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PTSD in the Combat Veteran: Using Roy’s Adaptation Model to Examine the Combat Veteran as a Human Adaptive System

Posttraumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat and i’i poised to he a con­ siderable health risk for our military veterans, To date, there is a paucity of nursing research that examines PTSD in this vulnera­ ble population. The purpose of this article is to demonstrate how Roy’s Adaptation Model can be an effective framework for nurses to understand the phenomenon of posttraumatic stress disorder in the combat ,•eteran population, Current research conducted on PTSD across other disciplines is highlighted within the context of Roy’s model to elucidate the idea of the combat veteran as a human adapth’e system and to identify gaps for future nursing research.

of witnessing life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. Those suffering from its effects expe­ rience three symptom clusters: (1) avoidance through emotional numbing, anxiety, and depression; (2) hyperarousal symptoms such as irritability, impaired concentration, hypervigilcnce, and increased startle response; and (3) reliving the trauma through dissociation, flashbacks, and nightmares. The presence of these symptoms has a tremendous influence on the individual’s ability to perform their occupational, social, and family responsibili­ ties. Furthermore, the mental health of military service members

                                                                                                                         can impact military organizational productivity and effective­

To date, there is a paucity of nursing research conducted on the phenomenon of posttraumatic stress disorder (PTSD) in the military veteran population. It is the most prevalent mental dis­ order developing in response to the combat experience and, in considering the current militruy conflicts in Iraq and Afghanistan with approximately 1.5 million soldiers serving in theater since 2001 (Shane, 2006), it has the potential to become a consider­ able hea1th risk for America’s military veterans. While actual PTSD epidemiologic studies of this conflict are absent from the literature, the Veterans Administration estimates that as of the end of 2006, one in four veterans discJrnrged from service have filed disability claims; over 60,000 for mental health issues (The National Security Archive [NSA], 2006). SecondaI)’ anal­ ysis of the National Vietnam Veterans Study repmt current and lifetime PTSD prevalence of 15% and 31%, respectively (Kulka et al., 1990), whereas studies of veterans from Operation Iraqi Freedom estimate PTSD prevalence rates of 5.4-12.1% (Kang, Natelson, Mahan, Lee, & Murphy, 2003).

According to lhe Diagnostic and Statistical Manual- W (American Psychiatric Association [APA], 2000), PTSD is a psychiatric disorder that can occur following the experience

ness and is critical to issues of retention, readiness, and mission capability (Riddle et al., 2007).

In light of nursing’s mientation toward the promotion of holistic health and the care of people throughout the we11ness­ illness continuum, nurses are in a unique position to help this vulnerable population in both civilian and military health care settings, through community outreach and intervention pro­ grams and research initiatives. Nurses in all settings should consider their patients at risk for trauma, PTSD, and associ­ ated comorbidities and need to be familiar with the risk fac­ tors, interventions, and resources available (Gill & Page, 2006). Moreover, nursing as a profession has a “social mandate to develop, disseminate, and use knowledge” (Fawcett, 1989, p. 692). Nursing themies and frameworks provide the guiding principles to develop research that can accomplish tllis go The purpose of this article is to demonstrate how Roy’s (1 Adaptation Model can be an effective framework for

to understand the phenomenon of post traumatic stress in the combat veteran population. Moreover, it

the philosophical foundation and advantages model, as compared to philosophies used

to frame and explicate a review of liter population. According to Roy (1989 ccm with the person as a total be· illness is a socially significant

ducted across other disciple sociology, and psychologic

ROY’S ADAPTATION MODEL

Philosophic and Scientific Perspectives

Roy’s Adaptation Model (RAM; 1989) reflects two ma­ jor philosophic foundations, humanism and what Roy calls veritivity, and two scientific perspectives, systems theory and adaptation-level theory. As the basis for her model, Roy (1989) defines humanism as a broad movement within philosophy and psychology that assumes the individual shares in creative power, acts purposefully, possesses intrinsic ho1ism, and strives to maintain integrity through interpersonal processes. The philo sophic basis of holistic nursing mirrors the philosophy of Hu­ manism inherent in Roy’s Adaptation Model. Roy (1989) also coined the philosophic principle of veritivity, which reflects the notion that there is purposefulness to human existence; a unity of purpose in all of manlcind; activity and creativity that exists to serve a common good; and the presence of inherent value and meaning in life. In Roy’s scientific application of systems theory, the individual, group, family, community, or society is viewed as a ho1istic, interdependent, complex living system that is continually interacting with, adapting to, and creating changes within the environment (Roy & Andrews, 1999).

