Those of us who have not had the misfortune of enduring war find it difficult to understand. Popular culture is rife with images of warfare, but nothing in civilian life actually compares to the experiences of combat. Combat stress includes not only the constant threat of injury and death, the horrors of witnessing violent death, and the moral ambiguity of killing others, but also an unrelenting accumulation of emotional and physical pressures: sleep deprivation, illness, the ongoing noise and impact of shell blasts, the stench of viscera, friendly fire, separation from loved ones, malnutrition, sexual assault, and so on, permeating one’s mental faculties 24/7, often to the point of injury.1
Combat veterans, therefore, represent a special group of individuals, unique in what they do and what they experience, as well as the subsequent burden they bear. One such veteran, Yuval Neria, PhD, has devoted his professional life to understanding extreme exposure to trauma including combat and war captivity, and its psychological consequences.2,3,4,5,6,7
“Research has improved our understanding of traumatic injuries by reliably defining diagnoses and documenting a range of long-term consequences,” said Dr. Neria. “But research has yet to provide a comprehensive psychobiological explanation for trauma related injuries, and we are just beginning to understand the different forms of war-related trauma.”
Dr. Neria, who served in the Israeli army in the 1973 Yom Kippur War, was injured and awarded the Medal of Valor, equivalent to the Congressional Medal of Honor. He is Director of the Trauma and PTSD Program at Columbia University Medical Center, Department of Psychiatry, and the New York State Psychiatric Institute (CUMC/NYSPI), where he is developing a state-of-the-art research and treatment program for returning war veterans.
“War breeds more than just fear; for example, war also confronts servicemen with an intensity of aggression, in others and themselves, which may differ from anything experienced in civilian life. This has a psychological “scarring” effect on certain soldiers. Other veterans are fixated on the loss of a buddy and suffer from traumatic grief.7 Some are more depressed, without any one outstanding trauma, yet worn down by operational stress to the point of being traumatized.” He added, “It’s imperative that we try to understand how to treat these various aspects of trauma, each of which deteriorates into the ‘downward spiral’ of PTSD.”
Post-traumatic Stress Disorder (PTSD)
Post-traumatic stress symptoms are many and varied. Symptoms may include vivid recurring memories of the trauma, severe anxiety, jumpiness, irritability and emotional withdrawal from friends and family, uncontrollable outbursts of anger, powerful urges to avoid any reminder of the trauma, and difficulty functioning from day to day. The symptom profile of PTSD permits clinicians and researchers to accurately diagnose and better treat and study the consequences of trauma exposure. Yet the experience of a combat veteran suffering from such symptoms encompasses much more than the list of symptoms. According to Dr. Neria, “A returning war veteran may often feel like a different person than he was prior to deployment. For many, being deployed for one or more tours, experiencing life threat, fatigue, and combat stress, is a life changing experience. Upon leaving the war zone and re-entering civilian life, a veteran can feel estranged, out of place, sometimes numb inside, and missing his service members.”
The emotional and cognitive injuries associated with war stress have been termed “invisible wounds.” Yet their invisibility only seems so at first. Left untreated, the reverberations of war can, in subtle and not-so-subtle ways, erode friendships, sever love relationships, ruin careers and professional aspirations, and dissolve vital bonds with children and parents.
“For some troops, it’s as if the war is reenacted in a personal context, destroying everything in its path,” said Dr. Neria.
PTSD brings the war home not only through vivid re-experiencing of the sensations and images of war, but through bodily and psychological pressures that echo the pressures of combat: insomnia, somatic discomforts, constant expectations of attack, nightmares, loneliness yet aversion to intimacy, self-recriminations, and so on. Over time, a “cascade” of negative outcomes descends. A comprehensive review of the psychosocial impact of war trauma demonstrates elevated rates among veterans of unemployment, divorce, loss of child custody, bankruptcy, incarceration, low emotional well-being, poor physical health, low productivity, and homelessness.8 Research also shows alarmingly elevated rates of domestic violence in veteran families, as well as secondary trauma among spouses and behavioral, academic and psychiatric problems among children.9,10,11,12
Untreated, PTSD can be fatal. Evidence strongly associates PTSD with increased mortality rates from suicide, homicide, “accidental” death, and medical problems such as coronary heart disease and cancer.8,13,14 Veterans with PTSD frequently have comorbid conditions (27%-75%), including major depressive disorder (MDD), traumatic brain injury (TBI), substance use disorders, and other anxiety disorders.8 Comorbidity implies greater severity and worse prognosis, and each comorbid condition, in turn, increases risk for negative outcomes.
