1. Beyond The Trauma:
Invisible Injuries of War
Andrea McSweeney
Edith Love
Rachel Powell

2. The military soldier may experience trauma in a variety of
circumstances, during training as well as war. In some cases, severe
injury and sometimes loss of life, may occur. Studies have shown that
the longest lasting effects seem to emerge from wartime experiences.
Many soldiers have been affected directly and indirectly after being
exposed to death and destruction during combat. Often they are
required to be on alert, ready at a moment's notice, waiting for days
or weeks at a time, for a confrontation to happen (National Center for
PTSD, 2010).

3.  Soldiers are always on alert with the threat of
losing their life when in combat. Many soldiers
survive events in which they witnessed the killing
of civilians and the death of fellow soldiers, even
their adversary.
 Even individuals in supporting roles, such as
medics, nurses, persons serving grave duty,
transport pilots, and Military Police, among others,
are at risk to develop problems.
 The internal thoughts of these events remain
strong and continues to interfere with their
functioning and enjoyment of life (Karmey, 2008)

4.  Stress injuries are invisible, which means they are often
overlooked by leaders and other professionals
 Stress injuries can provoke feelings of shame in soldiers,
resulting in their reluctance to admit to having terrifying
or horrible experiences
 The severity of any given traumatic stress injury is
unpredictable, it requires patience and understanding
during the treatment process
 Sometimes, the disabling effects of traumatic stress
injuries may be delayed in their onset until weeks or
months after returning from a deployment (Mettler, 2011)

5.  Post-traumatic stress disorder (PTSD) is a mental health condition that's
triggered by a terrifying event. Symptoms may include flashbacks,
nightmares and severe anxiety, as well as uncontrollable thoughts about
the event.
 After a traumatic event, many people have a difficult time adjusting and
coping with their thoughts . But with time and taking care of yourself, such
traumatic reactions usually get better. In some cases, though, the symptoms
can get worse or last for months or even years. Sometimes it may prevent
you from performing normal daily routines. In a case such as this, you may
need to seek intervention from a professional.
(National Center for PTSD, 2010)

6. There are many different ways that PTSD can impact your
everyday life.
• Flashbacks- reliving the trauma over and over, including
physical symptom like a racing heart or sweating.
• Bad dreams.
• Frightening thoughts.
Re-experiencing symptoms may cause problems in a person’s
everyday routine. They can start from the person’s own thoughts
and feelings. Words, objects, or situations that are reminders of
the event can also trigger re-experiencing (Tull, 2009).

7. • Staying away from places, events, or objects that are reminders of the
experience.
• Feeling emotionally numb or losing interest in things you use to care about
• Having trouble remembering the dangerous event.
• Feeling strong guilt, depression, or worry
• Losing interest in activities that were enjoyable in the past
Things that remind a person of the traumatic event can trigger avoidance
symptoms. These symptoms may cause a person to change his or her personal
routine. For example, after a bad car accident, a person who usually drives may
avoid driving/riding in a car (Tull, 2009).

8. • Being easily startled
• Feeling tense or “ on edge”
• Having difficulty sleeping, and/ or having angry
outbursts.
Hyper arousal symptoms are usually constant, instead of
being triggered by things that remind one of the
traumatic events. They can make the person feel
stressed and angry. These symptoms may make it hard to
do daily tasks, such as sleeping, eating, or concentrating
(Tull, 2009).

9. A traumatic brain injury also known as TBI is caused by
sudden blow or jolt to the head or a penetrating
head injury that disrupts the function of the brain.
 Depression is frequently noted in individuals with
chronic post-concussion syndrome (mild TBI).
 Individuals with TBI who experience depression post-
injury report more symptoms and more severe
symptoms than those TBI patients without depression.
 This can extend to the perception of other problems,
including cognitive problems in individuals with TBI,
with individuals with depression, anxiety and PTSD
reporting more problems with cognitive function than
other groups.
 Depression after TBI is linked to abnormal imaging
results, older age at time of injury, and higher levels of
depressive symptoms in the week following injury
(Tanielian T, 2008)

