How PTSD Became a Problem Far Beyond the Battlefield

Soldiers wait out a sandstorm in Iraq. (The inclusion of the soldiers pictured in this story should not be construed to indicate that any of them suffer from post-traumatic stress disorder.)
© Christopher Anderson/Magnum Photos.

The first time I experienced what I now understand to be post-traumatic stress disorder, I was in a subway station in New York City, where I live. It was almost a year before the attacks of 9/11, and I’d just come back from two months in Afghanistan with Ahmad Shah Massoud, the leader of the Northern Alliance. I was on assignment to write a profile of Massoud, who fought a desperate resistance against the Taliban until they assassinated him two days before 9/11. At one point during my trip we were on a frontline position that his forces had just taken over from the Taliban, and the inevitable counterattack started with an hour-long rocket barrage. All we could do was curl up in the trenches and hope. I felt deranged for days afterward, as if I’d lived through the end of the world.

By the time I got home, though, I wasn’t thinking about that or any of the other horrific things we’d seen; I mentally buried all of it until one day, a few months later, when I went into the subway at rush hour to catch the C train downtown. Suddenly I found myself backed up against a metal support column, absolutely convinced I was going to die. There were too many people on the platform, the trains were coming into the station too fast, the lights were too bright, the world was too loud. I couldn’t quite explain what was wrong, but I was far more scared than I’d ever been in Afghanistan.

I stood there with my back to the column until I couldn’t take it anymore, and then I sprinted for the exit and walked home. I had no idea that what I’d just experienced had anything to do with combat; I just thought I was going crazy. For the next several months I kept having panic attacks whenever I was in a small place with too many people—airplanes, ski gondolas, crowded bars. Gradually the incidents stopped, and I didn’t think about them again until I found myself talking to a woman at a picnic who worked as a psychotherapist. She asked whether I’d been affected by my war experiences, and I said no, I didn’t think so. But for some reason I described my puzzling panic attack in the subway. “That’s called post-traumatic stress disorder,” she said. “You’ll be hearing a lot more about that in the next few years.”

I had classic short-term (acute) PTSD. From an evolutionary perspective, it’s exactly the response you want to have when your life is in danger: you want to be vigilant, you want to react to strange noises, you want to sleep lightly and wake easily, you want to have flashbacks that remind you of the danger, and you want to be, by turns, anxious and depressed. Anxiety keeps you ready to fight, and depression keeps you from being too active and putting yourself at greater risk. This is a universal human adaptation to danger that is common to other mammals as well. It may be unpleasant, but it’s preferable to getting eaten. (Because PTSD is so adaptive, many have begun leaving the word “disorder” out of the term to avoid stigmatizing a basically healthy reaction.)

Because PTSD is a natural response to danger, it’s almost unavoidable in the short term and mostly self-correcting in the long term. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD. Rape is one of the most psychologically devastating things that can happen to a person, for example—far more traumatizing than most military deployments—and, according to a 1992 study published in the Journal of Traumatic Stress, 94 percent of rape survivors exhibit signs of extreme trauma immediately afterward. And yet, nine months later 47 percent of rape survivors have recovered enough to resume living normal lives.

Combat is generally less traumatic than rape but harder to recover from. The reason, strangely, is that the trauma of combat is interwoven with other, positive experiences that become difficult to separate from the harm. “Treating combat veterans is different from treating rape victims, because rape victims don’t have this idea that some aspects of their experience are worth retaining,” says Dr. Rachel Yehuda, a professor of psychiatry and neuroscience and director of traumatic-stress studies at Mount Sinai Hospital in New York. Yehuda has studied PTSD in a wide range of people, including combat veterans and Holocaust survivors. “For most people in combat, their experiences range from the best to the worst of times,” Yehuda adds. “It’s the most important thing someone has ever done—especially since these people are so young when they go in—and it’s probably the first time they’re ever free, completely, of their societal constraints. They’re going to miss being entrenched in this very important and defining world.”

Oddly, one of the most traumatic events for soldiers is witnessing harm to other people—even to the enemy. In a survey done after the first Gulf War by David Marlowe, an expert in stress-related disorders working with the Department of Defense, combat veterans reported that killing an enemy soldier—or even witnessing one getting killed—was more distressing than being wounded oneself. But the very worst experience, by a significant margin, was having a friend die. In war after war, army after army, losing a buddy is considered to be the most distressing thing that can possibly happen. It serves as a trigger for psychological breakdown on the battlefield and re-adjustment difficulties after the soldier has returned home.

Terrible as such experiences are, however, roughly 80 percent of people exposed to them eventually recover, according to a 2008 study in the Journal of Behavioral Medicine. If one considers the extreme hardship and violence of our pre-history, it makes sense that humans are able to sustain enormous psychic damage and continue functioning; otherwise our species would have died out long ago. “It is possible that our common generalized anxiety disorders are the evolutionary legacy of a world in which mild recurring fear was adaptive,” writes anthropologist and neuroscientist Melvin Konner, in a collection called Understanding Trauma. “Stress is the essence of evolution by natural selection and close to the essence of life itself.”

Soldiers in Korengal Valley, Afghanistan, in 2008.

Photograph by Tim Hetherington.

A 2007 analysis from the Institute of Medicine and the National Research Council found that, statistically, people who fail to overcome trauma tend to be people who are already burdened by psychological issues—either because they inherited them or because they suffered trauma or abuse as children. According to a 2003 study on high-risk twins and combat-related PTSD, if you fought in Vietnam and your twin brother did not—but suffers from psychiatric disorders—you are more likely to get PTSD after your deployment. If you experienced the death of a loved one, or even weren’t held enough as a child, you are up to seven times more likely to develop the kinds of anxiety disorders that can contribute to PTSD, according to a 1989 study in the British Journal of Psychiatry. And according to statistics published in the Journal of Consulting and Clinical Psychology in 2000, if you have an educational deficit, if you are female, if you have a low I.Q., or if you were abused as a child, you are at an elevated risk of developing PTSD. These factors are nearly as predictive of PTSD as the severity of the trauma itself.

Suicide by combat veterans is often seen as an extreme expression of PTSD, but currently there is no statistical relationship between suicide and combat, according to a study published in April in the Journal of the American Medical Association Psychiatry. Combat veterans are no more likely to kill themselves than veterans who were never under fire. The much-discussed estimated figure of 22 vets a day committing suicide is deceptive: it was only in 2008, for the first time in decades, that the U.S. Army veteran suicide rate, though enormously tragic, surpassed the civilian rate in America. And even so, the majority of veterans who kill themselves are over the age of 50. Generally speaking, the more time that passes after a trauma, the less likely a suicide is to have anything to do with it, according to many studies. Among younger vets, deployment to Iraq or Afghanistan lowers the incidence of suicide because soldiers with obvious mental-health issues are less likely to be deployed with their units, according to an analysis published in Annals of Epidemiology in 2015. The most accurate predictor of post-deployment suicide, as it turns out, isn’t combat or repeated deployments or losing a buddy but suicide attempts before deployment. The single most effective action the U.S. military could take to reduce veteran suicide would be to screen for pre-existing mental disorders.

It seems intuitively obvious that combat is connected to psychological trauma, but the relationship is a complicated one. Many soldiers go through horrific experiences but fare better than others who experienced danger only briefly, or not at all. Unmanned-drone pilots, for instance—who watch their missiles kill human beings by remote camera—have been calculated as having the same PTSD rates as pilots who fly actual combat missions in war zones, according to a 2013 analysis published in the Medical Surveillance Monthly Report. And even among regular infantry, danger and psychological breakdown during combat are not necessarily connected. During the 1973 Yom Kippur War, when Israel was invaded simultaneously by Egypt and Syria, rear-base troops in the Israeli military had psychological breakdowns at three times the rate of elite frontline troops, relative to their casualties. And during the air campaign of the first Gulf War, more than 80 percent of psychiatric casualties in the U.S. Army’s VII Corps came from support units that took almost no incoming fire, according to a 1992 study on Army stress casualties.

