For VCCC Libguide

1. Post-Traumatic Stress Disorder
(PTSD) in Iraq & Afghanistan
Veterans – The Impact on the
Community
Paula D. James, DNP, RN, CCNS

2. “…for the first time in recorded warfare, psychological
morbidity is likely to outstrip physical injury associated
with combat.” (Sammons & Batten, 2008, p. 921)

3. Introduction
• Over 2 million U.S. soldiers have deployed to Iraq
and Afghanistan since the beginning of the war in
2003.
• It is estimated that at least 300,000 have or may be
diagnosed with PTSD.
– This may just be the ‘tip of the iceberg’.
(Golding, 2011; Hafemeister & Stackey, 2010; Stiglitz & Bilmes, 2012; Tanielian & Jaycox, 2008;
Zeber, Noel, Pugh, Copeland & Parchman, 2010)

4. Introduction
• Current troop composition
– All volunteer forces
– Active Duty, Reserves, National Guard
– More women
– Troops are older
– Pre-existing medical conditions
– Tours of duty are longer
– Many veterans have served multiple tours in both Iraq &
Afghanistan

5. PTSD – The Diagnosis
• Concept developed in 1980 by the American
Psychiatric Association
– Majority of its’ use dealt with those involved in war.
– Definition expanded in 2000.
– Most recent revision, Diagnostic and Statistical Manual V
(DSM-V), May 2013.
• Criteria for diagnosis (American Psychiatric Association, 2013)
– The trigger
• Exposure to a very severe stressor – actual or potential
– Additional requirements

6. PTSD – The Diagnosis
• Cluster of attributes (American Psychiatric Association, 2013)
– Re-experiencing of the traumatic event
• Frequent upsetting dreams & painful memories
– Avoidance
• Experiences which provoke remembrance of the trauma
– Negative cognitions and mood
• Separation from others; Inaccurate perceptions of guilt related
to self or others; amnesia regarding significant parts of the
event
– Arousal
• Violent, uncontrolled, self-injurious behavior; problems with
sleeping; hyper-alertness
• The timeline

7. Understanding Why
• Tours of duty
– Longer
– Multiple tours in both Iraq and Afghanistan
• Increased risk of PTSD by 50%
(Demers, 2009)
• Challenges provided by these wars
– No “front lines”
– Differentiating combatants from non-combatants
– All members are at risk.

8. Understanding Why
• Groups at increased risk
– Women
• Lower rate than men, but increased chronicity
• Sexual assaults
• Combat
– Minorities
– Those who:
• Have suffered a previous traumatic event
• Lack a social support system
• Have other mental health diagnoses
• Have family members with mental health problems
• Department of Defense (DOD) Task Force on
Mental Health

9. The Stigma of Mental Illness
• Those who need care the most are the least likely
to seek it.
• What is stigma?

10. The Stigma of Mental Illness
• The stigma of mental illness
– Special considerations in the military
• Adverse career implications
• Inability to obtain a security clearance
• Perceived negative effects of medications
• Belief that help from relatives and colleagues is more beneficial
• Loss of faith in their abilities by others
(Harrison et al, 2004)
• Loss of self-worth and self-confidence
• Societal labeling
• Bias and inequity
(Corrigan et al, 2004)

11. The Impact of PTSD
• The member
• Co-workers
• Society
• Major issues
– Maintaining employment
– Estrangement
– Homelessness
• Veterans versus non-veterans
• Men vs. women
– Violence
(Harrison, Satterwhite & Ruday, 2010; Sammons & Batten, 2008)

12. Impact on the Family
• The effects of deployment
– At the end of 2009, more than 50% of deployed
personnel were married and 85% of them had dependent
children. (Hinojosa, Hinojosa, Nelson & Nelson, 2010)
• PTSD and the family
– Increase in domestic violence
– Increase in divorce
– Decreased social support for the veteran
• Increase in stress and worsening of the PTSD
(Khaylis, Polusny, Erbes, Gerwitz & Rath, 2011)

13. Other Factors to Consider
• When care is sought
– Who
• The veteran or their family member
– What
• Medical complaints vs. mental health issues
• Attempts to self-treat
– When
• Immediate vs. delayed
– Where
• Military, VA, Civilian provider

