Post traumatic Stress
Disorder (PTSD)
Medical Author: Roxanne
Dryden-Edwards, MD
Medical Editor: Melissa
Conrad Stöppler, MD
|
Disaster Survivors Face
PTSD Risk
Medical Author:
Melissa
Conrad Stöppler, MD
Medical Editor: William
C. Shiel Jr., MD, FACP, FACR
Post-traumatic stress
disorder (PTSD) is a psychiatric condition that can develop
following any traumatic, catastrophic life experience.
Recognition of this condition increased dramatically following
the war in Viet Nam, when many returning U.S. veterans
developed disturbing psychological symptoms and impaired
functioning. More recently, the 9/11 tragedy, the Asian
tsunami, the London bombings, and Hurricane
Katrina and its aftermath have left thousands of people at
risk for this potentially debilitating condition.
PTSD symptoms can develop
weeks or months, or sometimes even years, following a
catastrophic event. Along with survivors of natural disasters,
wars, and acts of terrorism, people who have been the victims
of violent crime or torture often develop symptoms of PTSD.
PTSD symptoms vary among
individuals and also vary in severity from mild to disabling.
PTSD Symptoms can include one or more of the following:
- "flashbacks"
about the traumatic event
- feelings of estrangement
or detachment
- nightmares
- sleep
disturbances
- impaired functioning
- occupational instability
- memory disturbances
- family discord
- parenting or marital
difficulties
|
|
What is posttraumatic stress disorder?
Posttraumatic stress disorder (PTSD) is
an emotional illness that develops as a result of a terribly frightening,
life-threatening, or otherwise highly unsafe experience. PTSD sufferers
re-experience the traumatic event or events in some way, tend to avoid
places, people, or other things that remind them of the event (avoidance),
and are exquisitely sensitive to normal life experiences (hyperarousal).
Although this condition has likely existed since human beings have endured
trauma, PTSD has only been recognized as a formal diagnosis since 1980.
However, it was called by different names as early as the American Civil
War, when combat veterans were referred to as suffering from
"soldier's heart." In World War I, symptoms that were generally
consistent with PTSD were referred to as "combat fatigue."
Soldiers who developed such symptoms in World War II were said to be
suffering from "gross stress
reaction," and many who fought in Vietnam who had symptoms of what is
now called PTSD were assessed as having "post-Vietnam syndrome."
PTSD has also been called "battle fatigue" and "shell shock."
Complex posttraumatic stress disorder (C-PTSD) usually results from
prolonged exposure to a traumatic event or series thereof and is
characterized by long-lasting problems with many aspects of emotional and
social functioning.
Approximately 7%-8% of people in the
United States will likely develop PTSD in their lifetime, with the
lifetime occurrence (prevalence) in combat veterans and rape
victims ranging from 10% to as high as 30%. Somewhat higher rates of this
disorder have been found to occur in African Americans, Hispanics, and
Native Americans compared to Caucasians in the United States. Some of that
difference is thought to be due to higher rates of dissociation soon
before and after the traumatic event (peritraumatic); a tendency for
individuals from minority ethnic groups to blame themselves, have less
social support, and an increased perception of racism for those ethnic
groups; as well as differences between how ethnic groups may express
distress. Other important facts about PTSD include the estimate of 5
million people who suffer from PTSD at any one time in the United States
and the fact that women are twice as likely to develop PTSD as men.
Almost half of individuals who use
outpatient mental-health services have been found to suffer from PTSD. As
evidenced by the occurrence of stress in many individuals in the United
States in the days following the 2001 terrorist attacks, not being
physically present at a traumatic event does not guarantee that one cannot
suffer from traumatic stress that can lead to the development of PTSD.
PTSD statistics in children and
teens
reveal that up to more than 40% have endured at least one traumatic event,
resulting in the development of PTSD in up to 15% of girls and 6% of boys.
On average, 3%-6% of high school students in the United States and as many
as 30%-60% of children who have survived specific disasters have PTSD. Up
to 100% of children who have seen a parent killed or endured sexual
assault or abuse tend to develop PTSD, and more than one-third of youths
who are exposed to community violence will suffer from the disorder.
What are the effects of PTSD?
Untreated PTSD can have devastating,
far-reaching consequences for sufferers' functioning and relationships,
their families, and for society. Women who were sexually abused at earlier
ages are more likely to develop complex PTSD and borderline personality
disorder. Babies that are born to mothers that suffer from this illness
during pregnancy
are more likely to experience a change in at least one chemical in their
body that makes it more likely (predisposes) the baby to develop PTSD
later in life. Individuals who suffer from this illness are at risk of
having more medical problems, as well as trouble reproducing. Emotionally,
PTSD sufferers may struggle more to achieve as good an outcome from
mental-health treatment as that of people with other emotional problems.
In children and teens, PTSD can have significantly negative effects on
their social and emotional development, as well as on their ability to
learn.
What causes PTSD?
Virtually any event that is
life-threatening or that severely compromises the emotional well-being of
an individual may cause PTSD. Such events often include either
experiencing or witnessing a severe accident or physical injury, receiving
a life-threatening medical diagnosis, being the victim of kidnapping or
torture, exposure to combat or to a natural disaster, other disaster (for
example, plane crash) or terrorist attack, being the victim of rape,
mugging, robbery or assault; enduring physical, sexual, emotional or other
forms of abuse, as well as involvement in civil conflict.
What are the risk factors and
protective factors for PTSD?
Issues that tend to put people at higher
risk for developing PTSD include increased duration of a traumatic event,
higher severity of the trauma experienced, having an emotional condition
prior to the event, or having little social support in the form of family
or friends. In addition to those risk factors, children and adolescents,
females, and people with learning disabilities or violence in the home
have a greater risk of developing PTSD after a traumatic event.
While disaster-preparedness training is
generally seen as a good idea in terms of improving the immediate physical
safety and logistical issues involved with a traumatic event, such
training may also provide important protective factors against developing
PTSD. That is as evidenced by the fact that those with more
professional-level training and experience (for example, police,
firefighters, mental-health professionals, paramedics, and other medical
professionals) tend to develop PTSD less often when coping with disaster
than those without the benefit of such training or experience.
Some medications have been found to help
prevent the development of PTSD. Some medicines that treat depression,
decrease the heart rate, or increase the action of other body chemicals
are thought to be effective tools in the prevention of PTSD when given in
the days immediately after an individual experiences a traumatic event.
What are the signs and symptoms of PTSD?
The three groups of symptoms that are
required to assign the diagnosis of PTSD are
- recurrent re-experiencing of the
trauma (for example, troublesome memories, flashbacks that are usually
caused by reminders of the traumatic events, recurring nightmares
about the trauma and/or dissociative reliving of the trauma),
- avoidance to the point of having a
phobia of places, people, and experiences that remind the sufferer of
the trauma and a general numbing of emotional responsiveness, and
- chronic physical signs of
hyperarousal, including sleep
problems, trouble concentrating, irritability, anger, poor
concentration, blackouts or difficulty remembering things, increased
tendency and reaction to being startled, and hypervigilance to threat.
The emotional numbing of PTSD may
present as a lack of interest in activities that used to be enjoyed (anhedonia),
emotional deadness, distancing oneself from people, and/or a sense of a
foreshortened future (for example, not being able to think about the
future or make future plans, not believing one will live much longer). At
least one re-experiencing symptom, three avoidance/numbing symptoms, and
two hyperarousal symptoms must be present for at least one month and must
cause significant distress or functional impairment in order for the
diagnosis of PTSD to be assigned. PTSD is considered of chronic duration
if it persists for three months or more.
A similar disorder in terms of symptom
repertoire is acute stress disorder. The major differences between the two
disorders are that acute stress disorder symptoms persist from two days to
four weeks, and a fewer number of traumatic symptoms are required to make
the diagnosis as compared to PTSD.
In children, re-experiencing the trauma
may occur through repeated play that has trauma-related themes instead of
through memories, and distressing dreams may have general content rather
than of the traumatic event itself. As in adults, at least one
re-experiencing symptom, three avoidance/numbing symptoms, and two
hyperarousal symptoms must be present for at least one month and must
cause significant distress or functional impairment in order for the
diagnosis of PTSD to be assigned. When symptoms have been present for less
than one month, a diagnosis of acute stress disorder (ASD) can be made.
Symptoms of PTSD that tend to be
associated with C-PTSD include: problems regulating feelings, which can
result in suicidal thoughts, explosive anger, or passive aggressive
behaviors; a tendency to forget the trauma or feel detached from one's
life (dissociation) or body (depersonalization); persistent feelings of
helplessness, shame, guilt or being completely different from others;
feeling the perpetrator of trauma is all-powerful and preoccupation with
either revenge against or allegiance with the perpetrator; and severe
change in those things that give the sufferer meaning, like a loss of
spiritual faith or an ongoing sense of helplessness, hopelessness, or
despair.
How is PTSD assessed?