Conversely, American airborne and other highly trained units in World War II had some of the lowest rates of psychiatric casualties of the entire military, relative to their number of wounded. A sense of helplessness is deeply traumatic to people, but high levels of training seem to counteract that so effectively that elite soldiers are psychologically insulated from even extreme risk. Part of the reason, it has been found, is that elite soldiers have higher-than-average levels of an amino acid called neuropeptide-Y, which acts as a chemical buffer against hormones that are secreted by the endocrine system during times of high stress. In one 1968 study, published in the Archive of General Psychiatry, Special Forces soldiers in Vietnam had levels of the stress hormone cortisol go down before an anticipated attack, while less experienced combatants saw their levels go up.

Shell Shock

All this is new science, however. For most of the nation’s history, psychological effects of combat trauma have been variously attributed to neuroses, shell shock, or simple cowardice. When men have failed to obey orders due to trauma they have been beaten, imprisoned, “treated” with electroshock therapy, or simply shot as a warning to others. (For British troops, cowardice was a capital crime until 1930.) It was not until after the Vietnam War that the American Psychiatric Association listed combat trauma as an official diagnosis. Tens of thousands of vets were struggling with “Post-Vietnam Syndrome”—nightmares, insomnia, addiction, paranoia—and their struggle could no longer be written off to weakness or personal failings. Obviously, these problems could also affect war reporters, cops, firefighters, or anyone else subjected to trauma. In 1980, the A.P.A. finally included post-traumatic stress disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.

Thirty-five years after acknowledging the problem in its current form, the American military now has the highest PTSD rate in its history—and probably in the world. Horrific experiences are unfortunately universal, but long-term impairment from them is not, and despite billions of dollars spent on treatment, half of our Iraq and Afghanistan veterans have applied for permanent disability. Of those veterans treated, roughly a third have been diagnosed with PTSD. Since only about 10 percent of our armed forces actually see combat, the majority of vets claiming to suffer from PTSD seem to have been affected by something other than direct exposure to danger.

This is not a new phenomenon: decade after decade and war after war, American combat deaths have dropped steadily while trauma and disability claims have continued to rise. They are in an almost inverse relationship with each other. Soldiers in Vietnam suffered roughly one-quarter the casualty rate of troops in World War II, for example, but filed for disability at a rate that was nearly 50 percent higher, according to a 2013 report in the Journal of Anxiety Disorders. It’s tempting to attribute this disparity to the toxic reception they had at home, but that doesn’t seem to be the case. Today’s vets claim three times the number of disabilities that Vietnam vets did despite a generally warm reception back home and a casualty rate that, thank God, is roughly one-third what it was in Vietnam. Today, most disability claims are for hearing loss, tinnitus, and PTSD—the latter two of which can be exaggerated or faked. Even the first Gulf War—which lasted only a hundred hours—produced nearly twice the disability rates of World War II. Clearly, there is a feedback loop of disability claims, compensation, and more disability claims that cannot go on forever.

Part of the problem is bureaucratic: in an effort to speed up access to benefits, in 2010 the Veterans Administration declared that soldiers no longer have to cite a specific incident—a firefight, a roadside bomb—in order to be eligible for disability compensation. He or she simply has to report being impaired in daily life. As a result, PTSD claims have reportedly risen 60 percent to 150,000 a year. Clearly, this has produced a system that is vulnerable to abuse and bureaucratic error. A recent investigation by the V.A.’s Office of Inspector General found that the higher a veteran’s PTSD disability rating, the more treatment he or she tends to seek until achieving a rating of 100 percent, at which point treatment visits drop by 82 percent and many vets quit completely. In theory, the most traumatized people should be seeking more help, not less. It’s hard to avoid the conclusion that some vets are getting treatment simply to raise their disability rating.

In addition to being an enormous waste of taxpayer money, such fraud, intentional or not, does real harm to the vets who truly need help. One Veterans Administration counselor I spoke with described having to physically protect someone in a PTSD support group because some other vets wanted to beat him up for faking his trauma. This counselor, who asked to remain anonymous, said that many combat veterans actively avoid the V.A. because they worry about losing their temper around patients who are milking the system. “It’s the real deals—the guys who have seen the most—that this tends to bother,” this counselor told me.

Soldiers at the Korengal barracks.

Photograph by Tim Hetherington.

The majority of traumatized vets are not faking their symptoms, however. They return from wars that are safer than those their fathers and grandfathers fought, and yet far greater numbers of them wind up alienated and depressed. This is true even for people who didn’t experience combat. In other words, the problem doesn’t seem to be trauma on the battlefield so much as re-entry into society. Anthropological research from around the world shows that recovery from war is heavily influenced by the society one returns to, and there are societies that make that process relatively easy. Ethnographic studies on hunter-gatherer societies rarely turn up evidence of chronic PTSD among their warriors, for example, and oral histories of Native American warfare consistently fail to mention psychological trauma. Anthropologists and oral historians weren’t expressly looking for PTSD, but the high frequency of warfare in these groups makes the scarcity of any mention of it revealing. Even the Israeli military—with mandatory national service and two generations of intermittent warfare—has by some measures a PTSD rate as low as 1 percent.

If we weed out the malingerers on the one hand and the deeply traumatized on the other, we are still left with enormous numbers of veterans who had utterly ordinary wartime experiences and yet feel dangerously alienated back home. Clinically speaking, such alienation is not the same thing as PTSD, but both seem to result from military service abroad, so it’s understandable that vets and even clinicians are prone to conflating them. Either way, it makes one wonder exactly what it is about modern society that is so mortally dispiriting to come home to.

Soldier’s Creed

Any discussion of PTSD and its associated sense of alienation in society must address the fact that many soldiers find themselves missing the war after it’s over. That troubling fact can be found in written accounts from war after war, country after country, century after century. Awkward as it is to say, part of the trauma of war seems to be giving it up. There are ancient human behaviors in war—loyalty, inter-reliance, cooperation—that typify good soldiering and can’t be easily found in modern society. This can produce a kind of nostalgia for the hard times that even civilians are susceptible to: after World War II, many Londoners claimed to miss the communal underground living that characterized life during the Blitz (despite the fact that more than 40,000 civilians lost their lives). And the war that is missed doesn’t even have to be a shooting war: “I am a survivor of the AIDS epidemic,” a man wrote on the comment board of an online talk I gave about war. “Now that AIDS is no longer a death sentence, I must admit that I miss those days of extreme brotherhood … which led to deep emotions and understandings that are above anything I have felt since the plague years.”

What all these people seem to miss isn’t danger or loss, per se, but the closeness and cooperation that danger and loss often engender. Humans evolved to survive in extremely harsh environments, and our capacity for cooperation and sharing clearly helped us do that. Structurally, a band of hunter-gatherers and a platoon in combat are almost exactly the same: in each case, the group numbers between 30 and 50 individuals, they sleep in a common area, they conduct patrols, they are completely reliant on one another for support, comfort, and defense, and they share a group identity that most would risk their lives for. Personal interest is subsumed into group interest because personal survival is not possible without group survival. From an evolutionary perspective, it’s not at all surprising that many soldiers respond to combat in positive ways and miss it when it’s gone.

There are obvious psychological stresses on a person in a group, but there may be even greater stresses on a person in isolation. Most higher primates, including humans, are intensely social, and there are few examples of individuals surviving outside of a group. A modern soldier returning from combat goes from the kind of close-knit situation that humans evolved for into a society where most people work outside the home, children are educated by strangers, families are isolated from wider communities, personal gain almost completely eclipses collective good, and people sleep alone or with a partner. Even if he or she is in a family, that is not the same as belonging to a large, self-sufficient group that shares and experiences almost everything collectively. Whatever the technological advances of modern society—and they’re nearly miraculous—the individual lifestyles that those technologies spawn may be deeply brutalizing to the human spirit.

“You’ll have to be prepared to say that we are not a good society—that we are an anti-human society,” anthropologist Sharon Abramowitz warned when I tried this theory out on her. Abramowitz was in Ivory Coast during the start of the civil war there in 2002 and experienced, firsthand, the extremely close bonds created by hardship and danger. “We are not good to each other. Our tribalism is about an extremely narrow group of people: our children, our spouse, maybe our parents. Our society is alienating, technical, cold, and mystifying. Our fundamental desire, as human beings, is to be close to others, and our society does not allow for that.”

