Healing Combat Trauma

The Suicide Profile: Clinically Known Risk Factors for Potential Suicides

I've got an old psychiatry textbook for medical students, written by a professor at Harvard Medical School named Robert J. Waldinger, M.D., and it's been interesting leafing through it and finding out what it has to say about PTSD (not much) and suicide (quite a lot).  The edition I have is the second edition (a third edition is in print), and it goes back almost 20 years, to 1990.  PTSD is covered in less than a page, but suicide has quite a bit of coverage, and much of what it says is interesting.

For example:

"A majority (60-80%) of people who commit suicide carry a diagnosis of depression.  Estimates of the risk of suicide in all mood disorders are as high as 15%, with the greatest period of risk within 5 years after the onset of the disorder.  The risk of suicide among people with mood disorders is 30 times that of the general population."

There's also this longer passage about who's most at risk for suicide.  The passage was written based on data that was available at the time -- 1990 -- and some of the percentages have changed up or down since then. However, as you read these factors, think about how many of them might be in play for combat veterans, in light of the recent rise in veteran suicides. Our observation?  Quite a few. See if you don't agree:

"Suicidologists have long searched for "suicide profiles." They have looked at everything from the phases of the moon to birth order in the family in an effort to solve the mystery of why certain people resort to suicide. The following are the risk factors most consistently identified in recent studies:

• Age- The risk of suicide ... is greatest for nonwhite males in their 20s and 30s, and rises again (in the elderly).  Nonwhite females have the highest suicide rate in young adulthood to age 40, with a decline thereafter.  In the last 25 years there has been a more than three-fold increase in the rate of suicide among adolescents and young adults (and this figure has only gone up);
• Sex - Men commit suicide three times more frequently than women.  However, women attempt suicide two to three times as often as men.  Men tend to use knives, firearms and other violent means of suicide, while women show a preference for self-poisoning;
• Race - The suicide rate is higher for whites than nonwhites. However the rate among young black adults in ghetto areas has recently increased sharply;
• Marital status - Suicide rates are lowest for married people and higher for those who are separated, divorced, or widowed;
• Living situation - People who live alone are at a higher risk of suicide than people who live with others;
• Employment status - People who are unemployed are at a higher risk of suicide than those who are working in or out of the home ...;
• Physical health - Physical illness, or the perception that one is ill, is more frequent among those who commit suicide.  In particular, there is a high correlation between completed suicide and visits to a physician for medical complaints during the preceding six (6) months.  The risk of suicide is significantly increased among people suffering from cancer and AIDS;
• Mental health- Among the mental illnesses that have been correlated with a high risk of suicide are depression, manic-depressive illness (bipolar disorder), and schizophrenia.  Non-fatal attempts are more prevalent among people with personality disorders, and adjustment disorders.  In general, the presence of major mental illness should alert the clinician to the possibility of suicide.  More than 90% of adults who commit suicide have an associated psychiatric illness;
• Alcohol abuse or addiction - Alcoholism markedly increases the risk of suicide;
• Previous suicide attempts - A history of suicide attempts has been estimated to increase the risk of completed suicide by as much as 64 times that of the general population.  At least 10% of suicide attempters eventually kill themselves;

The following factors, while less easily quantifiable, have also been associated with completed suicides:

• Hopelessness - Several studies have concluded that the specific symptom of hopelessness about one's life situation is more highly correlated with suicide than is the more general category of depression;
• Interpersonal loss- There is a high correlation between interpersonal loss and suicide.  Loss is defined as the separation from, divorce from, or death of a significant other, and may include relatives, friends, lovers, and therapists.  The risk of suicide is particularly high among alcoholic individuals who have suffered major interpersonal losses within the previous six (6) weeks;
• Life stresses - A high frequency of major life events in the previous six (6) months has been found among those who commit suicide.  Such events include job changes, moves, births, graduations, financial reversals, marriage, retirement and menopause.  Such changes are important to identify in assessing both the precipitants of a suicidal crises and the possibilities for therapeutic intervention;
• Interpersonal conflict - Long-standing intense interpersonal conflict with family members or other important people is associated with a high risk of suicide and has led some observers to characterize suicide as a fundamentally dyadic [definition] event.  Such conflict, if unremitting, may continue to jeopardize the life of the patient after a particular crisis has passed. "

Source: Psychiatry for Medical Students, Second Edition, by Robert J. Waldinger, M.D.  (Instructor in Psychiatry, Harvard Medical School, Director of Training, Massachusetts Mental Health Center, Boston, Massachusetts.)  Washington, DC: American Psychiatric Press, Inc.  (1990).

