PTSD & Mental Health
Across the Lifespan
Working with Veterans affected by combat & trauma experiences
Edgardo Padin-Rivera, Ph.D.
Chief, Psychology Services
February 26, 2015
VETERANS AND WARS
• There are approximately 20 million veterans alive today.
• 1.6 million (~8%) are women
• 9.3 million (~ 47%) are over 65
• Most veterans served
during wartime (>60%).
• Approximately 30-40%
were exposed to combat.
• The Vietnam era veteran,
~7.2 million living, is the
largest segment of the
veteran population.
*Source: US Census Bureau, 2013
AGE DISTRIBUTION OF U.S. VETERANS IN 2010
Data source: VettPop2011
VETERANS AND WARS
WWII (1941-1945) Veterans (16 million)
• Less than 1 million living today; Median age = 90
• Over 450 die daily
• More than 30% in combat.
• Approx. 25% have had
PTSD symptoms.
• Stoic, resigned to suffering
combat memories.
• Relatively uninformed on
MH issues.
VETERANS AND WARS
Korean War (1950-1953) Veterans
• Over 2 million war era veterans living; Median Age: 85
• ~ 850,000 living who served in combat.
• Very patriotic; but
mixed feelings about
“forgotten” status.
• Stoic, resigned to
painful memories,
similar values to WWII
generation.
VETERANS AND WARS
Vietnam War (1960-1975) Veteran Generation
• 9.1 million served on active duty; 6.9 million living.
• 2.5 million served in South Vietnam.
• 1.5 million (60%) in combat or exposed to direct combat.
• Avg. age=67; youngest is 55.
• First historical group to be
labeled with PTSD.
• PTSD estimates at between
7-28% depending on study.
VETERANS AND WARS
Vietnam War (1960-1975) Veteran Generation
• First veteran group to demand individual recognition
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for pain & suffering from war.
Many are bitter, disillusioned, conflicted about the war.
Many felt blamed, disparaged for participating in war.
Carry feelings of betrayal
by society.
Aware of PTSD, but tend
to mythologize.
More likely to talk about
experiences (but not all).
COMING HOME: FALLING OUT
Veterans Seeking Mental Health Services
• < 40% have been in combat zone.
• > 70% have been exposed to traumatic event.
• < 25% diagnosed with PTSD.
• > 45% suffer from multiple mental health issues.
• > 50% have substance abuse problems.
• Most have relationship problems at home or work.
COMING HOME: FALLING OUT
The Not-PTSD Syndrome
•
Memories may generate conflict,
pain, fear, disgust & may be
difficult to integrate into
self-concept.
•
Self-blame, guilt, or shame for
actions of war or failure to act.
•
Disillusionment with previous social & spiritual life.
•
Challenging core beliefs about self and intentions of others.
•
Experiences of death & loss lead to fear of intimate relationships.
Post-Traumatic Stress Disorder
PTSD is caused by exposure to such extreme stress that it
changes the way a person thinks, copes and behaves in
response to other stressful situations.
• The event involves the actuality or threat of serious harm
or death to self or others.
• Reaction to the event is ongoing distress and inability to
manage associated memories or emotions.
• Diagnostic criteria consists of multiple symptoms a person
may acquire long term (> 6 mos.) after exposure to an
intensely stressful event.
Post-Traumatic Stress Disorder
Underlying Problems in PTSD
• Inability to process an event into a memory
– Overwhelmed by emotions
– Unable to gain insight or place experience in history.
• Alienation from self & social connections
– Lost capacity for joy, pain, self-reflection
– Lost capacity to fully trust others emotionally
– Lost capacity to trust self-control
• Involuntary changes in physical reactions & brain activations.
• Highly reactive to environmental demands
• physiological reactivity (GSR, HR difficult to control).
Post-Traumatic Stress Disorder
PTSD is manifested through a constellation of 20 different
symptoms that may occur in someone after exposure to
extremely stressful (trauma) events.
Major symptom categories are:
B.
C.
D.
E.
Intrusive Re-experiencing events
Avoiding reminders of the events
Negative Mood & Cognitions
Constant or chronic physical
arousal
Post-Traumatic Stress Disorder
Associated Symptoms & Disorders
• Major Depression (MDD).
• Alcohol & Drug Abuse/Addictions.
• Phobias (crowds, enclosed places).
• Panic Disorders (Rain; Overpass).
• Stress-related Medical Disorders.
• Social & functional impairment:
work disruptions, marital, family
or relationship problems.
COMING HOME: FALLING OUT
Alcohol and Drug Abuse often associated with PTSD
• Work as way to dull post-trauma memories.
• Quick way to alleviate anxiety and painful emotions.
• Allows social interaction
without emotion inhibitions.
• Creates fast moving, transient
emotional states.
• Helps maintain status quo.
• Helps develop and reinforce
“safe” social alienation.
Post-Traumatic Stress Disorder
Stages of Coping Across the Lifespan
• Turmoil – disabling symptoms, inconsistent life progress.
• Repression – subconscious denial of symptoms or memories.
• Suppression – Consciously
denying any effects. “White
knuckle syndrome”.
• Vulnerability – adequate
functioning with limited
capacity for stress.
• Integration – successful
resolution and enhanced
functioning.
Traumatic Memories & Vulnerability
• Post-traumatic anxiety may resurface or surface for first
time in later life or end of life.
