Drleemd.org



Who is the Young Adult in 2013?

Addiction

Post-traumatic Stress Disorder

Traumatic Brain Injury

War and the Soul

A lecture done at the Veterans Administration Hospital

June 26, 2013

Steven R. Lee, MD

Young Adult Addiction

An addict is someone who has a persistent, compulsive dependence on a substance or a particular behavior even though he has experienced potentially harmful consequences while doing this substance or behavior. An addiction to a chemical such as alcohol, Xanax or Oxycontin is called a "chemical addiction". An addiction to a behavior such as binging on food, gambling or inappropriate, excessive sexual activity is called a "behavioral addiction".

The compulsion to use a substance or to do a behavior comes from an involuntary biological drive located in the pleasure centers of the brain. Once an addict has had an experience that gives him "pleasure", then the memory of this feeling is attached to the behavior that caused it. This is called "biological conditioning".

The efficiency of the release of pleasure from the first use of a substance takes on a special type of memory in the limbic system. This memory can be compared to imprinting of a baby duck with the first thing that it sees when it is born. The memory of this experience is branded into the pleasure centers as the quickest means of obtaining relief and is not easily extinguished.

"Pleasure" here is defined as any feeling that gives someone a sense of well-being or relief from anxiety. Pleasure could be the ability to laugh when someone is actually depressed. It can also be an escape from a sense of dread when someone is under constant pressure or fear. Therefore, once the addict discovers that using a substance provides pleasure, he has set up a Biological Conditioned Response. Whenever he is in an unpleasant or boring situation, he knows that by using that substance he can get immediate relief.

Biological conditioning is an involuntary reaction to a stimuli. Nature uses biological conditioning so we do not have to think about the details of the routine things that we do. This involves at least two events. One event is the stimulus and the other event is the response to the stimulus.

An addict generally uses his substance at the same time of the day or in similar situations repetitively (i.e. happy hour, in the evening, on the weekends). They develop a routine. After many repetitions, the brain develops an involuntary reaction to the initial stimulus (biological conditioning). When that time of the day or situation comes up, the addict has a very strong desire to use his substance. In fact, if he does not use his substance, he feels like something is wrong. If, in this routine, he finds that his substance gives him some sense of well-being or relief of stress, then every time he is stressed, he feels that he has to have his substance to get relief. When an addict who has been depressed for the past year, realizes that he is not depressed when he is using his substance, then his addiction has become, not just a recreational way to get high, but a necessary way to deal with life. This response will override any concerns about the consequences of using this substance (i.e. driving intoxicated, unsafe sex). He now has a "functional" reason why he has to use his substance.

Also, addiction is not "caused by" an event or a situation. It is not the result of tragedy in someone's life or because of the stress of a job. These situations may make an addiction worse, but they are not the cause of the addiction. You have to be "genetically prewired" to be able to have an addictive disease.

8.5 percent of the general population meet the criteria for substance abuse and dependence but, for young adults, this statistic is possibly three times higher. In a four-year study of college alcohol and drug use, "Wasting the Best and the Brightest: Substance Abuse at America's Colleges and Universities", the percentage of students abusing drugs between 1993 and 2005 increased in the following areas:

• 343 percent for opiates like Vicodin and OxyContin.

• 93 percent for stimulants such as Ritalin and Adderall.

• 450 percent for tranquilizers like Xanax and Valium.

• 225 percent for sedatives like Nembutal and Seconal.

• 100 percent for daily marijuana use.

• 52 percent for cocaine, heroin and other illegal drugs.

( Note: In the last 5 years the use of opiates have increased multifold and since Heroin is cheaper, the use of Heroin is beginning to replace the use of pharmaceutical opioids.)

The consequences of these increases have resulted in at least the following:

• 6 percent increase in deaths from alcohol-related injuries.

• 38 percent increase in injuries as a result of their own drinking.

• 21 percent increase in the number of alcohol-related arrests per campus.

• 83 percent of all campus arrests in 2005 were alcohol-related.

• An unknown percent of alcohol related rape/sexual assaults were also problems.

( Note: All of these percentages do not include the events that were reported as "accidents" when they should have been reported as preventable consequences of being intoxicated.)

Standard adult addiction programs are not designed to provide the structure necessary to confront the young adult's "acting out" behavior. The young adult is not yet capable of controlling and verbalizing many feelings. Many of these feelings are happening for the first time in their life. They express these feelings by "acting them out", sometimes in destructive ways, not fully realizing the consequences of what they are doing because of their lack of experiences in life. Unless this is managed, no addiction program is going to help the young adult deal with their addiction. 46.8% of all of those deployed since 2001 have been in the age range of 17 to 31 yo.

What is the Difference Between an Addict and a Non-Addict?

Addiction is a medical illness that some people have and others do not. Usually an addiction involves an activity that gives pleasure or instant relief from anxiety. Addicts have memories of what made them feel good in the past (i.e. alcohol, sex, etc.). This memory can be made conscious by events going on in the addict's life or by certain feelings they are having in the present. If they are sad, lonely, anxious or afraid, the brain remembers a solution that gives instant relief to deal with these bad feelings which is the use of their substance.

