PTSD and Cardiometabolic Disease

By T. Barry Levine, MD

In their medical practices, physicians T. Barry and Arlene Levine and Sammie Justesen began seeing young men and women who suffered from PTSD, and were also plagued by severe, advanced, and chronic diseases. Despite their young ages and physical training, many PTSD-afflicted veterans and first responders presented with accelerated aging and premature mortality. The authors realized that short-term stress can turn into full blown physical illness and become a living nightmare for the afflicted and their families. Yet, medical care is often fragmented because healthcare providers tend to treat PTSD as a purely psychiatric illness instead of treating the whole patient. Written from a mind-body perspective, this book explains PTSD and its treatment in a way both practitioners and patients will understand. While creating a bridge between specialties, the authors show why and how to address the neuropsychiatric underpinnings of PTSD, along with the serious psychosomatic dimensions of this disorder.

• Language: English
• Publisher: NorLights Press
• Release date: Jan 23, 2016
• ISBN: 9780996455992

T. Barry Levine, MD

T. Barry Levine, MD, is Chief Medical Officer, A.B.L.E. Medical Consulting. Dr. Levine received his medical degree from the Free University of Brussels. He completed his cardiology training at New York University and the University of Minnesota. He is board-certified in Internal Medicine and Cardiovascular Diseases. Dr. Levine has authored over 140 articles in peer-reviewed journals. He is a popular and sought-after speaker on topics such as coronary heart disease, heart failure, hypertension, pulmonary hypertension, dyslipidemia, arrhythmias, metabolic syndrome, diabetes, sleep disorders, and PTSD. Dr. Levine has been consistently named in annual listings such as “Guide to American Top Cardiologists,” “Leading Physicians in the World,” and “Who’s Who in America” and has also been recognized in “Best Doctors in America” and “Top Docs in Pittsburgh.” He, along with Dr. Arlene B. Levine, wrote the textbook Metabolic Syndrome and Cardiovascular Disease and its second edition. His publications for the general public are A Patient’s Guide to Heart Failure and Say NO to Aging: How Nitric Oxide (NO) Prolongs Life.

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Preface

We are cardiologists. Early in our training a wise cardiology instructor taught us not only to address a patient’s presenting issue but to also ask, Why is this person having the problem?

Each medical history typically begins with the introduction, The patient was in his usual state of health until… What happened at until? What propelled this patient from his healthy life into the medical system? Our instructor argued that stress was the biggest factor in many cases. What is stressing this patient? A few simple questions about family, financial, or work-related issues often turned up issues that could lead to the very symptoms the patient complained about. This wise physician treated the cardiology problem, but also set out to find solutions for each patient’s underlying stress.

In our later practice involving the treatment of coronary heart disease, end-stage heart failure, and heart transplantation, we saw many relatively young patients who were former Marines, SEALs, Army Rangers, combat veterans, policemen, firemen, and other first responders. Despite their young ages, these patients came to us with truly horrible heart disease and diabetes.

This seemed to be a paradox, because these first responders were young, athletic, highly trained, and should have been strong and healthy. It seemed absurd and almost bizarre that, following their service to our communities and country, physically fit men and women were plagued by severe and advanced chronic disease.

Yet, it wasn’t a paradox. Research has established that a career as a policeman or fireman is a risk factor for coronary disease. Clearly the same principle holds true for military combat service. We were concerned for these men and women who served our country so well.

We discovered that many veterans are unable to get the care they desperately need for PTSD issues. If they do manage to receive treatment, in many cases mental health care isn’t effective for PTSD. When they later develop medical problems, these patients wait for referrals and then wait again to see different specialists. Their care is fragmented because none of the healthcare providers are treating the whole patient.

As civilian cardiologists we have benefited from the liberty and peace in our land that our uniformed men and women ensure for us. We’re distressed by the increasing number of veterans who manage to survive combat in this long war, but are now afflicted with PTSD and debilitating chronic illness. As medical providers, we feel ashamed that, because of their service, our valiant men and women end up with a significantly higher risk of disease than the general population they protect.