Current Military Operations
The current military operations in Iraq and Afghanistan constitute a significant public health concern. Over 1.6 million U.S. military personnel have deployed to Iraq or Afghanistan since military operations began in 2001. Operation Iraqi Freedom (OIF), beginning in March, 2003, has been the largest sustained ground operation since Vietnam. The RAND Corporation study8 estimated 300,000 servicemembers and veterans of OIF and Operation Enduring Freedom (OEF) currently have combat-related PTSD and/or MDD, and approximately 320,000 have TBI.
PTSD and TBI have been labeled the signature injuries of the wars in Iraq and Afghanistan. Improved body armor, improved delivery of medical care on the battlefield, and rapid, 24-hour evacuation of injured soldiers to hospitals (versus 45 days in the Vietnam war) have radically shifted the fatality-to-wounded ratio from 1:2.4 in WWII, and 1:3 in Vietnam, to 1:9 in OIF.8 Soldiers are surviving injuries that once would have been fatal. The most common such injuries in OIF are multiple wounds resulting from improvised explosive device (IED) blasts, which frequently involve head and neck injuries, including severe brain trauma. Such injuries often result from, and constitute in themselves, severely traumatizing experiences, thus increasing risk for PTSD. Studies, in fact, show strong associations between TBI and PTSD, and TBI has also been associated with many negative outcomes, including chronic pain, suicide attempts, physical health problems, cognitive and interpersonal deficits, family difficulties, and other comorbid conditions.8,16
The consequences of war, though potentially devastating, are treatable. According to Dr. Neria, “Dealing responsibly with stress-injuries through validated, evidenced-based treatments gives a veteran a choice over fate: whether to serve or not, whether to suffer or not.”
Evidence-based psychotherapies of proven efficacy for PTSD include exposure therapy18,19 cognitive therapy20,21 and eye movement desensitization and reprocessing (EMDR).22 Other psychotherapy treatments are available for veterans with PTSD, though research is needed to test their efficacy. A current study at the Trauma and PTSD Program is comparing exposure therapy, interpersonal therapy (IPT), and relaxation therapy. Relaxation therapy, in which focus on bodily relaxation leads to decreased anxiety, has performed well in PTSD trials. IPT is a treatment that has demonstrated efficacy for depression and bulimia, and an initial trial found benefits for PTSD patients, focusing on the interpersonal consequences of PTSD.23 Another study at the Trauma and PTSD Program, scheduled to begin January 2009, will test a six-session, manualized cognitive-behavioral treatment for returning veterans. This study, led by Dr. Neria, introduces an innovative, flexible approach to the treatment of different types of war trauma, including classic fear-conditioned PTSD, traumatic grief, and moral injuries.
“Trauma is heterogeneous,” said Dr. Neria, “and exposure treatment doesn’t work for everyone. Those suffering pronounced relational conflicts may benefit from an interpersonal approach, while a different approach entirely may be needed for someone who has witnessed or participated in atrocities. Eventually, we want to streamline the patient-treatment matching process, making treatment more efficient. This will also minimize the expense of ineffective treatment.” He added, “A similar strategy applies to translational research in which we would like to target specific biological alterations of PTSD and develop more efficient and precise medications to address them.”
Effective evidence-based pharmacologic treatments exist for PTSD. Selective serotonin inhibitors (SSRIs) have received the most support to date.23 Recent evidence suggests that serotonin-noradrenaline reuptake inhibitors (SNRI) may also be effective.24 Benzodiazepines have shown negative results in clinical trials and are not appropriate for PTSD treatment.25
Treatment for TBI among war veterans is neither well understood nor well researched. A recent, large survey of OIF veterans found the impact of TBI on physical health was mediated by PTSD and MDD, indicating that TBI treatment needs to address its comorbid conditions.16 Future TBI research should routinely assess for PTSD and MDD and their effect on treatment response.
Access to Treatment
Treating the mental health needs of veterans requires specialized training. The military offers a variety of health care options to veterans and active-duty personnel through the Department of Defense (DoD), most commonly at Military Treatment Facilities (MTFs), and to veterans through the Department of Veteran Affairs (VA), including VA health facilities and clinics, VA polytrauma centers, and Vet Centers. Some veterans may also seek mental health care at civilian facilities financed through the military health care plan, TRICARE.8
Military health professionals understand the military culture in which mental health problems among veterans arise, are diagnosed, and treated, but access to such professionals is limited. There is an acute shortage of trained clinicians in the DoD, which suffers from high attrition in mental health personnel due to burn out, low pay, and conflicts in the dual role of officer and practitioner.8 Servicemembers interested in accessing mental health care face long wait lists, which often results in withdrawal.
Another limitation to access comes from the VA’s fixed budget. While there has been increased demand for VA mental health services, this increase does not reflect use by OIF/OEF veterans. Rather, recent demand has been five times greater among veterans from past wars. This may be due to changes in disability benefits, stress associated with aging and retirement, or reactivation of PTSD. At the same time demand for services has increased, the number of visits per patient has decreased by 38% from 1997 to 2005, implying poor continuity of care and higher drop-out rates.8
Yet another limitation to access occurs when deactivated reservists return to homes dispersed across the country, often not geographically near MTFs or VA facilities. Besides limited access to care, one study found mental health problems higher among reservists and Guardsmen (42.4%) than active-duty personnel (20.3%).26 Research to better understand and treat the needs of reservists and Guardsmen is needed.
