LT Cliff Overby II, M.M.

Jillian Jo Overby, M.Ed.

Best Practices:PTSD Student Veterans

Definition of PTSD• An anxiety disorder resulting from

exposure to an experience involving direct or indirect threat of serious harm or death; may be experienced alone (rape/assault) or in company of others (military combat) (www.ncptsd.va.gov)

National Center for PTSD• 7.8% of Americans experience PTSD• Women are at TWICE the risk to

experience PTSD• 30% of combat veterans experience PTSD

– Approximately 50% of Vietnam veterans experience symptoms

– Approximately 8% of Gulf War veterans have demonstrated symptoms (Duke and Vasterling 2005)

Relevance of Topic• Individuals with traumatic stress reactions may

not seek mental health care but do seek out other health and social services

• Only 1/3 of Iraq war veterans accessed mental health services first year of post-deployment (Hoge, Auchterloine & Milliken, 2006)

• Impact manifests across the lifespan• Each veteran will have a unique set of social,

psychological, and psychiatric difficulties

Signs and Symptoms• Three variations of stress disorders that

may be experienced:– Immediate– Acute– Chronic

• Depends on a variety of individual, contextual, and cultural factors.

Immediate: “Combat Fatigue”• Immediate psychological and functional impairment that

occurs in war-zone/battle or during other severe stressors during combat

• Caused by stress hormones• Features of stress reaction include:

– Restlessness– Withdrawal– Stuttering– Confusion– Nausea– Vomiting– Severe suspiciousness and distrust

Acute Stress Disorder (ASD)• Anxiety occurring within one month after exposure to

extreme traumatic stressor• Total duration of disturbance is two days to a maximum

of four weeks (i.e. occurs and resolves within one month)• Symptoms include:

– One re-experiencing symptom– Marked avoidance– Marked anxiety– Evidence of significant distress or impairment

• ASD is considered a predictor of PTSD, though not a necessary precondition (APA 1994)

Chronic: PTSD• Post Traumatic Stress Disorder is the chronic phase of

adjustment to a stressor across lifespan• Symptoms include:

– Recurrent thoughts of the event– Flashbacks/bad dreams– Emotional numbness (“It don’t matter”); reduced interest or

involvement in outside activities– Intense guilt or worry/anxiety– Angry outbursts and irritability– Feeling “on edge,” hyper-arousal/hyper-alertness– Avoidance of thoughts/situations that remind person of the

trauma (APA 1994)

Duration of PTSD• To meet criteria for PTSD, symptom

duration must be at least one month– ACUTE PTSD: duration of symptoms is fewer

than three months– CHRONIC PTSD: duration of symptoms is

three months or more• Often the disorder is more severe and

lasts longer when the stress is of human design (i.e. war-related trauma) (APA 1994)

Coexisting Problems• Veterans with PTSD are also at risk for:

– Depression and anxiety– Substance abuse– Spectrum of severe mental illnesses– Aggressive behavior problems– Sleep problems like nightmares, insomnia, or

irregular sleep schedules– Acquired brain injury

• Traumatic Brain Injury (TBI) (www.ncptsd.va.gov)

Where Are They?• Student veterans with PTSD are difficult to

identify:– Onset of symptoms may not occur for months to

years after trauma– Professionals may misdiagnose or not recognize

symptoms– Individual psychosocial factors may interfere with

individuals seeking help– Avoidant behaviors may result in an inability for others

to recognize the need for treatment

Identifying At-Risk Students• Symptoms of at-risk individuals:

– History of psychiatric problems– Poor coping resources or capabilities– Past history or trauma/mistreatment– Acute Stress Disorder (ASD)– Isolated– Finically burdened– Limited or no respite from work, family, or social

demands– Stigma or faulty belief systems around seeking help

Potential Consequences of PTSD

• Physiological Concerns:– Physical complaints are often treated symptomatically

rather than as an indication of PTSD

• Self-Destructive/Dangerous Behaviors:– Substance abuse– Suicide attempts– Risky sexual behavior– Reckless driving– Self-injury (www.ncptsd.va.gov)

Potential Consequences of PTSD

• Social and Interpersonal Problems:– Relationship issues– Low-self-esteem– Alcohol and substance abuse– School and employment problems– Homelessness– Trouble with the law– Isolation (www.ncptsd.va.gov)

