Post-traumatic stress disorder in combat veterans returning from Iraq and Afghanistan

PTSD

WHEN the PAST DOESN'T DIE

Post-Traumatic Stress Disorder

Introduction number of studies and other researches have yielded findings that many or most combat or war veterans who return home from the battlefield develop Post-traumatic Stress Disorder or PTSD. The disorder consists in reliving the memories of war, which a veteran re-enacts. Because of the nature of warfare and the veteran's own indoctrination to aggression, he also develops aggressive or violent behavior towards the members of his household and even outsiders at uncertain moments or episodes.

Military troops, due to militaries' lack of infrastructure, are at risk of having long-term psychological and social effects of PTSD.

Review of Literature

Doyle, L. (2007). Suicide Rates in U.S. Army Highest in 26 Years. The (London) Independent: Independent Newspapers UK Limited

Doyle writes about a military report on the rate of suicides among American soldiers fighting in Iraq and Afghanistan as reaching its highest in 26 years. Many of these soldiers were said to have exhibited symptoms of post-traumatic stress disorder or PTSD, specifically repeated flashbacks of combat experiences. They belonged to an "overstretched" U.S. Army, which was sent back to action more than in the past. According to the report, there were 99 confirmed suicides for 2006 as compared to 88 the year before it and 102 in 1991. Of this number, 28 were sent to Iraq and Afghanistan and twice as many were women sent to fight in the wars as those not sent. Causes were identified as "occupational" or "operational," destroyed relationships, legal and financial.

Army statistics showed 17.3 suicides per 100,000 soldiers in 2006. Thirty of the 99 confirmed were in war zones. More than 1.5 million U.S. troops have fought in Iraq and Afghanistan since 2001. There have been complaints from them about being "overstretched." A series of studies preceded these suicides, which showed an increase in mental health problems among them. The studies found a lack of adequate mental-health provision for the soldiers. Approximately 35% of them sought some type of mental-health treatment a year from their return home. The Army sent medical teams to them while at war to monitor their health, morale and related conditions. But returning soldiers were deprived of proper or adequate families. The Army, however, said they provided training programs, especially on suicide prevention, and added 25% more psychiatrist and other mental-health professionals to its ranks. It also said that it taught all soldiers how to recognize mental-health problems among themselves and to seek help when these occurred.

Elia, L. (2007). Staunching Veterans' Unseen Wound: Post-Traumatic Stress Disorder. Market Wire. Retrieved March 29, 2008 at http://findarticles.com/p/articles/pwwi/ls_200711/ai_n21097808

The author notes the findings of a 2004 study published at the England Journal of Medicine about 15-17% of returning soldiers from Iraq as likely to develop PTSD. The Department of Veterans Affairs had said that 25% of soldiers fighting in Afghanistan and Iraq were diagnosed as suffering from PTSD and other mental-health problems. It also said that these afflicted veterans seeking treatment increased by 70% within a year from June 30. The Veterans Administration likewise acknowledged almost 50,000 PTSD cases in the military personnel. Washington acknowledged only 30,000 wounded.

Elia emphasizes mental health as the second largest category of illness for U.S. veterans who fought in Iraq and Afghanistan and sought treatment. It is second only to orthopedic problems, but has been increasing at a faster rate than orthopedic cases. These cases occur just when the Veterans Affairs Department has been incurring budget shortage.

Yen, H. (2007). Repeated Deployments Called Serious Mental Health Risks. Deseret News (Salt Lake City): Deseret News Publishing Company

The Defense Department's Task Force on Mental Health said that repeated deployments of troops to Iraq and Afghanistan increased their risk of developing mental health problems. It reported that more than a third of these troops and veterans were already diagnosed with traumatic brain injury and post-traumatic stress disorder. With current shortages in money for health care and staffing and the escalating war in Iraq, these affected soldiers would tend to increase in number. It also said that the current system for psychological health care would not be able to meet the current and increasing needs.