One Great Book: "Home to War - A History of the Vietnam Veterans Movement," by Gerald Nicosia

"The Past Does Not Equal the Future" -- queue Tony Robbins -- well, unless we refuse to learn the copious lessons of the past, in which case it very well might -- or it might make the past look positively enlightened, by comparison.  Another take on the same thing, by the perennial, inveterate quotemeister himself, Ben Franklin: "Experience keeps a dear [expensive] school, but fools will learn in no other."  I'm reading the greatest book right now, recommended by another journalist who's interested in veterans issues -- "Home to War: A History of the Vietnam Veterans Movement," by Gerald Nicosia, linked here.  It's 2 lbs., 10 oz., 689 pages, and roughly 136 cubic inches of nowhere-else-to-be-found material on the actual history of what created the Vietnam veterans' movement, which informs the veterans' rights movement of today, including the efforts to destigmatize PTSD, figure out what it was, re-include it in the DSM manual for psychiatrists (where it had been removed), etc.  Just fascinating.  All the players are there -- dozens of politically important types, including John Kerry, Ron Kovic (if you've seen "Born on the Fourth of July," you know who he is) as well as therapeutically important ones -- Shad Meshad, Ray Scurfield, Arthur Blank, M.D., Sarah Haley, etc. 

As a late-model Child of the Sixties, I had completely forgotten how much sheer effort -- blood, sweat and tears -- it took to get certain things passed that we now take for granted: better care at the VA, better provisions in the GI Bill, etc.  I had totally forgotten about the armed protests, the hunger strikes and sit-ins at the VA, etc.  It made me wonder whether leaders of the current veteran rights movements actually KNOW this history, and know how far their predecessors had to go, to secure the rights veterans rely on today -- which still need to keep pace with the times, and haven't.  The book is just plain fascinating, and b/c it's relatively neutrally written (as opposed to written with partisanship), with a steadfast focus on the facts and the key participants -- and because it's based on 600 or so interviews with the actual players, it's both extremely well done (a PBS series in book form, but with more depth!) and should keep my interest for quite a while.  So fascinating to know, or begin to hazily recall, the all-important "backstory" of where we are today.  And the insights on the genesis of understanding PTSD are well worth revisiting, all on their own.  Great book - wish I'd known about it before. As more and more veterans send me (unsolicited, I might add) their life stories, or their experiences with PTSD, I have to say -- this book really puts an awful lot together, behind the scenes, as to why they suffered in silence for so long.  Wonderful effort, and a pleasure to read.

Too bad tomorrow is already "Father's Day," but if you're lacking a gift for a veteran dad, Vietnam era or later, and can find this in stock at a local bookstore, it's a superlative collection of everything that went before, and helps us to understand the issues of the present, through the highly informing prism of the past.

Israeli Military's Proactive Plan for Identifying and Treating Soldiers Who Have PTSD

Here in the U.S., in our usual myopic way, we can get bogged down in the news about returning servicemembers with combat trauma and PTSD and forget just how many other countries in the world have struggled with this problem as well, and often found their own solutions.  Internationally, Japan, Israel, Australia, England and Canada frequently search the Internet for news about who's doing what, and what's working, for treating PTSD worldwide -- according to data from Google's analytical trends.  Today, the Jerusalem Post has an article about how Israel's Defense Ministry is about to unveil a plan for evaluating and treating soldiers systematically who have been exposed to PTSD as part of their military service.  (The article in question is linked here.)  Their expectation is that 2,500 Israelis suffer from PTSD, in a country where military service is compulsory, and conflicts in the region frequently boil over into sustained violence. 

