Keywords

Introduction

Public awareness of posttraumatic stress disorder (PTSD), particularly among veterans, has risen dramatically due to increased media attention. However, accurate knowledge about the diagnosis, functional impact, and treatment of PTSD is frequently lacking among the general population. The requirement of exposure to a traumatic event that precipitates the development of symptoms makes PTSD unique among psychiatric disorders. However, while the majority of people will experience at least one potentially traumatic event in their lifetime, only a minority will go on to develop PTSD. Four clusters of symptoms characterize the current PTSD diagnosis: reexperiencing, avoidance, hyperarousal, and negative changes in cognitions (see Table 15.1 for specific diagnostic criteria). PTSD is often associated with profound difficulties in social, occupational, and physical health functioning and quality of life (e.g., Koenen et al. 2008; Schnurr et al. 2006; Zatzick et al. 1997).

Table 15.1 Core PTSD criteria clusters by version of DSM
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Serving in the military, particularly in combat, can increase the likelihood of trauma exposure. Combat service has been associated with higher rates of PTSD, depression, and alcohol misuse (Hoge et al. 2004; Kang et al. 2003; Kulka et al. 1990). Potentially traumatic military and combat-related experiences can include events occurring during rigorous training, life-threatening situations, being physically injured, bearing witness to death and dying, death and injury of comrades, interpersonal violence (e.g., sexual harassment and assault), and participation in actions that result in the injury or death of another. This chapter will provide an overview of PTSD, military and combat-related aspects, and clinical guidelines and treatments.

Case Study

Former US Army Staff Sergeant (Sgt.) Darren Smith (pseudonym) had just started his second semester at the local community college, after recently separated from military service. Although only 26 years old, Darren had already seen and dealt with situations that required him to take on a tremendous amount of responsibility. During his combat deployment in Afghanistan, he faced a number of situations where he or one of his comrades could have been injured or killed, including exposure to an improvised explosive device (IED) that hit his Humvee. He had needed to be aware, careful, and disciplined in his job to make sure that he was an asset to his team, not placing anyone else at risk. He had been in ambiguous situations where he was unsure of the best option but needed to make a decision. He made the best decision he could at the time but still sometimes pondered whether he could have done something different, if another decision would have been the better one.

Darren was unprepared for the anxiety and edginess he experienced soon after separation from the military, and he felt it even more acutely on the crowded busy campus. He wondered why he was unable to sleep until late hours at night, sometimes not falling asleep at all, and disturbed by the nightmares that would sometimes wake him once he did manage to fall asleep. Memories from his deployment often replayed in his mind, and he had trouble pushing them aside. He found himself easily angered by other students in his classes, who were texting or not pulling their weight during group assignments. He was determined to achieve his goal to transfer to a 4-year school and graduate in a healthcare-related area, as he wanted to pursue a career where he could make a difference in the lives of people. He was careful to turn in assignments on time, and he studied hard for his tests; however, he had trouble focusing during class and remembering information. There were even times he had to abruptly get up and leave the classroom, triggered by something someone said—usually about politics, war, or veterans. Finally, there were times that feelings of anxiety and depression became overwhelming, and he was unable to leave his apartment for the day or days at a time.

His grades during his first semester had been disappointing and he was at risk of academic probation . He wondered how much longer he would be able to continue to keep it together with little sleep and the frequent and vivid intrusive memories. Darren wasn’t sure what was wrong with him. He felt alone and missed the camaraderie of the military. Darren had heard of posttraumatic stress and he thought perhaps this was what he had. He wondered whether he should talk to someone, such as a doctor, but was ambivalent, as he had been able to handle worse situations and felt like he should be able to handle this on his own as well.

Historical Overview of PTSD

Conceptual Precursors

Although the PTSD diagnosis did not enter the DSM until its third edition in 1980, the concept of maladaptive posttraumatic reactions can be traced back to at least the ancient Greeks. Drawing attention to the similarities between post-deployment reactions some veterans face and the experiences of select characters in the ancient Greek epic poems the Iliad and the Odyssey, psychiatrist Jonathan Shay (King et al. 1999; Shay 1994) makes a compelling case for viewing ancient Greek warriors from a modern-day lens. However, the recognition of such a postwar or posttraumatic syndrome has only recently been examined from a psychological standpoint. Over two millennia later, in the American Civil War, “soldier’s heart” (or Da Costa’s syndrome) was observed as a condition characterized by cardiac abnormalities such as palpitations, chest pain, and difficulty exerting energy (Renshaw 2011).

Eventually professionals began to view this condition as more psychological in nature. The attention to trauma in psychiatry first gained significance through Pierre Janet’s (1889) book, L’automatisme psychologique, in which he explored how trauma can lead to severe dissociated states (van der Kolk et al. 1989). In World War I, the term “shell shock” referred to a collection of symptoms displayed by soldiers exposed to explosions from artillery rounds, combat weaponry, or other explosives (Renshaw 2011). Some of these soldiers expressed severe anxiety symptoms, others were dissociative or mute, and others had primarily psychosomatic complaints. Debate raged about whether there was an underlying physical origin of these symptoms, but many soldiers’ claims for disability, in Britain at least, were approved.

