Healthcare services for retired military are strained. State-level Veterans Affairs (VA) hospitals are working to rebuild their reputation after the 2014 allegations of widespread patient neglect and long wait times. The responsibility private medical providers have toward veterans is clear — one-third of VA hospitals and clinics report inadequate mental health staff and patients wait an average of eight weeks to see a VA counselor for post-traumatic stress disorder (PTSD). Even before the VA scandal, over half of returning veterans sought primary care outside of the VA system at private medical facilities.
Nursing’s Role in PTSD Treatment
Today it is critical for all nurses to understand the signs and symptoms of PTSD. According to the National Institute of Health (NIH), only about half of PTSD patients are receiving minimally adequate treatment. Active and retired military servicemembers make up the majority of PTSD cases and these patients lack access to the medical care they’ve been promised by the U.S. government.
For this reason, in an effort to raise awareness of PTSD and the fresh challenges it poses to all care providers, the American Nurses Association (ANA) has partnered with six major national nursing organizations to promote a new campaign called Joining Forces. The national initiative, led by former First Lady Michelle Obama, invites all nurses to make a pledge to educate themselves on PTSD and to provide the highest-quality care to military servicemembers, veterans and their families.
Please remember that post-traumatic stress disorder can affect anyone; this guide, along with the support of your healthcare provider, is intended to help you begin to understand, recognize, and cope with PTSD.
PTSD Among U.S. Veterans
Entities that measure PTSD among the U.S. population may choose to quantify variables such as: length of time after combat, the impact PTSD has on an individual or family, demographic data, or specific details about combat history. PTSD also occurs in the civilian population, although less frequently. For example, children who were present at the Boston Marathon bombings in 2013 have been subsequently diagnosed. Learn more about the myth that PTSD only affects vets here.
The Impact of War on Mental Health
The National Institute of Mental Health (NIMH) defines PTSD as a malfunction of the body’s natural fight-or-flight reaction to stress or perceived harm.
PTSD is not limited to those who have experienced trauma; witnessing a traumatic event can cause the disorder, as can the awareness of trauma to a close friend or relative.
PTSD patients commonly have:
- Flashbacks to a stressful event
- Feel endangered in everyday situations
- Have an overactive startle response
- Nightmares and intrusive thoughts
Any kind of trauma can cause PTSD. The instigating trauma can be one single event like an act of violence or a natural disaster or it can be a sustained, long-term trauma like childhood abuse or depression.
The effects of war have particular causes and effects for PTSD sufferers. All soldiers in wartime must adapt to the constant stressors of war, and their ability to successfully do so can depend on contextual and cultural variables unique to each soldier. In some cases, the challenges soldiers face can be permanently traumatizing.
Soldiers, many of whom are quite young, are conditioned mentally and physically for wartime challenges in advance of their deployment to a war zone. Constant alertness and hypervigilance keep soldiers alive, and “battle fatigue” is common and expected to some degree. Certain circumstances of combat can worsen trauma:
- Feeling ill-prepared for fighting: Many veterans describe anxieties over remembering moments when they were not prepared for combat. They most often cite a lack of supplies or weapons that put them in danger and a lack of information about the conflict and where they were deployed. Others explain that they were not well enough prepared to deal with nuclear, biological or chemical warfare.
- Collateral damage of combat: After a skirmish or other engagement with the enemy, it often falls to soldiers to clean up the engagement site. This can mean moving bodies, civilian or otherwise, or attending to the living wounded.
- Harsh environments: The experience of living and working in a harsh environment can be difficult. The lack of privacy, personal discomfort from the climate, and spartan living arrangements can all add up to enormous stress.
- Sexual harassment: Military servicemembers often deal with sexual harassment in addition to wartime-related stressors. The U.S. Department of Defense reported 1,400 cases of sexual harassment in one year, a number which only includes reported cases.
- Stateside concerns: Spending 6-8 months away from home is difficult for anyone, but this can be a particularly toxic circumstance for soldiers who have heavy obligations or concerns at home like the failing health or death of a family member. Being so far away and unable to support loved ones can ignite feelings of anger, helplessness and guilt even after they’ve come home.
Clinical Classifications of PTSD
PTSD, at its core, is about the mind’s failure to properly integrate an experience into an individual’s known reality. The traumatic event is so far outside the individual’s frame of reference that the brain cannot process the experience. When this happens, the brain’s ability to form and recall memories can be altered.
Subsequent symptoms can surface anywhere from months to years after the event and may drastically impact mental and physiological health. It is known that early intervention in PTSD has higher success rates, so it is important to be aware of the symptoms if you or a loved one is at risk.
Clinically, PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The most recent revision of this manual published by the American Psychiatric Association ( APA) updates the definition of PTSD, reflecting new research and understanding of the disorder. If you think you or a loved one may be suffering from PTSD, compare symptoms against these guidelines from the DSM-IV.
