Post Traumatic stress disorder of Gulf War Veterans Military personnel involved in service in the Gulf War have a greater prevalence of self-reported and medically detected medical and psychiatric conditions than those serving elsewhere in the military during the same time. Deviations from normal psychiatric conditions varied significantly from cognitive dysfunction and symptoms of alcohol abuse to post-traumatic stress disorder. Public awareness of post-traumatic stress disorder has increased following the Vietnam War and in contemporary context researchers focused their efforts on the effects of violence and the symptoms displayed by persons who have been involved in various types of traumatic events, including war. The primary purpose of this paper is to examine five different studies on the issue of post-traumatic stress disorder of Gulf War veterans, its effects, consequences, treatment techniques. Practically, post-traumatic stress disorder is revealed by the development of characteristic symptoms, which follow by a physically or psychologically traumatic event, ranging beyond normal human experience. Manifested symptoms include a reexperiencing of the traumatic event through importunate thoughts and memories, dissociative also called flashback episodes, avoidance of stimuli associated with the event, diminished responsiveness to the external world, sleep disturbances, staggering responses and angry emotional explosions. Although there is a certain variety of psychometric instruments, which are utilized in order to detect post-traumatic stress disorder, no standard tests have been found to have strong validity and reliability (APA, 211).
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In practice, the diagnosis of post-traumatic stress disorder can be considered to be complicated due to the presence of overlapping peculiarities associated with other psychiatric disorders, namely major depression, anxiety disorder and personality disorder.
In some cases, primary diagnosis of depression can confuse the detection of post-traumatic stress disorder. In addition, substance abuse can also complicate the diagnosis (APA, 209).
Clinical research indicates a high correlation between levels of post-traumatic stress disorder and alcohol abuse. The Research Triangle Institute conducted an extensive study of post-traumatic stress disorder and its impact on the psychosocial readjustment problems of Gulf War veterans. Data obtained from this study indicates that almost one-third of military personnel involved in Gulf War conflict, experienced post-traumatic stress disorder at some time since the return. Study final findings support the 37.5 percent psychiatric disability rate obtained from analysis if World War II combatants. Investigating the sample of 8,816 participants, the RTI researchers conclude that Gulf War experience can be perceived as a continuum varying from lower degrees of exposure to life-threatening combat and abusive acts of violence (Kemp, 513).
Study participants characterized impacting violence in terms of two different aspects: Combat violence as a result of direct combat life-threatening exposure; Continuous abusive violence during noncombat, during which soldiers lives are not threatened and the victims of the violence are unarmed. According to study conclusion, exposure to these two types of violence has a cumulative effect that resulted in post-traumatic stress disorder. From demographic point of view, the average age of participants, which corresponds to average age of combatants, constituted 23.8 years. 50 percent of Gulf War military personnel were married. Researchers indicated the high rate of divorce among veterans upon the return from the Persian Gulf. The RTI emphaises that the high divorce rate does not imply the Gulf War can be considered to be the specific cause of divorce, however, divorce can be comprehended as an additional traumatic event for Gulf War veterans, being a part of the cumulative experience that leads to post-traumatic stress disorder (Kemp, 527).
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Study conducted by the Iowa Clinical Institute investigated the sample of 2,790 participants on the presence of various mental and psychological deviations. Simultaneously, Gulf War military personnel was compared with non-Persian Gulf War participants. Gulf War veterans reported an 11 percent higher prevalence of symptoms of cognitive dysfunction; a nine percent higher prevalence of symptoms of fibromyalgia; a six percent higher prevalence of symptoms of depression; a three percent higher prevalence of symptoms of anxiety disorder; a two percent higher prevalence of symptoms of alcohol abuse, bronchitis, and asthma; a one percent rise in chronic fatigue and post-traumatic stress disorder; and an increase in the prevalence of sexual discomfort in both the respondent and the female partner of the respondent.