By World War II, phrases such as “combat fatigue ,” “combat stress reaction ,” and “battle neurosis ” began replacing older terms as common vernacular for similar syndromes. Still, the symptoms and theories behind these conditions remained diverse and little understood. One camp argued for physiological underpinnings, whereas others blamed mental processes. Edward Strecker, an American psychiatrist and consultant to the military, even blamed mothers for weakening their sons with letters from home that undermined their motivation for combat (Koenen et al. 2003). The US military leadership did not know what to think of these soldiers. Unfortunately, in 1943, Army General George Patton infamously struck in anger two Army soldiers suffering from “exhaustion” at a military medical facility (McCarthy and Petrakis 2010). Though his superior General Dwight Eisenhower, future president of the United States, made him apologize, the incident became emblematic of how some in the military view soldiers with less visible wounds. These attitudes and controversies continued into the Korean and Vietnam wars.

Treatments for these war-related conditions were as diverse as the theories of etiology. Generally afflicted soldiers were sent to a medical facility. Military psychiatrists were trained to treat combat fatigue or neurosis with a variety of methods ranging from rest to more invasive treatments like sodium amytal (a barbiturate derivative now known as amobarbital) and even electric shock in more severe cases (for a historical training video, see Pittman et al. 2012).

Modern Conceptualizations and Diagnosis

In 1980, the American Psychiatric Association published the first criteria for the newly coined posttraumatic stress disorder in the DSM-III. Criterion A, the traumatic event , was defined as “a recognizable stressor that would evoke significant symptoms of distress in almost everyone” (p. 238) and was described as “generally outside the range of usual human experience” (p. 236). The symptom criteria set the stage for decades of the three cluster conceptualization of PTSD: (1) reexperiencing, (2) avoidance and numbing, and (3) hyperarousal and hypervigilance (though not initially labeled as such). DSM-III also introduced subtypes and specifiers—acute (onset of symptoms within 6 months of trauma and present for less than 6 months), chronic (symptoms lasting longer than 6 months), and delayed (onset at least 6 months after trauma). DSM-III-R (American Psychiatric Association 1987) added greater specification of Criterion A with examples. DSM-IV and its text revision (DSM-IV, American Psychiatric Association 1994, 2000) attempted to address continued Criterion A controversy by removing the language “outside the range of usual human experience” and adding requirements of emotional reactions during the trauma of intense fear, helplessness, or horror. Changes to this definition raised rates of meeting the trauma criterion by 22 % (Jakupcak et al. 2009).

In 2013, the current DSM-5 made significant changes to the PTSD diagnosis (American Psychiatric Association 2013). First, it separated PTSD from the anxiety disorder section and created a new domain on trauma- and stress-related disorders. Criterion A was tweaked again by clarifying specific types of trauma that would or would not count (e.g., voluntarily watching violent YouTube videos does not count as traumatic, no matter how horrific) and removing the emotional reaction requirements. Importantly, the three clusters of symptoms were divided into four clusters: (1) intrusion, (2) avoidance, (3) negative alterations in cognition or mood, and (4) arousal and reactivity. The delayed onset specifier was maintained and joined by a “with dissociative symptoms” one. For a comparison of the various DSM criteria for PTSD, see Table 15.1.

Importantly, the PTSD diagnosis has had a fair share of criticisms over the years (Bodkin et al. 2007; Rosen and Lilienfeld 2008; Rosen et al. 2008, 2010) (cf., Yehuda and McFarlane 2009). Even Robert Spitzer, one of the architects of the DSM-III (APA 1980) that introduced PTSD, has recognized how controversial it has been in terms of its uniqueness (high comorbidity), specific criteria, overall validity, and use in practice (Spitzer et al. 2007).

Epidemiology of PTSD

Prevalence

Understanding the epidemiology of PTSD is an ongoing and vital task for researchers (Blanco 2011). In the first National Comorbidity Survey with a general US population sample, lifetime exposure to DSM-III-R-defined trauma was 55.7 % (60.7 % in men, 51.2 % in women), and the lifetime prevalence of PTSD was 7.8 % (5.0 % in men, 10.4 % in women) (Kessler et al. 1995). In a replication using DSM-IV criteria, lifetime PTSD prevalence was similar at 6.8 % (3.6 % in men; 9.7 % in women), and unlike the first study, the replication reported 12-month prevalence, which was at 3.6 % (1.8 % in men, 5.2 % in women) (Kessler et al. 2005; National Comorbidity Survey 2005).

