- 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)