The significance of the Israeli announcement is that the soldiers will be treated according to a "set psychological and medical format," meaning systematically and methodically.  Their understanding is that PTSD treatment succeeds better if initiated earlier, so evaluating all soldiers soon after military service will increase the chances of favorable treatment outcomes.  According to the article, three years ago the military started thinking through how to create a protocol that would involve every soldier, and optimize chances of finding and treating PTSD.  The protocol was developed by Zeev Waisman and Dr. Dan Dolfin.

Two interesting comments from the article express a vision that the U.S. might be wise to emulate:

"A soldier who comes out of battle will immediately be evaluated and we will see what type of treatment he needs," Waisman said. "Nothing is done today in a regulated fashion and we want all treatment to be according to a protocol."

The process begins by inserting the soldier's profile into the system which will then offer several courses for treatment that could include medicines, psychological therapy, family therapy, sex therapy and others. Waisman said that the Ministry of Defense hoped to convince other organizations to adopt the new format which will be evaluated in two years.

Stateside, it's not even clear that the various branches of the Armed Forces share a similar protocol for identifying and treating PTSD -- most likely, they do not.  With far more servicemembers at risk for PTSD than the Israelis have, we could do worse than to imitate what the Israeli Defense Ministry is putting into action as a plan to deal with PTSD, and return exposed servicemembers to better mental and emotional health.

"Give an Hour" Helps Fill Veterans Counseling Gap

Give an Hour -- the foundation that matches member psychogists and counselors with veterans and their families in need of counseling at no charge -- to fill the currently unmet gap in mental health services, has been in the news recently.  (You can learn more about Give an Hour's founder, Barbara V. Romberg, Ph.D., in her bio, linked here). It's truly fantastic to see this public-spirited act of service on the part of Give an Hour; at the same time, it's a shame that private industry, so to speak, has to jump in to fill the unmet gap of mental health care -- the need for which care is an entirely predictable "soft cost" of going to war.  Nevertheless, good stuff, and very altruistic and forward-thinking on the part of Dr. Romberg and her organization.

From a press release:

The American Psychiatric Foundation, Lilly Foundation And Give An Hour Join Forces To Provide Mental Health Care To Iraq And Afghanistan Veterans

Heeding the call of a growing public health crisis -- the unmet mental health needs of returning soldiers and their families -- Give an Hour (GAH) and the American Psychiatric Foundation (APF) announced a major expansion of a nationwide effort to help U.S. veterans returning from Iraq and Afghanistan.

GAH and APF, the philanthropic and educational arm of the American Psychiatric Association (APA), will be using a $1 million grant from the Lilly Foundation to recruit and educate volunteer mental health professionals, who will become part of a network aiming to bridge the gap in mental health services for soldiers returning from service, as well as their families. Among troops returning from Iraq and Afghanistan, approximately 40 percent of soldiers, a third of Marines, and half of the National Guard members report psychological problems, but mental health services are in short supply.

"This all-volunteer effort provides badly needed support to help our veterans, many of whom come home with mental health needs," said U.S. Representative Steve Buyer (R-Indiana), Ranking Member, House Committee on Veterans' Affairs. "I applaud the hard work of Give an Hour, the American Psychiatric Foundation, and the Lilly Foundation, which are stepping up to help those who have selflessly served."

Efforts will be made to create a large, national, volunteer network over the next three years to address postwar mental health issues such as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), drug abuse, anxiety and depression.

"This grant will allow us to get out the message that help is available. We want to normalize what our military personnel and their families are experiencing and support the sacrifices that they are making by providing critical mental health support at no cost," said Barbara V. Romberg, Ph.D., founder and president of GAH. "We will be educating the military community and broader public about these mental health needs in hope of helping veterans keep their lives and families intact."