In military and veteran populations, studies have shown a greater prevalence of PTSD and a reduced gender difference. Three large studies have looked at PTSD by era (see Table 15.2). The National Vietnam Veterans Readjustment Study (NVVRS) conducted in the 1980s (thus on DSM-III criteria) found a lifetime prevalence of 30.9 % in men and 26.9 % in women veterans (Kulka et al. 1988, 1990). At the time of the study, 15.2 % of male and 8.1 % of female veterans were diagnosed with PTSD. Marmar et al. (2015) conducted a follow-up study of veterans who had participated in the NVVRS, the National Vietnam Veterans Longitudinal Study (NVVLS). Over two decades following the original study, a significant number of male and female veterans continued to meet criteria for a full diagnosis or subthreshold PTSD symptoms (11.2 % and 8.7 %, respectively). Among deployed Gulf War veterans, Kang et al. (2003) found 12.1 % met the cutoff score based on self-reported symptoms. This was a threefold increase of risk compared to non-deployed Gulf War era veterans. For Operation Enduring Freedom/Operation Iraqi Freedom veterans, the most recent era of combat veterans, a similar current prevalence rate of PTSD (13.8 %) has been reported (Tanielian and Jaycox 2008). Predominately male (over 75 %), risk by gender for the Gulf War and Operation Enduring Freedom/Operation Iraqi Freedom veteran samples was not reported. More recently, a meta-analysis of 33 studies involving 4,945,897 veterans estimated PTSD prevalence to be 23 % among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (Fulton et al. 2015).

Table 15.2 Major representative studies of deployed military veterans’ rates of PTSD
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Risk and Resilience Factors

Research has identified multiple risk and resilience factors for the development of PTSD. These factors include characteristics of the trauma survivor, his or her reactions, and the event itself. For one, risk factors for higher trauma exposure, such as gender, age, socioeconomic status, and area of residence (violent neighborhoods, war-torn countries), tend to overlap with risk factors for developing PTSD (e.g., Gapen et al. 2011; Johnson and Thompson 2008; Norris et al. 2002). Of factors preceding the trauma, meta-analyses have shown female gender, family history of mental illness, previous trauma exposure, prior adjustment, adverse childhood events (particularly abuse), and lower socioeconomic status to be correlated with PTSD (Brewin et al. 2000; Ozer et al. 2003). The most powerful predictors were related to current factors—trauma severity, perceptions of life threat, and emotional intensity. The strongest predictor overall was whether the individual dissociated during or in the immediate aftermath of the trauma (Ozer et al. 2003).

Interestingly, military and veteran samples showed several differences in the Brewin et al. (2000) meta-analysis. The following characteristics were stronger risk factors for PTSD in military populations: younger age, lack of education, minority ethnicity, other adverse childhood experiences, trauma severity, and lack of social support. Unlike in the civilian samples, gender was not associated with risk in military and veteran samples.

The above meta-analyses unfortunately omitted other important factors such as attachment, personality, and genetic variables that have also been shown to play important roles. First, attachment variables, especially considering their relation to childhood experiences, social support, and beliefs about oneself and others, may be potentially important factors to consider in the context of PTSD. While attachment insecurity may act as a risk factor (Benoit et al. 2010; Besser et al. 2009; Scott and Babcock 2010), it can also result from trauma exposure (Bogaerts et al. 2008; Cloitre et al. 2008; Sandberg et al. 2010; Twaite et al. 2004). One clear connection between attachment and PTSD lies in how they both involve social cognition and object relations—namely, views and representations of self and others (Westen 1991). One recent study found that object relation variables of self-esteem and qualitative representations of others partially mediated the relationship between adult attachment and PTSD symptoms (Ortigo et al. 2013). These theoretical and empirical connections among attachment, social cognition, and PTSD have led some theorists to incorporate attachment-based frameworks into treating trauma (Allen 2005; Stein and Allen 2007).

Second, of the personality characteristics identified, general negative emotionality, lack of constraint, and unstable self-esteem have been implicated in risk for PTSD and its comorbid disorders (e.g., Kashdan et al. 2006; Miller 2003; Miller et al. 2006). Finally, and likely intersecting with attachment and personality factors, genetic influences and gene-environment combinations have been identified as risk factors (e.g., Binder et al. 2008; Gillespie et al. 2009; Heim et al. 2009; Jovanovic and Ressler 2010; Norrholm and Ressler 2009). In sum, findings have generally supported the role of main effect and interactions among genetic, biological, environmental, and individual difference variables in how an individual responds to trauma and their subsequent risk for PTSD.

Veteran-specific research has also looked at risk factors. Using data from the National Vietnam Veterans Readjustment Study (NVVRS), Kulka et al. (1988, 1990) summarized that the most consistent prewar risk factors for PTSD development included the number of problem behaviors in childhood, antisocial personality disorder (before age 18), lower socioeconomic status in family of origin, and family history of mental illness. Controlling for these factors reduced the observed greater risk for PTSD in African-American and Latino American service members , but it did not completely eliminate this observed difference. In a reanalysis of the data, King et al. (1999) found an important gender difference. For men, war zone stressors (e.g., perceived threat, atrocities) were most predictive of PTSD, but for women, postwar factors (e.g., social support) were most important. In a longitudinal study of Vietnam veterans, Koenen et al. (2003) found predictors of a more chronic course of PTSD included high combat exposure, reports of negative community response returning from deployment, ethnic minority status, depression symptoms, and anger. Social support was again found as a protective factor.

