Col. Jeffrey S. Yarvis presented on the complexities of reintegrating returning veterans and the subtleties of PTSD, emphasizing the community’s role in supporting psychological health. He highlighted key factors for veteran recovery, the significance of social connections, and the prevalence of subthreshold PTSD among military personnel. Yarvis advocated for a collaborative approach involving leadership and healthcare providers to address mental health issues effectively.

1. COL Jeffrey S. Yarvis, Ph.D., MSW, M.Ed.
Reintegrating Returning Warriors and the Subtleties
of PTSD: Practice, Research and Policy.
Presented to the INTERNATIONAL MEDICAL REHABILITATION,
MENTAL HEALTH SUPPORT, INSTITUTIONAL AND POLICY
CONSIDERATIONS AND TACTICAL BATTLEFIELD MEDICINE
CONFERENCE IN UKRAINE 28-30 APRIL 2015, KYIV, UKRAINE
This briefing is unclassified and reflects the opinion of the presenter

2. Purpose: A personal mandate
• Good Governance=Good
(Mental) Health
• Introduction to Trauma and the
Intimacy of Trauma
• Subthreshold PTSD
• International Scholarship
• Trauma Transmission
• Informs US policy and Clinical
Practice

3. What you do matters!
Tactical
To
Practical
Recognize the important
change inherent in the shift to
a new model that places the
emphasis on building and
sustaining social connections

4. Keys to success: Community-Based
Agencies
Leaders
People
4Relationships

5. Keys to Success: It Takes a Community
“Psychological health is a community
responsibility. Leaders, front-line
supervisors, peers, friends, family
members, health care providers, and other
helping agency members must all
collaborate in building resilience,
recognizing signs of distress and illness,
serving as links to helping resources, and
following up with those who have
accepted or rejected assistance”. (p. 18)
Defense Health Board
5

6. Effect
Sustainable Care and Independent Vets
Measure of Effectiveness
Indicators
Basis for evaluating the status of our MOE. Shifts in cultural or political
behavior or capability that is being measured. May be associated
with a key node (Rehab Hospitals for example).
Criteria
Indicators we have observed with our limited data collection ability
Keys to Success: Evidenced-Based Objectives

7. COMBAT STABILITY OPS
MED CIV-MIL
OPERATIONS
INTER-AGENCY COOPERATION
KEYS TO SUCCESS:
FOCUSED PARTNERSHIPS=
Ulkraine
Doctrine – Policy – Processes Funding
Streams – Working Together
US Military
Coalition
Forces
DoS, MN Agencies, IGOs, IOs,
NGOs, Private sector, academia
DoD Security
Cooperation
DoS,
MN Agencies
IGOs
IOs
NGOs
Development
SHAPING
LEAD AGENCY
TRANSITIONS
Key: Military Instrument Diplomatic, Political & Economic Instruments Synergy

8. BH Care and the Warrior
“We all serve!”
Veteran = ?

9. BH care starts with medical care

10. HBO Alive Day Memories: A
Tribute
John Jones
Marine Staff Sgt.
Hometown: San Antonio, TX
Age: 30
Date of Injury: 1/3/2005
List of Injuries: Double amputee
below the knees, shrapnel in
parts of thighs and wrists, some
memory and hearing loss, post
traumatic stress disorder.
http://www.hbo.com/aliveday/index.html
04.08.10 (adapted by: J. Martin)

11. Women and Warriors
A reality…

12. OIF/OEF Veterans
– Almost 1M OEF/OIF veterans have left active duty and are
eligible for VA services (since FY2002) (currently 1.7M
OIF/OEF veterans)
– 51% from AC; 49% from RC
– 43% have already obtained VA care
 (44% AC & 42% RC)
 (Male 88%; Female 12%)
 (59% age 29 or younger)
 (76% Army or Marine)
The three most common health issues:
– Musculoskeletal (50%)
– Mental Health (46%)
– Symptoms, Signs and Ill-Defined Conditions (43%)
02.25.10 (adapted by: J. Martin)