For U1e purpose of framing the current literature on PTSD, each of the key concepts within Roy’s Adaption Model wrn be explained and then relevant literature will be presented to explain how the concept could potentially manifest within in the combat veteran. Roy and Andrews (1999) describe the indi­ vidual person as a Human Adaptive System with thinking and feeling capacities that are rooted in consciousness and mean­ ing. The individual functions as a whole to express meaningful human behavior that effectively adapts to changes within the environment, and in turn, changes the environment. \Vith this in mind, the key concepts within Roy’s Model to be reviewed are Stimuli, Coping Processes, Adaptive Modes, and Behavior.

Stimuli

According to RAM, the individual is an adaptive system that involves the complex interaction of both intemal stimuli (mig­ inating from within the seJD and external stimuli (originating from the environment) that provoke a response. These stimuli form the environmental circumstances within which the indi­ vidual effectively adapts. Roy and Andrews (1999) describe common stimuli: the individual’s culture, socioeconomic sta­ tus, ethnicity and belief system, age, gender, and heredity; the structure and tasks of a family or aggregate that influence the individual; the integrity of the individual’s adaptive modes and their perception and knowledge of the stressor; and environmen­ tal considerations, including changes in the internal or external environment, medical management, use of drugs, alcohol, and tobacco, and political or economic stability.

Research findings on PTSD support Roy’s concept of key internal and external stimuli that influence whether the combat veteran is effectively able to adapt with his or her wartime experience or whether he or she develops PTSD. Ultimately, these stimuli affect the person’s adaptation level, which is “a changing point influenced by the demands of the situation and the internal resources … that makes humans constantly move towards mastery” (Roy & Andrews, 1999, p. 33). The literature on PTSD identifies a number of internal and external stimuli that influence a soldier’s likelihood of developing and sustaining PTSD.

A meta-analysis of the risk factors for PTSD demonstrated

significant correlations between lower military rank, educa­ tional level, and socioeconomic status and greater symptoms of PTSD (Brewin, Andrews, & Valentine, 2000). Additionally, primary and secondary analysis of the National Vietnam Vet­ erans Readjustment Study suggests a relationship between race and PTSD due to a greater predisposition towards developing PTSD among Hispanic and Asian Americans (The Manage­ ment of Post-Traumatic Stress \VorJcing Group, 2004). Further research suggests this may be secondary to more severe warzone exposure experienced by minorities or to the presence of adverse race-related events while these individuals served in the military (Loo, Fairbank, & Chemtob, 2005; O1tega & Rosenbeck, 2000). Additionally, gender has emerged as a substantial risk factor for the development of PTSD in the military veteran. Rates of clinically diagnosed PTSD are twice as common in women as in men (Breslau, 2002). This may be the result of a woman’s penchant for seeking professional help more often than men and the result of higher rates of rape, childhood sexual abuse, and sexual harassment among women as associated risk factors. Research bas shown that a woman’s exposure to sexual stress such as rape or sexual harassment accounted for a four-fold increase in 1isk in the development of PTSD over exposure to duty-related stress alone (Fontana & Rosenbeck, 1998). A retro­ spective study of a sample of women in the United States diag­ nosed with chronic PTSD who also reported a history of sexual or physical assault ha a four to five times greater likelihood of having chronic PTSD over those who were victims of nonviolent crimes without prior assault (Nayback, 2008; Resnick, Kilpatric, & Danst’Y, 1993). Moreover, women who experienced major trauma reported worse quality of life outcomes, earlier psy­ chiatric morbidity, and higher medical service utilization than men exposed to similar levels of trauma (Holbrooke & Hoyt,

2004).

The individual’s family and community environment can sig­ nificantly impact the development of PTSD as well. In the cur­ rent conflicts in Iraq and Afghanistan, repeated deployments of service members have placed incredible burdens on military families by way of compromised relationships with spouses and children; gender shifts in role responsibilities as greater numbers of women deploy to combat, leaving behind their male spouse as the primary family caretakers; concerns with fi­ nances; and changes in social support networks with subsequent deployments (Baum, 2004; Paulson & Krippner, 2007). Several studies demonstrate that post-deployment social support and the absence of ongoing life stressors have been shown to be the greatest protective factors against the development of PTSD in the post-deployment period (Brewin et al., 2000; Litz, Gray, Bryant, & Adler, 2002).