In looking at more limited variables in a Gulf War sample, Kang et al. (2003) found greater risk for female, ethnic minority, and older veterans as well as those that had experienced multiple forms of combat stress. For Operation Enduring Freedom/Operation Iraqi Freedom veterans, one study found that combat experiences and perceived threat predicted PTSD and that low pre-deployment preparedness resulted in higher perceived life threat across levels of actual combat experience (Renshaw 2011). Increased risk for PTSD has also been associated with longer deployments and higher levels of combat exposure (Schell and Marshall 2008). Finally, Ramchand et al. (2015) conducted an extensive review of studies of risk factors among veterans who served in Afghanistan and Iraq, finding generally that individuals with lower levels of education and younger age, higher combat exposure and more deployments, and deployment-related injury were at increased risk for PTSD. Moreover, pre-deployment and deployment factors found to be of importance in this review included prior stressors and childhood adversity, preparedness for and leadership during deployment, concerns for family during deployment, and social support.

Type of Traumatic Stressor

The type of trauma experienced is also a crucial variable in predicting risk for PTSD. In addition to life-threatening stressors, several types of events particular to military and combat service have gained attention as important to consider. These include the death or injury of military comrades which can lead to profound grief, participation in or witnessing events that conflict with one’s morals and values (i.e., moral injury), and military sexual trauma (MST) (see for review McCaslin et al. 2015).

Loss of Comrades

Bonds formed during military training and combat are uniquely strong. These bonds, including a strong sense of responsibility for one’s comrades, are cultivated during military and combat service (Papa et al. 2008). Thus, losses of comrades can profoundly impact service members , resulting in symptoms of posttraumatic stress and grief for years and even decades following the death. Significant numbers of combat veterans experience such losses. Between 63 and 80 % of US service members who served in Afghanistan and Iraq reported knowing someone who had been seriously injured or killed, and a smaller (20–25 %) but significant number reported having a buddy shot or hit close by (Thomas et al. 2010; Hoge et al. 2004; Toblin et al. 2012).

Notably high levels of grief symptoms, distinct from symptoms of PTSD and depression, have been reported in samples of Vietnam veterans who had lost comrades during their military service (Pivar and Field 2004). Indeed, levels of grief reported by these veterans were comparable to individuals who had recently experienced the death of a spouse. Grief symptoms can manifest in various ways and have been associated with poorer physical health, occupational functioning, sleep disturbance, fatigue, and pain—including musculoskeletal and back pain and headaches (Toblin et al. 2012). In addition to loss-related grief symptoms, veterans may also experience feelings of guilt for surviving when their comrade did not and/or self-blame stemming from a belief that the death was preventable (Currier and Holland 2012).

Moral Injury

Exposure to or participation in events that conflict with one’s core values and moral beliefs has been shown to increase the risk for PTSD over and above exposure to other combat stressors (Currier et al. 2013; Litz et al. 2009). Exposure to these kinds of stressors has been termed “moral injury,” and research on this phenomenon has dramatically increased during the past decade. The types of events that can lead to moral injury are broad, including betrayal by others (e.g., leaders and peers), participation in events that lead to the injury or death of civilians or enemy combatants, helplessness in the face of suffering, and situations that present an ethical or moral dilemma for service members (see Litz et al. 2009; Maguen and Litz 2012 for reviews; Currier et al. 2013; Stein et al. 2012). In one study of veterans who had served in Afghanistan and Iraq, the most common types of experiences endorsed were betrayal from leaders and of personal values, overly harsh treatment of civilians, and survivor guilt (Currier et al. 2013). Other surveys of this era of service members found that approximately half reported directing fire at or shooting enemy combatants and witnessing ill or injured women or children whom they were unable to help (50 % and 48 % to 60 %, respectively), approximately a third reported responsibility for the death of an enemy combatant (23–32 %), and over 5–9.7 % reported responsibility for the death of a noncombatant (Thomas et al. 2010; Hoge et al. 2004).

Moral injury can lead to psychiatric symptoms including feelings of shame and guilt, and functional difficulties, as well as having profound existential and spiritual impact (e.g., loss of meaning). Killing or injuring others in the context of combat has been associated with increased PTSD symptoms among veterans who have served in Iraq and Afghanistan, over and above exposure to other combat stressors (Currier et al. 2013; Maguen et al. 2010, 2013; Litz et al. 2009 for review). Stein et al. (2012) examined the relationship of the type of moral injury event with symptom type. The authors reported that reexperiencing symptoms were best predicted by moral injury acts committed by the individual, whereas state anger was most related to acts committed by others, such as enemy violence or betrayal. Litz et al. (2009) discussed the cognitive processes related to the development of moral injury, suggesting that the morally injurious events do not fit with preexisting moral schemas, resulting in emotional responses to the event.

Assessment instruments have been developed that can assist the clinician in better understanding the veteran’s experience. These include the Moral Injury Events Scale (Nash et al. 2013) and the Moral Injury Questionnaire – Military Version (Currier et al. 2013). An eight-step treatment for moral injury was proposed by Litz et al. (2009). The treatment addresses various components including cognitive processing, therapeutic alliance, education, and other areas such as social connection and self-forgiveness.

