Beyond The Trauma:

Invisible Injuries of War

Andrea McSweeney

Edith Love

Rachel Powell

Quotable Quotes -- Eleanor Roosevelt on the Human Cost of War

:

"Dear Lord, Lest I continueMy

complacent wayHelp me to rememberSomehow out thereA man died for me today.As long as there be warI then mustAsk and answerAm 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

COMBAT RELATED STRESS

• 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).

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)

COMBAT STRESS INJURIES

COMBAT STRESS INJURIES

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)

Post Traumatic Stress Disorder (PTSD) 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)

Re-experiencing symptoms:

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).

Avoidance symptoms:

• 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

.

Hyper arousal symptoms:

• 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).

Traumatic Brain Injury (TBI )

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)

Guidelines For TBI Survivors Things to Avoid

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 zoneReturn to combat too soon…

May result in susceptibility to repeat concussion

May put the Soldier and fellow Soldiers at risk

(MACE)

Major Depressive EpisodeA 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: Over the past month have you been bothered by (if yes, please explain):

1. Little interest or pleasure in doing things?

2. Feeling down, depressed or hopeless?

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)

Major Depressive Disorder

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

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).

Treatment OptionsThe 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)

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)

Reactions to Combat Stress Injuries

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)

Military ResourcesOn 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)

Department of Defense

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).

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.

Department of Veterans’ Affairs (VA)

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).

Readjustment Counseling ServicesVA 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/.

Vet Center Services

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)

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.

Reflections

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)

Reflection

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)

Reflection 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)

References 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 .

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

one comes home from war unchanged…but with early screening and adequate access to counseling, the psychological and neurological effects of combat are treatable.

FINAL THOUGHTS