PTSD Presentation

Understanding Post Deployment
Issues

AS THE DISORDER IS DEFINED TODAY, IT INVOLVES THREE KINDS OF SYMPTOMS.
 1. HYPERAROUSAL.
 INDIVIDUALS WITH PTSD ARE IRRITABLE, EASILY STARTLED, AND CONSTANTLY ON GUARD.
THEY SLEEP POORLY AND HAVE DIFFICULTY CONCENTRATING.
 2. RE-EXPERIENCING OR INTRUSION.
 THEY RECALL THE TRAUMATIC EVENT INVOLUNTARILY IN THE FORM OF VIVID MEMORIES,
NIGHTMARES, AND FLASHBACKS. THEY MAY FEEL OR EVEN ACT AS THOUGH IT IS HAPPENING
AGAIN. ANY OBJECT, SITUATION, OR FEELING THAT REMIND THEM OF THE TRAUMA MAY CAUSE
INTENSE DISTRESS.
 3. AVOIDANCE AND EMOTIONAL NUMBING.
 THEY AVOID FEELINGS, THOUGHTS, PERSONS, PLACES, AND SITUATIONS THAT EVOKE
MEMORIES OF THE TRAUMA. THEY LOSE INTEREST IN THEIR USUAL ACTIVITIES. THEY FEEL
ESTRANGED FROM OTHER PEOPLE AND EVEN FROM THEIR OWN FEELINGS.

THESE THREE SETS OF SYMPTOMS HAVE A COMMON THEME
---FIXATION ON THE TRAUMA.

WITH EXPOSURE TO CONSTANT DAILY TRAUMA ,SUSTAINED OVER LONG
PERIODS OF TIME, WITH MULTI DEPLOYMENTS ,
THEPTSD WOUND IS INEVITABLE.

(C)DESTINATION FOR SUCCESS -
OPERATION OUTREACH 2007 3

The body and brain contain a highly attuned,
primitive system that can sense danger, which
triggers a body-wide response.

 The job of the amygdala
 The biochemical cascade: hypothalamus is
triggered, pituitary and adrenal glands flood
the blood stream with stress hormones
(epinephrine, norepinephrine, cortisol)
 Release of norepinephrine increases
alertness, focus, short term memory, pupil
dilation, increased muscle tone (fight or flight
response)
 The impact of the meaning of the situation as
dangerous and life threatening.
 The impact on the hippocampus (memory) and
the orbitofrontal cortex (problem solving and
planning).

OPERATION (C)DESTINATION FOR SUCCESS -
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 Increased blood pressure
 Increased heart rate
 Constriction of blood vessels
 Increased activation of lungs
and quickened breathing
 Increased perspiration
 Liver excretes extra doses of
glucose

OUTREACH 2007 5

Stress hormones activate immediate shut down
of any bodily system not needed for immediate
survival including:

 Digestion
 Hunger
 Sleep
 Sex
 Digestion

 Hypervigilance
 Trouble falling asleep or staying
asleep
 Generalized anxiety (inability to
relax)
 Exaggerated startle response (to
sudden noises, touch, or memory
cues associated with the trauma)
 Headaches, back aches, general
malaise
 Unintentional weight loss or
gain

OUTREACH 2007 7

Once external conditions have
returned to normal, the body remains
on high alert, reacting to neutral cues
as if they were a warning.

Once chronic PTSD sets in, a myriad of
health conditions may occur in different
parts of the body:

 Cardiac
 Arterial
 Lower gastrointestinal tract
 Musculoskeletal
 Dermatological
 Autoimmune

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 Chronic Fatigue Syndrome
 Fybromyalgia
 Irritable Bowel Syndrome
 Alopecia
 Lower back pain
 Multiple chemical sensitivity
 Interstitial cystitis
 Unexplained
aches, pains, and problems
that may be related to stress
reactions.

OUTREACH 2007 9

Hormonal flooding helps to fend off threats,
but ensures that traumatic memories are
imprinted deeply in the amygdala.

