By Katherine van Wormer, MSSW, PhD

In response to the veterans of the Vietnam War and the militancy of the antiwar movement, the American Psychiatric Association acknowledged the symptoms of Post Traumatic Stress Disorder (PTSD). The diagnosis of PTSD was then included in the DSM (Diagnostic and Statistical Manual of Mental Disorders). The feminist movement was influential in advocating for a diagnosis in recognition of the trauma of rape.

The DSM IV-R described PTSD, in short, as the “re-experiencing of an extremely traumatic event that the person has experienced or witnessed, accompanied by symptoms of increased arousal (such as sleep disturbance, irritability, hypervigilance, difficulty concentrating) and by avoidance of stimuli associated with the trauma and numbing.”

Combat-Related PTSD

After the war in Vietnam was over, some 30 percent of Vietnam combat veterans suffered from PTSD; flashbacks to horrible near-death situations were common. A study conducted in 2003 involved 6,200 soldiers who had served in Iraq and Afghanistan several months before. Research was conducted by a team of social scientists at the Walter Reed Army Institute of Research.

Results showed that one in six of the veterans displayed symptoms of PTSD, major depression, or anxiety; 12 percent had symptoms of PTSD alone. (These figures are an underestimate as the study was done before the far more brutal urban combat efforts got underway.) The risk of developing trauma rose in proportion to the number of instances of combat in which the soldier had engaged.

According to a more recent Post-Deployment Health Reassessment, which is administered to all service members, 38 percent of regular soldiers and 31 percent of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49 percent. Those who had served repeated deployments were at extremely high risk of problems and the toll on their family members was great.

The exact rate of PTSD in women veterans is unknown. Studies conducted after the Gulf War  concluded that female service members were more likely than their male counterparts to develop PTSD. This is consistent with the 2 to 1 ratio of female to male PTSD sufferers in the general population.

Males with psychological symptoms from battle, however, are three times more likely to be given a diagnosis of PTSD than females, according to the Pentagon Task Force report.

One explanation for this may be cultural expectations that make it difficult for society and mental health providers to recognize women as combatants. Additionally, there is a tendency to diagnose women as having depression, anxiety and borderline personality disorder instead of combat-related PTSD.

For several reasons, the impact of the Iraq and Afghanistan wars is expected to be more severe than the impact of previous wars. (1) The experience of combat, engagement in gun battles, and handling the bodies of dead comrades is a constant in these wars, (2) the experience of killing people at close range is a frequent occurrence, (3) extended lengths of service with only short periods of rest and recuperation in between are taking a psychological toll on soldiers; and (3) many of the injuries in this war are to the brain.

Traumatic Brain Injury

Traumatic brain injury, or TBI, is the signature injury of the war in Iraq. This injury may come to characterize this war just as Agent Orange did with the war in Vietnam. The injury is often hard to recognize — for doctors, for families and for the troops themselves.

Symptoms of TBI vary. They include headaches, sensitivity to light or noise, behavioral changes, impaired memory and a loss in problem-solving abilities. Months after being hurt, many soldiers may look fully recovered, but their brain functions remain labored.

To identify cases of TBI, doctors at Walter Reed Army Medical Center screened every arriving soldier who had been wounded in an explosion, in a vehicle accident or fall, or by a gunshot wound to the face, neck or head. They found TBI in about 60 percent of the cases. Most of the survivors were in their early twenties. Slightly more than half had permanent brain damage. In severe cases, victims must relearn how to walk and talk.

Among surviving soldiers wounded in combat in Iraq and Afghanistan, TBI accounts for a much larger proportion of casualties than it has in other recent U.S. wars. According to the U.S. Army Institute of Surgical Research, 22 percent of the wounded soldiers from these conflicts who have passed through the military’s Regional Medical Center in Germany had injuries to the head, face, or neck.

TBI screening was recently begun at National Naval Medical Center in Bethesda, Maryland. Over 80 percent of the wounded Marines and sailors were found to have temporary or permanent brain damage from head wounds.

These wounds are the sort that many soldiers in previous wars never lived long enough to suffer. The body armor used today keeps people alive, but the shock wave from the bomb explosion can damage brain tissue. Those who survive head injuries often suffer from emotional problems, including difficulty with memory and anger management, as well as high rates of depression, alcohol use, and post-traumatic anxieties.

Consequences of PTSD and TBI

According to the National Mental Health Association (NMHA), 25-30 percent of people exposed to severe trauma, and 5-10 percent of people exposed to moderate trauma are at high risk of developing substance use problems. Clients in treatment with the dual diagnosis of PTSD and substance misuse have high relapse and treatment failure rates. Wounded war veterans with head injuries are also at high risk for substance-related problems.