13. Mental Health Issues among
OIF/OEF Veterans: Are women
Diagnosed Properly?
• Mental health problems reported among 46% of
eligible OEF/OIF veterans who have presented to
VA (those Veterans actively seeking health care)
• Provisional MH diagnoses include:
– PTSD 101,882
– Nondependent Abuse of Drugs: 30,406
– Depressive Disorder: 69,474
– Affective Psychoses 39,825
– Neurotic Disorders: 55,842
– Alcohol Dependence: 18,054
– A total of 193,879 unique patients have received a DX
of a possible mental disorder
02.25.10 (adapted by: J. Martin)

14. PTSD : A need to understand…
“ A mental disturbance provoking pain, excessive joy, hope or
anxiety, where it affects its temper, and rate, impairing general
nutrition and vigor”
• William Harvey, 1628

15. Vietnam

16. Same or Different Today?
Ex. Videos

17. Is there a stigma today?

18. Leadership Mitigates
Stigmatizing Effects

19. Most Observed Reactions
to Trauma
 Fear and anxiety
 Intrusive thoughts about the trauma
 Nightmares of the trauma
 Sleep disturbance
 Feeling jumpy and on guard
 Concentration difficulties

20. Common Reactions
to Trauma
 Avoiding trauma reminders
 Feeling numb or detached
 Grandiosity
 Feeling angry, guilty, or ashamed
 Grief and depression
 Negative image of self and world
 Sexual Dysfunction
– The world is dangerous
– I am incompetent
– People can not be trusted

21. PTSD: Diagnostic Criteria
• Stressor
• Intrusion Symptoms (aka re-experiencing)
• Avoidance
• Negative Alterations in Cognitions and Mood
• Alterations in Arousal and Reactivity (aka
Numbing to Hyperarousal)
• Duration
• Functional Significance
• Exclusions

22. Diagnosing Subthreshold PTSD
“Pending further guidance,
subthreshold PTSD should continue to
be coded as an Unspecified Anxiety
Disorder” (ICD-9 300.00; ICD-10 F41.9
OTSG/MEDCOM PTSD Policy Memo
Para 7b(3)

23. Is PTSD clear to you?
• A common anxiety disorder that develops
after exposure to a terrifying event or ordeal
in which grave physical harm occurred or
was threatened.
• Confounds two distinct constructs-stress
and mental traumatization.
• Is a retrospective construct.
• How cohesive is PTSD across different
groups?
• Comorbidity

24. Taxonomic Issues
• Kraeplin’s classification system based on
medical model –affecting predictive validity.
• Appears to be diagnostic yardstick with a
sliding scale.
• No one size fits all category has persisted
over time.
• Debate over what constitutes normal and
pathological responses
• PTSD has been a “labile polymorphic
disorder”- Solomon.

25. Overarching Research
Question
Is Subthreshold
PTSD
Clinically
Relevant?

26. Subthreshold PTSD
• Symptom presentation that does not
meet criteria necessary for diagnosis of
PTSD BUT is sufficient for clinical
attention.
• Defined as:
-Meeting criteria for Re-experiencing, &
-Meeting criteria for one Avoidance/
Numbing or Hyperarousal
• Fairly common in at risk populations.

27. Recent studies:
Subthreshold PTSD Prevalence
• Community sample. Marshall et al.'s (2001)
study noted 9 percent had full PTSD and
another 18.9 percent had subthreshold PTSD.
• Out-patient psychiatric patients. The most
recent study on subthreshold PTSD noted that in
1,000 patients, 156 (12 percent) met criteria for
full PTSD, 84 (7 percent) for subthreshold
PTSD, and 460 (35.4 percent) for trauma
histories (Zlotnick et al., 2002).

28. Subthreshold PTSD and
Veterans
• Asmundson (2002) found that subthreshold
PTSD paralleled full PTSD in terms of
symptomatology.
• Two Croatian veteran’s studies of 3,217
personnel showed 16.22 percent with current
PTSD and 25 percent with partial PTSD one
year after the war (Komar and Vukusic, 1999),
and the rate of current PTSD increased to 24
percent just one year later (Kozaric-Kovacic,
1999), suggesting that some of the
subthreshold group had developed full
PTSD.

