Healing Combat Trauma

Combat Veterans, PTSD and Domestic Violence - A Sometimes Deadly Combination

Domestic Violence a Growing Problem for Veterans

“The increasing number of veterans with posttraumatic stress disorder [PTSD] raises the risk of domestic violence and its consequences on families and children in communities across the United States,” says Monica Matthieu, Ph.D., an expert on veteran mental health and an assistant professor of social work at Washington University in St. Louis. “Treatments for domestic violence are very different than those for PTSD. The Department of Veterans Affairs [VA] has mental health services and treatments for PTSD, yet these services need to be combined with the specialized domestic violence intervention programs offered by community agencies for those veterans engaging in battering behavior against intimate partners and families.”

Matthieu and Peter Hovmand, Ph.D., a domestic violence expert and an assistant professor of social work at Washington University, are merging their research interests and working to design community prevention strategies to address this emerging public health problem.

“The increasing prevalence of traumatic brain injury and substance use disorders along with PTSD among veterans poses some unique challenges to existing community responses to domestic violence,” says Hovmand. “Community responses to domestic violence must be adapted to respond to the increasing number of veterans with PTSD. This includes veterans with young families and older veterans with chronic mental health issues.”

VA research shows that male veterans with PTSD are two to three times more likely than veterans without PTSD to engage in intimate partner violence and more likely to be involved in the legal system.

— Source: Washington University in St. Louis

Projects Target PTSD-Related Relationship Aggression

"Living with posttraumatic stress disorder (PTSD) can strain any relationship—sometimes to the point of violence against a loved one. University of Arkansas psychologist Matthew T. Feldner, Ph.D., is part of two national research projects aimed at preventing relationship aggression in couples coping with PTSD and treating this type of aggression when it has already developed.

“The main aims of these projects are to reduce the number of new cases of interpersonal violence and reduce the number of cases already existing,” Feldner says. “We teach couples skills for better relationship behaviors, such as how to communicate better and how to manage anger.”

All people receiving these interventions will be closely monitored and referred for more intensive individual therapy should the need arise. Rather than going back to focus on the roots of the PTSD, Feldner says the couples in these interventions “will focus on the here and now of how the PTSD is affecting their relationship.” While teaching couples about the features of PTSD and improving their relationships, the group treatment can also serve as a gateway to further treatment for PTSD and other services.

If these interventions succeed in preventing or treating relationship aggression, Feldner says that these would be groundbreaking, landmark projects. “Ultimately, we are hoping we can conduct these interventions in such a way that they could be useful for the VA and could be extended to community populations as well, for situations that are not specifically military,” Feldner says."

— Source: University of Arkansas, Fayetteville

Getting Stuck to Get Unstuck: Army Studies Acupuncture for PTSD

An article from March 6, 2008 talks about the "Army PTSD Study on Track to Present Findings This Year."

Findings from a study on the effectiveness of acupuncture as a treatment for PTSD among military personnel may be reported later this year, according to research officials at the US Army’s prestigious Walter Reed Medical Center in Washington, DC.

According to the government web site www.clinicaltrials.gov initial report on the study, untreated PTSD “leads to decreased force readiness and increased health care utilization. Yet, service members with the disorder may be resistant to traditional treatments or find them undesirable because of side-effects, stigma, and long-term commitment.

“Acupuncture, which has few known side effects, holds promise as an effective treatment option for PTSD. Acupuncture has been shown to improve well-being and has been successfully used to treat stress, anxiety and pain conditions.”

Col. Charles C. Engel , principal investigator of the project, reports that data collection and primary statistical analysis have been completed and secondary analysis is currently underway. He says that the project intends to report data at upcoming professional conferences. These include the Force Health Protection conference in Albuquerque and the International Society for Trauma Stress Studies (ISTSS) in Chicago.

