There are an estimated 200,000 women currently serving in active duty in the armed forces and this number is expected to grow.1
In fact, the women veterans population is expected to increase from 9% to 17% by 2043.1 The prevalence of posttraumatic stress disorder (PTSD) among women veterans has been increasing throughout the years due to the dynamic change of women’s roles in the armed forces. In the 1700s, women took on supportive roles such as cooks, nurses, laundresses, and seamstresses. Since the lifting of the ban of women participating in direct combat by the Department of Defense in 2013, women are now more prominent on the front lines with their male comrades in active duty and direct combat roles.2 These roles are more prominent in the latest cohorts associated with Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and current issues of Iraq and Afghan conflict.
With no limitations to partake in active duty and direct combat roles, women in the armed forces are now exposed more frequently to specific stressors that put them at higher risk for developing mental health disorders such as PTSD. For the recent women veterans population that participated in OEF/OIF conflicts, rates indicate women have a 1.7 to 2.5 higher chances of developing PTSD than male veterans.2 It has been recognized that OEF/OIF women veterans are likely to seek help more than men but typically utilize non-military centered primary care services.3 Common barriers that prevent women veterans from obtaining health care services from the United States Department of Veteran Affairs (VA) are knowledge deficits in eligibility of these services and the availability of gender-sensitive services for their condition.3 As nurse practitioners (NPs) and physician assistants (PAs) are assimilating into primary care provider (PCP) roles, we need to be aware of the strong prevalence of PTSD in this small but growing population and understand how to appropriately assess, screen, diagnose, treat, and manage this condition.
What is PTSD?
The American Psychiatric Association (APA) defines PTSD as a condition that causes significant distress or impairment from exposure to actual or threatened death, serious injury, or sexual violation.4 PTSD is diagnosed when symptoms from the following four distinct symptom clusters are experienced 30 days after the traumatic event: intrusion, avoidance, negative alternations in cognition and mood, and alterations in arousal and reactivity.
Symptoms associated with intrusion involve the individual experiencing recurrent, involuntary, and intrusive distressing thoughts, memories, dreams, and flashbacks about the traumatic event.5 Avoidance involves symptoms that are associated with persistent avoidance of memories, thoughts, or feelings associated with the traumatic event, which include people, places, conversations, activities, objects, and situations. Negative alternations in cognition and mood include symptoms such as dissociative amnesia, which is the inability to remember important personal information or events, displaying persistent and exaggerated negative beliefs about oneself or others, blaming oneself, persistent negative emotional state of fear, horror, anger, guilt, shame, having a diminished interest in significant activities, feelings of detachment from others, or unable to display positive emotions. Symptoms associated with the hyperarousal symptom cluster include having irritable, reckless, or destructive behavior, angry outbursts, being verbally or physically abusive towards people, hypervigilance, exaggerated startle response, concentration problems, and sleep disturbance.
Studies have demonstrated that women typically present with symptoms in the hyperarousal cluster of having an exaggerated startle response and exhibiting emotional distance.6 Particularly, research centralized on women veterans from the OEF/OIF cohort who are diagnosed with PTSD present with symptoms associated with insomnia, difficulty sleeping, concentration difficulties, and distress from reminders of traumatic events.6,7 Reports of avoiding places or thoughts that are associated with the traumatic event are also prevalent in this population. Women veterans are at increased risk of developing PTSD when encountering a traumatic event associated with direct combat violence exposure or military sexual trauma (MST).
Direct Combat Exposure
Women veterans in the OEF/OIF and Afghan and Iraq conflict cohort experience more combat exposure than women in the past eras. In one survey with 185 female OEF/OIF women veterans who have PTSD, 70% stated that they had at least one combat experience which involved improvised explosive devices, incoming artillery, rocket, or mortar fire while some witnessed dead bodies or human remains.3 Research demonstrates there is a strong correlation between elevated stress and uncontrollable threat of one’s life, combat-related injury and experience, and the development of PTSD symptoms in women veterans when compared to men.2,3,8
Military Sexual Trauma (MST)
Another significant stressor that puts women veterans at high risk of developing PTSD is exposure to MST. One in five women veterans have reported experiencing MST.9 Research has shown that OIF/OEF women veterans who experience MST are five to eight times more likely to develop PTSD compared to those with no history of MST.3 MST is defined by the VA as any sexual activity against one’s will which involve being pressured into sexual activities, unable to consent to sexual activities, or being physically forced into sexual activities.3 Other experiences include unwanted sexual touching or grabbing, threatening, offensive remarks about a person’s body or sexual activities, and/or threatening or unwelcome sexual advances.3 Along with the traumatic experience, women veterans have claimed that symptoms are exacerbated from the stress associated with not wanting to break unit cohesion and therefore, feeling isolated.9
Detrimental Effects of PTSD
If PTSD is under diagnosed and left untreated, it can have detrimental effects to the person physically, mentally, and emotionally. Individuals with PTSD can isolate themselves from support and social situations, which increases attempts of suicide. Women veterans with PTSD have been reported to have higher rates of obesity, fibromyalgia, irritable bowel syndrome, emphysema, and sexually transmitted diseases.8 These conditions develop when PTSD fails to be recognized and diagnosed promptly as lack of control of symptoms can lead to the development of risky behaviors in attempt to cope with the disorder, which include alterations in diet, substance use problems, increase in multiple sexual partners, and smoking. Research shows that women veterans with PTSD are also more likely to be diagnosed with comorbid mental conditions such as depression, anxiety disorders, substance abuse, or eating disorders.10
Screen and Treat
About 83% of women veterans receive their health care from non-VA practices.11 Reasons for refraining from VA services include being unaware of veteran status and belief that the VA provides male-centered care.2 NPs and PAs of non-VA primary practices need to be comfortable with identifying women veteran patients, evaluating their military history, and screening for PTSD. By conducting a thorough interview of their medical history and military experience, risk factors for having PTSD can be identified and appropriate screening can be conducted.
