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INTRODUCTION

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in the deployment of hundreds of thousands of US military personnel to Afghanistan and Iraq since 2002. Recent reports note that substantial numbers of returning veterans are seeking mental health services from Department of Veterans Affairs (VA) health facilities. For example, 35% of OIF veterans accessed mental health services in military facilities during their first year after returning from deployment to Iraq. That rate is much higher than the rates after deployment to Afghanistan (OEF) or other deployments, such as Bosnia (Hoge et al. 2006). More than 17% of the US Army soldiers and marines returning from deployment to Iraq screened positively for a mental health problem more than 3 months after their return, and 12% of the returning troops screened positively for posttraumatic stress disorder (PTSD) (Hoge et al. 2004).

Descriptions of soldiers suffering from combat stress after a war go back to ancient Greek texts. However, it is the experiences of military psychiatrists in World War II that were instrumental in spurring the medical profession into the modern era of psychiatric diagnosis. The psychiatric profession, however, did not formally recognize the long-term effects of combat stress as a disorder until decades later. Military psychiatrists felt that psychiatric disorders were more pervasive and serious than they had expected before the war. They also believed, contrary to prevailing views, that psychologic maladjustment could be triggered by an external stressor (Grob 1994). Their influence was felt in classifying different types of mental illness in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was published in 1951 by the American Psychiatric Association (APA).



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Posttraumatic Stress Disorder: Diagnosis and Assessment 1 INTRODUCTION Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in the deployment of hundreds of thousands of US military personnel to Afghanistan and Iraq since 2002. Recent reports note that substantial numbers of returning veterans are seeking mental health services from Department of Veterans Affairs (VA) health facilities. For example, 35% of OIF veterans accessed mental health services in military facilities during their first year after returning from deployment to Iraq. That rate is much higher than the rates after deployment to Afghanistan (OEF) or other deployments, such as Bosnia (Hoge et al. 2006). More than 17% of the US Army soldiers and marines returning from deployment to Iraq screened positively for a mental health problem more than 3 months after their return, and 12% of the returning troops screened positively for posttraumatic stress disorder (PTSD) (Hoge et al. 2004). Descriptions of soldiers suffering from combat stress after a war go back to ancient Greek texts. However, it is the experiences of military psychiatrists in World War II that were instrumental in spurring the medical profession into the modern era of psychiatric diagnosis. The psychiatric profession, however, did not formally recognize the long-term effects of combat stress as a disorder until decades later. Military psychiatrists felt that psychiatric disorders were more pervasive and serious than they had expected before the war. They also believed, contrary to prevailing views, that psychologic maladjustment could be triggered by an external stressor (Grob 1994). Their influence was felt in classifying different types of mental illness in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was published in 1951 by the American Psychiatric Association (APA).

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Posttraumatic Stress Disorder: Diagnosis and Assessment PTSD attained formal recognition by the psychiatric profession after the Vietnam War. PTSD was formally recognized as a disorder in the DSM in 1980 and psychiatric casualties are now seen in the same light as medical casualties, that is, worthy of diagnosis and treatment. CHARACTERISTICS OF POSTTRAUMATIC STRESS DISORDER PTSD is a psychiatric disorder that can develop after the direct, personal experiencing or witnessing of a traumatic event, often life-threatening. The essential characteristic of PTSD is a cluster of symptoms that include: Re-experiencing—intrusive recollections of a traumatic event, often through flashbacks or nightmares, Avoidance or numbing—efforts to avoid anything associated with the trauma and numbing of emotions, Hyperarousal—often manifested by difficulty in sleeping and concentrating and by irritability (APA 2000). If those symptoms last for a month or less, they might be indicative of acute stress disorder; however, for a diagnosis of PTSD to be made, the symptoms must be present for at least a month and must cause “clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning” (APA 2000). Although the onset typically occurs shortly after exposure to a traumatic event, the lag time between exposure and full manifestation of the condition can be variable and in some cases long; if the onset of symptoms occurs more than six months after the trauma it is referred to as delayed onset. Over the long term, PTSD can also be chronic or recurrent (Friedman 2003). In some cases, PTSD occurs alone, but most people who have PTSD also have other psychiatric disorders, such as major depressive disorder (Black et al. 2004; Kessler et al. 1995), that occur either with or after the development of PTSD. Numerous traumatic events or stressors are known to influence the onset of PTSD; however, not everyone who experiences a traumatic event or stressor will develop PTSD. Its development depends on the

