iraq/afghanistan veterans: transition challenges and strategies marybeth a. o’sullivan, rn, bsn...

Iraq/Afghanistan Veterans: Iraq/Afghanistan Veterans: Transition Challenges and Transition Challenges and

StrategiesStrategies

Marybeth A. O’Sullivan, RN, Marybeth A. O’Sullivan, RN, BSNBSN

Veterans Upward BoundVeterans Upward BoundUniversity of University of

Massachusetts, BostonMassachusetts, Boston

July 25, 2008July 25, 2008

DisclaimerDisclaimer

The views expressed in this The views expressed in this presentation are those of the presentation are those of the author’s and do not necessarily author’s and do not necessarily reflect the official policy of the reflect the official policy of the Department of the Navy, Department of the Navy, Department of Defense, U.S. Department of Defense, U.S. Government or the University of Government or the University of Massachusetts.Massachusetts.

Workshop OverviewWorkshop Overview Discuss Iraq/Afghanistan veteran profile Discuss Iraq/Afghanistan veteran profile Review Historical Perspectives of PTSDReview Historical Perspectives of PTSD Discuss pathologies of combat:Discuss pathologies of combat:

- Incidence of Disorders- Incidence of Disorders

- Post Traumatic Stress Disorder (PTSD)- Post Traumatic Stress Disorder (PTSD)

- Mild Traumatic Brain Injury (mTBI)- Mild Traumatic Brain Injury (mTBI) Provide insight into dealing with academic Provide insight into dealing with academic

challenges facing the combat veteran challenges facing the combat veteran population.population.

Apply practical learning techniques and Apply practical learning techniques and solutions to common learning difficulties with solutions to common learning difficulties with combat veterans.combat veterans.

Iraq/Afghanistan Veteran Iraq/Afghanistan Veteran ProfileProfile

Gender: 85% male; 15%female.Gender: 85% male; 15%female. Military service: 40% of those deployed are Military service: 40% of those deployed are

National Guard/Reserve. National Guard/Reserve. Age: “older population”.Age: “older population”. Since October 2001 >1.74 million men and Since October 2001 >1.74 million men and

women deployed to Iraq and Afghanistan; women deployed to Iraq and Afghanistan; 280,000 re-deployed.280,000 re-deployed.

89% reported being ambushed or attacked.89% reported being ambushed or attacked. 93% reported being shot at.93% reported being shot at. 86% reported knowing someone who was 86% reported knowing someone who was

seriously injured or killed. seriously injured or killed. (NCPTSD 2008)(NCPTSD 2008)

Incidence of Incidence of PTSD in the Veteran PTSD in the Veteran

populationpopulation One in three Iraq veterans have suffered from One in three Iraq veterans have suffered from

Post Traumatic Stress Disorder, (PTSD) major Post Traumatic Stress Disorder, (PTSD) major depression or generalized anxiety.depression or generalized anxiety.

One in six Afghanistan veterans have suffered One in six Afghanistan veterans have suffered from PTSD, major depression or generalized from PTSD, major depression or generalized anxiety.anxiety.

Many unreported cases due to stigma Many unreported cases due to stigma perceived.perceived.

(NCPTSD 2006)(NCPTSD 2006)

Incidence of Incidence of PTSD in the Veteran PTSD in the Veteran

populationpopulation About 30% of men and women who have been in a About 30% of men and women who have been in a

war zone experience Post Traumatic Stress war zone experience Post Traumatic Stress Disorder.Disorder.

More than half of all male Vietnam veterans, and More than half of all male Vietnam veterans, and just under half of Vietnam female veterans have just under half of Vietnam female veterans have experienced clinically serious stress reaction experienced clinically serious stress reaction symptoms.symptoms.

Gulf War estimates are as high as 8%.Gulf War estimates are as high as 8%. General population: prevalence of PTSD is 4-6%; General population: prevalence of PTSD is 4-6%;

10% will have clinically diagnosable PTSD 10% will have clinically diagnosable PTSD sometime in their lives.sometime in their lives.