This is an old problem, and today’s vets are not the first Americans to balk at coming home. A source of continual embarrassment along the American frontier—from the late 1600s until the end of the Indian Wars, in the 1890s—was a phenomenon known as “the White Indians.” The term referred to white settlers who were kidnapped by Indians—or simply ran off to them—and became so enamored of that life that they refused to leave. According to many writers of the time, including Benjamin Franklin, the reverse never happened: Indians never ran off to join white society. And if a peace treaty required that a tribe give up their adopted members, these members would often have to be put under guard and returned home by force. Inevitably, many would escape to rejoin their Indian families. “Thousands of Europeans are Indians, and we have no examples of even one of those aborigines having from choice become European,” wrote a French-born writer in America named Michel-Guillaume-Saint-Jean de Crèvecoeur in an essay published in 1782.

One could say that combat vets are the White Indians of today, and that they miss the war because it was, finally, an experience of human closeness that they can’t easily find back home. Not the closeness of family, which is rare enough, but the closeness of community and tribe. The kind of closeness that gets endlessly venerated in Hollywood movies but only actually shows up in contemporary society when something goes wrong—when tornados obliterate towns or planes are flown into skyscrapers. Those events briefly give us a reason to act communally, and most of us do. “There is something to be said for using risk to forge social bonds,” Abramowitz pointed out. “Having something to fight for, and fight through, is a good and important thing.”

Certainly, the society we have created is hard on us by virtually every metric that we use to measure human happiness. This problem may disproportionately affect people, like soldiers, who are making a radical transition back home.

It is incredibly hard to measure and quantify the human experience, but some studies have found that many people in certain modern societies self-report high levels of happiness. And yet, numerous cross-cultural studies show that as affluence and urbanization rise in a given society, so do rates of depression, suicide, and schizophrenia (along with health issues such as obesity and diabetes). People in wealthy countries suffer unipolar depression at more than double the rate that they do in poor countries, according to a study by the World Health Organization, and people in countries with large income disparities—like the United States—run a much higher risk of developing mood disorders at some point in their lives. A 2006 cross-cultural study of women focusing on depression and modernization compared depression rates in rural and urban Nigeria and rural and urban North America, and found that women in rural areas of both countries were far less likely to get depressed than urban women. And urban American women—the most affluent demographic of the study—were the most likely to succumb to depression.

In America, the more assimilated a person is into contemporary society, the more likely he or she is to develop depression in his or her lifetime. According to a 2004 study in The**Journal of Nervous and Mental Disease, Mexicans born in the United States are highly assimilated into American culture and have much higher rates of depression than Mexicans born in Mexico. By contrast, Amish communities have an exceedingly low rate of reported depression because, in part, it is theorized, they have completely resisted modernization. They won’t even drive cars. “The economic and marketing forces of modern society have engineered an environment promoting decisions that maximize consumption at the long-term cost of well-being,” one survey of these studies, from the Journal of Affective Disorders in 2012, concluded. “In effect, humans have dragged a body with a long hominid history into an overfed, malnourished, sedentary, sunlight-deficient, sleep-deprived, competitive, inequitable and socially-isolating environment with dire consequences.”

For more than half a million years, our recent hominid ancestors lived nomadic lives of extreme duress on the plains of East Africa, but the advent of agriculture changed that about 10,000 years ago. That is only 400 generations—not enough to adapt, genetically, to the changes in diet and society that ensued. Privately worked land and the accumulation of capital made humans less oriented toward group welfare, and the Industrial Revolution pushed society further in that direction. No one knows how the so-called Information Age will affect us, but there’s a good chance that home technology and the Internet will only intensify our drift toward solipsism and alienation.

Meanwhile, many of the behaviors that had high survival value in our evolutionary past, like problem solving, cooperation, and inter-group competition, are still rewarded by bumps of dopamine and other hormones into our system. Those hormones serve to reinforce whatever behavior it was that produced those hormones in the first place. Group affiliation and cooperation were clearly adaptive because in many animals, including humans, they trigger a surge in levels of a neuropeptide called oxytocin. Not only does oxytocin create a glow of well-being in people, it promotes greater levels of trust and bonding, which unite them further still. Hominids that were rewarded with oxytocin for cooperating with one another must have out-fought, out-hunted, and out-bred the ones that didn’t. Those are the hominids that modern humans are descended from.

Marines help one of their wounded in Afghanistan in 2010.

By Brennan Linsley/AP Images.

According to one study published in Science in June 2010, this feedback loop of oxytocin and group loyalty creates an expectation that members will “self-sacrifice to contribute to in-group welfare.” There may be no better description of a soldier’s ethos than that sentence. One of the most noticeable things about life in the military is that you are virtually never alone: day after day, month after month, you are close enough to speak to, if not touch, a dozen or more people. You eat together, sleep together, laugh together, suffer together. That level of intimacy duplicates our evolutionary past very closely and must create a nearly continual oxytocin reward system.

Hero’s Welcome

When soldiers return to modern society, they must go through—among other adjustments—a terrific oxytocin withdrawal. The chronic isolation of modern society begins in childhood and continues our entire lives. Infants in hunter-gatherer societies are carried by their mothers as much as 50 to 90 percent of the time, often in wraps that keep them strapped to the mother’s back so that her hands are free. That roughly corresponds to carrying rates among other primates, according to primatologist and psychologist Harriet J. Smith. One can get an idea of how desperately important touch is to primates from a landmark experiment conducted in the 1950s by a psychologist and primatologist named Harry Harlow. Baby rhesus monkeys were separated from their mothers and presented with the choice of two kinds of surrogates: a cuddly mother made out of terry cloth or an uninviting mother made out of wire mesh. The wire-mesh mother, however, had a nipple that would dispense warm milk. The babies invariably took their nourishment quickly in order to rush back and cling to the terry-cloth mother, which had enough softness to provide the illusion of affection. But even that isn’t enough for psychological health: in a separate experiment, more than 75 percent of female baby rhesus monkeys raised with terry-cloth mothers—as opposed to real ones—grew up to be abusive and neglectful to their own young.

In the 1970s, American mothers maintained skin-to-skin contact with their nine-month-old babies as little as 16 percent of the time, which is a level of contact that traditional societies would probably consider a form of child abuse. Also unthinkable would be the common practice of making young children sleep by themselves in their own room. In two American studies of middle-class families during the 1980s, 85 percent of young children slept alone—a figure that rose to 95 percent among families considered “well-educated.” Northern European societies, including America, are the only ones in history to make very young children sleep alone in such numbers. The isolation is thought to trigger fears that make many children bond intensely with stuffed animals for reassurance. Only in Northern European societies do children go through the well-known developmental stage of bonding with stuffed animals; elsewhere, children get their sense of safety from the adults sleeping near them.

More broadly, in most human societies, almost nobody sleeps alone. Sleeping in family groups of one sort or another has been the norm throughout human history and is still commonplace in most of the world. Again, Northern European societies are among the few where people sleep alone or with a partner in a private room. When I was with American soldiers at a remote outpost in Afghanistan, we slept in narrow plywood huts where I could reach out and touch three other men from where I slept. They snored, they talked, they got up in the middle of the night to use the piss tubes, but we felt safe because we were in a group. The Taliban attacked the position regularly, and the most determined attacks often came at dawn. Another unit in a nearby valley was almost overrun and took 50 percent casualties in just such an attack. And yet I slept better surrounded by those noisy, snoring men than I ever did camping alone in the woods of New England.

Many soldiers will tell you that one of the hardest things about coming home is learning to sleep without the security of a group of heavily armed men around them. In that sense, being in a war zone with your platoon feels safer than being in an American suburb by yourself. I know a vet who felt so threatened at home that he would get up in the middle of the night to build fighting positions out of the living-room furniture. This is a radically different experience from what warriors in other societies go through, such as the Yanomami, of the Orinoco and Amazon Basins, who go to war with their entire age cohort and return to face, together, whatever the psychological consequences may be. As one anthropologist pointed out to me, trauma is usually a group experience, so trauma recovery should be a group experience as well. But in our society it’s not.

“Our whole approach to mental health has been hijacked by pharmaceutical logic,” I was told by Gary Barker, an anthropologist whose group, Promundo, is dedicated to understanding and preventing violence. “PTSD is a crisis of connection and disruption, not an illness that you carry within you.”

