PTSD can coexist independently with other mental health problems and contributes to poor physical health, severe distress, chronic suffering, and impairment ( Haagen et al., 2015). Military personnel that have deployed to combat zones may be exposed to life-threatening stressors in combat, injury, and witness suffering and death, and therefore are at a higher risk of developing PTSD complications. ( Haagen et al., 2015). Increased risk of PTSD has been closely correlated with combat experiences, documented beginning in the Vietnam-era and continuing into the Iraq War ( Sundin et al., 2010). Multiple PTSD assessments have shown increases during the post-deployment year, possibly due to the stresses of reintegration or initial elation masking signs and symptoms. With the constant deployments to Iraq, PTSD rates pre-deployment versus post-deployment were significantly higher upon return ( Sundin et al., 2010).

Post-traumatic stress disorder (PTSD) is a significant mental condition and is becoming a serious public health challenge. Presently, over two percent of the population in the United States has PTSD ( Ghaffarzadegan et al., 2016). In the military context, 11 to 20% of the military personnel who served in Iraq and Afghanistan have diagnosed and undiagnosed PTSD ( Ghaffarzadegan et al., 2016). Notably, PTSD results from a traumatic event during a war. The event may result from combat or a non-violent traumatic situation such as a terror attack, sexual assault, acute injury, and family violence. Although non-violent PTSD is prevalent among citizens in the United States, the lifetime prevalence of the disorder is common among combat-exposed PTSD cases. In addition to that, PTSD is highly comorbid with other psychological conditions such as trauma, depression, anger, violence, shame, guilt, and substance abuse ( Armenta et al., 2018). Individuals with PTSD experience the psychological effects of trauma, negative mood, cognition, and increased physical stimulation ( Armenta et al., 2018).

Accordingly, the intensive use of combat during recent military operations in Iraq and Afghanistan is one of the primary causes of PTSD ( Armenta et al., 2018). The finding is consistent with research by Kelley et al. (2013) that suggests that exposure to combat is one of the risk factors for PTSD. PTSD increases depending upon the intensity of the combat. In addition to that, chronic PTSD among the military and veterans was seen to have emanated from psychological and physical health comorbidities. The severity of PTSD is dependent upon the persistence of the symptoms exhibited in an individual ( Bannister et al., 2018). Primarily, these findings suggest that individuals with comorbid conditions such as multiple physical symptoms could have severe PTSD symptoms as opposed to those without any complications in their physical bodily functioning. Comorbid conditions increase instances of dysregulation of the autonomic nervous system and interoceptive functions ( Bannister et al., 2018). Physical health comorbidities are associated with changes in pain perception and physical symptoms that remind victims of a traumatic event in their lives. This would infer that exposure to combat and underlying physical health conditions is a risk factor for PTSD among military personnel and veterans.

In times of war, military personnel rarely experience sufficient sleep because they are in a constant hypervigilant mode. In a study by Brewin et al. (2012), participants who claimed to sleep for less than four hours were more likely to be at risk for PTSD than those with longer sleep patterns. For military personnel and veterans, sleep was an essential predictor of long-term and persistent PTSD. Lack of sufficient rest is common among service members who are deployed. Sleep pattern problems following a traumatic event place individuals at a higher risk of PTSD ( Brewin et al., 2012). Disruptive sleeping patterns cause comorbid conditions among victims. In effect, this also increases the potential risk of PTSD.

Lack of social support is another factor contributing to PTSD among military personnel and veterans. When military men and women are in a war, they leave their families behind. Lack of social support among military personnel contributes to susceptibility to post-traumatic stress disorder. Similarly, during and after deployment, social support decreases the severity of PTSD among military personnel and veterans ( Bannister et al., 2018). After return from deployment or retirement, military personnel may be at risk of PTSD due to changes in social relationships ( Bannister et al., 2018). When in combat, familiarity with war and relationships with other soldiers were a constant. However, upon retirement, social connections change and there is more time and exposure to family members. Such changes could trigger PTSD symptoms.

It has long been documented that women experience PTSD at twice the rate of men ( Kessler et al., 1995; McDuff, 2004; Norr et al., 2016). Some researchers postulate that Anxiety Sensitivity is experienced at higher levels by women and has a bidirectional escalation impact when coupled with PTSD ( Norr et al., 2016). A fear response develops from anxiety reactions based on traumatic events and may be transposed to generalized anxiety reactions. Cognitive, physical, and social concerns are all aspects of Anxiety Sensitivity. “Women tended to report more frequent concentration difficulties and distress from reminders whereas men tended to report more frequent nightmares, emotional numbing, and hypervigilance” ( King et al., 2013).

