The Vietnam War and the plight of veterans in USA have generated much media interest because of its comprehensibility, easy accessibility, and since it added public interest to disasters of great magnitude. For many, PTSD places responsibility for their suffering on factors outside themselves, factors over which they often had neither responsibility nor control (Friedman, 2000) thus providing an explanatory model. Gersons and Carlier (1992) looking at the history of PTSD, commented that the introduction of the new diagnosis of PTSD was seen and felt to be in recognition of the psychological consequences of war, especially as experienced by Vietnam veterans. After the description of PTSD in the 1980, there was a major increase in research interest in PTSD (Blake, Albano, & Keane, 1992) with majority of them being on victims of war or sexual violence.
Post Traumatic Stress Disorder (PTSD)
PTSD is a natural emotional reaction to a deeply shocking and disturbing experience. It is a normal reaction to an abnormal situation. Post Traumatic Stress Disorder (PTSD) is defined in DSM-IV, the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual. For a doctor or mental health professional to be able to make a diagnosis, the condition must be defined in DSM-IV or its international equivalent, the World Health Organization’s ICD-10. The focus of the DSM-IV (American Psychiatric Association, 1994) definition of Post Traumatic Stress Disorder is a single life-threatening event or threat to integrity. However, the symptoms of traumatic stress also arise from an accumulation of small incidents rather than one major incident.
History of PTSD
PTSD is considered to be the renaming or the synthesis of an age-old condition. The psychological effect of exposure to combat-related traumatic events, then called physioneurosis was first scientifically studied in 1941 by A. Kardiner (Kolb, 1993). Research interest in this area peaked during and after the world wars. Keiser’s (1968) book The Traumatic Neurosis describes specific problems following trauma supporting the existence of PTSD prior to the Vietnam War. The studies done among survivors of World War II death & prisoner of war (PoW) camps, and the Vietnam War accelerated the growth of studies related to PTSD among military personnel.
In 1968, the Diagnostic and Statistical Manual of Mental Disorders (2nd ed., DSM-II; American Psychiatric Association, 1968, p.49) mentioned about the effects of traumatic stress as ‘fear associated with military combat and manifested by trembling, running, and hiding’. In 1969, the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death (8th ed.; ICD-8; World Health Organization, 1969, p.158) referred to condition as ‘combat fatigue’. Common patterns in the psychological sequel of women who had been sexually assaulted, termed as rape trauma syndrome, and combat related trauma contributed to a set of cluster of symptoms that represented PTSD.
Posttraumatic stress disorder (PTSD) was introduced in ICD in its 9th edition, in 1978, and in DSM in its 3rd edition, in 1980. In 1994, the acute short-term effects of exposure to a traumatic event were introduced in DSM-IV as acute stress disorder (ASD).
Measures of PTSD
I. Structured Clinical Interviews
The Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon & First, 1990) has been the interview most frequently used to date to evaluate the presence or absence of PTSD. The SCID provides a comprehensive evaluation of Axis I and Axis II diagnoses. The PTSD module is concise and relatively easy to administer and score, while addressing the major diagnostic features of the disorder. Kulka et al. (1990) found a kappa of .93 when a second clinician listened to audiotapes of the target interview and then made independent diagnoses. McFall et al. (1990) reported 100 percent diagnostic reliability between two clinicians who completed independent SCIDs on ten subjects. Keane, Kolb and Thomas (1988) observed a kappa of .68 for PTSD SCID diagnoses derived from two independent clinicians who individually interviewed the same patients (N = 37). Kulka et al. (1990) also found the SCID diagnosis to be strongly correlated with other indices of PTSD (i.e., the Mississippi Scale, the Impact of Event Scale, the PK-Scale of the MMPI). These results suggest that the PTSD module of the SCID is a measure with respectable reliability and validity. The limitation of this instrument is that it yields only dichotomous information about each symptom and therefore severity of disorder and changes in symptom level cannot be easily detected.
