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Karen Estrada, M.S. Research Analyst Founder - Military Health Matters ( Milhealth’s Directory of Military Health Information Resources & Research

Proud 82nd Airborne Mom “H-Minus”


re·sil·ience–noun The power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity.

The word “resilience” comes from the Latin resalire, which means “to jump again”. Thus resilient people “jump again”, but instead of coming down in the same place as if nothing had happened, they land a bit to one side or the other, so that they can keep moving forward.

To say they are resilient does not mean that they are invulnerable. It means that they know how to get on with their lives despite their injuries and without becoming fixated on them.



Because resilience can be learned, it can be strengthened.

People use varying strategies to build their resilience.

An approach to building resilience that works for one person might not work for another.

Individuals do not react the same way to traumatic or stressful life events.

Developing resilience is a personal journey.

By definition, resilience means "bouncing back“ or "returning to form.�

Resilience can best be understood as a type of response to intense stress. Resilience to stress is not the same as resistance to stress ‌ because resistance implies there is no response to stress.

FACES OF RESILIENCY MILITARY Individual & Family SFC Daniel Metzdorf – Who refused to quit. SSG Danny Bougher – An example of ‘community’ resilience.

Our Family

SFC Daniel Metzdorf U.S. Army Parachute Team graduates first wounded warrior ‌. the Golden Knights. ‌.an above the knee amputee who was assigned to the Parachute Team through the Wounded Warrior program. . He endured the rigorous training and testing that each of his fellow Soldiers endured and was able to graduate alongside his peers during a jump demonstration and knighting ceremony. To be selected to the team, an individual must be on active duty status, have completed 150 free fall parachute jumps and have a good military and civilian record.

Ceremony: knighted as an official member of the Golden Knights.

31 Oct 2008

SSG Danny Bougher

Infantry Fire Team Leader, with the 2nd Bn., 505th Parachute Infantry Regiment, 3rd Brigade Combat Team, 82nd Abn. Div. …after returning from his 3rd TOD (Iraq), on 10 Dec 2007, SSG Beougher died when his vehicle was struck by another vehicle that veered into his path of travel in North Fort Myers, Fla. Saturday. The unidentified driver of the offending vehicle ….fled on foot ….

SNAP SHOT OF OUR MILITARY There are about three million people serving in the Armed Forces. •

There are nearly 1.8 million children of active duty, National Guard and Reserve parents.

Deployments are not new to military families, but since 9/11 many parents have been deploying, sometimes on multiple tours, to combat zones for months or more than a year at a time.

Separation has become a way of life for these families. •

Service members also frequently go on Temporary Duty (TDY), which can range from a few days to six months.


Active Duty -AGE BY BRANCH

MARITAL STATUS • Active Duty - Married 55.2% Air Force- highest proportion of married members: 60.6% Senior enlisted & senior officers-are more likely to be married. • Dual-military marriages (married to other military personnel) 6.7% Air Force has > % ‘dual military’ marriages: 12.8% > % of female military personnel in dual-military- marriages than males. Marine Corps members (females): 26% Air Force members(female): 30% of • Reserve-Component-Married 49% Air Force reserve-(highest): 60.6% Marine Corps reserve (the lowest): 30.8% Senior enlisted and senior officers were more likely to be married (same as active component).

DIVORCE RATE Military divorce rate increases in 2009 [27 NOV 2009] FY 2009 [ended Sept. 30] 27,312 divorces [estimated] Married members/ active-duty Army, Air Force, Navy and Marine Corps, [per Pentagon] 765,000 [nearly] Divorce rate of about 3.6 % [2009] vs. 3.4 % [2008] Reservists Divorce rate: 2.8 % [2009] vs. 2.7 [2008] **according to figures from the Defense Manpower Data Center.

2008 to 2009 slight difference only. [Attributed to programs, interventions, etc.] Still, the figures show a slow but steady upward trend in recent years. 3.6 % vs. 2.6 % [2001] (beginning of the war in Afghanistan.) According to the CDC (Centers for Disease Control ) civilian divorce rate in 2005: 43 % of all first marriages end in divorce within 10 years.

Active-component members: • 43% have two children (avg) • Largest % - minor dependents – 41% (5 yrs old – younger) Single with children - 5% • Dual-Military w/Children - 3% • Reserve-component members Average – 2 children Largest % - children 6–14 years old


#2 DEPLOYMENT STRESSORS Non-Combat Related Combat Related

Examples of deployment „non-combat related‟ stressors • • • • • • • • • •

Excessive heat & cold Boredom Lack of privacy Inadequate availability of supplies & equipment Inadequate availability of food and potable water Difficulties in communicating with home Long deployments Lack of time ‘off’ Family issues/concerns Poor leadership/chain of command

These stressors are potentially modifiable by the military…unlike ‘combat-related’ stressors. A potentially modifiable variable, deployment- related stressors was more strongly linked with possible PTSD than any other variable (particularly, family /leadership issues). Karen Estrada, MS 2nd Annual Military Health Support Systems Conference. Resilience-Mitigating the Threat of Mental Illness, Current & Future Research. 21-23 April 2010. Washington, DC.

Active-Duty Soldiers | Suicides March 2010 13 [potential] All 13 cases [under investigation] February 2010 8 [confirmed] 10 [pending investigation] 2 additional [deaths under investigation]

December 2009 3 [confirmed] 7 [remain under investigation] Army [2009] 22 [confirmed] 34 [pending cause of death]


January 2010 [confirmed] 11 [remain under investigation]

2010 2003-04 Deployment Raises Suicide Rate April 2003 - Sept 2004 (Deployed-Iraq) 17- to 24 yrs/age : 64 %. This rate was nearly triple the suicide rate for 25- to 34-year-olds.

Deployment - Combat Related Stressors In a study, a survey containing measures of: • psychopathology Suicide • resilience • social support was completed by veterans (OEF/OIF) between 2003-07.


