PTSD: An Epidemic of Trauma

War is an amplifier for trauma. It deals out plenty of physical destruction, but not all scars are visible; some of its most persistent wounds are psychological. In the American Civil War, the continued distress of troops following a tour of duty was called soldier’s heart, in WWI, it was known as shell shock, and in WWII they referred to it as combat fatigue4. Now we know it as posttraumatic stress disorder (PTSD). Although PTSD remains closely associated with military service in the public consciousness (and indeed, many servicemen and women suffer from the disorder due to their time in combat), the majority of those suffering from PTSD are not soldiers and are traumatized far from a battlefield.

Although PTSD has a long history, it was thought of as a soldier’s condition, and was largely forgotten between wars. It was only codified as an accepted disorder in the 1980s, and its signs and symptoms, which are currently understood to include intrusive memories of the traumatic event, avoidance of reminders of the event, emotional numbing, and hyperarousal (heightened emotional reactivity to trauma-related cues, and increased sensitivity)4, have continued to evolve since then6. It is the only major mental disorder where the cause is thought to be known: an event that poses a threat to the physical integrity of oneself or others and induces intense fear, helplessness, or horror4. Because PTSD is associated with extreme situations, it seems like it should be a rare condition. It isn’t. About 8% of American adults will experience PTSD (5% of men and 10.4% of women)3.

The front lines

The connection between war and PTSD is clear; PTSD rates increase with increased exposure to combat2, and combat has a good chance (about a 39% likelihood) of causing PTSD. Combat experience is one of the most common causes of the disorder in men3. Because about 2.1 million US service members have deployed to Iraq or Afghanistan in Operations Iraqi Freedom, New Dawn, and Enduring Freedom1, this is a major concern for the armed forces. The estimated prevalence of PTSD among US troops returning from deployment is generally thought to be 17% or less7. However, this could be an underestimate, as the prevalence of the disorder increases during the first year after deployment, and possibly even longer7.

ptsd
War is hell.

The home front

While war results in more than its fair share of PTSD, combat is far from the only cause. Most cases of PTSD result from trauma that occurs much closer to home. Natural disasters, fire, and floods are all common inciting events. Witnessing someone else being badly injured or killed outside of battle is one of the most common causes of PTSD in men, and results in about as many cases of PTSD as combat. It is also far more likely to happen: about 36% of men witness this kind of event, while only 6.4% of men experience combat3.

Not all traumatic events are equally likely to cause PTSD. While men are more likely than women to experience a traumatic event, women are more likely to experience a trauma with a high probability of causing PTSD: 67.6% of women compared to 44.6% of men that experienced trauma in their lifetime develop PTSD. For both men (65% of those reporting it as their most upsetting trauma) and women (45%), rape is the trauma most likely to result in PTSD. Women are far more likely to be raped, contributing to higher rates of PTSD in women overall: 20% of women develop PTSD if exposed to a trauma, about twice the rate of traumatized men3. The statistics are horrifying: globally, 18% of women, nearly 1 out of every 5, are raped, as well as 3% of men, or 1 of every 33. One of every 6 American women will be the victim of an attempted or completed rape in their lifetime, and there are currently an estimated 17.7 million rape victims who identify as women in the US. These attacks happen far from the terror of war; they are usually local and intimate, with 50% occurring within a mile of the victim’s home, and about 2/3 being perpetrated by someone the victim knows5.

A moving target

PTSD is not an isolated condition; it creates myriad complications and cascading effects. It is likely to co-occur (be comorbid) with other related disorders, like depression or generalized anxiety disorder; as much as 88% of men and 79% of women with PTSD will also be diagnosed with another disorder. The underlying cause of the condition may be obscured; a person who experiences one traumatic event is likely to experience two or more3. And of course, PTSD affects not only the person who has been traumatized, but also their families and loved ones. PTSD negatively impacts parenting practices and parenting alliance (the relationship between parents) in the first year after trauma1.

Stigma may reinforce the damaging effects of PTSD. Only 23-45% of troops that were positive for a mental health disorder, including PTSD, following deployment sought help in the year after their tour of duty. Only 38-45% of those diagnosed with a disorder were interested in getting help, and the single biggest barrier to mental healthcare access was stigma2. This is tragic. Patients who got any amount of treatment had an average of 36 months of symptoms, while those who didn’t averaged 64 months. However, there is significant progress to be made in the treatment of PTSD; although there is a 50% chance of remission even two years after trauma, more than 1/3 of those diagnosed never fully remit, whether or not they receive treatment3.

PTSD is often seen as an aftershock of combat; the terrible resurfacing of war after the fighting is long over. But the reality is far more disconcerting. The majority of PTSD is caused by trauma experienced at home, in the course of everyday lives. The leading causes are not uncommon events, and the most frequent are domestic violence and sexual assault against women. It turns out, the battle is in our backyards and we’re all combatants.

