PTSD: The Shadow of Combat

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PTSD The Shadow of Combat
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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
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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 gt 1 month Cause clinically
significant distress or impairment in functioning
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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
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Labels
Fright Neurosis Combat/War Neurosis Shell
Shock Survivor Syndrome Operational
Fatigue Compensation Neurosis
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Stats

• 1.6 million troops deployed to OEF/OIF to date
• Approximately 40 have accessed VA care
• Three most common presenting problems Musculoskel
  etal Ailments
• Mental Disorders (PTSD, SA/D, Depressive)
• Symptoms, Signs, and Ill Defined Cond.

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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)

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Demographic Characteristics of OEF and OIF
Veterans Utilizing VA Health Care

• OEF/OIF
  Veterans
• (n
  347,750)
• Gender
• Male
  88
• Female 12
  
• Age Group
• lt20 7
  
• 20-29 51
  
• 30-39 23
  
• 40 18
  
• Branch
• Air Force
  12
• Army 64
  
• Marine 13
  
• Navy
  11
• Unit Type
• Active 52
  
• Reserve/Guard 48
  
• Rank

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Frequency of Possible Diagnoses Among OEF and OIF
Veterans

• Diagnosis (n
  347,750)
• (Broad ICD-9 Categories)
  
  Frequency
•  
• Infectious and Parasitic Diseases (001-139)
  40,956 11.8
• Malignant Neoplasms (140-208)
  3,248 0.9
• Benign Neoplasms (210-239)
  13,910
  4.0
• Diseases of Endocrine/Nutritional/ Metabolic
  Systems (240-279)
  75,850 21.8
• Diseases of Blood and Blood Forming Organs
  (280-289) 7,675
  2.2
• Mental Disorders (290-319)
  
  147,744 42.5
• Diseases of Nervous System/ Sense Organs
  (320-389)
  121,473 34.9
• Diseases of Circulatory System (390-459)
  
  56,900 16.4
• Disease of Respiratory System (460-519)
  
  71,087 20.4
• Disease of Digestive System (520-579)
  
  110,449 31.8
• Diseases of Genitourinary System (580-629)
  
  37,118 10.7
• Diseases of Skin (680-709) 55,797
  16.0
• Diseases of Musculoskeletal System/Connective
  System (710-739) 165,439
  47.6
• Symptoms, Signs and Ill Defined Conditions
  (780-799)
  138,043 39.7
• Injury/Poisonings (800-999)
  
  73,767 21.2
•  

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Frequency of Possible Mental Disorders Among
OEF/OIF Veterans since 2002

•  
• Disease Category (ICD 290-319 code)
  Total Number of GWOT
  Veterans
• PTSD (ICD-9CM 309.81)
  75,719
• Depressive Disorders (311)
  50,732
• Neurotic Disorders (300) 40,157
  
• Affective Psychoses (296) 28,734
• Nondependent Abuse of Drugs (ICD 305)
  21,201
• Alcohol Dependence Syndrome (303) 12,780
• Special Symptoms, Not Elsewhere Classified (307)
  7,685
• Sexual Deviations and Disorders (302) 7,076
• Drug Dependence (304) 5,764
• Specific Nonpsychotic Mental Disorder
• due to Organic Brain Damage (310)
  4,654

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Three Different Types of Stress Injuries
Combat/Operational Stress
Stress Adaptations
Stress Injuries
Positive Behaviors
Negative Behaviors
Traumatic Stress
Operational Fatigue
Grief

• Due to a terrifying or horrible event

• Due to the wear and tear of deployment

• Due to the loss of friends and leaders

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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
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Beliefs That Can Be Damaged By Traumatic Stress
Belief in ones basic safety Belief in being the
master of oneself and ones environment Belief in
whats right moral order Belief that our
cause is honourable Belief that every troop is
valued Belief in the basic goodness of people
(especially oneself)
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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
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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

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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)

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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)

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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

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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

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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

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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

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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

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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
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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

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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

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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

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Hoge at al. (2006)

• Combat Experiences
• OEF OIF OTHER
• Any 46.0 65.1 7.4
• Witnessed 38.1 49.5 5.3
• Discharged 6.2 17.8 0.4
• Felt in Danger 24.6 50.3 3.2

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References

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