Representing 16% of the American military, just over 200,000 women currently serve in American armed forces. Experts expect the population of women veterans to increase from 9% to 17% by 2043. 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.
These roles have more prominent in the latest cohorts associated with Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and the recent conflicts in Iraq and Afghanistan.
Women and the modern military
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.
Of the veterans who participated in OEF/OIF conflicts, rates indicate women have a 1.7 to 2.5 higher chances of developing PTSD than male veterans. OEF/OIF women veterans are more likely to seek help than men. However, they typically utilize non-military centered primary care services.
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.
Nurse practitioners (NPs) and physician assistants (PAs) assimilating into primary care provider (PCP) roles need to be aware of the strong prevalence of PTSD in this small but growing population. They need to 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. PTSD is diagnosed when symptoms from the following four distinct symptom clusters are experienced 30 days after the traumatic event:
- Negative alternations in cognition and mood
- 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.
Avoidance involves persistent avoidance of memories, thoughts, or feelings associated with the traumatic event. This may include people, places, conversations, activities, objects, and situations.
Negative alternations in cognition and mood include symptoms like dissociative amnesia, or the inability to remember important personal information or events. Other symptoms may include 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 inability 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, hypervigilance, exaggerated startle response, concentration problems, and sleep disturbances.
Studies have demonstrated that women typically present with symptoms in the hyperarousal cluster. They often demonstrate exaggerated startle response and exhibit emotional distance. Research on women veterans from the OEF/OIF cohort who were diagnosed with PTSD showed symptoms associated with insomnia, difficulty sleeping, concentration difficulties, and distress from reminders of traumatic events.
This population also exhibited an avoidance of places or thoughts associated with the traumatic event. 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 involving improvised explosive devices, incoming artillery, rocket, or mortar fire while some witnessed dead bodies or human remains.
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.
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. 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.
The VA defines MST as any sexual activity against one’s will. It may involve being pressured into sexual activities, inability to consent to sexual activities, or being physically forced into sexual activities. 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.
Along with the traumatic experience, women veterans have claimed that symptoms are exacerbated from the stress associated with not wanting to break unit cohesion. This can lead to feelings of intense isolation.
Detrimental effects of PTSD
If PTSD is under-diagnosed and left untreated, it can have detrimental physical, mental, and emotional effects. Individuals with PTSD can isolate themselves from support and social situations, which increases suicide attempts. Women veterans with PTSD have been reported to have higher rates of obesity, fibromyalgia, irritable bowel syndrome, emphysema, and sexually transmitted diseases.
These conditions develop when PTSD is not recognized and diagnosed promptly. Lack of control of symptoms can lead to the development of risky behaviors in an attempt to cope with the disorder.
These may 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.
Screen and treat
About 83% of women veterans receive their health care from non-VA practices. They may refrain from accessing VA services for several reasons, including the belief that the VA provides male-centered care.
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.
The NP or PA needs to identify the patient’s military or veteran status. Ask if they are currently serving or have served in the military, as they might not always identify themselves as veterans. Establishing trust and rapport with the patient will allow her to become more responsive to the interview and divulge important pieces of information to make an accurate diagnosis. Once the practitioner has confirmed the patient is a veteran, conduct a structured interview to evaluate her military experience, using the U.S. Department of Veteran Affair’s Military Heath Pocket Card.
Military Heath Pocket Card
The Military Health History Pocket Card serves as a guide to a structured interview. This interview is designed 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. They can also explore potential mental and physical issues that need to be addressed.
Questions in each category allow 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. 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. This 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 patient that presents with any symptoms of anxiety, fear, or insomnia.
Diagnosis and treatment
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 patient screens positive using the PC-PTSD tool and her military history supports this, the NP or PA should conduct an interview to explore those positive responses. This will assist in making 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. First-line treatment for individuals with PTSD is a selective serotonin uptake inhibitor.
When diagnosed with PTSD, NPs and PAs should refer female veterans 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.
Practitioners can also direct their patients towards the Veterans Affairs website: https://www.ptsd.va.gov.
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- US Department of Veteran Affairs. Military Health Pocket Card for Clinicians. http://www.va.gov/OAA/pocketcard/
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