Jayne Davis, DCoE Public Affairs on May 1, 2014
Raise your hand if you’re searching for answers to questions about you or your loved one’s mental health. This month, mental health experts from Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) answer questions asked by service members, veterans, families and health care providers on DCoE social media. We’re devoting this time to encourage you to speak up about mental health concerns affecting you or your military family.
Are you feeling depressed or anxious?
Are you having trouble understanding behaviors of a loved one with posttraumatic stress disorder?
Caregiving puts tremendous stress on the caregiver; do you wonder how you can cope?
Do you have a comment to share that could inform or encourage others who may be reluctant to speak up?
We’re calling this month-long event a “Living Blog” because we’ll add questions and answers to it throughout the month. DCoE subject matter experts will work to provide answers within 24 hours of receiving your questions. We invite you to ask questions on any of these three platforms:
– Post a question to our wall
– Comment with your question on a related post
– Our handle: @DCoEPage
– Hashtag: #AskDCoE
– Scroll down to the comment section below and ask your question
If you submit your question through Facebook or Twitter, we’ll notify you when the question and answer is posted here. We’ll post questions and answers all month, so please check back frequently.
Reaching out for help requires strength and fortitude. The stigma of seeking help for mental health concerns keeps many from getting answers, let alone asking questions. Don’t let this be you. Break down those barriers. Start here:
I don’t agree that getting help won’t ruin their career. My husband served for 15 years, and was set (and approved) for his last re-enlisted to take him to 20 years. He started showing extreme signs of PTSD, and sought help. After his commanders spoke to the psych Dr., he was notified his re-enlistment was denied. He out processed in a month. Also he had been prescribed heavy dose of medications, that created all kinds of issues (mania, hallucinations, psychosis, etc.) a month before he was denied the re-enlistment. After he got out, the base Dr. told me my husband should have pushed for a medical retirement. They failed him all around. He is also not the only one I have heard of that they push them out with no retirement when PTSD comes into play. I’ve heard of many being over 14 years of service. Some at 17 and 19.
As you start by pointing out, it’s difficult to assert the truth of generalities. What is true for many is certainly not the truth for all. I’m sorry to hear of the extraordinary challenges your husband faced in his experience of PTSD and in his attempt to preserve his military career. As with severe physical injuries and conditions that impact fitness for duty, there are those conditions of a psychological nature that impact fitness for duty, military readiness and worldwide deployability. To those warriors with an unfaltering commitment of service, such as your husband, having their psychological conditions documented in their military medical record can surely feel as if that action “ruined” their careers. That belief also rests on the assumption that leaving a severe psychological condition medically unattended would be inconsequential, which is not true. Without proper care, any medical condition can worsen and adversely impact many aspects of a person’s life, including freedom from pain/distress, ability to function and relationships. There may have been many factors involved in the decisions regarding your husband’s fitness for duty status, treatment prognosis, and both medical and administrative courses of action — I will not presume to know what was right. I do hope that your husband has since received care that has made a difference and has improved his quality of life. He remains eligible for PTSD treatment in the VA, which might be a consideration, depending on his current needs. You should also consider your own support needs as a family member and caregiver. Please feel free to access the DCoE Outreach Center at 866-966-1020 or email@example.com for 24/7 information assistance. You can also engage in the center’s live chat feature found at www.realwarriors.net/livechat. – Navy Capt. Anthony Arita, Deployment Health Clinical Center director
I’m being MEB'd for PTSD. I’ve been treated for it since my deployment in 2007, but I’ve made only marginal improvement, and some symptoms have worsened or developed. Due to a recent and prolonged hospitalization, I’m now in the IDES process. What concerns me is that I’ve had a dozen different providers over the past five years, and they’ve swapped or changed (Axis I/II) codes, and now included personality disorders (which are not a disability) in my NARSUM. It’s been as bad as having one doctor saying no one else had been right, and changed my diagnosis completely. Apart from having to get an outside opinion, I’m trying to find a military authority that can provide interpretation of the military medical terms, and how I can address these inconsistencies to the IPEB. The process doesn’t allow me to engage the local providers, and this falls outside of the role of the PEBLO. I need these statements explained to me in a way that isn’t solely focused on ratings, but rather the conditions, whether fit or unfit. Ideas?
