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Post Traumatic Stress Disorder

With hundreds of thousands of soldiers having served in Iraq, conservative estimates indicate that 1 in 6 are returning from combat suffering from major depression, generalized anxiety, or post-traumatic stress disorder (PTSD), which can be as crippling as any physical wound. NOW investigates if the Department of Veterans' Affairs (VA) is equipped to treat these soldiers who have risked their lives for their nation. Can the VA deal with this influx of new cases while meeting the needs of current veterans?

During the Civil War they called it "nostalgia"; after World War I, "shell shock"; World War II, "battle fatigue." All generations have known the terrible psychological aftereffects of war but it was until after the Vietnam conflict that they were given an official definition. In 1980, Post Traumatic Stress Disorder first made it into the pages of the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, the official diagnostic cannon, published by the American Psychiatric Association. At first, the diagnosis could be applied to those who had experienced a "recognizable stressor that would evoke significant symptoms of distress in almost everyone." That criteria was later revised to:
[T]he stressor event must fulfill two basic requirements: 1) "The person experienced, witnessed, or was confronted with an event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and 2) the person's response involved intense fear, helplessness, or horror" In DSM-IV, (APA, 1994)
Of course, PTSD as a diagnosis can be applied to many stressful events but those who work with veterans have been in the forefront of defining and treating the disorder. The VA offers an FAQ on its Web site which succinctly defines PTSD's symptoms:
1.What is PTSD?

Post-Traumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, abuse (sexual, physical, emotional, ritual), and violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life.

PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

2.What treatments are available for PTSD?

Elements common to many treatment modalities for PTSD include education, exposure, exploration of feelings and beliefs, and coping skills training. Additionally, the most common treatment modalities include cognitive-behavioral treatment, pharmacotherapy, EMDR, group treatment, and psychodynamic treatment.

More on PTSD from the Department of Veterans Affairs.

Some among the medical and veterans' advocacy community are worried that the VA will not be able to meet the needs of returning soldiers from Iraq and keep up with those veterans with PTSD from previous conflicts. In testimony before the House Appropriations Committee in April 2005, Dr. Joseph English noted that "in 2003 alone more than 77,800 veterans received specialized care for PTSD with tens of thousands more receiving some type of care through their primary care clinic." But English also noted that VA spending on mental health has decreased by 25 percent since 1996. A recent NEW ENGLAND JOURNAL OF MEDICINE study of returning soldiers found that from 15.6 to 17.1 percent showed signs of PTSD or general anxiety and severe depression. The study also pointed out additional challenges to those suffering getting treatment as "Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care."

There are calls in Congress for greater funding and further study of PTSD. Currently, early diagnosis relies on the answers that those about to head home give to these four questions in the Department of Defense's post-deployment health assessment questionnaire:

Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you
  • have had any nightmares about it or thought about it when you did not want to?
  • tried hard not to think about it or went out of your way to avoid situations that remind you of it?
  • were constantly on guard, watchful, or easily startled?
  • felt numb or detached from others, activities, or your surroundings?
As evidenced by the Harvard study and others, some returning soldiers also avoid answering "yes" to the questions in order to speed their deployment home. A recent GAO study for the Committee on Veterans' Affairs, House of Representatives suggested follow-up surveys at several intervals after veterans' return as PTSD can sometimes take years to manifest itself.

Additional resources on PTSD and veteran's needs. Sources: VA AND DEFENSE HEALTH CARE, Report to the Ranking Democratic Member, Committee on Veterans' Affairs, House of Representatives: September 2004; "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," NEW ENGLAND JOURNAL OF MEDICINE, July 1, 2004; House Committee on Veterans Affairs; National Center for PTSD.

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