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Coming Home with Posttraumatic Stress Disorder

Westgard, Elizabethe MSN, RN

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AJN, American Journal of Nursing: May 2009 - Volume 109 - Issue 5 - p 11
doi: 10.1097/01.NAJ.0000351482.30993.48
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Elizabethe Westgard

To date, of the 1.8 million military personnel who have served in the Middle East, 6% to 11% of those returning from Afghanistan, and 12% to 20% of those returning from Iraq, are coming home with posttraumatic stress disorder (PTSD), according to the National Center for Posttraumatic Stress Disorder (NCPTSD). Once home, many lack easy access to Department of Veterans Affairs (VA) services; others do not use them for fear of stigma or other reasons. Nurses should expect to encounter these veterans in various settings and be prepared to offer appropriate intervention.

Diagnostic criteria for PTSD include having experienced or witnessed "an event or events that involved actual or threatened death or serious injury" and responding with "intense fear, helplessness, or horror," according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). (For the full criteria, consult the DSM-IV-TR.) Although trauma can induce PTSD in anyone, such events are more prevalent during war. Those at risk include all members of the armed forces, as well as U.S. civilians working in Iraq or Afghanistan. Studies in veterans of previous wars have found that having more combat experience or being younger, female, or Hispanic or African American increases the risk.

Some symptoms of PTSD such as sleep problems and irritability can have other causes, and the majority of people with PTSD have concurrent psychological conditions such as depression or anxiety. This makes diagnosis challenging. The Eisenhower Army Medical Center recommends asking patients directly whether they've experienced war—and adds that a lack of recall or efforts to avoid talking about wartime events can also be symptomatic. Patients may report experiencing hopelessness, detachment from family and friends, or flashbacks or dreams about war. Three validated PTSD screening tools are described in the federal clinical guidelines for managing PTSD ( The NCPTSD provides information on where to obtain these and other tools (, and has developed checklists for military personnel and civilians ( Treatment options include individual and group counseling, pharmacotherapy, or both.

Veterans with PTSD face special barriers in seeking care. According to the Walter Reed Army Institute of Research, the stigma associated with mental health treatment prevents many veterans from seeking help. Some may not do so until the disorder interferes with their functioning in other areas, such as family relationships. And although PTSD symptoms usually emerge immediately or soon after the events, in some cases onset is delayed by months or years. If treatment is delayed, free VA benefits may no longer be available. Distance can hamper access when veterans do not live near a VA facility.

Veterans of any war who need help navigating veterans' services organizations can find a representative through Vietnam Veterans of America (see Nurses can provide information about resources available to civilians, such as those offered through the Social Security Administration. (Nurses who treat patients with PTSD should be aware that they're at some risk for compassion fatigue and secondary trauma stress and should themselves have support.)

In January, retired army general Eric K. Shinseki was confirmed as secretary of Veterans Affairs. He pledged specifically to "increase quality, timeliness and consistency of claims processing" and "ensure adequate resources and access points" for all veterans. His commitment to transparent processes will also help care providers and administrators work together to develop best-practice protocols for screening and treating Americans coming home from war with PTSD.

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