Download “The Reintegration of Veterans with PTSD Back into Their

“The Reintegration of Veterans with PTSD Back into Their Communities Through the
Use of Public Health Initiatives”
Brief History of PTSD:
There have been great advances over the course of the last 60 years in the documentation
and acknowledgement of PTSD. It wasn’t until 1980 that PTSD was codified as a disorder in
the Diagnostic and Statistical Manual of Mental Disorders (DSM). PTSD is an issue that will
affect approximately between 1 in 5 or 1 in 6 Americans who will have undergone a traumatic
event at least once in their lifetime. It is the most commonly studied and perhaps the most
debilitating mental disorder that takes place after a disaster. (Galea, Nandi & Vlahov, 2004)
Much of the knowledge that we have today comes from years of study of our nation’s
veterans from where they have been placed in conflicts that have forever changed them. PTSD
has been referred to in the past before it was classified as a mental disorder as “nervous shock,
shell shock, traumatic neurosis, and rape related fear and anxiety.” (Galea, Nandi & Vlahov,
2004)
PTSD can affect anyone that undergoes a traumatic event. Many of the studies conducted
involve veterans because of the sample size of the population that is affected and the amount of
research that has been done on this community. Relevant factors accounting for the variability
of estimates in cohorts include the methodology and conceptual factors. This accounts for the
differences in prevalence rates across nations, generations, cultures, conflicts/wars, and studies
among other data. (Aust, 2010)
The data can be “fuzzy” or difficult to interpret at times because symptoms can be
underlying for as long as 30 years without surfacing. Many Vietnam era veterans reported
having chronic PTSD symptoms 20-25 years after the experience. There are statistics for
PTSD, TBI, depression, and suicide among this population of veterans and the fact that more
soldiers die by their own hand than by combat operations now is a sobering thought of the
reality that these men and women face. Statistics like 50% of those affected by PTSD do not
seek help or treatment for it, and the belief that the real number of those affected by PTSD and
or depression is actually much higher than the documented 1 in 5 people and that of these, only
½ of them get minimally adequate treatment. (Veterans & PTSD, 2013)
PTSD as it Pertains to Epidemiology & Biostatistics:
“Historically speaking, epidemiologic studies of wars have been conducted after the end of
hostilities. This is not the case with the OEF/OIF conflicts. Studies on PTSD among OEF/OIF
Veterans have brought about new observations and recommendations for future research.
Because of the importance of specific study design and characteristics to inferential power,
studies have been grouped by design type, and due to space limitations, do not always cover
other important health or mental health outcomes.“ (Litz & Schlenger, 2009)
The use of biostatistics to analyze and interpret data to better understand the underlying
issues that affect one’s mental health is being done in numerous facilities by experts in multiple
fields of mental & behavioral health as well as its affects to physical health. The relationships
between these conditions and how they are interlinked is a subject that many people are unable
to fully understand and it is one of the reasons that increases in research and funding have
been a topic of concern in recent years in addition to the nation’s financial responsibility. Over 4
billion dollars per year is currently paid out in disability payments to veterans that suffer from
PTSD. After 13 years of the country being at war, the estimates of 100,000 to 300,000
OIF/OEF veterans are considered to be at significant risk of developing chronic PTSD. The use
of biostatistics will help guide the course of treatment that is provided to people who suffer from
PTSD and possibly help alleviate some of the financial obligation required to address the
growing population of veterans that are at risk for chronic PTSD. The Strong Star Research
Consortium is one institute that is assigned to address this issue and more information can be
found in regards to their research at www.strongstar.org for a list of the projects. (Thomas,
2012)
Biostatistics in regards to PTSD comes from the statistical information of mental health
studies and the treatment of these patients. One of the influences that a recent study attributes
to the increase in PTSD is the fact that many people are now commonly exposed to multiple
deployments due to the high troop levels in both Iraq & Afghanistan. This phenomenon has
created a higher number of (PTSS) posttraumatic stress symptoms or homefront stressors such
as occupational problems and relationship or family problems. This is an increasingly common
occurrence among National Guard soldiers. Nearly ½ of the soldiers in the military have
experienced multiple deployments and the soldiers chances of being affected by PTSD
significantly increases with each consecutive deployment. Homefront stressors pertaining to
marriage, family, or work, are among the factors associated with this increased PTSD risk from
soldiers serving on multiple tours. This causes the soldier to manage repeat cycles of
deployment separations and readjustments to the homefront. Previous research has found that
these readjustment stressors are related to PTSD. (Interian, Kline & Janal, 2014)
This study on PTSS had one major aim, to better understand the role of homefront stressors
as a pre-deployment risk factor for PTSS among service members with multiple deployments.