The part of the brain that initially responds to a bad situation or to a bad feeling is the limbic system. This is the more primitive part of our brain and it does not care about the consequences of what may happen after the addict deals with the bad feeling through his addictive behavior. In fact, the limbic system does not even have memories of the consequences. It only remembers what gave relief. The cortex is that part of our brain that remembers all past consequences of behaviors. The cortex also stores what the person has learned from other peoples' consequences who have done the same behavior. Normally, when a person experiences bad feelings, the limbic system demands that the addict find immediate relief. The cortex filters these demands by flooding the person's consciousness with all of the memories of what happened the last time he decided to respond in that particular way. The person then has to make a decision of whether or not he will do that response demanded by the limbic system. Unfortunately, some substances (i.e. alcohol at large doses) come with a mechanism that disinhibit the person by not allowing the cortex to bring to consciousness the possible consequences of that behavior. The addict then proceeds with his addictive behavior.

Maturation of the Prefrontal Cortex

The prefrontal cortex, the part of the frontal lobes lying just behind the forehead, is often referred to as the “CEO of the brain.” This brain region is responsible for cognitive analysis and abstract thought, and the moderation of “correct” behavior in social situations. The prefrontal cortex takes in information from all of the senses and orchestrates thoughts and actions to achieve specific goals.

The prefrontal cortex is one of the last regions of the brain to reach maturation. This delay may help to explain why individuals before the age of 25 act the way they do. The so-called “executive functions” of the human prefrontal cortex include:

• Focusing attention

• Organizing thoughts and problem solving

• Foreseeing and weighing possible consequences of behavior

• Considering the future and making predictions

• Forming strategies and planning

• Ability to balance short-term rewards with long term goals

• Shifting/adjusting behavior when situations change

• Impulse control and delaying gratification

• Modulation of intense emotions

• Inhibiting inappropriate behavior and initiating appropriate behavior

• Simultaneously considering multiple streams of information when faced with complex and challenging information

This brain region gives an individual the capacity to exercise “good judgment” when presented with difficult life situations. Brain research indicating that brain development is not complete until near the age of 25, refers specifically to the development of the prefrontal cortex.

The time lag between the growth of the limbic system, where emotions originate, and the prefrontal cortex, which manages those emotions creates a problem for the less than 25 yo Veteran who has PTSD, is addicted, and possibly has a traumatic brain injury. The limbic system explodes during puberty, but the prefrontal cortex does not develop as fast as the limbic system. This area of the brain keeps maturing for another 8 years. This means that emotions might outweigh good judgment for some young adults even when they are not intoxicated.

As the brain matures, one thing that happens is the pruning of the synapses. The synapse is a microscopic area in the brain where one neuron connects to another neuron or where one idea connects with another idea. This is necessary for problem solving. Synaptic pruning does not occur randomly. It depends on how any one brain pathway is used. By cutting off unused pathways (pruning), the brain eventually settles into a structure that is most efficient for that person, creating well-worn grooves for the pathways that the person uses most. Synaptic pruning intensifies after rapid brain-cell proliferation during childhood and again in the period that encompasses adolescence and the 20's. The longer that the young adult is active in his addiction during this pruning, the harder it will be to change patterns of behavior.

The process of recovery is "practicing" repetitively healthy coping skills with other addicts who are also in the recovery process. In the same way that a musician has to learn how to make the right sounds from their instrument without thinking about where to specifically put each finger for every note, an addict has to know how to respond to life situations without their substance. Daily attendance of 12 Step meetings along with meeting with a "sponsor" will finally replace the old life style that supported an active addictive disease. Knowledge by itself does not mean that an addict is in recovery; it takes practice over and over again. There is not a medication or a short cut for redeveloping biological pathways in the brain except for repetitive practice in the school of life "one day at a time".

To make matters worse, some substances (i.e. alcohol at large doses, Xanax, Klonopin) come with a mechanism that disinhibit the person by not allowing the Cortex to bring to consciousness the possible consequences of that behavior.

If someone is genetically prewired to be able to use large amounts of alcohol or opiates and these substances give immediate relief, this individual is a set up to overuse these substances. Also, once the young adult feels this relief, this biological conditioned response is part of their being and is not easily extinguished even though that person knows that continued use is potentially dangerous. It takes months to extinguish this drive which was created sometimes in just one day.

When the young adult soldier returns home, cannot find a job, feels displaced even from his family, then finds something that gives immediate relief from stress and makes them feels extra good, the limbic system records that memory. The limbic system then drives the young adult back to that substance again and again. Unfortunately, without having more comprehensive experiences in life, the young adult cannot appreciate the real dangers of driving a car too fast or having unprotected, inappropriate sexual activity.

The one thing that insurance companies know is that the risk factor (and higher premiums) for unmarried, young adults 25 years old or younger, are much higher than for older, married adults. This is an actuarial (statistical) fact based on the number of accidents and traffic violations that are dramatically higher for teenagers and young adults.

