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Lorissa McKay

Professor McGriff

ENC 1102

2 December 2019

PTSD in Combat Veterans: A Growing Concern

According to the website for the National Center for PTSD, PTSD-like symptoms have

been identified in combat veterans since the beginning of war documentation(Friedman).

Consequently, combat PTSD is an aspect of military service that can be a major factor for any

service member serving in a time of war. In the United States, we currently have living Veterans

of World War II, the Korean War, the Vietnam War, the First Persian Gulf War, the Second

Persian Gulf War(commonly known as Operation Iraqi Freedom), and the War in Afghanistan.

These veterans range in age from the oldest, at 110 years old, to new enlistments as young as 18.

PTSD rates vary for each cohort, and it follows that the aftermath and struggles that these men

and women face with their diagnoses vary as well. For the last two decades post 9/11, American

service members have seemingly been involved in continuous combat on multiple fronts. The

experiences they have been immersed in have created ripple effects in their home lives that last

long after a deployment ends. Post traumatic stress disorder is affecting more and more families

and soldiers as the war on terror continues into the present day. The protracted nature of this war

on terrorism has created a problem that can seem invisible, even as it is vast. While the public

and Veteran’s Affairs Administration try to do what they can to treat American service members
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at home, resources for and awareness of the evolving complexities of the issue still need to

improve to adequately serve our Veterans.

Awareness of Combat-related PTSD and its prevalence and symptoms has spread

throughout the United States since the American Psychiatric Association first named it in 1980

Diagnostic and Statistical Manual of Mental Disorders(Friedman), yet our service members

continue to be at high risk of developing Post Traumatic Stress Disorder, and with that diagnosis

the possible complications of lifelong symptoms, suicide, depression, violence, poor coping

skills, and ruined relationships. Some Americans may feel that enough is being done, that the

systems already in place from the Veteran’s Administration are doing the job of healing our war

fighters. I believe we have a very long way to go before that is true. It is imperative that we

change and revitalize the treatment of Combat PTSD at every level for the evolving needs of our

generations of Veterans. To do that, we must first create and utilize mechanisms and screening to

prevent service members from being adversely affected by their trauma, continue to develop and

research effective treatments, and finally, we as a society must increase overall awareness of the

complexities and comorbidities of the disorder.

PREVENTION

Preventing Combat PTSD altogether seems like an impossibility while our

country still has battles to fight. How could it be possible to stop a person from reacting

in extreme ways to what are indisputably extreme circumstances of trauma? In fact, the

dual approach of first screening service members for probability of developing PTSD,

and then preemptively treating them for it before it develops is actually not far from

reality. Perhaps the most intriguing and exciting idea for the future quality of life of all
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combat Veterans is the continued development of reliable screening and prevention

policies.

In a 2015 meta-analysis of current research on combat PTSD, Chen Xue and

others were able to identify certain demographic traits that increased the probability of

developing PTSD(Xue, et. al.). These traits could be used in conjunction with other

screening processes to focus efforts on those that are most likely to benefit. Essentially,

streamlining the process of intervention and prevention with standardized selection

criteria. In another cutting edge process, the U.S Army has developed a new biological

screening method; a blood test that can tell medical providers and unit commanders just

how likely a person will return from a combat deployment with PTSD symptoms(“Army

Blood Test”). Again, this sounds so scientific as to almost be unbelievable, but with a lot

of potential for good. If soldiers can be screened before entering combat, perhaps those

with a greater chance of PTSD can be pre-treated in some way to prevent the trauma from

having lasting ill-effects.

New scientific developments like biological screening and demographics analysis

are exciting, but perhaps even more crucial to the ultimate goal of prevention is unit

preparedness. Combat commanders have not always balanced the need to encourage

bravery and stoicism with the complementary concern of sensitivity to individuals

exposed to trauma. A soldier should never go through what Army Medic Jonathan Nurell

did in his journey home from war with PTSD(“The US Military and Old vs. New”).

According to a CBS News report, the Army command delayed sending him home for his

PTS, and it resulted in months of suffering for him and his family(“The US Military and

Old vs. New”). My interpretation of the Armys’ slow treatment of Jonathan Nurell,
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against his doctor’s orders, is that the military is not consistently taking PTSD as

seriously as it should be. Compounding the culture of the commands themselves, are the

service members who have their own cultural barriers to seeking mental health care. As

described in the book “Invisible Wounds of War:...”

