From "Managing Stress"

www.jbpub.com/managingstress/exercises/view.cfm
(If any exercise gets distressing, stop.)
Chapter Title
1 The Nature of Stress
2 The Physiology of Stress
3 Stress and Disease
4 Toward a Psychology of Stress
5 The Stress Emotions: Anger and Fear
6 Stress-Prone and Stress-Resistant Personalities
7 Stress and Human Spirituality
8 Cognitive Restructuring
9 Behavior Modification
10 Journal Writing
11 Art Therapy
12 Humor Therapy (Comic Relief)
13 Creative Problem Solving
14 Communication Skills
15 Time Management
16 Additional Coping Techniques
17 Diaphragmatic Breathing
18 Meditation
19 Hatha Yoga
20 Mental Imagery and Visualization
21 Music Therapy
22 Massage Therapy
23 Tai Chi Ch'uan
24 Progressive Muscular Relaxation
25 Autogenic Training
26 Clinical Biofeedback
27 Nutrition and Stress
28 Physical Exercise

Copyright © 2001 Jones and Bartlett Publishers

PTSD workbook


Managing Traumatic Stress Through Art: Drawing From the Center
By Barry M. Cohen, M.A., A.T.R., Mary-Michola Barnes, M.A., A.T.R., and Anita B. Rankin, M.A.
Foreword by Joan A. Turkus, M.D.
This workbook is a valuable, practical, and above all useful contribution to the abuse recovery field. Through a series of artwork exercises, survivors of trauma are offered an opportunity to enhance present-day mastery in a grounded, creative, and gentle way. The more I read, the more excited I got about being able to recommend this fine workbook to clients and workshop participants.
-Nancy J. Napier, M.F.C.C., author of Recreating Your Self: Help for Adult Children of Dysfunctional Families and Getting Through The Day: Help for Adults Hurt as Children
Three art therapists have collaborated to produce this unique workbook. Designed especially for trauma survivors, Managing Traumatic Stress Through Art introduces inventive ways to understand, manage, and transform the aftereffects of trauma. This dynamic workbook consists of carefully structured step-by-step art projects, augmented by tear out images, and writing experiences.
The book's first section, Developing Basic Tools For Managing Stress, is devoted to establishing a safe framework for trauma resolution. The second section, Acknowledging and Regulating Your Emotions, helps the trauma survivor to make sense of overwhelming emotional experiences. The final section, Being and Functioning in the World, focuses on self and relational development, leading into the future.
Managing Traumatic Stress Through Art will inspire survivors to explore the aftermath of traumatic stress as it affects self-image, relationships with others, and functioning in the world. The 26 projects in this book encourage creative growth and help to establish a sense of personal safety, while exploring and honoring feelings of anger, fear, shame, and sadness. The art experiences are broad enough to be of value to survivors of a wide variety of traumatic experiences, ranging from childhood abuse to accidents to disabling mental illness.
This workbook offers an opportunity to everyone, regardless of previous experience or artistic talent, to manage symptoms of traumatic stress in a creative, life-affirming way.
"This beautifully written guidebook for victims of trauma is a remarkable achievement in the effort to empower the survivor....and the authors are exquisitely sensitive to the needs of their audience for safety and structure. This will be useful to survivors, therapists, and counselors in all areas of traumatic stress."
-David Read Johnson, Ph.D., Director, Outpatient Services, National Center for PTSD, VA Medical Center, West Haven, CT
"I am wildly enthusiastic about this book. I think it's one of the best things I've ever seen for survivors....It provides survivors with a realistic and hopeful process, utilizing art, that guides them from honoring the past to releasing emotions safely to building an array of healthy coping strategies to a sense of empowerment and hope."
-Eliana Gil, Ph.D., Director, Center for Advanced Clinical Development, Springfield, VA
"The authors convincingly demonstrate that art making and writing can be an essential part of the process of healing from severe trauma in one's life....This is a valuable resource."
-Cathy A. Malchiodi, M.A., A.T.R., L.A.T., L.P.C.C., Director, Institute for the Arts and Health and Editor, Art Therapy
"This wonderful workbook offers trauma survivors an intelligent, safe, and enjoyable way to bring artwork into their personal healing process. I highly recommend it."
-Margot Silk Forrest, editor, The Healing Woman
Title: Managing Traumatic Stress Through Art
Author: Barry Cohen et al
Price: $22.95
Format: Paperback
Number of Pages: 192
All information on these pages
© the Sidran Institute, 1995-2002

More information at www.patiencepress.com
bookstore


PTSD Self-Help Book


Kelly Mack first suggested this book:

"Post-Traumatic Stress Disorder Sourcebook"
Author(s): Glenn Schiraldi
ISBN: 0737302658
DOI: 10.1036/0737302658
Format: Softcover, 446 pages.
Pub date: January 1, 2000
Copyright: 2000
$18.95 US
Product Line: McGraw-Hill/Contemporary Books
Related Titles by Category:
• Health & Fitness -- Reference
• Self-Help -- General
Description

For the millions who suffer from the effects of a traumatic experience, this book offers help and hope and provides the diverse elements needed for lasting recovery. Trauma can take many forms, from the most disturbing of circumstances such as witnessing a murder or violent crime to the subtle trauma of living with the effects of abuse or alcoholism. Deep emotional wounds often seem like they will never heal, but Schiraldi has helped and witnessed survivors recover, grow, and find happiness.
By helping people recognize the coping mechanisms and by dealing directly with the effects of a traumatic experience, there is a great reason for hope. The Post-Traumatic Stress Disorder Sourcebook is a guide for both survivors and their loved ones, helping them to see that on the other side of their pain is recovery and growth.
Explains the psychic defenses that can go into effect to protect a victim from further emotional harm
Provides information on triggers and the debilitating effects of post-traumatic stress disorder
Addresses how the healing process can begin and how fear diminishes through a variety of medic and non-medicinal treatment methods.
Contents
Part I: About PTSD
Chapter 1. PTSD Basics
Chapter 2. Making Sense of the Bewildering Symptoms: Understanding Anxiety and Dissociation
Chapter 3. Associated Features
Chapter 4. Frequently Asked Questions
Part II: About Healing, Recovery, Growth
Chapter 5. Principles of Healing, Recovery, and Growth
Chapter 6. Treatment Approaches: Professional, Medication, Group, and Self-Managed
Part III: Preparations
Chapter 7. Stabilization and Balance
Chapter 8. Taking Care of Your Health
Part IV: Managing Symptoms
Chapter 9. Affect Management
Chapter 10. Reducing General Arousal
Chapter 11. Breathing Retraining
Chapter 12. About Relaxation
Chapter 13. Progressive Muscle Relaxation
Chapter 14. Autogenic Training
Chapter 15. Meditation
Chapter 16. Managing Anger
Chapter 17. Eye Movement
Chapter 18. Intrusion Management
Part V: Treatment
Chapter 19. Principles of Memory Work
Chapter 20. Cognitive Restructuring
Chapter 21. Confiding Concealed Wounds
Chapter 22. Resolving Guilt
Chapter 23. Thought Field Therapy
Chapter 24. The Rewind Technique
Chapter 25. Traumatic Incident Reduction (TIR)
Chapter 26. Eye Movement Desensitization and Reprocessing (EMDR)
Chapter 27. The Counting Method
Chapter 28. Dream Management and Processing
Chapter 29. Healing Imagery
Chapter 30. Healing Rituals
Chapter 31. Grieving Losses
Chapter 32. Making Sense of Trauma: Coming to Terms with Suffering
Chapter 33. Hypnosis
Chapter 34. Expressive Art Therapies
Chapter 35. Life Review
Chapter 36. Building Self-Esteem
Chapter 37. Unfinished Business: Resolving Anger
Chapter 38. Prolonged Exposure
Chapter 39. Complementary Approaches
Part VI: Moving On
Chapter 40. Transitioning
Chapter 41. Intimacy and Sexuality
Chapter 42. Meaning and Purpose
Chapter 43. Spiritual and Religious Growth
Chapter 44. Happiness, Pleasure, and Humor
Chapter 45. Relapse Prevention
Chapter 46. Summing Up
Appendices
Appendix 1. The History of PTSD
Appendix 2. Assessing Abuse
Appendix 3. The Brain and Memory
Appendix 4. Psychiatric Disorders
Appendix 5. 72-Hour Emergency Preparedness
Appendix 6. Time Management
Appendix 7. Rape and Sexual Assault Facts and Myths
Appendix 8. Medication Facts and Guidelines
Appendix 9. Victim, Survivor, Thriver
Appendix 10. Resources
Author Biography

Glenn R. Schiraldi, Ph.D., has served on the stress management faculty at the U.S. Pentagon and the University of Maryland, where he received the Outstanding Teacher Award in the College of Health and Human Performance. He is the author of various articles and books on human mental and physical health, including Conquer Anxiety, Worry and Nervous Fatigue: A Guide to Greater Peace; Hope and Help for Depression: A Practical Guide; Facts to Relax By: A Guide to Relaxation and Stress Reduction; and Building Self-Esteem: A 125-Day Program. He serves on the Board of Directors of the Depression and Related Affective Disorders Association. He is a graduate of the U.S. Military Academy, West Point, and holds graduate degrees in Health Education from Brigham Young University and the University of Maryland.

Myths and Facts About PTSD


Posttraumatic stress disorder, or PTSD, is a complex disorder that is often misunderstood. PTSD may develop following exposure to extreme trauma -- a terrifying event or ordeal that a person has experienced, witnessed, or learned about, especially one that is life-threatening or causes physical harm. The experience causes that person to feel intense fear, horror or a sense of helplessness. Not everyone who experiences a traumatic event will develop PTSD, but many people do.

MYTH: PTSD only affects war veterans.

FACT: Although PTSD does affect war veterans, PTSD can affect anyone. Almost 70 percent of Americans will be exposed to a traumatic event in their lifetime. Of those people, up to 20 percent will go on to develop PTSD. An estimated 1 out of 10 women will develop PTSD at some time in their lives.
Victims of trauma related to physical and sexual assault face the greatest risk of developing PTSD. Women are about twice as likely to develop PTSD as men, perhaps because women are more likely to experience trauma that involves these types of interpersonal violence, including rape and severe beatings. Victims of domestic violence and childhood abuse are at tremendous risk for PTSD.

MYTH: People should be able to move on with their lives after a traumatic event. Those who can't cope are weak.

FACT: Many people who experience an extremely traumatic event go through an adjustment period following the exposure. Most of these people are able to return to leading a normal life. However, the stress caused by trauma can affect all aspects of a person's life including mental, emotional and physical well-being. Research suggests that prolonged trauma may disrupt and alter brain chemistry. For some people, a traumatic event changes their views about themselves and the world around them. This may lead to the development of PTSD.

MYTH: People suffer from PTSD right after they experience a traumatic event.

FACT: PTSD symptoms usually develop within the first three months after trauma, but may not appear until months or years have passed. These symptoms may continue for years following the trauma, or, in some cases, symptoms may subside and reoccur later in life, which is often the case with victims of childhood abuse.
Some people don't recognize that they have PTSD because they may not associate their current symptoms with past trauma. In domestic violence situations, the victim may not realize that their prolonged, constant exposure to abuse puts them at risk.

http://www.sidran.org/ptsdmyths.html

PTSD AFFECTS WOMEN TOO NOT LIMITED TO MILITARY COMBAT PERSONNEL

WHAT IS PTSD?
PTSD is an anxiety disorder resulting from emotional distress resulting from a traumatic experience, and according to mental health professionals, define this condition as an ordeal that goes over the usual scope of a person’s experience that is notably distressing to anybody. It is a real illness requiring treatment.

WHAT CAUSES PTSD?
People who have experienced or witnessed a life threatening such as surviving acts of terrorism , war or battle, and on a personal level an individual who has been a victim of a cruel crime, domestic violence where a family member has been hit or harmed by a parent or a spouse, or sometimes by belligerent siblings, sexual trauma. Other provoking stimuli surviving an auto and airplane accidents, natural disasters. Or any event where a person believes, they might die. And it can trigger symptoms of depression, anxiety, anger of periodic distressing nightmares.