It sounds like you’ve had a frustrating journey over the past several years. While many military members who seek care in the military health system can expect a good response to the many evidence-based treatments available and return to full readiness, certainly there are some who don’t experience that outcome and are processed for medical board action. Although it’s improving, the IDES process can be challenging to navigate and there can be many providers who are involved in the care and administrative elements along the way. I applaud your effort to get to the bottom of your actual diagnoses. This is an important step to take, particularly as you look to take responsible steps to have your conditions and symptoms addressed. Please know that you have the right to ask any of your providers to explain and help you understand any of the diagnoses they have assigned to you; they have a professional and ethical obligation to do so. You also have the right to expect that your providers will discuss the treatment options (i.e., what works for what conditions, what might work best for you, and what’s available in your local area) with you and also to use terms that anyone can understand. I suggest that you make an appointment with a military mental health provider to focus solely on helping you understand your diagnoses and overall treatment options. You should inform them of your PEB status and bring your copies of administrative documents (PEB-related) and discharge summary from your recent hospitalization for review. Be patient, as this might involve much documentation for your provider to review. Again, what you’re doing is a critical step in understanding your psychological health conditions. We all can benefit from taking similar responsible steps, as we all are vital participants in our health care decisions and, ultimately, in charge of our overall health. – Navy Capt. Anthony Arita, Deployment Health Clinical Center director
I was once a Soldier, and am married to a Soldier now, I understand. We have two children one each from our previous marriages. The younger one suffers from a traumatic brain injury with an ADHD like effect. When my spouse was deployed, managing my ADHD child was not terribly bad, but upon my spouses return the strict rules were laid down again. While my spouse was deployed, it was extremely difficult to do all the tasks it takes to run a home, work a 50 hour a week job, take care of the kids, find time to get online four hours after my bedtime, with my spouse for a short hour (only because I know how important it is to them when they are deployed), cut the grass, cook the meals, shop for the family, take both the kids to their weekly psychology and monthly psychiatrist appointments, attend a college class because the military is requiring me to get a degree, attend monthly drills and a two week military leadership course and still find time to enforce every single rule that my husband had in place. They were normal, pick up after yourself rules. But sometimes nagging a child to do them seemed to take more time than to just pick up the pair of shoes, and lessened the frustration on my part. After his return, this posed a huge issue on my family. My son was so defiant because he thought of my husband as mean and cruel. In which he wasn’t, yes he came back from his third tour with PTSD; the ADHD now had a partner oppositional defiant disorder. My son refused to eat for nearly a week; he became delusional and was hospitalized for a week and a half. It’s now three years later and he is still just as defiant as when my husband came home. We have tried the positive reinforcement to no avail. No matter how strict I am, the kids know that I will love them unconditionally, so naturally they try to take advantage of dear old mom and know when mom is spread too thin. Without quitting my job just to manage the household and the teen children, how can I sustain existing rules with a child like this for future deployments?
Jackie, thank you for reaching out. You certainly have a full plate and a number of challenges. Having a teenager can be a challenge in itself, but one with traumatic brain injury (TBI), ADHD symptoms, and oppositional behaviors certainly increases the complexity of parenting him. It’s important that you continue to have him seen by mental health professionals, and specifically a neuropsychologist, to address his TBI and behavioral concerns. They can also assist you to fine tune your parenting approaches and provide suggestions to help address your child’s behaviors.
Parenting is a full-time job and challenging under normal circumstances. It becomes even more challenging when blending two families, being a military family subject to dislocation and deployments, and also having your military spouse return from deployment with PTSD. There are many effective interventions for oppositional defiant behaviors and a mental health professional can help you and your spouse work together to address the challenges that come along with loving a child who struggles with this disorder. What children often need is consistency and structure; however, the expectations must be realistic and achievable in order to be effective. You and your husband may want to engage in couples counseling to ensure you’re on the same page as this will help to reduce oppositional behaviors in your child. If your spouse hasn’t sought professional treatment for his PTSD, please encourage him to do so. While many military members are reluctant to seek help, perhaps out of concerns about career impacts or how others might view a diagnosis, there are very effective treatments for PTSD in the military. Please see some of the real life stories that attest to this at our Real Warriors Campaign website, www.realwarriors.net.
