Psychiatric / Mental Health

Recognizing posttraumatic stress disorder in military veterans

More than a half million members of the military have become our newest veterans. Compared to veterans of previous conflicts, Iraq and Afghanistan combat veterans as a group are likely to be slightly older, include more women, and come from the Reserves or National Guard.

Recent veterans are eligible for 5 years of free health care from the Department of Veterans Affairs (DVA) after discharge. But many new veterans also have private insurance and choose to visit a private healthcare provider instead. This means nurses working in civilian settings need to be able to recognize the health risks associated with service in Iraq or Afghanistan. This article focuses on combat-related post-traumatic stress disorder (PTSD), an anxiety disorder that alters a person’s mental, emotional, and physical health and impairs daily functioning.

Recent studies of military personnel found that while small numbers of service members had probable PTSD before their initial deployment to Iraq, the probable PTSD rate more than doubled after deployment and continued to climb on reassessment about 6 months later. Research shows PTSD is combat-related. Military personnel reported substantial psychologically traumatic experiences, such as being attacked, shooting at the enemy, and knowing someone who was wounded or killed. This underscores the growing potential for PTSD. What’s more, research is uncovering a strong risk for PTSD after physical trauma, including mild traumatic brain injury, such as from an explosive blast or a fall.

Possibly contributing to the increased PTSD rate is the number of women in the military. Female sex is a risk factor for PTSD, although women usually have a lower overall lifetime risk of trauma. Reasons for this vulnerability aren’t well understood, but sexual assault is reported more often by women and is a particularly toxic type of traumatic experience. In a large, population-based study of Gulf War veterans, women reported more military sexual harassment and sexual abuse than men. For both men and women, sexual trauma increased the likelihood of PTSD. Yet such trauma doesn’t fully explain the increased PTSD risk in women. Healthcare providers should specifically ask about a history of sexual assault in both men and women.

Re-experiencing, hyperarousal, and avoidance or numbing

PTSD can occur in response to experiencing, witnessing, or learning about a life-threatening event. A person who reacts to the traumatic event with intense fear, helplessness, or horror is at risk for PTSD.

Combat exposure in a war zone not only qualifies as trauma but typically involves multiple traumatic experiences. After stressful or traumatic events, people commonly feel agitated, anxious, or jumpy. They may dream about the traumatic event or find themselves thinking about it when they should be concentrating on other things. However, some people try to avoid reminders of the event.


Although it’s normal to experience acute distress after a trauma, the distress usually abates over time. But for some people, the response is more intense and lasts longer than 1 month after the event. These individuals may meet the diagnostic criteria for PTSD. If signs and symptoms persist beyond 3 months, the condition is considered chronic. Chronic PTSD has been associated with social problems (divorce and domestic violence), occupational disruption (unemployment and frequent job changes), and various physical health problems.

Re-experiencing the trauma

Commonly, PTSD sufferers think about their traumatic experiences at inconvenient times. Sometimes this distraction is a response to a cue or reminder of the experience, such as a reminiscent smell, sound, or taste. The memory is accompanied by physiologic responses similar to what they experienced at the time of the event. They may find themselves caught up in the memory for a moment, as in a daydream.

In situations where this dissociation is more pronounced, the term “flashback” commonly is used to describe mentally “flashing back” to the event as though it were happening in the present. Patients also may report their sleep includes vivid, disturbing dreams that reflect the traumatic events in content or theme. Partners and spouses report loved ones with PTSD are restless when sleeping. To meet the diagnostic criteria for PTSD, re-experiencing symptoms must be accompanied by psychological distress or physiologic reactivity (for instance, rapid heart rate).

Hyperarousal

Besides having intense memories, people with PTSD show signs and symptoms of an overactive central nervous system. For instance, they may have a heightened startle response to an unexpected noise or movement, such as fireworks, exhaust backfire from vehicles, or even a child’s toy (say, a Jack-in-the-box). They’re overly vigilant to their surroundings and experience a distorted sense that a threat exists. They report feeling anxious most or all of the time and may present to primary caregivers or the emergency department complaining of panic attack symptoms (rapid heartbeat, chest pain, difficulty breathing, sweating), which mimic those of angina or myocardial infarction.

