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PTSD IN MALE SOLDIERS AND VETERANS.
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Post-Traumatic Stress Syndrome as a psychological disorder.... More...
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Paper Abstract:
Post-Traumatic Stress Syndrome as a psychological disorder. Changing definition of PTSD by the APA's Diagnostic & Statistical Manual (DMS). Contributive causes of PTSD. Practices relating to PTSD and the underlying concepts and assumptions. Characteristic symptoms. Psychotherapy and pharmacolgic treatment. Importance of diagnosis. Nursing interventions.
Paper Introduction:
PTSD IN MALE SOLDIERS AND VETERAN POPULATIONS
Introduction: The Concept of PTSD as a Psychological Disorder
Over the last several decades, a great many books and journal articles have been written about Post-Traumatic Stress Syndrome (PTSD) in soldiers and veterans (e.g., Chalsma, 1998; Joseph, Williams & Rule, 1997; Zima, 2000). However, Cuervo-Rubio (2001) points out that it was not until 1980 that the American Psychiatric Association began to formally identify and acknowledge this disorder. At this time, Cuervo-Rubio states, the APA had a limited view of what could cause PTSD as well as a limited conceptualization of the disorder. In this regard, the APA’s Diagnostic and Statistical Manual (DSM) defined the condition as developing from an experience that anyone would find traumatic, leaving no room for individual perception or experienc
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(1997). The APA (DSM-IV, 1994) lists several clusters ofsymptoms that are characteristic of PTSD. (2 ). The Illinois Council on Long Term Care (1996) also reports that someveterans may not feel comfortable in the group setting and it is suggestedthat for these veterans one-on-one counseling (at least in the initialtherapy stages) is probably the best method. Those who provide care for victims of trauma should be familiar with normal and pathological reactions following trauma and know how to identify those at high risk of developing adverse reactions and problems of adjustment (p. L. The question therefore becomes, what criteria and methods can nurses'profitably employ in their nursing diagnoses as related to male soldiersand veterans with PTSD? Nursing Connections, 8(1), 55-63. (2 ). Shearer, R. Post-traumatic stress disorderand the elderly combat veteran. As with PTSD that develops in non-soldiers or veterans, there aremany factors that play into the etiology of military personnel's experienceof PTSD (Ford, Ruzek & Niles, 1996). The construction of disorders: Exploringthe growth of PTSD and SAD. In an interesting bibliographic essay on a wide variety of PTSD casesand the interventions used on these patients, Beall (1997) reports thatcounseling is one effective method that has been utilized. Trauma counseling: what is it and does it existwithin the caring professions? (2 ). In short then, the APA currently views PTSD as thedevelopment of a set of specific symptoms following exposure to apsychologically traumatic event that produces fear, helplessness and horror--a definition that adequately applies to the experience of war and combatand related trauma associated with the military. The chambers of memory: PTSD in the lifestories of U.S. (1996). Post-traumaticstress: Effects on elderly veterans, Designing a treatment plan: The valueof group therapy. It has also been advised by King, King,Erickson, Huang, Sharkansky and Wolfe (2 ) that diagnosis of thecondition can be difficult and time consuming and should, if it is to becomplete, include not only the APA criteria but also testing usingstandardized psychometric instruments for the assessment of PTSD. With respect to psychotherapy, Lange, Lange and Cabaltica (2 )report that while treatments differ considerably, most all focus theirefforts on first breaking the pattern of self-defeat common to PTSDpatients by re-examining the traumatic event and the patient's response toit as part of the effort to produce acknowledgment of the incident and amore integrated understanding of said. The DSM IV adds that the disorder can beespecially severe or long lasting when the stressor is of human design(e.g. & Cabaltica, R. Northvale, NJ: Jason Aronson. (1997). & Niles, B. A., Erickson, D. Cognitivetherapy is also sometimes used to challenge