1 Running Head: POSTTRAUMATIC STRESS DISORDER

Posttraumatic Stress Disorder Research Paper Jay Hayden James Madison University

POSTTRAUMATIC STRESS DISORDER Posttraumatic Stress Disorder Research Paper Sustained ground warfare used to be a distant memory in the minds of many Vietnam veterans. But, with todays combatants in Iraq and Afghanistan facing longer durations of deployment these veterans are now returning home to face readjustment issues of their own. This new population of maladjusted veterans has motivated researchers to renew studies surrounding the mental health effects of military combat. Past studies have consistently found that military combat can produce considerable mental health problems in veterans, such as Post Traumatic Stress Disorder (PTSD). My research also explores this relationship by providing an overview of the definition, risk factors, prevalence, and treatment practices for soldiers with PTSD (Hoge, Castro, Messer, McGurk, Cotting, and Koffman, 2004). The Diagnostic and Statistical Manual of Mental Disorders (2000) defines PTSD as an anxiety disorder characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of the stimuli associated with the trauma (p.429). Traumatic events that could produce PTSD may include: military combat, violent personal assault, terrorist attack, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe accidents, or being diagnosed with a life threating illness. While a variety of traumatic experiences could lead to PTSD, no variability exists regarding the criteria that must be met for a diagnosis. Specifically, for an individual to be diagnosed, they must have experienced, witnessed, or been confronted with an event or events

that involved actual or threatened death or serious injury, or a threat to physical integrity of selfothers, and responded with intense fear, helplessness or horror (p.463). Furthermore, the individual must have persistently reexperienced the traumatic event through distressing images,

POSTTRAUMATIC STRESS DISORDER thoughts, dreams, flashbacks, or intense physiological-psychological reactivity (American Psychiatric Association, 2000) Additionally, the individual must have persistently avoided any stimuli associated with

the trauma and experienced numbing of their general responsiveness. Examples of these criteria include avoiding thoughts, activities, and people associated with the trauma as well as having feelings of detachment or estrangement from loved ones. Furthermore, persistent symptoms of increased arousal must be present within the individual that did not exist prior to trauma. An indication of this criterion could be an individuals difficulty falling or staying asleep, hypervigilance, exaggerated startled response, or outbursts of anger. And lastly, all of the aforementioned criteria must be present for more than 1 month and cause clinically significant impairment in the individuals social, occupational, and daily functioning (American Psychiatric Association, 2000). In addition to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, clinicians rely on a variety of checklists, scales, and self reports to measure PTSD within soldiers. Examples of such assessments include the Clinician Administered PTSD Scale (CAP) which measures the severity of the PTSD, the PTSD Checklist-Military Version (PCL-M) which evaluates the degree to with an individual has been bothered by the PTSD symptoms, the Primary Care PTSD (PC-PTSD) which inquires about avoidance behaviors, intrusive thoughts, hypervigilance, and emotional numbing, and the Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Re-Assessment (PDHRA). Both of these last assessments ask the individual about mental health concerns relating to PTSD symptoms such as depression, aggression, and whether they would like mental health care. However, the PDHA is issued

POSTTRAUMATIC STRESS DISORDER directly after the soldier has returned from deployment, and the PDHRA is performed 3 to 6 months after the veteran has returned (Peterson et al., 2011). Consequently, after the veterans symptoms have been assessed as meeting all the

diagnostic criteria, he or she may then receive a PTSD diagnosis. But, depending upon the onset of the individuals symptoms, he or she will then be given a specified classification of Acute, Chronic, or With Delayed Onset PTSD. Accordingly, Acute PTSD occurs when the duration of symptoms have persisted for less than three months, and Chronic PTSD occurs when the symptoms have lasted three months or longer. Conversely, when at least six months have elapsed between the traumatic event and the onset of symptoms, the individual is classified as With Delayed Onset PTSD (American Psychiatric Association, 2000). The risk factors associated with general PTSD are not as universally agreed upon as its definition and diagnostic criteria. But, research has commonly referred to soldiers as a demographic most at risk for traumatic exposure and PTSD development (Keane, Marshall, & Taft, 2006). Just within the past nine years, the United States has deployed approximately two million military personnel to Iraq and Afghanistan. It has been estimated that 5-17% of these returning veterans are a significant risk for developing combat-related PTSD (Peterson et al, 2011). Castro (2009) suspects that soldiers are exposed to additional PTSD risk factors if they experienced combat and perceived their leadership negatively. Yarvis (2011) also suggests the duration of a soldiers deployment is a predictive factor. Specifically, he proposes that soldiers who are frequently deployed for long periods of time are at greater risk for developing PTSD (as cited in Tanielian & Jaycox, 2008). Yarvis also states that the characteristics of the traumatic event itself, pre-trauma factors, and post trauma factors should be taken into account as further risk factors for developing PTSD.