“Soldiers, sailors, airmen, and marines are encouraged to develop inner strength

and self-reliance. They take pride in their toughness and ability to “shake off” ailments or

injuries. One former battalion surgeon noted that his marines did not

want to seek help for any medical problems and took pride in their never having

stepped foot into a battalion aid station.”(Burnam, M. Audrey, et al. 249)

This passage illustrates exactly how reluctant these men and women are to admit

to being anything less than fit. Many military men and women are looked at as heroes,

and with that comes an extra burden of toughness and stoicism. In my opinion, this

mindset increases the responsibility that the command leadership has to counteract the

culture of outer toughness and intervene, screen, and treat those that need it. Only once

all levels of the military leadership is proactive, prepared, and equipped with the most up-

to-date techniques will we have a hope of preventing future cases of PTSD.

TREATMENT

Unfortunately, it appears that far too few Veterans are being properly treated for PTSD.

In a VA study, Dr. Karen Seal revealed that only 9.5% of newly diagnosed Iraq and Afghanistan

War Veterans attended the recommended number of treatment visits to the VA in the first year

after diagnosis with PTSD(Seal et. al. 5). This number is only those that were identified as

actually having PTSD. One can imagine that there are also those that go undiagnosed and miss

attending any treatment at all. A possible reason for this disconnect between diagnosed Veterans
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and seeking treatment is that most PTSD treatments were not developed specifically for combat

PTSD, and hence, do not address a signature feature of it that is unique to war- that of “moral

injury”(Litz, et. al. 696). “Survivor guilt” is another combat related stress that could contribute to

the unaddressed symptoms of civilian treatments(Tramontin). Veterans with survivor’s guilt or

moral injuries may not feel their symptoms are addressed in standard treatment. The standard

treatments are developed from “the civilian world, chiefly with sexual assault

victims.”(Tramontin) It is understandable that while PTSD from sexual assault might be very

similar in some ways, there are fundamental differences between the traumas. In addition,

civilian mental health care providers are not all familiar with certain unique aspects of Combat

PTSD, and that is important, since not everyone has access to a VA facility. In a discouraging

survey, the majority of 132 practitioners responded that they did not feel equipped to effectively

treat the military population or their families for PTSD(Tramontin). Practitioner confidence

seems like a crucial factor in treatment success. One brand new example of a military combat

specific treatment from early 2019 is called 3MDR. It is a therapeutic treatment in the early

stages of development which brings many aspects of therapy together by combining virtual

reality with exposure therapy and treadmill walking(Jancin 1). The fact that 3MDR is being

tested on military veterans during its development is a positive indicator that it will be tailored to

the unique challenges and symptoms that accompany Combat PTSD.

On a positive note, at least many effective treatments for PTSD do exist, and more are

being studied every day. While I believe that Post Traumatic Stress can have lifelong effects, I

also believe that it is beatable. Experts in the field of psychiatry have identified accepted

evidence-based treatments that are standards of care for Post Traumatic Stress. According to the

National Center for PTSD, therapies, antidepressants, and emerging treatments are part of a large
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group of treatment possibilities that can be optimized for each individual under the guidance of

their doctor(“PTSD Treatment Basics”). Traditional therapy, service animals, and

pharmacological medicine are all well-known to the public as effective against PTSD, and

together with some of the new military-specific treatments in development, my hope is that

Veterans will finally have that vital combination of emotional, physical, moral, and familial

relief for their complex varieties of symptoms.

COMPLEXITY

Many Veterans with PTSD feel as though they have never left the battle. The symptoms

of hyper-vigilance, attachment avoidance, anxiety, aggression, insomnia, irritability, panic, and

flashbacks seem completely out of place in a safe home with a family, but to a service member

with PTSD, it feels the same as their war zone. Vietnam Veteran Ed Cardenas described his life

with PTSD poignantly in a documentary by Kara Frame. “When was I in Vietnam? It was last

night, it was this morning. Five minutes ago before you asked me. And I will probably go back

tonight.”(qtd in “I Will Go Back Tonight.”) Treatment for PTSD should be just as encompassing

and complex as the disorder itself. As described by Mr. Cardenas, PTSD can infiltrate every area

of a person’s life. A treatment approach that meets the medical, emotional, familial and societal

needs of our Veterans in a thorough manner is the only possible way to honor the sacrifices and

commitments they have made that placed them in the position of needing help.