This individualizing of mental health is not just an American problem, or a veteran problem; it affects everybody. A British anthropologist named Bill West told me that the extreme poverty of the 1930s and the collective trauma of the Blitz served to unify an entire generation of English people. “I link the experience of the Blitz to voting in the Labour Party in 1945, and the establishing of the National Health Service and a strong welfare state,” he said. “Those policies were supported well into the 60s by all political parties. That kind of cultural cohesiveness, along with Christianity, was very helpful after the war. It’s an open question whether people’s problems are located in the individual. If enough people in society are sick, you have to wonder whether it isn’t actually society that’s sick.”

Ideally, we would compare hunter-gatherer society to post-industrial society to see which one copes better with PTSD. When the Sioux, Cheyenne, and Arapaho fighters returned to their camps after annihilating Custer and his regiment at Little Bighorn, for example, were they traumatized and alienated by the experience—or did they fit right back into society? There is no way to know for sure, but less direct comparisons can still illuminate how cohesiveness affects trauma. In experiments with lab rats, for example, a subject that is traumatized—but not injured—after an attack by a larger rat usually recovers within 48 hours unless it is kept in isolation, according to data published in 2005 in Neuroscience & Biobehavioral Reviews. The ones that are kept apart from other rats are the only ones that develop long-term traumatic symptoms. And a study of risk factors for PTSD in humans closely mirrored those results. In a 2000 study in the Journal of Consulting and Clinical Psychology, “lack of social support” was found to be around two times more reliable at predicting who got PTSD and who didn’t than the severity of the trauma itself. You could be mildly traumatized, in other words—on a par with, say, an ordinary rear-base deployment to Afghanistan—and experience long-term PTSD simply because of a lack of social support back home.

Anthropologist and psychiatrist Brandon Kohrt found a similar phenomenon in the villages of southern Nepal, where a civil war has been rumbling for years. Kohrt explained to me that there are two kinds of villages there: exclusively Hindu ones, which are extremely stratified, and mixed Buddhist/Hindu ones, which are far more open and cohesive. He said that child soldiers, both male and female, who go back to Hindu villages can remain traumatized for years, while those from mixed-religion villages tended to recover very quickly. “PTSD is a disorder of recovery, and if treatment only focuses on identifying symptoms, it pathologizes and alienates vets,” according to Kohrt. “But if the focus is on family and community, it puts them in a situation of collective healing.”

Israel is arguably the only modern country that retains a sufficient sense of community to mitigate the effects of combat on a mass scale. Despite decades of intermittent war, the Israel Defense Forces have a PTSD rate as low as 1 percent. Two of the foremost reasons have to do with national military service and the proximity of the combat—the war is virtually on their doorstep. “Being in the military is something that most people have done,” I was told by Dr. Arieh Shalev, who has devoted the last 20 years to studying PTSD. “Those who come back from combat are re-integrated into a society where those experiences are very well understood. We did a study of 17-year-olds who had lost their father in the military, compared to those who had lost their fathers to accidents. The ones whose fathers died in combat did much better than those whose fathers hadn’t.”

According to Shalev, the closer the public is to the actual combat, the better the war will be understood and the less difficulty soldiers will have when they come home. The Israelis are benefiting from what could be called the shared public meaning of a war. Such public meaning—which would often occur in more communal, tribal societies—seems to help soldiers even in a fully modern society such as Israel. It is probably not generated by empty, reflexive phrases—such as “Thank you for your service”—that many Americans feel compelled to offer soldiers and vets. If anything, those comments only serve to underline the enormous chasm between military and civilian society in this country.

Veterans share a group hug in Park City, Utah, in July 2008.

By Ed Kashi/VII.

Another Israeli researcher, Reuven Gal, found that the perceived legitimacy of a war was more important to soldiers’ general morale than was the combat readiness of the unit they were in. And that legitimacy, in turn, was a function of the war’s physical distance from the homeland: “The Israeli soldiers who were abruptly mobilized and thrown into dreadful battles in the middle of Yom Kippur Day in 1973 had no doubts about the legitimacy of the war,” Gal wrote in the Journal of Applied Psychology in 1986. “Many of those soldiers who were fighting in the Golan Heights against the flood of Syrian tanks needed only to look behind their shoulders to see their homes and remind themselves that they were fighting for their very survival.”

In that sense, the Israelis are far more like the Sioux, Cheyenne, and Arapaho at Little Bighorn than they are like us. America’s distance from her enemies means that her wars have generally been fought far away from her population centers, and as a result those wars have been harder to explain and justify than Israel’s have been. The people who will bear the psychic cost of that ambiguity will, of course, be the soldiers.

A Bright Shining Lie

‘I talked to my mom only one time from Mars,” a Vietnam vet named Gregory Gomez told me about the physical and spiritual distance between his home and the war zone. Gomez is a pure-blooded Apache who grew up in West Texas. He says his grandfather was arrested and executed by Texas Rangers in 1915 because they wanted his land; they strung him from a tree limb, cut off his genitals, and stuffed them in his mouth. Consequently, Gomez felt no allegiance to the U.S. government, but he volunteered for service in Vietnam anyway. “Most of us Indian guys who went to Vietnam went because we were warriors,” Gomez told me. “I did not fight for this country. I fought for Mother Earth. I wanted to experience combat. I wanted to know how I’d do.”

Gomez was in a Marine Corps Force Recon unit, one of the most elite designations in the U.S. military. He was part of a four-man team that would insert by helicopter into enemy territory north of the DMZ and stay for two weeks at a time. They had no medic and no backup and didn’t even dare eat C rations, because, Gomez said, they were afraid their body odor would give them away. They ate Vietnamese food and watched enemy soldiers pass just yards away in the dense jungle. “Everyone who has lived through something like that has lived through trauma, and you can never go back,” he told me. “You are 17 or 18 or 19 and you just hit that wall. You become very old men.”

American Indians, proportionally, have provided more soldiers to America’s wars than almost any other ethnic group in this country. They are also the product of an ancient and vibrant warring culture that takes great pains to protect the warrior from society, and vice versa. Although those traditions have obviously broken down since the end of the Indian Wars, there may be something to be learned from the principles upon which they stand. When Gomez came home he essentially isolated himself for more than a decade. He didn’t drink, and he lived a normal life except that occasionally he’d go to the corner store to get a soda and would wind up in Oklahoma or East Texas without any idea how he got there.

He finally started seeing a therapist at the V.A. as well as undergoing traditional Indian rituals. It was a combination that seemed to work. In the 1980s, he underwent an extremely painful ceremony called the Sun Dance. At the start of the ceremony, the dancers have wooden skewers driven through the skin of their chests. Leather thongs are tied to the skewers and then attached to the top of a tall pole at the center of the dance ground. To a steady drumbeat, the dancers move in a circle while leaning back on the leather thongs until, after many hours, the skewers finally tear free. “I dance back and I throw my arms and yell and I can see the ropes and the piercing sticks like in slow motion, flying from my chest towards the grandfather’s tree,” Gomez told me about the experience. “And I had this incredible feeling of euphoria and strength, like I could do anything. That’s when the healing takes place. That’s when life changes take place.”

America is a largely de-ritualized society that obviously can’t just borrow from another society to heal its psychic wounds. But the spirit of community healing and empowerment that forms the basis of these ceremonies is certainly one that might be converted to a secular modern society. The shocking disconnect for veterans isn’t so much that civilians don’t know what they went through—it’s unrealistic to expect anyone to fully understand another person’s experience—but that what they went through doesn’t seem relevant back home. Given the profound alienation that afflicts modern society, when combat vets say that they want to go back to war, they may be having an entirely healthy response to the perceived emptiness of modern life.

One way to change this dynamic might be to emulate the Israelis and mandate national service (with a military or combat option). We could also emulate the Nepalese and try to have communities better integrate people of different ethnic and religious groups. Finally, we could emulate many tribal societies—including the Apache—by getting rid of parades and replacing them with some form of homecoming ceremony. An almost universal component of these ceremonies is the dramatic retelling of combat experiences to the warrior’s community. We could achieve that on Veterans Day by making every town and city hall in the country available to veterans who want to speak publicly about the war. The vapid phrase “I support the troops” would then mean actually showing up at your town hall every Veterans Day to hear these people out. Some vets will be angry, some will be proud, and some will be crying so hard they can’t speak. But a community ceremony like that would finally return the experience of war to our entire nation, rather than just leaving it to the people who fought.

