PTSD Diagnostic Criteria A.

The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior)
 
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
 
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2. Recurrent distressing dreams of the event.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and disassociate flashback episodes, (including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
 
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
 
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.

3. Inability to recall an important aspect of the trauma.

4. Markedly diminished interest or participation in significant activities.

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (e.g., unable to have loving feelings)

7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
 
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hyper vigilance
5. Exaggerate startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. What If ? What if you think you might be among those who have PTSD from your combat experiences? (I understand that your unit went through some highly stressful combat.) How can you recognize it? Perhaps the best sign is combat-related nightmares. However, these nightmares don't need to be exact replays of the actual combat experiences. Often they're weird take-offs on those experiences, and may involve, for example, the presence of family members or acquaintances you didn't even know in Vietnam or other war experiences. But nightmares aren't essential. Unwanted, intrusive daydreams often signal PTSD. At their most severe, these may involve a sense of loss of contact with reality, in which case they're called flashbacks.
 
Other PTSD features include becoming very emotionally or physically upset when reminded of combat experiences, trying to put such memories out of ones mind, and trying to avoid being reminded of combat experiences. There are also other features that a qualified diagnostician can explain to you.
 
The good news about PTSD is that the natural course in most cases is progressive improvement. However, relapses are possible indefinitely, and it's not uncommon that veterans, who initially had PTSD but then became symptom-free for years, start having their symptoms again when they encounter another stressful life experience. The other good news is that effective treatments are available, including various kinds of therapy and medication. What should you do if you think you might have PTSD related to your Vietnam or other war service? The first thing I recommend is filing a claim with the Department of Veterans Benefits.

1) Many vets have problems with the government, and would rather complain than become part of the solution. I highly recommend that all Vets become part of a Veterans' Service organization such as the DAV or Vietnam Veterans of America. There is power in numbers, and these organizations are our voice in Washington.

Vietnam Veterans need to know that Lyndon B. Johnson is no longer President, and that the WWII vets that once ran much of the VA have been replaced by Vietnam era Veterans.

2) Veterans MUST take a personal interest in their claim. NO ONE should know their claim better than themselves.

3) YOU MUST keep copies of all correspondence with the VA. All communications should be sent certified mail, returned receipt requested. NO EXCEPTIONS. Title 38, United States Code, Chapter 1 is the section of Federal law which deals with Veterans pensions (compensation), bonuses, and Veterans' Relief. Being familiar with this code will help you greatly in perfecting your claim. A person who knows and understands his/her rights under this code will be far more successful than the person who doesn't take time to look at the full code, however, your main focus should be in Part 3 Adjudication and Part 4 Schedule for rating disabilities. The VVA, DVA, VFW, American Legion, or other veterans’ service organizations usually help persons who do this. One important reason to file a claim is to stand up and be counted. It's important that society recognize the detrimental effects, both physical and psychological, of war on people's health. (This is not to say that war is always bad. It's only to say that a nation that is contemplating war, and persons who are thinking of enlisting in it, should be informed of the risks.)

A second reason for filing a claim is that if granted, it entitles you to free care in the VA for your service-connected condition. In some cases, the VA will even pay for outside care.

A third reason for filing a claim is to receive compensation payments if you are disabled. Persons who find this thought objectionable should be aware that it's possible to have a 0% service-connection. This means being recognized as having the condition and being entitled to free medical care, but not receiving any monthly payments if you are not disabled. What if you have filed for service connection and been turned down, and you continue to think your case is legitimate? The answer here is persistence. In some VA Regional Offices, turning down a first application is almost a knee-jerk reaction, and meritorious cases may need to be appealed once, twice, or even more before they are recognized. If you can't stomach the thought of going to a VA Medical Center for treatment, and some vets who are not very fond of the Federal Government can't, you might consider trying a Vet Center near you (formerly called Vietnam Veterans Outreach Centers, these are now open to vets of all wars.) The environment is often more friendly there.

Most Vet Centers provide their own treatment and are even authorized to pay for private treatment in certain circumstances. Finding good psychiatric treatment isn't always easy. Like all other walks of life, some therapists and doctors are more competent than others. If you need treatment, don't settle for a therapist or a setting that doesn't feel right to you. Ask for a change. Keep trying until you get what you need. Again, in dealing with the VA, patience and persistence are paramount. But keep in mind that there are many highly capable professionals in the VA.

