Post-traumatic stress disorder in war veterans

PTSD for War Veterans and Families

SOME WOUNDS DO NOT HEAL

PTSD History, Study, Effects and Treatments for War Veterans

Post-traumatic Stress Disorder or PTSD symptoms develop in response to life-threatening trauma, typically among multiply deployed soldiers in war zones, such as Iraq and Afghanistan. Most of them are younger than 25, of lower rank, genetically predisposed and female. Broad categories of symptoms are re-experiencing distress, avoidance and hyperarousal, leading to overall personal malfunctioning and a host of interaction problems with the family and the community. Current treatments include rehab, counseling, medication and a virtual environment world approach. Until enough is known and done about PTSD, the returning war veteran and his family must suffer the condition and all its consequences.

Introduction and History

PTSD or Post-Traumatic Stress Disorder is a form of anxiety, which develops from exposure to, or an experience of, a frightening event or threatening ordeal (National

Institute of Mental Health, 2010). Such events or ordeals include violent personal assaults, disasters, accidents or military combat. PTSD is a new term but it has existed in modern medicine until the American Psychiatric Association classified it in 1980 (More Focus Media Group Inc., 2010). For centuries, people have suffered extreme stress as a result of trauma. But the ironic advancements of modern age have raised stress to a high level, which produced the disorder. Research reveals that bombings, terrorist attacks and other global tragedies conduce to the prevalence. Hence, it characteristically develops in war fighters. Persisting terrifying thoughts and memories of their war trauma recur without warning. They feel emotional numbness, fear, detachment and aggression, especially towards household members, who were once close to them (NIMH). PTSD severely affects not only the afflicted returning war veteran but also his family.

Body

High Rates

Official records in 2007 showed that PTSD cases among returning veterans from Iraq ranged from 12-20% (Roehr, 2007). Of the 1.5 million deployed by this year, more than 52,000 received treatment from the Department of Veterans Affairs. Dr. Evan Kanter informed the 135th annual meeting of the American Public Health Association that a minimum of 300,000 returning soldiers from Iraq develop PTSD. This number costs an estimate of $600 billion in health care, which costs more than the war itself at $500 billion. Dr. Kanter reported that 25% of the first returning 100,000 veterans from Iraq and Afghanistan were diagnosed at the DVA with mental conditions, the most common of which was PTSD. There was underreporting at first as the veterans did not want to delay their return. Moreover, mental health conditions like the PTSD have a delayed and insidious onset (Roehr).

The 17 official PTSD symptoms are broadly categorized into re-experiencing memories and distress, avoidance and hyperarousal (Roeh, 2007). Avoidance takes the form of withdrawal, emotional numbing, detachment, and memory gaps. Hyperarousal is expressed as irritability, anger outbursts, hypervigilance and exaggerated startle and in insomnia and poor concentration. Other features are poor occupational and social function, depression, suicidal ideation, alcohol and drug abuse, guilt, shame, inability to trust, over-controlling, few or no close relationships, extreme isolation, unemployment, divorce, domestic violence and child abuse. Returning veterans are also said to be twice as likely as the general population to die of suicide, according to official records. Dr. Kanter pointed to unprecedented multiple deployments to a combat zone as a risk factor with trauma intensity and duration as predictive factors. Those sent to war at multiple times are sicker and costlier to take care of. More than half a million of them have been deployed twice or more, according to Dr. Kanter. Recovery takes time and depends on limiting exposure to triggers, restoring balance, fulfilling physical and emotional needs and limiting alcohol and stimulants use. Dr. Kanter added that PTSD has very telling effects on families. It causes marital problems and problems on children's personality and behavior, family violence and strong likelihood of generational transmission of violence (Roehr).

Effects of Repeated Deployments

Recent surveys conducted with 2,543 National Guard members deployed to Iraq in

2008 revealed that they were thrice as likely to develop PTSD as those not previously deployed (Kline et al., 2010). Those deployed were also more likely to develop major depression and poorer physical functioning than the general population. The sampled respondents in the survey were 2,995 New Jersey National Guard members undergoing pre-deployment medical assessment for deployment to Iraq in 2008. They had significantly varied demographic and military characteristics. The deployed were older, many of them women and coming from racial or ethnic minorities, better educated and likely to be fully employed (Kline et al.).

