Operational Stress Injuries and Other Traumatic Stress: Therapies and Treatment for Veterans
Chapter 3: Mental Health Diagnoses and Therapies Associated with an Operational Stress Injury
This chapter reviews in detail these diagnoses including a full description, associated symptoms, and relevant therapies.
Appendix 1 lists all relevant medication.
Many people experience or witness extremely distressing events during their lifetime, but few go on to develop PTSD.15 Studies show that approximately 50% of the general population will experience at least one traumatic event during their lifetime. Of these, 7 to 8% will develop PTSD.16,17
PTSD is talked about in the media most often in relation to military service and it is one of the most common OSIs.
However, there are many other areas of human experience that can put people at risk of developing PTSD. Childhood physical or sexual abuse can lead to PTSD in adulthood. Public safety personnel such as police, firefighters, emergency measures services (EMS), and rescue workers are also at risk. Other experiences such as domestic or physical assault, rape, accidents, robberies, and natural disasters can also be risk factors.
It does not matter if these experiences actually result in physical injury (although many do). It is the belief that injury or death is coming that is one of the criteria for PTSD. People who witness frightening and traumatic events are also at risk.18
There are commonalities among people who develop PTSD; the severity of the traumatic event, having poor or no social support before or after the trauma, a history of childhood abuse, mental illness or a family history of mental illness, living or having lived in poverty, and ongoing life stresses. Being female also heightens one’s chances of developing PTSD.19
Additionally, many people are at increased risk for PTSD as a result of experiences outside of a work-related setting such as survivors of sexual or interpersonal violence, refugees, 2SLGBTQ+ populations, Indigenous Peoples, people experiencing homelessness, as well as survivors of major accidents or disasters. Each of these groups face a distinct set of circumstances, complexities, and challenges that impact the diagnosis, treatment, and management of PTSD.20
Factors that protect against developing PTSD are having a secure personal support system, having access to an understanding forum to talk about what has happened, and learning, or already knowing about, ways of coping with adverse life events.
Symptoms
There are four areas of symptoms that make up a diagnosis of PTSD.21,22
1. Intrusion. Examples are: Unwanted and unbidden memories of the traumatic event, nightmares, and flashbacks. Flashbacks are a sudden state of altered consciousness where people re-experience aspects of the traumatic event, as if it were happening in the present. Flashbacks can involve one or more senses, such as seeing visions of the traumatic event, hearing the related sounds or smells.
2. Avoidance. Certain places, sounds, smells, sights, or even words summon feelings of the fear that people felt during the trauma so, understandably, they avoid these “triggers” as much as possible. But this strategy often results in limiting more and more aspects of everyday life, to the point of isolation – not seeing friends, and even avoiding leaving the house. In addition, adding to the burden, it is possible that the number of triggers to be avoided can actually in-crease. These avoidance symptoms are very difficult to overcome.
3. Negative changes in thoughts and emotions. People may fixate on the trauma. Memory may be affected to the point people can’t recall important features of the event. They now know the world can be dangerous and they worry that more traumatic events are around every corner. People feel that no one understands what they’ve been through. They may feel extremely angry that nobody warned them and now, it appears, no one will help them (even if people are trying). Self-blame is a common symptom. They may feel guilty for surviving when others didn’t or they feel ashamed because, if they’d just reacted differently, said something, fought back, they could have saved themselves or others. At the same time, people can feel emotionally numb, lose interest in their usual activities and lack a sense of future or purpose.
4. Changes in emotional arousal and in reactions. Irritability and sudden angry outbursts are common symptoms of PTSD. People may lose their temper with little provocation. They startle easily. They are wary and tend to look over their shoulder a lot of the time, which is called hypervigilance. With their brain occupied in this way, they have difficulty thinking, remembering, and concentrating.
Current research is examining the structural and chemical changes in the brains of people with PTSD.23 One finding is that there is too much activation of the fear circuitry, as well as changes in neurotransmitter and hormone regulation.
It is estimated that 50% of people with PTSD also experience major depressive disorder.24
Medications for PTSD
After diagnosis, a major aspect of your treatment may include medication.
Medications all have a brand name and a chemical name (both are often listed on your prescription bottle). They can be used interchangeably, confusing patients.
In addition, medications used for one disorder can be helpful for other disorders and vice versa. Therefore, there can be considerable overlap in discussing medication whether you have been diagnosed with depression, anxiety, or post-traumatic stress disorder.
You and your doctor will be making the final decision on which medication (or combination of medications) is best for you.