Also keep in mind that the rate of alcoholism is very high among veterans with PTSD. If you have a drinking problem, help is also available. Like PTSD, the VA is a leader in the research and treatment of alcoholism. Finally, if the above information doesn't apply to you, count your blessings, and support those among you who are less fortunate. Roger K. Pitman, M.D. Assoc. Prof. of Psychiatry Harvard Medical School For additional information on PTSD such as Global assessment of Functioning (GAF), VA Rating for PTSD, getting evidence, writing a stressor letter and where to get help, and research, please go to:
 

http://www.brothersboundbyhonor.com/ptsd.html 

Claims;  The Basics

The claims process is one of the most frustrating and intimidating areas of a Veterans life after service. Anyone who has struggled with getting a claim approved, or has had to wait as finances ran out, relationships became strained, or has just given up and surrendered to the system, will tell you it takes its' toll emotionally, physically and often times financially. This section of the site is designed to help those already in the claims process, or about to open a claim to better understand how the VA works, what they are looking for, where to find help, and provide many helpful tips and information that will equip you to file a " Ready to Rate" claim and get the all the benefits you deserve under the law. Important Advice Before discussing the claims process there are a few important things that must be noted.

 PTSD: What you need to know Brad Johnson | November 03, 2005 As the wars in Iraq and Afghanistan wear on, hundreds of thousands of veterans are at significant risk for a particularly distressing and impairing mental health syndrome: Posttraumatic Stress Disorder. First documented in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in 1980, PTSD becomes a serious risk when a service member experiences, witnesses, or is confronted with an event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others -- welcome to any day in the Global War of Terror.

What does PTSD look like? As members of the military community, each of us should be alert to the following key symptoms among the combat veterans we care for: Recurrent and intrusive distressing recollections of the event, including images, thoughts and perceptions (seeing a comrade's dead body or experiencing flashbacks of the sounds of explosions and screaming) Recurrent and distressing nightmares of the traumatic event Intense psychological distress when exposed to cues or reminders of any aspect of the trauma Extreme physical reactivity (e.g., racing pulse, sweating, intense fear) when exposed to any cues or reminders of the trauma Persistent avoidance of any reminder (e.g., conversations, thoughts, activities, places, and people) of the traumatic event A general numbing in responsiveness; the person feels detached and estranged from others and may have little range in emotion and few strong feelings A sense of a foreshortened future; having come close to death, the person sees it as immanent Hypervigilance (constantly scanning the environment for danger) Exaggerated startle response (especially to sudden movement or loud noises) Poor concentration Irritability/anger Disturbances in one's ability to sleep Keep in mind that not all of the symptoms will be present in every case, and veterans may mask the symptoms through nondisclosure or self-medication with alcohol and other drugs.

Further, some service personnel are at greater risk for developing PTSD than others. Beyond the severity of the traumatic event itself, key risk factors include poor social support after the trauma, additional life stressors, adverse childhood events, lower education, prior traumatic exposure, and gender -- women are at greater risk. One particularly malignant feature of PTSD is a sense of shame or guilt associated with beliefs that one should have or could have done more during the traumatic period. If comrades died, then survivor guilt can add powerful fuel to PTSD fire.

Psychiatric prevalence studies from the Iraq theatre are only now beginning to reveal the extent of the problem. A landmark study published last year in the New England Journal of Medicine revealed that approximately 16% of those returning from Iraq suffered from mental health problems, the most prominent among them being PTSD. Other common psychiatric outcomes include depression, substance abuse, marital discord, and impulsive anger.

Among veterans, prevalence is directly proportional to exposure to combat. In the New England Journal Study, those without exposure to a firefight had only a 4% probability of a PTSD syndrome -- about what we find in the general population. But after one firefight, the rate rose to 9.3%. It then jumped to 20% for veterans who endured five or more combat episodes. Yet these rates may actually understate the scope of the PTSD problem among American vets.

Army Surgeon General, LT. General Kevin Kiley, reported last month that among 1000 Army soldiers surveyed three to four months after returning from Iraq, a full 30% had developed stress-related mental health problems. This is not surprising in light of the fact that PTSD sometimes manifests itself only months, sometimes even years, after the traumatic event. Called “delayed onset” PTSD, this sleeper version of the disorder makes accurate diagnoses at discharge a serious challenge to mental health providers. What's worse, service members often refuse to disclose disturbing symptoms common of PTSD, either due to distrust of the mental health establishment or because they are embarrassed to seek help.

PTSD seems to be triggered both by the traumatic event, and the person's response to it -- intense fear, hopelessness, and horror, and make no mistake, all human beings react with horror given the right traumatic situation. Various strands of medical research suggest that the intense bursts of brain activity during traumatic experiences may actually lay down new neural pathways in the brain -- the prime culprits when it comes to the recurring symptoms of PTSD and the substantial difficulty finding a genuine cure.