Military Sexual Trauma (MST)

Military sexual trauma (MST) is a term that refers to potentially traumatic events such as sexual harassment and assault. The Department of Veterans Affairs (VA) definition of MST is the following: “psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or [on] active duty for training” (US Code 1720D of Title 38) (see for review McCaslin et al. 2015). Sexual harassment events include a range of behaviors such as offensive sexual comments and display of pornographic materials. MST can occur at any point in military training and service, not only during combat service. Military sexual trauma has been associated with increased risk for physical health problems (Frayne et al. 1999; Kimerling et al. 2007; Kimerling et al. (2010) Turchik et al. 2012); psychological problems including PTSD, depression, anxiety, substance use disorders, and sexual dysfunction (e.g., Kang et al. 2005; Kimerling et al. 2007, 2010; Turchik et al. 2012; Yaeger et al. 2006); and other functional impairments (Skinner et al. 2000).

Annual prevalence rates of sexual assault within the military have been estimated at 6.8 % in females and 1.8 % for male service members . Rates of sexual harassment were reported to range between 9–31% for women and 3–7% for men, depending on the type of harassment (Lipari et al. 2008). Although a greater percentage of women report such events than men, the actual numbers impacted are equivalent because of the higher percentages of men serving in the military. Rates of MST are likely underreported because of barriers to reporting MST within the military. These barriers include the potential repercussions of reporting an incident perpetrated by a fellow service member who may be higher in rank or against fellow comrades from the same unit and the stigma associated with such events (e.g., perceptions that the individual should have been able to stop or may have contributed to the event; Turchik and Wilson 2010). Turchick and Wilson (2010) discussed the factors that can contribute to difficulties in recognizing and reporting sexual harassment and assault while serving in the military. In particular, the authors noted that the interaction between having a minority of women (approximately 20 %) service members and a strong masculine orientation can lead to an environment that condones such behaviors.

Resilience

Resilience, in addition to risk, is also essential to understand. Meta-analyses have identified perceived social support to be a strong predictor of decreased likelihood of PTSD development (Brewin et al. 2000; Ozer et al. 2003). Level of perceived social support has been found to prospectively predict the development of PTSD (Dinenberg et al. 2014). Cross-sectional and longitudinal studies have shown social support also predicts greater likelihood for recovery from PTSD (Charuvastra and Cloitre 2008). Similarly, just as insecure attachment is a risk factor, secure attachment can be protective (Ortigo et al. 2013). Additional factors found in previous studies to be related to resilience include optimism, cognitive flexibility, and active coping skills (for review, see Iacoviello and Charney 2014).

Resilience to trauma, though, may be conceptually broader than simply not developing PTSD. Some individuals experience personal growth as well, not just despite of but because of experiencing a trauma (Pals and McAdams 2004; Wilson 2006). Tedeschi et al. (1998) coined the term “posttraumatic growth” (PTG) to describe any positive psychological changes such as “an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life” (Tedeschi and Calhoun 2004, p. 1). Previous research has reported mixed findings regarding the relationship of posttraumatic growth to PTSD, with various studies reporting a linear relationship (For review see Shakespeare-Finch and Lurie-Beck 2014). Moreover, some research has suggested that this relationship may be curvilinear, with highest levels of posttraumatic growth developing when PTSD symptoms are moderate (e.g., Butler et al. 2005; McCaslin et al. 2009). Finding meaning from the trauma can be a fundamental component of posttraumatic growth. If posttraumatic growth exists (for a critical review, see Zoellner and Maercker 2006), then its predictors may have both overlapping and independent factors compared to PTSD.

Comorbidity of PTSD

Comorbidity of PTSD with other disorders is a complex issue that involves distinguishing between truly co-occurring disorders and seemingly comorbid conditions that are due to symptom overlap (Keane and Wolfe 1990). The overlap of PTSD symptoms with other disorders is particularly problematic for some critics (Bodkin et al. 2007; Rosen and Lilienfeld 2008). They argue that instead of a discrete disorder, current PTSD criteria just collect various reactions people may have after a trauma. PTSD’s high comorbid rates with mood and anxiety disorders (e.g., major depressive disorder, phobias, generalized anxiety, and panic disorder), substance abuse, and personality pathology (Deering et al. 1996; Keane and Wolfe 1990; Southwick et al. 1993) point to this issue. Nevertheless, comorbidity is an issue for many psychiatric conditions.

In veteran populations, PTSD is also highly comorbid with other conditions. The National Vietnam Veterans Readjustment Study (NVVRS) (Kulka et al. 1988) showed higher rates of mood and anxiety disorders in male and female Vietnam veterans, but one of the highest comorbid conditions was lifetime alcohol use disorder—almost three-quarters of the male Vietnam veterans with PTSD had met criteria for alcohol dependence or abuse in their lifetime. For Operation Enduring Freedom/Operation Iraqi Freedom veterans, Tanielian and Jaycox (2008) narrowed in only on depression, traumatic brain injury (TBI), and PTSD and reported that the 13.8 % of Operation Enduring Freedom/Operation Iraqi Freedom veterans who had PTSD included 5.5 % who likely had all three conditions, 3.6 % with PTSD and depression, 1.1 % with PTSD and TBI, and 3.6 % with only PTSD. In another sample of Operation Enduring Freedom/Operation Iraqi Freedom veterans, Pittman et al. (2012) reported a high correlation (r = 0.77) between PTSD symptoms and depression symptoms. A similarly high correlation between PTSD symptoms and depression was found in recent studies of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans (e.g., McCaslin et al. in press; Larson and Norman 2014). Unfortunately, screening positive for PTSD is associated with a fourfold increase in risk for suicidal ideation as well (Jakupcak et al. 2009).

