PTSD & Mental Health Across the LifespanWorking with Veterans affected by combat & trauma experiences

Edgardo Padin-Rivera, Ph.D.Chief, Psychology ServicesFebruary 26, 2015

VETERANS AND WARS

• There are approximately 20 million veterans alive today.

• 1.6 million (~8%) are women

• 9.3 million (~ 47%) are over 65

• Most veterans servedduring wartime (>60%).

• Approximately 30-40%were exposed to combat.

• The Vietnam era veteran, ~7.2 million living, is thelargest segment of theveteran population.

*Source: US Census Bureau, 2013

AGE DISTRIBUTION OF U.S. VETERANS IN 2010

Data source: VettPop2011

WWII (1941-1945) Veterans (16 million)

• Less than 1 million living today; Median age = 90• Over 450 die daily• More than 30% in combat.• Approx. 25% have had

PTSD symptoms.• Stoic, resigned to suffering

combat memories.• Relatively uninformed on

MH issues.

VETERANS AND WARS

Korean War (1950-1953) Veterans

• Over 2 million war era veterans living; Median Age: 85• ~ 850,000 living who served in combat.• Very patriotic; but

mixed feelings about“forgotten” status.

• Stoic, resigned to painful memories, similar values to WWIIgeneration.

VETERANS AND WARS

Vietnam War (1960-1975) Veteran Generation

• 9.1 million served on active duty; 6.9 million living.• 2.5 million served in South Vietnam.• 1.5 million (60%) in combat or exposed to direct combat.• Avg. age=67; youngest is 55. • First historical group to be

labeled with PTSD.• PTSD estimates at between

7-28% depending on study.

VETERANS AND WARS

Vietnam War (1960-1975) Veteran Generation

• First veteran group to demand individual recognitionfor pain & suffering from war.

• Many are bitter, disillusioned, conflicted about the war. • Many felt blamed, disparaged for participating in war.• Carry feelings of betrayal

by society. • Aware of PTSD, but tend

to mythologize.• More likely to talk about

experiences (but not all).

VETERANS AND WARS

COMING HOME: FALLING OUT

Veterans Seeking Mental Health Services

• < 40% have been in combat zone. • > 70% have been exposed to traumatic event.• < 25% diagnosed with PTSD. • > 45% suffer from multiple mental health issues.• > 50% have substance abuse problems.• Most have relationship problems at home or work.

The Not-PTSD Syndrome • Memories may generate conflict,

pain, fear, disgust & may bedifficult to integrate intoself-concept.

• Self-blame, guilt, or shame foractions of war or failure to act.

• Disillusionment with previous social & spiritual life. • Challenging core beliefs about self and intentions of others. • Experiences of death & loss lead to fear of intimate relationships.

COMING HOME: FALLING OUT

PTSD is caused by exposure to such extreme stress that it changes the way a person thinks, copes and behaves in response to other stressful situations.

• The event involves the actuality or threat of serious harmor death to self or others.

• Reaction to the event is ongoing distress and inability to manage associated memories or emotions.

• Diagnostic criteria consists of multiple symptoms a person may acquire long term (> 6 mos.) after exposure to an intensely stressful event.

Post-Traumatic Stress Disorder

Underlying Problems in PTSD

• Inability to process an event into a memory– Overwhelmed by emotions– Unable to gain insight or place experience in history.

• Alienation from self & social connections– Lost capacity for joy, pain, self-reflection– Lost capacity to fully trust others emotionally– Lost capacity to trust self-control

• Involuntary changes in physical reactions & brain activations.• Highly reactive to environmental demands• physiological reactivity (GSR, HR difficult to control).

Post-Traumatic Stress Disorder

PTSD is manifested through a constellation of 20 different symptoms that may occur in someone after exposure to extremely stressful (trauma) events.

Major symptom categories are:B.Intrusive Re-experiencing events C.Avoiding reminders of the eventsD.Negative Mood & CognitionsE.Constant or chronic physical

arousal

Post-Traumatic Stress Disorder

Associated Symptoms & Disorders

• Major Depression (MDD).

• Alcohol & Drug Abuse/Addictions.

• Phobias (crowds, enclosed places).

• Panic Disorders (Rain; Overpass).

• Stress-related Medical Disorders.

• Social & functional impairment: work disruptions, marital, family or relationship problems.

Post-Traumatic Stress Disorder

Alcohol and Drug Abuse often associated with PTSD

• Work as way to dull post-trauma memories.

• Quick way to alleviate anxiety and painful emotions.

• Allows social interactionwithout emotion inhibitions.

• Creates fast moving, transientemotional states.

• Helps maintain status quo.

• Helps develop and reinforce “safe” social alienation.

COMING HOME: FALLING OUT

Stages of Coping Across the Lifespan

• Turmoil – disabling symptoms, inconsistent life progress.• Repression – subconscious denial of symptoms or memories.• Suppression – Consciously

denying any effects. “Whiteknuckle syndrome”.• Vulnerability – adequate

functioning with limitedcapacity for stress.• Integration – successful

resolution and enhancedfunctioning.

Post-Traumatic Stress Disorder

• Post-traumatic anxiety may resurface or surface for first time in later life or end of life.

• Deteriorating cognitivecontrols may make itmore difficult to suppress or repressmemories.

• Losses of supportiverelationships may besource of re-activation.