Several pre-military family and community factors also have been Jinked to greater PTSD morbidity. Several environmental factors experienced during childhood, such as a family belief­ system consistent with a lack of perceived control, emotional and physical abuse, early separation from parents, economic deprivation, and familial history of mental illness such as anx­ iety disorder, depression, and antisocial personality disorder, demonstrate a strong predictive relationship in the development of PTSD (Cabrera, Hoge, Bliese et al, 2007; Gahm, Lucenko, Retzlaff, & Fukuda, 2007; Nayback (in press); Paulson & Kripp­ ner, 2007).

Moreover, the military conununity espouses an identity with its own informal codes, values, and traditions. This military cultural framework within which soldiers are immersed stresses discipline, unit cohesion and bonding, and personal self-control. This can often shape their perceptions and recollections of war­ zone experiences (Tick, 2005). Strong unit cohesion and high unit morale, as well as adequate training and resources in the combat environment, have been identified as measures to pro­ mote resiliency against PTSD (Armfield, 1994). Additionally, the influence of media perception, coverage, and support for the war or soldier can either promote or lower a soldier’s re­ sistance to developing PTSD symptoms (Paulson & Krippner, 2007).

A number of trauma related factors contribute to the develop­ ment of PTSD as well. Both the greater the severity of war-zone stressor exposure and the nature of interpersonal trauma expe­ rienced (i.e., rape, torture, atrocity exposure, or prisoner of war status) more strongly predicted the development and mainte­ nance of PTSD symptoms (The Management of Post-Traumatic Stress \Vorking Group, 2004). In addition, soldiers who sus­ tained physical injury as a result of combat have a two- to threefold increased risk of PTSD (Grieger et al., 2006). Even in studies conducted on soldiers involved in peacekeeping op­ erations, military combat hospital personnel, and civilians who experienced little or no combat exposure, high perceived threat to life was positively associated with development of PTSD symptoms (Bo1ton, Gray, & Litz, 2006; Dirkzwager, Bramsen, & Van der Ploeg, 2005).

In a meta-analysis by Brewin et al. (2000), a number of stud­ ies reported a significant relationship between veterans who de­ velop PTSD and the presence of comorbid psychiatric disorders, most notably depression, substance abuse, and personality dis­ orders. Behavioral genetic studies demonstrate heritable traits that can account for variances in how sensitive individuals are to trauma and their predispositions toward mental disorders and substance abuse (Tharpar & McGuffin, 1996).

Coping Processes

Roy and Andrews (1999, p.46) define coping processes as the “innate or acquired ways of interacting with the chang­ ing environment.” Roy classifies individual coping processes in two ways: innate coping processes, which are genetically deter­ mined and automatic, or acquired coping processes, which are learned strategies for managing stimuli. The concept of coping also includes two individual coping dimensions, which are cat­ egorized as the regulator coping subsystem, which is the body’s automatic neural, chemical, and endocrine response to stress, and the cognator coping subsystem, which is the individual’s cognitive-emotive coping resources comprising judgment, per­ ceptual and infommtion processing, learning, and emotion.

\Vithin the stress and coping literature, the two predomi­ nant classifications that characterize coping efforts are problem­ focused and emotion-focused. Problem-focused coping at­ tempts to deal directly with the stressor while emotion-focused coping attempts to alleviate the emotional distress that is a con­ sequence of the stressor (Sharkansl-‘)’ et al., 2000). Another effort to classify coping describes the method of coping as either approach-based or avoidance-based. Approach-based coping seeks to directly resolve the stressor whereas avoidance­ based coping tries to avoid thinking about the stressor or its effects (Moos, 1990).

Poor coping resources or capacities increases the risk for posuraumatic pathology (Ruzek et al., 2004). For instance, in­ dividuals who used higher percentages of approach-based cop­ ing strategies to manage their combat-related stress reported fewer psychological symptoms (Sharkansky et al., 2000). Sim­ ilarly studies of civilian hospitalized burn victims who used emotion-focused and avoidance-based coping reported more PTSD symptoms (Fauerbach, Richter, & Lawrence, 2002). There are also significant associations between dispositional difficulty forgiving others and oneself and negative religious coping, which includes interpersonal religious discontent, ques­ tioning God’s powers, and appraisal of a problem as God’s punishment, with difficulties in mental health for veterans with PTSD (Witvliet, Phipps, Feldman, & Beckham, 2004).