(NCPTSD 2006)(NCPTSD 2006)

Vietnam Veterans:Vietnam Veterans:A Resurgence of PTSDA Resurgence of PTSD

Since 9/11 59% increase in Vietnam Vets seeking Since 9/11 59% increase in Vietnam Vets seeking counselingcounseling

Two factors contributing to the spike:Two factors contributing to the spike: - continuous news coverage of the war on - continuous news coverage of the war on terrorism, “exposure by proxy”terrorism, “exposure by proxy” - retirement; veteran workaholics kept wartime - retirement; veteran workaholics kept wartime memories at baymemories at bay Effective intervention came late, and Effective intervention came late, and

inconsistent, if utilized at all inconsistent, if utilized at all Condition is episodic, individual subject to re-Condition is episodic, individual subject to re-

trauma,trauma, recurrence is unpredictablerecurrence is unpredictable

Contributing FactorsContributing Factors

Combat troops live 24/7 with terror for Combat troops live 24/7 with terror for undetermined length of deploymentundetermined length of deployment

Warfare specialty vs. “support” personnel, Warfare specialty vs. “support” personnel, allall troops are at risk troops are at risk

Rules of engagement different in urban Rules of engagement different in urban warfare/unable to identify enemy from warfare/unable to identify enemy from “innocent” bystanders“innocent” bystanders

Contributing FactorsContributing Factors

Deployment extensionsDeployment extensions Poor nourishment/water shortagePoor nourishment/water shortage Austere living conditionsAustere living conditions Issues from the home frontIssues from the home front Pre-existing mental health issues not Pre-existing mental health issues not

addressedaddressed Being shot at/shooting another Being shot at/shooting another

human beinghuman being

What isWhat is Post Traumatic Stress Post Traumatic Stress

Disorder?Disorder?

Post Traumatic Stress Disorder (PTSD) is Post Traumatic Stress Disorder (PTSD) is a debilitating condition that can occur a debilitating condition that can occur after exposure to a terrifying event or after exposure to a terrifying event or ordeal in which grave physical harm ordeal in which grave physical harm occurred or was threatened.occurred or was threatened.

““PTSD is the inability to flip the PTSD is the inability to flip the

switchswitch from combat soldier to every day from combat soldier to every day

citizen tocitizen to stop reliving the war at so high a stop reliving the war at so high a

frequencyfrequencythat it interferes with the ability to that it interferes with the ability to

function.”function.”

Betsy StreisandBetsy Streisand U.S. News & World Report, Oct. U.S. News & World Report, Oct.

20062006

PTSD:PTSD:Three Defining SymptomsThree Defining Symptoms

Spontaneous re-experiencing or reliving Spontaneous re-experiencing or reliving of event (flashbacks or hallucinations), of event (flashbacks or hallucinations), intrusive memories, nightmares intrusive memories, nightmares


Acts as though danger is still present: Acts as though danger is still present: Increased irritability, anger, difficulty Increased irritability, anger, difficulty sleeping, startles easy, hyper-arousal, sleeping, startles easy, hyper-arousal, misinterprets other’s intentions or actions misinterprets other’s intentions or actions as aggressive or dangerous, on the as aggressive or dangerous, on the lookout for danger, hyper-vigilancelookout for danger, hyper-vigilance


Avoidance behavior Avoidance behavior (activities/situations/people/ (activities/situations/people/ conversations avoided which are conversations avoided which are associated with the trauma), difficulty associated with the trauma), difficulty remembering important details of event, remembering important details of event, thinks he/she has no future or that his/her thinks he/she has no future or that his/her lifespan may be shortenedlifespan may be shortened

