WARRIOR STRESS

The term "warrior stress" describes a common reaction to the intense nature of military service, especially during the times of war. This stress typically resolves with time; however, some warriors find themselves "stuck" in combat mode after returning home. When it's characterized by trauma-related re-experiencing (i.e. nightmares, flashbacks), hyper-arousal, and avoidance, it is known as "Post-traumatic Stress Disorder" (PTSD); a condition that is clinically classified as an Anxiety Disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR). This article describes the basics of PTSD and several other related topics.

POST-TRAUMATIC STRESS DISORDER
The diagnosis of PTSD is based on the following six criteria according to DSM-IV-TR1:
(These are general guidelines only and will be changed in the next version (DSM-V) in order to more accurately reflect the nature of stress- and trauma-related disorders.)
1. Exposure to a traumatic event together with a particular subjective response to the event,
2. Persistent re-experiencing of the event,
3. Persistent avoidance of stimuli associated with the event or numbing of general responsiveness,
4. Persistent hyper-arousal,
5. Duration of symptoms in excess of one month, and,
6. Clinically significant distress.


Lifetime prevalence rates of PTSD in the general population range from 1% to 14%1 and one in four survivors of a traumatic experience will suffer from chronic PTSD.2 Rates of PTSD range from 7% to 11.8% in primary care out-patients3-4 and between 3% and 50% for Persian Gulf (“Gulf War I”) military personnel.5 PTSD is a widely recognized consequence of combat trauma; recent findings from Operation Iraqi Freedom (OIF) combat veterans found between 15.6% and 17.1% suffered from some severe emotional difficulties, including PTSD.6 Likewise, the National Vietnam Veterans Readjustment Study (NVVRS)7 found that more than 15% of male Vietnam Theatre Veterans (VTV) met criteria for current PTSD and 30% met diagnostic criteria for lifetime PTSD, while 9% of female VTVs met current PTSD criteria and 27% met lifetime criteria for PTSD related to Vietnam combat trauma.

PTSD commonly co-occurs with other psychiatric disorders. Data from epidemiologic studies indicate that a majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage meet criteria for three or more other psychiatric diagnoses.8-9 The most frequent comorbid diagnoses are depressive disorders, substance use disorders, and other anxiety disorders.9 PTSD also commonly co-occurs with chronic pain,10 and pain conditions, such as combat injury, may exacerbate PTSD. Comorbid diagnoses are particularly common among people suffering from combat-related PTSD. In one study of combat-related PTSD, 56% of combat veterans had comorbid diagnosis of substance abuse or dependence, 52% had a comorbid diagnosis of depression, and 16% were diagnosed with an additional anxiety disorder.11 Another study found that 45% of individuals diagnosed with PTSD after experiencing combat stress had one or more comorbid diagnoses.12 Research indicates that diagnosis of any additional disorders in the presence of PTSD complicates the treatment process and weakens the prognosis for recovery.8



DEPRESSION AND PTSD
Some research has found evidence that depression is the most commonly co-occurring disorder in those suffering from PTSD.13 In one study supported by NIMH, more than 40% of patients with PTSD had depression when evaluated at both one month and 4 months following the traumatic event.15 The high rate of comorbidity between PTSD and depression has been hypothesized to result from a number of factors including similar etiology and a large amount of relatedness among symptoms.15,16 It is also clear that history of a previous depressive disorder puts a person at increased risk for the development of PTSD once traumatic exposure occurs.9 Comorbidity of PTSD and depression has been shown to make accurate diagnosis difficult, and has been associated with greater symptom severity and lower levels of functioning. Similarly, having both disorders increases the likelihood that patients will attempt suicide.15,17,18

ALCOHOL USE AND PTSD
Substance use disorders (including alcohol abuse and dependence) represent another class of disorders commonly co-occurring with PTSD. In two community studies of Vietnam veterans with PTSD, 22%7 and 39% (Centers for Disease Control, 1988) also exhibited current alcohol abuse or dependence. One hypothesis for this phenomenon is that people with PTSD use alcohol as a means to self-medicate their debilitating symptoms.9 This hypothesis is supported by the finding that a diagnosis of PTSD increases a person’s risk of developing an alcohol use disorder. However, research has also demonstrated that people with PTSD (particularly males) are more likely than others with a similar background to have an alcohol use disorder that preceded PTSD.19,20

Whatever the cause of comorbidity between PTSD and alcohol use disorders, it is clear that excessive alcohol use can worsen the symptoms related to PTSD including sleep disturbance, difficulty concentrating, emotional numbing, social isolation, anger and irritability, depression, and hyper-vigilance. Alcohol can also reduce a person’s ability to cope with traumatic memories and stress. A number of factors complicate the treatment of comorbid PTSD and alcohol use disorder. While alcohol use may appear to help symptoms of PTSD by decreasing the severity and number of nightmares, it may also exacerbate the cycle of avoidance found in PTSD.21 Furthermore, people with comorbid PTSD and alcohol abuse/dependence are at increased risk for premature termination of therapy, and take a longer time to remit from an episode of chronic.22,23

PAIN AND PTSD
A number of studies have been conducted to assess the co-occurrence of PTSD and chronic pain symptoms. In one study 10% of 225 patients referred to the VA pain clinic met criteria for PTSD.10 In another study 9.5% of a sample of patients attending a multidisciplinary chronic pain center met criteria for “posttraumatic pain syndrome”.24 Patients referred for assessments of a chronic pain resulting from a traumatic event have an even higher prevalence of PTSD. In a study to assess the extent to which work-related injuries were associated with PTSD, assessments of 139 injured workers with chronic pain referred to a rehabilitation program indicated that 34.7% reported symptoms consistent with PTSD.25 Rates of PTSD in patients for which pain is secondary to a motor vehicle accident range from 30-50%.26-28 Another study examined the self-report of pain, affective distress, and disability in pain patients with and without PTSD symptoms. Their results indicated that patients with accident-related pain and high PTSD symptoms reported higher levels of pain and affective distress compared to patients with accident-related pain and without PTSD.29

Studies examining the prevalence of chronic pain in patients with a primary diagnosis of PTSD have reported even higher rates of other comorbid conditions. McFarlane et al. reported that pain was the most common physical complaint (45% back pain and 34% headaches) in a sample of PTSD patients reporting physical symptoms.30 Beckham et al. performed a study to investigate chronic pain patterns in Vietnam veterans with PTSD and found that 80% reported the presence of a chronic pain condition.31 In addition, increased levels of PTSD re-experiencing symptoms were associated with increased pain level and pain-related disability. White and Faustman reported that 60% of 543 veterans treated for PTSD had an identified medical problem and that 25% showed some type of musculoskeletal or pain problem.32

The co-occurrence of pain and PTSD may have implications for both conditions. Patients with chronic pain related to trauma and PTSD experience more intense pain and affective distress,29,33 higher levels of life interference,34 and greater disability than pain patients without trauma or PTSD.35 Chibnal and Duckro found that patients with PTSD and traumatic headache pain had higher levels of depression and suppressed anger than non-PTSD traumatic headache pain patients.26 In addition, patients with post-traumatic headache reported more frequent pain and had a poorer prognosis than did non-traumatic headache patients.36 Thus, the presence of both PTSD and chronic pain may increase the symptom severity of either condition.

This review illustrates the impact that PTSD has had military veterans over the past decades. Depressed mood, pain, insomnia, and significant alcohol or drug use often follow undiagnosed or untreated warrior stress. Warriors should seek professional behavioral health support for these symptoms.

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