Post-Traumatic Stress Disorder in the Military Essay Example for Free

Post-Traumatic Stress Disorder in the Military Essay I.  Ã‚  Ã‚   Abstract Stoked by an adversarial media and the run-up to Presidential elections next year, the trauma afflicting our body politic often seems more important than the deaths, physical disability and post-trauma stress disorder that afflict servicemen on the frontlines. In this paper, I review the historical origins and verify the prevalence of what was whimsically called â€Å"soldier’s heart† in the Civil War and â€Å"disordered action of the heart† (DAH) or neurasthenia at the turn of the century and has now gained cognizance as â€Å"battlefield fatigue† or PSTD.    The etiology is vast, since combat stress seems to provoke a great many physical, physiological and anxiety-related disorders.   Lastly, I investigate the treatment options.   War is ever a violent business.   If the North-South Civil War shocked Americans with unheard-of casualty counts and the violence of battles waged at the dawn of the industrial age, World War I traumatized the world with the unremitting violence brought to bear in hopes of breaking the stalemate that was the Western front.   Poison gas, the machine gun, barbed wire, and massed artillery bombardment sent casualty counts sky high.   Besides the United States, 17 other countries on both sides of the â€Å"war to end all wars† suffered no less than 5.7 million soldiers killed and another 12.8 million wounded. Soldiers at the frontline were brutalized by the sheer violence of artillery bombardments, the random deaths these caused and the experience of seeing an unceasing number of their fellow soldiers slaughtered by gas or machine gun fire.   It was then that the nervous condition first termed â€Å"war neurosis† or â€Å"neurasthenia† manifested in great numbers.   Eventually, the equivalent term â€Å"shell shock† came into wider use. Combat stress reactions first came to the attention of the medical establishment (psychiatry was in an embryonic stage then) in the second half of the 19th century and early in the 20th when physicians came to recognize adverse reactions that had more to do with sustained exposure to battle conditions than any physical injury.   In retrospect, the Civil War condition then termed â€Å"soldier’s heart† was really a form of â€Å"combat stress reaction†. During the Boer War waged by the British in South Africa (1899-1902), due notice had already been given to either â€Å"disordered action of the heart† (DAH) or neurasthenia/shellshock.   Retrospective analysis of British soldiers who had been pensioned off for these conditions (Jones, Vermaas, Beech, Palmer, et al. 2003) found no especially significant difference in mortality compared to comrades who filed for disability owing to bullet or shrapnel wounds. The Russia-Japanese War of 1904 and 1905 gave Russian physicians their first reported exposure to, and the opportunity to try and treat, nervous breakdowns owing to the stress of warfare, compounded by the demoralization of losing to the Japanese. Later in the 20th century, the evolving nature of the battlefield and the enemy – World War II, the Vietnam War, the Iraq and Afghan occupations being the more prominent examples – created unexpected new sources of stress that complicated the combat fatigue syndrome and led to the broader â€Å"post-traumatic stress disorder† coming into wide use.   So whereas â€Å"combat fatigue† referred to â€Å"a mental disorder caused by the stress of active warfare†, â€Å"PTSD† revolved on post-combat â€Å"fatigue, shock or neurosis†. V.  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Statement of the Problem: In this research paper, we review the available authoritative sources to assess: The continuing prevalence of PSTD in the varied conditions of modern warfare. Short- and long-term therapy employed to resolve the disorder. The extent to which familial and community support ameliorates PSTD and improves patient outlook. For a world that has experienced unremitting conflict since World War II, whether orthodox warfare, low-intensity conflict or insurgency, chances are that anticipating and providing therapy for stress disorders will be a continuing concern. VI.  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Literature Review A.  Ã‚   The Character of Modern Conflict In the aftermath of the Great War many people believed that they had seen the most terrible war the world will ever see. History would prove them wrong. In the century that followed, war became even more traumatic and horrifying in its brutality. From the Russian civil war to the present conflict in Iraq, war took an ever-heavier toll on the human psyche. Technology improved the methods by which death might be delivered but it has done nothing to strengthen the minds of those who had to bear it. The Russian civil war that succeeded until after World War I was a horror to behold. Thousands died in the fighting between the White Russians and Red Russians. Thousands more froze in the winter for lack of appropriate gear. Worse, many civilians were murdered by both sides on mere suspicion of being collaborators. World War II was a litany of terrors. Whole societies were brainwashed into supporting the war from an ideological standpoint. Millions of Jews were gassed and burned in the holocaust simply being Jews. The SS, the KGB and the Kempetai would murder anyone at whim. Thousands of women were kidnapped and raped as â€Å"comfort women† by the Imperial Japanese Army. More than the individual or large-scale slaughter of men, the true horror of WWII was the torture it inflicted on societies. Entire cities were razed to the ground in terror bombing. Cities became prison cells where starving denizens were forced to labor endlessly. Men went off to war leaving women to tend the factories and leaving no one to care for the children. Then there was the Atomic Bomb. A scant few scores of thousands died. Both cities were leveled to the ground. The radioactive damaged would endure for years. Even those who tried to help the victims were themselves victimized by the radiation. In Korea and Vietnam, millions were fielded in grueling civil wars. Korean fought against Korean backed by Communist and Imperialist masters. The same would be true for Vietnam but with the inclusion of terrible chemical weapons that defoliated forests and would cause harm for generations to come.   