patients' irrational beliefsabout the trauma and to re-shape or reframe more rational notions (Lange,Lange & Cabaltica, 2 ). Nursing Interventions In a discussion of PTSD in soldiers and veterans and treatmentinterventions used by nurses as well as other health care personnel, Pearn(2 ) reports that while a variety of interventions are possible, theunderlying conceptual foundation regarding treatment and management of thedisorder is that intervention should focus on gaining insight into problem,assisting in bolstering and/or developing effective coping skills, dealingwith the associated symptoms and consistently monitoring outcomes with theunderstanding that the slower the general progress, the poorer theprognosis. Journal of the Army Medical Corps,146(3), 165-17 . Identifying andtreating VA medical care patients with undetected sequelae of psychologicaltrauma and post-traumatic stress disorder. Meta-analysisof risk factors for posttraumatic stress disorder in trauma-exposed adults.Journal of Consulting Clinical Psychology, 68(5), 748-766. References Alexander, D. Current and future drug treatment forposttraumatic stress disorder patients. They includedaytime fantasies, traumatic nightmares, and psychotic re-enactments orflashbacks in which the person with the disorder, in a dissociative state,actually re-experiences the trauma. In this regard, the APA's Diagnostic andStatistical Manual (DSM) defined the condition as developing from anexperience that anyone would find traumatic, leaving no room for individualperception or experience of an event. The soldiers' perceptual style andgeneral beliefs about himself and the world also can play a role in thedevelopment of PTSD (Cuervo-Rubio, 2 1). Cuervo-Rubio, R. 4. Nursing Diagnosis The importance of adequate diagnosis of PTSD has been succinctlystated by Alexander (2 ) who notes that: It is unethical and incompetent to deny the scale and nature of human reactions to trauma. Understanding Post-Traumatic Stress Disorder: A psychosocial perspective on PTSD andtreatment. (2 ). Document available: www.va.gov. J., & Wolfe, J. The goalhere is said to be to expose the trauma and therefore demystify it in theveterans mind. In this regard,Cuervo-Rubio (2 1) reports that differential diagnoses includes adjustmentdisorder, major depressive disorder, acute stress disorder, conversiondisorder, obsessive-compulsive disorder, and a number of functional andorganic disorders such as schizophrenia, other psychotic disorders, mooddisorders with psychotic feature, delirium, some substance-induceddisorders (especially those presenting with psychotic symptoms), andpsychotic disorders due to a general medical condition. &.(2 1). CHOICE, 34(6), 917-93 . A. The secret war: Don't miss post-traumaticstress disorder in World War II vets. Associated features - Alcohol and/or drug abuse can often befound in the PTSD patient, usually as an attempt to rid oneself of painfulflashbacks, loneliness and/or panic attacks. One of the reasons why the diagnosis of PTSD is difficult is becauseit can be accompanied by underlying neurologic or physical disorders(Brewin, Andrews & Valentine, 2 ) which is why a physical check-up isalso in order as part of the general diagnostic effort. NY: Wiley. He begins toidentify with the feelings of others and finally starts to allow themselvesgreater insight and understanding of the specific nature of hispsychological condition. M. The APA (DSM-IV, 1994) further noted that PTSD can also develop inchildren who have experienced sexual molestation, even if this is notviolent or life-threatening. Washington, DC: APA. All of the foregoing symptoms must be present for at least 1 month 6. Ford, J.D., Ruzek, J. Document available: www.ncptsd.org. For this kind of acknowledgment to occur merely uncovering memoriesis not enough: these memories need to be modified and transformed, i.e.placed in their proper context and reconstructed into neutral or meaningfulnarratives (Palmer, 2 ). S. 42 :Group treatment of posttraumatic stress disorder. Beddoes, P. Symptoms As noted earlier, the concept of PTSD as a mental disorder ischaracterized as the development of a discrete set of symptoms followingexposure to some type of traumatic event. Regarding symptoms as they specifically apply to male soldiers orveterans, Snell and Padin-Rivera (1997) have noted that while the symptomsdefining PTSD are often spotted in soldiers who have fought in Vietnam andother combat-related events taking place since this period, the conditionis highly under-diagnosed among WWII and Korean era veterans. (2 ). The authorsspeculate that this under-diagnosis is due both to clinical inattention andthe way this generation of soldiers coped with traumatic memoriesthroughout their lives. torture, rape). (1994). (2 1). Hidden scars: posttraumaticstress disorder. Therefore, in therapy, memory paradoxicallybecomes an act of creation, rather than the static recording of eventswhich is characteristic of trauma-based memories (Palmer, 2 ). 