According to the web site, the project was intended to enroll up to 75 subjects, all active duty personnel. Researchers were to gauge the subjects’ PTSD status and response to treatment with the PTSD Checklist during a 12-week, randomized, waitlist-controlled trial. Participants were to receive an eight-session course of acupuncture treatment, and were to be evaluated throughout the study by way of clinical assessments and an independent assessing acupuncturist.

According to the study staff, all subjects were to receive a standardized protocol, based on Chinese medicine principles, for “clearing and calming” during the first four treatment sessions. During the fifth through eighth sessions, individualized treatments were to be given according to Chinese medicine diagnosis. All acupuncture services were to be performed by licensed acupuncturists who were graduates of the TAI Sophia Institute located in nearby Laurel, Maryland.

Marjorie Shovlin, a licensed acupuncturist in Washington, DC, was one of the acupuncturists providing treatment during the 18-month study period. She gave a presentation on the study methods and goals at the 18th annual NADA conference in May of last year.

Heart Un-Healthy: Study Shows PTSD Bad for Combat Veterans' Hearts

A Reuters story on Wednesday, citing a study in the July/August issue of Psychosomatic Medicine, raised PTSD as a risk factor for cardiac disease.   (That story is linked here.)

The study was done with Vietnam veterans, and it showed that once other factors were accounted for, PTSD caused twice as many study deaths from heart disease as researchers  expected.  The upshot of the study is that veterans with PTSD should try to overcome their PTSD as early as possible, through counseling and whatever other means prove effective (that wasn't really part of the study), because otherwise, PTSD continues to raise health risks decades after it first shows up, as it has with these Vietnam veterans, who are now in middle age.

PTSD: it's not good for your psyche, and it's not good for your body either.  The best thing you can do, if at all humanly possible, is find ways to move through it, so it harms you as little as possible. WAY easier said than done, we realize.  This study, however, is just another reminder -- not that we needed one -- that combat trauma/PTSD are not good for human beings to suffer: not at first, and not later.

But you know... if there were ever (another) good reason to check into something like "Mind Body Medicine," which we've talked about on the blog here recently, this is one of those opportunities.  Even hearing something like "PTSD [which you couldn't avoid; you were in combat] raises your risk of heart disease [which by implication you can't avoid, now that you involuntarily have PTSD] -- or the even cheerier "raises your risk of early death!" [lovely...] is plenty stressful.  And chronically elevated stress levels, don'tchaknow, aren't good for your heart (or your health in general.)  The good news is, there are things you can do for yourself, in addition to whatever your doctor prescribes, that are low-tech, sometimes even high-touch solutions, that can create more peace and calm in your life with which to face whatever crises you may have, including health ones.  Don't just let this news discourage you: let it prompt you to look into all of what your options are, for a healthier, and ideally longer life.

Murder, They Wrote: Statistics on Recent Combat Veterans and Homicides

The Spring/Summer 2008 issue of the American Psychological Associations' Section VII newsletter contains an interesting article on the "postdeployment homicide" statistics of combat veterans, that basically follows up on the study published in the New York Times in January of 2008, which we blogged about, here, while expanding on it and doing additional research.  The findings are quite worth reading.

(The study's authors are Kyle Burchett, David Ferreira and Glenn Sullivan, all from the Virginia Military Institute.)

They write:

A relationship between criminal behavior and Posttraumatic Stress Disorder in combat veterans has been hypothesized almost since the inclusion of PTSD in DSM-III (e.g. Wilson & Zigelbaum, 1983). Some researchers (e.g. Chemtob, Novaco, Hamada, Gross, & Smith, 1997) have posited that combat veterans may be more prone to entering a cognitive, behavioral, and physiological “survival mode” when confronted with threats in civilian environments, and may be more likely to respond to perceived threats with overwhelming aggression. Multiple studies, beginning with the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990), have shown dramatically higher rates of violence among combat veterans with PTSD compared to combat veterans without PTSD. Beckham and colleagues (Beckham, Feldman, Kirby, Hertzberg, & Moore, 1997), for example, found rates of 22 violent acts in the past year for help-seeking combat veterans with PTSD, versus 0.2 violent acts for combat veterans without PTSD. One implication of the extant research is that combat exposure per se does not appear to increase violence risk, although the severity and quality of an individual’s combat experiences (e.g. participation in atrocities) may effect postdeployment violent behavior insofar as these factors mediate he development of PTSD.

