Shannon McCaslin-Rodrigo, Ph.D.Health Science Specialist

National Center for PTSD, VA Palo Alto Health Care SystemStaff Psychologist

City College of San Francisco Veterans Outreach ProgramAssistant Professor (Vol)

University of California, San Francisco

Combat Stress Injuries in Returning Veterans:

The Importance of Community

http://www.youtube.com/watch?v=M9Uai2wyJhY

~ 2,400,000 deployed service members in support of OIF/OEF/OND1

◦ > 1,040,000 deployed more than once◦ >36,000 deployed more than 5 times

~15% female

~59% married

> 40% of active duty service members have children2

~ 39% of returning Veterans from rural areas

Our Nations Returning Veterans

101/12, Defense Manpower Data Center2ICF international; 3VHA Office of Rural Health

Trauma: General Population and Combat Overview of PTSD Co-occurring Conditions and “Polytrauma” Community and VA Partnership

Overview

Trauma

Examples of psychological trauma◦ Witnessing someone being badly injured or killed ◦ Being involved in a fire, flood, or natural disaster ◦ Being involved in a life-threatening accident◦ Being physically or sexually assaulted◦ Having a life-threatening illness (including traumatic

childbirth)◦ Being in combat

Although we might say a negative event was traumatic (e.g., a divorce, loss of job, etc.) these do not technically qualify as traumas.

What is trauma?

Over half the general population will experience at least one trauma◦ 61% men and 51% women

Witnessing injury or death◦ 36% men and 15% women

Life-threatening accident◦ 25% men and 14% women

Fire or natural disaster◦ 19% men and 15% women

Sexual Assault◦ 10% men and 31% (14-17%) women

Kessler et al. (1995)

How Common is Trauma?

Traditional Combat Traumas◦ Firefights◦ Seeing or handling mutilated bodies◦ Death and dying◦ Medical care in the field◦ Captivity/POW

Torture Non-traditional Combat Traumas

◦ Atrocities and abusive violence◦ Guerilla-style warfare

IEDs, suicide bombs, civilian combatants Other Military Traumas

o Sexual assaulto Accidents (MVAs, falls, burns, explosions, etc.)o Physical Assaults

Traumas of Military Service

Extended opportunity for life threat and death, grief and loss 78% reported seeing destroyed homes and villages 67% (95%) reported seeing dead bodies or human remains 65% reported having hostile reactions from civilians 63% (93%) reported receiving small arms fire 61% (89%) reported being attacked or ambushed 59% (86%) reported knowing someone who was seriously injured

or killed 37% reported engaging in a firefight 19% (48%) reported being directly responsible for death of enemy

combatant (14%) reported being responsible for death of non-combatant (22%) reported having buddy shot or hit who was near you 11% (22%) reported engaging in hand-to-hand combat 10% (14%) reported being wounded/injured

*Reported during deployment (reported after deployment)

War-Zone Stressors (OIF)

Combat stressors: ◦ 51% reported they had been in serious

danger of being injured or killed on at least several occasions during the deployment

Non-combat stressors: “high/very high trouble or concern”◦ 87% uncertain redeployment◦ 71% long deployment length◦ 55% lack of privacy or personal space◦ 54% boring or repetitive work

Exposure to War-Zone Stressors in OIF

23% of female users of VA reported experiencing at least one sexual assault while in military◦ < 1% of male ???

Rates higher in wartime◦ Persian Gulf War

Sexual assault (7%) Physical sexual harassment (33%) Verbal sexual harassment (66%)

Military Sexual Trauma (MST)

Flight-or-Fight-or-Freeze Response: A Sympathetic nervous system response to threat

Uniqueness of trauma exposure in combat◦ Training◦ Extended exposure◦ Breadth of experience

What Happens During Trauma?

What Happens after Trauma?

0102030405060708090

100

Trauma 6 Months 1 year 2 Years

Mild

Mod

erat

e

Sev

ere

Chronic Delayed Recovery Resilience

Bonanno (2004)

For most readjustment takes time◦ Cultural adjustment (e.g., structure, camaraderie)◦ Family role adjustment◦ Work and skill adjustment◦ Grief/loss◦ Symptoms as skills/adaptive (awareness; sleep)

For some recovery is challenging◦ Visible injuries

Physical injuries◦ Invisible injuries

Physical injuries such as tinnitus, sequelae of mTBI Psychological injuries such as PTSD and Depression

After Combat Exposure

Overview of PTSD

Anxiety Disorder First included in DSM-III in 1980 Current diagnostic criteria: Traumatic Stressor

◦ Exposure to a trauma involving actual or threatened injury to self or others

◦ Involving fear, helplessness, or horror

Intrusive recollections of the experience (1) Avoidant/Numbing (3) Hyper-arousal (Keyed up) (2) Present for at least 1 month Significant distress or impairment

What is PTSD?

APA, 2000

Reexperiencing

Hyper-arousal

Avoidance

Symptom Interplay

People, places, conversations, thoughts, situations, etc.

