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Understanding Military Posttraumatic Stress Disorder (PTSD). 22 June 2013. With thanks to Maj Gen Kirk Martin & Armed Forces Health Surveillance Center & Association of Military Surgeons. by Col William W. Pond, MD Indiana State Air Surgeon (& Baghdad, & Balad & Kuwait & Qatar, etc.

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By col william w pond md indiana state air surgeon baghdad balad kuwait qatar etc

With thanks to Maj Gen Kirk Martin &

Armed Forces Health Surveillance Center &

Association of Military Surgeons

by Col William W. Pond, MD

Indiana State Air Surgeon

(& Baghdad, & Balad & Kuwait & Qatar, etc


Ptsd crisis nicholas horner iraq
PTSD Crisis ?Nicholas Horner, Iraq

  • April 6, 2009 Altoona, PA

  • After return from SW Asia, quiet, did not leave home

  • Slept poorly, found crying in basement by mother

  • Panic attacks, doors always locked

  • Explosive moods, argument with wife in morning

  • Afternoon drinking 2 pitchers of beer.

  • Walked to Subway back door, cut electrical wires, shot out utility box

  • Shot 2 inside and apologized, “Sorry, I didn’t wanna have to do that to you.”

  • Shot another while trying to steal a car

  • Rage, insomnia, emotional numbness do not qualify as insanity

  • Convicted of murder, PTSD “not an excuse for murder”

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Compare chistopher stone cold mountjoy
Compare:Chistopher “Stone Cold” Mountjoy

  • March 31, 2012, Fort Carson

  • Sin City Disciples Motorcycle Club enforcer

  • Street barricaded, crouched behind trash bin

  • Ambushed cars of victim

  • Victim previously beaten and was allegedly returning to retrieve wallet

  • 5 associates charged with murder

  • Mountjoy, an active duty soldier, served as sergeant-at0-arms for local Sin City disciples

  • Mountjoy deployed to Afghanistan in 2011

  • PTSD claimed as defense to actions

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder

Col William Pond, IN SAS


Congratulations, Ken, you have just purchased your very own low mileage Hummer

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Aeromedical Evacuation own low mileage Hummer

Col William Pond, IN SAS


Ptsd is one of several mental disorder diagnoses
PTSD is one of several mental disorder diagnoses own low mileage Hummer

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Acute stress disorder asd or posttraumatic stress disorder ptsd
Acute Stress Disorder (ASD) or own low mileage HummerPosttraumatic Stress Disorder (PTSD)

  • Reaction to stress and subsequent dysfuction is a temporal continuum.

  • Duration of symptoms less than 30 days is ASD

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd what is it and how is it defined
PTSD—What is it and how is it defined? own low mileage Hummer

  • Traumatic event

    • Patient must feel seriously threatened to self or others

    • Must have intense negative emotional response

  • Persistent re-experiencing

    • Flashback memories, bad dreams, re-experiencing the event—all evoke intense negative response to events that remind patient

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd more signs
PTSD—More signs own low mileage Hummer

  • Avoidance and emotional numbing

    • Avoiding stimuli associated with event such as thoughts or talking about it

    • Avoiding places, or people who remind

    • Inability to recall major parts of event

    • Decreased ability to feel emotions

    • Expectation of short future or doom

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd arousal disturbances
PTSD Arousal Disturbances own low mileage Hummer

  • Anger poorly controlled, “flies of the handle” easily

  • Difficulty falling or staying asleep

  • Hypervigilence or hyperalert

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd criteria impairment
PTSD Criteria--Impairment own low mileage Hummer

  • PTSD not present unless significant impairment

    • Social relationship—spouse, children, parents, and coworkers (the ones who may notice first)

    • Occupation—job function changes, e.g. late to work, lack of attention to detail, or excessive attention to detail

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Physiologic changes accompanying ptsd
Physiologic changes accompanying PTSD own low mileage Hummer

Fight or Flight response

  • Fast Heart rate

  • Hyperventilation, breathing deep and fast

  • Quivering or shaking

  • Easily startled with loud noises

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd may co exist and be synergistic with traumatic brain injury tbi
PTSD may co-exist and be synergistic with Traumatic Brain Injury (TBI)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Is ptsd a new disease newly recognized or newly recategorized
Is PTSD a new disease, Injury (TBI)newly recognized or newly recategorized?

  • First report 490 BC Herodotus noted soldier blind after Battle of Marathon

  • 1800s military doctors noted “exhaustion” with mental shutdown.

  • During WWII 10% of American soldiers were hospitalized for mental disturbances between 1942 and 1945.

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Previous diagnoses of what is now ptsd
Previous diagnoses of what is now PTSD Injury (TBI)

  • Railway Spine

  • Stress Syndrome

  • Shell Shock

  • Battle Fatigue

  • Traumatic War Neurosis

  • PTSD since 1980s

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd risk and protective factors
PTSD Risk and Protective Factors Injury (TBI)

  • 50-90% of the American population experienced a traumatic event, but only 8% develop PTSD

  • 70-90% of deployed military members experience a traumatic event, but only 15% develop PTSD

  • Why not everyone?