POSTTRAUMATIC STRESS DISORDER Lapierre, Schwegler, and LaBauve (2007) research also recommends two possible risk factors for combatants developing PTSD. Soldiers who were separated or divorced reported higher levels of PTSD symptoms as opposed to their married troop members. This finding highlights the importance of social support and close relationships to soldiers, especially in regards to how they may block PTSD symptoms from forming. Secondly, junior enlisted soldiers reported experiencing more PTSD symptoms. This risk factor may exist since junior members tend to see more traumatic events but do not have as much training or knowledge as their higher ranked troop members. With abundant risk factors surrounding veterans with PTSD, it is no surprise that the prevalence of this disorder is equally as widespread and disputed, especially pertaining to the impact of ethnicity and culture on the development of this disorder. Keane et al. (2006)

reviewed a variety of studies exploring this relationship and found little consistency among their results. In particular, in 1990, one study found that Hispanic and African American veterans had higher prevalence rates of PTSD as compared to their Caucasian, Asian, and Native American service members (as cited in Kulka, Schlenger, Fairbank, Hough, Jordan, et al., 1990). Five years later, another study examining this relationship found that African Americans, Native Americans, and Asian Americans reported higher rates of PTSD as opposed to Caucasian and Hispanics who witnessed the same trauma (as cited in Kessler, Sonnega, Bromet, Hughes, and Neleson, 1995). And in 2004, another study found that veterans of Japanese ancestry have a lower probability of developing PTSD when compared to Caucasian veterans (as cited in Friedman, Schnurr, Sengupta, Holmes, & Ashcraft, 2004). Other studies related to the prevalence of PTSD continue to support this variability. Studies involving recent Iraq War veterans suggest 4-17% are afflicted with PTSD. However,

POSTTRAUMATIC STRESS DISORDER this prevalence rate appears to lessen when the veterans are from non-Western nations (Richardson, Frueh, and Acierno, 2010). Furthermore, Richardson (2010) suggests that 13% of soldiers deployed between 2001 and 2005 had PTSD. In particular, these rates of PTSD were highest amongst those aged 18-24 years old and lowest amongst those 40 years old or older (as cited in Seal, Bertenthal, Miner, Sen, and Marmar, 2007). One study conducted by Lapierre et al. (2007) proposes an even higher prevalence of PTSD in recently returned soldiers. Specifically, their results indicate that 44% of the soldiers they studied had clinically significant levels of PTSD symptoms as well as depressive symptoms. While their research did not

diagnosis the soldiers, their assessment of PTSD symptoms suggest an extremely elevated rate of mental health concerns for many of our recent veterans. As evident by the discrepancies in reported prevalence rates, the most effective therapeutic treatments for combat related PTSD are equally as disputed. Due to this variability, clinicians employ a multitude of therapeutic strategies to treat PTSD. These treatments can range from traditional talk therapy to alternative treatments such as yoga, massage therapy, and tai chi. However, the three techniques that have managed to gain the most support amongst all this diversity are: Prolonged Exposure Therapy, Cognitive Processing Therapy, and Pharmacological Treatments (Peterson, Luethcke, Borah, E., Borah, A., and Young-McCaughan, 2011). According to Peterson et al. (2011), Prolonged Exposure (PE) Therapy has the most scientific support for treating PTSD. Specifically, this therapy requires the veteran to attend ten to twelve sessions lasting 90 minutes in length and consist of four main components: psychoeducation, breathing training, imaginal exposure, and invivo exposure. These components seek to teach veterans about PTSD, how to become more relaxed, and how to become habituated

