Awareness of Combat Stress Injuries and the resources available to prior and active duty service members and their families

1. Beyond The Trauma:
Invisible Injuries of War

2. Quotable Quotes -- Eleanor Roosevelt on the Human Cost of War
:
 "Dear Lord,
 Lest I continue My complacent way Help me to
remember Somehow out there A man died for me
today. As long as there be war I then must Ask
and answer Am I worth dying for?”
During the World War II era, almost 25% of the nation served in the
military. Today it’s about 1% of the nation currently serves in the
military. This often translate to mean that many people do not
understand the cost of war or the sacrifieces military families make
execpt those who are directly affected by the war. “This prayer is
probably more relevant now more than ever”.
http://www.healingcombattrauma.com/2011/12/quotable-quotes-eleanor-
roosevelt-on-the-human-cost-of-war.html

3. • The military soldier may experience trauma in a variety of circumstances, during
training as well as war. In some cases, severe injury and sometimes loss of life,
may occur. Studies have shown that the longest lasting effects seem to emerge
from wartime experiences. Many soldiers have been affected directly and
indirectly after being exposed to death and destruction during combat. Often they
are required to be on alert, ready at a moment's notice, waiting for days or weeks
at a time, for a confrontation to happen.
(National Center for PTSD, 2010).

4.  Soldiers are always on alert with the threat of losing their life when in combat.
Many soldiers survive events in which they witnessed the killing of civilians and
the death of fellow soldiers, even their adversary.
 Even individuals in supporting roles, such as medics, nurses, persons serving
grave duty, transport pilots, and Military Police, among others, are at risk to
develop problems.
 The internal thoughts of these events remains strong and continues to interfere
with their functioning and enjoyment of life (Karmey, 2008)

5.  Stress injuries are invisible, which means they are often overlooked
by leaders and other professionals
 Stress injuries can provoke feelings of shame in soldiers, resulting in
their reluctance to admit to having terrifying or horrible experiences
 The severity of any given traumatic stress injury is unpredictable, it
requires patience and understanding during the treatment process
 Sometimes, the disabling effects of traumatic stress injuries may be
delayed in their onset until weeks or months after returning from a
deployment
(Mettler,2011)

6.  Post-traumatic stress disorder (PTSD) is a mental health condition that's
triggered by a terrifying event. Symptoms may include flashbacks,
nightmares and severe anxiety, as well as uncontrollable thoughts about
the event.
 After a traumatic event, many people have a difficult time adjusting and
coping with their thoughts . But with time and taking care of yourself, such
traumatic reactions usually get better. In some cases, though, the symptoms
can get worse or last for months or even years. Sometimes it may prevent
you from performing normal daily routines. In a case such as this, you may
need to seek intervention from a professional.
National Center for PTSD (2010)

7. There are many different ways that PTSD can impact your everyday life.
• Flashbacks- reliving the trauma over and over, including physical
symptom like a racing heart or sweating.
• Bad dreams.
• Frightening thoughts.
Re-experiencing symptoms may cause problems in a person’s everyday
routine. They can start from the person’s own thoughts and feelings.
Words, objects, or situations that are reminders of the event can also
trigger re-experiencing (Tull, 2009).

8. • Staying away from places, events, or objects that are reminders of the experience.
• Feeling emotionally numb or losing interest in things you use to care about
• Having trouble remembering the dangerous event.
• Feeling strong guilt, depression, or worry
• Losing interest in activities that were enjoyable in the past
(Tull, 2009)
Things that remind a person of the traumatic event can trigger avoidance symptoms.
These symptoms may cause a person to change his or her personal routine. For example,
after a bad car accident, a person who usually drives may avoid driving or riding in a car
.

9. • Being easily startled
• Feeling tense or “ on edge”
• Having difficulty sleeping, and/ or having angry outbursts.
Hyper arousal symptoms are usually constant, instead of being triggered
by things that remind one of the traumatic events. They can make the
person feel stressed and angry. These symptoms may make it hard to do
daily tasks, such as sleeping, eating, or concentrating (Tull, 2009).

10.  A traumatic brain injury also known as TBI is caused by sudden
blow or jolt to the head or a penetrating head injury that disrupts
the function of the brain.
 Depression is frequently noted in individuals with chronic post-
concussion syndrome (mild TBI).
 Individuals with TBI who experience depression post-injury
report more symptoms and more severe symptoms than those
TBI patients without depression.
 This can extend to the perception of other problems, including
cognitive problems in individuals with TBI, with individuals
with depression, anxiety and PTSD reporting more problems
with cognitive function than other groups.
 Depression after TBI is linked to abnormal imaging results, older
age at time of injury, and higher levels of depressive symptoms
in the week following injury.
(Tanielian T, 2008)