The study found that despite comprehensive health screenings by state and federal military authorities, repeated deployments of New Jersey National Guard troops to Iraq may result in medical health impairments (Kline et al., 2010). Furthermore, the Office of the U.S. Army Surgeon General reported that multiple deployments adversely affect work performance during deployment (Kline et al.). These findings support those of the earlier study by Roehr.

Trends and Risk Factors of PTSD and Depression

Using Veterans Affairs data, this study identified these among 29,000 veterans sent to Iraq and Afghanistan and received VA healthcare upon their return between 2002 and 2008 (Seal et al., 2009). These soldiers developed the disorders after deployment to Iraq and Afghanistan 4-7 times higher than at earlier periods. They were younger than 25 years old, female and greater exposure to combat. A substantial increase in mental health diagnoses after the Iraq War and seeking VA healthcare drew apprehensions and called for early intervention to prevent the chronic disorders (Seal et al.).

The prevalence and risk for mental health conditions among Operation Iraq Freedom and Operation Enduring Freedom in Afghanistan veterans increased after the start of the Iraq War in March 2003 (Seal et al., 2009). Reasons behind were decrease in public support and lower morale among the soldiers; unexpected threats to life in the Iraq insurgency for a lack of definable "front-line;" multiple and longer deployments and increased media coverage. Those aged 16-24 and in active duty were at the highest risk for PTSD and alcohol and drug abuse. And these younger soldiers who were at the lower rank had a greater exposure to combat. As to gender, women were likelier to develop depression than men. And the lack of social support or inability to sustain a close relationship may also affect post-deployment mental health problems. Target screening and early intervention into particular subgroups can be the best prevention of chronic mental health and social and occupational disorders (Seal et al.).

Susceptibility

Genetic make-up strongly predisposes certain individuals to PTSD, anxiety and depression (Cassels, 2008). This was the finding of a unique study conducted with 12 multigenerational families by Dr. Armen Goenjian of the University of California Los Angeles Department of Psychiatry and Bio-behavioral Sciences and his team. The 200 respondents experienced the devastating and massive earthquakes in Armenia in 1988. The study found that 41% of them developed PTSD symptoms and 61% depressive symptoms due to genetic factors (Cassells).

Previous to this unique study, the known risk factors for PTSD were female gender, past history and family history of anxiety and exposure to traumatic experiences (Cassells, 2008). Early studies on twins, however, suggested a genetic link between PTSD and anxiety and PTSD and depression. But no research was undertaken to explore the connection because of the difficulty of family studies on PTSD. These studies typically involved single individuals rather than whole families on their exposure to particular traumas. Dr. Goenjian and his team overcame this difficulty. Their respondents were survivors of the earthquakes, which killed 17,000 people and destroyed more than half of the city. Information on their objective and subjective experiences was obtained from every participant. This included the destruction of their homes, deaths of relatives, the sight of dead bodies, getting injured or witnessing the injuries of others. They also expressed fears of earthquakes, getting hurt or dying and the injuries and death of others. They were parents and children, grandparents and grandchildren, siblings and other relatives of families during the quakes. The study found that the genetic makeup of the majority of them rendered them vulnerable to developing PTSD, anxiety and depressive symptoms. Moreover, the team found that the disorders develop from shared genes and not only from environmental factors, such as upbringing. Vulnerability is shared by 3 phenotypes as the more important causes of disease than environmental factors. This puts PTSD, anxiety and depression under one diagnostic category of disorders. The study can help in the identification of the specific, shared genes involved (Cassells).

The Physical and Mental Health Status of Deployed Service Members

The currently involvement of the U.S. military in massive, long-term and complex combat operations around the world requires that its deployed service members be in optimum health conditions in body and mind (Smith et al., 2004). A millennium cohort study conducted with more than 77,000 service members from 2001-2003 as part of a big longitudinal, population-based military health study provided the response to the need. Findings showed that 95% of the respondents' overall health status was slightly higher compared to that of the general U.S. population of the same age and sex. Factors identified with the favorable health status were male gender, married state, higher educational attainment, higher military rank and inclusion in the Air Force service. Lower quality of health was associated with increased use of health care, PTSD, disability, behavioral risk factors and death. The study also found that deployment experiences from 1998-2001 did not reduce favorable health status (Smith et al.).

