What is the Cause of PTSD among War Veterans?
Author: Josh Valdez
Post-Traumatic Stress Disorder, known has PTSD, has been a growing concern in the military combat world since Vietnam. United State combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder compared to the general population. Self-compassion, characterized by self-kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD (Hiraoka, et al. 2015). It has continued to evolve has recent studies and treatment plans have been completed, but it is still a disorder that has many military medical professionals mind boggled. Military veterans experience a high prevalence of psychopathologies such as posttraumatic stress disorder (PTSD). Relationships between physical and psychological health are increasingly recognized (Abouzeid, et al. 2012). In recent years, the great debate has been over if PTSD is caused by sociological factors or from psychological factors in both men and women. In fact research shows that women are twice as likely as men to develop PTSD after experiencing traumatic events due to harassment including rape from fellow soldiers (Kasinof 2014). Women have had fewer interpersonal and economic supports and had greater exposure to different types of trauma while also having different levels of diverse types of pathology than their male counterparts (Fontana, Rosenheck, and Desai 2010).
There is considerable public and professional concern about the mental health status of veterans deployed to Iraq and Afghanistan as well as how to engage and retain symptomatic veterans in treatment. (Harpaz-Rotem, et al. 2014) When looking at the research, it shows that war veterans returning home from Afghanistan and Iraq, who have participated in Operations Iraqi Freedom and Enduring Freedom have been misdiagnosed or didn’t receive a diagnoses for PTSD at all. Research has shown that mild traumatic brain injury (MTBI) and posttraumatic stress disorder (PTSD) are considered the "signature injuries" of combat soldiers returning from Iraq and Afghanistan. Both disorders can greatly affect the functioning of soldiers, yet the disorders often go undetected or are misdiagnosed by both military and civilian health care providers (Jones, Young, and Leppma 2010). A study among Iraq and Afghanistan veteran correlated that initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP (Mott, et al. 2014). PTSD is a recent topic of interest to medical professionals have tried to understand this mental disease more intensely, there has even been studies where professionals attempt to assess whether a diagnosis of concussion given at a Veterans Healthcare Administration secondary traumatic brain injury assessment impacted either posttraumatic stress disorder symptomatology or other variables at the time veterans sought treatment for PTSD (Romesser, et al. 2011). Because there are still so many unknowns about PTSD and how to proceed with treatment, this will be an ongoing furthering study that we will be seeing in the future. In the mean time keeping in mind that many of these injuries will not be visible and will include physical wounds, post-traumatic stress disorder (PTSD), depression, and traumatic brain injuries (TBI) requiring certain accommodations (Church 2009).
Internal and External Factors:
Medical professionals, alongside with Sociologists and Psychologists, are trying to determine if PTSD is caused by external factors or internal factors. As of today, research shows that it is a mixture of both external traumatic events coinciding with a lack of self-purpose or meaning in life are current correlating factors with those who suffer from PTSD. Currently the symptoms and treatment programs that have been discovered have proven beneficial to aiding those war veterans postdeployment to regulate back into and function within society. Post-traumatic stress disorder symptoms assessed both before and after military separation significantly predicted functional difficulties across all domains except unlawful behavior (Larsen and Norman 2014). However many times it is argued that as a society we should treat veterans differently 'in recognition of' both 'their service' and 'the intense stress and mental and emotional toll' of combat. The former factor suggests there being a 'social contributions' or gratitude-based discount, whereas the latter factor points towards a 'mental disturbance' discount (Lee 2013). Post-traumatic stress disorder can also be associated with physical aggression in some veterans, and co-occurring depression increases the risk of committing aggressive acts. Also depressive symptoms indirectly mediated the relationship between PTSD and two forms of aggression: verbal aggression and physical aggression toward self. In contrast to some prior studies of intimate partner violence in veterans with PTSD, no mediation relationship between depression and physical aggression toward others was found (Angkaw, et al. 2013). Some of the symptoms who most recent war veterans show are feelings such as critical depression, hyperarousal or hypertension, and wavering doubt in a meaning to life (Blackburn and Owens 2015). According to a study in the Journal of Traumatic Stress, the PTSD symptom clusters, numbing and avoidance symptoms were the strongest predictors