Post-Traumatic Stress Disorder:
The Current State of PTSD
Kriss Gross
Argosy University

GRADE 300/300

Post-Traumatic Stress Disorder:
The Current State of PTSD
When Johnny came “marching home”, there were ticker-tape parades and family and friends threw parties in celebration of their military member’s safe arrival home. Unfortunately, being home came with its own set of problems, as an increasing number veterans face a battle in their own minds. That battle is Post-Traumatic Stress Disorder (PTSD), and it has been affecting veterans for decades, as an anxiety disorder brought about by the exposure to a traumatic event that causes a “pathological memory”, which then emerges with symptoms of “generalized feelings of fear and apprehension” (Butcher, 2010, p. 158). The number of veterans diagnosed with PTSD and being treated through the Veterans Health Administration (VHA) has tripled since 2001; emphasizing the vital need for established therapies (Eftekhari, Ruzek, Crowley, Rosen, Greenbaum, & Karlin, 2013).
According to the U.S. Department of Veterans Affairs (VA), as of September 1, 2013, 625,953 veterans are being compensated for PTSD. The rise in the number of veterans presenting with PTSD is thought to be in direct correlation to longer deployments, decreased time between deployments and the increasing number of deployments (Cook, Dinnen, O'Donnell, Bernardy, Rosenheck, & Hoff, 2013). In order to be compensated for the disorder, veterans must meet the requirements set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the PTSD Checklist-Military (PCL-M) (VA (3), 2013). The PCL-M currently uses DSM-IV criteria and is being updated to incorporate the DSM-5. While information regarding DSM-5 is available, for the remainder of this report all reference to the DSM will be based on criterion from the DSM-IV-TR (4th Edition-Text Revised).
When discussing the over 6 million veterans being compensated for PTSD, these veterans have all been diagnosed with the disorder and are being treated or have been advised of treatment options. According to Dr. Travis Caldwell, head psychiatrist at the VA Mental Health Center-Jacksonville (VAMHC-J) in Jacksonville, NC, the majority of the veterans seen at the facility are Marines returning from deployments from Afghanistan and Iraq, with Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). Jacksonville is home to Camp Lejeune Marine Corps Base; a multi-service military installation with Marines, Navy and a small number of Army and Air Force personnel. The majority of Dr. Caldwell’s clients are male, active duty and former Marine and Navy personnel; however some female Marines and Sailors are also being treated. During an interview with Dr. Caldwell, (personal communication, December 19, 2013), discussions about diagnosis, treatment and other aspects were covered. Caldwell stated the criterion in the DSM is followed when assessing and determining a diagnosis for the clients at the VAMHC-J and that the PCL is one of the required assessment tools. It is also important to keep in mind, when developing a diagnosis of PTSD that veterans may present with many symptoms similar to PTSD; however, the length of time the client has been experiencing them is important, as Acute Stress Disorder (ASD) can mirror some characteristics of PTSD. The difference is that onset of PTSD can take several weeks or months to emerge; while ASD usually occurs within 4 weeks after a traumatic event, lasting for a minimum of two days and a maximum of four weeks (Butcher, 2010, p. G-1).
The PCL-M (VA (3), 2013) is a 17-item self-report assessment tool that accounts for symptoms that veterans may be experiencing due to the trauma or traumas endured during deployments with OIF/OEF. The PCL-M enlists a numbered rating scale; using 1-5 (1-not at all, to 5- extremely) is also used during a structured or semi-structured interview referred to as Clinician-Administered PTSD Scale (CAPS) (VA (2), 2013). The CAPS tool is considered the “gold-standard” for evaluation and determining a diagnosis of PTSD. The traumas being experienced include being directly affected by, involved in, or witness to the explosion of Improvised Explosive Devises (IEDs), suicide bombings, direct fire, mortar attacks and other traumatic events. The PCL-M asks questions such as: The Marines under Caldwell’s care report stories of personal injury, the injury and often the death of fellow Marines. They also share experiences related to being the one who caused the death of an enemy, especially when the attack was at close range (VA (2), 2013).
