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Posttraumatic Stress Disorder | PTSD | Mental Health: Seeking Care with TRICARE
Anyone who has been through a trauma—violent crime, sexual violence, natural disasters, mass shooting, or combat—can develop posttraumatic stress disorder.
PTSD affects approximately 3.5% of U.S. adults every year and an estimated one in 11 people will be diagnosed within their lifetime, statistics show. Women appear to be twice as likely as men to have PTSD. Data available from the Military Health System Data Repository show that in 2021, approximately 2.2% of active-duty service members had a PTSD diagnosis.
What is PTSD?
“PTSD is a psychiatric disorder of the inability to forget,” U.S. Public Health Service Capt. (Dr.) Joshua Morganstein succinctly explained.
“Our memories diminish for things over time. In [PTSD], sometimes the opposite occurs where memories become even more amplified,” he explained. “The natural process of extinguishing a memory or diminishing it is interfered with. So being able to forget is important.”
Additionally, “In their life experience, people with PTSD tend to overestimate the likelihood and severity of future threats,” he said. “PTSD alters our perception of threats in the future and our ability to assess risk around threats.”
Morganstein is the deputy director of the Center for the Study of Traumatic Stress and vice chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Four Characteristics of PTSD
There are four different “clusters” of symptoms associated with PTSD, Morganstein said.
One is “intrusion, where people might repeatedly have thoughts, or involuntary memories, flashbacks or nightmares that involve a sense of reliving the traumatic experience.”
Another is “avoidance of things that remind them of the traumatic event, people, places, activities, objects, or even situations that might trigger a distressing memory.”
PTSD patients “also have alterations in cognition and mood. They might have trouble remembering important aspects of the traumatic event. Sometimes, these aspects may have been helpful in altering their perception of the event in a more positive way,” he noted. Instead, they have “tunnel vision” in terms of which parts of the memory stick with them.
“They may have the negative or distorted thoughts or beliefs about themselves, or guilt and shame, like ‘I'm bad,’ or about other people where they might believe no one else is trustworthy.”
There may be “elements of moral injury” associated with PTSD, “a belief that someone didn't do something that they should have done or did something that they should not have done. And guilt and shame often cause people to isolate themselves more,” removing them from others and from care, Morganstein said.
The last characteristic is alterations in arousal and reactivity. PTSD patients may want “their back to be against the wall, anywhere they are, so that they feel that they can see any potential threats that may emerge. People might also be easily startled or have problems with concentration or sleeping.”
Addressing Barriers to Care for PTSD
Stigma is one reason people may not seek out PTSD care.
“They may perceive that they are weak, or that there's something wrong with them if they need care. They may also be concerned about external types of stigma, where they worry that their friends or neighbors or coworkers or supervisors will think poorly of them,” Morganstein said.
“Military members also fear negative job implications or adverse effects on their ability to hold a security clearance.” However, a report from the Defense Counterintelligence and Security Agency, which adjudicates security clearances, revealed that of the more than 2.3 million security clearance reviews between 2012-2018, only 12 individuals (about 0.005% of all cases) had their clearance denied or revoked due to psychological health concerns. For more information, please visit https://health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Real-Warriors-Campaign/Articles/Security-Clearances-and-Psychological-Health-Care
Morganstein stated, “The actual risk of losing a clearance is likely far lower than many service members perceive.” He noted that educating service members to help them better understand actual impact versus feared impact can be helpful to lower barriers to help-seeking.
Some people do not know exactly where to get care or how to begin care. Morganstein said, “Oftentimes, it is a person's significant other who will identify a concern and help to lead them to care. Ensuring family members are educated and aware about issues of PTSD is an important part of lowering barriers to care and helping people engage in care.”
Peers and leaders can also play a role in helping people get to care.
Peers can encourage someone who is having difficulties to connect with helping services, including medical care. “Leaders can encourage and lower barriers to help-seeking by acting as a role model and ensuring people have time and support in getting medical care,” Morganstein said.
When teams and leaders build a culture to encourage early help-seeking among peers, supervisors, chaplains, and medical services, this helps ensure service members get help before serious troubles emerge and lessens the stigma once they are in care.
“This type of organizational approach optimizes force health protection and fosters military readiness,” he emphasized.
Keeping Patients in Treatment is a “Major Challenge”
However, one of the biggest challenges “is simply keeping people engaged.”
Keeping people in care can be difficult for several reasons. “Exposure-based therapies require people to re-experience the trauma as part of the therapy and many people want to avoid that because it can feel upsetting,” Morganstein said.
“Medications can have variable efficacy and people may not perceive benefits initially, so it’s important to help set expectations about potential side effects of the treatments and the time it may take to see significant improvement,” he pointed out.
Often there are other conditions like depression or substance use occurring and, if these are not identified and treated, their presence can undermine the effectiveness of treatment focused on PTSD.
Ways to Treat PTSD
In addition to exposure-based therapies, there are medications that can directly or indirectly help people with PTSD.
Good sleep is also particularly important. “Poor sleep makes it difficult for people to evaluate things, manage stressors, communicate effectively, navigate conflict, and solve problems,” he said.
Can Exercise Be Beneficial for PTSD?
“Tolerability and willingness to stay engaged in any given treatment are very significant issues to consider, along with the effect size or the benefit, the amount of benefit that the particular treatment may or may not provide,” he said.
Studies show exercise is beneficial for both physical and mental health.
“The evidence on the effect of exercise for alleviating the symptoms of PTSD is encouraging,” said Dr. Marija Kelber, Evidence Synthesis and Dissemination Team lead at the Defense Health Agency Psychological Health Center of Excellence in Silver Spring, Maryland.
A systematic review of 11 studies published in the journal Military Medicine in November 2021 summarizes both military and civilian studies on the effects of exercise for PTSD. “It showed that exercise reduced PTSD symptom severity, and it had a beneficial effect on depression, sleep, substance use, and quality of life,” she said.
The authors of the study concluded exercise can be an effective addition to PTSD treatment. However, “the body of evidence is not yet mature enough to determine what type of exercise is most effective,” and more research is needed “before strong conclusions can be made,” Kelber said.