In order to clinically diagnose PTSD in a patient, physicians consider traumatic event(s) in a patient’s history and identify symptom clusters. Other variables, like the duration of symptoms and their impact on daily living, are also considered.
Remember, while your own assessment is important, there is no substitute for a physician’s diagnosis and treatment. For some PTSD sufferers, treatment in the private sector is an option; the Affordable Care Act may offer treatment options to others.
These are the symptom clusters of PTSD according to the DSM-IV:
PTSD Symptom Clusters Table
|Source: DSM-IV, PyschCentral|
|Criterion A||Exposure to Trauma||Has suffered direct or indirect exposure to a trauma involving death, serious injury or sexual violence|
|Criterion B||Re-Experiencing Trauma||Is unable to suppress memories of the trauma; suffers from intrusive thoughts, nightmares and flashbacks|
|Criterion C||Avoidant Behavior||Actively avoids thoughts, people and situations that trigger traumatic memories|
|Criterion D||Depression||Suffers from feelings of helplessness, despair, and isolation; experiences reduced memory and cognitive function|
|Criterion E||Anxiety||Feels constantly on edge and hyper-alert, has difficulty concentrating, managing emotions, and suffers from sleep disorders and overactive startle reflexes|
|Criterion F, G and H||Incidence||These criterion assess the extent to which the first five criteria interfere with an individual’s ability to function on a day-to-day basis|
For more information on PTSD resources for servicemembers, contact your state Veteran’s Affairs Office.
Identifying PTSD Symptoms in Patients
A number of mental disorders often develop in PTSD patients, these are the primary effects of the disorder. Patients most commonly suffer from panic disorder, depression, OCD, separation anxiety or oppositional defiant disorder. Most recently, researchers confirmed that the incidence of preterm births is four times higher in women with PTSD than in women who have not been exposed to trauma.
The secondary effects of PTSD can be equally damaging. A number of medical conditions have been tied to PTSD. In a study of Vietnam veterans, PTSD was associated with increases in diseases of the skin, gut, coronary artery and musculoskeletal system. Other chronic conditions have been proven to be related to exposure to trauma. Memory can also be adversely affected; many people who have experienced trauma have a smaller hippocampus, the region of the brain where memories develop.
Using the clinical criteria above (symptom clusters), physicians and medical specialists can make highly informed diagnoses and recommendations to PTSD patients. But when it comes to noticing the subtle effects of trauma, families and friends are often the best and first line of defense for PTSD sufferers.
Remember that not all trauma victims will experience PTSD, but the probability is significant; according to the PTSD Alliance, “It is estimated that almost 70 percent of adults in this country have experienced a traumatic event at least once in their lives and that up to 20 percent of these people go on to develop PTSD.” Families are advised to watch for basic changes in mood, behavior or functionality as a veteran re-enters civilian life:
- Abnormal stress: Developing within the first 30 days after the trauma, Acute Stress Disorder or ASD is often the precursor to an official PTSD diagnosis. Patients with ASD describe confusion and an out-of-body sensation. Having had PTSD or other mental disorders prior to the traumatic event makes ASD more likely.
- Difficulty sleeping: Intrusive thoughts and the constant sensation of being alert for danger can interfere with healthy sleep patterns. Nightmares are also common in PTSD patients.
- Anger issues: Anger is part of the natural response to a perceived danger, causing us to shift into survival mode. In most cases, this anger recedes after the threat has passed, however, PTSD patients are unable to switch off the anger response. Irritability, muscle tension, aggression and problems with relationships are extremely common in PTSD patients.
- Substance abuse: It is not at all unusual for PTSD patients to turn to alcohol or illegal substances for relief from unrelenting symptoms. An addictive disorder can develop, whether from pain medications prescribed for injury or from self-medication. It is estimated that over half of PTSD patients are dependent on alcohol, and over 30% on drugs.
The earlier treatment begins, the lower the risks of self-harm and long-term damage.
There are dozens of reasons why early detection is critical for PTSD sufferers. Suicide rates in PTSD sufferers are high.
- In 2012, more active-duty soldiers died by their own hands than in combat.
- In the fall of 2013, it was estimated that 22 veterans per day committed suicide. Shockingly, this figure is probably higher; many suicides directly related to combat go unreported.
- While veterans only make up 7% of the population, they account for 20% of U.S. suicides.
When it comes to increasing the survival odds of PTSD patients, the biggest non-negotiable is access to high-quality medical care. As a nation, we simply aren’t there yet. Families and nurses alike can choose to pledge their commitment to the Joining Forces campaign that’s dedicated to increasing the level of care and reducing stigmas against PTSD sufferers.
