- It is my pleasure to introduce tonight's guests:
Dr. Tim Juergens and Michael Messina
who will be joining us here tonight.
Dr. Juergens is the Mental Health Service Chief
at the William S. Middleton Memorial Hospital
and Clinical Assistant Professor of Psychiatry
at the University of Wisconsin
School of Medicine and Public Health.
And Dr. Messina is the director
of the post-traumatic stress disorder clinical team
and psychology executive
at the William S. Middleton Memorial Hospital as well.
Please join me in welcoming Dr. Juergens and Dr. Messina.
(applause)
- Well, thank you very much.
And thank you for joining us here this evening
as we talk about post-traumatic stress disorder
and traumatic brain injury,
and particularly talk a little bit
about the veteran experience with that.
When we go through this tonight,
what we'd like to do is talk a little bit,
have Dr. Messina start talking about PTSD,
and then I'll go through traumatic brain injury
a little bit.
We'll talk about the combination of these,
which is not uncommon,
and also what that is like on a typical experience.
So that can be quite different for different people.
These are of note
of how there are very many different types of injuries.
These are two that have the potential to be ones
that are sometimes described as "invisible wounds,"
because people don't always have the outward, physical signs
that someone walking up to them immediately notices,
"Oh, there's something going on here."
So, without more awareness to these types of things,
there's certainly a risk that they get misinterpreted
or symptoms get misjudged by people who are encountering
or talking to people who have post-traumatic stress
and traumatic injury.
So with that, I'd like Dr. Messina to come up
and talk about PTSD.
- Well, thank you.
It's an honor to speak here tonight.
I'm gonna start off by just defining what trauma is,
because in the context of PTSD,
there's a very specific definition that we tend to use
when we talk about trauma.
And it's defined in the Diagnostic and Statistical Manual
for Medical Disorders.
This is basically the bible of mental health diagnosis
for mental health practitioners.
And trauma is defined as "exposure to actual
"or threatened death, serious injury, or sexual violence."
And there's common types of traumas
that we tend to see in our clinic.
Combat, physical or sexual assault,
life-threatening accidents, like a motor-vehicle accident,
natural disaster, or sudden loss of a loved one,
through accident or through violence.
Trauma was once thought to be a rare experience,
for people in the general population,
but when you look at more recent epidemiological studies,
trauma is actually a fairly common occurrence for people.
And it ranges from 60 to 90 percent
in the general population.
It really depends on the study that you look at,
the methodology in that study,
and how trauma is defined.
So the more broad trauma is defined,
the higher the rate of occurrence is usually reported
in that study.
There's common reactions to trauma
that happen for most people.
So if you've been through a traumatic experience,
most likely you'll have some of the reactions
that I'm gonna talk about this evening.
And what you'll see is on the left side of the screen here
are some of those common reactions.
And I'm calling them reactions,
because in the aftermath of a trauma,
for a period of time, that's what they are.
They're normal reactions to an abnormal event.
It's only over a longer period of time
that those become symptoms.
Re-experiencing symptoms are a way
in which somebody re-experiences their trauma.
So, in intrusive, distressing memories,
flashbacks or nightmares.
Avoidance is experienced
by trying to avoId trauma cues or triggers
that remind somebody of the traumatic event
or bring up some of those uncomfortable emotions.
Avoidance can also be experienced as emotional numbing,
so kind of shut down emotionally,
to blunt some of that emotional distress.
And then hyperarousal.
So this would be increased vigilance to your surroundings,
anger, sleep difficulties.
This is not an exhaustive list
of what those common reactions are,
but some of the hallmark symptoms
in reactions, in this case, after a trauma.
And those reactions actually have an adaptive purpose,
as it follows a trauma event.
So if you look at, on the left,
the re-experiencing symptoms,
what you'll see on the right side of the screen
are how those things may be adaptive
when you're still in an environment
where threat is likely.
So those re-experiencing symptoms help
with accessing memories that warn of danger,
which then prepares you better to respond to a threat.
With the avoidance symptoms,
you'll be avoiding trauma cues,
things that are warning of danger
and therefore more prepared to deal with threat.
And hyperarousal, like increased vigilance,
will help you scan your environment,
identify that threat quickly, and respond.
