A Comprehensive Look at Psychological Effects and Treatment of Post Traumatic Stress Disorder in Military Combat Veterans
Post Traumatic Stress Disorder (PTSD) is considered a type of anxiety disorder. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans (about 1700,000 people) in all, have experienced clinically significant stress reaction symptoms. Dennis Tenety, a 1969 Vietnam veteran wrote, “I've seen bodies ripped to pieces by bullets, blown into millions of scraps by bombs, and pierced by booby traps. I’ve smelled the stench of bodies burned. I’ve heard the air sound like it was boiling from rounds flying back and forth. I’ve lived an insanity others should never live... (Fire in the Hole, 18)”.
Post Traumatic Stress Disorder is an common result of military combat, which is evident from previous wars such as War World II and Vietnam. As such, it is crucial to study the psychological effects of PTSD, as well as current treatment interventions in order to have a strong knowledge of how to help veterans reacclimate into society. In addition, research is analyzed so that veterans may live full lives without being plagued by this debilitating disorder. This article begins by providing general background information about Post Traumatic Stress Disorder. From there, the topic will broaden itself to incorporate specific psychological effects of this psychopathology, as well as a description and analysis of outcome literature on commonly used therapeutic techniques for PTSD. Ultimately, this piece suggests that not only are the long-term effects of PTSD severe, but that it is in society’s best interest to develop more treatment research so that veterans have the opportunity to maintain a higher level of functioning.
Description and Criteria (DSM-IV)
Post traumatic Stress Disorder typically develops after an individual witnesses or experiences a traumatizing event in which they believed or were in danger of death, bodily harm or sexual trauma. PTSD is lasting and often causes prolonged fear, helplessness, horror and agitation. Examples of traumatic events could be assault, rape, war or witnessing the death of a loved one or natural disaster. Most people who experience a traumatizing event with have a negative reaction including crying, hyperventilating, shock and anxiety but for the personal who ultimately develops PTSD, those symptoms are intensified and don’t go away over time. It as if the trauma occurred recently over and over again wreaking havoc on the person’s life in a variety of ways. For some folks, symptoms do not emerge until years later sometimes triggered by a relatively benign event. Symptoms fall into four categories which are reliving the event, avoiding, increased arousal and negative thoughts and mood.
Reliving the event is typically in the form of flashbacks or believing the trauma is happening all over again. This experience can be very real for the personal and cause an acute anxiety reaction, panic attack or violence. Avoiding behaviors typically mean the effected individual has a tendency to avoid people, places and things that may trigger anxiety or traumatic memories for example crowded public areas, conflict situations and places that have loud noises. Increased arousal is when seemingly small events and mundane interactions with people provokes a negative and pronounced reaction from the individual for example crying, shaking, yelling and hostility. Finally, negative cognitions and mood typically presents itself as chronic negative intrusive thoughts and subsequent depression, anxiety and unpredictable behavior for example anger management problems and “being a loose cannon.”
In order for an individual to meet the criteria for a true PTSD diagnosis the person must have been exposed to trauma in which they themselves experienced, witnessed or was confronted with an event which involved actual or threatened death or serious physical injury to self or others. In addition, the individual’s reaction must have been intense fear, helplessness or horror. Other effects of PTSD include, recurrent and intrusive upsetting recollections, recurrent dreams, acting and feelings as though the event were reoccurring (flashbacks), intense psychological distress in reaction to internal or external cures which symbolize the event and finally, physiological reactivity to internal or external cues which symbolize the event. Also, persistent avoidance of stimuli and numbing of general responsiveness, which is indicated by three of the following: efforts to avoid thoughts, feelings or conversation associated with the event, efforts to avoid activities, places or people associated with the trauma, inability to recall important parts of the event, significant diminished participation in activities, feelings of detachment from others, less expressive emotionally and lastly, a sense of an expected diminished future. More symptoms can be increased arousal, trouble sleeping, irritability and angry outbursts, difficulty focusing, hypervigilencec and an exaggerated startle response. (DSM-IV-TR, 2000).