Signs and Symptoms of Signs and Symptoms of PTSDPTSD

Social impairment, detachment, loss of interestSocial impairment, detachment, loss of interest Memory deficits Memory deficits Concentration difficultyConcentration difficulty Numbing, referred to as “a freezing of the heart”Numbing, referred to as “a freezing of the heart” ““Hundred mile stare”Hundred mile stare” Anger outburstsAnger outbursts Feelings of intense guiltFeelings of intense guilt Recurrent dreams/nightmares/frightening Recurrent dreams/nightmares/frightening

thoughtsthoughts Sleep disordersSleep disorders

Physical Changes Found In Physical Changes Found In PTSDPTSD

Elevated levels of stress hormones such as Elevated levels of stress hormones such as noradrenalin and adrenalinenoradrenalin and adrenaline

Hyperactive sympathetic nervous systems; Hyperactive sympathetic nervous systems; exaggerated increases in heart rate and blood exaggerated increases in heart rate and blood pressure.pressure.

Reduction in the volume of the hippocampusReduction in the volume of the hippocampus

and amygdale region of the brain (emotions, and amygdale region of the brain (emotions, learning and memory).learning and memory).

Alteration in brain processes. Alteration in brain processes.

MRI View of MRI View of

Post Traumatic Stress Post Traumatic Stress DisorderDisorder

What is Traumatic Brain What is Traumatic Brain Injury (TBI)?Injury (TBI)?

Traumatic Brain Injury (TBI) is caused by a blow Traumatic Brain Injury (TBI) is caused by a blow or jolt to the head or a penetrating head injury or jolt to the head or a penetrating head injury that disrupts the function of the brain.that disrupts the function of the brain.

Caused by external physical force to the head Caused by external physical force to the head The severity of injury to the brain ranges from The severity of injury to the brain ranges from

mild and undetected, to severe and life mild and undetected, to severe and life threatening.threatening.

(DVBIC/CBHCO 2006) (DVBIC/CBHCO 2006)

Mild Traumatic Brain Mild Traumatic Brain InjuryInjury(mTBI)(mTBI)

A “concussion” which results from a blow to the A “concussion” which results from a blow to the head and causes the brain to strike the skullhead and causes the brain to strike the skull

No structural damage to the brainNo structural damage to the brain Occurs with or without loss of consciousnessOccurs with or without loss of consciousness Acceleration-deceleration injuryAcceleration-deceleration injury ““Shaken Soldier” SyndromeShaken Soldier” Syndrome Closed head injury may be missed when more Closed head injury may be missed when more

visible injuries require immediate attention.visible injuries require immediate attention. mTBI may go undetected for several years.mTBI may go undetected for several years. (DVBIC/CBHCO 2006) (DVBIC/CBHCO 2006)

Mild Traumatic Brain Mild Traumatic Brain InjuryInjurymTBImTBI

The “signature” injury/disability from current war.The “signature” injury/disability from current war. In the war zone, the injury is caused by the In the war zone, the injury is caused by the

sudden explosion from Improvised Explosive sudden explosion from Improvised Explosive Devices (IED), Rocket-Propelled Grenades (RPG), Devices (IED), Rocket-Propelled Grenades (RPG), land mines, roadside bombs.land mines, roadside bombs.

Many have been exposed to six and as many as 20 Many have been exposed to six and as many as 20 bomb blasts.bomb blasts.

15% of all wounded veterans have struggled with 15% of all wounded veterans have struggled with TBITBI

(DVBIC/CBHCO 2006)(DVBIC/CBHCO 2006)

Combat Mechanism of Combat Mechanism of InjuryInjurymTBImTBI

Iraq characterized by different kind of weaponry: Iraq characterized by different kind of weaponry: explosive munitions.explosive munitions.

Blasts from IEDs and RPGs cause “over Blasts from IEDs and RPGs cause “over pressurization waves” upon detonation. pressurization waves” upon detonation.

Understanding the complexity of this injury is critical Understanding the complexity of this injury is critical to helping our troops achieve optimal transition.to helping our troops achieve optimal transition.