HOW DO YOU KNOW IF YOU HAVE PTSD?
A person could have PTSD and never know it, as symptoms can start at once and after the trauma event that stimulated it. Or it can be delayed for a long time, affecting an individual months or even years after the event. symptoms are not unusual and, unrestrained, could slip to more critical difficulties in daily life such as social problems and with family members, friends, co-workers; brushes with the law; and even substance abuse. And PTSD can happen to anyone at any age, even children.
Symptoms of PTSD are:
Feeling of detachment from other people. Become angry very easily. Always on lookout for danger, have a hard time trusting or getting close to people, and may discover the inability to express loving feelings. Incapable of working or take care of the children at home, unable to enjoy life wholeheartedly and substance abuse such as alcohol or drugs.
Flashback incidents, and they happen without warning. For instance, a sound, an image, a certain odor, anniversaries of the event are trigger mechanisms for the agonizing memory to happen in full force, causing the person to relive the situation once more in familiar surroundings.
Reason why an individual lives it all over again is because of the psychological experience is so horrifying and so different from day by day affairs they can’t fit it into what they know about the world. So to understand what occurred, their mind continues to invoke the memory, as if to further to comprehend the situation and make it blend in.
Still feel fearful most of the time. A person jumps and feels very upset when something happens without warning. Anxiety or dread shakes up in mind or made to feel apprehensive or a reason to be alarmed.
Nightmares are also common. You often have nightmares or scary thoughts and frightening recalls of the horrifying event and it also happens without warning. For example, increased frighten feeling consisting of being jumpy, jittery, shaky, difficulty concentrating or sleeping. And another problem is difficulty in sleeping, and muscles are tense.
Avoidance is a different copy mechanism in addressing the mental state related pain. It is when a person purposely keeps from anything or stay away from places that reminds them of the horrifying event. Most often issues that are not presently linked to the injury are also sidestepped. For example going out in the evening if the trauma occurred at night.
Another way of to ease anxiety is struggling to push down painful thoughts. Which leads to numbness, where a person has a problem in having both fearful and pleasant or loving feelings. And they develop a mental block to remember decisive details of the traumatic event.
Feel guilt and shame because you lived, they died. A lot of people blame themselves for things they felt they did or did not do to survive. A person feels this way because during the situation that caused the trauma, they acted in a way that they would have not otherwise have done. Also, sometimes other people place the blame on the individual for the hurt.
It is and indication a person is taking responsibility for what happened. Yet this may make a person feel somewhat more in control, it can also lead to feelings of helplessness and depression.

SEEKING HELP
A time comes when an individual has a need to seek more help to overcome the traumatic event. Those who have encountered first hand with nerve-wracking events, and people with emotional problems are more disposed to seek professional help.
For some, asking for help from health care professionals is not easy, as it is hard for them, as well as being impossible for others. Main reason why they don’t seek help is because they believe they have not sought help with a long-lived stumbling block, why should they do it now.
Yet, most folks when they have a physical ailment, they do not procrastinate to pursue Medical treatment, yet some people prefer to maintain the mental matters blocked. Many a time, those with emotional difficulties may speculate whether they actually require support and question whether anyone could conceivably make a change in how they think. And you wonder if you are the only person with this illness. The answer is no.
And a lot of people don’t want to talk about the issue because they refuse to talk about themselves because it is too painful to recall the agonizing occurrences that might have reinforced their tribulations. Though these thoughts are common, when they finally decide to seek help, their concerns normally breaks down to emotions of comfort and less mental anxiety when relief is finally looked for.

HOW IS PTSD TREATED?
Tell the doctor about the frightening images, depression, hard time in sleeping, and anger. Convey to the doctor if these problems keep you away from living every day life. Also ask the doctor for a check up to be sure that you don’t have some other illness.
Doctor may give medications to help the person feel less afraid and tense. Yet it could take a few weeks for the medicine to take affect.
Relating your experience to a specially trained doctor or counselor helps many people who have PTSD. This therapy can help an individual work out their terrible experience.
People can learn how to manage PTSD, and the medical personnel are there to help.

How can treatment help PTSD?
On the Internet, to and look for the VHA Facilities Locator link under “Health Benefits and Services” or go to
VA Medical Centers/Hospitals and Readjustment Counseling Services (Vet Centers) have professional staff who are able to treat PTSD. The provide mental health services for veterans and therapy is suited to individuals established on an evaluation, including a physical exam, interviews and standards weighing the magnitude of the PTSD. Care may consist of “out patient day program or a day hospital. Group therapy” and medication can also be used.
Treatment can help the veteran to know symptoms of PTSD and present life difficulties and learn to manage in a more effective manner with traumatic memories.
Ways you can cope:
Family, friends, church or other community resources can help, and join or begin a support group, as their support has a prominent role in recovery. By talking about your encounters in elating how you feel it gives you an opportunity to air out your feelings about the event rather than keeping them bottled up. And makes it easier to deal with disturbing events in a support group.
Continue to interact with people, and help others.
Instead of lacking interest in everyday activities, get back in the daily routine.
Find and take the time to grieve if need to.
Establish small goals before attempting large matters. Take one day at a time.
Eat a balanced diet, as stress poses an more of a demand on one’s health.
Take a break and go for a walk, stretch, exercise. A useful way to lessen stress.
Make sure you receive a lot of rest and sleep, as more sleep is needed when feeling strained .
Relax and find an activity that you like doing.
Stay away from stressful events.

PTSD LINKS
DEPARTMENT OF VETERANS AFFAIRS
http://www.va.gov/

Veterans Administration Facilities Directory
Listing of all 50 states
http://www.va.gov/sta/guide/division.asp?divisionId=1
In these listings includes VA Medical Center/Hospital
Outpatient Clinic
Community Based Outpatient Clinic
Vet Centers/Veteran’s Outreach Centers — Gulf War vets are also included.
I don’t remember all the categories, but I do know Vietnam, Grenada. I know there are others.
Note: VA website has a lot of information to check out.
MILITARY VETERANS (POST TRAUMATIC STRESS DISORDER)
PTSD REFERENCE MANUAL
http://www.ptsdmanual.com/
NATIONAL CENTER FOR PTSD
HELP FOR VETERANS WITH PTSD AND THEIR FAMILIES
http://www.ncptsd.org/facts/veterans/fs_help_for_vets.html
NATIONAL INSTITUTE OF MENTAL HEALTH
Can find free information online at
http://www.nimh.nih.gov
ON-LINE CONSUMER HEALTH PUBLICATIONS INDEXED BY KEYWORD
http://www.nih.gov/health/consumer/conkey.htm
TREATMENT OF PTSD
http://www.ptsdsupport.net/treatments.html
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL INSTITUTE OF HEALTH
http://www.nih.gov/health/consumer/conkey.htm
Letters across page for PTSD, click on page or scroll down

This message has been edited. Last edited by: CherryRead,

Major Depressive Disorder

Depression: Up and Down the Roller Coaster

By Louise from her own experience with depression
Written for Internet Mental Health
February 1998

My experience with depression leads me to describe one of its worst features: its variable symptoms. These symptoms not only make the experience of depression particularly distressing for the patient but also confuse and mislead those who deal with the depressed person. No one really wants to meet or speak with someone who is depressed. Whenever a positive change occurs, everyone hopes that it is a permanent improvement. When this proves not to be so, impatience soon appears. Depressed persons soon find that many people avoid them. Only the “normal” or “up” phases of the disease are acceptable to others. But rejection during the “down” phases can considerably add to the depression. Early Phases

In the course of a developing depression, it is common for there to be a wide variation in mood during the day. The morning is generally unpleasant. Darkness of mood prevails. Then as the day progresses, the mood lightens. By night, a person may feel quite normal. Gradually a change occurs. The dark times get longer and longer. If sleeplessness develops, the morning hours can be quite terrible. It is at this time that suicidal thoughts can appear. The individual cannot envision living in such darkness, day after day. Soon the darkness may last the whole day and also the evening. The depressed person dreads going to sleep. All that can be expected is a repetition of the same dark pattern. After a few days of this, the wish to die may become very strong. Depressed persons are not rejecting life as such. They are not rejecting any purpose that they may believe they have on earth or purpose that other people may suggest they have. Depressed persons are rejecting what they have become. “I do not recognize this person.” “I have become such a caricature of my former self!” “Look at me!” “I am completely anxious. I am afraid to be alone in my house. I am terrified when I have free time that I might have to spend at home. I am afraid to do things on my own. Anxiety makes me wring my hands incessantly. I am totally tense. I feel foolish, unable to do things that children easily do.” The death of such a creature would seem to be a blessing. At this stage of the depression, one is at the bottom of the roller coaster. Nor is there any hope of going up. During Treatment

After treatment of depression begins with antidepressants, improvement is slow. Antidepressants do not take effect until four to six weeks. During this time, the depression can continue its insidious growth. One has to cope with the side-effects of the antidepressants as well as all the darkness of the depression. The medication may help with sleep and this is a great blessing. But one is still very much on the bottom of the roller coaster. Great will-power is needed to have hope that some change will come. This period can be painful with regard to other people. Their patience may well wear thin. Most people assume that one's mental attitude is totally self-chosen. If one is not cheerful, it is by choice. During this time one is immensely grateful for a faithful friend. After some weeks the antidepressants begin to take effect. The depressed person feels less down, at first for part of the day, then for more of the day. But the mornings can still be bad and thoughts of death can still haunt. Side-effects of the antidepressants become less severe but do not disappear altogether. During this phase a person may feel that all the symptoms are some kind of horrible nightmare. “This can't be happening to me” “I was always able to be cheerful and happy.” “How I want to be off these pills and just be normal again” But the hard and painful truth has to be faced: the depression is real and will not go away by itself. One cannot just throw away the medication, however much this may seem desirable. Human nature has proved to be frail in a most painful way. During Recovery

At last some light seems to appear. “I am beginning to feel normal” “Up the roller coaster I go. And I will NEVER, NEVER go down again.” What an illusion! Depression is not a weak disease; it is one that specializes in cruel effects. Just as one begins to feel normal, the depression can return with a complete vengeance. This happened to me. On Sunday I feel normal, to some degree. I can ignore the side-effects of the antidepressants as long as I don't feel too bad. On Monday, as I face a series of decisions, I am as bad as I ever was, even at the beginning of the disease. Everything is dark. I want to die, thinking of suicide. I am anxious. I cannot make up my mind about the smallest details. I am most afraid and panic at the idea of being alone. Here I am at the bottom of the roller coaster once more. What are my choices? None, really. However much I wish to die and wish that this ridiculous person I have become to die, I know that death is not an option. I must continue with the medication and hope that I will go up the roller coaster once more. There can be no facile optimism with depression. I might want to be well NOW. Every person I meet impatiently wants me to be well and never to hear again about depression. But it is not going to be so. Recovery from depression may take months. Gradually I hope to be able to stay up the roller coaster. With other people, as I go up and down, I may have to learn to be a good actress. With some friends I will be able to speak of my pain. Depression is a roller coaster ride. It has taught me to have boundless compassion for those who are at the bottom of the roller coaster and to share their tears.

Internet Mental Health (www.mentalhealth.com) copyright © 1995-1999 by Phillip W. Long, M.D.

This message has been edited. Last edited by: CherryRead,

PANIC DISORDER

(sample story}
It started 10 years ago. I was sitting in a seminar in a hotel and this thing came out of the clear blue. I felt like I was dying."


"For me, a panic attack is almost a violent experience. I feel like I'm going insane. It makes me feel like I'm losing control in a very extreme way. My heart pounds really hard, things seem unreal, and there's this very strong feeling of impending doom."


"In between attacks there is this dread and anxiety that it's going to happen again. It can be very debilitating, trying to escape those feelings of panic."



People with panic disorder have feelings of terror that strike suddenly and repeatedly with no warning. They can't predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike. In between times there is a persistent, lingering worry that another attack could come any minute.
When a panic attack strikes, most likely your heart pounds and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. You may genuinely believe you're having a heart attack or stroke, losing your mind, or on the verge of death. Attacks can occur any time, even during nondream sleep. While most attacks average a couple of minutes, occasionally they can go on for up to 10 minutes. In rare cases, they may last an hour or more. Panic Attack Symptoms


-- Pounding heart
-- Chest pains
-- Lightheadedness or dizziness
-- Nausea or stomach problems
-- Flushes or chills
-- Shortness of breath or a feeling of smothering or choking
-- Tingling or numbness
-- Shaking or trembling
-- Feelings of unreality
-- Terror
-- A feeling of being out of control or going crazy
-- Fear of dying
-- Sweating
Panic disorder strikes at least 1.6 percent of the population and is twice as common in women as in men. It can appear at any age--in children or in the elderly--but most often it begins in young adults. Not everyone who experiences panic attacks will develop panic disorder-- for example, many people have one attack but never have another. For those who do have panic disorder, though, it's important to seek treatment. Untreated, the disorder can become very disabling.
Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may spawn phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding an elevator, you may develop a fear of elevators and perhaps start avoiding them.
Some people's lives become greatly restricted--they avoid normal, everyday activities such as grocery shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, they avoid any situation they fear would make them feel helpless if a panic attack occurs. When people's lives become so restricted by the disorder, as happens in about one-third of all people with panic disorder, the condition is called agoraphobia. A tendency toward panic disorder and agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop the progression to agoraphobia.
Studies have shown that proper treatment--a type of psychotherapy called cognitive-behavioral therapy, medications, or possibly a combination of the two--helps 70 to 90 percent of people with panic disorder. Significant improvement is usually seen within 6 to 8 weeks.
Cognitive-behavioral approaches teach patients how to view the panic situations differently and demonstrate ways to reduce anxiety, using breathing exercises or techniques to refocus attention, for example. Another technique used in cognitive-behavioral therapy, called exposure therapy, can often help alleviate the phobias that may result from panic disorder. In exposure therapy, people are very slowly exposed to the fearful situation until they become desensitized to it.
Some people find the greatest relief from panic disorder symptoms when they take certain prescription medications. Such medications, like cognitive-behavioral therapy, can help to prevent panic attacks or reduce their frequency and severity. Two types of medications that have been shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines. text taken from ANXIETY DISORDERS: DECADE OF THE BRAIN (NIMH).