Other manifestations of hyperarousal include sleep problems, fatigue, irritability, and poor concentration. Sleep problems include difficulty falling or staying asleep and disruptions in the natural sleep cycle. Persons with PTSD may be awakened by distressing dreams or nightmares. They may need to get up and check the safety of their home during the night, or they may stay awake and watch television or have a cigarette or drink in an attempt to calm themselves. They’re at high risk for developing substance or alcohol dependence, along with the health and social problems that accompany these disorders. Irritability or outbursts of anger are common, too. Studies suggest more men than women report drug and alcohol use and episodes of anger after traumatic events.

Avoidance or numbing

People with PTSD commonly avoid situations that remind them of the trauma or make them feel anxious. They may refuse to watch news coverage of war, may decline invitations to family gatherings where conversations about their service may arise, or may avoid veteran support groups.

This avoidance can be disabling, as reported by veterans in interviews. Some Iraq veterans avoid driving because of their experiences with improvised explosive devices there. Others worry they may revert to illegal or hazardous combat driving techniques, such as not stopping for red lights or driving on sidewalks to avoid foreign objects in the road. Additional reports include avoiding grocery stores because of discomfort in crowds (these can be dangerous in Iraq and Afghanistan). Avoidance also may manifest as inability to remember aspects of the traumatic event.

Energy spent avoiding reminders of traumatic experiences leaves persons with PTSD feeling isolated, depressed, and numb. They may be unable to form or maintain close relationships due to a sense of detachment from others. Their disconnection may evolve into a depressed mood with reduced pleasure and interest in activities. Some sufferers show a restricted range of affect (emotional inexpressiveness or blunting).

Approximately 50% of persons with PTSD experience significant depressive symptoms. Studies show women report more signs of avoidance and depression than men. Many persons with PTSD experience a sense that the future holds little interest—a finding that warrants a suicide assessment.

Screening

During a hospital stay or a visit to a primary healthcare provider, a veteran or family member may confide in you about worrisome symptoms that suggest PTSD. Many PTSD sufferers adopt avoidance behaviors, which deters them from seeking help and contributes to underdetection of the disorder.

However, PTSD often is accompanied by such mental and physical conditions as depression, anxiety, substance abuse, headache, stomachache, and chronic pain. When veterans seek care for these problems, stay alert for and address traumatic stress symptoms, elicit the patient’s trauma history, screen for PTSD, and recommend referrals and follow up as appropriate. (See Good clinical practice for combat veterans below.)

Good clinical practice for combat veterans

By using an interdisciplinary approach, healthcare providers are more likely to recognize and successfully address the physical, mental, and emotional effects of PTSD in veterans. If a patient has PTSD signs or symptoms, experts recommend that care providers:

  • thank the veteran for his or her service to the country
  • ask about traumatic experiences (specifically about sexual trauma)
  • listen to the patient’s story
  • validate feelings about common trauma reactions
  • screen for PTSD symptoms explicitly.
  • If the patient has a positive PTSD screen:
    • identify your concern for the patient and emphasize the need for follow-up
  • screen for suicidal ideation
  • refer the patient to an appropriate clinician for a complete psychological evaluation and treatment recommendations
  • arrange for follow-up assessment and health teaching.
  • Primary Care: Post-traumatic stress disorder screen (PC-PTSD) below presents a four-item PTSD screening tool for use in primary care and medical settings. It’s widely used by the Department of Defense (DoD) and DVA. A patient who answers “yes” to three or more items has probable PTSD and needs further evaluation. If results suggest PTSD, follow-up evaluation for suicidal ideation is critical.Primary Care: Post-traumatic stress disorder screen (PC-PTSD)In your life have you ever had an experience so frightening, horrible, or upsetting that, in the past month, you:
    • have had nightmares about it or thought about it when you did not want to? YES / NO
  • tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO
  • were constantly on guard, watchful, or easily startled? YES / NO
  • felt numb or detached from others, activities, or your surroundings? YES / NO
  • Taking a history of the trauma

    To encourage discussion of sensitive information, set the right tone. Below are introductory statements and examples of questions you can use to start a discussion on combat and sexual trauma with a veteran. Acknowledge the strong feelings the discussion may provoke while keeping the trauma assessment brief and factual.