References

  1. Creech, SK, W Hadley, &B Borsari. (2014). The impact of military deployment and reintegration on children and parenting: a systematic review. Professional Psychology: Research and Practice, 45: 452-464.
  1. Hoge, CW, CA Castro, SC Messer, D McGurk, DI Cotting, & RL Koffman. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351: 13-22.
  1. Kessler, RC, A Sonnega, E Bromet, M Hughes, & CB Nelson. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52: 1048-1060.
  1. Pitman, RK, AM Rasmusson, KC Koenen, LM Shin, SP Orr, MW Gilbertson, MR Milad, & I Liberzon. (2012). Biological studies of post-traumatic stress disorder. Nature Reviews Neuroscience, 13: 769-787.
  1. Rape, Abuse, and Incest National Network. Statistics. Web. 1 April 2015.
  1. Sareen, J. (2014). Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment. Canadian Journal of Psychiatry, 59: 460-467.
  1. Sundin, J, NT Fear, A Iverson, RJ Rona, & S Wessely. (2010). PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychological Medicine, 40: 367-382.

Image source: Creative Commons, http://en.wikipedia.org/wiki/Thousand-yard_stare

Leishmaniasis: Battle Scars

Aliases: It is currently known as leishmaniasis, but historically it went by the misleadingly adorable name “Jericho buttons”, due to the high number of cases near the city of Jericho.

Leishmaniasis is an old disease that has been made new, thanks to humanity’s propensity for destruction. It originates in the Old World, and while it still wreaks havoc there, it has also found new frontiers. It follows at the heels of poverty, conflict, and environmental disturbance- including urbanization, deforestation, and climate change- and afflicts some of the poorest people on the planet3.

Like many other diseases, leishmaniasis has spread by piggybacking on the effects of suffering. It usually affects the poor and malnourished, and it opportunistically infects the immunocompromised (people with weak or suppressed immune systems), such as those who are HIV positive1. Unfortunately, it has been very successful. There are an estimated 1.3 million new cases of leishmaniasis each year, and 20,000-30,000 fatalities3. The disease is now found in 90 countries, spanning the tropics, subtropics, and southern Europe, and has reached every continent except Antarctica and Australia2.

War has played a significant role in the modern resurgence of leishmaniasis. Armed conflict increases the ranks of susceptible people, by displacing and depriving them. The large-scale deployment of troops to regions where the disease is endemic (normally occurs) has also caused a jump in the number of cases1. Operation Iraqi Freedom exposed many US soldiers to the pathogen; troops reported being repeatedly bitten by sandflies. As a consequence, case numbers in the US reached levels that hadn’t been seen since WWII4. We may finally have an answer to Edwin Starr’s classic question: “War, what is it good for?” 

leishmaniasis
Good god, y’all.

Cause: Leishmaniasis is caused by more than 20 species of protozoan, aptly named Leishmania, that are transmitted by the bite of infected sandflies. This disease knows how to get around: a whopping 90 species of sandfly can transmit the pathogen, and it has about 70 animal reservoir host species, including humans3.

Consequence: There are three forms of leishmaniasis: visceral (aka kala-azar; the most serious form), cutaneous (the most common form), and mucocutaneous. Visceral leishmaniasis (VL) symptoms can be a long time coming. It can take anywhere from months to years after the infected bite for symptoms to emerge2. These include irregular fever, weight loss, enlargement of the liver and spleen, and anemia. VL is fatal, if untreated. There are an estimated 200,000-400,000 new cases a year, with 90% occurring in 6 countries: Bangledesh, Brazil, Ethiopia, India, South Sudan, and Sudan. Cutaneous leishmaniasis (CL) causes skin lesions, usually ulcers, on exposed parts of the body3, which occur within a few months of transmission2, and can leave permanent scars and disability in their wake. Over two thirds of the million or so new cases of CL each year occur in 6 countries: Afghanistan, Algeria, Brazil, Columbia, Iran, and the Syrian Arab Republic. Mucocutaneous leishmaniasis (ML) is generally a secondary infection resulting from untreated CL2. It destroys the mucous membranes of the nose, mouth, and throat. Ninety percent of ML cases occur in 3 countries: Bolivia, Brazil and Peru3.

Cure: Leishmaniasis is very treatable3. VL is most effectively treated with liposomal amphotericin (B L-AMB), however there is growing interest in combination therapy, in the hopes of reaching shorter treatment times1. There are myriad treatments for CL, ranging from topical ointments to cryotherapy4. Which is best remains a matter of debate1. All three forms of leishmaniasis can be combatted with preventative measures, including insecticide treated bed nets, sandfly control, disease surveillance, and control of reservoir hosts3.

References

  1. Antinori, S, L Schifanella, & M Corbellino. (2012). Leishmaniasis: new insights from an old and neglected disease. European Journal of Clinical Microbiology and Infectious Disease. 31: 109-118.
  1. Leishmaniasis. Centers for Disease Control and Prevention. 10 January 2013. Web. 13 March 2015.
  1. Leishmaniasis. World Health Organization. February 2015. Web.13 March 2015.
  1. Weina, PJ, RC Neafie, G Wortmann, M Polhemus, & NE Aronson. (2004). Old world leishmaniasis: an emerging infection among deployed US military and civilian workers. Clinical Infectious Diseases, 39: 1674-1680.

Image source: Creative Commons, http://commons.wikimedia.org/wiki/File:JerichoButtons.jpg