As we celebrate Veterans Day (and Remembrance Day in Canada) and honoring military veterans, many of us think back to World War I but also many other wars throughout history. I recalled the 1980s, when Iran was engaged in an almost decade-long war with Iraq, and millions were killed or injured on both sides. In the West, the older generations may recall World War II and the Vietnam War, while the younger ones remember the more recent wars in Iraq and Afghanistan. We think of the millions who have fought, who have come back with injuries, and those who died serving their countries. But the numbers we rarely think about: How many live with Post Traumatic Stress Disorder (PTSD), a disorder often associated with but far from limited to those who served in or experienced wars.
What is PTSD? The official definition for PTSD, as noted in DSM-5, requires “exposure to actual or threatened death, serious injury, or sexual violence” directly or vicariously; presence of intrusive symptoms such as memories or dreams; avoidance of trauma-related stimuli; and the presence of negative changes in mood (e.g. inability to feel happiness) and cognition (e.g. distorted view of the causes and effects of the trauma) (DSM-5; APA 2013).
PTSD did not officially exist before 1980. Historically, most doctors (except military psychiatrists) assumed that exposure to horrific events in war could result only in temporary stress reactions, but this view changed following Vietnam, when some psychiatrists insisted that many veterans still suffered from severe stress-related symptoms long after having returned from the war (while many others developed delayed stress reactions) (McNally, 2003).
These psychiatrists then lobbied to have “post-Vietnam syndrome” included in the upcoming — at that time DSM-3. They also argued, using clinical findings, that the same kind of stress reaction occurred in survivors of other highly stressful events such as “rape, natural disaster, or confinement in a concentration camp”. Eventually these efforts led to a new diagnosis, called PTSD, being included in DSM-3 (McNally, 2003).
In the following years, a new professional association, the International Society for Traumatic Stress Studies (ISTSS), was founded and soon after the Journal of Traumatic Stress, a scholarly journal focusing on trauma, was launched by the Society.
Today I have been granted the privilege of interviewing the former president of ISTSS, Dr. Paula P. Schnurr, PhD, who is currently the Executive Director of VA’s National Center for PTSD. She is also Research Professor of Psychiatry at Dartmouth, and a fellow of the American Psychiatric Association and the Association for Psychological Science.
Dr. Schnurr’s research focuses on treatment for PTSD and the effects of trauma on quality of life and physical health. She has written or edited over a hundred scholarly articles, chapters, and books.
EMAMZADEH: Thank you very much for agreeing to do this interview, Dr. Schnurr. Unlike other psychological disorders, say, anorexia or depression, PTSD cannot be diagnosed unless the clinician can pinpoint a specific cause, a particular event that caused the trauma. Does this complicate diagnosing people who can not recall a major traumatic event?
SCHNURR: No, this does not complicate diagnosing people. If a person does not remember having an event, that person does not have PTSD. Some of the key symptoms of PTSD are re-experiencing the event through distressing memories, dreams, strong reactions to reminders of the event, and avoidance of people, places, or feelings that remind a person of the event. A person who had experienced a traumatic event and had no memory of the event, but who had other significant symptoms, might have a different disorder.
EMAMZADEH: PTSD is a psychological disorder, but it is also associated with some physical health problems. Could you describe some of these health issues and how they affect the quality of one’s life?
SCHNURR: PTSD is associated with negative perceptions of health and greater use of healthcare, as well as increased likelihood of a range of medical conditions, including cardiovascular problems, diabetes, and arthritis. In addition, people who have PTSD may experience greater difficulty coping with chronic health problems and have greater functional limitations relative to those who do not have PTSD. It is important to understand that these same kinds of problems are also seen in other psychiatric conditions such as depression, although there is some evidence that PTSD may lead to even more physical health problems than depression does. People with PTSD are more likely than people without PTSD to engage in behaviors that could lead to poor health (such as smoking, excessive alcohol and drug use, lack of preventive care), but the association between PTSD and poor health is also likely explained by biological and psychological correlates of PTSD.
EMAMZADEH: I understand that exposure therapy is one of the best psychological treatments we have for PTSD, though some researchers suggest that many therapies seem to have similar efficacy — something that you have argued against (Ehlers et al., 2010). Could you discuss the best empirically supported treatments available for PTSD?
SCHNURR: There are a many effective treatments for PTSD. The most effective psychotherapies are known as “trauma-focused” because they involve processing the memories, thoughts, or feelings related to the event. The therapies with the best evidence are Prolonged Exposure, Cognitive Processing Therapy, and Eye Movement Desensitization and Reprocessing. The most effective medications are sertraline, paroxetine, fluoxetine, and venlafaxine, which are antidepressants. The best psychotherapies are more effective than the best medications, but it is important to understand that both types of treatment are effective.
EMAMZADEH: In a recent paper you and your co-authors have argued that the development of new medications for PTSD has “stalled” (Krystal, et al., 2017). Speaking to some PTSD patients, I have learned that many are being treated with multiple medications (e.g. anticonvulsants, beta-blockers, and low-dose antipsychotics). There is limited research on these combinations but some patients are willing to try anything to get some relief. What are potential solutions to this medication crisis?
SCHNURR: Some people may experience a great deal of relief with medication, but there is a need for more effective medications. The answer to your question is that we need more research and we need to think outside of the box — specifically, we need research on medications that target novel pathways other than the medications that have been shown to be effective now.
EMAMZADEH: Back in the 1990s, the National Comorbidity Survey found that the lifetime prevalence of PTSD in the general population was 8%. What are your estimates as to the percentage of PTSD among returning Veterans?
SCHNURR: For Veterans returning from a deployment to a warzone in Iraq or Afghanistan, the estimate is that 13-20% have PTSD.
EMAMZADEH: Is trauma experienced by soldiers serving in war fundamentally different from, say, the trauma of being raped, having a car accident, or trauma that civilians experience from simply living in war zone? And do they require different treatments?
SCHNURR: There are both similarities and differences among the different types of traumatic events, but there is no evidence that Veterans with PTSD require different types of treatments than non-Veterans require.
EMAMZADEH: What are some obstacles that Veterans and others face in receiving treatments? In chapter 12 of the 2011 book, Caring for Veterans With Deployment-Related Stress Disorders: Iraq, Afghanistan, and Beyond, which you co-edited, one of the barriers noted is stigma. In what way is stigma a barrier and what are some other ones?
SCHNURR: Stigma is a barrier to receiving mental health care in general, both for Veterans and non-Veterans. People may not want to appear weak or have others think they are “crazy.” This may be a particular concern in active duty personnel and first responders, such as police and firefighters, but anyone could have these concerns. Although stigma is one of the barriers to seeking mental health treatment among Veterans and non-Veterans, many factors contribute to treatment-seeking. Research that has looked at stigma as a predictor of treatment-seeking suggests that beliefs about mental illness and mental health treatment drive treatment-seeking more so than concerns about being stigmatized by others. Factors such as access, transportation, and caregiving responsibilities can affect treatment seeking as well.
EMAMZADEH: My last question concerns people who are reading this article, be they Veterans or civilians, people who think that they have some PTSD symptoms but who are reluctant to seek help. What would you tell them? Despite the shortcomings in treatment of PTSD, should they seek treatment? Are there resources or websites you would like to recommend to them?
SCHNURR: My primary message is one of hope. There are effective treatments. I would encourage readers to look at these resources on our website, www.ptsd.va.gov, that explain more about PTSD and PTSD treatment (www.ptsd.va.gov/public/understanding_ptsd/booklet.pdf) and how to make decisions about treatment (www.ptsd.va.gov/apps/decisionaid). I also would encourage readers to visit AboutFace, in which Veterans talk about what it was like to have PTSD, how they knew they needed care, and how treatment helped. Even though all of the stories are from Veterans, much will ring true to anyone who has been through a traumatic event and may be dealing with PTSD. Lastly, we have developed a range of apps and self-help programs that people may find helpful (www.ptsd.va.gov/public/materials/apps/index.asp).
EMAMZADEH: Thank you very much Dr. Schnurr for your time. Greatly appreciated.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author
Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., … Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30, 269–276.
Krystal, J. H., Davis L. L., Neylan, T. C., Raskind, M. A., Schnurr, P. P., Stein, M. B., … Huang, G. D. (2017). It is time to address the crisis in the pharmacotherapy of posttraumatic stress disorder: A consensus statement of the PTSD Psychopharmacology Working Group. Biological Psychiatry, 82, e51–e59.
McNally, R. J. (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology, 54, 229–252.
Ruzek, J. I., Vasterling, J. J., Schnurr, P. P., & Friedman, M. J. (2011). Caring for veterans with deployment-related stress disorders: Iraq, Afghanistan, and beyond. Washington, DC: American Psychological Association Press.