The findings go against the reported poor health status of returning veterans, especially in Iraq and Afghanistan (Smith et al., 2004). They suggest a mentally and physically healthier military population that the general population. The outcomes of the study will be useful in evaluating health after deployment in a large, population-based military cohort (Smith et al.).

Mild Head Trauma and Chronic Headache

While these complaints are common among service members deployed to Iraq, there was a previous lack of systematic studies into those returning from Iraq (Theeler & Erickson, 2009). This retrospective cohort study of 81 such returning veterans was a response to the lack. It found that 41% of them had a history of head or neck trauma while deployed in Iraq. Others had concussion with or without loss of consciousness and accompanying traumatic neck injury. None of the complaints led to moderate or severe traumatic brain injury. The most common cause was exposure to blasts, 67% of which led to head and neck injuries. Most of the headaches started within a week from trauma and some of them said the headaches made pre-existing headaches worse. The headaches were of the migraine type in 78% of the respondents. This type, the frequency, duration and resulting disability were found to be similar in those with or without a history of head or neck trauma. The headaches were also found similar to non-traumatic headaches reported at a military specialty clinic (Theeler & Erickson).

Fibromyalgia Pain, a Prime Suspect

Fibromyalgia pain is another suspicious condition linked to PTSD. Fibromyalgia

Syndrome or FMS is a chronic pain condition of unknown origin (Staud, 2004). It is characterized by diffuse pain and tenderness for more than 3 months. Most of those stricken are women who complain of insomnia, fatigue and psychological distress. Systemic illnesses sometimes co-occur with FMS, such as polymyalgia rheumatica, rheumatic arthritis, inflammatory myopathies, systemic lupus erythematosus, and joint hypermobility syndrome. Diseases like hepatitis C, Lyme disease, coxsackie B. infection, HIV and parvovirus infection are said trigger FMS. About half of patients say the chronic syndrome starts after a traumatic event (Staud), hence, its connection with PTSD.

Research showed that more than half of all patients with FMS suffer from PTSD in the U.S. And Israel (Staud, 2004). FMS patients presented similarly increased rates to veterans in Vietnam and other war zones. FMS typically occurs after a severe traumatic event and accompanied by behavioral, emotional, function and physiologic symptoms. They relate similar threatening traumatic experiences and emotional responses of horror, helplessness or intense fear. PTSD symptoms include a re-experience of some traumatic event, avoidance and increased arousal. The trauma is associated with increased body and physical complaint, including pain. Research demonstrated that the incidence of FMS increased in 21% of PTSD cases studied and, consequently, also increased distress and functional impairment. Evidence has, however, still to prove that PTSD either causes or brings about FMS. The closest to do this to-date was the evidence provided by prospective studies of adults with neck injuries, which suggested that those with PTSD had a 10 times increased risk of developing FMS within a year from their injury (Staud).

Women as Partner-Victims of Violence in PTSD

An ethnically varied sample of 157 abused women from crisis shelters and the community presented symptoms of intimate partner violence or IPV and symptoms of physical health and PTSD disorder (Woods et al., 2009). These included detailed physical symptoms for which women in intimate abusive relationships sought health care; the connection of the symptoms to IPV and PTSD; and the unique predictors of physical health symptoms. The respondents had an average age of 33+, were in an abusive relationship for more than 5 years and experienced any or all of the four groups of physical health symptoms. These symptoms were grouped into neuromuscular, stress, sleep and gynecologic symptoms. Respondents who experienced more severe IPV reported stronger physical health and PTSD symptoms. These are avoidance and threats of violence or risk of homicide for which 75% of the women sought treatment in the last 6 months. About half of them were African-American and half were white (Woods et al.).