Although PTSD occurs following violent personal assault, terrorist attacks, and natural disasters, combat-related PTSD accounts for the lion's share of cases among younger service-age populations.

When it comes to helping veterans with PTSD, the U. S. Veterans Affairs Health Care system will be left holding the bag. Is the V.A. system ready? Not surprisingly, that depends on whom you ask. Although the VA insists it is ready for the challenge, the House Committee on Veterans Affairs has expressed strong concern about the VA's capacity to manage the sheer volume of PTSD cases returning from the Middle East. At a congressional briefing hosted by the American Psychological Association last spring, representatives Ted Strickland (D-Ohio), Brian Baird (D-Washington), and Rob Simmons, (R-Connecticut) urged a room full of congressional staffers to more actively push for funds allocated directly to PTSD programs within the VA.

In July, Veterans Affairs Committee Chairman Steve Buyer (R-Indiana) expressed frustration with the VA's apparent inability to accurately predict how much funding it actually needs to tackle the PTSD problem among returning vets. In fairness to the VA system, treatment for PTSD runs the gamut from short-term intervention to long-term therapies punctuated by inpatient hospitalizations. At times, psychotropic medications help assuage the worst symptoms.

Because different U.S. conflicts have produced different prevalence rates and manifestations of the disorder, it may take years before the VA has an accurate read on the scope and nature of Iraq and Afghanistan related PTSD. Those of us fortunate enough to work with, love, or provide medical care for combat veterans must be alert to the signs of this insidious disorder. Service members suffering the symptoms of PTSD need to understand them as part of a medical syndrome and know that appropriate treatments are quite likely to significantly reduce symptom intensity.