POSTTRAUMATIC STRESS DISORDER

to the feared traumatic memory. While PTSD patients typically want to avoid thoughts related to their traumatic exposure, this therapy requires the veteran to confront these thoughts. Namely, this confrontation is achieved by having the veteran repeatedly retell his or her story surrounding their traumatic event until habituation is reached. Cognitive Processing Therapy has also gained support as an empirically sound treatment of PTSD. This type of therapy consists of 12, one-hour sessions including psychoeducation, exposure, and cognitive restructuring. Conversely, exposure of the traumatic event occurs through the veteran writing an account of the trauma. He or she is then asked to reread their account at home and aloud during their therapy sessions. Additionally, the veteran is asked to develop an impact statement to help them recognize the maladaptive cognitions surrounding the trauma. Examples of impact statements veterans include are its all my fault or I cant trust anyone and may emerge because the traumatic event does make sense with the veterans beliefs. This faulty thinking is then challenged by the clinician until the veteran achieves a more accurate sense of self and others. The clinician may also focus the last few sessions on the veterans cognitions surrounding safety, trust, intimacy, and power since these tend to be particularly problematic in PTSD (Peterson et al. 2011). Pharmacological Treatments involving antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are another commonly used approach for PTSD (Keane et al., 2006). Specifically, SSRIs such as Paroxetine and Sertraline are typically recommended for treating combat related PTSD symptoms and can help lessen symptoms involving anxiety and depression. Additionally, Alpha-blockers have been used to treat PTSD symptoms involving sleep disturbances. Unfortunately, there is a lack of research evaluating PTSD and the combined

POSTTRAUMATIC STRESS DISORDER use of medication and psychotherapy or individual medication strategies, and more research is sorely needed (Peterson et al., 2011). Recently, a controversial treatment has been studied involving the selective blockade of

the right stellate ganglion and has yielded inspiring results for veterans with PTSD. The purpose of this new treatment is to permanently alleviate panic and anxiety symptoms of PTSD by using a blockade to mimic the use of pharmacological treatments that block the receptors of the sympathetic nervous symptom. A baseline assessment of the patients PTSD symptoms was taken a day prior to the procedure and again one day after and demonstrated immediate and significant relief for both of the participants involved. While this unconventional procedure sounds extreme, this research found that the treatment is safe, minimally invasive, and already producing significant results within its first trial. Of course, additional studies are needed to support the efficacy of this research (Mulvaney, McLean, and de Leeuw, 2010). Discussing the treatment options for PTSD is definitely needed to improve the lives of veterans with PTSD. However, all of this discussion can help no one if veterans are still hesitant to seek treatment. Unfortunately, a large stigma exists within the military community related to seeking help. Largely, veterans think that asking for treatment will mean that their peers will see them as weak or as a coward. Additionally, looking for help can be an embarrassing process for veterans and may raise concerns for them regarding later employment and advancement in their military career (Yarvis, 2011). Yarvis (2011) postulates the military could reduce this stigma amongst soldiers by presenting mental health care as a routine health maintenance similar to getting a medical checkup. Sadly, troubling evidence surrounding this stigma was recently found in returning Iraq veterans. Within this study, 16% of the soldiers interviewed presented with symptoms

POSTTRAUMATIC STRESS DISORDER associated with PTSD. But, when these same soldiers were questioned about seeking treatment, 6 out of 10 believed their fellow service members would lose confidence in them and that they would be treated differently by their commanders. Additionally, 65% of these soldiers felt that their peers would identify them as being weak (as cited in Hoge, Terhakopian, Castro, Messer, and Engel, 2007). Clearly, until this stigma is reduced amongst veterans, many veterans will continue to suffer in silence and live untreated.