 Recurring intrusive thoughts
 Flashbacks
 Memory loss
 Difficulty with focus, concentration, &
sustained attention
 Difficulty learning new information
 Misperception of facial cues

Pioneer Psychiatrist Bessel Van derKolk
observed that the content of nightmares of
veterans with PTSD had remained the same
for 15 years.

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 Time distortion
* Either stretching or losing time, often associated with
biochemistry of hyper-activation or numbing.

 Distractedness
* Difficulty with details
* Misdiagnosed ADD or ADHD
(Attention Deficit Disorders)
* Short term memory loss

 Obsessive Thinking
* Rigid planning and organizing
* Chronic anxiety
* Difficulty with change, transitions, or interruption of schedule
* Repetitive behaviors (to bind anxiety)
* Dissociation


 Sorrow, grief, despair, loneliness
 Loss of a reasonable, safe
world, shattered dreams
 Yearning for normalcy, sense of safety
 Feeling out of control of one’s life;
helplessness
 Sense of impending doom or death
 Unusual amounts of
anger, resentment, irritation, rage
 Oscillation between intense feelings
(biochemical surge) and emotional
numbing (endogenous opioids)
 Guilt, shame, and humiliation

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Avoidance & Isolation:
 Normal activities and events may provoke
anxiety, panic, or fear of becoming out of
control

Damaged Relationships:
 Over controlling
 Avoidance of intimacy
 Over reacting to situations
 Inability to share feelings
 Mood swings

Dangerous Behaviors:
 High risk behaviors, flirting with disaster
 Unconscious attraction to dangerous
situations
 The traumatized brain creates an
uncontrolled and unconscious addiction
to the biochemicals released when one is
feeling threatened (real or perceived).

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Substance Abuse & Addiction:
 May initially provide some relief to
overwhelming feelings
 Ultimately create larger problems (increased
risks, domestic abuse, problems at work,
depression, etc.)
Self Mutilation or Repetitive Self Injury:
 May help to regulate emotional states
 Either help centralize overwhelming feelings
or provide a sense of feeling alive (if numbed
out)
Compulsive Busyness:
 Avoidance of internal emotional states
 Binding anxiety
 Avoidance of relationships or social events
 Workaholic

OUTREACH 2007 14

 Multi and Extended Deployments
 Strain Relationships (Dear John/Jane Letters)
 Money Problems
 Occupational Problems

 71% of Military Suicides Use Fire Arms
 15% to 17% of Suicide Victims Have
PTSD

Service Members need to have a
decompression period –
a more gradual transition back to civilian
life.

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 THE FIFTH EDITION OF THE AMERICAN PSYCHIATRIC
ASSOCIATION'S DIAGNOSTIC MANUAL MAY PUT LESS
EMPHASIS ON THE DIAGNOSIS OF PTSD AND MORE ON
THE RANGE OF RESPONSES AND INDIVIDUAL
VULNERABILITY.

 FOR NOW IT IS IMPORTANT TO REMEMBER THAT
NOT ALL TRAUMAS ARE ALIKE, THAT ANY TRAUMA WILL
AFFECT PEOPLE DIFFERENTLY.

 HOWEVER,WITH EXPOSURE TO CONSTANT DAILY
TRAUMA ,SUSTAINED OVER LONG PERIODS OF
TIME, WITH MULTI DEPLOYMENTS , PTSD IS INEVITABLE.


(C) 2007 - DESTINATION FOR
OPERATION OUTREACH SUCCESS 17

Acute phase of PTSD:
 Exacerbated symptoms of re-experiencing (of
trauma).
 Avoidance & Arousal
 Compromised basic psychosocial functioning

Three main goals required at this stage:
 Basic needs & safety
 Trust-Positive therapeutic alliance
 Assessment of current coping strategies-substance
abuse, medication needs


Therapist needs to use common language (understand
and use military jargon) with clients.