Sexual assault is a traumatic event that has traditionally been gender-linked to women. “Compared to individuals without sexual trauma, veterans in the VA who reported any type of military sexual trauma were more likely to have PTSD, depressive and substance use disorders, as well as aggressive/impulsive control problems, even after adjusting for a number of demographic and military service‐related variables ( Tiet et al., 2015). The trauma of sexual assault has been indicated as the highest risk predictor of PTSD. Military sexual assault (MSA) is more prevalent in women and has been identified as requiring differing levels of treatment techniques than PTSD trauma experienced by men, including combat trauma. As a response, the Department of Veterans Affairs developed the Women’s Treatment Rehabilitation Programs. However, due to the disproportionate number of men to women in the military, the number of men who were victimized by MSA is greater than the total number of women identifying as MSA survivors. In Fiscal Year 2002, 29,418 women and 31,797 men reported MSA in their VA treatment ( Tiet et al., 2015).

Notably, there has been a significant increase in the number of women enrolled in the military. Women comprise about 15% of the Department of Defense Active Duty Force ( Goldstein et al., 2017). The scope of women’s roles has changed over the years resulting in significant exposure to a variety of military stressors. In a study by Kelley et al. (2013), women reported more incidences of non-combat trauma when compared to men. In contrast, the rate of lifetime trauma exposure among women is less when compared to men. However, female veterans reported having more depressive symptoms due to exposure to combat as opposed to men ( Kelley et al., 2013). While in combat, women encounter sexual assault more frequently than their male counterparts. Sexual assault is the leading cause of PTSD among female military personnel ( Goldstein et al., 2017). After a sexual assault, the other leading stressor is the feeling of danger due to fear of being killed. The perceived threat is the second leading cause of PTSD among female military personnel and veterans ( Goldstein et al., 2017).

The rates of PTSD among military women were higher as opposed to their male counterparts. Such differing extents of PTSD between military men and women were associated with gender differences in trauma perceptions and appraisals ( Crum-Cianflone & Jacobson, 2014). Women were more likely to be exposed to other traumatic events, such as childhood sexual abuse and intimate partner violence. When women are deployed as military members and assigned to combat tasks in Iraq and Afghanistan, which are regions prone to violence, their perceptions could be altered hence increasing their vulnerability to PTSD.

“Race can impact one’s everyday experiences and mental health through explicit or implicit definitions (e.g., self-identification or racial stereotyping), and how those definitions shape interactions and access to resources. Ethnic identity, related to one’s cultural group, is important because ethnic norms and beliefs may impact the validity of psychological diagnoses, the acceptability of and response to evidence-based treatments, and the development of culturally competent care” ( Onoye et al., 2017). PTSD has been seen to cluster by race, ethnicity, and gender. The demographic groups most likely to experience reported PTSD include Asian/Pacific Islander women and African American men. Emotional numbing has been reported in highest numbers by Latino women. In 1990, in the National Vietnam Veteran Readjustment Study concluded that the veterans with the highest PTSD rates were African American and Latino. Recent research has suggested that Latino veterans experience PTSD at higher rates than Caucasian veterans because of “greater endorsement of positive symptoms (e.g., hypervigilance, intrusive thoughts, and flashbacks).” In comparing race and gender, Caucasian female veterans were more likely to report childhood sexual trauma, whereas African American female veterans were more likely to report physical assault ( Onoye et al., 2017). A study of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) female combat veterans found that those most likely to report PTSD were from non-majoritive racial/ethnic groups, with the highest levels presenting in Latino and Native groups ( C'de Baca et al., 2016).

“Epidemiologic studies have reported substance abuse and posttraumatic stress disorder (PTSD) diagnoses as risk factors for suicide among Veterans Health Administration (VHA) patients” ( Gradus et al., 2017). The study found that in female Veterans Health Administration (VHA) patients, initial self-harm (ISH) could be predicted by the intersection of PTSD and alcohol abuse or dependency. This interaction was not as strong in male VHA patients. The intersectionality of PTSD and drug abuse or dependency indicated a strong probability of self-harm. This interaction did not produce the same results in male VHA patients ( Gradus et al., 2017). Substance abuse is more prevalent in women with PTSD. “PTSD often co-occurs with other mental health disorders and problematic behaviors, including substance misuse” ( Nunnink et al., 2010). Female veterans are more likely to be under-diagnosed in this area and less likely to receive substance abuse treatment.