The Task Force sought more money and a radical shift in the focus of treatment to prevention and screening from waiting for afflicted soldiers to voluntarily seek treatment. Soldiers were not too encouraged to come out on their own. They were subjected to ridicule or else their entire career would suffer if they admitted they had PTSD.

The Task Force found that 38% of soldiers and 31% of marines suffered from psychological problems, such as traumatic brain injury and post-traumatic stress disorder, after they returned from the fight. The incidence was much higher in the National Guard at 49%. Repeated deployments would raise the figure higher. Furthermore, the Task Force discovered from its visits at 38 military bases that most of these soldiers would not even seek the care and treatment they needed. Soldiers who have returned from battle did not have the provision. Mental-health programs have been limited to active-duty military personnel. Members of the family were excluded and forced to look for civilian health care providers, which were also few, inappropriate and small. The Government Accountability Office recently found that only 22% of returning troops from Iraq and Afghanistan, who showed symptoms of PTSD, were referred by Pentagon health care providers for mental health assessment.

Business Editors (2007). Therapy Battles War-Related Mental Health Conditions.. Business Wire: Gale Group

Families of soldiers returning from active duty have been struggling against the side effects of war at an alarming rate. They need not wait for their turn at military mental-health systems. They could consult with mental-health experts for their war-related mental-health conditions, such as PTSD. The National Center for PTSD initially estimated that 18% of those fighting in Iraq and 11% in Afghanistan would develop PTSD. Their families could help by recognizing and understanding the symptoms of the disorder. These are flashbacks or reliving traumatic events at war, nightmares, sleep disturbances, anger and irritability, fear and anxiety, shame or guilt, suicidal thoughts, great and deep sadness and grief, relationship problems, and extreme alcohol or drug use.

Psychotherapy can help the veterans. There are treatment programs, which can alleviate these symptoms. Marriage and family therapists can assess, diagnose and treat these sufferers.

Speckman, S. (2006). Program Aims to Help Vets "Reintegrate.." Deseret

Statement of the Problem

Dire experiences in the battlefield create wounds and disturbing memories, which a returning war veteran brings back home with him. Many of these memories remain unresolved and recur as torments to the veteran. Studies show that symptoms of PTSD usually begin three months after the trauma. From their onset, these symptoms may present themselves for six months or longer. Some of these symptoms become chronic or remain untreated. In most cases of PTSD, the veteran relives and re-enacts the horror of their war experience in the form of domestic violence. This paper intends to draw evidence from previous studies on the relationship between PTSD and domestic violence.

Method and Research Instruments

This paper uses the descriptive and normative method of research in recording, describing, interpreting, analyzing and comparing the data gathered from four previous studies on PTSD and domestic violence. These previous studies utilized interviews of inpatients with severe mental illness, surveys and an analysis of violent behavior in 116 combat veterans..

Discussion and Conclusion

PTSD can grow out of a traumatic experience, such as military combat (American Family Physician 2003). Not every soldier develops it but when he does, he can feel quite alone or guilty about surviving while others did not. The experience can continue for months or years. A doctor can detect PTSD through a consulting patient's symptoms, such as nightmares, flashbacks and painful memories. The event is obsessive and produces fear and panic with each recall. The recall may also be accompanied by an upset stomach or a headache. He avoids thoughts, feelings, persons or places associated with the event. He finds sleep difficult. He is often angry, irritable and unable to pay attention or concentrate. PTSD is treated with medicines for depression or anxiety, consulting with a mental health professional and following doctor's instructions regarding taking medications. Treatment takes long but symptoms are expected to disappear when instructions are followed completely and consistently. These instructions include details on sleep, eating before sleep, exercise and a balanced diet (American Family Physician)..