The study examined these stressors at two time points. Post-deployment and pre-deployment.
By examining homefront stressors at these two time-points, the study assesses the impact of
different longitudinal patterns that these stressors have on PTSS. This is done by assessing the
effects of having homefront stressors at both time points versus one time point or another, or
neither. The study focuses on 196 respondents out of a possible 922 because the 196 had
previously been deployed at least once to either OIF/OEF in the past and 27.6% had tours
before OEF/OIF. Information collected from the study included age, gender, marital status,
education level, rank, employment status, ethnicity, parental status, pre-disposition to stressors
or existing PTSD, combat exposure and other variables. Please see the attached tables for
more info. (Interian, Kline & Janal, 2014) The below tables will give you a perspective of the
demographics of those involved in this study and the information that is used to derive the
biostatistics for this study. A summary of what the study revealed is included.
Table 1. Sample Characteristics
Variable
n or M
% or SD
Note
1.
N = 196. Age, marital status, education, employment status, rank, and military
occupational specialty were reported during Wave 1. OEF/OIF = Operation Enduring
Freedom/Operation Iraqi Freedom; PTSS = posttraumatic stress symptoms; MOS =
military occupational specialty.
Gender
Male
169
86.2
Female
27
13.8
17–25
23
11.8
26–39
112
57.4
40+
60
30.8
Married or living as
93
47.4
Never married
75
38.3
Widow/separated/divorced
26
13.3
Age (years)
Marital status
Parental status
No children
104
53.1
One or more children
92
46.9
White
83
42.3
Latino
47
24.0
Black
51
26.0
Other
15
7.7
High school or less
55
28.1
Some college
102
52.0
College graduate or more
39
19.9
Fulltime
167
85.2
Part-time
12
6.1
Unemployed
17
8.7
1
177
90.3
>1
19
9.7
Enlisted
176
91.2
Officer
17
8.8
Combat arms
60
32.3
Combat support
73
39.2
Race/ethnicity
Education
Employment
Previous OEF/OIF deployments
Rank
MOS
Combat service support
53
28.5
0
143
73.0
≥1
53
27.0
0
124
63.3
≥1
72
36.7
Wave 1 PTSS
26.9
11.8
Wave 2 PTSS
31.1
15.5
Combat exposure
5.2
7.2
Homefront stressors (Wave 1)
Homefront stressors (Wave 2)
PTSS was assessed using a well-established measure the 17-item PTSD Checklist-Civilian
Version or (PCL-C). For descriptive analyses the utilization of the 50-point cutoff for identifying
PTSD cases was used, which is commonly used in other research. The PCL-C was
administered at Waves 1 and 2. Internal consistency with the current sample was .95 at Wave 1
and .97 at Wave 2. Home front stressors were measured in waves 1 & 2 with a series of yes &
no questions as it pertained to various amounts of time in regards to wave 1 because the
variable of time since the soldier’s last deployment was different to each candidate. Wave 2
pertained to a 15 month window of 3 months prior to deployment and the 12 months for the
duration of the deployment. For all control measures, please see the actual study at this link.
http://onlinelibrary.wiley.com/doi/10.1002/jts.21885/full
Table 2. Multivariate Analysis of the Risk of Homefront Stressors on PTSS at Post
deployment
Step 1
Variable
B
SE B
Step 2
B
SE B
Step 3
B
SE B
Note
1.