It might also begin to re-assemble a society that has been spiritually cannibalizing itself for generations. We keep wondering how to save the vets, but the real question is how to save ourselves. If we do that, the vets will be fine. If we don’t, it won’t matter anyway.

https://www.vanityfair.com/news/2015/05/ptsd-war-home-sebastian-junger

Military women are at the same risk of PTSD as men, study finds


A woman takes part in a training exercise at Marine Corps Base Quantico. (Molly A. Burgess/Courtesy of Veterans Affairs Research Communications)

As high-ranking military chiefs debate allowing women into the front lines of combat, researchers from the Department of Defense and Veterans Affairs are adding new research to the mix: Women warriors are at the same risk of post-traumatic stress disorder as men.

The finding, published in the latest issue of the Journal of Psychiatric Research, offers insight into the long-term mental health effects of military service for women — including experience with combat. The evidence pads the argument in favor of allowing women to join infantry and some elite units of the military, the subject of fierce debate.

The study looked at more than 2,300 pairs of men and woman deployed to Iraq or Afghanistan and matched based on a number of variables — such as combat exposure, age, race, military occupation, marital status and pay grade. The researchers followed the pairs for an average of seven years and found that 6.7 percent of women and 6.1 percent of men developed PTSD.

[How did these two women become the first to complete Army Ranger School?]

The researchers said the difference was not statistically significant and that there wasn’t a difference in severity for those who did develop the disorder.

Previous studies have been a bit of a mixed bag in terms of PTSD rates among military women, but some studies have reported that women are at higher risk of PTSD. That’s commonly been used as an argument against letting women fight alongside male peers on the front lines.

But those studies focus on military populations as a whole, regardless of the individuals’ previous cases of PTSD. Women in the general civilian population are also more likely to suffer interpersonal trauma — such as sexual assault — through people who they’re familiar with.

“We were able to adjust for a number of things that people were unable to adjust for in the past,” said Shira Maguen, an author of the study and a mental health director of the the San Francisco VA Medical Center. “This issue of exposure is extremely important. We’re looking at different types of exposure.”

In this study, researchers only looked at men and women who had no previous indications of PTSD, and found there’s no difference in newly developed cases of the disorder. That’s also why this study is reporting a lower PTSD rate among veterans than earlier estimates, which put the disorder at as high as 20 percent for returning Iraq and Afghanistan veterans.

[As women finish Ranger course, military faces new pressure on gender barriers]

Keeping track of the PTSD is important, as an estimated 2.7 million American veterans of the Iraq and Afghanistan wars are affected by it. The disorder is triggered by traumatic events, with symptoms including flashbacks, nightmares, bouts of anger and severe anxiety. For most people, the symptoms go away over time, but for others, they are a difficult hurdle in living a normal life.

While it can be treated with the use of antidepressant medications and psychotherapy, only half of veterans seek treatment — and of those, only half get “minimally adequate care,” according to a study by  the Rand Corp.

The study came out at a time of heightened interest in women’s future role in the military combat. In early 2013, then-Defense Secretary Leon Panetta rescinded the ban on women in combat, giving the different branches of the military until January 2016 to request exceptions to the new policy.

https://www.washingtonpost.com/news/to-your-health/wp/2015/08/21/military-women-are-at-the-same-risk-of-ptsd-as-men-study-finds/?utm_term=.136526316a55

Women Veterans: Her Own Field of Combat

We met her at an LA Collaborative meeting.  That’s the Los Angeles Veterans Collaborative, a group of community stakeholders, agencies and representatives serving veterans and military families in Greater Los Angeles. Like the NVF’s Women Veteran Outreach Coordinator Leaphy Khim, this woman Is a veteran.  The two of them sat together in an early morning focus group for women veterans. Melanie Brown raised the issue of the scarcity of services for women who were pre-9/11 vets like her.  Many agencies serve post 9/11 veterans only. She was quick to volunteer to put together a list of agencies who work specifically with women veterans. She and Leaphy struck up a conversation that led to more conversations about their experiences as women vets, and the needs of women veterans.

Brown’s experience as a US Army veteran in the years before 9/11 held its own kind of combat. In a war zone, yes, but not what you’re expecting.  This wasn’t the desert or the jungle. This was basic training. Brown made a short, animated documentary about her experience.  Her “Lion in a Box” is available on Vimeo.

Watching it, I remembered the nurses in Vietnam, what they experienced in the field hospitals and also after hours.  How their lives were so different from what they would have been stateside. And I thought of the women vets we see in our outreach.  Mary Ann Mayer, our Women Veteran Outreach Director, says this about them. “Here is the incredible strength of women veteran survivors of MST. These women can get knocked down, and still not break. They inspire me every single day.”

It takes a special kind of woman to want to train for combat.  Melanie Brown is that woman.  It riles her when someone makes the assumption that because she was not in a designated combat zone, she had an easy time of it. Her experience of harassment and unfair treatment is painful to watch, the more so because you know it’s not unusual.  At the risk of repeating myself, here’s from my blog of 8/4 this year:

Forty percent of military women have experienced MST (Military Sexual Trauma) while 67% have experienced sexual harassment. And these figures don’t include unreported cases. Multiple studies show that PTSD from Military Sexual Trauma (MST) is twice as severe as combat PTSD.

The level of reported incidents of MST have risen, but the number of cases actually going to court hasn’t kept pace with the increase of reports. What we (still) have here is a situation where there doesn’t seem to be accountability for actions. Attention is drawn to problems and issues, and that’s all well and good.  That’s the first step. What we need is substantive change.

There are ranking officers in the military justice system who see the need for change.  Likewise in the Senate.  Likewise in the ranks of women veterans who are telling their stories now. Let’s hope it’s just a matter of time, but let’s do keep the pressure on.

If you know a veteran who needs help, here’s our Lifeline for Vets number where they can talk vet-to-vet: 888.777.4443.

https://nvf.org/women-veterans-field-combat/

Wounded Warriors Family Support

Percent of total expenses spent on programs and services: 83%

Not to be confused with the Wounded Warrior Project — which also does fine work, but allocates just 60% of its donations to programs while spending a staggering 34% on fundraising initiatives — Wounded Warriors Family Support lends its assistance to the loved ones of injured veterans.

The publicized version of their job includes family retreats where loved ones can blow off steam, but some of their lesser-known initiatives include a welding program for veterans with the United Auto Workers union and Ford and a caregiver respite program that provides supplemental services for those taking care of wounded veterans. It addresses not only the injured veterans themselves, but the impact their injury has on their family and loved ones. It’s simple recognition that when one person goes off to war, their family isn’t immune to that war’s effects — and needs just as much help getting back to “normal” as veterans do.

https://www.wwfs.org/

The KKK Recruiting Veterans This is the article yesterday’s post was referring.

The Ku Klux Klan (KKK) might sound like a cultural relic, hardly taken seriously in the 21st century, but it is actively recruiting American Veterans. A recent VICE documentary takes an inside jour…

Source: The KKK Recruiting Veterans

The Link Between Traumatic Brain Injury and Combat PTSD

Image result for brain

Unfortunately, many soldiers experience traumatic brain injury when in combat, but is traumatic brain injury (TBI) linked to later combat posttraumatic stress disorder (PTSD)? Two recent studies examined the link between traumatic brain injury and PTSD in marines and army soldiers.

Link Between TBIs and Combat PTSD

In a study published last year, Association Between Traumatic Brain Injury and Risk of Posttraumatic Stress Disorder in Active-Duty Marines1 shows that 19.8% of Marines reported sustaining a deployment-related TBI where most (87.2%) were mild in nature. It was noted that while predeployment PTSD symptoms and severity of combat intensity did predict a higher risk of postdeployment combat PTSD, a better predictor was the experience of a TBI during deployment. Moderate or severe TBIs predicted the presence of PTSD symptoms at three months postdeployment more than mild TBIs did.

What this all means that a TBI during deployment actually predicts the presence of PTSD symptoms better than other known risk factors and that the more severe the TBI, the greater the risk of combat PTSD.