In PTSD it is common for individuals to describe a sense of guilt for having survived. Furthermore, some common features are avoidance patterns, marital conflict and loss of job often times due to self-destructive and impulsive behavior. PTSD is also associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic Disorders, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Phobia, Specific Phobia and Bipolar Disorder (DSM-IV-TR, 2000). This information denotes how PTSD can affect countless aspects of life.
In general, lifetime prevalence was determined using community-based studies. It was divulged that 8% of the American adult population will suffer from PTSD at some point in their life. Additionally, studies of at-risk populations (people exposed to specific incidents of trauma) reached prevalence rates of one-third to more than half of those exposed. Members specifically mentioned to be considered at-risk are those involved in military combat, captivity and politically motivated internment and/or genocide (DSM-IV, 2000).
There is a 19% risk of suicide attempts in individuals whose symptoms go untreated. Furthermore, there is also an increased risk of chronic medical illness including but not limited to hypertension, asthma, peptic ulcer and high blood pressure (Davidson and Foa, 1993).
Post Traumatic Stress Disorder was formally coded in the DSM-III in 1980. Although this disorder was only recently diagnostically identifiable within the last thirty-five years, it was had a long tradition, masquerading under many names such as “soldier’s heart”, “battle fatigue”, “combat neurosis”, “traumatic neurosis” and commonly “shell-shock”. Historically, interest in traumatic disorders only popularized during times of war and waned during times of peace. For example, The DSM-I, which was published after World War II (American Psychiatric Association, 1952) recognized traumatic neurosis and emphasized it in the nomenclature. On the other hand, the DSM-II (American Psychiatric Association, 1968), which was published twenty years after War World II but before Vietnam, only mentions trauma related disorders as an example of situational disturbances of adult life (Davidson and Foa, 1993).
It is now understood that PTSD does not only come about as a reaction to wartime but also to other traumatic experiences as well such as physical or sexual abuse, life-threatening accident or natural disaster.
The National Vietnam Readjustment Survey Report concerning PTSD among Vietnam War veterans was a large scale study looking at 5,000 subjects. The sample was explicitly selected because it can be accurately generalized to other soldiers around the world exposed to particularly violent and gruesome combat. The survey was taken in 1988, a proportional relevant time given that the Vietnam War occurred during the 1960’s and 1970’s. In this way it is possible to more clearly see the direct effects of war exposure on veterans specifically.
The estimated lifetime prevalence of the sample was 30.9% for men and 26.9% for women. Furthermore, 22.5% of the men and 21.2% of the women have had sub-threshold symptoms of PTSD at some point in their lives. This equals to more than half of all male Vietnam veterans and almost half of all female Vietnam veterans or about 1,700,000 Vietnam veterans in all- have experienced symtomology stemming from PTSD. Approximately 15.2% of all male Vietnam veterans (479,000 men who served in Vietnam) and 8.1% of all female Vietnam veterans (610) were diagnosed with Post Traumatic Stress Disorder (NVVR, 1988).
On a related note, there were also significant Axis IV type problems due to the overall stress reaction of being exposed to constant violence and fear of death. For instance, 14.1% report extreme levels of marital problems often times involving violence, and 23.1% have significant levels of parenting problems. Almost half of all male Vietnam veterans living with PTSD had been arrested or in jail at least once -34.2% more than once- and 11.5% had been convicted of a felony. The estimated lifetime prevalence of alcohol abuse or dependence among males is 39.2%. The estimated lifetime prevalence of drug abuse or dependence among male theater veterans is 5.7% (NVVR, 1988). These figures give a realistic idea of the staggering effects of PTSD on the United States population.
A Case Study
In the book Vietnam: Casebook (1988) by Jacob D. Lindy, M.D. the author tells the story of a therapist’s experience working with a middle-aged Vietnam veteran. The patient named Abraham had served in Vietnam from age 19 to 22. During his second tour of duty he was exposed to heavy combat around the Iron Triangle, which is now known for its massive bloodshed. Memories of numerous traumatic experiences began to haunt him after his return, becoming intrusions in his day-to-day functioning and sleep. For instance, Abraham began to relive the horror of carrying out the bodies of members of his company that had been slaughtered in an ambush. During his vivid recollections he actually saw and smelled “logs” which were the charred bodies of what remained from a helicopter crash. Abraham was at this time also prone to intense headaches and shaky hands.
