Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Why Lack of Understanding of PTSD is Preventing Effective Screening for Iraq Veterans – Jay Myung

The term post-traumatic stress disorder slowly made its way into existence in the period following the Vietnam War. At the time, symptoms resembling PTSD were labeled shell shock and were blamed on veterans themselves for having gone to war in the first place. The American public and government were highly scrutinized for their degradation of returning soldiers, and since then numerous support groups as well as the Vietnam Veterans Memorial in Washington, D.C. have been dedicated in support and recognition of Vietnam veterans.

In 2003, Operation Iraqi Freedom was launched representing the largest ground operation effort since the Vietnam conflict (2). Approximately two-thirds of those deployed to Iraq are aware of someone that was killed or seriously injured. Ground forces have experienced more explosive warfare in the current conflict compared to any previous combat.

It is this type of explosive warfare that has specifically been associated with PTSD (3). Recent studies suggest an unprecedented number of soldiers returning from Iraq with symptoms of PTSD since their deployment in 2003 (1-8, 13). One study conducted in 2004 showed PTSD among 17% of returning soldiers, while another study conducted in 2006 showed positive screening for 19% of those deployed. In comparison, 15.2% of Vietnam veterans involved in close combat were diagnosed with PTSD (5).

PTSD that is not recognized and treated can have devastating consequences. Panic attacks, substance abuse, depression, and ultimately suicide are all known complications. Among Iraq veterans with PTSD, eleven fatalities from suicide were reported during 2003-2004. The following year twenty-two cases were reported.

Current screening interventions primarily consist of a pre and post deployment checklist. This checklist screens for general medical and mental health conditions and was updated in September 2007 to include additional questions on behavioral health and traumatic brain injury. Additional screening measures include active screening by primary care physicians, as well as an online voluntary self-assessment that can be taken at any time.

Altogether, these measures do not yield significant improvements in PTSD screening among soldiers returning from Iraq [4, 6]. The screening checklists contain a superficial set of questions that lack an understanding of PTSD. They address observable symptoms while ignoring that they occur within an environment, and that the military environment in particular carries with it unique considerations. The remainder of this discussion involves a look into how current screening checklists are missing a significant portion of PTSD among Iraq veterans due to stigmas, awareness of PTSD, and differences in gender.

The PTSD Stigma

There are generally two stigmas surrounding PTSD in the military. The first involves the perception that those with PTSD are weak (13). From boot camp, social inoculation to be strong and disciplined is heavily emphasized. Cadets model one another as well as their commanding officers in cognition and behavior. The presence of nightmares, anxiety, and depression can therefore be seen as outside the realm of accepted behavior. Soldiers can easily be looked down upon by peers and commanding officers (13). And since PTSD is not rank-specific, higher-ranking officers may have a more difficult time coming to terms with surrounding stigmas.

The second stigma involves job placement. It is common knowledge among soldiers that reporting positively to any of the questions on screening surveys may result in a mandatory visit to a physician or mental health professional. A recommendation produced from this visit can jeopardize consideration of current and future military jobs and assignments. This is especially true if a particular ailment warrants detachment from the military for either a temporary or prolonged period (12, 15). Recently, a soldier with eight years of combat experience and two tours in Iraq was arrested for seeking treatment for PTSD. He described receiving inadequate recognition and treatment within the military. His ailments were so detrimental to his daily functioning that he had to leave the army to seek treatment elsewhere. His withdrawal was not recognized by the military and he was subsequently arrested (19).

To the general public, these stigmas may not appear strong enough to deter one from reporting symptoms and seeking treatment. According to one study involving the general population, stigmas associated with future job prospects accounted for only 10% of failures to seek medical attention, while embarrassment from peers accounted for 13%. The same study conducted among soldiers returning from the Bosnia conflict showed that 61% of participants were reluctant to seek recognition and treatment specifically due to worries about their career, while 43% were worried that they might be looked at differently or down upon by peers (12). The numbers illustrate a marked contrast between the worries of life in the military compared to that of the general public.

Now consider that of the soldiers reporting symptoms resembling PTSD, only 23%-40% sought medical attention for their ailment. The soldiers that sought treatment were also twice as likely to admit that stigmas presented a barrier to seeking care and reporting symptoms (13). In another study, the two most commonly perceived barriers to admitting symptoms and seeking treatment were career risks (50%) and altered peer perceptions (50%-65%)(8). These two stigmas clearly carry significant weight with regard to how soldiers report symptoms on screening forms. The data suggest that the number of soldiers that denied symptoms due to such barriers may in fact be substantial. These soldiers remain at large suffering panic attacks and generalized anxiety on a daily basis.

Beliefs About PTSD

PTSD is a condition that requires medical attention just like any other disease. According to the health belief model, behavior in response to a condition is based on perceived severity, vulnerability, barriers, and benefit. The combination of these factors may predict whether a behavior will be taken. Barriers in the form of stigmas were described above. Perceived severity, vulnerability, and benefit may provide further explanation regarding denial of symptoms on screening checklists.

Soldiers returning from war may be more apathetic towards seeking treatment than the general public. In a study conducted among the general population, more than 50% of subjects reported that they did not perceive an adequate benefit associated with seeking medical attention. More than 30% did not consider their mental health condition severe enough to seek attention (16). Among Iraq soldiers, 85% of those screened positively for a mental health condition recognized that they had a problem, but only 45% were interested in seeking treatment. The avoidance was mostly due to a perceived lack of severity and benefit. For instance, 55% avoided care because it was too difficult to get off of work, while 25%-38% expressed a lack of trust in healthcare professionals (13).