The Diagnostic Interview Scale (DIS-NIMH) is a highly structured interview that correlated highly with other known measures of PTSD (Watson et al., 1991) but when used in a community sample, where the base rate of PTSD was low, the DIS performed poorly, with estimates of .23 for sensitivity and .28 for kappa (Kulka et al. 1991).
The PTSD-Interview by Watson et al. (1991) yields both dichotomous and continuous scores, thus addressing some of the limitations of the SCID and DIS. Reports of high test-retest reliability (.95), internal stability (alpha = .92), sensitivity (.89), specificity (.94), and kappa (.82) recommend this instrument for use in diagnosing PTSD. Compared to other clinical instruments, this instrument asks the subjects to make their own rating of symptom severity, thereby minimizing the role of the experienced clinician in the diagnostic process.
The Structured Interview for PTSD (SI-PTSD) (Davidson et al.1989) has continuous and dichotomous symptoms ratings. High test-retest reliability (.71), inter-rater reliability (.97 – .99) and perfect diagnostic agreement (N = 34) have been reported. Utility analyses have revealed sensitivity of .96, specificity of .80, and a kappa of .79 when compared to the SCID.
The Clinician Administered PTSD Scale (Blake et al., 1990) is available in both lifetime and current versions. The CAPS contains 17 diagnostic symptoms of PTSD, its 8 associated features, symptom severity measures in terms of frequency & intensity, indices of impairment in social and occupational functioning, and an assessment of validity of patient responses. The CAPS also provides continuous and dichotomous scores to suit the needs of the investigator/ clinician. Sound psychometric properties in terms of reliability and validity have been reported (Weathers, 1992).
II. Self-report scales
The PK-Scale of the MMPI (Keane et al., 1984) consists of 49 items that differentiated PTSD from non-PTSD patients in both a test sample and a cross-validation sample of veterans. Eighty-two percent of 200 subjects were correctly classified using a cut-off score of 30. Subsequent studies have not found the same diagnostic hit rate. The performance of PK in the NVVRS (Kulka et al., 1991) indicates that the MMPI-2 (Lyons and Keane, 1992) modifications have not altered the general interrelationship of PK with other measures of PTSD.
The Mississippi Scale (Keane, Caddell & Taylor, 1988) is available in both combat and civilian versions. It is a 35 item instrument that has high internal consistency (alpha = .94), test-retest reliability (.97), sensitivity (.93), and specificity (.89). This instrument performed effectively in both clinical settings (e.g., McFall, Smith, Roszell et al., 1990) and in field/community settings (e.g., Kulka et al., 1991), indicating its general utility for measuring PTSD across settings and for different purposes (e.g., research or clinical).
Impact of Event Scale (Horowitz, Wilner & Alvarez, 1979) focuses upon the assessment of intrusions and avoidant/numbing responses. IES is the single most widely used instrument for assessing the psychological consequences of exposure to traumatic events. The scale has good internal consistency (.78 for intrusion, .82 for avoidance) and test-retest reliability (.89 for intrusion, .79 for avoidance). Recent studies have found the IES to correlate well with other indices of PTSD. The Impact of events scale-Revised (IES-R) (Weiss and Marmer, 1997) to parallel the DSM-IV criteria for PTSD, is also self-report measure designed to assess current subjective distress for any specific life event. The three sub scales measures, avoidance (the tendency to avoid thoughts or reminders about the incident), intrusion (difficulty in staying asleep, dissociative-like re-experiencing of when experiencing true flash-back), and hyper arousal (feeling irritated, angry, difficulty in getting sleep). In addition to the 3 subscale scores, IES-R gives an overall impact of events score (sum of the 3 subscales) also.
PTSD scale for the SCL-90 derived by Saunders et al. (1990) has 28-items that best discriminated women with crime-related PTSD from non-cases. Using the Diagnostic Interview Scale (DIS) as criterion, this scale obtained good sensitivity (.75) and high specificity (.90).