N = 193. Model 1: R2 =.36; Adj R2 = .33; Model 2: R2 =.38; Adj R2 = .35 R-squared
change p = .015; Model 3: R2 = .41; Adj R2 = .38 R-squared change p = .002. Model 2: Pre
deployment home front stressors, β = .154. Model 3: Post deployment home front
stressors, β = .214. PTSS measured with PTSD Checklist. Marital status was
dichotomized to meet linear regression assumptions (never married vs. other
categories). PTSS = posttraumatic stress symptoms; SE = standard error.
2.
*p < .05. **p < .01. ***p < .001.
Intercept
2.73
9.02
4.58
8.93
3.99
8.73
0.57***
0.08
0.54***
0.08
0.52***
0.08
Previous trauma
0.10
0.54
−0.05
0.54
−0.20
0.53
Age
0.31**
0.12
0.28*
0.12
0.30**
0.11
Gender
5.20
2.78
4.62
2.76
4.50
2.69
Marital status
2.46
2.71
1.82
2.68
0.62
2.65
Parental status
−0.22
2.42
−0.72
2.39
−0.77
2.34
Military preparedness
−0.03
0.53
0.04
0.53
0.00
0.51
Combat exposure
0.42**
0.14
0.40**
0.14
0.25
0.15
Unit cohesion
−0.18*
0.08
−0.19*
0.08
−0.16*
0.08
home front Stressors
–
–
1.97*
0.80
1.25
0.81
Post deployment home front
–
–
–
–
2.88**
0.92
Pre deployment PTSS
stressors
“First, 7.1% of the respondents had probable PTSD (i.e., PCL-C ≥ 50) at Wave 1; 14.3% met
this criterion at Wave 2. Next, Wave 2 PTSS, as well as Wave 1 and Wave 2 home front
stressors, were compared according to the sample characteristics listed in Table 1. Wave 2
PTSS were significantly higher among female respondents, F(1, 194) = 4.88, p = .028. Home
front stressors significantly differed according to age category (17–25, 26–39, and ≥ 40 years) at
both waves: Wave 1, F(1, 192) = 3.61, p = .029; Wave 2, F(1, 194) = 3.47, p = .033. Home front
stressors at both waves also significantly differed according to marital status: Wave 1, F(1, 191)
= 10.48, p < .001; Wave 2, F(1, 191) = 7.35, p < .001. Pairwise comparisons (not shown)
showed that the youngest age group and those who were single reported significantly fewer
home front stressors at both waves. Finally, soldiers with children reported significantly more
home front stressors at Wave 1, F (1, 194) = 8.4, p = .004, and Wave 2, F(1, 194) = 6.40, p =
.012).” (Interian, Kline & Janal, 2014)
Table 3. Patterns of Homefront Stressors Occurring Before and After a New Deployment
and the Risk of PTSS at Post deployment
Variable
B
SE B
Note
1.
PTSS measured with PTSD Checklist-Civilian Version. R2 = .43; Adj R2 = .39. No
stressors: n = 102; new stressors: n = 41; reduced stressors: n = 22; chronic stressors: n
= 31. Chronic homefront stress, β = .22. Marital status was dichotomized to meet linear
regression assumptions (never married vs. other categories). PTSS = posttraumatic
stress symptoms.
2.
*p < .05. **p < .01. ***p < .001.