    In a private, quiet setting after establishing rapport with the veteran, begin the trauma history and screen by stating the following: “Sometimes stressful or difficult things happen to people. I would like to ask you a few questions about troubling experiences that can happen to people, to see if any apply to you. I’ll also ask you some questions to see how much you are bothered by the experiences. We do this to monitor your health and get you the help you might need.”

    “When you were deployed, did you see combat, enemy fire, or casualties?”

    “Do you find it bothers you to think about your deployment? If yes, what is it that bothers you?”

    “Has anyone ever used sex to hurt you or made you do something sexually you did not want to do?”

    If the patient reports no pertinent events, state: “Tell me about a time in your life when you were afraid for your life or when something happened that really upset you.”

    Treatment

    When making referrals for a patient with PTSD, use a collaborative approach that involves the patient and family members so the best course of treatment can be pursued. With the patient’s permission, include close family members or support persons at the initial stages of diagnosis and treatment so they can be educated about the condition along with the patient.

    First-line treatments for PTSD include trauma-focused psychotherapy and psychoactive medications. In general, recommended psychotherapies involve “exposure” techniques. Prolonged Exposure Therapy, Eye Movement Desensitization and Reprocessing, and Cognitive Processing Therapy (CPT) are empirically supported, standardized treatment approaches that use exposure as a primary component. Classified as cognitive behavioral therapies, they’re designed to help patients recall traumatic events in detail rather than continuing to avoid the memories, as well as to identify the thoughts that maintain fear and worsen symptoms.

    During psychotherapy, patients learn effective coping techniques to manage the anxiety that emerges. With repetition over time, they learn they don’t have to be afraid of or avoid the traumatic memories. This cognitive change results largely from the behavioral exposure and can be enhanced by strategies that target maladaptive thinking.

    CPT, for example, directly addresses guilt and shame-inducing thoughts (“I should have known something bad would happen”) by teaching patients to challenge the irrational belief that they are to blame and therefore must suffer. Research suggests that targeting the cognitive aspect is especially appropriate when guilt is a component of the person’s response to the event.

    Typical psychoactive medications used to manage PTSD are the antidepressants known as selective serotonin-reuptake inhibitors (SSRIs). Drug therapy also may include mood stabilizers and sleep aids. For more information on empirically supported prescribing guidelines, see www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp.

    Make sure patients who are taking SSRIs understand that these drug affect the brain’s neurotransmitters to alter the emotional experience, but don’t directly affect the thoughts that drive the patient’s fear. Consider, for instance, a veteran who is afraid to go outside in the dark because he was ambushed at night. An antidepressant can reduce the anxiety or physiologic response while he’s outside in the dark, whereas psychotherapy can reduce his fear-based beliefs about the dark. Research documents success in treating patients with PTSD, with partial or complete remission in most cases.

    Life-long management

    Although PTSD treatments can relieve symptoms, these often return. Resurfacing of intense feelings from the past prompted by the current conflicts in Iraq and Afghanistan could explain the recent increase in enrollment of Vietnam veterans in PTSD programs at the DVA.

    Nurses can help by assessing for resurgence of symptoms or onset of new symptoms, which suggests PTSD is reemerging. Stay alert for behavior changes, nightmares, increased use of drugs or alcohol, relationship problems, and frequent job changes. If these occur, rescreen the patient for PTSD or ask informally about a return of symptoms. Ensure appropriate follow-up to evaluate the patient for current health and PTSD symptoms, medication adherence and side effects, and progress or setbacks. Also work to remove barriers to health care. Encourage behaviors that ease stress, such as regular exercise, proper nutrition, and good sleep habits.

    Your ability to assess for PTSD is vital to improving recognition of the disorder and helping PTSD sufferers begin and maintain discussions about symptoms and management. Recognition starts the educational process. It helps sufferers understand the physical, mental, and emotional effects of PTSD and promotes help-seeking and self-management. A DoD study found an increase in veterans’ self-referrals to mental health services after screening and discussion of PTSD symptoms with a clinician. See Internet resources on combat-related PTSD below for resources on combat-related PTSD.

    Internet resources on combat-related PTSD

    Fact sheets for healthcare professionals and handouts for patients and families are readily available at the following websites.

    Selected references

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.

    Boscarino JA. Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med. 1997;59:605-614.

    Boscarino JA. Posttraumatic stress disorder and physical illness: results from clinical and epidemiologic studies. Ann NY Acad Sci. 2004;1032:141-153.

