PTSD and the Returning Military, Research Paper Example

Abstract

Post-Traumatic Stress Disorder, while not a new illness, is one increasingly explored, and the numbers of returning military personnel from recent wars provide an enormous field of study for those seeking to understand and treat veteran PTSD.  Out of a vast expanse of research, certain studies are presented that reveal differing approaches.  There is work focused on aggression as a common symptom, as other studies explore the impact of insomnia, as well as how varying stages of deployment play into PTSD occurrence rates.  In all this, two facts may be ascertained.  The first is the ironic and regrettable number of participants enabled by these recent wars.  The second arises from a considered reflection on the research examined, and may be expressed as a concern that such research may disregard, even in its efforts to help, the essential nature of PTSD as a survival construct for these individuals.

Introduction

Post-Traumatic Stress Disorder (PSTD) is by no means a new phenomenon.  The relatively recent research of it, in fact, indicates that PTSD has long been in place, if not recognized as a psychological construct with a specific identity.  Simply, as individuals have always, and frequently, exhibited abnormal behaviors and suffered from a variety of symptoms following extreme episodes, there is a greater understanding today of the distinct correlation between the two.  Moreover, this expanded understanding encompasses the reality that the circumstances generating PTSD may be of any kind; it is the aspect of trauma alone that links them, whether that trauma is induced from childhood abuse, being a party to a fatal accident, or having been in military combat.  It is as well acknowledged that, as causal factors vary, so too is the range of degree of PTSD virtually limitless, as the appearances of symptoms also follow no strict trajectory of timing.  This is an intrinsically personal disorder, rendering the forms it may take equally individual.

These elements established, it is nonetheless a reality that one type of experience appears to uniformly enable or create PTSD: military service.  In the early years of the 20^th century, returning servicemen from World War I manifested a range of conditions generally rendering resuming “normal” life difficult, if not impossible.  Even as the field of military psychiatry was being developed to investigate these occurrences, the term “shell shock” was applied to label these cases of dysfunction, just as in previous eras other attempts to identify and address the problems were offered, if in regrettable ways.  The Vagrancy Act was introduced in England in 1824, for example, to punish veterans from the Napoleonic Wars who, once home, demonstrated the disquieting habit of exposing themselves in public. A century earlier, soldiers exhibited strange and consistent depression following combat were diagnosed with “nostalgia” (Jones, Wessely, 2005, pp. 2-3).    These admittedly crude attempts to confront a significant issue have, thankfully, given way to more enlightened modes of address, and the research on PTSD as it relates to veterans is both vast and growing.  In all of this lies a tragic irony; as more and more men and women are sent off into war, the greater are the opportunities to view and assess exactly how PTSD develops and manifests itself.  In the following, research on the most recent military experiences of the military will be examined, with the aim of discerning, as nearly as possible, the existing state of thinking in regard to veteran-related PTSD.

Literature and Discussion

It may be argued that the greatest measure of the effects of modern research on military PTSD lies, not in modes of treatment, but in the intent and effort.  The recent United States involvements in the Gulf, Iraq, and Afghanistan have prompted studies both ongoing and innumerable, and taking various forms of investigation.  If, as noted, there is an inherently tragic element in that so extensive a field of subject matter exists, it is equally true that dedication to exploring the nature of it is appropriate to the challenge.

One behavior typically identified within veterans is undue aggression, and a 2007 study seeks to investigate precise relationships between combat experience and overt hostility following it, as: “Numerous studies have found that veterans with PTSD are more likely to commit aggressive acts than veterans without PTSD or the general public” (Jakupcak, Conybeare, Phelps, Hunt, Holmes, Klevens, & McFall, 2007, p.  946).  More precisely, the study is prompted by two specific concerns: that there remains too great a reliance on research developed from work on Vietnam veterans, and that the more recent veterans are likely to reveal incipient, or subthreshold, PTSD, which would be greatly beneficial to observing forming tendencies and patterns of the disorder.  To that end, Afghanistan and Iraq veterans who had reported having issues to local health authorities comprised the sampling, after being screened to include only those with combat experience.  Following multiple and carefully documented testing, the results uniformly reveal pronounced levels of anger within the participants, and despite varying degrees of actual combat exposure and other issues, such as problem drinking.  The study, moreover, through comparison with research done on veterans not exhibiting PTSD, confirms that consistent hostility is linked to PTSD in these cases.  There is as well evidence here that challenges the Vietnam studies, which focused more on anger as a trait evolving many years after combat; here, as was uncovered, the seemingly inexplicable aggression, typically generated by no external forces in the veterans’ lives, is demonstrated shortly after, or immediately upon, the return home (Jakupcak et al, 2007,  p. 950).  It is equally important to note that those veterans studied exhibiting subthreshold PTSD evinced hostility levels in accordance with the likelihood of fully developing the disorder.

