The US withdrawal from Afghanistan stirs memories of trauma among veterans.
When the United States withdrew from Afghanistan earlier this year, clinicians noted a sharp increase in calls to veteran crisis center hotlines.1 One survey found that 90% of veterans with a history of mental illness were experiencing new or worsening symptoms since the country fell.2
For veterans with posttraumatic stress disorder (PTSD), news about Afghanistan brought back powerful memories of traumas many of them were trying to forget. Nightmares invaded their sleep, intrusive thoughts distracted them from work and family, and flashbacks were so powerful there was no place to hide.
PTSD has a complicated history and neurobiology, and an array of potential comorbidities. In order to diagnose and treat it, clinicians should understand all these factors, and tailor their treatment plans accordingly.
The Prevalence of PTSD and Comorbid Disorders
Civil War General William Tecumseh Sherman put it bluntly when he said, “War is hell.” For veterans with PTSD, that hell can seem inescapable. Between the Iraq and Afghanistan wars, an estimated 500,000 US troops, about 20%, have been diagnosed with PTSD.3,4
However, less than half of veterans in need of mental health services receive treatment. Of those who do get help, less than one-third receive evidence-based care.3 And of the 5 million service members being cared for by the US Department of Veterans Affairs (VA), only 8% have been diagnosed with PTSD. Left untreated, PTSD can lead to hospitalization, unemployment, and poverty.4
There are myriad reasons for this lack of appropriate care. Veterans face unique barriers in getting treatment for PTSD and other mental health conditions. From the minute they enter the military, service members are trained to be tough. This, after all, is what gives them the mettle needed to survive. However, this attitude can also feed stigma, as any mental health condition might be considered a sign of weakness.
When the bullets stop flying and service members return home, the horrors they hoped to forget often follow. These unprocessed traumas bang on the door of their subconscious, demanding attention. However, talking about traumas can be an extremely uncomfortable experience, one that threatens to trigger retraumatization.
There are also societal barriers to access. Veterans who seek services from the VA must have received either an honorable or general discharge and, even then, there are usually long waits to receive services. Those living in rural areas are even less likely to get access.
Instead, many veterans turn to drugs and alcohol to dull the pain. In the 1980s, a study of Vietnam veterans with PTSD found that 74% had a comorbid substance use disorder (SUD).3 A more recent study found 76% met the criteria for both alcohol and SUDs.3
Adding to the complexity, mood and anxiety comorbidity rates are high with PTSD and can complicate diagnosis and assessment. Veterans with PTSD are 3 to 5 times more likely to have major depressive disorder. Many also have anxiety disorders.3
It leaves many veterans wondering if they are irreparably broken. Between the wars in Afghanistan and Iraq, more than 30,000 veterans have died by suicide.2 It is a statistic that belies a troubling need for care.
History of PTSD
PTSD has gone by many names over the years. During the Civil War, it was called irritable heart. During World War I, soldiers called it shell shock. After the Vietnam War, when almost 25% of soldiers required some kind of psychiatric care, it was known as post-Vietnam syndrome.3
The work of Charles Myers, MD, during World War I is widely credited with how PTSD is treated today. A medically trained psychologist, Myers was brought on by the British military to study and treat soldiers who were unable to function without any discernible cause.5
At the time, many viewed shell shock as cowardice. Myers, on the other hand, argued that it was a psychiatric condition that caused affected soldiers to dissociate from a traumatic experience and repress its memory. The treatment, he concluded, involved connecting the traumatic memory back into one’s awareness through a series of psychotherapy sessions. These were ideally held within a military setting but away from gunfire.
PTSD became an official diagnosis in the third edition of the DSM. Initially considered an anxiety disorder, PTSD is part of a separate group of trauma- and stressor-related disorders in DSM 5. DSM 5’s PTSD diagnosis also includes witnessing an event as a qualifying trauma.