    Clum GA, Calhoun KS, Kimerling R. Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women. J Nerv Ment Dis. 2000;188:671-678.

    Cozza SJ, Benedek DM, Bradley JC, Grieger TA, Nam TS, Waldrep DA. Topics specific to the psychiatric treatment of military personnel. In: National Center for Post-Traumatic Stress Disorder, Walter Reed Army Medical Center, eds. Iraq War Clinician Guide. 2nd ed. 2004:4-20.

    Foa EB. Trauma and women: course, predictors, and treatment. J Clin Psychiatry. 1997;58(suppl 9):25-28.

    Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: Guilford Press; 2000.

    Friedman MJ. Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. Am J Psychiatry. 2006;163:586-593.

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    Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry. 2002;159:1576-1583.

    Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.

    Kang H, Dalager N, Mahan C, Ishii E. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol. 2005;15(3):191-195.

    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048-1060.

    Lewis L. Iraq war stirs memories for Vietnam vets. National Public Radio [Morning Edition]. September 25, 2007. http://www.npr.org/templates/story/story.php?storyId=14529768. Accessed February 3, 2010.

    Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298(18):2141-2148.

    Norman, SB, Means-Christensen, AJ, Craske MG, Sherbourne CD, Roy-Byrne PP, Stein MB. Associations between psychological trauma and physical illness in primary care. J Trauma Stress. 2006;19:461-470.

    Price JL, Stevens SP. Partners of veterans with PTSD: caregiver burden and related problems. National Center for PTSD Fact Sheet. May 22, 2007. http://ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_partners_veterans.html?opm=1&rr=rr113&srt=d&echorr=true. Accessed February 3, 2010.

    Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among US men. Am J Public Health. 2002; 92(1): 59-63.

    Prins A, Kimerling R, Leskin G. PTSD in Iraq War veterans: implications for primary care. U.S. Department of Veterans Affair, National Center for PTSD. http://www.ptsd.va.gov/professional/pages/ptsd-iraq-vets-primary-care.asp. Accessed February 3, 2010.

    Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70(4):867-879.

    Riddle JR, Smith TC, Smith B, et al; for Millennium Cohort Team. Millennium Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. J Clin Epidemiol. 2007;60(2):191-202.

    Rona RJ, Fear NT, Hull L, Wessely S. Women in novel occupational roles: mental health trends in the UK Armed Forces. Int J Epidemiol. 2007;36:319-326.

    Rothbaum BO, Cahill SP, Foa EB, et al. Augmentation of sertraline with prolonged exposure in the treatment of PTSD. J Trauma Stress. 2006;19:625-638.

    Schell TL, Marshall, GN. Survey of individuals previously deployed for OEF/OIF. In: Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Center for Military Health Policy Research; 2008:87-115.

    Schneiderman AI, Braver ER, Kang HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. Am J Epidemiol. 2008;167:1446-1452.

    Schnurr PP, Green BL. Understanding relationships among trauma, post-traumatic stress disorder, and health outcomes. Adv Mind Body Med. 2004;20(1):18-29.

    Screening for PTSD in a primary care setting. National Center for PTSD Fact Sheet. May 22, 2007. http://ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed February 3, 2010.

    Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home. Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167:476-482.

    Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull. 2006 ;132(6):959-992.

    Marycarol Rossignol is an associate professor in the Department of Adult Health at Seton Hall University in South Orange, New Jersey. Helena K. Chandler is a staff psychologist at the War Related Illness & Injury Study Center, Veterans Affairs New Jersey Healthcare System in East Orange.

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2 thoughts on “Recognizing posttraumatic stress disorder in military veterans”

  1. Laura says:

    This is a good article. I would like to find professionals willing to study PTSD as a result of divorce… It’s most likely to be considered Chronic PTSD. Everyone thinks war when you mention the term, but the symptoms relate well to other exposure to trauma in life especialy in divorces where Parental Alienation Syndrome is present.

  2. Vicki Nenner, RN, MSN says:

    I was a USAF Nurse in Japan for 4 years during Vietnam and I cared for many battle casualties. When they were wounded, many of them fell in rice paddies, which were fertilized with animal and human feces. To this day, when I talk about my nursing experiences during that time, I often mentally “smell” the characteristic odor of Pseudomonas drainage from those days.

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