IrritabilityProblems sleepingAlways being on high alert

Intrusive thoughts or imagesNightmaresTriggers

Lifetime prevalence: 7.8%◦ Women (10.4%) twice as likely as men (5%)

Risk of developing PTSD after trauma◦ Women (20.4%) 2.5 times more likely than men (8.1%)

Rates of PTSD vary depending on trauma type and severity◦ Natural disaster: 4-5%◦ Motor Vehicle Accident: 8-12%◦ Rape: 40%◦War

Vietnam War: 18-30% OIF: 13-20% OEF: 6-12%

Sub-threshold symptoms can impact functioning and quality of life

*Rates vary depending on time since trauma and diagnostic criteria used

How Common is PTSD?Disorder of Recovery

Brewin et al. (2000); Ozer et al. (2003)

Risk Factors of PTSD

Pre-trauma• Prior Trauma• Psychological Adjustment • Family History of

Psychopathology• Childhood Abuse 

Peri-trauma• Perceived life threat• Dissociation (largest)• Emotional Responses• Trauma Severity

Post-trauma• Social Support• Additional Life Stressors

Comorbidity of PTSD With Other Psychiatric

Disorders

Kessler R, et al. Arch Gen Psychiatry, 1995

3

Drug Abuse

Major Depression

Social Phobia

Agoraphobia

Gen Anxiety d/o

Panic d/o

>3 diagnoses

Patients With and Without a Lifetime History of PTSD (%)

With PTSD

Without PTSD

0 20 40 60

“Signature Injuries” of OEF/OIF/OND

War Injuries 6,483 (06/2012)U.S. service members killed serving in OIF/OEF/OND

An estimated 48,505 Wounded in Action

Greater percentage surviving their wounds

◦ Battlefield medicine◦ Gear

War No. WIA/KIA

Killed in Action

WoundsLethality

(%)Revolutionary War, 1775-1783

10,623 4,435 42War of 1812,1812-1815

6,765 2,260 33Mexican War, 1846-1848

5,885 1,733 29Civil War (Union Force),1861-1865

422,295 140,414 33

Spanish-American War, 1898

2,047 385 19World War 1, 1917-1918

257,404 53,402 21World War II, 1941-1945

963,403 291,557 30Korean War, 1950-1953

137,025 33,741 25Vietnam War, 1961-1973

200,727 47,424 24Persian Gulf War, 1990-1991

614 147 24OIF/OEF, 2001-present

10,369 1,004 10Gawande, 2004http://www.defense.gov/news/casualty.pdf

Mental Health Conditions (10/01 – 1/08)

440,000 (28%) have probable PTSD or Major Depression

Only 53% have sought treatment Only half have received better than

“minimally adequate treatment” (RAND, 2008)

Most Common Diagnoses PTSD Depression Anxiety Substance Use Disorders Adjustment Disorders 27% met 3 or more diagnoses (Seal et al., 2007)

Common Problems Sleep disturbance Anxiety while driving Anxiety in crowds Anger and irritability Hypervigilence Social withdrawal Grief and guilt Increased alcohol use

Polytrauma: Injuries to multiple body parts and organs occurring as a result of blast-related wounds seen in OEF/OIF/OND

65% of combat injuries by Improvised Explosive Devices (IEDs), landmines, shrapnel, and other blast phenomena.

> 90% surviving injuries

multiple visible injuries (tissue wounds) hidden injuries hearing loss; confusion)

Polytrauma: Clinical Triad

Lew et al., 2009

Overlap in symptoms◦ PPCS, PTSD symptoms, Pain

Concentration difficulties Impaired memory Avoidance Anxiety Depression Irritability

Impact of co-morbidity Importance of focusing on function

◦ Target for treatment◦ Need for interdisciplinary teams and consultation

A Complicated Picture

5 Centers◦ acute, comprehensive ◦ inpatient rehabilitation

Polytrauma Network Site◦ 23 specialized programs

87 Polytrauma Support Clinic Teams (PSCT) in VA Medical Centers ◦ Interdisciplinary rehabilitation teams

VA Services

Working Together to Serve Veterans

> 2 million deployed to Iraq or Afghanistan ◦ Consider families, children

49 % returning Veterans seek VA care◦ General barriers to seeking mental health care

Stigma of mental illness Logistical barriers (e.g., time for appointments) Lack of knowledge (e.g., treatments and resources)

◦ Engagement in VA mental health care Medical record/confidentiality (e.g., military career) Availability of services in rural areas Availability of spouse and family care

Need and Barriers

Call for partnership – meeting Veterans where they are (NAMI)

Opportunities for serving Veterans◦ Rural communities◦ Academic settings◦ Employment settings◦ Family members

Increased Veteran services in the community

◦ Increasing awareness (e.g., screening; culture)◦ Training & resources that can support practice◦ Referring to and collaborating with VA services◦ Referring to and collaborating with community

agencies

Partnership

Community involvement initiatives◦ SAMHSA – Policy Academies◦ Community Blueprint◦ Got Your 6◦ Joining Forces◦ From the War Zone to the Home Front

Mental health providers in the community◦ Give an Hour◦ SOFAR: Strategic Outreach to Families of All

Reservists ◦ The Soldiers Project ◦ Local non-profits: Returning Veteran's Project (OR)

Community Coming Together

VA mission to serve Veterans◦ Specialized programs◦ OEF/OIF programs and teams◦ Women’s programs◦ Research

Working together◦ Improved communication◦ Improved tools in the hands of consumers and

providers◦ Dissemination of products and knowledge

Community and VA Partnership

City College of San Francisco/SFVAMC Veterans Outreach Program (CCSF VOP)◦ VA VITAL initiative – 25 academic/VA programs

Established August 2010 Outreached to 673 Veterans (47%

OEF/OIF/OND) Veterans enrolled in VA healthcare Campus community

◦ Partnering with: Faculty (e.g., coursework, consultation) academic counselors disability services

Example of Partnership

Thank you for your time & attention

Shannon.McCaslin@va.gov

Acknowledgements:

Eric Kuhn, PhDJacy Leonardo, PhDSuzanne Best, PhD