Biology of PTSD

Since PTSD as a diagnosis emerged in the late 1970s, researchers have been working to better understand its pathophysiological and neurological underpinnings. Given the devastating impact that trauma symptoms can have on functioning and well-being, both for the person living with PTSD and others in their life such as significant others and family members, much attention has been given to identifying predictive and diagnostic PTSD biomarkers. This is especially true for military populations where trauma is often a necessary and unavoidable consequence of war. However, identifying relevant biomarkers is difficult because many studies cannot disentangle whether a biological abnormality is a risk factor for developing PTSD or a consequence of the disorder or of the trauma itself. Nevertheless, predicting who might be more susceptible to developing PTSD is particularly salient for military populations where a predictive biomarker would have significant value. In addition, psychophysiological and neurological indices of resilience to the development of PTSD could be beneficial and facilitate interventions aimed at preventing PTSD in vulnerable populations.

Neuroanatomy

Research generally points to three areas of the brain implicated in the development and maintenance of PTSD: the amygdala, hippocampus, and prefrontal cortex. The amygdala is relevant to PTSD due to its role in the formation and storage of emotion-laden memories, including fear-based memories. Probably not surprisingly, research consistently shows that amygdala abnormalities are present with PTSD (e.g., Huang et al. 2014), although at this time, research has not yet disentangled whether this is a cause or a consequence of PTSD. The hippocampus is another important brain region due to its role in the consolidation of memories, with a number of studies demonstrating that veterans with PTSD have smaller hippocampi and impaired hippocampal functioning, with some research suggesting that this is both a risk factor (e.g., Gilbertson et al. 2002) and a consequence of PTSD (Woon et al. 2010). Research also points to reductions in the size and impairment of functioning of the prefrontal cortex (e.g., Arnsten et al. 2015), which is the part of the brain that assists with making decisions and with planning behavior . It is important to note that cortisol, adrenaline, and noradrenaline, which will be discussed in subsequent sections, all play a critical role in these areas of the brain for the formulation of emotional memories, including trauma-related memories.

Autonomic Dysregulation

Dysregulation of both the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS) has been implicated in military-related PTSD. These two branches of the autonomic nervous system (ANS) exert influence over the organs of the body, maintaining important bodily functions and assisting in adaptive responding to changes in the environment, including stressful situations. The sympathetic nervous system is particularly important for quickly responding to threatening situations through catecholamine release (e.g., adrenaline and noradrenaline) in what is called the fight-or-flight response, which is an automatic response that maximizes the likelihood of successfully handling a physically dangerous situation. It thus makes sense that abnormalities in this defense mechanism could be either a cause or a consequence of PTSD. Indeed, some evidence suggests that a particularly heightened sympathetic nervous system response immediately following the trauma could be a risk factor for developing PTSD (e.g., Apfel et al. 2011), in addition to contributing to PTSD symptomatology, which has informed some pharmacologic interventions for PTSD (e.g., Boehnlein and Kinzie 2007). Consistent with these findings, elevations in cardiovascular indices have been observed in combat veterans with PTSD, which is particularly important given the higher risk of developing cardiovascular issues such as heart disease in this population (e.g., Coughlin 2011).

The literature on parasympathetic nervous system activity has been less extensive. The parasympathetic nervous system is under the control of the vagus nerve, which influences the heart and every bodily organ to maintain homeostasis. The parasympathetic nervous system controls the restorative features of the autonomic nervous system and has been called the rest-and-digest response (in direct contrast to the fight-or-flight response of the sympathetic nervous system). Although still in preliminary stages, some studies suggest that veterans with PTSD might have lower than normal basal levels of parasympathetic activity (e.g., Lakusic et al. 2007) and might not show typical autonomic nervous system responses to stressful situations (e.g., Sahar et al. 2001). It is important to note that not all findings have been consistent across the autonomic nervous system literature for PTSD, which might be attributable to individual differences in other factors that influence autonomic functioning.