Traumatic Memories & Vulnerability

Understanding the Emotions of Vulnerability

Turmoil at this stage of life include fears of• Aging body and deterioration of hearing, vision, taste, smell,

touch/pain.• Failing kidney/prostate, ability to walk, deterioration of

heart & lungs function.• Brain Aging: Difficulties in memory, new learning, language

and speech, decision-making and planning capacities.• Pre-existing medical or other mental Illnesses may result in

declines in reality testing or disorganized thoughts. • Veteran may be aware but may need (want) to be in denial.

Traumatic Memories & Vulnerability

Understanding the Emotions of Vulnerability

• Threat to life inherent in surgery or terminal illness may elicit emotions of original trauma, triggering memories & symptoms.

• Those who coped by suppression, repression, or avoidance may be especially vulnerable to overwhelming anxiety if memories reactivated.

• Life review, normally a healing process, can lead to intenseanxiety, sadness, guilt, or anger when trauma experiences need integrating.

• Veteran with history of social isolation and avoidance mayfind self without supportive relationships or caregivers.

Traumatic Memories & Vulnerability

Engagement questions for Veterans: • If veteran status known, ask, ‘What branch of service were you in?’

• Then, if not known, ask “Where did you serve in the military?”

• Acknowledging that aspect oftheir lives increases chances ofestablishing a connection.

• You may then ask: “Did you experience combat?”

• Then, “Do any of your experiencesor memories from the military orcombat upset or bother you?”

• You decide when to move on. Listen. Be non-judgmental.

Traumatic Stress Assessment

INTERVENTION CHALLENGES

Myths that hinder caregiver–patient communication

• Myth that once a person has PTSD they will always have it. • Myth of PTSD veteran as angry, vocal, asocial, crybaby.• Myth that every combat veteran suffered terrible trauma.• Myth that painful, bittersweet, or conflictual

memories are PTSD.• Myth that person HAS to talk about their

trauma to feel better or come to peaceabout their life.

• Myth that suppression of feelingsor memories is a bad way of coping.

Basic Needs a Patients:

• Clean & Safe Environment

• Engaging, not intrusive, not patronizing staff

• Consistency & control, e.g., knowing what comes next.

• Inpatients: mild stimulationon a regular basis.

INTERVENTION STRATEGIES

If PTSD is suspected or evident, consider the following:

1. Engage (listen) quietly, being witness to veteran experience can sometimes be enough.

2. Do not push to process traumatic material.

3. Normalize & educate on PTS.4. Emphasize patient’s control

over medical decisions.5. Link patients in support.6. If Sx. are severe, ask for

PTSD consultation.

INTERVENTION STRATEGIES

Normalize & Educate • Basic Tenet #1: PTS is normal human reaction to extremely

stressful events.

• Basic Tenet #2: Symptoms are manageable.

• Basic Tenet #3: Confusing and conflicting emotions areto be expected.

• Basic Tenet #4: Talking is difficult, but connection with otherscan help.

INTERVENTION STRATEGIES

Link patients in Support• Find ways for patients to provide support to each other

through groups (story telling, readings, sharing pictures).

• Link patients: Look for role models of integration.

• Develop activities that fill need to address memories(prayer, writing letters tobuddies, verbal journals)fill need to create legacy.

INTERVENTION STRATEGIES

Challenges from caregiver and staff reactions:

• May experience strong negative emotional reactions to PTS symptoms, especially with patients who are suspicious, resistant, confrontational, or highly distressed.

• May over-identify with patient resulting in excessive sympathy for their suffering, anger at military, society, patient, even self.

• May have difficulty engaging emotionally at any level, leaving patient to feel caregiver is cold, uncaring, stiff, or hostile.

STAFF & CAREGIVER CHALLENGES

STAFF & CAREGIVER CHALLENGES

Staff & Caregiver Education when a veteran has symptoms:

• Inform caregivers of manifest PTSD difficulties or symptoms.

• Provide information on how these can interfere with care.

• Provide reassurance to staff who have strong emotional reactions to patient (e.g., sympathy, anger, guilt).

• Develop a set of PTSD resources (see resources guide).

• Locate consultants with PTSD expertise.

Collaboration Enhances Caring

• All disciplines need to understand how PTS may affect veterans' physical, emotional, and spiritual care.

• Caregivers and family members mayneed to practice patience & serene“quiet engagement” to deal withagitation and restlessness.

• Principal interventions areexpressing honor, dignity andgratitude for service.

STAFF & CAREGIVER CHALLENGES

Immediate goal is to provide comfort & manage symptoms.

Approaching the Paradox of PTSD Symptoms

• Physical vs. Emotional pain.

• Recall vs. Re-experience.

• Insight vs. Spiritual Peace

• Guilt or Shame vs. Pride

STAFF & CAREGIVER CHALLENGES

Ve t e r a n p e r c e p t i o n o f p o s i t i v e c o m m u n i t y s u p p o r t , w h e t h e r o r n o t i t i s u s e d , i s o n e o f t h e b e s t k n o w n a n t i d o t e s t o c h r o n i c m e n t a l h e a l t h p r o b l e m s a f t e r a t r a u m a t i c e v e n t .

RESILIENCY RESOURCES: COMMUNITY SUPPORT

If you see a returning service member this month, just say

thank you.