For individuals who may be wondering if
they should seek evaluation for PTSD by their medical or mental-health
professional, self-tests may be useful. The National Institute of Mental
Health and offers a self-test for PTSD. The assessment of PTSD can be
difficult for practitioners to make since sufferers often come to the
professional's office complaining of symptoms other than anxiety
associated with a traumatic experience. Those symptoms tend to include
body symptoms (somatization), depression, or substance abuse. Individuals
with PTSD may present with a history of making suicide
attempts. In addition to depression and substance abuse disorders, the
diagnosis of PTSD often co-occurs (is comorbid with) bipolar
disorder (manic depression), eating disorders, and other anxiety
disorders like obsessive
compulsive disorder, panic
disorder, and generalized anxiety disorder.
Most practitioners who examine a child
or teenager for PTSD will interview both the parent and the child, usually
separately, in order to allow for each party to speak freely. Interviewing
the child in addition to the adults in their life is quite important given
that while the child or adolescent's parent or guardian may have a unique
perspective, there are naturally things the young person may be feeling
that the adult is not aware of. Another challenge for diagnosing PTSD in
children, particularly in younger children, is that they may express their
symptoms differently from adults. For example, they may go backward or
regress in their development, become accident-prone, engage in risky
behaviors, become clingy, or suffer from more physical complaints as
compared to adults with PTSD. Traumatized younger children may also have
trouble sitting still, focusing, or managing their impulses and therefore
be mistaken as suffering from attention
deficit hyperactivity disorder (ADHD).
Sometimes, professionals will use a
structured psychiatric interview for children in its entirety or just the
portion that assesses PTSD in order to test for PTSD. Examples of such
tools include the Diagnostic Interview for Children and
Adolescents-Revised (DICA-R), the Diagnostic Interview Schedule for
Children-Version IV (DISC-IV), and the Schedule for Affective Disorders
and Schizophrenia
for School Age Children (K-SADS). There are also some PTSD-specific
structured interviews, like the Clinician-Administered PTSD Scale-Child
and Adolescent Version, the Child PTSD Checklist, and the Child PTSD
Symptom Scale. For the assessment of the severity of PTSD symptoms in
children, structured interviews like the Child Posttraumatic Stress
Reaction Index, the Child and Adolescent Trauma Survey, and the Trauma
Symptom Checklist for Children are sometimes used. The Child Trauma
Screening Questionnaire has been found by some professionals to be useful
in predicting which children who endure a traumatic event will go on to
develop PTSD.
How is PTSD treated?
Treatments for PTSD usually include
psychological and medical treatments. Providing information about the
illness, helping the individual manage the trauma by talking about it
directly, teaching the person ways to manage symptoms of PTSD, and
exploration and modification of inaccurate ways of thinking about the
trauma are the usual techniques used in psychotherapy
for this illness. Education of PTSD sufferers usually involves teaching
individuals about what PTSD is, that it is caused by extraordinary stress
rather than weakness, how it is treated, and what to expect in treatment.
This education thereby increases the likelihood that inaccurate ideas the
person may have about the illness are dispelled, and any shame they may
feel about having it is minimized. This may be particularly important in
populations like military personnel that may feel particularly stigmatized
by the idea of seeing a mental-health professional and therefore avoid
doing so.
Teaching people with PTSD practical
approaches to coping with what can be very intense and disturbing symptoms
has been found to be another useful way to treat the illness.
Specifically, helping sufferers learn how to manage their anger and
anxiety, improve their communication skills, and use relaxation techniques
can help individuals with PTSD gain a sense of mastery over their
emotional and physical symptoms. Cognitive therapy can help people with
PTSD recognize and adjust trauma-related thoughts and beliefs by educating
sufferers about the relationships between thoughts and feelings, exploring
common negative thoughts held by traumatized individuals, developing
alternative interpretations, and by practicing new ways of looking at
things. This treatment also involves practicing learned techniques in
real-life situations.
Eye-movement desensitization and
reprocessing (EMDR) is a form of cognitive therapy in which the
practitioner guides the person with PTSD in talking about the trauma
suffered and the negative feelings associated with the events, while
focusing on the professional's rapidly moving finger. While some research
indicates this treatment may be effective, it is unclear if this is any
more effective than cognitive therapy that is done without the use of
rapid eye movement.
Families of PTSD individuals, as well as
the sufferer, may benefit from family counseling, couples' counseling, parenting
classes, and conflict resolution education. Family members may also be
able to provide relevant history about their loved one (for example, about
emotions and behaviors, drug
abuse, sleeping habits, and socialization) that people with the
illness are unable or unwilling to share.
Directly addressing the sleep problems
that can be part of PTSD has been found to not only help alleviate those
problems but to thereby help decrease the symptoms of PTSD in general.
Specifically, rehearsing adaptive ways of coping with nightmares (imagery
rehearsal therapy), training in relaxation techniques, positive self-talk,
and screening for other sleep problems have been found to be particularly
helpful in decreasing the sleep problems associated with PTSD.
Medications that are usually used to
help PTSD sufferers include serotonergic antidepressants (SSRIs) like fluoxetine
(Prozac), sertraline
(Zoloft), paroxetine
(Paxil), and medicines that help decrease the physical symptoms associated
with illness, like clonidine
(Catapres), guaneficine (Tenex), and propranolol.
Individuals with PTSD are much less likely to experience a relapse of
their illness if antidepressant treatment is continued for at least a
year. SSRIs are the first group of medications that have achieved approval
by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD.
These medicines have been found to help PTSD sufferers modify information
that is taken in from the environment (stimuli) and to decrease fear.
Research also shows that this group of medicines tends to decrease
anxiety, depression, and panic. SSRIs may also help reduce aggression,
impulsivity, and suicidal thoughts that can be associated with this
disorder.
Other less directly effective but
nevertheless potentially helpful medications for managing PTSD include
mood stabilizers like lamotrigine
(Lamictal), tiagabine
(Gabitril), divalproex
sodium (Depakote), as well as mood stabilizers that are also
antipsychotics, like risperidone
(Risperdal), olanzapine
(Zyprexa), and
quetiapine
(Seroquel). Antipsychotic medicines seem to be most useful in the
treatment of PTSD in those who suffer from agitation, dissociation,
hypervigilance, intense suspiciousness (paranoia), or brief breaks in
being in touch with reality (brief psychotic reactions).
Benzodiazepines
(tranquilizers) have unfortunately been associated with a number of
problems, including withdrawal symptoms and the risk of overdose and have
not been found to be significantly effective for helping individuals with
PTSD.
How can people cope with PTSD?
Some ways that are often suggested for
PTSD patients to cope with this illness include learning more about the
disorder as well as talking to friends, family, professionals, and PTSD
survivors for support. Joining a support group may be helpful. Other tips
include reducing stress by using relaxation techniques (for example,
breathing exercises, positive imagery), actively participating in
treatment as recommended by professionals, increasing positive lifestyle
practices (for example, exercise,
healthy eating, distracting oneself through keeping a healthy work
schedule if employed, volunteering whether employed or not) and minimizing
negative lifestyle practices like substance abuse, social isolation,
working to excess, and self-destructive or suicidal behaviors.
Where can people get help?
- Air Force Palace HART
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com
- American Love and Appreciation Fund (for
veterans)
1-305-673-2856
- Army Wounded Warrior Program
Phone: 1-800-237-1336 or 1-800-833-6622
- DHSD Deployment Helpline
Phone: 1-800-497-6261
- Marine for Life
Phone: 1-866-645-8762
Email: injuredsupport@M4L.usmc.mil
- Military One Source
Phone: 1-800-342-9647
http://www.militaryonesource.com/
- Military Severely Injured Center
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com
- National Coalition Against Sexual
Assault
Phone: 1-717-728-9764
- National Alliance for Mentally Ill
Phone: 1-800-950-6264
- National Mental Health Association
Phone: 1-800-969-6642
- Navy Safe Harbor
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com
- Operation Comfort (for veterans and
their families)
Phone: 1-866-632-7868 (1-866-NEAR TO U)
- PTSD Information Hotline
Phone: 1-802-296-6300
- PTSD Sanctuary
Phone: 1-800-THERAPIST
- Rape, Abuse and Incest National Network
Phone: 1-800-656-HOPE
http://www.rainn.org
The future
As the use of the Internet continues to
expand, so will internet psychiatry. This is particularly true given that
it may be quite useful in specifically providing access to psychotherapy
for individuals with PTSD. Other areas that researchers are targeting to
improve recovery for PTSD sufferers include expanding research on EMDR,
studying how PTSD can be more specifically treated in various ethnic
groups, and discovering how to best prevent people from developing the
illness.
- Posttraumatic stress disorder (PTSD)
is an emotional illness that was first formally diagnosed in soldiers
and war veterans and is caused by terribly frightening,
life-threatening, or otherwise highly unsafe experiences.
-
- PTSD symptom types include
re-experiencing the trauma, avoidance, and hyperarousal.
-
- PTSD has a lifetime prevalence of
seven up to 30%, with about 5 million people suffering from the
illness in any one year. Girls, women, and ethnic minorities tend to
develop PTSD more than boys, men, and Caucasians.
-
- Complex posttraumatic stress disorder
(C-PTSD) usually results from prolonged exposure to traumatic event(s)
and is characterized by long-lasting problems that affect many aspects
of emotional and social functioning.
