MANAGEMENT BRIEF
 

Number 14 Overviews of Health Care Topics for VA Senior Managers April 2000 

Post-traumatic Stress Disorder— 

A Problem of War and Peace 

“PTSD, referred to at one time as battle fatigue, affects the lives of many of our nation’s veterans. 

VA Research is working to improve the treatment of this illness.” 

John G. Demakis, MD 

Director, Health Services Research and Development Service 

sentative sample of 3,016 American veterans who served durThere are several diagnostic criteria for PTSD, but the 

What is post-traumatic stress disorder? 

ing the Vietnam era, showed that the estimated lifetime prevamost important is exposure to a “traumatic stressor.” This lence of PTSD among this population is 30.9 percent for men 

traumatic stressor, or event, could involve actual or threat- and 26.9 percent for women.3 

ened death or serious injury; witnessing an event that in- Those with PTSD often have concomitant, or comorbid, 

volves death or injury, or threat to physical integrity; or illness(es). The most common disorders associated with 

learning about an unexpected or violent death, serious harm, PTSD are alcohol or substance abuse disorders, anxiety disoror the threat of death or injury of someone close.1

 For ex­ ders, personality disorders, major affective disorders, and 

ample, combat exposure, physical abuse, rape, or witnessing dysthymia (chronic, low-level depression).2

 For example, 

someone else being badly injured or killed would be consid­ according to the NVVRS, the estimated lifetime prevalence 

ered traumatic stressors. Additional criteria include persistent of alcohol abuse or dependence among male veterans with 

reexperiencing of the traumatic event that can manifest as PTSD is 39.2 percent, and the estimated lifetime prevalence 

traumatic nightmares, daytime fantasies, and psychotic reen­ of drug abuse or dependence among male veterans is 5.7 

actments known as PTSD flashbacks. Other symptom criteria percent.3 

include avoidance behavior, in which the person will avoid 

anything that might remind them of the trauma. People with Why is PTSD an important issue for VA managers? 

Given the high prevalence of PTSD among veterans, inciated with anxiety disorder, such as insomnia, irritability or 

PTSD also often display symptoms that resemble those assocluding a significant number of aging veterans,4

 as well as the 

hypervigilance. Research has shown that PTSD can persist comorbidity associated with this condition, PTSD has a subfor decades and, in some persons, for a lifetime and is often stantial effect on veterans’ health. In fact, PTSD is now recmarked by remissions and relapses.2 ognized as “a major public health problem for all military 

veterans and active-duty personnel.”5 PTSD often has profound negative effects on functioning and well-being, espeThe National Comorbidity Survey, which gathered inforHow does PTSD impact veterans’ health? 

cially in chronic cases.6 Further, since comorbidity is 

mation on more than 8,000 adult Americans, indicates that the associated with a more severe course of illness, poorer treatprevalence of PTSD among men and women is 7.8 percent ment outcome, and greater impairment, early recognition and 

and 10.4 percent, respectively. The National Vietnam Veter­ treatment of PTSD is critical. 

ans Readjustment Survey (NVVRS) that focused on a repreVA HSR&D Management Brief April 2000 Page 1 of 3 
In order to improve VA health care for veterans with PTSD, we must increase our knowledge 

about this complex disorder. Below are recent findings from a few HSR&D studies that focus on 

some important issues related to the treatment and prevention of PTSD. 

Study shows risk of PTSD for those on 

peacekeeping missions 

Previous studies have shown that military personnel deployed to peacekeeping missions in places such as Somalia 

were at risk for PTSD and other mental disorders.7,8 This 

HSR&D study sought to continue research on modern peacekeeping operations and further examine the long-term mental 

health consequences of such duty. Specifically, this study 

examined the mental health consequences of the Bosnia 

peacekeeping mission and factors that may hinder treatmentseeking in this population of future veterans. 