Finally, it’s important to recognize the stress and secondary impacts of caring for and supporting family members with persisting psychological health and TBI conditions. There are steps you can take to minimize some of the stress so you feel less overwhelmed. One important way to take care of your psychological and physical health is to make sure you’re getting good quality sleep, which will help you restore your resilience and feel more able to face the challenges in front of you. Keeping yourself healthy is critical to successful parenting, particularly during those times when you have to function as a single parent or carry much of the load yourself. This blog post on the importance of taking care of yourself while managing caregiver responsibilities might be helpful (http://www.dcoe.mil/blog/14-03-25/Caregivers_What_Seeds_Are_You_Planting.aspx). Also, there’s the Parenting for Service Members and Veterans website (http://militaryparenting.dcoe.mil/), which provides parenting information, tools and exercises to help support military families. For additional information about psychological health conditions, TBI, treatments and support resources, please call the DCoE Outreach Center, 866-966-1020, which is available 24/7 and staffed by professional health resource consultants. You can also reach them via firstname.lastname@example.org or live chat at www.realwarriors.net/livechat. – Dr. Vladimir Nacev, board certified clinical psychologist
Where can I get good reliable reproducible patient education brochures on managing PTSD and chronic pain?
Claribel, the Department of Veterans Affairs (VA) National Center for PTSD website has a section for veterans, general public, family and friends and it includes a page titled, “Chronic Pain and PTSD: A Guide for Patients” at http://www.ptsd.va.gov/public/problems/pain-ptsd-guide-patients.asp. You can print the information or email the website link from the “Share this page” box in the top right corner.
Two additional tools that also address PTSD and pain but are targeted for clinicians and clinic leaders are the “Posttraumatic Stress Disorder Pocket Guide: To Accompany the 2010 VA/DoD Clinical Practice Guideline for the Management of Post-traumatic Stress” and “Implementing the 2010 VA/DoD Clinical Practice Guideline for Post-traumatic Stress: A Guide for Clinic Leaders.” These tools can be downloaded at http://www.healthquality.va.gov/guidelines/MH/ptsd/. – Cmdr. Angela Williams-Steele, USPHS psychologist
I was receiving counseling for depression and anxiety after returning from a long Afghan deployment and my 4th tour there and didn't feel I was getting anything out of the one on one counseling. I was tested several times, and the results for PTSD were borderline, but I definitely have most of the symptoms, not all as severe as some, but I know how I feel in certain situations but my psychologist didn't want to diagnose me with it because she said it would hurt my deployment and transfer options. Is this true and what should I do? I wanted more group type therapy that they didn't offer.
First, let me commend you on seeking out professional attention to address your psychological symptoms. Your actions represent what it means to be responsible, courageous, and proactive in shaping your psychological health, which are vital to optimal functioning and readiness. From your description, it sounds like your provider views your symptoms to be subclinical, which is to say that they do not have the sufficient magnitude, duration, or adverse impact in your life to warrant formal documentation in your health record. If a service member has a severe enough condition, whether it be physical or psychological in nature, it could affect your fitness for duty status, which in turn has subsequent impacts on overall readiness, deployability, eligibility for accepting new assignments, or eligibility to perform particular duties. Let me emphasize that, more than the diagnosis or participation in treatment alone, it is the assessment of readiness and fitness for duty that has the most significant bearing on career impacts. In the vast majority of cases, people can expect positive responses to treatment and a full recovery from their symptoms. You and your provider can discuss what treatment modality or supports would be best suited to your individual needs, circumstances, and desired level of participation and what the availability of those resources would be in your local area (e.g., group therapy is not available in all specialty clinics). Again, I encourage you to discuss this with your mental health provider who can best address the intersection of your need and available resources. A great general resource for information on psychological health conditions, treatments, and anything you would like to better understand about psychological health is our DCoE Outreach Center, which is available, 24/7, toll-free, at 866-966-1020. – Navy Capt. Anthony Arita, Deployment Health Clinical Center director
I have been diagnosed with PTSD by the VA (30%) in 2009; however, I have noticed that it's affecting me more; lack of friends, increased (undiagnosed) OCD, and easily stressed. Should I go back to the VA? If so, what do I need to bring them as proof?
