They carried malaria tablets, love letters, 28-pound mine detectors, dope, illustrated Bibles, each other. And if they made it home alive, they carried unrelenting images of a nightmarish war that history is only beginning to absorb.
Tim O’Brien, 1998
The Things They Carried
While we often associate post traumatic stress disorder with military Veterans who have been exposed to the traumas and violence of war, PTSD may also arise in civilian women, children, and teens. Populations at risk need special attention and careful assessment to not miss the clues of PTSD that may be disguised as other issues such as depression, eating disorders, attention deficient hyperactivity disorders, or mental health disorders.
PTSD in Veterans
A survey of nearly 1200 Veterans in West Virginia found that approximately 20% reported having been told that they had PTSD. The Veterans studied ranged in age from 19 to 94 years, with an average of 54 years (Gradus, 2017). The age of the Veteran was not as significant as the exposure to a traumatic injury, violence, or exposure during their military service.
The earliest PTSD research occurred when women in the military were not exposed to combat, so the findings reflected a male population. Today women in the military are at an equally high risk for exposure to traumatic events, especially during times of war. Currently, about 15% of all military personnel are women. Although men are more likely to experience combat, a growing number of women are now being exposed to combat. In addition, women in the military are at higher risk for exposure to sexual harassment and/or sexual assault than men. Sexual violence or rape are common triggers for PTSD among women.
The Rand study of Veterans (Rand, 2008) found that only half of those who need treatment for PTSD issues seek treatment. Sadly, the study also showed that only slightly more than half of those who received treatment got minimally adequate care.
This study also found that nearly 20% of these service members had experienced a traumatic brain injury (TBI) during deployment, signaling the traumatic injury as the trigger for PTSD. According to the Centers for Disease Control & Prevention (CDC), TBI is more common in the general population than previously thought. In 2013 more than 2.8 million TBI-related emergency visits were reported in the United States (Taylor et al., 2017).
National Vietnam Veterans Readjustment Study
The Vietnam war sadly resulted in more than 25% of all Veterans later being diagnosed with PTSD. The National Vietnam Veterans Readjustment Study (NVVRS) conducted between November 1986 and February 1988, comprised interviews of 3,016 American Veterans selected to provide a representative sample of those who served in the armed forces during the Vietnam era. The estimated lifetime prevalence of PTSD among these Veterans was 30.9% for men and 26.9% for women. Of Vietnam Veterans, 15.2% of males and 8.1% of females were currently diagnosed with PTSD at the time the study was conducted (Kulka et al., 1990). Much of our current knowledge comes from this early research and population.
Gulf War Veterans
Kang and others (2003) conducted a study to estimate the prevalence of PTSD in a population-based sample of 11,441 Gulf War Veterans from 1995 to 1997. PTSD was assessed using the PTSD Checklist rather than interviews, with those scoring 50 or higher considered to have met criteria for PTSD. The prevalence of current PTSD in this sample of Gulf War Veterans was 12.1%. Further, the authors estimated the prevalence of PTSD among the total Gulf War Veteran population to be 10.1%.
Iraq and Afghanistan Veterans
These Veterans served in the Operation Enduring Freedom and Operation Iraqi Freedom from 2001 (Iraq) and 2003 (Afghanistan) to the present. In 2008 the RAND Corporation, Center for Military Health Policy Research, published a population-based study that examined the prevalence of PTSD among previously deployed Iraq and Afghanistan Veterans, which demonstrated almost 15% of Veterans exhibited symptoms of PTSD (Tanielian & Jaycox, 2008). PTSD was assessed using the PTSD Checklist, as in the Gulf War Veterans study. Among the 1,938 participants, the prevalence of current PTSD or depression was 13.8% (US DVA, 2016).
From all these hallmark studies, and more, clearly our military Veterans are at greater risk to develop PTSD. Knowing this risk and the frequent result of homelessness, healthcare professionals should be more astute at asking assessment questions and using screening tools for early identification of PTSD.