Most damaging to Abraham was the memory of killing a young boy and his grandfather, and then being forced to lie next to them for hours, hiding, as they slowly died. The patient many years later began to grapple with a sharp sequestered psychosis due to Post Traumatic Stress Disorder resulting from a severe delayed grief and guilt reaction. After the war, Abraham managed fairly well, maintaining full employment, marriage and raising a son. The patient related a recurrent dream he began to have. According to Abraham, “I was on a boat and the boat sank. I swam to shore alone and entered a dark building. Someone huge was chasing me and I tried to get away. Then I was on a rollercoaster, but someone was still chasing me, and I felt very frightened.(118)” Eventually, the patient began to hallucinate the Vietnamese boy, causing disturbance to him personally and professionally (Lindy, 1988).
Through the course of psychotherapy, Abraham spent many hours recounting his horrific experiences within the safety of the therapeutic environment. Regardless, during these months of therapy, the patient began to experience even more intense recollections in the forms of vivid nightmares and flashbacks. Abraham was able to resurrect the Vietnamese boy gradually by understanding many nuances of his past experience and its meaning in order to relinquish this psychotic reminder of his trauma in Vietnam. Through therapy, Abraham was able to resolve several of his issues. For example, the patient was still wrestling with extreme anger towards his captain who he believes led them to danger, resulting in his friend’s death. Also, Abraham was able to begin to recognize the connection between hiding his experiences from his wife and resenting his family (Linday, 1988).
Towards termination of therapy, the patient began to cope more effectively with his past experiences, allowing for a healthier day-to-day living. Both the therapist and the patient left with a sense of accomplishment and camaraderie for having worked so hard together for many months. Clinically, the patient showed definite improvement during the course of treatment. The most noticeable areas of improvement mentioned by the patient were in his relationships with his wife and son. Furthermore, his sleep-disturbances decreased significantly as did suicidal ideation (Lindy, 1988).
Psychological Effects of PTSD
Drug and Alcohol Abuse
A longitudinal study conducted by Shipherd, Stafford and Tanner in 2004 looked at drug and alcohol use as it relates to PTSD symptoms. The study followed 1006 (806 males and 200 females) non-seeking treatment, Persian Gulf War veterans over the course of six years. It was hypothesized that drugs and alcohol are used in order to self medicate, as a reaction to painful and terrifying symptoms. This theory is a common conception regarding mental illness in general, especially with PTSD. The study focused on specific types of symptoms as it relates to substance abuse (2004).
The three symptoms of PTSD targeted were arousal, avoidance and re-experiencing. Of the three, arousal was found to be the highest predictor of drug use. On the contrary, alcohol was not found to be related to symptoms at all. This is an unexpected finding considering the high rates of comorbidity between PTSD and alcoholism. Indeed, this finding is not consistent with the self-medication hypothesis. Thus, the relationship between alcohol and PTSD is a complex one which needs to be studied possibly from a different angle. (Shipherd et al., 2004).
Drugs, on the other hand, were found to be related to symptoms. This supports the original theory that veterans self-medicate. Under this premise, it is apparent that just one of the negative effects of PTSD is substance abuse. In relation to this, substance abuse can also lead to other psychosocial problems such as marital conflict, child neglect or abuse, occupational and financial difficulties (Shipherd et al., 2004).
Another study examined the relationship between alcohol use and PTSD symptoms among Red Cross workers who responded to the 9/11/2001 attacks. for age, gender, and worksite (Simons, Gaher, Jacobs, Mayer and Jimenez, 2005).
These results suggest that there is a functional relation between posttraumatic stress symptoms and alcohol consumption. The study indicates that efforts to cope with traumatic stress symptoms may manifest in increases in alcohol consumption (Jeffrey Simons et al., 2005). The finding in this study further supports the theory of self-medication in PTSD victims.
Suicidality and Substance Abuse
Another study examined the role of PTSD and drug dependence in suicidal ideation and suicide attempts among Vietnam veterans. (Price, Risk, Haden, Lewis, Spitznagel, 2004).