In January 2008 the New York Times published a list of 121 U.S. veterans who had been charged with homicide after returning from deployments in Iraq or Afghanistan (Sontag & Alvarez, 2008). This list, and the series of articles that followed it, provoked strong reactions from some veterans’ advocates. Many expressed concern that the nation’s most recent veterans were being portrayed as “ticking time bombs” who pose a risk to civilian society. The authors of the present article examined the 121 homicide cases presented in the Times’ study from a clinical perspective, with the intent of clarifying the association between combat exposure and postdeployment violence in the dataset.

In addition to the information on each case available on the Times’ website, we gathered corroborative data from independent media outlets -- most commonly online versions of newspapers serving the localities where the crimes had occurred. In more than 80% of the cases, we gathered significantly more information about the perpetrator than was available in the original Times article. In fewer than 10% of the cases, we were unable to find any additional information about the case and relied solely on the account provided by the Times.

All but one of the 121 offenders were male (99.2%). The majority of the offenders (53.7%) were between 18 and 24 years old, and 85% were under age 30. Of the cases in which race/ethnicity was known, Caucasians represented the majority (54.4%), followed by Hispanics (23.5%) and African-Americans (22.1%). The most represented service branches were Army (62.8%) and Marine Corps (30.6%). Over 90% of the charged offenders had served in Iraq, and 10.7% had served in Afghanistan; two of the 121 has served in both countries. Eleven offenders (9.1%) had deployed overseas twice during the current hostilities and five (4.1%) had deployed three times.

The homicide victims included strangers (35.2%), friends/acquaintances (23.0%), spouses/girlfriends (18.8%), children (8.3%), and Other/Unknown (14.7%). As in the general population, handguns were the most frequently employed murder weapon. The most common criminal charge was first-degree (i.e. willful and premeditated) murder (55.7%). At the time of this study (April 2008), nearly 30% of the cases were still pending (i.e. th veterans had been charged but not convicted). Seven of the veterans on the Times’ list (5.8%) had been acquitted of the homicide charges against them. None of the veterans received a Not Guilty by Reason of Insanity acquittal, although considerations related to combat-exposure and self-defense appear to have influenced prosecutors in at least one case (e.g. Matthew Sepi). More than one-fifth of the cases (20.5%) involved vehicular manslaughter or homicide. All but one of these vehicular cases were primarily substance-related – the prototypical homicide victim in these cases was the passenger in a vehicle driven by an intoxicated veteran.

We reviewed the compiled case material for evidence of combat exposure. In the vast majority of cases (92%), some evidence of combat exposure was provided in media accounts of the criminal proceedings. In 40% of the cases, combat exposure appeared certain: news reports included details regarding combat decorations, injuries sustained by the accused in battle, or testimony by commanding officers or multiple fellow unit members regarding IEDs, mortar attacks, clearing buildings, etc. In an additional 52% of the cases, combat exposure appeared probable: friends or family members of the accused veteran referred to combat exposure, the veteran’s unit was known to have engaged in combat during the veteran’s deployment, the area in which the veteran operated (e.g. Fallujah) was known for intense combat, etc.

We also evaluated the case files for evidence of psychiatric symptoms. Due to the nature of our data, we could not achieve anything resembling a formal diagnosis, but we reliably detected significant psychiatric symptoms related to PTSD, Antisocial Personality Disorder, Substance Abuse, or psychosis in 114 of the 121 cases (94.2%). Only four (3.5%) of the veterans demonstrated psychotic symptoms.