Combat PTSD has so many sides to it that the true complex nature of it can be missed

during screening, diagnosis and treatment. Some people believe that C- PTSD is simply a case of

jumpy nerves or shell-shock. Research shows that it is just the opposite of simple. “Simple”

never describes PTSD because it is a great many things, and doesn’t present in the same way in

each individual. Symptoms also vary in severity and frequency. PTSD symptoms affect
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individuals, their relationships, jobs, and communities. Management of PTSD can also be a

lifelong consideration for Veterans and their families. In one case described on the NPR radio

show “All Things Considered”, a Vietnam Veterans’ PTSD was triggered after he was diagnosed

with a terminal illness; the anxiety, fear, and powerlessness he must have felt as a result of his

medical diagnosis and treatments triggered flashbacks of the war(Dembosky, 2017). This

exemplifies the tragic fact that some people may never be free of the potential for lifelong effects

and symptoms from a diagnosis of PTSD.

Adding layers to the complexity of diagnosing and treating PTSD, the effects of the

disorder itself can also keep sufferers from seeking help. In a study done on Veterans of

Afghanistan and Iraq, soldiers who were screened as likely to have PTSD via questionnaire, were

twice as likely to have mental resistance against mental health treatment(Hoge et. al. 10). It is a

tragic irony when the illness itself serves to block the cure. The complexities of PTSD

presentation can allow it to remain silently waiting, only to pop out when people least expect it

or are prepared to handle it. Anything from soldiers on their deathbeds, strife with children,

spouses not getting along, violence, work-related stress and more could combine with post

traumatic stress and initiate a triggering of symptomatic PTSD. Unfortunately for them, most of

the world just isn’t prepared to make allowances for behaviors that arise from untreated PTSD.

Sufferers also risk further indignities of a military culture that seems intolerant to

perceived weakness. According to Hoge et. al, some of the common objections of Veterans to

getting help for their PTSD symptoms are “I will be seen as weak”, “It would harm my career”,

“Members of my unit would have less confidence in me”, and “My leaders would blame me for

the problem”(Hoge et. al. 10). What this indicates to me is that service members are willing to

neglect their own mental health to seem brave, or to avoid backlash from their peers or superiors.
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Stigmatization is an important issue that is a barrier to effective care for these individuals.

Rightly so, considering there has been evidence that the military and Department of Defense

have likely been summarily dismissing service members whose service-connected PTSD or other

injuries caused them to act out behaviorally. This is another tragic aspect of the military cultural

treatment of PTSD symptomatic Veterans. Being dishonorably, or other than honorably

discharged from the military after exhibiting anti-social, addictive, violent, or other behaviors as

a direct result of PTSD is adding insult to injury for many, because with those designations

attached to a discharge, the Veteran is ineligible for treatment coverage through the VA.

According to a Government Accountability Office report, “More than 13,000 service members

separated from the military for misconduct in recent years suffered from post-traumatic stress

disorder, traumatic brain injury or another disorder and were prevented from receiving treatment

from the Department of Veterans Affairs because of their discharge status.”(Wentling) The irony

of the military dropping service men and women after combat injuries and trauma rendered them

unable to effectively reintegrate into their jobs and society is not only obvious, but ultimately

unfairly punishes some of the most selfless citizens of the United States. We can, and should do

better to ensure that all factors of Combat PTSD are considered at every level, so that each

soldier, sailor, airman and marine is treated with the care and respect they deserve.

CONCLUSION

Although outreach, awareness, and treatment of service members with combat-related PTSD has

come a long way since it was first identified, too many continue to suffer the constant symptoms

of untreated or inadequately treated PTSD. Veterans are also at high risk of comorbidities like

depression, alcohol and drug abuse. Their families suffer right along with them, in many cases.

The fact that the military itself, which deployed these brave people into a war zone in the first
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place has also continued to injure them by inadequate treatment and inappropriate discharge is

the most tragic of all. As a proud and thankful country, we can do better for those who serve and

their families. My position is that each of us needs to pay attention to funding, awareness, and

treatment options for our Veterans. Anyone that cares about the brave people of our country that

place themselves in harms way with selfless dedication, should care about this topic. PTSD is

one of the two signature wounds of the modern wars in the United States, and it won’t be going

anywhere until we make it go away. This matters because there is a lot we are capable of

changing as everyday citizens and voters, and more attention on this subject will create more

opportunities for improvement.