Other Addictive Characteristics

Addicts have fewer internal cues (i.e. nausea with alcohol) to set limits as to how much substance they can use or when to stop a behavior that gives them pleasure or relief. The addict's repetitive use of the substance also causes a progressive increase in tolerance to the benefits such that the addict has to use larger and larger amounts of their substance in order to get the same effect they got the first time they used. At large doses of the substance (i.e. alcohol, Xanax, Oxycontin), the inhibitions of our mature part of our brain (i.e. Do Not Drive 100 MPH!) are blocked and the addict responds to the Limbic system's need for immediate gratification. The rational, objective part of our brain, the cortex, is ignored in order to experience that immediate gratification no matter what the consequences may be.

Unfortunately, the drive to repeat the same behavior eventually takes top priority in the addict's life such that every other aspect of their life become secondary to the "behavior". Family, school, job, relationships, God and the law all become secondary to the "behavior". Anyone who tries to prevent the addict from doing the compulsion will be considered the enemy.

Rationalization, minimization and frank denial become well refined responses to anyone's questions and concerns. Addicts will convince themselves that they are righteous in their statements of how others are interfering in their life. They feel that others are trying to take away their right to make their own decisions by questioning their judgment and treating them like a child.

Addicts even become convinced that their behaviors and use of substances are necessary to deal with their depression, to calm down, to be able to get to sleep or to be able to focus. In reality, if Oxycontin, alcohol or marijuana were healthy treatments for anxiety, depression or Attention-Deficit Disorder, we would prescribe these substances as a standard of care for these problems.

An addict is born preprogrammed to be an addict. He did not just decide one day to be an addict. This is not an excuse for their behavior. An addict is totally responsible for all of the consequences of their addiction. Addiction is a medical illness. Addiction is not caused by someone else's behavior. Addiction is not caused by being abused in the past, having a poor support system, being raised in the ghetto, by being a "spoiled brat", by being a "bad kid" or by being "weak and lazy". Addiction is not caused by a Post Traumatic Stress Disorder. All of these issues may affect how long it takes an addict to get into recovery but these factors did not "cause" the addiction.

What allows an alcoholic to drink a fifth of whiskey one night and not get sick, then get up in the morning and go to work? What allows an opiate addict (i.e. Oxycontin, Roxycodone) to take a narcotic and get "high" when 92% of the population taking a narcotic gets sedated? It all has to do with genetics. You have to be "genetically prewired" to be able to use these substances without bad side effects. Most of the population is not physically capable of taking large quantities of a substance on a regular basis and to be able to function. Most people have nausea and vomiting with large quantities of alcohol. Most people have nausea, sedation, constipation and/or dysphoria with any dose of a narcotic such that they would only use a narcotic if the need to stop pain outweighed the side effects.

WHAT IS RECOVERY?

Recovery is the process of (1) abstinence from your compulsive behavior; (2) being totally honest with yourself and with others about who you are and (3) living a "spiritual" life integrated as a responsible participant in our society. "Spiritual" here means at least recognizing that there is a power greater than yourself. Recovery requires the addict to be a whole person, to deal with the past, the present and the future through self-reflection and to take responsibility for their life.

Abstinence is not the same as recovery. The term abstinence refers to an addict not using their substance of choice but still doing all of the same behaviors involved with their addiction. This is sometimes referred to as being a "dry drunk". Because of the progressive nature of the addiction and the defenses used to maintain an active addiction, addicts who stop using but who do not change their addicted behavior will tend to be angry, rigid and controlling. In fact, it is not uncommon for friends and loved ones of some addicts to prefer the addict to continue to use than to just be abstinent. Recovery means stopping the substance and then working the steps to repair the damage created by the addiction. This will require an addict to live a responsible and totally honest life as they face the consequences of their addiction.

HOW LONG DOES IT TAKE?

An addict between the ages of 18 and 26 (who is functioning at their chronological age)requires 4 to 6 months of structured treatment before they can return to their "normal" life (full time employment, school, pursuing intimate relationships). This is a longer period of time than it takes for someone older than 26 because the young adult's personality, and more importantly his "maturity", is still a work in progress.

The first 5 to 6 weeks of treatment involve the experiential understanding and integration of the principles of the first two steps of the "12 Steps" into the addict's daily lifestyle. This is done through a partial hospitalization program of daily instruction for six hours per day with a structured residence where the newcomers to recovery are watched and directed.

The third step, which starts around the fifth or sixth week, involves taking what they have learned into real life situations. The addict moves from Ridgeview's Recovery Residence to a three-quarter way house in a community outside of Ridgeview Institute. A three-quarter way house is a half-way house of other recovering addicts that is more supervised.

Around this time is the first major potential for relapse because there is a change from constant supervision to moving to a three-quarter way house where there are times when the addict has an opportunity to be by himself. The young adult may begin to regress to his old ways of doing things as he unconsciously fears that he is not ready to make this step outside of having the constant supervision of the Ridgeview recovery residence.

After the first 4 to 6 months of treatment, many of those "recovering addicts" can begin the process of reintegrating into their life outside of a daily structured therapeutic setting. They can leave a three quarter-way house and move back home or onto a college campus. It will still take another 6 months before they will completely change the biological conditioned response to life events through a life of recovery versus their past life of addiction.