And anger, when you think of fight or flight,
anger is an experience that brings you closer
to that fight response,
where you'll then react to the threat.
So how does PTSD develop?
One thing that we think about
is what's called associative learning.
So if you look at the screen, for this soldier,
there's gonna be certain elements
of this soldier's environment
that are associated with fear and danger
and threat and possibly trauma.
And so this screen highlights some of those things.
Here we have children laughing,
the density of the housing,
debris, ethnic dress,
the dust in the air, sound of gravel,
the physical pain that the person carries with them,
the group of kids, military gear,
and the smell of trash.
So all of these things, while taken by themselves,
or in isolation, may not mean anything,
in a trauma environment, they're a signal for danger.
There are certain changes that happen,
in terms of how somebody thinks about the world around them,
themselves and other people.
And when those beliefs become fixed over time,
that's when PTSD can develop.
And here's some examples of things that people often think
after they've been through trauma.
These are things that veterans have told us
when we're treating them.
"IEDs can be planted anywhere."
So an IED is an improvised explosive device.
"I must have done something to ask for this."
"I trusted this man; it's my fault."
"He died on my watch."
"Markets and crowds are unsafe."
"You can never let your guard down."
So you can see how if this is something you're carrying
with you into civilian life,
these beliefs are not going to help you
necessarily cope effectively.
So when we talk about recovery,
there is a natural recovery that occurs
after a traumatic experience.
For a large portion of people that experience trauma,
this is what we see.
There's an onset of these reactions.
And then over time, without any intervention,
these symptoms, or reactions I should say,
will decrease, and the person will return to their baseline.
And they'll go back to life as it was before,
for the most part.
For some people though,
there's an interruption in that recovery process.
So that natural recovery is interfered with.
And there's a critical point at which that happens,
and certain things that we know
can contribute to which path a person goes down.
Some of those things
that impact the path are fixed,
maybe not so malleable kinds of characteristics
about the person or their environment.
So social support is important in how somebody recovers.
The more social support you have,
the more likely you are to recover.
Certain demographic characteristics,
such as gender and ethnicity can also play a part
in what recovery looks like
and how likely it is to happen.
More malleable types of psychological processes
that take place
but that contribute to the maintenance of symptoms
are avoidance and negative beliefs.
And I'm gonna talk about that more specifically
in a little while.
Avoidance...
you can see that all these things
associated with trauma or danger
in this environment can generalize from a trauma environment
for a veteran that's in a combat situation.
It extends from the combat environment
to their civilian life
And these things start to become cues
in their civilian life, that now trigger symptoms of PTSD.
And as you avoid these things, you isolate more,
and then you get caught in a vicious cycle,
in which that avoidance is reinforced,
because you stay away from the things that make you anxious.
And same with these unhelpful beliefs.
As you carry these beliefs with you,
like, "I missed that IED.
"My friend died; it's my fault."
That can translate to civilian life,
"I'm not competent. I can't make good decisions.
"I'm dangerous."
Or "I asked for this.
"I must've done something wrong.
"I'm no good. I'm trash.
"I don't deserve to be happy."
If those are the thoughts and beliefs you're taking forward
with you, recovery will be difficult.
So I'm gonna shift now to Dr. Juergens,
and he's gonna talk about traumatic brain injury.
So, Tim.
- Thanks.
So when we look at traumatic brain injury,
there's numerous definitions,
all actually fairly close to each other.
So the Department of Defense comments about
"induced structural injury or physiological disruption
of brain function, due to external force to the head."
And with that, someone also would have to have
some other symptom,
impacts on consciousness, on memory, on mental status,
neurologic deficits,
or other intracranial lesion-type findings.
And other big organizations,
the CDC and the World Health Organization
all have fairly similar definitions.
What does this look like across time?
So numbers from December 2014
show that all service looking over the last 14 years or so
was about 313,000 head injuries,
traumatic brain injuries.
Numbers from August of 2015 bring this slightly up
to like 333,000, though very similar percentages.
And the thing that you notice on here,
the big yellow on the pie,
is the mild traumatic brain injury section.
Following markedly below that are people who have moderate,
and then some unclassified,
and then, less frequently,
severe and penetrating head injuries.
Some with the way helmets are right now,
there is some improvement
that people have less penetration injuries.