GAH is recruiting mental health professionals to volunteer one hour each week for a minimum of one year to provide direct services in person, by phone or in consultation with schools and community organizations that serve the military community. Services are wide-ranging and include marital and family therapy, substance abuse counseling and treatment for PTSD. APF brings strong ties to the psychiatric community and is actively encouraging psychiatrists to join the network.

"This grant will help us reach our goal of recruiting 10 percent of the 400,000 mental health professionals in the United States by 2015 to assist in this effort," said Dr. Richard K. Harding, M.D., president of the APF. "It is an ambitious goal, but we are confident it can be achieved."

The Department of Defense (DoD) is making an unprecedented attempt to encourage personnel to seek mental health treatment, but a significant increase in demand, in some areas, has forced the rationing of services, created long waiting lists and limited individual counseling sessions. In addition, some members of military families such as parents, siblings and unmarried partners do not qualify for care through the Veterans Administration or DoD but are affected nonetheless by the mental health of the veteran.

"We're privileged to be able to give something back to our troops, but we know there's still much more to be done," said Steven Paul, M.D., executive vice president for science and technology and president of Lilly Research Laboratories. "Lilly is fully committed to assuring that the best possible medicinal treatments are available, but unfortunately, we also know that having access to the best care -- in this case mental health services -- is essential."

About Give an Hour
Give an Hour is a nonprofit 501(c)(3), founded in September 2005 by Dr. Barbara V. Romberg, a psychologist in the Washington, D.C., area. The organization's mission is to develop national networks of volunteers capable of responding to both acute and chronic conditions that arise within our society. Currently, GAH is dedicated to meeting the mental health needs of the troops and families affected by the ongoing conflicts in Iraq and Afghanistan. Give an Hour now has approximately 1,200 providers across the nation and continues to recruit volunteer mental health professionals to its network. For more information or to volunteer to become part of the effort, please visit http://www.giveanhour.org.

About The American Psychiatric Foundation
The American Psychiatric Foundation is the charitable and educational subsidiary of the American Psychiatric Association. The mission of the foundation is to advance understanding that mental illnesses are real and can be effectively treated. For more information, please visit the foundation's web site at http://www.psychfoundation.org.

About Lilly
Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organizations. Headquartered in Indianapolis, Ind., Lilly provides answers -- through medicines and information -- for some of the world's most urgent medical needs. Additional information about Lilly is available at http://www.lilly.com.

From Give an Hour's website:

Our Mission
Our mission is to develop national networks of volunteers capable of responding to both acute and chronic conditions that arise within our society. Our first target population is the U.S. troops and families who are being affected by the current military conflicts in Afghanistan and Iraq. Give an Hour is asking mental health professionals nationwide to literally give an hour of their time each week to provide free mental health services to military personnel and their families. Research will guide the development of additional services needed by the military community, and appropriate networks will be created to respond to those needs. Individuals who receive services will be given the opportunity to give an hour back in their own community.

Our Focus
Our organization is currently focusing on the psychological needs of military personnel and their families because of the significant human cost of the current conflicts. Over 1.6 million troops have been deployed in Afghanistan, Iraq, and the Persian Gulf since September 11, 2001. Nearly 550,000 of these troops have been deployed more than once. According to the U.S. Department of Defense, as of May 15, 2008, nearly 4,600 American troops have died in Iraq and Afghanistan. Roughly 32,875 U.S. troops have been injured during these conflicts.

In addition to the physical injuries sustained, countless servicemen and servicewomen have experienced psychological symptoms directly related to their deployment. According to a RAND report released in April 2008, over 18 percent of troops who have served in Iraq and Afghanistan--nearly 300,000 troops--have symptoms of post-traumatic stress or major depression. At the same time, about 19 percent of service members reported that they experienced a possible traumatic brain injury. And let us not forget: millions of Americans belong to the families of these servicemen and servicewomen. Spouses, children, parents, siblings, and unmarried partners of military personnel are all being adversely affected by the stress and strain of the current military campaign.