For example, an addict who habitually responds to his anxious feelings by using a drug, develops a specific, biological response pathway (stimulus-reaction). It takes a year to "re-program" the brain to form a new response through repetitive, healthy living. After 3 months, when he is living his third Step, the recovering addict can recognize intellectually what he needs to do and will change his behaviors accordingly but the response will not come as a natural, involuntary reaction for a year.

Young adults with oppositional/defiant problems, unstable psychological problems and basic immaturity require more time in treatment than what is provided in the Ridgeview Young Adult Program. Once they are initially stabilized at Ridgeview, these young adults need "Extended Care" which is a residential treatment program which takes from 6 months to a year to stabilize these problems so that the addict can then deal with the principles of the 12 Steps. The young adult may also have to work through past emotional, physical and sexual traumatic events that continue to set them up for relapse.

Timeline Summary by Week

Weeks 1&2- Assessment and Education

A-Orientation, expectations, medical screening, blood and urine lab

work, family assessment, psychiatric assessment, medication,

addiction assessment, past emotional, physical and sexual trauma

assessment, eating disorder assessment

B-Begin Step One of the Twelve Steps- Concepts of powerlessness and

unmanageability (Admits there is a problem and accepts consequences.)

C-Basic education of life skills including how to eat right, sleep right

and exercise. Smoking as an addiction, respect for others and their

property, appropriate relationships with the opposite sex and basic

responsibilities in life are all discussed.

Week 3- Step Two

Recognizing that there is a power greater than themselves and being

open to this power; Spirituality as a part of their life.

Week 4

Usually by now the young adult is ready to interview for a three-

quarter way house, or it will be clear that they need "extended care".

Week 5

Step Three is the clear understanding of Steps One and Two. Living Step

Three takes practice by working the first two steps with others in

recovery.

Move from the Ridgeview Recovery Residence into 3/4 way house.

Week 6- Starts IOP (Intensive Outpatient Program) and begin interviewing

for part time job or application for school.

Week 7- Begins part time job or school.

Week 8- Discharge from Ridgeview program

High potential for relapse unless working program diligently.

Faced with enough free time to develop intimate sexual relationships

versus staying focused on their recovery. They have to do one or the

other because they cannot do both.

Week 12

Begins working Step Four which requires that they are solid in the first

three steps. The risk here is that, if they are not solid in the first three

steps, then as they review their past, they may relapse because they

will not be able to deal with the shame and guilt of what they did as an

active addict.

Week16

Some recovering addicts are capable of leaving the three-quarter way

house and moving back home and others need to stay longer.

MEDICATION

Any patient that has an Opiate Dependency will be placed on either Naltrexone or Vivitrol. The risk for accidental overdose after a relapse is dramatically high. We do not have specific numbers since the percentage of young adults using opiates is continuing to increase dramatically over the past 10 years. Over a three year period there were 6 young adults that were in the Young Adult Addiction Program at Ridgeview Institute with the diagnosis of Opiate Dependency that died after leaving our program. If these individuals had been on Naltrexone or Vivitrol, they still may have relapsed but since they probably would not have gotten high after the first of opiate, they may have been able deal with the relapse and would have gotten help to stop the progression of the relapse. All of these individuals were not in a good recovery and were not on Naltrexone or Vivitrol. After the first use of the opiate, they "got right" and progressed into their old patterns of use.

It is usually the third dose of opiate, when the relapsed addict uses a big dose, overdoses and dies from the overdose. Naltrexone decreases the desire to use opiates and alcohol (craving) by binding with the opiate receptors in the brain. If the addict uses an opiate or drinks alcohol, then he will not get the good feeling he has been used to and will have time to then ask himself if he really wants to continue in the relapse.

The Young Adult Addiction Program does not support the use of harm reduction opioids such as Suboxone or Methadone. These drugs do have a place in the overall treatment of addicted patients but our program is set up to help the patient to obtain complete recovery. In our experience, young adults usually end up using these drugs as well as their drug of choice. Sometimes it is safer for the addict to be on a prescribed opioid instead something bought illegally in order to attempt to regulate the dosage and to avoid the criminal element that sells the drugs. Most young adults have not been in their addiction long enough to have tried and failed several treatment approaches. Suboxone and Methadone are alternatives to total recovery once the conventional treatments do not work. Harm reduction opioids would be next step to keep the addict from continuing to be associated with the "drug" community. In the acute phase of treatment these drugs may be used for medical detoxification. When used this way the drug will be tapered down and stopped.

Outcome Study for 2012

~95% of the patients in the Young Adult Addiction Program are Caucasian, have been in college, have never been married, have parental support financially and emotionally, and are at Ridgeview Institute because of their parents insurance. About two thirds of the patients are male and have an Opiate Dependency diagnosis. All of the patients have to want treatment to stop their addiction and have to agree to communication with their parents.

~90% of patients in our program have a separate psychiatric diagnosis apart from their addiction. ~90% had to be "incentivized" to come to the program meaning that they did not ask to be admitted on their own initiative. Patients admitted to the program either had legal charges pending, had been cut off financially, or were kicked out of the house because of their behavior secondary to their addiction.