of interpersonal and social functioning, and hyperarousal symptoms were the strongest predictors of overall severity and distress (Shea, et al. 2010). These feelings can lead to behaviors such as emotional hiding and increased usage of alcohol as a way to cope with traumatic past events. The Veterans Affairs (VA) health care system studied about follow-up care for alcohol misuse among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with and without alcohol use disorders (AUD) and/or posttraumatic stress disorder (PTSD). Among the OEF/OIF VA outpatients with alcohol misuse, those with AUD had higher rates of follow-up for alcohol misuse than those without (Grossbard, et al. 2013). Many veterans turn to illegal substance abuse if they feel like alcohol doesn’t have a calming effect on them. (Back, et al. 2014) Thus, by re-experiencing symptoms that were associated with alcohol use problems and substance use problems, and avoidance symptoms were associated with increased psychosocial difficulties and decreased perceptions of post deployment social support groups (Pietrzak, et al. 2010). The Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC) also expressed the idea of psychiatric comorbidity where many times war veterans have more than one psychiatric diagnoses and understanding this relationship, new avenues for engaging and enhancing treatment outcomes related to social support for veterans of this cohort may be identified. Additional longitudinal research could help evaluate the effect of PTSD symptom clusters, social support type, and trauma exposure type on these relationships (Brancu, et al. 2014).
The Department of Veterans Affairs Ann Arbor Healthcare System’s Serving Returning Veterans Mental Health Program surveyed 536 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) war veterans from Michigan and Ohio and found that approximately 30% of veterans screened positive for PTSD. All sources of social support, as well as emotional hiding, were significantly associated with screening positive for PTSD. Each unit increase of emotional hiding from spouses or significant others, friends, and family was associated with a 32% to 44% increase in odds of screening positive for PTSD (Duax, et al. 2014). Because such behaviors can develop it is important to help our war veterans have a strong social support group. Many times these social support groups consist of a wife or girlfriend, family, or even a group of therapists helping this returned soldier have the support he needs to make the adjustment back from war, suggesting that interventions to bolster psychological resilience and postdeployment social support may help reduce the severity of traumatic stress and depressive symptoms in OEF/OIF veterans (Pietrzak, et al. 2009). It is important to be able to teach both the war veterans along with those in his support group about what to expect and what to do when moments of depression hit or hypertension. Researchers from Therapeutic Recreation Journal stated that the purpose of their study was to provide evidence-based outcomes related to a couples adaptive sports event intended to facilitate posttraumatic growth, increase marital satisfaction, leisure satisfaction, feelings of competence in sports, and reduce symptoms of posttraumatic stress disorder (PTSD) for veterans with PTSD and their significant others (Bennett, et al. 2014). Groups have also used surfing to help the veterans adjust to civilian life (Rogers, Mallinson, and Peppers 2014). The more their support group can learn about aiding the veterans the better chance he has to recover from PTSD in a short amount of time. Recognizing other therapists that that Group-based exposure therapy has not produced as much PTSD symptom reduction as Prolonged Exposure (PE) within a United States (Ready, et al. 2012), this support group can make the war veteran feel like he is important and if held accountable to his group. They can also feel like there is a meaning to what they are supposed to be doing in life. One of The most commonly cited barrier for those who chose both antidepressant treatment and PE was time to participate. (Kehle-Forbes, et al.) Although the worry is that the global PTSD relates to seeking mental health care, however, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization available to the war veterans (Blais, et al. 2014). If this support team starts to fail the war veteran, feelings such as feeling like a burden for the people who are helping their recovery and thus leading to an increase of emotional hiding. There is an increased need to help war veterans realize that those events in life has now past, they need to now realize and address this acceptance stage by starting to overcome combat related losses. Currently, many of the war memorials help serve this cause. In a study performed including 62 male Vietnam combat war veterans found the importance of Memorials by helping bring closer a certain event. This shows them that what they have reoccurring inside their minds is over. It is done. It brings them back to reality and helps them realize they made it through that moment. It helps overcome the combat-related losses one might feel. It plays a huge part in the mourning process (Watkins, Cole, and Weidemann 2010).