Client learns about positive and negative symptoms of
PTSD

PositiveNegative
Intrusive thoughts Lack of pleasure
Nightmares Numbing
Flashbacks Alienation

 Symptoms of PTSD
 Common co-occurring conditions
 Effects of PTSD on the body
 Effects of PTSD on the psyche
 Effects of PTSD on others (ie: family, co-workers)


 Recovery is facilitated by teaching effective
coping strategies so clients can adaptively
handle daily stressors.
 The telling (and re-telling) of their experiences
(both in individual and group therapy)
 The gradual reestablishment of interpersonal
relationships at home and work.

Modalities:
 Individual Therapy: Literature, videotapes
 Psychoeducational Groups for veterans & their
families


Purpose:
 Reduction in stress response results in reduction of
re-experiencing of trauma symptoms and memory
activation
 Reduction of avoidance behaviors results in as
coping strategies improve
 Reduction of avoidance behaviors results in
opportunities for corrective information in various
domains that may be associated with the trauma

Strategies:
 Relaxation through guided imagery
 Deep breathing
 Skills training


Direct Therapeutic Exposure (DTE) is the most
systematic, efficient, and well studied

DTE is utilized in many formats:
 Systematic desensitization
 Implosive Therapy
 Flooding
 Eye Movement Desensitization Reconstruction (EMDR)
 Thought Field Therapy
 Counting Method

Note: Exposure therapy is contraindicated in some cases:
 Inability to maintain stable, working therapeutic relationship
 Continual relapses with substance abuse
 Acute suicidal or homicidal ideation


 Therapist must be able to tolerate high levels of
emotional upheaval from clients during exposure
therapy.

 Therapist must be aware of and in control of their
own emotional responses/triggers to client
reactivity.

 Therapist must teach and prepare clients for
unavoidable situations and conditions which may
trigger trauma responses.

 Therapist must have a solid historical
understanding of the client and what he/she may
have been exposed to prior to combat-related
trauma (ie: domestic abuse, childhood abuse)


PTSD is increasingly being recognized as a phasic
disorder, with symptoms that wax and wane over
time.

 Prepare client for anniversary reactions

 Must be a proactive, collaborative problem solving
approach to life’s stressors

 Relapse prevention is addressed throughout treatment

 Long term interpersonally oriented group therapy as
necessary

 Aftercare planning for resolution of long term
psychotherapy issues which may be related to prior
trauma: (childhood abuse, sexual abuse, neglect.)

A brief course in pharmacology

OPERATION OUTREACH SUCCESS, LLC 25

 Provides something helpful/useful to the veteran

 Does not lead to tolerance (of the medication)

 Does not lead to abuse (of the medication)

 Cannot be used to commit suicide (ie: Prozac)

 Does not require blood testing

 Does not cut a person off from the world or himself

 Causes few, bearable side effects


 Selective Serotonin Reuptake Inhibitors (SSRI’s): fluoxetine (Prozac),
sertraline (Zoloft), paroxetine (Paxil), etc.
 Beta blockers: propranolol (Inderal), nadolol (Corgard), atenolol
(Tenormin)
 Buspirone (Buspar)
 Low dose lithium

Other drugs used for special circumstances:
 Desyrel (Trazadone) for sleep
 Quinine for nocturnal myoclonos
 Low dose antipsychotics for violent urges and mood stability:
thioridazine (Mellaril), mesoridazine (Serentil)


 Benzodiazepines: diazepam (Valium), alprazolam (Xanax), lorazepam
(Ativan)

 Caffeine

 Alcohol

 Yohimbine

 ANY illegal drug

Future Drugs: “Fear Pill” (Propranolol, Inderol)


 A psychiatric condition controlled with proper
medication should not automatically lead to non
deployment.

 Recommendation for deployability should rest with the
clinical judgment of the treating clinician or physician.

 Medications used safely together are SSRI’s and sleep
medications.

 Service members taking medications should not
automatically be disqualified for any duty assignment.

 Medications needed for serious or complex
medical/psychiatric conditions are not usually suitable
for extended deployments


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