Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 Anxiety Disorders, Trauma, and the Obsessive–Compulsive Spectrum Anxiety is as universal as sadness. There are many things to fear in life, and not worrying about them would be a mistake. So at what point can one say that anxiety is irrational? Although the usual guideline is that emotions are excessive when they cause dysfunction, the boundary between normal and pathological anxiety can be arbitrary (Horwitz & Wakefield, 2012). Anxiety is a psychological experience, separated from syndromes with prominent physical symptoms. Yet it has long been known that internalizing disorders often present with unexplained physical distress, particularly in specific cultures and social settings (Gone & Kirmayer, 2010). This may account for the overlap between anxiety and physical symptoms (Simms et al., 2012). Also, in clinical settings, anxiety and depression often coexist. One of the most common presentations of psychological distress in primary care is a mixture of both (Goldberg & Goodyer, 2005). It is not known which is primary, which is secondary, or whether both are manifestations of a common process. Although there is symptomatic overlap between anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive– compulsive disorder (OCD), these conditions have a different clinical presentation and are now in separate sections of the manual. (This chapter discusses all three.) It is not certain that this separation into categories on the basis of overt symptoms is valid, given that family members with one anxiety disorder tend to have another (Bienvenu et al., 2012) and because research on community 144 EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 5 populations shows a strong overlap between all syndromes related to anxiety and internalization (Tambs et al., 2009). Panic Disorder and Generalized Anxiety Disorder DSM-IV described five forms of anxiety disorder (panic, generalized anxiety disorder, OCD, phobia, and PTSD), two of which have now been moved into other groups. It may be worth looking back in history to see how all these distinctions came into use. DSM-II had a category called “anxiety neurosis,” which DSM-III divided into two types. One was more chronic (generalized anxiety disorder or GAD), characterized by constant worry and physical symptoms. The other was more acute (panic disorder), characterized by recurrent attacks. The main reason for this separation was the idea that GAD and panic have different pathological pathways and require different methods of treatment (Klein, 1987; Norton et al., 1995). The clinical picture of panic disorder is one of the classic syndromes in psychiatry. Its definition has not changed in DSM-5. GAD has been retained, but at one point, it was proposed to rename it as “generalized anxiety and worry disorder” (reflecting a key feature: worry about events that are unlikely to happen). Other proposed changes involved a less chronic course (excessive anxiety and worry occurring on more days than not for 3 months or more, instead of 6 months as in DSM-IV), a list of symptoms related more specifically to worry, a set of behaviors associated with worry, and a reduced number of required associated symptoms (one out of four rather than three out of six). Andrews and Hobbs (2010) tested these proposals in community and clinical samples and did not observe increased prevalence. As we have seen, however, even minor changes in wording in DSM manuals can lead to diagnostic “epidemics.” In the end, none of these changes appeared in the final version of DSM-5. EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 146 | Part II Specific D i ag n ose s GAD is still not a precise diagnosis, and it has high levels of comorbidity with other disorders, including phobias, depression, and substance abuse (Stein, 2001). Patients with GAD or major depressive disorder do have different symptom patterns (Kessler et al., 2010), which justifies the decision to separate them. Also, Moffitt et al. (2010), reporting on long-term follow-up studies of children who had been anxious and depressed, found that anxiety and mood problems show longitudinal stability and remain distinct over time. Phobias Phobias are familiar diagnoses. Because the classic picture of a specific phobia need not lead to serious dysfunction, specialists in psychiatry rarely see these cases. Agoraphobia, on the other hand, is not a phobia at all but, rather, a complication of panic disorder (Wittchen et al., 2010). One change in DSM-5 is the removal of the requirement that phobias be recognized by patients who suffer from them as irrational. Not all patients understand that point. But Zimmerman et al. (2010) found that making the change had little effect on diagnosis. Social phobia (now called social anxiety disorder) appears to be common (Davidson et al., 1993). However, given the high prevalence of symptoms of social anxiety and shyness in community populations, this category may be too broadly defined (Wakefield et al., 2005). To give a diagnosis to anyone who has trouble speaking in public or attending a social event could be another example of mission creep (not to speak of disease-mongering). Since antidepressants have been widely promoted for treatment of social anxiety, this diagnosis has opened a lucrative market for the pharmaceutical industry. Some have even suggested that it was invented specifically to market medication to a large number of people previously considered to be normally shy (Lane, 2007). Finally, separation anxiety disorder (formerly “school phobia”) has been moved from the childhood section to the anxiety disorders EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 7 chapter. We need more research about how this syndrome develops and changes in adult life. Posttraumatic Stress Disorder and Acute Stress Disorder These diagnoses are placed by DSM-5 in a separate chapter related to trauma and stress. Yet almost all mental disorders have some relationship to adverse life events. Moreover, disorders considered to be “posttraumatic” also reflect biological predispositions as well as social factors that shape their clinical presentation. The idea that PTSD is one of the few disorders for which we know the etiology is mistaken. Most people who are exposed to trauma do not develop PTSD, and those who do usually have high neuroticism, previous traumas, and prior symptoms (McNally, 2009). PTSD was a new diagnosis in DSM-III, and it has been controversial ever since. The criteria have often been criticized, and they have changed in every edition of the manual. Yet clinicians seem to love this diagnosis, probably because it suggests an etiology. Researchers may be more likely to understand that its causes are highly complex, but practitioners can be tempted by the simplicity of cause and effect. The DSM-5 definition combines a putative cause (a traumatic event) with a set of characteristic symptoms. Criterion A describes the trauma: an event that is life-threatening, could lead to serious injury, or involves sexual violence. Although a subjective reaction of distress is no longer specifically required, “traumas” should be stressors that would be threatening to anyone. However, the door is left open for a much broader concept. DSM-5 allows for directly experiencing the traumatic event, witnessing in person an event occurring to others, learning that a violent or accidental event occurred to a close family member or close friend, or exposure to details of traumatic events in the line of work. An exclusion states that this criterion does not apply to exposure through electronic media, television, movies, or pictures, unless it is work-related. EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 148 | Part II Specific D i ag n ose s Clearly, this definition widens the scope of the “A criterion” and could lead to increased prevalence and increased diagnosis. The question remains: What is meant by the word “traumatic” (Breslau & Kessler, 2001)? It is clear when one experiences a direct threat to one’s own life. But being a bystander or an observer is not clear (Friedman et al., 2011). These problems have affected the validity of research on PTSD ever since the diagnosis was included in DSM-III (Spitzer et al., 2007). DSM-IV criteria were broad, producing a community prevalence as high as 7.8% (Kessler et al., 1995). In short, the most serious concern is that DSM-5 has not narrowed down the definition of a traumatic event. One can only hope that clinicians will use their common sense and not overdiagnose a condition that already suffers from inflated prevalence. Four groups of symptoms characterize PTSD: intrusion (re-experiencing the trauma), avoidance of situations that elicit memories, alterations in cognition and mood (this feature is new in DSM-5), and increased arousal. All symptoms must last more than 1 month. These clinical features of PTSD must be present, and one cannot diagnose it in their absence (which can happen in practice). Moreover, the diagnosis of PTSD describes a heterogeneous syndrome (Rosen & Lilienfeld, 2008). Some cases are prototypical, but as with so many other mental disorders, symptoms vary, and there are no biological markers. Clinicians should keep in mind that the nature of a trauma makes little difference to response (Roberts et al., 2012). There tends to be too much focus on the severity of trauma in clinical practice. Patients who report a trauma may receive a diagnosis whether or not symptoms are actually related to an event. Moreover, the definition of a trauma is not always observed so that divorce or bereavement can sometimes be counted as “traumatic.” With the expansion of PTSD, the majority of the population could end up being considered as “survivors.” McNally (2009) notes that overdiagnosis weakens the concept and fails to focus on its key idea: the psychological impact of severe trauma. Yet even exposure to life-threatening combat in wartime does not predictably lead to PTSD (McNally, 2009). EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 9 Another problem concerns the extent to which PTSD is a reaction to trauma as opposed to the uncovering of a temperamental vulnerability to stressful events. PTSD is a syndrome that reflects intrinsic sensitivities as much as adversities. Most people exposed to trauma, even severe trauma, never develop PTSD (Paris, 2000). The most common response to exposure is not mental disorder but, rather, resilience and recovery. In fact, PTSD is as much a consequence of personality as of events. For example, McFarlane (1989) showed that PTSD in firefighters was best predicted by traits of neuroticism prior to exposure rather than by the danger of the fire. The same conclusion has emerged from studies of PTSD in large community samples (Breslau et al., 1991). In summary, the major unsolved problem with PTSD, as with so many other disorders in DSM-5, is an unclear boundary with normality. It is easy to expand a category to the point that it describes phenomena that are not pathological. In reality, life is full of adversity—it never really gives us a break. The conclusion should be that PTSD has suffered from diagnostic