PTSD among military personnel


The Vietnam War and the status of U.S. veterans have generated media interest both for their level of understanding, easy access, and public interest as it adds to disasters of great magnitude. For many, the PTSD claims responsibility for the suffering of factors external to themselves, factors over which often had no control or responsibility (Friedman, 2000), providing an explanatory model. Gersons and Carlier (1992) looks at the history of post-traumatic stress disorder, said the introduction of new diagnoses of PTSD looks and feels to be in recognition of the psychological consequences of war, especially as experienced by Vietnam veterans. After the description of PTSD in 1980, there was a significant increase in research interest in posttraumatic stress disorder (Blake, Albano, & Keane, 1992) with most of them victims of war sexual violence.

Post Traumatic Stress Disorder (PTSD)

PTSD is a natural reaction to an emotional experience very shocking and disturbing. It is a normal reaction to an abnormal situation. Post Traumatic Stress Disorder (PTSD) is defined in the DSM-IV, the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. For a doctor or mental health professional to make a diagnosis, the condition must be defined in the DSM-IV or its international equivalent, the World Health Organization ICD-10. The focus of the definition of DSM-IV (American Psychiatric Association, 1994) PTSD is a single life-threatening event or threat to integrity. However, post-traumatic stress also arise from an accumulation of small incidents rather than a major incident.

History of PTSD

PTSD is considered a name change or a synthesis of old age requirement. The psychological effect of exposure to combat-related traumatic events, physioneurosis then called was the first scientific study in 1941 by A. Kardiner (Kolb, 1993). Interest in research in this field reached its peak during and after the world wars. (1968) Keiser's book describes the traumatic neurosis specific problems after trauma supports the existence of PTSD before the war in Vietnam. Studies among the survivors of World War II and the death of prisoners of war (POW) camps, and the Vietnam War accelerated the growth of studies related to post-traumatic stress disorder among military personnel.

In 1968, the Diagnostic and Statistical Manual of Mental Disorders (2 nd edition, DSM-II. American Psychiatric Association, 1968, p.49) mentions about the effects of traumatic stress as the fear associated with military combat and manifested by trembling, running and hiding.  In 1969, the Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (8 th ed;. ICD-8, the World Health Organization, 1969, p.158) refers to the status of fatigue combat.  Common patterns in the psychological effects of woman who had been sexually assaulted, known as rape trauma syndrome, and combat-related trauma contributed to a whole set of symptoms that represents PTSD.

Posttraumatic stress disorder (PTSD) was introduced in the ICD in its 9th edition in 1978, and DSM, in its 3rd edition, 1980. In 1994, the short-term acute effects of exposure to a traumatic event have been introduced in the DSM-IV acute stress disorder (ASD).

Measures of PTSD

I. structured clinical interviews

Structured Clinical Interview for DSM-III-R (SCID, Spitzer, Williams, Gibbon and First, 1990) has been the most widely used interview to date to assess the presence or absence of PTSD. The SCID provides a comprehensive assessment of Axis I diagnoses and Axis II. The module PTSD is concise and relatively easy to administer and score, while facing the main diagnostic features of the disease. Kulka et al. (1990) found a kappa of 0.93, when a second clinician listened to audiotapes of the interview destination and then did separate diagnosis. McFall et al. (1990) reported a 100 percent reliability of diagnosis between the two physicians who completed independent SCIDs ten items. Keane, Kolb and Thomas (1988) found a kappa of 0.68 for the SCID PTSD diagnosis from two independent physicians interviewed individually in the same patients (N = 37). Kulka et al. (1990) also found the SCID diagnosis to be strongly correlated with other indices of PTSD (eg, Mississippi Scale, the Impact of Event Scale, the scale of the MMPI-PK). These results suggest that the magnitude of post-traumatic stress disorder in the SCID is a measure of the reliability and validity respectable. The limitation of this instrument is that it yields only dichotomous information about each symptom and therefore the severity of the condition and changes in the level of symptoms can not be easily detected.

Diagnostic Interview Scale (DIS-NIMH) is a highly structured interview that a high correlation with other known measures of PTSD (Watson et al. , 1991), but when used in a community sample, where the base rate of PTSD was low, the DIS poor performance, with estimates of 0.23 for sensitivity and 0.28 for the kappa (Kulka et al . 1991).

The PTSD-Interview conducted by Watson et al. (1991) yields scores for both dichotomous and continuous, responding to some of the limitations of the SCID and DIS. Reports of high test-retest reliability (.95), internal stability (alpha = 0.92), sensitivity (0.89), specificity (0.94) and kappa (0.82) recommend this instrument for use in the diagnosis of PTSD. Compared with other clinical instruments, this instrument asks subjects to make their own assessment of the severity of symptoms, minimizing the role of physician experienced in the diagnostic process.