Statement of VIETNAM VETERANS OF AMERICA Submitted byThomas J. Berger, Ph.D., ChairmanVVA National PTSD & Substance Abuse Committee & Richard Weidman Executive Director for Policy & Government Relations Vietnam Veterans of America Before the Subcommittee on PTSD of the Committee on Gulf War & Health: Physiologic, Psychologic, And Psychosocial Effects of Deployment-Related Stress Institute of Medicine Of the National Academy of Sciences Regarding Post Traumatic Stress Disorder (PTSD) Diagnosis, Treatment, and Compensation July 6, 2006 Distinguished members of the Subcommittee on Post Traumatic Stress Disorder of the Committee on Gulf War and Health: Physiologic, Psychological, and Psychosocial Effects of Deployment-Related Stress, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on the current state of the clinical diagnoses and the disability compensation claims process as accorded our nation’s veterans suffering from PTSD. Foremost, Vietnam Veterans of America applauds this Committee for its obvious concern about the mental health care of our troops and veterans that we saw evidenced at your first public meeting. The quality of your questions and demeanor indicated the both the sincerity and the sophistication of your concern.  No one really knows how many of our troops in Iraq and Afghanistan have been or will be affected by their wartime experiences. Despite the early intervention by psychological personnel, no one really knows how serious their emotional and mental problems will become, nor how chronic both the neuro-psychiatric wounds (particularly PTSD) and the resulting impact that this will have on their physiological health. However, recent reports have suggested that troops returning from service in Afghanistan and Iraq are suffering mental health problems at a rate higher than the levels seen in Vietnam War veterans. Other reports indicate that the service members who served in a war zone in Iraq or elsewhere are getting sick at a higher rate than those who were not deployed. In fact, VVA has no reason to believe that the rate of veterans of this war having their lives significantly disrupted at some point in their lifetime by PTSD will be any less than those estimated for Vietnam veterans by the National Vietnam Veterans Readjustment Study. Results of the NVVRS demonstrated that some 15.2 percent of all male and 8.5 percent of all female Vietnam theater veterans were current PTSD cases (i.e., at some time during six months prior to interview). Rates for those exposed to high levels of war zone stress were dramatically higher (i.e., a four-fold difference for men and seven-fold difference for women) than rates for those with low-moderate stress exposure. Rates of lifetime prevalence of PTSD (i.e., at any time in the past, including the previous six months) were 30.9 percent among male and 26.9 among female Vietnam theater veterans. Comparisons of current and lifetime prevalence rates indicate that 49.2 percent of male and 31.6 percent of female theater veterans, who ever had PTSD, still had it at the time of their interview. Thus the NVVRS was a landmark investigation in which a national random sample of all Vietnam Theater and era veterans, who served between August 1964 and May 1975, provided definitive information about the prevalence and etiology of PTSD and other mental health readjustment problems. The study over-sampled African-Americans, Latinos, and Native Americans, as well as women, enabling conclusions to be drawn about each subset of the veterans’ population. The NVVRS enabled the American public and medical community first become aware of the documented high rates of current and lifetime PTSD, and of the long-term consequences of high stress war zone combat exposure. Because of its unique scope, the NVVRS has had a large effect on VA policies, health care delivery and service planning. In addition, because the study clearly demonstrated high rates of PTSD and strong evidence for the persistence of this disease, it was generally accepted that the VA would pursue a follow-up or longitudinal study of the original participants in this seminal research project. In 2000 Congress, by means of Public Law 106-419, mandated the VA to contract for a subsequent report, using the exact same participants, to assess their psychosocial, psychiatric, physical, and general well being of these individuals. It would enable it to become a longitudinal study of the mortality and morbidity of the participants, and draw conclusions as to the long-term effects of service in the military period, as well as about service in the Vietnam combat zone in particular. The law requires that VA use the previous report as the basis for a longitudinal study. In 2000 the VA solicited proposals for non-VA contractual assistance to conduct a longitudinal study of the physical and mental health status of a population of Vietnam era veterans originally assessed in the NVVRS. It is apparent that a longitudinal follow-up to the NVVRS is necessary in order to meet the requirements of the law, and to do what just makes sense in both policy and scientific terms. However, not