Traumatology19(2) 154 –157© The Author(s) 2012Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1534765612457220tmt.sagepub.com

Article

Combat exposure carries with it a particularly high emo-tional risk due to the exposure to terror and violence, and is thus particularly associated with negative psychopathology (Hoge et al., 2004). Over 1.9 million U.S. military personnel have served in Operations Enduring Freedom/Iraqi Freedom (OEF/OIF; Institute of Medicine, 2010) and according to the Department of Veterans Affairs’ National Center for PTSD, 11% to 20% of returning soldiers are diagnosed with post-traumatic stress disorder (PTSD). When soldiers experience combat-related violent deaths of fellow soldiers, they are likely to develop a stress response that may linger for many years. However, little is known about the impact of combat-related loss and behavioral health indices such as depression, social support, and subsequent association with PTSD.

A pattern in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994 symptom clusters of PTSD has been iden-tified for those who have suffered a loss (Raphael, Martinek, & Wooding, 2004). Raphael et al. (2004) argue that the dis-tinction between normal bereavement and traumatic bereave-ment is avoidance/numbness symptoms, while reexperiencing/intrusion symptoms are present in both PTSD and normal bereavement. Accordingly, people who experience a non-combat loss do not avoid intrusive thoughts, but seek them out for comfort as welcomed memories of the lost person. However, those who have experienced loss due to traumatic circumstances will attempt to avoid intrusive images. Raphael et al. propose that survivors who experience the death of

someone close to them may respond similarly to intrusion symptoms but those who experience traumatic loss will endorse more avoidance items than those who experience a less violent loss.

Sudden, unexpected losses are generally considered to be the most difficult and exhibit the most prolonged recovery course. While the loss of a child is widely believed to be the most severe loss one can endure, Holmes and Rahe (1967) ranked the death of a spouse as the most demanding of all stressor events. Relevant to this study, researchers have veri-fied that for many soldiers, losing a close friend to combat is akin to the grief experienced by the loss of a spouse (Litz & Schlenger, 2009). Thus, when violent death in combat occurs, it is very likely that survivors may develop a chronic stress response.

Social support may mediate the health effects of coping with the combat-related loss of fellow soliders. Social support resources have been found to impact PTSD (Booth-Kewley,

457220 TMTXXX10.1177/1534765612457220TraumatologyChapman et al.

1HSRD/RRD Center of Excellence: Maximizing Rehabilitation Outcomes, Tampa, FL, USA2James A. Haley Polytrauma Center and Veterans Hospital, Tampa, FL, USA

Corresponding Author:Paula Chapman, HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes and James A. Haley Veterans’ Hospital, Polytrauma Center, VAMC (118M) Grand Oak Plaza, 8900 Grand Oak Circle, Tampa, FL 33637, USA. Email: Paula.Chapman4@va.gov

Exploring Combat-Related Loss and Behavioral Health Among OEF/OIF Veterans With Chronic PTSD and mTBI

Paula Chapman1,2, Christine Elnitsky1, Ryan Thurman1, Andrea Spehar2, and Kris Siddharthan2

Abstract

While combat-related loss is likely to result in the development of lingering stress responses, little is known about its impact on behavioral health. The purpose of this study was to present preliminary results on war-related losses and behavioral health among Operations Enduring Freedom/Iraqi Freedomveterans. Veterans who suffered losses, to include noncombat losses (relationships back home) that occurred while the combatant was in the combat theater, reported more stress, depressive symptoms, and combat experiences. Outcomes were worse for veterans reporting two losses. Most notable was the decline in social support as losses increased. Also of note, avoidance and arousal symptom clusters were the most endorsed. While the pattern was more pronounced for those experiencing loss, results were consistent regardless of number of losses.

Keywords

combat-related loss, PTSD, OEF/OIF

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Chapman et al. 155

Larson, Highfill-McRoy, Garland, & Gaskin, 2010), act as a protective factor for mental health problems (Galea, 2002), and prevent depression (Pietrzak et al., 2009; Vanderhorst & McLaren, 2005). Among veterans, higher levels of social support have been found to mediate the effects of combat exposure and to predict lower susceptibility to PTSD and greater resilience to stress and psychosocial functioning (Pietrzak et al., 2009; Pietrzak, Goldstein, Malley, Rivers, & Southwick, 2010). Identification of modifiable determinants of health status may inform the design of interventions that could mitigate mental health consequences of combat-related loss.

