Overview Of Health Problem
Overview of Health Problem
For years it has been widely known that one of the most insidious aspects of war is not what occurs on the battlefield, but what happens to our brave military men and women when they return home from war: Post Traumatic Stress Disorder. Post Traumatic Stress Disorder (PTSD), often considered an invisible wound of wartime experience, is routinely diagnosed by qualified mental health practitioners through a series of criterion outlined in the Diagnostic Statistical Manual IV (DSM-IV). According to (Lancaster, Teeters, Gros, & Back, 2016), the DSM-IV denotes an individual with PTSD must experience the following for at least one month— “at least one re-experiencing and avoidance symptom… at least two arousal and reactivity symptoms, …and least two cognition and mood symptoms” (p. 2).
Re-experiencing symptoms include repetitive memories and nightmares replaying the trauma-inducing event, feelings of depersonalization, and extended mental distress and anxiety, and changes in arousal such as increased aggressiveness, and hypervigilance. Avoidance, another diagnostic symptom, includes anxiety-ridden memories, reflections and reimagining the event. And lastly, negative changes in cognition and mood include continuous negative thought patterns, cognitive distortions surrounding blame, or heightened emotions related to the trauma; isolative feelings and anhedonia (National Institute of Mental Health, n.d.). Not only are the above criteria mentally and physically distressing to the experiencer, they often cause and are diagnosed alongside other psychiatric comorbidities such as depression and substance use disorders which will be discussed later in this paper.
This invisible, post-war psychological struggle is thought to have existed since the beginning of the trauma-inducing activity. According to Reisman (2016), one the first mentions of PTSD was recorded by the Greek historian Herodotus: “In writing about the Battle of Marathon in 490 B.C., Herodotus described an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier himself had not been wounded” (p. 623). Moreover, psychological injuries and symptoms have been well acquainted with war-induced trauma and featured in the histories of numerous cultures (Abdul-Hamid & Hughes, 2014). It was not until the late 1970’s that the name Post Traumatic Stress Disorder was adopted into scientific literature which then became an official diagnosis outlined in the DSM-III in 1980 (Reisman, 2016).
Unfortunately, today, it is rather challenging to pin down exactly how many veterans have experienced or are diagnosed with PTSD. Some of the statistical data that does exist are from The U.S. Department of Veteran Affairs’ National Center of PTSD, which reports that, in a given year, about 12% of Gulf War vets battle with PTSD, while about 30% of Vietnam vets have been challenged with the disorder at some point in their life (U.S. Department of Veteran Affairs). To add to the unclarity, PTSD is also a complex and multifactorial issue, where detailed data concerning PTSD among age groups, races, sex, and key factors that impact the risk and severity of PTSD, are sparse.
According to the TIME magazine article, Unlocking the Secrets of PTSD, The National Academy of Sciences reported that around 20% of 2.6 million U.S. military veterans who served in Afghanistan and Iraq may test positive for PTSD. Furthermore, 25% of veterans who served in wars following the 9/11 terrorist attack that sought medical attention from the VA in 2011 also presented with PTSD (Thomson, 2015). The article continues to report that 13.5% of veterans in the recent war have met PTSD diagnostic requirements for PTSD, were other studies report positive PTSD screenings in veterans are closer to 20% to 30% (Reisman, 2016). Essentially, it is difficult to tell how many veterans actually have PTSD which further speaks to the need for studies to uncover hard facts.
While there is a substantial amount of information regarding PTSD for white males, there is considerably less data about minorities and women. The information that is available, from the U.S. Department of Veteran Affairs’ 2017 Minority Veterans Report, states that minorities do experience higher rates of PTSD (5.8%) compared to their white counterparts (5.0%). The report further discusses how some minorities (African American and Hispanics), are more likely than whites to develop PTSD because these groups are at greater risks of facing traumatic life experiences outside of war, increasing their overall risk for PTSD. The underrepresentation of women in statistical data surrounding PTSD is alarming due in part that gender may be a particularly important factor to consider in understanding the nuances that lead to uniquely impactful stress-inducing situations such as military sexual trauma/assault (MST). Sufferers from MST, who are predominantly women, were found to be three times more likely to suffer from mental health issues including PTSD (Smith, 2017).
A meta-analysis of military personnel and veterans found there are 18 significant predictors/risk factors of PTSD which include; gender, being a minority, having lower levels of education, military specialization, length of time in war and number of deployments, a history of traumatic life events, and a history of psychological issues (Xue et al., 2015). Further risk factors included in the meta analysis are extended battle exposure, firing or wielding a weapon, and witnessing a traumatic injury or death, to name a few (Xue et al., 2015). Protective factors decreasing veterans’ chances of acquiring PTSD include social support as the strongest determinant to mitigating PTSD, feeling connected to a cohesive unit, possessing a resilient personality trait, and being a male (James, Van Kampen, Miller, & Engdahl, 2013).
