A Chat with Our Experts

Insights on the evolution of PTSD

Dr. Terence M. Keane is the director of the Behavioral Science Division of the National Center for PTSD at the VA Boston Health Care System and a professor of psychiatry and psychology and assistant dean for research at Boston University School of Medicine.

In January 2016, he was named the 2015 recipient of VA's John Blair Barnwell Award for his worldwide leadership in research on traumatic stress, particularly PTSD, and for his longtime service to VA and his profession. The Barnwell Award is the highest honor given by VA Clinical Science Research and Development.

Keane, who received the award from VA Secretary Robert McDonald in Boston on Jan. 15, 2016, spoke with VARQU about his work and career.

VARQU: How did you get involved in working on posttraumatic stress?

Keane: I did an internship in 1977-78 at the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Miss., and I started work there in 1978. My graduate focus was on addiction, and I kept noticing a common theme, common stories, and common problems among the people on the alcohol unit coming in for addiction care.

The common problems were flashbacks, nightmares, and drinking to try to mitigate the effects of their combat experiences. At that time, no one was talking about this—certainly not in the professional literature.

People were talking about Vietnam Veterans being a troubled group and being angry. Vietnam Veterans themselves were saying that they had gotten the short end of the stick, in terms of professional and societal help and support for them.

So I was wading into a controversial area. But I still wanted to work on addiction, and the more I worked in this area the more I came to see the effects of war trauma. In 1979, during my first year at VA, the VA put out a request for applications to help in understanding Vietnam-theater Veterans and their problems.

I wrote a grant that was eventually funded by the Office of Research and Development [ORD], and that was really the beginning. I leapt out of the addictions area and into the Vietnam stress area, which is what they called it then. It wasn't until 1980 that I found out what was going on in other parts of the country.

There was no Internet then, and we don't really appreciate how slowly things moved in those days. I remember going to hear someone lecture about the problems of Vietnam Veterans, and I said, "Wow! This is really interesting. This is what I'm seeing, too."

I also remember seeing the movie "The Deer Hunter" in 1979, and I said to the person I was with, "This is what I'm studying." That's when I realized this was a much bigger thing than just what I was seeing, as a 26-, 27-year-old kid in Jackson. Things did move slowly, but we were early to the table.

We were funded to create the program in 1979 and word got out on the street in Mississippi that there was a small group of people who were out to help Vietnam-theater Veterans. Word spread locally, and my chief of staff said, "I don't know what you're doing, Terry—but it's helping Veterans, so keep doing it!" They gave me free rein, which is a remarkable thing. They were hugely supportive of me and the program we set up.

It was slow, it was controversial, and it was a struggle. We were paddling against the tide, but eventually it all changed and we won the battle by using science and scientific tools and by being absolutely committed to trying to provide the best possible care to these people who later on were deemed to have PTSD.

My work was supported by the local hospital, which wasn't always the case for others, and it was supported by ORD, whose funding allowed me to hire people and get the program off the ground.

I owe a great debt to VA. I wish I could have taken credit for this having had a much broader impact than just on Vietnam-era Veterans and combat Veterans. I think I put it together that it was all war trauma, but along the way I realized that women who had been sexually assaulted, and experienced violence, were also victims—and that the work I did in VA had great generalizability in America.

How did PTSD become recognized as a disorder?

I had relatively little to do with that. It was very much a convergence of factors, and Vietnam Veterans themselves played a key role. In New York, Art Egendorf and Jack Smith combined with some very senior psychiatrists, including my friend Robert Jay Lifton, who was a very important voice. Hy Chattan, who's now sadly gone, was a vocal supporter of the notion that this is a specific disorder.

In the 1980s, the women's movement was becoming very, very strong and active—so the whole notion of intimate partner violence and sexual assault and rape was suddenly getting a great deal of attention. Here at Boston City Hospital—which is now Boston Medical Center—there was work going on by Ann Burgess and Lynda Lytle Holmstrom. They wrote an article in 1974 called "Rape Trauma Syndrome," and that was very important. It brought the women to the table, that women were traumatized by these experiences. Retrospectively, this isn't a surprise, but then it was not well accepted.

There was a third vector of information that was really important. John Krystal is with the National Center for PTSD and is chair of the department of psychiatry at the Yale School of Medicine. His father was Henry Krystal, who interviewed hundreds of people who had been in concentration camps in Europe. He termed what he observed as "KZ syndrome" or concentration camp syndrome, and that was another key vector of converging information for the PTSD diagnosis.