Works Cited

"Army blood test could help identify troops suffering from PTSD." Adverse Event Reporting

News, 17 Sept. 2019, p. 7+. Gale Academic OneFile,

https://link.gale.com/apps/doc/A600665981/GPS?u=navyship&sid=GPS&xid=54aa1f21.

Accessed 3 Nov. 2019.

Burnam, M. Audrey, et al. "Systems of Care: Challenges and Opportunities to Improve Access to

High-Quality Care." Invisible Wounds of War: Psychological and Cognitive Injuries,

Their Consequences, and Services to Assist Recovery, edited by Terri Tanielian and Lisa

H. Jaycox, RAND Corporation, 2008, pp. 245-326. Gale eBooks,

https://link.gale.com/apps/doc/CX1769900022/GVRL?u=navyship&sid=GVRL&xid=a7

5a6ffc. Accessed 3 Nov. 2019.


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Dembosky, April. “Reverberations of War Complicate Vietnam Veterans’ End-of-Life-Care.”

All Things Considered. NPR, 16 Dec. 2017. Radio. Accessed online

www.npr.org/sections/health-shots/2017/12/16/569961321/reverberations-of-war-

complicate-vietnam-veterans-end-of-life-care

Friedman, Matthew J. History of PTSD in Veterans: Civil War to DSM-5. National Center for

PTSD. “PTSD: National Center for PTSD.” VA.gov: Veteran Affairs. 15 Aug. 2013,

www.ptsd.va.gov/. Accessed November 8, 2019.

Healy, Jack. Apology, but No Explanation, for Massacre of Afghans. The New York Times 23

Aug. 2013. Accessed online 20 Nov. 2019. www.nytimes.com/2013/08/23/us/an-apology-

but-no-explanation-from-soldier-who-massacred-civilians.html

I Will Go Back Tonight. Dir. Frame, Kara. 16:20-16:34

http://www.iwillgobacktonight.com/video. Accessed 3 Nov. 2019.

Jancin, Bruce. "WALK AND TALK THERAPY: 3MDR intervention explored for refractory

PTSD." Clinical Psychiatry News, Apr. 2019, p. 1+. Gale Academic OneFile,

https://link.gale.com/apps/doc/A586014886/GPS?u=navyship&sid=GPS&xid=fc33a759.

Accessed 3 Nov. 2019.

Litz, Brett T., et al. "Moral Injury and Moral Repair in War Veterans: A Preliminary Model and

Intervention Strategy." Clinical Psychology Review, vol. 29, no. 8, 2009, pp. 695-706.
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ProQuest, https://search.proquest.com/docview/42439114?accountid=28179,

doi:http://dx.doi.org/10.1016/j.cpr.2009.07.003.

"Post-Traumatic Stress Disorder (PTSD)." The Gale Encyclopedia of Psychology, edited by

Bonnie Strickland, 2nd ed., Gale, 2001, pp. 505-507. Gale eBooks,

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c41b48. Accessed 3 Nov. 2019.

“PTSD Treatment Basics.” National Center for PTSD. Oct. 2011.

https://www.ptsd.va.gov/understand_tx/tx_basics.asp. Accessed 21 Nov. 2019.

Seal KH, Maguen S, Cohen B, et al. VA mental health services utilization in Iraq and

Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma

Stress. 2010;23(1):5–16. doi:10.1002/jts.20493

"The US Military and Old vs. New Ways of Thinking about Soldiers with PTSD." BBC Studios

Americas Inc, 26 Jan. 2017. Gale Health and Wellness,

https://link.gale.com/apps/doc/UUFDKW707952201/HWRC?u=navyship&sid=HWRC&xi

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Tramontin, Mary. "Exit wounds: current issues pertaining to combat-related PTSD of relevance

to the legal system." Developments in Mental Health Law, Jan. 2010, p. 23+. Gale Academic

OneFile,
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Accessed 21 Nov. 2019.

Wentling, Nikki. Pentagon Issued 'Bad Paper' Discharges to Troops with Mental Illnesses. Stars

and Stripes. 2019. www.military.com/daily-news/2017/05/17/pentagon-issued-bad-paper-

discharges-troops-mental-illnesses.html Accessed 21 Nov. 2019.

Xue, Chen, et al. "A Meta-Analysis of Risk Factors for Combat-Related PTSD among Military

Personnel and Veterans." PLoS ONE, vol. 10, no. 3, 2015. Gale Academic OneFile,

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Accessed 21 Nov. 2019.

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