Abouzeid, Marian, Helen L. Kelsall, Andrew B. Forbes, Malcolm R. Sim, and Mark C. Creamer. 2012. "Posttraumatic Stress Disorder and Hypertension in Australian Veterans of the 1991 Gulf War." Journal of Psychosomatic Research 72(1):33-8.
Angkaw, Abigail C., Bridgett S. Ross, James O. E. Pittman, Alexandra M. Y. Kelada, Mar¡a A. M. Valencerina, and Dewleen G. Baker. 2013. "Post-Traumatic Stress Disorder, Depression, and Aggression in OEF/OIF Veterans." Military Medicine 178(10):1044-050.
Back, Sudie E., Therese K. Killeen, Andrew P. Teer, Emily E. Hartwell, Amanda Federline, Frank Beylotte, and Elizabeth Cox. 2014. "Substance use Disorders and PTSD: An Exploratory Study of Treatment Preferences among Military Veterans." Addictive Behaviors 39(2):369-73.
Bennett, Jessie L., Neil R. Lundberg, Ramon Zabriskie, and Dennis Eggett. 2014. "Addressing Posttraumatic Stress among Iraq and Afghanistan Veterans and Significant Others: An Intervention Utilizing Sport and Recreation." Therapeutic Recreation Journal 48(1):74-93.
Blackburn, Laura and Gina P. Owens. 2015. "The Effect of Self Efficacy and Meaning in Life on Posttraumatic Stress Disorder and Depression Severity among Veterans." Journal of Clinical Psychology 71(3):219-28.
Blais, Rebecca K., Katherine D. Hoerster, Carol Malte, Stephen Hunt, and Matthew Jakupcak. 2014. "Unique PTSD Clusters Predict Intention to Seek Mental Health Care and Subsequent Utilization in US Veterans with PTSD Symptoms." Journal of Traumatic Stress 27(2):168-74.
Brancu, Mira, NiVonne L. Thompson, Jean C. Beckham, Kimberly T. Green, Patrick S. Calhoun, Eric B. Elbogen, Allison T. Robbins, John A. Fairbank, and H. Ryan Wagner. 2014. "The Impact of Social Support on Psychological Distress for U.S. Afghanistan/Iraq Era Veterans with PTSD and Other Psychiatric Diagnoses." Psychiatry Research 217(1-2):86-92.
Church, Thomas E. 2009. "Returning Veterans on Campus with War Related Injuries and the Long Road Back Home." Journal of Postsecondary Education and Disability 22(1):43-52.
Duax, Jeanne M., Kipling M. Bohnert, Sheila A.M. Rauch, and Andrew M. Defever. 2014. "Posttraumatic Stress Disorder Symptoms, Levels of Social Support, and Emotional Hiding in Returning Veterans." Journal of Rehabilitation Research & Development 51(4):571-78.
Fontana, Alan, Robert Rosenheck, and Rani Desai. 2010. "Female Veterans of Iraq and Afghanistan Seeking Care from VA Specialized PTSD Programs: Comparison with Male Veterans and Female War Zone Veterans of Previous Eras." Journal of Women's Health 19(4):751-57.
Grossbard, Joel R., Eric J. Hawkins, Gwen T. Lapham, Emily C. Williams, Anna D. Rubinsky, Tracy L. Simpson, Karen H. Seal, Daniel R. Kivlahan, and Katharine A. Bradley. 2013. "Regular Article: Follow-Up Care for Alcohol Misuse among OEF/OIF Veterans with and without Alcohol use Disorders and Posttraumatic Stress Disorder." Journal of Substance Abuse Treatment 45(5):409-15.
Harpaz-Rotem, Ilan, Robert A. Rosenheck, Robert H. Pietrzak, and Steven M. Southwick. 2014. "Determinants of Prospective Engagement in Mental Health Treatment among Symptomatic Iraq/Afghanistan Veterans." The Journal of Nervous and Mental Disease 202(2):97-104.