In turn, the Viet Cong and Khmer Rouge executed savage campaigns against their own people. The Arab-Israeli and Iraq-Iran wars would institutionalize child-soldiery. Israel had a scant 4 million citizens to oppose over 200 million Arabs. When attacked by the Arabs, Israel would be forced to deploy all its manpower, along with women, to help fight off the invaders. Chemical weapons were also used. The Israelites were left to defend their small nation against all their neighbors. Iraq and Iran would field child soldiers in countless thousands. They would be given rifles then thrown into battle against hardened veterans in the hope of at least slowing down the enemy. Muslim killed each other over essentially religious disputes. But perhaps the worst war of the 20th century would be the War on Terror. In the past the enemy was a specific country or group of countries. If they bomb our territory we can bomb theirs. But today, the enemy is not a nation. Today, servicemen in Iraq or Afghanistan do not know where or when the enemy will strike. All they know is that the enemy is out there lurking amongst a hostile population. The war on terror also has another unsavory aspect. The ‘enemy’ resort to bombing civilian targets back home. Worse, the soldiers know that their victories will only make the enemy more desperate and make them retaliate more against innocent civilians. As if the violence of outright warfare and low-intensity conflict were not enough, American and British forces of occupation as well as the soldiers of every nation that serve in U.N. peacekeeping forces confront at least equal prospects of PTSD.   Whether in the Korean DMZ, the former Yugoslavia, Iraq, Afghanistan, Somalia, Lebanon, Ireland, or Timor, every soldier on such assignments faces a multitude of perils. In many cases, peacekeeping forces are in a low-intensity-conflict situation but hampered by rules of engagement that deny them the right to shoot first and shrug it off as a mistake.   The potential for battlefield fatigue climbs higher with alien cultures and religions, a seemingly ungrateful, resentful and even hostile native population, suicide attacks, well-armed guerillas, booby traps, mortar and improvised missile attacks.   Such occupying forces are also apt to lose the public relations war for being unable to stop factions from slaughtering each other such as happened in Iraq, Afghanistan, Israel, Lebanon, East Timor and Rwanda.   And perhaps the unkindest cut of all is when their own country’s media deliberately distort the casualty count from fratricidal or genocidal conflict as having been caused by the occupying or peacekeeping forces! B.  Ã‚   Incidence of â€Å"Shell Shock†, PTSD and Precipitating Events When â€Å"shell shock† came to be widely recognized in World War I, the initial hypothesis was that it was induced by an inordinate number of fatal casualties.   In fact, about 10% of all military forces then engaged succumbed on the battlefield, double the rate in World War II (less than 5%, in great part because the wide availability of sulfanilamide averted more deaths from battlefield infection).   Later came the realization that it was total casualty count that really mattered.   Historical research shows that around 56% of soldiers on the Western Front were either killed or wounded.   When every other fellow in one’s platoon gets hit, fatally or not, it is no wonder that stress casualties were as numerous as battle casualties. The term itself, â€Å"shell shock† reveals the ingrained belief that psychiatric casualties from the horrors of the battles of the Somme, Marne, Ypres, etc. had suffered concussion (physical trauma to the head or brain) from a close call with an exploding artillery shell.   Nearly a decade elapsed before a British War Office Committee realized (Military History Companion, 2004) that battle exhaustion and other varieties of war neuroses accounted for a far greater proportion of cases than concussion did. Great Britain having entered the fray early, the numbers of servicemen afflicted with â€Å"shell shock† and assorted neuroses were significant. By 1939, some 120,000 British ex-servicemen had received final awards for primary psychiatric disability or were still drawing pensions – about 15% of all pensioned disabilities – and another 44,000 or so †¦ were getting pensions for ‘soldier’s heart’ or Effort Syndrome. (Shephard, 2000) In the post-World War II era, the Vietnam war can be counted the most traumatic for the U.S. military, not least because of the failure to achieve a clear-cut victory and the dissatisfaction of the American public with a war that dragged on so long.   Since the fall of Saigon in 1975, estimates of the long-term incidence of â€Å"post-Vietnam syndrome† (now recognized as PTSD) among veterans varied from a high of 30% in 1989 and a slightly lower 21% in 1996 (Allis, 2005). The most authoritative review in recent years, by researchers from Columbia University and other institutions, suggested that the lower end of the range was the more realistic figure: nearly 19 percent of Vietnam War veterans succumbed to PTSD as a direct result of military combat.   In addition, The more severe the exposure to war zone stresses, the greater the likelihood of developing post-traumatic stress disorder and having it persist for many years, said Bruce P. Dohrenwend, an epidemiologist at Columbia University. (McKenna, 2006). Fast forward to the current occupation of Iraq.   The Defense Department reports, based on a sample survey of over 1,600 Army soldiers and Marines, that around one-third (30 percent) of those who had been in â€Å"intense combat† were diagnosed with such mental health problems as PTSD and depression.   Incidence appeared higher among soldiers deployed to Iraq at least twice and for more than six months at a time (Bookman, 2007).   So distressing is the occupation, according to an Army study, that one in six of close 1 million soldiers â€Å"surged† to Afghanistan and Iraq will very likely be afflicted with PTSD (Allis, op. cit.). The reality turned out to be worse.   Even more appalling estimates of incidence were reported by what has to be the most thorough accounting of the prevalence of post-traumatic stress disorder (PTSD) and conditions resembling chronic fatigue syndrome (CFS), a survey by Kang, Natelson, Mahan, Lee, Murphy (2003) on the entire population of 15,000 Gulf War and 15,000 non-Gulf-War veterans.   