Barriers to Treatment
The impact of limited access to treatment is substantial. Of the approximately 508,400 servicemembers with PTSD, MDD, or TBI, or some combination of the three, more than two-thirds have not received minimally adequate mental health treatment in the prior year.8 Yet the lack of care only partly reflects the Veteran Administrations’ (VA) fixed resources and the shortage of DoD personnel; it also indicates the stigma military personnel attach to mental health care.
Hoge et al. (2004)27 found that 60% to 77% of veterans of the Iraq war who screened positive for PTSD, GAD, or MDD did not seek treatment, and were twice as likely as other veterans to report concern about possible stigmatization and other barriers to seeking mental health care. On measures of perceived barriers to care, the most frequently cited items were “I would be seen as weak” (65%) and “My unit leadership might treat me differently” (63%). Similarly, RAND (2008) 8 found that servicemen in need of care endorsed numerous barriers, including concerns that treatment would not be kept confidential (29%), would harm their career (44%), and would lower the respect and confidence of their comrades (38%), leaders (23%) and family (12%).
Evidence suggests that the stigma associated with mental health care is partially an effect of military training.8,27 War represents a different moral circumstance than society; in fact, a central component of military training involves preparing the conscience for acts of war. This point has no analogy in civilian society, and indeed contradicts civic ethics. Yet conscience matters in war because it can interfere with necessary action, which can, in turn, endanger one’s own life and the lives of one’s comrades. Therefore, what many soldiers have been trained to fear, perhaps more than death, is the perception of failure or weakness.1
This fear is compounded by military culture. Security clearance and career advancement require mental fitness in the eyes of leadership, and among servicemen it is well known that confidentiality in military mental health services is not an option. On a military base, a referral for mental health counseling requires an escort.8 Applications for security clearance, until recently, inquired about previous mental health care. Most servicemen learn to confide in their comrades, or chaplains, or they just “bury it.” 8
Trust in leadership becomes a still more complex issue in times of war. In the field, servicemen come to trust their comrades and often unit commanders with their lives—but this trust does not easily extend up the chain of command, to leaders removed from risks on the front-line. When leadership decisions can endanger one’s life, the threshold for tolerating error is lowered.28
Mistrust can extend all the way up the ranks. A recruit might experience as a betrayal the fact that current U.S. government has repeatedly changed the rules of deployment, calling servicemen back more frequently and for longer tours.8 This effect might be intensified among Guardsmen, given the dramatic shift in their role from stateside civic operations to combat overseas. A traumatized soldier might view the VA, devoted exclusively to the medical and mental health needs of war veterans, with mistrust, given its association with the military. A battle-weary soldier might suspect that the interests of the VA, ostensibly in synch with his own, might actually coincide with the military need to patch up and redeploy soldiers.
These barriers to care constitute a public health concern. Many returning servicemen attempt the transition back into civilian life on their own, or with help from family and friends. Yet military returnees face psychological challenges that can negate the best of intentions. They may try to “bury it,” but will encounter an unfortunate fact: time does not heal chronic PTSD. The National Vietnam Veterans Readjustment Study (NVVRS) estimated that, in 1998, 15 percent (472,000) of those who had served in Vietnam three decades earlier still met diagnostic criteria for active PTSD. A prospective, longitudinal study of Israeli veterans of the 1982 Lebanon war found that assessments performed 1, 2, 3 and 20 years after combat revealed enduring, severe posttraumatic residues.29
“We ought to learn from past mistakes,” said Dr. Neria. “and create a supportive, caring environment for returning veterans. Our research program has an ambitious agenda, to test a range of state-of-the-art, evidence-based treatments as part of a broad research portfolio, in order to identify innovative psychotherapy and psychopharmacologic treatments. We want to ensure that the many thousands of veterans close to us in New York have the best care possible. We also aspire to create an effective model for practical and effective treatment that can be adopted elsewhere, and to improve our knowledge about the determinants of combat related PTSD. We believe that treating returning service members in civilian health care facilities, such as the New York State Psychiatric Institute, should appeal to many veterans because of our neutrality, professionalism, and enthusiasm.”
Veterans interested in treatment at the Trauma and PTSD Program at CUMC/NYSPI may call (212) 543-6747, or log on to http://columbiatrauma.org. Treatments are funded by research grants and free-of-charge. Confidentiality is ensured as data is monitored with anonymous ID#s, and there are no external communications regarding patient information.