Hiraoka, Regina, Eric C. Meyer, Nathan A. Kimbrel, Bryann B. DeBeer, Suzy B. Gulliver, and Sandra B. Morissette. 2015. "Self-Compassion as a Prospective Predictor of PTSD Symptom Severity among Trauma-Exposed U.S. Iraq and Afghanistan War Veterans." Journal of Traumatic Stress 28(2):127-33.
Jones, Karyn D., Tabitha Young, and Monica Leppma. 2010. "Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Returning Iraq and Afghanistan War Veterans: Implications for Assessment and Diagnosis." Journal of Counseling & Development 88(3):372-76.
Kasinof, Laura. 2013. "Women, War, and PTSD." Washington Monthly 45(11):18.
Kehle-Forbes, Shannon, Melissa A. Polusny, Christopher R. Erbes, and Heather Gerould. 2014. "Acceptability of Prolonged Exposure Therapy among U.S. Iraq War Veterans with PTSD Symptomology." Journal of Traumatic Stress 27(4):483-87.
Larson, Gerald E. and Sonya B. Norman. 2014. "Prospective Prediction of Functional Difficulties among Recently Separated Veterans." Journal of Rehabilitation Research & Development 51(3):415-27.
Lee, Youngjae. 2013. "Military Veterans, Culpability, and Blame." Criminal Law & Philosophy 7(2):285-307.
Mott, Juliette M., Sasha Mondragon, Natalie E. Hundt, Melissa Beason-Smith, Rebecca H. Grady, and Ellen J. Teng. 2014. "Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD." Journal of Traumatic Stress 27(3):265-73.
Pietrzak, Robert H., Marc B. Goldstein, James C. Malley, Alison J. Rivers, and Steven M. Southwick. 2010. "Structure of Posttraumatic Stress Disorder Symptoms and Psychosocial Functioning in Veterans of Operations Enduring Freedom and Iraqi Freedom." Psychiatry Research 178(2):323-29.
Pietrzak, Robert H., Douglas C. Johnson, Marc B. Goldstein, James C. Malley, and Steven M. Southwick. 2009. "Psychological Resilience and Postdeployment Social Support Protect Against Traumatic Stress and Depressive Symptoms in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom." Depression & Anxiety 26(8):745-51.
Ready, David J., Edward M. Vega, Virginia Worley, and Bekh Bradley. 2012. "Combining Group-Based Exposure Therapy with Prolonged Exposure to Treat U.S. Vietnam Veterans with PTSD: A Case Study." Journal of Traumatic Stress 25(5):574-77.
Rogers, Carly M., Trudy Mallinson, and Dominique Peppers. 2014. "High-Intensity Sports for Posttraumatic Stress Disorder and Depression: Feasibility Study of Ocean Therapy with Veterans of Operation Enduring Freedom and Operation Iraqi Freedom." American Journal of Occupational Therapy 68(4):395-404.
Romesser, Jennifer, Shuying Shen, Maija Reblin, John Kircher, Steven Allen, Toni Roberts, and William R. Marchand. 2011. "A Preliminary Study of the Effect of a Diagnosis of Concussion on PTSD Symptoms and Other Psychiatric Variables at the Time of Treatment Seeking among Veterans." Military Medicine 176(3):246-52.
Shea, M. Tracie, Anka A. Vujanovic, Abigail K. Mansfield, Elizabeth Sevin, and Fengjuan Liu. 2010. "Posttraumatic Stress Disorder Symptoms and Functional Impairment among OEF and OIF National Guard and Reserve Veterans." Journal of Traumatic Stress 23(1):100-07.
Watkins, Nicholas, Frances Cole, and Sue Weidemann. 2010. "The War Memorial as Healing Environment: The Psychological Effect of the Vietnam Veterans Memorial on Vietnam War Combat Veterans' Posttraumatic Stress Disorder Symptoms." Environment & Behavior 42(3):351-75.