only has the VA failed to meet the letter of the law, there has been no effort to build upon the resources accumulated from this unique and comprehensive study of Vietnam veterans in a highly cost-efficient and scientifically compelling manner. Forwarded courtesy of Paul “Parker” Kasper in Alabama.. No Purple Hearts are awarded for the often hidden wounds of posttraumatic stress disorder, but ultimately those wounds can be deadly--linked to suicides, accidents and, over the long term, increased risk of death from cardiovascular diseases and cancer (Boscarino, 2005). Aware of the risks, government agencies, veterans groups and the U.S. Congress in recent months have grabbled with identification, treatment and benefit issues for the growing number of troops and veterans afflicted with PTSD. Hidden Combat Wounds: Extensive, Deadly, Costly By Arline Kaplan Psychiatric Times January 2006 Vol. XXV Issue 1 No Purple Hearts are awarded for the often hidden wounds of posttraumatic stress disorder, but ultimately those wounds can be deadly--linked to suicides, accidents and, over the long term, increased risk of death from cardiovascular diseases and cancer (Boscarino, 2005). Aware of the risks, government agencies, veterans groups and the U.S. Congress in recent months have grabbled with identification, treatment and benefit issues for the growing number of troops and veterans afflicted with PTSD. "Studies indicate that troops who serve in Iraq are suffering from [PTSD] and other problems brought on by their experiences on a scale not seen since Vietnam," according to one report (Robinson, 2004). The National Vietnam Veterans' Readjustment Survey (from 1986 to 1988) found that 15.2% of male and 8.5% of female Vietnam War veterans suffered from current PTSD (Schlenger et al., 1992). In Iraq and Afghanistan, the visible manifestations of the mental health toll of U.S. combat operations include suicides and medical evacuations. Official Army statistics from March 19, 2003, through July 31, 2005, indicated that 6.4% of the 19,801 soldiers evacuated from Iraq and 7.2% of the 1,733 evacuated from Afghanistan had psychiatric problems. Among the 1,275 psychiatric disorder evacuations from Iraq, 596 were for depression, 109 for suicidal ideation and 91 for PTSD. There have been 53 suicides among service members fighting in Iraq and nine among those fighting in Afghanistan, as reported in a review of suicide data from 2003 to July 19, 2005 (Ireland, 2005). Yet most suicides, according to veteran groups and media accounts, occur after troops return home. One highly publicized case was that of Marine reservist Jeffrey Lucey, deployed to Iraq for five months. When he returned home to Belchertown, Mass., he began drinking heavily and suffering from insomnia, night sweats, hallucinations and panic attacks. He received treatment at a Veterans Affairs facility, where he was described by one physician as having PTSD, depression with psychotic features, suicidal ideation and acute alcohol intoxication. One day, Lucey's father came home to find his son had hung himself in the cellar. On Lucey's bed were the dog tags of two unarmed Iraqi prisoners he said he had been forced to shoot (Srivastava, 2004). A recent Associated Press story (2005) reported that three men who had served with the Army's 10th Special Forces in Iraq returned home and committed suicide shortly thereafter. Other statistics and surveys are equally revealing. The Figure illustrates medical surveillance data obtained from the Army's Center for Health Promotion and Preventive Medicine on health assessment responses completed between January and August of 2005 by 193,131 troops returning from Operation Iraqi Freedom (OIF). Col. Charles Hoge, M.D., chief of psychiatry and behavior services at the Walter Reed Army Institute of Research, told the U.S. House Committee on Veterans Affairs' Health Subcommittee last July that 19% to 21% of troops who have returned from combat deployments meet criteria for PTSD, depression or anxiety. Of these, 15% to 17% of troops who served in Iraq and 6% of those who served in Afghanistan had PTSD symptoms when surveyed three to 12 months after their deployments. In general, PTSD rates were highest among units that served deployments of 12 months or more and had more exposure to combat. The numbers are similar to those published in another study (Hoge et al., 2004). Researchers studied the prevalence of mental health problems among members of three Army units and one Marine Corps unit before deployment or three to four months after returning from deployment to Iraq or Afghanistan. The rates of PTSD were significantly higher after combat duty in Iraq (18.0% for Army units and 19.9% for the Marine group) than before deployment (9.4%). There was a strong relationship between combat experiences-such as being shot at, handling dead bodies or killing enemy combatants-and the prevalence of PTSD. The study also found that the fear of stigmatization deterred some active duty personnel from seeking mental health care even when they recognized the severity of their psychiatric problems.