Information was gathered in 1995-97. Gulf War veterans reported significantly higher incidence of PTSD (adjusted odds ratio = 3.1, 95% confidence interval: 2.7, 3.4) and CFS (adjusted odds ratio = 4.8, 95% confidence interval: 3.9, 5.9). Furthermore, â€Å"the prevalence of PTSD increased monotonically across six levels of deployment-related stress intensity (test for trend: p 0.01). Back home, the Department of Veterans Affairs reported on an investigation of principally Persian Gulf War veterans (79%) who had availed of the National Referral Program (NRP) and visited war-related illness and injury study centers meant for combat veterans with unexplained illnesses . Over the period from January 2002 to March 2004†¦ The more common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry†¦ environmental hazards, stress†¦A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral (Lincoln, Helmer, Schneiderman, Li, et al. 2006). The political furor over U.S. deployment in the Middle East has led to permutations, including what Baker (2001) refers to as â€Å"Gulf War Illness†.   The more combat exposure they had had, the greater the likelihood that veterans manifest depression, PTSD, fibromyalgia, anxiety, and have generally poorer â€Å"health-related quality of life†. For the British, a more sanguine view about involvement in Iraq may explain a finding that deployment to that strife-torn arena does not necessarily lead to increased risk of PTSD. Simon Wessely of the Kings Centre for Military Health Research at Kings College London reports that there is no evidence of anything like an Iraq war syndrome and that British troops returning from deployment were no more likely than U.K.-based soldiers to succumb to PTSD, anxiety or depression (New Scientist, 2006).   Wessely seemed heartened by the fact that PTSD casualties this time around were significantly lower than during the earlier, even less controversial Persian Gulf War of 1991. He also explained the advantage vis-à  -vis incidence of around 20% for U.S. troops on three facts.   First of all, British troops are more battle-hardened. Two-thirds of British troops have been in deployments elsewhere, compared with only 10 per cent of US troops.   Secondly the US also uses more reservists (in the form of National Guard units) and has responsibility for the worst of the hostile combat zones.   To an outside observer, the adversarial stance of the U.S. press and the inability of the American public to withstand sustained conflicts not amenable to victory over a visible enemy also count as contributing factors. It would take an Englishman to look into the topic but tongue-in-cheek analysis by Ismail et al. (2000) of U.K. Gulf War veterans revealed that the chances of falling prey to PTSD are greater with lower rank (and, presumably, lower social status) and if one leaves the service. Some research has shown that, far from being a steady state or amenable to permanent remission, PTSD has a way of recurring with the re-occurrence of the original precipitating factors or other less specific pressures, such as with serious illness or the sudden lifestyle change of retirement.   In Israel, reactivation is a constant possibility owing to the fact the nation is always in a state of war with recalcitrant enemies so this potential trigger has come under scrutiny (Nachshoni Singer, 2006).   Case studies suggested that PTSD can recur even when the call to duty is for a family member. C.  Ã‚   Symptomatology In World War I, â€Å"shell shock† was observed principally as nervous fatigue.   The famous photograph (see Figure 1, above) of a patient manifesting the â€Å"thousand-yard stare† became the enduring image of intolerable combat stress: glassy-eyed fatigue, slow reactions, indecisiveness, being detached from one’s immediate surroundings, and a certain vagueness about that needed doing first. So great were the numbers afflicted and so vividly did the novel phenomenon manifest itself that even the popular press in the U.K. could accurately report the symptoms of battle trauma: â€Å"Something was wrong. They put on civilian clothes again and looked to their mothers and wives very much like the young men who had gone to business in the peaceful days before August 1914. But they had not come back the same men. Something had altered in them. They were subject to sudden moods, and queer tempers, fits of profound depression alternating with a restless desire for pleasure. Many were easily moved to passion where they lost control of themselves, many were bitter in their speech, violent in opinion, frightening. (Shephard, op. cit.) The unfortunate circumstance of decades of unending small-scale conflict and insurgency campaigns post-World War II have enabled military psychiatrists to more fully define three key facets of combat neurosis and PTSD: fatigue, psychosomatic manifestations and neurotic symptoms. Fatigue is the common denominator behind indecision and inability to concentrate, memory loss, constant waffling about priorities, little initiative, significantly slowed reaction time, seriously downgraded alertness and thought processes, taking refuge in obsessing and nitpicking unimportant details, and, most telling of all, difficulty with even routine tasks. The element of neurosis crops up as fearfulness, anxiety, irritability, depression, confusion, paranoiac tendencies, fear of loss of control, and self-destructive behavior such as substance abuse or suicide. Consequently, PTSD patients manifest the entire spectrum of somatically-induced disorders: headaches, backaches, (see also Mayor, 2000) being constantly high-strung, shaking and tremors, sweating, nausea and vomiting, loss of appetite, abdominal distress, frequency of urination, urinary incontinence, palpitations, hyperventilation, dizziness, muscle and joint pain (see also Ricks, 1997),   insomnia and other sleep disorders.   Barrett et al. (2002) found this psychosomatic explanation incomplete.    In a telephone survey of 3,682 Gulf War veterans and control subjects of the same era, the authors revealed that â€Å"Veterans screening positive for PTSD reported significantly more physical health symptoms and medical conditions than did veterans without PTSD. They were also more likely to rate their health status as fair or poor and to report lower levels of health-related quality of life.