Please see Appendix 1 for a full listing of medications.
Alternative treatment
Cannabis
Although medical marijuana has been legal in Canada for years (and recreational cannabis for some time now), physicians remain skeptical about prescribing it (although VAC funds eligible cases). There is a reason for this. Care of all their patients must be informed by evidence-based medicine. Because it has been illegal, academic research has tended to look at the harms of cannabis use – not its benefits. Physicians do not have access, yet, to enough research to guide their decision-making when asked to prescribe medical marijuana.
There are warnings, however. While cannabis use can help PTSD, it may also lead to overuse and possible addiction.25
Visit the Mood Disorders Society of Canada website for a comprehensive publication called Cannabis and You.
As with depression and anxiety, the best results occur when medication is paired with therapy. The following are therapies especially for PTSD.
The Three-Phase Model
The three-phase model of PTSD treatment informs the therapies described below. Each therapy has its own approach to treatment but all will address, in some way, the following:
Phase 1: Safety and Stabilization. This involves developing skills to self-soothe and to pay close attention to self-care. The skills provide a platform of emotional and physical safety from which to move through other aspects of the chosen therapy.
Phase 2: Trauma memory processing. People will begin to talk through their experiences of trauma in a safe and secure way, pacing themselves as slowly as they wish. As much as possible, people begin to make sense of the traumatic events that have shaped their lives. This is typically not a linear process. People can go back and forward in time as it suits them.
Phase 3: Recognition. People’s experiences of trauma become part of their lives but no longer define them or drive their thinking and actions. They can go on to grow and develop and they are in charge of their own life decisions.
Prolonged Exposure Therapy
While it has a different name, this form of therapy is desensitization therapy for phobias. Its goal is to help people control their fears by re-experiencing their trauma (in small steps) and while using relaxation techniques and coping strategies. It begins with the absolutely least threatening version of the traumatic event – identified and agreed to by the person experiencing PTSD. Over time, there is a very gradual increase in the details along with a precise description of emotions and bodily sensations. This cannot be rushed. It goes exactly at the pace the person with PTSD can tolerate.26
Cognitive Restructuring
This form of therapy helps people “restructure” their thoughts and memories in a realistic way. Examples can be: It was not my fault, there is no need to feel shame or guilt. There was nothing I could have done.
The overall goal of both these therapies is to allow people to integrate their traumatic memories into their life story. Doing so takes away the power of their memories to run their lives in distressing and negative ways. In short, to make the memories part of who they are.
Cognitive Processing Therapy27
Cognitive processing therapy has four stages:
Stage 1: Education on the kinds of thoughts and emotions that accompany PTSD: Some you will be aware of while others are unconscious. These thoughts may be worsening your PTSD.
Stage 2: Writing an account of your trauma: When completed, your therapist will ask you to read it aloud in your sessions. Once out in the open, you can identify which thoughts and feelings are contributing to the prolonging of your PTSD.
Stage 3: Once identified, you can develop skills and strategies to address these negative thoughts and feelings in a more healthful way.
Stage 4: You and your therapist develop positive ways to manage these thoughts and feelings outside of therapy.
Anger Management
Many people without a diagnosis of PTSD can have difficulty managing their anger and PTSD places people at a much higher risk of outbursts and assaults. Anger management is a process of learning to monitor the early signs of your anger and then, learning skills to deal with it effectively. This form of skill development does not ask you to avoid being angry (it’s a natural human emotion) or to hold it in. Instead, you learn how to express anger effectively – before you reach the blow-up stage.28
Eye Movement Desensitization and Reprocessing Therapy
(EMDR)
In this therapy people follow a stimulus back and forth with their eyes (a light or the therapist’s finger) while they are processing their traumatic memories. The theory is that the rhythmic eye movements help them to integrate their memories into a more whole sense of self, while at the same time, diminishing the intrusive power of the trauma.29
Peer Support for PTSD
It is hopeful and uplifting to be with people who have gone before you, who have survived and even thrived.
Peer support groups are run by and for people who have had similar experiences to yours. There are no professionals involved.
Peer support may also involve one-on-one relationships where you informally go out for coffee, for example. This also allows you an opportunity to give back by volunteering to provide support – if you want to.
Peer support is especially useful for those who are members of particular professional cultures; military, police, EMS, firefighters, or rescue workers. In fact, they may be comfortable only when they are among members of their own profession who “get it.”
Resources
Operational Stress Injury Social Support (OSISS). A national peer support network for serving members, Veterans and their families. They are in multiple locations across the county.
