Post-traumatic Stress Disorder:
More Than Just Anxiety
By Micaila Britto
You hear a noise, which takes you back to a time and place you would prefer to forget. Or you have been in a horrific accident or witnessed one, and the memory will not go away. You have been involved some way in a bombing, which has caused damage to a building and the loss of innocent lives. You have persistent frightening thoughts or memories of these ordeals and you feel emotionally numb, especially with people you were once close to. This is not just a common case of anxiety, but could very well be the result of post-traumatic stress disorder.
What exactly is post-traumatic stress disorder, more commonly known as PTSD? According to Dr. Antoinette Zeiss, Ph.D., who is deputy chief consultant for Mental Health Services, PTSD, with the Mental Health Office of the Department of Veterans Affairs (DVA), PTSD is an ailment resulting from exposure to an experience involving direct or indirect threat of serious injury or death. The trauma may be based on an event experienced while alone, as in cases of rape or assault, or in the company of others, such as in combat or terrorist incidents, according to National Center for PTSD materials. The events that cause PTSD are called “stressors.” They include but are not limited to natural disasters (i.e., floods, earthquakes), accidents (i.e., car accidents, airplane crashes, large fires), or deliberate man-made disasters such as bombings, torture, or genocide, according to the Fact Sheet on Veterans with Post-Traumatic Stress Disorder (PTSD), available on the National Center for Post-Traumatic Stress Disorder (NCPTSD) Web site. When a veteran, or anyone for that matter, is involved in any of these types of incidents, it can trigger persistent, frightening thoughts and memories of the ordeal.
When this occurs, it can cause feelings of emotional numbness – especially concerning people with whom victims of PTSD were once close. Additionally, victims may experience sleep problems, feel detached, or be easily startled, said Zeiss. These effects can often cause recurrent thoughts of the traumatic events, reduced involvement in work or outside interests, hyper-alertness, anxiety and irritability, and suicidal thoughts. PTSD is a wound that is not visible to the human eye, and the DVA is committed to giving veterans world-class care for the disorder.
Over the course of America’s wars and conflicts, PTSD has been called “exhaustion,” “chronic fatigue,” “shell shock,” and “seeing the elephant,” to name just a few of the expressions. During the early 1800s, military doctors began to diagnose soldiers with exhaustion following the stress of battle. This exhaustion was the result of the soldiers mentally shutting down due to individual or group trauma caused by combat. The only real treatment of America’s vast Civil War population of soldiers was to bring them to the rear for a while and then send them back into battle. Through extreme and often repeated combat stress, the soldiers became fatigued as a part of the body’s natural shock reaction, often showing symptoms decades after the end of the conflict, said Zeiss.
Emerging in World War I and continuing into World War II, the terms “shell shock” and “combat fatigue” were commonly used to describe the symptoms of veterans who were exposed to extensive combat trauma. These veterans exhibited extreme stress and anxiety as a result, Zeiss said. The Korean and Vietnam conflicts were no different, and military medicine was benignly negligent regarding the condition. Amazingly, the accepted term of “post-traumatic stress disorder” did not come into existence until approximately 1980. Similar denials were even more evident in the medical literature of the period.
In 1952, when the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published, what we know today as PTSD was referred to as “stress response syndrome” and was caused by “gross stress reaction.” Yet, in the second addition of the DSM-II published in 1968, trauma-related disorders were all lumped together and called “situation disorders,” Zeiss said. Less technical and official books on the subject were a bit more charitable to PTSD sufferers. In her book, Recovering From The War: A Woman’s Guide to Helping Your Vietnam Veteran, Your Family and Yourself, Patience Mason told a tragic and disturbing story. Mason wrote that Vietnam veterans treated for PTSD during that period were informed if their symptoms lasted more than six months after their return from Vietnam, they had a “preexisting” condition, making it a “transitional situational disorder” and thus not service-connected. The result of these callous actions caused many Vietnam veterans to become the “walking wounded,” and more than likely attributed to the high rates of suicide, substance abuse, and homelessness suffered by veterans of that period. In 1980, when the DSM-III was published, the title “post-traumatic stress disorder” was finally used and placed in a sub-category of “anxiety disorders.” Again, in 1994, when the fourth edition was published, not only was it referred to under “anxiety disorders;” it was also listed under a new section called “stress response,” Zeiss said. Since that time, PTSD has been recognized as a real and present medical condition that is a direct result of traumatic events, especially close combat and terrorism.