† D.  Ã‚   Long-term Effects No doubt, psychosomatic disorders are of a piece with another syndrome physicians like to point to chronic multisymptom illness (CMI).   Building on earlier studies that demonstrated CMI being more common among veterans who deployed to Saudi Arabia and Kuwait in contrast with those who had never participated in that campaign, Blanchard, Eisen, Alpern, Karlinsky, Toomey, Reda, Murphy, Jackson and Kang (2006) set out to assess the situation ten years after deployment and found that veterans were twice as likely to develop CMI: Cross-sectional data collected from 1,061 deployed veterans and 1,128 nondeployed veterans examined between 1999 and 2001 were analyzed. CMI prevalence was 28.9% among deployed veterans and 15.8% among nondeployed veterans (odds ratio = 2.16, 95% confidence interval: 1.61, 2.90). Blanchard et al. noted that those who did suffer from CMI had already been diagnosed for anxiety and depression unrelated to PTSD prior to 1991.   Common CMI manifestations comprised frank medical symptoms, metabolic and psychiatric disorders.   And those afflicted were more likely to smoke, besides reporting distinctly inferior quality of life. M Hotopf, Anthony S David, Lisa Hull, Vasilis Nikalaou, et al. (2003) carried out one of the more comprehensive and authoritative studies of long-term effects, a two-stage cohort study on British soldiers who had deployed during the 1991 Persian Gulf War or on peacekeeping duties in Bosnia. The study relied on four instruments: â€Å"self reported fatigue measured on the Chalder fatigue scale; psychological distress measured on the general health questionnaire, physical functioning and health perception on the SF-36; and a count of physical symptoms.†Ã‚   Military personnel who had been deployed elsewhere served as control group. Table 1 Prevalence of Categorical   Outcomes (Values are percentages [.95 CL] unless otherwise indicated) Gulf Bosnia Era Stage 1 Stage 2 Ratio* (new cases/recovered cases) Stage 1 Stage 2 Ratio* (new cases/recovered cases) Stage 1 Stage 2 Ratio* (new cases/recovered cases) Fatigue cases 48.8 (45.4 to 52.2) 43.4 (39.9 to 46.8) 0.65 (0.45 to 0.85) 29.0 (25.6 to 32.4) 32.7 (28.6 to 36.8) 1.21 (0.83 to 1.59) 22.8 (20.0 to 25.6) 22.0 (18.6 to 25.4) 0.91 (0.56-1.26) Post-traumatic stress reaction cases 12.4 (10.7 to 14.2) 10.8 (9.1 to 12.5) 0.73 (0.47 to 0.99) 5.7 (4.0 to 7.4) 6.0 (4.2 to 7.8) 1.07 (0.49 to 1.65) 4.0 (2.6 to 5.3) 6.6 (4.8 to 8.4) 2.45 (0.88-4.02) General health questionnaire cases 40.0 (36.8 to 43.2) 37.1 (33.8 to 40.4) 0.79 (0.59 to 1.00) 29.2 (25.5 to 32.9) 31.5 (27.4 to 35.6) 1.25 (0.84 to 1.67) 25.3 (21.7 to 28.9) 23.8 (20.1 to 27.6) 0.88 (0.56-1.20) Self reported Gulf war syndrome 18.6 (16.2 to 21.1) 15.8 (13.3 to 18.2) 0.58 (0.25 to 0.90) All prevalence estimates are weighted for sampling. * Values of 1 indicate declining prevalence. Ratios are weighted for sampling. Gulf veterans evinced a higher prevalence of fatigue, post-traumatic stress reaction, self-reported Gulf War syndrome and general health compared to the other two cohorts. The difference is consistent throughout stages 1 and 2. However, the veterans in question did show some improvement on all four measures over time. Table 2 Scores (.95 CL) for Continuous Measures, by Cohort and Stage Gulf Bosnia Era Stage 1 Stage 2 Difference Stage 1 Stage 2 Difference Stage 1 Stage 2 Difference SF-36* physical function 90.3 (88.3 to 91.3) 88.7 (87.6 to 89.9) -1.6 (-2.5 to -0.7) 95.4 (94.4 to 96.4) 92.9 (91.6 to 94.1) -2.6 (-3.8 to -1.3) 92.1 (90.6 to 93.6) 90.8 (89.2 to 92.3) -1.3 (-2.7 to 0.1) SF-36* health perception 65.8 (64.1 to 67.5) 65.9 (64.2 to 67.6) 0.1 (-1.2 to 1.4) 76.2 (74.4 to 77.9) 72.9 (71.0 to 74.8) -3.3 (-5.1 to -1.6) 76.8 (75.0 to 78.6) 74.4 (72.4 to 76.4) -2.4 (-4.2 to -0.6) General health questionnaire 14.5 (14.1 to 14.9) 14.2 (13.8 to 14.5) -0.3 (0.1, -0.6) 13.1 (12.7 to 13.6) 13.2 (12.7 to 13.7) 0.1 (-0.4 to 0.6) 12.4 (12.0 to 12.8) 12.9 (12.5 to 13.3) 0.5 (0.05 to 1.0) Fatigue 17.8 (17.4 to 18.1) 16.9 (16.5 to 17.2) -0.9 (-1.2 to -0.6) 15.6 (15.2 to 16.0) 15.3 (14.9 to 15.7) -0.3 (-0.7 to 0.2) 14.7 (14.3 to 15.0) 14.9 (14.5 to 15.3) 0.2 (-0.2 to 0.6) Total symptoms 11.0 (10.4 to 11.6) 10.7 (10.1 to 11.3) -0.3 (-0.8 to 0.1) 6.2 (5.6 to 6.8) 7.9 (7.3 to 8.5) 1.7 (1.2 to 2.3) 5.3 (4.8 to 5.8) 6.4 (5.8 to 7.0) 1.1 (0.6 to 1.6) All scores are weighted for sampling. For SF-36 scores, negative differences in mean indicate a worsening in health. For other scales, negative scores indicate an improvement in health. * SF-36 scales range from 0-100, with higher scores indicating better health.   Table 3- Incidence and Persistence of Outcomes. (Values presented with 0.95 CLs) Incidence Persistence Cohort Risk Crude odds ratio Corrected odds ratio* Risk Crude odds ratio Corrected odds ratio* General health questionnaire cases: Gulf 20.2 (16.4 to 24.0) 1.0 1.0 61.8 (57.3 to 66.3) 1.0 1.0 Bosnia 21.2 (16.7 to 25.8) 1.1 (0.7 to 1.5) 0.9 (0.6 to 1.4) 58.9 (51.9 to 65.8) 0.9 (0.6 to 1.1) 1.1 (0.7 to 1.6) Era 15.4 (11.4 to 19.4) 0.7 (0.5 to 1.1) 0.7 (0.5 to 1.1) 48.4 (41.0 to 55.9) 0.8 (0.6 to 1.1) 0.6 (0.4 to 0.8) Fatigue cases: Gulf 18.8 (14.4 to 23.1) 1.0 1.0 69.7 (66.4 to 73.0) 1.0 1.0 Bosnia 19.8 (15.1 to 24.4) 1.1 (0.7 to 1.6) 0.9 (0.6 to 1.5) 59.9 (54.2 to 65.6) 0.6 (0.5 to 0.9) 0.7 (0.5 to 1.0) Era 11.2 (7.5 to 15.0) 0.6 (0.3 to 0.9) 0.5 (0.3 to 0.9) 58.2 (53.1 to 63.4) 0.6 (0.5 to 0.8) 0.7 (0.5 to 0.9) Post-traumatic stress reaction cases: Gulf 5.0 (3.6 to 6.4) 1.0 1.0 51.8 (44.8 to 58.9) 1.0 1.0 Bosnia 4.0 (2.5 to 5.5) 0.8 (0.5 to 1.3) 0.8 (0.4 to 1.5) 38.9 (24.3 to 53.3) 0.6 (0.3 to 1.2) 0.8 (0.4 to 1.8) Era 4.6 (3.0 to 6.2) 0.9 (0.6 to 1.5) 0.9 (0.5 to 1.5) 54.8 (37.8 to 71.9) 1.1 (0.5 to 2.4) 1.2 (0.6 to 2.7) * Controlled for demographic variables (age, sex, rank, marital status). Comparing scores for continuous measures, one sees that Gulf War veterans were less healthy at both stages of the longitudinal study, though they were stable as far as health perceptions were concerned and reported a statistically-significant, if slight, reduction in fatigue. One concedes that physical functioning declined for all three cohorts. Additionally, Gulf veterans were more likely to experience persistent fatigue compared with the Era and Bosnia cohorts, a finding that remained significant after controlling for potential confounders (P = 0.009). Overall, despite being less likely to manifest less fatigue (48.8% at stage 1, 43.4% at stage 2) and a lower prevalence of psychological distress (40.0% stage 1, 37.1% stage 2) over time, veterans of the Gulf War reported a decline in physical function on the SF-36 (90.3 stage 1, 88.7 stage 2).   