A survey of 1,300 paratroopers three months after they had returned to Fort Bragg, N.C., after spending a year in Iraq found that 17.4% of the soldiers had PTSD symptoms (Associated Press, 2004). In another study comparing the mental health of men and women in violence-prone jobs (e.g., medics, mechanics, drivers) in Iraq, researchers found that 11% of the men and 12% of the women had PTSD symptoms when they were screened three months after their deployment ended (Elias, 2005). What Is the DOD Doing?   Furthermore, VVA doubts that the journalistic op/ed stuff Satel writes about PTSD could show up in reputable scholarly journals where a decent peer review process would shred her facile, superficial assertions. By now it should be clear that her intended audience is politicians and policy-makers, not academics who have standards for what constitutes credible research and scholarship. VVA would also argue that use of the standardized and validated PTSD diagnostic assessment tools in the “Best Practices Manual for PTSD…” would pick up any fractious PTSD disability claims and provide for better guidance in developing individualized treatment plans.VVA notes the absence of VA research outside of that conducted at the National Center for PTSD on the physiological manifestations of PTSD and co-morbid medical/health conditions such as that conducted by Dr. Joseph Boscarino (1). For the veteran suffering from acute, long-term PTSD, can one reverse the endocrine changes that occur? Or reverse physical changes in the brain? Of course not… But without such research efforts, the VA will continue to labor under the fallacy that “PTSD is all in your head…”VVA acknowledges that the culture of the VA mental health system itself may play a yet undefined role in this current debate over PTSD and VA compensation. For example, the studies of Sayer and Thuras (1), as well as Kimbrell and Freeman (2) suggest that VA clinicians had a more negative view of the treatment engagement of veterans who were seeking compensation and of clinical work with these patients in comparison with those veterans not seeking compensation and those certified as permanently disabled and thus not needing to reapply for benefits. The longer VA clinicians had been working with veterans who had PTSD, the more extreme were these negative perceptions. What is clear to us is that these clinical “researchers” are not even aware that their patients seek service connection so that the veteran will not have to pay for medical treatment for a condition that they believe resulted from their military service. This, and the sense of validation are often more important to the individual veteran that any compensation payment he or she may derive (and deserve!) as a result of this psychiatric wound(s) that are every bit as real as a gun shot wound, if properly diagnosed according to the VA’s own “Best Practices Manual.”There are numerous other points that we wish to make to you before you wrap up this project, but we will close here for now with urging that this panel strongly recommend that VA complete the National Vietnam Veteran Longitudinal Study (NVVLS) exactly as directed by Public Law 106-419. Because that sample is not limited to those who use VA, the results will validate the prevalence of PTSD in the last previous large generation of combat veterans.Thank you for your kind attention. I will be pleased to answer any questions you may have.References1. Boscarino, J. A. 2006. Post-traumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann. Epidemiol. 16: 248-258.2. Sayer, N. A. and Thuras, P. 2002. The influence of patients’ compensation-seeking status on the perception of veteran’s affairs clinicians. Psychiatry. Serv. 53: 210-212.3. Kimbrell, T.A. and Freeman, T. W. 2003. Clinical care of veterans seeking compensation. Psychiatry. Serv. 54:910-911. The national study examined the causes of death among 15,288 male U.S. Army veterans 16 years after they had completed a telephone health survey, which included questions related to PTSD symptoms and substance abuse, and 30 years after their military service. The study confirmed that PTSD was associated with an adjusted all-cause mortality for both Vietnam War era and theater veterans. For PTSD-positive theater vets, the postwar mortality for all-cause, cardiovascular, cancer and external causes (e.g., deaths from suicides, homicides, accidents) was about twice as high as that of Vietnam War veterans without PTSD. The study was not a sample of patients who show up at VA hospitals, "it was a random sample of all U.S. Army veterans, some of whom got PTSD from Vietnam and some of whom got PTSD from life, and they die after a significant period of time," the study's author, Joseph Boscarino, Ph.D., told PT. The study results point to the importance of prevention and treatment, Boscarino noted. "If we can prevent or reduce the anxiety levels, we can prevent the long-term psychological sequelae … and we can also reduce [physical] disease outcomes," he said. "We know there are effective treatments for PTSD, the combination therapies are effective and the drug therapies are effective. Cognitive-behavioral therapy appears to be one of the most cost-effective methods, in my opinion, but there are other methods out there that have been effective." Boscarino acknowledged that various institutions might be concerned about the cost, compensation and disability issues connected with PTSD's link to medical conditions. "I got a call from a military person who said this kind of study is going to affect the nation's defense budget. I responded that it might be the case, but we have an obligation to the men and women in the Armed Forces. We can prevent [PTSD] from happening and if we do so, we will have lower costs, better quality of life and more productivity." Boscarino also believes that because of efforts by the DoD and VA, outcomes among troops experiencing PTSD who are returning from Iraq and Afghanistan may be much better than those for Vietnam War veterans. "When I was doing my postdoctoral fellowship at the West Haven [Connecticut] VA Hospital in the late 1970s, they were diagnosing many of the combat veterans as being alcoholic and psychotic. They probably were, but it likely had a lot to do with their undiagnosed PTSD," he said, explaining that the PTSD diagnosis was first included in the DSM-III in 1980. The VA, he said, now has the tools to screen, diagnose, refer and treat PTSD that it did not have 30 and 40 years ago. Is the VA Ready? In September 2004, the U.S. Government Accountability Office (GAO) raised questions as to whether the VA could meet an increase in demand for PTSD services at its facilities, emphasizing, "The VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers." It