shannon mccaslin-rodrigo, ph.d. health science specialist
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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
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