Ebook: Coping with Posttraumatic Stress Disorder in Returning Troops

This Advanced Research Workshop (ARW), “Wounds of War II: Coping with Posttraumatic Stress Disorder in Returning Troops,” was convened to discuss the topic of increased Posttraumatic Stress Disorder in service men and women around the world. Research has shown that those who have served in both combat missions and peacekeeping operations are at an increased risk for posttraumatic stress disorder (PTSD). Research suggests that this may result from their “wounds of war”. Some wounds may be more “invisible”; such as depression, stress, and chronic pain, while others are more visibly apparent; such as physical disabilities. Whatever the wound, however, it seems they may all lead to an increased risk of PTSD. During this workshop, we discussed many aspects of military PTSD and how to more effectively deal with this issue. Specifically, some of the questions addressed were:

1. Vulnerability to PTSD: Are certain types of people at higher risk for getting PTSD (background, ethnicity, childhood trauma, etc)?

2. Diagnostic and Assessment Issues surrounding PTSD: Which methods are used to diagnose and assess the disorder?

3. Preventing PTSD in soldiers: What ways can the military prepare soldiers so they don’t develop PTSD?

4. Treatment of PTSD: What are the latest treatment and therapy opportunities for soldiers after they have been diagnosed with PTSD?

5. PTSD comorbid with other disorders: What are the symptoms and consequences associated with PTSD?

Through this workshop, we have come closer to understanding what programs are already in place in various countries for detection, assessment, prevention, and treatment. We have begun to learn from these existing plans and can start to formulate a more common set of best practices and guidelines which can be implemented throughout organizations in all our countries; having as our common goal to always seek to serve our service members more effectively.

This Advanced Research Workshop has given participants an opportunity to foster essential international collaborative research on military PTSD, a common and disabling consequence of war, terrorism, and natural disasters. As a result, it represents an important landmark in efforts to help soldiers and civilians of NATO and partner nations become more resilient in the face of international conflict.

This publication, which contains full papers focused on the key presentations during the workshop, acts as the permanent record of this event; a tangible documentation of the ideas that formed the basis of discussion and collaboration at the workshop. This text is organized to mirror the program from the event so as to provide an overview of the ideas of presenters and participants in the ARW.

Financial support for the workshop was provided by several sponsors. Great thanks to the primary funder, the NATO Science for Peace and Security Programme. In addition, we would like to acknowledge the generous contributions of the Croatian Ministry of Health and Social Welfare, the University Hospital Dubrava, the United States Army Medical Research and Materiel Command, the Virtual Reality Medical Center (VRMC), and the Austrian Ministry of Defence (MoD).

The workshop was organized and this accompanying publication was compiled and edited jointly by the Interactive Media Institute, San Diego, California, USA and the Virtual Reality Medical Institute, Brussels, Belgium. Professor Brenda K. Wiederhold, program Co-chair, conceived the overall design of the workshop and recruited Co-chairs Professor Dragica Kozarić Kovačić, of the University Hospital Dubrava in Zagreb, Croatia, Professor Kresimir Cosic, of University of Zagreb, the Croatian Parliament, and Colonel Carl Castro of the United States Army Medical Research and Materiel Command to help with the event. With the assistance of her Co-chairs, Dr. Wiederhold selected and invited the majority of the speakers and participants, and Conference Coordinators Mr. James Cullen and Ms. Emily Butcher organized logistics including registration, travel, lodging and meals, assembling of workshop materials, and other arrangements for the ARW. Professor Dragica Kozarić Kovačić and Professor Cosic extended invitations to several distinguished international speakers, further improving the quality of the workshop. A special thank you to Mag. Christian Marolt who uncovered the beautiful Austrian location where the event took place and Mr. John Law and Mr. Don Bui who were responsible for the artistic design of all event-related materials. Mr. Cullen along with Ms. Lily Saleh and Ms. Emily Butcher reviewed the conference program and full manuscripts, helping with editing and assembly of this and other associated texts.