The baseline mental health status was evaluated for approximately 3,800 US military personnel before they were 

deployed to Bosnia (e.g., pre-deployment psychopathology, 

prior exposure to stressful overseas missions, and pre-deployment exposure to major life stressors). A cohort of these soldiers were interviewed a year later. The follow-up interview 

evaluated peacekeepers’ appraisals of various experiences in 

Bosnia (positive peacekeeping experiences, general overseas 

mission stressors, negative peacekeeping experiences, and 

traumatic events), PTSD, general psychiatric symptomatology, and a measure of treatment needs and attitudes about 

seeking care. 

Findings from this study show that approximately 77 percent of soldiers evaluated in the pre-deployment phase reported being exposed to at least one potentially traumatic 

event (PTE) prior to deployment. And, of those peacekeepers 

who experience at least one PTE, 29 percent met criteria for 

PTSD. Preliminary analyses from the post-deployment follow-up revealed that the most stressful aspects of the Bosnia 

peacekeeping mission were challenges related to witnessing 

the aftermath of death and destruction, observing suffering, 

and experiencing stress about peacekeeping duties, which are 

difficult for combat trained soldiers. 

VA will be able to use the findings from this study to prepare special educational and treatment programs that address 

the unique mental health needs of veterans deployed to peacekeeping operations. VA is working in collaboration with the 

DoD, sharing expertise so that men and women in service as 

well as veteran peacekeepers will benefit from both primary 

and secondary forms of intervention. 

Ehlich PJ, Roemer L, and Litz, BT. Post-traumatic 

stress disorder following service in a peacekeeping mission: 

The importance of qualitative thematic assessment. 

American Journal of Psychiatry, 154:1319-1320, 1997. 

HSR&D study #IIR 96-051 

Witnessing serious injury to others 

can result in PTSD 

More than 7,000 military women served in Vietnam; 

86 percent of these women served as nurses and were exposed to extreme traumatic stressors. Since gender has 

proved to have a significant impact on the prevalence, 

manifestation, and treatment response of many diseases/ 

conditions, this HSR&D study examines the psychophysiology of PTSD in regard to female, combat veterans. Participants in this study are female nurse veterans who 

served in Vietnam. Specifically, this project attempts to determine whether a pre-identified set of biologic markers 

can significantly differentiate female nurse Vietnam veterans with and without PTSD. These same markers have 

been shown to differentiate male PTSD and non-PTSD 

groups. 

While this study is ongoing, data from one of the biologic markers indicates the first important psychophysiologic validation of the impact of “witnessing” an event as 

a recognized stressor in the pathogenesis of PTSD. In other 

words, this study offers psychophysiologic support that 

witnessing serious injury to others, in the absence of threat 

to oneself, can be a stressor sufficient to result in PTSD. 

As many people have witnessed others being seriously 

injured, (natural disasters, accidents, etc.), these results impact both the veteran and general populations. Increasing 

our understanding about the genesis of PTSD in women is 

vital to prevention and early treatment, especially since 

women are twice as likely as men to have PTSD at some 

point in their lives3

 and represent an increasing segment of 

our armed forces. 

Carson MA, Paulus LA, Lasko NB, et al. Psychological 

assessment of post-traumatic stress disorder in Vietnam 

nurses who witnessed injury or death. Journal of Clinical 

Consulting in Psychology. In press. 

HSR&D study #NRI 95-049 

Study suggests gender differences 

in PTSD disability claims 

Although VA has standard protocol to determine a 

claimant’s eligibility for PTSD-related disability benefits, 

the granting of such benefits has varied across regions. Recently, concerns have been raised that PTSD claims for 

men and women are processed differently. Utilizing data 

from the Special Interest Resources System (SIRS), this 

VA HSR&D Management Brief Number 14, April 2000 Page 2 of 3 
HSR&D study sought to examine both gender and regional 6. Friedman MJ, Schnurr, PP. 1995. The relationship bedifferences in PTSD claims approval rates after adjusting for tween trauma, post-traumatic stress disorder, and physical 

combat exposure. health. In MJ Friedman, DS Charney, & AY Deutch (eds.), 

The SIRS contains data on all veterans who filed a PTSD Neurobiological and clinical consequences of stress: 

claim since 1980: 191,701 men and 5,249 women. Since From normal adaptation to post-traumatic stress disorder. 