-
- Symptoms of C-PTSD include problems
regulating feelings, dissociation or depersonalization; persistent
depressive feelings, seeing the perpetrator of trauma as all-powerful,
preoccupation with the perpetrator, and a severe change in what gives
the sufferer meaning.
-
- Untreated PTSD can have devastating,
far-reaching consequences for sufferers' medical and emotional
functioning and relationships, their families, and for society.
Children with PTSD can experience significantly negative effects on
their social and emotional development, as well as their ability to
learn.
-
- Although almost any event that is
life-threatening or that severely compromises the emotional well-being
of an individual may cause PTSD, such events usually include
experiencing or witnessing a severe accident or physical injury,
getting a frightening medical diagnosis, being the victim of a crime
or torture, exposure to combat, disaster or terrorist attack, enduring
any form of abuse, or involvement in civil conflict.
-
- Issues that tend to put people at
higher risk for developing PTSD include female gender, minority
ethnicity, increased duration or severity of, as well as exposure to,
the trauma experienced, having an emotional condition prior to the
event, and having little social support. Risk factors for children and
adolescents also include having any
learning
disability
or experiencing violence in the home.
-
- Disaster preparedness training may be
a protective factor for PTSD.
-
- Medicines that treat depression (for
example, serotonergic antidepressants or SSRIs), decrease the heart
rate (for example, propranolol) or increase the action of other body
chemicals (for example, hydrocortisol) are thought to be effective
tools in the prevention of PTSD when given in the days immediately
after an individual experiences a traumatic event
-
-
- Individuals who wonder if they may be
suffering form PTSD may benefit from taking a self-test as they
consider meeting with a practitioner.
-
- Professionals may used a
clinical interview in either adults, children, or adolescents, or one
of a number of structured tests with children or adolescents to assess
for the presence of this illness.
-
- Diagnosing PTSD can present a
challenge for professionals since sufferers often come for evaluation
of something that seems to be unrelated to that illness at first.
Those symptoms tend to be physical complaints, depression, or
substance abuse. Also, PTSD often co-occurs with manic depression,
eating disorders, or other anxiety disorders.
-
- Challenges for assessment of PTSD in
children and adolescents include adult caretakers' tendency to be
unaware of the extent of the young person's symptoms and the tendency
for children and teens to express symptoms of the illness in ways that
are quite different from adults.
-
- Treatments for PTSD usually include
psychological and medical treatments. Education about the illness,
helping the individual talk about the trauma directly, exploration and
modification of inaccurate ways of thinking about it, and teaching the
person ways to manage symptoms and are the usual techniques used in
psychotherapy. Family and couples' counseling, parenting classes, and
education about conflict resolution are other useful psychotherapeutic
interventions.
-
- Directly addressing the sleep
problems that are associated with PTSD has been found to help
alleviate those problems, thereby decreasing the symptoms of PTSD in
general.
-
- Medications that are usually used to
help PTSD sufferers include serotonergic antidepressants (SSRIs) and
medicines that help decrease the physical symptoms associated with
illness. Other potentially helpful medications for managing PTSD
include mood stabilizers and antipsychotics. Tranquilizers have been
associated with withdrawal symptoms and other problems and have not
been found to be significantly effective for helping individuals with
PTSD.
-
- Some ways that are often suggested
for PTSD patients to cope with this illness include learning more
about the illness, talking to others for support, using relaxation
techniques, participating in treatment, increasing positive lifestyle
practices, and minimizing negative lifestyle practices.
VA
Rating of PTSD
The
following is from Title 38 USC Chapter One Part 4:
General
Rating Formula for Mental Disorders:
Total
occupational and social impairment, due to
100
such
symptoms as: gross impairment in thought
processes or communication; persistent delusions
or
hallucinations; grossly inappropriate behavior;
persistent danger of hurting self or others;
intermittent inability to perform activities of
daily
living (including maintenance of minimal
personal hygiene); disorientation to time or
place;
memory loss for names of close relatives,
own
occupation, or own name.......................
Occupational
and social impairment, with
70
deficiencies in most areas, such as work, school,
family
relations, judgment, thinking, or mood, due
to such
symptoms as: suicidal ideation;
obsessional rituals which interfere with routine
activities; speech intermittently illogical,
obscure, or irrelevant; near-continuous panic or
depression affecting the ability to function
independently, appropriately and effectively;
impaired impulse control (such as unprovoked
irritability with periods of violence); spatial
disorientation; neglect of personal appearance and
hygiene; difficulty in adapting to stressful
circumstances (including work or a work like
setting); inability to establish and maintain
effective relationships...........................
Occupational
and social impairment with reduced
50
reliability and productivity due to such symptoms
as:
flattened affect; circumstantial,
circumlocutory, or stereotyped speech; panic
attacks
more than once a week; difficulty in
understanding complex commands; impairment of
short-
and long-term memory (e.g., retention of
only
highly learned material, forgetting to
complete tasks); impaired judgment; impaired
abstract thinking; disturbances of motivation and
mood;
difficulty in establishing and maintaining
effective work and social relationships...........
Occupational
and social impairment with occasional
30
decrease in work efficiency and intermittent
periods
of inability to perform occupational tasks
(although generally functioning satisfactorily,
with
routine behavior, self-care, and conversation
normal), due to such symptoms as: depressed mood,
anxiety, suspiciousness, panic attacks (weekly or
less
often), chronic sleep impairment, mild memory
loss
(such as forgetting names, directions, recent
events)...........................................
Occupational
and social impairment due to mild or
10
transient symptoms which decrease work efficiency
and
ability to perform occupational tasks only
during
periods of significant stress, or; symptoms
controlled by continuous medication...............
A mental
condition has been formally diagnosed, but
0
symptoms are not severe enough either to interfere
with
occupational and social functioning or to
require
continuous medication.....................
Global
Assessment of Functioning (GAF)
DSM-IV
SUMMARY TABLE
Axis
1:
Clinical
disorders
|
Axis
2:
Personality/
developmental disorders
|
Axis
3:
Relevant
physical disorders
|
Axis
4:
Psychosocial
and Environmental problems
|
Axis
5:
Global
Assessment of Functioning
|
Examples:
·
Anxiety disorders
·
Mood disorders
·
Dissociative disorders
·
Substance-related disorders
·
Schizophrenia
·
Sexual & gender-identity disorders
·
Eating disorders
|
Examples:
·
Paranoid personality disorder
·
Antisocial personality disorder
·
Narcissistic personality disorder
·
Borderline personality disorder
·
Dependent personality disorder
|
Examples:
·
Infectious & parasitic diseases
·
Endocrine, nutrional, metabolic, immune
diseases
·
Diseases of nervous system & sense organs
·
Congenital anomalies
|
Examples:
·
Problems with primary support group
·
Problems related to social environment
·
Educational problems
·
Occupational problems
·
Housing or economic problems
|
Examples:
100
= Superior functioning in a wide range of
activities
50
= Serious symptoms or impairment in social,
occupational, or school functioning
10
= Persistent danger of severely hurting self or
others
|
The VA requires that
a GAF score be given at least every 90 days, however,
most mental health workers
will list a GAF with each visit. Both the US Court of
Veteran Appeals and the Board of veterans' Appeals
consider a GAF of 50 to represent "Serious"
symptoms.
Psychiatrists
and Psychologists use a rating scale - the Global
Assessment of Functioning (GAF) - scale to assess how
well the individual is able to function in his/her
environment.
00-10
|
persistent
danger of hurting self; can't maintain
standard of self-care
|
11-20
|
danger
of hurting self; unable to maintain
self-care; impairment in communication
|
21-30
|
delusions,
hallucinations; major impairment in
most areas; lack of judgement
|
31-40
|
some
impairment in reality testing; major
impairment in select areas
|
41-50
|
serious
symptoms (suicidal ideation but low
risk); serious impairment in one area
|
51-60
|
moderate
symptoms in most areas
|
61-70
|
mild
symptoms; able to function with some
problems in relationships and work
|
71-80
|
slight
impairment; transient symptoms
|
81-90
|
good
functioning
|
91-100
|
happy.
healthy, and content
|
|
VA
Compensation and Pention Exam (PTSD)
Initial
Evaluation for Post-Traumatic Stress Disorder (PTSD)
#
0910 Worksheet
Name: |
SSN: |
Date
of Exam: |
C-number: |
Place
of Exam: |
A. Identifying Information:
B.
Sources of Information:
-
records
reviewed (C-file, DD-214, medical records, other
documentation)
-
review
of social-industrial survey completed by social
worker
-
statements
from collaterals
-
administration
of psychometric tests and questionnaires
(identify here)
C.
Review of Medical Records:
-
Past
Medical History:
-
Previous
hospitalizations and outpatient care.
-
Complete
medical history is required, including history
since discharge from military service.
-
Review
of Claims Folder is required on initial exams
to establish or rule out the diagnosis.
-
Present
Medical History - over the past one year.
-
Frequency,
severity and duration of medical and
psychiatric symptoms.
-
Length
of remissions, to include capacity for
adjustment during periods of remissions.
D.
