Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279)
Diseases of Blood and Blood Forming Organs (280-289)
Mental Disorders (290-319)
Diseases of Nervous System/ Sense Organs (320-389)
Diseases of Circulatory System (390-459)
Disease of Respiratory System (460-519)
Disease of Digestive System (520-579)
Diseases of Genitourinary System (580-629)
Diseases of Skin (680-709)
Diseases of Musculoskeletal System/Connective System (710-739)
Symptoms, Signs and Ill Defined Conditions (780-799)
Injury/Poisonings (800-999)
(n = 347,750)
Frequency *
40,956
3,248
13,910
75,850
7,675
147,744
121,473
56,900
71,087
110,449
37,118
55,797
165,439
138,043
73,767
%
11.8
0.9
4.0
21.8
2.2
42.5
34.9
16.4
20.4
31.8
10.7
16.0
47.6
39.7
21.2
*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; veterans 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.
Frequency of Possible Mental Disorders
Among OEF/OIF Veterans since 2002
Disease Category (ICD 290-319 code)
Number of
GWOT Veterans
PTSD (ICD-9CM 309.81)
Depressive Disorders (311)
Neurotic Disorders (300)
Affective Psychoses (296)
Nondependent Abuse of Drugs (ICD 305)
Alcohol Dependence Syndrome (303)
Special Symptoms, Not Elsewhere Classified (307)
Sexual Deviations and Disorders (302)
Drug Dependence (304)
Specific Nonpsychotic Mental Disorder
due to Organic Brain Damage (310)
*
Total
75,719
50,732
40,157
28,734
21,201
12,780
7,685
7,076
5,764
4,654
Three Different Types of Stress Injuries
Combat/Operational Stress
Stress
Adaptations
Positive
Behaviors
Negative
Behaviors
Stress
Injuries
Traumatic
Stress
Operational
Fatigue
Grief
 Due to a
 Due to the  Due to the
terrifying or
wear and tear loss of friends
horrible event of deployment and leaders
Traumatic Events in OEF/OIF
Multi-casualty incidents (SVBIEDs, ambushes)
Friendly fire
Death or maiming of children and women
Seeing gruesome scenes of carnage
Handling dead bodies and body parts
“Avoidable” casualties and losses
Witnessed or committed atrocities
Witnessed death/injury of a close friend or leader
Killing unarmed or defenseless enemy
Being helpless to defend or counterattack
Injuries or near misses
Killing someone up close
eliefs That Can Be Damaged By Traumatic Stress
Belief in one’s basic safety
Belief in being the master of oneself and
one’s environment
Belief in “what’s right” — moral order
Belief that our cause is honourable
Belief that every troop is valued
Belief in the basic goodness of people
(especially oneself)
Causes of Shame or Guilt In Traumatic
Stress Injuries
Surviving when others did not
Failing to save or protect others
Killing or injuring others
Helplessness
Failing to act
Loss of control
Even just having stress symptoms of any
kind
RAND Study (2008)
• 1965 service members from 24 communities
• 50%+ reported a friend seriously wounded or
•
•
•
•
killed
45% saw dead or wounded noncombatants
10% reported injuries requiring hospitalization
18.5% met criteria for PTSD or depression
19.5% reported mTBI during deployment of
which 1/3 reported concurrent PTSD or
depression
PTSD and Mild Traumatic Brain
Injury (TBI)
• Slightly more than half of combat injuries early
•
•
in OIF came from explosions
29% evacuated from combat theater to WRAMC
had evidence of TBI (Jan 2003-Feb 2007)
Approximately 15% of all wounded vets have
suffered TBI (4,471 cases diagnosed between
October 2001 and September 2007)
TBI
• Physical damage by external blunt or penetrating trauma
• Acceleration-Deceleration Movement (whiplash) resulting
•
in tearing or nerve fibers, bruising/contusion of brain
Scraping of brain across bony base of skull leading to
olfactory, oculomotor, acoustic nerve damage.
– Loss of sense of smell and reduction of taste
(anosmia), double and/or blurred vision, dizziness or