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Incidence rate decreases with age
Incidence rate decreases with age. Injury (TBI)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Predisposing factors
Predisposing factors Injury (TBI)

  • Associated life stresses, e.g. marital problems

  • Pre-existing psychological problems

Posttraumatic Stress Disorder

Col William Pond, IN SAS



So is heat
So is heat Injury (TBI)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder

Col William Pond, IN SAS


Amputations as a marker of permanent severe injury
Amputations as a marker of permanent severe injury Injury (TBI)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Proximity Injury (TBI)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder exhibited psychiatric disturbances of varying degrees

Col William Pond, IN SAS


Posttraumatic Stress Disorder exhibited psychiatric disturbances of varying degrees

Col William Pond, IN SAS


The va has ptsd specialists in the community
The VA has PTSD Specialists exhibited psychiatric disturbances of varying degreesin the community

  • PTSD Outpatient clinics

    • PTSD Clinical Teams

    • Substance use combined with PTSD treatment

    • Women’s Stress Disorder Treatment Teams

Posttraumatic Stress Disorder

Col William Pond, IN SAS


The va has ptsd inpatient resources in the community
The VA has PTSD Inpatient Resources exhibited psychiatric disturbances of varying degreesin the community

  • PTSD Intensive Inpatient Programs

    • Day Hospitals

    • Evaluation and Brief Treatment Units

    • Residential Rehabilitation

    • PTSD Domiciliary

Posttraumatic Stress Disorder

Col William Pond, IN SAS


The va has ptsd specialists in the community1
The VA has PTSD Specialists exhibited psychiatric disturbances of varying degreesin the community

  • Vet Centers

    • By Veterans, records confidential

Posttraumatic Stress Disorder

Col William Pond, IN SAS


You our community are important
You, our community, are important exhibited psychiatric disturbances of varying degrees

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Prevention and treatment
Prevention and treatment exhibited psychiatric disturbances of varying degrees

  • **Family, community, employers, ministers can be of invaluable assistance**

  • By fostering recognition and early intervention

  • By listening empathetically—do not give false assurances even if well intentioned, e.g. “It’ll be all right, I know how you feel.” (because you do not, unless you have been there)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Your support is invaluable, and therapeutic, like the children’s notes of support on the concrete wall

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Are our warriors seeking care
Are Our Warriors Seeking Care? children’s notes of support on the concrete wall

Less than 50%of our Warriors who meet the criteria for a behavioral health diagnosis report receiving care

Marriages, spouses and children are also impacted by war

Spouses have fewer stigma concerns and are more likely to pursue behavioral healthcare


Battlemind overview
Battlemind Overview children’s notes of support on the concrete wall

  • What is Battlemind?

    • A Warrior’s inner strength to face adversity, fear and hardship during combat with confidence and courage; it’s the will to persevere and win

  • Comparable to resiliency:

    • The ability to recover rapidly from misfortune

  • Battlemind

    • also refers to the U.S. Army’s premiere psychological resiliency building program and speaks to Warrior skills


Army battlemind program stresses positive factors such as
Army BATTLEMIND Program children’s notes of support on the concrete wallstresses positive factors, such as

  • Buddies (cohesion) vs. Withdrawal

  • Accountability vs. Controlling

  • Targeted Aggression vs. Inappropriate Aggression

  • Tactical Awareness vs. Hypervigilance

  • Lethally-Armed vs. “Locked and Loaded” at Home

  • Emotional Control vs. Anger/Detachment

  • Mission Operational Security (OPSEC) vs. Secretiveness

  • Individual Responsibility vs. Guilt

  • Non-Defensive (combat) Driving vs. Aggressive Driving

  • Discipline and Ordering vs. Conflict


Taking care of the soldier’s mind is as important as taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Pastoral care is invaluable
Pastoral Care is invaluable taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Treatment
Treatment taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

  • Cognitive behavioral programs

    • Indentifying, challenging and modifying biased or distorted thoughts and interpretations about the event and its meaning

  • Confronting avoided situations, people or places in a graded and systematic manner (in vivo exposure)

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd treatment
PTSD Treatment taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

  • Addressing the traumatic memory in a controlled safe environment (imaginal exposure)

  • EMDR (eye movement desensitization) probably most likely due to the re-engagement of the memory, cognitive reprocessing and coping.

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Posttraumatic Stress Disorder taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

Col William Pond, IN SAS


Ptsd medications not the first line
PTSD Medications taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.(not the first line)

  • Beta blockers – for decreasing the sympathetic fast heart rate, jittery, hyperarousal and sleep disturances.

  • Benzodiazepines (Valium)—should be used with caution (relieve acute anxiety, but do not treat underlying cause of PTSD

  • Prazosin—for nightmares

  • Topiramate—for flashbacks and nightmares.

  • SSRI Antidepressants

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd treatment1
PTSD Treatment taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

  • Imperative to foster an expectation that member will recover with treatment and time, just as would occur in any other condition such as a broken arm or pneumonia.

  • Important also to remove secondary gain—Member is not disabled, but duty limited.

  • Return to normal work environment is therapeutic and should be accomplished with concessions as necessary

Posttraumatic Stress Disorder

Col William Pond, IN SAS


Ptsd treatment prognosis and duration
PTSD Treatment Prognosis and Duration taking care of the body—a sense of camaraderie is a powerful antidote to a sense of loneliness and hopelessness.

  • (Lost my crystal ball)—depends upon patient response, but in general,

  • Many patients receive substantial relief from 8-12 ninety minute sessions.

  • If there is no secondary gain and if treatment is appropriate and timely, symptoms can be expected to become manageable within 1-2 months.

  • Goal is not to forget or to hide, but rather to maximize function.

Posttraumatic Stress Disorder

Col William Pond, IN SAS


  • A psychological reaction is not uncommon after a severe stressful situation.

  • Recovery is expected with timely support and compassionate treatment.

  • Home and camaraderie are integral to recovery.

  • Family and community are invaluable in recognition, support and treatment.

  • Your support means more than you will ever know

  • We are grateful for it.

  • Thank you

Posttraumatic Stress Disorder

Col William Pond, IN SAS


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