Post Traumatic Stress Disorder

Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD) Powerpoint Presentation

Guide To: Post Traumatic Stress Disorder

I've seen bodies ripped to pieces by bullets, blown into millions of scraps by bombs, and pierced by booby traps. I've smelled the stench of bodies burned. I've heard the air sound like it was boiling from rounds flying back and forth. I've lived an insanity others should never live..." -- Dennis Tenety, Fire in the Hole

What is it?

Post-Traumatic Stress Disorder (PTSD) has been around for a very long time. Military medicine had recognized this condition with a variety of labels. During the Civil War the condition was called "Soldier's Heart." By WWI, it was re-named "Shell Shock," and during WWII, "Battle Fatigue." Korean War veterans were diagnosed with "War Neurosis," and "Vietnam Syndrome" was the label for that generation of veterans. VA was service connecting former combatants with a "Nervous Condition" or some other type of disorder prior to the advent of PTSD.

Post-Traumatic Stress Disorder is a condition recognized by the American Psychiatric Association (APA). Criteria for diagnosing PTSD are published in the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM-IV). PTSD first appeared in this manual, published by the APA, in 1980 after significant research studies with Vietnam combat veterans.

PTSD may occur after a person has been exposed to a traumatic event in which the person experienced or witnessed an event that involved death, serious injury, or mass destruction. This could include events that occur in war, natural disasters, and acts of terrorism, crime or abuse. For veterans, in particular, stressful traumatic events include combat zones, peacekeeping missions, training accidents, disasters, medical emergencies, and assaults. These events cause the survivor to react with intense fear, helplessness, hopelessness and horror.

Symptoms of PTSD include, but are not limited to:

• Recurrent, intrusive, and distressing thoughts about the event
• Recurrent dreams, nightmares (sometimes called "night-terrors")about the event
• Flashbacks (a sense of reliving the event)
• Distress caused by reminders of the event (sights, sounds, smells)
• Alienation, isolation, and avoidance of people and places
• Emotional numbing
• No sense of future
• Survivor guilt (for having survived when others did not, or for behavior required for survival)
• Difficulty falling or staying asleep
• Anger and rage
• Difficulty concentrating or remembering
• Hyper-vigilant, or survivalist behavior
  Exaggerated startled response (usually to loud noises)

These symptoms may lead to substance abuse or other self-destructive addictive behavior.

Who Gets It?

Anyone can experience PTSD symptoms after being exposed to a traumatic event. A PTSD diagnosis is NOT a sign of weakness or malingering, but rather is a normal reaction to a horrific situation. There is no way to predict who will and who will not develop PTSD symptoms because it depends on how people perceive a situation, and what other experiences they have had in the past. Some people may be more affected than others based on their perceptions and learned views of the world. Current research shows that there may also be genetic or biological factors that influence how a person will react to extreme stress.

In the military, there are many dangers that service members are trained to deal with, and usually they are able to function during a traumatic time. However, when the war is over or the crisis resolved, and troops have deployed home, then psychiatric problems can begin to appear. It is not unusual for problems to appear months or years after the initial trauma. Sometimes, experiencing another stressful situation, like job or marital problems, or even military retirement brings on symptoms.

Often during deployments, the service members' families have had to get along without them, so when they come home, they often feel out of place, and not needed. Military reunions are glamorized in the media, and, although joyous, they can be very stressful. Families can also be affected by PTSD. Living with someone who has PTSD symptoms can be stressful. Many spouses of Vietnam veterans have reported feeling as if PTSD is contagious. Children will mimic the behaviors and attitudes of their parents. If PTSD symptoms have led to violence in the home, then another generation of PTSD sufferers has been created. Family counseling is always recommended when a person has been diagnosed with PTSD. If you are still on active duty, and experiencing domestic violence or child abuse, you should contact the Family Advocacy Program (FAP) for assistance or the Mental Health Clinic.

For many military women sexual harassment, assault, and rape are the cause of their PTSD. However, these incidents often go unreported because the women are usually of lower rank than their assailants, or are in their chain of command. If they report, they are at risk of being shunned, or losing their jobs. There are many other complicating factors that affect military women who have been raped, which are different from the civilian community. Military women are faced with issues of betrayal, role identification (Soldier/Victim) and loyalty to their service after being assaulted. This can be even more difficult if the rape occurred in a combat zone. The Navy operates the Sexual Assault Victim Intervention (SAVI) program.

Perpetrators may also experience PTSD symptoms after an incident because of their own behavior or past history.

What Can Be Done?

There is help available. Whether you were in the military many years ago, or if you are still in uniform, there are trained professionals who understand military trauma and PTSD treatment. VA has over 206 Vet Centers and Sexual Assault Treatment Programs nationwide. The Vet Centers were started for Vietnam veterans, but now offer services to veterans from WWII, Korea, Panama, Lebanon, Grenada, Persian Gulf, Haiti, Somalia, and Bosnia. You can contact your local VA hospital to find out what services are available closest to you, and if you are eligible. The Vet Centers offer group therapy, individual counseling, marriage and family counseling. VA also has inpatient PTSD programs, residential treatment, and day hospital programs. In addition, VA has special programs for substance abuse, homeless veterans, and women's coordinators for female veterans.