vertigo
– Usually remit after several days or weeks (nerves
recover or regenerate)
Levels of TBI
• Mild
– LOC for less then 30 minutes w/normal CT
and/or MRI
– Altered mental state: “dazed,” “confused,”
“seeing stars”
– PTA less then 24 hours (unable to store or
retrieve new information)
– Glasgow Coma Scale (GCS): 13-15
Levels of TBI
• Moderate
– LOC less than six hours w/abnormal CT and/or MRI
– PTA less than seven days
– GCS: 9-12
• Severe
– LOC greater than six hours w/abnormal CT and/or
MRI
– PTA greater than seven days
– GCS: 1-8
Post-Concussion Syndrome (PCS)
• Symptoms immediately post-injury may include:
–
–
–
–
Memory, attention, concentration deficits
Fatigues, poor sleep, dizziness, headaches
Irritability, depression
Anxiety
• Most common: free-floating anxiety, fearfulness, intense
worry, generalized uneasiness, social withdrawal, heightened
sensitivity, related dreams
• Recovery (mild TBI) expected within 4-12
weeks; however, some symptoms may linger for
months to years
Assessment
• Post concussion
Syndrome (PCS)
–
–
–
–
–
–
–
–
–
–
Insomnia
Memory Deficits
Poor Concentration
Depressed Mood
Anxiety
Irritability
Headache
Dizziness
Fatigue
Noise/Light Intolerance
• PTSD
–
–
–
–
–
–
–
–
–
–
Insomnia
Memory Deficits
Poor Concentration
Depressed Mood
Anxiety
Irritability
Intrusive symptoms
Emotional Numbing
Hyperarousal
Avoidance behavior
Mild TBI among OIF Returnees
(Hoge et al., 2008)
• 2,525 soldiers included in study (assessed
3-4 months post-deployment)
– 5% (124) reported injury with LOC (up to
several minutes)
– 10% (260) reported injury with altered mental
status w/out LOC
– Four soldiers reported LOC longer than 30
minutes
– 17% (435) reported other injuries
TBI Among OIF Returnees
(Hoge et al., 2008)
Of those who reported LOC, 44% met
criteria for PTSD, as compared to:
-27% of those with altered
mental state
-16% of those with other injuries
-9% of those with no injuries
Blast Injuries
• Over 50% of combat injuries result from bombs,
•
•
grenades, land mines, missles, mortar/artillery
shells
Account for majority of brain injury in theater
with GSWs, falls, and MVAs close behind
TBI among service members as high as 22%
– 2003-2008: over 6,600 TBI
– Four major polytrauma centers (MN, CA, FL, VA):
923 OEF/OIF patients with TBI
Blast Injury
• Blast injuries results from pressure
generated from an explosion which
causes in overpressurization
• Air-filled organs (ears, lung, GI tract) and
organs surrounded by fluid filled cavities
(brain, spinal cord) susceptible
Hoge et al. (2006)
• 01 May 2003 – 30 April 2004:
– OEF (Afghanistan)
– OIF (Iraq, Kuwait, Qatar)
– Other (Bosnia, Kosovo, etc.)
• N = 303,905 Marines and Soldiers
– OEF: 11.3% of 16,318
– OIF: 19.1% of 222,620
– Other: 8.5% of 64,967
Hoge at al. (2006)
• Combat Experiences:
OEF
Any
46.0%
Witnessed
38.1%
Discharged
6.2%
Felt in Danger 24.6%
OIF OTHER
65.1% 7.4%
49.5% 5.3%
17.8% 0.4%
50.3% 3.2%
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
Kessler R et al. Arch Gen Psychiatry 1999;56:617-626.
Therapeutic Intervention
Teach 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 techniques

help 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


Cognitive-Behavioral Therapy


Helping confront painful thoughts and feelings
Helping process thoughts and feelings
Interpersonal therapies

Understanding 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 hippocampus

Associated 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
Pharmacotherapy

cognitive therapy
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
References
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•
•
•
•
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•
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