PTSD was the most stable over the 25-year period, at around 12-14% each year. Drug dependence was the highest at approximately 45.1% in 1971 immediately following discharge from the army. By 1996 this rate has decreased all the way down to 16% initially in 1972 and then to 5.9% by 1996. On the contrary, rates of suicidality increased from 1971 to 1985 and have leveled off at around 8%. Not surprisingly, it was found that both PTSD and drug dependence (which historically go hand in hand) prolonged the duration of suicidal ideation and suicide attempts for this population (Price, 2004).
This study has implications for the possible causal relationship between PTSD, drug dependence, and suicidality over time. Therapies to enhance coping strategies and drug alternatives may be the first step in reducing suicidality as it relates to PTSD. Early intervention in this area can not only save many lives but also reduce health care burdens for the treatment of suicidality for many years (Price, 2004).
Another study considered suicidality without substance abuse. The purpose of the study was to determine if patients with a history of major depressive episode and comorbid PTSD have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with major depressive episode but no PTSD. In addition, to explore how PTSD comorbidity might increase risk for suicidal behavior in major depressive episode, the researchers studied the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity (Maria Oquendo et al., 2005).
It was found that patients with a lifetime history of PTSD were significantly more likely to have attempted suicide. The PTSD group also had higher objective depression, impulsivity, and hostility scores. There was also a higher rate of comorbid personality disorder; and were more likely to report a childhood history of abuse. However, cluster B personality disorder was the only independent variable related to lifetime suicide attempts in a multiple regression model (Oquendo et al., 2005).
PTSD is frequently comorbid with major depressive episode, and this enhances the risk for suicidal behavior. In other words, a major depressive episode coupled with PTSD is much more likely to cause a patient to act violently towards themselves (Oquendo et al., 2005).
Stress and Physical Health
Benyamini and Solomon (2005) conducted a study investigating the association between PTSD and cumulative life stress on physical health. A sample of 504 Israeli veterans was studied, 20 years after the 1982 war in Lebanon. This study was based on the already existent evidence that stress can adversely effect both physical and mental health. From there a hypothesis was assimilated, arguing that PTSD, over the course of a lifetime, would undoubtedly result in health compromising stress (Benyamini & Solomon, 2005).
Benyamini and Solomon discussed the difference between combat stress reaction (CSR) and posttraumatic stress disorder. CSR is defined as the psychological breakdown actually on the battlefield, impairing the soldier cognitively, affectively and behaviorally. CSR is considered to be first and foremost, functional. In other words, the soldier actually stops functioning as combatant and begins to breakdown. PTSD, as described previously, is a severe stress reactions after the danger is gone. The relationship between the two is clear. Veterans who experienced CSR on the battlefield were much more likely to develop PTSD after the war (2005).
Markedly, it was proven in this study that veterans who experienced CSR during the war and were diagnosed with PTSD 20 years after the war, reported worse physical health, more chronic illness, heightened somatic symptoms and engagement in risky behavior. It is apparent that the possibility exists that CSR could be a precursor for the occurrence of PTSD occurring (Benyamini & Solomon, 2005). Regardless, it is easily seen that PTSD symptoms can dramatically affect not only physical health, but attitude towards safe behavior. Perhaps being exposed to many near death experiences during combat, calls into question living safely in the future. Further research is needed to examine this aspect of PTSD.
Another study by Craig N. Sawchuk et al. (2005) compared the strength of the association of lifetime PTSD and lifetime major depression on Cardio Vascular Disease (CVD) among Northern Plains American Indians. A total of 1414 participants aged 18–57 years completed a structured interview that assessed psychiatric diagnoses, alcohol abuse, CVD, and traditional CVD risk factors including age, sex, education, diabetes, high blood pressure, and smoking.
This study found that rates of lifetime PTSD and major depression were 15% and 8%. CVD was more commonly reported by participants with PTSD than by those without PTSD (12% v. 5%. In addition, more participants with major depression reported CVD than did non-depressed participants (14% v. 6%.) PTSD was significantly associated with CVD even after controlling for traditional CVD risk factors and major depression. (Sawchuck et al., 2005).
This study surmised that future research should examine the association and mechanisms of PTSD and Cardio Vascular Disease prospectively. This study further implicates PTSD as a major variable effecting mental health and physical health, on many different levels.
