COMMENTARY
The Sequelae of Our Millennial War Daniella David, MD and Spencer Eth, MD
‘‘The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood’’ Theodore Roosevelt, 1910
T
his year, a young veteran of the Afghanistan warVin treatment for posttraumatic stress disorder (PTSD), depression, and chronic pain in our medical centerVkilled himself. Friends posted an online memorial video. A combat buddy, viewing his own image in the memorial, disappeared from his college dormitory. Police found him and brought him to the Veterans Affairs (VA) hospital, where he was admitted involuntarily with a first psychotic episode. These two young men carry a burden of psychiatric illness that bears both similarities and differences to that of their Vietnam or Gulf War era predecessors. Although each war fought during the past century afforded psychiatrists unique insights into the frequently devastating consequences of combat, the current Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) campaigns offer novel challenges. Approximately 1.6 million Americans have served in war since 2001. Approximately one third of these returning soldiers are experiencing symptoms of PTSD, depression, and/or traumatic brain injury (TBI), and comorbidity with alcohol misuse and interpersonal violence has been reported in about half of these cases (Thomas et al., 2010). As described in a small study of Vietnam veterans with chronic PTSD and without recent substance use (n = 30) in this issue (Lindley et al., 2014), psychotic symptoms are also frequently reported in this population and may correlate with dissociation and severity of combat exposure. These phenomena do not seem to be part of a classic psychosis phenotype and are unlikely to be related solely to malingering. Of interest, the reported psychotic symptoms in this study also did not correlate with depression but did exhibit an association with attention difficulties on cognitive examinations. Although recent substance abuse was denied by the subjects in this study, earlier use of hallucinogenic drugs can have long-lasting effects that could confound the analysis of psychotic symptoms. The difficulty distinguishing dissociative PTSD phenomena from other etiologies of anomalous psychotic experiences has been noted for many years (Shaner and Eth, 1989; Van Putten and Emory, 1973) and will surely apply to OIF/OEF veterans whose frequent neurological comorbidity adds yet another layer of complexity. Veterans with chronic PTSD have been found to have an increased burden of physical illness, with elevated rates of disorders in most organ systems, and mortality (Boscarino, 2004, 2006). In a study of 74 active-duty male Special Operations Forces personnel in this issue, Bryan et al. (2014) report the associations among PTSD avoidance and numbing symptoms and increased somatic symptoms as well as high utilization of medical services. Their data are consistent with the impressions of many clinicians that neglecting emotional pain will frequently translate into complaints of physical ailments. Today’s returning soldiers do not have to confront Vietnam era antiwar sentiments, but they often feel estranged for other reasons. They represent the small segment of the US populace who volunteered to participate in a heroic conflict. Most citizens have no meaningful connection to the reality of these wars and what our soldiers have endured, despite the universal awareness of the enormity of the 9/11 attack on American soil. Frequent redeployments contribute to repetitive trauma exposure, as well as extended separation from family and other social supports. Paradoxically, although the military bonds are extremely strong and cohesive, many returning veterans find themselves contending with isolation and alienation in civilian life. This, in turn, leads to difficulties with re-engagement in education and/or
Miami VA Healthcare System, Miami, FL; and Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL. Send reprint requests to Daniella David, MD, Miami VA Healthcare System, 1201 NW 16th Street, 116A, Miami, FL 33125. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0088 DOI: 10.1097/NMD.0000000000000075
88
www.jonmd.com
The Journal of Nervous and Mental Disease
& Volume 202, Number 2, February 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Journal of Nervous and Mental Disease
& Volume 202, Number 2, February 2014