Examination (Objective Findings):
Address
each of the following and fully describe:
History
(Subjective Complaints):
Comment on:
Premilitary
History (refer to social-industrial survey if
completed)
-
describe
family structure and environment where raised
(identify constellation of family members and
quality of relationships)
-
quality
of peer relationships and social adjustment
(e.g., activities, achievements, athletic and/or
extracurricular involvement, sexual
involvements, etc.)
-
education
obtained and performance in school · employment
-
legal
infractions
-
delinquency
or behavior conduct disturbances
-
substance
use patterns
-
significant
medical problems and treatments obtained
-
family
psychiatric history
-
exposure
to traumatic stressors (see CAPS trauma
assessment checklist)
-
summary
assessment of psychosocial adjustment and
progression through developmental milestones
(performance in employment or schooling, routine
responsibilities of self-care, family role
functioning, physical health,
social/interpersonal relationships,
recreation/leisure pursuits).
Military
History
-
branch
of service (enlisted or drafted)
-
dates
of service
-
dates
and location of war zone duty and number of
months stationed in war zone
-
Military
Occupational Specialty (describe nature and
duration of job(s) in war zone
-
highest
rank obtained during service (rank at discharge
if different)
-
type
of discharge from military
-
describe
routine combat stressors veterans was exposed to
(refer to Combat Scale)
-
combat
wounds sustained (describe)
-
clearly
describe specific stressor event(s) veteran
considered particularly traumatic. Clearly
describe the stressor. Particularly if the
stressor is a type of personal assault,
including sexual assault, provide information,
with examples, if possible.
-
indicate
overall level of traumatic stress exposure
(high, moderate, low) based on frequency and
severity of incident exposure (refer to trauma
assessment scale scores described in Appendix
B).
-
citations
or medals received
-
disciplinary
infractions or other adjustment problems during
military
NOTE:
Service connection for post-traumatic stress
disorder (PTSD) requires medical evidence
establishing a diagnosis of the condition that
conforms to the diagnostic criteria of DSM-IV,
credible supporting evidence that the claimed
in-service stressor actually occurred, and a link,
established by medical evidence, between current
symptomatology and the claimed in-service stressor.
It is the responsibility of the examiner to indicate
the traumatic stressor leading to PTSD, if he or she
makes the diagnosis of PTSD. Crucial in this
description are specific details of the stressor,
with names, dates, and places linked to the
stressor, so that the rating specialist can confirm
that the cited stressor occurred during active duty.
A diagnosis of PTSD cannot be adequately documented
or ruled out without obtaining a detailed military
history and reviewing the claims folder. This means
that initial review of the folder prior to
examination, the history and examination itself, and
the dictation for an examination initially
establishing PTSD will often require more time than
for examinations of other disorders. Ninety minutes
to two hours on an initial exam is normal.
Post-Military
Trauma History (refer to social-industrial survey
if completed)
-
describe
post-military traumatic events (see CAPS trauma
assessment checklist)
-
describe
psychosocial consequences of post-military
trauma exposure(s) (treatment received,
disruption to work, adverse health consequences)
Post-Military
Psychosocial Adjustment (refer to
social-industrial survey if completed) · legal
history (DWIs, arrests, time spent in jail)
-
educational
accomplishment
-
employment
history (describe periods of employment and
reasons)
-
marital
and family relationships (including quality of
relationships with children)
-
degree
and quality of social relationships
-
activities
and leisure pursuits
-
problematic
substance abuse (lifetime and current)
-
significant
medical disorders (resulting pain or disability;
current medications)
-
treatment
history for significant medical conditions,
including hospitalizations
-
history
of inpatient and/or outpatient psychiatric care
(dates and conditions treated)
-
history
of assaultiveness
-
history
of suicide attempts
-
summary
statement of current psychosocial functional
status (performance in employment or schooling,
routine responsibilities of self care, family
role functioning, physical health,
social/interpersonal relationships,
recreation/leisure pursuits)
E.
Mental Status Examination
Conduct
a brief mental status examination aimed at screening
for DSM-IV mental disorders. Describe and fully
explain the existence, frequency and extent of the
following signs and symptoms, or any others present,
and relate how they interfere with employment and
social functioning:
-
Impairment
of thought process or communication.
-
Delusions,
hallucinations and their persistence.
-
Eye
Contact, interaction in session, and
inappropriate behavior cited with examples.
-
Suicidal
or homicidal thoughts, ideations or plans or
intent.
-
Ability
to maintain minimal personal hygiene and other
basic activities of daily living.
-
Orientation
to person, place and time.
-
Memory
loss, or impairment (both short and long-term).
-
Obsessive
or ritualistic behavior which interferes with
routine activities and describe any found.
-
Rate
and flow of speech and note any irrelevant,
illogical, or obscure speech patterns and
whether constant or intermittent.
-
Panic
attacks noting the severity, duration, frequency
and effect on independent functioning and
whether clinically observed or good evidence of
prior clinical or equivalent observation is
shown.
-
Depression,
depressed mood or anxiety.
-
Impaired
impulse control and its effect on motivation or
mood.
-
Sleep
impairment and describe extent it interferes
with daytime activities.
-
Other
disorders or symptoms and the extent they
interfere with activities, particularly:
-
mood
disorders (especially major depression and
dysthymia)
-
substance
use disorders (especially alcohol use
disorders)
-
anxiety
disorders (especially panic disorder,
obsessive-compulsive disorder, generalized
anxiety disorder)
-
somatoform
disorders
-
personality
disorders (especially antisocial personality
disorder and borderline personality disorder)
Specify
onset and duration of symptoms as acute, chronic,
or with delayed onset.
F.
Assessment of PTSD
-
state
whether or not the veteran meets the DSM-IV
stressor criterion
-
identify
behavioral, cognitive, social, affective, or
somatic change veteran attributes to stress
exposure
-
describe
specific PTSD symptoms present (symptoms of
trauma re-experiencing, avoidance/numbing,
heightened physiological arousal, and associated
features [e.g., disillusionment and
demoralization])
-
specify
onset, duration, typical frequency, and severity
of symptoms
G.
Psychometric Testing Results
-
provide
psychological testing if deemed necessary
-
provide
specific evaluation information required by the
rating board or on a BVA Remand.
-
comment
on validity of psychological test results
-
provide
scores for PTSD psychometric assessments
administered
-
state
whether PTSD psychometric measures are
consistent or inconsistent with a diagnosis of
PTSD, based on normative data and established
"cutting scores" (cutting scores that
are consistent with or supportive of a PTSD
diagnosis are as follows: PCL > 50;
Mississippi Scale > 107; MMPI PTSD
subscale a score > 28; MMPI code type: 2-8 or
2-7-8)
-
state
degree of severity of PTSD symptoms based on
psychometric data (mild, moderate, or severe)
-
describe
findings from psychological tests measuring
problems other than PTSD (MMPI, etc.)
H.
Diagnosis:
-
The
Diagnosis must conform to DSM-IV and be
supported by the findings on the examination
report.
-
If
there are multiple mental disorders, delineate
to the extent possible the symptoms associated
with each and a discussion of relationship.
-
Evaluation
is based on the effects of the signs and
symptoms on occupational and social functioning.
NOTE:
VA is prohibited by statute, 38 U.S.C. 1110, from
paying compensation for a disability that is a
result of the veteran's own ALCOHOL OR DRUG ABUSE.
However, when a veteran's alcohol or drug abuse
disability is secondary to or is caused or
aggravated by a primary service-connected disorder,
the veteran may be entitled to compensation. See
Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir.
2001). Therefore, it is important to determine the
relationship, if any, between a service-connected
disorder and a disability resulting from the
veteran's alcohol or drug abuse. Unless alcohol or
drug abuse is secondary to or is caused or
aggravated by another mental disorder, you should
separate, to the extent possible, the effects of the
alcohol or drug abuse from the effects of the other
mental disorder(s). If it is not possible to
separate the effects in such cases, please explain
why.
I.
Diagnostic Status
J.
Global Assessment of Functioning (GAF):
NOTE:
The complete multi-axial format as specified by
DSM-IV may be required by BVA REMAND or specifically
requested by the rating specialist. If so, include
the GAF score and note whether it refers to current
functioning. A BVA REMAND may also request, in
addition to an overall GAF score, that a separate
GAF score be provided for each mental disorder
present when there are multiple Axis I or Axis II
diagnoses and not all are service-connected. If
separate GAF scores can be given, an explanation and
discussion of the rationale is needed. If it is not
possible, an explanation as to why not is needed.
(See the above note pertaining to alcohol or drug
abuse, the effects of which cannot be used to assess
the effects of a service-connected condition.)
DSM-IV is only for application from 11/7/96 on.
Therefore, when applicable note whether the
diagnosis of PTSD was supportable under DSM-III-R
prior to that date. The prior criteria under
DSM-III-R are provided as an attachment.
K.
Capacity to Manage Financial Affairs: Mental
competency, for VA benefits purposes, refers only to
the ability of the veteran to manage VA benefit
payments in his or her own best interest, and not to
any other subject. Mental incompetency, for VA
benefits purposes, means that the veteran, because of
injury or disease, is not capable of managing benefit
payments in his or her best interest. In order to
assist raters in making a legal determination as to
competency, please address the following:
What
is the impact of injury or disease on the veteran's
ability to manage his or her financial affairs,
including consideration of such things as knowing
the amount of his or her VA benefit payment, knowing
the amounts and types of bills owed monthly, and
handling the payment prudently? Does the veteran
handle the money and pay the bills himself or
herself?