29. Implications of Time
• 1.7 million Vietnam vets 49 percent had
PTSD (830,000)
• The contribution of sub-threshold
PTSD would add another 350,000
veterans potentially in need of
treatment (Weiss et al.,1992).

30. Studies of Veterans
• New Zealand Vets, increased
psychological distress was
reported only months after
the deployment (MacDonald
et al., 1999).
• Asmundson, et al. (2002)
and Boisvert et al.(2003)
found that Canadian
peacekeepers demonstrated
greater amounts of
depression and poorer
health after deployment.
• 15,931 Norwegian U.N.
peacekeepers serving in
Lebanon from 1978-1991,
mortality due to suicide
increased by 43 percent
(Thoresen and Mehlum,
1999).

31. Deployment
• Veterans deployed more than once are 3.676 times
more likely to be diagnosed with some level of PTSD
than veterans never deployed. A spectrum
disorder?
(Yarvis et al., 2005; Yarvis and Schiess, 2008, Yarvis, 2008)
• Risk Factors:
• Trauma History
• Gender
• Number of Deployments
• Age
Highest risk: Unmarried females deployed more than once.

32. What can comorbidity tell us?
• Veterans who present with depression or
alcohol problems should raise suspicion for
PTSD or subthreshold PTSD.
• Veterans who present with symptoms of
PTSD should be screened for co-existing
depression and alcohol problems.
• Veterans at subthreshold levels may seek
treatment for other medical conditions and
left untreated for their trauma symptoms may
develop full PTSD.

33. The Sounds of Combat …

34. The Sounds of Combat …
Stress

35. Weather

36. Poverty

37. Passive Posture & Locus of Control

38. First Exposure and
Anticipatory Stress

39. Cultural Differences

40. Home-front, the Media
& Unit Casualties
Events shaping
attitudes toward
returning vets.

41. Death of Children
• Critical incidents

42. Military-Induced Family Separation:
Reintegration and Leaving Again

43. Spouse Satisfaction with Army Life
Associated with Length of Separation

44. How do I explain
what I’ve seen?
A Witness to Evil
&
The Loudness of
Silence…
The Subtleties of
Coming home.

45. Adapted or Maladapted?
• Cohesion
• Accountability
• Targeted Aggression
• Tactical Awareness
• Armed
• Emotional Control
• Mission Security/OPSEC
• Individual Responsibility
• Combat Driving
• Withdrawal
• Controlling
• Inappropriate Aggression
• Hypervigilance
• “Locked and loaded”
• Anger and Detachment
• Secretiveness
• Guilt
• Aggressive Driving
• Conflict
• Discipline/Ordering
• WRAIR, LTC Carl Castro-Adapted from Battlemind
At War At Home

46. Problems with this model

47. Family Systems Moving
Through Time
• “Families comprise people who
have a shared history and a
shared future.” -Betty Carter
and Monica McGoldrick
• Boundaries shift
• Psychological Distance
Changes
• Roles are constantly redefined
• In general, defining what
“normal” family patterns look is
becoming more difficult
• Values driven
• Trajectories change and
Family Development altered

48. Relationship
Between PTSD and Social Support
• One of the strongest predictors of recovery
following trauma is social support
– Perceived social support (PSS)
– Received social support (RSS)
• Interaction is complicated
– PSS is often negatively related to trauma severity
– RSS is often positively related to trauma severity
• Deterioration of perceived social support over
time may contribute to increased symptoms

49. Intergenerational Trauma-
Holocaust
• Shoah
• Slavery
• Disaster
• Forced Migration
• Genocide
• War

50. Parental PTSD
and Children’s Distress
• Children of Vietnam veterans with PTSD,
compared to children of veterans without PTSD,
are more likely to experience symptoms
– 36% vs. 14% indicated symptoms severe enough to
cause distress on GHQ (Westerink & Giarratano, 1999)
– more and more severe behavior problems reported
(Kulka et al., 1988)
– 23% vs. 0% had received psychiatric treatment
(Davidson et al., 1989)