We attempted to follow with all of the patients that successfully finished our program and agreed to our discharge recommendations which was 54% of all patients admitted to the program. Out of the patients that we were able to reach, 57 % of those patients were still in recovery after a year of leaving the program. 43% of those patients had relapsed at least once.

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) is now part of a new section in DSM 5 called the Trauma and Stressor Related Disorders. PTSD has characteristic symptoms that can develop after the direct experience of an extremely traumatic stressor such as the threat of a violent death or serious injury. Formal diagnostic criteria require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual’s response to the event—intense fear, helplessness or horror, according to DSM-IV—has been deleted because that criterion proved to have no utility in predicting the onset of PTSD.

DSM-5 pays more attention to the behavioral symptoms that accompany PTSD.

There are now four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal.

• Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.

• Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event.

• Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.

• Arousal is marked by aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-vigilance or related problems. The current manual emphasizes the “flight” aspect associated with PTSD; the criteria of DSM-5 also account for the “fight” reaction often seen.

The number of symptoms that must be identified depends on the cluster. DSM-5 would only require that a disturbance continue for more than a month and would eliminate the distinction between acute and chronic phases of PTSD.

Posttraumatic stress disorder had been classified as an anxiety disorder but is now part of a new category of Trauma and Stressor-related disorders; the characteristic symptoms are not present before exposure to the violently traumatic event. Typically the individual with PTSD persistently avoids all thoughts, emotions and discussion of the stressor event and may experience amnesia for it. However, the event is commonly relived by the individual through intrusive, recurrent recollections, flashbacks and nightmares. PTSD is distinct from the briefer acute stress disorder, and can cause clinical impairment in significant areas of functioning.

PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations. During traumatic experiences the high levels of stress hormones secreted suppress hypothalamic activity which may be a major factor towards the development of PTSD.

PTSD causes biochemical changes in the brain and body that differ from other psychiatric disorders such as major depression.

Three areas of the brain whose function may be altered in PTSD have been identified: the prefrontal cortex, amygdala, and hippocampus. Much of this research has utilized PTSD victims from the Vietnam War.

Genetics

There is evidence that susceptibility to PTSD is hereditary. Approximately 30% of the variance in PTSD is caused from genetics alone. For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD compared to twins that were dizygotic (non-identical twins).

Epigenetics

Gene and environment studies alone fail to explain the importance the developmental stressor timing exposure to the phenotypic changes associated with PTSD. Epigenetic modification is the environmentally induced change in DNA which alters the function rather than the structure of the gene. The biological mechanism of epigenetic modification typically involves the methylation of cytosine within a gene which produces decreased transcription of that segment of DNA.

Risk factors

Although most people (50–90%) encounter trauma over a lifetime about 20-30% develop PTSD but over half of these people will recover without treatment. Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity. A person that never established secure relationships and learned coping skills as a young child if exposed to a traumatic experience is more likely to develop PTSD than one that developed good coping skills and has a support network.

Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood. Peritraumatic dissociation in children is a predictive indicator of the development of PTSD later in life. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems. Proximity to, duration of, and severity of the trauma also make an impact, and interpersonal traumas cause more problems than impersonal ones.

Other Traumas of Veterans returning from Iraq and Afghanistan

Since September 11, 2001, 2.4 million military personnel have deployed to Iraq and Afghanistan. To date, roughly 1.44 million have separated from the military and approximately 772,000 of these veterans have used VA health care.

The three most common diagnoses of Veterans were musculoskeletal ailments (principally joint and back disorders), mental disorders, and “Symptoms, Signs and Ill-Defined Conditions.” Musculoskeletal injury with chronic pain is the most common health concern in this patient population.

|Diseases of Musculoskeletal System Connective |434,552 |56.3 |

|Tissue (710-739) | | |

|Mental Disorders (290-319) |404,060 |52.3 |

.

Frequency of Mental Disorders among

OEF/OIF/OND Veterans Evaluated at VA Facilities Since FY 2002

| Diagnosis (ICD-9-CM) |Total Number of OEF/OIF/OND Veterans |

|Post-traumatic stress disorder (PTSD) (309.81) | 217,082 |

|Alcohol Dependence Syndrome (303) | 46,753 |

|Nondependent Abuse of Drugs (305)15 | 32,908 |

|Special Symptoms, Not Elsewhere Classified (307) | 28,165 |

|Specific Nonpsychotic Mental Disorder due to Organic Brain Damage | 26,925 |

|(310) | |

|Drug Dependence (304) | 24,550 |

|Sexual Deviations and Disorders (302) | 24,550 |

In Iraq and Afghanistan daily temperature extremes range from over 100 degrees Fahrenheit during the day to subfreezing temperatures at night. There are frequent sand storms and hygiene may be severely compromised. Heat stroke, frostbite, upper and lower respiratory complaints,

fungal or bacterial skin infections, and dental concerns are common. High impact noise from weapons, vehicles, and aircraft can result in acoustic injury; hearing loss and tinnitus are among the most common service connected health conditions. Military personnel often carry heavy

combat equipment, including body armor, weaponry, and supply packs, sometimes exceeding 100 pounds.