Post-traumatic Stress Disorder is common among war veterans returning home from the battlefield and bringing these painful memories. Among the most troubling symptoms are flashbacks, often triggered by sounds, smells, feelings or images (Turkington 1999). Through these, the veteran relives the entire experience and completely loses touch with current reality. He goes through it again for minutes or even hours, believing that it is happening all over again. In addition to flashbacks, his "intrusive" symptoms can include sleep disorders, nightmares, and intense distress. "Avoidance" symptoms include avoiding the feeling, inability to remember the event, inability to experience the emotion and a sense of a shortened future. He also experiences increased arousal, sleeping problems, hyper-alertness, memory and concentration problems, moodiness, and - violence. Children with PTSD often develop learning disabilities and memory or attention problems. They become more dependent, anxious or self-abusive. Treatment deemed most helpful for PTSD consists of medication combined with supportive and cognitive-behavioral therapies. Medications can include anxiety-reducing medications and antidepressants, like fluoxetine. Sleep problems can be managed with anti-anxiety drugs, such as alprazolam, although their long-term use can develop adverse side effects, such as increased anger. Support and cognitive behavioral therapy will aim at reducing negative thought patterns and self-talk, change specific actions and thoughts through relaxation training and breathing techniques. Effectiveness of the treatment depends on the extent of the trauma and the person's personality and genetic make-up. Records show that sufferers who received appropriate medication, emotional support, and counseling achieved a significant level of improvement. However, prolonged exposure to severe, such as sexual abuse or other trauma, can leave permanent psychological scars (Turkington).

2004 study published in the England Journal of Medicine found that 15-17% of returning soldiers from Iraq were likely to develop PTSD (Elia 2007). Their number increased 70% within a year. The Veterans Administration acknowledged that there were almost 50,000 of such cases as against Washington's recognition of only 30,000 wounded soldiers in Iraq. Mental health was the second largest category of illness for these veterans and growing at a faster rate than the first largest category of orthopedic illnesses. This happened when the VA was encountering fund shortage (Elia).

A convincingly significant occurrence of aggression was observed among combat veterans with PTSD in comparison with those without PTSD (Begic 2001). Violent behavior has often been observed in war victims. Their educational level, low socio-economic status, maltreatment experience in childhood and previous types of violent behavior are factors to its development. Studies show that the lower the educational level or intelligence quotient, the greater the frequency of PTSD symptoms. Those who were exposed to previous mistreatment also tended to develop symptoms of PTSD, among them aggression or violence. It was often in the form of sexual or physical mistreatment in childhood. An investigation revealed that 26% of those with PTSD were previously subjected to mistreatment, as compared to only 10.8% without such previous mistreatment. The intensity of aggressive and other PTSD symptoms depends on the nature and extent of previous traumas. But violent behavior is the most frequent symptom of combat veterans with PTSD at almost 7 times more often than with veterans without PTSD. It is the most frequent reason for seeking help. Studies found that 37.1% of veterans consulted a psychiatrist for aggressive behavior on their own, by the police or upon the persuasion of a close person. In more than half of the studies veterans, violent behavior started more than a year after the veterans' return from war (Begic).

Other veterans entertained thoughts of suicide by an overdose of tablets, taking alcohol and pills, cutting their forearm veins or jumping from a high place (Begic 2001). The thought of suicide lodged in them for as long as a month to 8 months. The thought was often a result of a quarrel with their spouse, divorce, difficult economic situation, the suicide of someone they knew, and some other extreme difficulty. If he takes it out on others, he engages most frequently on hetero-aggression in the form of verbal, physical, sexual, traffic and aggression with the use of weapons. The aggression is either verbal or physical or both. Verbal aggression can be in the form of shouting or yelling, triggered during a conversation with known or unknown people. Physical aggression involves the use of physical force on living beings or objects, often under the influence of alcohol. Both types of aggression are repeatable. Among their consequences are light physical injuries, scratches, contusions, and hematomas. Certain issues accompany the physical aggression displayed by returning war veterans with PTSD. These are the legal regulations and sanctions for such a behavior; the frequent wish of the assailant to hide his act; and the victim does not report the incident promptly. The most frequent victims of these veterans' violence or aggression are the former or current spouse, a young child or an unknown person at 90% of those studied (Begic 2001). In most cases, the aggression was done repeatedly and aimed at the victim or victims of the first attack. The attack could be towards an animal or an object. Sexual aggression was another form. The veteran could display this form of aggression on his wife. He can be extremely demanding or promiscuous. Other forms of aggression were fast driving, disregarding traffic rules, signs and signals and driving under the influence of liquor (Begic).