PTSD: Myths and Facts
PTSD is frequently misunderstood and misrepresented in the media. The myths that surround this disorder are highly destructive to those who suffer from PTSD. Misconceptions that PTSD patients are weak, crazy or violent only serve to shame or scare patients from seeking treatment.
In one study, participants stated they avoided treatment because they did not want to be labelled as mentally ill. While veterans agreed that combat-related PTSD was a diagnosable condition, none of them felt that reaching out for treatment came without stigma.
The best way to combat myths and stigmas surrounding PTSD is to answer them head on:
MYTH #1: PTSD only affects veterans of war.
Although the majority of PTSD patients are veterans, anyone who is exposed to trauma can be affected. Survivors of devastating tragedies like natural disasters, fires or acts of violence often develop cases of PTSD that interfere with their ability to return to school, work or family life without treatment.
PTSD has no boundaries. It can affect anyone, regardless of
age, gender, race, ethnicity, or socio-economic background.
Victims of abuse, neglect or sexual assault carry a high lifetime risk of developing PTSD months or years after they’ve been victimized. Variables known to increase susceptibility to PTSD include:
- Trauma early in life
- Employment in high-risk fields like first response and the military
- Lack of a solid support system
- Family history of mental illness
- Drug or alcohol abuse
- History of child or sexual abuse
- Early separation from parents
- Presence of sleep disorders
MYTH #2: Strong-willed people can manage PTSD alone.
There is a long-held belief that if a soldier is strong, he or she is resilient enough to handle the effects of combat. Just as no one would deny a victim of a violent crime the right to treatment, former soldiers shouldn’t be expected to process traumatic memories of violence and loss alone and in fact, rarely do so successfully.
It cannot be overstated that PTSD is not a sign of weakness; nor is it weak or cowardly to ask for professional help. Anyone in contact with a PTSD patient should emphasize this message.
MYTH #3: PTSD makes you incurably violent and dangerous.
Portrayals of PTSD in the media are often sensationalized. Incidents like the murder-suicide event at Fort Hood by veteran Ivan Lopez create an image of PTSD sufferers as uncontrollably violent, angry and dangerous. In fact, veterans have no more potential for violence than anyone else, says PTSD specialist and psychologist Francine Roberts, PsyD.
Clinical psychologist Ingrid Herrera-Yee treats PTSD in the Washington DC area. Her husband is a staff sergeant in the Army National Guard. She explains, “Yes, there is anger and irritability (associated with PTSD), but it’s internalized. You’re more likely to see it as someone who is withdrawn anxious and numb, who’s lost interest in life. Some veterans explain it to me this way, ‘The last thing you want is to go lash out.'”
At the same time, statistics from one study show that untreated veterans with PTSD who are homeless, unemployed, underemployed and lack a functional family system commit violent crime at a higher rate than veterans in more stable situations. Again, medical treatment and social support are proven as the best weapon we have to fight back.
The worst case scenario of the perpetuation of myths surrounding PTSD is already happening. Confusion about the dangers of PTSD is leading to thousands of undiagnosed and ignored PTSD cases. This makes PTSD more devastating and more dangerous for everyone. An open and educated dialogue about the neglect of PTSD and the mental health of our veterans in general, is the only solution to the current problem of inadequate care.
Treatment and Best Practices
After an Institute of Medicine report found “critical gaps” and shortages in the nation’s systems of veteran care delivery in 2014, hospitals and clinics around the nation are devoting more resources toward PTSD care. In the interest of providing high-value care, both VA-funded facilities and private providers are working to better track patient outcomes and improve participation rates.
As of now, these updates are not mandated by law, but the IOM commission has made recommendations to begin rolling expansions and readjustments to Department of Defense and Pentagon budgets in 2015.
The Department of Veterans Affairs holds a standard-of-care minimum for therapy and treatment at eight hour-long sessions completed within 14 weeks. There are no current motions to revise these standards; the priority of the VA is first to increase the proportion of patients who complete treatment. As of now, only 53% of Iraq and Afghanistan veterans finish the 14 week counseling program.
PTSD patients are treated with psychotherapy, medications or a combination of the two.
- Exposure therapy, whereby patients use mental imagery to revisit the trauma scene
- Cognitive restructuring that uses talk therapy to reframe upsetting memories of trauma
- Stress inoculation training that teaches coping skills and anxiety reduction
- Anti-anxiety medication
- Beta blockers
Best Practices for Nurses
Nurses can make a definitive impact on the success or failure of a PTSD treatment regimen. It is the responsibility of nurses everywhere to tailor care to the unique needs of this patient population:
- Pledge to Support Joining Forces: As mentioned earlier, Joining Forces is an initiative sponsored by seven major nursing professional organizations in partnership with the White House dedicated to train every practicing nurse for PTSD care. Nurses can learn more and pledge to participate online.