By all measures used, this group also attested to worse health indicators: a higher incidence of illness and more persistent symptoms. Twelve years after helping smash the Iraqi incursion into Kuwait, the authors concluded, â€Å"Gulf war veterans continue to experience symptoms that are considerably worse than would be expected in an equivalent cohort of military personnel. However, Gulf war veterans are not deteriorating and do not have a higher incidence of new illnesses† (Hotopf et al., op. cit.) E.  Ã‚   Treatment Recommendations and Best Practice 1.  Ã‚  Ã‚  Ã‚  Ã‚   World War I Since little is known about the methods Russians used to treat their shock casualties during the Russo-Japanese War, the noted English psychologist Charles Myers – first University Lecturer in Cambridge (for the course Experimental Psychology) and appointed Consulting Psychologist to the Army in 1916 – is generally credited with the first systematic effort to treat PTSD (Bartlett, 1937). While espousing the benefits of a congenial environment, psychotherapeutic regimens and even hypnosis, Myers was very emphatic about the value of providing succor as promptly as possible.   Key to his proposals, therefore, was the establishment of special centers and rest homes close to the frontlines. By Christmas 1916, two developments led to modifications of Myers’ preferred regimen.   First, the British Adjutant General resisted physicians’ opinions that a soldier was a shock casualty and insisted on obtaining a certification from the victim’s commanding officer to the effect that the trauma was due to physical causes.   This attitude was shared by the eminent British neurologist Sir Gordon Morgan Holmes, CMG CBE FRS, who was put in charge of the very active northern part of the front in December.   Physicians reacted to the delays in committing victims to neurological centers by sending the men back to their units and urging their superiors to both monitor and engage with them. By 1917, therefore, treatment for â€Å"not yet diagnosed nervous† (NYDN) had evolved to embrace the so-called â€Å"PIE principles†: Proximity – treatment close to the front and within earshot of the fighting to convince the soldier there was nothing wrong with him; Immediacy treat without delay and give equal priority with wounded casualties; and, Expectancy – assure all victims of their return to the front after due rest and recovery. Reviewing the CSR toll after the war, the British War Office saw fit to recommend treatment programs that included: Physical therapy – baths, application of mild electric current (recall that medicine has advanced greatly in the eight decades since then), massage rest and general recuperation; Psychotherapy emphasizing â€Å"explanation, persuasion and suggestion†; and, Crafts and hobbies; Hypnotherapy in selected cases for inducing deep sleep and evoking repressed memories. As a rule, the British view of the time was weighted toward returning the afflicted soldier to useful employment in civilian life.   For the military establishment was gravely concerned about the battlefield dangers of patients who manifested severe anxiety neuroses, other neuroses that required confinement in a mental institution or expert treatment back in the U.K itself. Exhaustive research on combat stress reactions in the intervening years failed to prove conclusively that PIE-based programs were effective in forestalling PTSD (U.S. Dept of Veterans Affairs, n.d.).   Hence, American Armed Forces are now more likely to be administered some variation of the BICEPS model: Brevity Immediacy Centrality or Contact Expectancy Proximity Simplicity 2.  Ã‚  Ã‚  Ã‚  Ã‚   World War II The catastrophic experiences of World War I did not   seem to adequately inform or pervasively improve Allied preparations as war clouds loomed in Europe.   A generation had passed and British army doctors had generally served in France in the earlier conflict.   Still, Shephard notes (op. cit.), they initially floundered about and it was not until 1942 that the first psychiatric hospital was even set up (for the then-beleaguered Middle East Force).   When the time came to invade Normandy in June 1944, British army physicians quickly forsook the expectancy principle and routinely returned battle trauma patients home over the Channel. For their part, the Americans initially imposed rigid screening pressures for mental ability in the rush of patriotic fervor that followed Pearl Harbor.   Soon enough, this was abandoned for having no validity.   Too many who tested well succumbed to â€Å"battlefield exhaustion†.   In late 1943, the U.S. military approved a plan to add a psychiatrist to the T.O. E. of every Army division shipping overseas but it was not implemented until March 1944, when the drive up the Italian â€Å"boot† was well underway. This late in the war, nonetheless, the Allies made an important discovery: camaraderie and unit cohesion were effective shields against â€Å"exhaustion†.   This finding naturally enough placed a premium on strong, effective leadership. The Germans were more unequivocal in placing great reliance on the quality of the officer corps.   In their view, the â€Å"war neuroses† that sapped the will of their fighting men was tantamount to cowardice and deserved to be treated as such.   Beginning in 1942, however, when the Allies started the counterattack and the Afrika Korps was stymied, hospitalizations owing to battlefield trauma became too numerous to ignore (Belenky, 1987). 3.  Ã‚  Ã‚  Ã‚  Ã‚   New approaches in the Post-War Period Among other developments, the Israelis simplified PIE procedures by heightening the degree of support administered but keeping therapeutic confinement short.   That this works at all is testimony to a nation of citizen-soldiers who must keep the economy working while perpetually staying on a war footing. F.  