Deployment-Related TBIs and Future Risk of PTSD and Other Mental Illness

Traumatic brain injury (TBI) is common in deployed soldiers but can a TBI increase a person's risk of combat-related posttraumatic stress disorder (PTSD).In the latest study, Prospective Longitudinal Evaluation of the Effect of Deployment-Acquired Traumatic Brain Injury on Posttraumatic Stress and Related Disorders: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)2, 4,645 soldiers who were deployed to Afghanistan were studied and results showed that 18% of soldiers experienced mild TBIs while 1.2% of soldiers experienced more-then-mild TBIs during deployment. Even after taking into account other known risk factors for combat PTSD causes such as pre-deployment mental health, prior TBIs and severity of deployment stress, it was found that:

  • There was a greater risk of posttraumatic stress disorder at the three month and nine month mark.
  • There was a greater risk of generalized anxiety disorder (GAD) at the three month and nine month mark.
  • There was a greater risk of a major depressive episode at the three month mark.
  • Suicide risk may be elevated at the three month mark but the relationship did not reach statistical significance.

This study shows that there is a risk of, not only PTSD for those who have suffered a TBI, but also other mental health issues as well.

The Link Between Traumatic Brain Injuries and Posttraumatic Stress Disorder

While we don’t currently understand why the link between TBIs and PTSD exists, it’s clear that it does. What this, like other studies, suggests is that PTSD is, indeed, a physical illness and not “all in one’s head” like some would have you believe (You Don’t Have A Mental Illness: It’s All In Your Head!). What this means for soldiers is that greater care should be taken in screening for PTSD after a TBI is sustained and, critically, even mild injuries can increase a soldier’s risk of PTSD.

While this may seem like a bleak finding, really it is not. What this finding does is further our understanding of combat PTSD and it allows us to further target risk groups to better treat those in the military as a whole; because, we know that treatment of combat PTSD is possible and we know that people successfully recover from combat PTSD every day.

Article link: https://www.healthyplace.com/blogs/understandingcombatptsd/2015/09/the-link-between-traumatic-brain-injury-and-combat-ptsd/

PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next

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Miriam Reisman

More than a decade of war in the Middle East has pushed post-traumatic stress disorder (PTSD) to the forefront of public health concerns. The last several years have seen a dramatic increase in the number of Iraq and Afghanistan war veterans seeking help for PTSD,1 shining a spotlight on this debilitating condition and raising critical questions about appropriate treatment options and barriers to care.

While PTSD extends far beyond the military—affecting about eight million American adults in a given year2—the problem is especially acute among war veterans. Not only are recent veterans at higher risk of suffering from PTSD than those in the general population,3 they also face unique barriers to accessing adequate treatment.4 These include the requirement that they have either an honorable or general discharge to access Department of Veterans Affairs (VA) medical benefits, long waiting lists at VA medical centers, and the social stigma associated with mental illness within military communities.4,5 According to a study conducted by the RAND Center for Military Health Policy Research, less than half of returning veterans needing mental health services receive any treatment at all, and of those receiving treatment for PTSD and major depression, less than one-third are receiving evidence-based care.5

PTSD in Combat Veterans

The existence of war-induced psychological trauma likely goes back as far as warfare itself, with one of its first mentions by the Greek historian Herodotus. In writing about the Battle of Marathon in 490 b.c., Herodotus described an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier himself had not been wounded.6 Such accounts of psychological symptoms following military trauma are featured in the literature of many early cultures, and it is theorized that ancient soldiers experienced the stresses of war in much the same way as their modern-day counterparts.7

The symptoms and syndrome of PTSD became increasingly evident during the American Civil War (1861–1865).8 Often referred to as the country’s bloodiest conflict, the Civil War saw the first widespread use of rapid-fire rifles, telescopic sights, and other innovations in weaponry that greatly increased destructiveness in battle and left those who survived with a myriad of physical and psychological injuries.

The Civil War also marked the start of formal medical attempts to address the psychological effects of combat on military veterans. Jacob Mendez Da Costa (1833–1900), a cardiologist and assistant surgeon in the U.S. Army, undertook research on “irritable heart” (neurocirculatory asthenia) in soldiers, and during the Civil War, this PTSD-like disorder was referred to as “Da Costa’s syndrome.” 9 Da Costa reported in the American Journal of Medical Science that the disorder, marked by shortness of breath, rapid pulse, and fatigue, is most commonly observed in soldiers during times of stress, especially when fear is involved.9

Over the next century of American warfare, PTSD would be described by many different names and diagnoses, including “shell shock” (World War I), “battle fatigue” (World War II), and “post-Vietnam syndrome.” An estimated 700,000 Vietnam veterans—almost 25% of those who served in the war—have required some form of psychological care for the delayed effects of combat exposure.10 The diagnosis of PTSD was not adopted until the late 1970s, and it became official in 1980 with inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.11

Prevalence of PTSD in Veterans

Estimates of PTSD prevalence rates among returning service members vary widely across wars and eras. In one major study of 60,000 Iraq and Afghanistan veterans, 13.5% of deployed and nondeployed veterans screened positive for PTSD,12 while other studies show the rate to be as high as 20% to 30%.5,13 As many as 500,000 U.S. troops who served in these wars over the past 13 years have been diagnosed with PTSD.14

It is not clear if PTSD is more common in Iraq and Afghanistan veterans than in those of previous conflicts, but the current wars present a unique set of circumstances that contribute heavily to mental health problems. According to Paula P. Schnurr, PhD, Executive Director of the VA National Center for PTSD, the urban-style warfare tactics in Afghanistan and Iraq, marked by guerrilla attacks, roadside improvised explosive devices, and the uncertain distinction between safe zones and battle zones, may trigger more post-traumatic stress in surviving military members than conventional fighting.15

In addition, Dr. Schnurr notes, improvements in protective gear and battlefield medicine have greatly increased survivability—but at a high price. “Between the way we’re protecting the troops and responding to injuries on the ground, a lot of soldiers are surviving with very significant injuries who would not necessarily have survived before,” she says. “And they’re returning stateside with both the physical and psychological trauma.”

Comorbidity of PTSD in Veterans

Complicating the diagnosis and assessment of PTSD in military veterans are the high rates of psychiatric comorbidity.2 Depression is the most common comorbidity of PTSD in veterans. Results from a large national survey show that major depressive disorder (MDD) is nearly three to five times more likely to emerge in those with PTSD than those without PTSD.16 A large meta-analysis composed of 57 studies, across both military and civilian samples, found an MDD and PTSD comorbidity rate of 52%.17

Other common psychiatric comorbidities of PTSD in military veterans include anxiety and substance abuse or dependence.1820 The National Vietnam Veterans Readjustment Study, conducted in the 1980s, found that 74% of Vietnam veterans with PTSD had a comorbid substance use disorder (SUD).21 In one study of recent veterans, 63% of those who met the diagnostic criteria for alcohol use disorders (AUDs) or drug use disorders had co-occurring PTSD, while the PTSD prevalence among those who met criteria for both AUDs and drug use disorders (e.g., alcohol dependence and cocaine abuse) was 76%.22

Studies also suggest that veterans with comorbid PTSD and SUD are more difficult and costly to treat than those with either disorder alone because of poorer social functioning, higher rates of suicide attempts, worse treatment adherence, and less improvement during treatment than those without comorbid PTSD.23,24

PTSD is associated with physical pain symptoms, as well. For veterans returning from Iraq and Afghanistan, chronic pain continues to be one of the most frequently reported symptoms.25,26Approximately 15% to 35% of patients with chronic pain also have PTSD.27

Risk Factors for PTSD in Veterans

A number of factors have been shown to increase the risk of PTSD in the veteran population, including (in some studies) younger age at the time of the trauma, racial minority status, lower socioeconomic status, lower military rank, lower education, higher number of deployments, longer deployments, prior psychological problems, and lack of social support from family, friends, and community (Table 1).28 PTSD is also strongly associated with generalized physical and cognitive health symptoms attributed to mild traumatic brain injury (concussion).29

Table 1

Significant Risk Factors for Combat-Related PTSD in Military Personnel and Veterans28

Female gender has also been implicated as a potential risk factor for PTSD in veterans.28,30 A number of factors may account for these findings, including a history of military or civilian sexual assault, which may increase a woman’s risk for PTSD.31 According to one study, during 2002–2003, approximately 22% of screened female veterans reported military sexual trauma (MST), a term adopted by the VA to refer to sexual assault or repeated threatening sexual harassment that occurred while the veteran was in the military.32

Despite numerous studies, according to Dr. Schnurr, whether PTSD is a greater risk to female veterans than male veterans is still largely unknown. However, she says that as women continue to play more active roles in the wars in Iraq and Afghanistan and are increasingly exposed to combat situations, their likelihood of experiencing PTSD rises.

