The U.S. veteran population of about 22 million is estimated to represent > 9% of U.S. adults. 1 Of veterans using health services, a growing proportion have been deployed in Iraq or Afghanistan. The VA and DoD have made it a priority to address the health care needs of service members and veterans affected by these wars, with a particular focus on posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). This review highlights key developments in assessment and treatment of PTSD.
Epidemiology
Although studies have produced widely varying estimates of the prevalence of PTSD following deployment to Iraq or Afghanistan, more consistent estimates have been obtained by appropriately grouping studies that used a similar methodology. 2 Current PTSD prevalence after Iraq and Afghanistan deployments has averaged 5% to 6% in general military population samples that included support personnel from all services (constituting about two-thirds of deployed forces) and 13% in studies that focused on operational infantry units exposed to direct combat. 2
Among Iraq and Afghanistan war veterans who have sought care at VA treatment facilities, > 25% have received a diagnosis of PTSD (Karen H. Seal, MD, written communication, December 2014). Although combat frequency and intensity is the most prevalent predictor of PTSD in this population, other types of trauma, such as sexual assault, can confer a risk as high as direct combat. 3 Another strong correlate with postdeployment PTSD has been deployment-related mTBIs (concussions), especially following blast exposure. The most likely mechanism for this seems to be the extreme life-threatening context in which these concussions occur. 4
Posttraumatic stress disorder has been linked with a host of comorbid conditions, including depression, anxiety disorders, substance use disorders, physical symptoms, anger, aggression, complicated grief, and risky behaviors. 5-7 Deployments also have been shown to have cumulative effects on the psychological health of military spouses and children. 8,9
Diagnosis
One of the most important developments in PTSD is the new definition, which was released in May 2013 in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), replacing the definition that has proved highly useful for clinical, neurobiologic, research, and public health purposes for > 25 years. 10 The PTSD definition underwent much more extensive changes in the DSM-5 than did any other common mental disorder affecting adults. Changes included moving this diagnosis out of the anxiety disorders chapter into a separate “Trauma- and Stressor-Related Disorders” chapter, which now includes adjustment disorder.
The A trauma criteria were revised, including removal of criterion A2 (response of “fear, helplessness, or horror”), in part because individuals who train for traumatic events as part of military and first responder occupations often do not report this response. The 3 symptom-criteria clusters were divided into 4 clusters: B (intrusion), C (avoidance), D (negative alternations in cognitions and mood), and E (alternations in arousal and reactivity). Three symptoms were added, bringing the total from 17 to 20, and many symptoms were substantially reworded.
The implications of these revisions are an active area of investigation. However, initial evidence suggests that these changes have not necessarily improved the clinical utility of the definition. 11,12 Although research suggests that the 2 criteria sets result in a similar prevalence of PTSD, they do not identify the same individuals, and there is no evidence that clinical accuracy is any greater when using the revised definition.