PTSD Among Military Personnel: A Review

Introduction

The Vietnam War and the plight of veterans in USA have generated much media interest because of its comprehensibility, easy accessibility, and since it added public interest to disasters of great magnitude. For many, PTSD places responsibility for their suffering on factors outside themselves, factors over which they often had neither responsibility nor control (Friedman, 2000) thus providing an explanatory model. Gersons and Carlier (1992) looking at the history of PTSD, commented that the introduction of the new diagnosis of PTSD was seen and felt to be in recognition of the psychological consequences of war, especially as experienced by Vietnam veterans. After the description of PTSD in the 1980, there was a major increase in research interest in PTSD (Blake, Albano, & Keane, 1992) with majority of them being on victims of war or sexual violence.

Post Traumatic Stress Disorder (PTSD)

PTSD is a natural emotional reaction to a deeply shocking and disturbing experience. It is a normal reaction to an abnormal situation. Post Traumatic Stress Disorder (PTSD) is defined in DSM-IV, the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual. For a doctor or mental health professional to be able to make a diagnosis, the condition must be defined in DSM-IV or its international equivalent, the World Health Organization’s ICD-10. The focus of the DSM-IV (American Psychiatric Association, 1994) definition of Post Traumatic Stress Disorder is a single life-threatening event or threat to integrity. However, the symptoms of traumatic stress also arise from an accumulation of small incidents rather than one major incident.

History of PTSD

PTSD is considered to be the renaming or the synthesis of an age-old condition. The psychological effect of exposure to combat-related traumatic events, then called physioneurosis was first scientifically studied in 1941 by A. Kardiner (Kolb, 1993). Research interest in this area peaked during and after the world wars. Keiser’s (1968) book The Traumatic Neurosis describes specific problems following trauma supporting the existence of PTSD prior to the Vietnam War. The studies done among survivors of World War II death & prisoner of war (PoW) camps, and the Vietnam War accelerated the growth of studies related to PTSD among military personnel.

In 1968, the Diagnostic and Statistical Manual of Mental Disorders (2nd ed., DSM-II; American Psychiatric Association, 1968, p.49) mentioned about the effects of traumatic stress as ‘fear associated with military combat and manifested by trembling, running, and hiding’. In 1969, the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death (8th ed.; ICD-8; World Health Organization, 1969, p.158) referred to condition as ‘combat fatigue’. Common patterns in the psychological sequel of women who had been sexually assaulted, termed as rape trauma syndrome, and combat related trauma contributed to a set of cluster of symptoms that represented PTSD.

Posttraumatic stress disorder (PTSD) was introduced in ICD in its 9th edition, in 1978, and in DSM in its 3rd edition, in 1980. In 1994, the acute short-term effects of exposure to a traumatic event were introduced in DSM-IV as acute stress disorder (ASD).

Measures of PTSD

I. Structured Clinical Interviews

The Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon & First, 1990) has been the interview most frequently used to date to evaluate the presence or absence of PTSD. The SCID provides a comprehensive evaluation of Axis I and Axis II diagnoses. The PTSD module is concise and relatively easy to administer and score, while addressing the major diagnostic features of the disorder. Kulka et al. (1990) found a kappa of .93 when a second clinician listened to audiotapes of the target interview and then made independent diagnoses. McFall et al. (1990) reported 100 percent diagnostic reliability between two clinicians who completed independent SCIDs on ten subjects. Keane, Kolb and Thomas (1988) observed a kappa of .68 for PTSD SCID diagnoses derived from two independent clinicians who individually interviewed the same patients (N = 37). Kulka et al. (1990) also found the SCID diagnosis to be strongly correlated with other indices of PTSD (i.e., the Mississippi Scale, the Impact of Event Scale, the PK-Scale of the MMPI). These results suggest that the PTSD module of the SCID is a measure with respectable reliability and validity. The limitation of this instrument is that it yields only dichotomous information about each symptom and therefore severity of disorder and changes in symptom level cannot be easily detected.

The Diagnostic Interview Scale (DIS-NIMH) is a highly structured interview that correlated highly with other known measures of PTSD (Watson et al., 1991) but when used in a community sample, where the base rate of PTSD was low, the DIS performed poorly, with estimates of .23 for sensitivity and .28 for kappa (Kulka et al. 1991).

The PTSD-Interview by Watson et al. (1991) yields both dichotomous and continuous scores, thus addressing some of the limitations of the SCID and DIS. Reports of high test-retest reliability (.95), internal stability (alpha = .92), sensitivity (.89), specificity (.94), and kappa (.82) recommend this instrument for use in diagnosing PTSD. Compared to other clinical instruments, this instrument asks the subjects to make their own rating of symptom severity, thereby minimizing the role of the experienced clinician in the diagnostic process.

The Structured Interview for PTSD (SI-PTSD) (Davidson et al.1989) has continuous and dichotomous symptoms ratings. High test-retest reliability (.71), inter-rater reliability (.97 – .99) and perfect diagnostic agreement (N = 34) have been reported. Utility analyses have revealed sensitivity of .96, specificity of .80, and a kappa of .79 when compared to the SCID.

The Clinician Administered PTSD Scale (Blake et al., 1990) is available in both lifetime and current versions. The CAPS contains 17 diagnostic symptoms of PTSD, its 8 associated features, symptom severity measures in terms of frequency & intensity, indices of impairment in social and occupational functioning, and an assessment of validity of patient responses. The CAPS also provides continuous and dichotomous scores to suit the needs of the investigator/ clinician. Sound psychometric properties in terms of reliability and validity have been reported (Weathers, 1992).

II. Self-report scales

The PK-Scale of the MMPI (Keane et al., 1984) consists of 49 items that differentiated PTSD from non-PTSD patients in both a test sample and a cross-validation sample of veterans. Eighty-two percen

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