More research is needed to better understand these and other risk factors for PTSD and to help clinicians and other care providers offer the necessary treatment before symptoms become chronic.28 Several large VA studies are under way that include both psychological and neurobiological measurement, Dr. Schnurr says. She notes the benefit of studying the effects of war-related acute stress in real time, using both pre- and post-deployment assessments, as well as data from military members currently in theater. “These wars have given us the best opportunity to longitudinally track what happens to people and to examine the risk and resilience factors associated with the outcomes,” she adds.

Defining and Redefining PTSD

The VA defines PTSD as “the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury.” 29 In addition to military combat, PTSD can result from the experience or witnessing of a terrorist attack, violent crime and abuse, natural disasters, serious accidents, or violent personal assaults.

In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5),33 moving PTSD from the class of “anxiety disorders” into a new class of “trauma and stressor-related disorders.” As such, all of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. DSM-5 categorizes the symptoms that accompany PTSD into four “clusters”:

  • Intrusion—spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress
  • Avoidance—distressing memories, thoughts, feelings, or external reminders of the event
  • Negative cognitions and mood—myriad feelings including a distorted sense of blame of self or others, persistent negative emotions (e.g., fear, guilt, shame), feelings of detachment or alienation, and constricted affect (e.g., inability to experience positive emotions)
  • Arousal—aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance or related problems.33

PTSD can be either acute or chronic. The symptoms of acute PTSD last for at least one month but less than three months after the traumatic event. In chronic PTSD, symptoms last for more than three months after exposure to trauma.34

PTSD Diagnosis and Assessment

Two main types of measures are used to help diagnose PTSD in veteran populations and assess its severity: structured interviews and self-report questionnaires.34 The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is considered the gold standard for PTSD assessment in both veterans and civilians.35 The detailed 30-item interview has proven useful across a wide variety of settings and takes approximately 30 to 60 minutes to administer.

The well-validated PTSD Checklist for DSM-5 (PCL-5) is one of the most commonly used self-report measures of PTSD.36 Administration of the 20-item questionnaire is required by the VA for veterans being treated for PTSD as part of a national effort to establish PTSD outcome measures. The PCL-5 can be completed in five to seven minutes.36

Another widely used self-report measure for veterans is the Mississippi Scale for Combat-Related PTSD, a 35-item questionnaire in which respondents are asked to rate how they feel about each item using a five-point Likert scale (e.g., “Before I entered the military, I had more close friends than I have now.” [1 = not at all true to 5 = extremely true]).37

Nonpharmacological Treatment Of PTSD in Veterans

The use of psychological interventions is regarded as a first-line approach for PTSD by a range of authoritative sources.3840 Of the wide variety of psychotherapies available, cognitive behavioral therapy (CBT) is considered to have the strongest evidence for reducing the symptoms of PTSD in veterans and has been shown to be more effective than any other nondrug treatment.41

Two of the most studied types of CBT—cognitive processing therapy (CPT) and prolonged exposure (PE) therapy—are recommended as first-line treatments in PTSD practice guidelines around the world, including the guideline jointly issued by the VA and the Department of Defense (DoD).29,3842

First developed to treat the symptoms of PTSD in sexual assault victims,42 CPT focuses on the impact of the trauma. In CPT, the therapist helps the patient identify negative thoughts related to the event, understand how they can cause stress, replace those thoughts, and cope with the upsetting feelings.

PE therapy has been shown to be effective in 60% of veterans with PTSD.43 During the treatment, repeated revisiting of the trauma in a safe, clinical setting helps the patient change how he or she reacts to memories of traumatic experiences, as well as learn how to master fear- and stress-inducing situations moving forward. PE and CPT treatments each take approximately 12 weekly sessions to complete.44,45

EMDR

Once highly controversial, eye-movement desensitization and reprocessing (EMDR) has been gaining acceptance and is now recommended as an effective treatment for PTSD in both civilian and combat-related cases in a wide range of practice guidelines.29,40,46,47 In EMDR, the therapist guides patients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. The general theory behind EMDR is that focusing on other stimuli while revisiting the experience helps the patient reprocess traumatic information until it is no longer psychologically disruptive.

Pharmacotherapy of PTSD in Veterans

Some patients do not respond adequately to nondrug treatment alone, may prefer medications, or may benefit from a combination of medication and psychotherapy. In these cases, pharmacotherapy is also recommended as a first-line approach for PTSD.3840

Selective Serotonin Reuptake Inhibitors

Antidepressants are currently the preferred initial class of medications for PTSD, with the strongest empirical evidence available to support the use of the selective serotonin reuptake inhibitors (SSRIs).48Currently, sertraline and paroxetine are the only drugs approved by the Food and Drug Administration (FDA) for the treatment of PTSD.49

All other medications for PTSD are used off-label and have only empirical support and practice guideline support.49 These include the SSRI fluoxetine and the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine, which are recommended as first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD. Venlafaxine acts primarily as an SSRI at lower dosages and as a combined SNRI at higher dosages.

Although SSRIs are associated with an overall response rate of approximately 60% in patients with PTSD, only 20% to 30% of patients achieve complete remission.50 In a study of extended-release (ER) venlafaxine, the response rate was 78%, and the remission rate was 40% (both assessed with an abbreviated version of CAPS) in patients with PTSD.51 Hyperarousal, however, did not show significant improvement. The ER formulation of venlafaxine is approved for patients with major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder.52

Second-Line Therapies

Second-line therapies for PTSD are less strongly supported by evidence and may have more side effects. They include nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors.5355Prazosin has been found to be effective in randomized clinical trials in decreasing nightmares in PTSD. It blocks the noradrenergic stimulation of the alpha1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time.56,57

Alternative Pathways

Antidepressants have been the central focus of pharmacotherapy research in PTSD, but better treatments are greatly needed. “Right now, the interest is in novel medication development rather than simply relying only on the SSRIs that we have because we only get so far with them,” Dr. Schnurr says.

Researchers are looking closely at the role of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory neurotransmitter glutamate in PTSD. Both GABA and glutamate play a role in encoding fear memories, and therapeutic research targeting these systems may open new avenues of treatment for PTSD. For example, the novel multimodal anti depressant vortioxetine (Trintellix, Takeda) modulates GABA and glutamate neurotransmission.

According to ClinicalTrials.gov, several ongoing studies are investigating the efficacy of vortioxetine and another new multimodal antidepressant, vilazodone (Viibryd, Allergan), in PTSD. Both drugs have been approved by the FDA for the treatment of depression but not for PTSD.

Anticonvulsants or antiepileptic drugs, which affect the balance between glutamate and GABA by acting indirectly to affect these neurons when their neuronal receptor sites are activated, could also provide a useful option in treatment of PTSD symptoms in patients who fail first-line pharmacotherapy. Topiramate, an anticonvulsant used to treat certain types of seizures, has demonstrated promising results in randomized controlled trials with civilians and veterans with PTSD.58 Topiramate is currently listed in the VA/DoD Clinical Practice Guideline for PTSD as having no demonstrated benefit, and further studies are needed regarding the place of this drug in PTSD treatment.59

Clinical research also suggests that smoking cannabis (marijuana) is associated with reduced PTSD symptoms in some patients. One study indicated that PTSD patients reported an average 75% reduction in CAPS symptom scores while using cannabis.60

Although the use of medical marijuana to treat PTSD remains controversial, recent actions by the federal government have brought veterans closer to being able to obtain medical marijuana. In April 2016, the Drug Enforcement Administration approved the first-ever controlled clinical trial to study the effectiveness of cannabis as a treatment for PTSD in military veterans, and in May, Congress voted to lift a federal ban that has prevented veterans’ access to medical marijuana through the VA in states that allow it. Medical marijuana is legal in 23 states and the District of Columbia for the treatment of glaucoma, cancer, human immunodeficiency virus, and other conditions.