11.  Risking another brain injury (skiing, contact sports,
motorcycles, etc.)
 Alcohol and illicit drugs
 Caffeine or “energy enhancers”
 Cough, cold, allergy meds containing pseudoephedrine
 Over the counter sleeping aids
 Returning too soon to a high risk area in a combat zone
Return to combat too soon…
 May result in susceptibility to repeat concussion
 May put the Soldier and fellow Soldiers at risk
(MACE)

12. A Major Depressive Episode is when an individual experiences a discrete episode of persistent and
pervasive emotional depression. There must be at least 5 symptoms from the list below that persist
for at least 2 weeks. One of the symptoms must be a depressed mood or loss of interest. These are
two-questions generally asked during the screening process:
1. Depressed Mood
2. Markedly diminished interest or pleasure in all or almost all activities.
3. Significant weight loss or gain, or increase/decrease in appetite.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness inappropriate guilt.
8. Diminished concentration or indecisiveness.
9. Recurrent thoughts of death or suicide.
(American Medical Network)

13.  Major depression is a mood state that goes well beyond temporarily
feeling sad or blue. It is a serious medical illness that affects one’s
thoughts, feelings, behavior, mood and physical health. Depression is a
life-long condition in which periods of wellness alternate with recurrences
of illness (American Psychiatric Association, 2000).
 Major Depressive Disorder is more commonly known as depression
 Women are two times more likely to be affected by Major Depressive Disorder
than men
 Causes may vary from biological to psychological
 Most episodes of depression usually end over a period of time
 Major Depression can last for years
 Successful treatment of depression does not guarantee that it will not reoccur

14. The most common form of treatment is medication; various
prescription medications exist for the purpose of treating
depression
Ex: Prozac and Zoloft
Cognitive therapy-This type of talk therapy helps you recognize
the ways of thinking (cognitive patterns) that are keeping you
stuck — for example, negative or inaccurate ways of perceiving
normal situations.
(American Psychiatric Association, 2000)

15.  PTSD
 TBI (often misdiagnosed)
 Mood disorders
 Substance abuse
 Job change/unemployment
 Marital discord/family stressors
 Impending combat deployment
 Chronic stress
 Chronic pain
 Anxiety
 Misuse of Medication
 Financial problems
 Loss of spirituality
(Geisinger)

16. Rates of PTSD,
depression and TBI
•About 300,000 currently suffer from PTSD or major depression
•About 320,000 reported experiencing TBI during deployment
(Rand, 2008)

17. On Aug. 31, President Barack Obama signed an executive order to improve access to
mental health services for veterans, service members and military families. Obama
directed DOD, the VA, the Department of Health and Human Services (DHHS) and the
Department of Education to develop a National Research Action Plan that will include
strategies to improve early diagnosis and treatment effectiveness for TBI and PTSD. He
further directed DOD and DHHS to conduct a comprehensive mental health study, with
an emphasis on Major Depression, PTSD, TBI, and related injuries to develop better
prevention, diagnosis, and treatment options (Office of the Press Secretary, 2012)

18. The Department of Defense is responsible for providing the military
Forces needed to deter war and protect the security of our country.
The major elements of these forces are the Army, Navy, Marine Corps,
and Air Force, consisting of about 1.4 million men and women on
active duty.
 They are backed, in case of emergency, by the 1.2 million members of
the Reserve and National Guard. In addition, there are about 670,000
civilian employees in the Defense Department. Under the President,
who is also Commander in Chief, the Secretary of Defense exercises
authority, direction, and control over the Department, which includes
the separately organized military departments of Army, Navy, and Air
Force, the Joint Chiefs of Staff providing military advice, the
combatant commands, and defense agencies and field activities
established for specific purposes (U.S. Department of Defense).

19. The VA offers many benefits other than health care to dependents and survivors
according to the Federal Benefits for Veterans, Dependents and Survivors VA
Pamphlet.
 Education/Training
 Home loan guaranty
 Life insurance
 Burial and memorial services
When working with military connected families it is important to discuss the VA and
its benefits with your clients. It is also important to encourage the veteran to enroll for
VA healthcare benefits immediately after separation from the military. Sometimes
family members are also eligible for benefits so it is important for social workers to
know that the VA can be a great resource for military families (Department of Veterans
Affairs, 2010).

20. VA provides readjustment counseling at 207 community-based Vet Centers located in all 50 states,
the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands to help combat veterans
readjust to civilian life.
Eligibility: Veterans are eligible if they served on active duty in a combat theater during World War
II, the Korean War, the Vietnam War, the Gulf War, or the campaigns in Lebanon, Grenada, Panama,
Somalia, Bosnia, Kosovo, Afghanistan, Iraq and the Global War on Terror. Veterans, who served in
the active military during the Vietnam Era, but not in the Republic of Vietnam, must have requested
services at a Vet Center before Jan. 1, 2004.
Services: Vet Center staff provides individual, group, family, military sexual trauma, and
bereavement counseling. Services include treatment for post-traumatic stress disorder (PTSD) or help
with any other military related issue that affects functioning within the family, work, school or other
areas of everyday life, plus a wide range of other services including outreach, education, medical
referral, homeless veteran services, employment, VA benefit referral, and the brokering of non-VA
services.
Bereavement Counseling: Bereavement Counseling is available to all family members including
spouses, children, parents and siblings of service members who die while on active duty. This includes
federally activated members of the National Guard and reserve components. Bereavement services
may be accessed by calling (202) 461-6530.
For additional information, contact the nearest Vet Center or visit: http://www.vetcenter.va.gov/.