Millennium Cohort data suggest that deployment is associated with higher rates of smoking initiation and smoking recidivism than age- and gender-matched civilians, particularly with prolonged deployment, multiple deployments, or combat exposure. The prevalence of

smoking in younger veterans is as high as 40 % (compared with 20 % in non veterans). Combat has been linked to other cardiovascular risk factors, including hypertension; deployed individuals reporting multiple combat exposures were 1.33 times more likely to be diagnosed with

hypertension compared with individuals who deployed, but did not engage in combat. A large retrospective analysis of cardiovascular risk factors in OEF/OIF/OND veterans with co-morbid mental health diagnoses found elevated rates of reversible cardiovascular risk factors, including tobacco use, hypertension, dyslipidemia, obesity, and diabetes.

TBI and Suicide Risk

Traumatic brain injury (TBI) is often referred to as the “signature injury” of the current conflicts. Depending on the study and definition, the incidence of mild to moderate TBI has been reported to be as high as 10–20%. A mild TBI is the same thing as a the term concussion. A TBI can occur from an explosive blast wave without any object hitting his head or his head hitting anything. Actually, TBI accounts for 40% of all deaths from acute injuries in the United States.

Concussion is caused by deformity of the deep structures of the brain, leading to widespread neurological dysfunction that can result in impaired consciousness or coma. Concussion is considered a mild form of diffuse axonal injury and usually resolves over a few weeks to a month.

Diffuse axonal injury is characterized by extensive, generalized damage to the white matter of the brain. Strains of the tentorium and falx during high-speed acceleration/deceleration produced by lateral motions of the head may cause the injuries. Primary blast exposure can cause this kind of injury.

Craig Bryan, PsyD, ABPP, National Center for Veterans Studies, Salt Lake City, Utah, and Tracy Clemans, PsyD, Mental Illness Research Education Clinical Center, Denver, Colorado, found that among military personnel, the severity of depression, posttraumatic stress disorder (PTSD), and TBI symptoms themselves significantly increased as the number of TBIs increased. "Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide." The study was published online May 15 in JAMA Psychiatry.

Outcome measures were obtained through the use of the Behavioral Health Measure depression subscale, the PTSD Checklist-Military Version, concussion symptoms, and Suicide Behaviors Questionnaire-Revised.

No TBIs Single TBI Multiple TBIs

Depression 0.3 0.6 1.2

PTSD 18.9 27.5 35.3

Concussive Symptoms 0.7 2.2 4.1

Table. Increased Psychiatric and Concussive Symptom Severity

The likelihood of individuals reporting any past suicidal ideation also significantly increased with the number of TBIs, occurring in:

No TBIs Single TBI Multiple TBIs

Past Suicidal Ideation 0 6.9% 21.7%

Two studies have examined the risk of harmful alcohol use post deployment after a combat-acquired TBI. The findings of these two studies demonstrate a link between combat-acquired TBI and actual drinking behavior. (American Journal of Psychiatry, Vol. 170, Number 4, April, 2013.)

A recent study used a 2008 Department of Defense population-based survey of service members to assess the association of self-reported combat-acquired TBI with post deployment binge drinking. For those returning from a combat deployment in the past year and had experienced a TBI, these soldiers were associated with increased odds of past-month frequent (at least weekly) binge drinking after controlling for demographic characteristics, lifetime combat exposure, and post traumatic stress disorder.

Another self-report survey study was of service members from the United Kingdom returning from Iraq and Afghanistan. The results of this study found that those who experienced a mild TBI were 2.3 times more likely to report possible alcohol misuse than those without a TBI.

A third study of veterans from these wars in Veterans Administration medical clinics measured diagnoses rather than consumption behaviors, as did the Miller et al, study, and found that those with ongoing post concussive symptoms from a TBI were twice as likely to have addiction-related disorder diagnoses compared with veterans without a TBI.

Psychotherapeutic interventions

Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.

The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures.

Behavioral and Cognitive Behavioral therapy

Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD by the United States Department of Defense. In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.

Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies. Many of these therapy methods have a significant element of exposure and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.

Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence. The success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. The US Department of Veterans Affairs has been actively training mental health treatment staff in prolonged exposure therapy and Cognitive Processing Therapy in an effort to better treat US Veterans with PTSD.

Eye movement desensitization and reprocessing (EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association and the United States Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations. However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.

United States

The National Comorbidity Survey Replication has estimated that the lifetime prevalence of PTSD among adult Americans is 6.8%, with women (9.7%) more than twice as likely as men (3.6%) to have PTSD at some point in their lives. More than 60% of men and more than 60% of women experience at least one traumatic event in their life. The most frequently reported traumatic events by men are rape, combat, and childhood neglect or physical abuse. Women most frequently report instances of rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse. 88% of men and 79% of women with lifetime PTSD have at least one comorbid psychiatric disorder. Major depressive disorder, 48% of men and 49% of women, and lifetime alcohol abuse or dependence, 51.9% of men and 27.9% of women, are the most common comorbid disorders.

The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9% for males and 26.9% for females.