Now it’s our turn to help protect and heal these remarkable men and women.

T. Barry and Arlene Levine

From Sammie Justesen:

The effects of PTSD recently hit home for me when I spoke with the wife of a former high school classmate. I still remember saying goodbye to him after we graduated from high school in 1966, shortly before he left for Viet Nam. His wife told me he’s been plagued with very bad PTSD ever since. I was surprised by how profoundly this man’s life was changed by serving in Viet Nam.

As a cardiac nurse I met veterans whose hearts and vascular systems aged too early. As a homecare nurse I met veterans in their homes and discovered many of them lived below poverty level and deliberately isolated themselves. As a business owner I employed combat veterans who had serious emotional issues. In Sandpoint, Idaho I met Viet Nam vets who lived in compounds surrounded by razor wire, deep in the forest. What would their lives have been like without PTSD?

To further bring home the point, a recent newspaper article in my home state of Indiana reported that four National Guard veterans from Evansville who served together in Iraq have committed suicide:

"Ronald Zeller was the first. He died on March 18, 2011. Then William Waller in 2013; Justin Williams in 2013, and April James in 2015.

"On a warm spring day 18 months after her friend Justin died, April James spent a laughter-filled evening with friends, then curled up with her three dogs to watch TV. Around 3 a.m., she walked to her backyard with a pistol and shot herself.

To the families, the suicides seemed to come with little warning. Now they see there were signs all along. (Higgins, Jessie)

Again I ask: What would their lives have been like without PTSD?

PTSD: Healing the War within Mind and Body is written for men and women like Ronald, William, Justin, and April—and for the people who care for them. As healthcare professionals, family members, and friends, we must find a way to do more for our soldiers and first responders.

Sammie Justesen, RN

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Introduction

Combat-induced PTSD is not a sign of weakness.

Combat PTSD is a sign of strength.

It is the result of doing what others fear to do.

—The Battle Buddy Foundation

Why do so many of our ex-SEALs, Marines, and combat veterans develop diabetes and advanced heart disease along with PTSD? Post-traumatic stress disorder (PTSD) is more than a psychiatric injury. Exposure to combat trauma and the suffering of PTSD causes disabling mental anguish, as well as physical symptoms, that may go undetected for long periods of time. In addition, we now know that PTSD substantially increases physical health risks.

In a cruel twist of fate, long after the last battle has ended, PTSD-afflicted combat veterans suffer from accelerated aging, age-related chronic diseases, and premature mortality. Having left war trauma behind, PTSD sufferers find that not only their souls, but their bodies, remain chronically at war.

PTSD begins as a psychological injury. In many cases the affected service member would be fine except for overwhelming mental trauma. Trauma stress can injure nerve cells in the brain akin to a physical injury. Like a physical wound, the original trauma injury then evokes secondary stress responses that further damage brain structure and function. At that point, what should have been only a post-traumatic stress injury turns into the post-traumatic stress disorder, a living nightmare for the afflicted and their families. This condition is disabling and hard to treat.

That’s why this book sets forth the argument in favor of coordinated care—a holistic approach. As a start, such an integrated approach will bring together the different specialties to treat PTSD in its entirety, by combining general medical treatments with psychiatric practices, and vice versa.

But the holistic approach entails more. As it turns out, the stress pathways that underlie the mental problems of PTSD and also cause physical illnesses are the same. We cannot separate the mind from the body. Mental anguish causes physical ailments, and physical illness worsens mental function. On the positive side of this equation, improving mental health will help ease physical problems—and vice versa.

For thousands of years, religion, philosophy, and medicine have touted the interaction between mind and body. Short-term overwhelming stress can be followed by long-term somatic pathology. That’s why PTSD is a disorder of the entire person, affecting body, mind, and spirit. The ultimate cost of PTSD is staggering for the affected patients, their families, and our entire society.