For further info,

browse the tAPir Links
or join the discussion at the tAPir BBS

http://www.algy.com/anxiety/clinks/clinks.cgi
© 1993 - 2000 tAPir

2003 Edition

Survivor Benefits

Dependency and Indemnity Compensation (DIC)
DIC Payments to Surviving Spouse | DIC Payments to Parents and Children
Special Allowances | Restored Entitlement Program for Survivors

Death Pension

Dependency and Indemnity Compensation (DIC) payments may be available for surviving spouses who have not remarried, unmarried children under 18, helpless children, those between 18 and 23 if attending a VA-approved school, and low-income parents of deceased service members or veterans. To be eligible, the deceased must have died from: (1) a disease or injury incurred or aggravated while on active duty or active duty for training; (2) an injury incurred or aggravated in line of duty while on inactive duty training; or (3) a disability compensable by VA. Death cannot be the result of willful misconduct. If a spouse remarries, eligibility for benefits may be restored if the marriage is terminated later by death, annulment or divorce.
DIC payments also may be authorized for survivors of veterans who were totally service-connected disabled when they died, even though their service-connected disabilities did not cause their deaths. The survivor qualifies if: (1) the veteran was continuously rated totally disabled for a period of 10 or more years immediately preceding death; (2) the veteran was so rated for a period of at least five years from the date of military discharge; or (3) the veteran was a former prisoner of war who died after Sept. 30, 1999, and who was continuously rated totally disabled for a period of at least one year immediately preceding death. Payments under this provision are subject to offset by the amount received from judicial proceedings brought on account of the veteran's death. The discharge must have been under conditions other than dishonorable.

DIC Payments to Surviving Spouse

Surviving spouses of veterans who died after Jan. 1, 1993, receive $948 a month. For a spouse entitled to DIC based on the veteran's death prior to Jan. 1, 1993, the amount paid is $948 or an amount based on the veteran's pay grade. See the "Tables" section of this booklet for more information.

DIC Payments to Parents and Children

The monthly payment for parents of deceased veterans depends upon their income. There are additional DIC payments for dependent children. A child may be eligible if there is no surviving spouse, and the child is unmarried and under age 18, or if the child is between the ages of 18 and 23 and attending school. See the "Tables" section of this booklet for more information on DIC for children.

Special Allowances

Surviving spouses and parents receiving DIC may be granted a special allowance to pay for aid and attendance by another person if they are patients in a nursing home or require the regular assistance of another person. Surviving spouses receiving DIC may be granted a housebound special allowance if they are permanently housebound. The current allowances for spouses are shown in the "Tables" section of this booklet.
Restored Entitlement Program for Survivors
Survivors of veterans who died of service-connected causes incurred or aggravated prior to Aug. 13, 1981, may be eligible for special benefits. This benefit is similar to the benefits for students and surviving spouses with children between ages 16 and 18 that were eliminated from Social Security benefits. The benefits are payable in addition to any other benefits to which the family may be entitled. The amount of the benefit is based on information provided by the Social Security Administration.

Death Pension

Pensions based on need are available for surviving spouses and unmarried children of deceased veterans with wartime service. Spouses must not have remarried and children must be under age 18, or under age 23 if attending a VA-approved school. Pension is not payable to those with estates large enough to provide maintenance. The veteran must have been discharged under conditions other than dishonorable and must have had 90 days or more of active military service, at least one day of which was during a period of war, or a service-connected disability justifying discharge for disability. If the veteran died in service but not in line of duty, benefits may be payable if the veteran had completed at least two years of honorable service. Children who became incapable of self-support because of a disability before age 18 may be eligible for a pension as long as the condition exists, unless the child marries or the child's income exceeds the applicable limit. A surviving spouse may be entitled to higher income limitations or additional benefits if living in a nursing home, in need of aid and attendance by another person or permanently housebound.
The Improved Pension program provides a monthly payment to bring an eligible person's income to a support level established by law. The payment is reduced by the annual income from other sources such as Social Security paid to the surviving spouse or dependent children. Medical expenses may be deducted from the income ceiling. Pension is not payable to those who have assets that can be used to provide adequate maintenance. Maximum rates for the Improved Death Pension are shown in the "Tables" section of this booklet.

Home Loan Guaranties

A VA loan guaranty to acquire a home may be available to an unmarried spouse of a veteran or servicemember who died as a result of service-connected disabilities, or to a spouse of a servicemember who has been officially listed as missing in action or as a prisoner of war for more than 90 days. Spouses of those listed as prisoners of war or missing in action are limited to one loan.

Dependents' Education

Monthly Payments | Work-Study | Counseling Services | Special Benefits
Educational Loans | Home Loan Guaranties | Montgomery GI Bill Death Benefit
Educational assistance benefits are available to spouses who have not remarried and children of: (1) veterans who died or are permanently and totally disabled as the result of a disability arising from active military service; (2) veterans who died from any cause while rated permanently and totally disabled from service-connected disability; (3) service members listed for more than 90 days as currently missing in action or captured in line of duty by a hostile force; (4) service members listed for more than 90 days as currently detained or interned by a foreign government or power.
The termination of a surviving spouse's remarriage - by death, divorce, or ceasing to live with another person as that person's spouse -will reinstate Dependents' Educational Assistance benefits to the surviving spouse. Benefits may be awarded for pursuit of associate, bachelor or graduate degrees at colleges and universities - including independent study, cooperative training and study abroad programs. Courses leading to a certificate or diploma from business, technical or vocational schools also may be taken.
Benefits may be awarded for apprenticeships, on-the-job training programs and farm cooperative courses. Benefits for correspondence courses under certain conditions are available to spouses only. Secondary-school programs may be pursued if the individual is not a high-school graduate. An individual with a deficiency in a subject may receive tutorial assistance benefits if enrolled halftime or more. Deficiency, refresher and other training also may be available.
Monthly Payments: Payments are made monthly. The rate is $670 a month for full-time school attendance, with lesser amounts for part-time training. A person may receive educational assistance for fulltime training for up to 45 months or the equivalent in part-time training. Payments to a spouse end 10 years from the date the individual is found eligible or from the date of the death of the veteran. VA may grant an extension. Children generally must be between the ages of 18 and 26 to receive education benefits, though extensions may be granted.
Work-Study: Participants must train at the three-quarter or full-time rate. They may be paid in advance 40 percent of the amount specified in the work-study agreement or an amount equal to 50 times the applicable minimum wage, whichever is less. Participants under the supervision of a VA employee may provide outreach services, prepare and process VA paperwork, and work at a VA medical facility or perform other approved activities. They may also help at national or state veterans' cemeteries in addition to assisting in outreach services furnished by State Approving Agencies.
Counseling Services: VA may provide counseling services to help an eligible dependent pursue an educational or vocational objective.
Special Benefits: An eligible child over age 14 with a physical or mental disability that impairs pursuit of an educational program may receive special restorative training to lessen or overcome that impairment. This training may include speech and voice correction, language retraining, lip reading, auditory training, Braille reading and writing, and similar programs. Certain disabled or surviving spouses are also eligible for special restorative training. Specialized vocational training also is available to an eligible spouse or child over age 14 who is handicapped by a physical or mental disability that prevents pursuit of an educational program.

Educational Loans

Loans are available to spouses who qualify for educational assistance. Spouses who have passed their 10-year period of eligibility may be eligible for an educational loan. During the first two years after the end of their eligibility period, they may borrow up to $2,500 per academic year to continue a full-time course leading to a college degree or to a professional or vocational objective that requires at least six months to complete. VA may waive the six-month requirement. Loans are based on financial need.

Montgomery GI Bill Death Benefit

VA will pay a special Montgomery GI Bill death benefit to a designated survivor in the event of the service-connected death of an individual while on active duty or within one year after discharge or release. The deceased must either have been entitled to educational assistance under the Montgomery GI Bill program or a participant in the program who would have been so entitled but for the high school diploma or length-of-service requirement. The amount paid will be equal to the participant's actual military pay reduction (discussed on "Education and Training" of this booklet), less any education benefits paid.

Federal Benefits for Veterans and Dependents

2003 Edition

Survivor Benefits

Dependency and Indemnity Compensation (DIC)
DIC Payments to Surviving Spouse | DIC Payments to Parents and Children
Special Allowances | Restored Entitlement Program for Survivors

Death Pension

Dependency and Indemnity Compensation (DIC) payments may be available for surviving spouses who have not remarried, unmarried children under 18, helpless children, those between 18 and 23 if attending a VA-approved school, and low-income parents of deceased service members or veterans. To be eligible, the deceased must have died from: (1) a disease or injury incurred or aggravated while on active duty or active duty for training; (2) an injury incurred or aggravated in line of duty while on inactive duty training; or (3) a disability compensable by VA. Death cannot be the result of willful misconduct. If a spouse remarries, eligibility for benefits may be restored if the marriage is terminated later by death, annulment or divorce.
DIC payments also may be authorized for survivors of veterans who were totally service-connected disabled when they died, even though their service-connected disabilities did not cause their deaths. The survivor qualifies if: (1) the veteran was continuously rated totally disabled for a period of 10 or more years immediately preceding death; (2) the veteran was so rated for a period of at least five years from the date of military discharge; or (3) the veteran was a former prisoner of war who died after Sept. 30, 1999, and who was continuously rated totally disabled for a period of at least one year immediately preceding death. Payments under this provision are subject to offset by the amount received from judicial proceedings brought on account of the veteran's death. The discharge must have been under conditions other than dishonorable.

DIC Payments to Surviving Spouse

Surviving spouses of veterans who died after Jan. 1, 1993, receive $948 a month. For a spouse entitled to DIC based on the veteran's death prior to Jan. 1, 1993, the amount paid is $948 or an amount based on the veteran's pay grade. See the "Tables" section of this booklet for more information.

DIC Payments to Parents and Children

The monthly payment for parents of deceased veterans depends upon their income. There are additional DIC payments for dependent children. A child may be eligible if there is no surviving spouse, and the child is unmarried and under age 18, or if the child is between the ages of 18 and 23 and attending school. See the "Tables" section of this booklet for more information on DIC for children.

Special Allowances

Surviving spouses and parents receiving DIC may be granted a special allowance to pay for aid and attendance by another person if they are patients in a nursing home or require the regular assistance of another person. Surviving spouses receiving DIC may be granted a housebound special allowance if they are permanently housebound. The current allowances for spouses are shown in the "Tables" section of this booklet.
Restored Entitlement Program for Survivors
Survivors of veterans who died of service-connected causes incurred or aggravated prior to Aug. 13, 1981, may be eligible for special benefits. This benefit is similar to the benefits for students and surviving spouses with children between ages 16 and 18 that were eliminated from Social Security benefits. The benefits are payable in addition to any other benefits to which the family may be entitled. The amount of the benefit is based on information provided by the Social Security Administration.

Death Pension

Pensions based on need are available for surviving spouses and unmarried children of deceased veterans with wartime service. Spouses must not have remarried and children must be under age 18, or under age 23 if attending a VA-approved school. Pension is not payable to those with estates large enough to provide maintenance. The veteran must have been discharged under conditions other than dishonorable and must have had 90 days or more of active military service, at least one day of which was during a period of war, or a service-connected disability justifying discharge for disability. If the veteran died in service but not in line of duty, benefits may be payable if the veteran had completed at least two years of honorable service. Children who became incapable of self-support because of a disability before age 18 may be eligible for a pension as long as the condition exists, unless the child marries or the child's income exceeds the applicable limit. A surviving spouse may be entitled to higher income limitations or additional benefits if living in a nursing home, in need of aid and attendance by another person or permanently housebound.
The Improved Pension program provides a monthly payment to bring an eligible person's income to a support level established by law. The payment is reduced by the annual income from other sources such as Social Security paid to the surviving spouse or dependent children. Medical expenses may be deducted from the income ceiling. Pension is not payable to those who have assets that can be used to provide adequate maintenance. Maximum rates for the Improved Death Pension are shown in the "Tables" section of this booklet.

Home Loan Guaranties

A VA loan guaranty to acquire a home may be available to an unmarried spouse of a veteran or servicemember who died as a result of service-connected disabilities, or to a spouse of a servicemember who has been officially listed as missing in action or as a prisoner of war for more than 90 days. Spouses of those listed as prisoners of war or missing in action are limited to one loan.