Also, there are a number of injuries that occur
outside of the context of explosions and gunshots.
Looking over time, year to year,
so these are the pieces that add up
to get to that total
of 300-plus-thousand traumatic brain injuries reported,
you will notice a trend,
that things markedly seem to be going up in 2006, 2007.
Kind of have leveled off, and maybe even trending down now,
though still quite high compared to before.
Part of that can be related to experiences going on
and additionally there is some mandatory recognition
of these injuries,
cause regular screening.
And that started in the mid, 2006, 2007 range.
So with mandatory screening and checking more people,
more of these injuries were identified.
And they do occur,
this is another piece just showing the yellow line
being those mild injuries,
which are a predominant number
of the traumatic brain injury category.
We've said that a few times,
so very shortly, I'll tell you how does someone fall
into mild, moderate, or severe-type categories?
Additionally, this does impact all branches of the service.
When you actually go the gross numbers,
there are a larger number of people in the army
who are impacted by a traumatic brain injury,
though fairly proportional to numbers
and where people are having their exposures.
Sometimes people from different branches
have other interpretations of that.
That isn't accurate.
And this is actually a remarkable slide, I thought.
Looking, so over 13 years of data,
what are the causes of traumatic brain injury
that have been diagnosed at military treatment facilities?
So you see multiple different causes here,
from falls being a very big one...
to accidents going on,
where people are struck by objects or machinery,
and certainly battle injuries,
and guns and explosives going on.
And so when we look at the different categories
of mild, moderate, severe, and penetrating,
what essentially goes on is a person is classified
as having a mild traumatic brain injury
when they are screened,
if they go through,
there's a threshold, and if you go past that threshold,
you are no longer mild.
And if you don't pass it on any of these three measures,
you kind of stay in the mild category.
So have you had a loss of consciousness
longer than 30 minutes?
If it's less than 30, you're still in the mild category.
Have you had a Glascow Coma Scale,
after at least 30 minutes after you've had your injury
in the 13 to 15 range, which is much less impaired
than someone who's not responsive and scoring
in the three to five range?
And have you had amnesia related
to your traumatic head injury?
If you've had that, has it lasted less than 24 hours?
Because very frequently,
when someone's brain has been jarred and hit,
they sometimes have amnesia to stuff prior,
and very frequently for at least the coming hours
and sometimes longer afterwards.
So this is kind of a breakdown of the table
of how all the details go for mild, moderate, severe.
Mild is also what sometimes gets worded as a concussion.
In some terminologies it probably falls closest to that.
A big caveat with some of this scoring system,
though this is how a lot of the data is detailed and charted
and tracked over time,
this mild category that says you've had a particular injury,
and how long were you unconscious,
more of the traumatic brian injury literature
in the recent years is finding
that smaller...
that head injuries essentially add up over time.
So multiple small blows
that might not even lead to loss of consciousness
actually might be worse for you over time.
This is actually why in some of the football
and other sports things,
they're studying this to find is there a way
to put something in a helmet to track
and almost like a radiation thing,
say, "Now you've had enough cumulative trauma.
"You have to stop playing."
Is where that may eventually get.
And they have actually found that in boxing,
while they used to ask,
"How many times have you been knocked out?"
That's going to be predictive
of how this may impact you cognitively.
What they have found is that
time sparring in the ring is actually a better predictor.
So, you know,
in the ring is probably when you're getting hit,
not quite knocked out, but you're jarring your brain a lot.
Mechanisms of injury,
when someone has a traumatic brain injury,
there's biomechanical components to this,
and we'll show a few pictures looking at that.
So maybe I'll wait until we show those.
There's also cell injury,
cytotoxic injury related to a lot of the damage
that can happen,
and various things flowing in and out of your cells.
And also, you do have risk for secondary injuries.
So people get hit in the head, they have a bleed.
That bleed pushes other things out of the way.
People have brain swelling,
and also they have inflammatory processes
that go on, related to that.
So now a little bit on the biomechanical injuries.
So your brain is kind of sitting cradled,
ideally protected inside your skull here,
and what happens,
let's say someone's head ends up hitting something
that causes it to stop.
