PTSD: What You Need to Know

As the wars in Iraq and Afghanistan wear on, hundreds of thousands of veterans are at significant risk for a particularly distressing and impairing mental health syndrome: Posttraumatic Stress Disorder. First documented in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in 1980, PTSD becomes a serious risk when a service member experiences, witnesses, or is confronted with an event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others -- welcome to any day in the Global War of Terror.



What does PTSD look like? As members of the military community, each of us should be alert to the following key symptoms among the combat veterans we care for:

• Recurrent and intrusive distressing recollections of the event, including images, thoughts and perceptions (seeing a comrade's dead body or experiencing flashbacks of the sounds of explosions and screaming)
• Recurrent and distressing nightmares of the traumatic event
• Intense psychological distress when exposed to cues or reminders of any aspect of the trauma
• Extreme physical reactivity (e.g., racing pulse, sweating, intense fear) when exposed to any cues or reminders of the trauma
• Persistent avoidance of any reminder (e.g., conversations, thoughts, activities, places, and people) of the traumatic event
• A general numbing in responsiveness; the person feels detached and estranged from others and may have little range in emotion and few strong feelings
• A sense of a foreshortened future; having come close to death, the person sees it as immanent
• Hypervigilance (constantly scanning the environment for danger)
• Exaggerated startle response (especially to sudden movement or loud noises)
• Poor concentration
• Irritability/anger
• Disturbances in one's ability to sleep

Keep in mind that not all of the symptoms will be present in every case, and veterans may mask the symptoms through nondisclosure or self-medication with alcohol and other drugs. Further, some service personnel are at greater risk for developing PTSD than others. Beyond the severity of the traumatic event itself, key risk factors include poor social support after the trauma, additional life stressors, adverse childhood events, lower education, prior traumatic exposure, and gender -- women are at greater risk. One particularly malignant feature of PTSD is a sense of shame or guilt associated with beliefs that one should have or could have done more during the traumatic period. If comrades died, then survivor guilt can add powerful fuel to PTSD fire.

Psychiatric prevalence studies from the Iraq theatre are only now beginning to reveal the extent of the problem. A landmark study published last year in the New England Journal of Medicine revealed that approximately 16% of those returning from Iraq suffered from mental health problems, the most prominent among them being PTSD. Other common psychiatric outcomes include depression, substance abuse, marital discord, and impulsive anger. Among veterans, prevalence is directly proportional to exposure to combat. In the New England Journal Study, those without exposure to a firefight had only a 4% probability of a PTSD syndrome -- about what we find in the general population. But after one firefight, the rate rose to 9.3%. It then jumped to 20% for veterans who endured five or more combat episodes.

Yet these rates may actually understate the scope of the PTSD problem among American vets. Army Surgeon General, LT. General Kevin Kiley, reported last month that among 1000 Army soldiers surveyed three to four months after returning from Iraq, a full 30% had developed stress-related mental health problems. This is not surprising in light of the fact that PTSD sometimes manifests itself only months, sometimes even years, after the traumatic event. Called “delayed onset” PTSD, this sleeper version of the disorder makes accurate diagnoses at discharge a serious challenge to mental health providers. What's worse, service members often refuse to disclose disturbing symptoms common of PTSD, either due to distrust of the mental health establishment or because they are embarrassed to seek help.

PTSD seems to be triggered both by the traumatic event, and the person's response to it -- intense fear, hopelessness, and horror, and make no mistake, all human beings react with horror given the right traumatic situation. Various strands of medical research suggest that the intense bursts of brain activity during traumatic experiences may actually lay down new neural pathways in the brain -- the prime culprits when it comes to the recurring symptoms of PTSD and the substantial difficulty finding a genuine cure. Although PTSD occurs following violent personal assault, terrorist attacks, and natural disasters, combat-related PTSD accounts for the lion's share of cases among younger service-age populations.

When it comes to helping veterans with PTSD, the U. S. Veterans Affairs Health Care system will be left holding the bag. Is the V.A. system ready? Not surprisingly, that depends on whom you ask. Although the VA insists it is ready for the challenge, the House Committee on Veterans Affairs has expressed strong concern about the VA's capacity to manage the sheer volume of PTSD cases returning from the Middle East. At a congressional briefing hosted by the American Psychological Association last spring, representatives Ted Strickland (D-Ohio), Brian Baird (D-Washington), and Rob Simmons, (R-Connecticut) urged a room full of congressional staffers to more actively push for funds allocated directly to PTSD programs within the VA. In July, Veterans Affairs Committee Chairman Steve Buyer (R-Indiana) expressed frustration with the VA's apparent inability to accurately predict how much funding it actually needs to tackle the PTSD problem among returning vets.

In fairness to the VA system, treatment for PTSD runs the gamut from short-term intervention to long-term therapies punctuated by inpatient hospitalizations. At times, psychotropic medications help assuage the worst symptoms. Because different U.S. conflicts have produced different prevalence rates and manifestations of the disorder, it may take years before the VA has an accurate read on the scope and nature of Iraq and Afghanistan related PTSD.

Those of us fortunate enough to work with, love, or provide medical care for combat veterans must be alert to the signs of this insidious disorder. Service members suffering the symptoms of PTSD need to understand them as part of a medical syndrome and know that appropriate treatments are quite likely to significantly reduce symptom intensity.