B.K. Wiederhold

Exposure to a traumatic event is required for the diagnosis of posttraumatic stress disorder (PTSD). It was first suggested that PTSD represents a normative response to exposure to extreme stressors, but it soon became evident that only a minority of individuals who experience a traumatic event will develop the disorder. However, the relation between psychopathological events, the phenomenology of the trauma, and neurobiological changes related to PTSD is not totally understood. The symptoms of PTSD are believed to reflect stress-induced changes in neurobiological systems representing an inadequate adaptation of neurobiological systems to exposure to severe stressors. Attempts are made to relate different neurobiological changes to the specific features represented in PTSD. It is not clear whether certain neurobiological changes in PTSD reflect preexisting vulnerability or consequences of trauma exposure. It is known that early life environmental events have persisting effects on central nervous tissue structure and function, a phenomenon called “developmental programming.” Further it is known that glucocorticoid hormone mediators may be involved in this process. It was suggested that changes in the glucocorticoid system are mediated by tissue-specific changes in gene expression. Recent studies suggest that epigenetic mechanisms may play an important role in the interplay between stress exposure and genetic vulnerability. In preclinical studies it was first suggested that epigenetic mechanisms may be involved in the modulation of gene expression in response to stressful stimuli. Recently, epigenetic differences in a neuron-specific glucocorticoid receptor (NR3C1) promoter between postmortem hippocampus obtained from suicide victims with a history of childhood abuse and those from either suicide victims with no childhood abuse or controls were found, indicating the involvement of these mechanisms in human adaptation to stress. Beside DNA methylation, histone modulation is involved in epigenetic regulation of gene expression by regulation of diverse chromatin-templated processes, including transcription. These covalent modifications of histones, including phosphorylation, acetylation, ubiquitination, deimination, and methylation, therefore affect the numerous processes involving chromatin, such as replication, repair, transcription, genome stability and cell death. PTSD may both act as environmental challenges if present in early life and may themselves be more likely in individuals made “vulnerable” by early life stress or even by appearance of PTSD in their parents.

This publication shortly reviews some latest studies in which development of posttraumatic stress disorder (PTSD) is discussed from the point of view of complex interaction between genetic, environmental and personality variables. PTSD is an ideal disorder from this point of view because it requires exposure to traumatic stressors. On the other hand very much depends on the past experience. Parental styles may have long lasting consequences for the individual responsiveness to stressors with regards of the genetic makeup. This reactivity is explained through epigenetic changes involving transcription factors, cortisol receptor being one of them. Existing experimental data are in good concordance and it is possible to suggest a model for PTSD development based on G×E.

During the war in Croatia, a number of soldiers were referred to psychiatrists for acute psychological disturbances due combat-related stress. The aim of this study was to determinate the clinical presentation and effect of applied treatment in soldiers who sought psychological help during the most intensive combat period 1991to 1992 and to investigate posttraumatic stress disorder (PTSD) prevalence eight years later as a probable acute stress reaction (ASR) outcome. We analyzed the available medical data on the symptoms and course of treatment of 350 soldiers who visited psychiatrist during 1991 and 1992 due to acute psychological disturbances. Out of first pool, 96 persons took part in research eight years later. General demographic questionnaire, list of traumatic events from Harvard trauma questionnaire and Mississippi scale for combat-related PTSD were applied. Soldiers with ASR visited psychiatrist on average once or twice, 64.9% of them returned to the front, 16.5 % were demobilized and 4% remained in psychiatric treatment. Average duration of frontline service was 112 days. Group debriefing came out as a successful treatment technique for ASR in terms of shortening disability period but had no effects on preventing chronic psychological disturbances. Eight years later, 26% veterans suffered from PTSD. Those with and without PTSD did not differ in age, socioeconomic status, and length of military service, ASR treatment and return to the frontline.