Is the perceived lack of severity justified? Suicide as a direct result of PTSD is approximately 0.13%, higher than in the general population (11). However rates may in fact be higher due to the intervening depression, substance abuse, anxiety disorders, and chronic PTSD that often precede suicide attempts. These chronic complications are often overlooked or considered insignificant when compared to suicide, and may account for the low sense of severity.

Is the perceived lack of benefit from care justified? The patients may not be aware that PTSD can be managed with medications, and that sufficient benefit and prevention can result from seeking care (13). Other interventions such as cognitive-behavioral therapy might be regarded as having a low probability of success. CBT actually produced the most benefit compared with many therapies when combined with medication (10).

The lack of awareness of treatment success combined with the notion that PTSD is not a significant condition can therefore easily lead to an intentional denial of symptoms on screening forms. The data suggest that these factors cannot be ignored.

PTSD and Gender

A clear understanding of gender differences was not recognized when developing the screening questionnaire. While this may not lead to an extensive number of missed cases, it may promote the increased morbidity for those women that were overlooked.

Past studies have clearly shown that PTSD is more common in women and that women are more likely to display different symptoms (10). For instance, women are more likely to experience physical manifestations in response to stimuli resembling previous traumatic episodes, and are more likely to avoid personal or environmental associations. The current screening form addresses this symptom in a single question. The problem is that there are only four questions addressing PTSD and a screening form is considered positive for PTSD when at least three of the questions are answered in the affirmative, regardless of whether the subject is male or female. While this may represent a gap in detection for anyone, women are particularly at risk of not getting screened appropriately because the symptoms they tend to experience are summarized in a single sentence and worth only a single point out of four.

Detection of PTSD among women is particularly significant due to increased risk factors and higher rates of complications. Women have higher rates of depression, suicide attempts, and anxiety than men (10). Women also respond differently to various treatments. Prolonged-exposure cognitive-behavioral therapy in particular appears to produce a significant improvement in PTSD symptoms and complications compared to other modalities for women in the military (10).


Vietnam veterans still suffer from chronic PTSD. The depression, anxiety, and withdrawal affect everyone involved. PTSD does not have devastating consequences such as those linked with smoking, but instead yields slow changes manifested in family, friends, and peers. These changes can be prevented but must first be recognized. Continued use of checklists as the primary method of screening for PTSD will undoubtedly allow many cases to go unnoticed.


  1. Kolkow TT, Spira JL, Morse JS, Grieger TA. Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Military Med. 2007 May;172(5):451-5.
  2. Erbes C, Westermeyer J, Engdahl B, Johnsen E. Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine. 2007 Apr;172(4):359-63.
  3. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine. 2007 Mar 12;167(5):476-82.
  4. Greenburg DL, Roy MJ. In the shadow of Iraq: posttraumatic stress disorder in 2007. Journal of General Internal Medicine. 2007 Jun;22(6):888-9.
  5. Nau JY. One quarter of American soldiers serving in Iraq and in Afghanistan suffer from mental health disorders. Review of Medicine Suisse. 2007 Mar 28;3(104):837.
  6. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry. 2007 Jan;164(1):150-3.
  7. Rona RJ, Hooper R, Jones M, Hull L, Browne T, Horn O, Murphy D, Hotopf M, Wessely S. Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. BMJ. 2006 Nov 11;333(7576):991.
  8. Hoge CW, Castro CA. Post-traumatic stress disorder in UK and US forces deployed to Iraq. Lancet. 2006 Sep 2;368(9538):837
  9. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association. 2007 Feb 28;297(8):820-30. Your browser may not support display of this image.
  10. Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, Resick PA, Thurston V, Orsillo SM, Haug R, Turner C, Bernardy N. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. Journal of Affective Disorders. Volume 68, Issues 2-3, April 2002, Pages 183-190
  11. Arif Khan, Robyn M. Leventhal, Shirin Khan, and Walter A. Brown . Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. Journal of Affective Disorders. 2002 Apr;68(2-3):183-90.
  12. Britt, T.W. (2000). The stigma of psychological problems in a work environment: Evidence from the screening of service members returning from Bosnia. Journal of Applied Social Psychology, 30, 1599-1618.
  13. Hoge, C.W., Castro, C., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13-22.
  14. Kimerling, R., & Calhoun, K.S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333-340.
  15. Meltzer, H., Bebbington, P., Brugha, T., Farrell, M., Jenkins, R., & Lewis, G. (2000). The reluctance to seek treatment for neurotic disorders. Journal of Mental Health , 9, 319-327.
  16. Reiger, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z., & Goodwin, F.K. (1993). The de facto U.S. mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85-94.
  17. Kudler H. The need for psychodynamic principles in outreach to new combat veterans and their families. Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry. 2007 Spring;35(1):39-50.
  18. Ann Scott Tyson. Repeat Iraq Tours Raise Risk of PTSD, Army Finds. The Washington Post. Wednesday, December 20, 2006; Page A19
  19. AWOL Soldier Seeking Treatment Arrested. The Associated Press. November 15, 2007. Http://,13319,156277,00.html.

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  • At December 11, 2007 at 6:41 AM , Anonymous Amy G said...


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