- Nash WP. The stressors of war. In: Figley, CF, Nash, WP, eds. Combat Stress Injury: Theory, Research, and Management. New York: Routledge, 2007.
- Neria Y, Solomon Z, Dekel R. Eighteen-year follow up of Israeli prisoners of war and combat veterans. The Journal of Nervous and Mental Disease, 1998; 186: 174-182.
- Neria, Y, Solomon Z, Ginzburg K, Dekel R, Enoch D, Ohry A, Posttraumatic residues of captivity: A follow-up of Israeli ex-Prisoners of War. Journal of Clinical Psychiatry, 2000; 61: 39-46.
4.Neria Y, Solomon Z, Ginzburg K, Dekel R. Sensation seeking, wartime performance, and long-term adjustment among Israeli war veterans. Personality and Individual Differences, 2000; 29: 921-932.
- Zakin G, Solomon Z, Neria Y. Hardiness, attachment style, and long term distress among Israeli POWs and combat veterans. Personality and Individual Differences, 2003; 34: 819-829.
- Neria Y, Koenen K. Self-Reported Physical Health in Israeli War Veterans with Combat Stress Reaction: An Eighteen-Year Follow-up Study. Anxiety, Stress, and Coping, 2003; 16: 227-
- Papa A, Neria Y, Litz B. Traumatic bereavement in war veterans. Psychiatric Annals, 2008: 38.
- The RAND Corporation. Invisible Wounds of War: psychological and cognitive injuries, their consequences, and services to assist recovery. Tanielian, T, Jaycox, LH, eds. Santa Monica, CA: RAND Corporation, 2008. www.rand.org
- Jordan BK, Marmar CR, Fairbank JA, et al. Problems in families of male Vietnam veterans with PTSD. Journal of Consulting and Clinical Psychology, 1992; 60(6): 916-926.
- Dirkzwager AJ, Bramsen I, Ader H, van der Ploeg HM. Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 2005; 19: 217-226.
- Solomon Z, Waysman M, Levy G, et al. From the front line to home front: a study of secondary traumatization. Family Process, 1992; 31(3): 289-302.
- Davidson JR, Smith RD, Kudler HS. Familial psychiatric illness in chronic PTSD. Comprehensive Psychiatry, 1989; 30(4): 339-345.
- Kubzansky LD, Koenen KC, Spiro A, et al. Prospective study of PTSD symptoms and coronary heart disease in the Normative Aging Study. Archives of General Psychiatry, 2007; 64(1): 109-116.
- Beckham JC, Moore SD, Feldman ME, et al. Health status, somatization, and severity of PTSD in Vietnam combat veterans with PTSD. American Journal of Pychiatry, 1998; 155(11): 1565-1569.
- Altmire J. Testimony of Jason Altmire. Hearing Before the Subcommittee on Health of the House Committee on Veterans’ Affairs. Washington, D.C., 2007.
- Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 2008; 358(5): 453-463.
- Koren D, Norman D, Cohen A, et al. Combat-related injury increases the risk for PTSD: an event-based matched injured-control study. American Journal of Psychiatry, 2005; 162: 276-282.
- Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines From the International Society of Traumatic Stress Studies. New York: Guilford, 2000.
- van Etten ML, Taylor S. Comparative efficacy of treatments for PTSD: a meta-analysis. Clinical Psychology and Psychotherapy, 1998; 5: 126-144.
- Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of PTSD in female rape victims. Journal of Consulting and Clinical Psychology, 2002; 70(4): 867-879.
- Monson CM, Schnurr PP, Resick PA, et al. Cognitive processing therapy for veterans with military-related PTSD. Journal of Consulting and Clinical Psychology, 2006; 74(5): 898-907.
- Davidson PR, Parker KC. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology, 2001; 69(2): 305-316.
- Davis LL, Frazier EC, Williford RB, et al. Long-term pharmacotherapy for PTSD. CNS Drugs, 2006; 20(6): 465-476.
- Baldwin DS. Serotonin noradrenaline reuptake inhibitors: a new generation for treatment of anxiety disorders. International Journal of Psychiatry in Clinical Practice, 2006; 10: 12-15.
- Friedman MJ. PTSD among military returnees from Afghanistan and Iraq. American Journal of Psychiatry, 2006; 163(4): 586-593.
- Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA, 2007; 298(18): 2141-2148.
- Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, metnal health problems, and barriers to care. New England Journal of Medicine, 2004; 351(1): 13-22.
- Shay J. Achilles in Vietnam. New York, NY: Scribner, 1994.
- Rosenheck R, Fontana A. Changing patterns of care for war-related PTSD at VA Medical Centers: the use of performance data to guide program development. Military Medicine, 1999; 164(11): 795-802.
- Solomon Z, Mikulincer M. Trajectories of PTSD: a 20-year longitudinal study. American Journal of Psychiatry, 2006; 163(4): 659-666.