165). Beall (1997) also notes that many of the most commonly employed multi-modal interventions, and those which have been found to be most effective,are said to consist of crisis intervention, substance abuse counseling,group counseling and the use of other support groups, e.g., attendance in agrief support group where buddies lost in the war and feelings about thisare discussed. (2 ). & Padin-Rivera, E. Inaddition, the specific procedures and methods used were also delineated inrelation to the underlying concepts and assumptions. In some cases, there canalso be insomnia, and frequent startle responses. W., King, L. Emergency Medical Services,29(8), 41-42. It is also noted that in cases of PTSD, counseling methods,no matter how widely disparate the form of the intervention, must emphasizecognitive--behavioral techniques for dealing with the three main symptomsof PTSD: intrusive thoughts or images, avoidance behavior, and disorderedarousal, especially irritability. Recommended techniques include:diaphragmatic breathing techniques, biofeedback, and visualizationtechniques. Persistent re-experiencing of the event 3. But what precisely are the natureof these symptoms? Lange, J. In thisregard, the authors point out that medication is given to control the mostdifficult of the symptoms such as flashbacks and this is then followed by avariety of psychotherapy interventions. Some examples of more directive and in-depth treatment are grouptherapy, and brief individual therapy sometimes called crisis interventiontherapy. At this time, Cuervo-Rubio states, the APAhad a limited view of what could cause PTSD as well as a limitedconceptualization of the disorder. American Psychiatric Association. Journal of the Illinois Council on Long Term Care, 141.Document available: www.nursinghome.org/closeup/cupdocuments/cu141.htm Joseph, S., Williams, R., & Yule, W. Persistent avoidance of stimuli associated with the trauma andreduced responsiveness to the environment 4. D. In terms of the actual process necessary to achieve the foregoingtreatment goal, in an article for the American Family Physician, Lange,Lange and Cabaltica (2 ) have noted that, typically, the treatmentprocess for PTSD is both pharmacologic and non-pharmacologic. Typically, the authors state, this intervention includesreview and discussion not only with the soldier or veteran but also withselected family members. It isrecommended that the intervention be used simultaneously with psycho-educational programs that provide patients and their families withinformation about the nature of posttraumatic syndrome. Thus, a pivotalconcept associated with treatment is to find a way in whichsoldiers/veterans can acknowledge the reality of what has happened withouthaving to re-experience the trauma all over again. In terms of pharmacotherapeutic agents given in the treatment ofPTSD, Friedman (2 ) reports that these can include serotonergicinhibitors for reducing avoidance and hyperarousal symptoms such asinsomnia; tricyclic antidepressants; monoamine oxidase inhibitors (onlyinfrequently used due to dangerous side effects); antiadrenergic agents toreduce nightmares, hypervigilance, and startle reactions; andbenzodiazephines to control depression and anxiety. Counselors in both the groupand the individual setting are required to encourage the veteran to talkabout his experiences and to listen attentively to what he says. Furthercomplicating diagnosis, Cuervo-Rubio states is the fact that someconditions may coexist with PTSD such as depression, suicidal tendencies,anxiety and alcohol and drug abuse. 