Intercept
7.56
8.73
No stress vs. new stress
−2.44
2.43
Relieved stress vs. new stress
−4.33
3.28
Chronic stress vs. new stress
9.39**
2.98
PTSS
0.50***
0.08
Homefront stressor group
Previous trauma
−0.14
0.52
Age
0.34**
0.11
Gender
5.58*
2.66
Marital status
1.30
2.69
Parental status
−1.48
2.32
Military preparedness
−0.15
0.51
Combat exposure
0.35*
0.14
−0.20**
0.08
Unit cohesion
“Analyses examined the effects of four subgroups with different patterns of home front
stressors: (a) no home front stressors before or after the new deployment (no stressors); (b)
home front stressors after but not before the new deployment (new stressors); (c) home front
stressors before but not after the new deployment (relieved stressors); and (d) home front
stressors both before and after the new deployment (chronic stressors). First, means for Wave 2
PTSS were generated for each of these groups and were found to be significantly different, F(3,
192) = 13.78, p < .001: (a) no stressors (M = 26.37, SD = 13.26), (b) new stressors (M = 32.24,
SD = 15.41), (c) relieved stressors (M = 31.09, SD = 12.44), and (d) chronic stressors (M =
44.94, SD = 16.22). The pattern of home front stressors was examined via multivariate analysis
in (Table 3). The group with new stressors was compared to each of the other three groups
showing a significant difference with the chronic stressors group. Compared to soldiers who
reported home front stressors occurring only after the new deployment (new stressors), soldiers
who had home front stressors both before and after the deployment (chronic stressors)
produced Wave 2 PTSS scores that were nine points higher.” (Interian, Kline & Janal, 2014)
This study revealed that the occurrence of home front stressors increased the risks of PTSS
and that soldiers were more likely to develop precursors to PTSD if PTSS was present before
and after the deployment. Overall, the issues that pertain to the lifestyle or family of individuals
deployed are relevant to the mental health of the individual. The frustration that these people
endure because they can’t be present to address issues at the home front due to being
separated and having no control or involvement in the situation leaves a sense of
powerlessness and creates a chain reaction of thought processes which I attribute to being the
leading cause for increases in PTSS and PTSD as a result of multiple deployments. This
causes undue hardships on the family structure and as a result makes reintegration into the
home front & community after the deployment increasingly difficult for all involved.
Biological and Molecular Effects as it Pertains to PTSD:
The biological & molecular effects of psychological stressors have multiple effects that
transpire throughout the endocrine system. Hormones are released in a series of different chain
reactions that each have a distinct effect & chemical reactions are then set into motion that
continue the chain of events that influence the response of the body’s endocrine & nervous
system. This chemical reaction is a response to the stimulation & signals that the brain
interprets & can vary on intensity based on different factors. The following examples of studies
about the biological & molecular characteristics of PTSD are suspected to have neurological
effects on the individual affected & could vary in degrees based on the severity of the trauma &
the susceptibility of the individual involved in the trauma.
Studies in animals have shown that exposure to severe stress can damage the
hippocampus & similar studies in humans suggest a link exists in the amount of volume present
in the hippocampus correlates with vulnerability to psychological trauma. The smaller
hippocampal volume constitutes a risk factor for the development of stress related
psychopathology & individuals with smaller hippocampal volume are more susceptible to
instances of PTSD than those with larger levels of hippocampal volume. (Gilbertson, Shenton
& Ciszewski, 2002)
Another study of the Serotonergic & Noradrenergic markers of PTSD & Depression has
shown that research on the biological pathophysiology of PTSD found evidence of the roles of
catecholamine & serotonin (5-HT). This finding on the increases of the catecholaminergic or
sympathetic nervous system (SNS) activity in PTSD patients is fairly consistent across studies.
For example, combat veterans with PTSD have shown significantly higher 24-hour urinary
excretion with plasma concentrations of catecholamine, noradrenaline (NE), adrenaline, &
dopamine, versus the normal control group, other psychiatric patients, or combat veterans
without PTSD. These combat veterans have shown significantly higher rise in plasma (NE) &
peripheral (SNS) activity than normal volunteers following acute stressors within the laboratory
with stimuli reminiscent of the trauma linked to their PTSD. PTSD patients also have
significantly decreased platelet counts suggesting down-regulation of α2-adrenoceptors (α2ARs) on platelets within the bloodstream. Laboratory trials with yohimbine, a α2-AR antagonist
that blocks the presynaptic α2-AR auto-receptor resulted in significantly higher plasma levels of
3-methoxy-4-hydroxyphenylglycol (MHPG), the major NE metabolite. This was more prominent
in PTSD veterans than in control groups.