A 2011 study from Georgia State University and San Diego State University found that rates of PTSD diagnosis increased significantly when troops were stationed in combat zones, had tours of longer than a year, experienced combat, or were injured. Military personnel serving in combat zones were 12.1 percentage points more likely to receive a PTSD diagnosis than their active-duty counterparts in non-combat zones. Those serving more than 12 months in a combat zone were 14.3 percentage points more likely to be diagnosed with PTSD than those who served less than one year. Experiencing an enemy firefight was associated a 18.3 percentage point increase in the probability of PTSD, while being wounded or injured in combat was associated a 23.9 percentage point increase in the likelihood of a PTSD diagnosis. For the 2.16 million U.S. troops deployed in combat zones between 2001 and 2010, the total estimated two-year costs of treatment for combat-related PTSD are between $1.54 billion and $2.69 billion.

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War and the Soul

by Edward Tick, PhD.

War fosters an intimacy based upon sameness: We are of the same unit, nationality, and cause, and we share the same threat to our lives. This bond of brothers can develop into a positive or a negative energy. This intimacy under the constant threat of death engenders for some the deepest love they ever experience. This love may involve one's willingness to die for their brothers-in-arms. This love lasts a lifetime and even beyond death. The soldier who survives may translate this love into a lifetime of advocacy work as "his calling to serve his brothers".

This intimacy of fellow warriors can drive a soldier to want revenge. Mythology and history are full of stories in which the loss of cherished friends impels one to kill. In the Iliad, Achilles had quit the field of combat after having lost faith in the cause-as soldiers have done from mythical Troy through modern Iraq. But when his beloved companion-in-arms, Patroklos was killed, Achilles returned to the battlefield. To a cornered Trojan prince pleading for his life, Achilles answered, "In days past...I had a mind to spar the Trojans...But now there's not a chance-no man that heaven puts in my hands will get away from death...You'll die in blood until I have avenged Patroklos."

In war our soul must make a choice to kill or be killed. In order to kill the soldier has to make the killing impersonal. The slain are not people but a body count even if you are not the direct agent of that person's death. The bombardier on a B59, the nurse in an offshore hospital, and the supply officer all can feel that they are dealing with death and dying and it affects who they are.

In order to heal and come home, survivors must learn to feel again. Unfortunately, awakening to the humanity of dead former enemies produces an anguish that in itself may become an impediment to healing. Some may wonder if they have the right to survive when so many others died.

In Viet Nam, soldiers evolved the phrase, "It don't mean nothin", to tolerate the wholesale destruction surrounding them. To the soul caught up in the rules of slaughter, one dead or ten, a hundred or a thousand or a million "don't mean nothin'. " When we arrive at "don't mean nothin", we are in the realm of Stalin and Mephistopheles, saying "This one is not the first-or the last; there will be others; their suffering does not matter." This is the danger confronting every one of us today.

From the 1950's until his death, Erik Erikson worked to expand psychoanalytic theory. Before the diagnosis of PTSD, Erikson described the damage done to patients he treated for "war neurosis" as an identity disturbance. He expanded the Freudian notion of early psychological growth stages into the epigenetic principle that demonstrates human development through the entire life cycle. According to Erikson, one of the most important achievements of development is a sound identity, formulated during adolescence and culminating at the ages at which we typically send young people off to war. He extended the significant sphere of influence on the psyche from one's parents to the entire society. And he demonstrated that our progress through later life stages is dependent on our development in previous stages.

"What impressed me most," Erikson wrote about veteran patients, "was the loss in these men of a sense of identity. They knew who they were; they had a personal identity. But it was as if, subjectively, their lives no longer hung together-and never would again. There was a central disturbance of ...ego identity...the ability to experience oneself as something that has continuity and sameness, and to act accordingly," Erikson's teachings seem to have had the most impact on our understanding of the struggles of adolescence and the concept of identity crisis. But his notion that a veteran must rebuild a coherent identity is important.

Judith Herman, a pioneer in understanding and offering strategies for recovery from violent trauma, proposes an alternative analysis of PTSD. She emphasizes these common and critical dimensions: multiple symptoms, somatization, dissociation, and severe or pathological changes in affect, relationships, and identity.

Post-traumatic stress disorder is a constellation of fixated experience, delayed growth, devastated character, interrupted initiation, and supported recovery. Many of their symptoms-lack of impulse control, confused sexuality, drug and alcohol abuse, intimacy and employment problems, emotional explosiveness, mistrust of authority, alienation- characterize adolescence in our culture. Many veterans with PTSD are, psychically, shell-shocked teenagers unable to enter adulthood with its demands and rules. They have not figured out who they have become. They cannot shape their new self into an identity that can give them inner order, strength and meaning and help them find a place in society and the cosmos.

PTSD is primarily a moral, spiritual, and aesthetic disorder-in effect, not a psychological but a soul disorder. All of its aspects concern dimensions of the soul, inasmuch as the soul is the part of us that responds to morality, spirituality, aesthetics, and intimacy. Many survivors of war feel that they lost their soul because they had to do atrocities that were not part of their moral identity. Many even remember when their soul left their body. They feel that they lost their identity of who they were and are an empty shell of the person they used to be. The process of restoring the soul and healing the self takes time and is different for each survivor.