As mentioned earlier, veterans rarely present with PTSD as their only condition. Veterans also present with comorbid psychiatric issues such as depression, substance use disorder (SUD), drug use disorder (DUDs), anxiety and suicide. A large national survey concerning Major Depressive Disorder (MDD) highlighted the most prevalent psychiatric comorbidity with PTSD (depression) is three to five times more likely to be diagnosed in PTSD positive individuals than those without the disorder (Reisman, 2016). Riesman (2016) further writes:
74% of Vietnam veterans with PTSD had a comorbid substance use disorder (SUD), 63% of recent veterans who were diagnosed with alcohol use disorders (AUDs) or drug use disorders (DUDs) had co-occurring PTSD, and the prevalence of PTSD among those who met criteria for both AUDs and DUDs was 76%. (p. 624)
Increased reports of chronic and severe pain have also been determined as consequence of PTSD compared to those without the disorder, which may be due in part to the injuries sustained during battle (Reisman, 2016).
The U.S. government has set multiple plans via its Healthy People 2020 goals and objectives which aim to assist citizens with psychiatric issues and substance use disorders. These objectives include increasing depression screenings, suicide prevention resources, facilities that provide onsite or referral mental health treatment, treatment for co-occurring substance abuse individuals, and reducing substance abuse to protect the health, safety, and quality of life for all. (The Office of Disease Prevention and Health Promotion, 2011). These measures will also have a sizable impact on the nation’s economy, which, as it stands, has reportedly cost the Veterans Health Administration more than $2 billion ($8,300 per person) in the first year of treatment of Afghanistan and Iraq soldiers. This does not include the comorbidity economic burden of suicide, substance use, and depression which reaches the hundreds of billions of dollars (Congress of the United States Congressional Budget Office, 2012).
In the transactional model of the stress and coping theory, stress is regarded as a relational or ‘transactional’ concept between individuals and their environment. This theory focuses on two concepts, cognitive appraisal and coping. Cognitive appraisal begins as an individual becomes aware of and interprets a stressor as being positive, dangerous, or irrelevant, and is termed primary appraisal. Secondary appraisal occurs as an individual determines whether or not he or she has sufficient coping resources to overcome the stressor. The concept of appraisal allows for understanding of the differentiation among an individual’s response to stress that may have occurred in an objectively similar environment. When looking to improve stress and coping strategies, appraisal enables individuals to identify causes of stress and barriers to their inability to implement an effective coping strategy. Both personal and situational factors can influence an individual’s appraisals, and these must be identified in order to devise coping strategies that are individually specific (Baqutayan, 2015).
Coping is defined as the cognitive and behavior efforts made to master, tolerate, or reduce external and internal demands and conflicts among individuals (Baqutayan, 2015). Coping strategies can be split into those which are problem-focused and those which are emotion-focused. Problem-focused coping attempts to influence the situation or environment causing the stressor, where emotion-focused coping works to target the individual’s response to the stressor.
Hans Selye initially introduced the term stress to mean, “the sum of all nonspecific changes caused by function or damage” (Baqutayan, 2015). The term allostatic load refers to “the wear and tear on the body” that accumulates through repeated or chronic exposure to stress. An increase in allostatic load has direct negative side effects on an individual on both a biochemical and psychological level (Thayer, 2016). Symptoms of increased allostatic load are manifested through a series of biochemical changes termed by Hans Selye as the General Adaptation Syndrome (GAS) (Baqutayan, 2015). The body begins by initiating the fight or flight response which is manifested through increased blood pressure, increased heart rate, increased blood flow and increase pulmonary dilation (Baqutayan, 2015). The body then enters into the resistance phase during which the body’s fight or flight response long outlasts the stimulus that provoked the initial onset. This resistance causes chronic elevation in blood pressure, blood glucose, inflammation, among other manifestations that ultimately contribute to a decline in health (Thayer, 2016).
It is imperative to veterans’ health that the transactional theory of stress and coping identify the stressors that exacerbate PTSD symptoms and additional stressors that may lead to an increase risk for SUD in war veterans. Once the stressors are identified, resources to cope may be evaluated, and then an individual can work to increase coping strategies to target his or her specific stress. It has been proven that both problem- and emotion-focused coping are effective, however, one may better suit certain situations or an individual’s preferences (Baqutayan, 2015). Overarchingly, an increase in social support throughout the process of stress and coping has shown significant decrease in stress response and improved coping among individuals suffering from PTSD (Baqutayan, 2015).
Relationship of Theory to Health Issue
Veterans returning home after active duty encounter various types of obstacles that they must now tackle when adjusting to a baseline of normality. These obstacles may include coping with seeing a horrific battle, having medical injury, or witnessing the loss of a fellow soldier, any and all of which can lead to undiagnosed PTSD. Nurses are an integral part of the interprofessional team providing care for the veterans. Nurses are trained in providing the best quality care to their patients and are readily available to provide education about the disease process based on research.
