**3.2.1 Men in the military**

34 Post Traumatic Stress Disorders in a Global Context

symptoms that overlap include: anhedonia, sleep problems, irritability, and difficulty concentrating. Due to the high comorbidity of posttraumatic stress disorder and major depressive disorder, some have suspected that counting the same symptom for both disorders accounts for much of the comorbidity rather than the disorders actually cooccurring. A study by Elhia and colleagues (2008) demonstrated that the disorders do in fact frequently co-occur because when the symptoms that overlap with depression and anxiety are removed, the lifetime prevalence figure for posttraumatic stress disorder only decreases from 6.81% to 6.42%. Removing the overlapping symptoms would cause some individuals to reach a subclinical level, but it is valuable to be aware that the disorders are in fact distinct. Concern about the overlap in criteria may become even more common because the proposed changes will make posttraumatic stress disorder less distinct from depression. It is being proposed that the current symptoms, which are very similar to those of major depressive disorder remain in the criteria. Furthermore, it has been proposed that additional criterion that also overlaps with major depressive disorder be added to the diagnostic criteria. It is unclear how this change will impact future comorbidity of posttraumatic stress

disorder and major depressive disorder, which may prove to be a problem.

continue to be adapted within the Diagnostic Statistical Manual.

arousal cluster to receive a diagnosis.

differences in posttraumatic stress disorder.

**3. Epidemiology** 

**3.1 Prevalence** 

Additional changes that are being proposed include adding an extra symptom to the hyperarousal cluster and removing the distinction between chronic and acute posttraumatic stress disorder (American Psychological Association, 2010). Other minor changes are being proposed to reword some of the criteria in order to provide clarity. Removing the distinction between chronic and acute posttraumatic stress disorder is being proposed because there is not enough evidence to show that they are separate concepts rather than just two separate time points on the same continuum. The additional symptom that may be added to the hyper-arousal cluster includes engaging self-destructive or reckless behavior. With the additional symptom, individuals would need to have three of six symptoms from the hyper-

We have clearly come a long way in our understanding of posttraumatic stress disorder throughout the years, but there are many aspects of the disorder that we still do not understand. As we learn more about the mechanisms of the disorder, the definition will

Prevalence estimates of posttraumatic stress disorder are important because they can be used to determine how to allocate resources for those affected by the disorder (Ramchand et. al., 2010). This section will present prevalence figures for the general population and the figures for the current and past wars, and will conclude with a discussion about the gender

In the general population of the United States, posttraumatic stress disorder has been found to have a lifetime prevalence of 6.8 percent (Kessler et. al., 2005). Posttraumatic stress disorder is frequently seen in military personnel due to their elevated potential for exposure to trauma during combat. In the current war in Iraq and Afghanistan, the prevalence of posttraumatic stress disorder in soldiers post-deployment is believed to be between 10.3% and 17% (Sundin et. al., 2009). The prevalence of posttraumatic stress disorder for Vietnam Veterans ranges from 8.5% to 19.3% and between 1.9% and 24% for soldiers in the Persian Men in the military are vulnerable to an array of traumatic situations during combat. Individual differences exist and dictate whether a person has a heightened likelihood for developing posttraumatic stress disorder and how severe the stressor must be in order for them to develop the disorder (See the section on etiology for a more in depth discussion of individual differences in vulnerability for developing posttraumatic stress disorder). Some soldiers may be traumatized by just hearing the sounds of explosions due to a fear of being harmed by an explosive device. More resilient soldiers may obtain posttraumatic stress disorder from being involved an automobile accident while deployed or by being exposed to an explosive device that detonated near them or injured someone around them. Furthermore, they could be traumatized from engaging in hand-to-hand combat or in a firefight with the enemy. Finally, soldiers could be traumatized while retrieving severely injured soldiers or collecting bodies or body parts of soldiers who were killed in combat. Women in the military are also at risk for being involved in the previously mentioned traumatic situations, but have a decreased likelihood because their job assignments are intended to keep them away from direct combat. The list of potential combat scenarios provided is not meant to be all-inclusive, as there are a number of unpredictable situations in war that can cause a soldier to develop posttraumatic stress disorder.