Freud speculated that eros and thanatos, the drive toward union and the drive toward death, are twin aspects of the one life force. Freud believed that these twin drives exist in an eternal duality. Eros drives us together, thanatos apart. Eros is the core of love and sex; thanatos is the core of suicide if turned against the self and of violence if turned against other people or nations.

In Greek mythology Eris is the sister of Ares, the god of war, whom the Romans called Mars. Eros is the son of the golden Aphrodite, the goddess of love and beauty, Venus to the Romans. Greek mythology expresses the overwhelming power that occurs when these two forces-war and love, belligerence and beauty-come together.

Dr. Tick spends much of the book explaining how the core of mythology explains the conflict a soldier encounters when going to war and returning home. He explains how Homer uses the Iliad and the Odyssey as a textbook to explain this journey of any warrior. Many human emotions are embodied in this journey. The passion in war making transforms a combatant's relations to love and sex, and to beauty and order and form, in a way that comprises some of the most difficult dimensions of the survivor's inner world. These dimensions are soul-based, of our very essence. They work differently in the survivor. We can't force veterans to adjust back into mainstream civilian culture without addressing this fundamental difference. We must support the reshaping of identity in these terms, just as we do in others.

The positive dimensions of passion that surface during and after warfare are no less compelling. A spontaneous sense of brotherhood emerges and lasts for the rest of their life. Revenge is one expression of how war can transform love. In this case into passionate hatred. How fierce and personal, how reflexive and universal, how connected to lust is the desire for revenge! If a warrior's brother is killed, the warrior can go into a marauding killing spree.

Developing an abnormal sex drive is another example of how war can transform one's relation to love and passion. This change can range from no sexual desire to attempting to have sex with everyone. The soldier may feel so deeply imprinted with death that he needs sex to feel the touch of life again. He may have such a hunger for the restoration of life that only the intensity of erotic arousal can promise to fulfill. The spouse may feel used and dirty from the need for a variety of sexual experiences while the survivors often do not feel shame and may actually feel justified as if they are acting of necessity. Also, some survivors will say that the act of killing is far more intimate and erotic than love or sex can ever be. The thrill of the kill, the feel of the rifle or knife, the intimacy of hand to hand combat can either be exciting or cause horror.

War is death. Veterans and survivors are saturated with it. The long-term impact is extensive. Survivors typically suffer nightmares that may recapitulate traumatic incidents. They see themselves killing again, or friends and enemies dying again. They may feel moral anguish that the people they killed did not deserve to die. Often, as we have seen, they feel more intimacy with the dead than with the living, as if they themselves were already dead.

It seems that survivors cannot find peace unless they make peace with the legions of dead with whom they may have any relationship-as relative, friend, comrade in arms, former enemy, or even as their killer. Relations with the missing and the dead , and with death itself, are at the core of the soul wound we call post-traumatic stress disorder.

When we understand PTSD as an identity disorder and a soul wound, we can begin to understand the ways to heal it. A veteran or survivor with PTSD can heal if he or she embraces the mythic dimensions of the war experience truly to develop the identity of spiritual warrior.

Veterans commonly use their defenses, some of them learned in war, to avoid feeling the pain of their condition. Their emotional volatility commonly overwhelms the facilitators who would help them, which may explain in part why many strategies counsel avoidance of painful memories. Yet war is such a profound immersion in death that revisiting it in memory is essential for the survivor to recover in heart and mind.

The imagined return is the key factor in addressing PTSD appropriately as an identity disorder. In contrast to stress reduction strategies that counsel avoidance of disturbing memories, the healing cleansing of veterans can only occur when we relive memories and their accompanying feelings so that they may be expressed and relieved. The imagined descent into the past is often the most difficult step a survivor must take. It becomes a personal odyssey into the Underworld in search of one's lost soul.

This reliving of the past has to balanced against the survivor's desire to punish himself for what he has done or to punish someone else as a way to release his rage for putting him in the situation he was in at the war theater. 58,000 Americans were killed in Vietnam but over a 100,000 survivors of that war committed suicide. 1.5 million+ survivors developed PTSD and 150,000 are homeless nightly and these are just the statistics of the Vietnam war. The Gulf War in 1990 resulted in 262,586 disabled veterans. The statistics of American survivors of the Iraq and Afghanistan will be much more than all of these.

Close study of myths and rituals traditional peoples used to facilitate this journey home from the battlefield reveal four essential steps: purification and cleansing, storytelling, restitution in the family and the nation; and initiation as a warrior.

Cleansing and purification of body and soul often occur through a thorough catharsis. The body needs to release the adrenalin rush it still feels and disown the addiction to that rush it developed during the war. It must be radically slowed down, literally brought back to earth. It needs to empty the sickness it felt during combat and may still carry. The heart also has to release the anguish it could not experience during combat.

Our society must accept the responsibility for its war making. To the returning veteran, our leaders and people must say, "You did this in our name and because you were subject to our orders. We lift the burden of your actions from you and take it onto our shoulders. We are responsible for you, for what you did, and for the consequences.

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