The Structured Interview for PTSD (SI-PTSD) (Davidson et al. 1989) has continued symptoms and dichotomous classifications. Test-retest reliability (0.71), inter-rater reliability (97-99) and perfect agreement of diagnosis (n = 34) have been reported. Analysis has shown the usefulness of sensitivity 0.96, specificity 0.80, and a kappa of 0.79 compared with SCID.

Posttraumatic stress disorder clinician administered scale (Blake et al., 1990) is available throughout life and current versions. The CAPS contains 17 diagnostic symptoms of PTSD, the 8 functions associated with the measures of severity of symptoms in terms of frequency and intensity, the rate of deterioration in social and occupational functioning as well as evaluating the validity of patient responses. The CAPS also provides dichotomous and continuous outcomes to suit the needs of the researcher  clinician. Sound psychometric properties in terms of reliability and validity have been reported (Weathers, 1992).

II. Report scales of self-

The PK-scale of the MMPI (Keane et al., 1984) consists of 49 items that PTSD did not differ from patients with PTSD, in a test sample and a cross-validation sample of veterans. One hundred eighty-two of 200 subjects were correctly classified with a cutoff score of 30. Subsequent studies have not found the same rate of stroke diagnosis. The performance of the NVVRS PK (Kulka et al., 1991) indicates that the MMPI-2 (Lyons and Keane, 1992), the changes have not altered the general relationship of PK with other measures of PTSD.

Mississippi Scale (Keane, Caddell & Taylor, 1988) is available in both combat and civilian versions. It is a 35-point instrument has high internal consistency (alpha = 0.94), test-retest reliability (0. 97), sensitivity (0.93) and specificity (0.89). This instrument out effectively, both in clinical settings (eg, McFall, Smith, Roszell et al., 1990) and in field conditions  community (eg, Kulka et al., 1991), indicating its usefulness general post-traumatic stress disorder through the measurement of parameters and for different purposes (eg, research or clinical).

Impact of Event Scale (Horowitz, Wilner, and Alvarez, 1979) focuses on the evaluation of the responses of intrusion and avoidance  numbing. IES is the most widely used to evaluate the psychological consequences of exposure to traumatic events. The scale has good internal consistency (0.78 for intrusion, .82 for avoidance) and test-retest reliability (0.89 for intrusion, .79 for avoidance). Recent studies have found the IES to correlate well with other indices of PTSD. The impact of event scale-Revised (IES-R) (Weiss and Marmar, 1997) parallel to the DSM-IV criteria for PTSD, also self-report measure designed to assess current subjective distress for any specific life event. The three measures subscales, avoidance (the tendency to avoid thoughts or memories about the incident), intrusion (difficulty staying asleep, dissociative, as re-experiencing when experiencing true flash-back), and hyper arousal ( feeling irritable, angry, trouble sleeping). Besides the three subscale scores, IES-R gives an overall impact score events (sum of the three subscales) as well.

PTSD scale for the SCL-90 obtained by Saunders et al. (1990) has 28 items that most discriminated women with PTSD related to non-crime cases. Using the Diagnostic Interview Scale (DIS) as criterion, this scale was good sensitivity (0.75) and high specificity (0.90).

Penn Inventory (Hammarberg, 1992) was developed and validated with veterans and veterans exposed to trauma do not. This 26-item instrument has high internal consistency (alpha = 0.94), and test-retest reliability (0.96). The sensitivity was found to be 0.90 and the specificity was 1.0 in a sample of 83 veterans, and a sample of the sensitivity of disaster survivors was 0.94 and specificity of 1.0 .

Other self-report measures of PTSD include, Modified PTSD Scale (MPSS-SR) (Falsetti et al., 1993), Diagnostic Scale Posttraumatic stress disorder (PDS) (Foa, 1995), and Davidson Trauma Scale ( DTS) (1997).

III. Psychophysiological assessment of PTSD

Exposure to a traumatic event signals a systematic response caused by several physiological measurement domains (eg, heart rate, skin conductance, EMG, and blood pressure). Blanchard et al. (1982) found that heart rate response could correctly classify 95.5 percent of the combined sample of 11 male Vietnam veterans suffering from PTSD and 11 veterans controls. Blanchard et al. (1982) and Malloy et al. (1983) found that this reactivity predicts the diagnosis of PTSD, while auditory and visual use. Pitman et al. (1987) also observed similar reactivity using personal scripts of traumatic events that are read to subjects. A clinical trial of 15 sites conducted by the Program of the Department of Veterans Affairs Cooperative Study later discovered that psycho-physiological approach to assessment could be a useful diagnostic tool in cases of discrimination of post-traumatic stress disorder non-cases (Keane et al., 1988). Biological alterations of the central noradrenergic activity, the hypothalamic-pituitary-adrenal endogenous opioid system and the sleep cycle have been associated with PTSD (Friedman, 1991). Therefore, a biological approach can complement psychological diagnostic techniques.