Suicidal behavior is a global public health problem. Patients with different psychiatric disorders, such as alcohol and substance use disorders, depression, bipolar affective disorder, schizophrenia, posttraumatic stress disorder (PTSD), personality disorders and altered behaviours frequently have suicidal thoughts, ideas and frequently develop suicidal behavior. However, there are a lot of psychiatric patients who do not have suicidal thoughts or suicidal ideation, who do not display suicidal behavior, and who never attempt suicide. Suicide is believed to be a multi-determined act, precipitated by a complex interplay of different socio-cultural factors, biological factors, traumatic events, a history of psychiatric disorders and particular personality traits. Neurobiological basis of suicidal behavior is not completely understood, however, the disturbances in the function of the major neuroendocrine and neurotransmitter systems, such as the hypothalamicpituitary-adrenal (HPA) axis, serotonin, noradrenalin, dopamine, gamma-amino butyric acid (GABA), glutamate, endogenous opioids, and plasma cholesterol status, are assumed to be responsible for the development of suicidal behavior. The evidence from the literature suggests that genetic factors play an important role in the predisposition to suicidal behavior. Therefore, the data from the family, twin, and adoption studies all point to a genetic predisposition to suicide and suicidal behavior. Genetic studies are focused on the search for the candidate genes related to suicide and suicidal behavior. The most frequently investigated genes are the genes related to serotonin, noradrenalin and dopamine transporters, receptors and enzymes involved in the synthesis and degradation of these neurotransmitters, genes related to glutamatergic system, GABA and to neurotrophic factors and genes related to neuroendocrine system. However, despite the numerous studies showing the association of particular genes and suicidal behavior, the genetic risk factors for suicidal behavior, such as susceptibility genes that contribute to suicidal behavior, are still not yet confirmed, and there are a lot of non-replication in these results. Since the transmission patterns of suicidal behavior is complex, involving both environmental and genetic factors, precipitated by the complex interactions of the multiple genes, multiple alleles are implicated in the development of suicidal behavior. Therefore, more studies are needed to fully understand the genetic basis of suicidal behavior. The search for the genetic risk factors of suicidal behavior is an important task in the studies of the genetic susceptibility to suicide, since these studies might help in identifying subjects prone to develop suicidal behavior, who might attempt and/or complete suicide. These subjects might be properly treated and suicidal behavior might be prevented, in order to decrease the suicide rate. Therefore, an important goal in psychiatry is to evaluate the risk factors of suicidal behavior, in order to prevent suicidal behavior, to early identify the individuals prone to attempt suicide, to use the best possible treatment strategies to save lifes and to prevent suicidal attempts and suicide.

Proteomics is a branch of biological sciences concerned with proteome research. Proteome studying involves structural and interaction analysis of proteins on a large scale, especially their position and function. As protein expression is the mediator of genetic vulnerability, proteomics is enabling research into etiology of psychiatric disorders through discovery of potential biomarkers. They can be found by comparing qualitative and quantitative protein expression data from healthy and diseased individuals using the technique of differential display. Biomarkers could fill the gaps in the extremely complex diagnostics of posttraumatic stress disorder (PTSD), and potentially show the direction for further development of pharmacotherapy. Previous studies have shown qualitative and quantitative changes in the brain, cerebrospinal fluid and peripheral tissue proteins in many neurodegenerative and some psychiatric disorders. In this pilot study our aim was to show differential display of the proteomic profiles from the serum of three patients with combat-related PTSD as compared to three healthy controls. Chosen participants with PTSD were of similar age, had similar traumatic experiences and were on similar medications, with no psychiatric comorbidities. Large-scale proteomic approach and mass spectrometry with the use of human proteomic databases were employed as identification tool for discovering the differences between serum proteomic profile in PTSD and healthy controls. In this pilot study we found 122 qualitatively different proteins and more than 22 quantitative differences between individuals with PTSD and healthy controls. These results indicated direction for a larger analysis of this type in people with PTSD. Selected group of proteins found in differential display of the 2D gels will be used for identification of biomarkers in further studies. This pilot study offers a good basis for further proteomic research, which could help in better diagnosis and treatment of PTSD, as well as clarification of its etiology.

The aim of the study is analysis of psychological characteristics of 38 wounded war veterans (males, aged 40 years, have 11,5 years of schooling on average) wounded in the war waged on the territory of former Yugoslavia (1991-1995) and treated in special institutions for rehabilitation. Controls are 419 war veterans and 968 non-combatants (soldiers without war experience). Horovic’s scale of stress impact (IES-R) and Profile Index Emotions test (PIE-JRS) were used.