employment activities. As reported in this issue (Bryan et al., 2014), there is a positive association between a sense of work-related accomplishment and better physical health in Special Operations Forces personnel. If this finding is generalized to other service populations, it would suggest the importance of aggressive interventions focused on early reintegration of returning veterans into school and/or work systems. There is also an increased awareness of the prevalence of sexual trauma occurring in the armed forces. On the basis of VA data collected between 2002 and 2010 (US Department of VA, Office of Mental Health Services, Military Sexual Trauma Support Team, 2011), military sexual trauma (MST) was endorsed by 22% of women and 1% of men. Another patient of ours, a Marine veteran in her early 20s with a history of childhood adversity, reported that she was driven repeatedly to self-destructive behavior by hearing the voices of the five Marines who had raped her while she was deployed overseas. The military and the VA systems have not been well prepared to appreciate and manage the consequences of these noncombat traumatic experiences or to cope with illnesses and treatment responses that vary as a function of sex and sexuality. MST-focused outpatient and residential treatment programs have been developed in recent years, and new policies are being promulgated and endorsed widely in the VA system. This is particularly important because an increasing number of women are serving in the military (14.5% of all active duty), some of whom will assume combat roles. Sex differences in mental health reactions after combat have been described and may increase (Woodhead et al., 2012). Openly gay and lesbian soldiers join women in changing military demographics. Further, transgender veterans are requesting care at VA facilities around the country, and their special medical and psychiatric needs may be vexing for a healthcare system that, until recently, focused mostly on treating heterosexual male veterans. The signature injury of the OIF/OEF theatre is mild TBI (mTBI). Improvised explosive devices, prevalent in both Iraq and Afghanistan, shake and concuss the central nervous system. This disorder is not well understood, and treatment strategies have not gained general acceptance (Iverson, 2010). Recent studies have raised the question of iatrogenic disability associated with mTBI (Roth and Spencer, 2013), because the neuropsychological consequences may typically be limited (Vasterling et al., 2012). Despite evidence that the functional impairment is associated mostly with psychiatric symptoms (PTSD and depression), providers and veterans frequently misperceive the problems as being caused by frank nerve damage. Aggressive management of pain (the ‘‘fifth vital sign’’), although clearly indicated for many wounded warriors, may confer a higher risk for physiological and psychological dependence on opioid medication. Chronic pain, PTSD, depression, and mTBI combine to create a fertile substrate for possible substance abuse and overdose, especially in individuals who are also prescribed hypnotics for sleep or are misusing alcohol (Seal et al., 2012). Indeed, opioid analgesics play the predominant role in pharmaceutical overdose deaths, either alone or with other drugs (Jones et al., 2013). Suicidal behavior is a multifactorial phenomenon whose prevalence has been reported to be increased in veterans of all ages and diagnoses (Hoge and Castro, 2012). Between January 1, 2008, and December 31, 2010, there were 870 confirmed suicides and 1964 suicide attempts among our troops (Bush et al., 2013). Unexpectedly, a recent study of current and former military personnel observed between 2001 and 2008 found the risk for suicide to be associated with male sex and mental disorders but not with military-specific variables (LeardMann et al., 2013). In addition to deaths of their buddies in combat, OIF/OEF service members are in contact with an unusual number of civilian casualties. As a result, many soldiers and veterans experience loss, guilt, and moral injury. In a recent report, guilt and shame in this population were associated with suicidal ideation (Bryan et al., 2013). * 2014 Lippincott Williams & Wilkins
Commentary
News of war-related losses travels instantaneously through social media, potentially reinforcing survivor guilt and intensifying traumatic impact that may lead to consequences such as those experienced by the young veteran who viewed the online memorial referenced earlier. Many commentators contend that a suicide implies a clinical or system failure and that all such deaths are preventable. This belief has the unintended effect of scapegoating families and therapists who may not have acted negligently in any way. On the other hand, the political attention devoted to the ‘‘epidemic’’ of military suicides has augmented financial support for mental health programs that translates into staffing initiatives, resulting in better access to evidencebased care for all veterans (Katz et al., 2013). Compounding the obstacles in addressing the mental health needs of returning OIF/OEF veterans is the difficulty enrolling and maintaining them in treatment. As reported by Hoge et al. (2004), relatively soon after the start of the war, more than 60% of service men and women who had a mental health problem avoided treatment, likely because of concerns about the stigma attached to such treatment. The VA system has ‘‘rolled out’’ several evidence-based psychotherapeutic interventions for PTSD and trained many of its clinicians in providing these therapies, in addition to offering evidence-based pharmacotherapy. However, as eloquently described by Harpaz-Rotem et al. (2014) in this issue, rates of attrition of OIF/ OEF veterans from mental health treatment are robust. In trying to understand the possible contributing factors, Harpaz-Rotem et al. (2014) assessed 