Role of personality in the development of PTSD

The contribution of personality traits pre-deployment and exposure to traumatic events during deployment to the development of symptoms of PTSD has been studied (Bramsen, Dirkzwager, and Van Der Ploeg, 2000) among the 572 male veterans Protection Force of the United Nations in the former Yugoslavia. Apart from exposure to traumatic events during deployment of the personality traits of negativism and psychopathology had the most unique contribution to predicting the severity of the symptoms of PTSD.

Among a random sample of 1,007 young adults, with a rate of PTSD in those exposed to traumatic events, 23.6% and a prevalence of 9. 2%, Breslau, Davis, Andreski, and Peterson (1991) found that risk factors for PTSD after exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety .

Carlier, Lamberts, and Gersons (1997) were among the 262 traumatized police, in which 7% had PTSD and 34% had symptoms of PTSD or subthreshold PTSD, the severity of trauma was the only predictor of symptoms of PTSD identified at both 3 and 12 months after trauma. At 3 months post-trauma symptoms was predicted more than introversion, difficulty expressing feelings, emotional exhaustion at the time of trauma, lack of time allowed by the employer to come to terms with the trauma, dissatisfaction with organizational support, job insecurity and the future. At 12 months post-trauma, posttraumatic stress symptoms provides further by the lack of hobbies, acute hyperarousal, after traumatic events, job dissatisfaction, brooding over work and lack of support for social interaction in the private sphere.
Individuals who have experienced one or more traumatic events were selected (N = 3238) of respondents in the National Comorbidity Survey II (N = 5877). In separate regression analysis, elevated levels of neuroticism and self-criticism was significantly associated with each PTSD among men and women who had experienced one or more traumatic events. After controlling for types of traumas experienced and other previously identified factors, neuroticism remained significantly associated with PTSD in women and neuroticism and self-criticism remained significant in men (Cox, MacPherson, Enns, and McWilliams , 2004).

The main vulnerability factors for both PTSD and PTSD subliminal neuroticism and adverse events in early childhood found in a study involving 1721 older adults (Van Zelst, De Beurs, Beekman, Deeg, and Van Dyck, 2003).

A review of studies of personality in the etiology and expression of PTSD by Miller (2003) concludes that high negative emotionality (NEM) is the personality factor of risk for developing PTSD, while under restriction  inhibition (CON) and low positive emotionality (PEM) to serve as moderator factors that influence the form and expression of the disease through their interaction with the NMS. Premorbid personality characterized by high NEM combined with low PEM is thought to predispose to trauma to the affected person to a form of internalization of post-traumatic response is characterized by marked social avoidance, anxiety and depression. On the other hand, high NEM combined with low CON is hypothesized to predict a form of outsourcing of posttraumatic reaction characterized by marked impulsivity, aggression, and a propensity toward substance abuse antisociality.

Cluster analysis (Miller, Grief, and Smith, 2003), multidimensional personality questionnaires (MPQs) completed by veterans revealed subgroups that differ in measures related to outsourcing, compared with the internalization of distress. The MPQ profile outsourcing group was defined by low strength and avoid injury, along with high alienation and aggression. People in this group also had stories of crime and high rates of substance-related disorder. In comparison, the MPQ profile of the group was characterized by the internalization of smaller positive emotional alienation and aggression and more restricted, and people in this group showed high rates of depressive disorder. These findings suggest that the provisions towards outsourcing versus internalizing psychopathology may account for the heterogeneity in the expression of posttraumatic responses and patterns of comorbidity.

Schnurr, Friedman, and Rosenberg (1993) sought to assess predictors of combat-related symptoms over time the life of PTSD among 131 men in Vietnam and Vietnam veterans who had taken the MMPI in college and were interviewed in adulthood with the Structured Clinical Interview for DSM-III-R. Scores on the MMPI basic scales were used to predict exposure to combat, the life history of any exposure to the symptoms of PTSD given, and lifetime PTSD classification (only the symptoms, subthreshold PTSD or full PTSD). The results indicated that scores on MMPI scales were within the normal range and there is an agreed stopping combat exposure. The scales of hypochondriasis, psychopathic deviate, masculinity-femininity and paranoia predicted PTSD symptoms. Introversion depression, hypomania, and social provides diagnostic classification among subjects with symptoms of PTSD. The effect was maintained when the amount of combat exposure was controlled. This supports the findings of similar studies that pre-military personality can affect vulnerability to lifetime PTSD symptoms in men exposed to combat

Comorbidity with anxiety disorders

Co-morbidity studies have shown the strongest link PTSD with anxiety disorders than other disorders. There is a strong family history of anxiety disorders, affective disorders in patients with PTSD. PTSD symptoms of panic disorder, phobic anxiety, generalized anxiety disorder and obsessive-compulsive actions. PTSD, including anxiety disorders involve an abnormality in sympathetic activity.