While it may appear relatively expected that veterans with PTSD would display undue aggression, given the turbulent nature of the disorder, this work is valuable in that it suggests a specific avenue of treatment, which may go to addressing the disorder as whole.  There is already evidence supporting specific intervention: “Anger management skills training has been found to improve anger control among Vietnam combat veterans with PTSD”  (Jakupcak et al, 2007,  p. 951).   What seems promising, then, is the employing of this distinct approach as a key to unlocking the deeper disorder.  Anger is often a “masking” mechanism, wherein the behavior is in place to deny existing conditions.  It is an avoidance measure, so the direct addressing of it may reveal unknown issues within the veteran promoting or maintaining the PTSD.   It also appears that the novelty of the hostility as occurring within these recent veteran is profoundly important, as it suggests that the anger is not developed as a response to long periods of societal rejection, as in the Vietnam War veterans, but as a direct consequence of the combat just engaged in, or the environments of it.

The nature of PTSD is itself something of a translation; trauma, repressed, is expressed in whatever behaviors the sufferer’s mind deems effective in doing so, and that irrational and heightened levels of hostility are among these is hardly surprising.  Similarly, insomnia is identified as common in veteran PTSD, and a recent study explores more deeply how the symptom actually exacerbates the disorder.  More exactly, the study concerns itself with, not why the combat circumstances create the insomnia, but with the question: “How does the lack of restorative sleep associated with insomnia trigger other psychological symptoms?”  (Wright, Britt, Bliese, Adler, Picchioni, & Moore, 2011,  p.  1241).  The participants, primarily male and all having recently engaged in active duty in Iraq, were selected as having been exposed to traumatic conditions repeatedly, rather than as having been diagnosed with PTSD.  This approach allows for a less restricted examination of insomnia as developmental to PTSD, since consistent sleeplessness is identified as an agent in behavioral, emotional, and mental issues.  Nearly 2,000 veterans were studied, and with timing lapses to account for effects of prolonged insomnia.  The results were not entirely conclusive, but the assessment indicates disturbing patterns: “Insomnia at 4 months postdeployment was a signi?cant predictor of depression and PTSD symptoms at 12 months postdeployment” (Wright et al, 2011,  p. 1251).  Not unexpectedly, and going to the earlier study, this depression often took the form of increased hostility.

Here, then, is another example wherein the recent influx of veterans from traumatic combat situations provides crucial subject matter for investigating PTSD.  It also seems that the insomnia targeted has far-reaching implications for further study.  As, again, the participants did not necessarily have PTSD themselves, the entire study serves as a kind of subthreshold approach, because it is documented that the consequences of sleep deprivation promote behaviors identical to those associated with PTSD.  Depending on the duration and degree of the insomnia, symptoms range from minor irritability, and an inability to concentrate, to hallucinations, and absence of awareness of external realities.  The association with PTSD, then, is all too evident.

Another study in place to investigate the trajectories of veteran PTSD breaks down a variety of timing variables, and explores how borderline cases of PTSD during deployment develop, or fail to do so, following service.  As elsewhere, prior research prompts this: “Over 43% of deployed Iraq/Afghanistan combat-exposed  U.S. service members with baseline  PTSD symptoms maintained symptoms following deployment” (Vasterling, Proctor, Friedman, Hoge, Heeren, King, & King, 2010,  p. 42).  1542 soldiers were the participants, selected to represent National Guard service members actually deployed, combat personnel, and those not deployed.  Extensive interviews and recorded experiences from the participants were used to assess PTSD levels, and then correlated in terms of predeployment, active service, and postdeployment periods.  The results invariably reveal an expected rise in severity during service, with higher levels of postdeployment PTSD evident in those veterans engaged in lengthier and/or more traumatic combat situations.  Perhaps most interestingly, National Guard personnel presented the widest shifts in symptoms;  these soldiers had lowers levels of symptoms than did active duty personnel before going into service, and had higher levels of PTSD following deployment (Vasterling et al, 2010,  p. 48).