That part of the brain certainly gets smashed,
and there's a mechanical crushing of it
on the front of the head
But there's also an effect
at the opposite side of the brain,
in part from the pull and in part from this brain
that's kind of sitting in a fluid,
bobbing and then sloshing back
and hitting the back of the head.
So you get this,
what they call a coup and countrecoup reaction
on this type of head injury.
Additionally, as you notice
when you see some of the ridges here
in your brain and your skull,
there are certain areas that are kind of more prone,
because they can hit up against those ridges
when your brain suddenly, you know,
you're moving, your skull stops,
and your brain kind of keeps moving.
And so people's temporal lobes are vulnerable too
to these types of traumas.
You also see this kind of arrow on the top
that's kind of rotating around there.
So people who get torsional injuries
can cause much damage
that especially can happen a bit lower on your brain stem,
beyond, you know,
a lot of your higher executive thing happen up higher.
A lot of your more primitive and basic things are happening
in your lower brain,
and those are vulnerable.
So here, kind of looking,
and I show this because
when we talk about some of the most vulnerable places
that get impacted by traumatic brain injury,
it's of value to know what their primary functions are.
Again, when we talk about primary functions
of the frontal lobe or temporal lobe,
there's general areas, but your brain is fairly versatile,
so it's not always this exact area does this,
and this exact area does that.
There is a lot of overlap with that.
But you look at this and you see the frontal lobes,
the temporal lobes, the parietal lobes,
and the occipital lobes.
And then when you kind of slice that brain in half
and look at a cross-section,
you can see where the cerebellum is kind of the gray piece
on the bottom, and your limbic system is embedded in there.
Cerebellum has a lot to do with gait and balance,
so you mess that up on someone,
they will have difficulty with both of those.
This is a slice, a piece of the brain.
So you take this cross-section,
and then you cut a piece out.
And you see there are all kinds of tracks
that go along here.
So one could imagine
that as a person's brain gets twisted or sheared,
that you can rip through those.
And so when you look at a neuron,
you have dendrites,
where all kinds of information is coming through
to a cell body,
and then that's going down an axon
to transmit it to another nerve.
And these are very fragile pieces
that can be damaged quite easily.
Many times people notice things,
if they've had a car accident or hit their head,
they lose their sense of smell for a while.
And what's happening is your,
from your smell, these connect right up to your brain,
actually very closely here.
And those can get sheared or stretched.
And so whether they get stretched,
and they're damaged,
you briefly lose your smell.
Someone gets hit hard enough
that those tear completely,
you might not recover from that.
And someone would say,
"You know, I've never had my smell back after that injury."
And while we can tell that very easily
on a single sense like smell,
very likely, those similar type processes are happening
to how you problem solve,
how you plan, how you form words,
those kinds of things.
Another thing, very interesting
and more noted in recent years,
is the comparison of what a brain looks like
after repetitive trauma,
compared to what a brain
in a person with Alzheimer's looks like.
And, indeed, you do start with repetitive blunt force,
as well as blast waves
show some of these buildup of tau proteins,
which are similar to what can happen in Alzheimer's.
It's not an absolute pathway,
but it does not typically bode well
that someone would not want to have that.
Now we've talked a bit about the back and forth
when someone's head.
So an explosion occurs,
a person gets thrown from a vehicle,
their body suddenly stops.
they have the bottom piece, the tertiary blast injury.
They may have shrapnel, that either hits their helmet
and causes another similar type phenomenon
or that penetrates their helmet
and then actually causes blunt tissue damage to their brain.
And then we have this piece
that is fairly unique to military situations
and very few others,
but this blast injury.
So when someone is near an explosion,
the sound wave hits and pulsates through
and essentially is destructive to tissue.
And it's unclear quite how destructive that is.
There also is very clear things that when that hits,
blood vessels, even outside of the skull,
that it thrusts, increase pressures into the vessels
through your brain and other things.
So there is a lot of unclear damage that is happening
because of those types of injuries
or in explosions and exposures.
And those types of things would tend to be even more global
than other things, just by the nature
of a wave moving through your brain.
So we talked about those different lobes,
and so we'll just briefly mention
about your frontal and temporal lobes,
just because those are two that are fairly vulnerable
to blunt traumatic injury.
So frontal lobe's, we said, executive function
think higher cognitive skills, so memory, language,
judgement, impulse control, social behavior, personality.