Suggested nonpharmacological and pharmacological treatments for PTSD are listed in Table 2.

Table 2

Selected Treatments for PTSD in Veterans

Combined Pharmacotherapy and Psychotherapy

Medications and psychotherapies are used both separately and in combination to treat the symptoms of PTSD, as well as related comorbid diagnoses. Guidelines suggest a combination may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either approach alone.61 For example, studies have shown combined SSRIs and psychotherapy appear to be more effective than treatment with either intervention used alone.62

Reducing Benzodiazepine Use Among Veterans

The VA/DoD Clinical Practice Guideline for PTSD cautions against any use of benzodiazepines to manage core PTSD symptoms because evidence suggests that they are not effective and may even be harmful.29However, despite this guidance, almost one-third of VA patients being treated for PTSD nationally were prescribed benzodiazepines in 2012, says Nancy Bernardy, PhD, Associate Director for Clinical Networking at the VA National Center for PTSD.

According to Dr. Bernardy, the rates of benzodiazepine use among veterans with PTSD are declining, but focused interventions are needed to achieve further reductions. She says the VA is studying the use of an academic detailing approach to share decision support tools around the appropriate use of these drugs.63The initiative targets subgroups of veterans with PTSD in which there are increased rates of benzodiazepine prescription, including those with comorbid substance use disorders and those with comorbid traumatic brain injury. Designed to be used by providers with their patients, the decision support tools incorporate safety concerns related to the targeted subgroups and offer tapering guidance and information on alternative, evidence-based treatments for PTSD.

“It’s taken a while, but we’re beginning to see success,” Dr. Bernardy says of the initiative, adding that the involvement of family members is an integral part of the tapering process. The VA is also looking at other models for increasing engagement in evidence-based PTSD treatment through shared decision-making.

“Shared decision-making has not been used widely,” Dr. Bernardy says. “So we are trying to create a culture where providers meet with patients and discuss PTSD treatment options—the pros and cons of each—and then let patients and family members make the best decisions for their care.”

Treatment-Resistant PTSD

For patients with PTSD who do not respond to initial drug treatment, it may be necessary to explore additional pharmacotherapy options to control their symptoms. A number of pharmacological agents, including antipsychotics, antiadrenergic drugs, and anxiolytics, have also demonstrated some efficacy in treating PTSD.64,65

However, for most pharmacological therapies, there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more clinical studies in this area.66 According to Dr. Schnurr, psychotherapy remains the most effective treatment for PTSD. “Antidepressants may be effective,” she says, “but we see more results—and we also see more durable results—with the psychotherapies because they essentially go to the heart of helping the patient address the problem.”

Economic and Societal Burden of PTSD

The need for better solutions is shown by the immense economic and societal burden of PTSD. First-year treatment alone for Iraq and Afghanistan veterans treated through the VA costs more than $2 billion, or about $8,300 per person.67 Health care costs for veterans with PTSD are 3.5 times higher than costs for those without the disorder.67 According to the VA, PTSD was the third most prevalent disability for veterans receiving compensation in 2012 (572,612 veterans), after hearing loss and tinnitus.68

PTSD and Suicide

Veterans now account for 20% of all suicides in the U.S., with the youngest (18–24 years of age) four times more likely to commit suicide than their nonveteran counterparts of the same age. An estimated 18 to 22 veterans die from suicide each day.69 According to a recent study published in JAMA Psychiatry, the likelihood of suicide increases once a person leaves active military service, and that risk is further increased in veterans whose service time was less than four years.70

The association between PTSD and suicide has been a subject of debate, with some studies showing that PTSD alone is associated with suicidal ideation and behavior,71,72 and others indicating that the higher risk is due to comorbid psychiatric conditions.73

Barriers to Effective PTSD Treatment

Despite efforts to increase access to appropriate mental health care, many military veterans continue to face barriers to getting PTSD treatment. The largest single barrier to timely access to care, according to a VA audit, is the lack of provider appointment availability.74 An acute shortage of doctors in the VA, particularly in primary care, combined with the rising population of veterans seeking treatment, has led to months-long waiting times.75

Poor availability of mental health services in many parts of the U.S. also presents a significant barrier for Iraq and Afghanistan veterans and their families.76 Mental health specialists tend to concentrate in larger urban areas, and even in those areas, there are disparities in the per capita number of psychiatrists. Some rural areas have none.77,78 According to the VA Office of Rural Health, veterans from these areas are less likely than urban veterans to access mental health services, in part because of the greater distances they must travel.79

One of the most frequently cited barriers to veterans getting timely and adequate care for PTSD is the social stigma associated with mental illness.80,81 Research indicates that service members may feel ashamed and embarrassed to seek treatment, perceive mental illness as a sign of a weakness, or feel that it is possible to “tough it out.”81

According to Dr. Schnurr, considerable effort has been made to destigmatize seeking mental health treatment among military veterans. For example, the VA is developing initiatives to enhance collaborative care services that integrate mental and physical health, which is thought to help minimize the stigma associated with PTSD. Additionally, the VA has implemented various outreach initiatives, such as the “About Face” awareness campaign, a series of online videos that introduces viewers to veterans who have experienced PTSD and provides guidance on seeking care.

“It’s a culture change,” Dr. Schnurr says. “By working at both the community level and within the system, we are trying to comprehensively make the changes that will make it easier for veterans to recognize that they need help and then to seek help.”

In an effort to address access to care issues, the VA is focusing on telehealth or the use of tele communications technology to provide behavioral health services to veterans diagnosed with PTSD. Telehealth, which can be both convenient and destigmatizing, has particular potential in rural areas, where a large portion (38%) of VA enrollees diagnosed with PTSD live. A recent study of rural veterans with PTSD showed that receiving psychotherapy and related services via telephone or video conferencing can have positive effects, including the initiation of and adherence to appropriate treatment.82

In another study of rural veterans in VA care, patients who received treatment remotely had greater reductions in PTSD scores at six months and at one year than those who were offered on-site care. According to the researchers, participants in the telemedicine group were much more likely to engage in their own care, a critical component of recovery.82

Community-Based PTSD Care

Research indicates that community-based mental health providers are not well prepared to take care of the special needs of military veterans and their families, including evidence- based treatment of PTSD and depression.83 According to Dr. Schnurr, there has not been sufficient dissemination and implementation of the most effective psychotherapies in community-based settings, such as primary care practices, behavioral health centers, substance-abuse treatment facilities, and hospital trauma centers. To help meet these needs, the VA developed the PTSD Consultation Program for Community Providers (vog.av@tlusnocDSTP), which offers free education, training, information, consultation, and other resources to non-VA health professionals who treat veterans with PTSD.

A number of initiatives across the country provide training and/or treatment support to providers who offer services to veterans with PTSD. The Center for Deployment Psychology, a nationwide network of medical centers, trains military and civilian behavioral health professionals to address the emotional and psychological needs of military personnel and their families through live presentations, online learning resources, ongoing consultation, and education.84 Star Behavioral Health Providers is a resource for veterans, service members, and their families to locate behavioral health professionals with specialized training in understanding and treating military service members and their families.85 The service is currently offered in California, Michigan, New York, Indiana, Ohio, Georgia, and South Carolina.

Challenges and Opportunities Ahead

While many important advancements have been made over the past few decades in understanding and treating symptoms of PTSD, the rising number of American veterans who suffer from the disorder continues to be a serious national public health problem. Cognitive behavioral therapy is a widely accepted method of treatment for PTSD, but there is clearly an urgent need to identify more effective pharmacological approaches for the management of symptoms, as not all patients will respond adequately to psychotherapy or evidence-based/first-line pharmacotherapy. Further understanding of the underlying physiological and neurological processes will be helpful in developing new and effective therapies to treat PTSD.

Research also suggests further opportunities for the VA and other health care systems to develop new and innovative ways to overcome barriers to treating veterans with PTSD. With veterans and their families increasingly seeking care outside of the VA system, community providers play a key role in helping to address these challenges. It is critical they receive the education, training, and tools to improve their understanding of and skills for addressing the needs of this unique population.

Link to article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047000/