inflation. PTSD is reserved for patients disabled by symptoms for months after a negative life event. Prior to 1 month, these reactions constitute an “acute stress reaction,” which is a much more common syndrome. There has always been a gap between reactions to adversity and the characteristic symptoms of PTSD. One cannot entirely blame DSM for that problem. There are political and historical reasons why PTSD has been defined in such a broad way. Like some other categories in psychiatry, it can be used to convey social meaning. The diagnosis carries a powerful emotional punch, and it provides validation for reactions to adversity. Patients may like the diagnosis because suffering from PTSD allows them to consider themselves as victims of circumstance. It is not an accident that the introduction of this diagnosis into the manual came at a time when large numbers of Vietnam veterans were being seen at VA hospitals, creating a need for a diagnostic concept to frame treatment (Young, 1997). But most war veterans do not develop PTSD, and those who seek treatment have other problems. Because of our sympathy for EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 150 | Part II Specific D i ag n ose s these men, rates of disorder in the veteran population have been greatly overestimated, and it was even found that some claimants for benefits on the basis of the diagnosis had never been in combat (McNally, 2003). Young (1997) concluded that many cases were shoehorned into a PTSD diagnosis to justify free treatment for a wide variety of symptoms. In summary, DSM-5 has tinkered with PTSD but has not addressed its fundamental problems. As it stands, the diagnosis fails to consider individual variations in response to life events, and it fails to correct the widely believed but oversimplified and mistaken impression that trauma is the sole or main cause of the disorder. Obsessive–Compulsive Disorder OCD and conditions in the OCD spectrum are now in a separate chapter. Although every psychiatrist sees patients with OCD, it is far from easy to treat (Stein & Fineberg, 2007). The definition has not changed in DSM-5. It describes a syndrome of obsessions and compulsions (most patients have both) that lead to significant dysfunction. The classical picture, in which patients can spend hours on rituals, is easy to diagnose, although the most severe cases present symptoms that seem uncomfortably close to psychosis. OCD is now considered to lie in a spectrum (Fineberg et al., 2010). It includes body dysmorphic disorder, trichotillomania, stereotypic movement disorder (tics), and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). But research on these conditions is thin. For example, although family studies show that all these disorders cluster together (Hollander et al., 2009), more lack spectrum disorders than those who have them. In the OCD spectrum, the decision to add a new diagnosis of “hoarding disorder” (Mataix-Cols et al., 2010) aroused some controversy. This syndrome may not qualify as a separately diagnosable mental disorder because it describes a single symptom EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 5 1 (previously considered a sign of obsessive–compulsive personality disorder). Media reports have sometimes described patients dying as a result of being trapped in their own hoard, but such cases are rare. Hoarding is common in attenuated forms that have been estimated to affect as many as 5% of the general population (Samuels et al., 2008). Obviously, quite a few people hate to throw things out. (Interest in this problem even inspired a TV “reality” program.) But to diagnose a mental disorder, patients need to be functionally disabled. The DSM-5 definition includes difficulty in parting with possessions, associated with an urge to save them, the accumulation of possessions, and clinically significant distress or functional impairment. Although it may be useful to put this syndrome, which all clinicians see from time to time, in the manual, it remains to be seen whether it deserves separate categorization. Two other conditions have made an entry into this spectrum. Body dysmorphic disorder has been moved from somatic conditions, as has hair-pulling disorder (trichotillomania). Both have some common features with OCD, but no one knows why some people have obsessive thoughts and carry out rituals, whereas others worry about their appearance or pull their hair. This is uncharted territory. In summary, although the deck has been reshuffled, none of the anxiety disorders have been radically revised in DSM-5. (The changes in PTSD criteria do not seem to be major.) This is fortunate because these conditions have not yet been as much a focus of research as mood disorders. We need to know more before making further changes. EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 Other Diagnostic Groupings This chapter briefly discusses the remaining chapters of DSM-5. Most of these categories illustrate the same problems that affect the manual as a whole—problems in validating diagnoses and in separating mental disorders from problems in living. Neurocognitive Disorders Psychiatrists view neurocognitive disorders as central to their mandate. In practice, other physicians may identify cases, but the prominent presence of emotional and behavioral symptoms often leaves psychiatrists in charge of treatment. In DSM-IV-TR, these conditions were described as “delerium, dementia, amnestic, and other cognitive disorders.” But because dementia, amnestic symptoms, and other signs of brain disease can coexist in the same patients, it makes more sense to apply a common descriptor. A separate grouping of delerium describes disturbances in awareness and cognition that arise from medical conditions, with specific diagnoses depending on etiology. Although cognitive impairment has characteristic clinical features and a course associated with specific changes in the brain, early diagnosis can be difficult. Sometimes pathology is only definitively identified at autopsy. Often, a differential diagnosis has to be made with mood disorder, which can also lead to loss of concentration and memory. Finally, an early diagnosis does not necessarily change prognosis (Kempler, 1995). 198 EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 O ther D i a gno st i c G ro u p i n g s | 1 9 9 DSM-5 has made a number of changes in its classification (Ganguli et al., 2011). This group is now relabeled as neurocognitive disorders. This diagnosis implies a broader and more neutral view about course and disability than “dementia” (which suggests inevitable deterioration). Neurocognitive disorders can take mild or severe forms, and they are further specified if the etiology is known. Thus, a diagnosis requires decline in one or more cognitive domains (as reported by the patient or a reliable informant), confirmed by psychological testing (between 1 and 2 standard deviations below norms for a mild disorder and 2 or more for a severe disorder), and deficits must interfere with independence. DSM-5 lists some of the most common causes of neurocognitive disorder, including Alzheimer’s disease, vascular disease, frontotemporal degeneration, traumatic brain injury, Lewy body disease, Parkinson’s disease, HIV infection, the effects of substance abuse, Huntington’s disease, and prion disease. If no cause is known, a diagnosis of neurocognitive disorder, not otherwise specified, can be made. The most important research in this area has focused on Alzheimer’s disease, which presents with prominent early memory loss and a chronic course. This condition can meet criteria for either mild or severe neurocognitive disorder, depending on the stage of progression. (Although “Alzheimer’s” remains a subtype, most diagnoses in medicine eventually lose their connection to the physician who first described them.) DSM-5 added a category of “mild neurocognitive disorder” to account for cases in which patients have cognitive changes long before anything is visible on a brain scan. But the introduction of the minor type has some potential to create problems. There is no definitive way of distinguishing the effects of aging on memory or attention from an early stage of disorder. Like attenuated psychosis, mild symptoms could either be a precursor of illness or a normal variant. Although a broader definition makes false negatives less likely, it makes false positives more likely. The danger is that people with normal cognitive changes will be given an incorrect (and EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 200 | Part II Specific D i ag n ose s alarming) diagnosis. DSM-5 runs the danger of classifying aging as pathological. The problem would be resolved if we had biological markers that could be measured early in the course of these illnesses. But neuroimaging findings appear too late, and we need a marker that can be identified earlier and that reliably predicts a deteriorating course. That remains a task for the future. It also remains to be seen whether the revised system in DSM-5 will have greater clinical utility than its predecessors. Rabins and Lyketsos (2011), reviewing changes in DSM-5, supported most of decisions made by the workgroup. If there is no absolute requirement for memory impairment, the diagnosis can be made through a wide range of effects. DSM-5 also requires the use of a standardized procedure, which could be either a mini-mental status or a psychological test to confirm a deficit. It is always better to have a measure that is at least partly independent of clinical observation. I only wish that this principle had been applied more generally in the manual. In summary, the new system makes sense and is not difficult to use. The problem is that like many other revisions in the manual, it introduces a severity-based and dimensional approach to diagnosis that could identify false positives. Somatic Symptom Disorder Somatic symptoms are poorly understood orphans in the diagnostic classification. Chronic fatigue and pain are among the most common complaints of patients described in the past as “psychosomatic” (Shorter, 1993, 1994). Although research on unexplained physical symptoms in medicine has been thin, when patients present in this way, physicians in primary care often send them to psychiatrists for evaluation and treatment. (It is usually not the patient who initiates the referral but, rather, the doctor, after a series of unfruitful investigations.) EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 O ther D i a gno st i c G ro u p i n g s | 2 0 1 In the past, somatic syndromes were described as “hysteria”— a perjorative and misleading term that dates back to Hippocrates. Later, symptoms that resembled neurological conditions were called “conversion,” a Freudian term that was retained in DSM-IV, now changed to functional neurological symptom disorder. The criteria for this new diagnosis no longer include, as did previous editions, the difficult-to-prove statement that psychological conflict lies behind these symptoms. Other patients present with medically unexplained pain, a syndrome considered a diagnosis in its own right by DSM-IV (but not by DSM-5). Other