Psychological Reactions to Combat; 12+ Years into the Long War

COL (Ret) Elspeth Cameron Ritchie, MD, MPH

Chief Clinical Officer

Department of Behavioral Health

Washington DC

Elspeth.Ritchie@dc.gov

Elspeth.Ritchie@us.army.mil

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OUTLINE

1. Background and History 2. 9/11 at the Pentagon3. Post-Traumatic Stress Disorder4. Suicide in the Army5. Complementary and Alternative

Medicine for PTSD1. Including dogs!

6. Veterans and the Public Mental Health System

7. Way Ahead

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A Brief History of Psychological Reactions to War

• World War I--“shell shock”, over evacuation led to chronic psychiatric conditions

• World War II--ineffective pre-screening, “battle fatigue”, lessons relearned, 3 hots and a cot

• The Korean War---initial high rates of psychiatric casualties, then dramatic decrease

Principles of “PIES” (proximity, immediacy, expectancy, simplicity)

• Vietnam– Drug and alcohol use, misconduct– Post Traumatic Stress Disorder identified later

• Desert Storm/Shield– “Persian Gulf illnesses”, medically unexplained physical

symptoms• Operations Other than War (OOTW)

– Combat and Operational Stress Control, routine front line mental health treatment

9/11 in Washington DC

• Beautiful clear fall day

• New York attack

• Pentagon burning

• Reports of bombs elsewhere

• Are We at War?

Combat Stress Control Principles Applied

• Proximity, Immediacy, Expectancy. Simplicity

• DiLorenzo Clinic at the Pentagon– Army, Air Force, Navy personnel operations for medical and

mental health services

• -Groups– People more open to talk in workplace or at ‘coffee rounds”

Development of A Sustained Response

• Family Assistance Center

• Operation Solace

The Pentagon Family Assistance Center

• Tended to families of all victims• The Sheraton in Crystal City

– Extended family, children – Most lived there for up to a month

• Services– Informational briefings– Red Cross– Department of Justice, FBI– Counseling– Childcare

• recreation

– Medical care– DNA collection

The Pentagon Memorial at the Dedication-

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Operation Enduring Freedom/Operation Iraqi Freedom/Operation New

Dawn• Numerous stressors

– Multiple and extended deployments– Battlefield stressors

• IEDs, ambushes, severe sleep deprivation, – Medical

• Severely wounded Soldiers, injured children, detainees

• Changing sense of mission

• Strong support of American people for Soldiers

• Major Focus of senior Army Staff

• Numerous new programs developed to support Soldiers and Families

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The Army since 9/11

• Volunteer Army– Know they are going to war– Seasoned, fatigued– Large Reserve Component– Reserve, National Guard

• Elevated suicide rate• Wounded Soldiers• Effects on Families

– Continuous deployments– Families of deceased– Families of wounded

• Difficult Economy– Recruiting now easier

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Range of Deployment-Related Stress Reactions

• Mild to moderate– Combat Stress and Operational Stress Reactions (Acute)

– Post-traumatic stress (PTS) or disorder (PTSD)

– Symptoms such as irritability, bad dreams, sleeplessness

– Family / Relationship / Behavioral difficulties

– Alcohol abuse

– “Compassion fatigue” or provider fatigue

– Suicidal behaviors

• Moderate to severe– Increased risk taking behavior leading to accidents

– Depression

– Alcohol dependence

– Completed suicides

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PTSD DSM IV Diagnostic Concept

• Traumatic experience leads to:• Threat of death/serious injury

• Intense fear, helplessness or horror

• Symptoms (3 main types)• Reexperiencing the trauma (flashbacks, intrusive thoughts)

• Numbing & avoidance (social isolation)

• Physiologic arousal (“fight or flight”)

• Which may cause impairment in• Social or occupational functioning

• Persistence of symptoms

mTBI may be associated with PTSD, especially in the context of Blast or other weapons injury

DSM 5 Definition of PTSD

• Removes Criterion A-2

• Additional criteria– Somatic reactions

– Sleep

– Depressive symptoms

– Anger and irritability

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Evidence Based Approaches for PTSD

• Psychotherapy– Cognitive behavioral therapy

• Cognitive processing therapy

– Prolonged exposure

• Pharmacotherapy– SSRIs

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New and Innovative Approaches

• Other Pharmacotherapies– 2nd Generation Antipsychotics

• Integrative therapies– Acupuncture

– Stellate ganglion block

– Yoga

– Canine therapy

– Technology• Virtual reality

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Suicide Rates from 1990-2009

**Comparable civilian rates were only available from 1990-2006

Army rate projected toExceed U.S. population rate**

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1st Qtr

DoD Suicide Deaths/Rates Branch CY 2001-2010

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Risk Factors for Suicide in Army Personnel

• Major Psychiatric Illness Not a Significant Contributor– Adjustment disorders, substance abuse common

• Relationships

• Legal/Occupational Problems

• Substance Abuse

• Pain/Disability

• Weapons– 70% with firearm

• Recent Trends– Older, higher rank, more females

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• The Department of Defense has mandated annual and post-deployment screening for PTSD and depression

– Post-deployment Health Assessment (PDHA): Conducted within 30 days of service members returning from deployment (begun 1998, s/p first Gulf War)

– Post-deployment Health Re-assessment (PDHRA): Conducted within 3-6 months for service members returning from deployment (began 2005 in Army)

– Periodic Health Assessment (PHA): Conducted annually (2009)

• Screening is based on an interview with a behavioral health care provider using a standardized interview guide. Service members at risk will received immediate intervention or a mental health referral.