So you had women who had been raped; concentration camp survivors who suddenly, 20 or 25 years after their liberation, were talking about their experiences of trauma; and then you combined that with a very vocal, very vociferous Vietnam Veteran movement. This is what Robert Spitzer at Columbia, who was in charge of reorganizing and updating the Diagnostic and Statistical Manual of Mental Disorders (DSM), heard. Bob listened—he was a very good listener—and he decided PTSD was a very important addition to the psychiatric nomenclature to characterize the effects of all of these kinds of events on some people.

Bob included PTSD in the DSM in 1980, and within a year, VA acknowledged PTSD as an important problem that Veterans possessed in significant numbers—and we were off to the races! My career was initially looking at how you assess this, how you diagnose this, how you conceptualize it, and how do you view these things—and then how do you provide psychological treatments for it. That's what we did early on.

It was that work that I did in the early '80s, I think, that led to the Barnwell Award and was recognized in the citation as affecting the way VA cares for people with PTSD, and how we evaluate and treat them today.

How has PTSD care changed or improved for today's new Veterans, compared with those you treated in the 1970s and '80s?

I think the amount of new information to help clinicians in our health care system to care for returning Veterans is astounding. Knowing what we knew then and what we know now about appropriate care for people, I think VA is clearly the premier health care system to take care of PTSD of all kinds, and the world's experts in combat-related PTSD.

The fact is we have different psychological treatments for PTSD, and many diagnostic tools to help us make great diagnoses. None of this was available 30 or 40 years ago. VA has been a champion and a pioneer with its research and clinical programs.

The enormous transition, though, came with the first Persian Gulf War, and with the leaders of that war in DoD. They realized and recognized the problem that had occurred in Vietnam. These leaders—Gen. [Norman] Schwarzkopf was one, but there were many others, including [former VA Secretary] Gen. [Eric] Shinseki—clearly wanted to avoid that. They made many efforts to ensure that the people fighting the war and the decision to go to war were separate, and the country followed their lead.

I think the difference in OEF/OIF was the decision made in the first Gulf War that they were going to provide the best possible care for anyone who fought in that war, and they really tried to do that. At the beginning of that war, there was a huge infusion of resources to VA to provide psychological care for those returning, and that infusion has been maintained and increased to a large extent. I think it had to do with the leadership of DoD and VA saying, "Yes, we've got to do this, and we're going to put the resources into it."

The expansion of programs in this country has been astounding, both in Defense-centered programs and in VA medical centers.

The other key transition point occurred in the 2000s. VA did something that has never been done before. Psychologist Dr. Antonette [Toni] Zeiss, who is VA's former chief consultant for mental health, and is now retired, worked with people around the country to train the work force and to be engaged in what is the largest effort at dissemination of evidence-based treatments in the history of mental health.

We are continuing to provide education and training to psychologists, psychiatrists, and social workers in evidence-based psychotherapies and pharmacotherapies for problems that are common in the Veteran population. The responsibility for this amazing effort belongs to Toni Zeiss, who was the leader, although there were many others involved.

This dissemination meant that we had a work force that was prepared to evaluate and treat combat-related PTSD, which had never happened before in this country. That was a tremendous change for this current cohort of war Veterans, and something that we claim responsibility for.

Another thing that's really important is the development of new technology and how important this new technology has been in caring for returning Veterans. More than half of returning Veterans live in rural areas, which is different from prior wars, when people went back to cities and stayed in cities.

It's tough to drive three and a half hours from northern New Hampshire to Boston for a psychotherapy session, so telehealth, in its different modalities, has been very helpful. VA has led the country in this area in many ways, and I am hopeful we can continue to do so.

We have to be national leaders in the use of the Internet for treatments. Some of our largest clinical trials in Boston were on the use of Internet-based treatments for people with PTSD. My own group has developed treatments that are delivered on the Internet and have very, very powerful effects.

The whole area of telehealth has allowed us to reach people who may not have been reachable in the past, coupled with in-person and in-house care that make it a very powerful addition to the mental health treatment of returning war Veterans.

One other thing—VA and DoD have begun a unique collaboration in the past few years. It's called the Consortium to Alleviate PTSD, and I co-lead it with Dr. Alan Petersen, an Air Force Veteran, from the University of Texas Health Science Center in San Antonio. VA and DoD are both supporting this consortium with large amounts of money.