The results of IES-R have shown existence of the two equal groups - one with posttraumatic stress disorder (PTSD) and the other without. Their group protocols on PIE were then compared (t-test). Combatants versus non-combatants express considerably lower reproduction, protection and BIAS (p<0,001) but higher orientation and deprivation (p<0,005). The wounded, in comparison both with combatants and non-combatants express higher protection (p<0,005) and deprivation (p<0,001), but lower orientation (p<0,005). The wounded with PTSD achieve significantly lower scores on the aggression dimension (p<0,001).

Physical injury reduces chance the for development of anxiety or conflictive feelings related to the traumatic event, because unlike psychic traumas, physical injuries cause much more sympathy and affection of environment often enabling away out from the stressful situation (leaving the combat area and going to treatment or sick leave). Obtained results show that injuries can be (to the wounded) a protective mechanism for the occurrence and development of PTSD.

Background: The Austrian Centre for Operations Preparation (COP) is the organizational body of the Austrian Armed Forces to provide for international and multinational tasks, especially for the preparation and redeployment activities of Peace Support Operations (PSO). The two military psychologists of the COP are responsible for the adequate psychological training and preparation for deployment, the accompanying psychological care-giving for soldiers and their relatives during the mission, but also for the homecoming phase after the end of mission. If necessary, e.g. in case of severe stress symptoms, psychopathological reactions or posttraumatic stress disorder, clinical psychological treatment is provided.

Aims: The presentation gives a short overview of the psychological measures applied at the COP for relocated soldiers after Peace Support Operations of the Austrian Armed Forces.

Main Contribution: Psychological post-mission measures: psychological preparation for redeployment; feedback through after-deployment questionnaire; psychological debriefing and screening of each homecomer; application of the screening instrument “Homecomer-Check-List” (HCL); provision of further clinical psychological treatment.

Conclusions: Among the various psychological measures applied during all phases of PSO, especially since 2007 the homecoming- and after-deployment phase was brought more into focus. The applied psychological measures help to make the repatriation more effective and the homecoming more successful for all persons involved. One of the current intentions of the Austrian Armed Forces Psychological Service is the establishment of a trauma-centre with two clinical psychologists for the treatment of PTSD-patients.

There is an absence of reliable data on how best to engage and treat veterans of the armed forces who have mental health problems. This paper will describe the development of a psychosocial care pathway for Welsh veterans who have mental health problems. A prototype care pathway was developed following focus groups with both experts and ill veterans and their careers. It was then tested on ten ill veterans consecutively referred to an outpatient Veterans Community Mental Health Service with three-month follow-up. Their feedback was used to refine the pathway for a further phase of testing. The key themes from the phase one pilot are discussed in this chapter.

Eight years of war and repeated deployments have led to both physical and psychological wounds in the United States Army. This paper will discuss both old and new challenges, including suicide, posttraumatic stress disorder (PTSD), traumatic brain injury (TBI) and pain management. While an array of behavioral health services has long been available to address the troubling effects on our Soldiers and Families, these services are clearly strained. These services include Combat and Operational Stress Control, routine behavioral health care, and suicide prevention. Pre-clinical services, such as Chaplains, Military One Source and Army Community Service also offer support. We have multiple other initiatives to provide outreach, education and training, including “Battlemind,” Combat and Operational Stress Control, Warrior Adventure Quest and RESPECT-MIL. There continue to be major challenges that will face our service members, their Families and the United States.

Aggression and/or impulsivity are frequent characteristics of the patients with posttraumatic stress disorder (PTSD), even the DSM-IV criteria include “irritability and outbursts of anger” as one of persistent symptoms of increased arousal. In this paper we will review recent theories regarding aggression in patients with posttraumatic stress disorder. Results of our study, with the aim to find the difference in aggression between PTSD patients and patients with other psychiatric diagnoses, will be shown.