Signs and Symptoms of Signs and Symptoms of mTBImTBI

Mild Traumatic Brain InjuryMild Traumatic Brain InjuryInsomnia/sleep problemsInsomnia/sleep problemsImpaired memoryImpaired memoryPoor concentration/attentionPoor concentration/attentionDepressionDepressionAnxietyAnxietyIrritability/mood changesIrritability/mood changesHeadacheHeadacheDizziness/ImbalanceDizziness/ImbalanceExcessive Fatigue: physical and mentalExcessive Fatigue: physical and mentalNoise/light intoleranceNoise/light intoleranceRinging in the ears (tinnitus)Ringing in the ears (tinnitus)Vision change: blurred or visionVision change: blurred or vision


mTBI vs. PTSD:mTBI vs. PTSD:Overlapping Signs and Overlapping Signs and

SymptomsSymptomsMild Traumatic Brain InjuryMild Traumatic Brain InjuryInsomnia/sleep problemsInsomnia/sleep problemsImpaired memoryImpaired memoryPoor concentration/attentionPoor concentration/attentionDepressionDepressionAnxietyAnxietyIrritability/mood changesIrritability/mood changesHeadacheHeadacheDizziness/ImbalanceDizziness/ImbalanceExcessive Fatigue: physical Excessive Fatigue: physical

and mentaland mentalNoise/light intoleranceNoise/light intoleranceRinging in the ears (tinnitus)Ringing in the ears (tinnitus)Vision change: blurred or Vision change: blurred or

doubledouble

Post Traumatic Stress DisorderPost Traumatic Stress DisorderInsomnia/sleep problemsInsomnia/sleep problemsImpaired Memory Impaired Memory Poor concentration/attentionPoor concentration/attentionDepressionDepressionAnxietyAnxietyIrritability/mood changesIrritability/mood changes

Stress symptomsStress symptomsEmotional numbing/100 mile Emotional numbing/100 mile

starestareAvoidanceAvoidance

* Diagnosis made through * Diagnosis made through troop history/witnesses'’ troop history/witnesses'’ accountaccount

Incidence of mTBI? Incidence of mTBI? Estimated that 1 in 5 returning troops may Estimated that 1 in 5 returning troops may

have brain injury; (1 in 10 sustained a have brain injury; (1 in 10 sustained a concussion or more in 2006)concussion or more in 2006)

20% of U.S. troops are coming home with S&S 20% of U.S. troops are coming home with S&S of mTBI, and are unawareof mTBI, and are unaware

Why the increase in incidence? Technological advances in battlefield gear, Technological advances in battlefield gear,

reduces deaths, increases severity of injuries to reduces deaths, increases severity of injuries to head and limbs.head and limbs.

Modern military medicine allows for life-saving Modern military medicine allows for life-saving trauma care in the war zone with immediate trauma care in the war zone with immediate transport to definitive care and rehabilitation.transport to definitive care and rehabilitation.

Obstacles to TreatmentObstacles to Treatmentof PTSD and mTBIof PTSD and mTBI

Over forty percent of those experiencing mental Over forty percent of those experiencing mental healthhealth

problems associated with combat refuse treatment problems associated with combat refuse treatment duedue

to fear that treatment will:to fear that treatment will: - hurt their image- hurt their image - ruin their military careers/promotions- ruin their military careers/promotions - cause negative perception from peers, family - cause negative perception from peers, family and leadershipand leadership - limit civilian career opportunities- limit civilian career opportunities

Cognitive Consequences of Cognitive Consequences of PTSD and mTBIPTSD and mTBI

Attention and concentration difficultyAttention and concentration difficulty Information processing (speed and efficiency Information processing (speed and efficiency

changes)changes) Learning, memory information retrieval Learning, memory information retrieval

difficultydifficulty Abstract reasoning sluggishAbstract reasoning sluggish Executive functions slowed Executive functions slowed - problem solving- problem solving - planning- planning - Insight/awareness - Insight/awareness - Sequencing- Sequencing

Additional Classroom Additional Classroom ChallengesChallenges

Additional Stressors (home, work, Additional Stressors (home, work, unit, etc.)unit, etc.)