Significant symptoms related to PTSD were reported in 85 of the 121 cases we examined (70.2%). Family members, friends, judges, defense attorneys (and even prosecutors) referred to veterans’ nightmares, insomnia, intrusive thoughts, survivor guilt, hyperarousal, hypervigiliance, intense anger, depressed mood, and suicidal ideation. In general, we searched for evidence that the veteran had returned from combat somehow “changed” or disturbed. Approximately 34% of the veterans in this sample demonstrated PTSD symptoms only, an additional 19% exhibited PTSD and comorbid Substance Abuse, and almost 17% appeared to display symptoms of both PTSD and Antisocial Personality Disorder.

We identified 39 cases that appeared to involve significant symptoms associated with Antisocial Perrsonality Disorder (ASPD; 32.2%). Evidence for ASPD included committing violence for material gain (e.g. killing a spouse for the insurance money), killing during the commission of a felony (e.g. shooting a gas station attendant during the course of a robbery), evidence of substantial criminal activity prior to the instant offense, callous disregard for others, lack of remorse, etc. In general, we searched for evidence of pre-deployment antisocial behavior or instrumental (versus expressive) aggression. Almost 17% of the veterans in this sample (n=19) demonstrated ASPD symptoms only, an equal number exhibited comorbid ASPD and PTSD, and one displayed comorbid ASPD and Substance Abuse.

Finally, each judge rated the strength of the association between the violent act reported in each case and the combat experiences of the accused veteran. We used a seven-point scale in which “1” indicated no relationship and “7” indicated the strongest possible linkage (i.e. the crime would not have been committed “but for” the combat exposure). The mean rating for the entire sample was 5.2 (standard deviation = 1.9). Over 50% of the sample was rated “6” or higher and less than 5% received ratings of “0.” This approach requires further validation but a similar procedure may prove useful in assessing public attitudes toward hypothetical criminal cases in which combat-related PTSD is presented as a mitigating factor.

The prevalence of PTSD symptoms in this sample of combat veterans charged with homicide (70.2%) is much greater than has been found in other samples of returning veterans. This finding appears to be consistent with prior research that suggests that PTSD mediates the frequency and severity of violent behavior among combat veterans. However, it is also extremely important to note that a substantial minority of veterans in this sample (n=20; 16.5%) exhibited no symptoms of PTSD and appeared rather to demonstrate behaviors associated with habitual criminality. Criminal cases involving recent veterans, like those of Vietnam veterans before them, are likely to be marked by either legitimate claims of diminished culpability or cynical attempts to malinger the effects of trauma.

Social support is a strong protective factor against PTSD. To date, the over 1.4 million American soldiers that have been deployed to Iraq or Afghanistan have received generally positive reactions to their homecoming.

Unfortunately, this public support is not guaranteed and might be negatively affected by misinterpretation of news reports regarding violent combat veterans. Should public support for veterans deteriorate for any reason, an already immense public health problem could become even less manageable. It would be terrible for the public to conclude erroneously that returning veterans are inherently dangerous. This is why the Veterans of Foreign Wars and other veterans’ advocacy groups have taken pains to point out that the murders in the Times’ dataset yield an estimated 8.6/100,000 homicide rate in the veteran population, which they contrast to the 29.3/100,000 rate among American men aged 18 to 24.

References

Beckham, J.C., Feldman, M.E., Kirby, A.C., Hertzberg, M.A., & Moore, S.D. (1997). Interpersonal violence and its correlates in Vietnam veterans with chronic Posttraumatic Stress Disorder. Journal of Clinical Psychology , 53(8), 859-869.

Chemtob, C.M., Novaco, R.W., Hamada, R.S., Gross, D.M., & Smith, G. (1997). Cognitive-behavioral treatment for severe anger in post-traumatic stress disorder. Journal of Consulting and Clinical Psychology, 62, 827-832.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.