Based on your examination, do you believe that the
veteran is capable of managing his or her financial
affairs? Please provide examples to support your
conclusion.
If you believe a Social Work Service assessment is
needed before you can give your opinion on the
veteran's ability to manage his or her financial
affairs, please explain why.
L.
Other Opinion: Furnish any other specific opinion
requested by the rating board or BVA remand (furnish
the complete rationale and citation of medical texts
or treatise supporting opinion, if medical literature
review was undertaken). If the requested opinion is
medically not ascertainable on exam or testing please
state why. If the requested opinion can not be
expressed without resorting to speculation or making
improbable assumptions say so, and explain why. If the
opinion asks " ... is it at least as likely as
not ... ", fully explain the clinical findings
and rationale for the opinion. M. Integrated Summary
and Conclusions
-
Describe
changes in psychosocial functional status and
quality of life following trauma exposure
(performance in employment or schooling, routine
responsibilities of self care, family role
functioning, physical health,
social/interpersonal relationships,
recreation/leisure pursuits)
-
Describe
linkage between PTSD symptoms and aforementioned
changes in impairment in functional status and
quality of life. Particularly in cases where a
veteran is unemployed, specific details about
the effects of PTSD and its symptoms on
employment are especially important.
-
If
possible, describe extent to which disorders
other than PTSD (e.g., substance use disorders)
are independently responsible for impairment in
psychosocial adjustment and quality of life. If
this is not possible, explain why (e.g.,
substance use had onset after PTSD and clearly
is a means of coping with PTSD symptoms).
-
If
possible, describe pre-trauma risk factors or
characteristics than may have rendered the
veteran vulnerable to developing PTSD subsequent
to trauma exposure.
-
If
possible, state prognosis for improvement of
psychiatric condition and impairments in
functional status.
-
Comment
on whether veteran is capable of managing his or
her financial affairs.
Writting
Your Stressor Letter
Please contact one the individuals listed at the end of
the page for more information and any questions you have
There are two basic steps to receive a disability from
the Veterans Administration for PTSD. The first step is
filing a claim with the VA for PTSD. The second, and
most Important, is submitting a stressor letter. Most
combat veterans do not trust the government or the VA.
This is understandable considering the treatment most
veterans received during and after the Vietnam War. But
the VA has improved in most places, and the benefits are
there for the combat veterans. The VA does not go
looking for the combat veteran with PTSD. You mush push
aside any bad feelings and make the effort to receive
the earned benefits.
As ridiculous at it may seem, all combat veterans must
not only prove that they were in combat, they must also
prove that they were in the military. This process
screens out the phony combat veterans. It is surprising
how many combat veterans have surfaced who were on top
secret missions, and of course, there is no record of
their even being in the military because their missions
were so secret.
You can file a claim on your own, but there are several
veteran’s organizations who will represent you on a
disability claim. You will need to sign a power of
attorney. You sign this paper and send it back through
the mail. This gives the Service Officer your permission
to represent you in your claim. Please be aware that
there are many poor Service Officers. If you are not
offered immediate help, with eagerness, move on until
you find a Service Officer who is eager to help you. All
Veterans Groups have Service Officers, so shop alll of
them until you find a person your are comfortable with
or contact us and we will try to help you.
This is the single most important factor in obtaining
disability for the combat veteran. After your claim has
been filed, usually within 30 to 60 days, you will
receive a letter from the VA stating that they have
received your claim for PTSD. Then you will be asked to
submit a stressor letter. This is a written record of
combat experiences which you felt were life threatening
or have caused you to display symptoms of PTSD. They
will also note that they understand how difficult this
can be for some veterans (thinking about war experiences
and writing them down). And for many this is difficult.
Some can't write well. Some are too terrified to think
in detail about their war experience.
Chances are the average veteran cannot write a stressor
letter that will pass the rating board. Once a stressor
letter has been rejected by the rating board, the
process to receive disability can be long and
discouraging. Many veterans give up and never receive
the disability they deserve. The VA will tell-you how to
write the letter or what details to include. If the
letter is rejected, many combat veterans will give up
before appealing the rating board decision. So a veteran
must submit a solid stressor letter to pass the rating
board. This is my area of expertise. I know what to put
in the letter and how to present it so that the rating
board will grant any where from 10% to 50% disability
just from your stressor letter without rejection and VA
appeal hearings. It will be impossible to receive a 100%
rating from a stressor letter, but once the VA agrees
you are disabled, you can appeal for a higher
percentage.
PTSD IS A RECOGNIZED DISORDER WHICH DOES NOT GO AWAY.
THE REACTIONS TO COMBAT STRESS OFTEN BECOMES A PERMANENT
PART OF THE VETERAN'S PERSONALITY.
COMP EXAM
At some point after you file for disability, either
before or after you have submitted your stressor letter,
you will receive a letter asking you to come to the
nearest VA Hospital in your area for a Compensation
Examination. This just means that you are going to speak
to a VA psychiatrist. The psychiatrist will ask you many
questions about your background (including your
childhood and current social life) and your war service.
The meeting with the doctor will probably last anywhere
from 20 to 45 minutes. The VA will also reimburse you
with a small travel allowance for coming.
You must show up for this comp exam. If for some reason
you can't make it, then call the VA and they will
schedule you again. Most of all, relax. This
psychiatrist is not your enemy, and it is his or her job
to send a report to the VA regional office as to whether
you show symptoms of PTSD. The psychiatrist Is
Impartial. If you show symptoms of PTSD, it will be
reported without any favor toward the VA. So relax and
answer questions to the best of your knowledge. Always
stress the negative side of your life...never the
positive. Just like at the close of the stressor letter.
You can do this and still tell the truth just by
avoiding the positive.
Here are some things not to say at a Comp Exam
1. My life is okay. It's not or you wouldn't be there.
2. I sometimes hear voices. Hearing voices can lead to a
diagnosis of schizophrenia, and your PTSD claim may be
rejected.
3. I am happily married. It has often been decided that
having PTSD automatically means an unhappy marriage. It
can but not always.
4. I love my job. I have been there twenty years. If you
have managed to keep one job, it may be determined that
you interact normally and do not have PTSD. You can have
one job and still be miserable. It's a matter of
survival.
5. I have lots of friends. Never admit you have lots of
friends. Chances are you don't anyway. At least, not
like the friends you made in combat situations who you
can trust with your life.
6. Don't threaten the doctor. Some veterans scream,
yell, and threaten to kill the doctor in an attempt to
show symptoms of PTSD. 99% of the time this is an act
and won't help your claim. The main thing is to stress
the negative side of your life, just as in the end of
the stressor letter. If you have had a substance abuse
problem since before your war service, it would be best
not to mention it. Stress the fact that you are
depressed and have nightmares and feel that the war has
altered your life. Just remember to stress the negative
instead of anything positive in your life.
For additional information and help with writing a
stressor letter please go to: http://silverrose.org/ptsd.html
Coping
with PTSD and Recommended Lifestyle Changes for PTSD
Patients
A
National Center for PTSD Fact Sheet
By
Joe Ruzek, Ph.D.
Coping
with PTSD
Because
PTSD symptoms seldom disappear completely, it is usually
a continuing challenge for survivors of trauma to cope
with PTSD symptoms and the problems they cause.
Survivors often learn through treatment how to cope more
effectively.
Recovery
from PTSD is an ongoing, daily, gradual process. It
doesn't happen through sudden insight or
"cure." Healing doesn't mean that a survivor
will forget war experiences or have no emotional pain
when remembering them. Some level of continuing reaction
to memories is normal and reflects a normal body and
mind. Recovery may lead to fewer reactions and reactions
that are less intense. It may also lead to a greater
ability to manage trauma-related emotions and to greater
confidence in one's ability to cope.
When
a trauma survivor takes direct action to cope with
problems, he or she often gains a sense of personal
power and control. Active coping means recognizing and
accepting the impact of traumatic experiences and then
taking concrete action to improve things.
Positive
coping actions are those that help to reduce anxiety and
lessen other distressing reactions. Positive coping
actions also improve the situation in a way that does
not harm the survivor further and in a way that lasts
into the future. Positive coping methods include:
Learning
about trauma and PTSD-It
is useful for trauma survivors to learn more about PTSD
and how it affects them. By learning that PTSD is common
and that their problems are shared by hundreds of
thousands of others, survivors recognize that they are
not alone, weak, or crazy. When a survivor seeks
treatment and learns to recognize and understand what
upsets him or her, he or she is in a better position to
cope with the symptoms of PTSD.
Talking
to another person for support-When
survivors are able to talk about their problems with
others, something helpful often results. Of course,
survivors must choose their support people carefully and
clearly ask for what they need. With support from
others, survivors may feel less alone, feel supported or
understood, or receive concrete help with a problem
situation. Often, it is best to talk to professional
counselors about issues related to the traumatic
experience itself; they are more likely than friends or
family to understand trauma and its effects. It is also
helpful to seek support from a support group. Being in a
group with others who have PTSD may help reduce one's
sense of isolation, rebuild trust in others, and provide
an important opportunity to contribute to the recovery
of other survivors of trauma.