- Continuing Education: With the sharp rise in PTSD and related problems, like suicide and drug addiction among soldiers, the nursing industry recognizes the need for specialized training for professionals who care for these patients.
- Familiarity with diagnostic criteria: Many symptoms of PTSD, like insomnia, anxiety or depression, can be standalone diagnoses or exist alongside other mental health diagnoses. Because PTSD can develop over time, it may be difficult to spot at first. Be aware of the symptom clusters that the DSM-IV has defined.
- Encouraging healthy habits: While nurses are trained to urge patients to take care of themselves, this message can be especially helpful for the PTSD patient. The process of reintegrating memories of trauma can be all-consuming.
Best Practices for Self-Treatment
Used in conjunction with professional treatment, forms of self-help can include:
- Socializing: Feeling like you need to be away from people is a common reaction, but, in actuality, this withdrawal will not help you get better. Remaining in contact with your family and circle of friends will eventually feel normal and even enjoyable.
- Support groups: Connecting with other PTSD sufferers who experienced similar trauma can do much to combat feelings of isolation. Being part of group discussions naturally exposes you to new ideas about how best to cope; even online discussion groups can provide this benefit. Support groups are not necessarily the same thing as group therapy. While they may be moderated by a therapist, their value lies in the connection and camaraderie with people in similar circumstances.
- Avoid self-medication: The temptation to numb your feelings with alcohol or drugs may be very difficult to resist. Combat veterans who were given opiate painkillers as part of a treatment plan for injury are at particular risk for this. While these substances may offer temporary relief from symptoms, they may ultimately delay your recovery or cause additional relationship problems.
- Volunteer: A key symptom of PTSD is a sustained feeling of helplessness. Volunteering is a beneficial way to reclaim a sense of power; choosing to do something positive for another person reinforces the idea that you do have choices in life.
Best Practices for Loved Ones
Family and friends of someone suffering from PTSD can also take specific steps toward helping a loved one recover, while still maintaining familial relationships that may be under strain.
- Patience: A major feature of cognitive behavior therapy involves talking through the trauma and learning to process it properly. If your loved one needs to continually repeat the details of the trauma he or she experienced, make the time to listen. Avoid pointing out that a trauma survivor may seem to be stuck on repeat, and never insist that someone “get on with life” or something similar. Alternatively, other PTSD patients may find it extremely difficult to talk about the trauma. This silence can be part of a healthy recovery. Do not encourage the sufferer to talk about their experience if it causes discomfort; however, do make it clear that you are there and willing to listen whenever they feel ready to reach out.
- Triggers: Most PTSD sufferers experience triggers that initiate an onslaught of symptoms. Try to understand unique details surrounding the trauma so that you can be aware of them. Anniversary dates, particular individuals, or auditory or olfactory inputs are typical triggers.
- Resilience: Remember that PTSD happened to your loved one. While this person may seem closed off, distant, numb or angry, make an effort not to take it personally.
- Recovery from PTSD is a process. Your loved ones will be much more successful at said process if they do not have to deal with drama from people who misunderstand.
It can’t be stated strongly enough: PTSD can affect anyone. This is a complex disorder and surviving it requires an open-minded and holistic treatment approach. In order to establish a high-quality level of care as standard, every member of the community needs to be committed to “joining forces”, so to speak. Whether or not you’re a nurse, Joining Forces challenges us to find unique and important ways to raise awareness about PTSD in our communities, our medical systems and within our own families. Good luck!
- U.S. Veterans Affairs PTSD page: This page provides access to all government publications relevant to PTSD and other forms of traumatic stress.
- PTSD Overview Online Course: This free course is available online or by podcast.
- At War: Notes from the Front Lines: A New York Times’-sponsored series of blogs from the battlefield, dating back to the post-9/11 era of engagement.
- Mental Health Screening Test: MilitaryMentalHealth.org provides a free screening test for PTSD and other mental health disorders.
- PTSD Alliance E-Books: The PTSD Alliance has provided two e-books on PTSD for free download.
- American Nurse Today: This informative article is directed toward nurses who treat military veterans.
- Have You Ever Served?: This website, developed exclusively for military veterans by the American Academy of Nursing, contains a wealth of resources for veterans and the professionals who treat them.
- Military Mental Health: This resource Guide, for patients and practitioners, was compiled by the American Psychiatric Nurses Association.
- Iraq War Clinician’s Guide: This manual, developed with the Department of Defense, addresses the unique needs of Veterans of the Iraq and Afghanistan wars.
Department of Veterans Affairs: State Offices and VHA locations
Since allegations of delayed care shook the Department of Veterans Affairs in 2014, offices at the state-level have increased efforts to supply timely and thorough care for PTSD patients. While the circumstances are unfortunate, this means that there has never been a better time for servicemembers and their families to contact their local VAs to learn more about PTSD diagnoses and resources.