PTSD is expressed by 4 main clusters of symptoms: reexperiencing the trauma in the form of intrusive memories, flashbacks, or nightmares; avoidance of anything that reminds an individual of the event; arousal and hyperreactivity, such as being easily startled or feeling tense; and effects on cognition and mood that include negative thoughts, feelings of guilt or blame, or a loss of interest. To receive a diagnosis of PTSD, these symptoms have to last more than a month and be functionally impairing.6
Although anyone experiencing a trauma may have these reactions, symptoms usually fade over time and do not lead to PTSD. For others, however, the symptoms are severe, persist, and cause significant dysfunction.
The disorder can be diagnosed by using the Clinician-Administered PTSD Scale for DSM 5, a 30-item structured interview.7 It is considered the gold standard for measuring PTSD in clinical trials, but it is difficult to use in a clinic setting. The PTSD Checklist for DSM 5 is a 5- to 7-minute questionnaire that may be more practical to use in the clinic. It is regularly used to establish national PTSD outcome data.8
Veterans From the Afghanistan Theater
Since the 9/11 terrorist attacks in 2001, 775,000 troops have served in Afghanistan on a mission to retaliate and stabilize the region. More than 2400 died, about 20,000 were wounded, and countless others have been haunted by what they have seen and experienced.9
When the Taliban regained control of Afghanistan in August, texts to the Veterans Crisis Line jumped 98% compared to a year prior. Chats and phone calls rose 40% and 7%, respectively.1 While this is troubling, the VA also noted it was an encouraging sign that more veterans were seeking help for their mental health issues. One survey revealed that one-third of veterans seeking counseling were doing so for the first time.2
About 70% of veterans have struggled with mental health issues since serving in the Afghanistan war.2 Since August, 90% of Afghanistan service members have experienced new or worsening mental health issues. About 75% are experiencing new or worsening symptoms of depression, 58% have started or increased drug or alcohol use, and 64% have new or worsening thoughts of suicide.2
Although anyone can develop PTSD, combat veterans tend to experience more severe symptoms and lower remission rates compared to noncombat-related PTSD.10 Indeed, the kind of warfare experienced in Afghanistan is likely to put anyone on edge. This includes guerrilla attacks, roadside and suicide explosives, and a wary uncertainty about safe zones and battlegrounds. When an attack can come from anywhere at any time, the amygdala will be more active, and PTSD may be more likely.
Although improvements in body armor and combat medicine protect service members who would have died from their wounds in earlier wars, it leaves them with psychological scars as well as possible PTSD, brain injury, and a host of other lifelong debilities.11
Troops today are serving at younger, more impressionable ages.1 They are also serving longer, with Afghanistan tours lengthened from 12 to 15 months.11 In the Vietnam War, troops mostly served a single tour. Now, more than half return to action, with some serving more than 5 tours.9 Studies have shown that morale decreased and psychiatric problems as well as the use of psychotropic medication increased during the second or third deployment. Similarly, communication with family was difficult, and separation or divorce rates increased.9
Younger age, female gender, minority background, as well as lower socioeconomic status, military rank, and education all indicate a higher risk of PTSD.3 In addition to trauma from battle, sexual trauma is common in the military, with about 1 in 3 women and 1 in 50 men reporting military sexual trauma (MST).3 With fewer women in the military, 1 in 3 veterans who report MST are men.3
Beyond PTSD: Moral Injury
In addition to PTSD, many Afghanistan combat veterans also suffer from moral injuries, which occur when a trauma cuts so deep it violates an individual’s moral beliefs.12 Moral injury also describes an individual’s internal conflict over things they have done to others, actions they have failed to do, and events they have witnessed others doing or failing to do. Examples of moral injury include killing others (innocent or not), dismembering bodies, torturing others, or abandoning comrades during battle.12
Moral injury is highly common among service members, with at least 1 symptom appearing in 90% of veterans and 80% of active duty military.12 It is a separate and distinct syndrome from PTSD that can co-occur and be influenced by the same event. Although it shares similar symptoms with PTSD, it would be a mistake to treat it the same. In fact, the existence of unresolved moral injury can hinder the treatment of PTSD, as well as depression and anxiety.12
Shame is the underlying theme of moral injury. It is shaped by the event that caused it, and it continues to develop for years after a service member has returned home.13 Disgust also plays a major role. Studies indicate that elevated levels of disgust, whether moral or bodily, can increase intrusive thoughts and tend to be higher in those with PTSD.14
Moral injury also involves feelings of guilt, betrayal, loss of meaning and trust, difficulty forgiving, self-condemnation, and inner conflict over moral implications. Moral injury can shake a patient’s spirituality and call into question their relationship with a higher power.15 It is also correlated with social anxiety isolation, depression, and suicide.13
Neurobiology of PTSD
As the understanding of PTSD has advanced, it has become clear that it is a neurobiological disorder driven by environmental trauma. It is likely a product of both nature and nurture and may be caused by a combination of biological vulnerability and trauma.
PTSD involves the amygdala, prefrontal cortex, and hippocampus. The amygdala regulates intense emotions, particularly fear. It governs fear conditioning and contributes to symptoms of altered arousal and reactivity. The prefrontal cortex regulates conditioned fear, normally turning down the alarm signal from the amygdala. PTSD can occur when decreased activity in the prefrontal cortex prevents it from appropriately regulating heightened activity in the amygdala.9
The hippocampus can help buffer the effects of increased amygdala activity. There is evidence to suggest that the hippocampus tends to be smaller in those with PTSD, but it is not entirely clear whether that is the cause of PTSD or the result of it. Studies of identical twins have indicated that a smaller hippocampus at baseline may make people more vulnerable to developing PTSD.9
A Holistic Approach to Treatment
Since the fall of Afghanistan, 31% of veterans have sought professional mental health services for the first time.2 It is a sign of hope that barriers to treatment are softening. Telemedicine, in particular, has become a useful way to reach patients who are either hesitant to engage in treatment or live in remote places.
A 2014 survey of 7600 veterans revealed that those who believed they needed treatment, kept a positive attitude, and had strong social networks were more likely to be successfully treated for PTSD.9 However, treating PTSD can be a challenge, and current treatment options are not always effective.
Close to 60% of those with PTSD do not achieve remission, and although treatment-resistant PTSD is hard to define, up to one-third of patients do not find relief with current therapies.3 Chronic PTSD can lead to decreased life satisfaction as well as increase suicide risk and depression rates.9
Trauma-informed care seeks to tailor treatment around the unique vulnerabilities of each patient. The goal is to help a patient process their PTSD experiences without retraumatizing them in the process. To do this, clinicians need to fully understand every aspect of a patient’s traumatic event, including earlier ones. Additionally, they put a high emphasis on safety, encourage patients to rebuild control, and teach them to build upon their individual strengths.16
Homeless veterans with PTSD, in particular, can benefit from trauma-informed care. While veterans comprise 7% of the total US population, they represent 12% of homeless adults.17
Providing a trauma-informed approach necessitates adapting treatment to the needs of these patients. It helps earn their trust and protects them from retraumatization. PTSD is like a giant wound that many veterans will carry throughout their lives. Healing must start from the inside out. As clinicians, our job is to help them integrate the experience of trauma without being overwhelmed by it.
Promising Treatment Options for PTSD
Cognitive behavioral therapy (CBT). There are 2 types of CBT used as first-line treatments of PTSD. With cognitive processing therapy, therapists teach patients coping skills and help them identify negative thoughts associated with a traumatic event and replace those thoughts with coping skills. With prolonged exposure (PE), patients revisit the trauma repeatedly in a safe, clinical setting to change how they react to the memories of the event. PE has an efficacy rate of about 60% of veterans with PTSD.3
Pharmacology. In treating PTSD, the use of medications, specifically selective serotonin reuptake inhibitors (SSRIs), is to make therapy more effective by reducing the intensity of the overwhelming anxiety caused by PTSD. This anxiety can limit how effectively patients are able to discuss and process their trauma in therapy, which can hinder the healing process. SSRIs have a 60% rate of response in patients with PTSD, but only 20% to 30% achieve complete remission.3 The use of psychedelics, such as ketamine and psilocybin mushrooms, is also currently being researched in their potential to treat PTSD, but these studies are still in the early stages of understanding how they might be useful.