Ã‚  Ã‚   Treatment Success Rates There is some evidence that proximal treatment is successful   Despite the dual stress of fighting another occupying force, the Syrian Army, and Palestinian â€Å"refugees†, nine in ten CSR were reported fit to return to their units within three days but only 40% for those evacuated to a hospital ship cruising the eastern Mediterranean or back home (Gabriel, 1986).   In turn, the U.S. Army claims in its manual â€Å"Combat Stress Control in a Theater of Operations† a similar success rate for proximate treatment (85%) in the Korean War (U.S. Army, Combat Stress Control in a Theater of Operations, n.d.).   However, neither source tracked the long-term mental health of these soldiers, precisely the context in which one would expect PTSD to manifest. A ray of hope is, however, cast by an authoritative Columbia University study (McKenna, op. cit.) suggesting that the majority of Vietnam war veterans spontaneously recovered from PTSD over time, frequently without having recourse to treatment from mental health professionals. VII.  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Conclusions This review of the literature affirms that the advent of combat stress went hand-in-hand with the advent of industrial-era weaponry (in the Civil War) and mechanized warfare in succeeding conflicts.   PTSD has many manifestations, can recur without warning and is certainly debilitating. Even with the advent of psychotherapy, occupational therapy and tranquilizers, treatment centers still purvey variations on the BICEPS and PIE theoretical models, the latter developed by British physicians during World War I.   There remains a great deal of uncertainty about the proximity component of the PIE model – returning the soldier to combat – after suffering CSR.   It seems battlefront physicians take â€Å"successful cure† to mean being able to return warm bodies to the frontlines.   Critics assert that re-exposure to combat is likely to aggravate matters in the future and perhaps even precipitate PTSD altogether.   Though the longest available cohort study spanned just 10 years, there is no question now that PSTD has long-term effects. Future researchers need to investigate more thoroughly the psychosocial, military, and environmental risk factors that stimulate onset or, on the other hand, recovery.   One factor that bears investigation in-depth is the impact of victory or setbacks in a campaign. To the extent that high morale and good leadership have been shown to have a moderating or even protective effect, one wonders what are the effects of fighting for survival (e.g. Israel), of community and country united behind a war effort (the Korean War, the Malayan emergency), of service in prior conflicts (the British SAS), of guilt and angst over being the globe’s last remaining policeman, and of coping with feudal cultures whose people are just as willing to apply savage tactics against U.S. servicemen as against each other.   At the very least, further research might seek to determine the impact of attainable victory in sharp contrast with the ennui and self-destructive impatience over protracted conflict that mark American discourse today.   VIII.  Ã‚  Ã‚   References Allis, S. Globe Staff (2005). â€Å"Frontline† examines wars psychological toll  :[THIRD Edition]. Boston Globe, p .E.5. Baker, D. G. (2001). Diagnostic status and treatment recommendations for Persian Gulf War Veterans with multiple nonspecific symptoms.  Military Medicine,166(11), 972-81. Barrett, D. H, Doebbeling, C. C., Schwartz, D. A, Voelker, M. D, et al.  (2002). Postraumatic stress disorder and self-reported physical health status among S. military personnel serving during the Gulf War period: A population-based study. Psychosomatics,43(3),  195-205. Bartlett, F.C (1937). Cambridge, England, 1887-1937. American Journal of Psychology 50, 97-110. Belenky, G. (1987) Contemporary studies in combat psychiatry: (Contributions in military studies). Westport, CT: Greenwood Press. Blanchard, M.S. Eisen, S. A., Alpern, R. Karlinsky, J. Toomey, R., Reda, D. J. et. al. (2006). Chronic multisymptom illness complex in gulf war I veterans 10 years later. American Journal of Epidemiology,  163(1),  66-75. Bookman, J. (2007,  May  9). OUR OPINIONS: War strains troops, U.S. credibility  :[Main Edition].  The Atlanta Journal Constitution, A.14. Brits less fazed by iraq war.  (2006,  May). New Scientist,190(2552),  7. FM8-51: Combat Stress Control in a Theater of Operatio ns US Army Publication. Ismail K.,   Blatchley N.,   Hotopf, M.,   Hull L.,   et al.  (2000). Occupational risk factors for ill health in Gulf veterans of the United Kingdom.  Journal of Epidemiology and Community Health,54(11),  834-8. Lincoln, A. E., Helmer, D.A., Schneiderman, A. I., Li, M. et al. (2006). The war-related illness and injury study centers: A resource for deployment-related health concerns. Military Medicine, 171(7), 577-85. Gabriel, R.A., Ed. (1986) Military Psychiatry. Hotopf, M., David, A.S., Hull, L., Nikalaou, V., et al. (2003) Gulf war illness-Better, worse, or just the same? A cohort study. British Medical Journal. (International edition). London: Dec 13, 2003. Vol. 327, Iss. 7428; pg. 1370. Jones, E., Vermaas, R.H., Beech, C., Palmer, I. et al.  (2003). Mortality and postcombat disorders: U.K. veterans of the boer war and world war I.  Military Medicine,168(5),  414-8. Kang , H. K., Natelson, B. H.,   Mahan, C. M., Lee, K. Y.,   Murphy, F. M..  (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among gulf war veterans: A population-based survey of 30,000 veterans.  American Journal of Epidemiology,157(2),  141. Mayor, S. (1997). Gulf war research given go ahead.  British Medical Journal,314(7074),  95. Mckenna, Phil (2006). Stress syndrome affected one in five Vietnam veterans. (August 21) Boston Globe, C.3. Military History Companion (2004) The Oxford Companion to Military History. Oxford: Oxford University Press. Nachshoni, T. Singer, Y. (2006). Reactivation of combat stress after a family members enlistment. Military Medicine, 171(12), 1211-4. Ricks, T. E. (1997). Many military officers say gulf war syndrome results from the stress of war, not chemicals. Wall Street Journal (Eastern Edition), p. A14. Shephard, B (2000). A War of Nerves. Cambridge: Cambridge UP. United States Department of Veterans Affairs Treating Survivors in the Acute Aftermath of Traumatic Events.