Talking
to your doctor about trauma and PTSD-Part
of taking care of yourself means mobilizing the helping
resources around you. Your doctor can take care of your
physical health better if he or she knows about your
PTSD, and doctors can often refer you to more
specialized and expert help.
Practicing
relaxation methods-These
can include muscular relaxation exercises, breathing
exercises, meditation, swimming, stretching, yoga,
prayer, listening to quiet music, spending time in
nature, and so on. While relaxation techniques can be
helpful, they can sometimes increase distress by
focusing attention on disturbing physical sensations or
by reducing contact with the external environment. Be
aware that while uncomfortable physical sensations may
become more apparent when you are relaxed, in the long
run, continuing with relaxation in a way that is
tolerable (i.e., interspersed with music, walking, or
other activities) helps reduce negative reactions to
thoughts, feelings, and perceptions.
Increasing
positive distracting activities-Positive
recreational or work activities help distract a person
from his or her memories and reactions. Artistic
endeavors have also been a way for many trauma survivors
to express their feelings in a positive, creative way.
This can improve your mood, limit the harm caused by
PTSD, and help you rebuild your life. It is important to
emphasize that distraction alone is unlikely to
facilitate recovery; active, direct coping with
traumatic events and their impact is also important.
Calling
a counselor for help-Sometimes
PTSD symptoms worsen and ordinary efforts at coping
don't seem to work. Survivors may feel fearful or
depressed. At these times, it is important to reach out
and telephone a counselor, who can help turn things
around.
Taking
prescribed medications to tackle PTSD-One
tool that many with PTSD have found helpful is
medication treatment. By taking medications, some
survivors of trauma are able to improve their sleep,
anxiety, irritability, anger, and urges to drink or use
drugs.
Negative
coping actions help to perpetuate problems. They may
reduce distress immediately but short-circuit more
permanent change. Some actions that may be immediately
effective may also cause later problems, like smoking or
drug use. These habits can become difficult to change.
Negative coping methods can include isolation, use of
drugs or alcohol, workaholism, violent behavior, angry
intimidation of others, unhealthy eating, and different
types of self-destructive behavior (e.g., attempting
suicide). Before learning more effective and healthy
coping methods, most people with PTSD try to cope with
their distress and other reactions in ways that lead to
more problems. The following are negative coping
actions:
Use
of alcohol or drugs-This
may help wash away memories, increase social confidence,
or induce sleep, but it causes more problems than it
cures. Using alcohol or drugs can create a dependence on
alcohol, harm one's judgment, harm one's mental
abilities, cause problems in relationships with family
and friends, and sometimes place a person at risk for
suicide, violence, or accidents.
Social
isolation-By
reducing contact with the outside world, a trauma
survivor may avoid many situations that cause him or her
to feel afraid, irritable, or angry. However, isolation
will also cause major problems. It will result in the
loss of social support, friendships, and intimacy. It
may breed further depression and fear. Less
participation in positive activities leads to fewer
opportunities for positive emotions and achievements.
Anger-Like
isolation, anger can get rid of many upsetting
situations by keeping people away. However, it also
keeps away positive connections and help, and it can
gradually drive away the important people in a person's
life. It may lead to job problems, marital or
relationship problems, and the loss of friendships.
Continuous
avoidance-If
you avoid thinking about the trauma or if you avoid
seeking help, you may keep distress at bay, but this
behavior also prevents you from making progress in how
you cope with trauma and its consequences.
Recommended
Lifestyle Changes – Taking Control
Those
with PTSD need to take active steps to deal with their
PTSD symptoms. Often, these steps involve making a
series of thoughtful changes in one's lifestyle to
reduce symptoms and improve quality of life. Positive
lifestyle changes include:
Calling
about treatment and joining a PTSD support group-It
may be difficult to take the first step and join a PTSD
treatment group. Survivors say to themselves, "What
will happen there? Nobody can help me anyway." In
addition, people with PTSD find it hard to meet new
people and trust them enough to open up. However, it can
also be a great relief to feel that you have taken
positive action. You may also be able to eventually
develop a friendship with another survivor.
Increasing
contact with other survivors of trauma-Other
survivors of trauma are probably the best source of
understanding and support. By joining a survivors
organization (e.g., veterans may want to join a
veteran's organization) or by otherwise increasing
contact with other survivors, it is possible to reverse
the process of isolation and distrust of others.
Reinvesting
in personal relationships with family and friends-Most
survivors of trauma have some kind of a relationship
with a son or daughter, a wife or partner, or an old
friend or work acquaintance. If you make the effort to
reestablish or increase contact with that person, it can
help you reconnect with others.
Changing
neighborhoods-Survivors
with PTSD usually feel that the world is a very
dangerous place and that it is likely that they will be
harmed again. It is not a good idea for people with PTSD
to live in a high-crime area because it only makes those
feelings worse and confirms their beliefs. If it is
possible to move to a safer neighborhood, it is likely
that fewer things will set off traumatic memories. This
will allow the person to reconsider his or her personal
beliefs about danger.
Refraining
from alcohol and drug abuse-Many
trauma survivors turn to alcohol and drugs to help them
cope with PTSD. Although these substances may distract a
person from his or her painful feelings and, therefore,
may appear to help deal with symptoms, relying on
alcohol and drugs always makes things worse in the end.
These substances often hinder PTSD treatment and
recovery. Rather than trying to beat an addiction by
yourself, it is often easier to deal with addictions by
joining a treatment program where you can be around
others who are working on similar issues.
Starting
an exercise program-It
is important to see a doctor before starting to
exercise. However, if the physician gives the OK,
exercise in moderation can benefit those with PTSD.
Walking, jogging, swimming, weight lifting, and other
forms of exercise may reduce physical tension. They may
distract the person from painful memories or worries and
give him or her a break from difficult emotions. Perhaps
most important, exercise can improve self-esteem and
create feelings of personal control.
Starting
to volunteer in the community-It
is important to feel as though you are contributing to
your community. When you are not working, you may not
feel you have anything to offer others. One way
survivors can reconnect with their communities is to
volunteer. You can help with youth programs, medical
services, literacy programs, community sporting
activities, etc.
The
information on this Web site is presented for
educational purposes only. It is not a substitute for
informed medical advice or training. Do not use this
information to diagnose or treat a mental health problem
without consulting a qualified health or mental health
care provider.
All
information contained on these pages is in the public
domain unless explicit notice is given to the contrary,
and may be copied and distributed without restriction
If
And How To Tell Others About PTSD
If
you've been in treatment for PTSD, you'll know by now
that talking to counselors and doctors about your PTSD
is essential to self-care. But if you haven't ever
sought care for PTSD, we recommend that you do so.
Talking about PTSD to a professional counselor in your
VA or local Vet Center has meant the beginning of a
better life for many, many veterans.
But
here we're focusing on talking to other people - your
partner, family members, friends, work or volunteer
colleagues.
There
are many possible benefits to telling others that you
have PTSD. They can come to understand you better and
support you more. They may realize that when you're
angry or need to leave a situation, it's not because
you dislike them but more about your symptoms and
struggles. They can come to be more accepting of your
fears, irritability, withdrawal, or other PTSD
symptoms.
Partners
and family members have a special need to learn about
PTSD. In fact, good care for you will often mean that
those close to you need to become better educated
about PTSD: what it is, how it can result from traumas
like combat or sexual assault, what happens in
treatment, what happens in the process of recovery,
what things trigger your symptoms, and what they can
do to help support your recovery.
On
a case-by-case basis, it may also be important to tell
people you work, volunteer, or socialize with about
your PTSD. If they know about PTSD, they will be more
likely to react in a helpful way when your PTSD
worsens or you have problems related to PTSD.
Here
are some things to consider as you decide if, when,
and how to tell another person about your PTSD:
-
Talk
about this with your counselor before telling
others and think together about the pro's and
con's of talking.
-
Choose
carefully whom you tell. There should be a good
reason to tell them, and there are times when it
will not be necessary or wise to tell a particular
person.
-
Think
about their possible reactions. Will they be
understanding; will they listen?
-
Think
about and prepare what you are going to say.
-
Test
the water a little. Try a brief conversation and
see how they react.
-
When
doing this for the first or second time, choose
someone that you are confident will be
understanding and supportive.
-
Don't
tell them about your traumatic experiences, unless
you and your counselor decide there is some reason
to do so. Other people need to understand what
your experience is now, not what happened to you.
You can tell them, briefly and generally, what
happened, if you choose ("I saw people
die" or "I almost died" or "I
saw terrible things"). But there is no reason
to go into the details.
-
Tell
them why you are explaining about your PTSD: that
part of your recovery means letting people
important to you know what's going on with you,
discussing what problems you might occasionally
experience, and making some plans for how to deal
with problems if they arise.
Very
occasionally, someone might react badly when you tell
them about your PTSD. They might be scared of you
("crazy Vietnam vet") or they might appear
uncomfortable. Usually, this will be due to ignorance,
a lack of understanding of war and other trauma, and
of trauma reactions. Commonly, they will not know what
to say. Most people don't know much about the impact
of trauma on human beings, and they have not had the
opportunity to talk about emotional problems with
someone who is experiencing them.