Our military leaders are well aware of the human cost of this campaign. Indeed, they are attempting to address the psychological needs of the troops through a variety of programs within the military culture. Unfortunately, the tremendous number of people affected makes it impossible for the military to respond adequately to the mental health needs in its greater community. For example, according to the RAND study, only 43 percent of troops reported ever being evaluated by a physician for their head injuries. Moreover, returning combat veterans suffering from depression, anxiety, and post-traumatic stress disorder (PTSD) are not routinely seeking the mental health treatment they need. RAND also reports that only 53 percent of service members with PTSD or depression sought help over the past year.

A major barrier preventing military personnel from seeking appropriate treatment is the perception of stigma associated with treatment. Many fear that seeking mental health services will jeopardize their career or standing. Others are reluctant to expose their vulnerabilities to providers who are often military personnel themselves, given the military culture’s emphasis on strength, confidence, and bravery. Servicemen and servicewomen might be more inclined to seek help if they know that the services provided are completely independent of the military. By providing services that are separate from the military establishment, we offer an essential option for men and women who might otherwise fail to seek or receive appropriate services.

We are also offering services to parents, siblings, and unmarried partners who are not entitled to receive mental health benefits through the military. Although these individuals may have access to mental health services through other means, they are less likely to seek the help they need and deserve if that help is difficult to find or costly. Our goal is to provide easy access to skilled professionals for all of the people affected by the current war. The participating mental health professionals offer a wide range of services including individual, marital, and family therapy; substance abuse counseling; treatment for post-traumatic stress disorder; and counseling for individuals with traumatic brain injuries. Whether it is a young military wife who is anxious because her four-year-old has had nightmares since her husband’s deployment or a father who is struggling to cope with his son's loss of a leg as a result of an explosion in Iraq, both will receive the assistance they need to move through their experience. The healthier the support system for the returning troops, the lower the risk of severe or prolonged dysfunction within these military families.

Our Plan
Give an Hour is reaching out to the military community in several ways. As a member of America Supports You, a Department of Defense program that provides opportunities for citizens to show their support for the U.S. Armed Forces, we are identifying individuals involved in post-deployment processing of returning troops. We are developing collaborative relationships with the commanding officers of returning troops so that these officers are aware of and comfortable with the services we provide. We are also working closely with a number of veterans service organizations to promote our services directly to the family members of troops. Furthermore, we are working with individuals affiliated with Walter Reed Army Medical Center in Bethesda, Md. We are also collaborating with the Veterans Administration to distribute information about our services through Vet Centers across the country.

Finally, we are promoting our services to the military community and the public through a media campaign that includes print, television, and radio coverage. In fact, our founder and president, Dr. Barbara Romberg, has been interviewed in national media outlets from the Washington Post to NPR's Diane Rehm Show, Ladies' Home Journal, and HD Net's World Report.

Give an Hour recruits mental health professionals in several ways. We have been endorsed by the American Psychiatric Association and the National Association of Social Workers and are seeking endorsements from other major mental health organizations. Only licensed mental health professionals are included in the network. Licenses are verified. Non-licensed pastoral providers may be included in the network as long as they meet other criteria, including membership in professional organizations. In addition to coordinating with national organizations, we also recruit mental health professionals through professional publications and Web sites.

As of May 2008 we have a redesigned Web site, expanded to include materials to guide visitors seeking services as well as reference materials to inform mental health professionals. Only mental health professionals trained and experienced to work with trauma victims will identify themselves as available to work with soldiers who have experienced combat. We are working with experts in the trauma field to prepare materials for our Web site and to find appropriate mental health professionals for recruitment.

The Eli Lilly and Company Foundation recently awarded Give an Hour, in partnership with the American Psychiatric Foundation, a major grant that will allow us to spread our message to the leaders of the mental health community in every state. 

We are recruiting volunteers from a number of organizations and institutions as well as through our Web site to assist us in the implementation of our program. Volunteers from retired military personnel to members of military families to concerned civilians throughout thte country are helping Give an Hour. Volunteers are checking licenses, distributing brochures, and coordinating community partnership opportunities for those troops and family members interested in giving back an hour to their own community.