Yes, I definitely encourage you to go back to the VA for assessment and treatment of the concerns you mentioned. Trouble establishing friendships, OCD symptoms and being easily stressed could be related to your prior PTSD diagnosis or it could be something else, so it's important you share the challenges you’re experiencing and get evaluated by a mental health provider. You don’t need proof of any kind to make an appointment with the VA to address your concerns. If you have questions related to your service connection rating, I suggest you seek advice from your state VA representative located in your local VA facility. In the meantime, you may want to check out these resources or self-assessment tools from the Defense Department, including AfterDeployment (http://afterdeployment.dcoe.mil/), which provides anonymous self-assessments targeting a variety of psychological health concerns. Also, there are some mobile apps designed to help users understand, monitor and manage mental and emotional health issues. Visit http://t2health.dcoe.mil/products/mobile-apps and check out “T2 Mood Tracker,” “Breathe2Relax” and “PTSD Coach.” And a resource specifically for veterans is Make the Connection (http://maketheconnection.net/). The website provides information, shares real stories from veterans and helps you find professionals and services near you that specialize in helping veterans. – Dr. Chris Crowe, clinical psychologist
Q: I have both PTSD and the neurological injury from mefloquine as diagnosed by the Navy. Who can I go to for help?
– Bill Manofsky
We suggest contacting our DCoE Outreach Center for assistance. The center is available 24/7 and is staffed by licensed, master's-level health resource consultants who are trained in psychological health and traumatic brain injury. After talking to you about your concerns, the health resource consultants can provide free, customized information to address your specific needs and help connect you to local resources in your area. You can contact the DCoE Outreach Center at 866-966-1020, email email@example.com or live chat with someone at realwarriors.net/livechat. – George Lamb, LCSW, DCoE outreach chief
Q: Since my son returned from Afghanistan, he spends all his time either alone in a dark room, on the computer or his smartphone playing games, or out drinking. Our family thinks he has a problem but he doesn't and won't see a therapist. He says he wants us to leave him alone. Are there any video games, mobile apps or web-based tools you could suggest that may help?
– Concerned mom
I understand you’re concerned about your son’s behaviors. It’s difficult to understand and sometimes hurtful to think a loved one doesn’t want to engage with us. Games allow us to escape, and sometimes that’s just what we need. But when games start to take the place of reality, there’s cause for concern. However, certain types of games are created to help improve mental health. For example, the 2012 video game, “Little Inferno,” starts like a regular distraction game but eventually unfolds to help the player see that there’s a reality outside of the house to engage in. National Center for Telehealth and Technology (T2) is developing “Virtual Lifestyle Coach,” an interactive, videogame-like coach to get people up and moving into healthier behaviors. This kind of game could be the perfect segue for your son, as physical activity improves a person’s mood.
Since your son is already spending much of his time on the computer, you might gently suggest he check out some websites and mobile apps we’ve developed. Military Pathways (http://www.militarymentalhealth.org/) provides free, anonymous mental health and alcohol self-assessments that could help your son become more aware of how he feels and whether he could benefit from talking to a health professional. Moving Forward (http://startmovingforward.dcoe.mil) is an educational and life coaching program that teaches a step-by-step approach to effectively manage life’s challenges, overcome obstacles and deal with stress. AfterDeployment (http://afterdeployment.dcoe.mil/) provides anonymous self-assessments targeting psychological health challenges commonly faced after a deployment. For mobile apps, visit http://t2health.dcoe.mil/products/mobile-apps and check out “T2 Mood Tracker,” “Breathe2Relax” and “Positive Activity Jackpot.” – Dr. David Cooper, psychologist
Q: At what level of PTSD diagnosis determines redeployment of a troop currently deployed in AOR ... If symptoms are manageable from patient and [company commander’s] perspective?
– Deployed company commander
There are no formal “level(s)” of PTSD. The decision to keep a troop, diagnosed with PTSD, in an area of responsibility (AOR) or to redeploy is one that should be made only after consultation with the patient’s provider and the patient. The provider will help you sort through the risks and benefits of continued duty in AOR, especially as those challenges relate specifically to your troop. The provider may require you to initiate a commander directed mental health evaluation in order for you to receive a formal written report. The provider will make a recommendation to you, and you will have the decision authority to retain or return. Many troops are able to function with PTSD symptoms, but others are unable to focus, and those individuals may be better suited to a mission not in AOR. – Dr. Kate McGraw, psychologist
Q: How is DCoE addressing burden of chronic psychiatric symptoms from mefloquine toxicity?