patients constantly worry about being sick, which earned them a DSM-IV diagnosis of hypochondriasis (another term associated with Hippocrates). Most of these patients can now be diagnosed with illness anxiety disorder. The new category of somatic symptom disorder (SSD) includes many patients previously diagnosed with somatization disorder, hypochondriasis, and pain disorder, and it can be coded for severity. It combines all these syndromes, with the aim of making the category more valid (Dimsdale & Levenson, 2013). Another category, important for consultation–liaison psychiatry, is psychological factors affecting medical conditions. The rare entity of factitious disorder describes patients who fake physical disorders. Psychiatrists may see these cases in consultation, and they are included under somatic symptom disorders (Krahn et al., 2008), even though these patients are consciously pretending to be sick. It also has the twist that some cases involve other people, such as children, leading to the concept of “Munchausen’s by proxy.” Body dysmorphic disorder, which was in this group in DSM-IV, has been moved to the obsessive–compulsive disorder spectrum. The DSM-5 approach offers a simplification of a complex system that clinicians found difficult to use. Somatization disorder, a term introduced in DSM-III, described a picture marked by multiple physical complaints over many years and was studied and described by psychiatrists at Washington University in St. Louis but uncommon in other settings. Epidemiological research using DSM-IV definitions has confirmed that this entity is rare, with prevalence estimated at 0.2% (Kessler et al., 2005a). Among the many thousands of EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 202 | Part II Specific D i ag n ose s consults I have conducted during the past 40 years, I can remember seeing only a few cases. Moreover, the construct of somatization disorder was idiosyncratic, restrictive, and tended to reinforce a mind–body dichotomy. In summary, somatic symptom disorders can be divided into complex somatic symptom disorder (CSSD; multiple symptoms, excessive concern about health, and chronicity), simple somatic symptom disorder (one main symptom with duration of at least 1 month), illness anxiety disorder, and functional neurological disorder. Subcategories describe cases in which somatic complaints, hypochondriasis, and pain are most prominent. The most frequent criticism I have heard from colleagues is that pain syndromes are distinct in clinical features and treatment and do not mix easily with other somatic symptoms. DSM-5 diagnoses of somatic syndromes were found to remain stable over a 1-year period (Rief et al., 2011). However, the specific symptoms that patients present vary with time and place. They are a function of a social “symptom pool” and reflect ways in which social forces shape the way patients experience distress (Shorter, 1993). Most people express distress through the body, and in many cultures, dysphoric emotions such as depression present as fatigue or pain rather than as mental states (Kleinman, 1991). Dissociative Disorders Whereas somatic symptom disorders are common, dissociative disorders are uncommon—so uncommon, in fact, that they may not even exist (Lynn et al., 2012). More than 100 years ago, the French psychiatrist Pierre Janet coined the term “dissociation” to describe a state of mind in which different aspects of identity become separated, splitting consciousness to make some parts of memory and personality unavailable to other parts (Carroy & Plas, 2000). Dissociation is a dramatic phenomenon that has fascinated the general public—as well as some mental health professionals. Psychologist Morton Prince (1906) EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 O ther D i a gno st i c G ro u p i n g s | 2 0 3 wrote a book describing a patient with multiple personalities. Fifty years later, The Three Faces of Eve (Thigpen & Cleckley, 1957) became a bestseller that was turned into a successful Hollywood movie. In the 1970s, the theory that dissociation into multiple personalities is the result of child abuse was popularized in another bestseller, Sibyl (Schreiber, 1973). This book was at least partly responsible for an epidemic of diagnosis of multiple personality disorder (Piper & Merskey, 2004). Rieber (2006) showed that the case history of Sibyl (real name Shirley Mason) was a fabrication. The story was created by a troubled but compliant patient, an overenthusiastic therapist, and an author looking to make money. Sibyl invented her multiple personalities—as well as a history of child abuse that claimed to explain them—to please her therapist, Cornelia Wilbur, who found a journalist (Flora Schreiber) to write the book. These conclusions have been confirmed by examining all documents in the case, showing that Shirley Mason’s childhood was normal (Nathan, 2011). Multiple personality (now relabeled “dissociative identity disorder” or DID) seems to be an artifact brought on by suggestive therapy techniques (Piper & Merskey, 2004). Patients are actively encouraged to present additional personalities, and hypnosis is used to elicit them. These procedures do not produce dissociative phenomena in everyone, but they can do so in susceptible patients. Dissociation is a common symptom in other mental disorders, but it can be reinforced when therapists become fascinated with it. The claim that dissociation is due to childhood trauma is doubtful. Most people who were abused as children never develop such symptoms, and therapies that aim to uncover putatively repressed traumatic events make use of hypnosis—a technique that elicits dramatic stories and false memories (Paris, 1996). The concept of repressed memories of trauma has led to a rash of accusations against families, and for a while, working in a day-care center sometimes threatened to become a high-risk occupation. Contrary to the drama that has driven the epidemic of multiple personality disorder, there is no consistent relationship between trauma and dissociation (Lynn et al., 2012). Rather, a capacity to dissociate in EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 204 | Part II Specific D i ag n ose s specific patients can be exaggerated by social forces, which is what happened in the 1990s. Up to a few decades ago, these conditions were considered very rare. They were included in the classification system only after being described in medical journals. In DSM-II, dissociative disorders were a subtype of “hysterical neurosis.” But with the demise of both terms (“hysteria” and “neurosis”) in DSM-III, dissociative disorders were orphaned. The paradoxical result was that they had to be placed in a separate grouping. That decision proved fateful. Ever since 1980, as textbooks of psychiatry seemed to be required to follow the DSM system, each version has had a chapter on dissociative disorders. Most psychiatrists never make diagnoses of dissociative disorders, and most have never seen a case. But a group of mavens and true believers have promoted the concept. Textbook chapters end up being written by these “experts,” whereas psychiatrists who believe the diagnoses are a serious mistake have unsuccessfully lobbied for their elimination. Sometimes it takes only one powerful voice to determine what gets in, or stays in, the DSM manual. In this case, it belongs to the influential Stanford psychiatrist David Spiegel, who has promoted dissociative disorders for decades (Spiegel, 1994). There was no chance of a change once a task force was struck that included Spiegel. Those who recommended elimination of the group were ignored. In the end, the DSM-5 approach to dissociative disorders (Spiegel et al., 2011) contains only minor revisions. We all have to live with DSM-5, so textbooks will continue to have a chapter on dissociative disorders, and psychiatric residency programs will have to teach trainees about them. Yet although dissociative symptoms are seen in practice, they are not separate disorders. As for DID, DSM-5 should have been willing to declare it mythical. One can only hope that once its proponents have passed from the scene, the diagnosis will wither away with time. Although the syndrome of multiple personality is an artifact of therapeutic suggestion, trance and possession states are not. They are common ways of expressing distress in some cultural groups EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 O ther D i a gno st i c G ro u p i n g s | 2 0 5 (During et al., 2011). These conditions, even if they are syndromes, could find a place in another chapter of the manual. Sleep–Wake Disorders This group of disorders was only introduced to the manual in DSM-IV. How did practitioners manage without them until 1994? Most anomalies of sleep seen in psychiatric practice are associated with other diagnoses (Breslau et al., 1996). However, some sleep disorders are not associated with other mental disorders, so a new grouping was created. These syndromes are uncommon, and they may belong less to psychiatry than to neurology. The detailed criteria in DSM-IV were written for subspecialists who run sleep clinics. Speaking on behalf of the workgroup, Reynolds and Redline (2010) suggest that the new classification will be user-friendly for general psychiatrists. It is difficult to see how this can be true. The categories of sleep–wake disorders include primary insomnia, hypersomnolence, narcolepsy/hypocretin disorders, obstructive sleep apnea hypopena disorder, central sleep apnea, sleep-related hypoventilation, set of circadian rhythm sleep disorders, disorder or arousal, nightmare disorder, rapid eye movement sleep behavior disorder, restless leg syndrome, and substance-induced sleep disorder. These are all rare syndromes, and a few are new categories. This shows how the DSM process works. Specialists tend to be splitters rather than lumpers. Because most psychiatrists pay less attention to this chapter, diagnoses can proliferate without objection. What Was Left Over I have not discussed every last disorder in DSM-5 but, rather, concentrated on the ones that are most important for practice. Yet even after listing a few categories that are little but symptoms, DSM-5 still had to have its own chapter of “other” disorders. As anyone EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 206 | Part II Specific D i ag n ose s knows who has tried to develop a filing system, this is usually inevitable. Some of these other diagnoses ended up in Section III. Nonsuicidal self-injury (NSSI) is one of these. This behavioral pattern is common but not always explained by other diagnoses. There has been a recent increase in the prevalence of NSSI among adolescents (Lloyd-Richardson et al., 2007). Cutting oneself on the wrist (or less visible areas) is not usually suicidal behavior but functions as a means of regulating negative affects (Linehan, 1993). Some adolescents who self-harm develop borderline personality disorder, associated with unstable mood, unstable relationships, and other forms of impulsivity. Most simply experiment with cutting, driven by social contagion (Winchel & Stanley, 1991), and most will remit