There are many studies which examine coping strategies that target improving PTSD and SUD outcomes. The interventions necessary for the treatment and maintenance of these disorders is highly affected by the poor coping skills of veterans (Matthew.T.B., Rachel. K., Madhur.K., Marcel.O.B., Christopher.W., Jodie.T, 2014). Avoidance coping is one of the strategies in which the person orients their thoughts, emotions, and behavior away from the unpleasant experience (e.g., denying, choosing not to engage or confront). Some studies that found that patients with PTSD or SUD try to use this avoidance strategy as one of their coping skills, which can, in turn, exaggerate their symptoms and conditions. For such individuals suffering from PTSD, the use of drugs or alcohol may be implemented because it helps them alleviate some pain, stress, and related consequences (Matthew.T.B., et.al., 2014). Avoidance coping is one of the widely used coping mechanisms, which can have negative consequences in the long run among veterans seeking treatment. The complete contrast to avoid coping is Active Coping, wherein the symptoms are tackled and treated in anticipation of great outcomes. One such therapy, which is widely used for the treatment of PTSD, SUD, is of cognitive behavioral therapy (Matthew.T.B., et.al., 2014).
One other battle the veterans are often combatting, in their daily life is the stigma around seeking care or help. This further leads to an increase in stress, more alcohol drinking and substance use disorder (De La Rosa, Delaney, Webb-Murphy, & Johnston, 2015). Research on drinking motives has shown that individuals use alcohol as a means to regulate their emotions and that, for some, it may be a means of coping in lieu of other emotional strategies, such as engaging in goal-directed behavior (Stephen M.M., et al., 2016). In relation to PTSD symptoms and drinking to cope, there is an added concern of stigmatization with seeking help, which is prevalent among veterans (Stephen M.M., et al., 2016). A study of active military personnel found a relation between PTSD and AUD, and the stigma around seeking help (De La Rosa., et al., 2015). The failure to seek help can have a negative effect on the health outcome and wellbeing of the veterans.
Veterans with PTSD and major depressive disorder (MDD) are a vulnerable population and are at higher risk for cannabis use disorder (CUD). One study examined the relationship between PTSD and MDD with cannabis use frequency and its related problems, as well as the role of three coping-oriented cannabis use motives (coping with negative affect, situational anxiety, and sleep). (James et al., 2016). Evidence has been primarily focused on the comorbidity between PTSD and cannabis use and CUD, depression appears to co-occur with cannabis use and its dependence among veterans. Just as using alcohol, as one of the coping methods, cannabis is rapidly gaining its popularity and is used broadly to regulate emotions, decrease stress, and aid with sleep (The Office of Disease Prevention and Health Promotion, 2011).
Overall, PTSD and poor coping mechanisms like SUD and AUD affect a large number of military veterans. Understanding the factors that contribute to PTSD is the first step for nurses to address how to care for these veterans. Of equal importance, it is imperative to understand the stress and coping strategies that veterans can turn to such as substance abuse and alcohol abuse if not given healthy coping options. Our job as nurses is to identify possible signs and symptoms of individuals who may be suffering with PTSD and are at risk for maladaptive coping strategies such as SUD and AUD.
Dr. Kathleen Wheeler, a psychiatric nurse practitioner, has a book entitled, “A Call for Trauma Competencies in Nursing Education,” which states it is the nurse’s job to first identify the signs of trauma in a patient “and assist in providing resources and stabilization in order to prevent PTSD” (Wheeler, 2018, pg.20). These signs can include reckless or self-destructive behavior and regular sleep disturbances. Using resources such as Reisman’s study, “PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next,” to understand the history of PTSD and the statistics of the populations it affects is a good start. We need to know that 20-30% of the US military may be living with PTSD. We need to understand that there is less data on those living with PTSD in minority groups such as African Americans, Hispanics, women and LGBTQ, and that they may be suffering with PTSD at greater rates and/or more severely than their white counterparts. According to Baquatyan’s “Stress and Coping Mechanisms: A Historical Overview.” we need to understand the methods of stress and coping and the effects they have on the body. And finally, we need to realize the connection between the failed coping skills and PTSD and how they can evolve into SUD and AUD as seen in the study entitled, “Combat Experience and Problem Drinking in Veterans: Exploring the roles of PTSD, coping motives, and perceived stigma” by Matthew Tyler Boden.
As nurses, it is imperative to educate ourselves with the available resources and studies to understand the connections between PTSD, coping, and substance use to better treat our patients. We also need to point these soldiers in the right direction to help with reducing the weight of the stigma that comes with asking for help. Without addressing these pertinent issues within our veteran community, we fail as nurses and more importantly, we fail our patients.