137 symptomatic OIF/OEF veterans accessing mental health services in a VA healthcare system. They found that the severity of PTSD symptoms (especially re-experiencing) and the support of fellow soldiers promoted engagement, whereas PTSD and depression severity and a higher education level were associated with treatment retention. As we better understand these overlapping variables, we may be better able to design individualized approaches to facilitate completion of the treatment process. Recent changes to the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), may have an impact on the PTSD prevalence in returning OIF/OEF veterans, which, in turn, may affect service-connected pensions for years to come. A recent study suggests good concordance between DSM-IV and DSM-5 in the diagnosis of PTSD, although fewer subjects met criterion A for trauma exposure according to DSM-5 (Calhoun et al., 2012). It remains to be seen how these changes will affect future compensation examinations for OIF/OEF veterans. The direct exposure to OIF/OEF combat experienced by our forces during their deployment is unquestionably a risk factor of traumatic sequelae. However, acute and chronic PTSD are not the only trauma-related diagnostic categories proposed in the new version of the ICDVICD-11. Refugees from the global civil wars that involved genocide, mutilation, torture, rape, and forced migration (‘‘ethnic cleansing’’), such as those that occurred in sub-Saharan Africa and the former states composing Yugoslavia, have exhibited psychiatric and medical comorbidity of even greater frequency, severity, complexity, and chronicity than those experienced by our veterans. Palic and Elklit’s (2014) article on complex PTSD in this issue demonstrates that in addition to DSM-IV axis I symptoms, traumatized Bosnian refugees may also exhibit a panoply of axis II cluster A psychopathology, specifically paranoid and schizotypal personality patterns. Their findings are somewhat different than prior studies that reported a high overlap of complex PTSD with borderline personality disorder traits, and it is likely that the timing of trauma exposure (childhood versus adulthood), the duration and repeated nature of the traumatization, and the time elapsed since the traumatic events occurred all play a role in the shaping of axis I and axis II symptoms in this population of survivors. On the basis of these studies and those of earlier victims of atrocities such as holocaust survivors (Yehuda and Bierer, 2008), we may also be concerned www.jonmd.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
89
The Journal of Nervous and Mental Disease
Commentary
about the later appearance of second-generation emotional effects in the offspring of refugees that represent the enduring traumatic legacy of being a survivor of mass inhumanity. The peril to our troops returning from Iraq and Afghanistan will not end when the last combat soldier comes home. Some of our millennial veterans will need long-term care for both neuropsychiatric and medical comorbidities. Recent studies demonstrate a growing appreciation of the complex roles of resilience, early life stress, and postdeployment social support in symptom formation, as well as the underappreciated phenomenon of posttraumatic growth (Gallaway et al., 2011). We are hopeful that these concepts will help us identify psychopathology early, develop preventive interventions, and deliver more effective treatments promptly for our wounded warriors, with the substantial promise of enhancing the quality of life and diminishing the risk for premature death. We owe our soldiers whose faces were marred by dust and sweat and blood nothing less. DISCLOSURES The authors declare no conflict of interest. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the US Government. REFERENCES Boscarino JA (2004) Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies. Ann N Y Acad Sci. 1032:141Y153. Boscarino JA (2006) Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann Epidemiol. 16:248Y256. Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B (2013) Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depress Anxiety. 30:55Y60. Bryan CJ, Stephenson AJ, Morrow CE, Staal M, Haskell J (2014) Posttraumatic stress symptoms and work-related accomplishment as predictors of general health and medical utilization among Special Operations Forces (SOF) personnel. J Nerv Ment Dis. 202:105Y110. Bush NE, Reger MA, Luxton DD, Skopp NA, Kinn J, Smolenski D, Gahm GA (2013) Suicides and suicide attempts in the U.S. Military, 2008Y2010. Suicide Life Threat Behav. 43:262Y233. Calhoun PS, Hertzberg JS, Kirby AC, Dennis MF, Hair LP, Dedert EA, Beckham JC (2012) The effect of draft DSM-V criteria on posttraumatic stress disorder prevalence. Depress Anxiety. 29:1032Y1042. Gallaway MS, Millikan AM, Bell MR (2011) The association between deployment-related posttraumatic growth among U.S. Army soldiers and negative behavioral health conditions. J Clin Psychol. 67:1151Y1160. Harpaz-Rotem I, Rosenheck RA, Pietrzak RA, Southwick SS (2014) Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan Veterans. J Nerv Ment Dis. 202:97Y104.