What
do you want to tell them about your PTSD? It may be
especially helpful to tell them about the parts of
your PTSD reactions that might affect them: your
difficulty in expressing positive feelings, your
difficulty in getting close to another person, your
irritability or anger, your difficulty in going into
busy or crowded places, your occasional social
isolation, your difficulties in being in social
situations, and so on. Also tell them about the basic
symptoms of PTSD.
You
can explain things in a positive and prideful way. You
can say (in your own words, expanding on what you
want) that war (or other trauma) affects many people
in very powerful ways that continue long past the
trauma itself, that you are actively working at
self-care by learning coping tools and getting
counseling and other forms of regular support, and
that part of your self-care action is to talk to
people that are important to you about what PTSD is
and how it can affect you.
As
you strengthen your recovery and become more skilled
in using your coping tools, you will gradually become
more comfortable in talking to others about what is
going on with you.
|
This
information is from the VA's National
Treatment Center for PTSD at Menl Park, CA,
part of the VA's Palo Alto Health Care
System
The
information on this Web site is presented
for educational purposes only. It is not a
substitute for informed medical advice or
training. Do not use this information to
diagnose or treat a mental health problem
without consulting a qualified health or
mental health care provider. All information
contained on these pages is in the public
domain unless explicit notice is given to
the contrary, and may be copied and
distributed without restriction.
|
Post
Traumatic Stress Disorder (PTSD) became part
of the American vocabulary after the Vietnam
War as its affects on veterans became
widely publicized. Now, a new generation of
American veterans are again victims of PTSD.
This series explores the impact of politics on
the funding, diagnosis and treatment of
veterans suffering from PTSD. It examines the
propaganda used to justify a reduction in
benefits to veterans with PTSD and the effort
to redirect blame for the ravages of war to
the soldiers themselves.
Part
I: Stacking the Deck
- With trillion dollar estimates for the Iraq
war, the Administration looks to cut costs,
eyeing treatment for the returning PTSD
wounded veterans.
Part
II: Ration & Redefine
- Redefining PTSD and substance abuse as
moral/spiritual failings opens the door to
cheaper unregulated, unlicensed faith-based
"treatments."
Part
III: Malign & Slime
- Propaganda is used to stigmatize veterans
seeking help, reduce benefits to veterans with
PTSD and to blame the soldiers for their own
illness.
PTSD
Resources
| About
the Authors
Specialized
PTSD Treatment Programs in the U.S. Department of
Veterans Affairs
A
National Center for PTSD Fact Sheet
The
Department of Veterans Affairs Medical Centers
provides a network of more than 100 specialized
programs for veterans with PTSD and works closely with
the Vet Centers
operated by VA's Readjustment Counseling Service.
Each
specialized PTSD program offers veterans education,
evaluation, and treatment conducted by mental-health
professionals from a variety of disciplines (such as
psychiatry, psychology, social work, counseling, and
nursing).
Outpatient
PTSD Programs include three basic types of clinics in
which veterans meet with a PTSD specialist for
regularly scheduled appointments. PTSD Clinical Teams
(PCTs) provide group and one-to-one evaluation,
education, counseling, and psychotherapy. Substance
Use PTSD Teams (SUPTs) offer outpatient education,
evaluation, and counseling for the combined problems
of PTSD and substance abuse. Women's Stress Disorder
Treatment Teams (WSDTTs) provide women veterans group
and one-to-one evaluation, counseling, and
psychotherapy.
Day
Hospital PTSD Programs include two basic approaches to
providing a "therapeutic community."
Veterans with PTSD can attend these community programs
several times weekly for social, recreational, and
vocational activities as well as for counseling. Day
Treatment PTSD Units provide one-to-one case
management and counseling, group therapy, education,
and activities in order to help clients live
successfully with PTSD. Treatment and socialization
activities are scheduled for several hours each day
during the day and evening hours. Residential (Lodger)
PTSD Units also offer one-to-one case management and
counseling, group therapy, education, and activities
for several hours each day. While enrolled in daytime
and evening PTSD treatment, lodger clients may live
temporarily in secure quarters that do not have
24-hour nursing supervision.
Inpatient
PTSD Programs include four basic types of service and
are conducted while veterans reside in hospital units
that provide 24-hour nursing and psychiatric care.
Specialized Inpatient PTSD Units (SIPUs) provide
trauma-focused evaluation, education, and
psychotherapy for a period of 28 to 90 days of
hospital admission. Evaluation and Brief Treatment of
PTSD Units (EBTPUs) provide PTSD evaluation,
education, and psychotherapy for a briefer period
ranging from 14 to 28 days. PTSD Residential
Rehabilitation Programs (PRRPs) provide PTSD
evaluation, education, counseling, and case management
that focuses on helping the survivor resume a
productive involvement in community life. PRRP
admissions tend to be 28 to 90 days. PTSD Substance
Use Programs (PSUs) provide combined evaluation,
education, and counseling for substance use problems
and PTSD. PSU admissions range from 14 to 90 days.
For
more information about these treatment programs,
including locations and contact information, go to the
United States Department
of Veterans Affairs
website. The website provides
a wide range of information on veterans' benefits and
treatment facilities.
THE
ENDLESS TOUR: VIETNAM, PTSD and the SPIRITUAL VOID By
www.trafford.com/robots/02-0383.html
-
Rev.
Amy L. Snow, M.A., author
The Endless Tour: Vietnam, PTSD, and the Spiritual
Void
THE ENDLESS TOUR: VIETNAM, PTSD and the SPIRITUAL VOID
By
Additional
Links
What
is P.T.S.D United
Kingdom Site (excellent)
The
Ex-Services Mental Welfare Society, COMBAT STRESS,
exists to serve ex service personnel. For over 80 years,
they have been the only services charity specializing in
helping those of all ranks from the Armed Forces and the
Merchant Navy suffering from psychological disability as
a result of their service. Through their national
network of welfare officers, they visit clients at home
in order to establish how best we can improve their
quality of life. Through out their three treatment
centers, we provide rehabilitative treatment which aims
to help the victim cope with his or her disabilities and
to enjoy a better quality of life. In over 80 years of
operation, the society has provided some 75,000 veterans
of the two World Wars and the many conflicts since with
a unique lifeline. Currently, the Society takes about
600 veterans onto its
books each year, the youngest in their early twenties,
the oldest in their seventies. There are people in
receipt of help who between them represent service in
every campaign which the British Armed services has been
engaged from the start of World War 2 to the present
day. Should you wish to contact Combat Stress please
speak to Keith Hudson (NIVA Welfare Officer) on Tel:
07880535314. Or alternativly contact Combat Stress
directly:-
Head Office
Tyrwhitt House, Oaklawn Road
Leatherhead, Surrey KT22 0BX
Telephone Number: 01372 841600
Email Address:
contactus@combatstress.org.uk
Notes taken from Combat Stress
Active
Duty Military
Below
is a list of information currently available from the
National Center for PTSD about active duty military. For
more information, click on the related links and/or
search the PILOTS
database for a more complete listing of articles
available on this topic.