First, the NP or PA needs to identify the patient’s military or veteran status by asking if they are currently serving or have served in the military as they do not always identify themselves as veterans.2 Establishing trust and rapport with the women veteran patient will allow her to become more responsive to the interview and divulge important pieces of information to make an accurate diagnosis. Once it is confirmed the patient is a veteran, a structured interview, using the U.S. Department of Veteran Affair’s Military Heath Pocket Card, can be conducted to evaluate her military experience.
The Military Health History Pocket Card was created to guide a structured interview to evaluate a patient’s military history. This is particularly useful for non-VA PCPs. The NP or PA can use this pocket card to explore critical pieces of information of the veteran’s military experience to explore potential mental and physical issues that need to be addressed.12 Particular questions in each category of the Military Health Pocket Card allows the NP or PA to identify risk factors that indicate a red flag for PTSD. NPs or PAs should focus on the questions that evaluate for MST and traumatic events associated with combat exposure as there is a direct correlation with these two events and diagnosing PTSD in the women veterans population. The questions that evaluate stress reactions and adjustment problems on the Military Health History Pocket Card are the same questions on the primary care PTSD (PC-PTSD) screening tool, which is a reliable four item questionnaire used to screen patients for PTSD. This tool should also be used to screen for PTSD in any military personnel or in the patient that presents with any symptoms of anxiety, fear, or insomnia.13 A positive PC-PTSD results if the patient answers “yes” to any three of four questions. If the patient screens positive, she should automatically be evaluated for suicidal ideation or thoughts. If a woman veteran patient screens positive using the PC-PTSD tool and her military history supports this, the NP or PA should conduct an interview to explore positive responses in order to make a PTSD diagnosis that meets the DSM-5 criteria. Research indicates the most effective treatment for PTSD is cognitive behavioral therapy in combination with pharmacotherapy, if appropriate.14,15 First line of treatment for individuals with PTSD is a selective serotonin uptake inhibitor.14
When diagnosed with PTSD, NPs and PAs are encouraged to refer female veteran patients to women’s mental health services offered by their closest VA hospital. This ensures that the patient receives the best individualized, evidence-based care that focuses on this particular population. Women veteran patients need to be educated and reassured that there are available and abundant culture and gender-sensitive resources geared towards their population at the VA to help manage and treat PTSD effectively. These patients can also be directed towards the Veterans Affairs website: http://www.ptsd.va.gov/public/PTSD-overview/women/womens_mental_health_services.asp.
- US Department of Veteran Affairs. Projected veteran population http://www.va.gov/vetdata/docs/quickfacts/Population_slideshow.pdf. Accessed February 21, 2016.
- Crum-cianflone NF, Jacobson I. Gender differences of postdeployment post-traumatic stress disorder among service members and veterans of the Iraq and Afghanistan conflicts. Epidemiol Rev. 2014;36:5-18.
- Calhoun PS, Schry AR, Dennis PA, et al. The Association Between Military Sexual Trauma and Use of VA and Non-VA Health Care Services Among Female Veterans With Military Service in Iraq or Afghanistan. J Interpers Violence. 2016
- American Psychiatric Association. Post Traumatic Stress Disorder. http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf. Accessed February 21, 2016.
- Sareen, J. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis. In: UpToDate, ed. Stein, MB, Waltham, Ma; 2015.
- Hourani L, Williams J, Bray R, Kandel D. Gender differences in the expression of PTSD symptoms among active duty military personnel. J Anxiety Disord. 2015;29:101-8.
- King MW, Street AE, Gradus JL, Vogt DS, Resick PA. Gender differences in posttraumatic stress symptoms among OEF/OIF veterans: an item response theory analysis. J Trauma Stress. 2013;26(2):175-83.
- Dobie DJ, Kivlahan DR, Maynard C, Bush KR, Davis TM, Bradley KA. Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med. 2004;164(4):394-400.
- US Department of Veteran Affairs. Military Sexual Trauma. http://www.ptsd.va.gov/public/types/violence/military-sexual-trauma-general.asp
- Maguen S, Cohen B, Ren L, Bosch J, Kimerling R, Seal K. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder. Womens Health Issues. 2012;22(1):e61-6.
- US Department of Veteran Affairs. Resources for Non-VA Providers, Medical Students. http://www.womenshealth.va.gov/WOMENSHEALTH/programoverview/providers.asp Accessed February 21, 2016.
- US Department of Veteran Affairs. Military Health Pocket Card for Clinicians. http://www.va.gov/OAA/pocketcard/. Accessed February 21, 2016. (4)
- Prins, A., Ouimette, P., Kimerling, R., et al. (2003). The Primary Care PTSD Screen (PC-PTSD): Development and operating characteristics, Primary Care Psychiatry, 2003; 9: 9-14. doi: 10.1185/135525703125002360
- Barbara, R. Psychotherapy for posttraumatic stress disorder in adults. In: UpToDate, ed. Stein, MB, Waltham, MA; 2015.
- Stein, M. Pharmacotherapy for posttraumatic stress disorder in adults. In: UpToDate, ed. Stein, MB, Waltham, MA: 2015