In the United States, PTSD has become distressingly prevalent, yet we continue treating it with outmoded methods. Current management focuses on the psychiatric symptoms of this condition, with little awareness of the long-term physical issues. Effective care for PTSD calls for the participation of diverse healthcare providers from a wide variety of fields: MDs, PhDs, nurse practitioners, physician assistants, social workers, and lifestyle therapists. Spouses, friends, and family members should be part of the team as needed. Treating PTSD calls for those with expertise in neurology, psychology, psychiatry, rehab medicine, general medicine, endocrinology, cardiology, pain medicine, sleep medicine, and others.

Our goal is to facilitate a new kind of integrated therapy that targets body, mind, and spirit. This book is written for professional and lay healthcare providers who work with those who suffer from PTSD, especially in the military setting. We hope to create a bridge between highly divergent specialties:

• to familiarize providers in neurology, psychology, and psychiatry with the serious psychosomatic dimensions of PTSD patients;

• to familiarize those who care for somatic diseases in PTSD patients with the neuropsychiatric underpinnings of this disorder.

The book also aims to be an educational resource for men and women who are suffering from PTSD and for their caregivers.

Within these pages, providers who specialize in somatic diseases will gain insight into the neuropsychiatric underpinnings of PTSD, including how every system in the body responds to trauma.

Mental health providers will understand the need to integrate their care with comprehensive general or internal medicine services.

Holistic therapy is also part of our multifaceted treatment approach—a way to target underlying pathways and prevent or reverse the mental and physical symptoms of PTSD.

This text also touches on traumatic brain injury (TBI). Mild TBI might be considered a case of telescoped PTSD: both conditions cause surges of stress-signaling pathways that further damage brain function and structure and compromise the recovery from physical and psychological brain injuries.

Other important sections of the book review ways to enhance resil-ience, screen for PTSD, prevent PTSD from occurring, and encourage post-traumatic growth.

We also review current therapies, including pharmacological and cognitive behavioral treatments for PTSD. These chapters detail how lifestyle changes and drug treatments can reverse destructive stress pathways. We describe the neuroprotective effects and promises of these treatments for healing somatic symptoms, enhancing neuropsychiatric function, and improving the quality of life for patients and their loved ones.

In a vicious circle, the mental and physical symptoms of PTSD feed on each other to create anguish for victims and greater challenges for the treatment community. In addition, these hidden issues increase the overall healthcare burden of our society.

We hope this book will help improve the lives of our military veterans and others who serve the greater good.

~ ~ ~

PTSD Today

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Chapter 1: Today’s Military Veterans

We sleep safe in our beds

because rough men stand ready in the night

to visit violence on those who would do us harm.

—George Orwell

War-related stress disorders among returning military personnel have been on the rise. Warzone engagements create unique stressors, including chronic threat, multiple lengthy deployments, and loss. However, much of the distress service members experience occurs after their deployment as they try to reintegrate with their families and civilian society. Any accompanying physical injury makes these challenges even more daunting.

The Scope of War

More U.S. military service members have been deployed since 9/11/2001 than in the previous 40 years. As of September 2013 and beyond, more than 2.6 million troops served overseas in the post-9/11 long war as part of

• Operation Iraqi Freedom (OIF),

• Operation New Dawn in Iraq,

• Operation Enduring Freedom (OEF) in Afghanistan, and Operation Inherent Resolve in Iraq and Syria.

Over one million of these men and women served multiple deployments. As of February 2014, we have seen 6,664 casualties and 51,904 wounded. Almost 750,000 disability claims have been filed, with 137,911 (18%) of the claimants receiving disability benefits.

In addition to increased military activity, and unlike earlier wars, our recent campaigns include more women and married soldiers who are older and more ethnically diverse. This change in the demographics leads to increased combat and noncombat stresses (Callahan 2010).