Some people may remember if you've read about Phineas Gage,
the person on the railroad who had an injury go through.
He still seemed to function
but started to lose his impulse control,
didn't really do much planning,
and definitely changed his personality.
Your temporal lobe, again, these have a lot of overlap
with memory, emotions, smell, perception, music,
aggression falls into here,
as well as a lot of language tracks can go through there.
So a person who's had damage here might have difficulty
with various word finding, wtih forming various words,
even when they know what they wanna say.
This is a fairly busy slide,
and I just want to show this is a model
about the influences of neurobehavior outcome
after traumatic brain injury.
And while there's factors pre-injury, going into it,
I think the thing to focus on here
is that there are very clearly, after an injury,
there's cognitive issues going on,
there's emotional issues going on,
there's behavioral issues,
and physical disturbances happening.
And these happen through a whole spectrum of things,
from attention to memory
to how someone communicates with other people.
Emotionally, from anxiety to range.
Behaviorally, some people could be apathetic
and seem to almost not care about some things
that you think and maybe they used to care about
and be worried about.
They might not plan so well for their future,
and they also could have episodes
and issues with disinhibition and aggression.
Physically, pain, headaches,
visual symptoms are very common.
And I think while we use a lot of those words
and talk about attention and talk about memory
and executive function,
I think probably thinking more in terms
"What does this look like?"
And I thought it was well-worded to say
a memory deficit, you could say is trouble remembering,
or really clinically you see things.
Hey, she frequently misses appointments.
She's avoiding things. She's not responsible.
This might happen at school.
The place we have to be quite sensitive in our clinics.
Healthcare often falls on the consumer
to take the responsibility to do things.
So now this is a patient who's been scheduled
two, three times for appointments, hasn't shown up.
What happens in most clinics?
"They're not showing up.
"They're not interested in engaging.
"Let's move on."
Might even in some clinics, not our VA clinics, but others,
actually almost be banned from clinics,
that, you are no longer invited to receive services here.
So I think people have to be quite aware of what is going on
in these situations.
Often he says he'll do something
but doesn't get around to it.
And you can imagine the tension that creates
in relationships and work situations.
She talks about the same thing
or asks the same question over and over,
and I feel like I just answered that.
Attention deficits can look like trouble paying attention,
certainly, or oh he keeps changing the subject,
or there's a million things going on
and nothing ever gets done.
There's five different projects.
That can also happen outside of TBI context,
but, again, looking at changes
and how people have been is very important.
If this wasn't typical for this person and now it is.
And very much multi-tasking becomes markedly more difficult.
So if someone tries to do two things at once.
If you even when talking to someone, instead of saying,
"Would you like to,"
you know, people often ask questions that say,
"Do you want your appointment here?
"And also I wanna make sure you know about this with medications."
Like that might be too many things
for someone to take at one time.
You might have to do very linearly one piece,
answer it, move to the next piece.
In executive things, often I've heard laziness brought up,
someone doesn't follow through.
You know, so these start to be a reflection,
and viewed as these are character traits
of this person, rather than this is an impact from this...
unfortunate injury that's happened.
And when people start labeling...
uncooperative, stubborn,
sometimes that impacts how much people want to help
or step in to help people.
And unawareness, just on a similar type thing,
could say someone is insensitive.
A big thing that I see with couples especially,
is he doesn't seem to even care.
All these awful things are happening.
All this is falling apart.
And he seems to either be oblivious.
You ask him about it, he says everything's fine.
Another risk in our healthcare system,
where there's lots of demands,
Often when someone says they're fine,
many people take them at word,
because there's plenty of people saying they're not fine,
and they're kind of yelling that, so if someone says,
"Hey, I'm fine." You say, "That sounds good."
And I think we have to be very careful not to do that
in these types of situations.
So now looking,
we've talked, you know, Dr. Messina has talked
about post-traumatic stress and trauma,
and now we've talked a little
about traumatic brain injury,
you look at how these two may interact.
One, these two could happen
related to a simultaneous event in many cases,
such as an explosion.
Two, if someone has had a brain injury,
and their brain is impaired and in some ways
has a lower threshold to be able to tolerate stresses
and cope with things.
