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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.

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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 > 1 month

    • Cause clinically significant distress or impairment in functioning

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Spontaneous re-experiencing of the trauma

Startle responses


Depression and Guilt


Multiple physical complaints


Impaired concentration and memory

Disturbed sleep and distressing dreams

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Fright Neurosis

Combat/War Neurosis

Shell Shock

Survivor Syndrome

Operational Fatigue

Compensation Neurosis

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  • 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.”

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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)


Male 88 %

Female 12

Age Group

<20 7

20-29 51

30-39 23

≥40 18


Air Force 12

Army 64

Marine 13

Navy 11

Unit Type

Active 52

Reserve/Guard 48


Enlisted 92

Officer 8

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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

*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.

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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


  • 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 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)

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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


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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  • 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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Post concussion Syndrome (PCS)


Memory Deficits

Poor Concentration

Depressed Mood






Noise/Light Intolerance



Memory Deficits

Poor Concentration

Depressed Mood



Intrusive symptoms

Emotional Numbing


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:


    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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  • Arenofsky, J. (2008). Traumatic brain injury: An exploding problem. VFW Magazine, 95(5), 14-20.

  • Arnkoff, D.B., Class, C.R., & Shapiro, S.J. (2002). Expectations and preferences. In J.C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp.335-356). Oxford: Oxford University Press.

  • Foa, E.B., Keane, T.M., & Friedman, M.J. (eds.). (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. The Guilford Press: New York.

  • Follette, V.M., Ruzek, J.I., & Abueg, F.R. (eds.). (1998). Cognitive-behavioral therapies for trauma. The Guilford Press: New York, pp. 162-190.

  • Friedman, M.J. (2006). Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. American Journal of Psychiatry, 163(4), 586-593.

  • Friedman, M.J. (2000). Posttraumatic stress disorder: The latest assessment and treatment strategies. Compact Clinicals: Kansas City, MO.

  • Iraqi War Clinician Guide (2nd edition). National Center for Post-Traumatic Stress Disorder

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  • Kushner, M.G., & Sher, K.J. (1991). The relation of treatment fearfulness and psychological service utilization: An overview. Professional Psychology: Research and Practice, 22, 196-203.

  • Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C.C., & Castro, C.C. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine, 358(5), 453-463.

  • Hoge, C.W., Auchterloine, J.L., & Milliken, C.S. (2006). Mental health problems, use of mental health service, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295(9), 1023-1032.

  • Hoge, C.W., Castro, C.A., Messner, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13-22.

  • Kennedy, J.E., Jaffee, M.S., Leskin, G.A., Stokes, J.W., Leal, F.O., & Fitzpatrick, P.J. (2007). Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 895-920.

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  • McFall, M., Malte, C., Fontana, A., & Rosenheck, R.A. (2000). Effects of an outreach intervention on use of mental health services by veterans with posttraumatic stress disorder. Psychiatric Services, 51, 369-374.

  • Murphy, R. (2006). Clinical methods for fostering combat veterans’ engagement in mental health treatment. Two day workshop held at Salisbury, North Carolina VA Medical Center

  • Newman, C.F. (1994). Understanding client resistance: Methods for enhancing motivation to change. Cognitive and Behavioral Practice, 1, 47-69.

  • Prochaska, J.O. and DiClemente, C.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.

  • Taylor, S. (2003). Outcome predictors for three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Cognitive Psychotherapy, 17(2), 149-162.

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  • Taylor, S. (ed.). (2004). Advances in the treatment of posttraumatic stress disorder: Cognitive-behavioral perspectives. Springer Publishing Company: New York

  • Zweben, A., & Li, S. (1981). The efficacy of role induction in preventing early dropout from outpatient treatment of drug dependence. American Journal of Drug and Alcohol Abuse, 8(2), 71-83.