21.  Provide readjustment counseling in a caring manner to eligible veterans
and their families.
 Provide a broad range of counseling, outreach and referral services, to
help veterans make a satisfying post-war readjustment to civilian life.
Individual Counseling
Group Counseling
Sexual Trauma Counseling
Marital/Family Counseling
Bereavement Counseling
Drug and Alcohol Referral
Employment Guidance
Benefits Assistance/Referral
Liaison with VA & Community Resources (Vet Centers)

22.  When a soldier discloses a history of TBI, this is not confirmation
that one actually occurred…however
 The failure to report an event or seek medical help does not mean
that a TBI did not occur
 When symptom onset is delayed by days to weeks after a TBI, the
symptoms are most likely due to other causes than the TBI
 The symptoms associated with PTSD and Major Depression are
often delayed in onset
(Flynn, Fredrick)

23.  As the soldier begins to return to a functional or routine
lifestyle, a physical or emotional stressor may cause re-
occurrence of the symptoms
 It is important to remember that soldiers are not defined by
their TBI, PTSD, or mental illness.
 Often it is necessary to involve the spouse, significant others,
and in some cases the children, in the educational and healing
process of the soldier
(Flynn, Fredrick)

24.  Soldiers need time to tell their story and receive the
comprehensive evaluation that they deserve – this can not be
accomplished in a understaffed setting or a clinic with
inadequately trained staff
 It is important for providers to be competent when
implementing services; improper interventions can present a
delay in an individual’s progress. Sometimes providers do
more harm by the treatment they prescribe
(Flynn, Fredrick)

25. Affairs, Department of Veterans. (2012, April 05). History-VA History. Retrieved January 24, 2013, from US Department of
Veterans Affairs: www.va.gov/about_va/vahistory.asp
American Journal of Psychiatry. (2011). Pre-Deployment Mental Health Screening of Soldiers reduces Combat Stress.
American Journal of Psychiatry , 21 (4), 7.
American Medical Network. (n.d.). Major Depressive Episode. Retrieved January 24, 2013, from American Medical Network:
www.health.am
American Psychiatric Association. (2000). Diagnostic and Statistical manual of mental disorders: DSM-IV-IV (4th ed.).
Arlington, VA, USA.
Department of Veterans Affairs. (n.d.). Understanding Post Traumatic Stress Disorder. Retrieved January 20, 2013, from
hhtp://www.ptsd.va.gov/public/understanding_ptsd/booklet.pdf
Flynn, Fredrick. Lessons Learned in the Care of Our Wounded Warriors.Madigan Army Medical Center, TBI Program.
Geisinger. (n.d.). Combat Stess Injuries. Retrieved January 22, 2013, from Center for Health Research: www.geisinger.org
Karmey, B. R.-O. (2008). Invisible Wounds Predicting the Immediate and Long Term Consequences of Mental Health Problems in
Veterans of Operation Enduring Freedom and Opearation Iraq Freedom. Rand Corporation .

26. Lawhorne, C. a. Combat-Related Traumatic Brain Injury and PTSD: A Resource and Recovery Guide. Lanham, Maryland, USA:
Government Insitute.
LH, T. T. (2008). Invisible Wounds of War. Santa Monica, California, USA: Rand Corporation.
Mettler, M. a. (2011). Healthwise for Life. Boise, Idaho, USA: Healthwise for Life.
National Association of Social Workers. (n.d.). Social Work and Veterans. Retrieved January 09, 2013, from National Association of
Social Workers: Psych Central Staff. (2012, July 09). Major Depressive Episode Symptoms. (P. Central, Producer) Retrieved January 20,
2013, from Psych Central: www.psychcentral.com
National Center for PTSD (2010) .Returning from War: A Guide for Families of Military Members. Department of Veterans Affairs.
Retrieved January 22, 2013, from http://www.ptsd.va.gov/pdf/familyguide.pdf.
Office of the Press Secretary(2012). Fact Sheet: President Obama Signs Executive Order to Improve Access to Mental Health Services
for Veterans, Service Members, and Military Families. Retrieved January 28, 2013, from www.whitehouse.gove/veterans.
Tanielian T, a. J. (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist
Recovery. 292.
Tull, M. (2009, July 08). An Overview of PTSD Symptoms. Retrieved January 22, 2013, from about.com: www.ptsd.about.com
U.S. Department of Defense. (n.d.). Department of Defense. Retrieved January 22, 2013, from US Department of Defense:
www.defense.gov