THE PTSD POPULATION
In medical literature, PTSD started out as a “syndrome” and slowly turned into a “disorder.” According to the DSM, a “syndrome” is a group of signs and symptoms that collectively characterize or indicate a particular disease or abnormal condition, whereas a “disorder” is a clinically recognized illness. As mentioned, PTSD ultimately changed from being a part of a collective indicator to a singular illness, a significant medical distinction and very important for those who suffer from it.
According to the Fact Sheet on Veterans with Post-Traumatic Stress Disorder (PTSD) – March 2006, approximately 317,000 veterans with a primary or secondary diagnosis of PTSD were receiving treatment or were treated at DVA medical centers and clinics in Fiscal Year 2005. During the same time period, more than 50,000 veterans received PTSD-related services at Vet Centers across America. In total, nearly 16,000 Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans have been seen for PTSD at DVA medical centers from Fiscal Years 2002 to 2005, while another 3,000 OIF/OEF veterans were seen at DVA Vet Centers during this same period, according to NCPTSD.
Today, the DVA has more than 200,000 veterans who have been listed as having PTSD as a service-connected disability. These veterans’ service eras range from before World War II to the present day, as shown in the table below.
This is a large population, and it should be noted that these numbers do not reflect returning OIF/OEF veterans, and include only those veterans who have been screened and diagnosed with PTSD. The actual number is likely much higher, due to veterans who have never allowed themselves to be screened for the condition.
DVA AND PTSD TODAY
The Department of Veterans Affairs orientation toward returning combat veterans incorporates a public health approach to care and treatment. Education and training for the returning troops, their families, other providers in the community, and the general population will help to ensure veterans are informed of the availability of employment and educational benefits, and of course, health care opportunities that are afforded to them.
In 2005, Congress mandated that the DVA medical centers in Waco, Texas; Canandaigua, N.Y.; and San Diego, Calif., be recognized as Mental Health Centers of Excellence, with a major emphasis on PTSD. Additionally, more than 40 Returning Veterans Outreach, Education and Care (RVOEC) programs were established at the same time, with at least one in each of the DVA’s health care regions. These RVOEC program offices were established in hopes of identifying and managing the stress-related disorders and decreasing the long-term burden this disease has on the returning troops
DVA MEDICAL CENTER PROGRAMS
Currently, the DVA operates a network of more than 160 specialized programs that are internationally recognized for the treatment of PTSD through their medical centers and clinics. One particular program consists of PTSD clinical teams that provide outpatient treatment and work closely with the other DVA treatment programs, including Vet Centers and the community. Additionally, there are specialized outpatient PTSD programs, including 108 PTSD clinical teams, seven outpatient Women’s Stress Disorders and Treatment Teams, and nine PTSD day hospitals. Around the country, there are specialized inpatient units, brief-treatment units, and residential programs. There also is a specialized inpatient treatment unit in Palo Alto, Calif., and others are being established that specifically serve women veterans, Zeiss said.
In October 2003, the DVA’s Under Secretary for Health established a Special Committee on PTSD, which assesses the department’s capacity to diagnose and treat the disorder and provide guidance on the DVA’s education, research, and benefits activities regarding PTSD, according to the testimony of Dr. Harold Kudler, co-chairman of the special committee, before the House of Representatives. In addition, the DVA’s readjustment counseling is provided through 207 community-based Veterans Centers in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam. These Vet Centers are not located in DVA medical centers, but are located outside department facilities, often in shopping malls and other community settings.