Our Vision
Our primary focus will always be to attend to those in need by linking them to individuals in our society best equipped to respond effectively. In addition, we will develop research and educational programs to further promote the value and importance of a new kind of volunteerism. We hope to encourage an increase in shared responsibility for those citizens who are suffering. We need only look at the outpouring of aid and support following both the terrorist attacks of September 11, 2001, and Hurricane Katrina in August 2005 to see the potential we have to become a truly compassionate and united nation. And we need only look at the significant costs of the war in Iraq and the relief efforts for Katrina’s victims to see that federal and state governments are already strained beyond their means. We have not only the potential but the duty to help one another in times of need.

For more information, contact Barbara V. Romberg, Ph.D., Founder and President, Give an Hour.  Her email address is linked here.

Sweet Dreams Are Made of This - One Potential Coping Tool for PTSD's Nightmares

"To sleep, perchance to dream..." said Hamlet in his famous soliloquy, in the Shakespeare play of the same name.  It's not so much the dreams PTSD sufferers are worried about, it's the nightmares that bring bad memories rushing back, or otherwise destroy a night's sleep. People with PTSD can be so agitated about their nightmares that they try to put off sleeping altogether, numbing themselves first with drugs or alcohol to keep the nightmares at bay.  (Of course, that creates more problems than it solves, but it's perfectly understandable why that might happen.)  (That's an EEG diagram of healthy, uninterrupted sleep, by the way, at left.)  Now, one novel technique, publicized by a military trauma specialist, may hold out some hope to those whose experience of nightmares prevents them from getting a good night's (and restorative night's) sleep, so crucial to good health, psychologically and physiologically speaking.

In an article published in the Air Force Times of August 9, 2007, linked here, Navy Commander and combat psychologist Beverly Dexter, Ph.D. discusses a somewhat controversial concept she's developed that apparently helps some troops sleep better through the night.  The concept is called "planned dream intervention," although it might more accurately be called, "proactive nightmare intervention," because the goal is to keep a terrifying nightmare from interrupting an otherwise good night's sleep -- essentially by seeing it through to its conclusion, the very thing the sleeping person beset with nightmares usually is too terrified to let actually happen.  I have no idea what to make of this whole concept, and whether it's the concept that's confusing, or the article that describes it just not doing a good enough job of conveying how it really works.  Or, maybe the concept itself has some kinks to work through. What sort of universal applicability does it have?  Only to some types of nightmare sufferers, or does it have validity for all?  Would some types of patients benefit more from this than others?  Does it matter how long (in terms of months or years) people have had the nightmares for?  These and other questions are not really addressed in the article.  It sounds like Dr. Dexter herself says that the concept sounds too good to be true, but she claims it really works, and the article lists a number of examples of people who it's helped.  From the article, it also seems like it's generated a certain amount of buzz as a topic, among troops and military chaplains.  Dr. Dexter, whose bio is linked here, is planning a book on the subject, to come out sometime in 2008.  The book's tentative title is "No More Nightmares:  How to Use Planned Dream Intervention to End Nightmares," but it doesn't seem to be in print yet -- at least, Amazon doesn't have it listed.

According to the article, Dr. Dexter served as the chief of the Combat Stress and Readiness Clinic at Al Asad Air Base in Iraq, and works at the Naval Medical Center in Portsmouth, VA when she's not deployed.

Similarities Explored in How Cops and Troops Experience Trauma Cumulatively, Develop PTSD

Lately we've been taking a look at crucial concept in the linkage between combat trauma and PTSD -- the "dose-response relationship," which is apparently a more or less linear relationship between more combat trauma experienced and greater chance of developing PTSD.  (Earlier blog entries on that topic are linked here and here.)

On the Web, every once in a while you find a gem -- some good and useful material -- in its entirety, and one such "find" is Mary Elizabeth Claire's Ph.D. thesis at Drexel University, available online, called "The Relationship between Critical Incidents, Hostility, and PTSD Symptoms in Police Officers."  (The thesis is linked here.)