The Penn Inventory (Hammarberg, 1992) was developed and validated with both combat veterans and trauma-exposed non-veterans. This 26-item instrument has high internal consistency (alpha = .94), and test-retest reliability (.96). Sensitivity was found to be .90 and specificity was 1.0 among a sample of 83 veterans, and in a sample of disaster survivors sensitivity was 0.94 and specificity of 1.0.
Other self-report measures of PTSD include, Modified PTSD Scale (MPSS-SR) (Falsetti et al., 1993), Posttraumatic Stress Disorder Diagnostic Scale (PDS) (Foa, 1995), and Davidson Trauma Scale (DTS) (1997).
III. Psycho-physiological assessment of PTSD
Exposure to cues of a traumatic event provoked a systematic physiological response across several measurement domains (e.g., heart rate, skin conductance, EMG, and blood pressure). Blanchard et al. (1982) found that the heart rate response could correctly classify 95.5 percent of the combined sample of 11 male Vietnam veterans suffering from PTSD and 11 non-veteran controls. Blanchard et al. (1982) and Malloy et al. (1983) found that this reactivity predicts the PTSD diagnosis while using auditory and audiovisual cues. Pitman et al. (1987) also observed similar reactivity using personal scripts of traumatic events that were then read to subjects. A 15-site clinical trial conducted by the Department of Veterans Affairs’ Cooperative Study Program later found that psycho-physiological assessment approach could be a useful diagnostic tool in discriminating cases of PTSD from non-cases (Keane et al., 1988). Biological alterations in central noradrenergic activity, the hypothalamic-pituitary-adrenocortical axis, the endogenous opioid system, and the sleep cycle have been associated with PTSD (Friedman, 1991). Therefore a biological approach can complement psychological diagnostic techniques.
Role of personality in the development of PTSD
The contribution of predeployment personality traits and exposure to traumatic events during deployment to the development of PTSD symptoms was studied (Bramsen, Dirkzwager, & Van Der Ploeg, 2000) among 572 male veterans of UN Protection Force in former Yugoslavia. Other than exposure to traumatic events during deployment, personality traits of negativism and psychopathology had the highest unique contribution to the prediction of PTSD symptom severity.
Among a random sample of 1007 young adults, with rate of PTSD in those who were exposed to traumatic events being 23.6% and a lifetime prevalence of 9.2%, Breslau, Davis, Andreski, & Peterson (1991) found that risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety.
Carlier, Lamberts, & Gersons (1997) found among 262 traumatized police officers, in which 7% had PTSD & 34% had posttraumatic stress symptoms or subthreshold PTSD, trauma severity was the only predictor of posttraumatic stress symptoms identified at both 3 and 12 months posttrauma. At 3 months post-trauma, symptomatology was further predicted by introversion, difficulty in expressing feelings, emotional exhaustion at time of trauma, insufficient time allowed by employer for coming to terms with the trauma, dissatisfaction with organizational support, and insecure job future. At 12 months post-trauma, posttraumatic stress symptoms were further predicted by lack of hobbies, acute hyperarousal, subsequent traumatic events, job dissatisfaction, brooding over work, and lack of social interaction support in the private sphere.
Individuals who experienced one or more traumatic events were selected (N=3238) from respondents of the National Comorbidity Survey Part II (N=5877). In separate regression analyses, elevated levels of neuroticism and self-criticism were each significantly associated with PTSD among men and women who had experienced one or more traumatic events. After controlling for types of traumas experienced and other previously identified factors, neuroticism remained significantly associated with PTSD in women and both neuroticism and self-criticism remained significant in men (Cox, Macpherson, Enns, & Mcwilliams, 2004).
The strongest vulnerability factors for both PTSD and subthreshold PTSD were neuroticism and adverse events in early childhood as found in a study involving 1721 older adults (Van Zelst, De Beurs, Beekman, Deeg, & Van Dyck, 2003).