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Hoge CW, Castro CA (2012) Preventing suicides in US service members and veterans. JAMA. 308:671Y672. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 351:13Y22. Iverson GL (2010) Clinical and methodological challenges with assessing mild traumatic brain injury in the military. J Head Trauma Rehabil. 25:313Y319. Jones CM, Mack KA, Paulozzi LJ (2013) Pharmaceutical overdose deaths in the United States, 2010. JAMA. 309:657Y659. Katz IR, Kemp JE, Blow FC, McCarthy JF, Bossarte RM (2013) Changes in suicide rates and in mental health staffing in the Veterans Health Administration, 2005Y2009. Psychiatr Serv. 64:620Y625. LeardMann CA, Powell TM, Smith TC, Bell MR, Smith B, Boyko EJ, Hooper TI, Gackstetter GD, Ghamsary M, Hoge CW (2013) Risk factors associated with suicide in current and former US military personnel. JAMA. 310: 496Y506. Lindley SE, Carlson E, Hill KR (2014) Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress disorder. J Nerv Ment Dis. 202:91Y96. Roth RS, Spencer RJ (2013) Iatrogenic risk in the management of mild traumatic brain injury among combat veterans: A case illustration and commentary. Int J Phys Med Rehabil. 1:1. Palic S, Elklit A (2014) Personality dysfunction and complex posttraumatic stress disorder among chronically traumatized Bosnian refugees. J Nerv Ment Dis. 202:111Y118. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC (2012) Association of mental health disorders with prescription opioids and highrisk opioid use in US veterans of Iraq and Afghanistan. JAMA. 307:940Y947. Shaner A, Eth S (1989) Can schizophrenia cause posttraumatic stress disorder? Am J Psychother. 43:588Y597. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW (2010) Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 67:614Y623. US Department of Veterans Affairs, Office of Mental Health Services, Military Sexual Trauma Support Team (2011) Military sexual trauma (MST) screening report fiscal year 2010. Van Putten T, Emory W (1973) Traumatic neuroses in Vietnam returnees. A forgotten diagnosis? Arch Gen Psychiatry. 29:695Y698. Vasterling JI, Brailey K, Proctor SP, Kane R, Heeren T, Franz M (2012) Neuropsychological outcomes of mild traumatic brain injury, post-traumatic stress disorder and depression in Iraq-deployed US Army soldiers. Br J Psychiatry. 201:186Y192. Woodhead C, Wessely S, Jones N, Fear NT, Hatch SL (2012) Impact of exposure to combat during deployment to Iraq and Afghanistan on mental health by gender. Psychol Med. 42:1985Y1996. Yehuda R, Bierer LM (2008) Transgenerational transmission of cortisol and PTSD risk. Prog Brain Res. 167:121Y135.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Sequelae of Our Millennial War Daniella David, MD and Spencer Eth, MD
‘‘The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood’’ Theodore Roosevelt, 1910
T
his year, a young veteran of the Afghanistan warVin treatment for posttraumatic stress disorder (PTSD), depression, and chronic pain in our medical centerVkilled himself. Friends posted an online memorial video. A combat buddy, viewing his own image in the memorial, disappeared from his college dormitory. Police found him and brought him to the Veterans Affairs (VA) hospital, where he was admitted involuntarily with a first psychotic episode. These two young men carry a burden of psychiatric illness that bears both similarities and differences to that of their Vietnam or Gulf War era predecessors. Although each war fought during the past century afforded psychiatrists unique insights into the frequently devastating consequences of combat, the current Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) campaigns offer novel challenges. Approximately 1.6 million Americans have served in war since 2001. Approximately one third of these returning soldiers are experiencing symptoms of PTSD, depression, and/or traumatic brain injury (TBI), and comorbidity with alcohol misuse and interpersonal violence has been reported in about half of these cases (Thomas et al., 2010). As described in a small study of Vietnam veterans with chronic PTSD and without recent substance use (n = 30) in this issue (Lindley et al., 2014), psychotic symptoms are also frequently reported in this population and may correlate with dissociation and severity of combat exposure. These phenomena do not seem to be part of a classic psychosis phenotype and are unlikely to be related solely to malingering. Of interest, the reported psychotic symptoms in this study also did not correlate with depression but did exhibit an association