Capstone Project: Post-Traumatic Stress Disorder Symptoms and Symptom Management in the Combat Veteran

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Posttraumatic stress disorder (PTSD) has been recognized by a growing number of healthcare authorities and U.S. governmental agencies as a serious and potentially debilitating condition in combat veterans returning from tours of duty in Iraq and Afghanistan. Although estimates vary from troubling to extremely alarming, the incidence and prevalence of PTSD among this population is far higher than for the general population in the United States, and the adverse effects of the condition are further exacerbated by a number of other factors, including early life stress, different levels of individual resiliency and a potential genetic predisposition as well. The consequences of untreated PTSD can be severe, including suicide, another trend taking place among the combat veteran population that has researchers scrambling for answers and efficacious treatments. This study provides a review of the relevant literature concerning PTSD to determine its causes, symptoms and treatments. The study found that at present, two diametrically different treatment modalities are being used by the Departments of Defense and Veterans Affairs for PTSD. The findings that emerged from this study and personal experiences to date, though, indicate that there is no "magic bullet" available and clinical interventions remain focused on treating the symptoms of PTSD while the search for a cure continues.

Table of Contents

Introduction

Review of the Literature

Proposed Project Method

Findings

Conclusions and Discussion

Post-Traumatic Stress Disorder: Symptoms and Symptom Management in the Combat Veteran

Introduction

This study, "Post-Traumatic Stress Disorder: Symptoms and Symptom Management in the Combat Veteran," is focused on identifying current treatments for post-traumatic stress disorder (PTSD) in general and for American combat veterans returning from tours of duty in the Middle East in particular. This study was important because the estimated prevalence of PTSD among U.S. Iraq War veterans currently exceeds 12% among veterans who recently returned from overseas, and even higher at 16% among service members evaluated a year following their return from duty in Iraq (Vasterling, Proctor, Friedman, Hoge, Heeren, King & King, 2010). These PTSD rates are comparable to those experienced among veterans return from combat tours in Afghanistan where combined samples of U.S. service members have been estimated at 14% with the development of new cases exceeding 7% for service members exposed to combat (Vasterling et al., 2010).

The implications of these trends are alarming because of the enormous human and economic consequences that are associated with PTSD. In this regard, Shad, Suris and North (2011) emphasize that, "Post-traumatic stress disorder (PTSD) is increasingly recognized as a serious and potentially debilitating condition in combat veterans returning from Iraq and Afghanistan" (p. 4). Moreover, current estimates may be low because of the confounding nature of PTSD and how it manifests in different people. For example, Shad and her associates add that, "Because PTSD can take months or years to fully manifest and many troops are subjected to multiple deployments, the prevalence of veteran PTSD may be expected to increase" (p. 4). Likewise, Nelson (2011) emphasizes that while the prevalence rates for PTSD among the general population is around 7.8%, the prevalence rates of PTSD for combat veterans returning from combat tours in the Middle East are estimated to be at least 17% and most authorities agree that this estimate is low -- in some cases far too low (Kearney, McDermott, Malte, Martinez & Simpson, 2012).

Moreover, other authorities believe that the actual prevalence rate of PTSD among the combat veteran population may be as high as 52% (Corso, Bryan, Morrow, Appolonio, Dodendorf & Baker, 2009) or 60% (Kearney et al., 2012), and some go so far as to suggest that the actual prevalence rate of PTSD among returning combat veterans may be far higher because the overwhelming majority (about 90%) of combat veterans who develop PTSD do not seek treatment (Kilmer, Eibner, Ringel and Pacula, 2011). Because of the complexity of the condition and the different ways it manifest over time, clinicians have met with mixed results in their different therapeutic approaches. For instance, Southwick, Gilmartin, McDonough and Morrissey (2006) emphasize that, "Chronic combat-related post-traumatic stress disorder is notoriously difficult to treat. While numerous therapeutic approaches have been tried in this population, success rates generally have been modest to moderate" (p. 161)..