also pointed out that at six VA facilities investigators visited, the staff said they were able to keep up with current number of veterans seeking PTSD services, but might not be able to meet an increase in demand (GAO, 2004). One year later, Gordon H. Mansfield, deputy secretary of the VA, testified before the House Committee on Veterans' Affairs, "The VA is aware that there has been particular interest about mental health issues among OEF [Operation Enduring Freedom, Afghanistan] and OIF veterans and VA's current and future capacity to treat these problems, in particular PTSD," he said. "First, I want to assure the Committee that VA has the programs and resources to meet the mental health needs of returning OEF and OIF veterans. Second, in regard to PTSD among OEF and OIF veterans, I want to assure you that the PTSD workload that we have seen in these veterans has been only a small percentage of our overall PTSD workload. In [fiscal year] 2004, we saw approximately 279,000 patients at VA health care facilities for PTSD and 63,000 in Vet Centers. Our latest data on OEF and OIF veterans indicate that as of February 2005, approximately 12,300 of these veterans seen as patients at [VA medical centers] VAMCs carried an ICD-9 code corresponding to PTSD. It is important to note, however, that this represents approximately 4.5% to 5% of VA's overall PTSD population. Additionally, more than 3,500 veterans received services for PTSD through our Vet Centers. Allowing for those who have received services at both VAMCs and Vet Centers, a total of approximately 14,600 individual OEF/OIF veterans had been seen with actual or potential PTSD at VA facilities following their return from Iraq or Afghanistan. This figure represents only about 3% of the PTSD patients VA saw in FY 2004." PTSD Benefits Controversy A controversy over benefits exploded last August when the VA, acting on its Inspector General (IG)'s report, said it would audit files of 72,000 veterans who were receiving full disability benefits for PTSD alone or in combination with other conditions. That announcement generated a widespread backlash. Some veterans groups protested that the review of PTSD cases was an excuse to cut benefits for older veterans and toughen qualifications for future ones. The Senate passed an amendment to a military/VA appropriation bill seeking to restrict the audit. Press reports linked one man's suicide to the impending review (Benjamin, 2005). In November 2005, the VA dropped its full-scale audit plans, stating that most of the problems came from administrative errors and not fraud. The focus on VA benefits for PTSD originally grew out of complaints from veterans about regional inequities in disability ratings and payments. For example, less than 3% of Illinois' disabled veterans are rated 100% disabled for PTSD, as compared to almost 13% in New Mexico (VA Office of the IG, 2005). Because of those complaints, in May 2005 the VA Inspector General examined the files of 2,100 randomly selected veterans with PTSD disability ratings. It found that 527 (25%) lacked documents to verify that a traumatic service-connected incident occurred before compensation benefits were granted. That 25% error rate equates to $860.2 million in questionable compensation payments in FY 2004, the IG report said. The IG also cited a dramatic increase in veterans filing for disability compensation for PTSD since 1999 (Table). After the VA conducted its own review of the 2,100 cases cited in the IG's report, VA Secretary R. James Nicholson released a statement saying, "The problems with these files appear to be administrative in nature, such as missing documents, and not fraud. In the absence of evidence of fraud, we're not going to put our veterans through the anxiety of a widespread review of their disability claims." Instead, the VA plans to improve its training for personnel who handle disability claims and toughen administrative oversight. "Not all combat wounds are caused by bullets and shrapnel," Nicholson said. "We have a commitment to ensure veterans with PTSD receive compassionate, world-class health care and appropriate disability compensation determinations." References Associated Press (2005), Special Forces suicides raise questions. Oct. 19. Available at: www.military.com/NewsContent/0,13319,78508,00.html. Accessed Nov. 17, 2005. Associated Press (2004), Survey: soldiers suffer stress disorder. Aug. 10. Available at: www.armytimes.com. Accessed Nov. 17, 2005. Benjamin M (2005), The V.A.'s bad review. Available at: www.salon.com/news/feature/2005/10/26/suicide/index.html. Accessed Oct. 27, 2005. Boscarino JA (2005), Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann Epidemiol Aug 11 [Epub ahead of print]. Elias M (2005), Stress equal for female soldiers--Women do no better, no worse than men. USA TODAY Aug 18, D5. GAO (2004), VA and Defense Health Care. More Information Needed to Determine if VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder. Available at: www.gao.gov/cgi-bin/getrpt?GAO-04-1069. Accessed Nov. 16, 2005. Hoge CW, Castro CA, Messer SC et al. (2004), Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Eng J Med 351(1):13-22 [see comments]. Ireland RR (2005), Suicide Prevention and Suicide Rates. Washington, D.C.; Office of Assistant Secretary of Defense. Robinson SL (2004), Hidden Toll of the War in Iraq. Washington, D.C.: Center for American Progress. Available at: www.americanprogress.org. Accessed Nov. 17, 2005. Schlenger WE, Kulka RA, Fairbank JA et al. (1992). The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 5:333-363. Srivastava M (2004), Swallowed by pain. Dayton Daily News. Oct. 11. Available at: www.daytondailynews.com/project /content/project/suicide/daily/1011lucey.html. Accessed Nov. 17, 2005. VA Office of the IG (2005), Review of State Variances in VA Disability Compensation Payments. Report No. 05-00765-137. Available at: www.va.gov/oig/52/reports/2005/VAOIG-05-00765-137.pdf. Accessed Nov. 17, 2005. [PDF}\   Nicotine Raises PTSD Risk Monday, December 26, 2005 Post-traumatic stress disorder, or PTSD, is a common consequence of experiencing traumatic events or prolonged periods of stress and threat. However, a new study finds that nicotine addiction may significantly increase the risk of developing PTSD after trauma as well. According to the study, which was conducted by the Harvard University School of Public Health, dependence on nicotine products such as cigarettes can make individuals significantly more vulnerable to chronic PTSD after a traumatic event, compared with their non-smoking peers who undergo similarly traumatic events. The study found that the rate of PTSD among combat veterans who smoked was 