Ann Muczynski, LCSW Erie VA Medical Center

 Define PTSD as a psychiatric disorder  Outline PTSD symptomatology  Discuss potential behavioral impacts especially related to law enforcement/ criminal activity  Brief look at overlap with Traumatic Brain Injury (TBI)

 As defined by the American Psychiatric Association, PTSD is an anxiety disorder.  The essential feature is the development of characteristic symptoms following exposure to an extreme traumatic stressor in which the person experienced, witnessed, or was confronted with actual/threatened death or serious injury, or a threat to the physical integrity of self or others.  The response must involve fear, helplessness, or horror.

 Some examples of traumatic events we see often with Veterans may include military combat, terrorist attacks, violent personal assaults (including physical and sexual), torture, incarceration as a POW, providing medical care to the seriously injured, and morgue duties.  Witnessed events common with Veterans include witnessing the violent death/injury of others and witnessing dead bodies or body parts.

 PTSD symptomatology falls into 3 clusters that include re-experiencing, avoidant behavior, and increased arousal.  Re-experiencing symptomatology (one or more): ◦ Recurrent and intrusive recollections of the event ◦ Recurrent distressing dreams ◦ Acting/feeling as if the event were reoccurring (flashbacks) ◦ Psychological distress on exposure to reminders ◦ Physiological reactivity on exposure to reminders

 Avoidant behaviors (3 or more): ◦ Avoid thoughts, feelings, & conversations associated with the trauma ◦ Avoid activities, places, & people associated with the trauma ◦ Inability to recall aspects of the trauma ◦ Decreased interest in activities ◦ Feeling detached from others ◦ Restricted range of affect ◦ Sense of a foreshortened future

 Increased arousal (2 or more): ◦ Difficulty falling or staying asleep ◦ Irritability or outbursts of anger ◦ Difficulty concentrating ◦ Hypervigilance ◦ Exaggerated startle response  Do you see some of these behaviors in the Veterans you encounter in the criminal justice system?

 Common associated features can include: ◦ Depression ◦ Paranoia/mistrust ◦ Phobic avoidance ◦ Emotional disinhibition ◦ Self-destructive and impulsive behavior ◦ Dissociative symptoms ◦ Hopelessness ◦ Loss of previously sustained beliefs ◦ Hostility ◦ Impaired relationships ◦ Social withdrawal

 In reviewing the symptomatology and common associated features, it becomes readily apparent that PTSD can lead to potential legal problems.  Over a number of years working with Veterans suffering from PTSD, common legal problems patients encountered have included: ◦ Various MV violations: Speeding, reckless driving, accidents, road rage ◦ Hostility-related violations: A&B, domestic violence, resisting arrest, malicious wounding, attempted murder, murder, destruction of property

◦ Substance abuse-related violations: DUI, DIP, various drug-related violations ◦ Dissociative-related violation: Breaking & entering, trespassing, fighting ◦ Weapons-related violations

 Thinking about PTSD symptomatology as the root cause: ◦ Chronic insomnia/fatigue, decreased concentration, anxiety, recklessness, self-destructive behavior, and irritability/anger can all lead to MV violations. ◦ OEF/OIF Veterans: exposure to road side bombs and IEDs can generalize to unusual driving behaviors. ◦ Dissociation/flashbacks, emotional liability, paranoia, exaggerated startle/wired up, anger/irritability, and impaired interpersonal relationships can all lead to hostility-related violations.

◦ Substance abuse is unfortunately a very common way in which Veterans attempt to cope with the myriad of PTSD symptomatology, although a poor coping mechanism. Substance abuse can lead to many significant legal violations. ◦ Dissociation/flashbacks can often lead to violations of ‘being in the wrong place’ such as breaking and entering, unlawful entry, trespassing. ◦ PTSD usually impacts a Veteran’s view of the people and the world and often shakes the foundation of their belief systems…what is moral/ethical, right and wrong, and acceptable human behavior.

◦ Suspiciousness and paranoia, as well as reckless behavior, often lead to weapons-related violations. ◦ Survivor’s guilt, depression, emotional numbing, and ‘just not caring’ can be a recipe for illegal behavior, as well as suicide.

 In recent survey indicates that of those who have experienced a TBI, from 37 to 44% also have overlapping PTSD or depression.  Unfortunately, many of our returning Iraq/Afghanistan Veterans are experiencing these co-morbidities.  Due to overlapping symptoms, legal issues associated with PTSD are also relevant for TBI.

 PTSDTBIInsomnia Poor concentrationPoor ConcentrationDepressionAnxietyIrritability Emotional numbingFatigue Flashbacks/nightmaresHeadache HypervigilanceDizziness AvoidanceNoise/light Intolerance

Flashbacks nightmares hypervigilance avoidance Headaches dizziness fatigue noise/light sensitivity

 What about the overlap? Think about associated legal problems. Insomnia, poor concentration, irritability, anxiety/depression

◦ PTSD can be a devastating illness affecting thought, emotions, and behaviors. ◦ Veterans of the recent conflicts diagnosed with PTSD have a higher percentage of TBI, another debilitating disorder. ◦ Left untreated, Veterans suffering from PTSD have a greater probability of becoming involved in the legal system secondary to their symptomology. ◦ Fortunately, there are excellent treatments offered for this disorder if Veterans choose to engage.