Veterans who contemplated suicide were more likely to screen positive for • PTSD • depression • alcohol problems Experienced more psychosocial difficulties • stigma • barriers to care Also- lower resilience and social support. PTSD, depression, and increased psychosocial difficulties were most strongly linked to suicide ideation. Increased social support and sense of purpose and control were the factors most protective against suicide ideation.

Army Suicide Prevention Training Program The Army is currently engaged in a three-phased Suicide Prevention Training Program that will reach Soldiers, Department of the Army civilians, and Family members. Phase I [completed March 15] Army-wide suicide stand-down. Phase II [Currently underway and is scheduled to reach the entire Army community by July 15] Includes a suicide prevention 'chain-teach’. Phase III Will continue indefinitely through annual training requirements In addition to specific suicide prevention programs, another major focus for Army leaders is eliminating the stigma associated with seeking mental health care.


MILITARY SPOUSES Military Spouses have similar rates of mental health problems when compared to soldiers. However, spouses were more likely to seek out care for their problems and less concerned about 'stigma'. Spouses whose husbands were deployed 1-11 months had the following mental health problems (per 1000): • • • •

Depressive disorders: 27.4 cases Sleep disorders: 11.6 cases Anxiety: 15.7 cases Acute Stress Reaction/Adjustment Disorders: 12.0 cases

Spouses whose husbands were deployed > 11 months • • • •

Depressive disorders: 39.3 Sleep disorders: 23.5 Anxiety: 18.6 Cases Acute Stress Reaction/Adjustment Disorders: 16.4 cases

ALCOHOL USE Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems.

"Risky" or "hazardous" drinking has been defined in the United States as: • more than 7 drinks per week • more than 3 drinks per occasion for women • more than 14 drinks per week or • more than 4 drinks per occasion for men

"Harmful drinking" describes persons who are currently experiencing: • physical harm • social harm • psychological harm …from alcohol use but do not meet criteria for dependence.

Alcohol abuse and dependence is associated with repeated negative physical, psychological, and social effects from alcohol.

ALCOHOL & SUBSTANCE ABUSE High exposure to threatening situations and atrocities was associated with a positive screen for alcohol misuse.

In one study: a number of soldiers who had screened ‘positive’ for ‘hazardous’ alcohol use ‘post-deployment’, screened ‘negative’ at a subsequent ‘pre-deployment’ screening. This was attributed most likely to the ban on alcohol use during deployments. At redeployment, soldiers ‘may’ engage in excessive drinking behavior .

Substance Abuse Self-Medication + PTSD PTSD + Substance abuse result in poorer treatment outcomes. Association of problematic substance behaviors - individuals ‘self-medicate’ in order to reduce PTSD symptoms.

PTSD fluctuations are associated with problematic substance behaviors rather than ‘just’ substance abuse. More research needs to be done on substance abuse and PTSD ‘comorbidity (co-occurrence).


Demographic Variables • Age 18-21 yrs (Most at risk). >27 yrs (Least risk).

• Education Some college or college degree (Least risk).

• Marital Status (has a significant association to PTSD). Divorced (Most at risk) Never married (‘mid’) Married (Least risk).

• Combat Exposure “Feeling I could be killed at any time.” “IED or booby trap exploding near me.” “Having hostile reactions from civilians.”

PTSD SYMPTOMS Re-Experiencing Re-experiencing symptoms are symptoms that involve reliving the traumatic event. This is called a "flashback." Reliving the event may cause intense feelings of fear, helplessness, and horror similar to the feelings they had when the

Avoidance Avoidance symptoms are efforts people make to avoid the traumatic event.

Emotional Numbing Numbing symptoms are another way to avoid the traumatic event. Individuals with PTSD may find it difficult to be in touch with their feelings or express emotions toward other people.

Hyperarousal People with PTSD may feel constantly alert after the traumatic event. This is known as increased emotional arousal, and it can cause difficulty sleeping, outbursts of anger or irritability, and difficulty concentrating.

Direct and indirect killing during combat –what is the impact on the mental health of our troops? Killing in Combat (KIC) is a significant predictor of: • PTSD symptoms • Alcohol Abuse • Poor psychosocial functioning (anger management, relationship difficulties) The experience in killing may be associated with ‘moral’ injury and changes in spirituality/religion. Many military personnel have reported that they have received criticism or been subject to insensitive questioning. Some also have felt they were ‘being judged’ for their actions. “The assessment and acknowledgement of killing experiences may help prevent the perpetuation of shame, stigma and secrecy of taking a life in combat”

SYMPTOMS OF MILD TBI (mTBI)/CONCUSSION Headaches Dizziness Excessive Fatigue (Tiredness) Concentration Problems Forgetting Things (Memory Problems) Irritability Balance Problems Vision Change Sleep Disturbance

Concussion/mTBI Screening (Military)-Click on graphic.

Traumatic Brain Injury Acquired brain injury, Head injury, Head trauma, TBI Symptoms of Severe TBI (including all of mTBI): • • • • • • • • •

headaches that gets worse or do not go away repeated vomiting or nausea convulsions or seizures inability to awaken from sleep dilation of one or both pupils of the eyes (also known as anisocoria) slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation

Severe Traumatic Brain Injury is associated with: loss of consciousness for over 30 minutes, or amnesia. Concussion/mTBI Screening (Military)-Click on graphic.

March 2010 p.25

PTSD | TBI | mTBI Which came first, the chicken or the egg?

Ninety-four combat veterans identified from positive traumatic brain injury screens were seen in the Veterans Affairs Connecticut Healthcare System from April 1, 2007 to March 30, 2008.



Which Came First?


Eighty-five percent of the veterans with positive screens met the American Congress of Rehabilitation Medicine definition of probable traumatic brain injury.

mTBI Symptom reporting was similar for veterans with and without a history of traumatic brain injury. Veterans with both posttraumatic stress disorder and traumatic brain injury were more likely to report falling as a mechanism of injury and indicated that they had suffered a head injury during deployment.