• Deteriorating cognitive
controls may make it
more difficult to
suppress or repress
memories.
• Losses of supportive
relationships may be
source of re-activation.
Traumatic Memories & Vulnerability
Understanding the Emotions of Vulnerability
Turmoil at this stage of life include fears of
• Aging body and deterioration of hearing, vision, taste, smell,
touch/pain.
• Failing kidney/prostate, ability to walk, deterioration of
heart & lungs function.
• Brain Aging: Difficulties in memory, new learning, language
and speech, decision-making and planning capacities.
• Pre-existing medical or other mental Illnesses may result in
declines in reality testing or disorganized thoughts.
• Veteran may be aware but may need (want) to be in denial.
Traumatic Memories & Vulnerability
Understanding the Emotions of Vulnerability
• Threat to life inherent in surgery or terminal illness may elicit
emotions of original trauma, triggering memories &
symptoms.
• Those who coped by suppression, repression, or avoidance
may be especially vulnerable to overwhelming anxiety if
memories reactivated.
• Life review, normally a healing process, can lead to intense
anxiety, sadness, guilt, or anger when trauma experiences
need integrating.
• Veteran with history of social isolation and avoidance may
find self without supportive relationships or caregivers.
Traumatic Stress Assessment
Engagement questions for Veterans:
• If veteran status known, ask, ‘What branch of service were you in?’
• Then, if not known, ask “Where did you serve in the military?”
• Acknowledging that aspect of
their lives increases chances of
establishing a connection.
• You may then ask:
“Did you experience combat?”
• Then, “Do any of your experiences
or memories from the military or
combat upset or bother you?”
• You decide when to move on.
Listen. Be non-judgmental.
INTERVENTION CHALLENGES
Myths that hinder caregiver–patient communication
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Myth that once a person has PTSD they will always have it.
Myth of PTSD veteran as angry, vocal, asocial, crybaby.
Myth that every combat veteran suffered terrible trauma.
Myth that painful, bittersweet, or conflictual
memories are PTSD.
• Myth that person HAS to talk about their
trauma to feel better or come to peace
about their life.
• Myth that suppression of feelings
or memories is a bad way of coping.
INTERVENTION STRATEGIES
Basic Needs a Patients:
• Clean & Safe Environment
• Engaging, not intrusive, not patronizing staff
• Consistency & control, e.g.,
knowing what comes next.
• Inpatients: mild stimulation
on a regular basis.
INTERVENTION STRATEGIES
If PTSD is suspected or evident, consider the following:
1. Engage (listen) quietly, being witness to veteran experience
can sometimes be enough.
2. Do not push to process
traumatic material.
3. Normalize & educate on PTS.
4. Emphasize patient’s control
over medical decisions.
5. Link patients in support.
6. If Sx. are severe, ask for
PTSD consultation.
INTERVENTION STRATEGIES
Normalize & Educate
• Basic Tenet #1: PTS is normal human reaction to extremely
stressful events.
• Basic Tenet #2: Symptoms are manageable.
• Basic Tenet #3: Confusing
and conflicting emotions are
to be expected.
• Basic Tenet #4: Talking is difficult,
but connection with others
can help.
INTERVENTION STRATEGIES
Link patients in Support
• Find ways for patients to provide support to each other
through groups (story telling, readings, sharing pictures).
• Link patients: Look for
role models of integration.
• Develop activities that fill
need to address memories
(prayer, writing letters to
buddies, verbal journals)
fill need to create legacy.
STAFF & CAREGIVER CHALLENGES
Challenges from caregiver and staff reactions:
• May experience strong negative emotional reactions to PTS
symptoms, especially with patients who are suspicious,
resistant, confrontational, or highly distressed.
• May over-identify with patient resulting in excessive sympathy
for their suffering, anger at military, society, patient, even self.
• May have difficulty engaging emotionally at any level, leaving
patient to feel caregiver is cold, uncaring, stiff, or hostile.
STAFF & CAREGIVER CHALLENGES
Staff & Caregiver Education when a veteran has symptoms:
• Inform caregivers of manifest PTSD difficulties or symptoms.
• Provide information on how these can interfere with care.
• Provide reassurance to staff who have strong emotional
reactions to patient (e.g., sympathy, anger, guilt).
• Develop a set of PTSD resources (see resources guide).
• Locate consultants with PTSD expertise.
STAFF & CAREGIVER CHALLENGES
Collaboration Enhances Caring
• All disciplines need to understand how PTS may affect
veterans' physical, emotional, and spiritual care.
• Caregivers and family members may
need to practice patience & serene
“quiet engagement” to deal with
agitation and restlessness.
• Principal interventions are
expressing honor, dignity and
gratitude for service.
STAFF & CAREGIVER CHALLENGES
Immediate goal is to provide comfort & manage symptoms.
Approaching the Paradox of PTSD Symptoms
• Physical vs. Emotional pain.
• Recall vs. Re-experience.
• Insight vs. Spiritual Peace
• Guilt or Shame vs. Pride
RESILIENCY RESOURCES: COMMUNITY SUPPORT
Ve t e ra n p e rc ep t i o n o f p o s i t i ve c o m mu n i t y
support, whether or not it is used, is one of
t h e b e st k n o w n a n t id o t e s t o ch ro n ic m e n t a l
h e a lt h p ro ble m s a f t e r a t ra u m at ic eve n t .
If you see a returning service member
this month, just say thank you.