Eye-movement desensitization reprocessing (EMDR). After ensuring a patient is prepared to process their trauma, this treatment works to replace negative images and beliefs with more positive ones. During treatment, a patient pays attention to a back-and-forth sound or movement while recalling a traumatic event. The sound or movement gives them a focus that allows them to explore and process their trauma.
Transcranial magnetic stimulation (TMS). TMS is showing potential as a possible future treatment. It works by delivering highly focused magnetic fields to modulate neural circuits in the brain. It is currently used for patients with treatment-resistant depression. Studies indicate TMS could be used to treat the poor extinction of traumatic memory by targeting the prefrontal cortex.18
Yoga/meditation. Yoga and breathing-based meditation are thought to help calm the hyperactive sympathetic nervous system brought on by PTSD. In one study, veterans who practiced Sudarshan Kriya yoga showed reductions in PTSD scores, anxiety symptoms, and respiration rate.19 In another study, half of the group of veterans who practiced transcendental meditation for 3 months did not meet the criteria for PTSD at study completion, compared to a control group at 10%.20 Mindfulness has also been shown to indirectly reduce self-stigma felt by many veterans as well as other symptoms of PTSD.21
Spiritually integrated treatments. For veterans suffering from moral injury, programs such as Building Spiritual Strength can help trauma survivors address a variety of spiritual concerns.22 In these programs, which are administered by trained chaplains, veterans explore issues of forgiveness, their relationship with a higher power, and why that higher power allows evil to occur in the world.
Cannabis. While the use of cannabis is still under investigation, it seems to have a positive effect on those with PTSD. One study found that cannabis lowered threat-related activity in the amygdala.23 A second study observed that cannabis seemed to diminish the intensity of memories associated with trauma.24 The use of cannabis to treat PTSD has not been approved by the US Food and Drug Administration and remains illegal in many states.
The attitude toward PTSD in veterans has come a long way since it was first viewed as an issue of cowardice. Medicine recognizes it as neurobiological disorder with a strong environmental component. Advances in research and a growing acceptance of alternative treatment options seem to be opening new doors. This growing knowledge around PTSD may even help reduce its stigma and encourage more service members to step forward and seek help.
The best treatment may involve addressing multiple components of the brain-environment interaction that leads to the disorder. This can include cognitive and behavioral therapies to address distorted thoughts and process the trauma, medications such as SSRIs to reduce amygdala activity, breathing and meditation-based therapies to calm the effects of excessive amygdala activity, and hopefully, in the future, brain stimulation techniques to stimulate the prefrontal cortex.
It will be important for clinicians to understand and convey to patients our current thinking of PTSD: It has a neurobiological basis and is not the fault of the sufferer. It is time to end the stigma and the suffering in silence.
Dr Vaishnavi is a neuropsychiatrist, cognitive neuroscientist, adjunct associate in the department of medicine at Duke University, and a psychiatrist with MindPath Care Centers. Ms Thompson is an Adolescent and Adult Psychiatric Mental Health Nurse Practitioner with Community Psychiatry.
1. Kime P. There’s been a surge in veterans contracting the VA crisis line since Afghanistan collapse. Military News. August 31, 2021. Accessed October 5, 2021. https://www.military.com/daily-news/2021/08/31/theres-been-surge-veterans-contacting-va-crisis-line-afghanistan-collapse.html
2. Following Taliban takeover, 9 in 10 Afghanistan vets have exacerbated mental health symptoms. Online Therapy. Accessed October 5, 2021. https://www.onlinetherapy.com/taliban-takeover-exacerbates-vets-mental-health-symptoms/