PHYSICAL & PSYCHOLOGICAL TRAUMA RARELY APPEAR IN ISOLATION. “Both traumatic brain injury and posttraumatic stress disorder are almost always defined in part by the same events and the same self-reported symptoms.”

PTSD Symptoms Functional impairment hyperarousal re-experiencing avoidance…

mTBI Symptoms headaches, memory problems, sleep problems…

physical cognitive emotional

PTSD had a larger affect on these symptoms

(physical, cognitive, emotional)

than mTBI

mTBI found to adversely affect long-term recovery from PTSD

POST-OIF/OEF CLINICAL PRESENTATION In contrast to mild TBI in civilian settings, recovery from combat-related concussions is complicated by at least four factors: 1. The physically and emotionally traumatic circumstances in which many concussions are sustained. 2. The potentially repetitive and cumulative nature of concussions sustained over a tour (or multiple tours) of combat duty. 3. The high incidence of comorbid mental health conditions [1,27]. 4. The difficulty in following typical recommendations for postconcussion care (e.g., rest).

The following comorbid mental health conditions interfere with normal cognitive functioning • PTSD • depression • associated /iintrusive thoughts • concentration difficulty • poor sleep

They are likely to be detrimental to the resilience essential to overcome PTSD. On the other hand, these mental health conditions associated with TBI are like cause • cognitive impairment • emotional control Thus, for the OIF/OEF veteran with comorbidity, the overall recovery process is complicated and prolonged by this cycle.

mTBI & PTSD In a study of OEF and OIF veterans, respondants w/ positive mTBI screens were compared with respondants w/‘negative’ mTBI screens.


Those with a positive screen were likely to: • Be younger • Have PTSD • Report fair or poor overall health concerns • Report unmet medical and psychological needs • Score higher on measures of psychosocial difficulties and perceived barriors to mental health care. Those who reported loss of consciousness were associated with > greater work-related difficulties and unmet psychological needs. PTSD was the mediator between mTBI and all of these factors.

PTSD THERAPIES Cognitive therapy. This type of talk therapy helps you identify and change self-destructive thought (cognitive) patterns. Exposure therapy. This behavioral therapy technique helps you safely confront the very thing that you find upsetting or disturbing, so that you can learn to cope effectively with it. (also: Virtual Exposure Therapy – VRE) Eye movement desensitization and reprocessing (EMDR). This type of therapy combines exposure therapy with a series of guided eye movements that help you process traumatic memories. Cognitive behavior therapy (CBT). This approach combines cognitive and behavior therapy to help you identify unhealthy beliefs and behaviors and replace them with positive ones. Rational-Emotive Behavior Therapy (REBT). In REBT, cognitive distortions, called irrational beliefs, are recognized as logical fallacies which involve distorted thinking. Pharmacotherapy and group therapy.

Web�Based Behavioral Therapies The web-based TRICARE Assistance Program (TRIAP) makes use of web-based technologies to: * Deliver information and counseling services to our beneficiaries * Determine if web-based technologies increases efficiency of identifying beneficiaries who need behavioral health care * Identify behavioral health needs of our beneficiaries earlier * Refer and get beneficiaries access to the appropriate level of behavioral health care more effectively. TRICARE Behavioral Health Care Services Flyer



PILOTS Database Search Number of articles about trauma published (in non-speciality journals) Trauma Related-Anxiety Disorders

• 1981-85: > 16.3% • 2000-05: > 38%* *A increase in publications from international authors/contributors (Trauma/Trauma Stress publications) reflective of the War on Terror as a "Global" war not just a "U.S." conflict.

A search using Google's News Archive on "PTSD" was conducted 6 JAN 2010: Number of Articles (English language): • 2001 (@start of OEF): 811 • 2003 (@start of OIF): 1,160 • 2009: 3,480

("Quality of life" OR cognitive*) AND PTSD AND 2000-2007 (*Publication Date]. 2000 2001 2002 2003 2004 2005 2006 2007

3 citations 6 citations 6 citations 18 citations [6-7 Portuguese] 140 163 210 200

(PubMed (NIH) - 04 APR 2010)


The ancients thought the BRAIN was a radiator, cooling the blood. The human brain is the most complex object known to us. It contains billions of nerve cells, each of which may make thousands of connections, in immense networks of circuitry that control our sense of self and our appreciation of – and interaction with – the world around us. In the last half century we learned that we are born with raw circuitry that quickly tunes itself to the environment we encounter. Now we are learning that the properties that allow nerve cells to achieve this "plasticity" in response to the early environment are controlled by the very same genes that drive learning and memory in adults.

amygdala (pronounced: uh-mig-duh-luh), keeps track of experiences that trigger strong emotions.

Emotional memories seem to be etched into the amygdala indelibly.

A better understanding of this mechanism will contribute to improved treatments for fear regulation and chronic stress disorders .

Extinction involves a control exercised by the medial prefrontal cortex over the amygdala (To calm the emotions of the amygdala.)

Mind & Brain amygdala



• keeps track of experiences that trigger strong emotions.

•once a certain thing or situation triggers a strong fear reaction….

•warns the person by triggering a fear reaction every time he or she encounters (or even thinks about) that thing or situation.



cerebral cortex

The amygdala, and in particular the Ace (central nucleus of the amygdala) , contributes to a heightened state of arousal during conditioned fear.

Subsequent studies showed that the amygdala plays a central role in the emotion of fear, whatever the nature of the sensory stimulus that triggers it.

Frontolimbic structures involved in fear conditioning have also been associated with hypothalamic-pituitary-adrenal (HPA)-axis modulation, including amygdaloid, hippocampal, and ventromedial prefrontal cortex regions.