Dependents' Education

Monthly Payments | Work-Study | Counseling Services | Special Benefits
Educational Loans | Home Loan Guaranties | Montgomery GI Bill Death Benefit
Educational assistance benefits are available to spouses who have not remarried and children of: (1) veterans who died or are permanently and totally disabled as the result of a disability arising from active military service; (2) veterans who died from any cause while rated permanently and totally disabled from service-connected disability; (3) service members listed for more than 90 days as currently missing in action or captured in line of duty by a hostile force; (4) service members listed for more than 90 days as currently detained or interned by a foreign government or power.
The termination of a surviving spouse's remarriage - by death, divorce, or ceasing to live with another person as that person's spouse -will reinstate Dependents' Educational Assistance benefits to the surviving spouse. Benefits may be awarded for pursuit of associate, bachelor or graduate degrees at colleges and universities - including independent study, cooperative training and study abroad programs. Courses leading to a certificate or diploma from business, technical or vocational schools also may be taken.
Benefits may be awarded for apprenticeships, on-the-job training programs and farm cooperative courses. Benefits for correspondence courses under certain conditions are available to spouses only. Secondary-school programs may be pursued if the individual is not a high-school graduate. An individual with a deficiency in a subject may receive tutorial assistance benefits if enrolled halftime or more. Deficiency, refresher and other training also may be available.
Monthly Payments: Payments are made monthly. The rate is $670 a month for full-time school attendance, with lesser amounts for part-time training. A person may receive educational assistance for fulltime training for up to 45 months or the equivalent in part-time training. Payments to a spouse end 10 years from the date the individual is found eligible or from the date of the death of the veteran. VA may grant an extension. Children generally must be between the ages of 18 and 26 to receive education benefits, though extensions may be granted.
Work-Study: Participants must train at the three-quarter or full-time rate. They may be paid in advance 40 percent of the amount specified in the work-study agreement or an amount equal to 50 times the applicable minimum wage, whichever is less. Participants under the supervision of a VA employee may provide outreach services, prepare and process VA paperwork, and work at a VA medical facility or perform other approved activities. They may also help at national or state veterans' cemeteries in addition to assisting in outreach services furnished by State Approving Agencies.
Counseling Services: VA may provide counseling services to help an eligible dependent pursue an educational or vocational objective.
Special Benefits: An eligible child over age 14 with a physical or mental disability that impairs pursuit of an educational program may receive special restorative training to lessen or overcome that impairment. This training may include speech and voice correction, language retraining, lip reading, auditory training, Braille reading and writing, and similar programs. Certain disabled or surviving spouses are also eligible for special restorative training. Specialized vocational training also is available to an eligible spouse or child over age 14 who is handicapped by a physical or mental disability that prevents pursuit of an educational program.

Educational Loans

Loans are available to spouses who qualify for educational assistance. Spouses who have passed their 10-year period of eligibility may be eligible for an educational loan. During the first two years after the end of their eligibility period, they may borrow up to $2,500 per academic year to continue a full-time course leading to a college degree or to a professional or vocational objective that requires at least six months to complete. VA may waive the six-month requirement. Loans are based on financial need.

Montgomery GI Bill Death Benefit

VA will pay a special Montgomery GI Bill death benefit to a designated survivor in the event of the service-connected death of an individual while on active duty or within one year after discharge or release. The deceased must either have been entitled to educational assistance under the Montgomery GI Bill program or a participant in the program who would have been so entitled but for the high school diploma or length-of-service requirement. The amount paid will be equal to the participant's actual military pay reduction (discussed on "Education and Training" of this booklet), less any education benefits paid.

The Twelve-Step Approach to PTSD

Written by Joel Brende, MD
Mercer University School of Medicine


Step One (Power)

Our first step is to accept the fact that we have become powerless to live meaningful lives.
Even though we had the power to survive against the worst combat conditions, we must admit we have become powerless to win the battle against a new enemy—our memories, flashbacks, and combat instincts. Some of us have become powerless over the continuing wish to gain revenge over those sudden impulses to hurt those who cross us or unsuspectingly annoy us. We even hurt those who try to love us, making it impossible to love and care for our friends and family. So we isolate ourselves and cause others to avoid, dislike, or even hate us. Our attempts to live meaningful lives and fight this psychological and emotional hell which imprisons us seems to be in vain. We now find ourselves powerless to change it.

Step Two (Seeking Meaning)

Our next step is to seek meaning in having survived.
If we are to survive this new battle, we seek meaning in having survived. We want to believe we have survived for a purpose. We would like to be free from nagging thoughts telling us we should never have left the battlefield alive—the place where our comrades gave their lives in war. We want to believe our lives will serve a better purpose if we are alive rather than dead. Thus, even though we often doubt that living is better than dying, we seek to find meaning in life rather than death, and hope to find life a privilege rather than a burden.


Step Three (Trust)

Our third step is to begin to find relief by seeking help from God as we understand Him, and from persons we can learn to trust.
If we are to find relief, we seek a source of help from persons whom we can learn to trust. Many of us also would like to trust God, as individually understood, and ask Him to show
us the way out of our mental prisons, renewing our sensitivities to human emotions and spiritual qualities we fear we have lost.

Step Four (Self-Inventory)

We will make a searching, positive inventory of ourselves.
After taking the step of seeking and accepting help, we find ourselves aware of many negative qualities. In fact, although we might be willing to trust, we may fear that revealing ourselves to others will only be a negative experience. Thus, we ask a person we trust, and a higher power, to help us see our positive qualities. In that way, we can honestly evaluate the presence of both desirable and undesirable qualities.

Step Five (Rage)

We will admit to ourselves, to God, and to a person whom we trust, all our angry feelings and homicidal rage.
With an awareness that we are not alone, with improved self-esteem, and with a newfound desire to trust, we hope to understand the reason for our continuing rage. We will take the risk of revealing our angry feelings to a person we trust and God as individually understood. In so doing, we will discover that our anger is likely to be our only defense against helplessness and experiencing other emotions. Thus, this important step will help us open the door to other painful memories and emotions.

Step Six (Fear)

We will open the doors to the past and reveal to God and another person whom we trust, our frightening, traumatic memories.
After beginning to realize that anger is often a defense against fear, we will now begin to understand the link between the two. In this way, we can begin to accept the fact that fear is normal and relief from fear may be found by facing it with the help of someone we trust and of God, as individually understood.

Step Seven (Guilt)

We will ask forgiveness from God as we understand Him, and recognize we are thus free from condemnation.
We ask for and accept forgiveness from God, and a person whom we trust, for committing, participating in, or knowing about acts committed which were unacceptable in our eyes, causing suffering and grief for other persons and now causing us to feel tormented with guilt and self-blame. After having accepted forgiveness from God and from another person(s), we can now forgive ourselves. But we recognize that old habits of self-condemnation are difficult to break. Thus, self-forgiveness must be a daily matter.

Step Eight (Grief)

We seek strength and support from God and another person to finally grieve for those whom we left behind.
We seek strength to complete the grieving process for those who have died. We would like to finally be free, shedding tears without being lost in unending grief. This means also being able to understand the link between grief and all the feelings we have harbored for many years: anger at those who left us alone, guilt about surviving while others were killed, remorse for failing to save people who died, and yearnings to join those whose bodies have already been buried.

Step Nine (Forgiveness vs. Self-Condemnation)

We reveal to ourselves, God, and those we trust, all remaining suicidal or self-destructive wishes, and make a commitment to living.
We wish to expose and purge those negative forces within us which still may prevent us from making a complete commitment to life. Thus, after further self-evaluation, we reveal to ourselves, to God, and tho those whom we trust, all remaining suicidal wishes, and ask to be purged of the remaining, destructive, death forces which have ourselves and others. Then, we seek and accept God’s daily strength to make a daily commitment to living.

Step Ten (Forgiveness vs. Revenge)

We reveal to ourselves, God, and another person, all remaining wishes for revenge, and ask for God’s strength to give these up.
We seek and accept God’s strength to give up our wishes for revenge toward those who hurt us and injured or killed our friends and loved ones so we can learn the full meaning of love of God, of others, and of ourselves.

Step Eleven (Finding Purpose)

We seek knowledge and direction from God for a renewed purpose for our lives.
Having been freed from those burdens which have kept us from having meaningful and purposeful lives, we are ready to find a renewed purpose for our lives. Recognizing that God’s power also can be a source of strength to live, we will daily seek freedom from old burdens or new problems through prayer, meditation, and a daily surrender to God. In this way, we can continue to find daily freedom from the past prison of rage, guilty memories, and impacted grief, and gain a knowledge of His purpose for our lives and the endurance to carry it out.

Step Twelve (Loving and Helping Others)

Having experienced spiritual rebirth, we seek God’s strength to love others and to help those who suffer as we have.
Having had a spiritual awakening as a result of these steps, we seek to carry this message and to help all those who suffered as we have suffered.

Six Keys to Recovery:


1. Seek help from God, family, friends, and support groups.
Start by being willing to trust people again. Be selective - choose people and conversations that give guidance, and help to heal your wounds, to ease your fears, and to give you hope.

2. Accept personal responsibility for your life.
You cannot and need not change the past -- You can change what you do today.

3. Choose to forgive.
First, forgive yourself. Then one by one, forgive others. How? Here are some suggestions.


Say a prayer to specific people. Talk about your pain and then your desire to forgive.
Write a ghost letter to individuals - express your pain and then your desire to forgive.
Meditate and ask God to teach you how to forgive.
Read about forgiveness.
Write a Lesson about Forgiveness that could be presented in school.
Realize that your heart dictates your health. You must forgive in order to recover.
4. Grieve for those left behind.
There is a tremendous sense of loss and separation from life as it once was. All the rules are changed. As with any loss, a person needs time to accept and adjust to the emptiness and confusion. Crying never seems to bring relief. But it's a start. Anger, guilt, resentment, justification are all part of this process. You can say a prayer to all the things that are lost - and the people who were left behind. You can have a memorial ceremony to acknowledge and grieve for these dearly departed ones. You can write a letter to individuals to whom you wish to say "good-bye" -- speak of all unresolved issues and seal the letter. Bury it in the ground and place an ornament of some kind to mark the spot if you like.

5. Be willing to give up thoughts & feelings of revenge.
Your body, soul and mind have reached the limits of endurance. It is a vulnerable time for destructive, self-defeating thoughts and behaviors to kill you, since the trauma did not. Your choice is whether to give up, to wreak havoc, or to begin to heal. Any negative thoughts - thoughts of blame, guilt, anger, resentment, envy, hate, blood lust, or self-destruction are to be acknowledged, released, and denied future access to your wounded self. Have a hot line to call someone if you get tangled up in your thoughts, or if you begin to hurt yourself or others.
Don't wait - deal with it as early as you can. Click here for emergency numbers.

6. Help Others.
Healing comes from helping. Veterans who recover best help other veterans and suffering people. Healing comes from feeding and clothing homeless veterans on the streets, from talking to and going to the home of a veteran who is having a hard time and listening to him, from volunteering for a stand-down, and from going to The Wall with other veterans. Healing also comes from being involved with your wife and your children - being emotionally present in your family. It may take time to allow others to affect your emotions, or your confused mind. But get help and get it now. It's not too late to find some peace and enjoyment in this troubled world. What doesn't kill you most certainly DOES make you stronger. You are still here and you are still YOU. Lots of support is available so the choice to be healed is yours, and yours alone. Why not make the rest of your days as healthy and pleasant as possible?

Things to do

You need to try & reconnect to the present/get grounded.


--Sometimes that can be touching familiar things around you,a scent that is pleasant to you now & has no connection to the past.
--Lots of aroma stuff out there,find an essential oil that you can keep near you or in a pocket if this happens away from home.
--Look at your feet & surroundings,make sure your feet are firmly on the floor/ground.
--Drink something very cold.
--Turn on the TV,exercise (tai chi is good).
--If you have a pet find him/her and make physical contact.
--Tell someone you live with or could call that you have these problems. Contact that person.
If you are in this stage frequently & feel very unsafe or can't seem to get control,call therapist,have someone take you to ER.
--Make sure all guns,knives,swords,etc.are locked away or given to some one for safe keeping.


Intervene ASAP before you become more & more drawn into the past.