These results suggest that central presynaptic α2-ARs are sub-sensitive in PTSD patients.
No significant alterations in 24-hour urinary (NE) excretion & lower arterialized plasma (NE)
concentrations have been found in other studies although no research has examined plasma
tyrosine, the precursor of (NE), in patients or veterans with PTSD. Evidence of (NE) in the brain
determined by tyrosine concentrations, are reflected in the plasma. This is measured by the
molar ratio of tyrosine to other amino acids which compete for the same cerebral uptake site.
The competing amino acids (CAA) are tryptophan, phenylalanine, leucine, isoleucine, & valine.
During stressful events the plasma tyrosine & the tyrosine/CAA increase & the increases in the
tyrosine/CAA ratio is related to increased brain noradrenergic turnover. (Maes, Lin & Verkerk,
1999)
Other studies have tried to identify the implications & relationships between trauma memory
for pharmacological treatments which have been proposed for the prevention of PTSD & the
idea of reprocessing trauma memories to bring about recovery through treatments such as
invasive exposure therapy. Psychological accounts of PTSD & the biological concept for
reconsolidation of active memories suggest that physiological arousal enhances the
reprocessing of traumatic memories. Use of drugs that influence arousal through chemical
means may then have effects after the trauma & depend on the psychosocial context that they
are used in, thus in theory helping to prevent the development of PTSD in some trauma victims,
but impeding recovery in others who would do well without such treatments. This would mean
that you would have to be preemptively treating someone with drug related therapies before
they were exposed to the traumatic event in order to use some of these treatments successfully.
(McCleery & Harvey, 2004)
There are many things that can trigger a traumatic event activating a person’s fight-or-flight
response which is the body’s instinctual reflex to possible trauma & works as a survival
mechanism normally by increasing the biological output of molecular responses such as the
increase of hormones such as adrenaline or body systems such as arterial blood pressure,
oxygen exchange in the lungs & many other effects. This natural response has given man
many advantages over the course of evolution. There are instances though that this natural
mechanism displays a dysfunction which happens when a functional impairment causes an
individual to become psychologically traumatized creating PTSD within the individual because
their normal defense mechanisms against trauma has failed to operate & process the
information in a manner that is traditionally in line with the body’s normal functioning. These
individuals are among the population that is biologically susceptible to the pathophysiology that
causes PTSD. These pathological features found in patients with PTSD overlap similarly in
patients with traumatic brain injury paralleling the shared signs & symptoms of these syndromes
in clinical studies. The signs & symptoms of PTSD appear to reflect a persistent & abnormal
adaptation of neurobiological systems to the stress of a witnessed traumatic event. The
neurobiological systems that regulate stress responses include certain endocrine &
neurotransmitter pathways as well the network of brain regions known to regulate fear &
behavior at both conscious & unconscious levels. (Sherin & Nemeroff, 2011)
Psychosocial & Behavioral Health Factors Influenced by PTSD:
Public Health is concerned with the psychosocial and behavioral health factors of the
community at large. There are various measures to discuss how public health can gauge these
concerns but here we will focus on the ecological model of health behaviors which are identified
as the five following factors. 1) Intrapersonal factors 2) Interpersonal relations 3) Institutional
factors 4) Community factors & 5) Public policy. These factors along with the psychological
model of health behavior or health belief model help explain how we interact with the world
around us and how the world around us can influence our behaviors & our actions. When you
associate these factors to the behavioral outcomes related to people who suffer from PTSD, we
may finally be able to understand the relationship of the events leading to the patient’s behavior
after being exposed to the traumatic event. (Schneider, 2012)
One study that focuses on the specific symptom clusters of 1) hyper-arousal 2) reexperiencing 3) numbing and 4) avoidance as it pertains to reabuse of women exposed to
intimate partner violence or (IPV) is of particular interest. I say that this is related to veterans
with PTSD because there are different types of experiences that can cause PTSD and many of
these symptoms are standard across all PTSD patients. Some are women veterans that
experienced spousal abuse or rape, while others are combat related. These symptoms are
common symptoms associated with PTSD. Hyper-arousal will be present in people that suffer
from PTSD and sometimes cause an increase in the severity of the response to episodes where
the patient is re-experiencing the traumatic scenario. The other symptoms numbing and
avoidance will have different effects on the individuals and how they interact with others. All of
these symptoms will affect the interpersonal relations of an individual that suffers from PTSD.