The findings were consistent with the allostasis and allostatic load perspective (Woods et al., 2009). The perspective holds that all types of IPV are associated with greater physical health and PTSD symptoms. The findings support those of previous research on the broad range of symptoms experienced by battered women. The symptoms reported by the present study's respondents were vague and nonspecific. Among these were low back pain, fatigue, muscle weakness, pounding heartbeats, lightheadedness, stomach cramps, and sleep difficulties. The avoidance symptom was the most indicative of PTSD. Those who experience trauma or PTSD are more likely to seek health car in primary care settings (Woods et al.).

Effects on Children

A study conducted with 154 veterans with war-related PTSD found that the disorder asserts a strong and complex influence over the development of their children (Klaric et al., 2008). The influence shows at different ages and can be long-lasting in their children's bio-psychological functioning and personality. It recommended the creation of strategies for preventing and treating traumatized families (Klaric et al.).

A family member with PTSD has a strong chance of negatively influencing other family members and damaging family solidarity and life (Klaric et al., 2008). This is especially likely to children who are the most vulnerable members of the family. Many previous studies have shown that children of combat veterans with PTSD incurred more frequent and serious developmental, behavioral, and emotional problems than those without PTSD. These affected children developed problems with authority, depression, anger, hyperactivity and flaws in personal relationships. They were also more aggressive, used opiate drugs, had learning difficulties and difficulties regulating their own emotions. The study also suggested that direct war experience could reduce the veterans' capacity to function properly as parents and this could lead to the difficulties in the development and behavior of their children (Klaric et al.).

An earlier investigation showed a strong influence of veterans' PTSD in Vietnam, Korea and World War I on their children's developmental problems (Klaric et al., 2008). Researcher believed that children may react to their parents' disturbed emotional states and behavior and develop symptomatic disorders themselves. These reactions may be exaggerated crying, overeating, psycho-physiological instability, hyperactivity or apathy and delayed development. It has also been observed that children react more to parental distress than to real danger. They may also develop a kind of secondary traumatic stress. This makes parental reactions play an important role as model of children's behavior on how to cope with stress (Klaric et al.).

The respondent-veterans in this present study belonged mostly to lower economic status, were unemployed, and chronically ill (Klaric et al., 2008). Chronic illness is another source of difficulty and stress for the whole family. The collective crises deriving from the veteran-father's PTSD negatively influence the development and functioning of his children. A role-model player like the father cannot provide a strong attachment to his children, who need it as a safe emotional base in their delicate development and in coping with stress and distress themselves. The veteran with PTSD is prevented by his unsolved stresses from paying attention to his family members' needs. Hyperarousal destroys trust. His unresolved sadness and fear of another loss prevent him from establishing that needed attachment with his children. Instead, aggression and poor anger management lead to rage, outbursts, anger, hostility and even violence and abuse of children as family members avoid provoking the ailing veteran (Klaric et al.).

Treatments

A six-month follow-up cohort study on the extended use of the hypno-sedative zopiclone filled the need for the lack of such detailed research for combat-related PTSD (Alderman & Gilbert, 2009). Zopiclone is an approach to sleep disturbances. A convenience sample 26 combat veterans with PTSD were asked to use the hypno-sedative for 6 months and subjected to psychometric and sleep assessments. Results showed that, during the follow-up after six months of study, the respondents continued to use zopiclone on a regular basis and for an extended period. Its efficacy in addressing sleep disturbance was low. The study concluded that zopiclone may not increase risk for dependence (Alderman & Gilbert).

The National Center for PTSD follows guidelines in extending care to PTSD

Veterans (Ruzek et al., 2007). These are to connect with the returning veteran, connect him with other returning veterans, provide practical help for his specific problem, and respond to his broad needs as a unique individual. In accomplishing these objectives, the Center provides education on PTSD reactions, trains the PTSD veteran on coping skills, conducts cognitive restructuring and provides family counseling. It extends outpatient treatment, residential rehabilitation treatment, and pharmacotherapy to the veteran and his family. It administers benzodiazepines, anti-allergenics and antidepressants. Recently, it recommends the use of selectrive serotonin reuptake inhibitors or SSRIs. It also encourages the integration of treatment into other existing specialized PTSD services (Ruzek et al.).