Although, many Marines report a “high or rush” during and immediately after they engaged and killed the enemy, it is afterward, when the adrenaline has subsided, that their conscience turns on them, often causing feelings of remorse and guilt (Caldwell, 2013). The symptoms the Marines are displaying during assessment reflect the lasting effect these traumas cause to those involved. Caldwell shared the physiological symptoms displayed during assessment, when the Marines must relive the experience during these explanations. Visible indicators of stress can be seen as sweating, with the marine reporting an elevated heart rate, trouble breathing, tears, and often displaying an agitated demeanor. Another assessment tool, the Combat Exposure Scale (CES) is used to validate the experiences being expressed by the Marines. The CES, like the PCL-M, also uses a numbered rating scale, using 1-5, no or never to the highest number or percentage of times had the Marine experienced the traumatic events. Examples of the questions asked include: “Did you ever go on combat patrols or have other dangerous duty?” “Were you ever surrounded by the enemy?” “How often did you fire rounds at the enemy? “ The responses are then scored and used to determine the likelihood and diagnosis of PTSD (VA (4), 2013).
After the assessment and diagnosis is reached the task of determining effective treatment begins. Dr. Caldwell stated that treatment of PTSD is a joint effort between the client and clinician, where building a relationship based on trust and a sense of feeling comfortable in the clinician’s care, the client can be introduced to several viable, tested and researched therapy options. Caldwell also related that probable issues of diversity were limited; however, he reiterated that ultimately, the client made the choice of whether or not to continue based on personal or cultural implications. The first, Cognitive Processing Therapy (CPT) is used to aid the client by developing alternative avenues to cope with and understand the overwhelming thoughts and memories of the events that cause the stressors of PTSD. Clients are guided through a four-part process that helps them understand their symptoms and become more aware of their thoughts and feelings; CPT teaches skills to learn how to “question or challenge” their thought process and finally, to accept the new way that they perceive themselves, others who are important to them and the positive changes their outlook. The observed effectiveness of CPT has been recognized by the VA and training programs for VA therapists connects them with experts in CPT so they can implement the therapy into routine clinical care and provide clients, on a national level, with the best possible outcome (VA (5), 2013).
The second treatment, Prolonged Exposure Therapy (PET), is another well recognized avenue of treatment endorsed by the VA's Office of Mental Health Services (VA (6), 2013). Much like CPT’s four-part process, PET also follows a four stage therapy model utilizing education, breathing, real world practice, and talking through the trauma. Starting with education, PET helps the client understand their reactions to situations and the symptoms they are experiencing, followed by gaining an overall knowledge of the goals set within the treatment. Clients are then introduced to breathing exercises that help them remain calm when experiencing a stressful situation. Stage three, real world practice (vivo exposure), engages clients as they advance through situations they previously avoided, such as a client whose trauma involved a blast from an IED, while transporting follow Marines in a convoy, may avoid driving, The final stage in PET involves “talking through the trauma” or imaginal exposure. This part of the therapy involves a continued conversation about the events that caused the onset of PTSD, by reassuring the client that they do not have to fear their memories. While it may be difficult in the beginning, continuing to talk about the traumatic event helps them to gain an understanding of what happened and why they came to react the way they did; eventually having less negative emotions and stress reactions in surroundings that might remind them of the traumatic event (VA (6), 2013).
Individual therapies, like CPT and PET are often combined with group therapies, giving clients the opportunity to share their experiences with others who have been through the same or similar traumas and are also struggling with PTSD. The group setting allows fellow veterans to help each other, by building relationships based on a common goal of getting through each day and sharing what each of them has learned that helps them cope, with everyday stressors. Group therapy also gives clients the sense that they are not alone; that other veterans have the same emotions of shame, guilt, anger, rage, and fear and by sharing they build a system of trust, which leads to improved self-esteem and confidence. It also teaches them that they don’t have to continue to be overwhelmed by the past traumas; that it’s permissible to start living in the present. Another added therapy, medication, can also aid clients attending group and individualized therapies by reducing the overwhelming feelings of sadness and worry. These medications, selective serotonin reuptake inhibitors (SSRIs), are antidepressants that help ease symptoms so therapies are more easily managed (VA (7), 2013).