Implications for Students• Impact on well-being• Employability• Challenges for military reservists• Military versus civilian life issues• Job turnover and maintenance• Failing grades• Steady employment or school attendance is one

predictor of better long-term functioning

Recommended Accommodations for the Instructor:

• Give information in writing• Provide detailed, regular feedback and guidance• Provide positive reinforcement• Provide clear expectations and consequences• Allow for flexible start time• Combine small breaks into one larger break during long

class sessions• Allow for breaks during short classes• Plan uninterrupted work time

Recommended Accommodations for the Student:

• Divide large assignments• Allow music via headset• Count one occurrence for all PTSD-related absences• Allow for work at home• Extended time on tests and assignments (allow make up

work in event of absence)• Provide additional time for new responsibilities• Restructure assignments during times of stress

Recommended Accommodations for the Classroom:

• Reduce distractions• Lighting• Identify and remove environmental triggers• Allow presence of a support animal• Allow student to complete assignments from home• Provide a note-taker• Provide PTSD Awareness training to students, faculty,

staff, and administration

Recommendations for Student Activities:

• Coping can be easier when involved in social activities• Encourage students with PTSD to participate in student

activities• Keep in mind all recommended accommodations for the

classroom and the student• Work with the Student Activities Director• Help student find a “mentor” or “buddy” to participate in

activities with• PARTICIPATE in student activities yourself!

Recommendations when Dealing with High Emotions:

• Allow telephone calls during class time to contact doctors or counselors

• Use stress management techniques• Allow frequent breaks• Develop strategies with the student for dealing with

conflict

Dealing with Angry Students• Anger is often the most troublesome problem• Attempt to understand anger from the student’s

perspective• Intervene

– Recognition– Establish boundaries/rules– Follow emergency procedures if necessary

• Preemptively discuss the advantages and disadvantages of anger expression in the classroom

• Seek consultation• Refer to counselors/student services for further

assistance

Procedures to Follow:• Specific procedures to follow if a student

demonstrates PTSD symptoms during your class:– Display calmness– Provide reassurance– Orient to place– Take a break– Guide– Recommend an appropriate referral

Take Home Points• Essential Features of PTSD:

– Re-experiencing symptoms (nightmares, intrusive thoughts)– Avoidance of trauma cues– Numbing/detachment from others– Hyper-arousal

• A variety of factors including personal, cultural, and social characteristics, coping abilities, experiences in war, and the post-deployment/civilian environment all contribute to the level, severity, and duration of stress factors

• Work with students individually to find accommodations that fit both the needs of the student and the classroom

References• American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

American Psychiatric Association: Washington, D.C. • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Text Revised. American Psychiatric Association: Washington, D.C.• Cozza, S.J., Benedek, D.M., Bradley, J.C., Grieger, T.A. (2004). Topics specific to the psychiatric treatment of

military personnel. In Iraq War Clinician’s Guide (2nd Ed.). http://www.ncptsd.va.gov/war/guide/index.html• Duke, L.M. & Vasterling, J.J. Epidemiological and methodological issues in neuropsychological research on

PTSD. In Neuropsychology of PTSD: Biological, Cognitive and Clinical Perspectives. Vasterling & Brewin, Eds. The Guilford Press: 2005.

• Harvey, A.G., & Bryant, R.A. (1998). Predictors of acute stress following mild traumatic brain injury. Brain Injury, 12, (2): 147-154.

• Harvey, A.G. & Bryant, R.A. (2000). Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following traumatic brain injury. The American Journal of Psychiatry, 157, (4): 626-628.

• Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D. (2004). Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. The New England Journal of Medicine, 35, (1): 13-22.

• Hoge, C.W., Auchterloine, J.L., Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deplloyment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023-1032.

• Insurance Information Institute. http://www.iii.org. • National Center for PTSD. http://www.ncptsd.va.gov• Prins, A., Ouimette, P., Kimerling, R., Camerond, R.P., Hugelshofer, D.S., Shaw-Hegwar, J., Thraikill, A., Gusman,

F.D., Sheikh, J.I. (2004). The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9 (1), January 2004, 9-14.