Now what happens when they have a traumatic experience?
Are they more likely to develop post-traumatic stress,
because maybe they are not going to be that group
that recovers and over time just gets better.
More likely to float in the chronic symptom things
if there's not intervention.
And a thing that is very concerning
and a worry I would have when I see this
is, boy, we've talked about all that brain impairment.
How on earth is someone with that going to cope
with post-traumatic stress?
How are they possibly going respond
and work with whatever treatments
we have about PTSD.
And indeed, when we look at some of the overlap
of these two conditions,
there are some decent brain imaging studies
that show large areas of overlap
in the prefrontal cortex,
in the amygdala, in the hippocampus, where you'd say
vulnerable to traumatic brain injury,
involved in post-traumatic stress.
These allow for certainly some concerns
that these would impact each other adversely.
And, indeed, when you even look at symptoms here,
there are some that stand more unique
to traumatic brain injury,
like headache, blurred vision,
and some that stand more on post-traumatic stress
regarding avoidance and re-experiencing,
but there are a huge consolation
of symptoms that people have and experience
that really could fall due to one or the other or both,
like insomnia, memory difficulties,
emotional instability, irritability.
So, standing completely one or completely the other,
you could have these.
Together, it very much complicates the treatment.
And, with that, we'll have Dr. Messina talk
a little bit about a little bit more of the comorbidities.
- So we just wanted to give you an idea
of the prevalence rates of PTSD
and also its comorbidity with traumatic brain injury.
So that's what this slide shows.
And you'll see for the general population,
the lifetime prevalence of PTSD is seven percent.
So that means that seven percent of people
may develop PTSD at some point in their lifetime.
And then when you look at veterans
from all eras of service, it goes up to 30 percent.
And then the prevalence rates
across the different eras of service,
like the Gulf War, is 10 percent,
or Operation Enduring Freedom, which is Afghanistan,
Operation Iraqi Freedom is 14 percent,
and then for Vietnam the prevalence rate is nine percent.
And I found one study.
It was actually hard to find this statistic,
but the comorbidity rate of PTSD
and traumatic brain injury is 44 percent,
at least for veterans in that particular era of service.
So a high rate of comorbidity there.
As Tim had mentioned,
you might wonder if somebody has a traumatic brain injury,
can they successfully receive treatment
for PTSD, given some of the cognitive limitations
that may come with having a TBI?
And there's research that clearly shows yes.
And, actually, people can have a very successful experience
receiving psychotherapy for PTSD.
This shows figures from two different studies
where the clinical sample was veterans from OEF and OIF
who had a range of TBI from the mild end of the spectrum
all the way to the severe end of the spectrum.
And you can see from pre- to post- treatment,
so the beginning of treatment to the end of treatment,
there is quite a significant decrease
in their PTSD symptoms.
And the PCL, which is the PTSD checklist,
is what was used to measure PTSD symptoms
from that pre- to post- assessment point.
So we just wanted to highlight that.
And these are two treatments
that are considered our gold standard treatments for PTSD:
prolonged exposure and cognitive processing therapy.
And some of the mechanisms of change
that I'm talking about tonight are actually
what are targeted in these particular interventions.
So, how do we address PTSD
and get people off that chronic path
that you saw earlier onto that path of recovery?
So, imagine a veteran with PTSD walks
into a busy grocery store.
And this is often a very challenging kind of exercise
for a veteran with this condition.
It triggers a lot of anxiety, a lot of hypervigilance,
so scanning and being on guard,
and a desire to escape that situation, to get away from it.
And what you see here,
represented on this curve, is avoidance.
So you walk into that busy store,
your guard goes up, your anxiety goes up,
and what do you want to do?
You want to get out of there.
And that's usually what happens when PTSD goes unchecked.
So the person leaves, and they feel better.
They feel a sense of relief,
because they've escaped that situation.
Certain thoughts that may be going through their mind
when that avoidance happens is,
"This is a dangerous situation.
"I've gotta get out of here.
"Something awful could happen."
And so you see the anxiety drop off dramatically
when that escape takes place, as that anxiety peaks.
So avoidance is a reinforcing thing.
And that is what gets a person caught up
in this very vicious cycle with their PTSD symptoms.
So, how do we change that?