A study was conducted on 62 male participants of a domestic violence program meant to keep them active within the program (Gerlock 2004). The purpose was to discover how PTSD related to the severity of domestic violence. The participants were mainly Caucasian, aged 20-62. Those who completed the program were younger than 35 with higher self-ratings of relationship mutuality, less stress and post-traumatic stress and were regularly court-monitored. The non-completers, on the other hand, had higher risks of repeated domestic violence than completers. Non-completers preferred shorter programs as longer ones required more travel time from their work. As a consequence, 2/3 of them dropped from the program. The study found that a child who witnessed domestic violence was more prone to PTSD and to severe and frequent domestic violence as an adult. The connection between higher PTSD levels, domestic abuses and their failure to complete the program was the chief concern of the study.

A female partner is a woman who is currently involved in a long-term ongoing adult relationship with a war veteran (Nelson 1996), particularly one with PTSD. The female partners of war veterans with PTSD who exhibit domestic violence may have different symptoms and circumstances, but there are also many, which they hold in common. They share common roles, which are caretaking, gender roles, survivor skills and psychological symptoms. The household of a typical violent or aggressive returning war veteran with PTSD is disorderly. The uncertainty prevailing among the members of that household triggers the veteran's PTSD symptoms. He is often convinced that he is helpless to these symptoms and their effects and the family members feel the blame for the flare-up. The four specific areas of interpersonal problems within the households, relating to PTSD, are coping with the veteran's PTSD symptoms, the female partner's unmet needs, violence, and emotional abuse. In a war, a veteran learns that expressing feelings other than hostility and aggression is a weakness and costs lives. He learns how to cope and survive combat through anger. This is why he uses it when he feels helpless and weak. This is why the frequency of expressions of hostility and physical aggression is greater in those experiencing PTSD than in those not experiencing it. This conclusion may explain the commonly hostile or angry emotional climate of many PTSD veterans' family systems (Nelson).

Violence occurs in this home setting not only when the veteran is angry (Nelson 1996). This is very unsettling to the female partner who feels uncertain about when the violent outburst will occur. It can be with a flashback or a nightmare. During a flashback, the veteran is not aware of his actions or towards whom he is direction these actions. These actions are "dissociative" states, lasting from an hour to several hours or days, during which the veteran relives the events and behaves as though the event were reoccurring at that moment. Many female partners have reported getting hit by these veterans while experiencing a nightmare of this kind. Hence, their overwhelming anxiety that others or events beyond their control influence their lives (Nelson).

Another study on 133 male veterans with combat-related PTSD at a psychiatric inpatient unit revealed that 90^ of them were victims of abuse or assault themselves as children and as adults (Lapp et al. 2005). The abuses were physical, mental or sexual. Almost all of them were exposed to combat (Lapp et al.).

A study conducted by the National Institute of Mental Health Diagnostic found that psychiatric disorders were common among 8 million Vietnam War veterans from 1965-75 (Eisen 2004). These disorders were mainly alcohol abuse or dependence and smoking. The finding called the attention of the authorities to confront the illness among the veterans (Eisen).

Another study showed that most soldiers suffering from PTSD also suffered from co-morbid conditions, such as psychiatric disorders (Kozavic-Kovacic 2005). Many of them displayed psychotic symptoms other than flashbacks and dissociative reactions. Furthermore, personality disorders predisposed them to developing PTSD. Alcohol dependence was a risk factor common in them. These psychotic symptoms differ from flashbacks and strongly link to the trauma. They also provide evidence to the existence of complex PTSD, which has to do with changes in affect regulation, consciousness, self-perception, the offender, relationships, and one's set of meanings (Kozavic-Kovacic).