PTSD among female military personnel

The psychological impact of military service and experiences associated as post-traumatic stress disorder commonly studied in the Vietnam War (1959 to 1975) veterans. Significant stressors among female military personnel hazardous occupational tasks ranged from sexual assault (Wolfe et al. 1993). Women exposed to combat veterans for the service were mostly Army nurses (Dienstfrey, 1988). In the first study of women and war stress involved 89 women Vietnam veterans, 50% experienced symptoms suggestive of PTSD, and 20% had symptoms significantly detrimental (Schnaier, 1985). Interviews (Norman, 1988) among the 50 nurses who served in the Vietnam War, found that the intensity of stressors during the war were related to continued high levels of intrusive stress symptoms and avoidance. Military service at a younger age, less military and professional experience, trauma with extensive occupational exposure to death and dying were associated with poor adaptation of the postwar period (Paul, 1985). Army nurses with less than two years RN experience prior to assignment found an increased risk of negative outcomes such as poor social relationships, and difficulty coping with stressful situations (Baker et al., 1989).

The National Vietnam Veterans readjustment study (Kulka et al., 1990) using the Mississippi Scale for Combat-related PTSD found that women had lower rates of PTSD than men combatants and women with the disorder in relation to the exposure level war zone. One study (Leda, Rosenheck, and Gallup, 1992) among Vietnam veterans 19,313 compared with men, women significantly greater proportion of homeless veterans were diagnosed with severe psychiatric disorders.

Social support functions as an important moderator of PTSD initial. Tramo et al (1985) found that despite clear exposition, the active duty female personnel had PTSD significantly less than their cohorts of veterans discharged, suggesting that social support serves as an important mediator in the reduction of disorder PTSD.

Leon et al. (1990) found that deal with the largest share of guilt, and focuses on negative affect and cognitions were associated with poorer outcome among women Vietnam veterans. Coping patterns characterized by expressing feelings, seeking emotional support, and seek the meaning of life events were associated with good psychological functioning, while the use of guilt, isolation, and anxiety are related to Current psychological dysfunction among nurses Vietnam veteran (Leo, Ben-Porath, and Hjemboe, 1990).
Similar to the civilian population, a history of trauma is a vulnerability factor for PTSD. Wolfe, Brown and Bucsela (1992) evaluated 76 women veterans before the start of Operation Desert Storm and later at the height of the military struggle and found that those who had previously reported high levels of PTSD were more susceptible to greater distress. The female Vietnam veterans with wartime exposure before are at risk for stress symptoms intensified after the recurrence of military combat.

Treatment of PTSD

There are five identifiable traumatic syndromes that require different treatment approaches (Marmar, et al, 1993;. 1995). They are;

1. the normal stress response is characterized by a single traumatic event that causes intense discrete intrusive memories, denial of numbness, unreality, and arousal. Individual or group information is used to full recovery.

2. acute catastrophic stress reaction is to panic reactions, cognitive disorganization, disorientation, dissociation, severe insomania, tics and other movement disorders, paranoid reactions, and the inability to handle even basic personal care, work and interpersonal functions. Treatment includes immediate support, removal from the scene of trauma, medications for immediate relief of anxiety and insomnia, and psychotherapy.

3. Uncomplicated PTSD, where the group, psychodynamic, cognitive-behavioral, pharmacological, or combination thereof used for treatment (Herman, 1992; Scurfield, 1993).

4. PTSD comorbid with other disorders is more common than uncomplicated PTSD is associated with disorders such as depression, alcohol  substance abuse, panic disorder and anxiety disorders and therefore deserves a concomitant therapy.

5. Post-traumatic personality due to prolonged exposure to traumatic childhood sexual abuse. You can have a borderline personality disorder, somatoform disorder, or dissociative identity disorder. Behavioral problems include impulsivity, aggression, sexual activity, eating disorders, alcohol  drugs and self-destructive actions. Emotional problems include mood lability, anger, depression and panic. Cognitive problems are fragmented thoughts, dissociation, and amnesia. Inpatient behavioral involvement and affect the management, with emphasis on family functioning, vocational rehabilitation, social skills training and rehabilitation of alcohol  drugs is for people diagnosed with personality disorder PTSD.

Need for assessment of the potential post-traumatic stress disorder at the time of recruitment

From the above discussion shows that the prevalence of PTSD among military personnel deserve a closer look and the development of preventive strategies. It has been noted that PTSD is not simply a side effect of combat-related events. In peacetime too, dysfunctional coping strategies of stress, such as suicide, attacking the officers, soldiers running havoc, etc. have been reported excessive alcoholism. Although rare, cases of suicide have been reported even training academies.