With that in mind, the objectives of this study are to (a) explore symptoms of post-traumatic stress, depression, and social support in terms of frequency and type of loss; and (b) explore the symptom clusters among OEF/OIF vet-erans who report losses while deployed to a combat theater of operations.

Data and MethodsParticipants

Twenty-two OEF/OIF veterans with a current diagnosis of PTSD and comorbid mild traumatic brain injury (mTBI) were recruited into the PTSD portion of an ongoing tele-rehabilitation study at the James A. Haley Polytrauma Center and Veterans Hospital in Tampa (VA, USA). Fourteen veterans agreed to participate. Nurses working in the Post-Deployment Health Clinic at the Tampa VA referred OEF/OIF veterans who might qualify for the study. Those who were referred had indicated interest in participating in a 3-year, quasi-experimental study to evaluate the effect of care coordination on PTSD and mTBI outcomes. Baseline data were utilized for this study, and all participants were diagnosed with chronic PTSD and concomitant mTBI. Inclusion criteria required that partici-pants be OEF/OIF veterans receiving medical services through the Tampa VA; reside within 2 hr of the Tampa VA; have a diagnosis of combat-related PTSD and comorbid mTBI, as noted by the Computerized Patient Record System; and be medically stable as determined by the patient’s physician. Subjects excluded were those severely injured or institutionalized at the time of the study. The sample consisted of all males, with the majority of the sample self-described as White (85%, n = 11); 36% (n = 5) were of Hispanic ethnicity. Veterans ranged in age from 26 to 55 years (M = 39, SD = 9).

MeasuresVeterans’ self-ratings of PTSD symptoms were assessed using the PTSD Checklist-Military Version (PCL-M; Weathers & Ford, 1996). Depression symptoms were assessed using the Beck Depression Inventory II (BDI-II; Beck, Steer,

& Brown, 1996). Exposure to combat was assessed using the Combat Experiences Scale (CES; L. King, D. King, Vogt, Knight, & Samper, 2006). Social support was assessed using the Unit Support Scale (USS; King et al., 2006; Vogt, Proctor, D. King, L. King, & Vasterling, 2008).

Loss was assessed using two questions: “While deployed, did you lose a buddy or valued leader?” and “While deployed, did a spouse or girl/boy friend leave you?” Veterans were categorized as experiencing one, two, or no losses while deployed, depending on the number of affirmative answers they provided to the two questions.

ProceduresParticipants were approached in the Post-Deployment Health Clinic at the Tampa VA upon arrival for a scheduled appoint-ment. After obtaining informed consent, a chart review and interview were conducted to determine eligibility. Those eligible were enrolled and administered the demographic questionnaire. Baseline survey instruments were accessed and completed via Survey Monkey.com™.

Statistical AnalysisData were nonparametrically distributed, requiring the use of Mann–Whitney and Kruskal–Wallis tests, and a two-tailed Spearman’s ρ correlation coefficient at p < .05.

ResultsPCL-M scores ranged from 43 to 76, with a median of 64.0 (M = 62.07, SD = 10.22). BDI-II depression scores ranged from 14 to 60, with a median of 31.0 (M = 33.14, SD = 13.55). CES scores ranged from 5 to 14, with a median of 11.0 (M = 10.64, SD = 2.65). USS social support scores ranged from 26 to 59, with a median of 48.0 (M = 46.43, SD = 9.48). Main study variables stratified by loss are provided in Table 1. Veterans reporting any loss scored higher on all measures. While scores of both the PCL-M and the BDI-II were higher for those who had experienced a combat-related loss, the larg-est disparity, +48% among veterans with a loss, was observed with the BDI-II (34.8 ± 13.9 vs. 23.5 ± 7.8, p < .314). Furthermore, combat veterans who experienced a loss reported significantly more combat experiences than veterans without a loss (11.4 ± 1.9 vs. 6.0 ± 1.4, p < .05). While no statistically significant differences were observed for one or two losses exclusively—possibly due to our small sample size—veterans reporting two losses scored 14% higher on the PCL-M (66.5 ± 6.4 vs. 58.5 ± 13.4, p < .538) and 33% higher on the BDI (39.7 ± 11.6 vs. 29.8 ± 15.1, p < .319).

Regardless of the experience of a loss, OEF/OIF veterans reported avoidance/numbing symptoms as most prominent, followed by arousal symptoms. However, this pattern was more pronounced for those experiencing a loss. These pat-terns were also analyzed by frequency of loss (Figure 1) and

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156 Traumatology 19(2)

type of loss (Figure 2). Similar patterns were found, but were less pronounced for those who reported two losses.