with attention difficulties on cognitive examinations. Although recent substance abuse was denied by the subjects in this study, earlier use of hallucinogenic drugs can have long-lasting effects that could confound the analysis of psychotic symptoms. The difficulty distinguishing dissociative PTSD phenomena from other etiologies of anomalous psychotic experiences has been noted for many years (Shaner and Eth, 1989; Van Putten and Emory, 1973) and will surely apply to OIF/OEF veterans whose frequent neurological comorbidity adds yet another layer of complexity. Veterans with chronic PTSD have been found to have an increased burden of physical illness, with elevated rates of disorders in most organ systems, and mortality (Boscarino, 2004, 2006). In a study of 74 active-duty male Special Operations Forces personnel in this issue, Bryan et al. (2014) report the associations among PTSD avoidance and numbing symptoms and increased somatic symptoms as well as high utilization of medical services. Their data are consistent with the impressions of many clinicians that neglecting emotional pain will frequently translate into complaints of physical ailments. Today’s returning soldiers do not have to confront Vietnam era antiwar sentiments, but they often feel estranged for other reasons. They represent the small segment of the US populace who volunteered to participate in a heroic conflict. Most citizens have no meaningful connection to the reality of these wars and what our soldiers have endured, despite the universal awareness of the enormity of the 9/11 attack on American soil. Frequent redeployments contribute to repetitive trauma exposure, as well as extended separation from family and other social supports. Paradoxically, although the military bonds are extremely strong and cohesive, many returning veterans find themselves contending with isolation and alienation in civilian life. This, in turn, leads to difficulties with re-engagement in education and/or
Miami VA Healthcare System, Miami, FL; and Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL. Send reprint requests to Daniella David, MD, Miami VA Healthcare System, 1201 NW 16th Street, 116A, Miami, FL 33125. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0088 DOI: 10.1097/NMD.0000000000000075
88
www.jonmd.com
The Journal of Nervous and Mental Disease
& Volume 202, Number 2, February 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Journal of Nervous and Mental Disease
& Volume 202, Number 2, February 2014
employment activities. As reported in this issue (Bryan et al., 2014), there is a positive association between a sense of work-related accomplishment and better physical health in Special Operations Forces personnel. If this finding is generalized to other service populations, it would suggest the importance of aggressive interventions focused on early reintegration of returning veterans into school and/or work systems. There is also an increased awareness of the prevalence of sexual trauma occurring in the armed forces. On the basis of VA data collected between 2002 and 2010 (US Department of VA, Office of Mental Health Services, Military Sexual Trauma Support Team, 2011), military sexual trauma (MST) was endorsed by 22% of women and 1% of men. Another patient of ours, a Marine veteran in her early 20s with a history of childhood adversity, reported that she was driven repeatedly to self-destructive behavior by hearing the voices of the five Marines who had raped her while she was deployed overseas. The military and the VA systems have not been well prepared to appreciate and manage the consequences of these noncombat traumatic experiences or to cope with illnesses and treatment responses that vary as a function of sex and sexuality. MST-focused outpatient and residential treatment programs have been developed in recent years, and new policies are being promulgated and endorsed widely in the VA system. This is particularly important because an increasing number of women are serving in the military (14.5% of all active duty), some of whom will assume combat roles. Sex differences in mental health reactions after combat have been described and may increase (Woodhead et al., 2012). Openly gay and lesbian soldiers join women in changing military demographics. Further, transgender veterans are requesting care at VA facilities around the country, and their special medical and psychiatric needs may be vexing for a healthcare system that, until recently, focused mostly on treating heterosexual male veterans. The signature injury of the OIF/OEF theatre