Cerebral Malaria and PTSD

Note: If you are having PTSD related problems and you are having problems with your VA claim and you also had malaria in that tropical paradise Vietnam, I suggest you print this article and send it in along with your statement in support of claim. If you had malaria, they can not reverse brain damage. When they say treatable it does not mean curable.
UI/VAMC study says patient's history of malaria may be a clue to many Vietnam vets' psychological and other health problems


Library: MED Keywords: VETERANS MALARIA CEREBRAL VIETNAM PTSD PSYCHOLOGY VA
IOWA CITY, Iowa --

Cerebral malaria should be considered as seriously as post- traumatic stress disorder (PTSD) or Agent Orange exposure as an underlying cause of long-term medical and psychological problems faced by some Vietnam War veterans, according to a study by a University of Iowa and Veterans Affairs Medical Center (VAMC) psychologist.
In an article published in the November issue of the Journal of Nervous and Mental Disease, Nils R. Varney, UI adjunct professor of psychology and a staff neuropsychologist at the VAMC in Iowa City, and his colleagues report that many cerebral malaria survivors from the Vietnam War have a number of neuropsychiatric symptoms that can persist for years after the acute illness has been treated.
It is estimated that as many as 250,000 Vietnam veterans suffered cerebral malaria. Contracted from mosquitoes, the illness causes an encephalitis, or inflammation of the brain. This can result in damage to cerebral nerve tissue in the frontal-temporal areas of the neocortex.
"Cerebral malaria does a number of different things to a patient's brain that cause a variety of neurological problems," Varney says. "Clinical reports from 500 B.C. through the 20th century noted that patients who survived the illness frequently developed depression, impaired memory loss, personality change and proneness to violence as long-term effects of the disease. These are symptoms that have been reported by many Vietnam veterans for years and are often treated strictly as PTSD."
The researchers compared the neuropsychiatric status of 40 Vietnam combat veterans who contracted cerebral malaria between 1966-1969 with 40 Vietnam veterans with similar wartime experience who suffered gunshot or shrapnel wounds during the same period. The participants underwent numerous tests for sensory, cognitive and behavioral symptoms.
Findings indicated that, when compared to wounded combat veterans who did not contract cerebral malaria during their service, the veterans who had malaria reported more problems with depression, subjective distress, auditory information processing, memory, emotional instability and seizure-like symptoms.
Interestingly, Varney notes, the malaria-related health concerns among Vietnam veterans are similar to what British troops faced in 19th century India during the height of the British Empire. Nineteenth-century physicians documented these cases and considered malaria a leading cause of mental illness in British-occupied regions.
"It's well-chronicled in the medical literature from that period, but basically it's been forgotten, since malaria has not been a major problem in industrialized western nations for decades," Varney says.
The study results may offer new hope to many Vietnam veterans with neurological and psychological problems that have not responded to previous treatments. The findings suggest that doctors consider a history of malaria in any medical, psychological or psychiatric workup of Vietnam veterans because a positive response could change diagnosis and treatment. Anticonvulsant medications can be beneficial in treating symptoms that affect cerebral malaria survivors. "I would suspect that doctors who treat Vietnam veterans with unexplained and untreatable neurological or psychological problems would find a significant number of them with a history of malaria," Varney says. "And that means there's a different way to assess these cases. It's not solely PTSD or Agent Orange exposure that's causing these problems, which are the only explanations these veterans have had to hang their hats on. Now we may be able to move these patients into a category where their problems make sense, what is wrong with them is known and well-documented, and it's treatable."
The study was funded by the U.S. Department of Veterans Affairs.

Reposted from another PTSD Website,

Cherry

Stressing The Point

When is a Post Traumatic Stress Disorder Claim Legitimate...and When Is It Not

by Mark I. Levy, M.D. Asst. Clinical Professor Psychiatry
University of California San Francisco
School of Medicine
Email mark@levymd.com
Website http://www.levymd.com
(Expanded version of an article first published in the November 1995 issue of For the Defense, the monthly journal of the Defense Research Institute, Chicago, Illinois.)

In prehistoric times, when our earliest ancestors lived in dread of their mortal enemy, the saber-toothed tiger, those cave men (and women) who were fortunate enough to be genetically endowed with the quickest "fight or flight" reactions survived, and became our ancestors. That's where the story begins... a story which flourishes today in a medical-legal climate where Post-Traumatic Stress Disorder (PTSD) claims comprise a substantial and costly portion of personal injury and employment litigation....

Introduction

Until recent years, personal injury claims generally alleged orthopedic injuries from automobile, industrial or slip and fall accidents. A small portion alleged neurological injuries, but those involving the brain were limited to closed head injuries and brain trauma: mental trauma, i.e., psychological injury, was rarely a basis for litigated claims. However, the recent sea change in our cultural and social attitudes has resulted in an epidemic of psychological injury claims not only in connection with personal injury suits but also as a by-product of "repressed memory/false memory" hysteria as well as in the field of employment law where sexual harassment and discrimination claims alleging PTSD are growing with leaps and bounds. The dramatic size of several recent psychological injury/ sexual harassment awards (e.g. $7 million punitive damages against the San Francisco law firm Baker and Mckenzie) has not escaped the attention of trial attorneys. As a result, the plaintiff's bar is developing increased psychological sophistication, both in selecting cases and litigating them. Consequently, in both Personal Injury and Employment Law, Psychological Injuries now comprise an important component of claims. This change in the litigation climate makes it essential for both insurance and employment law defense counsel, as well as claims adjusters, to become knowledgeable about the medical-legal concept of mental trauma.

Among the various psychiatric diagnoses found in psychological injury claims, the major stress diagnosis, PTSD, is one of the most highly compensated. Consequently, in recent years natural disasters (such as earthquakes, floods or fires) or man-made disasters (such as airplane crashes, industrial accidents, assault, rape) as well as workplace allegations of discrimination, abuse or sexual harassment, have generated a rising tide of psychological damage claims with allegations of PTSD. As a result, in order to properly manage these claims, both defense counsel and insurance claims adjusters require a sophisticated and detailed understanding of the psychiatric diagnosis of PTSD: what it is, and -- possibly more importantly -- what it is not.
The diagnostic criteria for PTSD are complex encompassing event, re-experiencing and numbing phenomena. Although some claimants unquestionably meet these criteria, other individuals may not. Knowing how to distinguish between the two groups will make it easier for a defense team to defeat inappropriate claims as well as rapidly settle and avoid costly litigation of claims that are clearly legitimate.

Since many members of the plaintiff's bar remain unsophisticated in their understanding of how to assess and litigate psychological injuries (as opposed to the more concrete closed head injuries), the defense team with a good understanding of the nature of this type of injury will have a decided advantage.

The History of PTSD

Called PTSD since the Viet Nam War, this condition had a long and interesting history. This stress syndrome has been called many things in the 150 years since it was first recognized but every definition had several characteristics in common, including re-experiencing, numbing and physiological arousal. The process of Darwinian "natural selection" supported the evolution of people with highly developed stress responses; those pre-historic people with the most effective "fight or flight" reflexes became our ancestors. Curiously, during the 19th Century, what is known today as PTSD was called "Railway Spine" and was associated with what we would today call "hysterical" physical symptoms -- i.e. "anxiety" expressed as bodily complaints -- seen in people who had been involved in railway accidents but who suffered no bodily injuries.

Fight or Flight

"Fight or flight" is driven by the neuro-chemical hormone adrenaline and results in a range of psycho-physiological responses to danger. These include increased pupil size so that more information can enter the eye, increased heart rate so that oxygen can be pumped to the muscles and brain, and the conversion of glycogen to glucose so that rapidly contracting muscles and essential organs are supplied with sufficient energy to function. These physiological changes encourage men and women to become aggressive or rapidly run away when confronted by danger.

Modern man is still "hard wired" with this physiological reflex--it is our legacy from ancient times. However, when a man or woman employed in business or a profession is feeling threatened in their workplace or boardroom, they would be regarded as bizarre if they suddenly rose from their chair and ran from the room or engaged in physical combat with an opponent. Under most circumstances, threats as perceived may not be threats in reality and the threatened person must sit and bear it. This conflict between our minds and our physiological reflexes is responsible for the modern medical entities known as Stress Response Syndromes. Stress is also responsible for a range of secondary illnesses that can arise from the work environment including cardiovascular and immune system diseases.

PTSD is a condition that arises from exposure to life-threatening circumstances and it was first diagnoses among some of the survivors of wartime combat. Throughout W.W.I the syndrome was known as "Shell Shock" and was thought to be primarily motivated by the soldier's effort at self preservation. In World War II it was called "War Neurosis" or "Combat Fatigue." The modern diagnosis of PTSD, a by-product of the Viet Nam War, falls within the general DSM-IV category of "Anxiety Disorders," sub-category of "Stress Disorders." Listed below are the DSM-IV's diagnostic criteria for PTSD, followed by my detailed discussion of these criteria.

PTSD is a Discreet Phenomenon, not a Continuum

Like pregnancy, PTSD is defined as something one has or does not have: for medical-legal purposes, there are no "shades of PTSD gray" (even though in actuality and in some current research, the condition is viewed more in terms of a gradient of symptoms). Medical-legally, however, one is either in or out of the diagnosis, according to whether or not the individual fulfills the six specific, detailed criteria, the so-called "A-F" criteria.

The "A" Criteria, the Event: A Threshold Concept

In a nutshell, the "A" criteria require an individual to have been exposed to a life-threatening circumstance. Earlier incarnations of the DSM used a broad and overly inclusive yardstick, "outside of the range of normal human experience," but this criterion was considered too loose and was easily abused in its interpretation. With the recent publication of DSM-IV , the "A" criteria have been tightened considerably. The new wording requires that "the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death (emphasis added) ." Even the secondary phrase, "or serious injury, or a threat to the physical integrity of self or others" implies a grave degree of bodily threat. It was the intention of the DSM-IV subcommittee to tighten the "A" criteria so that it conformed more closely to the kind of actual life-threatening circumstances, such as combat, where PTSD was first observed. In essence, the trauma must be sufficiently severe that it ruptures a person's "bubble of invulnerability." Most of the time people avoid thinking about the possibility of death in order to carry on their daily lives without constant, high levels of anxiety.

The Re-Experiencing or "B" Criteria

PTSD victims re-experience the trauma over and over and over again, in a variety of different ways. This results from the psyche's effort to "master" overwhelming perceptual stimuli. The event is revisited repeatedly in an effort to manage and eventually integrate the traumatic stimuli that originally overwhelmed the victim's psychological equilibrium. The "B" criteria include five different re-experiencing phenomena, any one of which is deemed sufficient to meet this diagnostic criterion.

-----Recurrent or Intrusive Distressing Recollections of the Event, Including Images, Thoughts or Perceptions.
Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed
PTSD victims are never able to quite "forget" the event which traumatized them. They think/dream about it intermittently throughout their waking (and sleeping) hours and often feel persecuted by their inability to repress the recurrent distressing images.

-----Recurrent or Distressing Dreams of the Event.
Note: In Children there may be frightening dreams without recognizable content.
These recurrent images of the trauma intrude upon the victim's sleep in the form of disturbing dreams and nightmares. Unlike normal dreams, which utilize symbolism to conceal from consciousness the dreamer's actual life conflicts and concerns, PTSD dreams are often literal representations of the traumatic event. The starkly realistic presentation of the dreamer's traumatic experience reflects the psyche's inability to master, process and integrate these overwhelming stimuli, through the disguising processes of sublimation and symbol formation.

-----Acting Or Feeling As If The Traumatic Event Were Recurring (Includes A Sense Of Reliving The Experience, Illusions, Hallucinations And Dissociative Flashback Episodes, Including Those That Occur On Awakening Or When Intoxicated).
Note: In young children, trauma-specific reenactment may occur.
The victim frequently feels a sense of deja vu as if reliving the experience, sometimes in the form of illusions or hallucinations, frequently when in physiologically altered states of consciousness such as those induced by alcohol, drugs or sleep. Young children may actually re-enact the traumatic events in their play behavior, alone or with others.

-----Intense Psychological Distress At Exposure To Internal Or External Cues That Symbolize Or Resemble An Aspect Of The Traumatic Event.
PTSD victims may experience extreme anxiety or even panic upon exposure to circumstances that either literally or symbolically remind them of the traumatic circumstances.

-----Physiological Reactivity On Exposure Or Internal Or External Cues That Symbolize Or Resemble An Aspect Of The Traumatic Event.
Traumatized Viet Nam War combat veterans, for example, frequently confuse their perceptions from ordinary experiences of every day life with those that date back to the traumatic event. For example, a traumatized combat veteran hearing an automobile muffler backfiring, may experience the sound as if it is wartime gunfire. Accordingly, the person may re-experience the full range of psycho-physiological responses known as "combat alert" (akin to "fight or flight reactions") as if he were back on the battlefield.

The Numbing And Avoidance Or "C" Criteria

Persistent Avoidance Of Stimuli Associated With The Trauma And Numbing Of General Responsiveness (Not Present Before The Trauma), As Indicated By Three (Or More) Of The Following: As a psychological defense against being overwhelmed and feeling helpless, traumatized individuals are constantly oscillating between re-experiencing the trauma and trying to avoid it. Their efforts to avoid may take many forms, of which any three listed below fulfills the "C" criteria.

-----Efforts To Avoid Thoughts, Feelings, Or Conversations Associated With The Trauma

An airline stewardess who was brutally raped and beaten in a hotel during a work related "layover," for several weeks told no one about the assault, not her fellow employees nor her family, and only admitted the assault when her grown daughter pressed her to explain why her mood was so different.

-----Efforts To Avoid Activities, Places Or People That Arouse Recollections Of The Trauma

Typically, someone who suffers from PTSD will avoid revisiting the site of the trauma. A young woman who was savagely beaten, kicked in the head, and believed she was going to be killed by hoodlums who assaulted her in the parking lot of a well known national restaurant chain, avoided ever revisiting not just the particular restaurant where the assault occurred but any other facility with the chain's name on it.

-----Inability To Recall An Important Aspect Of The Trauma

Not infrequently, a seriously traumatized person will be amnesic for particular events or periods of time during the trauma. They may say that their memory is like a stop-frame movie from which moments or extended periods of time are lost and the memory jumps from before to after the missing segments.

-----Markedly Diminished Interest Or Participation In Significant Activities

Another young woman who was beaten in the restaurant parking lot incident referred to above underwent a dramatic personality change following the assault: she was transformed from an outgoing, vivacious, independent and "feisty" young person, someone who performed publicly in an entertainment group, to a frightened, withdrawn, isolated girl who would not even leave her house to go food shopping without the protective companionship of family members. In her withdrawn state, she gained fifty pounds, creating an additional "buffer zone" around herself that shielded her from the outside world.