Marshal, Panuzio and Taft (2005) conducted a meta analysis of existing literature concerning prevalence, consequences, correlates, and treatment of intimate partner violence among military veterans. One of the most startling findings was that intimate partner violence across representative samples of veterans was up to three times higher than civilian samples. This type of violence was also found to be highly correlated with PTSD. Such findings imply that targeting PTSD itself in the military could serve to reduce domestic violence perpetrated by veterans (Marshall, Panuzio, Taft, 2005).
This research also suggests that standard treatment modalities of intimate partner violence in the military are not effective among active duty servicemen. This literature review points towards the idea that perhaps a “one size fits all” approach doesn’t work. Such treatments should be tailored to fit men’s different psychiatric needs as well making significant efforts to decrease the stigma of mental health services in the military. This may improve motivation for men dealing with PTSD and violence to change (Marshall et al., 2005).
Two major studies will now be reviewed in detail with special emphasis concerning method, outcome, and validity. There is little to date research on exposure, stress inoculation, and cognitive restructuring therapies applied specifically to military veterans. As such, and for the purpose of this literature review, the two experiments discussed will concern therapies which were designed for female assault and rape victims. Although this is a different population from most veterans, it is applicable in that these specific interventions are currently approved and used for PTSD patients, regardless of the type of trauma.
Exposure, Stress Inoculation and a Combination Therapy
Cognitive behavioral approaches in PTSD have been the most extensively studied treatments (Foa & Meadows, 1997). These include mostly variations of exposure therapy and anxiety management programs. Exposure therapy guides clients to reliving memories of the traumatic event. It also helps the patient to confront once avoided situations which trigger distress and thoughts of the trauma. By exposing the patient to their fears within the safety of the therapeutic setting, the individual can start to process what happened to them in a healthy manner (Foa & Meadows, 1997). This technique is to date, the most empirically supported (meaning backed by research) PTSD intervention (NCP 2005). Stress inoculation training typically consists of education and learning of coping skills, including deep muscle relaxation training, breathing control, assertiveness, role playing, covert modeling, thought stopping, positive thinking and self-talk. (Rothbaum et al., 2000). Stress inoculation training, a type of anxiety management, is among the most useful psychotherapeutic treatments for patients (Foa et al., 1999b)
A brief summary of these findings points out that the three treatments performed equally well on most measures. PE alone, which focuses on exposure to trauma-related memories and situations, was superior on anxiety and global social adjustment and yielded larger effect sizes on severity of PTSD, depression, and anxiety at post-treatment and follow-up. The authors considered the theory that the combined treatment put an excessive demand on patients ((Foa et al., 1999). Selecting a treatment for a given disorder must be based on how well it can lessen its severity. Experts have suggested that the evaluation of treatment effectiveness should involve a broader spectrum of symptoms. Prolonged exposure was superior to SIT and PE–SIT in reducing anxiety and superior to PE–SIT in reducing depression. Another crucial consideration is the practicality of proper utilization of the treatment among non-expert clinicians. SIT consists of various components, all of which must be effectively taught by the therapist and learned by the participant. PE is less complex and thus may be more readily practical and available to clinicians outside of specialized settings (Foa et al., 1999).
Prolonged Exposure With and Without Cognitive Restructuring
Foa, Hembree, Cahill, Rauch, Riggs, Feeny, and Yadin (2005) conducted an experiment which compared the treatment of prolonged exposure with and without cognitive restructuring. It was hypothesized that PE/CR would be superior to PE alone on all four measures. It was hypothesized that participants who failed to achieve excellent response on self-reported PTSD at eight sessions would further improve after additional sessions(Foa et al., 2005).
Cognitive restructuring entails identifying irrational thought patterns, feelings, and behavior that emerge after a traumatic event. The patient is gradually taught to substitute new and healthier thoughts. This allows the patient to develop new emotional and behavioral patterns (Grohols, 2006). On the average, treated patients with PTSD remain somewhat symptomatic (Cahill & Foa, 2004). Moreover, the treatments developed in academic clinical centers are not widely used by clinicians in the community who treat patients with trauma-related disturbances mainly because they don’t have the training (Becker, Zayfert, & Anderson, 2004). The following study, looks at these issues by examining two strategies for improving outcome and by comparing outcome in an academic center and a community clinic (Foa et al., 2005). Because there is such a wide range of PTSD symptoms, some experts such as Kilpatrick, Veronen, and Resick believe that treatment programs with multiple techniques will be more effective than any single approach. Accordingly, most cognitive-behavioral therapy (CBT) programs for PTSD involve several techniques(Foa et al., 2005).