– Dr. Remington Nevin
The Defense Department (DoD) recognizes the concerns related to the use of mefloquine and is actively engaged in advancing our understanding of its impact on the health and readiness of our service members. Current policy mandates that all department health care providers are knowledgeable about the proper use, contraindications, warnings and precautions for mefloquine, especially with respect to neurobehavioral effects (http://www.health.mil/~/media/MHS/Policy%20Files/Import/13-002.ashx and http://www.health.mil/~/media/MHS/Policy%20Files/Import/09-017.ashx). The department is also stepping up efforts to translate evidence, and grow our knowledge base in psychological health, into practice and policy to support better care, better health, increased readiness and best value. The Military Health System works to provide high-quality, evidence-based care to service members with mental health concerns, regardless of the cause, through extensive pre- and post-deployment mental health assessments. The system provides primary care providers trained in the early detection and management of mental health symptoms; specialty care treatment options including psychotherapy and/or medications; and forward-deployed mental health providers and behavioral health providers embedded in line units. – Cmdr. Meena Vythilingam, USPHS psychiatrist
Q: My friend endures PTSD, but does not seek help because of the impact it will have to his military career. We know all the hype about it not impacting the career, but because he is a pilot, the second he goes in he would be grounded, which IS a big impact to his career. What advice could you give?
– Concerned friend
As a former Air Force pilot, I understand first-hand your friend’s sensitivity to any potential reason for being grounded. But my perspective changed after I became a psychologist in the Air Force as I came to understand the medical provider’s priority to support service members, especially to keep them in their jobs. If there’s a condition that warrants a change in duty status, the goal is to return the person to full duty as soon as possible. I’d recommend you advise your friend that there’s great value to him in identifying potential issues early. Early intervention can make treatment easier, prevent escalation of symptoms, and increase chances of a quick return to duty. In contrast, if a medical issue is not addressed, there’s an increased risk to his performance and career, and to his fellow airmen, as symptoms worsen. You might liken his situation to dealing with issues detected during a pre-flight check of an aircraft - flag them and fix them so the aircraft can go back up as soon as possible. – Dr. Mark Bates, psychologist
Q: Why is self-loathing a big trait with depression and alcoholism?
Some individuals may use alcohol to avoid negative thoughts and feelings, such as negative feelings about themselves. Self-loathing, specifically, is not usually related to psychological conditions. However, feelings of worthlessness or disgust with oneself may be associated with psychological health conditions and can be a symptom or sign of deeper psychological health concerns. Many individuals who engage in daily drinking or have alcoholism do so to avoid negative feelings and thoughts or do so to avoid the pain associated with depression or other psychological health disorders. Some chronic drinkers believe that excessive drinking is a form of inflicting self-harm, which can be associated with intense negative feelings towards oneself (like feelings of worthlessness). There are numerous reasons why individuals turn to alcohol to cope with negative thoughts, feelings and/or psychological health symptoms. If you or a loved one engages in self-destructive alcohol behaviors, it is recommend you seek help. If you think that you, or someone you know, may have a problem with alcohol, seek help from medical providers, leaders or battle buddies. Below are some resources:
Q: Does the DoD formally recognize moral injuries?
Yes. While moral injury is not clinically defined, nor captured as a formal diagnosis, it is recognized as real. The Defense Department provides a wide range of medical and non-medical resources for service members seeking assistance in addressing moral injuries. From a medical perspective, there are no clinical practice guidelines specifically for moral injury. However, DoD mental health providers often address moral injury in combination with treating psychiatric disorders. For example, during treatment for PTSD, depression or other mental health conditions, patients may disclose information that suggests they have experienced a moral injury (e.g., guilt from accidentally killing a civilian during a combat operation or some other dilemma) and clinicians will help patients explore their feelings of guilt, anguish or other troubling thoughts/feelings they have about the incident.
The military system also provides an extensive network of chaplain care. Chaplains understand how spirituality in the military intersects with war and trauma, and chaplains have various degrees of training in addressing moral dilemmas and the integration of experience and meaning.