-----Feeling Of Detachment Or Estrangement From Others

More than simple detachment or loneliness, PTSD victims tend to experience themselves as "outside looking in," as though they are no longer a part of life's events but are beyond a transparent barrier, restricted to the role of an observer.

-----Restricted Range Of Affect (e.g., Unable To Have Loving Feelings)

It is very common for those suffering from PTSD to suddenly lose the ability to experience strong feelings, for example an inability to love or to care about others who are dear to them. This disconnectedness can seriously damage marital, parent-child or workplace relationships.

-----Sense Of Foreshortened Future (e.g., Does Not Expect To Have A Career, Marriage, Children, Or A Normal Life Span)

Not infrequently, people with PTSD no longer think of themselves as having a future. This is not the same as having suicidal feelings, since the victim has neither the plan nor the intention of killing himself. Rather, these thoughts result from the sudden rupture of their "bubble of invulnerability." Having experienced a close encounter with death, it's ever presence can no longer be effectively denied. PTSD victims may simply resign themselves to the belief that sooner rather than later, life will end.

Symptoms Of Increased Arousal, The "D" Criteria

Due to the effects of adrenaline directly upon the central nervous system, PTSD is always associated with signs of increased arousal (not present before the trauma) as indicated by two (or more) of the following:

-----Difficulty Falling Or Staying Asleep

Sleep disturbances usually begin immediately after the trauma, although in some cases upsetting dreams may not occur for days, weeks or even months. Typically, the PTSD patient has difficulty falling asleep or staying asleep, fearing that something terrible may again happen to them if they relax their guard against sleep. Instead of sleeping, they remain alert. One traumatized woman compromised between her conflicting impulses to remain awake and needing sleep by setting her alarm clock to awaken her every two hours, throughout the night, in order to inspect all the rooms of her house and reassure herself that no intruders were present. Soon, however, she awakened throughout the night at two hourly intervals before the alarm sounded. This practice continued for years after the trauma.

-----Irritability Or Outbursts Of Anger

Irritability and sometimes rapid fluctuations of mood occur with most people who suffer from this disorder. Sometimes it is experienced as "waves of emotion" that cause the PTSD patient to rapidly shift between focused attention and tearfulness. At other times, tempers are short and the victim "snaps" angrily and inappropriately at friends, family or colleagues. This lability of mood is worsened by the ingestion of alcohol or intoxicating drugs.

-----Difficulty Concentrating

Typically, PTSD patients have difficulty reading. If they can read, it is only for very brief intervals, or only illustrated magazines. Even watching television, although easier than reading, may be marked by lapses of attention and difficulty staying focused. The attention difficulties are likely to be the result of intrusive thoughts or images that both distract attention and increase feelings of anxiety. The entire process feels "out of control" which, in a self reinforcing manner, further increases anxiety and decreases attention.

-----Hypervigilance

Hypervigilance, or the state of being in extreme alert, is partially driven by the central nervous system's response to increased adrenaline and partially by the confusion of perceptions described above as the re-experiencing or "B" criteria.

-----Exaggerated Startle Response

This is also a symptom of the physiologically stimulated central nervous system anticipating further frightening experiences , similar to the original overwhelming trauma. In certain natural catastrophes, such as earthquakes, victims are repeatedly re-traumatized for days or weeks as aftershocks recur. Marked anxiety results in brisk physiological reflex responses including an exaggerated startle response. One individual originally traumatized by the San Francisco Loma Prieta Earthquake of 1989 and subsequently by aftershocks, eventually developed large reactions to shocks of even minute magnitude. Eventually, his nervous system was so tense in anticipation of the possibility of another large quake that he remained in a state of high alert: he startled easily, and his feet left the ground if anyone closed a door behind him or made a noise unexpectedly.

The duration of the disturbance (i.e. the symptoms in criteria b,c and d) lasts longer than one month. This is a somewhat arbitrary criterion. However, its purpose is to distinguish between brief, transient stress response reactions (called in the DSM-IV Acute Stress Disorder) and the more serious, lasting, Post-Traumatic Stress Disorder. Nevertheless, for practical clinical purposes, if a psychiatrist or other mental health professional strongly suspects a diagnosis of PTSD because of the enormity of the trauma and the presence of sufficient B,C and D criteria symptoms, it would be irrational and medically inappropriate to delay treatment for 30 days until the duration criterion had been fulfilled, especially since the best recoveries from PTSD occur when therapeutic measures are introduced early. For litigation purposes, however, "premature" PTSD diagnoses can be attacked when they are applied to symptoms that have not lasted for a minimum of one month. Often these are Acute Stress Reactions that will resolve spontaneously within a short time.

Clinically Significant Distress Or Impairment In Social, Occupational Or Other Important Areas Of Functioning, The "F" Criterion

The "F" criterion means that simply fulfilling the "A - E" criteria is not, in itself, enough to make the diagnosis of PTSD. In addition, the condition must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Of course, "clinically significant" is a broad concept that is subject to a wide range of interpretations based upon the examining clinician's experience and judgment. However, the individual's family, work, school and social lives are explored in detail to determine if this criterion is met. For practical purposes, it is difficult to conceive of a situation in which the Event Criterion is met and the "B - F" criteria are adequately met and the individual does not demonstrate clinically significant distress or functional impairment in these other areas of their life. If a claimant shows no significant impairment of functioning in work, social or family life, it is highly unlikely that they are suffering from genuine PTSD.

Acute, Chronic Or Delayed Onset

Finally, the PTSD diagnosis requires a specification of "Acute" (if the duration of symptoms is less than three months), "Chronic" (if the duration of symptoms is three months or more), or "Delayed Onset" (if the onset of symptoms is at least six months after the stressor).

Differential Diagnosis

As with many psychological conditions, individuals experiencing PTSD may be diagnosed with other problems. These "differential," or alternative, diagnoses include Adjustment Disorder, Acute Stress Disorder, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Mood Disorder, Substance Abuse, Organic Brain Syndrome and Malingering. The existence of nine diverse alternative diagnoses indicates that some of the signs and symptoms of PTSD are also found in other mental conditions. However, this multiplicity of alternatives neither indicates that PTSD is an imprecise diagnosis nor that it is very difficult to accurately determine. Nevertheless, the diagnosis will only be accurate to the extent that the examiner has carefully evaluated a person in terms of the very specific "A" through "F" criteria.

Psychoanalysts Are Particularly Suited To Talk To A Jury

Psychoanalysts are psychiatrists (M.D.'s) or psychologists (Ph.D.'s) who have completed extensive advanced training beyond that required for their psychiatric or psychological certifications. They are specifically trained as careful observers who can understand a person's present behavior in terms of their past experiences. This perspective enables psychoanalysts to supplement the static DSM-IV diagnosis with a dynamic psycho-historical understanding of why an individual behaves in a particular way. Because this is an explanation drawn ultimately from the individual's unique life story, it is frequently heard by a jury as more plausible and comprehensible than an assemblage of dry criteria and technical jargon. Simply stated, psychoanalysts are able to "tell a story" that is cohesive, interesting and that makes sense to a careful listener. It is not surprising, therefore, that many of the most effective psychiatric medical-legal experts are also trained psychoanalysts.

Treatment Of PTSD

For most individuals suffering from PTSD, the treatment consists of psychotherapy and pharmacotherapy.
-----Psychotherapy. Psychotherapy has as its purpose to help the individual master and integrate the overwhelming stimuli generated by the traumatic event. One very effective method is abreaction which is helping the patient discuss and re-experience the ideas and emotions associated with trauma in the safety of a therapeutic setting so that these reactions can be mastered. This therapy may necessitate that the patient review the events that occurred as well as their own actions and emotional reactions to those events. Depending upon the strength of the psychological defenses of a person who has PTSD, psychotherapeutic treatment may be required for a period lasting from six months to several years. Since estimated length of required treatment is an important parameter of any settlement negotiation, it is very important for the psychiatric expert consultant to carefully review these estimates in terms of the plaintiff's general level of defensive functioning. For example, a PTSD plaintiff who is able to adjust to a new job, successfully manage intimate relationships or embark upon arduous vacation travel is unlikely to have markedly impaired psychological defenses and will probably not require extensive treatment.
Another aspect of psychotherapy is didactic, i.e. educational. The patient is told what he or she is likely to expect in the days, weeks and months ahead, so that those reactions can be anticipated and not experienced as a loss of control or feeling "crazy," feelings which may further traumatize the victim, by temporarily increasing his/her anxiety and delaying recovery. This aspect of the therapy can be accomplished either in individual sessions or in a group debriefing session lead by a knowledgeable therapist who is experienced both in conducting PTSD debriefings and in treating people with this condition.

-----Psychopharmacotherapy. Excessive anxiety or sleep disturbance can frequently be managed with temporary prescription of minor anti-anxiety medications such as Xanax (alprazolam) or Ativan (lorazepam). Transient sleep disturbances can be managed with the short term use of mild hypnotics (sleeping pills) such as Dalmane (flurazepam) or Restoril (tamazepam). All of these medications contain the potential for abuse and addiction.

Depression And Guilt. Not infrequently, significant depression also develops during the days and weeks following a traumatic event, especially if the traumatized individual feels rational or irrational responsibility for the trauma, feels guilt that he/she survived while others did not (survivor's guilt), or if the traumatic event and resulting losses resonate consciously and unconsciously with significant earlier life losses experienced by the individual. Under these circumstances, more intensive treatment is required. Psychotherapy must investigate and explore both the early life experiences and losses that have been re-activated by the recent traumatic event. As an adjunct to psychotherapy, anti-depressant medication such as Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine) or Wellbutrin (buproprion) may be very helpful in rapidly relieving depressive symptoms, reducing anxiety and restoring normal sleep. Antidepressant medications are all non-addictive.


http://expertpages.com/news/ptsd.htm

From May/June 2004 "Psychotherapy Networker"
. . . . .

CLINICIAN'S DIGEST

By Garry Cooper

New Views on Depression
Diagnosis and Treatment

In Diagnoses originally formulated to sharply delineate a mental disorder often grow fuzzy over time. Nevertheless, therapists can become so accustomed to them that we fail to recognize their imprecision and lack of clinical usefulness. Depression is a good example. Evolving research indicates that even the current DSM breakdown of depression into major, dysthymic, recurrent, single episode, and not otherwise specified doesn’t adequately describe the condition, and that a clearer conceptual map of depression is needed to help therapists make better treatment decisions, tailored to each individual client.

Using brain imaging to study the brains of depressed people, Emory University neurologist Helen Mayberg has found at least three different neural pathways for depression. Mayberg says that diagnosing depression is like diagnosing a weak arm in someone. “A lot of things can give you a weak arm,” she adds, “but you’d never suggest the same treatment for everyone with a weak arm. You have to understand what’s causing it.” Many new depression researchers believe that the key to more sharply diagnosing and treating depression may lie in better history-taking, a more precise neurological roadmap, or both.

In her latest study, Mayberg used brain scans to find out how antidepressants and cognitive behavior therapy (CBT) affected the brains of people who responded positively to their treatments. Published in the January Archives of General Psychiatry, the study results indicate that people who undergo 15 to 20 sessions of successful CBT show decreasing brain activity in the frontal cortex—the “higher” level of the brain linked to how we think about ourselves. This decrease in higher-brain activity translates into less brooding and less likelihood of responding to negative circumstances with self-critical thinking, which are the kinds of changes that CBT promotes. Mayberg’s brain scans reveal that the dampening down of these brain regions then leads to increased activity in the more primitive limbic levels, where emotions are brewed and memories formed. As these brain changes occur, people are more likely to take action, to respond with emotional energy, and to learn new ways of responding to negative situations. The brain scans of CBT clients thus reveal a top-down action—a decrease in higher-level negative thoughts and an increase in lower-level emotional energy.

In contrast, the brains of people whose depression improved with paroxetine show decreased activity in the more primitive brain regions, followed by an increase in the higher, cognitive levels. These may be the people who, before treatment, respond to negative situations more viscerally than cognitively. This visceral reaction may flood the higher brain levels with negative affect and fuel negative thoughts. By decreasing activity in the primitive, limbic brain centers, antidepressants may shut off the negative emotional ignition and free the cognitive levels to make more accurate appraisals of external events.

The different actions of medications and CBT, says Mayberg, may explain why some depressed people do worse on antidepressants: if you give antidepressants to someone whose depression is triggered by higher-level negative thinking, the medication may actually increase the depressed or anxious thoughts, while suppressing the emotional energy of the limbic brain areas.

Resources
New Views On Depression Diagnosis: Archives of General Psychiatry (January 2004): 34-41.



From the Editor - Case Study - In Consultation - Networker News - Tools of the Trade
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©Psychotherapy Networker Inc 2003

From The New England Journal of Medicine
http://content.nejm.org/cgi/content/full/351/1/13

Previous Volume 351:13-22 July 1, 2004 Number 1

Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care

Charles W. Hoge, M.D., Carl A. Castro, Ph.D., Stephen C. Messer, Ph.D., Dennis McGurk, Ph.D., Dave I. Cotting, Ph.D., and Robert L. Koffman, M.D., M.P.H.


Editorial
by Friedman, M. J.

ABSTRACT

Background The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.

