Bostonia: The Alumni Magazine of Boston University

Michele Parkinson survived the near-daily bombings in Kirkuk. She managed the blood. She handled the nausea as she picked through the pockets of a corpse, searching for an ID. What she couldn't get through, it turns out, was a trip to the pharmacy back home in Massachusetts.

A sergeant first class in the National Guard, Parkinson had been evacuated from Iraq in 2005, suffering from severe and medically mysterious headaches. When she arrived at Fort Dix, she thought she was home free. And she felt fine — as long as she was in the company of other soldiers.

On a trip to the National Cemetery in Washington, D.C., she left her group of fellow soldiers to use the restroom. "When I came out of the stall, it seemed like there were a thousand women standing there," she recalls. "It was maybe about twenty. I went into a panic. I couldn't breathe, I started shaking. I pushed my way out, and I ended up falling to my knees. When I looked around and saw my soldiers standing there, I calmed right down.

“That was the beginning of it.”

Within days of arriving home, says Parkinson, she started to experience extreme anxiety. One day at her pharmacy, she started to shake, and broke down in tears.

“I just totally lost it,” she says. “For ten days I couldn’t walk out my door without breaking down.”

Parkinson is among the 190,000 military women who have served in Iraq and Afghanistan since 2001. And she’s among the 20 percent of servicewomen who develop post-traumatic stress disorder (PTSD), a debilitating, life-threatening anxiety disorder that may affect as many as 300,000 veterans of the current wars. When we hear about military-related PTSD, it’s mostly in worst-case scenarios: damaged men doing destructive things when they return from service. But women develop PTSD at more than twice the rate men do. Their suffering, generally quieter, is far less publicized, far less researched, and until recently, far less treated. Before this war, its primary cause was sexual trauma, not combat trauma. But now, with women returning from combat deployments in greater numbers than ever before in U.S. history, the Department of Veterans Affairs is scrambling to meet a need whose scope is still unknown. Much of the research to determine the need and shape a solution is being conducted at the VA’s National Center for Post-Traumatic Stress Disorder, many of whose leading investigators are Boston University professors who do their work at the VA Boston Healthcare System in Jamaica Plain.

Illustration by Hadley Hooper

It was one of the most extreme days of my life.

Deconstructing PTSDs

Post-traumatic stress disorder didn’t exist as a diagnosis until 1980, says Terence Keane, a School of Medicine professor of psychiatry, who is the director of the Behavioral Sciences Division of the National Center for PTSD and who developed many of the most widely used PTSD assessment tools. That’s when it was added to the Diagnostic and Statistical Manual of Mental Disorders, thanks to a research push in the 1970s by Keane and other pioneers in the field.

But long before then, medical professionals understood that the effects of trauma added up to a persistent set of symptoms in many thousands of sufferers. Shell shock, battle fatigue, post-Vietnam syndrome: these were a few of the names given to the severe adjustment problems experienced by some veterans of twentieth-century wars. As researchers began looking closely at what was happening with Vietnam veterans, others noticed remarkably consistent symptoms in some women who had been sexually assaulted and raped — a condition then called rape trauma syndrome — and in Holocaust survivors, who suffered from what was referred to as KZ syndrome.

“These researchers started to communicate with each other,” Keane says, building a body of evidence for a single diagnosis that wasn’t specific to the origin of the traumatic experience.

Researchers now believe that 20 to 25 percent of people exposed to a traumatic event will develop PTSD, Keane says. The diagnosis encompasses four types of symptoms: reexperiencing, reliving the trauma through nightmares and flashbacks, sometimes brought on by triggers like a car backfiring; avoidance, compulsively steering clear of places or people even loosely associated with the trauma, working too much, or drinking too much; numbness, a lack of warmth for family members, a lack of trust, a lack of interest in favorite activities; and hyperarousal, a jittery sense of panic, a constant state of alert, trouble sleeping, trouble concentrating, and irritability.

These symptoms can become powerfully destructive. They can lead to substance abuse, broken relationships, unemployment, and suicide. And they can result in physical illnesses like obesity, heart disease, and diabetes.

Why some people are resilient in the face of trauma and others are not is a matter of continuing interest. “PTSD appears to develop in people who’ve had multiple exposures to trauma, and also different kinds of exposure,” Keane says. Past trauma is like kindling, providing fuel when new trauma occurs.

Another risk factor, it turns out, is gender. Epidemiological studies in the 1990s helped establish that women, although less likely than men to be exposed to a traumatic event, are much more likely to develop PTSD. The reason is unclear.

The Numbers

20 Percent of women in the military develop PTSD, compared with 8 percent of men.

20 Percent of women report experiencing military sexual trauma, compared with 1 percent of men.

194,000 Number of women in active-duty military service. They make up between 14 and 15 percent of all active-duty forces and 11 percent of the deployment to Iraq and Afghanistan.