People with major depression are not merely feeling down or blue. Sadness and hopelessness have overwhelmed almost all aspects of their lives. They have difficulty sleeping and trouble getting up in the morning. They can’t concentrate at work or at home. Their thinking has become slow and confused. Decisions are difficult. They pull away from relationships. They have no energy.30
Your doctor will ask how long you’ve been feeling this way. Formally, the diagnostic criterion is “more than two weeks” but practically, many people struggle much longer before they ask for help.
Some specific symptoms of depression include:31
- persistent deep sadness
- feelings of worthlessness or guilt
- irritability
- muddy and slowed thinking, difficulty concentrating, remembering and making decisions
- loss of interest in work, relationships and leisure activities
- slowed movement and talking
- low energy
- troubling alterations in sleep patterns; difficulty getting to sleep, staying asleep, waking up too early or sleeping too much
- noticeable weight gain or weight loss
- thoughts of suicide or, most frightening, suicide attempts
Canada Suicide Prevention Service, Crisis services for all Canadians
CALL 1-833-456-4566 (available 24/7)
TEXT 45645 (available 4pm to Midnight Eastern Time Zone)
Local Resources and Supports (by region) crisisservicescanada.ca/en
Sometimes, people experience physical pain in various places in their body and this discomfort is what brings them to their physician. Over time, however, despite real suffering, there seems to be no identifiable cause for the pain. This is a signal to you and your doctor that what you may really be dealing with is depression.32
Other Types of Depression33
Persistent Depressive Disorder or Dysthymia
This is a less debilitating form of depression where people continue to function but life is sad and grey. This can last for years with people thinking that this is just the way life is.
Post-partum Depression
Post-partum depression is much more serious than just the baby blues – feelings of being overwhelmed, anxious and sad that a mother may experience for a few days to a couple of weeks. People with post-partum depression experience ongoing deep sadness, guilt, poor sleep (even when they have quiet time to themselves), irritability, excessive worry about the baby’s health, and a lack of joy – just when the world expects them to be celebrating. Adding to the confusion can be the naturally-present stressors of having a newborn.
In its most severe and rare form, post-partum depression can evolve into post-partum psychosis where both mother and child are at severe risk. Post-partum psychosis means that the mother’s thinking has lost touch with reality. She may be hearing voices, or she may believe her baby is going to die. She may even think that she and her baby would be better off dead. It cannot be stressed strongly enough that a mother with post-partum psychosis must get to the Emergency Department and see a doctor immediately.
Psychotic Depression
Here, a person’s depression occurs with false beliefs (delusions) and sometimes hallucinations (e.g. hearing voices). Neither are based in reality nor are they believable to others. Anyone who develops psychotic symptoms along with their depression should see a doctor immediately.
Seasonal Affective Disorder (SAD)
This is an intermittent form of depression thought to be triggered by the lack of sunlight, most often felt in the winter but can emerge at other times. Sometimes SAD is mild and requires no treatment, while others experience it in more severe forms. Many of the symptoms are listed under the topic of major depressive disorder. Treatment (medication and specialized light boxes that simulate sunshine) will help.
Depression with Anxiety 34
About 50% of people diagnosed with depression are also diagnosed with anxiety. The reverse is also true; 50% of those diagnosed with anxiety are also likely to experience a depression.
People with both anxiety and depression may have poorer responses to anti- depressant medication. They also report more severe symptoms and their lives may be affected more deeply.35 That said, if you have these combined disorders, do not give up hope!
Research has shown that medication combined with therapy gives the best results for people with depression and also for people with anxiety and post-traumatic stress disorder (PTSD).
All therapies described below are time-limited and goal-focused. You work with your therapist to identify the problems that are concerning you and together, you develop solutions. In other words, reflection and exploration are combined with skill development and action.
Cognitive Behavioural Therapy (CBT)
CBT therapists teach you how your emotions can affect your thinking and your behaviours. They also show you how it is a two-way street. Behaviours can also affect thinking and emotions. By bringing these connections to your awareness and learning coping strategies, you become much more in control of these factors and you can interrupt or even prevent entirely a downward spiral.
Mindfulness-based Cognitive Behavioural Therapy
CBT is used with mindfulness meditation which helps you identify thoughts and feelings – and observe them objectively rather than reacting to them automatically. It creates an additional level of awareness of how unrecognized thoughts and feelings are impeding your recovery.
Interpersonal Therapy
This form of therapy focuses on you and how you are dealing with the relationships and stressors in your life. The things life throws at you do not cause mental illness but, if unresolved, they can certainly interfere with your recovery.
