1. Jim Boehnlein, M.D. Associate Director for Education, VA Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC) Professor of Psychiatry, Oregon Health and Science University

2. Outline OEF/OIF context PTSD throughout history Associated disorders PTSD symptoms and diagnosis Comprehensive PTSD treatment

3. Afghanistan- Operation Enduring Freedom (OEF) Iraq- Operation Iraqi Freedom (OIF) 1,800,000 OEF and OIF Veterans have left active duty and become eligible for VA health care since FY 2002 60% Active Duty troops 40% Reserve and National Guard 46% of total separated OEF/OIF Veterans have obtained VA health care since FY 2002 (cumulative total)

4. Frequency of Possible Diagnoses among OEF and OIF Veterans 265,450 (52%) Diseases of Musculoskeletal System/Connective System 233,443 (46%) Symptoms, Signs and Ill Defined Conditions 243,685 (48%) Mental Disorders 202,298 (40%) Diseases of Nervous System/ Sense Organs *These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2009; Veterans can have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 508,152; percentages add up to greater than 100 for the same reason.

5. PTSD Through the Decades- Labeling and Perception Railway Spine Syndrome Irritable Heart Shell Shock Post-concussion syndrome Concentration Camp Syndrome

6. Etiological Models of PTSD Biological Cognitive Sociocultural

7. Co-morbid Conditions and PTSD Mood Disorders Other Anxiety Disorders Substance Abuse Disorders Traumatic Brain Injury

8. Overlapping Symptoms of PTSD and TBI Impaired concentration Impaired memory Irritability Depression Anxiety

9. Importance of Accurate Diagnosis Relieve suffering Effective treatment Prognosis Employment/Education Stigma- not pathologizing Educating patients/families

10. Common PTSD Symptoms Common PTSD Symptoms Intrusive thoughts Nightmares Irritability Startle reactions Avoidance Emotional detachment Social isolation Anniversary reactions

11. Current Stressors Can Reactivate Memories of Prior Trauma Psychological and emotional stress Physiological reactivity Exposure to symbolic cues

12. Barriers to Treatment- Beliefs and Values Avoidance Pride in self-reliance Loss of control/autonomy Treatment is for those who are weak, “crazy” Provider will not understand or believe trauma Societal rejection

13. PTSD Treatment Education Symptomatic relief of comorbid conditions Reduction of hyperarousal symptoms with medication Psychotherapy Reduction of other stresses Social and vocational

14. Questions After Trauma Unpredictability of life and death Loss Moral Complexities

15. Core Assumptions Altered by Trauma Belief in personal invulnerability Perception of an understandable world Trust in self and others

16. Healing After Trauma Trust Security Acceptance Meaning Identity Social Connectedness

17. Psychotherapeutic Themes Trust Self Worth Grief and Mourning Anger and Revenge Control Meaning

19. National Center for PTSD http://www.ptsd.va.gov/professional/index.asp