The results of the most recent research indicate veterans returning from tours of duty in the Middle East as part of America's Global War on Terrorism (i.e., Operation Enduring Freedom or OEF and Operation Iraqi Freedom or OIF) diagnosed with psychiatric disorders are at higher risk for suicide (Jakupcak, Vannoy, Imel, Cook, Fontana, Rosenheck & McFall, 2010; Lighthall, 2010; Gomulka, 2010). The onset of suicidal ideation or attempting suicide may represent preliminary steps toward completed suicide. Hence, active suicidal ideation or recent suicide attempts are often used as markers of elevated suicide risk. To prevent suicides, it is critical to identify and understand the risk and protective factors for elevated suicide risk among OEF/OIF Veterans with mental disorders (Jakupcak et al., 2010). Beyond the enormous toll PTSD exacts in terms of human costs, the social costs associated with treating PTSD among combat veterans has been estimated to be as high as a billion dollars over the next 2 years (Kilmer et al., 2011).

In addition, Jakupcak and his associates (2007) stress that in spite of the consistent relationships that have been identified with respect to PTSD and anger, PTSD and hostility, and PTSD and aggression, the majority of the research to date has been focused on the experiences of Vietnam combat veterans and these studies have evaluated their experiences decades after their military service. According to Jacupcak et al., "With a growing number of combat veterans returning from deployments in Iraq and Afghanistan, additional research is needed to determine whether these relationships exist among this new cohort" (p. 946). Moreover, the nation is already facing a veritable epidemic of dementia among the elderly, and Qureshi, Kimbrell, Pyne, Magruder, Hudson, Petersen, Yu, Schulz and Kunik (2010) report that there is already an increased prevalence and incidence of dementia in older veterans who suffer from PTSD, and these rates can be expected to rise further in the future. Therefore, taken together, these trends clearly indicate that perhaps even hundreds of thousands more returning Iraq and Afghanistan combat veterans may go on to develop PTSD in the future with a corresponding need for efficacious treatments that remain elusive today. This study was based on continuing personal and professional interest in the treatment and management of PTSD.

Review of the Literature

This chapter provides a review of the relevant peer-reviewed and scholarly literature concerning PTSD and its effects on combat veterans. The study's guiding research question is followed by a discussion of issues to be explored below.

Research Question. The study's guiding research question was, "What are the typical symptoms of PTSD and how are these symptoms currently being treated and managed in combat veterans?

Issues to be Explored. Three fundamental issues are explored in the literature review chapter as follows:

1. The causes of PTSD;

2. The symptoms of PTSD; and,

3. The treatment and management of PTSD.

Review of the Relevant Literature

The causes of PTSD. The Diagnostic and Statistical Manual of Mental

Disorders, 4th edition text revision (2000) (DSM-IV) indicates that PTSD is characterized by re-experiencing the traumatic event/s, hyperarousal, avoidance of stimuli associated with the trauma/s and a general numbing of emotions. The latest diagnostic criteria established by the DSM-IV state that an individual must have:

1. Witnessed, experienced, or otherwise been confronted with an event that involved actual or possible death, grave injury, or threat to physical integrity; and,

2. The individual's response to such a traumatic event must include severe helplessness, fear or horror.

Researchers working with the Department of Veterans Affairs and the University of Texas Southwestern Medical Center, Dallas further define PTSD as "an anxiety disorder that may develop following exposure to trauma" (Shad, Suris & North, 2011, p. 4). A consistent theme that quickly emerges from the literature is that while anyone can develop PTSD, exposure to combat conditions in particular appears to be a precipitating factor. In this regard, Shad et al. report that, "Qualifying trauma exposures may include personal experience of, or directly witnessing, a sudden, unexpected event that threatens life or limb, such as combat trauma, a serious motor vehicle accident, terrorist attacks, natural disasters, or violent personal assault (e.g., rape), as well as learning of the sudden traumatic death of a loved one" (2011, p. 4).

Although everyone is unique and different levels of resiliency can mitigate some of these effects (Hagenaars & van Minnen, 2011), some people appear to be at higher risk because of preexisting mental schemas or past traumatic life experiences that can exacerbate future traumatic experiences. For instance, according to Cockram, Drummond and Lee (2010), "A number of factors appear to determine the course, severity and nature of post-trauma psychological reactions. These are usually divided into pre-trauma, trauma and post-trauma factors" (p. 166). While the severity of the trauma, such as combat exposure, is a primary factor in the etiology… [END OF PREVIEW]

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