We will probably have about 12 to 15 treatment trials from this consortium. It's an unprecedented collaboration between DoD and VA in an effort to treat one of the signature wounds from these past 15 years. There's a second consortium, called the Chronic Effects of Neurotrauma Consortium (CENC), which is a similar collaboration to improve our understanding of blast injuries that are creating cognitive and emotional problems for Veterans.

We have a much larger work force in mental health than in the past; we have a well-trained work force, in terms of the dissemination of education efforts; and technology has improved our reach in ways we could never have done before. Criticisms notwithstanding, so many good things are happening that we can be justifiably proud.

Are we the best mental health care system in the country? We are. Not by a little—by a lot.

Are there unique characteristics of Iraq and Afghanistan Veterans with PTSD, and are there ways in which their experience is distinct from previous generations?

All generations of war Veterans are different. The current generation of war Veterans is different, I think, because of the support that exists within VA and outside VA for them. Veterans and their mental health problems are in the news almost daily. This is a good thing, because it keeps it front and center in this country that these are long-term problems. Their issues are not things that necessarily dissipate after six months or a year. They require attention, and the virtue of the media coverage is that it will keep these problems at dead center, and that will be a good thing for the cohort.

I think they are getting the kind of careful coverage of their problems that places the responsibility for these problems on their military service and the war-zone experiences within their service. I also think this is a really big departure from what's been done in the past. That, to me, makes it easier for people to come forward for help.

It helps to destigmatize the problems that they are having, and it also communicates to their spouses and parents that there is help out there, and they need to help their loved one access what is available—and then the system can take over and help.

Some people would argue that we [VA] should reach out more. Well, it's very difficult to reach out in mental health because there are privacy laws on the books that prevent us from doing things. But the system can help if it is accessed, and that, to me, is a very welcome change. The destigmatization of these problems is also a remarkable metamorphosis over the course of my years doing this.

What factors can complicate PTSD treatment?

Just to bring things full circle, I got into this business by observations in an addictions unit, and the alcohol problems remain problems on a PTSD unit, whether you're male or female—whether your PTSD issues are caused by war or sexual assault or violence.

Alcohol is a big obstacle or problem for someone with PTSD, and it seems to me that making sure we have treatments that can concurrently manage alcohol and PTSD is very important. We've developed a program called VetChange, an integrated Internet-based program for alcohol and PTSD. There was a research article on VetChange, published in 2013, which demonstrated the powerful effects of this kind of combined treatment, and I think more and more of this is going to take place.

There is a proliferation of programs on drugs and alcohol and PTSD, but we need to do more and we need to make these things more broadly available. That's the direction in which I've gone—Internet interventions.

What else are you working on now?

There are two things—one is VetChange, and the second is a project we've developed with support from DoD and the National Center for PTSD. We've assembled a cohort of current war Veterans and this cohort was initially 1,649 people in size. Two-thirds of them have PTSD, the other third does not. Half of them are men, and half are women.

We have been following them for seven years. It's called Project VALOR (Veterans After-Discharge Longitudinal Registry), and we are studying these people closely over time. They've given us permission to look at their service medical records and VA electronic health records. We've interviewed them on the phone: they live all over the country. And we've asked them to complete a number of different psychological questionnaires about their experiences, symptoms, and other information.

We've published a number of papers on Project VALOR already, and we continue to interview the cohort, and follow them, and we hope to do so for another period of years.

Last week, I was meeting with a gynecological surgeon at the Boston VA, who said she was very interested in what she was seeing in the hospital's gynecological clinics, and the surgeries she's doing on women Veterans. She described the health problems that she was seeing, which were very unusual, in the large numbers of surgeries she's performed on women Veterans who experienced military sexual trauma.

I told her that Project VALOR would be a perfect cohort of people for her to work with. Yesterday, we had a meeting with the staff of the project, and proposed a study of the women in Project VALOR to see if the trends she is observing locally is a national trend among these women.

We never thought we would look at women in terms of these outcomes, but we're able to look at the information we have from them to see if what the surgeon has discovered is a national trend. And if it is, we'll be able to send out an alert nationwide that primary care physicians and gynecological surgeons in women's clinics may need to be alert to these issues. That's why I think Project VALOR is such an important initiative for us to continue to study.

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