72%, significantly higher than the PTSD rate for non-smoking veterans at 52%. MOST PTSD TREATMENTS NOT PROVEN EFFECTIVE MOST PTSD TREATMENTS NOT PROVEN EFFECTIVE Scientists Find That One Therapy Is Shown to Help Disorder; Evidence of Drugs' Benefits Inconclusive By Shankar Vedantam Washington Post Staff Writer Friday, October 19, 2007; A03 The majority of treatments for post-traumatic stress disorder that are used to treat hundreds of thousands of veterans lack rigorous scientific evidence that they are effective, according to a report issued yesterday by a panel of the federal government's top scientists. The report by the National Academies emphasized that the therapies might not be useless. Rather, it said, the evidence is weak when it comes to drawing any kind of conclusion about most of them. The findings of the panel, widely considered the nation's most influential scientific arbiter, will have far-reaching consequences. The report comes when awareness of PTSD has risen as a result of its incidence among veterans returning from the wars in Iraq and Afghanistan. "If a treatment that is not shown to be efficacious is nevertheless delivered to veterans, and if the treatment is relatively inert, even if it does not harm the veterans, it may demoralize the veteran," said Richard McNally, a Harvard University psychologist and PTSD expert. "Providing treatments that do not have a good basis in evidence can result in people not improving, therefore getting demoralized and therefore not seeking treatment that can actually help them." The report did find strong evidence that one particular treatment known as exposure therapy was effective; the technique asks patients to repeatedly reimagine traumatic events as a way to make the events lose their potency. In a statement, the Department of Veterans Affairs said it was ramping up its ability to provide this therapy to patients. But the panel failed to find evidence that any medication was effective in treating PTSD -- this included the drugs Paxil and Zoloft, which have been approved by the Food and Drug Administration to treat the disorder. "A very high percentage of people who have been diagnosed with PTSD are on medications," said Larry Scott, the founder of the advocacy group VA Watchdog dot Org, which serves as an information clearinghouse for veterans. Most of the evidence supporting the use of medications and psychological therapies for PTSD has been assembled by pharmaceutical companies that make the drugs or by researchers with conflicts of interest in the outcome of the studies, and lack independent and rigorous proof, the report said. The researchers also found there was insufficient evidence to support the use of a range of psychotherapies known as cognitive restructuring, coping skills training, eye-movement desensitization and reprocessing therapy, and group therapy. Cognitive restructuring is a technique that trains patients to reinterpret a traumatic event from a different perspective. In the eye-movement therapy, patients are asked to think about traumatic memories while tracking quick movements of a therapist's finger. A host of complicated political, economic and medical issues swirl around the issue of PTSD in a time of war. Many veterans advocacy groups are convinced that the government is trying to limit the spiraling costs of treating the flashbacks, anxieties and co-occurring psychiatric disorders that mark PTSD. "I see the IOM report and the VA's acceptance as an indication that the agency will continue to move away from pharmaceutical-based therapies and group therapy for veterans with PTSD and continue to push their agenda of cognitive processing therapy as a 'cure,' as stated by former VA Secretary Jim Nicholson," Scott added. "If VA declares a veteran 'cured' of PTSD, this will mean the reduction or loss of disability compensation." In the new report, scientists said evidence for many issues besides treatment efficacy was also limited. It is not clear, for example, how early treatment for PTSD should be started or how long such therapy should be offered. "We found much of the research on PTSD to have major limitations when judged against contemporary standards for conducting trials," said Alfred O. Berg, professor of family medicine at the University of Washington, who chaired the panel that conducted a comprehensive review of the evidence for PTSD treatments. Part of the problem, Berg said, is that studies for PTSD have been conducted over a long period of time. The modern standards the panel sought to apply simply happened to be much higher. "Our report certainly must raise questions about treatments and whether they are effective or not, but our assessment of inadequate evidence does not mean the treatments are ineffective," Berg said. "It could mean some of the therapies are more effective than the exposure therapy, where we did find proof of effectiveness" but only that the other therapies lack evidence to show that this is the case. Berg and another author, David Matchar, a professor of medicine at Duke University Medical Center, said a sustained national effort for high-quality research on PTSD, with a special focus on veterans and minority groups, was needed. Edna B. Foa, a professor of clinical psychology in the department of psychiatry at the University of Pennsylvania, and one of the pioneers in developing exposure therapy as a PTSD treatment said the technique was based on the insight that many victims of trauma do all they can to avoid being reminded of traumatic events. A rape victim might avoid going out in the evenings, while someone injured in an auto accident might avoid getting into any kind of vehicle. Soldiers might avoid movies or TV shows about war. Two things happen in this process, Foa said. Patients come to replace actual recollections of trauma with other perceptions -- taking on blame and guilt, for example, for being afraid. Second, by avoiding situations, patients can fail to see that much of life is not dangerous -- the movie is only fiction. Foa said she has patients recount traumatic events aloud with their eyes closed. She records the patient, and then has the patient listen to the tape repeatedly. "People don't recover because they avoid thinking about the trauma," Foa said. "Every time the trauma comes to the mind, they push it away. They don't allow themselves to process and digest the memory, so it keeps on haunting them with nightmares, flashbacks." Foa also has patients make lists of situations that trigger anxiety and encourages them to deliberately expose themselves to the least-frightening situation. As people realize that many situations are harmless, Foa said they replace images of self-doubt and helplessness with a more healthy outlook.