when followed over time (Moran et al., 2012). This proposal originally had criteria requiring self-injury on 5 or more days in the past year without suicidal intent and associated with an attempt to deal with negative affect. However, when this concept, as well as a second iteration called “suicidal behavioral disorder,” proved unreliable in field trials, it was left out of the final version of Section I. In my view, defining mental disorder by a few symptoms, no matter how common, goes against the basic principles of nosology. DSM-5 also has a separate chapter including two diagnoses seen in children: encopresis and enuresis. These are only symptoms, but they seem to have been included to describe cases with no obvious causes. The manual notes that enuresis should only be diagnosed when not explicable by a medical condition. Adjustment Disorders This group was introduced in DSM-III to describe conditions in which patients experienced symptomatic reactions to stressors but did not meet criteria for any mental disorder. The reaction to a stressor needs to be somewhat exaggerated, but it is defined as temporary, going away when the stressor goes away (or at least within EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 15 O ther D i a gno st i c G ro u p i n g s | 2 0 7 6 months after exposure). IN DSM-IV, stressors were coded, albeit inaccurately, on Axis IV. In DSM-5, adjustment disorders are listed in the chapter on trauma and stressor-related disorders. The difficulty is how to determine the difference between a normal reaction to a stressful event and a mental disorder, however mild. Adjusting to stress is not an illness, but clinicians may use this category whenever something difficult is going on in a patient’s life but the patient does not meet criteria for a more substantive diagnosis. Adjustment disorders could be normal variants that only serve the purpose of describing people who are not ill. The category may have been kept in the manual to justify seeing such patients in consultation or treatment. However, this may be another example of how psychiatry medicalizes life. Patients With No Mental Disorder Believe it or not, there are some patients who come to clinical attention without meeting criteria for any disorder listed in DSM. A diagnosis may nonetheless have to be given when insurance requires one. The “V codes” listed at the end of the manual are designed to describe consultations for life problems that are not disorders. The list includes marital strife, conflict with children, and unemployment. Obviously, all these problems can also occur in people who do have mental disorders. Proposals to add a new group to the manual, called “relational disorders” (Beach et al., 2006), were motivated more by insurance than by science. Psychiatrists who practice marital and family therapy wanted to have their work validated by a diagnosis. Those who practice psychotherapy to treat normal life problems were in the same position. If this idea had been accepted, it might have achieved the goal of making the prevalence of mental disorder in the population 100%. However, this grouping did not find its way into DSM-5. EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 208 | Part II Specific D i ag n ose s A Word in Summary This brings us to the end of our survey of DSM-5 diagnoses. The classification of mental disorders is far from hard science. It is a rough-and-ready way of making sense of a wide variety of conditions. This is a necessary task, but we need not view DSM categories as “real.” Some diagnoses would be recognized as illnesses by almost anyone. Others continue to be controversial, largely because they medicalize the human condition. We need to keep in mind that DSM is not a “bible” but, rather, a work in progress. EBSCO : eBook Collection (EBSCOhost) - printed on 7/31/2018 9:41 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Psychotherapy Theory, Research, Practice, Training 2010, Vol. 47, No. 3, 296 –305 © 2010 American Psychological Association 0033-3204/10/$12.00 DOI: 10.1037/a0021161 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. NOT SUPPOSED TO FEEL THIS: TRADITIONAL MASCULINITY IN PSYCHOTHERAPY WITH MALE VETERANS RETURNING FROM AFGHANISTAN AND IRAQ WILLIAM LORBER HECTOR A. GARCIA Milwaukee Veterans Affairs Medical Center, Milwaukee, WI VAMC, San Antonio, TX, and University of Texas Health Science Center Traditional masculine socialization presents challenges in psychotherapy, for example, by decreasing the likelihood of help-seeking and by making emotionladen content more difficult to address. While this has been established in civilian populations, more intense forms of masculine socialization found in military settings may amplify such issues in male veteran populations. Male veterans returning from and Afghanistan (OEF) and Iraq (OIF) exhibit strong traditional masculine socialization and generally present in a unique manner. It is posited that OEF/OIF male veterans’ unique presentation is in large part because of an interaction between high degrees of endorsement of traditional masculine gender role norms, relative youth, recency of distressing events, and recent experience in the social context of the military where traditional masculinity is reinforced. The impact of these variables on the psychotherapeutic process for male OEF/OIF veterans is significant and likely adds to ambivalence about change and increases dropout from psychotherapy. Modifications of traditional psychotherapeutic approaches designed to address traditional masculine gender role norms and their many interactions with other variables are discussed. William Lorber, Milwaukee Veterans Affairs Medical Center, Milwaukee, WI; and Hector A. Garcia, VAMC, PTSD Clinical Team, San Antonio, TX, and Department of Psychiatry, University of Texas Health Science Center. William Lorber is now also affiliated with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin. Correspondence regarding this article should be addressed to William Lorber, PhD, Milwaukee Veterans Affairs Medical Center, 5000 W. National Avenue, Milwaukee, WI 53295. E-mail: william.lorber@va.gov 296 Keywords: military veterans, masculinity, emotion, posttraumatic stress disorder, prolonged exposure This is an unprecedented moment in the United States. Psychological science has never had so much information about how to alleviate war-related psychological suffering while such large numbers of service members return from war. This opportunity poses many challenges, particularly regarding male veterans who historically are reluctant to seek psychotherapy and who may be difficult to engage. While this may be the case for male veterans of all eras, for male veterans returning from service in Afghanistan in Operation Enduring Freedom (OEF) or in Iraq in Operation Iraqi Freedom (OIF), issues of masculinity may influence help-seeking and psychotherapy in distinctive ways that call for unique adjustments to the psychotherapeutic process. This paper will address ways traditional masculine gender role norms (TMGRNs) are expressed in male OEF/ OIF veterans and modifications to traditional psychotherapeutic approaches that best meet the needs of this population. Traditional Masculine Gender Socialization and Psychotherapy Gender socialization for men in the United States may instill a number of TMGRNs (Addis & Mahalik, 2003), including: those that promote This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Section: Masculinity and Male OEF/OIF Veterans independence and self-reliance (Brannon & David, 1976), focus on competition and power (Mahalik, Good, & Englar-Carlson, 2003), disdain for homosexuality and feminine traits (Mahalik, Locke et al., 2003; O’Neil, Helms, Gable, David, & Wrightsman, 1986) awareness of the potential value of aggression (Mahalik, Locke et al., 2003), valuing of strength (David & Brannon, 1976), maladaptive ways of coping with distress such as substance use (Mahalik, Good et al., 2003), and emotional control (Mahalik, Locke et al., 2003). Until recently, masculinity research had largely focused on reducing negative aspects of traditional masculinity to improve functioning. In a pattern similar to the study of other psychological phenomena (Duckworth, Steen, & Seligman, 2005), recent approaches have expanded upon this valuable line of inquiry and applied the perspective of positive psychology to the study of masculinity. These more recent studies have highlighted benefits that come from masculinity-related facets such as male self-reliance, the worker/provider tradition in men and male courage (Kiselica & Englar-Carlson, pp. 276 –287, this issue). Both approaches have demonstrated that TMGRNs are not by definition problematic; it is only when these norms are adhered to in ways that negatively impact the functioning of self or others that adherence is considered harmful and is therefore called gender role conflict (O’Neil et al., 1986), gender role stress (Eisler & Skidmore, 1987), or male gender role strain (Pleck, 1995). TMGRNs, gender role conflict, stress, and strain have been associated with changes to the psychotherapeutic process for civilian men, for example, by making help-seeking less likely (Addis & Mahalik, 2003). The gender role conflict construct of restrictive emotionality (fear about emotional expression and difficulty expressing emotions; O’Neil et al., 1986) has been associated with less psychological help-seeking in the past and decreased likelihood of present or future help-seeking (Good, Dell, & Mintz, 1989). Masculine gender role norms and stresses may also necessitate adjustments to the process of psychotherapy. For instance, restrictive emotionality and valuing emotional control may make men less willing to address emotional content in session, requiring changes in the ways that emotions are addressed. Traditional Masculinity in Military Culture Men are exposed to a degree of masculine socialization (Levant, 1996) that, in the United States, has been associated with lessened helpseeking for mental health concerns (Addis & Mahalik, 2003) and may call for changes to psychotherapeutic approaches (Mahalik, Good et al., 2003). However, masculine socialization may be more intense for those who serve in the military (Brooks, 2005; Eisenhart, 1975). For example, military training may focus on instilling emotional control because it is believed that the ability to control emotion under duress promotes survival and mission completion. This “secondary socialization” (Arkin & Dobrofsky, 1978) occurs in the Armed Services where strong conformity to hypermasculine ideals, particularly emotional control, is institutionalized and part of a strategy to prepare men for combat. Though there are many, one good example is a slogan used across the branches of service and aimed at the suppression of fear, particularly during basic training: “pain is fear leaving the body.” Male veterans often combine what it means to be a man and a soldier (Eisenhart, 1975) and refer to the experience and expression of emotions other than anger as “weak.” These perspectives create avoidance, rigid emotional control, and can make veterans reluctant or unwilling to