Screening and Surveillance Annual and Post Deployment Screens

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Screening and Surveillance The DoD Suicide Event Report

• The Department of Defense implemented the DoD Suicide Event Report (DoDSER) based on the Army Suicide Event Report (ASER), which was validated by the U.S. Army Medical Research and Materiel Command.

• DoDSERs are submitted for suicide behaviors that result in death, hospitalization or evacuation from theater.

• Data collected from standardized records (e.g., medical records, CID).• Army DoDSERs due w/in 60–days.• Objective, detailed, and standardized informationcollected: • Comprehensive data (method, location,

fatality)– Extensive risk factor data

• Dispositional or personal• Historical or developmental• Contextual or situational• Clinical or symptom factors

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Past Suicide Mitigation Approaches

• Analysis of Incident Suicides– DOD Suicide Event Report (DODSER)– Epidemiologic Consultations (EPICONS)

• Clinical interventions to identify and treat high risk individuals• Training Soldiers, Leaders and Family Members to recognize and

respond– ASSIST– ACE– Battlemind– Beyond the Front– Stand-Down Training

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Suicide Risk Assessment

Behavioral health care providers and key unit members play an active role in the management and treatment of suicidal Soldiers.

• Improve suicide assessment and evaluation (primary care, behavioral health clinic, VA).

– Establish best clinical practices and standards of care– Train behavioral health and medical care providers at all levels– Conduct routine reviews and audits to ensure compliance

• Improve engagement and retention in behavioral health care employing motivational interviewing techniques.

• Involve close family members and friends where ever possible.

• Inform and educate unit leaders as appropriate.

• Enhanced focus on postvention efforts (maintain vigilance post crisis), including cases of completed suicides.

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Evidence-Based Treatments

Adapt evidence-based treatments for suicidality among Soldiers.

• Two generally accepted psychotherapeutic approaches for treating suicidal patients:

– Cognitive behavioral therapy (based on social learning theory that focuses on changing distorted beliefs and cognitions about self and the world).

– Dialectical behavioral therapy (a cognitive behavioral approach that includes social skills and problem solving).

• Treat the underlying behavioral health disorder.

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Population-Based Strategies for Suicide Mitigation

• The best evidence-based suicide mitigation strategies are optimal identification of high-risk groups and treatment of suicidal individuals

• “Gatekeeper” strategies, which identify high risk individuals, may decrease suicides if identification leads to appropriate clinical management or reduction of stress

• Recent literature suggests interventions which decrease risk-factors in the population may impact suicide rates

• Current Army suicide mitigation programs focus on identification/treatment of high risk individuals, not groups.

• Incorporating strategies to mitigate risk-factors in the general Army population and among specific high risk groups may decrease risk for suicide in the population

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Causal Factors for Violence Among Soldiers

•Multiple individual, unit, and community factors appear to have converged to shift the population risk to the right

Average Risk Higher Risk

Very High Risk

Lower Risk

Very Low Risk

Number / Severity of Risk Factors

Individual, Unit, and Environment Factors

Facts

Individual• Criminality/Misconduct• Alcohol / Drugs• BH Issues (untreated/under-treated)

Unit• Turnover• Leadership (Stigma)• Training / Skills

Environment• Turbulence• Family Stress / Deployment• Community• Stigma

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Strategies to Decrease Violence• While it is important to identify and help individual Soldiers, the biggest impact will come from programs that shift the overall population risk back to the left

• Effective medical treatment can prevent individuals from increasing in risk or decrease their risk, but it cannot shift overall population risk very much

Army Campaign Plan: • Health Promotion, Risk Reduction, and Suicide Prevention• Increase Resiliency• Decrease Alcohol/Drug Abuse• Decrease Untreated/Undertreated BH• Decrease Stigma to Seeking Care• Decrease Relationship/Family Problems• Decrease Legal/Financial Issues

Installation:• Reintegration (Plus)

Mobile Behavioral Health Teams

Mental Toughness Training Resiliency Training Military Family Life Consultants Decompression Reintegration Warrior Adventure Quest