1/6 One in six veterans of the wars in Iraq and Afghanistan will develop PTSD; the figure is higher among National Guard members and reservists and among service members with multiple deployments.

Patricia Resick Patricia Resick has pioneered a cognitive therapy that teaches PTSD patients new ways to think about their trauma.

Traumatic Triggers

Patricia Resick and other Boston University researchers in the Women’s Health Sciences Division of the National Center for PTSD are looking hard for answers, studying the psychology, psychobiology, and treatment of the disorder in women veterans. Their work is just now starting to fill large gaps in a field where the vast majority of research has been done on men.

One thing they would like to know is why 20 percent of women in the military develop PTSD, compared to only 8 percent of men. Resick, a professor of psychiatry and psychology and the director of the women’s division, says that some of it has to do with the kind of trauma women experience.

In general, whether in the military or out, sexual trauma is a more significant risk factor for PTSD than combat or the types of trauma that men generally experience, says Resick. “Combat, car accidents, fights — those are impersonal events,” she says. “When women are traumatized, they’re often traumatized by people who are supposed to love or protect them.” In a military setting, “your commanding officer is an authority figure who is supposed to protect you,” she says. “Your fellow officers or soldiers are supposed to have your back. So when one of them attacks you, it’s a huge betrayal.”

Sexual assault and severe sexual harassment — collectively known as military sexual trauma (MST) — is nearly epidemic in the armed services. Amy Street, a MED assistant professor of psychiatry, who leads a VA support team devoted to the issue, says that VA screenings for MST, mandated since 1992 for every veteran, reveal that 20 percent of servicewomen report sexual assaults or severe, threatening harassment, compared to 1 percent of men. Those numbers, she says, are probably an underestimate. And many women veterans report that the sense of betrayal is compounded — and the trauma and shame intensified — when the chain of command fails to act on a reported incident, minimizes it, or even punishes women who report assaults.

Street recently found that even reservists, those military part-timers who serve two weeks a year and one weekend a month, experience “high and impactful” rates of MST, among both women and men. “So even people who had other lives outside of the military tended to experience a lot of harassment and assault,” she says, “and even ten or twenty years later, those experiences were associated with higher rates of depression, poorer functioning, and higher rates of PTSD.”

Suzanne Pineles Suzanne Pineles is looking at how hormones affect the onset of PTSD, and its longevity, in women.

Women may also have a biological susceptibility to PTSD, a theory that Suzanne Pineles, a MED assistant professor of psychiatry, is exploring. Pineles, the clinical coordinator of the VA’s Women’s Stress Disorder Treatment Team, is working with a $760,000 grant from the VA to see how women’s menstrual cycles might affect PTSD — its onset, symptoms, and longevity. Researchers have tended to avoid looking at the psychobiology of PTSD in women, perhaps because the fluctuating hormones of the menstrual cycle have been seen as complicating the picture. These same hormones may be the very keys to understanding the disorder in women.

“Estrogen and progesterone both affect stress-producing hormones and physiological processes associated with PTSD,” says Pineles. “In this study, instead of trying to control for it, we’re exploring the differences.”

To do that, she will use what psychologists call the prepulse inhibition task, which measures how well people are able to “gate,” or filter out, irrelevant information. “If you give someone a startle stimulus” — like a mild electric shock — “they’ll startle,” Pineles says. “But if they have a little warning, almost imperceptible, they’ll startle less.”

A previous study had suggested that people with PTSD lack a robust ability to gate — to filter out unnecessary information — when compared to people without PTSD. It’s also known that healthy women in the luteal phase of their menstrual cycle (when progesterone is spiking) gate less well than women in the early follicular phase (when progesterone is low) or than men. Pineles wants to see how much greater the effect is in women with PTSD, so she’ll look at a group of women both with and without the disorder. She’ll compare their performances on filtering tests and on fear response tests, measuring hormone levels as she goes. It could be that menstrual phases contribute not only to onset, but to the fact that women maintain PTSD symptoms longer than men.

Pineles has also done cross-gender research into so-called attentional biases, in an effort to learn whether PTSD is an overreaction to a trauma or an inability to recover from a trauma.

“If you see a bear, your attention will be drawn to it, because it’s threatening,” she says. “That’s adaptive, but people with anxiety disorders have more of that attentional bias, so they’re more drawn to the bear.”

Pineles studied Vietnam veterans and a group of women veterans who’d been sexually assaulted, and she found the same effect in both groups: the trouble wasn’t that they responded more quickly or dramatically to trauma — it was that they could not disengage from trauma.

“Their attention gets glued” on the traumatic trigger, she says. “It’s like they’re stuck.”

I feel numb all the time.

Amy Street Amy Street is helping launch a study to collect some of the first good data on combat and sexual trauma among women veterans of Iraq.