In addition, a total of 14.7 percent of Persian Gulf War military personnel versus 6.6 percent of non-Gulf War personnel had symptoms of two or more medical and psychiatric conditions. Post-traumatic stress disorder was reported in 36 percent of Gulf War participants (Williams, 48).
Phone call was the main method used while conducting the study, and the average duration of the call constituted 12 min. During phone interviews, Gulf War veterans were asked regarding known exposures during the war. The researchers concluded that most of the self-reported Gulf War exposures are directly related to many of the medical and psychiatric conditions (Williams, 51).
In addition, the study revealed that being involved in the Gulf War significantly affected the self-reported assessment of quality of life and functional health of respondents.
Gulf War veterans reported considerably lower measures of social and physical functioning as well as mental health. From the critical point of view, the similarity between percentage of post-traumatic stress disorder cases found in the different samples by the RTI and the Iowa Clinical Institute implies to adequacy of presented date. However, self-reporting system of the second study is less reliable both in terms of limited sample and data-collecting procedure. The Department of Defense comprehensive clinical evaluation programme includes assessement for people who have left the armed forces after serving in the Gulf. The clinical procedure of the programme includes the secondary specialist opinion and tertiary specialized care programme. Simultaneously, the clinical procedures adopted at the Persian Gulf registry, another veteran assessment program, differ ones at the clinical evaluation programme, and constitute two-stage process. Thus, by May 1997, 67989 Gulf veterans had been assessed at the Persian Gulf registry, and by March 1997, 26 252 had been examined in the clinical evaluation programme.
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Of 5970 patients who had been assessed at the Persian Gulf registrys phase 2 examinations by May 1997, 35% were diagnosed with musculoskeletal and connective tissue conditions, 32% as having mental disorders, and 28% with loss of memory and other general symptoms (Williams, 61-62).
Simultaneously, according to results obtained from the clinical evaluation programme, of 20000 participants 19% had diseases of the musculoskeletal system, 18% were diagnosed with mental disorders, and 18% with signs, symptoms and ill defined conditions. Of those having a primary diagnosis of a mental disorder, 19% were qualified as having a tension headache, 17% had a major depressive disorder not elsewhere classified, and 15% had prolonged post-traumatic stress disorder (Williams, 63).
The primary purpose of both assessment programmes was to examine the variety of health deviations, and mental deviations in particular. Although there are similarities between two previous studies, conducted by the RTI and Iowa Clinical Institute, and those two programmes, it is difficult to make specific comprarisons. All programmes present substantial proportion of participants characterized with conditions that are not available for adequate diagnosis and classification.
Moreover, it is impossible to compare the prevalance of psychiatric disorders, in particular post-traumatic stress disorder in those samples. The clinical findings in the first 1000 veterans diagnosed in the Ministry of Defences Gulf war medical assessment programme revealed similar results. Study revealed that fatigue, joint and muscle aches and pains, as well as and affective symptoms, in particular mood change and anxiety, were registered as the most common symptoms. According to research data, many other symptoms were indicated, however but no clinically consistent pattern existed to suggest a common underlying disease process. From the critical point of view, the dilemma lies in case definition. Although a recent US study offered a symptom based case definition (presence of one or more chronic symptoms of post-traumatic stress disorder), British studys definition was designed as a research tool to focus future research efforts rather than as a set of diagnostic criteria, and since sample consisted of self selected, mostly ill veterans, and no have standardized data on the duration of symptoms were available, meaningful comparative data cannot be derived (Williams, 76).
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A number of important changes in the mental health field and in the larger health care environment have contributed to an increasing emphasis on designing and monitoring of Gulf War veterans mental health care of Gulf War veterans, diagnosed with post-traumatic stress disorder. Practically, early versions of the principal instrument for evaluating managed care organizations had only one measure for the quality of mental health care towards Gulf War veterans: the percentage of inpatients hospitalized for a post-traumatic stress disorder who received an outpatient visit within 30 days of discharge (Fontana, 237).