Sleep disturbanceSleep disturbance Time ManagementTime Management Panic attacksPanic attacks

Learning Learning Accommodations Accommodations

Accommodations:Accommodations:Concentration/MemoryConcentration/Memory

Use white noise machine or Use white noise machine or environmental soother to cover noiseenvironmental soother to cover noise

Use a headset to listen to music without Use a headset to listen to music without words words if if music wouldn’t be a distractionmusic wouldn’t be a distraction

Increase natural lighting or increase full Increase natural lighting or increase full spectrum lightingspectrum lighting

Encourage use of cubicle area, sit away Encourage use of cubicle area, sit away from other students or other distractionsfrom other students or other distractions

(JAN (JAN

’07)’07)

Accommodations:Accommodations:Concentration/MemoryConcentration/Memory

Study in an environment that doesn’t have Study in an environment that doesn’t have a lot of visual or auditory distractionsa lot of visual or auditory distractions

Plan for uninterrupted reading/studying Plan for uninterrupted reading/studying timetime

Tape recorders or micro tape playersTape recorders or micro tape players Lap top computers for note taking, notes Lap top computers for note taking, notes

on discs, note takerson discs, note takers

(JAN (JAN ’07)’07)

Accommodation:Accommodation:Concentration/MemoryConcentration/Memory

FM technology/used with hearing aideFM technology/used with hearing aide Hard copies of notes provided from Hard copies of notes provided from

instructor or other student, outlinesinstructor or other student, outlines Printed materials, double spaced and with Printed materials, double spaced and with

larger print (printed materials can be larger print (printed materials can be scanned into the computer and screen scanned into the computer and screen reading software can be utilizedreading software can be utilized

Books on tape Books on tape

Accommodations:Accommodations:Test-takingTest-taking

Quiet environmentQuiet environment Extended timeExtended time Administer test on the computerAdminister test on the computer Oral ExaminationsOral Examinations Index cards, blank paper, and/or ruler Index cards, blank paper, and/or ruler

(help keep place on line)(help keep place on line)

(JAN (JAN ’07)’07)

Accommodations:Accommodations:Time Time

Management/Performing or Management/Performing or Completing TasksCompleting Tasks

Encourage daily TO-DO listsEncourage daily TO-DO lists Divide large assignments into smaller tasks Divide large assignments into smaller tasks

and steps/daily or weeklyand steps/daily or weekly Schedule weekly meetings with Retention Schedule weekly meetings with Retention

Advisor, tutor or mentor to determine if goals Advisor, tutor or mentor to determine if goals are being metare being met

Remind students of different deadlines via Remind students of different deadlines via memos or emailmemos or email

Use alarm watch or times as a reminder for Use alarm watch or times as a reminder for meetings and classesmeetings and classes

(JAN ’07)(JAN ’07)

Accommodations:Accommodations:Panic attacks/StressPanic attacks/Stress

Maintain privacyMaintain privacy Encourage a short breakEncourage a short break Go to a designated “safe” zone (maintain Go to a designated “safe” zone (maintain

accountability)accountability) Contact a support personContact a support person Encourage student to walk away from Encourage student to walk away from

frustrating situations and confrontationsfrustrating situations and confrontations Encourage use of relaxation techniques: bio-Encourage use of relaxation techniques: bio-

feedback, yogafeedback, yoga (NCPTSD (NCPTSD

2006)2006)

Accommodations: Accommodations: Panic Attacks/StressPanic Attacks/Stress

Provide positive reinforcementProvide positive reinforcement Boundary setting Boundary setting Establish liaison with local Vet Centers/Refer Establish liaison with local Vet Centers/Refer

when necessarywhen necessary Encourage use of campus gym or athletic Encourage use of campus gym or athletic

center for stress reliefcenter for stress relief Educate staff and faculty on PTSD and mTBIEducate staff and faculty on PTSD and mTBI Know campus policies for dealing with Know campus policies for dealing with

critical incident involving studentcritical incident involving student

(VUB/UMass)(VUB/UMass)

Any answers..?Any answers..?

Any questions?Any questions?

Thank you!Thank you!

iraq/afghanistan veterans: transition challenges and strategies marybeth a. o’sullivan, rn, bsn...

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