A Looming Crisis

Of the 1.6 million service members who have deployed to Iraq and Afghanistan since 2001, at least one in six is at risk of developing PTSD. That’s hundreds of thousands of fragile, wounded veterans flooding the VA — or worse, not flooding the VA and self-destructing elsewhere. The Department of Defense has responded to the looming crisis, pledging $25 million over the next five years — its largest PTSD grant ever — to put in place the best treatments for the disorder. One of the two treatments being studied is called cognitive processing therapy (CPT), and it was developed by Resick.

“People walk away from traumatic events having shattered any preexisting positive beliefs they might have had about themselves or the world,” she says. In CPT, a systematic twelve-session program, therapists take their patients through the trauma and attempt to find out what meanings they’ve assigned it, and where they’re getting stuck.

Most people blame themselves, Resick says, because they want to think they had more control over the event than they did. CPT helps people let go of that blame, and it also helps them cope with the reality that “sometimes traumas happen and we can’t prevent them,” she says. “Bad stuff can happen, and it could happen again, and then people only have the choice of coping or not coping. That idea is so scary for some people that they will go way out of their way not to believe it.”

CPT is dramatically successful in treating rape victims and battered women, the populations for whom Resick developed it. In one study, she found that 80 percent of women lost their PTSD diagnosis and had, on average, a 75 percent reduction in symptoms after twelve sessions.

Resick’s current project will look at active military personnel and compare CPT’s effectiveness in group versus individual treatment. The study could have significant policy ramifications, because many VA hospitals provide only or mostly group treatment.

“If it turns out that groups don’t work as well, that will have budgetary implications, and the VA will have to plan accordingly,” Resick says. “Group treatment is more cost-effective, and if it turns out that group is as good as individual, then it’s justifiable.”

Resick is also teaching the therapy to clinicians across the country. “Last year we trained 1,200 therapists, 800 just in the VA,” she says. “We’ll train another 800 this year, and 800 the year after. There’s never been a systematic movement like this, to teach therapists to use evidence-based treatments. The VA has invested in this, and I think we’re having an impact.”

One big question that remains unanswered involves the experiences of women in combat settings. Women are prohibited by law from serving in direct ground combat troops, but in the Iraq and Afghanistan wars, any deployment is a combat deployment, “This is guerilla war, so anything you do is dangerous,” says Amy Street, the specialist in military sexual trauma. She and colleagues at the National Center for PTSD are launching a study that she hopes will provide some of the first solid information on combat-induced trauma in women and on the kinds of MST women experience in war zones. “And the thing we really don’t know is how women are doing following deployment.” she continues. “Because we get asked the question all the time, about whether these direct ground combat positions should be open to women. It’s a hot political topic.” ■

I wan't to be like I was.

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On Friday, 11/7/2008 at 12:46pm, Terri Tanielian (CAS'90) wrote:

This was an excellent discussion of the issues surrounding PTSD among women and a nice tribute to the work that Patty Resick has been championing for years. I was also grateful for your use of the statistic that PTSD may affect as many as 300,000 veterans of the current wars. I believe you drew this statistic from a recent RAND study for which I was the primary author and study director. The 300,000 figure featured in our study (and most of the news coverage since its release) referred to the total number that were affected by either PTSD or depression at the time of study. In our work, we found that rates of depression were similar to the rates of PTSD, yet depression is rarely discussed as a mental health consequence of war. Our study also estimated that if left untreated or undertreated, the two-year costs to society associated with these conditions is $6.2 billion. Ensuring that more clinicians use the type of therapy discussed by Dr. Resick has the potential to lower this figure by $2 billion in just two years. To obtain these cost savings, however, will require system-level changes across US health care.

My colleagues and I are continuing our own work on these topics and expect to have additional data to report next Spring/Summer. Longitudinal data on the mental health consequences among Iraq and Afghanistan veterans and particularly the impact on women are sorely needed, as well as data that examine the impact of services on their outcomes. I applaud Dr. Resick for her work and tireless dedication to these issues.

On Wednesday, 10/20/2008 at 7:25pm, Susan Avila Smith wrote:

For veterans with military sexual trauma wanting support and information from peers please visit: We will help you get onto your road to health.

On Wednesday, 10/20/2008 at 1:18pm, Anne Sherman Thomson wrote:

Having coordinated a home care program at the VA in Butler, PA for 27 years I know the VA has fine programs for dealing with PPTPSD. We had WW1 vets who talked about signs of PTSD (think they called it "shell shock"). Sgt. Parkinson is absolutely correct in urging vets to seek help. It is available and many caring professionals that I knew did a marvelous job.

On Thursday, 10/16/2008 at 1:18pm, Rev. Martin Fors wrote:

I really appreciate this article and have forwarded it to Laurie Sloane of the National Center for PTSD at the VA in White River Junction. I hope that most of our alumni and professors read this.

On Wednesday, 10/15/2008 at 10:36am, Susan C. Stinson wrote:

Thank you so much for posting this piece. I am currently working with college students who are veterans (of the wars in Iraq and Afghanistan, in particular), and footage of their military brothers and sisters talking about this condition may be helpful to them. I'll let you know!

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