Marital or Family Therapy
Your partner (or family members) attend sessions with you and together, you work on identifying problems and try out solutions. These are important relationships and if they are not in good working order, they can drag you down and worsen of your mental illness.
Group Therapy
People come together based on a shared experience, in this case a particular diagnosis of mental illness. The therapist acts as a resource and a facilitator as group members share experiences, their first-hand knowledge and coping tips. Group therapy is a unique form of comfort because you may have felt alone in your struggle. It is empowering to know there are others just like you. There may also be specialty mental illness groups for women only, men only, seniors, teenagers, or the 2SLGBTQ+ community – as examples.
Psycho Education
As the name implies, this is a time-limited group for educating you about your illness – like this publication. The underlying theory is that the more you know, the better equipped you are going to be to partner with your medical advisors, manage your medications, and monitor the symptoms of your illness.
Treatment Resistant Depression 36
If you and your doctor, and then your psychiatrist, have tried a number of medications and you are not getting better – or you get better for a while but your depression returns, you are experiencing treatment resistant depression.37 No one is giving up on you. There is much more that can be done.
When your psychiatrist reviews your situation, they may choose to try more medication combinations but they may also suggest neurostimulation such as electroconvulsive therapy (ECT) or repetitive transcranial stimulation (rTMS). Both have been studied and found as effective.38
Neurostimulation Interventions
ECT
With ECT, patients receive a light sedative prior to treatment, so that they are asleep when the treatment occurs and they have no memory of it afterwards (much like during minor surgery or certain medical tests). ECT involves using a controlled electric current to induce a mild seizure in one area of the brain. ECT has been used for many years, and has improved over time. It is usually used for people with severe depression who do not respond to other treatments. It is one of the most effective treatments for major depressive disorder and treatment resistant depression.
rTMS
rTMS requires a magnetic generator (coil) to be placed near your head. It emits a small electric current called electromagnetic induction. Special note: Some patients may be anxious about neurostimulation treatments. Don’t hesitate to discuss your options with your psychiatrist so you feel that your decision is fully informed.
Anxiety disorders are the most common mental illnesses. Approximately 12% of Canadians are affected in any given year.39 The good news is that anxiety is highly treatable.
An anxiety disorder is characterized by ongoing and excessive worry with generalized fear and overwhelming stress. It can also have physical symptoms such as irregular heart beats, shortness of breath, and sweating.40
Anxiety can occur with depression or can occur on its own.
Generalized Anxiety Disorder
People are anxious and worried most of the time and about many different things – things that others would not see as bothersome. They expect the worst even though they have no evidence that disaster is about to strike. They may have narrowed their lives and limited their activities, feeling that this will keep them safe from catastrophe. These feelings can last for years without treatment but, for a formal diagnosis, the specified period is 6 months.
Panic Disorder
Terror can suddenly strike in response to a specific experience or it can occur completely out of the blue. Accompanying physical symptoms are overwhelming; sweating, chest pains and a feeling of choking. People can feel that they are dying. If the panic attack is tied to a place or event, people start to avoid these at all costs. However, if the attacks occur with no identifiable trigger, people begin to isolate as they never know where or when their panic attack may occur.
Social Anxiety Disorder
People are extremely self-conscious, fear that they will be judged negatively by others, or that they might say or do something that will make others dislike them. They are also afraid of embarrassing themselves in some unspecified way. They stay away from social situations and become isolated and alone.
Specific Phobias
People develop an unreasoned fear of objects or situations out of proportion to the danger they pose. Common examples would be snakes, spiders or a fear of flying, but exactly what people are afraid of can be as unique as they are. Agoraphobia (agora is the Greek word for a public gathering place) is the fear of going out of one’s homes. Some people with phobias can work but they typically follow exactly the same route to and from daily. They tolerate their workplace and their home but very little else.
Obsessive compulsive disorder (OCD)
People with OCD have repeated and obsessions that cause them overpowering worry. Examples are: they’ve left the stove on, they didn’t lock their front door, their hands are covered in germs, and other thoughts specific to who they are as individuals. In response, they have developed rituals that must be performed, called compulsions. If repeated often enough, these behaviours can temporarily calm their fears. Untreated, OCD is debilitating and interferes with most aspects of life.43
of PTSD. Available at: apa.org/ptsd-guideline/ptsd.pdf
mdsc.ca/what-better-feels-like/
mdsc.ca/edu/what-is-depression
pubmed.ncbi.nlm.nih.gov/12706951