Another unique approach to PTSD is the creation of a virtual environment world or VEW to augment traditional psychotherapy, according to the team of health experts behind the concept (Brauser, 2009). VEW simulates everyday tasks, which the veteran with mild PTSD can manage and control with a therapist in a mundane setting. The first concept presented by the experts was the grocery, a common environment, which easily presents multiple but manageable challenges to one with PTSD. In the virtual environment, the veteran and the therapist can confront and overcome obstacles that challenge social reintegration. The therapist can customize the program to adjust specifics pertaining to the veteran, such as the appearance and number of shoppers in the grocery, lightning and noise levels, to fit his requirements. The experts perceived VEW as a great promise and addition to the current care delivery whatever the distance. For her part, Dr. Melissa Kaime, director of the Congressionally Directed Medical Research Program, believed it was very innovative, practical and "exciting stuff," which younger people, comfortable with virtual environments, can relate with and appreciate (Brauser).

Conclusion

Despite the assurance of the findings of a millennium cohort study that military service members are in healthy and healthier than the general population of the same age and sex, superfluous evidence from many other studies shows that a large number of deployed soldiers develop PTSD symptoms, mainly from great exposure to combat. They are frequently younger than 25, of lower rank and deployed more than once to war zones, such as in Iraq and Afghanistan. They exhibit PTSD symptoms upon their return and when seeking treatment. PTSD is believed to be heritable or predisposes a person to it when traumatic stressors trigger the condition. Headaches, head trauma and FMS have also been observed in most returning war veterans with PTSD. Their families reflect the brunt of the disorder in the form of intimate partner violence in women and damaged or stunted personal development in their children. Among the treatments to PTSD are the non-addictive hypno-sedative zopiclone, a set of general guidelines of care by the National Center for PTSD and, recently, a virtual environment world approach. A lot more needs to be uncovered and done to address this disorder more rationally. In the meantime, PTSD severely affects not only the afflicted returning war veteran but also his family. #

ANNOTATED BIBLIOGRAPHY

Alderman, C.P. And a.L. Gilbert (2009). A qualitative investigation of long-term

Zopiclone use and sleep quality among Vietnam War veterans with PTSD

The Annals of Pharmacotherapy . 43 (10): 1576-1582. Retrieved on May 16, 2010

from http://www.medscape.com/viewarticle/710019

The authors address self-reported difficulties of combat veterans with PTSD and their routine use of hypno-sedatives, specifically zopiclone. The study uses a six-month follow-up cohort study, psychometric and sleep assessments on the dependence aspect of the sedative. No detailed research previously addressed the benefits and detriments of the long-term use of zopiclone by war veterans with PTSD nor its limitations in managing insomnia. The qualitative study fills that need in exploring the characteristics of the drug and its usage for the long-term management of sleep disturbances of war veterans stricken with PTSD in a natural setting. It connects with an earlier Australian research on the daily use of minor tranquilizers by 70% of surveyed Vietnam War veterans longer than 6 months. The most commonly used minor tranquilizer for the purpose was nonbenzodiazepine hypnosedative zopiclone. The authors were directors of reputable hospital pharmacy and research centers in South Australia.

Brauser, D. (2009). Virtual environment may help veterans with PTSD/TBI better adjust to civilian life. Medscape Medical News. Retrieved on May 16, 2010 from http://www.medscape.com/viewarticle/708531

Lead investigator Dr. Charles Levy and his expert team of physicians, nurses, therapists, digital articles and computer engineering specialists created a virtual world environment or VWE to help veterans with mild PTSD and traumatic brain injury cope with the stresses of everyday civilian life. Attention and memory deficits, impaired cognitive processing, anxiety, impulsiveness, emotional outbursts and uneasiness in crowds are among the symptoms of PTSD. Traditional psychotherapy requires repeat clinic visits difficult for many returning veterans. Dr. Levy and his team offered an intuitive and accessible proof-of-concept prototype as a response to this problem. They applied the concept to a typical grocery setting where the veterans and therapists can log in from various locations and interact as avatars. This acclimatizes veterans to daily tasks, confront and overcome barriers to social reintegration virtually at first. Captain E. Melissa Kaime of the Congressionally

Directed Medical Research Programs thinks it is exciting stuff.