• Consistent Stigma Reduction themes

Average Risk Higher Risk

Very High Risk

Lower Risk

Very Low Risk

Number / Severity of Risk Factors

Population Interventions

Selected Dog ProgramsSupplement Traditional Rehabilitation/Therapy Programs

• Animal Assisted Activities• Animal Assisted Therapy• Specialized Facility Canines • Military Therapy Dogs

– Combat Stress Units

• Walter Reed • Warrior Transition Battalion Work

and Education Programs– Service dog training

• Paws for Purple Hearts

– Dog behavior/obedience and care training• Washington Humane Society

Canine Assisted Therapy and Army MedicineAMEDD Journal April to June 2012

How training service dogs addresses PTSD symptoms

PTSD Symptom Clusters

• Re-experiencing (B)

• Avoidance and Numbing (C)

• Increased Arousal (D)

Re-experiencing symptoms

*Grounding in the here and now*

• Train dog to have positive associations w/noises etc.

• Dogs have the ability to redirect through touch

• Changing the context; “I didn’t have a dog in Iraq”

• Lower anxiety when triggered -

Avoidance and numbing symptoms

Avoidance

• Need to socialize service dogs in the community

• Dogs serve as social lubricants. Isolation is not an option.

• Dogs require a daily schedule, a reason to wake up

• Participate in a meaningful activity, pos. sense of purpose

Numbing

• Need to use positive emotions to reinforce behaviors

• Fake it until you make it

• Mindfulness, living in the moment, affective domain

• Learning effective communication skills, assertiveness

Symptoms of increased arousal

• Concentrate on dog’s training, not self survival

• Practice emotional regulation w/ commands & praise

• Sleep comfort

• Opportunity to practice patience experientially

• Learn to synchronize with low aroused dogs

Training also impacts behaviors/symptoms that are common for Warriors but may not be part of

diagnostic criteria.

•Parenting skills

•Pain management

•Trust issues

•Grief and loss issues

The Public Mental Health System and Veterans

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“State Example” Washington DC

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• A Tale of Two Cities– Home to Very High Income and Very Low Income– Very Transient residents and multi-generational families

• “City-State” - Collapsed Political Structure– State and local functions; Mayor is Governor, City Council is State

Legislature

• Federal and Local Governments Co-Exist– Relatively stable economy– Small tax base (federal buildings, universities, hospitals, nonprofit

organizations)

• Under the Thumb of Congress– No vote in Congress, no 10th amendment protection– No legislative or budget autonomy– DC National Guard only activated by the President

• Geographically Condensed– All urban, height restrictions on buildings– 19 hospitals, 19 nursing homes, but no state prison

WASHINGTON, DCunique characteristics

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• Both home-grown and transient consumers

• Consumers come to DC for a variety of reasons:

– Some believe there are lots of jobs– Some believe there are better services– It’s easy to establish residency– “Right to shelter” - access to housing for

the homeless– “Someone put me on the bus to come

here”– Anger at government– Perceived access to the government– Monuments and free museums– In love with the First Lady

Washington, DCa magnet

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Homeless Veterans

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Veterans are 12% of the adult homeless in Wash DC2/3rds are chronically homeless30% have histories of substance abuse28% mental health conditions

Relationship Between DBH, the VA and the Military

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Overall themes

• Disconnects between Department of Veterans Affairs system, military, academics and public mental health system

– At least in Washington DC– Military residents rotate through CPEP (the Psych ER for DC)– Residents from academic institutions rotate through VA

• Disconnects between programs and psychiatric societies and state mental system

• SAMHSA Policy Academy attempting to improve– Economic security– Health care– Homelessness– Education– Criminal justice

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VA in Washington DC

• Hospital in Wash DC serves National Capital Region (NCR)– Homeless outreach

– Supported employment

• Various residential/nursing facilities outside region

• “Central” VA in downtown DC

• Vet Centers

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Military in and around Wash DCWalter Reed Army Medical Center—closed

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Walter Reed National Military Center—in Bethesda

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Pentagon

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Other Military Facilities in the NCR• Andrews Joint Base

• Bolling Joint Base

• Ft Belvoir with new community hospital

• Quantico Marine Base

• Ft Meade

• Defense Center of Excellence

• National Intrepid Center of Excellence

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Current Efforts in Collaboration• Getting patients into systems of care and supported

employment

• Combined homeless outreach meetings

• Asking question at Access Help Line “Are you a veteran?”

• Office of the Attorney General teaching VA on commitments, involuntary hospitalization, etc.

• Discussing with psychiatric societies

• Training police on working with veterans

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Veterans Courts

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80 veterans courts

Schools and Veterans

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Increasing number of Veterans organizations in schools

Future efforts• Greater interaction of VA, military, public mental health,

academic medicine

• More organized community supports for returning veterans

• More integrations for return home efforts

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Questions/DiscussionElspeth.Ritchie@us.army.mil

Elspeth.Ritchie@dc.gov

Combat and Operational Behavioral Healthwww.bordeninstitute.army.mil