In a survey of 1,965 service members from 24 communities across the U.S., participants reported exposure to a wide range of traumatic events while deployed, with half saying they had a close friend who was seriously wounded or killed, 45% reporting they saw dead or seriously injured non-combatants, and over 10% saying they were injured themselves and required hospitalization (Tanielian T 2008).

In addition, stress may be higher now due to:

• the more complex environment in post-9/11 war zones,

• a downsized military,

• the multifaceted and complex rules of engagement,

• the increased number and duration of deployments to war zones, and enhanced survivability due to improved body armor and better medical care.

These and other factors have increased the mental effects of combat stress, including depression, anxiety, and post-traumatic stress syndrome. The incidence of mental symptoms seems disproportionately high among veterans when compared to physical injuries (Callahan 2010). Together with blast head trauma, stress disorders have become the signature injuries sustained by U.S. military personnel in recent conflicts. This higher incidence of deployment-related stress disorders also affects parents, spouses, and children of active military personnel and veterans.

What is Post-Traumatic Stress Disorder?

War subjects some of its participants to more than

any person can bear, and it destroys them.

War makes others stronger.

For most of us, it leaves a complex legacy.

—Phil Klay

Post-traumatic stress syndrome is not an inherent mental disorder or illness. It is an injury akin to traumatic brain injury (TBI), except the offending insult is not physical, but psychological. By its very definition, PTSD occurs after a cataclysmic event (or series of events) that destroy a person’s fundamental assumptions about his or her identity, the inherent wholesomeness of the world, and the future. During combat or other extreme trauma, a person’s value system may be turned upside down in an instant. The initial response is extreme fear and shock.

This calamitous shattering of values and beliefs leads to the many negative psychological effects of trauma. As it evolves, PTSD brings a host of unwelcome symptoms: persistent and intrusive re-experiencing of past trauma, avoidance of trauma-related cues, enhanced fear, emotional numbing, hyperarousal, sleep disturbances, and changes in thinking, mood, and social integration. The cost of PTSD is staggering for affected patients, their families, and our society.

We now know that short-term stress can lead to long-term physical illness. Traumatic stress is a major challenge to victims’ psychological and physical health in equal measure.

While PTSD occurs with victims of domestic abuse, natural disasters, sexual assault, and accidents, this book will focus on high risk groups that include:

• military combat personnel,

• trauma victims,

• disaster workers, and

• first-responders.

In a vicious circle, the mental and physical symptoms of PTSD feed on each other to create more anguish for victims and greater challenges for the treatment community. In addition, these hidden issues increase the overall healthcare burden of our society.

PTSD is a vexing condition to diagnose and even to define. People do not always realize they have PTSD, because the symptoms may not appear for months or years after returning from deployment or being involved with a traumatic event. In addition, the symptoms may come and go, making it hard to know if the problem is gone for good or simply dormant.

Recognizing the symptoms and getting help are the two most critical steps with PTSD. Yet, this disorder can also be challenging to diagnose because it leaves no scars or biological markers and physicians must rely on each patient’s testimony. Caregivers may see a wide variety of symptoms and symptom clusters.

Like other combat injuries, PTSD has a terrible extended impact. Pain syndromes, drug use, marital and family issues, unemployment, homelessness, psychological problems, psychosis, and suicide are some of the problems caused by severe or untreated PTSD. Long term, the individual, societal, and economic toll of untreated war-related PTSD continues growing long after the battles have ended.

Yet, the very existence of PTSD reflects our innate humanity—our sense of decency and morality. There are atrocities of such magnitude, such savagery, barbarity, and vicious brutality that human sensibility cannot fathom the experiences, and the mind is unable to cope.

Stories from U.S. Veterans

"I am back again from hell with loathsome thoughts to sell;

secrets of death to tell; and horrors from the abyss."