3. Reisman M. PTSD treatment for veterans: what's working, what's new, and what's next. P T. 2016;41(10):623-634.
4. US Department of Veterans Administration. Office of Research & Development. Study explores reasons why veterans seek—or don’t seek—PTSD care. April 24, 2014. Accessed October 5, 2021. https://www.research.va.gov/currents/spring2014/spring2014-25.cfm
5. Jones E. Shell shocked. Monitor on Psychology. 2012;43(6):18. Accessed October 5, 2021. https://www.apa.org/monitor/2012/06/shell-shocked
6. Torres F. What is posttraumatic stress disorder. American Psychiatric Association. August 2020. Accessed October 5, 2021. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
7. US Department of Veterans Affairs. Clinician-administered PTSD scale for DSM-5 (CAPS-5). Accessed October 5, 2021. https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp
8. US Department of Veterans Affairs. PTSD checklist for DSM-5 (PCL-5). Accessed October 5, 2021. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
9. Lamothe D. How 775,000 US troops fought in one war: Afghanistan military deployments by the numbers. The Washington Post. September 11, 2019. Accessed October 5, 2021. https://www.washingtonpost.com/national-security/2019/09/11/how-us-troops-fought-one-war-afghanistan-military-deployments-by-numbers/
10. Larkin MB, McGinnis JP, Snyder RI, et al. Neurostimulation for treatment-resistant posttraumatic stress disorder: an update on neurocircuitry and therapeutic targets. J Neurosurg. 2020:1-9.
11. Kinney W. Comparing PTSD among returning war veterans. JMVH. 2012;20(3):21-23. Accessed October 5, 2021. https://jmvh.org/article/comparing-ptsd-among-returning-war-veterans/
12. Koenig HG, Youssef NA, Pearce M. Assessment of moral injury in veterans and active duty military personnel with PTSD: a review. Front Psychiatry. 2019;10:443.
13. Gaudet CM, Sowers KM, Nugent WR, Boriskin JA. A review of PTSD and shame in military veterans. Journal of Human Behavior in the Social Environment. 2016;26(1):56-68.
14. Ojserkis R, McKay D, Badour CL, et al. Alleviation of moral disgust, shame, and guilt in posttraumatic stress reactions: an evaluation of comprehensive distancing. Behav Modif. 2014;38(6):801-836.
15. Norman SB, Maguen S. Moral injury. US Department of Veterans Affairs. Accessed October 5, 2021. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
16. Kelly U, Boyd MA, Valente SM, Czekanski E. Trauma-informed care: keeping mental health settings safe for veterans. Issues Ment Health Nurs. 2014;35(6):413-419.
17. Dinnen S, Kane V, Cook JM. Trauma-informed care: a paradigm shift needed for services with homeless veterans. Prof Case Manag. 2014;19(4):161-170; quiz 171-172. https://alliedhealth.ceconnection.com/files/TraumaInformedCareAParadigmShiftNeededforServicesWithHomelessVeterans-1403007342071.pdf
18. Clark C, Cole J, Winter C, et al. A review of transcranial magnetic stimulation as a treatment for post-traumatic stress disorder. Curr Psychiatry Rep. 2015;17(10):83.
19. Seppälä EM, Nitschke JB, Tudorascu DL, et al. Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress. 2014;27(4):397-405.
20. Bellehsen M, Stoycheva V, Cohen BH, Nidich S. A pilot randomized controlled trial of transcendental meditation as treatment for posttraumatic stress disorder in veterans.J Trauma Stress. 2021. Online ahead of print.
21. Barr N, Davis JP, Diguiseppi G, et al. Direct and indirect effects of mindfulness, PTSD, and depression on self-stigma of mental illness in OEF/OIF veterans.Psychol Trauma. 2019.
22. Harris JI, Usset T, Voecks C, et al. Spiritually integrated care for PTSD: a randomized controlled trial of "Building Spiritual Strength." Psychiatry Res. 2018;267:420-428.
23. Rabinak CA, Blanchette A, Zabik NL, et al. Cannabinoid modulation of corticolimbic activation to threat in trauma-exposed adults: a preliminary study. Psychopharmacology (Berl). 2020;237(6):1813-1826.
24. Raymundi AM, da Silva TR, Sohn JMB, et al. Effects of ∆9-tetrahydrocannabinol on aversive memories and anxiety: a review from human studies. BMC Psychiatry. 2020;20(1):420.