Sontag, D., & Alvarez, L. (2008). Across America, deadly echoes of foreign battles. Retrieved January 15, 2008, from http://www.nytimes.com/2008/01/13/us/13vets.html

Wilson, J.P., & Zigelbaum, S.D. (1983). The Vietnam veteran on trial: The relation of Post-Traumatic Stresss Disorder to criminal behavior. Behavioral Sciences and the Law, 1(3), 69-83.

Editor's note: Thanks to psychology graduate student, Melanie Goodman, for pointing out this article!

Mind Body Medicine: Healing the Wounds of War

When I started this blog over two years ago now, I was hoping that somehow James S. Gordon, M.D., and the Center for Mind-Body Medicine which he founded in Washington, DC, would somehow get involved in the prospect of bringing mind-body medicine to the troops.  Gordon is a Harvard-trained psychiatrist, with impeccable credentials, who has a lifetime interest in expanding patient care into new areas, particularly Complementary and Alternative Medicine (CAM), and mind-body medicine in particular.  (Mind-body medicine is a shorthand way of re-combining the two "halves" of medicine perhaps unjustly sundered in an arbitrary Cartesian mind-body split.  Much of Eastern thought, rather than Western, never saw them divided at all.)  In a previous lifetime, where I interviewed luminaries in the natural medicine field, Gordon was a favorite interviewee - smart, genial and with a very forward-thinking grasp of what mind-body medicine could accomplish.  Gordon, who was featured in the Bill Moyers series on PBS, Healing and the Mind, was a frequent lecturer at the Smithsonian Institution in Washington, DC, and for years had served as the head of the White House Commission on Complementary and Alternative Medicine.  He is also a Clinical Professor in the Departments of Psychiatry and Family Medicine at Georgetown University Medical School.

But more to our purposes, when war broke out in Kosovo, he and the Center for Mind-Body Medicine (CMBM) took their methods into the region, creating a program called "Healing the Wounds of War," to help war-torn schoolchildren and their caregivers manage the trauma they had undergone, through a sustained, devastating conflict.  What I was hoping -- and I kept checking the CMBM website periodically to find out -- was that they would leapfrog off their successes with PTSD in Bosnia and Kosovo, and Israel and the Middle East, and develop something geared to PTSD in servicemembers, and the conflicts in Afghanistan and Iraq.  For years, nothing was obvious (yet), but here's some of their success with children in Kosovo.  Notice what symptoms the program helped with, how impressive the statistics are, and make the conceptual leap to how this might help with combat veterans and/or their families:

The clinical efficacy of the CMBM program with traumatized children has been repeatedly demonstrated. In a pilot study in which high school teachers in the Suhareka region of Kosovo used the CMBM model, levels of posttraumatic stress disorder in high school students were reduced from an average of 88% to 38% in only six weeks (read the research, published in Journal of Traumatic Stress, April 2004, linked here). Participants have also reported the following documented effects of CMBM trainings, including: the alleviation of their own stress and trauma; decreases in anxiety and depression; increased optimism; decreased anger; and increased capacity to help others.

You can read more about the program's specific successes, here.  Or, you can read a general overview of the program and what's involved, here.  You can also read Dr. Gordon's bio, here.

Similarities Explored in How Cops and Troops Experience Trauma Cumulatively, Develop PTSD

Lately we've been taking a look at crucial concept in the linkage between combat trauma and PTSD -- the "dose-response relationship," which is apparently a more or less linear relationship between more combat trauma experienced and greater chance of developing PTSD.  (Earlier blog entries on that topic are linked here and here.)

On the Web, every once in a while you find a gem -- some good and useful material -- in its entirety, and one such "find" is Mary Elizabeth Claire's Ph.D. thesis at Drexel University, available online, called "The Relationship between Critical Incidents, Hostility, and PTSD Symptoms in Police Officers."  (The thesis is linked here.)

While we might prefer her thesis to be about combat veterans and PTSD (heh), the reality is, there's quite a bit of overlap or s