One of the ways we do that is
through something called exposure.
This basically means confronting your fears
and doing it in a very structured way.
And we do this with a treatment called prolonged exposure.
And the idea here is that we stop avoidance,
and we have the person basically go back
into this environment
and, rather than avoid it,
stay in it long enough to get kind of a natural recovery
in their anxiety, in their distress.
So what happens is that anxiety peaks.
But rather than avoiding this time
and getting that immediate reinforcement from avoidance,
they stay there and hopefully learn something new
and acclimate to that environment.
And what happens is, in the absence of threat,
that anxiety naturally comes down.
And so what you think may change
as a result of that change
in your emotional experience over time, something like
"This situation wasn't as dangerous as it felt.
"I can tolerate my anxiety.
"I don't have to avoid to feel better."
And over time, as we repeat that exercise
over and over and over again,
what we get is not just a reduction of distress
in that particular situation, in that moment
but, over the course of repeating the exercise,
the anxiety peaks lower and goes down faster,
where eventually walking into a place
like a busy grocery store
is no longer so difficult or so threatening.
And I should say, in this treatment,
we do the same thing with the trauma memory.
So part of that is reviewing and retelling the memory
in a safe place and in a structured way
where you can confront those difficult emotions
and again see that a memory is different than that trauma,
and it does not have to mean
it's something you can't tolerate.
Over time, this is what you'll see
as you repeatedly review that memory.
The other part we want to address is how you think.
And we do this more directly
in the cognitive processing therapy that I mentioned.
It's how we think about the event, not the event itself,
that often causes the lasting distress.
So you'll see a situation here.
This is often a typical scenario for an OEF or OIF veteran,
where they're driving on the highway
and they see a piece of garbage on the side of the highway
and the immediate thought is, "It's happening again.
"I need to get out of here."
And the consequence is fear and anxiety,
swerving the car, speeding up,
and not wanting to be in that environment any longer.
This simplifies a process,
but the ultimate goal, through treatment,
is to change that thought process.
And that takes a lot of hard work
and a lot of steps in between here,
but you'll see that this situation looks very different
for the person later on as they address
and challenge those unhelpful thoughts.
So, here, same situation but the thought this time is,
"I'm not in Iraq. It's safe, and I'm home."
That thought and buying into that thought,
which is not easy,
changes the emotional experience and the behavior.
So here the consequence would be a calmer person,
being in control of the vehicle, decreased fear and anxiety.
So, we're going to now present a case
that represents what we've talked about
and addresses some of the challenges
when somebody's dealing with these issues.
So, the veteran we're going to describe is a male,
28-year-old Army OEF/OIF veteran.
So this is somebody that served two deployments,
one to Iraq, one to Afghanistan.
He's married and has a three-year-old son.
And his trauma was an IED blast,
and this blast actually killed several of his friends.
One of the individuals had a serious injury on the scene.
He tried to provide direct assistance
in a life-saving intervention,
and it failed, and the person died.
So that was the trauma that he came in with,
and a lot of the symptoms resulted from that.
I should also mention that this is somebody
that had a traumatic brain injury on the milder side
but was experiencing some symptoms from that as well.
- And now in his late 20s, returned home.
He's finding that he's having chronic headaches.
He had hoped that these would go away
but they seem to have persisted, maybe even gotten worse.
He's having trouble concentrating in school,
saying he's not able to finish his assignments,
and that when the teacher is talking
he can listen for about 10 minutes,
but after that he loses his focus.
Sometimes he's distracted,
and sometimes he just says he can't take it
and feels like maybe he shouldn't be there.
And then he's also really found
that he's having difficulty controlling his anger.
He said he's always been a strong guy
but not someone who would fly off the handle at people.
And now he's doing that all over the place.
He says that, when talking to him,
we do try to find
what are a person's goals?
What are they seeking to get to in their recovery?
And a few things that he noted were,
"I want to feel like I can live my life
"and not feel guilty about it.
"I don't want to live there,
"back in Iraq, Afghanistan, all the time.
"Also, I want to be closer to my wife and son."
He was particularly worried because he hadn't before,
and now he found himself once grabbing his son pretty hard
and thinking he might have really hurt him
and hadn't had thoughts of hitting him before
and actually had those thoughts and that really scared him.