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Posttraumatic Stress Disorder: Diagnosis and Assessment intensity of the traumatic event or stressor and on a host of risk and protective factors occurring before, during, and after the trauma. COMMITTEE’S TASK AND APPROACH In response to growing national concern about the number of veterans who might be at risk for PTSD and other mental health problems as a result of their military service, VA asked the Institute of Medicine (IOM) to conduct a study on the diagnosis and assessment of, and treatment and compensation for PTSD. An existing IOM committee, the Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress, was asked to conduct the diagnosis, assessment, and treatment aspects of the study because its expertise was well-suited to the task. The committee was specifically tasked to “review the scientific and medical literature related to the diagnosis and assessment of PTSD, and to review PTSD treatments (including psychotherapy and pharmacotherapy) and their efficacy.” In addition, the committee was given a series of specific questions from VA regarding diagnosis, assessment, treatment, and compensation. The questions pertaining to diagnosis and assessment of PTSD and the committee’s responses are provided in Appendix A. This report is a brief elaboration of the committee’s responses to VA’s questions, not a detailed discussion of the procedures and tools that might be used in the diagnosis and assessment of PTSD. The committee decided to approach its task by separating diagnosis and assessment from treatment and preparing two reports. This first report focuses on diagnosis and assessment of PTSD. Given VA’s request for the report to be completed within 6 months, the committee elected to rely primarily on reviews and other well-documented sources. The committee began its task by reviewing the DSM-IV diagnostic criteria for PTSD because they are well-accepted and used by VA’s compensation and pension program, as required by the Code of Federal Regulations (38 CFR 4.130). DSM-IV is also accepted and relied upon by private health-insurance companies, Medicare, Medicaid, and the Social Security Administration. The committee will produce a second report that will focus on treatments for PTSD; it will be issued in December 2006. A separate

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Posttraumatic Stress Disorder: Diagnosis and Assessment committee, the Committee on Veterans’ Compensation for Post Traumatic Stress Disorder, has been established to conduct the compensation study; its report is expected to be issued in December 2006. ORGANIZATION OF THE REPORT Chapter 2 examines the clinical approach to the diagnosis and assessment of a patient who might have PTSD, and Chapter 3 highlights some of the instruments that might be used in assessment. Appendix A presents a series of questions posed by the VA about diagnosis and assessment of PTSD and the committee’s responses to them. Appendix B discusses an approach to the validation of any disorder and highlights the progress made in establishing PTSD as a disorder. Appendix C provides a brief overview of some of the risk and protective factors that might influence whether a person will develop PTSD. REFERENCES APA (American Psychiatric Association). 2000. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. Black DW, Carney CP, Peloso PM, Woolson RF, Schwartz DA, Voelker MD, Barrett DH, Doebbeling BN. 2004. Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors. Epidemiology 15(2):135–142. Friedman MJ. 2003. Post Traumatic Stress Disorder: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals. Grob GN. 1994. The Mad Among Us: A History of the Care of America’s Mentally Ill. New York: Free Press. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351(1):13–22.

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Posttraumatic Stress Disorder: Diagnosis and Assessment Hoge CW, Auchterlonie JL, Milliken CS. 2006. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295(9):1023–1032. Kessler RC, Sonnega A, Bromet E, Hughes M, et al. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52(12):1048–1060.

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