experience the emotions they learned to “turn off.” Reluctance to experience emotions associated with masculine socialization can appear similar to emotional avoidance in Posttraumatic Stress Disorder (PTSD). However, emotional avoidance in PTSD functions largely to prevent the experience of distress related to traumatic events, where, by contrast, in masculine socialization it is geared toward preventing distress related to the conflict of that emotion with one’s masculine identity (Mahalik, Locke et al., 2003; O’Neil et al., 1986). In this sense, traditional masculine socialization and PTSD generate two different but related and interacting motivations for avoiding emotions. Men are not the only ones who endorse views that align with traditional masculine norms. Civilian women, and to a larger degree women veterans, often endorse views such as valuing competition and power, hiding perceived weakness as well as maintaining self-reliance and emotional control. Nevertheless, men and women differ in terms of gender socialization regarding 297 Lorber and Garcia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. these beliefs and the behaviors they generate. According to traditional gender socialization, men should behave in the ways described above, and women should not. While this paper addresses issues that arise for male OEF/OIF veterans, more research is needed to address the impact of gender expectations on the psychological functioning of women veterans. Unique Features of OEF/OIF Veterans Additional masculine socialization via the military, or “secondary socialization” (Arkin & Dobrofsky, 1978), influences veterans of all eras. However, special consideration of the influence of TMGRNs in male OEF/OIF veterans may be useful because OEF/OIF veterans have recently been immersed in military culture where traditional masculine views are reinforced. It is also possible that the intensity of emotions associated with recent exposure to traumatic events encourages male OEF/OIF veterans to fall back on masculine gender role norms, for instance, those regarding emotional control and concealment of perceived weakness. The relative youth of most male OEF/OIF veterans may also contribute to distinct presentation regarding issues of masculinity in two ways. First, endorsement of TMGRNs is stronger in younger populations (Levant & Richmond, 2007). Second, while traditional masculine norms reinforced by military culture may lead to volitional avoidance of emotion, a history of adherence to these norms may prevent the development of emotion regulation skills (Levant, 1998). This in turn may compound male veterans’ difficulty coping with the emotional effects of the combat theater, especially young male veterans who may not yet have had other life experiences stimulating the development of emotion regulation skills. Lorber, Proescher, and Hendrickson (2007) found that only lack of emotion regulation skills (vs. nonacceptance of emotional responses, difficulties engaging in goal-directed behaviors, impulsivity, emotional awareness, clarity of emotional experience; Gratz & Roemer, 2004) predicted degree of PTSD symptoms in male OEF/ OIF veterans, even after controlling for fear of emotion. Combined, these factors may lead these veterans to overemploy familiar traditional masculine approaches. 298 Viewing Symptoms as Nonnormative: “I Am the Only One” Many male OEF/OIF veterans are under the misimpression that they are alone among their returning peers in their experience of psychological symptoms. This view is spurred by certain aspects of military culture, particularly adherence to TMGRNs asserting that men should be independent and strong (Brannon & David, 1976). When adhered to rigidly, this norm tends to prompt men to conceal psychological symptoms from each other (Addis & Mahalik, 2003). This in turn promotes the view that these symptoms are nonnormative or due to personal weakness. In addition, acknowledging problems stands in opposition to men’s military identity, an identity that includes expectations of strength, independence, and invulnerability to the stressors of combat (Arkin & Dobrofsky, 1978). The expectation for men to be unaffected by combat or other military experiences may further contribute to the concealment of psychological problems. These phenomena have been found to decrease helpseeking for civilian men (Addis & Mahalik, 2003) and may do so for veterans as well. They also represent common themes in psychotherapy that are best addressed early on in the process. Substance Use Substance use is in accord with TMGRNs as a means of coping with distressing emotions while emotional processing and expression are not (Mahalik, Good et al., 2003). For these and other reasons, many male OEF/OIF veterans use alcohol and drugs to cope with distress, further complicating the clinical picture. The relationship for men between masculinity beliefs and the instrumental use of substances to cope with distress is a common one (Moller-Leimkuhler, 2002) and not unique to veterans of this era (Isenhart, 1993). However, at present, male OEF/OIF veterans appear to use substances more than veterans of other eras. For instance, in a study that compared a 95% male OEF/OIF veteran sample to a 100% male Vietnam sample, OEF/OIF veterans were found to use alcohol more often than Vietnam veterans (Erbes, Curry, & Leskela, 2009). The authors did not speculate about the reasons for the difference, but it is likely because of numerous factors. For example, greater endorsement of TMGRNs in younger populations (Levant & Special Section: Masculinity and Male OEF/OIF Veterans Richmond, 2007) may contribute to higher substance use in OEF/OIF veterans because these norms support substance use as a means of coping with distress. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Higher Rates of Dropout Close adherence to TMGRNs may complicate the psychotherapeutic process in important ways—for example, by contributing to dropout. We observe that male OEF/OIF veterans drop out of psychotherapy at much higher rates than do their female counterparts or veterans of other eras. In our observation, dropout rates appear to be independent of psychotherapeutic approach. Corroborating these impressions, a predominantly male sample (95%) of OEF/OIF veterans dropped out of psychotherapy at more than twice the rate of a 100% male Vietnam veteran sample (Erbes et al., 2009). OEF/OIF veterans also attended significantly fewer sessions and noshowed more frequently than did Vietnam veterans. These differences were not accounted for by degree of symptom distress or employment status. This study did not assess endorsement of TMGRNs or stigma, but the authors did suggest that stigma may play a role in dropout. Stigma reinforced by masculinity issues, recent military experience, war-related distress, and limited emotion regulation skills may contribute to dropout by making psychotherapy particularly aversive for male OEF/OIF veterans. These factors may engender the belief that postdeployment distress should not be experienced, that psychotherapy is inappropriate and that talking about troubling events is too painful, not constructive, or not permitted. Recommendations Rigid adherence to TMGRNs presents challenges to psychotherapists treating male OEF/ OIF veterans. We have had success by modifying existing psychotherapeutic approaches to address the effect of TMGRNs, with emphasis on ways that these norms influence emotional experience, processing, and expression. Typically, we find it useful to apply modified versions of psychoeducation, motivational interviewing, and interventions designed to increase emotional awareness, regulation, and expression. Psychoeducation Psychoeducation is the foundation of effective psychotherapies and often helps to normalize the experience of symptoms, which is especially important for OEF/OIF veterans. As stated, norms of military masculinity tend to strongly disfavor help-seeking, emotional processing, and emotional expression. Military training and culture promotes what the veterans call a “suck it up” attitude where emotions are disregarded. As a result, male OEF/OIF veterans often report that help-seeking feels to them like complaining, thus they may feel reluctant to initiate or sustain psychotherapy. We find it beneficial to normalize their discomfort in addressing psychological concerns and reframe “complaining” as reporting or describing. A number of approaches can be useful in destigmatizing the experience of aversive emotions. These include a heavy emphasis on psychoeducation regarding the neurobiology of emotions (e.g., nonvolitional role of limbic system in the experience of emotions), normalization of distress (e.g., emotional distress as a natural reaction to a war zone), and use of destigmatizing analogies (e.g., barriers to emotions as protective “dams” that were useful in the war zone but may no longer be adaptive). When working with PTSD, the connection between cognitive and emotional avoidance and the maintenance of PTSD symptoms should also be highlighted. We have also found psychoeducation addressing TMGRNs to be effective. Discussion of masculinity should include positive aspects of TMGRNs and should point out that these norms are not necessarily maladaptive, but can be if adhered to in inflexible ways. Veterans quickly recognize masculine norms and their effect on emotional well-being. They also readily report the etiology of these norms in childhood and in the military. An overarching goal of psychoeducation should be to impart the message that experiencing symptoms after deployment to a war zone is common and not a sign of personal weakness but of the strength of war-related experiences. Furthermore, psychoeducation should target socialized proscriptions against experiencing and expressing emotions other than anger— psychoeducation should be aimed at giving “permission” for these male veterans to feel and express what they choose. 