Male military personnel are more likely to drink alcohol with the rate of alcohol dependence twice as high for males as females ( Kelley et al., 2013). A significant proportion of individuals with PTSD have substance abuse issues. Approximately 11% of current veterans with combat experience have issues with substance abuse ( Price et al., 2004). Military personnel and combat veterans have a higher instance of substance abuse as opposed to the general population. Combat veterans may attempt to cope with their present symptoms by using drugs and alcohol instead of seeking psychiatric treatment ( Price et al., 2004). For veterans, social integration may be challenging, and in most cases, veterans are expected to adjust quickly without guidance and supervision. In effect, this worsens their PTSD symptoms, and they may opt for alcohol and use drugs to forget their past traumatic events as a means of self-medication.

Post-traumatic stress disorder directly correlates with substance abuse and often worsens substance use by making a recovery less likely ( Boden et al., 2012). Approximately 35–50% of those currently experiencing issues with substance abuse have comorbid post-traumatic stress disorder ( Boden et al., 2012). Individuals with substance abuse issues and PTSD use drugs more severely than those experiencing issues with substance abuse or PTSD alone. For some, drugs may serve as solace to forget traumatic events and situations experienced in war ( Boden et al., 2012)

The following research questions guided the inquiry and survey design.

Post-traumatic stress disorder (PTSD): Defined by the DSM-5 as a severe mental disorder that occurs after an individual undergoes a traumatic experience that is emotionally overwhelming ( Sochenko & Gabinska, 2017).

Traumatic instances: Defined by Sochenko and Gabinska (2017), in the context of PTSD in military personnel, as war, natural disasters such as earthquakes, manmade disasters such as terrorist attacks, sexual assault, rape, robbery, torture, imprisonment, sudden death of a loved one, illness, interpersonal conflict, forceful displacement, among many incidences.

Veteran: Defined by the Department of Veterans Affairs as 38 U.S.C.§ 101 (2) a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable; 13 CFR § 125.11 a Reservist or member of the National Guard called to Federal active duty or disabled from a disease or injury incurred or aggravated in line of duty or while in training status qualify as a veteran.

Armed forces: Defined by 10 U.S.C. § (a) (4) as the Army, Navy, Air Force, Marine Corps, Space Force, and Coast Guard.

Active duty: Defined by 10 U.S.C. § (d) (1) as “full-time duty in the active military service of the United States. Such terms include full-time training duty, annual training duty, and attendance, while in the active military service, at a school designated as a service school by law or by the Secretary of the military department concerned. Such term does not include full-time National Guard duty.”

Anxiety sensitivity: Defined by the American Psychological Association as “fear of sensations associated with anxiety because of the belief that they will have harmful consequences. For example, an individual with high anxiety sensitivity is likely to regard feeling lightheaded as a sign of impending illness or fainting, whereas an individual with low anxiety sensitivity would tend to regard this sensation as simply unpleasant. Research indicates that anxiety sensitivity is a trait like risk factor that has been linked to the development of panic attacks and panic disorder” ( APA, 2020).

Military sexual trauma (MST): Defined by Veterans Affairs as “term used by VA to refer to experiences of sexual assault or repeated, threatening sexual harassment that a Veteran experienced during his or her military service. The definition used by the VA comes from Federal law (Title 38 U.S. Code 1720D) and is “psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training.” Sexual harassment is further defined as "repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

Substance abuse: Defined by the American Psychological Association as “a pattern of compulsive substance use marked by recurrent significant social, occupational, legal, or interpersonal adverse consequences, such as repeated absences from work or school, arrests, and marital difficulties. DSM–IV–TR identifies nine drug classes associated with abuse: alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, and sedatives, hypnotics, or anxiolytics. This diagnosis is preempted by the diagnosis of substance dependence: If the criteria for abuse and dependence are both met, only the latter diagnosis is given. In DSM–5, however, both have been subsumed into substance use disorder and are no longer considered distinct diagnoses” ( APA, 2020).

Research setting. An online survey method was utilized to reflect attitudes of participants in response to questions posed regarding military experiences and Post-Traumatic Stress Disorder.

Participants. Participants included military personnel and veterans with any branches of the United States Military (Army, Navy, Marines, Coast Guard, Air Force, National Guard, and Reserve Component). Participants consented to participate in a survey that included questions about their experience with PTSD.

Recruitment Process. Participants for this study were recruited using a combination of strategies to ensure a diverse and representative sample. An online survey was distributed through several channels:

Survey Platform. The survey was hosted on the Qualtrics platform, which allowed participants to complete it using either a computer or a mobile device. The flexibility in platform ensured accessibility for a wide range of participants.