Brain's Neural Pathways Image by Images The human brain may contain up to one trillion neurons. These nerve cells are interconnected, as shown in this microscopic image, so that they can transmit electrical impulses—and information—to other cells. [ [10 Apr 2010].

What is known about conditioned fear: (1) that the sensory system through which the conditioning is applied often is well understood and can be used as a starting point to trace the pathways involved in the brain; and (2) the behavioural response of fear involves several well known, measurable, physiological changes, such as accelerated heart rate and elevated levels of stress hormones in the blood.

Functional MRI - fMRI

Functional MRI (fMRI) techniques can measure levels of “metabolic activity� in specific areas within the brain. Metabolic activity is the reaction between the chemicals and pathways in our bodies that help us live. This kind of measurement is possible because the oxygen-carrying molecule in blood, called hemoglobin, produces a different signal on MRI scans depending on whether or not it is bound to oxygen. In the motor area of the brain, there is a high level of metabolic activity during movement. For example, there is a lot of activity in the motor control area during finger tapping and the oxygen concentration falls. This is followed by an increase in blood flow and an increase in oxygen in the tissue.

The term plasticity describes the various ways in which the nervous system can change its function as a result of training, or in response to injury.

An example is the steady improvement in skill with a task over about 4 weeks of daily practice. Those who brush their teeth using a side-to-side motion, for instance, will initially feel clumsy with an up-and-down or a circular motion. After practice, the new motion seems natural.


This learning is due to rearrangement of how the brain handles its functions. Plasticity is one of the most fascinating mysteries of the human central nervous system. The brain was once thought to develop and then never change. But now many types of changes are known to occur, including the birth of new brain cells and the steady loss of brain cells in adulthood.

Mindfulness Training A University of Pennsylvania-led study in which training was provided to a high-stress U.S. military group preparing for deployment to Iraq has demonstrated a positive link between mindfulness training, or MT, and improvements in mood and working memory. Mindfulness is the ability to be aware and attentive of the present moment without emotional reactivity or volatility. The study found that the more time participants spent engaging in daily mindfulness exercises --the better their mood and working memory, (the cognitive term for complex thought, problem solving and cognitive control of emotions). The study also suggests that sufficient MT practice may protect against functional impairments associated with high-stress challenges that require a tremendous amount of cognitive control, self-awareness, situational awareness and emotional regulation.

Think of emotional resilience as armor for the mind, push-ups for the brain.

Casualties occur in war, accidents happen, good people die.

Nothing to be ashamed of if you survive.

Nothing to be guilty of if you survive.

It’s easy in hind sight to second guess your decisions or the decisions of others. You’re all heroes, you have made sacrifices. Those who didn’t make it back made the ultimate sacrifice. Would your buddy want you to be putting yourself through the wringer right now?. No, he/she would want you to drive on.

In Combat


Survival depends on discipline and obeying orders. Following orders kept you and those around you safe and in control. When an NCO or officer gives an order, we follow it. We don’t say “well, I don’t know if it’s a good idea, or I don’t feel like doing it.” Unless it’s unlawful or immoral, we follow that order. At Home: Inflexible interactions (ordering and demanding behaviors) with your spouse, children, and friends often leads to conflict.

Battlemind skills helped you survive in combat, but may cause you problems if not adapted when you get home.

"The best way to treat a death by heart attack is not CPR," “the best way is to prevent the heart attack. It's a lifestyle and culture change. And that's how we should look at mental health.�

What is Comprehensive Soldier Fitness? Comprehensive Soldier Fitness represents the Army’s investment in readiness of the force and quality of life for our Soldiers, Family members and Civilians by giving the same emphasis to psychological, emotional and mental strength that we have previously given to physical strength. The program uses individual assessments, tailored virtual training, classroom training and embedded resilience experts to provide

Soldiers with the critical skills needed to take care of themselves, their Families and their teammates in this era of persistent conflict.

The Development of Warrior Resilience Training WRT is based upon a combination of Rational Emotive Behavior Therapy (REBT) and the philosophy of Stoicism. The term comes from Stoic philosophy, that trained its followers to deal with adversity in a calm and rational manner, recognizing that all adversity can be seen as training.

In antiquity, Stoicism was highly useful to promote mental endurance and fortitude, and thus can be considered the original “resilience training.�

The two are closely related, since many of the theories underlying REBT were largely influenced by Stoic teachings.


RESILIENCE TRAINING Table 1 A Typical Warrior Resilience Training Syllabus  Mastering basic cognitive-behavioral Think-Feel-Act cycle and Ellis’ ABC theory of emotional disturbance.  Conflict management within Army organizations and on home front with family.  Anxiety and fear management within the combat zone and on operations.  Rational thinking and responses vs. emotion-driven reactions.  Future stressful scenario inoculation training.  Proven philosophical beliefs which inculcate resilience and endurance.  Emotional intelligence expression including appropriate grief, sorrow and frustration vs. depression, rage and apathy.  Group discussion of existentially vital issues for soldiers like death, loss and family separation. Table 2 Concepts from Stoicism that are Expected to help People deal with Adversity  Learning that adversity is a normal part of life; it happens to everybody  Learning to mentally prepare or rehearse for adversity  Learning what things you control and what you do not, and how to differentiate between the two  Learning to accept those things you can’t change  Learning to make decisions rationally rather than emotionally  Learning to temper your emotions and not let them control you  Learning that “suffering” itself is an interpretation and label which may amplify pain  Learning that negative emotions often come from unrealistic perceptions of events  Learning to view events more realistically, and thus reduce negative emotions  Learning to be less judgmental of others and oneself  Learning to live by your values and morals to the best of your ability  Striving to fulfill societal obligations, i.e. doing your duty to the Army, family, friends, country and society in general

WARRIOR RESILIENCE 2007/Warrior Resilience Training Table 3 Lessons Learned from Conducting Warrior Resilience Training  Maintain an open class.  Avoid the term group, therapy or counseling.  Select those clients who want to learn.  Teach principles separately to those who resent instruction or can draw class energy downward.  Give reading assignments, exercises and utilize evocative in-class role-plays and exercises.  Keep the interest level high!  Focus on leadership and future development.  The emotionally intelligent student of today is a better leader tomorrow.  Advertise and demonstrate the group at units, with Chaplains and with the Medical Community.  Teach the principles down at the unit level.  Use WRT as pre-stress inoculation and stress management maintenance training


Little research has examined factors that may be protective against traumatic stress and depressive symptoms and examine adaptive aspects of recovery… ….and protectection against the development of traumatic stress and depressive symptoms in combat. The study of the differential aspects of resilience and social support is important because it may provide insights into cognitive, behavioral, social, and spiritual factors that can be applied to the development of new training and treatment strategies that may protect military personnel exposed to trauma against the development of PTSD, depression, and related conditions. Psychological resilience and social support may be protective against traumatic stress and depressive symptoms by: • improving emotional regulation • decreasing fear-related appraisals and cognitions • promoting cognitions that the world is safe and nonthreatening, • enhancing self-efficacy and control • decreasing hypothalamic–pituitary–adrenal axis reactivity and stress-related physiological arousal. < … CONTINUED … >

Studies demonstrated: Most pronounced differences between the PTSD /no PTSD subjects: • individual feels in control of their life • knows where to turn for help • has a sense of purpose in their life Individuals with lower coping efficacy, have been linked to greater: • stress • intrusion • avoidence  higher resilience + post – deployment social support = < traumatic stress and depressive symptoms. “This finding is consistent with Bandura’s social cognitive theory, which maintains that beliefs about one’s capacity to manage and control events in life are important in determining behavioral and affective responses to highly stressful situations.” This reinforces the importance of cognitive-behavioral interventions that promote: • perceptions of control • self efficacy • acceptance of change • increased adaptive coping strategies The program, based on 30-plus years of scientific study and results, uses individual assessments, tailored virtual training, classroom training and embedded resilience experts to provide the critical skills our Soldiers, Family members and Army Civilians need.

What is it?

Why is it important? CSF marks a new era for the Army by comprehensively equipping and training our Soldiers, Family members and Army Civilians to maximize their potential and face the physical and psychological challenges of sustained operations. We are committed to a true prevention model, aimed at the entire force, which will enhance resilience and coping skills enabling them to grow and thrive in today's Army.

Tenets of Resilience Training Evidence-based: Built on findings from WRAIR’s Land Combat Study and MHAT I-VI Experience-based: Uses examples that Warriors can relate Explanatory: Highlights conflicted and/or misunderstood reactions Strengths-based: Builds on existing Warrior strengths and skills Team-Based: Self-confidence & self-awareness through helping their battle-buddy

The goal of CSF is to increase resilience and enhance performance by developing the five dimensions of strength:

Key Program Elements Global Assessment Tool Comprehensive Resilience Modules Master Resilience Training Sustainment Resilience Training

‘Project FOCUS’ (Families OverComing Under Stress).

APRIL IS MONTH OF THE MILITARY CHILD – CARING FOR OUR FAMILIES “When our Sailors and Marines deploy, our families are the foothold. We at Navy Medicine believe that not only do our warriors serve; families serve as well.” Vice Admiral Adam M. Robinson Jr., MC Surgeon General of the Navy

In June 2009, the Office of the Secretary of Defense Child and Family Policy determined FOCUS as a best practice program and requested BUMED support to expand Army and Air Force sites for services.

FOCUS is a family-centered resiliency training program based on evidenced-based interventions that enhance understanding, psychological health and developmental outcomes for highly stressed children and families. FOCUS has been adapted for military families facing multiple deployments, combat operational stress, and physical injuries in a family member. FOCUS has demonstrated that a strength-based approach to building child and family resiliency skills is well received by service members and their family members. This is reflected in high satisfaction ratings.

Notably, program participation has resulted in statistically significant increases in family and child positive coping, and significant reductions in parent and child distress over time, suggesting longer-term benefits for military family wellness. To date, over 81,000 service members, spouses, children and community providers have received services from FOCUS. More information regarding Project FOCUS can be found at:

In the United States today, about 1.2 million children have an active duty military parent.


The Child and Family Program is under the leadership of Dr. Stephen J. Cozza. Dr. Cozza, Professor of Psychiatry at the Uniformed Services University, serves as Associate Director of the Center for the Study of Traumatic Stress.

About Us Since its establishment in 2006, The Child and Family Program (CFP) of the Center for the Study of Traumatic Stress (CSTS) has been conducting research to advance scientific knowledge and clinical interventions that address the needs of children and families affected by trauma, especially military children and families. The focus of CFP research is on the impact of war including deployment stress, parenting and family function, and the impact of war injuries on military children and families.

Warrior Care The Center for the Study of Traumatic Stress (CSTS) addresses both the invisible and visible wounds of war through research, education and consultation. The invisible wounds of war include the mental health consequences of deployment. These can range from normal distress to the treatable mental disorders of depression, anxiety and post-traumatic stress disorder (PTSD). Warrior wounds can also involve health risks such as increased use of tobacco, alcohol and/or drugs that can result in violence to self, spouse and/or children. Information for : For the Warrior, Leadership, Providers, and Families.

“…the work of healing will take years. The wounds of this war have been horrendous. Vets with multiple amputations and brain injuries fill many of the beds of Walter Reed Army Medical Center and challenge our country’s ability to care for their minds, spirits and broken bodies for decades to come.”

“Our understanding of our vet’s needs is a priceless gift. Let us embrace them in an allenveloping support system so they can come home again.” Dr. Joyce Brothers When Our Troops Come Home Parade Magazine 16 April 2006

The Samarra 7 – C Co., 2-505 PIR, 3rd BCT 82nd Airborne Samarra, Iraq 05 Mar 2007.