PTSD in Civilian Women
The power we discover inside ourselves as we survive a life-threatening experience can be utilized equally well outside of crisis. I am, in every moment, capable of mustering the strength to survive again—or of tapping that strength in other good, productive, healthy ways.
Michele Rosenthal, 2012
Before the World Intruded
Although women and men report the same kind of symptoms, some symptoms are more common in women than in men. For example, women are more likely to be jumpy, to have more trouble identifying various emotions, and to avoid things that remind them of the trauma than men. Men are more likely to feel angry and to have trouble controlling their anger than women. Women with PTSD are more likely to feel depressed and anxious, while men with PTSD are more likely to have problems with alcohol or drugs. Both women and men who experience PTSD may develop physical health problems (US DVA, 2015).
According to WHO (2013), gender is an important determinant of mental health and mental illness because it determines the differential power and control men and women have over the socioeconomic aspects of their lives, their social position, status, and treatment in society and their susceptibility and exposure to specific mental health risks.
Risk factors more common for women in developing mental health disorders include gender-based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank, and unremitting responsibility for the care of others (Wong, 2017). Sexual violence toward women and the associated high rate of sexual violence has identified this as the largest group of people affected by PTSD.
Did You Know. . .
It is estimated that 1 in 4 women will be raped or a victim of sexual violence.
Half of all women will experience at least one traumatic event. According to the National Center for PTSD (2015), the most common trauma women experience is sexual assault or child sexual abuse. Approximately one-third of all women will experience sexual assault in their lifetime. Sexual assault is more likely to cause PTSD than other traumatic events. Women are also more likely to be neglected or abused in childhood, or to experience intimate partner violence.
PTSD in Civilian Men
Physicians, especially, do not reach out for mental health counseling or assistance even after exposure to traumatic events. Men generally do not seek help or support as much as women, which puts them at greater risk for PTSD and chronic mental health difficulties. The culture of resistance to seek help among men and especially male physicians is a barrier to much needed emotional help.
PTSD in Healthcare Professionals
Just as brave individuals who serve in our military experience trauma that haunts them, so do public service workers and first responders such as firefighters, police, and health workers. It is estimated 1 in 10 emergency workers suffer from PTSD (Eswaran, 2014).
Research shows that the nature of traumatic events can increase the risk of PTSD; these events include dealing with victims of sudden death, dealing with death or resuscitation of a baby or young child, and handling victims of car and train crashes. Studies also reveal that, although 20% of healthcare workers considered changing jobs due to high emotional stress, 71% of those did not reduce their work hours because of stress, nor did they seek professional help to deal with the stress (Laposa & Alden, 2003).
The challenging attitude of healthcare workers and first responders is that they are trained and available to help others, not to be helped themselves. They generally put others before their own needs and therefore become at risk for PTSD when confronted with traumatic events.
Nurses and other health workers are not exempt from trauma. Indeed, they witness physical and psychological trauma every day, and in some practice settings, such as emergency departments, nurses experience violent assaults from patients and visitors. Researchers at the University of Cincinnati found that 94% of ED nurse respondents reported at least one symptom of post traumatic stress disorder after a violent event, and 17% had scores high enough to be considered probable for PTSD (Gates et al., 2011).
The CDC recommends for emergency workers that they recognize the symptoms of PTSD for themselves and their colleagues. During the emergent event it is recommended that workers:
- Pace themselves
- Watch out for their colleges and be aware of those who are exhausted or stressed
- Take frequent rest breaks away from the work area if possible
- Eat, drink fluids, and sleep regularly
- Utilize formal mental health support provided
- Debrief after traumatic events
- Give themselves permission to feel disturbed about images they may have encountered and know that flashbacks are normal and will diminish with time
After the event, rescue workers, including healthcare professionals, should:
- Reach out for spiritual and emotional support from friends and colleagues
- Consider journaling their feelings
- Avoid making big decisions for a while after an event
- Avoid overuse of drugs and alcohol to feel better
- Spend time doing enjoyable activities
- Give yourself time to heal
PTSD in Children and Teens
Children and teens can also develop PTSD after sexual or other physical abuse, or witnessing family violence. or Some children has experienced horrific events such as the 2012 shooting at Sandy Hook School that killed 20 first-graders and 6 adults, or bomb explosions at public events such as the 2013 Boston Marathon. Gun violence in urban communities of color exposes children and families to continuing trauma.
Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma (National Center for PTSD, 2015). Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for those who have the most severe traumas, particularly those that involve people hurting other people, such as rape and assault. Girls are more likely than boys to get PTSD.
Even very young children experience abuse and neglect. Child Protective Services receives reports on the abuse or neglect of about 5.5 million children in a year. The actual number of abused and neglected children is unknown because many go unreported. Infants and young children are at greater risk of abuse than older children. Abuse includes emotional, sexual, and physical abuse as well as neglect. Early stress and trauma can change a child’s brain, leading to long-term effects on physical, mental and emotional growth (National Center for PTSD, 2015).
An improved understanding has expanded our knowledge of the population known to suffer from PTSD far beyond those who have served in the military. As Van Der Kolk explains,
In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers (Van Der Kolk, 2014, p.21).
Parents and other caregivers are not the only abusers of children. Studies show that violence between siblings is common and may be even more common than abuse by parents (Frazier & Hayes, 1994). An estimated 3 out 100 children are dangerously violent toward a brother or sister (Strauss & Gelles). A 2005 study found the number of assaults sibling-to-sibling each year is 35 per 100 and the rate was similar in children across all income levels and racial and ethnic groups. Family members often don’t view violent acts between siblings as abuse.
According to the CDC, 1 out of 4 girls and 1 out of 6 boys will experience some form of sexual abuse before the age of 18 (CDC, 2016). The perpetrator of childhood sexual abuse is usually someone the child knows.
A life-threatening illness such as childhood cancer can also lead to PTSD in both the child and the parent, according to research from the Children’s Hospital of Philadelphia (NCTSN, 2017). Researchers have been studying pediatric cancer–related PTSD and PTSS (post traumatic stress symptoms) since the 1990s. Among their findings, an estimated 30% to 45% of parents and siblings, and 15% to 20 % of childhood cancer survivors experience PTSS years after treatment ended. Their studies suggest a range of risk factors for persistent PTSS, including pre-existing vulnerabilities, prior behavioral or emotional concerns, and personal opinions about the medical event.
Researchers at Children’s Hospital Los Angeles (CHLA) found that between 25% and 35% of their young patients develop chronic medical PTSD. Those with chronic pain and retinoblastoma and those hospitalized in the pediatric intensive care unit (PICU) were at highest risk of developing PTSD.
Parents and other family members are also at risk:
A serious medical diagnosis is like throwing a rock into a pond—it has a ripple effect into every aspect of life. This is especially true in children, as they are still developing many of their coping and behavioral skills. If left untreated, PTSD can have long-term effects on sleep, cognitive development, peer and interpersonal relationships, schooling and education, and on how emotions are regulated (CHLA, 2015).
Traumatized children and teens may have different symptoms than adults, depending on the child’s age. Very young children may regress in their behaviors and life skills. For example, they may:
- Wet the bed, even though they have been toilet trained
- Forget how or refuse to talk. The late author Maya Angelou, who was raped when she was 6 years old, was mute for 5 years, during which time she read every book she could find, and as an adult told her story in I Know Why the Caged Bird Sings.
- Act out the traumatic event during playtime
- Being unusually clingy with a parent or other caregiver (NIMH, 2016)
Older children and teens are likely to react to trauma much like adults. However, they may also develop disruptive, disrespectful, or destructive behaviors, and have thoughts of revenge. Older children and teens may blame themselves for failing to prevent injury or deaths, which also increases their risk of chronic mental health disorders or even suicide (Finkelhor, 2005).
Test Your Knowledge
PTSD is what was once known as battle fatigue, and today we still identify it exclusively with Veterans.
Apply Your Knowledge
How can you help your own healthcare colleagues to assess and recognize symptoms of PTSD in each other? What resources do your own facility have for maintaining good mental health for its employees?