—Siegfried Sassoon

Asking for help isn’t easy for soldiers. These men and women have been taught to value strength and independence, which often translates into hiding their pain and dealing with problems on their own. Some feel survivor guilt about events that happened to them and may even think they deserve to be in pain. In some cases, the experiences feel too personal or embarrassing to talk about, even with close family members. And bringing painful topics into the light makes the pain worse for a time. Furthermore, when reactions are delayed, people who have PTSD may not even connect their symptoms to the traumatic event. In addition, many PTSD sufferers don’t know where to turn for help—or they can’t afford treatment.

Let’s look at what U.S. veterans have to say about PTSD:

Resilience

"Every guy has a different threshold for the terrible stuff of war. Everyone has a different size cup. Once it’s full, it’s full. The cup is the memories."

Memories

"Flashbacks are like a time machine. You literally re-live it in every way, down to your visceral responses and the same exact thoughts going through your mind. You attempt to scramble back into the present tense ASAP. This is the hardest aspect of PTSD to get under control."

Nights

"The point is, I never felt more alive after I woke up from the blast, it was a full-blown miracle, and I was happy. But if I fall asleep tonight, God forbid I dream about something like that. Every night is the same in my dreams; it’s always the RPGs, the grenades, followed by the small arms fire… But the IEDs are the worst because you don’t see those coming, you just feel your body get hit like a shock wave and by the time you come around, you’re checking your junk to make sure it’s still there. I deal with all this and more, and I deal with it alone. "

"The pain and the memories will never go away. I wish I could sleep one night without nightmares."

Returning home

"We were in the worst place in our lives… Despite it all, we made it out alive, but sometimes I think some of me stayed there."

"I am trying to make sense of whatever I have left that is me."

"I did not kill, I saved. The enemy, the civilian, the comrade, the children. They died in my arms, and I saved the ones who killed my comrades. My nights are consumed by horrors not seen by the normal ER nurse. Iraq ruined my life."

"PTSD not only hurts the soldier, it also hurts their families. How can one deal with such a condition, devoid of feelings toward your loved ones, and yet can’t let them go? Will the pain ever stop? Will the children be able to grow up knowing what love is? Through the grace of God, the pain will stop."

Flashbacks, Fear, and Hypervigilance

"I am not the brave squad leader I once was. I am not the first guy out of the Bradley anymore. I am not the point man on all those raids anymore. I have a family now and the world just frightens the hell out of me."

"Going to the movies is the worst: the crowds, the dark, the whispering cause panic."

"Even though I knew they were just fireworks on the 4th of July, to me they still sounded like incoming mortars. It took me right back to my deployment."

"Driving down the roads in my home town, I found myself noticing every piece of debris, avoiding every pothole."

Delayed Symptoms

"I came home and thought everything was fine. I had a few nightmares, but felt inadequate to talk about them. Marines are tough, and it wasn’t like I was at Iwo Jima. I buried those feelings for over 20 years, until one day everything changed. Slowly but surely my past was catching up with me. I had my first panic attack, and then another, and another. I couldn’t sleep. I was agoraphobic. Walmart was a battle zone for me. I caught myself releasing the rage inside of me on those that I love and care about the most."

Stigma

"In Army culture, especially in the elite unit filled with rangers and paratroopers in which I served, asking for help was showing weakness. My two Bronze Stars, my tours in Airborne and Special Operations units, none of these would matter. To ask for help would be seen as breaking. But, finally, when in the middle of the day I was forced to hide, shaking and crying in a concrete bunker, railing against the noise and the images in my head, and when I understood that to continue was to endanger the soldiers I was sent to Afghanistan to lead, I asked for help."

"We send our soldiers to war for our freedom and then lock them up when they are broken and of no use anymore."

Hope, Healing, and Medical Care

You may always be fighting some war in your head because you are now and forever a warrior. But you can learn to live as a warrior and not be at war.

If you lose hope, you lose the will to fight, and when that happens you have lost. Do not lose! Continue to march! Semper Fi!