Neuroendocrine Functioning

The hypothalamic-pituitary-adrenal (HPA) axis produces and excretes cortisol, which is often called “the stress hormone ” because of its role in facilitating the body’s adaptive response to a stressor. When faced with a threat of some kind, the body must maximize the use of energy and resources to most effectively cope with the stressor, and the HPA axis plays a central role in this process. It is important to note that although cortisol is central to the body’s stress response, it is also important for a variety of other important processes, with levels naturally waxing and waning across the day in a predictable pattern (also called the “diurnal rhythm”). In general, findings for cortisol related to a diagnosis of PTSD have been extremely mixed, with studies showing higher or lower than normal levels of cortisol, as well as both an exaggerated and blunted diurnal pattern. However, somewhat consistently, veterans with PTSD generally show a blunted response (e.g., Wahbeh and Oken 2013) but not always. A recent meta-analysis is suggestive that depression might be exerting an influence on these findings (Morris et al. 2012), but in general, more research is needed to disentangle the literature on cortisol in PTSD and evaluate the effects of other potential contributors to aberrant cortisol activity. It is possible that cortisol plays an indirect role in the onset and maintenance of PTSD through increased inflammation in the body, which has been noted in a number of studies identifying inflammatory biomarkers in veterans with PTSD (see Zoladz and Diamond 2013, for a review).

PTSD Assessment and Treatment

Given the high rates of comorbidity and often profound psychosocial consequences of PTSD among veterans, conducting a comprehensive assessment is essential prior to commencing treatment. Such an assessment should include information about military background and experience, and it should elicit information about PTSD-related conditions and functioning. Moreover, co-occurring physical conditions should be assessed. The co-occurring presence of chronic pain and traumatic brain injury (TBI) is of particular importance to inquire about during the assessment process. During the recent conflicts in Afghanistan and Iraq, the use of improvised explosive devices (IEDs) by the enemy and increased survival rates for veterans with severe injuries due to better protective gear and medical care have led to an increase in co-occurring PTSD, pain, and TBI—indeed, these particular injuries have been coined the “signature wounds” of this era of veterans (Clapp et al. 2010; Gironda et al. 2006; Sharp and Harvey 2001). Providing referrals for these co-occurring cognitive and physical conditions is extremely important in ensuring that patients receive needed comprehensive care.

Best Practices for Clinical Care

The VA/DoD Clinical Practice Guidelines for The Management of Posttraumatic Stress were first developed in 2004 as a collaborative effort between the Department of Veterans Affairs (VA) and the Department of Defense (DoD) to guide healthcare professionals who treat veterans or military personnel with acute stress and PTSD. The guidelines were updated in 2010 and then again in 2017 to reflect the current state of the literature. The working group, which consisted of researchers and expert clinicians in the area of trauma as well as experts in relevant fields and specialties, used review of empirical evidence and expert consensus to formulate a set of clinical practice guidelines (CPGs) to guide clinical decision-making when treating military trauma populations.

The guideline discusses a range of best practices for the ongoing assessment and management of acute stress responses and PTSD. This encompasses appropriate screening, assessment, diagnosis, treatment, and follow-up for trauma-related symptoms and common comorbid conditions within a collaborative care model for medical and mental health treatment settings. Each practice is given a rating using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (Andrews et al. 2013). Evidence is weighed based on factors such as the quality of the research (e.g., randomized controlled trial versus uncontrolled trial), number of available studies, relative benefit versus harm to the patient, and alignment with patient and provider preferences and values. Recommendations are then made based on the strength and direction of the evidence either for or against the practice and are provided on a continuum as follows: (1) “strong for,” (2) “weak for,” (3) “no recommendation for or against,” (4) “weak against,” and (5) “strong against.”.

The guidelines also include algorithms for facilitating care, including for acute stress reaction/disorder, assessment and diagnosis of PTSD, and management of PTSD. Recommendations are provided for pharmacotherapy and psychological interventions, as well as complementary and integrative treatments and other types of adjunctive approaches. Practices are presented within the context of time since the trauma and include early preventative interventions and interventions for PTSD. The guidelines address common comorbidities and co-occurring concerns that influence the overall patient presentation and can interfere with treatment outcome, such as substance use issues, chronic pain, persistent sleep difficulties, and relationship distress. It is important to remember that the clinical practice guidelines are intended to guide clinical decision-making within the context of good clinical judgment regarding specific patient needs and preferences. Prior to treating veterans with PTSD, it is suggested that providers consult the clinical practice guidelines to become familiar with recommended treatments. Further, it is extremely important that clinicians become familiar with military culture and context. The military has a distinct culture, and within this larger umbrella, there are unique cultural aspects of each military branch. The Department of Veterans Affairs and Department of Defense have developed online resources that provide education about military culture (see Table 15.3). Understanding the unique aspects of military culture can help the clinician to better appreciate the veteran’s experience, can improve therapeutic alliance, and can lead to a more accurate and comprehensive treatment formulation.