2. Journal of Gerontological Nursing, 23(1 ),13-19. W., & Hsieh, F. This makes PTSD a pivotal concept formental health nurses and emphasizes their need to master an understandingof both the disorder and its connection to the human capacity forresilience and ability to overcome trauma. J., Huang, M. Summary This paper examined PTSD in male soldiers and veterans. Psychological debriefing: historical militaryperspective. Psychopharmacologic agents arerecommended as adjunct treatment for severe cases of PTSD. Brewin, C. Relaxation techniques such as meditation and breathing exercisesare also often used in VA clinics for treatment of the disorder. The authors state that nurses should be especiallyvigilant for the occurrence of these symptoms among this group of veterans,and should also attempt to identify older veterans who might be at risk forresurfacing of PTSD symptoms. (1996). British Journal of Psychiatry, 177, 28 =281 Pearn, J. Snell, F.I. Each of these clusters is delineated by the APA (1994) asfollows: 1. In this regard, theCouncil states that group treatment is one of the most successfulintervention strategies nurses and other health care professionals can use.The Council notes that by hearing others talk about their own experiences,the veteran realizes he is not alone with his problems. Severaltopics were covered including the nature of the disorder, its symptoms,treatment, nursing diagnosis and nursing interventions. P., Friedman, M. Shearer and Davidhizar (1995) further note that studies of thecritical debriefing intervention, which is said to be most frequentlyutilized by clinical nurse specialists, have shown that it can increasepatients' willingness to communicate, and decrease their anxiety. These commonly help a bit but usually more directed psychotherapyis needed. (January, 1996). (1995). EDTNA ERCA, 22(3), 33-35. NCP Clinical Quarterly, 6(4), 77-82. (2 ). Treatment The central concept of treatment for the remediation of PTSD,according to Schnurr, Friedman, Lavori and Hsieh (2 1) centers around thenotion that the personality has experienced a failure to integrate atraumatic experience into autobiographical memory; it is theorized thatthere is some sort of dissociative process involved. Combat-related PTSD. Normal and pathological reactions to severestress: their features and management. Intrusive symptoms - Symptoms falling into this category are saidto be the most readily identifiable symptoms of the disorder. (2 ). Military Medicine, 165(6), 434-44 . Other contributive causes are said toinclude: the specific type of the combat related stressor, personalitycharacteristics of the soldier or veteran, and the general socialenvironment at the time of the trauma. R., Andrews, B., & Valentine, J. J., Lavori, P. These include: intrusivesymptoms, avoidant symptoms, symptoms of hyperarousal and associatedfeatures. & Davidhizar, R. However, in this context, nurses have a variety ofinterventions available to them for satisfying the requirements of thisfoundational notion of intervention in their work with male soldiers and/orveterans who have been diagnosed with PTSD (Beddoes, 1996). According to Beall, a multi-modal interventionstrategy approach is a strategy that includes an education element, a focuson increased awareness, and the encouragement in the soldier or veteran ofrealistic optimism toward treatment. In his discussion of the diagnosis of PTSD asrelated to soldiers and/or veterans, Cuervo-Rubio (2 1) notes that thediagnosis must be made using the six basic criteria set forth by theAmerican Psychiatric Association. Relaxation techniques are also said to be effective tools in helpingto reduce the stress associated with PTSD. Post-Traumatic stress disorder: A bibliographicessay. Stuhlmiller, C. Posttraumatic stress disorder andretrospectively reported stressor exposure: alongitudinal prediction model. PTSD IN MALE SOLDIERS AND VETERAN POPULATIONS Introduction: The Concept of PTSD as a Psychological Disorder Over the last several decades, a great many books and journalarticles have been written about Post-Traumatic Stress Syndrome (PTSD) insoldiers and veterans (e.g., Chalsma, 1998; Joseph, Williams & Rule, 1997;Zima, 2 ). (1995). Control Clinical Trials,22(1), 74-88. Palmer, I. These are: 1. (1997). Nurses, Stuhlmiller (1995) states stand, therefore, in the midst oftwo traditions, one that supports reliance on medical experience and theother, one of human resilience. Counseling canbe either short-term or long-term but it is recommended that the approachbe multi-modal in nature. The Illinois