It took two years of counseling and a couple of different meds before I found the right combination to help me keep on. It was close. I almost let it beat me. At one point I almost killed myself because I thought that was the only way to make it stop. Thank God I didn’t give up. There is help, there is hope.

I hope no one has to feel and sense the effects of PTSD; the thoughts, feelings, and emotions are the darkest, harshest, and deepest. My heart goes out to all of our military who survived the physical battle and now proceed to another battle—the longer and harder war of the mind. I pray that each veteran seeks treatment and support for this battle they face. Rely on other vets, because they are fighting alongside you.

~ ~ ~

Chapter 2: The Cost of PTSD

PTSD is a major public health concern in both the civilian and military populations, across race, age, gender, and socio-economic status. All aspects of the victim’s life are affected, from sleep, to family life, to job performance. Despite current treatments, many veterans continue suffering and some have given up hope.

Our entire society feels the impact when a group of citizens are plagued by long-lasting psychological suffering and compromised coping skills. This includes impulsive behavior, waking nightmares, insomnia, loss of contact with reality, thoughts of being transported back to the battlefield, and a range of emotions that includes horror, anger, shame, guilt, sadness, fear, anxiety, and suicidal ideation. Research shows that 80% of patients with PTSD also have at least one other significant medical or psychiatric disorder. Approximately one-third may succumb to alcoholism or drug abuse (Mills 2013), because there is a strong association and a common physiological basis between PTSD and substance use disorder (Toledano D 2013) (Sofuoglu M 2014). Sufferers of PTSD tend to use alcohol and other substances to help manage chronic anxiety (G. M. Pietrzak RH 2010).

PTSD and Families

It is well known that PTSD causes relationship problems and disrupts families. This disorder makes it hard to deal with financial matters and day-to-day pressures of life. Plus, there is difficulty empathizing with others, combined with poor anger control. For families, the degree of hardship and negative consequences rise with the amount of the service members’ exposure to traumatic life-altering experiences. The spouses and children of service members with PTSD are at risk for symptoms secondary traumatic stress. There are high rates of psychological disorders among military families, including learning and emotional problems in the children (Board on the Health of Select Populations; Institute of Medicine, Denning LA, Meisnere M, Warner KE, editors 2014).

Symptoms of avoidance separate PTSD sufferers from the people who care about them. Avoidance is associated with distressing psychosocial difficulties, decreased perceptions of post-deployment social support, and lower partner satisfaction (G. M. Pietrzak RH 2010). Numbing, withdrawal, and isolation can lead to the estrangement of family members. Sexual dysfunction is common.

A 2012 study showed that nearly two in three marriages of PTSD sufferers end in divorce. As the amount of time spent in deployment increases, so does the divorce risk among enlisted military personnel (Álvarez MJ 2012) (Fredman SJ Anxiety Disord) (Negrusa B 2014).

In turn, losing secure relationships and social support, combined with excessive worry and fear of change, further exacerbate the poor social functioning associated with PTSD (H. R. I. Tsai J 2012).

Hyperarousal contributes to family problems. Family members walk on eggshells lest they startle PTSD victims. This PTSD-related irritability, anger, and aggression may lead to a greater frequency and severity of domestic conflict as well as intimate partner violence (Álvarez MJ 2012) (Fredman SJ 2014) (Negrusa B 2014).

Poor Work Performance and Lost Jobs

Emotional outbursts, lack of concentration, frequent absences, and similar issues make working difficult for veterans with PTSD. Hyperarousal can also lead to concentration difficulties and impaired performance. Many people are unemployed or stuck in low paying jobs because of their symptoms. Experts state the United States’ economy loses $3 billion each year as a result of PSTD related work problems.

The inability of some PTSD patients to hold a job has contributed to an epidemic of homelessness among combat veterans (Pietrzak RH 2010). Analysis of data from the National Survey of the Vietnam Generation showed that PTSD in Vietnam veterans lowered the likelihood of working by 8.5% on average, and veterans who were able to work had lower hourly wages (Savoca E 2000).