Table 15.3 Websites, mobile applications (apps), and web-based trainings for patients and providers (Websites active at time of publication)
Full size table

Exposure-Based Treatments for PTSD

The most recommended individual behavioral treatments highlighted in the clinical practice guidelines for PTSD are based on cognitive behavioral principles and employ some component of exposure (i.e., actively talking or writing about the traumatic event). These include prolonged exposure (PE) (Foa et al. 2007) and cognitive processing therapy (CPT) (Resick and Schnicke 1993), both treatments that have been formally disseminated (“rolled out”) in VA Medical Centers across the nation. Fear conditioning models provide the basis for exposure-based therapies. Fear conditioning has been proposed as a main process by which PTSD symptoms develop (e.g., Orr et al. 2000). Generally, fear conditioning draws on behavioral principles wherein an individual learns to pair an aversive stimulus with neutral stimulus. For example, when a stressor occurs, this constitutes an unconditioned stimulus (UCS) which leads to an unconditioned response (UCR) of anxious arousal and fear. The stimuli and cues that were present in the environment at the time of the stressful or traumatic event then become associated with this event (conditioned stimulus, CS) and also elicit anxious arousal and fear (conditioned response, CR). If a veteran was in danger and witnessed his comrades killed in combat, the sensory contextual cues in the environment (e.g., what was seen, heard, felt) at the time of the event may become associated with a sense of fear and danger. After separating from the military, these contextual cues (e.g., what was seen, such as type of landscape, and heard, such as explosions or screaming) can themselves elicit anxious arousal or other emotions even in the absence of the original stressor. Even thoughts about the traumatic event may trigger intense emotional reactions. The experience of these intense emotional reactions can be extremely disruptive and can then lead the individual to avoid thoughts, places, people, and activities that have potential to elicit these reactions. Treatments such as cognitive processing therapy and prolonged exposure aim to create new learning through “exposing” the individual to the trauma in a safe environment and through providing space and tools for the individual to process through (e.g., cognitive restructuring) the event. These treatments can promote a better understanding of the event and disentangle the contextual cues and thoughts from the traumatic event itself, such that it no longer elicits such intense emotional reactions (i.e., fear extinction)—enabling individuals to engage more fully in life. Recent research has found greater fear conditioning in women (Inslicht et al. 2013). As noted earlier, women have been found to develop PTSD at higher rates than men, and the authors propose that differences in fear conditioning may be one mechanism through which women are at higher risk (Inslicht et al. 2013).

While cognitive processing therapy (CPT) and prolonged exposure (PE) have been shown to be effective in treating PTSD in veterans (Department of Veterans Affairs & Department of Defense 2010), not all veterans will necessarily be a match for the treatments or may not want to start with a treatment that requires a focus on the traumatic event. Cognitive processing therapy has also been shown to be effective even without the trauma exposure component (Resick et al. 2008), making this an attractive option for some veterans. Further, recent research has shown that for individuals with emotional regulation difficulties, providing a course of treatment focused on building emotional regulation skills may increase the acceptability and effectiveness of subsequent trauma-focused treatment (Cloitre 2015). One such treatment is Skills Training in Affective and Interpersonal Regulation Narrative Therapy (STAIR; Cloitre et al. 2006). This treatment targets the development of emotional regulation skills and increased social connectedness. Dialectical behavior therapy (DBT; Linehan 1993) is another stage-based skills building treatment shown to be helpful for individuals with a more complex presentation (Landes et al. 2013). As noted earlier, PTSD is often comorbid with other conditions such as depression. Acceptance and commitment therapy (ACT) is a widely used treatment for depression for civilians and has been shown to reduce symptoms of anxiety and depression in veterans (e.g., Walser et al. 2013).

Veterans with PTSD report more psychosocial functioning difficulties including poorer family relationships (Koenen et al. 2008) and higher rates of divorce and separation (Riggs et al. 1998; Cook et al. 2004). Given the important role of social connectedness and support in recovery from PTSD and in various domains of functional improvement, family and peer support interventions are important to consider, in addition to individual or group psychotherapies. Including a family or peer component to a veteran’s treatment plan has been found to be acceptable to many veterans and may increase engagement in psychotherapy (e.g., Khaylis et al. 2011; Jain et al. 2013).

Conclusion

Posttraumatic stress disorder (PTSD) is regarded as a “signature wound ” of combat service among the most recent cohort of veterans who served in Afghanistan and Iraq. While a minority will develop a full diagnosis of PTSD , even subthreshold levels of symptoms can be destructive to veterans’ social, occupational, and health functioning. Moreover, without intervention, symptoms can endure throughout one’s lifetime. Recent decades have seen a proliferation in PTSD research and treatment development. There are now evidence-based treatments that have promised to alleviate PTSD symptoms and to improve the quality of life of those who have survived often profoundly difficult events during military service. It is a privilege to serve the men and women who have served our country, and they are owed the very best treatment and support that can be provided.

Key Concepts

  1. 1.

    While more than half of the general population will experience a potentially traumatic event in their lifetime, only a minority will develop posttraumatic stress disorder (PTSD). Reported rates of PTSD are higher among veteran samples.

  2. 2.

    Risk factors for PTSD include trauma/event characteristics (e.g., level of trauma exposure), demographic and biological variables (e.g., gender, age, previous trauma exposure, history of mental illness), and psychosocial variables (e.g., social support).

  3. 3.

    Military sexual trauma (MST) and moral injury have been found to be predictive of PTSD in veteran samples and require additional attention during treatment.

  4. 4.

    Clinical practice guidelines (CPGs) are valuable in providing information about the recommended treatments for PTSD including evidence-based treatments such as prolonged exposure (PE) therapy, cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapy.