The Hidden Wounds of War Conference agenda includes: - A documentary screening and panel discussion in the morning - Lunch being provided from noon to 12:50PM - Three speakers in the afternoon addressing PTSD and suicide in the military, unique ways current war injuries alter the brain, and worship addressing needs of veterans with moral injury.

1. Agenda
9:00AM – Noon
•Showing of HBO Documentary “War Torn, 1861-2010”
•Panel Discussion
•Breakout Small Group Discussion
Noon- 12:50 Lunch will be provided
1:00PM – 4:00PM
•Colin A. Ross, M.D. – PTSD and Suicide in the Military
•Theodore F. Mauger, M.D. - Unique Ways Current War Injuries Alter
The Brain
•Chaplain COL Herman Keizer (ret.) - Worship that Addresses Needs of
Veterans with Moral Injury
2015 The Hidden2015 The Hidden
Wounds of War ConferenceWounds of War Conference

2. The Hidden Wounds of War Conference is made possible by the generousThe Hidden Wounds of War Conference is made possible by the generous
support and contributions made by:support and contributions made by:

4. Group 9
Joseph Martinez
Room: 138 E
Group 8
Elise Moore
Room: 136 E
Group 6
Dr. Colin Ross
Room: 119 E
Group 7
Chaplain Herman Keizer
Room: 121 E
Group 5
Dr. Theodore Mauger
Room: 117 E
Group 4
Dr. William Busby
Room: 109 D
Group 3
Elena Bridges
Room: Exhibition Hall
Group 1
Dr. Michael Ryan
Room: Auditorium Stage
Group 2
Dr. Mark Kane
Room: 107 D
Breakout GroupsBreakout Groups

5. The Goal: Fluidity of Spirit
PTSD AND SUICIDE IN THE MILITARY
Colin A. Ross, M.D.
Grand Rapids, Michigan
May 15, 2015
THE RELATIONSHIP BETWEEN TRAUMA

6. COLIN A. ROSS, M.D.
1701 Gateway, Suite 349
Richardson, Texas 75080
Phone: 972-918-9588
Fax: 972-918-9069
e-mail: rossinst@rossinst.com
www.rossinst.com

8. TRAUMA MODEL THERAPY
• The Problem of Attachment to the Perpetrator
• The Locus of Control Shift
• The Problem is Not the Problem
• Just Say ‘No’ to Drugs
• Addiction is the Opposite of Desensitization
• The Victim-Rescuer-Perpetrator Triangle

9. THE PROBLEM OF ATTACHMENT TO THE PERPETRATOR

10. The Locus of Control Shift
Power
Control
Mastery
Badness
PerpetratorChild

11. The Problem is Not the Problem

12. Just Say ‘No’ to Drugs

13. Addiction is the Opposite
of Desensitization

14. Victim - Rescuer - Perpetrator Triangle
Rescuer Perpetrator
Victim

15. SUICIDAL IDEATION AND SELF-BLAME AMONG
COMBAT VETERANS
The Locus of Control Shift
Pre-Combat Trauma
Suicide as Murder of the Self
Placing Oneself on Death Row
The Euthanasia Model of Suicide
Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.
American Journal of Psychotherapy,67, 309-322.

16. SUICIDAL IDEATION AND SELF-BLAME AMONG
COMBAT VETERANS
Survivor Guilt
Self-Blame for Death of a Fellow Soldier
Self-Blame for Deaths of Civilians and for Atrocities
Self-Blame for Being Raped by a Fellow Soldier
Self-Blame for Failure to Protect Loved Ones Post-
Deployment
Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.
American Journal of Psychotherapy,67, 309-322.

17. COLIN A. ROSS, M.D.
1701 Gateway, Suite 349
Richardson, Texas 75080
Phone: 972-918-9588
Fax: 972-918-9069
e-mail: rossinst@rossinst.com
www.rossinst.com

18. Unique Ways Current WarUnique Ways Current War
Injuries Alter the BrainInjuries Alter the Brain
Blast Induced Neuro Trauma (BINT) andBlast Induced Neuro Trauma (BINT) and
Posttraumatic Stress Disorder (PTSD) Due to the BlastPosttraumatic Stress Disorder (PTSD) Due to the Blast
Theodore F. Mauger, M.D.Theodore F. Mauger, M.D.
May 15, 2015May 15, 2015
U.S. Air Force Photo/Master Sgt. Scott Reed - C-17 Medevac mission, Balad AB, Iraq

19. Blast Injury TypesBlast Injury Types
A. Primary injury (compression and decompression)
1. Hollow organs receive direct impact i.e. ear with
tympanic rupture, lungs with collapse and air emboli.
2. Solid tissue suffers damage to the intracellular
architecture.
3. Blood over pressure associated with lung
compression with disruption of the vascular
architecture.

20. Blast WaveBlast Wave

21. Blast Injury TypesBlast Injury Types
A. Primary injury (compression and decompression) cont.
4. Air emboli and abrupt pressure changes primarily damage white matter/limbic
system which then affects personality - religion, intimacy and politics.
a) The hippocampus - new learning and orientation
b) The thalamus - emotional valence

22. Blast Injury TypesBlast Injury Types
B. Secondary Injury - being struck by objects with diffuse
effects - penetrating (especially bomb or improvised
explosive device shrapnel).
C. Tertiary Injury - acceleration-deceleration with diffuse
axonal injury from being thrown
D. Quaternary Injury - burns/toxic fumes (metabolic)

23. Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns
A. Post Concussion Syndrome/encephalopathy (blast, dAI,
anoxic and toxic injuries)
1. Affective Lability
a. Restlessness
b. Irritability
c. Depression
d. Anxiety
e. Decreased impulse control
2. Somatic Disturbances
a. Headache
b. Dizziness/vertigo
c. Broken sleep
d. Fatigue

24. Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns
3. Personality Changes Toward Cluster B Personality Types
a. Histrionic
b. Narcissistic
c. Borderline
d. Sociopathic
4. Fluctuating Level of Cognitive Deficits
a. Memory problems, especially problems with access to information
b. Concentration and attention deficits - ADD/ADHD pattern

25. Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns
B. Frontal Lobe Syndrome
1. Disinhibited type (medial)
a. Impulse control problems
b. Social disinhibition - no filter
c. Poor judgment
d. Lack of insight
2. Amotivational type (lateral)
a. Abulia
b. Negativism

26. Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns
C. Temporolimbic Syndrome (sphenoid cutting)
1. Ictal and non-ictal variant (based on EEG)
2. Kindling (the great mimicker) - rise in symptoms with sudden
discharge:
a. Poor impulse control
b. Affective lability
c. +/- sensory changes (paresthesias)
d. +/- motor changes (tics)
e. Experiential phenomena (very common)
f. +/- mini psychotic episodes
g. Any DSM V diagnosis

27. Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns
D. Affective (Mood) Disorder signs are common secondary to
decrease in neurotransmitter producing neurons. This is
separate from mood symptoms
1. Middle insomnia
2. Early morning awakening
3. Non-restorative sleep
4. Diurnal mood variation
5. Appetite disturbance
6. Psychomotor retardation
7. Anhedonia

28. E. Psychosis is rare, often late onset, and can be very
problematic
1. Usually with the ictal variant of the temporolimbic syndrome
2. Schizoaffective presentation
F. Violence and aggression
1. Intermittent explosive type
2. Part of disinhibition syndrome
3. Misinterpretation of cues
4. Similar to catastrophic reaction (fight/flight)
Brain InjuryBrain Injury
Symptom PatternsSymptom Patterns

29. PTSD - NeuroanatomyPTSD - Neuroanatomy
1. Amygdala - the primary
mediator of fear
2. Ventro-medial prefrontal
cortex (vmPFC), the primary
mediator of calm, positive
mood

30. PTSD Treatment ConsiderationsPTSD Treatment Considerations
“It is more important to know what sort of a
patient has a disease than what sort of a
disease a patient has”. - William Osler
“The fish with a hook in its mouth looks crazy to
the other fish who don’t have that hook in their
mouth” - Carl Menninger

31. PTSD Treatment ConsiderationsPTSD Treatment Considerations
3. Some experiences are PTSD inducers (even without the
full syndrome):
a. Being shot at - bullet, rocket, mortar
b. Being ambushed
c. Shooting another human being
d. Have seen others dying and dead, especially a friend
e. Having a history of MST (military sexual trauma) or other emotional
f. trauma
g. Various biases regarding disability by self and others
h. Work expectations
i. (Role expectations

32. PTSD TreatmentPTSD Treatment
ConsiderationsConsiderations
4. PTSD symptom triggers - sounds, sights, touch, and odors may lead to:
a. Reliving trauma experience i.e. through nightmares, flashbacks
b. Avoidance
c. Numbness
d. Hyperarousal
5. Common complications - especially prevalent without treatment
a. Substance abuse with drugs, alcohol
b. Psychiatric illness, i.e. depression
c. Relationship problems leading to divorce, loss of employment, etc.
d. Failures to meet expectations lead to feelings of hopelessness or sense
of incompetence

33. PTSD TreatmentPTSD Treatment
ConsiderationsConsiderations
6. Flashbacks - during a flashback event, the amygdala takes
control. Has been called an amygdala hijacking. Typically a 3 to
4 hour process to restore equilibrium.
a. Acute behavioral strategies
1. Withdraw from the environment
2. Oxygenate brain by slow, deep breathing
3. Avoid fleeing or fighting
4. Refocus on islands of health (positive memories)
5. Write down feelings and later, process the journaling

34. PTSD TreatmentPTSD Treatment
ConsiderationsConsiderations
7. Dual diagnosis (PTSD & alcoholism)
a. There is a deep sense of alienation with dual diagnosis.
1. Nearly 50% fail effort testing!
2. Essentially none with only one of the syndromes

35. NeurotransmittersNeurotransmitters
1. Serotonin - provides a sense of affective relatedness and
interpersonal
2. reward/punishment. Psychic anxiety when indequate supply.
3. Norepinephrine - alert
4. Dopamine - pleasure, reward, addictions, drive, emotional
engagement (the thalamus provides emotional valence)
5. Glutamic Acid - excitatory, neurotoxic in excess
6. Gamma-Aminobutyric Acid - calm
7. Acetylcholine - semantic memory

36. Medication TreatmentsMedication Treatments
General Principles
1.Restoration of function takes precedence over symptom
control.
a. Is your world getting bigger?
2.Regulate the sleep/wake cycle with focus on ‘wake’
a. Generally avoid long acting stimulants - caffeine
b. Modafinil, Armodafinil to promote wakefulness
c. Stimulants (methylphenidate, amphetamines, et.)

37. Medication TreatmentsMedication Treatments
3. Medication classes to avoid
a. Benzodiazepines
b. Narcotics
c. Anticholinergic medications
d. Older antipsychotic medications (movement disorders)

38. Medication TreatmentsMedication Treatments
4. Use medications which minimize alterations in brain
neurotransmitter function.
a. Omega 3 fatty acids
b. Vitamin D3 - target blood level
c. Antiepileptic medication
1) Gamma-Aminobutyric Acid enhancement -
gabapentin and pregabalin
d. Memantine - glutamic acid inhibition (lamotrigine does this
as well)
e. Amantadine

39. Questions?Questions?
Theodore F. Mauger, M.D.Theodore F. Mauger, M.D.
REFERENCES
Ketcham, Mark. Kilgore College Lecture - from youtube.com
Silver, Jonathan, neuropsychiatrist
Hammond, Richard - Invisible worlds from youtube.com
Goh, S.H. Singapore Medical Journal 2009; 50 (i):101-106 Blast causality, triage, and injury management

40. Worship That Addresses Needs
of Veterans with Moral Injury
Herman Keizer, Jr.
hkeizer@msn.com
1. Moral Injury--definition & causes
2. Recovery of Moral Identity After War
3. Importance of Congregations and
Communities in Soul Repair

41. 1. Moral Injury
Definition and Causes

42. Moral Injury
An Ancient Wound of War with a New Construct
“Throughout history, warriors have been confronted with moral and
ethical challenges and modern unconventional and guerrilla wars
amplify these challenges….[T]he lasting impact of morally injurious
experience in war remains chiefly unaddressed.”
Moral Injury is disruption in an individual’s confidence and
expectations about his or her own moral behavior or others’
capacity to behave in a just and ethical manner.
From “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention
Strategy,” B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva, and S. Maguen, (Dec.
2009) Clinical Psychology Review, 29, 695-706.

43. PTSD and Moral Injury
• PTSD is a fear-victim reaction to extreme conditions that
damage amygdala and hippocampus (limbic brain)
• Moral Injury requires a healthy prefrontal cortex where
empathy and moral thinking occur.

44. PTSD Can Result from Many Kinds of
Exposure to Trauma
Has a consistent symptom profile for traumatic
experiences:
Nightmares
Dissociative episodes
Panic attacks
Hypervigilance
Lack of conscious memory or memory fragments
18
18

45. Aspects of Moral Injury Formation
• Participation in events that challenge core beliefs or have no
clear moral choices, including violating moral codes of training
in a closed system.
• Use of personal agency that violates core moral beliefs.
• Reflection on memories and extreme conditions of extremity
• Agony of inner judgment against oneself.
• Feelings of grief, anger, despair, guilt, shame, remorse, betrayal,
contrition, depression, isolation, and loss of will to live.
• Collapse of moral identity and meaning system that supports it.

46. Disruption of Two Important
Relationships
•PTSD disrupts relationship to world when
it becomes unreliable
•Moral Injury disrupts relationship with self
when inner moral core is doubted

47. Military Culture and Moral Injury
• Military culture fosters moral and ethical codes of
conduct. In war, being violent and killing are normal.
Troops expect and are prepared for violence and killing.
• Still, even prescribed killing or violence may have a
lasting impact
• Most service members can assimilate what they see and
do in war because they are trained for it.

48. Uniqueness of Combat as Traumatic
Stressor
• Involves multiple events over an extended period of
time (7-12 months) with multiple deployments
• Creates a tightly closed system, so actions considered
immoral in other contexts are sanctioned and even
celebrated (e.g. killing) within rules of engagement
• Requires abrupt transition from one closed system
(combat) to a second open system (civilian) with little or
no process or support for transition
18
18

49. Morally Disrupting Aspects of War
Reflexive Fire Training
Dehumanization of Enemy
Killing
Survivor Guilt
Grief
Encountering and Handling human remains--major factor
Participation in torture or atrocities
Betrayal by Authorities
Doubt (uncertainty about goals or mission)

50. Losses in Returning to Civilian Life
"War is the foyer to hell; coming home is hell."
--Tyler Boudreau, Packing Inferno: The Unmaking of a Marine
• Loss of closest friends; isolation
• Loss of unit and closed system
• Loss or role / identity / career
• Loss of home – relocate off base
• Financial losses –
• Loss of Weapon - security
• Loss of family or capacity for intimacy– discord /
divorce
• Loss of community of support – self /family
• Loss of faith and meaning
• Loss of reason to live

51. 2. Recovery of Moral Identity
After War

52. Individual/Social Dimensions of
Recovery
 Writing personal narratives; externalizing inner
struggle and telling story
 Integrating memory/story into larger picture
 Reconnection with estranged others; veteran
support systems; community service
 Long-term support and accountability
community

53. Moral Repair Process
From B.T. Litz, et. al.
 Dialogue with Benevolent Moral
Authority
 Reparation and Forgiveness
 Fostering Reconnection
 Long-Term Planning

54. Dialogue with Benevolent Moral
Authority
Important to practice deep, nonjudgmental
listening to experiences that precipitated
moral injury, and
 To offer benevolent understanding of moral struggle,
 To affirm core moral beliefs that emerge,
 To discuss how reparation might occur in the current
context
 To offer support for self-forgiveness or forgiveness
from others.

55. Reparation and Forgiveness
 Offer opportunities for service to others and ways to
make a positive contribution to the lives of others.
 Accompany veterans in finding decency and
goodness in working for others
 Model self-forgiveness and repair of harm—process
of making amends

56. Fostering Reconnection
Encourage discussions of current
relationships
• Forming deeper connections
• Strategies for greater openness and sharing of
vulnerability and struggle
• Personal coping strategies for inevitable stress and
conflicts
• Reflection on broken relationships that can be repaired
in some form

57. Long-Term Planning
• As making amends and self-forgiveness begin to take
hold, encourage reflection on the future
• What would they like to see for themselves?
• Who will continue to matter to them and how can those
relationships be supported and enhanced?
• What values, beliefs, communities, etc. will continue to
sustain them moving forward?
• How will they cope with the challenges, setbacks, and
revisiting of war experiences that will come?

58. 3. Importance of Congregations
and Communities in Soul Repair

59. Spiritual Recovery
 Lamentation for losses
 Forgiveness; amends
 Transformation; renewal
 Reconstruct moral core values and
self-worth

60. Rituals of Loss
Liturgies for lamentation—dialogic in a
monologic world; hold complex feelings;
open doors to healing:
Complaint against God
Realization that conversation is with God
Remembrance of divine love and faithfulness
Restores God to soul

61. Support for Loss
 Amends
o Ex. Disaster Relief, Refugee Work
o Ex. Peace Missions
o Ex. Neighborhood Service Projects
 Forgiveness and Discipleship
 Absolution (letting go and moving on)

62. Transformation and Renewal
 Rhythms of the liturgical year bring renewal
 Transformation via constant repetition of
renewal
 Vicarious reliving of baptismal rebirth
 Sacramental structure of life
 Dramatic reenactment of sacred stories of
redemption here and now

63. Reconstruction
 Recognition of existence of a moral order
 System of meaning where personal life fits
 Behavior and moral choices make sense
 Joining not withdrawing
 Participation in meaning-making in midst of
moral ambiguity and difficult choices

64. Recommended Resources
Books:
Letters from a Fort Lewis Brig, Sgt. Kevin Benderman
Packing Inferno, Tyler Boudreau
Soul Repair, Rita Nakashima Brock and Gabriella Lettini
The Unfinished War, Walter Capps
Letters from Abu Ghraib, Joshua Casteel
On Killing, David Grossman
Shade It Black, Jess Goodell and John Hearn
What It Is Like to go to War, Karl Marlantes
Road from Ar Ramadhi, Camilo Mejia
Until Tuesday, Luis Carlos Montalvan
The Yellow Birds, Kevin Powers
Achilles in Vietnam, Jonathan Shay
The Untold War, Nancy Sherman
The Moral Treatment of Returning Warriors in Early and Modern Times, Bernard Vercamp

65. Websites:
Hauenstein Center http://hauensteincenter.org
www.conscienceinwar.org
www.britesoulrepair.org
www.ivaw.org/operation-recovery
Films:
Soldiers of Conscience
The Ground Truth
The Invisible War
Lioness
Restrepo
Stop-Loss
Taxi to the Dark Side