While we might prefer her thesis to be about combat veterans and PTSD (heh), the reality is, there's quite a bit of overlap or similarity in how police and veterans experience the events that contribute to PTSD, a fact she explains early on, when she writes:

...Although police officers are usually identified with emergency responders, the context in which police officers experience critical incidents is similar to situations experienced by military veterans. Violanti (1996a) identified six areas of police work that are comparable to the experiences of those that served in the Vietnam War: guerilla warfare at home, the identity of the enemy, a continual sense of insecurity, lack of support, witnessing abusive violence, and depersonalization. The first area, guerilla warfare, is similar to the current plight of many police officers. Violanti (1996a) describes police officers as serving in "peacetime combat."

In a segment entitled, Cumulative Effects of Exposure to Critical Incidents, she writes that:

Learning theory suggests that when an individual is exposed to a repeated stimulus, the person either habituates to the stimuli or becomes sensitized to it. When habituation occurs, the individual reduces their responsiveness to the stimuli while sensitization increases and heightens an individual’s responsiveness. Both behaviors are normal responses but how one reacts to a repetitive stimulus often depends on the intensity of the stimulus. A high intensity stimulus generally tends to sensitize a person to the stimulus while habituation occurs when a person is repeatedly exposed to low to moderate stimuli (Barker, 2001).

It is commonly assumed that individuals that encounter traumatic stressors frequently (e.g., police officers, firefighters) habituate to the stimuli, and therefore they are more resistant to the psychological effects of traumatic incidents. However, the opposing view, that the cumulative effect of critical incidents results in more posttraumatic stress symptoms, has become more empirically supported in recent years (Violanti, 1996b). These findings are congruent with the theories of learning since police officers experience high intensity stimuli on a routine basis thus becoming sensitized, not habituated, to the stimuli.

Several studies have investigated the cumulative effect of critical incidents and the development of PTSD symptoms. For example, Stephens and Miller (1998) conducted a study of 527 New Zealand police officers and found a positive relationship between the number of traumatic events and more PTSD symptoms. Trauma experienced prior to joining the police force was not related to PTSD symptoms while trauma experienced after joining the police force was related to more PTSD symptoms.

Martin et al. (1986) reported that 26% of the 56 police officers attending a sensitive crime seminar met criteria for PTSD. Moreover, the authors found PTSD was related to the number of incidents experienced by the officers. The most frequently endorsed symptom "Recurrent and intrusive recollection of the event" was endorsed by 47 % of the police officers. Martin et al. (1986) indicated it is not surprising that this symptom was endorsed most frequently since police officers continually place themselves in situations similar to previous traumatic incidents and have little opportunity to distance themselves from the incident. Likewise, only 11% of the officers reported in engaging in active avoidance of activities. Moreover, sensitization to the repetitive trauma appeared to occur for these police officers as evidenced by the frequent endorsement of hyperarousal and exaggerated startle response.

Mitchell (1999) reported on the qualitative descriptions of 426 officers above the rank of probationer in the United Kingdom. The officers were asked to describe the most memorable critical incident they experienced during their police career. Almost 75% of the descriptions involved death, and almost 33% of the deaths described involved traffic accidents. Although the Lockerbie Disaster and the crash of the RAF Chinook helicopter were frequently reported, traffic accidents were the largest category of memorable critical incidents described. Different occupational groups within the police department participated, however, 60% of the traffic incidents described as memorable and distressing were reported by current members of the traffic division. Thus, it appears that these officers did not habituate to the incidents in which they were commonly exposed, but instead became sensitized to such incidents. Additionally, the length of time since the accident ranged from two weeks to 25 years with a mean of 5.6 years, indicating that time did not ameliorate the impact of critical incidents in this sample.

Neylan et al. (2002) investigated the impact of critical incident exposure on the quality of sleep in 747 police officers from New York, New York, and Oakland and San Jose, California. The investigators found that cumulative critical incident exposure was associated with nightmares, a symptom of PTSD. Furthermore, sleep disturbances were strongly related to PTSD symptomatology and general psychopathology.

Sleep disturbances and how they contribute to PTSD is another well-deserved treatment that we'll have to leave, though, for another time...