A review of studies on personality in the etiology and expression of PTSD by Miller (2003) concludes that high negative emotionality (NEM) is the primary personality risk factor for the development of PTSD whereas low constraint/inhibition (CON) and low positive emotionality (PEM) serve as moderating factors that influence the form and expression of the disorder through their interaction with NEM. A pre-morbid personality characterized by high NEM combined with low PEM is thought to predispose the trauma-exposed individual towards an internalizing form of posttraumatic response characterized by marked social avoidance, anxiety, and depression. On the other hand, high NEM combined with low CON is hypothesized to predict an externalizing form of posttraumatic reaction characterized by marked impulsivity, aggression, and a propensity towards antisociality and substance abuse.
Cluster analyses (Miller, Greif, & Smith, 2003) of Multidimensional Personality Questionnaires (MPQs) completed by combat veterans revealed subgroups that differed on measures relating to the externalization versus internalization of distress. The MPQ profile of the externalizing cluster was defined by low constraint and harm-avoidance coupled with high alienation and aggression. Individuals in this cluster also had histories of delinquency and high rates of substance-related disorder. In comparison, the MPQ profile of the internalizing cluster was characterized by lower positive emotionality, alienation, and aggression and higher constraint, and individuals in this cluster showed high rates of depressive disorder. These findings suggest that dispositions toward externalizing versus internalizing psychopathology may account for heterogeneity in the expression of posttraumatic responses, as well as patterns of co morbidity.
Schnurr, Friedman, & Rosenberg (1993) tried to assess the predictors of combat-related life time symptoms of PTSD among 131 male Vietnam and Vietnam-era veterans who had taken the MMPI in college and who were interviewed as adults with the Structured Clinical Interview for DSM-III-R. Scores on the basic MMPI scales were used to predict combat exposure, lifetime history of any PTSD symptoms given exposure, and lifetime PTSD classification (symptoms only, subthreshold PTSD, or full PTSD). The findings indicated that scores on MMPI scales were within the normal range and no scale predicted combat exposure. Hypochondriasis, psychopathic deviate, masculinity-femininity, and paranoia scales predicted PTSD symptoms. Depression, hypomania, and social introversion predicted diagnostic classification among subjects with PTSD symptoms. The effects persisted when amount of combat exposure was controlled for. This supports the findings of similar studies that pre-military personality can affect vulnerability to lifetime PTSD symptoms in men exposed to combat
Co-morbidity with anxiety disorders
Co-morbidity studies have shown stronger link of PTSD with anxiety disorders than with other disorders. There is a stronger family history of anxiety disorders than of affective disorders in PTSD sufferers. PTSD shares symptomatology with panic disorder, phobic anxiety, generalized anxiety disorder, and obsessive-compulsive disorder. PTSD like anxiety disorders involves an abnormality in sympathetic system activity.
PTSD among female military personnel
The psychological impact of military service and associated experiences like PTSD were studied commonly among Vietnam War (1959 to 1975) veterans. The significant stressors among female military personnel ranged from hazardous occupational tasks to sexual assault (Wolfe et al. 1993). Women veterans exposed to combat during service were primarily Army nurses (Dienstfrey, 1988). In the earliest study of women and war stress participating 89 female Vietnam veterans, 50% experienced symptoms suggestive of PTSD, and 20% had significantly disruptive symptoms (Schnaier, 1985). Interviews conducted (Norman, 1988) among 50 nurses who served in Vietnam War, found that the intensity of war-time stressors were related to the continuation of higher levels of intrusive and avoidant stress symptoms. Military service at a younger age, less military and professional experience, occupational trauma involving extensive exposure to death and dying were associated with poor post war adjustment (Paul, 1985). Army nurses with less than two years of registered nurse experience prior to their assignment were found to be more at risk for negative outcomes like poor social relations, and difficulty in coping with stressful situations (Baker et al., 1989).
The National Vietnam Veterans Readjustment Study (Kulka et al., 1990) using the Mississippi Scale for Combat-Related PTSD found that females had lower rates of PTSD than male combatants, and women had the disorder in relation to the level of war-zone exposure. A study (Leda, Rosenheck, & Gallup, 1992) among 19,313 Vietnam Veterans found that in comparison with males, significant higher proportion of female homeless veterans were diagnosed as having major psychiatric disorders.