Council on Long Term Care (1996) has discussed severalnursing interventions suited to elderly veterans with PTSD but which willwork successfully with younger veterans as well. Some of themost frequently used interventions are discussed in this section of thispaper. Design of department of veterans affairs cooperative study no. 3. Zima, D. To provide a fullerunderstanding of this disorder, the paper presented here not only discussesspecific practices in relation to PTSD but also describes and discusses theunderlying concepts and assumptions associated with these practices. Events that could qualify as traumatic,according to the DSM IV, included: combat, sexual and physical assault,being held hostage or imprisoned, terrorism, torture, natural and man madedisasters, accidents, and receiving a diagnosis of a life threateningillness. L. According to Stuhlmiller (1995), PTSD as a mental health concept isparticularly relevant for mental health nurses. The currently acceptedconceptualization, as presented by the APA (1994) in the DSM IV acceptsthat PTSD is a psychological disorder that develops in response to eventsthat are threatening to life or bodily integrity, witnessing threatening ordeadly events, and hearing of violence to or the unexpected or violentdeath of close associates. (1998). Journal of Abnormal Psychology, 1 9, 624-633. Shearer and Davidhizar (1995) report that one of the most commonlyused nursing interventions for soldiers and veterans with PTSD is what hascome to be called critical incident debriefing consisting of anintervention that emphases review and discussion of the incident with afocus on obtaining a more coherent, integrated and rational perspective ofthe incident. In the discussionof each topic, an emphasis was placed on delineating the underlyingassumptions and concepts that shape practices in relation to PTSD. Beall, L. Journal of Psychosocial Nursing and MentalHealth Services, 33(4), 2 -23. T., Sharkansky,E. Illinois Council on Long Term Care. Friedman, M.J. In this regard,Stuhlmiller points out that while the notion of PTSD has gained tremendouspopularity in mental health circles over the years, its popularity itselfhas obscured the fact that most soldiers and veterans over history, haveendured the hardship of war and combat without treatment for this disorder. I. W. Exposure to a traumaticevent 2. Document available:www.aafp.org. Diagnostic and statisticalmanual of mental disorders (4th edition). King, D. Schnurr, P. Primary caretreatment of post-traumatic stress disorder. T., Lange, C. Vietnam Veterans. Traumatic stress disorders: a classification withimplications for preventionand management. The symptoms must cause significant impairment in social,occupational, or other areas of function Regarding these symptoms,Cuervo-Rubio (2 1) advises that if a veteran presents with some but notall of the required symptoms, diagnosticians still should not rule of PTSD.It is always possible that in the past, those symptoms not presenting atthe moment were in fact present. There is often a need to avoid feelings,thoughts, and situations that are reminiscent of the trauma, and a loss ofnormal emotional responses (or both). These are said to assist by reducing the tension, which theveteran is using as a psychological defense against remembering the trauma. Avoidant symptoms - This category of symptoms is characterized byemotional constriction or numbing. Persistent symptoms of increased arousal not present before thetrauma 5. The conceptualization of PTSD was, however, expanded when the DSM IIIwas revised in 1987, and the DSM IV (APA 1994) provides an even broaderdescription and delineation of the condition. However, Cuervo-Rubio (2 1) points out that it was not until198 that the American Psychiatric Association began to formally identifyand acknowledge this disorder. However, some therapeutic treatmentsare almost entirely psychoeducational and merely provide patients and theirfamilies with education about the disease, its symptoms, and copingmethods. Symptoms of Hyperarousal - Individuals with PTSD very often act asthough they were constantly being threatened which usually manifests itselfin panic attacks and generalized anxiety disorder. Chalsma, H. A PTSD patient may also showpoor control over impulses, which is believed to increase his risk ofsuicide.
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