10.  Risking another brain injury (skiing, contact sports,
motorcycles, etc.)
 Alcohol and illicit drugs
 Caffeine or “energy enhancers”
 Cough, cold, allergy meds containing pseudoephedrine
 Over the counter sleeping aids
 Returning too soon to a high risk area in a combat zone
Returning to combat too soon…
 May result in susceptibility to repeat concussion
 May put the Soldier and fellow Soldiers at risk
(Defense and Veterans Brain Injury Center, n.d)

11. A Major Depressive Episode is when an individual experiences a discrete episode of
persistent and pervasive emotional depression. There must be at least 5 symptoms
from the list below that persist for at least 2 weeks. One of the symptoms must be a
depressed mood or loss of interest. These are two-questions generally asked during
the screening process:
1. Depressed Mood
2. Markedly diminished interest or pleasure in all or almost all activities.
3. Significant weight loss or gain, or increase/decrease in appetite.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness inappropriate guilt.
8. Diminished concentration or indecisiveness.
9. Recurrent thoughts of death or suicide.
(American Medical Network, n.d.)

12. The most common form of treatment is medication; various
prescription medications exist for the purpose of treating
depression
Ex: Prozac and Zoloft
Cognitive therapy-This type of talk therapy helps you recognize
the ways of thinking (cognitive patterns) that are keeping you
stuck — for example, negative or inaccurate ways of perceiving
normal situations.
(American Psychiatric Association, 2000)

13.  Major depression is a mood state that goes well beyond temporarily
feeling sad or blue. It is a serious medical illness that affects one’s
thoughts, feelings, behavior, mood and physical health. Depression is a
life-long condition in which periods of wellness alternate with recurrences
of illness (American Psychiatric Association, 2000).
 Major Depressive Disorder is more commonly known as depression
 Women are two times more likely to be affected by Major Depressive Disorder
than men
 Causes may vary from biological to psychological
 Most episodes of depression usually end over a period of time but Major
Depression can last for years
 Successful treatment of depression does not guarantee that it will not reoccur

14. Rates of PTSD,
depression and TBI
•About 300,000 currently suffer from PTSD or major depression
•About 320,000 reported experiencing TBI during deployment
(Rand, 2008)

15.  The Department of Defense is responsible for providing
the military forces needed to deter war and protect the
security of our country. The major elements of these
forces are the Army, Navy, Marine Corps, and Air Force,
consisting of about 1.4 million men and women on
active duty.
 They are backed, in case of emergency, by the 1.2
million members of the Reserve and National Guard. In
addition, there are about 670,000 civilian employees in
the Defense Department. Under the President, who is
also Commander in Chief, the Secretary of Defense
exercises authority, direction, and control over the
Department, which includes the separately organized
military departments of Army, Navy, and Air Force, the
Joint Chiefs of Staff providing military advice, the
combatant commands, and defense agencies and
field activities established for specific purposes (U.S.
Department of Defense, 2012).

16. The VA offers many benefits other than health care to dependents and
survivors according to the Federal Benefits for Veterans, Dependents and
Survivors VA Pamphlet.
 Education/Training
 Home loan guaranty
 Life insurance
 Burial and memorial services
When working with military connected families it is important to discuss the
VA and its benefits with your clients. It is also important to encourage the
veteran to enroll for VA healthcare benefits immediately after separation
from the military. Sometimes family members are also eligible for benefits so
it is important for social workers to know that the VA can be a great resource
for military families (Department of Veterans Affairs, 2010).

17. VA provides readjustment counseling at 207 community-based Vet Centers located in
all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands to
help combat veterans readjust to civilian life.
Eligibility: Veterans are eligible if they served on active duty in a combat theater
during World War II, the Korean War, the Vietnam War, the Gulf War, or the campaigns
in Lebanon, Grenada, Panama, Somalia, Bosnia, Kosovo, Afghanistan, Iraq and the
Global War on Terror. Veterans, who served in the active military during the Vietnam
Era, but not in the Republic of Vietnam, must have requested services at a Vet Center
before Jan. 1, 2004.
Services: Vet Center staff provides individual, group, family, military sexual trauma,
and bereavement counseling. Services include treatment for PTSD or help with any
other military related issue that affects functioning within the family, work, school or
other areas of everyday life.
Bereavement Counseling: Bereavement Counseling is available to all family members
including spouses, children, parents and siblings of service members who die while on
active duty. This includes federally activated members of the National Guard and
reserve components.
(Vet Centers, 2012)

18.  Provide readjustment counseling in a caring manner to eligible veterans
and their families.
 Provide a broad range of counseling, outreach and referral services, to
help veterans make a satisfying post-war readjustment to civilian life.
 Individual Counseling
 Group Counseling
 Sexual Trauma Counseling
 Marital/Family Counseling
 Bereavement Counseling
 Drug and Alcohol Referral
 Employment Guidance
 Benefits Assistance/Referral
 Liaison with VA & Community Resources (Vet Centers, 2012)

19.  The symptoms associated with PTSD and Major Depression
are often delayed in onset
 When a soldier discloses a history of TBI, this is not
confirmation that one actually occurred…however
 The failure to report an event or seek medical help does not
mean that a TBI did not occur
 When symptom onset is delayed by days to weeks after a TBI,
the symptoms are most likely due to other causes than the TBI
 As the soldier begins to return to a functional or routine
lifestyle, a physical or emotional stressor may cause re-
occurrence of the symptoms (Flynn, n.d.)

20.  It is important to remember that soldiers are not defined by
their TBI, PTSD, or mental illness.
 Often it is necessary to involve the spouse, significant others,
and in some cases the children, in the educational and
healing process of the soldier
 It is important for providers to be competent when
implementing services; improper interventions can present a
delay in an individual’s progress. Sometimes providers do
more harm by the treatment they prescribe
 Soldiers need time to tell their story and receive the
comprehensive evaluation that they deserve – this can not
be accomplished in a understaffed setting or a clinic with
inadequately trained staff (Flynn, n.d.)

22.  http://www.aw2.army.mil/
 Army Wounded Warrior Program
 Christopher & Dana Reeve Foundation  www.ChristopherReeve.org/Military
 Dept of Veterans Affairs --My HealtheVet  http://www.myhealth.va.gov/
 Dept of Veterans Affairs: Polytrauma System  www.polytrauma.va.gov
of Care
 http://www.dav.org
 Disabled American Veterans
 http://www.militaryonesource.com
 Military One Source
 www.vetcenter.va.gov/
 Vet Center

23. Affairs, Department of Veterans. (2012, April 05). History-VA History. Retrieved January
24, 2013, from US Department of Veterans Affairs:
www.va.gov/ about_va/vahistory.asp
American Medical Network. (n.d.). Major Depressive Episode. Retrieved January 24,
2013, from American Medical Network: www.health.am
American Psychiatric Association. (2000). Diagnostic and Statistical manual of mental
disorders: DSM-IV-IV (4th ed.). Arlington, VA, USA.
Defense and Veterans Brain Injury Center (n.d.) Traumatic Brain Injury. Retrieved
January 15, 2013, from Defense and Veterans Brain Injury Center:
www.DVBIC.org
Department of Veterans Affairs. (n.d.). Understanding Post Traumatic Stress Disorder
Retrieved January 20, 2013 from:
http://www.ptsd.vagov/public/ understanding_ptsd/booklet.pdf
Flynn, F. (n.d) Lessons Learned in the Care of Our Wounded Warriors.Madigan Army
Medical Center, TBI Program.

24. Karmey, B. R.-O. (2008). Invisible Wounds Predicting the Immediate and Long Term
Consequences of Mental Health Problems in Veterans of Operation Enduring
Freedom and Opearation Iraq Freedom. Rand Corporation.
Mettler, M. a. (2011). Healthwise for Life. Boise, Idaho, USA: Healthwise for Life.
National Center for PTSD (2010) .Returning from War: A Guide for Families of Military
Members. Department of Veterans Affairs. Retrieved January 22, 2013, from
http://www.ptsd.va.gov/pdf/familyguide.pdf.
Tanielian T, a. J. (2008). Invisible Wounds of War:Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery. 292.
Tull, M. (2009, July 08). An Overview of PTSD Symptoms. Retrieved January 22, 2013, from
about.com: www.ptsd.about.com
U.S. Department of Defense. (n.d.). Department of Defense. Retrieved January 22, 2013, from
US Department of Defense: www.defense.gov

25.  This work was supported by Fayetteville
State University: Department of Social Work
 Mrs. Molly Williams, MSW, Professor-
Research Mentor