In our society PTSD extracts a high economic cost due to lost productivity, work absenteeism, suicide, and increased mental healthcare costs (Taylor 2006). A RAND study noted that the societal costs of PTSD and major depression for two years after deployment range from about $6,000 to more than $25,000 per case. Each American helps fund this with tax dollars.

High Medical Costs

The cost of treating PTSD is much greater than the cost of preventing it. Some veterans receive low-cost care from the VA, although this care impacts taxpayers. Others pay out of pocket for private care. Regardless, PTSD is an expensive condition to treat because it affects both mind and body. Many patients need years of therapy. Besides physical issues such as heart disease and hypertension, most people with PTSD have at least three psychological disorders, such as substance abuse, anxiety, and depression. Family members may also need therapy.

Legal Issues

Often overlooked are the legal issues involved with PTSD. Bankruptcy and divorce are all too common, and PTSD may lead to criminal behavior because of impaired judgment and inability to plan for the future—not to mention illegal drug use and aggression. Two studies show that the number of veterans in the criminal justice system is a national crisis. A 2008 study revealed that forty percent of veterans who suffer from PTSD have committed a violent crime since being discharged from the military. This translated into 120,000 criminal acts by veterans with PTSD (Daniel 2008).

The annual cost of PTSD to our society is in the billions of dollars and increases each year. Heart disease, cancer, diabetes, and other disorders are often in the news, but the dangers of untreated PTSD are mostly hidden from sight. Yet, PTSD is a major health crisis that affects more people than asthma or diabetes. In an economic sense, PTSD touches every citizen in the United States.

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Chapter 3: Post-Traumatic Growth—the Good News

That which does not kill us, makes us stronger.

—Friedrich Nietzsche

What if battlefield trauma and other stressful situations could actually be opportunities for growth? We know that a highly stressful life crisis can undermine a person’s fundamental assumptions about his or her identity and world, including the benevolence, predictability, controllability, and safety of our lives and the future. Shattered belief systems lead to the negative psychological consequences of trauma and PTSD.

However, trauma sometimes leaves a positive legacy. Some people survive, thrive, and experience psychological growth following traumatic experiences. Known as post-traumatic growth (PTG), the struggle of veterans to overcome extremely challenging life circumstances can lead to personal adjustments that help them recover sooner and build their emotional strength. Such PTG can occur in five areas:

1. recognizing new opportunities,

2. developing closer, more positive relationships,

3. increasing self-worth and personal strength,

4. finding a greater appreciation for life,

5. discovering deeper spirituality.

Especially among older adults, the strength gained from difficult experiences in the past may increase stress resilience and help moderate PTSD symptoms from new trauma exposure (Shrira A 2014).

Post-traumatic growth goes beyond the qualities of resilience, hardiness, and optimism, because it refers to moving beyond pre-trauma levels of adaptation. If I survived that, I can face anything, is a common statement. What doesn’t kill us, makes us stronger, also reflects this philosophy.

Resilience is the act bouncing back from traumatic experience, while post-traumatic growth means bouncing higher than ever before. The whole concept of superheroes comes from PTG. Fictional superheroes grow stronger and discover their personal missions in life after huge tragedies. In real life, actor Christopher Reeve who played Superman became a quadriplegic from an equestrian accident. After a period of depression, Reeve became a powerful advocate for victims of spinal cord injuries and his foundation has awarded more than $110 million to research.

Mental health professionals have a long history of looking only at what’s wrong with human functioning, says psychologist Anna A. Berardi, Ph.D., who directs the Trauma Response Institute at George Fox University in Portland, OR. But if you ask people, ‘Have you been through something difficult and come out the other side stronger, wiser and more compassionate?’ the majority of us would answer yes. That’s powerful proof that as humans we’re wired to grow as a result of hardship (Leavitt 2014).