Remember the fallen and live a life worthy of their sacrifices!

Thank you for your attention!



Karen Estrada, MS


RESILIENCE: PAGE REFERENCE CITATIONS-PDF pp 5-6 SAMHSA Resilience and Stress Management Resource Collection RESILIENCE [Accessed 26 MAR 2010] p7 Source: Naval Medical Center San Diego > NCCOSC Build Resistance. [28 MAR 2010]. p8 10 Things Military Teens Want You To Know. National Military Family Association 2008 [30 MAR 2010]. p9 Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Selected Populations; Institute of Medicine of the National Academies. 2010. pp. (Rutherford GW. (Chair, Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans and their families). TABLE 2.1 Service Members Deployed by Component as of April 30, 2009; p. 17. TABLE 2.2 Percentage of Active-Component Members by Age and Service Branch in 2009; p. 19 p 10 Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Selected Populations; Institute of Medicine of the National Academies. 2010; p. 21. p 11 Hogan PF, Furst Seifert R. Marriage and the Military: Evidence That Those Who Serve Marry Earlier and Divorce Earlier. Armed Forces & Society. 2010;36(3):420-438. Available at: [Accessed March 21, 2010]. p 12 Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Selected Populations; Institute of Medicine of the National Academies. 2010. pp. (Rutherford GW. (Chair, Committee on the Initial Assessment of BIBLIOGRAPHY 1

Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? Readjustment Needs of Military Personnel, Veterans and their families). FIGURE 2.1a Age of children (active component); FIGURE 2.1b Age of children (reserve component); p. 22 FIGURE 2.2 Counties of residence of deployed OEF and OIF Army (active-component) military personnel; p. 23 p 14 Booth-Kewley S, Larson GE, Highfill-McRoy RM, et al. Correlates of posttraumatic stress disorder symptoms in Marines back from war. J Trauma Stress. 2010 Feb;23(1):69-77. PubMed PMID: 20104587. Affiliation: Behavioral Science and Epidemiology Department, Naval Health Research Center, San Diego, CA 92106-3521, USA. pp 15-6 NEWS RELEASES - No. 115-10 17 Feb 2010. January Suicide Data. SOURCE: Army Releases March Suicide Data Apr 10 By Lt. Col. George Wright OCPA Media Relations Division. 10 Apr 2009 SOURCE: Chart - Apr 2003 â&#x20AC;&#x201C; Sept 2004 Suicide data: Air Force suicide prevention information is posted online at<>.â&#x2013;Ş p 17 Pietrzak RH, Goldstein MB, Malley JC, Rivers AJ, Johnson DC, Southwick SM. Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord. 2009 Oct 9. [Epub ahead of print] PubMed PMID: 19819559. p 18 Army Releases March Suicide Data Apr 10 By Lt. Col. George Wright OCPA Media Relations Division / 10 Apr 2009 SOURCE: [30 MAR 2010]. p 19 Suicide Awareness for Soldiers 2008 (ppt). Slide #1 Cover Slide/Training; Slide # 6 (ACE) [March 2010]. p 20 Mansfield AJ, Kaufman JS, Marshall SW, et al. Deployment and the use of mental health services among U.S. Army wives. N Engl J Med. 2010 Jan 4;362(2):101-9. PubMed PMID: 20071699. p 21 AHRQ Home > Clinical Information > U.S. Preventive Services Task Force (USPSTF) > Screening: Alcohol Misuse > Recommendation Statement. Agency for Healthcare Research and Quality. [Mar 2010].


Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? p 22 Wilk JE, Bliese PD, Kim PY, Thomas JL, McGurk D, Hoge CW. Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war. Drug Alcohol Depend. 2010 Apr 1;108(1-2):115-21. Epub 2010 Jan 8. PubMed PMID: 20060237. Affiliation: Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, MD 20910, United States. p 23 Ouimette P, Read JP, Wade M, Tirone V. Modeling associations between posttraumatic stress symptoms and substance use. Addict Behav. 2010 Jan;35(1):64-7. Epub 2009 Aug 19. PubMed PMID: 19729250; PubMed Central PMCID: PMC2763948. p 24 Booth-Kewley S, Larson GE, Highfill-McRoy RM, et al. Correlates of posttraumatic stress disorder symptoms in Marines back from war. J Trauma Stress. 2010 Feb;23(1):69-77. PubMed PMID: 20104587. Affiliation: Behavioral Science and Epidemiology Department, Naval Health Research Center, San Diego, CA 92106-3521, USA. p 25 Nebraska Department of Veterans Affairs. What is PTSD? [31 Mar 2010]. p 26 Maguen S, Lucenko BA, Reger MA, et al. The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. J Trauma Stress. 2010 Feb;23(1):86-90. PubMed PMID:20104592. PMID: 20104592 [PubMed - in process] p 27-8 Defense and Veterans Brain Injury Center (DVBIC), TBI & the Military: TBI Facts. [31 MAR 2010]. p 29 Armed Forces Health Surveillance Center. MSMR [Medical Surveillance Monthly Report] Deployment-related conditions<â&#x20AC;?TBIâ&#x20AC;?. March 2010 - Volume 17 / Number 03 p. 25. p 31 Hill JJ 3rd, Mobo BH Jr, Cullen MR. Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the Veterans Affairs traumatic brain injury screening program. Am J Phys Med Rehabil. 2009 Aug;88(8):605-14. PubMed PMID: 19620825. Affiliation: Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, Connecticut 06510, USA.


Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? p 32 Hill JJ 3rd, Mobo BH Jr, Cullen MR. Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the Veterans Affairs traumatic brain injury screening program. Am J Phys Med Rehabil. 2009 Aug;88(8):605-14. PubMed PMID: 19620825. Vanderploeg RD, Belanger HG, Curtiss G. Mild traumatic brain injury and posttraumatic stress disorder and their associations with health symptoms. Arch Phys Med Rehabil. 2009 Jul;90(7):1084-93. PubMed PMID: 19577020. p 33-4 Lew HL, Vanderploeg RD, Moore DF, Schwab K, Friedman L, Yesavage J, Keane TM, Warden DL, Sigford BJ. Overlap of mild TBI and mental health conditions in returning OIF/OEF service members and veterans. J Rehabil Res Dev. 2008;45(3):xi-xvi. PubMed PMID: 18629743. p 35 Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Posttraumatic stress disorder mediates the relationship between mild traumatic brain injury and health and psychosocial functioning in veterans of Operations Enduring Freedom and Iraqi Freedom. J Nerv Ment Dis. 2009 Oct;197(10):748-53. PubMed PMID: 19829203. p 36 Mayo Clinic PTSD Last updated 4/10/2009 12:00:00 AM Š 1998-2010 Mayo Foundation for Medical Education and Research (MFMER). [10 Apr 2010]. p 38 Schnurr PP. PTSD 30 years on. J Trauma Stress. 2010 Feb;23(1):1-2. PubMed PMID: 20131321. p 39 Schnurr PP, Kaloupek D, Sayer N, et al. Understanding the impact of the wars in Iraq and Afghanistan. J Trauma Stress. 2010 Feb;23(1):3-4. PubMed PMID: 20135677. pp 41-2 Brain Facts: A Primer on the brain and nervous system. Society for Neuroscience. p 43 Building Brains, Making Minds Lynn Nadel, Regents' Professor, Psychology These models can predict what will happen in the next minute, hour or decade, and allow us to behave in the most adaptive way. 23 Feb 2010. View lecture (67 mins) [31 Mar 2010]. p 44 [48] Brain Diagram: National Institute of Mental Health. Health Topics-Publications. [31 Mar 2010]. BIBLIOGRAPHY 4

Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? p 45-7 The Brain. [09 APR 2010]. Site developed, researched, and written by: Bruno Dubuc Douglas Hospital Research Centre. Cain ME, Kapp BS, Puryear CB. The contribution of the amygdala to conditioned thalamic arousal. J Neurosci. 2002 Dec 15;22(24):11026-34. PubMed PMID: 12486198. p 48 Hippocampus and fornix (limbic system) diagram. National Library of Medicine, National Institutes of Health. MedlinePlus. [31 Mar 2010]. Root JC, Tuescher O, Cunningham-Bussel A, et al. Frontolimbic function and cortisol reactivity in response to emotional stimuli. Neuroreport. 2009 Mar 4;20(4):429-34. PubMed PMID: 19225430. American Psychological Association. APA PsychNET, Thesaurus of Psychological Index Terms. [03 Apr 2010] Fear or Fun? Graphic. Nemours. KidsHealth, Teens, Your Mind, Mental Health, Fears and Phobias: [31 Mar 2010]. p 49 Brain's Neural Pathways Image by Images The human brain may contain up to one trillion neurons. These nerve cells are interconnected, as shown in this microscopic image, so that they can transmit electrical impulsesâ&#x20AC;&#x201D;and informationâ&#x20AC;&#x201D;to other cells. [ [10 Apr 2010]. p 50 The University of Arizona. A Series of 6 Lectures Exploring Our World and Ourselves. The University of Arizona College of Science. Building Brains, Making Minds. 21 MAR 2010. (Original lecture date: Tuesday, 2 March 2010). p 51 INTERACTIVE WEB ON THE HUMAN BRAIN & BEHAVIOR. THE BRAIN FROM TOP TO BOTTOM. [09 APR 2010]. Site developed, researched, and written by: Bruno Dubuc Affiliation:Douglas Hospital Research Centre. [31 Mar 2010]. p 52-3 Henson JW, Keogh BP. Plasticity: Teaching an old brain new tricks. Neurology 2010;74;e53-e55 [Information current as of 07 APR 2010]. BIBLIOGRAPHY 5

Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? American Psychological Association. APA PsychNET, Thesaurus of Psychological Index Terms. [03 Apr 2010] p 54 University of Pennsylvania. Mindfulness and Attention. About: The Penn Program for Mindfulness (PPM) helps you to manage stress. PPM is built upon a meditation-based process known as mindfulness. Meditation is one of the world's most ancient and widely practiced mind-body therapies. Western medicine is increasingly realizing the role of stress in health and disease. An expanding body of research and clinical evidence supports this. One recent study suggests that meditation may cause short-term and long-term neural changes. p 55-6 Battlemind I PPT Slide 23. Battlemind Prg based more on â&#x20AC;&#x2DC;adaptationâ&#x20AC;&#x2122; . p 57 Army Brig. Gen. (Dr.) Rhonda Cornum, director of the Army's comprehensive Soldier fitness program, in a recent news release. Resiliency: Chaplains learn, then share, the secrets of bouncing back. Posted 3/23/2010 Updated 3/23/2010 by Bo Joyner Air Force Reserve Command Citizen Airman. p 58 Comprehensive Soldier Fitness Brochure-2 pg. p 59 STOIC Image: Theophyleâ&#x20AC;&#x2122;s English Blog US Army Medical Department- /Comprehensive Soldier Fitness. This Web site provides Warriors, Family, Community members and Providers access to Resilience Training and presentations. Resilience Training Research Office, the Walter Reed Army Institute of Research and the Office of the Surgeon General, Army Medical Command. p 60-1 Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Psychological resilience and postdeployment social support project against traumatic stress and depressive symptoms in soldiers returning from Operations Enduring Freedom and Iraqi Freedom. J Spec Oper Med. 2009 Summer;9(3):67-73. PubMed PMID: 19739479. pp 62-3 Comprehensive Soldier Fitness: p 64 Division Website, Photo Gallery OEF. BIBLIOGRAPHY 6

Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? ADDITIONAL REFERENCES Adeleye A, Shohami E, Nachman D, et al. d-Cycloserine improves functional outcome after traumatic brain injury with wide therapeutic window. European Journal of Pharmacology. 2010;629(1-3):25-30. Chard KM, Schumm JA, Owens GP, Cottingham SM. A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. J. Traum. Stress. 2010:n/a-n/a. Available at: [Accessed April 16, 2010]. Christianson JP, Ragole T, Amat J, et al. 5-Hydroxytryptamine 2C Receptors in the Basolateral Amygdala Are Involved in the Expression of Anxiety After Uncontrollable Traumatic Stress. Biological Psychiatry. 2010;67(4):339-345. [Accessed April 16, 2010]. Dedert EA, Green KT, Calhoun PS, et al. Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001. Journal of Psychiatric Research. 2009;43(9):830-836. Elder GA, Cristian A. Blast-related mild traumatic brain injury: mechanisms of injury and impact on clinical care. Mt Sinai J Med. 2009;76(2):111-118. Golub Y, Mauch CP, Dahlhoff M, Wotjak CT. Consequences of extinction training on associative and nonassociative fear in a mouse model of Posttraumatic Stress Disorder (PTSD). Behavioural Brain Research. 2009;205(2):544-549. Helmer DA, Chandler HK, Quigley KS, et al. Chronic Widespread Pain, Mental Health, and Physical Role Function in OEF/OIF Veterans. Pain Medicine. 2009;10(7):1174-1182. Hennig-Fast K, Werner NS, Lermer R, et al. After facing traumatic stress: Brain activation, cognition and stress coping in policemen. Journal of Psychiatric Research. 2009;43(14):1146-1155. Kenny D, Hull M. Critical Care Nursesâ&#x20AC;&#x2122; Experiences Caring for the Casualties of War Evacuated from the Front Line: Lessons Learned and Needs Identified. Critical Care Nursing Clinics of North America. 2008;20(1):41-49. 23. McTeague LM, Lang PJ, Laplante M, et al. Aversive Imagery in Posttraumatic Stress Disorder: Trauma Recurrence, Comorbidity, and Physiological Reactivity. Biological Psychiatry. 2010;67(4):346-356. Marx BP, Brailey K, Proctor SP, et al. Association of Time Since Deployment, Combat Intensity, and Posttraumatic Stress Symptoms With Neuropsychological Outcomes Following Iraq War Deployment. Archives of General Psychiatry. 2009;66(9):996-1004. Marx BP, Foley KM, Feinstein BA, et al. Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses. Depress. Anxiety. 2010;27(3):287-293.


Â&#x160;Â&#x203A;Â&#x17D;Â&#x2014;ČąÂ&#x153;Â?Â&#x203A;Â&#x160;Â?Â&#x160;Ç°ČąȹȹȹȹȹȹȹȹȹȹȹȹȹȹÂ&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Č&#x2021;Â&#x153;ČąÂ&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ȹÂ&#x2018;Â?Â?Â&#x2122;ǹȌȌÂ&#x2013;Â&#x2019;Â&#x2022;Â&#x2018;Â&#x17D;Â&#x160;Â&#x2022;Â?Â&#x2018;Â&#x153;Â?Â&#x2019;Â&#x203A;Â&#x17D;Â&#x152;Â?Â&#x2DC;Â&#x203A;¢ǯÂ&#x2DC;Â&#x203A;Â?ȹȹȹȹȹĹ&#x2DC;Ĺ&#x2013;Ĺ&#x2014;Ĺ&#x2013;ČąÂ&#x152;Â? New AS, Fan J, Murrough JW, et al. A Functional Magnetic Resonance Imaging Study of Deliberate Emotion Regulation in Resilience and Posttraumatic Stress Disorder. Biological Psychiatry. 2009;66(7):656-664. Newsome MR, Scheibel RS, Hanten G, et al. Brain activation while thinking about the self from another personâ&#x20AC;&#x2122;s perspective after traumatic brain injury in adolescents. Neuropsychology. 2010;24(2):139-147. Ong W, Kim J, He X, et al. Changes in Brain Cholesterol Metabolome After Excitotoxicity. Mol Neurobiol. 2010. Available at: [Accessed Reger MA, Gahm GA, Swanson RD, Duma SJ. Association Between Number of Deployments to Iraq and Mental Health Screening Outcomes in US Army Soldiers. J. Clin. Psychiatry. 2009;70(9):1266-1272. Shah SP, Zimmerman D. Anterior Pituitary Dysfunction and Traumatic Brain Injury. Clinical Pediatric Emergency Medicine. 2009;10(4):256-259. Sherwood E. Clinical Assessment of Canadian Military Marriages. Clin Soc Work J. 2007;37(4):332-339. Spira J, Murphy J, MA; Wood D, et al. The Benefits of Virtual Reality Assisted, Biofeedback Facilitated, Graded Exposure Therapy for Combat PTSD. RTI International; Virtual Reality Medical Center Naval Medical Center San Diego. Tan G, Fink B, Dao TK, et al. Associations among Pain, PTSD, mTBI, and Heart Rate Variability in Veterans of Operation Enduring and Iraqi Freedom: A Pilot Study. Pain Medicine. 2009;10(7):1237-1245. Taylor MK, Mujica-Parodi LR, Padilla GA, et al. Behavioral predictors of acute stress symptoms during intense military training. J. Traum. Stress. 2009;22(3):212-217. Tuerk PW, Yoder M, Ruggiero KJ, Gros DF, Acierno R. A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology. J. Traum. Stress. 2010:n/a-n/a. Available at: [Accessed April 16, 2010]. Zhang L, Li H, Benedek D, Li X, Ursano R. A strategy for the development of biomarker tests for PTSD. Medical Hypotheses. 2009;73(3):404-409.


Resilience-Mitigating the Threat of Mental Illness, Current & Future Research.  

2nd Annual Military Health Support Systems Meeting Current and Future Force Medical Challenges to Support Deployed Forces. April 2010 Washi...

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