Considering the availability, effectiveness and positive outcomes in terms of care for veterans diagnosed with PTSD, the sociocultural factors are equally important to keep in mind. While this is an important aspect, these elements have not received the relevant consideration that these factors are essential to understanding the perspective that individuals have when attempting to adjust to a combat setting. Socio-cultural influences effect perceptions regarding the justification of entering combat, one’s ability to integrate with their unit, development of unity with fellow warriors, and the trust that they are under qualified leadership. These socially ingrained perceptions also affect how important it is that the conflict be entered into; is their own life worth the risk? When the perceptions have positive meaning then the likelihood of future onset of PTSD is minimalized. Early research has shown if all members of a unit have a unified outlook, believe they are a cohesive collection of individuals with a shared desire to meet their mission’s outcome, and have a common respect of each other and their command, the chances of an individual to succumb to combat stress is lessened.
A less favorable picture appears, however, when an overall distrust or animosity among members of the unit, from or toward the units’ command, leads to reduced morale and lowered resistance to combat stress. Further evidence indicates that veterans who return to an environment that viewed military involvement in the conflict in a negative light, such as that seen during the Vietnam era, there is less likely to be a positive community support system for military member to return to, thus increasing the probability of the onset of PTSD (Butcher, p. 166). This outcome is further complicated by the lack of community based mental health care facilities in minority communities; which is unfortunate, as there have been notable rises in therapy retention when local facilities are available (Butcher, 2010, pp. 589-590).
When concluding the interview with Dr. Caldwell, a comprehensive understanding of PTSD had been gained, acknowledging the disorder is caused by exposure to a traumatic event, wherein the client is directly or indirectly involved and that leads to symptoms of avoidance, numbness, shame, guilt, anger, rage, and fear. Determining a diagnosis is based on criterion set forth in the DSM and employed the use of several assessment tools, the PCL, CAPS, and CES, all designed to give clinicians a reliable and viable view of the clients exposure to a traumatic event and the symptoms being presented. Once a diagnosis of PTSD is determined, the treatment plan is discussed and should the client agree, therapy begins. Treatments include Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PET), group therapy, and medication if necessary. Sociocultural factors are also kept in mind when considering proposed treatment, although the decision is ultimately left to the client. While the evidence supporting the recommended treatments and their positive outcomes is abundant, the availability of treatment in some minority communities is lacking, and is need of further research to fill the gap, ensuring that all of our veterans receive the care and treatment they deserve.

References
Butcher, J., (2010). Abnormal Psychology, 14th Edition . Retrieved from http://online.vitalsource.com/books/0558241484
Cook, J. M., Dinnen, S., O'Donnell, C., Bernardy, N., Rosenheck, R., & Hoff, R. (2013, March). Iraq and Afghanistan veterans: national findings from VA residential treatment programs. Psychiatry, 76(1), 18-31. Retrieved from http://search.proquest.com.libproxy.edmc.edu/docview/1314534884?accountid=34899
Eftekhari, A., Ruzek, J/I., Crowley, J. J., Rosen, C.S., Greenbaum, M.A. & Karlin, B.E. (2013, July). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949-955. Retrieved from http://doi:10.1001/jamapsychiatry.2013.36
U.S. Department of Veterans Affairs, (2013). National Center for Veterans Analysis and Statistics. Retrieved from
(1) http://www.va.gov/vetdata/docs/quickfacts/fall_13_sharepoint.pdf
(2) http://www.ptsd.va.gov/professional/pages/assessments/ptsd-checklist.asp
(3) https://www.myhealth.va.gov/mhv-portalweb/anonymous.portal?_nfpb=true&_pageLabel=mentalHealth&contentPage=mh_screening_tools/PTSD_SCREENING.HTML
(4) http://www.ptsd.va.gov/professional/pages/assessments/assessment-pdf/CES.pdf
(5) http://www.ptsd.va.gov/public/pages/cognitive_processing_therapy.asp
(6) http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp
(7) http://www.ptsd.va.gov/public/pages/treatment-ptsd.asp