14. The Burden of Care
• The Veteran’s Affairs Health System
– “the largest health care system in the world”
(Iverson, Cornell & Smits, 2009, p.62)
– Overburdened in all respects
– Why they cannot respond as needed
• Chronically ill and aging Korean and Vietnam War veterans
• Numbers currently served (Geiling, Rosen & Edwards, 2012; Stiglitz &
Bilmes, 2012)
• Financial, materiel & personnel shortfalls – the most
significant being behavioral health (Bilmes, 2009)
– Access to care
• Rural areas
• Wait times

15. VA – Military - Civilian
• Preparing the civilian community to handle the
burden & recognize the problem
– Not adequately prepared – especially in the area of
PTSD
– Relating to the experience of war
– Need early screening, detection and treatment in primary
care clinics (Geiling, Rosen & Edwards, 2012)
• Looking past the initial diagnosis to prevent co-morbidities

16. Costs of Care
• Costs of care for PTSD & Major Depression (2007)
– 4-6.2 billion over a 2 year period
• Cost and availability of evidence-based care
• Projected cost of disability benefits and care for OIF
and OEF vets during their lifetime
– 589-934 billion (Stiglitz & Bilmes, 2012)

17. Things to Remember
• Veterans from previous conflicts may “re-experience”
their PTSD symptoms as a result of hearing about and
watching events in current conflicts and reliving past
events.
• Because of the failure or reluctance of those
experiencing post-traumatic stress to seek mental
health care, and the lack of mental health providers,
primary care providers are the health care providers
most frequently sought out.
• (Geiling, Rosen & Edwards, 2012; Prins, Kimerling & Leskin, 2007)

18. Conclusions
• The enormity of the situation
– Iraq
• Lingering issues
– Afghanistan
• Volatile setting
• Faceless insurgents in a war without front lines.
– Invisible effects of battle
– Where the needs are
• What we as healthcare providers need to do

19. (http://www.armytimes.com/news/2008/12/ap_dwyer_street_120808)
While we may have adequately prepared our military forces to
fight the war, the country was not adequately prepared for
their return. (Iverson, Cornell & Smits, 2009)

20. References
• Bilmes, L. (2007). Soldiers Returning from Iraq and Afghanistan: The
Long-term Costs of Providing Veterans Medical Care and Disability
Benefits. Harvard University, John F. Kennedy School of
Government, Faculty Research Working Paper Series, RWP07-
001, 1-20.
• Blakely, K. & Jansen, D.J. (2013). Post-Traumatic Stress Disorder and
Other Mental Health Problems in the Military: Oversight Issues for
Congress. Congressional Research Service, 7-5700, www.crs.gov,
R43175.
• Corrigan, P. (2004). How Stigma Interferes with Mental Health Care.
American Psychologist, 59, 614-625.

21. References
• Demers, A. (2009). The War at Home: Consequences of Loving a
Veteran of the Iraq and Afghanistan Wars. The Internet Journal of
Mental Health, 6, www.ispub.com.
• Frances, A., First, M.B., & Pincus, A.B. (2004). DSM-IV-TR Guidebook.
Washington, DC: American Psychological Association.
• Golding, H.L.W. (2011). Potential Costs of Health Care for Veterans
of Recent and Ongoing U.S. Military Operations. Statement before
the Committee on Veterans’ Affairs, United States Senate.
Washington, DC: Congressional Budget Office.

22. References
• Hafemeister, T.L. & Stackey, N.A. (2010). Last Stand!? The Criminal
Responsibility of War Veterans Returning from Iraq and
Afghanistan with Post-traumatic Stress Disorder. Indiana Law
Journal, 85, 88-141.
• Harrison, J.P., Satterwhite, L.F. & Ruday, W. (2010). The Financial
Impact of Post-traumatic Stress Disorder on Returning U.S. Military
Personnel. Journal of Healthcare Finance, 36, 65-74.
• . Hinojosa, R., Hinojosa, M.S., Nelson K., & Nelson, D. (2010). Veteran
Family Reintegration Primary Care Needs and the Benefit of the
Patient-Centered Medical Home Model. Journal of the American
Board of Family Medicine, 23, 770-774.
• Iverson, D.A., Cornell, M., & Smits, P. (2009). Medicine & Society – The
“Army of Lost Souls”. Virtual Mentor, American Medical
Association Journal of Ethics, 11, 61-71. www.virtualmentor.org