Analysis of An American Tragedy and What Makes it a Classic :: An American Tragedy Theodore Dreiser Essays

Analysis of An American Tragedy and What Makes it a Classic An American Tragedy is an intriguing, frighteningly realistic journey into the mind of a murderer. It is a biography of its era. And, it is also historical fiction. But what makes this novel a classic? While society has changed dramatically since 1925, Dreiser's novel, which shows the futility of "The American Dream" and the tragedies that trying to live it can cause, accurately summarizes social mores of this and any time period. Before Theodore Dreiser was born, his father, a devout German immigrant, lost everything when his large wool mill burned down (kirjasto.sci.fi 1). After a beam hit his head, Dreiser's father was subject to dramatic mood swings; this brain damage caused him to became an evangelist (Survey of American Literature 571). Theodore Dreiser, the twelfth of 13 children, was born in Terre Haute, Indiana, in 1871. By this time, his parents were poor, nomadic preachers. Their nomadic lifestyle meant that Dreiser did not have any companions outside his family. While travelling, his mother taught him to avoid degrading and destructive experiences (Hart 236). Certain that his parents were failures because of their strong morals and their constant preaching, he rebelled. Dreiser had no friends, money, social status, or sex life, which he craved. For most Americans, these were collectively "The American Dream." For Dreiser and his most famous character, Clyde Griffiths, living the American Dream -- t he evasive pinnacle of success -- became an obsession. That obsession led 13-year old Dreiser to Indiana University, which he flunked out of. Instead of preaching, he instantly abandoned his unsuccessful family for the promise of riches and women in industrial Chicago. After living in abject poverty for years (Parker 203), he worked as a journalist for both Chicago Globe and St. Louis's Globe-Democrat, which gave him a glimpse of high society. There, he married Sara White. Within months, the two separated permanently, and Dreiser became a nomad. While wandering, he studied the writings of Balzac, Darwin, Freud, Hawthorne, Huxley (wwnorton.com 1), Poe, and Spenser, from which he created two philosophical theories: social Darwinism governs society (Parker 203), and man's greatest appetite is sexual (kirjasto.sci.fi 1). Dreiser followed his philosophy; he typically had several affairs at once. In New York, Dreiser started Sister Carrie, a brilliant naturalistic piece. The book was sold only 500 copies; it was so "scandalous" that its owned publishers censored its printing in 1900 (Bucco 5).

Biopure Case Study Essay

Oxyglobin and Hemopure are two blood substitutes that Biopure Corporation was developing. Oxyglobin was recently approved by the FDA for veterinary use while Hemapure is estimated to be approved in two years for human use. If Oxyglobin is launched it will be the first blood substitute for the veterinary market a small and price sensitive market. There is a perceived risk by Ted Jacobs, the VP of Human Clinical Trials at Biopure, that if Oxuglobin, the vet product, is launched before Hemopure and at the low price of $150/unit, that it will become very challenging to sell Hemopure once launched at $800/unit. B. Market Analysis a)Human 14 million units of RBCs were donated in the United States in 1995, 12. 9 Million from volunteer donors and 1. 1 million from autologous donors (donate to self, few weeks prior to surgery). 50% of the blood supplies are handled by the American Red Cross. Of the 14 million units donated 2. 7 million are discarded due to expiration or contamination, 3. 2 million transfused into anemia patients and the remaining 8. 1 million transfused into surgery and trauma patients. Blood Collection is a struggle as post AIDS blood contamination paying for donation of blood units is prohibited by the law; it should be done on volunteer basis. Due to low rates of donation and short shelf-life, shortage of RBC units in medical facilities in not uncommon and therefore the need for blood substitutes in the human market is high. b)Veterinary The veterinary market is smaller than the humans as in 1995 2. 5% of 800 dogs/vet GP suffering from acute blood loss were deemed critical and received transfusion, for a total of 300,000 dogs (800Ãâ€"15,000 vet GPx 0.  025), although there is a potential to cover 30% of these pets or about or 3. 6 million dogs. These veterinary GP lack adequate supply of canine blood units lack of animal blood banks. Vets rely on housed donor animals which 84% of them are dissatisfied with the current available blood transfusion alternatives. This constitutes a big opportunity for Oxyglobin. C. Competition Biopure has two competitors for the human product, Baxter and Northfield both of whom are pursuing a Hemoglobin purified from outdated RBC at unit cost ranging from $8-$26 vs. Biopure’s hemoglobin purified from cattle at unit cost of $1. 50. Both Northfield’s and Baxter’s products are expected to launch 2 years after Oxyglobin and same year as Hemopure. Oxyglobin’s only competition is the blood collected from in-house animal donors. One important difference between Hemopure/Oxyglobin and competition is that Biopure’s products do not require storage at 4 °C and can be stored at room temperature; this is a significant difference because there is no added cost attributed to refrigeration. D. Pricing Hemopure as Baxter’s Hem Assist and Northfield is expected to be priced between $600-$800/unit and I suggest that it prices at the highest range of the spectrum because it does not require refrigeration and there will be perceived savings by pharmacists and hospital managers. On the other hand Oxyglobin and because of the â€Å"doubling rule† used by the vets meaning they charge pets owners double the price of the manufacturers ask price), it is arguable and to keep the drug affordable that the price ranges from $80-$100 per unit. Others argued that the price should be set at $200/unit because of all the advantages, added business and cost savings it brings to the practice and pet owners as well. II. Problem/Decision statement Two related issues need to be addressed by the CEO. †¢Should Oxyglobin be launched before Hemopure? Although Oxyglobin was granted approval by the FDA, few challenges remain to be sorted, such as: 1. Reluctance of veterinarians to use the product instead of blood from animal donors 2. Setting the price of the product at a rate that won’t affect the future sales of Hemopure 3. Devise a good distribution strategy for the product (manufacturer direct vs. distributor) On the other hand Hemopure needs to overcome the following obstacles: 1. FDA approval 2. Price of hemoglobin vs. blood transfusion ($600 vs. $125) 3. Fierce competition from Human hemoglobin by Baxter and Northfield 4. Uptake by physicians Biopure needs to launch its first product to start generating revenue, take the company public, raise more funds to support Hemopure’s Phase 3 trial and launch. Before deciding on launching Oxyglobin ahead of Hemopure, all the challenges mentioned above need to be addressed. III. Strategies for Improvement To overcome Oxyglobin’s challenges listed above, the following criteria need to be met: 1. Target Emergency care vet practices 2. Target large Vet practices (3+) 3. Set the price at $200 (see Appendix 1 for analysis) 4. Focus Marketing efforts on non-critical dogs Biopure should start by targeting emergency care vet practices as blood transfusion are more common there, 150 transfusion/year as compared to 17 at vet GP, penetration to