As with former Vietnam veterans, homelessness is becoming a major problem. But unlike with Vietnam veterans when the homelessness occurred after years of service, these returning soldiers who become homeless are doing so within a year or less. According to the National Coalition for Homeless Veterans in Washington, estimates are that thousands of persons who fought in Iraq and Afghanistan are living in shelters. Combat trauma is thought to be largely responsible for this problem.

Unable to cope, veterans with mental health problems and/or TBI turn to alcohol and drugs, lose their jobs and family support, and end up on the streets. The fact that heroin use is a growing practice among members of the military in Afghanistan, who can purchase the drug in the market place, is bound to have long-term repercussions as soldiers return.

According to the Task Force on Mental Health, the costs of military service do not dissipate after deployment. Heavy drinking is common among returning service people. Not surprisingly, strains in family functioning have been observed. Indeed, according to a 2006 survey, 20 percent of married soldiers planned to separate or divorce, a 5 percent increase from the previous year.

PTSD Treatment

Recent research reported by the National Mental Health Association reports that changes in the hippocampus—a part of the brain critical to emotion-laden memories—may be responsible for intrusive memories and flashbacks that occur in people with this disorder. This discovery opens the door to the possibility of greater use of medications in the prevention and treatment of PTSD.

Psychiatric researchers on war trauma from Israel recommend immediate intervention when mental health symptoms first arise. Cognitive-behavioral therapy and serotonin enhancing drugs have been found to be effective with Israeli veterans.

For many Vietnam veterans, viewing battle scenes from the Iraq war is a trigger for flashbacks of horrors experienced long ago. Significantly, figures from the U.S. Department of Veterans Affairs (VA) show a 36 percent rise since 2003 in the number of Vietnam veterans seeking help for trauma.

Women are seeking help due to both war trauma and victimization by their peers. Military sexual trauma is the term used by the VA to refer to a variety of sexual offenses ranging from verbal sexual harassment to assault and rape. The Veterans Health Care Act of 1992 authorized new and expanded services for women veterans including outreach and counseling services for sexual trauma incurred while serving on active duty.

Treatment of PTSD in women who have served in combat is in its infancy. A treatment intervention known as “Prolonged Exposure Therapy (PE)” is being used by the VA along with a cognitive approach. PE therapy gradually exposes the client to images of the threatening experience and has the client repeatedly recount his or her traumatic memories.

Presently, 600 therapists are being trained in these approaches for treatment of female veterans with combat trauma. Women’s Veterans Program Managers are now being placed at VA medical centers across the country. There are also programs for women who are homeless and those who are at risk of becoming homeless.

For treatment of persons with TBI, a brain trauma treatment system of specialized care centers has been organized. A social work case manager is assigned to every patient in treatment. It is likely that much more attention will be paid in the future to this crisis in soldiers returning from the war with serious brain trauma.

Deprivation of Mental Health Care

According to the Walter Reed survey, fewer than 40 percent of those members who meet strict diagnostic criteria receive mental health services. One factor is stigma. Over half of the soldiers who met criteria for a psychological health problem thought they would be perceived as weak if they sought help.

Another problem is diagnosis. Despite the high estimates of PTSD cases, only three percent of soldiers who have seen combat from 2003 to 2007 have been officially diagnosed with Post Traumatic Stress Disorder. According to a recent report from the Department of Defense Task Force on Mental Health, the Army is misdiagnosing those with PTSD.

Combat veterans are being diagnosed erroneously with personality disorder. This fact denies them their benefits because personality disorder is classified as a pre-existing condition and not considered treatable.

A class action lawsuit has been filed in federal court by two nonprofit veterans’ organizations requesting that veterans receive the medical care to which they are entitled. One focus of the lawsuit is the mishandling of PTSD disability claims.

To meet the inadequacies of the federal system, the Minnesota National Guide has initiated a program, called Beyond the Yellow Ribbon. This program requires all returning National Guard members from the state to attend regular counseling sessions to address practical matters as well as problems reconnecting with family members following combat stress. Illinois and several other states have developed similar programs to meet the emotional needs of returning National Guard troops.

How Social Workers Help

Social workers actively work with veterans within all branches of the military and as mental health practitioners. Trained in a holistic model of practice, they are well equipped to address a host of issues from the biological to spiritual with which returning veterans are dealing.

Social workers have a history of addressing the person-in-the-environment and attending to the interaction among clients, their families, and institutional systems. Clinical social workers, as licensed mental health practitioners, are knowledgeable about the psychological and social ramifications of PTSD and TBI.

Social workers view combat stress as not only an individual problem but also a family and community problem. Taking a multidimensional approach and given their training in cultural and counseling competencies, social workers are well suited to working in mental health departments within the military and with veterans who have readjustment problems. The Department of Veterans Affairs has recognized VA social work since 1926 and is affiliated with over 100 graduate schools of social work. The VA operates the largest and most comprehensive clinical training program for social work students – training 600-700 students per year.