Continuity of care is viewed by many as a primary indicator of the quality of outpatient mental health care in cases of post-traumatic disorder. The study conducted by A. Fontana and R. Rosenheck was to determine whether administrative measures of continuity of care were associated with greater improvements in the Gulf War veteran health status in the case of post-traumatic stress disorder. Continuity of care measured at the individual level was consistently associated with greater reductions in alcohol abuse but was not significantly related to any other outcomes after correcting for multiple comparisons (Niles, 116).
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In contrast, when site averages of continuity of care measures were used, there was no evidence of any relationship between continuity of care and better alcohol outcomes. In addition, prior to correcting for multiple comparisons, several continuity of care measures were associated with worse outcomes in post-traumatic stress disorder symptoms, alcohol and drug use, and violent behavior, usually associated with it (Niles, 119).
While these findings can be characterized as ambitious, researchers believe that analyses with site averages are less vulnerable to selection bias because lower levels of outpatient service use by the small number of veterans who abuse substances at each site will not substantially affect overall continuity of care at a particular site. These analyses thus tend to undercut the analyses conducted with individual level continuity of care measures and suggest that continuity of care measures, at least in the sample used for the study, are not consistently associated with desirable client outcomes. In interpreting these apparently paradoxical results, the potential biases that are inherent in observational studies that relate individual service utilization data to outcomes must be carefully considered. Especially in the case of substance abuse disorders, veterans who are doing poorly are less likely to attend treatment and may even be asked, as a matter of clinical policy, not to attend treatment when they are intoxicated from alcohol or high on drugs. Thus, the greater improvements in client health status observed in association with higher levels of continuity of care when measured at the individual level may reflect withdrawal from treatment or policy-related exclusion from treatment of veterans who are using alcohol or drugs, rather than the beneficial effects of continuity of care.
In this view the most plausible interpretation of the findings is not that continuity of care results in better outcomes, but rather that increased substance use results in poorer continuity of care. When site averages are used, however, selection bias is likely to be attenuated since poorer attendance by the minority of individual veterans diagnosed who abuse substances would not substantially affect overall continuity of care at a particular site. The disappearance of significant associations between continuity of care and improvements in post-traumatic stress disorder with the use of site averages may thus be attributable to the elimination of this potential selection bias. Analyses of average site values of continuity of care measures in fact resulted in associations of continuity of care with poorer outcomes, perhaps because sites with high continuity of care levels are more likely to retain patients who are doing poorly (Fontana, 249).
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Thus, the most straightforward interpretation of these admittedly ambiguous findings is that results with individual level continuity of care measures largely reflect selection biases of the type that are often encountered in the analysis of observational outcome data. From critical point of view, it is suggested that a useful methodological check on observational outcome studies would be to conduct analyses that average individual level continuity of care measures at the site level to check on potential selection biases. Important limitation of this study requires comment. Although a methodological strength of this study is that the sample is a diagnostically homogeneous VA inpatient sample, this may limit the generalizability of the findings with regard to other populations, diagnostic groups, health care systems, and to treatment that is initiated in the outpatient setting.
Additionally, the sample is not perfectly representative of veterans receiving treatment in programs that provide specialized inpatient treatment for military-related PTSD, although the magnitude of the differences is small. Bibliography American Psychiatric Association (1989).
Diagnostic and statistical manual of mental disorders. 3d Ed rev. Washington, D.C.: American Psychiatric Association Fontana A, Rosenheck R. (1999) Outcome Monitoring of VA Specialized Intensive PTSD Programs: FY 1999 Report.
West Haven, CT, Northeast Program Evaluation Center Kemp A, Ralwings E., Green B. (1998) Post-traumatic stress disorder (PTSD) in a military personnel: a shelter sample. Journal of Traumatic Stress 8(15) Niles DP, ed. (1993) Relationships between combat experiences, post-traumatic stress disorder symptoms and alcohol abuse among active duty veterans. Ann Arbor, Michigan ABN Williams T, ed. (2001).
Post-traumatic stress disorders: a handbook for clinicians. Cincinnati: Disabled American Veterans.