51. PTSD and Parenting Skills
Object Relations
• Clinical descriptions have characterized parenting by
veterans with PTSD as:
– Overprotective (or potentially avoidant) (Haley, 1984)
– Controlling, overprotective, demanding (Harkness, 1993)
– Enmeshed (Jurich, 1983; Rosenheck, 1986)
– Highly emotional (Rosenheck, 1986)
• Children of PTSD veterans describe families as:
– More conflicted (Westerink & Giarratano, 1999)
– Less Cohesive (Westerink & Giarratano, 1999)
• Veterans with PTSD are more likely than those without
PTSD to endorse severe parenting problems
– 54.7% vs. 17.3% (Jordan et al., 1992)

52. Understanding Children’s
Reactions to War Deployment
• Children are affected by their parents’ traumatic
experiences as well as their own
• Little scientific information about impact of parental
combat exposure on children
• Equally dangerous to assume uniform resilience or
uniform problems as a result of war exposure
• A real accounting of the trauma and its effects is an
opportunity to honor the service and sacrifice
• War trauma is a primary source of difficulty for all
military family members

53. Children’s Reactions to
Deployment
Percent reported with “Moderate” to “Very serious” problems
Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

54. Children Coping
with Deployment
Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

55. Child Maltreatment
and Deployment
• Rentz ED, Marshall SW, Loomis D, et al. Am J Epidem 2007
• McCarroll JE, Fan Z, Newby JH, et al., Child Abuse Rev, in
press
• Rate of military family maltreatment twice as high in period
after October 2002 compared to prior period versus no
change in nonmilitary family population during similar period
• Greatest rise in maltreatment appears to be attributed to child
neglect in younger children
• Rates of child neglect appear highest in junior enlisted
population

56. US ARMY
CHILD NEGLECT RATES 1989-2004
1-2 YEAR OLDS
McCarroll J et al, 2005

57. Factors Affecting Family Adjustment
During Deployment
• Families at increased vulnerability
– Families in transition
– Young families
– Families with problems prior to deployment
– Pregnant spouses
– Families with multiple needs

58. Typical Course of
Reintegration
• Family resilience is the rule, not the
exception
• Usual for families to return to the normal
routine
• Common to incorporate changes without
disability in family functioning
• HOWEVER…We don’t always “want” to
reintegrate. What does that mean?

59. Summary of Research on
Families During Deployment
• In general, military families appear robust and healthy
• Deployment can have negative impact some families
– Rarely reaches clinical levels
– Usually resolves post-deployment
– Pre-deployment functioning related to functioning during and
post deployment
• Unique aspects of OIF/OEF have not been studied with
respect to families

60. • Consistent evidence-based
practice is a high priority.
• Current policy is firmly
rooted in the VA/DoD PTS
Clinical Practice Guideline
(CPG), with updated
information on DSM-5.
Purpose of Policy: Provide Guidance on
Assessment and Treatment of PTSD

61. Evidence-Based PTSD Psychotherapies
From VA-DoD PTS CPG, 2010
SR
Significant Benefit Some Benefit Unknown
Trauma-focused
psychotherapy that
includes components of
exposure and/or cognitive
restructuring; or Stress
inoculation training
• Patient Education
• Imagery Rehearsal
Therapy
• Psychodynamic Therapy
• Hypnosis
• Relaxation techniques
• Group Therapy
• Family Therapy • Web-based CBT
• Acceptance and
Commitment Therapy
• Dialectical
Behavioral Therapy

62. CBT & VR Exposure Therapy
• VR exposure therapy
has been used for the
treatment of PTSD.

63. Healing SOUL Wounds: A
paradigm shift
02.25.10 (adapted by: J. Martin)

64. Questions &
Comments
254-553-2285
Jeffrey.S.Yarvis.mil@mail.mil
COL Jeffrey S. Yarvis, Ph.D.

65. 65
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