Traumatic experience has a strong impact on the psychological, biological and social equilibrium, despite the human being’s capacity to survive and adapt. posttraumatic stress disorder (PTSD) is a complex and dynamic syndrome of an organism’s stress reaction to a severe psychotrauma which alters the emotional response, leads to psychobiologic and neurohumoral changes, affects the cognitive and information-processing system, and modifies the mechanisms of adaptation and fight. Treatment of PTSD is a complex and multidimensional process, which integrates a biological, social and psychological approach, with the aim to normalize the response to stress and reduce maladaptive psychobiologic processes. Every model of treatment should include elements of psychoeducation, support, anxiety relief and lifestyle modifications. In this study, a psychotherapeutic program consisting of socio-therapeutic, psycho-educative and dynamic-oriented group approach was implemented. The purpose of this study was to assess the effectiveness of psychotherapeutic programs by evaluating the symptoms of PTSD, neurotic symptoms, depressiveness, ways of coping with stress and indicators of quality of life at the end of the program and a year afterwards. The results showed that treatment programs scheduled for PTSD groups led to changes in coping strategies, a reduction in symptoms of depression slight and increases in PTSD symptoms whereas most other neurotic symptoms and the quality of life remained unchanged during treatment.

The paper presents participation of Polish Military Contingents (PMC) in multinational missions and military operations in the years 2003-2009 with special attention paid to Operation Enduring Freedom (OEF) in Iraq and International Security Assistance Force (ISAF) in Afghanistan. The volume, structure and dy-namics of the PMC’s combat losses in these operations are presented. Our own experience in treatment of 111 veterans with combat-related stress disorders is discussed. The paper also presents a summary of attempts in use of the Virtual Reality Assisted Exposure-Based Treatment for veterans suffering of PTSD as well as problems occurring in treatment and re-adaptation of PMC veterans after their return to Poland.

The Israeli Ministry of Defense (MoD) has been conducting a large-scale posttraumatic stress disorder (PTSD) Survey in order to improve the condition of the MoD PTSD patients through the improvement of treatment and rehabilitation. Yearly milestones of the survey are annual collection of objective data regarding patients’ condition, collection of data regarding the treatments given and conducting statistical analysis. Between the years 2004-2009 the survey has been devoted to developing treatment guidelines for PTSD, pre- and post- MoD recognition, and to the assessment of the application of treatment guidelines and their affect on patient condition. Survey findings form the statistical background for composing the Israeli Clinical Guidelines for PTSD, which are written by the advisory committee and other experts. Our clinical guidelines are Patient-Oriented and relate to timescale, scale of illness severity and deficits in functioning and to close environment axis. The influence of the Clinical Guidelines’ integration among Israeli MoD therapists treating PTSD will be examined in the near future.

Seven years of militaries operations in Afghanistan and Iraq, thousands of soldiers deployed, many of them wounded or killed, yet, just a few posttraumatic stress disorder (PTSD) cases. The Romanian Department of Military Psychology has developed a psychological support program for the troops, which starts three months prior to their deployment and ceases two months after they begin to work again in their back home units, which means almost an year of psychological presence among the soldiers, in their main military activities. The program begins with a psychological selection so only the determined and emotional stable soldiers are chosen for the mission. Before the deployment, the Romanian troops are psychological trained for the theater specific conditions and risks by giving them information about combat stress, PTSD, acute stress disorder, different ways of intervention and by gradually increasing the difficulty of the military exercises. The most important part of the program is the presence of the psychologist inside the deployment camp where he can immediately assist a soldier in order to decrease the tension of combat stress and to stop the symptoms from becoming chronicle. The last part is the post-mission psychological evaluation where the specialists could identify the presence of PTSD, anxiety and depression disorders. The importance of this psychological support program will be discussed; especially the crucial impact of the psychologist inside the deployment camp where early intervention is mandatory for decreasing the chances of PTSD debut.

The U.S. Department of Veterans Affairs (VA) has not only been at the leading edge in the study of the effects of war on warriors deployed to combat, but it has also been recognized as the leader for treatments in Posttraumatic Stress Disorder, Chronic Pain and Stroke. Virtual Reality Therapy (VR) is a new and growing technology that utilizes computers to create computer-generated virtual, three-dimensional worlds that then can be utilized by patients to successfully treat Posttraumatic Stress Disorder and chronic pain. VR Therapy has also been successfully utilized to assist with stroke rehabilitation. VR Therapy can assist VA with meeting the U.S. Government’s mandate to increase the quality of care to a growing number of combat OIF/OEF veterans diagnosed with PTSD, chronic pain and/or stroke.