Adaptive Modes

Roy’s model has four adaptive modes in which the be­ haviors of individuals, in response to coping activities, can be observed. These four adaptive modes include: Physiologi­ cal/Physical Mode, Self-Concept Mode, Role Function Mode, and Interdependence Mode.

The Physiological Mode pertains to the individual and is the sum of all physical and chemical processes involved in the functions and activities of a living organism (Roy & Andrews, 1999).

In response to a traumatic stress reaction, the human body undergoes a number of physiologic responses, more specif­ ically, neurologic and endocrine adaptations. PTSD-affected individuals demonstrate reduced plasma beta-endorphin con­ centrations, which results in a diminished pain threshold and a naJoxone-reversible analgesic response to combat-related stim­ uli (Pittman et al., 1991). These findings point to tl1e likelihood of an opiodal system hyperregulation. Endorphins are part of the body’s adaptive response to stressful stimuli and are re­ leased into a person’s bloodstream during a “fight or flight” response to produce a calming, tranquilizing effect.

Additionally, evidence points to hypothalamic-pituitary­ adrenal and thyroid axis dysfunctions since PTSD-affected in­ dividuals also demonstrate low levels of serum and urine free cortisol, increased plasma norepinephrine levels, increased se­ cretions of neuronal corticotropin-releasing factor (CRF), and elevated total triiodothyyronine (T3) levels (Pittman et al., 1991). In response to fear or trauma, the amygdala of the brain, which is also responsible for hyperarousal, detemlines whether a sensory experience is hannful and initiates a biochemical and behavioral response to the perceived threat that affects all of these processes (Yehuda, 2004). In the PTSD-affected individ­ ual, the brain’s hippocampus, despite its function in helping to remember traumatic events through specific cues, no longer stimulates the amygdala in the response to stress. This discon­ nection between the hippocampus and amygdala accounts for the dissociative symptoms experienced by patients with PTSD. Neuroimaging studies demonstrate marked reductions in hip­ pocampal volume in a population of Gulf \Var veterans with PTSD (Vythilingam et al., 2005) and reduction in anterior cin­ gulate cortex volume, which regulates fear in the amygdala (Woodward et al., 2005). This destabilization of the autonomic

nervous system and amygdala results in symptoms of anxi­ ety, agitation, and diminished inhibitions (Paulson & Krippner, 2007, p.6).

Roy’s second dimension is the Self-Concept Mode. This is the composite of the beliefs and feelings an individual pos­ sesses about him- or herself at a given time (Roy & Andrews, 1999). According to Paulson and Krippner (2007), one of the most challenging aspects of overcoming a traumatic einotional experience is the loss of one’s individual perspective or per­ sonal mythology that ensures security and safety in the world. Research on cognitive processes in victimization indicates that major changes occur in an individual’s basic life assumptions that one’s environment is physically and psychologically safe; that events are predictable, meaningful, and fair; and that one’s own sense of self-worth is positive in relation to experiences with other people and events (Hunter, 2004). Many victims har­ bor personal myths that God is punishing them for their impiety

(Richards & Bergin, 1997). A study by Barrett et al.  (2002)

demonstrated a significant positive relation between PTSD and self-reported lower ratings of overall health status and health quality of life especially in the physical, emotional, and social domains.

Roy’s third dimension of Adaptive Modes is the Role Func­ tion Mode. This mode focuses on the roles that the individual occupies in society (Roy & Andrews, 1999). One of the common

dynamics seen in combal veterans with PTSD is that a number them distance or detach themselves from their families because of uncomfortable feelings with giving and receiving emotional closeness (Scurfield, 2006). Additional issues include severe spousal aggression, occupational instability, marital problems and divorce, and difficulties with parenting (McCarroll et al, 2000; Meagher, 2007; Peebles-Kleiger & Kleiger, 1994). Veter­ ans who reported discomfort in disclosing their experiences in Vietnam to family and friends demonstrated an increased risk for developing PTSD (Koenen, Stellman, Stellman, & Sommer, 2003).

Roy’s fourth and final adaptive mode is the Interdependence Mode. The individual focus for this mode pertains to the giving and receiving of love, respect, and value. Not everyone who experiences trauma or acute stress reactions will go on to de­ velop PTSD. Of those who do, they often engage in “emotional numbing” so that they will not have to share feelings with their trauma experience with anyone (Brown, 1994). This numbing is often taken to extremes and leads the veteran to avoid re­ sponsibilities, even important ones relating to the maintenance of friendships, mairiage, children, and Jong-term employment (Tedeschi & Calhoun, 1995). Encouraging veterans to maintain social support groups and to reconnect with loved ones is critical for helping the individual cope with the traumatic event (The Management of Post-Traumatic Stress Working Group, 2004).