23. References
• Khaylis, A., Polusny, M.A., Erbes, C.R., Gerwitz, A., & Rath, M. (2011).
Posttraumatic Stress, Family Adjustment, and Treatment
Preferences Among National Guard Soldiers Deployed to
OEF/OIF. Military Medicine, 176, 126-131.
• Koo, K.H. & Maguen, S. (2014). Military Sexual Trauma and Mental
Health Diagnoses in Female Veterans Returning from Afghanistan
and Iraq: Barriers and Facilitators to Veterans Affairs Care.
Hastings Women’s Law Journal, 25, 27-38.
• Litz, B. & Orsillo, S.M. (2007/2010). The Returning Veteran of the Iraq
War: Background Issues and Assessment Guidelines. National
Center for PTSD. Retrieved from
http://www.ptsd.va.gov/professional/pages/vets-iraq-war-
guidelines.asp

24. References
• Nayback, A.M. (2008). Health Disparities in Military Veterans with PTSD:
Influential Sociocultural Factors. Journal of Psychosocial Nursing
and Mental Health Services, 46, 42-53.
• Prins,A., Kimerling, R. & Leskin, G. (2007). PTSD in Iraq War Veterans:
Implications for Primary Care. National Center for PTSD.
Retrieved from
http://www.ptsd.va.gov/professional/pages/assessments/pc-
ptsd.asp.
• Prins, A., Ouimette, P., Kimerling, R., Cameron, R.P., Hugelshofer, D.S.,
Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., & Skeikh, J.I.
(2003/2010). Primary Care PTSD Screen (PC-PTSD). National
Center for PTSD. Retrieved from
http://pwww.ptsd.va.gov/professional/pages/ptsd-iraq-vets-primary-
care.aspcare.asp

25. References
• Romanoff, M.R. (2006). Assessing Military Veterans for Posttraumatic
Stress Disorder: A Guide for Primary Care Clinicians. Journal of
the American Academy of Nurse Practitioners, 18, 409-413.
• Sammons, M.T. & Batten, S.V. (2008). Psychological Services for
Returning Veterans and Their Families: Evolving
Conceptualizations of the Sequelae of War-Zone Experiences.
Journal of Clinical Psychology, 64, 921-927.
• Seal, K.H., Bertenthal, D.., Maguen, S. Gima, K., Chu, A., & Marmar,
C.R. (2008). Getting Beyond “Don’t Ask; Don’t Tell”: An Evaluation
of US Veterans Administration Post deployment Mental Health
Screening of Veterans returning From Iraq and Afghanistan.
American Journal of Public Health, 98, 714-720.

26. References
• Seal, K.H., Bertenthal, D., Miner, C., Sen, S. & Marmar, C. (2007).
Bringing the War Back Home. Archives of Internal Medicine, 167,
476-482.
• Stecker, T., Fortney, J.A., Hamilton, F. & Azjen, I. (2007). An
Assessment of Beliefs About Mental Health Care Among Veterans
Who Served in Iraq. Psychiatric Services, 58, 1358-1361.
• Tanielian, T. & Jaycox, L.H. (Ed.) (2008). Invisible Wounds of War:
Psychological and Cognitive Injuries, Their Consequences and
Services to Assist Recovery. The Rand Corporation
• U.S. Department of Veterans Affairs, National Center for PTSD.(2010).
Traumatic Stress in Female Veterans. Retrieved from
http://www.ptsd.va.gov/professional/pages/traumatic_stress_in_
female_vets.asp.

27. References
• U.S. Department of Veterans Affairs, National Center for PTSD.
(2007/2010). PTSD Screening and Referral: For Health Care
Providers. Retrieved from
http://www.ptsd.va.gov/professional/pages/screening-and-
referral.asp.
• Vogt, D. (2007). Research on Women, Trauma and PTSD. National
Center for PTSD. Retrieved from
http://www.ptsd.va.gov/professional/pages/women-trauma-
ptsd.asp
• Zeber, J.E., Noel, P.H., Pugh, M.J., Copeland, L.A. & Parchman, M.L.
(2010). Family Perceptions of Post-Deployment Healthcare Needs
of Iraq/Afghanistan Military Personnel. Mental Health in Family
Medicine, 7, 135-143.