Many individuals in the world suffer from stress. The United States military is no exception. In fact, many war fighters return from theater with combat stress symptoms. Sadly, they often worry about becoming stigmatized if they seek professional help. Fortunately, the new generation of war fighters seems to be very technologically-driven. Therefore, a new promising and less stigmatized way to reach out to service members could be via VR. The purpose of this article is to briefly discuss combat stress and how the virtual reality, along with biofeedback, may be use to help war fighters.

This paper presents a case of posttraumatic stress disorder (PTSD) in a 30-year old soldier of the Polish Military Contingent in Iraq who has narrowly escaped death three times. The first time was during a change of guard when he was unintentionally shot by his colleague from his personal weapon. The projectile penetrated the victim’s helmet, slid along its internal shell curvature and left the shell causing only a scratch on the scalp skin. This incident resulted in an acute stress reaction that vanished without any treatment. The soldier a month after the first incident experienced another traumatic incident. As a guard of honor he was “shot” in the same rear head area with the cap of a tube of cream, inadvertedly stepped on by a colleague. This incident caused a strong reaction to stress that could not be eliminated despite therapeutic activities undertaken by a psychologist and psychiatrist. The third event happened a couple of days later, during a rocket attack on the Diwaniyah base. Just before the attack the soldier was heading for the laundry but he returned from the laundry building as he forgot to take some of his dirty clothes. Right at that time a large-caliber projectile hit the laundry building, destroying it completely and killing an American civilian employee. After this incident the soldier was evacuated to the Clinic of Psychiatry and Combat Stress in Warsaw. Multi-form post-trauma stress disorders that developed in this soldier are described. The course of his comprehensive therapy during his two stays, totaling eight months in duration, in the Clinic are discussed. Also, a detailed description of the therapy using the method of controlled exposure to combat stressors in virtual reality (VR), supplemented with behavioral training consisting in a desensitization of an aversive reaction to contact with weapons at a shooting range, is presented. The comprehensive treatment activities resulted in an actual full remission of the PTSD symptoms. The soldier continues his service in a logistic support unit.

The use of Virtual Reality (VR) technology to support the treatment of patients with phobia, such as the fear of flying, is getting considerable research attention. VR treatment may provide substantial improvement in efficient use of therapist resources and accessibility by delivering the treatment over the internet, to multiple patients simultaneously. This motivated initial exploration into the possibilities of a multiple-patient Virtual Reality Exposure Treatment (VRET). With such a setup, one therapist can monitor and treat multiple-patients simultaneously, each having their own personal VR treatment at their own personal location. The approach taken was (1) a scenario-based investigation with six therapists that had extensive experience in treating patients with VRET, and (2) a controlled lab experiment with 27 (students) participants to examine the effect of an automated assistance function on the therapists’ workload and performance when treating three computer-simulated patients over the internet. The findings of both the scenario-based investigation and lab experiment are encouraging. They imply that a tele-delivered multi-patient VRET system might be possible in the future, thereby providing treatment at remote locations and making efficient use of therapist resources.

The use of virtual reality is not new in the treatment of psychological stress and anxiety disorders: virtual worlds are used to facilitate the activation of the stressful events during the exposure therapy. However, during the therapy, the virtual worlds are new and distinct realms, separate from the real-life emotions and behaviors. In fact, the patient’s behavior in the virtual world has no direct effects on his/her real-life experience, and emotions and problems experienced by the patient in the real world are not directly addressed in the virtual exposure. In this paper we present the INTERSTRESS project, a new technological paradigm for the treatment of psychological stress in soldiers, based on interreality. The main feature of interreality is a twofold link between the virtual and the real worlds: (a) behavior in the physical world influences the experience in the virtual one; (b) behavior in the virtual world influences the experience in the real one. This is achieved through 3D shared virtual worlds; biosensors and activity sensors (from the real to the virtual world); and personal digital assistants and/or mobile phones (from the virtual world to the real one). We will describe the different technologies involved in the interreality approach and the clinical rationale of the protocol. To illustrate the concept of interreality in practice, a clinical scenario regarding a soldier affected by acute psychological stress will be also presented and discussed.