Finally, DoD provides resources for service members to help address many mental health concerns, including moral injuries. The 24/7 DCoE Outreach Center provides psychological health and TBI information, resources and referrals for service members, veterans and their families by calling toll-free at 866-966-1020, or emailing firstname.lastname@example.org.
Military OneSource (http://www.militaryonesource.mil/) and the Military and Family Life Counseling programs provide service members and their families the opportunity to receive face-to-face non-medical counseling in a local community, by telephone or online using web-based secure chat at no cost. – Navy Capt. Anthony Arita, Deployment Health Clinical Center director
Q: How do we define mental health?
According to the Military Health System, “Mental health, or psychological health, encompasses the well-being of mind, body and spirit and contributes to overall health and resilience.” Read about tips for maintaining good mental health at http://health.mil/Military-Health-Topics/Operation-Live-Well/Focus-Areas/Mental-Wellness/Mental-Health.
Q: If a person suffers a traumatic experience or injury and has all the markers of PTSD as well as other mental health issues like panic attacks, agoraphobia, and depression; How should they be diagnosed and treated? It seems most military mental health providers shy away from diagnosing non-combat PTSD. Why is that?
The symptoms you mentioned of panic attack, agoraphobia, and depressed mood can all be explained by PTSD, or possibly could be in addition to PTSD. It depends if the symptoms are associated with the traumatic event, if they were present before the trauma, or if they are caused by an unrelated event. If the symptoms are caused by PTSD, then standard treatment for this disorder is often the best way to go. If the symptoms are in addition to PTSD, VA/DoD guidelines recommend a clinician treats PTSD and other co-occurring mental health conditions concurrently through an integrated treatment approach. However, there may be exceptions based on the severity of the other disorder(s) and the patient’s preferences. Military mental health providers do not distinguish between non-combat and combat related trauma when they diagnose and treat PTSD. What is most important is the person meets the criteria for this diagnosis regardless of the trauma setting. As such, PTSD can occur after someone experiences traumatic events other than combat to include a terrorist attack, sexual or physical assault or abuse, a serious accident, or a natural disaster. – Cmdr. Angela Williams-Steele, USPHS psychologist
Q: Is post-concussion syndrome considered a mental health problem or is it based on the symptoms resulting from the TBI?
Post-concussion syndrome is, by definition, symptoms and signs that persist as the result of a concussion, or blow to the head. The most common symptoms are headache, dizziness, tinnitus (ringing of the ears), sleep disturbances, and memory problems. Post-concussion syndrome is not a mental health problem. While it does have some symptoms in common with posttraumatic stress disorder, such as sleep disturbances, the reasons for the sleep problems are very different. – Dr. Donald Marion, senior clinical consultant
Q: My spouse is showing a lot of signs of PTSD but refuses to get help, what should I do?
In many instances, a spouse is in the best position to notice changes in a service member. If your spouse is experiencing symptoms such as nightmares, irritability, a tendency to avoid situations that remind her of deployment, a fear of crowds, or an increase in the amount of alcohol she consumes, posttraumatic stress disorder or other trauma and stressor related disorders might be an explanation. It’s important to discuss your observations and concerns with your spouse when you both are calm and have minimal distractions. I recommend you give specific examples of how her behavior and/or mood have changed and the impact these changes have on you and the family. Additionally, it’s important to convey to your spouse that her symptoms are common and treatable. You may want to introduce her to the Real Warriors Campaign and suggest she access resources available at http://realwarriors.net and view profiles of service members like herself who struggled with psychological health symptoms and sought help. Lastly, it’s extremely important that you continue to take care of yourself and your family as you further support your spouse. – Dr. James Bender, psychologist
Q: Are most mental health issues that result from deployments treatable?
The good news is that, yes, in most cases the behavioral health symptoms service members experience after deployments are treatable. And the best news is that treatment works. It’s normal to have a period of adjustment after returning home, but if symptoms linger and begin to notably impact daily functioning, it’s time to seek help. It’s important to understand some conditions won’t go away with time and require appropriate treatment. Evidence-based psychotherapy, medication, or a combination of both is used to effectively treat deployment related behavioral health issues. You can find more information about PTSD treatment options at dcoe.mil/PsychologicalHealth/PTSD_Treatment_Options.aspx. – Maj. Demietrice Pittman, Army psychologist