this market will measured by unit sold per care center and lower reliance on animal donors. To increase the market share further large vet practices with 3+ doctors as according to exhibit 7 pg 17 of the case, these practices have the highest â€Å"average monthly case load† of about 450 dogs per month, it’s imperative to measure a rapid incline in uptake of our product by these practices. Based on the analysis in Appendix 1, it is clear that setting the price at $100 is more lucrative but we have to plan for the launch of Hemopure and therefore we should consider setting the price at $200 to justify its launch at $600 to $800 in 2 years. We should monitor the sales of Oxyglobin at this price and monitor if the uptake from vets is increasing from the 5% predicted by the market analysis (table A). Finally, focusing the marketing effort on non-critical dogs is crucial as they are a sizeable market and because although veterinarians can justify using this product to critical dogs, it’s hard to justify that for non-critical dogs (pricing and efficacy should help support that). The cease of using animal donors in these clinics will show that Oxyglobin is successfully replacing this old practice. Alternatively it is important to think about the possibility of setting the price of Oxyglobin at $100 to reap as much benefit from being the first and only vet blood-substitute, in the event that Hemopure doesn’t get approval from the FDA. It’s highly probable that Hemopure won’t be successful in the clinic because it’s of cattle origin, they changed the formulation to be stable at room temperature (excipients could be toxic) and the concentrations used are much higher than their human counterparts. In this case and to mitigate this risk, lowering the price to a $100 will help the sales and uptake of the product by a larger market. The market research conducted prior to launch (Table A and B) shows that a high number of veterinarians and pet owners will use the product at the $100/$200(x2) price. Based on the calculations in Appendix 1, it is clear that setting the price at $100 is more lucrative to Biopure than pricing it at $150 or 200$ because of the double price rule which affects the uptake by both pet owners and vets. To be cognizant and not to jeopardize the future Hemopure launch, I recommend that we set the price at $200, because there is a need for a blood substitute as 84% of the vets are reporting overall dissatisfaction with the blood transfusion alternatives available in the marketplace. Secondly, Oxyglobin provides an alternative for animal blood donated by other animals which incurs the risk of matching and potential transfer of diseases. The storage at room temperature adds value as this will reduce the need to buy expensive refrigerators that need calibration, validation and maintenance. Finally, there no assurance that vets will automatically double the price of the product especially if they foresee a high demand by pet owners, a practice that we should encourage and help the vets appreciate the upside. Although blood transfusions in the veterinary market are infrequent and the market scope is limited, Oxyglobin has the potential to become a lucrative investment for Biopure. It is possible that Hemopure will not be licensed by the FDA, that humans will resist buying a product of cattle origin especially that human hemoglobins will be available around the same time by competitors and that physicians will not prescribe it for the reasons described above. To minimize these risks and to start generating revenue that will help the company grow, become public and raise more funding, I therefore recommend that we sell Oxyglobin first before the launch of Hemopure.

Origin of the Name the Dead Sea

When you hear the name Dead Sea, you might not picture your ideal vacation spot, yet this body of water has been attracting tourists for thousands of years. The minerals in the water are believed to offer therapeutic benefits, plus the high salinity of the water means its super easy to float. Have you ever wondered why the Dead Sea is dead (or if it really is), how salty it is, and why so many people drown in it when you cant even sink? Chemical Composition of the Dead Sea The Dead Sea, nestled between Jordan, Israel, and Palestine, is one of the saltiest bodies of water in the world. In 2011, its salinity was 34.2%, which made it 9.6 times more salty than the ocean. The sea is shrinking each year and increasing in salinity, but it has been salty enough to prohibit plant and animal life for thousands of years. The chemical composition of the water isnt uniform. There are two layers, which have different salinity levels, temperatures, and densities. The very bottom of the body has a layer of salt that precipitates out of the liquid.  The overall salt concentration varies according to depth in the sea and the season, with an average salt concentration of about 31.5%. During flooding, the salinity can drop below 30%. However, in recent years the amount of water supplied to the sea has been less than the amount lost to evaporation, so the overall salinity is increasing. The chemical composition of the salt is very different from that of sea water. One set of measurements of the surface water found the total salinity to be 276 g/kg and  ion concentration to be: Cl-: 181.4 g/kg Mg2: 35.2 g/kg Na: 32.5 g/kg Ca2: 14.1 g/kg K: 6.2 g/kg Br-: 4.2 g/kg SO42-: 0.4 g/kg HCO3-: 0.2 g/kg In contrast, the salt in most oceans is about 85% sodium chloride. In addition to the high salt and mineral content, the Dead Sea discharges asphalt from seeps and deposits it as black pebbles. The beach is also lined with halite or salt pebbles. Why the Dead Sea Is Dead To understand why the Dead Sea doesnt support (much) life, consider how salt is used to preserve food. The ions affect the osmotic pressure of cells, causing all of the water inside the cells to rush out. This basically kills plant and animal cells and prevents fungal and bacterial cells from thriving. The Dead Sea is not truly dead because it does support some bacteria, fungi, and a type of algae called Dunaliella. The algae supplies nutrients for a halobacteria (salt-loving bacteria). The carotenoid pigment produced by the algae and bacteria have been known to turn the blue waters of the sea red! Although plants and animals dont live in the water of the Dead Sea, numerous species call the habitat around it their home. There are hundreds of bird species. Mammals include hares, jackals, ibex, foxes, hyraxes, and leopards.  Jordan and Israel have nature preserves around the sea. Why So Many People Drown in the Dead Sea You might think it would be difficult to drown in water if you cant sink in it, yet a surprising number of people run into trouble in the Dead Sea. The density of the sea is 1.24 kg/L, which means people are unusually buoyant in the sea. This actually causes problems because its hard to sink enough to touch the bottom of the sea. People who fall into the water have a hard time turning themselves over and may inhale or swallow some of the saltwater. The extremely high salinity leads to a dangerous electrolyte imbalance, which can harm the kidneys and heart. The Dead Sea is reported to be the second most dangerous place to swim in Israel, even though there are lifeguards to help prevent deaths. Sources: Dead Sea Canal. American.edu. 1996-12-09. Bein, A.; O. Amit (2007). The Evolution of the Dead Sea Floating Asphalt Blocks:Ssimulations by Pyrolisis. Journal of Petroleum Geology. Journal of Petroleum Geology. 2 (4): 439–447.I. Steinhorn, In Situ Salt Precipitation at the Dead Sea, Limnol. Oceanogr. 28(3),1983, 580-583.