299 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Lorber and Garcia Many male OEF/OIF veterans drop out of psychotherapy and then return at a later time. Because of this, the psychotherapist must work with both a short and long time frame in mind. It can be helpful to prioritize immediate goals, for example, symptom management while also working toward longer-term goals such as trauma processing. However, these longer-term goals may not be achieved during a continuous set of sessions. Progress in these less-than-perfect circumstances may be conceptualized as “planting seeds” or moving veterans through stages of change in increments. Here, dropout can often be made less likely by focusing in early sessions on psychoeducation addressing common reasons for dropout, including the influence of traditional masculine norms about self-reliance and emotional control. Forming contingency plans in case of the veteran’s desire to drop out has also proven useful. Motivational Interviewing For reasons stated above, many male OEF/OIF veterans present with high ambivalence toward psychotherapy and change, which calls for unique interventions to keep them engaged. We have had success in lessening ambivalence using a version of motivational interviewing modified to address traditional masculine gender norms. Motivational interviewing strategies were developed to address ambivalence about psychotherapy and personal change in substance use disorders (Miller, 1983; Miller & Rollnick, 2002) and have been applied more recently to combatrelated PTSD (Murphy & Rosen, 2006; Murphy, Rosen, Cameron, & Thompson, 2002). However, these recent efforts with combat-related PTSD have focused primarily on issues related to readiness for change and problem recognition, following the format of the substance abuse psychotherapies from which they were derived. Though Murphy (2008) briefly describes cognitive and emotional roadblocks to successful psychotherapy that are relevant to masculinity, including “fear of feeling weak” and “fear of crying,” a more focused effort at targeting masculinity issues is in order, particularly when working with younger veterans. This effort must carefully consider the socialization of young men in the military as well as the influence of gender norms more broadly. As part of this approach, we use decisional balance exercises, which are common tools in 300 motivational enhancement therapy, to address ways that traditional masculine gender roles influence the choices these veterans make. Decisional balance exercises ask the client to list both the “good” and the “bad” aspects of maladaptive behaviors with the understanding that once clients (particularly ambivalent ones) list the positive outcomes of their behaviors they are also more likely to recognize negative outcomes (Miller & Rollnick, 2002). This can be applied to examine the utility of certain masculine norms, such as those regarding emotional control. Decisional balance exercises tend to stimulate personal investment because both sides of the issue are explored and are enumerated by the veteran, not the psychotherapist. This allows the veteran to feel a stronger sense of agency in behavioral change. This approach is in stark contrast to arguing with or lecturing to the veteran about the negativity of factors such as avoidance or emotional restriction. Decisional balance exercises also lessen stigma because they do not frame traditional masculine gender role beliefs as inherently bad nor good, but that their adaptiveness is context-dependent, which highlights the need for flexibility. Addressing Emotion Many returning veterans have difficulty processing and expressing emotion— difficulties that for some, arise from the belief that these behaviors are inappropriate for men. For others, the difficulty stems from their never having learned how to process or express emotion due to longterm adherence to TMGRNs that do not promote emotional awareness, processing or expression (Levant et al., 2003). Straightforward interventions can go a long way, particularly once masculinity-based reluctance to address emotions is addressed and veterans feel more comfortable doing so. For example, many veterans become better at expressing emotions by referring to a list of emotion words. They often are aware of emotions but are not used to putting their feelings in words because they do not believe they have permission to do so. We have also used elements of Levant’s psychotherapy for normative male alexithymia (Levant, 1998; Levant, Halter, Hayden, & Williams, 2009) where men act as investigators of others’ emotions to better recognize their own, then, act as investigators of their own emotions. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Section: Masculinity and Male OEF/OIF Veterans Male OEF/OIF veterans also demonstrate problems regulating difficult emotions. We find that many returning male veterans appear better able to benefit from psychotherapy after increasing their emotion regulation skills, particularly when applying trauma-focused psychotherapies that place a heavy burden on the client’s ability to regulate. This is similar to what has been found in female survivors of sexual assault in psychotherapy who are more likely to complete prolonged exposure after emotion regulation training (Cloitre, Koenen, Cohen, & Han, 2002). To increase emotion regulation skills, we work to improve emotion awareness, for example, via exercises that tie emotions to situations, thoughts, physiological reactions, behavior, and desired goals. Symptom management skills such as deep breathing and grounding exercises also help to manage intense emotions and arousal. By learning to apply these skills, patients become more aware that they can tolerate and in fact regulate aversive emotions. TMGRNs themselves often serve as an obstacle to emotion regulation because these veterans frequently assume that emotions other than anger are inappropriate. Therefore, sadness or anxiety is often intensified by masculinity-related guilt and shame. Consequently, addressing TMGRNs often improves emotion regulation. In summary, the larger goal when addressing emotion is to use approaches indicated by the veteran’s clinical presentation to encourage the experience and expression of emotion in a nonjudgmental setting. This way, veterans come to see that rigid adherence to socialized gender norms regarding emotions is not necessary and that the distress related to aversive emotions can be tolerated. Traditional Masculinity, Emotions, and Prolonged Exposure for PTSD TMGRNs make it more difficult for male OEF/OIF veterans to complete prolonged exposure for PTSD because they add an extra degree of avoidance. This issue is particularly important given the number of male OEF/OIF veterans reporting PTSD symptoms (Hoge et al., 2004) and because prolonged exposure has been proven effective in treating PTSD (Institute of Medicine, 2008). These psychotherapies can be made more effective for returning male veterans if special attention is made to the manner in which traumatic material is cognitively processed among PTSD sufferers. Daniel Wegner’s work has led to an understanding of the cognitive mechanisms underlying intrusive thoughts, notably the willful suppression of unwanted cognitive material, or thought suppression (Wegner, Schneider, Carter, & White, 1987). In essence, the more one attempts to suppress cognitive material, the more the material intrudes into consciousness, a phenomenon referred to as the rebound effect. Thought suppression has been implicated in the acquisition and maintenance of PTSD symptoms (Shipherd & Beck, 2005) and along with the rebound effect coincides with two of the three major symptom clusters of PTSD—avoidance and reexperiencing. It is easy to understand the motivation for avoiding traumatic memories given their aversive qualities. Traditional masculine gender roles may provide additional motivation to attempt to suppress traumatic memories because these memories promote experiencing emotions such as anxiety and depression that do not comport with traditional masculinity. However, the more these memories are avoided, the more they intensify in the form of reexperiencing symptoms, particularly intrusive memories, flashbacks, and nightmares. Psychotherapies such as prolonged exposure are designed to diminish reexperiencing and other symptoms by focusing on eliminating avoidance. This is accomplished through repeated exposure to traumatic memories (via audio recordings of the trauma narrative), as well as exposure to places and situations that create anxious arousal because they serve as reminders of traumatic events. These techniques, designed to eliminate avoidance, are essentially the opposite of thought suppression. Though found to be highly effective for treating PTSD (Institute of Medicine, 2008), prolonged exposure may produce anxiety and discomfort at the outset and it is often difficult for clients to get started. To prevent dropout during this early period, it is necessary to encourage the client to do the opposite of what a PTSD sufferer is strongly inclined to do, which is to avoid. Providing prolonged exposure to male OEF/ OIF veterans presents unique challenges. Our observations are that veterans who endorse TMGRNs find prolonged exposure to be especially difficult. It appears that for these veterans, the intrusive nature of traumatic memories is 301 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Lorber and Garcia often more extreme and the anxiety the memories arouse more intense. We theorize that for these individuals, there is twice the incentive to avoid. First, because we are often treating combatrelated PTSD, the material itself is by nature difficult—all the worst parts of combat are revisited. Here, one could argue that it is the content of the memories and the associated negative emotions that account for avoidance. However, for veterans who rigidly espouse certain masculine beliefs (e.g., that men should be invulnerable or always in control of their emotions) distress is not only because of experienced emotions, but because these emotions are themselves contrary to the veteran’s gender expectations and selfidentity. The protocol for prolonged exposure addresses ambivalence about psychotherapy. However, we have found that we can increase the likelihood of completion of prolonged exposure by adding discussion about TMGRNs and how they may promote ambivalence and avoidance. In these discussions, we focus on ways that norms regarding emotional control contribute to avoidance by complicating emotional experience, processing, and expression for men as well as how military culture may intensify these norms. Additionally, to normalize ambivalence and to illustrate the benefits of the procedure, we have shown videotaped interviews of male OEF/OIF veterans who have completed prolonged exposure to those considering this psychotherapy. We have found that showing these recordings has a discernable impact on ambivalence. We believe this is in part because seeing another male veteran describe his experience destigmatizes helpseeking and emotional expression. It also disabuses notions such as “I am the only one” as described above, thus normalizing the experience of psychological symptoms. Furthermore, the interviews address TMGRNs and their role in avoidance. Hearing fellow veterans discuss modifying their more rigid masculine beliefs in the service of improved functioning further lessens ambivalence, particularly among those struggling with TMGRNs in psychotherapy. Case Example Tom (name, psychotherapy site, and all other identifying information have been obscured to disguise the client’s identity) is a 25-year-old male who served in the Army as an infantryman 302 for a 12-month deployment in Iraq and presented to an outpatient PTSD clinic for 25 sessions. He reported a “normal” childhood with no prior trauma history. Tom stated that via his military training, he came to believe that he was “invincible.” He reported that he learned to ignore pain and “suck it up, drive on.” In Iraq, Tom participated in numerous house raids, some involving the deaths of insurgents and fellow soldiers, including friends. He was also involved in several firefights that occurred in urban areas when he shot and killed insurgents. In addition, Tom rode in convoys that were hit by rocket-propelled grenades and