Cassels, C. (2008). Susceptibility of PTSD, anxiety, depression hereditary. Medscape Medical News, 18: 261-266. Retrieved on May 19, 2010 from http://www.medscape.com/viewarticle/585791

Dr. Armen Goenjian of the UCLA Department of Psychiatry and Bio-behavioral Sciences offers a new insight into PTSD, anxiety and depression as heritable or developing more from genetic predisposition than environmental factors. The traditionally known risk factors were mainly female gender, past or family history of anxiety, and exposure to severe traumatic experiences. No previous studies assessed the genetic heritability of PTSD because it afflicts only individuals, not families, at a time. Dr. Goenjian, however, manages to fill this gap and need with a unique study of multigenerational families exposed to a disastrous earthquake in Armenia in 1988. The findings yield valuable and authoritative evidence on the heritability of PTSD symptoms. Anxiety and depression are as heritable as PTSD, based on shared phenotypes, the study adds. It then suggests that those who develop PTSD already possess a genetic predisposition to it and their exposure to severe trauma merely triggers it.

Klaric, M., et al. (2008). Psychological problems in children of war veterans with Post-traumatic Stress Disorder in Bosnia and Herzegovina: a cross-sectional study.

Croatian Medical Journal 49(4): 491-8. doi:10.3325/cmj2008.4.491. Retrieved on May 19, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2525831

The author-researchers of the cross-sectional study explore into the psychological problems veteran fathers with PTSD confront with their children as compared with veteran fathers without PTSD. Respondents are war veterans and their children in Bosnia and Herzegovia. Existing data reveal that children of combat veterans with PTSD more frequently develop authority problems, depression, anger, hyperactivity and failed personal relationships than children of veteran fathers without PTSD. They also frequently use opiate drugs, are poor learners and have poor emotional control. The authors use reliable general demographic data and data on the social and economic status of the respondents, specifically structured to arrive at the purpose of the study. Valuable results emphasize the damaging effect of PTSD not only on family unity but also on the overall development of children. Re-experiencing war trauma steals the veteran's attention from his family and produces far-reaching conflicts in his children's personality development and future.

Kline, a. et al. (2010). Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey army national guard troops: implications for military readiness.

American Journal of Public Health, 100 (2): 276-283. Retrieved on May 16, 2010 from http://www.medscape.com/viewarticle/716548

Assessing military readiness is the objective of pre-deployment surveys among National Guard members deployed in Iraq in 2008. Almost 25% were deployed more than thrice and developed PTSD. The Office of the U.S. Army Surgeon General itself reported 11.9% with PTSD. National Guard members manifested greater vulnerability than active-duty troops at a mental health risk at 6 months after deployment. Modern warfare demands repeated deployments and 38% of soldiers have been deployed more than once to Iraq since 2003. Most existing studies focus on post-deployment fitness conditions. Kline and her team examine pre-deployment health status. No clear standard for a medically fit fight force has been set. Functionality is viewed as a preferred criterion to a diagnostic assessment. The responsibility for identifying medically unfit soldiers rests in the PDHA-PDHRA. But the recent increase in health problems among previously Guard members questions the effectiveness of these agencies in performing their task.

Roehr, B. (2007). High rate of PTSD in returning Iraq war veterans. 135th Annual

Meeting and Exposition. Medscape Medical News. Retrieved on May 16, 2010 from http://www.medscape.com/viewarticle/565407

Staff psychiatrist Evan Kanter of the PTSD Outpatient Clinic of the VA Puget Sound Health Care System informs the 135th Annual Meeting of the American Public Health Association that a minimum of 300,000 of veterans deployed to Iraq are psychiatric casualties. They incur a lifetime cost of $660 billion, greater than that of the war itself. PTSD is among the most common diagnoses. Upon their return, only a few veterans presented mental health problems only to increase 4-7 times when re-assessed 3-6 months later. Cases are under-reported and the onset of PTSD symptoms is delayed. Dr. Kanter also notes the highest incidence of suicide in 26 years on record, increased cost in caring for these veterans who get sicker with each deployment and the adverse effects on their families. That recovery takes time is another emphasis of value to everyone involved and in constant touch with returning veterans with PTSD.