Procedures. Permission for this human subject study was obtained from the University of Central Oklahoma's Institutional Review Board (IRB) on June 26, 2020 (IRB Application #: 2020-052), with the study designated as exempt. Prior to accessing the survey, participants were presented with the consent information as the initial questions. They were given the option to select 'I agree to participate' or 'I do not agree to participate.' Those who agreed proceeded to complete the survey, while those who did not were directed away from the survey. All data collected remained confidential, stored in a password-protected digital file. Participants completed the survey at their convenience within the specified timeframe, and the study's purpose was fully disclosed to them before participation.

Participant primary tier demographic data was catalogued by race/ethnicity, gender, and age. Secondary tier demographic data included current military status, discharge type (if applicable), employment status, school status, service branch, rank, active-duty status, deployment status, and military occupational specialty.

The following multiple-choice response question was asked of the participants:

Based on an affirmative response to the question above, display logic generated the following questions:

The following open-ended questions were asked of participants:

The qualitative responses were categorized by emergent themes and systematic coding.

The following weighted scale questions were asked of participants:

The data was analyzed in quantitative descriptive examination to determine basic statistical descriptors of mean, median, mode, and standard deviation.

The researcher was responsible for ensuring that all participants understood the risks and benefits of the study. The researcher was also responsible for ensuring that the data collected, analyzed, and presented was accurate and displayed in a proper and professional manner. The biographical information affirms that the researcher, Candace Huitt, is a Caucasian female, aged mid-to-late “twenties,” with secondary connection to U.S. Armed Forces via family members and social avenues. The researcher has previous experience in journal research on the impact PTSD has on veterans and different treatments that have been previously recorded.

It was assumed that participants would respond truthfully. The results may be partial due to the limitations. First, the sample size was relatively small, which may limit the generalizability of the findings. Furthermore, the sample was confined to the Oklahoma area, which may restrict the applicability of the results to broader populations. Additionally, the study was conducted over the summer of 2020, which imposed constraints on the duration of data collection and may have affected the representativeness of the sample. Despite these limitations, efforts were made to ensure the validity and reliability of the study's findings.

Closed-ended question responses indicated a high rate of experiences during military service that prompted the respondents to seek mental health care services (96.55% reported at least one experience). Just over half (55.17%) indicated high levels of interest/willingness to utilize mental health care services. However, less than half (44.83%) of respondents indicated satisfaction with military-connected mental health care options. Almost two-thirds of respondents (63.66%) reported experiencing traumatic events during military service with 85% still reporting emotional connection to the event(s) and half correlating increased substance abuse to the event(s).

Open-ended surveys responses were coded thematically to identify emergent themes and patterns. Coping techniques respondents reported utilizing to address the memories of traumatic events experienced during military service included breathing exercises/meditation/quiet, therapeutic counseling, medication/medical marijuana, and activity/hobbies. Sleep disturbances due to traumatic events were reported by respondents as insomnia, trouble falling asleep, fatigue, dreams, inability to sleep without medication. Impact of traumatic events on relationships reported by respondents included divorce, lack of relationships, and difficulty communicating.

It is important to understand that more research is needed on the subject of the impact of PTSD on military personnel and veterans. Follow-up research will include interviews with military personnel and veterans about how PTSD has affected their lives. It would be beneficial to have an equal number of male and female respondents, as well as more variation across race/ethnicity, and service branches of the military. Partnership with the Veterans of Foreign Wars (VFW) would create a conduit for potential interview participants. The VFW will also provide access to potential participants with deployment experience, typically more likely to have experiences combat and related traumatic events. In contrast to the survey methodology as the only available resource due to COVID restrictions, interviews will provide more in-depth response and dialogue about traumatic experiences and resulting PTSD, as well as effects on sleep, relationships, education, and employment. To gain a better understanding of coping techniques respondents utilize to address the memories of traumatic events experienced during military service, it is also crucial to discuss the treatment options they have received and that are available to them. This will provide additional opportunities to explore partnerships within the veteran and military service agencies. Community collaboration is an integral tool in the fight against PTSD. In terms of outreach, both Veterans Affairs (VA) and American Legion should be part of the community outreach segment of the research. The VA and the American Legion both offer resources and guidance for those who suffer from PTSD. By obtaining these partnership resources, future research can focus on services to determine which are most beneficial in managing the effects of PTSD on veterans.

This research study will contribute to the body of research by establishing baseline data and practical implementation recommendations for best practices in service provision for military personnel and veterans who have experienced Post-Traumatic Stress Disorder.