Mark C. Russell, Ph.D., ABPP: Underestimating the True Prevalence of War Stress Injury in the Military

Media and official reports on prevalence rates of military war stress injury have focused almost exclusively on escalating rates of well-known war stress injuries such as PTSD, depression, generalized anxiety, substance abuse, and traumatic brain injury (TBI). Take a look at some of this week's headlines:

However, the true impact from war trauma cannot be reduced to a handful of psychiatric diagnoses, as some may want. It is a well-established, albeit uncomfortable, and conveniently ignored historical, medical and scientific fact that human adaptation to uncontrollable, unpredictable and potentially traumatic stress "causes" or significantly contributes to a wide-range of neurobiological, physical, cognitive, emotional and behavioral changes that, when chronic and/or severe enough, will inevitably cause significant physiological alterations in the brain-mind-body, eventually leading to physical and/or psychological breakdown. It's not just me saying it.

According to the National Institute of Medicine's exhaustive review of deployment-related stress effects on health:

"In the brain, there is evidence of structural and functional changes resulting directly from chronic or severe stress." The changes are associated with alterations of the most profound functions of the brain: memory and decision-making [Institute of Medicine, (2008). Gulf War and Health:
Volume 6. Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC: The National Academies Press, p. 62].

The toxic effects of war stress have been empirically linked to the immune and every other organ system. So what is this "spectrum" of war stress injuries?

The Spectrum of War Stress Injuries

Nearly all written accounts of war or combat stress, regardless of place in time, culture or national origin, describe a wide-range of stress-related injuries that can best be divided (albeit artificially) into two major classifications: "neuropsychiatric" and "medically unexplained conditions," oft called "war syndromes," "psychosomatic illness" and lumped into the VA's category of "Symptoms, Signs and Ill-defined Conditions (SSID)." By the way, approximately 32 percent of OEF/OIF veterans in the VA are diagnosed with SSID. Common symptoms are: chronic fatigue, muscle weakness, insomnia, headache, back pain, pseudo-seizures, diarrhea, muscle aches, joint pain, forgetfulness, concentration difficulties, nausea, gastrointestinal symptoms, respiratory problems, dizziness, rashes and palpitations. Recent syndromes include chronic fatigue, fibromyalgia and Gulf war syndrome. Individuals may develop either neuropsychiatric or somatic condition, or both.

Unfortunately, the term "psychosomatic" has been misconstrued over time, implying that physical symptoms and suffering are not genuine because there is no observable medical or neurological cause -- it's "all in your head," or "just stress." Nothing is farther than the truth. It bears mentioning that the absence of a medical finding does not rule out a potential medical cause from eventually being discovered -- medical history is replete with examples. Historically, medical and psychiatric professionals have classified war stress injuries based upon a particular constellation or pattern of symptoms identified or emphasized at a given time and cultural understanding. However, all describe a subset of the human stress response.

Neuropsychiatric Conditions

"Neuropsychiatric" is a term used during the world wars and up to Vietnam and refers primarily to so-called psychiatric disorders like major depression, generalized anxiety disorder, substance use disorders and PTSD using some of today's classification schemes, and these are the conditions that receive the predominant focus by the military and public sector. However, military members experiencing a war stress injury may self-report and/or be "screened" for a particular subset of symptoms and behaviors in the spectrum. Consequently, there are probably 17 or more "neuropsychiatric" diagnoses (accurate, or not), that war veterans may receive.

What diagnoses are not tracked? Here is a partial list of diagnoses that military personnel may receive after deployment that are not covered by the "big five" used to estimate costs and resource allocation (e.g., PTSD): adjustment disorders, ADHD, impulse control disorder, panic disorder, social phobia, depressive disorder NOS ("not otherwise specified"), psychotic disorder NOS, bipolar II disorder, conversion disorder, somatization disorder, dissociative amnestic disorder, cognitive disorder NOS, anxiety disorder NOS, partner-relational problem, dysthymic disorder, cyclothymic disorder, dissociative disorder NOS, occupational problem, pain disorder, and personality disorder.

War Stress and Trauma Impact on Mental and Physical Health

In September 2010, a news story posted by Live Science from the Journal of General Internal Medicine that did not get much public fanfare. The VA Palo Alto Health Care System and Stanford University conducted a large study on the health impact of 90,000 OEF/OIF veterans with and without a mental health diagnosis like PTSD. Results of the study confirmed decades of previous medical findings on the psycho-physical impact of war stress and trauma.

Overall, the study found that OEF/OIF veterans with and without a diagnosable mental health condition were being treated in the VA for 222 types of medical conditions! In all, 32 percent of female veterans diagnosed with PTSD had 10 or more diagnosed medical ailments, and 20 percent of male veterans diagnosed with PTSD had 10 or more diagnosed medical conditions.

Additionally, 11 percent of female veterans and 7 percent of male veterans had 10 or more diagnosed medical conditions. Other examples: In 2007 military epidemiologists found a high frequency of somatic complaints, including over 75 percent reporting fatigue, 70 percent sleep difficulties, 42 percent headaches, 50 percent joint pain and 23 percent gastrointestinal symptoms. [Hoge, C. W., Terhakopian, A., Castro, C. A, Messer, S. C., & Engel, C. C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164, 150-153]

This isn't a 21st century issue. For instance, a 1952 study with 1,475 World War II vets reported high rates of somatic complaints including insomnia (31.9 percent), headache (42.8 percent), irritability (48.6 percent), concentration (20.1 percent), restlessness (45.4 percent), gastrointestinal (41.7 percent), cardiovascular (21.9 percent) and musculoskeletal (34.8 percent); Brill & Beebe, 1952)

Given mental health stigma and barriers to care, we expect large numbers of military personnel seeking medical treatment after deployments. Early identification and intervention is critical to possibly reverse the effects of toxic war stress. In a future blog, I will discuss treatments for medically unexplained conditions.

For more by Mark C. Russell, Ph.D., ABPP, click here.

For more on PTSD, click here.

Read more: "Veterans and PTSD Treatment" and "How Memories Keep Us Apart: The Past Is Present."

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Mark C. Russell, Ph.D., ABPP: Underestimating the True Prevalence of War Stress Injury in the Military