The symptoms will also interfere with how an individual that suffers from PTSD will interact with
all of the ecological factors at varying levels depending on the severity of the patient’s PTSD
symptoms and whether they are controlled with medication & therapy or uncontrolled. (Krause,
Kaltman & Goodman, 2006)
Another study which focuses on smoking and anxiety in combat veterans from the Vietnam
War has found a link in the behaviors of substance abuse and those that suffer from PTSD.
(Beckham, 1999) This coincides with the amount of smoking or substance abuse that is done to
help the patient avoid or numb the experience which is the subject of their pain. This link
between PTSD and substance abuse or chemical dependency being more prevalent in this
population of veterans along with the appearance of other negative health behaviors has an
adverse effect on the degree in which ecological factors affect the veteran community. This will
cause the veteran’s intrapersonal relationship to change thus causing a reaction within the
community & changing their interpersonal relationships, thoughts and feelings toward
institutions and the reactions they have toward changes in public policy or the failure of changes
to be implemented in public policy. This cascade of events or domino effect can possibly be
averted for the next generation of veterans that suffer from PTSD through the proper
implementation of treatment establishing a healthy behavior model that engages the veteran
with positive reinforcements. This study with further research can provide the information to
help render advancements in the treatment of recent veterans who are beginning to experience
similar circumstances and symptoms as those in the study. Treatments like group therapy and
support groups are the key to establishing a positively structured environment that nurtures
development of social skills through interpersonal relationships and helps to reintegrate the
veterans into the community.
A study that involves compulsive behaviors provides an example of how a health belief
model can influence the psychosocial behaviors and influence the reintegration of veterans into
the ecological model of society. The specific duties that a veteran has during a combat
deployment creates a rehearsed response which becomes a learned behavior and influences a
belief that things must be done according to this to have the desired health outcome which in
many cases is survival or the survival of fellow soldiers, friends & comrades. This conditioning
translates into difficulties in reintegrating back into the society here on the home front. With
over 1.5 million soldiers deployed into the theater of operations and an estimate as high as 1020% of these veterans experiencing some type or form of PTSD symptoms, it is of particular
interest to better understand how PTSD can be displayed or induce other forms of mental health
disorders such as OCD or anxiety disorders. These disorders and the symptoms of PTSD are
presenting with different clinical outcomes compared to other instances of PTSD and will thus
complicate the treatment process and possibly creates a concern for the public health in how to
best address the treatment of this increasing population and return them into active members of
the community. (Tuerk, Grubaugh & Hamner, 2009)
Conclusion Summary:
The reintegration of veterans with PTSD back into the community through public health
initiatives is a lengthy and time consuming process. It is not something that happens over the
course of a night, through 1 meeting, or the application & use of medications. There is no cure
all or instant fix solutions. It is not completed with just a shot in the arm, a pill to pop, or the
duration of a course of a prescription drug. It is a life-long process with success being
measured in varying degrees. The public’s health has been sustained in part through the
contributions and sacrifices of the veteran community allowing for the continuation of the
American lifestyle. PTSD is perhaps the most painful mental disorder to have treatment for and
it can be a life-long process of treatment through either therapy or medication to manage and
control the symptoms. The reintegration of these veterans into being active and participating
members of society is paramount to the overall success of the community. They have valuable
skills and experience that contribute to the success of a sustainable economy and in order for
the structure of society to remain intact, the public health community needs to accommodate
planning and strategies to address how to best help reintegrate these individuals into the home
front.
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