1980, the first year PTSD was recognized as a compensable Philadelphia: Lippincott-Raven, pp. 507-524. 

diagnosis, 55 percent of male veterans’ claims for PTSD have 

been approved versus 43 percent of women’s claims. Of those 

PTSD claims that were denied, 5 percent of men and 2 percent of women appealed; ultimately, 

63 percent of the men’s appeals were granted versus 

7. Litz BT, et al. Post-traumatic stress disorder associated 

with peacekeeping duty in Somalia for U.S. military personnel. American Journal of Psychiatry, 154, 178-184, 

1997. 

42 percent of the women’s appeals. 8. Orsillo SM, et al. Psychiatric symptomatology associated 

Findings of this study showed that combat exposure was with contemporary peacekeeping: An examination of postthe strongest predictor of an approved disability claim, fol­ mission functioning among peacekeepers in Somalia. Jourlowed by unemployability. However, gender differences in nal of Traumatic Stress, 11, 611-625, 1998. 

PTSD claims approval rates persisted after adjusting for 

combat exposure and other variables. In addition, approval For more information about this issue of 

rates also vary by VISN. However, the study could not deter- MANAGEMENT BRIEF, or to send comments, contact: 

mine whether the differences noted were appropriate or inap- Gerry McGlynn, M.Ed., MDRC (152M), Manager, propriate; nor could it determine the direction in which any Information Dissemination Program, 150 S. Huntington bias might lie. Additional research using primary data collec- Avenue, Boston, MA 02130. Phone: 617-278-4433. 

tion is required to confirm or mitigate these findings. Fax: 617-278-4438. 

To see additional MDRC publications and reports, Principal Investigator: Maureen Murdoch, M.D., M.P.H., visit the Research and Development web page at Minneapolis VAMC, Minneapolis, MN. http://www.va.gov/resdev or the Intranet site at HSR&D study #GEN 97-002 http://vaww.va.gov/resdev, or utilize the MDRC 

Fax-on-Demand system by calling 617-278-4492. References: This is our fourteenth MANAGEMENT BRIEF. Please fax us your 

1. American Psychiatric Association: Diagnostic and suggestions and comments: 

Statistical Manual of Mental Disorders, Fourth Edition. ___________________________________________________________________ 

Washington, DC, American Psychiatric Association, 1994. ___________________________________________________________________ 

2. Friedman MJ. Post-traumatic stress disorder: ___________________________________________________________________ 

An overview. VA National Center for PTSD, Research 

and Education on Post-Traumatic Stress Disorder. ___________________________________________________________________ 

http://www.ncptsd.org/Overview.html, 2/28/00. ___________________________________________________________________ 

3. Epidemiological facts about PTSD. ___________________________________________________________________ 

VA National Center for PTSD, Research and Name: ____________________________________________________________ 

Education on Post-Traumatic Stress Disorder. Title: ______________________________________________________________ 

http://www.ncptsd.org/FS_Epidemiological_Facts.html 

2/28/00. Phone: ________________________ Fax: ____________________________ 

4. Schnurr PP. PTSD and combat-related psychiatric The MANAGEMENT BRIEF is produced by the Management Decision 

symptoms in older veterans. PTSD Research Quarterly. and Research Center, a program within VA’s Office of Research & 

2(1); Winter, 1991. Development, Health Services Research & Development Service. The 

purpose of the MANAGEMENT BRIEF is to provide VA senior management 

5. Schnurr PP, Friedman MJ. The National Center for PTSD: with a concise and timely overview of a specific health care topic that 

The past 10 years. PTSD Research Quarterly. 10(4); includes topic definition, benefits, VA research activities, and resources 

Fall, 1999. for further information. 

VA HSR&D Management Brief Number 14, April 2000 Page 3 of 3