He says, "I want to sleep all the way through the night.
"This has been an issue since I got back.
"And I want to finish school."
And, as you see with a lot of those things,
we, again, run into this marked overlap of symptoms,
where he can have...
finding himself in a classroom emotionally numb,
saying, "I can't stay engaged here."
Also having that, maybe related to his traumatic injury,
that his concentration is thwarted and blunted.
So, again, this is just a complicated picture to look at.
So now we'll talk a little about
where things go in his recovery process.
- So we try to take a patient-centered approach,
when it comes to recovery.
So, as Tim mentioned, asking about goals
and then trying to align what services we can offer,
either in the VA or what they seek out in the community,
to help with that recovery process.
So we've identified some things that are common for veterans
when they're seeking out help and engaged in recovery.
Some of these things are formal psychotherapy.
So for the veteran we're talking about,
he engaged in prolonged exposure
and had a successful outcome with that.
But it was important also to get his family involved.
And that's another thing that we've identified here.
That's really critical.
If you remember, social support is extremely important
in terms of how somebody fares
when it comes to coping with these kinds of things.
So, having his wife come in and meet with me
and educate her and him together about the treatment
and what this was gonna look like
and how they could support each other
as they went through this process was really critical.
And understanding the impact
on the whole family unit and dynamic at home
with the PTSD and the TBI
and how that kind of played out for them.
That helped us understand how to intervene.
Other sources of help and recovery can be medications.
Dr. Juergens is a psychiatrist,
so there's lots of medications
that are often prescribed to help with these symptoms.
Art therapy, and we're defining that very broadly here,
but that could be things
like photography, painting, or music.
A lot of our veterans are involved
in something called Guitars for Vets.
And so there's things like that that they can do.
Finding a sense of purpose is often really important.
So if you think about being a soldier in a combat situation,
you kind of have the ultimate sense of purpose
to protect your friends and to survive.
And coming home to civilian life,
sometimes it's hard to recalibrate what meaning is
and how to make a new sense of meaning in your life.
So, volunteer work may be a way to do that.
We have a lot of veterans volunteering at the VA hospital.
Another thing that's newer
and that veterans have really gravitated towards
was pets and animals.
Having pets that are companions,
some of them are even trained service animals
to help veterans with TBI and PTSD
to cope with certain symptoms
or certain triggers in their environment.
Wellness types of activities,
things we call complementary and alternative treatments,
like yoga, Tai Chi, and relaxation.
A lot of our veterans are not only engaged
in a more traditional psychotherapy
but they're doing these kinds of things too.
- Other things, particularly thinking
of traumatic brain injuries in mind,
making things in the environment linear, simpler,
having goals, feedback,
being much more deliberate about things
that maybe came somewhat automatically before.
And consistency is also a big piece of that.
People can do a lot better with routine,
when other things are more vulnerable to them.
Similar, there's numerous memory tools,
cueing mechanisms that can be taught, learned,
even used on phones,
to kind of enhance some of that experience.
And another big piece is family involvement.
This is in part for care of the particular veteran
that we have in our office,
because, really, this is a whole family unit.
This isn't an isolated being.
There are all kinds of people regularly interacting
with him or her.
And also because this does put tremendous strain on family.
So this is an experience that everyone feels,
the kids at home, the spouse at home.
These are very hard things to go through.
If someone is ill at home,
if there's a clear, short recovery path,
that is something most families can handle pretty well.
It becomes markedly more straining
when there's an unclear timeline,
there's unpredictable things that happen during the course,
and that is often the norm for traumatic brain injury
and many times with PTSD.
So, in conclusion, I think talking
that post-traumatic stress, post-traumatic stress disorder,
and traumatic brain injury are quite common
in many of our returning veterans
who are coming back from service.
And we have an obligation and duty
to do all that we can scientifically and service-wise,
I think, to try to help people recover
and reintegrate into their lives.
In combination with the symptoms have much overlap
and they also create many challenges
for veterans in recovery, as well as their families.
And finally, this recovery path is quite individual
and looks different for each person.
So while one person may find this really works for me,
what I think we really need to make sure is
that there's numerous things that a person can do,
and they find what best fits their path.
So, thank you very much.
- Thank you
(applause)