Fact
sheets
Other
Related Topics
Help
for Veterans with PTSD and Their Families
Answers
to some questions about PTSD and service-connected
disability that are frequently asked by veterans and
their families
Specialized
PTSD Treatment Programs in the U.S. Department of
Veterans Affairs
Brief
information about the Department of Veterans Affairs'
network of more than 100 specialized programs for
veterans with PTSD, including the Vet
Centers operated by VA's Readjustment Counseling
Service
Published
Information by National Center for PTSD staff
=Iowa
Persian Gulf Study Group
Self-reported
illness and health status among Gulf War veterans: a
population-based study [download
] [view]
Journal of the American Medical Association, January
15, 1997, vol 277, iss 3, pg 238-245
Bolton, Elisa Esthera; Litz, Brett T; Adler, Amy B;
Roemer, Lizabeth
Reports
of prior exposure to potentially traumatic events and
PTSD in troops poised for deployment [download]
[view]
Journal of Traumatic Stress, January 2001, vol 14, iss
1, pg 249-256
Erickson, Darin J; Wolfe, Jessica; King, Daniel W;
King, Lynda A; Sharkansky, Erica J
Posttraumatic
stress disorder and depression symptomatology in a
sample of Gulf War Veterans: a prospective analysis
[ddownloa]
[view]
Journal of Consulting and Clinical Psychology ,
February 2001, vol 69, iss 1, pg 41-49
Fontana, Alan; Litz, Brett T; Rosenheck, Robert A
Impact
of combat and sexual harassment on the severity of
posttraumatic stress disorder among men and women
peacekeepers in Somalia [download]
[view]
Journal of Nervous and Mental Disease , March 2000,
vol 188, iss 3, pg 163-169
Ford, Julian D; Chandler, Patricia; Thacker, Barbara
G; Greaves, David; Shaw, David; Sennhauser, Shirley;
Schwartz, Lawrence
Family
systems therapy after Operation Desert Storm with
European-theater veterans [download]
[view]
Journal of Marital and Family Therapy, April 1998, vol
24, iss 2, pg 243-250
Friedman, Matthew J; Southwick, Steven M; Charney,
Dennis S
Pharmacotherapy
for recently evacuated military casualties [download]
[view]
Military Medicine, July 1993, vol 158, iss 7, pg
493-497
King, Daniel W; King, Lynda A; Erickson, Darin J;
Huang, Mina T; Sharkansky, Erica J; Wolfe, Jessica
Posttraumatic
stress disorder and retrospectively reported stressor
exposure: a longitudinal prediction model [download]
[view]
Journal of Abnormal Psychology , November 2000, vol
109, iss 4, pg 624-633
Litz, Brett T
The
psychological demands of peacekeeping for military
personnel [download]
National Center for PTSD Clinical Quarterly, Winter
1996, vol 6, iss 1, pg 1, 3-8
Litz, Brett T; King, Lynda A; King, Daniel W; Orsillo,
Susan Marie; Friedman, Matthew J
Warriors
as peacekeepers: features of the Somalia experience
and PTSD [download]
[view]
Journal of Consulting and Clinical Psychology,
December 1997, vol 65, iss 6, pg 1001-1010
Litz, Brett T; Orsillo, Susan Marie; Friedman, Matthew
J; Ehlich, Peter J; Batres, Alfonso R
Posttraumatic
stress disorder associated with peacekeeping duty in
Somalia for U.S. military personnel [download]
[view]
American Journal of Psychiatry, February 1997, vol
154, iss 2, pg 178-184
Lundin, Tom
Collision
at sea between two Navy vessels [download]
[view]
Military Medicine, July 1995, vol 160, iss 7, pg
323-325
Lundin, Tom; Otto, Ulf
Swedish
soldiers in peacekeeping operations: stress reactions
following missions in Congo, Lebanon, Cyprus, and
Bosnia [download]
National Center for PTSD Clinical Quarterly, Winter
1996, vol 6, iss 1, pg 9-11
Morgan, Charles Andrew; Hazlett, Gary; Wang, Sheila;
Richardson, E Greer; Schnurr, Paula P; Southwick,
Steven M
Symptoms
of dissociation in humans experiencing acute,
uncontrollable stress: a prospective investigation
[download]
[view]
American Journal of Psychiatry, August 2001, vol 158,
iss 8, pg 1239-1247
Morgan, Charles Andrew; Kingham, Peter; Nicolaou,
Andreas L; Southwick, Steven M
Anniversary
reactions in Gulf War veterans: a naturalistic inquiry
2 years after the Gulf War [download]
[view]
Journal of Traumatic Stress, January 1998, vol 11, iss
1, pg 165-171
Morgan, Charles Andrew; Wang, Sheila; Mason, John W;
Southwick, Steven M; Fox, Patrick; Hazlett, Gary;
Charney, Dennis S; Greenfield, Gary
Hormone
profiles in humans experiencing military survival
training [download]
[view]
Biological Psychiatry , May 15, 2000, vol 47, iss 10,
pg 891-901
Morgan, Charles Andrew; Wang, Sheila; Rasmusson, Ann
M; Hazlett, Gary; Anderson, George; Charney, Dennis S
Relationship
among plasma cortisol, catecholamines, neuropeptide Y,
and human performance during exposure to
uncontrollable stress [download]
[view]
Psychosomatic Medicine , May-June 2001, vol 63, iss 3,
pg 412-422
Morgan, Charles Andrew; Wang, Sheila; Southwick,
Steven M; Rasmusson, Ann M; Hazlett, Gary; Hauger,
Richard L; Charney, Dennis S
Plasma
neuropeptide-Y concentrations in humans exposed to
military survival training [download]
[view]
Biological Psychiatry , May 15, 2000, vol 47, iss 10,
pg 902-909
Orsillo, Susan Marie; Roemer, Lizabeth; Litz, Brett T;
Ehlich, Peter J; Friedman, Matthew J
Psychiatric
symptomatology associated with contemporary
peacekeeping: an examination of post-mission
functioning among peacekeepers in Somalia [download]
[view]
Journal of Traumatic Stress, October 1998, vol 11, iss
4, pg 611-625
Polis, B David ; Polis, Edith; DeCani, John; Schwarz,
H P; Dreisbach, Lorraine
Effect
of physical and psychic stress on phosphatidyl
glycerol and related phospholipids [download]
[view]
Pontius, Edward B
Acute
traumatic stress: guidelines for treating
mass-casualty survivors from the Persian Gulf War
[download]
National Center for PTSD Clinical Newsletter, Winter
1993, vol 3, iss 1, pg 1, 4-5
Schwartz, Linda Spoonster
Women
in the military and women veterans [download]
National Center for PTSD Clinical Quarterly,
Summer/Fall 1994, vol 4, iss 3/4, pg 14-15
Sharkansky, Erica J; King, Daniel W; King, Lynda A;
Wolfe, Jessica; Erickson, Darin J; Stokes, Lynissa R
Coping
with Gulf War combat stress: Mediating and moderating
effects [download]
[view]
Journal of Abnormal Psychology , May 2000, vol 109,
iss 2, pg 188-197
Sloan, Patrick; Arsenault, Linda; McCormick, William
A; Dunn, Stephen; Scalf, Laurene
Early
intervention with Appalachian reservists in Operation
Desert Storm [download]
National Center for PTSD Clinical Newsletter, Winter
1993, vol 3, iss 1, pg 6-7, 12
Southwick, Steven M; Morgan, Charles Andrew; Darnell,
Adam; Bremner, J Douglas; Nicolaou, Andreas L; Nagy,
Linda M; Charney, Dennis S
Trauma-related
symptoms in veterans of Operation Desert Storm: a
2-year follow-up [download]
[view]
American Journal of Psychiatry , August 1995, vol 152,
iss 8, pg 1150-1155
Southwick, Steven M; Morgan, Charles Andrew; Nagy,
Linda M; Bremner, J Douglas; Nicolaou, Andreas L;
Johnson, David Read; Rosenheck, Robert A; Charney,
Dennis S
Trauma-related
symptoms in veterans of Operation Desert Storm: a
preliminary report [download]
[view]
American Journal of Psychiatry, October 1993, vol 150,
iss 10, pg 1524-1528
Southwick, Steven M; Morgan, Charles Andrew; Nicolaou,
Andreas L; Charney, Dennis S
Consistency
of memory for combat-related traumatic events in
veterans of Operation Desert Storm [download]
[view]
American Journal of Psychiatry , February 1997, vol
154, iss 2, pg 173-177
Southwick, Steven M; Morgan, Charles Andrew;
Rosenberg, Roberta
Social
sharing of Gulf War experiences: association with
trauma-related psychological symptoms [download]
[view]
Journal of Nervous and Mental Disease , October 2000,
vol 188, iss 10, pg 695-700
Weisæth, Lars; Mehlum, Lars; Mortensen, Mauritz S
Peacekeeper
stress: new and different? [download]
National Center for PTSD Clinical Quarterly, Winter
1996, vol 6, iss 1, pg 12-15
Wolfe, Jessica; Erickson, Darin J; Sharkansky, Erica
J; King, Daniel W; King, Lynda A
Course
and predictors of posttraumatic stress disorder among
Gulf War veterans: a prospective analysis [download]
[view]
Journal of Consulting and Clinical Psychology, August
1999, vol 67, iss 4, pg 520-528
Wolfe, Jessica; Kelley, John M
Following
Desert Storm: the impact on men and women [download]
National Center for PTSD Clinical Newsletter, Winter
1993, vol 3, iss 1, pg 8-9, 12
Wolfe, Jessica; Kelley, John M; Bucsela, Maria L;
Mark, William R
Fort
Devens Reunion Survey: report of Phase I [download]
[view]
Returning Persian Gulf troops: first year findings,
Northeast Program Evaluation Center, 1992, pg 19-44
Wolfe, Jessica; Proctor, Susan P; Davis, Jennifer
Duncan; Borgos, Marlana Sullivan; Friedman, Matthew J
Health
symptoms reported by Persian Gulf War veterans two
years after return [download]
[view]
American Journal of Industrial Medicine, 1998, vol 33,
iss , pg 104-113
Wolfe, Jessica; Sharkansky, Erica J; Read, Jennifer P;
Dawson, Ree; Martin, James A; Ouimette, Paige Crosby
Sexual
harassment and assault as predictors of PTSD
symptomatology among U.S. female Persian Gulf War
military personnel [download]
[view]
Journal of Interpersonal Violence, February 1998, vol
13, iss 1, pg 40-57
Wood, Dennis Patrick; Sexton, John L
Self-hypnosis
training and captivity survival
[download]
[view]
American Journal of Clinical Hypnosis, January 1997,
vol 39, iss 3, pg 201-211
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Access
information on how
to use and search
the PILOTS Database, the largest interdisciplinary
index to the worldwide literature on traumatic stress,
which contains over 22,000 abstracts.
The
information on this Web site is presented for
educational purposes only. It is not a substitute for
informed medical advice or training. Do not use this
information to diagnose or treat a mental health problem
without consulting a qualified health or mental health
care provider.
|