The Defense Department Task Force on Mental Health said that most of the returning soldiers and marines developed psychological problems like PTSD on their return after repeated deployments to Iraq and Afghanistan (Yen 2007). Most of them would not even seek care and treatment for their condition. Provisions for mental health were said to be wanting (Yen).

An increase in the number of returning soldiers with mental health was observed (Leider 2004). These mental health problems were minor depression, difficulty of re-integrating into society, and performing day-to-day tasks and PTSD. Some wives would have become independent, unfaithful or the soldier had become a stranger in his own home (Leider).

The rates of suicide among American soldiers returning from Iraq and Afghanistan were highest in 26 years (Doyle 2007). Most of them showed PTSD symptoms. They belonged to an "overstretch" U.S. Army, repeatedly deployed in those countries. Causes of the suicides were "occupational," "operational" affective, legal and financial in nature. It was also found that mental health programs for these returnees were lacking (Doyle).

The National Center for PTSD asked the families of these soldiers to help by recognizing and understanding the characteristic symptoms of the ailment (Business Editors 2007). These are flashbacks or reliving traumatic events at war, nightmares, sleep disturbances, anger and irritability, fear and anxiety, shame or guilt, suicidal thoughts, great and deep sadness and grief, relationship problems, and extreme alcohol or drug use. The family could also secure psychotherapy to alleviate the symptoms and seek the help of marriage and family therapists (Business Editors).

Another study disclosed that present informal peer debriefings before deployments had limited effects (MacDonald 2003). This suggested that better results could be obtained by trained peers who had the same experiences. At the same time, the recipients could feel more comfortable with insider-colleagues than with outsiders. It was also suggested that debriefings should be conducted after several incidents. CISD was not too effective in reducing PTSD in military cases (MacDonald).

HB 407 was passed by Utah legislators to help returning soldiers from Iraq and Afghanistan to "re-integrate" into civilian and family life (Speckman 2006). The State's Veterans Affairs division wanted them to know that they were not alone in their problem. These 161,000 veterans could acquire benefits and services due them like family counseling. A State contribution of $210,000 was given to fund an internet initiative and radio spots to provide the information and counseling costs (Speckman).

For its part, the Pentagon spent $4 million for virtual reality video games to help treat these soldiers traumatized by the effects of battle (Buncombe 2005). Through these games, military doctors could detect and measure the soldiers' reaction to combat situations through their heartbeat, blood pressure, rate of breathing and skin temperature. These presentations were accompanied by sounds of helicopters, sniper fire and mortars. Through these, the doctors could better diagnose PTSD and come up with better treatment. The soldiers could also monitor their own reactions and gain greater control over their own behavior in certain situations (Buncombe).

In conclusion, PTSD can develop from traumatic experiences, such as combat. Common symptoms are flashbacks, nightmares and battle fatigue. A number of these afflicted returnees have been observed to increase since the Iraq and Afghanistan offensives. Most of these sufferers were said to be aggressive personalities, whose family life is disorderly. They are also mostly victims of abuse and violence as children themselves. They display psychiatric disorder symptoms, such as alcohol abuse and smoking and psychotic symptoms other than flashbacks and dissociative reactions, characteristic of PTSD. They are inclined to avoid seeking help and not to complete domestic violence rehabilitation programs. They display mental health symptoms, such as minor depression and difficulty reintegrating into family and society and in performing daily tasks. Suicide rates have also gone up steeply in the last 26 years among these soldiers. Causes were said to be "occupational" or "operational" in nature. But families can help improve the chances of improvement for these soldiers by acquiring awareness and understanding of the symptoms. Soldiers for deployment may be better prepared for the experience by trained peers with the same experience rather than by current informal peer debriefings. And State-funded virtual reality video games are aimed at exposing them again to simulated combat experiences for military doctors to diagnose and better treat.