Methods We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.

Results Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

Conclusions This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.


The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including post-traumatic stress disorder (PTSD), major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of health care services.1,2,3,4,5,6,7,8 One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6 percent of all U.S. military service members on active duty receive treatment for a mental disorder each year.9 Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important health care concern among those serving there.
Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended.1,2,3,4,5,6,7,8 A problem in the methods of such studies is the long recall period after exposure to combat.10 Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment.

Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment11 and is encouraged in primary care settings,12 we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment.

We studied the prevalence of mental health problems among members of the U.S. armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.

Methods

Study Groups

We summarized data from the first, cross-sectional phase of a longitudinal study of the effect of combat on the mental health of the soldiers and Marines deployed in Operation Iraqi Freedom and in Operation Enduring Freedom in Afghanistan. Three comparable U.S. Army units were studied with the use of an anonymous survey administered either before deployment to Iraq or after their return from Iraq or Afghanistan. Although no data from before deployment were available for the Marines in the study, data were collected from a Marine Corps unit after its return from Iraq that provided a basis for comparison with data obtained from Army soldiers after their return from Iraq.

The study groups included 2530 soldiers from an Army infantry brigade of the 82nd Airborne Division, whose responses to the survey were obtained in January 2003, one week before a year-long deployment to Iraq; 1962 soldiers from an Army infantry brigade of the 82nd Airborne Division, whose responses were obtained in March 2003, after the soldiers' return from a six-month deployment to Afghanistan; 894 soldiers from an Army infantry brigade of the 3rd Infantry Division, whose responses were obtained in December 2003, after their return from an eight-month deployment to Iraq; and 815 Marines from two battalions under the command of the 1st Marine Expeditionary Force, whose responses were obtained in October or November 2003, after a six-month deployment to Iraq. The 3rd Infantry Division and the Marine battalions had spearheaded early ground-combat operations in Iraq, in March through May 2003. All the units whose members responded to the survey were also involved in hazardous security duties. The questionnaires administered to soldiers and Marines after deployment to Iraq or Afghanistan were administered three to four months after their return to the United States. This interval allowed time in which the soldiers completed leave, made the transition back to garrison work duties, and had the opportunity to seek medical or mental health treatment, if needed.

Recruitment and Representativeness of the Sample

Unit leaders assembled the soldiers and Marines near their workplaces at convenient times, and the study investigators then gave a short recruitment briefing and obtained written informed consent on forms that included statements about the purpose of the survey, the voluntary nature of participation, and the methods used to ensure participants' anonymity. Overall, 58 percent of the soldiers and Marines from the selected units were available to attend the recruitment briefings (79 percent of the soldiers before deployment, 58 percent of the soldiers after deployment in Operation Enduring Freedom in Afghanistan, 34 percent of the soldiers after deployment in Operation Iraqi Freedom, and 65 percent of the Marines after deployment in Operation Iraqi Freedom). Most of those who did not attend the briefings were not available because of their rigorous work and training schedules (e.g., night training and post security).

A response was defined as completion of any part of the survey. The response rate among the soldiers and Marines who were briefed was 98 percent for the four samples combined. The rates of missing values for individual items in the survey were generally less than 15 percent; 2 percent of participants did not complete the PTSD measures, 5 percent did not complete the depression and anxiety measures, and 7 to 8 percent did not complete the items related to the use of alcohol. The high response rate was probably owing to the anonymous nature of the survey and to the fact that participants were given time by their units to complete the 45-minute survey. The study was conducted under a protocol approved by the institutional review board of the Walter Reed Army Institute of Research.

To assess whether or not our sample was representative, we compared the demographic characteristics of respondents with those of all active-duty Army and Marine personnel deployed to Operation Iraqi Freedom and Operation Enduring Freedom, using the Defense Medical Surveillance System.13

Survey and Mental Health Outcomes

The study outcomes were focused on current symptoms (i.e., those occurring in the past month) of a major depressive disorder, a generalized anxiety disorder, and PTSD. We used two case definitions for each disorder, a broad screening definition that followed current psychiatric diagnostic criteria14 but did not include criteria for functional impairment or for severity, and a strict (conservative) screening definition that required a self-report of substantial functional impairment or a large number of symptoms. Major depression and generalized anxiety were measured with the use of the patient health questionnaire developed by Spitzer et al.15,16,17 For the strict definition to be met, there also had to be evidence of impairment in work, at home, or in interpersonal functioning that was categorized as at the "very difficult" level as measured by the patient health questionnaire. The generalized anxiety measure was modified slightly to avoid redundancy; items that pertained to concentration, fatigue, and sleep disturbance were drawn from the depression measure.

The presence or absence of PTSD was evaluated with the use of the 17-item National Center for PTSD Checklist of the Department of Veterans Affairs.4,8,18,19 Symptoms were related to any stressful experience (in the wording of the "specific stressor" version of the checklist), so that the outcome would be independent of predictors (i.e., before or after deployment). Results were scored as positive if subjects reported at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms14 that were categorized as at the moderate level, according to the PTSD checklist. For the strict definition to be met, the total score also had to be at least 50 on a scale of 17 to 85 (with a higher number indicating a greater number of symptoms or greater severity), which is a well-established cutoff.4,8,18,19 Misuse of alcohol was measured with the use of a two-question screening instrument.20

In addition to these measures, on the survey participants were asked whether they were currently experiencing stress, emotional problems, problems related to the use of alcohol, or family problems and, if so, whether the level of these problems was mild, moderate, or severe; the participants were then asked whether they were interested in receiving help for these problems. Subjects were also asked about their use of professional mental health services in the past month or the past year and about perceived barriers to mental health treatment, particularly stigmatization as a result of receiving such treatment.21 Combat experiences were modified from previous scales.22

Quality-Control Procedures and Analysis

Responses to the survey were scanned with the use of ScanTools software (Pearson NCS). Quality-control procedures identified scanning errors in no more than 0.38 percent of the fields (range, 0.01 to 0.38 percent). SPSS software (version 12.0) was used to conduct the analyses, including multiple logistic regression that was used to control for differences in demographic characteristics of members of study groups before and after deployment.23,24

Results

The demographic characteristics of participants from the three Army units were similar. The Marines in the study were somewhat younger than the soldiers in the study and less likely to be married. The demographic characteristics of all the participants in the survey samples were very similar to those of the general, deployed, active-duty infantry population, except that officers were undersampled, which resulted in slightly lower age and rank distributions (Table 1). Data for the reference populations were obtained from the Defense Medical Surveillance System with the use of available rosters of Army and Marine personnel deployed to Iraq or Afghanistan in 2003 (Table 1).


Table 1. Demographic Characteristics of Study Groups of Soldiers and Marines as Compared with Reference Groups.
http://content.nejm.org/cgi/content-nw/full/351/1/13/T1


Among the 1709 soldiers and Marines who had returned from Iraq the reported rates of combat experiences and frequency of contact with the enemy were much higher than those reported by soldiers who had returned from Afghanistan (Table 2). Only 31 percent of soldiers deployed to Afghanistan reported having engaged in a firefight, as compared with 71 to 86 percent of soldiers and Marines who had been deployed to Iraq. Among those who had been in a firefight, the median number of firefights during deployment was 2 (interquartile range, 1 to 3) among those in Afghanistan, as compared with 5 (interquartile range, 2 to 13; P<0.001 by analysis of variance) among soldiers deployed to Iraq and 5 (interquartile range, 3 to 10; P<0.001 by analysis of variance) among Marines deployed to Iraq.


Table 2. Combat Experiences Reported by Members of the U.S. Army and Marine Corps after Deployment to Iraq or Afghanistan.
http://content.nejm.org/cgi/content/full/351/1/13/T2


Soldiers and Marines who had returned from Iraq were significantly more likely to report that they were currently experiencing a mental health problem, to express interest in receiving help, and to use mental health services than were soldiers returning from Afghanistan or those surveyed before deployment (Table 3). Rates of PTSD were significantly higher after combat duty in Iraq than before deployment, with similar odds ratios for the Army and Marine samples (Table 3). Significant associations were observed for major depression and the misuse of alcohol. Most of these associations remained significant after control for demographic factors with the use of multiple logistic regression (Table 3). When the prevalence rates for any mental disorder were adjusted to match the distribution of officers and enlisted personnel in the reference populations, the result was less than a 10 percent decrease (range, 3.5 to 9.4 percent) in the rates shown in Table 3 according to both the broad and the strict definitions (data not shown).


Table 3. Perceived Mental Health Problems and Percentage of Subjects Who Met the Screening Criteria for Major Depression, Generalized Anxiety, Post-Traumatic Stress Disorder, and Alcohol Misuse.
http://content.nejm.org/cgi/content-nw/full/351/1/13/T3


For all groups responding after deployment, there was a strong reported relation between combat experiences, such as being shot at, handling dead bodies, knowing someone who was killed, or killing enemy combatants, and the prevalence of PTSD. For example, among soldiers and Marines who had been deployed to Iraq, the prevalence of PTSD (according to the strict definition) increased in a linear manner with the number of firefights during deployment: 4.5 percent for no firefights, 9.3 percent for one to two firefights, 12.7 percent for three to five firefights, and 19.3 percent for more than five firefights (chi-square for linear trend, 49.44; P<0.001). Rates for those who had been deployed to Afghanistan were 4.5 percent, 8.2 percent, 8.3 percent, and 18.9 percent, respectively (chi-square for linear trend, 31.35; P<0.001). The percentage of participants who had been deployed to Iraq who reported being wounded or injured was 11.6 percent as compared with only 4.6 percent for those who had been deployed to Afghanistan. The rates of PTSD were significantly associated with having been wounded or injured (odds ratio for those deployed to Iraq, 3.27; 95 percent confidence interval, 2.28 to 4.67; odds ratio for those deployed to Afghanistan, 2.49; 95 percent confidence interval, 1.35 to 4.40).

Of those whose responses met the screening criteria for a mental disorder according to the strict case definition, only 38 to 45 percent indicated an interest in receiving help, and only 23 to 40 percent reported having received professional help in the past year (Table 4). Those whose responses met these screening criteria were generally about two times as likely as those whose responses did not to report concern about being stigmatized and about other barriers to accessing and receiving mental health services (Table 5).


Table 4. Perceived Need for and Use of Mental Health Services among Soldiers and Marines Whose Survey Responses Met the Screening Criteria for Major Depression, Generalized Anxiety, or Post-Traumatic Stress Disorder.
http://content.nejm.org/cgi/content-nw/full/351/1/13/T4


Table 5. Perceived Barriers to Seeking Mental Health Services among All Study Participants (Soldiers and Marines).
http://content.nejm.org/cgi/content-nw/full/351/1/13/T5



Discussion

We investigated mental health outcomes among soldiers and Marines who had taken part in the ground-combat operations in Iraq and Afghanistan. Respondents to our survey who had been deployed to Iraq reported a very high level of combat experiences, with more than 90 percent of them reporting being shot at and a high percentage reporting handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant (Table 2). Close calls, such as having been saved from being wounded by wearing body armor, were not infrequent. Soldiers who served in Afghanistan reported lower but still substantial rates of such experiences in combat.

The percentage of study subjects whose responses met the screening criteria for major depression, PTSD, or alcohol misuse was significantly higher among soldiers after deployment than before deployment, particularly with regard to PTSD. The linear relationship between the prevalence of PTSD and the number of firefights in which a soldier had been engaged was remarkably similar among soldiers returning from Iraq and Afghanistan, suggesting that differences in the prevalence according to location were largely a function of the greater frequency and intensity of combat in Iraq. The association between injury and the prevalence of PTSD supports the results of previous studies.25

These findings can be generalized to ground-combat units, which are estimated to represent about a quarter of all Army and Marine personnel participating in Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan (when members of the Reserve and the National Guard are included) and nearly 40 percent of all active-duty personnel (when Reservists and members of the National Guard are not included). The demographic characteristics of the subjects in our samples closely mirrored the demographic characteristics of this population. The somewhat lower proportion of officers had a minimal effect on the prevalence rates, and potential differences in demographic factors among the four study groups were controlled for in our analysis with the use of logistic regression.

One demonstration of the internal validity of our findings was the observation of similar prevalence rates for combat experiences and mental health outcomes among the subjects in the Army and the Marine Corps who had returned from deployment to Iraq, despite the different demographic characteristics of members of these units and their different levels of availability for recruitment into the study.

The cross-sectional design involving different units that was used in our study is not as strong as a longitudinal design. However, the comparability of the Army samples and the similarity in outcomes among subjects in the Army and Marine units surveyed after deployment to Iraq should generate confidence in the cross-sectional approach. Another limitation of our study is the potential selection bias resulting from the enrollment procedures, which were influenced by the practical realities that resulted from working with operational units. Although work schedules affected the availability of soldiers to take part in the survey, the effect is not likely to have biased our results. However, the selection procedures did not permit the enrollment of persons who had been severely wounded or those who may have been removed from the units for other reasons, such as misconduct. Thus, our estimates of the prevalence of mental disorders are conservative, reflecting the prevalence among working, nondisabled combat personnel. The period immediately before a long combat deployment may not be the best time at which to measure baseline levels of distress. The magnitude of the differences between the responses before and after deployment is particularly striking, given the likelihood that the group responding before deployment was already experiencing levels of stress that were higher than normal.

