POV: What is Post-Traumatic Stress Disorder (PTSD) and what are some of the symptoms?
Dr. Shira Maguen: Post-traumatic stress disorder (PTSD) is an anxiety disorder that may develop after an individual is exposed to one or more traumatic events. During war military service members are exposed to a number of potentially traumatic events — ones in which the individual's life is in critical danger, he or she is seriously injured, and/or there is a threat to physical integrity, either to one's self or to others. In order to meet criteria for a diagnosis of PTSD, in addition to being exposed to at least one potentially traumatic event as described above, an individual must react with helplessness, fear or horror either during or after the event.
Individuals with PTSD exhibit four different types of symptoms, including:
- Reliving or re-experiencing the event — symptoms include nightmares, intrusive thoughts, flashbacks and psychological distress and physical reactivity in response to trauma cues.
- Avoidance — avoiding reminders of the traumatic event, including thoughts, emotions, people, places and conversations that may trigger memories of the traumatic event.
- Emotional numbing — symptoms include feeling emotionally numb or having reduced emotional experiences, detachment or estrangement from others, and being less interested in previously enjoyed activities.
- Arousal symptoms are very common in returning veterans, even in those who do not meet full criteria for a PTSD diagnosis. The most frequently reported problems are increased anger or irritability and difficulty sleeping. Other arousal symptoms include constantly being on guard, having difficulty concentrating and feeling jumpy or easily startled.
These symptoms cause difficulties in social relationships — with family, dating and friendships — and occupational functioning in work or school.
Although the symptoms and syndrome of PTSD have been observed in veterans for hundreds of years, PTSD was not formally recognized as a mental disorder until 1980, when it was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Today, PTSD is the most commonly reported mental health diagnosis following deployment to the Middle East: 12 to 13 percent of the Marines and soldiers who have returned from active duty have screened positive, as reported by Hoge and colleagues.*
POV: Is it common for soldiers returning from war to experience symptoms of PTSD?
Maguen: In addition to military personnel that meet full criteria for a PTSD diagnosis, many others display some combination of PTSD symptoms as they readjust to the challenges of civilian life after functioning under the constant life-threat they experienced during deployment. It is common to have some PTSD symptoms at first, especially hypervigilance, insomnia and nightmares as veterans try to integrate and process their war zone experiences. These symptoms are likely to be more intense for those who have returned recently, and many of these symptoms are likely to decrease over time as they adjust to civilian life.
One way to conceptualize many of these PTSD symptoms is to think of them as part of a stress-response continuum. At one end are individuals who are burdened by stressors at home at the same time that they are reminded of traumatic events that happened in the war zone, yet are coping well with few mental health symptoms and little functional impairment. These people are often able to reintegrate into their previous jobs with little disruption and return to their relationships, in which they can communicate about areas of difficulty. In the middle may be those who have a variety of PTSD symptoms, yet do not evidence clinically significant impairment in functioning. At the other end of the spectrum are veterans who are plagued with a host of PTSD symptoms and have difficulty functioning in their daily lives.
POV: Can you tell us about the research that has been done on the relationship between killing in war and PTSD?
Maguen: Despite this country's involvement in wars for hundreds of years, there has been little clinical research on the mental health impact of taking another life in combat among veterans, compared to the amount of research that exists about other potentially traumatic events that military personnel may experience in the context of war.
A few studies have detailed the elements of war-zone exposure that are necessary, but not sufficient, to create risk for chronic PTSD. In one study of Vietnam veterans, King and colleagues found that instances of traditional combat (e.g., firing a weapon, receiving fire), reports of atrocities/abusive violence (e.g., mutilation, killing civilians), feelings of fear and the degree to which soldiers experienced discomfort in a war zone were each associated with PTSD symptom severity.
In another study that examined killing in the context of committing atrocities during war within a larger model, Fontana and Rosenheck found a strong relationship between killing and PTSD. After taking killing into account, the atrocities variable no longer predicted PTSD symptoms, suggesting that killing could be the potent ingredient in predicting PTSD.
A third study conducted by MacNair involving Vietnam veterans also found a relationship between taking a life in combat and PTSD. Our preliminary results from a current study of Vietnam veterans have demonstrated that in addition to PTSD, killing is also associated with a number of mental health and functioning problems, even after taking exposure to general combat into account. Finally, we are currently in the process of conducting a study about the impact of killing on veterans returning from deployments to Iraq and Afghanistan. We are not aware of any other studies that document this relationship in newly returning veterans.
POV: Why is killing in war a potentially traumatic event that would lead to PTSD?
Maguen: Although soldiers are trained to kill, as cited in Soldiers of Conscience, killing is quite difficult for most individuals. Prior to killing another enemy combatant or a civilian, there is generally some type of life threat. The circumstances of killing also generally involve either the person him or herself being injured or in danger of being killed and often others being killed. Pulling the trigger, even in self defense, is not easy and is often accompanied by a series of complex emotional reactions before and after taking a life. These may involve helplessness, fear and/or horror either during or after killing. While some may react in this way, others may not, which is why assessment of reactions to killing is quite important.
Also, it is important to remember that just because an individual experiences killing as a traumatic event does not mean that the person will inevitability develop PTSD symptoms or a formal diagnosis of PTSD. Killing is difficult for many soldiers who may not develop PTSD, and those issues should be evaluated separately.