This points to a critical component of the subject, and one targeted by the researchers; namely, the extent to which anticipation creates stress, and how that stress promotes or enables PTSD development when service is active.  Put another this, this type of study in regard to veteran PTSD opens a door into an interesting and potentially valuable aspect of the disorder itself.  It asks the question: how greatly is trauma enabled by expectation of it, and may this be a mechanism that could avert the development of PTSD?  It is reasonable to infer, for example, that the National Guard members had a lessened expectation of actual combat, and that this rendered them more vulnerable to its effects.  In more simple terms, nothing, including war, is an experience confined only to itself; it is very much shaped by how it is perceived, both beforehand and afterward.  If such perceptions, then, render certain soldiers, as with the National Guard, more susceptible to the stress that evolves into PTSD, then it is conceivable that an altered perception could, in effect, “prepare” a soldier to be resistant to it.

As noted several times, there is an immense amount of research going into veteran PTSD, facilitated by the vast numbers of soldiers recently returning.  One study takes pains to address an ongoing difficulty in the work, in that research typically diverges between dysphoria and numbing models.  The former views the PTSD as an avoidance disorder, one more keenly linked to depression; the latter presents a model based on the individual’s inability to respond.  Complicating matters is that the nature of PTSD itself, and particularly in regard to veterans, often reveals aspects of both.  Meanwhile: “In spite of numerous efforts, the literature has yet to converge on a consistently supported factor solution for the structure of PTSD”  (Meis, Erbes, Kaler, Arbisi, & Polusny, 2011, p. 808).   The study in question then delves into an immensely complex process of differentiating PTSD experiences and cases based on accommodating the prevalent models, and employing 522 servicemen before, during, and after service in Iraq.  What is most interesting here is that the results conform to the expectations or predictions set forth by the research, and this suggests that the dual nature of the models is, perhaps, self-defeating.  More exactly, it is rational to conclude that, when an individual with PTSD demonstrates avoidance or dysphoric behaviors, a process of numbing is inevitable.  If any real information is gained here, it goes, in fact, to this evolutionary aspect of PTSD.  For example, the authors conclude that: “The stability of dysphoria, even from before to after combat deployment, supports the nontrauma-specific nature of this symptom cluster” (Meis et al, 2011, p. 816).  Their evidence indicates avoidance as a primary trait developed, in other words, when the combat circumstances are relatively tame.  This in itself, however, would seem to indicate a logical progression;  avoidance is a cognitive choice, at least initially, so it follows that the less cognitive behavior of numbing would either follow it or be more directly encouraged by real trauma.

This has been, in a sense, the pursuit of other research, in place to challenge an accepted maxim in the PTSD arena:  “The common assumption in PTSD theories is that avoidance interferes with recovery by preventing trauma survivors from habituating to the trauma memory” (Pineles, Mostoufi, Ready, Street, Griffin, & Resick, 2012,  p. 242).  The study in question employs crime victims, rather than veterans, as its participants, but the correlation between the traumas of crime and combat may be seen as valid, particularly as the concern here is to isolate any potential benefits from disabling avoidance as a coping mechanism.  Through measuring heart rates during interviews addressing the trauma with the participants, stress increases as reflecting challenged avoidance were then determined.  What emerged were indications that heightened reactivity, as expressed through increased heart rates, may indicate greater chances for recovery.  More exactly, as the dysphoria is not permitted to hold sway during the confrontation with the past trauma, the individual may be more freed to examine it less painfully.  Clearly, this applies to veterans, and particularly as war experiences cannot be reoccurring, and may then be more “safely” brought into the open.

Lastly, and openly acknowledging how the evolution of the war in Iraq created an immense opportunity for study, there is work seeking to better sort the conflicting information regarding the nature of PTSD in these veterans.  On one level, it seems the research is inspired by an interesting reality, in that there is a pronounced decrease in PTSD in UK soldiers, as opposed to U.S. (Sundin, Fear, Iversen, Rona,& Wessely, 2010,  p. 367).  On another, the authors are dissatisfied with how they perceive clinicians as “lumping together” Iraq PTSD cases, when in fact the circumstances of the conflict changed greatly over the years.  The authors then collect and examine existing studies thus far done on this population, with the intent of discerning differences in prevalence rates in a way providing information on potential defining points.  As the study’s title suggests, the claims are too conflicting because the data itself is accrued through too many constricting factors..  Some studies, for example, focus only on time spent in infantry position, with no actual awareness of how this translated to combat, or trauma, experience.  Some information was gleaned, in that most research conducted confirms that PTSD prevalence increases in the year following deployment (Sundin et al, 2010,  p.  378).  Beyond this, however, the authors have little to offer, save something of a collective sigh over the masses of conflicting data.

Conclusion

As has been made evident, research on PTSD as it relates to veterans is a constantly expanding effort, and one vastly enabled by the recent and lengthy conflicts in Iraq and Afghanistan.  Subjects of study, unfortunately, have been returning to U.S. shores by the droves in recent years, seemingly ideal for investigation into just how war experience generates the many issues within the disorder.  If anything seems clear from even a cursory examination of this research, it is that well-intentioned clinicians are devoting immense effort into trying to develop a means of treating a problem inherently resistant to treatment.  As noted, trauma is as intensely personal an experience as can be conceived, if only because each individual translates it in the manner felt, and usually subconsciously so, to be necessary for survival.  That soldiers develop avoidance and numbing mechanisms to cope is hardly surprising; more surprising, in fact, is that medical science would seem so ambitious to disable these mechanisms.  Clearly, the desire is to restore such individuals to healthy mental states, but the research indicates – perhaps in a further irony – that such concerns may do well to deeply consider first that the mind does not create such constructs randomly, and that a great deal of care must be exercised before attempting to “bypass” systems made by the individual to ensure survival.  In essence, the research explored points to painstaking efforts to analyze and address veteran PTSD, but with an insufficient regard to the reasons for its existence.

References

Jakupcak, M., Conybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Klevens, M., & McFall, M. E. (2007).  Anger, Hostility, and Aggression Among Iraq and Afghanistan War Veterans      Reporting PTSD and Subthreshold PTSD.  Journal of Traumatic Stress, 20 (6), 945-954.

Jones, E., & Wessely, S.  (2005).  Shell Shock To PTSD: Military Psychiatry From 1900 To The Gulf War.  New York: Psychology Press.

Meis, L. A., Erbes, C. R., Kaler, M. E., Arbisi, P. A., & Polusny, M. A.  (2011).  The Structure of PTSD Among Two Cohorts of Returning Soldiers:Before, During, and Following Deployment to Iraq.  Journal of Abnormal Psychology, 120 (4), 807-818.

Pineles, S. L., Mostoufi, S. M., Ready, C. B., Street, A. E., Griffin, M. G., & Resick, P. A. (2012). Trauma Reactivity, Avoidant Coping, and PTSD Symptoms: A Moderating Relationship?  Journal of Abnormal Psychology, 120 (1), 240-246.

Sundin, J., Fear, N. T., Iversen, A., Rona, R. J., & Wessely, S.  (2010).  PTSD after Deployment to Iraq: Conflicting Rates, Conflicting Claims.  Psychological Medicine, 40 (3), 367-382.

Vasterling, J. J., Proctor, S. P., Friedman, M. J., Hoge, C. W., Heeren, T., King, L. A., & King, D. W. (2010).  PTSD Symptom Increases in Iraq-Deployed Soldiers: Comparison with        Nondeployed Soldiers and Associations with Baseline Symptoms, Deployment         Experiences, and Postdeployment Stress.  Journal of Traumatic Stress, 23 (1), 41-51.

Wright, K. M., Britt, T. W., Bliese, P. D., Adler, A. B., Picchioni, D., & Moore, D.  (2011). Insomnia as Predictor Versus Outcome of PTSD and Depression among Iraq Combat Veterans.  Journal of Clinical Psychology, 67 (12), 1240-1258.