Monthly Archives: January 2015

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Suicide, Veterans, and PTSD

Suicide is a growing problem in our nation and not just among our veterans. Always more common among older folks, suicide is now a serious risk for adolescents, young veterans, and active military.


What drives people to commit suicide?

The simple answer is “pain”, either physical or emotional. But what causes that pain is anything but simple. In the USA, men commit suicide almost 4 times as often as women (19 deaths for every 100,000 men per year). Women try suicide more often but are less successful (5 deaths for every 100,000 women). In other countries the percentages may be equal or reversed.

The rate of suicide in our veterans is roughly twice that in the general population (38 deaths for every 100,000 veterans), and veterans commit 20% of all suicides in the US. (Veterans are 7% of the population). In 2012, more active duty military died from suicide than from combat. Surprisingly, our youngest veterans (17-24 years old) are most at risk.


Factors that increase the risk of suicide include:

1) Depression, bipolar disorder, substance abuse, and PTSD.

2) Lack of support–no family, no friends, no work, no money

3) Serious medical illness or injury

4) History of childhood abuse, sexual assault, or physical assault

5) History of suicide attempt or suicide in family

6) Access to lethal means

7) Lack of effective medical/ psychological care

8) No hope than things will improve


The link between PTSD and suicide is well established in a number of studies that have carefully ruled out alternative explanations.

In people suffering with PTSD, the symptoms of depression, frequent vivid flashbacks, severe irritability, jitteriness, and agitation, and a tendency to suppress rather than confront current stressors have been found to increase the person’s suicide risk.

In addition to those symptoms, PTSD can also lead folks to being alcoholic, jobless, homeless, and alienated from family and friends, all of which further increase their suicide risk.

Suicide is also linked to trauma, even without PTSD. Physical assault, sexual trauma, and childhood abuse all significantly increase the risk of suicide. It’s interesting that battlefield trauma only increases the risk if you actually were wounded.


How can we prevent it?

Current therapeutic approaches are very effective in preventing suicide, so the need is to get the suicidal person to accept professional care. But people planning suicide don’t usually announce it . . . Or do they?

Actually half the people who complete suicides have sought medical care in the previous 6 months.

There are a number of other behaviors that can warn you:

1) Making statements like, “I can’t go on like this.”

2) Talking about death/dying.

3) Saying goodbye to friends

4) Giving away belongings and pets

5) Buying a gun or lethal drugs

6) Withdrawing from people and activities

7) Engaging in dangerous behaviors

8) Sudden calm in someone who has been severely depressed.


What should you do if you suspect a friend is suicidal?

1) Talk to them about suicide. It won’t make things any worse, and it gives them a chance to tell someone how they feel.

2) Listen to what they say and take it seriously. Don’t judge or joke around or try to make a quick fix. Show them with your words and actions that you really care.

3) Find professional help and take your friend to the appointment.

4) Remove the means for committing suicide (guns, pills, etc.)

5) Follow up and encourage them to go back for treatment. Engage them in outside walks, exercise, and other fun activities.


Assessing a person’s risk of suicide.

Five questions to ask:

1) Are you thinking about suicide?

2) Do you have a plan?

3) Do you have what you need to carry out your plan?

4) Have you decided on a time and place?

5) Will you do it?

Low risk: Some suicidal thoughts, no plan, say they won’t commit suicide.

Moderate risk: Suicidal thoughts, vague plan that’s not very lethal, say they won’t commit suicide.

High risk: Suicidal thoughts. Specific plan that is highly lethal, still say they won’t commit suicide.

Severe risk: Suicidal thoughts. Specific plan that is highly lethal, and say they will commit suicide.


If a suicide attempt appears imminent, you need to get that person help and do not leave them alone.


Bottom line:

Suicide is a serious risk–especially for military veterans, folks with depression, and those who have a history of trauma. But if you can help them through the crisis and get them into treatment, you’ve given them a good chance for recovery.

I received a comment on this blog about spiritual/moral injury as an important factor in suicidal behavior. I strongly agree! In fact it’s such an important issue that I’ll try to write a separate blog about it. Thanks, Mark Dallner :-)






Fist and woman downsized

Violence in Veterans, Fact or Fiction?

In 2008 the NY Times found 121 homicides committed by OEF/OIF veterans and incorrectly concluded that our returning soldiers were bringing violence home. Better research revealed that the veterans’ homicide rate was much lower than the general population’s. But people still believe that veterans are violent. Are they wrong?


1)  94% of veterans will never commit a violent crime.

2)  During 1995-2001, there were 184 homicides in the USA caused by active-duty military and new veterans. From 2001-07, there were 349, an 89% increase when there were actually fewer troops stationed in the US than before.

3)  Of the homicides committed by OEF/OIF forces in the USA, one third of the victims were immediate family and one fourth were other members of the armed forces.

4)  Combat veterans are responsible for almost 21% of domestic violence calls nationwide and 20% of suicide calls.

5)  On the Domestic Violence Hotline, calls from military families tripled from 2006-2011, a time when abuse rates nationwide were declining.

6)  In one study, over 30% of a group of veterans diagnosed with PTSD self-reported committing at least one act of aggression in the previous year– mostly minor– but almost 11% self-reported at least one seriously violent act.

7)  At Fort Carson, Colorado, the number of soldiers charged with domestic violence rose more than 250% from 2006- 2009.

8)  Domestic abuse in the Army rose 177% from 2003-2010.

9)  A British study of Iraq and Afghanistan returning soldiers found that in those under 30 y/o, 20% had a conviction for violent offences compared with 6.7% of civilians the same age.

10)  A British study found that soldiers in combat roles were 50% more likely than those in noncombat roles to commit assault or threaten violence after returning home.

There are obvious inconsistencies between these numbers, which might be reconciled by considering the socioeconomic details of each group or clarifying definitions. But even with that taken into account, there is still a trend toward violence among returning veterans. Let’s look at some studies in more detail:


Dangerous PTSD Symptoms:

A study done in 2010 by NIMH, DVA, and UNC School of Medicine (Elbogen et al. Am. J Psychiatry Sep 2010 167(9)) focused on associations between anger and aggression and specific symptoms of PTSD.

They studied 676 veterans who had served since 9/11/2001, some with and some without PTSD, and found that PTSD hyper-arousal symptoms– anger and aggressiveness, irritability, difficulty concentrating, sleep deprivation, increased startle reflex, and high anxiety– were most often associated with excessive anger and aggressive behaviors.

Also connected with anger and aggression: a history of being deployed more than 1 year, firing a weapon during their service, and having undergone family violence prior to their service.

Specifically associated with difficulty controlling anger: having a parent with a criminal history, and being married.

Specifically associated with aggressive behavior: hyper-arousal symptoms, reoccurrences of a traumatic event, a family history of mental illness, and a history of childhood abuse.

In this study, PTSD hyper-arousal symptoms had the strongest association with anger/aggression issues. This is an interesting finding because it specifies which symptoms are most problematic, a big boost for our screening programs.

If you or a loved one is suffering with hyper-arousal symptoms, check out treatments in the blog: “Treating Hyper-Arousal.”


Other Causes of Aggression:

The same author headed another study two years later (Eric B. Elbogen, UNC School of Medicine, DVA, Journal of Clinical Psychiatry, 2012).

They surveyed nearly 1400 veterans who served in Iraq and/or Afghanistan after 2001 and found factors that PREVENTED violence: employment, meeting basic needs, living stability, social support, spiritual faith, ability to care for oneself, perceived self-determination, and resilience (ability to adapt to stress). They also found that a majority (over 75%) of veterans had these factors and posed a low threat of any violence.

Factors that INCREASED veterans risk of violence included: alcohol misuse, criminal background, veterans’ lifestyle– work, social and financial circumstances — as well as PTSD hyper-arousal symptoms. Of these factors, financial status was the most important. Veterans who didn’t have enough money to cover basic needs were more likely to report aggressive behavior than veterans with PTSD.

One-third of the survey respondents self-identified an act of aggression towards other people in the previous year. Most were minor problems, but eleven-percent of the respondents self-reported severe violence.

This study clearly shows that social and economic instability is a major factor in aggression. That means helping our veterans living in poverty is just as important as treating PTSD.


Domestic Violence:

Perhaps the most disturbing statistics come from studies about domestic violence. Rates among soldiers and veterans are clearly higher than those in the general population. (Marshall, et al. 2005; Sherman, et al. 2006; Tetan, Sherman and Han, 2009. Data from the Dept. of Justice, National Domestic Violence Hotline, NY Times, and Dept. of Defense.)

There are three patterns of partner violence, according to “The patterns and perceptions of interpersonal violence committed by returning veterans with PTSD” (J. of Family Violence, Vol. 25(8) 8/2010)).

1) Violence committed in anger.

2) Dissociative violence following a trigger or during a flashback.

3) Violence during sleep or upon awakening.

There were clear parallels between these categories and the veterans’ PTSD symptoms. Other studies also found a link between domestic violence and severe PTSD.

Another factor in domestic violence is the number of departures to, and returns home from deployment. These create stress in military families, and multiple transitions and deployments were significantly linked with domestic violence reports.

Added to the finding that families accounted for 1/3 of the victims of soldier and new veteran-committed homicides, this suggests an unmet need in educating and protecting the families of soldiers and returning veterans.

Treatment for flashbacks is covered in the blog: “Treating Flashbacks, Nightmares, and Intrusive Memories.” Nightmares and night terrors are often caused by hyper-arousal and usually respond to prazosin.



We don’t think of suicide as violence, but it is: violence turned against the self. The current statistics of 22 veterans a day is roughly twice the rate in the general population. The risk factors are much the same as for other types of violence, and violence against others may precede the suicide.

This number of suicides is a sad commentary on the misery many veterans have endured, and one that deserves its own blog: see Suicide, Veterans, and PTSD.


Bottom Line:

1) Most veterans are not violent.

2) Most people with PTSD are not violent.

3) Risk Factors for violence are: alcohol misuse, criminal background, PTSD hyper-arousal symptoms, and socioeconomic factors including lack of employment, poverty, and unstable living situations.

4) We can further reduce soldier and veteran violence by:  1) Providing annual screenings for substance abuse and PTSD and better access to appropriate treatment. 2) Assisting veterans who are without funds, homeless, unemployed, and have no social support. 3) Supporting military and veterans’ families through education about domestic violence, required reporting of domestic violence (already in place for child abuse), and more safe houses for endangered families.

Meditation google

Mindfulness Based Therapy for PTSD

Two years ago the University of Michigan and Ann Arbor VHC did a pilot study using Mindfulness-Based Cognitive Therapy in veterans with chronic PTSD. 73% showed significant improvement including decreases in avoidance symptoms and numbing, increased ability to focus on unpleasant thoughts and memories, a decrease in self-blame, and a tendency to see the world as less dangerous.

During this study, the Mindfulness-Based sessions lasted for 8 weeks and taught mindful eating, mindful body scanning for pain and tension, mindful movement and stretching exercises, and mindfulness meditation. The veterans were also instructed to practice at home with a recorded exercise and to do mindful walking, eating, and showering.

The results were published (Depression and Anxiety, 2013), and the U of M study was expanded to larger numbers and newly returned veterans. Researchers wrote, “Mindfulness-based therapies provide a strategy that encourages active engagement without explicit cognitive restructuring or exposure to trauma memories, are relatively easy to learn, and can be administered in an efficient group format.”


What is Mindfulness?

Originally the seventh step of the eight-step Buddhist path, Mindfulness is a practice of actively focusing on the here and now with an accepting, nonjudgmental attitude. In mindfulness meditation, distracting thoughts are not suppressed but viewed with acceptance, allowing the person to observe their own thoughts without a strong emotional attachment. In daily practice of mindfulness, you focus on fully engaging in and experiencing every-day behaviors, such as breathing, walking, and eating, while focusing completely on the here and now.

Regular mindfulness practice leads to more awareness of the present and acceptance of thoughts and emotions that were previously distressing, like triggers to old trauma memories. Mindfulness practice seems especially effective in reducing avoidance and arousal, and improving your ability to regulate emotions.


Earlier Research:

1) A study of Mindfulness-Based Meditation in substance and alcohol users in a prison population, published in J. of Cognitive Psychotherapy, Vol 19, 2005 found that Vipassana meditation reduced substance abuse severity, even in those with PTSD.

2) A study of 27 adult survivors of childhood sexual abuse, published in the Clinical Psychology Vol 66, 2010, used an 8-week mindfulness meditation-based stress reduction program plus daily home practice of mindfulness skills. The treatment group was followed for 24 for weeks with 3 refresher classes. A significant decrease in depressive symptoms was observed in 65% of the clients. Compliance was high, and the PTSD symptoms of avoidance and numbing also showed improvement.

3) A study of Mindfulness-based Stress Reduction in veterans with PTSD, published in J. Clinical Psychology, Vol 68, 2012, assessed the veterans before treatment, 2 months, and 6 months afterwards. They found significant improvements in PTSD symptoms, depression, behavioral activation, cognitions, acceptance, and mindfulness with 47.7% of the veterans showing clinically significant improvement in their PTSD.

4) A pilot study using Transcendental Meditation and published in Military Medicine, June 2011, showed a 50% reduction in PTSD symptoms after 8 weeks of practicing the stress-reducing technique. The researcher wrote: “These young men were in extreme distress as a direct result of trauma suffered during combat, and the simple and effortless Transcendental Meditation technique literally transformed their lives.”


Medical Findings:

A meta-review of neurobiological and clinical features of mindfulness meditators was done at the University of Bologna, Italy. They studied EEG results and found significant increases in alpha and theta activity during meditation. Neuroimaging showed activation of the Prefrontal cortex (which controls the amygdala and helps control emotions) and the Anterior Cingulate Cortex, (also involved in emotions). Long-term meditation was also associated with increased gray matter in cerebral areas related to attention.


New Studies Under Way:

All of these studies have energized researchers. Currently there are three large-scale studies underway. The first is a continuation of the U of Michigan/VA Health Center project in Ann Arbor.

The second is at the Center for Investigating Healthy Minds at the Waisman Center, U. of Wisconsin-Madison, which will investigate the impacts of Sudarshan Kriya Yoga Meditation on veterans with PTSD.

The third is at the Center for Mind-Body Medicine, and will work at the Southeast Louisiana Veterans Healthcare System. They plan to measure the effect of mind-body skills on PTSD, anger, sleep, depression, anxiety, health, and post-traumatic positive changes.


On-line sites Offering Mindfulness Meditations:

There are quite a number of online sites that offer free mindfulness meditations, including YouTube. Those listed below are only a starting place. Feel free to comment on your favorites.


Bottom Line:

Here is a way to reduce your PTSD symptoms with NO side effects. Go for it!

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