Post-traumatic growth may actually be common among U.S. veterans, including some who screen positive for PTSD. An analysis of data from several thousand veterans (National Health and Resilience in Veterans Study) showed that 50.1% of all veterans and 72.0% of veterans who screened positive for PTSD reported at least moderate PTG in relation to their worst traumatic event. Among veterans with PTSD, those with PTG reported better mental functioning and general health than those without PTG. Analysis of multiple variables showed that greater social connectedness, intrinsic religious beliefs, and purpose in life were independently associated with higher PTG (Tsai J 2014).

Interestingly, PTG may be more pronounced among people who have PTSD. A study that sought to clarify the relationship between PTSD, resilience, and PTG found that combatants who reported high-level PTSD symptoms also reported higher levels of positive psychological changes after severe adversity.

The study compared ex-POWs and comparable veterans of the 1973 Yom Kippur War, assessed at 18 and again at 30 years after the war. Researchers found resilience (defined as the absence of post-traumatic symptoms) and PTG were negatively correlated: resilient veterans reported the lowest levels of PTG, while participants diagnosed with clinical and sub-clinical PTSD showed higher levels of post-traumatic growth (Zerach G 2013).

On the other hand, a Japanese study of motor vehicle accident survivors examined the hypothesis that some factors of PTG, such as personal strength, relate to resilience, whereas other factors—such as appreciation of life—relate to PTSD symptoms. Upon analyzing questionnaire scores, researchers found that resilience was associated with openness to new opportunities, closer relationships with certain people, and greater strength. Growth features related to greater appreciation of life and deeper spirituality positively correlated with PTG (Nishi D 2010).

When it comes to PTSD treatment, experts differ on whether or not to integrate the concept of growth. Trying to rush people into growth can be counterproductive unless done with great care. Post-traumatic growth is a subjective concept that can’t be measured and means different things to each trauma survivor. However, knowing that something good can ultimately come from their struggles may be a ray of hope for those who suffer from PTSD and the people who care about them.

The Post-traumatic Growth Inventory

The Posttraumatic Growth Inventory (PGI) is an instrument for assessing positive outcomes reported by persons who experience traumatic events. The 21-item scale includes the topics

• New Possibilities

• Relating to Others

• Personal Strength

• Spiritual Changes

• Appreciation of Life

According to researchers, "Women tend to report more benefits than do men, and persons who have experienced traumatic events report more positive change than do persons who have not experienced extraordinary events. The Posttraumatic Growth Inventory is modestly related to optimism and extraversion. The scale appears to have utility in determining how successful individuals are in coping with the aftermath of trauma and reconstructing or strengthening their perceptions of self, others, and the meaning of events (Tedeschi RG 1996).

The original PGI is available online at: http://www.emdrhap.org/content/wp-content/uploads/2014/07/VIII-B_Post-Traumatic-Growth-Inventory.pdf (Shortened Link: http://dld.bz/dSyJK)

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Traumatic Brain Injury and PTSD

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Chapter 4: A Perfect Storm

The diagnostic mixture of traumatic brain injury (TBI) and PTSD has been called a perfect storm, because the combination of these two conditions is often devastating for victims of trauma and their families.

Traumatic brain injury results from an external mechanical force, usually a violent blow or jolt to the head. Of course an object that penetrates the skull, such as a bullet or shrapnel will also cause TBI. Shock waves from explosions are another cause. Serious TBI leads to bruising of tissues, bleeding, and other physical damage to the brain that usually has long-term effects. Moderate to severe TBI leads to severe impairment, while mild TBI (the type most often associated with PTSD) may be diagnosed when the victim has problems with activities of daily living.

Unlike many physical injuries, a damaged brain affects all aspects of a person’s life, including mental ability, personality, and daily activities. The brain doesn’t heal like other parts of the body, and recovery is usually uncertain. Each injury is unique. Furthermore, the