DiscussionResults of this study contribute to the knowledge about the relation between combat-related loss, PTSD, depressive symptoms, social support, and PCL symptom clusters among OEF/OIF veterans with chronic PTSD and comorbid mTBI. Compared to veterans who reported no combat-related losses, veterans who suffered losses reported more stress and depressive symptoms, and significantly more combat experiences. Stress, depression, and social support outcomes were worse for veterans who reported suffering two losses. Most notable was the spiraling down of social support as losses increased from zero to two. It is not sure whether this downward spiraling of social support is the veteran’s perception or the actual loss of social support. Intuitively, the more combat experiences endured, the more likely one is to experience the loss of at least a battle buddy or valued leader. With the continuation of the war in Afghanistan and the U.S. presence in Iraq, combat experi-ences are only likely to increase. Thus, personal experiences of loss are likely to continue to mount, resulting in the need for more rapid recognition and more specific treatments.

As indicated in previous literature, the avoidance symp-tom cluster was the most endorsed among the sample

(Hodgkinson, 1995; Raphael et al., 2004). However, con-trary to previous literature, arousal symptoms were more prominent than reexperiencing symptom clusters, a result not new to the authors (Chapman, Cabrera, & Figley, 2010). In addition, while the pattern was more pronounced for those experiencing loss, results were consistent regardless of whether a veteran reported experiencing a loss.

This brief report is not without its limitations. This study utilized a small sample of veterans with chronic PTSD with concomitant mTBI, and therefore statistical significance was hampered. There are also temporal or recall bias issues, as responding to the unit support measure required retrospec-tive thought. Another limitation is the question of loss itself. This question was limited in its dichotomous response. This resulted in the possibility of not capturing the actual number of losses by category (e.g., buddy, valued leader, relation-ship). Finally, the loss of a relationship may confound the assessment of social support. Future research should take these limitations into account.

This study has clinical implications. Preliminary results suggest that frequency and type of loss incurred may be good indicators of veterans likely to develop more enduring symp-toms of PTSD and comorbidities, such as depression and loss of social support. The experience of loss typically occurs dur-ing combat operations. Due to the nature of combat opera-tions and the training and readiness to complete the mission, there is no time allowed for normal grieving or rituals to

Table 1. Instrument Score Comparison by Loss.

No loss N = 2 One loss N = 6 Two losses N = 6 Any loss N = 12

Instrument Mean (SD) Median Range Mean (SD) Median Range Mean (SD) Median Range Mean (SD) Median Range

PCL-M 59.5 (6.4) 60 55-64 58.5 (13.4) 61.5 43-71 66.5 (6.4) 66 57-76 62.5 (10.9) 66 43-76BDI-II 23.5 (7.8) 24 18-29 29.8 (15.1) 26 14-49 39.7 (11.6) 39.5 28-60 34.8 (13.9) 36 14-60USS 47.0 (14.1) 47 37-57 48.8 (8.7) 50.5 35-59 43.8 (10.1) 45.5 26-57 46.3 (9.4) 47 26-59CES 6.0 (1.4) 6 05-Jul 11.7 (1.2) 11.5 10-13 11.2 (2.5) 11.5 7-14 11.4 (1.9) * 12 7-14

Note. PCL-M = Post-traumatic Stress Disorder Checklist-Military Version; BDI-II = Beck Depression Inventory II; USS = Unit Support Scale; CES = Combat Experiences Scale (*p < .05).

Figure 1. Number of losses by PTSD symptom cluster. Figure 2. Type of loss by PTSD symptom cluster.

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Chapman et al. 157

facilitate the grief process (Papa, Neria, & Litz, 2008). Thus, processing losses may not occur for months or even years. In addition, because the responsibility they feel for each other is similar to that felt by a parent for a child (Pivar & Field, 2004), long-term chronic conditions such as PTSD may develop if the loss is not properly addressed and processed in therapy. It is important that veterans suffering from multiple losses be identified so that more specific patient-centered ser-vices can be provided to these veterans, as it may be grief associated with loss that is the driving force behind the endur-ing symptoms associated with the PTSD diagnoses.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Congressionally Directed Medical Research Program (CDMRP) administered by the Department of Defense (DOD) Psychological Health/Traumatic Brain Injury (PH/TBI) Research Program. Some of this material is based upon work supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development HSRD/RRD Center of Excellence. Contents do not represent the views of the US Army, the Department of Veterans Affairs or the United States Government.

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