Regardless of whether this disorder is called war neurosis, shell shock, or combat fatigue, PTSD is becoming a common and discomforting occurrence that is steadily infiltrating the minds of our nations returning soldiers. The etiology behind this disorder has become clearly understood across the United States and our neighboring nations due to the universally accepted criteria outlined within the Diagnosis and Statistical Manual of Mental Disorders. Similarly, the variety of self reports, checklists, and assessment tools available to researchers has helped the scientific community to expand their research on PTSD symptoms in veterans. However, this variety of accessible measures may actually be one reason so many discrepancies exists regarding PTSD treatments, risk factors, and prevalence and may make it hard for future researchers to replicate past results. Potential risk factors for this disorder may include the soldiers: rank in troop, relationship status, duration of deployment, age during deployment, and level of combat exposure. Ethnicity also proved to be an extremely poor predictor of PTSD due the inconsistent and inconclusive results found over the last two decades. Additionally, the prevalence rates associated with this disorder range from a small percentage of 4% to an alarming rate of 44%. This extreme range provokes the scientific community to either panic over the disturbing

POSTTRAUMATIC STRESS DISORDER percentage of possibly afflicted military personnel or think that PTSD is no longer a large problem for our veterans.

10

Furthermore, results on the most effective PTSD treatments also vary among researchers. Cognitive Therapy, Prolonged Exposure, and Pharmacological Treatments are some of the most commonly agreed upon and used treatments. However, other alternative approaches are beginning to appear that entail a more metaphysical approach, such as tai chi and yoga, or the implementation of a permanent spinal blockade within the neck of the veteran. Sadly, the dearth of literature surrounding effective PTSD treatments paired with the stigma veterans' face for seeking treatment makes it seem nearly impossible to help any soldiers afflicted with this disorder. More literature reviews and research need to be conducted regarding the most efficacious techniques to treating PTSD, and a substantial mind shift among military personal surrounding the stigma of counseling and treatment is strongly needed. Once this stigma has been alleviated, hopefully more veterans will come forward for treatment, and researchers and clinicians will be able to help them with the most successful therapeutic strategies.

POSTTRAUMATIC STRESS DISORDER References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. (4th ed.). Washington, DC. Castro, C.C. (2009). Impact of combat on the mental health and well-being of soldiers and marines. Smith College Studies in Social Work, 79(3), 247-262

11

Friedman M.J., Schnurr P.P., Sengupta A., Holmes T., & Ashcraft M. 2004. The hawaii vietnam veterans project: Is minority status a risk factor for posttraumatic stress disorder? Journal of Nervous and Mental Disease, 192, 4250 Hoge C.W., Castro C.A., Messer S.C., McGurk D., Cotting D.I., & Koffman R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 1322 Hoge, C.W., Terhakopian, A., Castro, C.A., Messer, S.C., & Engel, C.C. (2007). Association of posttraumatic stress disorder with somatic symptoms, healthcare visits, and absenteeism among Iraq War veterans. American Journal of Psychiatry, 164,150 153 Keane, T. M., Marshall, A. D., & Taft, C. T. (2006). Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annual Review of Clinical Psychology, 2, 161197 Kessler R.C., Sonnega A., Bromet E., Hughes M., Nelson C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048 60 Kulka R.A., Schlenger W.E., Fairbank J.A., Hough R.L., Jordan BK, et al. (1990). Trauma and the VietnamWar Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel

POSTTRAUMATIC STRESS DISORDER

12

Lapierre, C. B., Schwegler, A. F., & LaBauve, B. J. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in iraq and afghanistan. Journal of Traumatic Stress, 20(6), 933-943 Mulvaney, S. W., McLean, B., & de Leeuw, J. (2010). The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat-related post-traumatic stress disorder; preliminary results of long-term follow-up: A case series. Pain Practice, 10(4), 359-365 Peterson, A., Luethcke, C., Borah, E., Borah, A., & Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war veterans. Journal of Clinical Psychology in Medical Settings, 18(2), 164-175 Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian & New Zealand Journal of Psychiatry, 44(1), 4-19 Seal K.H., Bertenthal D., Miner C.R., Sen S., & Marmar C. (2007). Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at department of veterans affairs facilities. Archives of Internal Medicine, 167(5), 476482 Tanielian, T., & Jaycox, L.H. (2008). Invisible Wounds of War: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, California: RAND Yarvis, J. S. (2011). A civilian social worker's guide to the treatment of war-induced ptsd. Social Work in Health Care, 50(1), 51-72