The mission of the Vet Centers is to feature a mix of direct counseling, and to help veterans in assessing programs that improve their social and economic prospects after the military. Additionally, the Vet Centers allow veterans who were involved in war traumas, or were a victim of sexual assault during their military service, to psychological counseling, family counseling, community outreach and education, and extensive social services and referral activities. These Vet Centers are staffed by a variety of personnel, including psychologists, nurses, and social workers. These teams are diverse in gender and ethnic background, and include veterans who have served in combat operations. Recently, 100 newly returned combat veterans have been added as outreach workers to assist personnel in the transition from the military to civilian life.
Thanks to the DVA’s committed approach to PTSD through research, education, and consultation, the NCPTSD was established in 1989, with a mandate to promote research into the causes and diagnosis of PTSD, properly train health care and related personnel in treatment, and to serve as an information resource for professionals across the nation and the world. The center has seven divisions with distinct but complementary responsibilities. These include behavioral science, women’s health sciences, clinical neurosciences, education, evaluation, Pacific Island ethno culture, and executive and resource center divisions. With the focal point on research, education, and consultation intertwined, they all work together to bring science into practice and ensure that clinical concerns guide scientific priorities.
The NCPTSD and the Department of Defense (DoD) have collaborated on studies, with research focused on large-scale clinical trials, epidemiology, diagnosis, psychobiology, and treatment of PTSD. Also, NCPTSD maintains a nationally recognized Web site (www.ncptsd.va.gov) with information about trauma and PTSD.
The Web site includes documents to help clinicians to diagnose and treat veterans returning from OIF/OEF, and a database with more than 21,000 articles. The NCPTSD also provides consultation to clinicians, scientists, and policy makers concerning treatment, research, and education regarding PTSD.
PANEL ON NATIONAL SUICIDE EXPERTS
According to an NCPTSD FactSheet on PTSD and suicide, “a large body of research … indicates a correlation between PTSD and suicide. There is evidence that traumatic events such as sexual abuse, combat trauma, rape, and domestic violence generally increase a person’s suicide risk. Considerable debate exists, however, about the reason for this increase. Whereas some studies suggest that suicide risk is higher due to the symptoms of PTSD, others claim that suicide risk is higher in these individuals because of related psychiatric conditions.”
In May 2008, Secretary of Veterans Affairs Dr. James B. Peake announced the names of the members who were appointed to two special panels. These panels will be making recommendations on ways the DVA can improve its programs in suicide prevention, suicide research, and suicide education. “There is nothing more tragic than the death by suicide of even one of the great men or women who have served this nation,” Peake said. “DVA is committed to doing all we can to improve our understanding of a complicated issue that is also a national concern.”
The first panel, the “Blue Ribbon Work Group on Suicide Prevention in the Veterans Population,” is comprised of government experts in various suicide prevention and education programs. Those experts came from agencies including the DoD, the Centers for Disease Control (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The five member panel group met June 11-13, 2008, with a goal to report with recommendations to the secretary within 15 days of the meeting.
The second panel, which consisted of nine members who are nationally renowned experts in public health suicide programs, suicide research, and clinical treatment programs, were to provide professional opinion, interpretation, and conclusions on information and data. They made recommendations on opportunities for improvement in DVA’s programs. Based upon the recommendations of these panels, the DVA established the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). This hotline is staffed around the clock, 365 days a year, by trained professionals who know how to help people if they need it. Additionally, the VA has released a Public Service Announcement by Emmy and Golden Globe Award-winning actor Gary Sinise, urging veterans in distress to contact the Suicide Prevention Hotline. Sinise is known for his portrayal of a troubled disabled veteran, “Lieutenant Dan,” in the Academy Award-winning motion picture Forrest Gump. Today DVA, with the NCPTSD and the National Suicide Prevention Lifeline, is ready to reach out with many programs and solutions for those veterans who need help on the long road back home.
*footnote – this article was originally published in the “Veterans Affairs and Military Medicine Year in Review 2007-2008 Edition