The survey instruments used to screen for mental disorders in this study have been validated primarily in the settings of primary care and in clinical populations. The results therefore do not represent definitive diagnoses of persons in nonclinical populations such as our military samples. However, requiring evidence of functional impairment or a high number of symptoms, as we did, according to the strict case definitions, increases the specificity and positive predictive value of the survey measures.26,27 This conservative approach suggested that as many as 9 percent of soldiers may be at risk for mental disorders before combat deployment, and as many as 11 to 17 percent may be at risk for such disorders three to four months after their return from combat deployment.

Although there are few published studies of the rates of PTSD among military personnel soon after their return from combat duty, studies of veterans conducted years after their service ended have shown a prevalence of current PTSD of 15 percent among Vietnam veterans28 and 2 to 10 percent among veterans of the first Gulf War.4,8 Rates of PTSD among the general adult population in the United States are 3 to 4 percent,26 which are not dissimilar to the baseline rate of 5 percent observed in the sample of soldiers responding to the survey before deployment. Research has shown that the majority of persons in whom PTSD develops meet the criteria for the diagnosis of this disorder within the first three months after the traumatic event.29 In our study, administering the surveys three to four months after the subjects had returned from deployment and at least six months after the heaviest combat operations was probably optimal for investigating the long-term risk of mental health problems associated with combat. We are continuing to examine this risk in repeated cross-sectional and longitudinal assessments involving the same units.

Our findings indicate that a small percentage of soldiers and Marines whose responses met the screening criteria for a mental disorder reported that they had received help from any mental health professional, a finding that parallels the results of civilian studies.30,31,32 In the military, there are unique factors that contribute to resistance to seeking such help, particularly concern about how a soldier will be perceived by peers and by the leadership. Concern about stigma was disproportionately greatest among those most in need of help from mental health services. Soldiers and Marines whose responses were scored as positive for a mental disorder were twice as likely as those whose responses were scored as negative to show concern about being stigmatized and about other barriers to mental health care.

This finding has immediate public health implications. Efforts to address the problem of stigma and other barriers to seeking mental health care in the military should take into consideration outreach, education, and changes in the models of health care delivery, such as increases in the allocation of mental health services in primary care clinics and in the provision of confidential counseling by means of employee-assistance programs. Screening for major depression is becoming routine in military primary care settings,12 but our study suggests that it should be expanded to include screening for PTSD. Many of these considerations are being addressed in new military programs.33 Reducing the perception of stigma and the barriers to care among military personnel is a priority for research and a priority for the policymakers, clinicians, and leaders who are involved in providing care to those who have served in the armed forces.


Supported by the Military Operational Medicine Research Program, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Md.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, the U.S. government, or any of the institutions with which the authors are affiliated.

We are indebted to the Walter Reed Army Institute of Research Land Combat Study Team: Lolita Burrell, Ph.D., Scott Killgore, Ph.D., Melba Stetz, Ph.D., Paul Bliese, Ph.D., Oscar Cabrera, Ph.D., Anthony Cox, M.S.W., Timothy Allison-Aipa, Ph.D., Karen Eaton, M.S., Graeme Bicknell, M.S.W., Alexander Vo, Ph.D., and Charles Milliken, M.D., for survey-instrument design and data collection; to Spencer Campbell, Ph.D., for coordination of data collection and scientific advice; to David Couch for supervising the data-collection teams, database management, scanning, and quality control; to Wanda Cook for design and production of surveys; to Allison Whitt for survey-production and data-collection support; to Lloyd Shanklin, Joshua Fejeran, Vilna Williams, and Crystal Ross for data-collection, quality-assurance, scanning, and field support; to Jennifer Auchterlonie for assistance with Defense Medical Surveillance System analyses; to Akeiya Briscoe-Cureton for travel and administrative support; to the leadership of the units that were studied and to our medical and mental health professional colleagues at Ft. Bragg, Ft. Stewart, Camp Lejeune, and Camp Pendleton; to the Walter Reed Army Institute of Research Office of Research Management; to David Orman, M.D., psychiatry consultant to the Army Surgeon General, Gregory Belenky, M.D., and Charles C. Engel, M.D., for advice and review of the study; and, most important, to the soldiers and Marines who participated in the study for their service.


Source Information

From the Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, Md. (C.W.H., C.A.C., S.C.M., D.M., D.I.C.); and First Naval Construction Division, Norfolk, Va. (R.L.K.).

Address reprint requests to Dr. Hoge at the Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Silver Spring, MD 20910, or at charles.hoge@na.amedd.army.mil.

References


The Centers for Disease Control Vietnam Experience Study Group. Health status of Vietnam veterans. I. Psychosocial characteristics. JAMA 1988;259:2701-2707.[Abstract]
Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population: findings of the Epidemiologic Catchment Area survey. N Engl J Med 1987;317:1630-1634.[Abstract]
Jordan BK, Schlenger WE, Hough R, et al. Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls. Arch Gen Psychiatry 1991;48:207-215.[Abstract]
The Iowa Persian Gulf Study Group. Self-reported illness and health status among Gulf War veterans: a population-based study. JAMA 1997;277:238-245.[Abstract]
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060.[Abstract]
Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposures among US men. Am J Public Health 2002;92:59-63.[Abstract/Full Text]
Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001;189:99-108.[CrossRef][ISI][Medline]
Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol 2003;157:141-148.[Abstract/Full Text]
Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002;159:1576-1583.[Abstract/Full Text]
Wessely S, Unwin C, Hotopf M, et al. Stability of recall of military hazards over time: evidence from the Persian Gulf War of 1991. Br J Psychiatry 2003;183:314-322.[Abstract/Full Text]
Wright KM, Huffman AH, Adler AB, Castro CA. Psychological screening program overview. Mil Med 2002;167:853-861.[ISI][Medline]
VA/DoD clinical practice guideline for the management of major depressive disorder in adults. In: Major depressive disorder (MDD): clinical practice guidelines. Washington, D.C.: Veterans Health Administration, May 2000. (Publication no. 10Q-CPG/MDD-00.) (Accessed June 4, 2004, at http://www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm.)
Rubertone MV, Brundage JF. The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. Am J Public Health 2002;92:1900-1904.[Abstract/Full Text]
Diagnostic and statistical manual of mental disorders. 4th ed. DSM-IV. Washington, D.C.: American Psychiatric Association, 1994.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999;282:1737-1744.[Abstract/Full Text]
Lowe B, Spitzer RL, Grafe K, et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses. J Affect Disord 2004;8:131-140.
Henkel V, Mergl R, Kohnen R, Maier W, Moller HJ, Hegerl U. Identifying depression in primary care: a comparison of different methods in a prospective cohort study. BMJ 2003;326:200-201.[Full Text]
Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996;34:669-673.[CrossRef][ISI][Medline]
Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD checklist (PCL): reliability, validity, and diagnostic utility. San Antonio, Tex.: International Society of Traumatic Stress Studies, October 1993. abstract. (Accessed June 4, 2004, at http://www.pdhealth.mil/library/downloads/PCL_sychometrics.doc.)
Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract 2001;14:95-106.[Abstract/Full Text]
Britt TW. The stigma of psychological problems in a work environment: evidence from the screening of service members returning from Bosnia. J Appl Soc Psychol 2000;30:1599-1618.[ISI]
Castro CA, Bienvenu RV, Hufmann AH, Adler AB. Soldier dimensions and operational readiness in U.S. Army forces deployed to Kosovo. Int Rev Armed Forces Med Serv 2000;73:191-200.
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. Belmont, Calif.: Lifetime Learning, 1982.
Menard S. Applied logistic regression analysis. 2nd ed. Thousand Oaks, Calif.: Sage, 2002.
Friedman MJ, Schnurr PP, McDonagh-Coyle A. Post-traumatic stress disorder in the military veteran. Psychiatr Clin North Am 1994;17:265-277.[ISI][Medline]
Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry 2002;59:115-123.[Abstract/Full Text]
Hoge CW, Messer SC, Castro CA. Pentagon employees after September 11, 2001. Psychiatr Serv 2004;55:319-320.[Full Text]
Schlenger WE, Kulka RA, Fairbank JA, et al. The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 1992;5:333-363.[ISI]
Carlier IVE, Lamberts RD, Gersons BPR. Risk factors for posttraumatic stress symptomatology in police officers: a prospective analysis. J Nerv Ment Dis 1997;185:498-506.[CrossRef][ISI][Medline]
Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-3105.[Abstract/Full Text]
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50:85-94.[Abstract]
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.[Abstract]
Deployment Health Clinical Center. Deployment cycle support and clinicians — practice guidelines. (Accessed June 4, 2004, at http://www.pdhealth.mil.)


Editorial
by Friedman, M. J.



This article has been cited by other articles:


Spurgeon, D. (2004). Fear of stigma deters US soldiers from seeking help for mental health. BMJ 329: 12- [Full Text]
Friedman, M. J. (2004). Acknowledging the Psychiatric Cost of War. N Engl J Med 351: 75-77 [Full Text]



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Study: Suicide risk no greater with newer anti-depressants

BY KAREN PATTERSON
The Dallas Morning News


DALLAS - (KRT) - A newer class of anti-depressants - controversial because of fear they may fuel suicidal behavior - might not be any riskier than older drugs, a study of United Kingdom patients has found.

Risk of suicide or suicidal behavior was high in the first month of therapy - and dramatically so in the first nine days - no matter which of four drugs patients took, Boston University scientists reported Wednesday in The Journal of the American Medical Association.

The 1993-99 study drew from nearly 160,000 first-time anti-depressant users who had filled a prescription for any one of four drugs. The drugs were the United Kingdom's four most prescribed anti-depressants.

"We found there really was no difference between the four," said Susan Jick of the Boston Collaborative Drug Surveillance Program, one of the study's authors.

Prozac and Paxil were the drugs in the controversial class of medicines, called selective serotonin-reuptake inhibitors, or SSRIs. In March, the U.S. Food and Drug Administration asked drug companies to warn the public that patients using SSRIs should be monitored closely, especially at the beginning of therapy, for suicidal feelings or deepening depression.

The other drugs in the study, from an older class of anti-depressants called tricyclics, were Elavil and a drug known generically as dothiepin, which is not available in the United States.

The researchers also found that there did not appear to be any difference among the drugs in their effects on youths ages 10 to 19, a topic of widespread public debate.

"I think this actually begins to address the problems people have in assessing suicide risk with anti-depressant medicines," said Dr. Madhukar Trivedi of the University of Texas Southwestern Medical Center at Dallas. "It is a very good study."

The research focused on about 570 patients who had killed themselves or displayed suicidal behavior, comparing them with more than 2,200 others who used the drugs without such problems. Suicidal thoughts or behaviors were four times as likely to occur within nine days of filling a first anti-depressant prescription - and almost three times as likely from day 10 to 29 of the prescription - as they were more than 90 days after filling the prescription.

Risk of actual suicide was 38 times as high during the first nine days of anti-depressant use, and five times as high during the rest of the first month, compared with more than 90 days out.

Based only on that, Trivedi noted, doctors can't say there's a link between the medicines and suicidal behavior. "What we can say is that when patients are so sick that they start an anti-depressant, that the first month is fraught with risk."

The findings offer a vital public health message, Jick said: "People who have recently started anti-depressants need to be monitored very carefully."

The scientists also studied patients who had stopped use of one of the drugs, to see whether some type of withdrawal occurs that may be related to suicidal thinking or behavior, but found no evidence for such a link.

One strength of the research is that it is based on real-world patients, not the more exclusive populations typically found in clinical trials, Trivedi said.

"The findings ... provide useful data in what is still a somewhat messy situation," Dr. Simon Wessely and Robert Kerwin, of the Institute of Psychiatry in London, wrote in an editorial accompanying the study. "Public anxiety fueled by media reports has transferred itself to the already nervous regulatory authorities, and it is unlikely that this study alone will restore confidence."

The FDA's warning might have led depressed patients to assume that starting medication is a risky endeavor that should be avoided, Trivedi said. But if depression is not treated, "the danger is profoundly higher than the danger they face when they start the anti-depressant."


© 2004, The Dallas Morning News.

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Republic of Vietnam, July 1, 1958 to March 28, 1973
Quemoy and Matsu Islands, August 23, 1958 to June 1, 1963
Taiwan Straits, August 23, 1958 to January 1, 1959
U.S. operations in direct support of the United Nations in the Congo, July 14, 1960 to September 1, 1962
U.S. operations of assistance to the Republic of Laos, April 19, 1961 to October 7, 1962
Berlin, August 14, 1961 to June 1, 1963
Cuba, October 24, 1962 to June 1, 1963
Congo, November 23, 1964 to November 27, 1964
Dominican Republic, April 28, 1965 to September 21, 1966
Korea, October 1, 1966 to June 30, 1974
Cambodia, March 29, 1973 to August 15, 1973
Thailand, March 29, 1973 to August 15, 1973
Cambodia, April 11, 1975 to April 13, 1975
Vietnam, April 29, 1975 to April 30, 1975
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