Despite the growing evidence that adding treatment components to imaginal plus in vivo exposure does not improve outcome, most treatment programs for PTSD include multiple components on top of a strong exposure base (Foa et al., 2005). These studies highlight the fact that effectual treatment compared to treatment actually administered to veterans isn’t cohesive. Modification of these treatments should be made based on the empirical evidence. In addition, this study specifically points to the fact that clinicians need to have more specialized training in the treatment of PTSD. This was found to be the biggest determining factor in prognosis, not the actual level of education.
General Treatment Information for Veterans
Specialized Centers for Veterans with PTSD
There is a belief that veterans treated at clinics with specific knowledge and training in military combat related PTSD have the best chance of benefiting from treatment. The general findings suggest that referrals to staff members with military culture knowledge and the effects of combat produced better overall outcome. This could be due to an opportunity for better rapport between the patient and the therapist which is known definitely to improve therapy outcomes for any population.
This study also exposed the fact that the earlier PTSD is diagnosed after the traumatic event occurs, the better their chances of improving (Lee, Gabriele, Bale). In other words, early screening and detection of psychiatric illness is crucial, as well as specialized PTSD clinics. It is important for therapists in these clinics to have specialized training in PTSD treatment. Although this seems a reasonable request for a population so likely to be exposed to trauma, so far this is not the reality.
VA Practice Patterns
The article by Rosen et al. in 2004 compares actual VA clinical practice patterns to the guidelines. Rosen et al. found that the VA’s area of strength included psychotherapy addressing symptom management, medication management and assessment of comorbid disorders. In this respect, VA guidelines were adhered to. Unfortunately, wait times at VA hospitals and satellite programs often drag out for months, putting the veteran at high risk and feeling disillusioned. There were some discrepancies between actual practice patterns and newly emerging guideline recommendations. Mainly these were types of interventions for PTSD exposure therapy, variability in assessment, anger management and psychosocial intervention for sleep. More research is needed to find out variables creating these results. This next generation of research can inform specific strategies to help increase use of better practices in caring for veterans with PTSD (Rosen et al., 2004).
Group therapy is a treatment approach used for PTSD, especially in VA settings. Kansas (2002) reviewed two studies exploring group treatment for veterans. The first study by Wallis showed significant reduction in trauma symptoms for group therapy patients. These symptoms included: anxiety, depression, intrusive experiences, avoidance, irritability, dissociation and tension reduction. This study looked at 402 veterans suffering from PTSD. One group was involved in group therapy daily as well as individual therapy. The other group was only exposed to individual therapy. Ultimately, the group exposed to group and individual experienced more noticeable PTSD symptom reduction.
Conclusion and Implications
Many years after combat, the effects of PTSD in veterans are severe. The VA desperately needs to increase their awareness of clinical implications in treatment by conducting more studies with larger sample sizes. PTSD effects many veterans, the symptoms linger and immediate diagnosis and treatment sustains the best results. It was also discovered that not only does immediate treatment rarely happen in the military but that common PTSD treatment (combination therapy) actually being used is really not the most effective. It is the federal government’s responsibility to incorporate necessary means to detect and treat PTSD in veterans coming back from active duty. This will not only promote a general societal gain but will also ensure a more effective military population.
Recently after it was discovered and publicly shared that the VA was not providing timely and reliable mental health treatment to veterans due to funding and staffing issues, the VA has responded by contracting out this responsibility to third party independant clinics and private practices throughout the country. MorMindful Therapy & Psychiatry is currently in the process of becoming credential with the Veteran's Affairs in order to take over the reins and begin providing mental health services to this largely undeserved population that exists in Boca Raton, Florida. If you or anyone you know is a United States Veteran or active duty, reach out at MorMindful@outlook.com to find out how to schedule an appointment which is paid for by the federal government.