Behavior

The observable outcome of the adaptation process is behav­ ior. Roy and Andrews (1999, p. 63) describe behavior as “all responses of the human adaptive system including capacities, assets, knowledge, skills, abilities, and commitments.” Behav­ ior includes both internal and external actions and reactions that are fmmulated as adaptive responses or ineffective responses. According to Roy (1989), adaptive responses are those behav­ iors that promote the integrity of the human system, whereas ineffective responses are those that neither promote integrity nor  contribute  to  the  adaptive  processes  of  sun 1ival,  growth, reproduction, or mastery.

Examples of ineffective responses demonstrated by veterans in response to their war-zone experience include chronic debil­ itating PTSD symptoms with higher rates of substance abuse, drug abuse and dependence, nicotine use, somatoform disorders, obesity, and suicidality among veterans diagnosed with PTSD (Beckham et al., 1995; Boscarino, 2006; Price, Risk, Haden, Lewis, & Spitznagel, 2004; Vieweg et al., 2006). Examples of adaptive responses include seeking mental health services, res­ olution of PTSD symptoms, posttraumatic growth, and mastery of the experience.

PHILOSOPHIC PERSPECTIVE OF RELATED RESEARCH

The majority of the research conducted by other disciplines on PTSD, although not explicitly stated, emerged from the Empilicist and Logical Positivist perspectives. Empiricism is rooted in the ideology that all knowledge stems from experience and is explicated from infonnation that is gathered through tl1e senses (Rodgers, 2005). The philosophy of Logical Positivism, in which the purpose of science was lo “predict, explain, and control events,” (Rodgers, 2005, p. 89) provided an additional foundation on which to study PTSD. The majority of the studies of PTSD thus far have focused on identification of diagnostic criteria, risk factors, and intervention evaluation so as to be able to explain, diagnose, and intervene with a patient with PTSD. Future research into PTSD addressed through Roy’s Humanis­ tic philosophy would further the body of nursing knowledge by examining the veteran’s individual experiences in coping with PTSD. Appropriate nursing interventions could be  developed and implemented to treat the patient from a holistic perspective, and allow them to participate in t11e creative process of healing.

DISCUSSION

This article highlighted a number of research findings on PTSD in the combat veteran placed in the context of Roy’s Adap­ tation Model. Roy’s model demonstrates how each individual responds to the internal and external stimuli that shapes their environment. The individual manifests the adaptation process through four modes: physiological, self-concept, role function, and interdependence modes of adaptation. Through the applica­ tion of regulator and cognator coping mechanisms, the individ­ ual exhibits either adaptive or ineffective responses, which then impact the stimuli, thus closing the loop of this systems-based model {see Figure 1). Because of its Humanistic philosophic un­ derpinnings and systems-based scientific approach, which view the individual as a holistic, creative, purposeful entity seeking

to adapt to both internal and external stimuli, Roy’s model pro­ vides an effective framework within which to understand how the military veteran functions as a human adaptive system when confronted with the stress of PTSD.

Current research into PTSD reflects philosophic underpin­ nings consistent with empi1icism in which researchers are at­ tempting to quantify and measure the phenomenon of PTSD. FULure nursing research directions for PTSD to be studied using Roy’s model as a guiding framework include: the effects of cop­ ing during combat and upon return home; the impact of training soldiers in more active approach-based coping styles; the role of forgiveness; interventional research to examine ways to nlit­ igate modifiable risk factors, such as levels of social support and resilience and to determine whether suggested interven­ tions significantly decrease human suffering and institutional costs; longitudinal studies to document the illness course and progression; the impact of the disorder on the family structure and function; and identification of demographic factors that in­ fluence the success of one intervention over another. Nursing is a discipline committed to protecting vulnerable populations agaiust stressors that impact health and illness. Nurses in every health care setting must educate veterans on the symptoms and course of PTSD, instill hope, facilitate recovery, and dialogue with the patient in planning care and interventions. Moreover, mental health nurses are in an exceptional position to implement current study findings and interventions and have the expertise to make a positive impact on the lives of traumatized military veterans through practice and research.

Declaration of interest: The author reports no conflicts of in­ terest. The author alone isresponsiblefor the content and writing

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