Social support functioned as a substantial moderator of initial PTSD. Stretch et al (1985) found that despite clear-cut exposure, female active duty personnel had significantly less PTSD than their discharged veteran cohorts, suggesting that social support served as an important moderator in the attenuation of PTSD.
Leon et al. (1990) found that coping involving increased self-blame, and focusing on negative affect and cognitions were associated with poorer outcome among female Vietnam veterans. Coping patterns characterized with expressing feelings, seeking emotional support, and searching for meaning in the events experienced, were associated with good psychological functioning, whereas use of self-blame, withdrawal, and anxious thoughts were related to current psychological dysfunction among Vietnam veteran nurses (Leon, Ben-Porath, & Hjemboe, 1990).
Similar to civilian population, previous history of traumatic experience is a vulnerability factor for PTSD. Wolfe, Brown, & Bucsela (1992) assessed 76 female veterans before the onset of Operation Desert Storm and later at the height of the military combat and found that those who had previously reported high levels of PTSD were more susceptible to greater distress. The female Vietnam veterans with prior wartime exposure are at risk of intensified stress symptoms after the recurrence of a military combat.
Treatment of PTSD
There are five identifiable posttraumatic syndromes that require different treatment approaches (Marmar, et al. 1993; 1995). They are;
1. the normal stress response, is characterized by single discrete traumatic event causing intense intrusive recollections, numbing, denial, feelings of unreality, and arousal. Individual or group debriefing is used for complete recovery.
2. acute catastrophic stress reaction, involves panic reactions, cognitive disorganization, disorientation, dissociation, severe insomania, tics & other movement disorders, paranoid reactions, and incapacity to manage even basic self care, work & interpersonal functions. Treatment includes immediate support, removal from the scene of trauma, medication for immediate relief from anxiety & insomnia, and psychotherapy.
3. uncomplicated PTSD, where group, psychodynamic, cognitive-behavioral, pharmacological or combination of these are used for treatment (Herman, 1992; Scurfield, 1993).
4. PTSD co-morbid with other disorders is more common than uncomplicated PTSD and is usually associated with disorders such as depression, alcohol/substance abuse, panic disorder, & anxiety disorders and therefore deserves concurrent treatment.
5. Post-traumatic personality is due to exposure to prolonged traumatic situations like childhood sexual abuse. They may have borderline personality disorder, somatoform disorder, or dissociative identity disorder. Their behavioral problems include impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse and self-destructive actions. The emotional problems include affect lability, rage, depression, and panic. Cognitive problems include fragmented thoughts, dissociation, and amnesia. Inpatient treatment involving behavioral and affect management with emphasis on family function, vocational rehabilitation, social skills training, and alcohol/drug rehabilitation is done for those diagnosed with posttraumatic personality disorder.
Need for assessment for proneness to PTSD at the time of personnel selection
From the above discussion it becomes evident that prevalence of PTSD among military personnel deserves a closer look and development of preventive strategies. It has been noted that PTSD is not merely an after effect of combat related events. In peace time too, dysfunctional coping strategies to stress like suicide, attacking superior officers, soldiers running amuck, excessive alcoholism etc have been reported. Though rare, cases of suicide have been reported even from training academies.
The chances of PTSD among soldiers working in LIC environment where they live in extremely uncertain environment are high. They live under the fear of unexpected attack at a unexpected time and direction. Such stresses cannot completely avoided. Only two strategies are possible here.
The importance of identifying PTSD proneness among candidates at the time of recruitment assumes importance here. Suitable psychological assessment techniques and tools have to be developed for this purpose. The development of such an assessment technique/tool must be preceded by a through survey of PTSD among military personnel and identifying personality and other variables that can predict PTSD proneness. This is essential for the improvement of mental health of the Armed Forces.