is mild TBI (mTBI). Improvised explosive devices, prevalent in both Iraq and Afghanistan, shake and concuss the central nervous system. This disorder is not well understood, and treatment strategies have not gained general acceptance (Iverson, 2010). Recent studies have raised the question of iatrogenic disability associated with mTBI (Roth and Spencer, 2013), because the neuropsychological consequences may typically be limited (Vasterling et al., 2012). Despite evidence that the functional impairment is associated mostly with psychiatric symptoms (PTSD and depression), providers and veterans frequently misperceive the problems as being caused by frank nerve damage. Aggressive management of pain (the ‘‘fifth vital sign’’), although clearly indicated for many wounded warriors, may confer a higher risk for physiological and psychological dependence on opioid medication. Chronic pain, PTSD, depression, and mTBI combine to create a fertile substrate for possible substance abuse and overdose, especially in individuals who are also prescribed hypnotics for sleep or are misusing alcohol (Seal et al., 2012). Indeed, opioid analgesics play the predominant role in pharmaceutical overdose deaths, either alone or with other drugs (Jones et al., 2013). Suicidal behavior is a multifactorial phenomenon whose prevalence has been reported to be increased in veterans of all ages and diagnoses (Hoge and Castro, 2012). Between January 1, 2008, and December 31, 2010, there were 870 confirmed suicides and 1964 suicide attempts among our troops (Bush et al., 2013). Unexpectedly, a recent study of current and former military personnel observed between 2001 and 2008 found the risk for suicide to be associated with male sex and mental disorders but not with military-specific variables (LeardMann et al., 2013). In addition to deaths of their buddies in combat, OIF/OEF service members are in contact with an unusual number of civilian casualties. As a result, many soldiers and veterans experience loss, guilt, and moral injury. In a recent report, guilt and shame in this population were associated with suicidal ideation (Bryan et al., 2013). * 2014 Lippincott Williams & Wilkins
Commentary
News of war-related losses travels instantaneously through social media, potentially reinforcing survivor guilt and intensifying traumatic impact that may lead to consequences such as those experienced by the young veteran who viewed the online memorial referenced earlier. Many commentators contend that a suicide implies a clinical or system failure and that all such deaths are preventable. This belief has the unintended effect of scapegoating families and therapists who may not have acted negligently in any way. On the other hand, the political attention devoted to the ‘‘epidemic’’ of military suicides has augmented financial support for mental health programs that translates into staffing initiatives, resulting in better access to evidencebased care for all veterans (Katz et al., 2013). Compounding the obstacles in addressing the mental health needs of returning OIF/OEF veterans is the difficulty enrolling and maintaining them in treatment. As reported by Hoge et al. (2004), relatively soon after the start of the war, more than 60% of service men and women who had a mental health problem avoided treatment, likely because of concerns about the stigma attached to such treatment. The VA system has ‘‘rolled out’’ several evidence-based psychotherapeutic interventions for PTSD and trained many of its clinicians in providing these therapies, in addition to offering evidence-based pharmacotherapy. However, as eloquently described by Harpaz-Rotem et al. (2014) in this issue, rates of attrition of OIF/ OEF veterans from mental health treatment are robust. In trying to understand the possible contributing factors, Harpaz-Rotem et al. (2014) assessed 137 symptomatic OIF/OEF veterans accessing mental health services in a VA healthcare system. They found that the severity of PTSD symptoms (especially re-experiencing) and the support of fellow soldiers promoted engagement, whereas PTSD and depression severity and a higher education level were associated with treatment retention. As we better understand these overlapping variables, we may be better able to design individualized approaches to facilitate completion of the treatment process. Recent changes to the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), may have an impact on the PTSD prevalence in returning OIF/OEF veterans, which, in turn, may affect service-connected pensions for years to come. A recent