### **3.2.2 Women in the military**

Women in the military are thought to have an increased probability of experiencing a traumatic event during their service because of their ability to be sexually assaulted. Female soldiers and male soldiers placed in non-combat positions experience the same level of risk for encountering a traumatic event during deployment. Female soldiers are additionally at risk for being sexually assaulted by other soldiers (Williams & Bernstein, 2011). Although men are also sexually assaulted while in the military, women are more frequently assaulted. Lipari and Lancaster (2003) found that in active duty personnel, 3% of women have been sexually assaulted while in the military as compared to 1% of men. Furthermore, Sadler and colleagues (2003) found in a sample of 558 female veterans, 28% had experienced a rape or

Combat Related Posttraumatic Stress Disorder –

**4.2.1 Basic psychological theories** 

the theories that followed it.

stress disorder.

History, Prevalence, Etiology, Treatment, and Comorbidity 37

theory, theory of shattered assumption, conditioning theory, and information-processing theory. This section will be followed by a discussion about some of the current psychological theories, including: emotional processing theory, dual representation theory, and Ehlers and Clark's (2000) cognitive theory on posttraumatic stress disorder. This section will conclude with a discussion on the biological correlates of posttraumatic stress disorder. It must be noted that the majority of the research on the biological aspects of posttraumatic stress disorder comes from correlational studies. Inferences cannot be made as to whether the biological abnormalities existed before the trauma and acted as a vulnerability for

*Stress response theory* posits that a person develops posttraumatic stress disorder when they are unable to reconcile their beliefs about the world with what happened during the trauma (Horowitz 1976 & 1986 as cited in Brewin & Holmes, 2003). People have an internal working model of how the world operates and a traumatic experience often violates some of those core beliefs. When the individual is unable to logically integrate what happened to them within their world-view, defense mechanisms become activated to repress the trauma. The defense mechanisms at play are said to mimic many of the avoidance and numbing symptoms of posttraumatic stress disorder. Since a drive to reconcile the trauma with one's world-view still unconsciously exists, the person will experience intrusive reminders of the trauma to force them to cope with what happened. The individual will continue to experience these symptoms until they resolve the discrepancy, which is said to explain why some suffer from chronic posttraumatic stress disorder. Clearly, this theory is highly rooted in psychodynamic principles. Although it does not explain the full range of symptoms in those with posttraumatic stress disorder, stress response theory provided a framework for

The *theory of shattered assumptions* is very similar to stress response theory in that it places an emphasis on the individual's assumptions about the world. According to this theory, the assumptions that are said to be the most important to how a person responds to trauma include believing that: the world is a good place, what happens within the world makes sense, and that they are generally a good person and worthy of having good things happen to them (Janoff-Bulman, 1992). One of the initial assumptions of this theory was that those with the most positive beliefs about the world would also be the most severely impacted by trauma. Since this belief was disproved by the fact that previous trauma serves as a risk factor for developing posttraumatic stress disorder, the theory was revised to say that those who have previously been exposed to trauma have already had their view of the world shattered. Having this negative outlook makes them vulnerable for developing posttraumatic stress disorder in the future. Similar to stress response theory, this theory provides an incomplete rationale for all of the symptoms associated with posttraumatic

The *conditioning theory* of posttraumatic stress disorder is based upon Mowrer's two-factor learning theory (1960 as cited in Brewin & Holmes, 2003). The process of fear acquisition occurs when a traumatic experience is paired with a neutral stimulus, resulting in a fear response to the previously neutral stimuli. Once the neutral stimulus becomes a conditioned stimulus, the person begins to generalize their fear to other situations (Keane, et. al., 1985 as cited in Brewin & Holmes, 2003). Using a behavioral framework, individuals with posttraumatic stress disorder should habituate to their feared stimuli due to the re-

acquiring the disorder or developed after being exposed to the trauma.

an attempted rape while in the military, 8% experienced some form of sexual coercion, and 27% experienced unwanted sexual attention. The Department of Defense (2004) found that 71% of the women seeking treatment for posttraumatic stress disorder, who had served in the Vietnam War and subsequent wars, had been raped while in the military. Some of the risk factors that increase a female soldier's chance of being sexually assaulted include being between the ages of 17 to 24 years old, using alcohol, and past history of sexual assault (Williams & Bernstein, 2011).