improvised explosive devises, though his vehicle was never hit. Tom reported that after about three such incidents, he became emotionally numb and the dangerous missions eventually became “just like going to work.” He stated that he “felt like a machine, I couldn’t feel anything.” Mortars and rocket-propelled grenades also frequently hit Tom’s base with the closest mortar exploding within 30 yards of his location. Upon return to the United States, Tom was experiencing PTSD but did not know what was bothering him. He felt shame for being troubled by his military experiences. His most distressing symptoms were intrusive images “playing like a movie over and over,” disturbed sleep, anger, and irritability that caused him to fight with his family and girlfriend. He also drank more than ever to alleviate symptoms and to sleep. Those around Tom noticed changes— his mother pleaded with him to get help. After a bar fight leading to injuries, 10 months after return from Iraq, Tom presented to the Veterans Administration (VA). At intake, Tom described deliberately trying to avoid intrusive traumatic memories by saying to himself repeatedly, “You’re a soldier and a police officer,” reminding himself of the solidity of his masculine stature and inferring that he should be invulnerable. When this failed to work, he would repeat to himself bluntly, “You’re the man-you’re the man.” Tom also downplayed the intensity of his experiences in Iraq and minimized problems in current functioning. He stated that it was hard to ask for help because “I’m a warrior, I’m not weak.” Psychoeducation intended to destigmatize was used over two sessions. This included normalizing symptoms and emphasizing that they are not an indication of personal weakness but of the power of war-related experiences. The interven- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Section: Masculinity and Male OEF/OIF Veterans tion also included a discussion of the neurobiology of emotions. Also addressed was the influence of TMGRNs on perception of symptoms, help-seeking and the processing, and expression of emotion. Tom reported that he “felt better” after both sessions. Tom did not show for his third session and did not respond to phone calls or a letter. He called 2 months later requesting an appointment stating that “things aren’t right” and that he has been drinking too much. Reasons for dropout were discussed in session three. Below is an excerpt from the session illustrating the reframe of emotional experience as part of the psychotherapeutic endeavor. Tom began by arguing that it was too difficult for him to acknowledge his distress, stating, “Men aren’t supposed to feel these emotions . . . I’m not supposed to feel this, that’s what makes it so hard.” Tom’s psychologist asked, “Where did you learn this?” “They teach us that in our training” Tom responded. The psychologist continued, “Why do you think they teach that?” Tom replied, “Because it makes you a better soldier. I mean, you can’t just break down right in the middle of a mission. You need to be strong, suck it up and move on to the next thing.” “This is true, but how realistic is it to not feel any emotion at all, ever again?” asked the psychologist. “No, not really realistic” Tom admitted after a few moment’s consideration. Tom’s psychologist pressed him, “What would you think of a man who was not affected by having friends killed in Iraq? Would you think he was strong?” “Not necessarily” Tom replied, “It’s rough to lose guys.” The psychologist continued, “So maybe it is normal to have painful emotions about such intense experiences. Maybe it’s not a question of strength or weakness, but something else, like caring about your friends.” At this point Tom stopped and pointedly reflected on this question. It was clear that this was a pivotal moment in psychotherapy where he began to seriously examine his internal rules about emotional experience. An extended discussion ensued regarding masculine socialization and emotion, which was initiated by this line of Socratic questioning. A modified motivational interviewing approach was then used to assess the value of emotional processing and expression versus avoiding traumatic events. Through decisional balance exercises, Tom came to see that it is “easier” to avoid aversive emotions and traumatic memories, but ultimately, not “better.” During the next three sessions, Tom became progressively more comfortable discussing traumatic experiences. He surprised himself by sharing a particularly traumatic incident (when his friend was killed in a house raid) having earlier stated that it was “way too much” to discuss. Despite these gains, Tom did drop out once again after discussing this incident, reappearing three weeks later. Upon return, Tom stated that it was difficult to talk about the incident but that he could see doing so was helping. Over the next eight sessions, Tom discussed this incident and processed some of the related emotional distress. Sessions also focused on the impact of such events on current functioning. His affect and mood improved, as did his functioning—those around him said he was becoming more of his old self and he agreed. Tom hesitantly agreed to try prolonged exposure. After completing prolonged exposure in 11 sessions, Tom no longer met formal criteria for PTSD as determined by a clinical interview and the PTSD Checklist-Military Version (Weathers, Litz, Herman, Huska, & Keane, 1993) While low levels of hyperarousal symptoms remained (mostly sleep disturbance), his reexperiencing and avoidance symptoms had significantly remitted by the end of psychotherapy. The resocialization process regarding masculinity and emotions was a crucial ingredient toward this result and was applied throughout the psychotherapeutic process. Indeed, emotional numbing is an avoidance criterion of PTSD and working toward approaching emotion in the manner described directly targets this symptom. By the end of psychotherapy, Tom was more comfortable processing and expressing emotion and doing so produced less conflict and shame. We believe addressing issues of masculinity and emotion greatly increases the likelihood that OEF/OIF male veterans will take part in psychotherapy and complete valuable and challenging interventions such as prolonged exposure. This is of critical importance given young male veteran’s tendency to drop out of psychotherapy across psychotherapeutic approaches, at least in part because of the influence of traditional masculinity on the processing and expression of emotion. 303 Lorber and Garcia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. The Psychotherapist’s Experience Working with OEF/OIF male veterans is often frustrating and almost always rewarding. A large source of frustration comes from witnessing the negative impact of TMGRNs as described above. The reward comes from seeing these men work through maladaptive beliefs, process their trauma and move forward with their lives. The psychotherapist teaches acceptance of emotional experience while maintaining a degree of emotional distance from the traumatic material. This requires balance between clinical objectivity and experiencing measured amounts of emotion— emotional attunement being requisite for any psychotherapeutic approach. However, when addressing traumatic material, psychotherapists bear witness to the horrors of trauma. In prolonged exposure therapy, trauma is addressed by definition in a repeated and prolonged fashion. It is common for beginning prolonged exposure psychotherapists to experience a degree of distress as trauma narratives unfold. As psychotherapy progresses, so do the horrific details. Fortunately, the same habituation process that alleviates anxiety in the client also works with the psychotherapist. The authors have noted it is possible to maintain empathy while gradually becoming more comfortable with graphic traumatic material repeatedly outlaid in prolonged exposure. Sometimes the graphic force of the narratives rattles even the most tenured psychotherapist. Just as keeping the material to oneself can be emotionally damaging to the client, so can it be for the psychotherapist. At these times, confidentially sharing troubling narratives with other psychotherapists can be helpful. Time-honored wisdom about self-care outside of work is important as well; time off should be used to enjoy life, just as we encourage our patients to do. Conclusions Traditional masculine socialization combined with military training alters the psychotherapeutic process for male veterans returning from Iraq and Afghanistan. TMGRNs, and other variables such as relative youth, recent experience in military culture and recent exposure to traumatic events, combine to complicate psychotherapy, in part because they impact returning male veterans’ willingness and ability to contend with emotions. 304 Although these factors play a role in shaping all psychotherapeutic interactions with this population, willingness and capacity to contend with emotions is critical in trauma focused PTSD psychotherapies such as prolonged exposure. Much of what we have applied to male veterans in this paper derives from work with civilian men. Correspondingly, modifications to traditional psychotherapeutic approaches we have found helpful with male veterans would also likely be helpful with civilian men who rigidly endorse TMGRNs. For example, motivational interviewing techniques that help to lessen masculinity-related ambivalence about psychotherapy for male veterans should in theory do the same for civilian men. It may be the case that our modifications are called for whenever there is difficult clinical work to do with those who rigidly endorse TMGRNs independent of veteran or civilian status. In conclusion, there are many unique challenges in psychotherapy with male OEF/OIF veterans. It falls on psychotherapists and researchers to understand the many challenges to this process, including the impact of TMGRNs. By addressing TMGRNs, we can advance toward helping this deserving population readjust to civilian life with less pathology and better self understanding. References ADDIS, M. E., & MAHALIK, J. R. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58, 5–14. ARKIN, W., & DOBROFSKY, L. R. (1978). Military socialization and masculinity. Journal of Social Issues, 34, 151–168. BRANNON, R., & DAVID, D. (1976). The male sex role: Our culture’s blueprint for manhood, and what it’s done for us lately. In D. David & R. Brannon (Eds.), The forty-nine percent majority: The male sex role (pp. 1– 48). Reading, MA: Addison Wesley. BROOKS, G. R. (2005). Counseling and Psychotherapy for Male Military Veterans. In G. E. Good & G. R. Brooks (Eds.), The new handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems, and treatment approaches (pp. 104 –118). San Francisco: Jossey-Bass. CLOITRE, M., KOENEN, K. C., COHEN, L. R., & HAN, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067–1074. DAVID, D., & BRANNON, R. (1976). The forty-nine percent majority: The male sex role. Reading, MA: Addison Wesley. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Section: Masculinity and Male OEF/OIF Veterans DUCKWORTH, A. L., STEEN, T. A., & SELIGMAN, M. E. P. (2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629 – 651. EISENHART, R. W. (1975). You can’t hack it little girl: A discussion of the covert psychological agenda of modern combat training. Journal of Social Issues, 31, 12–23. EISLER, R. M., & SKIDMORE, J. R. (1987). Masculine gender role stress: Scale development and component factors in the appraisal of stressful situations. Behavior Modification, 11, 123–136. ERBES, C. R., CURRY, K. T., & LESKELA, J. (2009). Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care for posttraumatic stress disorder. Psychological Services, 6, 175–183. GOOD, G. E., DELL, D. M., & MINTZ, L. B. (1989). Male role and gender role conflict: Relations to help seeking in men. Journal of Counseling Psychology, 36, 295–300. GRATZ, K. L., & ROEMER, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54. HOGE, C. W., CASTRO, C. A., MESSER, S. C., MCGURK, D., COTTING, D., & KOFFMAN, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22. Institute of Medicine. (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press. ISENHART, C. E. (1993). Masculine gender role stress in an inpatient sample of alcohol abusers. Psychology of Addictive Behaviors, 7, 177–184. KISELICA, M. S., & ENGLAR-CARLSON, M. (2010). The positive psychology/positive masculinity model: A new framework for psychotherapy with boys and men. Psychotherapy Theory, Research, Practice, Training, 47, 276 –287. LEVANT, R. F. (1996). The new psychology of men. Professional Psychology: Research and Practice, 27, 259 – 265. LEVANT, R. F. (1998). Desperately seeking language: Understanding, assessing, and treating normative male alexithymia. In W. Pollack & R. Levant (Eds.), New psychotherapy for men (pp. 35–56). New York: Wiley. LEVANT, R. F., HALTER, M. J., HAYDEN, E. W., & WILLIAMS, C. M. (2009). The efficacy of alexithymia reduction treatment: A pilot study. The Journal of Men’s Studies, 17, 75– 84. LEVANT, R. F., & RICHMOND, K. (2007). A review of research on masculinity ideologies using the male role norms inventory. The Journal of Men’s Studies, 15, 130 –146. LEVANT, R. F., RICHMOND, K., MAJORS, R. G., INCLAN, J. E., ROSSELLO, J. M., HEESACKER, M., . . . SELLERS, A. (2003). A multicultural investigation of masculinity ideology and alexithymia. Psychology of Men & Masculinity, 4, 91–99. LORBER, W., PROESCHER, E. J., & HENDRICKSON, A. (2007). Emotion regulation difficulties in returning male veterans predict PTSD symptoms. Paper presented at the Paper presented at the 41st meeting of the Association for Behavioral and Cognitive Therapies. MAHALIK, J. R., GOOD, G. G., & ENGLAR-CARLSON, M. (2003). Masculinity scripts, presenting concerns, and help seeking: Implications for practice and training. Professional Psychology: Research and Practice, 34, 123–131. MAHALIK, J. R., LOCKE, B., LUDLOW, L., DIEMER, M., SCOTT, R., GOTTFRIED, M., & FREITAS, G. (2003). Development of the conformity to masculine norms inventory. Psychology of Men & Masculinity, 4, 3–25. MILLER, W. R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11, 147– 172. MILLER, W. R., & ROLLNICK, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. MOLLER-LEIMKUHLER, A. (2002). The gender gap in suicide and premature death or: Why are men so vulnerable? European Archive of Psychiatry and Clinical Neuroscience, 253, 1– 8. MURPHY, R. T. (2008). Enhancing combat veterans’ motivation to change posttraumatic stress disorder symptoms and other problem behaviors. In H. Arkowitz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (pp. 57– 84). New York: Guilford Press. MURPHY, R. T., & ROSEN, C. S. (2006). Addressing readiness to change PTSD with a brief intervention: A description of the PTSD motivation enhancement group. Journal of Aggression, Maltreatment & Trauma, 12, 7–28. MURPHY, R. T., ROSEN, C. S., CAMERON, R. P., & THOMPSON, K. E. (2002). Development of a group treatment for enhancing motivation to change PTSD symptoms. Cognitive and Behavioral Practice, 9, 308 –316. O’NEIL, J. M., HELMS, B. J., GABLE, R. K., DAVID, L., & WRIGHTSMAN, L. S. (1986). Gender role conflict scale: College men’s fears of femininity. Sex Roles, 14, 335– 350. PLECK, J. H. (1995). The gender role strain paradigm: An update. In R. F. Levant & W. S. Pollack (Eds.), A new psychology of men (pp. 11–32). New York: Basic Books. SHIPHERD, J. C., & BECK, J. G. (2005). The role of thought suppression in posttraumatic stress disorder. Behavior Therapy, 36, 277–287. WEATHERS, F. W., LITZ, B. T., HERMAN, D. S., HUSKA, J. A., & KEANE, T. M. (1993). PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th annual meeting of the International Society for Traumatic Stress Studies. WEGNER, D. M., SCHNEIDER, D. J., CARTER, S. R., & WHITE, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5–13. 305 Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care Nina A. Sayer, Ph.D. Siamak Noorbaloochi, Ph.D. Patricia Frazier, Ph.D. Kathleen Carlson, Ph.D. Amy Gravely, M.A. Maureen Murdoch, M.D., M.P.H. Objective: The objectives of this study were to describe the prevalence and types of community reintegration problems among Iraq and Afghanistan combat veterans who receive U.S. Department of Veterans Affairs (VA) medical care, identify interests in interventions or information to promote readjustment to community life, and explore associations between probable posttraumatic stress disorder (PTSD) and reintegration problems and treatment interests. Methods: A national, stratified sample of Iraq-Afghanistan combat veterans receiving VA medical care responded to a mailed survey focused on community reintegration. Of 1,226 veterans surveyed, 754 (62%) responded. Prevalence and proportions were adjusted for potential nonresponse bias. Results: An estimated 25% to 56% of combat veterans who use VA services reported “some” to “extreme” difficulty in social functioning, productivity, community involvement, and self-care domains. At least one-third reported divorce, dangerous driving, increased substance use, and increased anger control problems since deployment. Almost all (96%) expressed interest in services to help readjust to civilian life (95% confidence interval [CI]=93%–99%). The most commonly preferred ways to receive reintegration services or information were at a VA facility, through the mail, and over the Internet. An estimated 41% (95% CI=36%–46%) screened positive for PTSD, and probable PTSD was associated with reporting more readjustment difficulties and expressing interest in more types of services, including traditional mental health services. Conclusions: IraqAfghanistan combat veterans who already receive VA medical care reported multiple current reintegration problems and wanted services and information to help them readjust to community life. These concerns were particularly prevalent among those with probable PTSD. Research is needed to explore nontraditional modes of service delivery, including the Internet. (Psychiatric Services 61:589–597, 2010) Dr. Sayer, Dr. Noorbaloochi, Dr. Carlson, Ms. Gravely, and Dr. Murdoch are affiliated with the Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, 1 Veterans Dr., Minneapolis, MN 55417 (e-mail: nina.sayer@med.va.gov). Dr. Frazier is with the Department of Psychology, University of Minneapolis. Portions of these data were presented at the U.S. Department of Veterans Affairs Health Services Research and Development annual meeting, Baltimore, February 11–13, 2009, and the American Psychological Association annual meeting, Toronto, Ontaria, Canada, August 6–9, 2009. PSYCHIATRIC SERVICES o ps.psychiatryonline.org o June 2010 Vol. 61 No. 6 O ver two million U.S. service members have been deployed to Iraq or Afghanistan since America’s engagement in the post–September 11 “war on terrorism,” approximately 27% of whom have been deployed more than once. Research suggests that the burden of mental disorders and symptoms, including posttraumatic stress disorder (PTSD), substance use disorders, and depression, is high among service members within the first year of returning from these deployments (1–5). Furthermore, with some notable exceptions (6), research suggests a rise with time since deployment in the rate of psychiatric problems among U.S. service members and veterans (3,7–10), which may indicate better problem detection and more psychiatric morbidity over time. Reports of increases in marital and occupational difficulties after military service in either Iraq or Afghanistan (Iraq-Afghanistan) (1,4,11,12) provide further evidence of postdeployment reintegration problems. Research on postdeployment health problems among Iraq-Afghanistan war veterans is needed to inform the development and resourcing of health services. However, the existing research base has several limitations for health services planning. First, many prevalence studies are based primarily or exclusively on samples of active-duty Army personnel and therefore do not provide information 589 about other types of service members (9), including activated National Guard and reserve troops, who may face unique circumstances during and after their deployment (3,13). Second, most studies describing rates of psychiatric symptomatology have assessed service members within the year after returning from their deployment (1,3,5,8,14,15), leaving unexamined their long-term adjustment problems. Third, because most prior studies have focused on psychiatric disorders, we know relatively little about the functional problems that Iraq-Afghanistan veterans face as they attempt to reintegrate into their home communities. Veterans may perceive problems functioning at home, school, or work to be as important as or more important than symptom resolution (16,17). Last, the treatment preferences of this new generation of veterans, which differs from earlier cohorts of veterans in terms of age, education, and comfort with technology, is understudied (18). This study was designed to address some of the above gaps in the literature. Our primary objectives were to describe the prevalence and types of community reintegration problems among Iraq-Afghanistan combat veterans who receive U.S. Department of Veterans Affairs (VA) medical care and to identify their interest in interventions or information to facilitate readjustment within the community. The VA plays a pivotal role in addressing Iraq-Afghanistan veterans’ postdeployment health care needs. It provides Iraq-Afghanistan combat veterans who were discharged under otherthan-dishonorable conditions with cost-free health care and medications for conditions possibly related to military service, regardless of their income level, for five years postdischarge (19). The VA is also the single largest provider of medical care to returning combatants. The secondary objective of this study was to explore associations between probable PTSD, reintegration problems, and treatment interests. PTSD is of particular concern because it is the most prevalent psychiatric disorder among returning combat troops and veterans (1,3–5,14,20–22). PTSD has also been associated with functional problems among veterans of 590 previous wars (23) and with ...
Purchase answer to see full attachment