study suggests good concordance between DSM-IV and DSM-5 in the diagnosis of PTSD, although fewer subjects met criterion A for trauma exposure according to DSM-5 (Calhoun et al., 2012). It remains to be seen how these changes will affect future compensation examinations for OIF/OEF veterans. The direct exposure to OIF/OEF combat experienced by our forces during their deployment is unquestionably a risk factor of traumatic sequelae. However, acute and chronic PTSD are not the only trauma-related diagnostic categories proposed in the new version of the ICDVICD-11. Refugees from the global civil wars that involved genocide, mutilation, torture, rape, and forced migration (‘‘ethnic cleansing’’), such as those that occurred in sub-Saharan Africa and the former states composing Yugoslavia, have exhibited psychiatric and medical comorbidity of even greater frequency, severity, complexity, and chronicity than those experienced by our veterans. Palic and Elklit’s (2014) article on complex PTSD in this issue demonstrates that in addition to DSM-IV axis I symptoms, traumatized Bosnian refugees may also exhibit a panoply of axis II cluster A psychopathology, specifically paranoid and schizotypal personality patterns. Their findings are somewhat different than prior studies that reported a high overlap of complex PTSD with borderline personality disorder traits, and it is likely that the timing of trauma exposure (childhood versus adulthood), the duration and repeated nature of the traumatization, and the time elapsed since the traumatic events occurred all play a role in the shaping of axis I and axis II symptoms in this population of survivors. On the basis of these studies and those of earlier victims of atrocities such as holocaust survivors (Yehuda and Bierer, 2008), we may also be concerned www.jonmd.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
89
The Journal of Nervous and Mental Disease
Commentary
about the later appearance of second-generation emotional effects in the offspring of refugees that represent the enduring traumatic legacy of being a survivor of mass inhumanity. The peril to our troops returning from Iraq and Afghanistan will not end when the last combat soldier comes home. Some of our millennial veterans will need long-term care for both neuropsychiatric and medical comorbidities. Recent studies demonstrate a growing appreciation of the complex roles of resilience, early life stress, and postdeployment social support in symptom formation, as well as the underappreciated phenomenon of posttraumatic growth (Gallaway et al., 2011). We are hopeful that these concepts will help us identify psychopathology early, develop preventive interventions, and deliver more effective treatments promptly for our wounded warriors, with the substantial promise of enhancing the quality of life and diminishing the risk for premature death. We owe our soldiers whose faces were marred by dust and sweat and blood nothing less. DISCLOSURES The authors declare no conflict of interest. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the US Government. REFERENCES Boscarino JA (2004) Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies. Ann N Y Acad Sci. 1032:141Y153. Boscarino JA (2006) Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann Epidemiol. 16:248Y256. Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B (2013) Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depress Anxiety. 30:55Y60. Bryan CJ, Stephenson AJ, Morrow CE, Staal M, Haskell J (2014) Posttraumatic stress symptoms and work-related accomplishment as predictors of general health and medical utilization among Special Operations Forces (SOF) personnel. J Nerv Ment Dis. 202:105Y110. Bush NE, Reger MA, Luxton DD, Skopp NA, Kinn J, Smolenski D, Gahm GA (2013) Suicides and suicide attempts in the U.S. Military, 2008Y2010. Suicide Life Threat Behav. 43:262Y233. Calhoun PS, Hertzberg JS, Kirby AC, Dennis MF, Hair LP, Dedert EA, Beckham JC (2012) The effect of draft DSM-V criteria on posttraumatic stress disorder prevalence. Depress Anxiety. 29:1032Y1042. Gallaway MS, Millikan AM, Bell MR (2011) The association between deployment-related posttraumatic growth among U.S. Army soldiers and negative behavioral health conditions. J Clin Psychol. 67:1151Y1160. Harpaz-Rotem I, Rosenheck RA, Pietrzak RA, Southwick SS (2014) Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan Veterans. J Nerv Ment Dis. 202:97Y104.
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& Volume 202, Number 2, February 2014
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