POV: What are the current rates of mental health problems in soldiers returning from Iraq and Afghanistan?
Maguen: A recent RAND study found that 1 in 5 veterans deployed to Iraq or Afghanistan suffered from PTSD or major depression. These rates are somewhat similar to those reported in other scientific studies. An initial report by Hoge and colleagues (2004) indicated that 16 to 17 percent of returning Operation Iraqi Freedom (OIF) combat veterans and 11 percent of returning Operation Enduring Freedom (OEF) combat veterans met screening criteria for at least one mental health disorder. In a more recent study, Hoge and colleagues (2006) found that the prevalence of screening positive for a mental health problem was 19 percent among service members returning from Iraq and 11 percent after returning from Afghanistan. Among OIF/OEF veterans seen at VA healthcare facilities, 25 percent received mental health diagnoses, with 56 percent of these meeting criteria for two or more mental health diagnoses (Seal et al., 2007).
Mental health problems are related to impairments in physical health and general functioning. For example, those with PTSD often experience difficulties in many domains of functioning such as relationships and employment. There have also been several studies that document the relationship between PTSD symptoms and physical health. In one recent study of newly returning veterans, those with PTSD also manifested more physical symptoms greater symptom severity, lower ratings of general health, more sick call visits and more missed workdays even after taking into account those who have been injured or wounded (Hoge and colleagues, 2007).
POV: How can someone with PTSD get help?
Maguen: Oftentimes, family and/or couples therapy can serve as a preventative measure, assisting family members with understanding the process of reintegration into civilian life as well as highlighting some of the readjustment symptoms that family members might observe in their loved ones. This process can also help the veteran learn how to reconnect and communicate with family members despite feeling like loved ones can never understand his/her experience. Working with the veteran and the family can decrease the process of isolation and avoidance within the family unit by opening channels of communication.
Going back to work or school can also be a challenging experience for veterans, especially as many might have difficulty relating to authority figures. Many have experienced situations in which they perceive that authority figures made decisions that were not in their best interest, and as a result understandably can be reactive in this context. Difficulties with concentration can also hamper work or school functioning, and therapies that help process the trauma can be helpful in this regard; providing the veteran with a space to process his or her experience ultimately can help reduce impairment in this arena.
Veterans who served as part of Operation Iraqi Freedom/Operation Enduring Freedom can currently get five years of free treatment at their local VA hospital. Many VA hospitals have designated PTSD Clinical Teams (PCT) that provide a wide array of treatments to returning veterans. At the San Francisco VA Medical Center, we offer a comprehensive PTSD diagnostic evaluation, skills-based therapy (e.g., stress and anger management), exposure-based therapies (e.g., Prolonged Exposure Therapy and Cognitive Processing Therapy), couples/family therapy and OIF/OEF adjustment groups. Prolonged Exposure Therapy and Cognitive Processing Therapy are two evidence-based treatments which have been shown to improve PTSD symptoms in veterans returning from war. There is currently a national effort to train mental health professionals across the nation to provide one or both of these treatments.
One of the biggest challenges that mental health-care professionals face in providing services to military personnel returning from deployments to the Middle East are obstacles related to stigma and barriers to care. In one study, among those who screened positive for a mental health disorder, only 23 to 40 percent received professional mental health care in the last year and only 38 to 45 percent were interested in receiving help. Furthermore, those who screened positive for a mental health disorder were twice as likely as those who did not meet screening criteria to report stigma and barriers to care for seeking mental health care.
There are many reasons that returning veterans do not seek mental health care, including common fears of being seen as weak (65 percent). One of the most important things that you can do if you know someone who is suffering from PTSD symptoms is to encourage them to seek treatment at their local VAhospital or at any facility that provides evidence-based treatments.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004; 351(1): 13-22.
Hoge CW, Auchterlonie JL, Milliken CS: Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295:1023-32.
Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007 Jan;164(1):150-3.
King DW, King LA, Foy DW, Gudanowski DM. Prewar factors in combat-related Posttraumatic Stress Disorder: Structural equation modeling with a national sample of female and male Vietnam Veterans. J Consult Clin Psychol. 1996; 64: 520-531.
MacNair RM. Perpetration-inducted traumatic stress in combat veterans. Peace and Conflict: Journal of Peace Psychology. 2002; 8: 63-72.
Seal KH, Bertenthal D, Miner CR, 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. 2007; 167, 476-82.
Rosenheck R, Fontana A. Changing patterns of care for war-related post-traumatic stress disorder at Department of Veterans Affairs medical centers: the use of performance data to guide program development. Mil Med. 1999 Nov;164(11):795-802.
Shira Maguen, Ph.D., is a staff psychologist on the Posttraumatic Stress Disorder Clinical Team at the San Francisco VA Medical Center and assistant professor in the Department of Psychiatry at the UCSF School of Medicine. Dr. Maguen is the recipient of a VA Health Services Research and Development Grant that examines the impact of killing in veterans of war. She has two additional grants that examine PTSD and co-morbid conditions in Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) women veterans and mild TBI and PTSD in OIF/OEF veterans. Her research interests fall under the umbrella of PTSD and include risk and resilience factors in veterans, evidence-based therapies for PTSD (e.g., Cognitive Processing Therapy), prolonged grief disorder and coping with the ongoing threat of terrorism in countries such as Israel.