There are also many private clinicians or not-for-profit agencies that offer specialized treatment for PTSD similar to care provided by VA. There are clinicians -- psychiatrists, psychologists, and social workers -- that are Certified Trauma Specialists (CTS) who are very qualified to treat PTSD. Interview potential therapists to be sure you feel they can help you. Get recommendations from other people, and do not be afraid to "shop around."

If symptoms are particularly severe and persistent, medication might be necessary. A psychiatrist should be consulted. You should have a complete physical exam to be sure there are no other conditions that are contributing to the problem.

Twelve step programs, like Alcoholics Anonymous, can be helpful. These self-help groups offer emotional support. There are meetings held all over, and at various times of day. Many groups are specifically for active duty service members and veterans. These groups are confidential. Check your local phone book for chapters near you.

There are a variety of military and veteran groups and chat rooms on the Internet. You can access the VA http://www.va.gov for medical and benefits information.

"...the voice I learned to hear in the (Vet) Center whispers. It tells me that I am wrong. It tells me that the cruel equations of weight and temperature and humidity were more powerful than a 19 year old's image of self and Corps. It tells me with logic cool and clear that the memory that will never go away is undeserved punishment, and that in that hour of that day I did the best a man could do and should be proud." -- Ron Zaczek,"Farewell Darkness"

How To File a VA Claim

If your PTSD is related to your time in the service, then you might be eligible for a service-connected disability from VA. You should contact The American Legion to find out more about your military benefits, regardless if you got out of the service years ago or are currently in the process of transitioning. You will need your DD214, military records, personnel (201) file, and any proof of combat awards or other reports that document your trauma (reports of a plane crash, ship sinking, explosion, rape or assault, duty on a burn ward or in graves registration, or POW status). If available, your own diary or a witness statement from a friend, roommate or the clergy can be very effective as evidence. You may need to have a VA exam if you have not seen a doctor. This exam is free. There are Department Service Officers (DSO) in every state listed in your phone book who can assist you. You can contact The American Legion by calling toll free 1-800-433-3318.

If you are a combat veteran, and received any of the following individual decorations you can submit them as evidence of a stressful event:

• Air Force Cross
• Air Medal with "V" Device
• Army Commendation Medal with "V" Device
• Bronze Star with "V" Device
• Combat Action Ribbon (CAR)
• Combat Infantryman Badge (CIB)
• Combat Medical Badge
• Distinguished Flying Cross
• Distinguished Service Cross
• Joint Service Commendation Medal with "V" Device
• Medal of Honor
• Navy Commendation Medal with "V" Device
• Navy Cross
• Parachutist Badge with Bronze Service
• Prisoner of War Medal
• Purple Heart
• Silver Star

On June 18, 1999, VA published the final new rule amending the regulations concerning the type of evidence required to establish service connection for PTSD. The ruling states, "Where a veteran engaged in combat with the enemy, VA must accept as sufficient proof of service connection for a claimed disease or injury satisfactory lay or other evidence of service incurrence or aggravation of such disease or injury, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of the incurrence or aggravation of the claimed disease or injury." VA has amended 38 CFR 3.304 (f) to include that a combat veteran's testimony regarding the claimed stressor may be accepted as conclusive and no further development for corroborative evidence is required, provided that the testimony is "satisfactory" and consistent with the circumstances, conditions, or hardships of the veteran's service. Additionally, 38 CFR 3.304 (f) was amended to require that the medical evidence for diagnosing PTSD comply with the DSM-IV. These changes apply to all combat veterans who have filed a claim since March 7, 1997.

If you are the victim of an assault, rape, domestic violence, mugging, stalking, or hate crime, and never reported the crime, the following is alternative evidence you can use to support your claim:

• Private civilian records
• Treatment records for a physical injury for the assault, but not reported as such
• Civilian police reports
• Reports from Crisis Centers
• Testimonial statements from friends (civilian and military), family, co-workers, clergy
• Personal diary or journal
• Request for changes in military assignment
• Increase in sick call or leave slips
• Change in military performance evaluations
• Increased use of prescription and over-the-counter medications
• Substance abuse and/or other compulsive behavior
• Request for a pregnancy test
• Request for HIV test or counseling for sexually transmitted diseases
• Counseling statements in personnel file
• Breakup of marriage or relationship
• Reports to Child Protective Services (in cases of domestic violence)

If You Are Still On Active Duty, Report The Crime!

Understanding The VA Rating Schedule

If you are going to file a claim for VA Compensation for PTSD, you should understand the way the VA rating schedule works. PTSD (code 9411) is classified as a Chronic Adjustment Disorder in the Code of Federal Regulations (CFR) 38, section 4.130. If service connection is granted, you will be assigned a percentage of disability ranging from 0% to 100%. If you are already service connected for another condition, then your new rating will be combined, not added, with the previous rating. Additional compensation may be provided for dependents; so be prepared to submit marriage and birth certificates.

If you disagree with your rating you can appeal your case through the Board of Veterans Appeals and ultimately the United States Court of Appeals for Veterans Claims. You should do this in cooperation with your service officer as well.

CFR 38 General Rating Formula For Psychoneurotic Disorders

• 100% Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.
• 70% - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships.
• 50% - Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.
• 30% - Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)
• 10% - Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.
• 0% - A mental conditional has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.

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