Army Spc. Ivan Lopez, the soldier who shot three people and wounded 16 others before taking his own life at Fort Hood, Texas, on Wednesday, was being treated for depression and undergoing evaluation for post-traumatic stress disorder, authorities said.
His "unstable psychiatric or psychological condition" is believed to be the "fundamental underlying factor" in the shooting, according to Lt. Gen. Mark Milley, the post's commanding general.
BuzzFeed spoke to mental health experts about the challenges of properly diagnosing PTSD — and the dangers of automatically connecting PTSD to murder.
What is PTSD?
Post-traumatic stress disorder may occur after one has been through a traumatic event including but not limited to combat exposure, sexual or physical assault, accidents, and natural disasters. According to the National Center for PTSD at the U.S. Department of Veterans Affairs, the four types of symptoms of PTSD are reliving the event/re-experiencing symptoms; avoiding situations that remind you of the event; negative changes in beliefs and feelings; and hyper-arousal or "feeling keyed up."
The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard classification of mental disorders used by mental health professionals in the United States, lists four major symptom clusters:
• Re-experiencing the event: For example, spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress.
• Heightened arousal: For example, aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-vigilance, or related problems.
• Avoidance: For example, distressing memories, thoughts, feelings, or external reminders of the event.
• Negative thoughts and mood or feelings: For example, feelings may vary from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
Symptoms typically start soon after the traumatic event but may not appear until months or years later, and may occur intermittently over many years.
How common is PTSD?
About 8% of all Americans will experience PTSD at some point in their lives, according to the Veterans Administration.
Women (10.4%) are twice as likely as men (5%) to develop PTSD, and they represent a small portion of those who have experienced least one traumatic event; 60.7% of men and 51.2% of women reported at least one traumatic event.
PTSD is far more common among men and women who have spent time in war zones: About 30%experience PTSD. An additional 20–25% have had partial PTSD at some point in their lives.
Of about 830,000 veterans who were treated at VA medical centers over the last decade, 29% were diagnosed with PTSD, according to the VA, which also found that 11–20% of Iraq and Afghanistan veterans report PTSD.
How is PTSD diagnosed?
PTSD is "one of the most reliably diagnosed disorders" in the DSM, said Paula P. Schnurr, who holds a Ph.D. in experimental psychology and is the acting executive director of the Veteran Affairs' National Center for PTSD. It can be diagnosed by a clinical interview, questionnaire, or a clinical interview with a set of standardized questions. The best methods, Schnurr said, combine all three.
The criteria has changed significantly since PTSD was first named as a diagnosis in 1980 after the end of the Vietnam War, said retired Col. Dr. Elspeth Cameron Ritchie, a longtime Army psychiatrist who is now the chief clinical officer for the District of Columbia's Department of Mental Health.
In 2013, the American Psychiatric Association added major changes to the DSM-5, including specific references to sexual assault and recurring exposure for first responders. Language detailing an individual's response to the event — intense fear, helplessness or horror, according to DSM-IV — was deleted "because that criterion proved to have no utility in predicting the onset of PTSD," wrote the APA. Ritchie said the latter was removed because "many soldiers who were well-trained could not necessarily feel 'intense fear.'" Additional criteria was added, including sleep problems, depression, and irritability.
How long does it usually take to diagnose someone with PTSD?
Some mental health practitioners told BuzzFeed it should only take one or two sessions to diagnose a patient with PTSD. The reason Lopez's evaluation took longer might have been "because there was something weird about him," said Martin Williams, a California-based psychologist who specializes in evaluating PTSD in criminal and civil matters. "It's simple: Either a person has the symptoms [for PTSD] or they don't. But if a therapist senses that there's something more going on, that would take longer."
But military experts said it often takes more time to diagnose veterans with PTSD due to a variety of complicating factors — one being that people are often tested for other disorders at the same time.
"It's really easy to lump everything together, but it's important to be precise in the definition," said Ritchie, who said less-experienced doctors may mistakenly "call everything PTSD."
Given that PTSD is associated with an increased likelihood of other disorders including depression, anxiety, and substance abuse, a good practitioner will strive to "understand the whole individual, not just the PTSD," Schnurr said. A full assessment can take anywhere from three to six hours, and often people prefer to break sessions up, she said.
A complete diagnosis should only take a few weeks at most "in an ideal world," Ritchie said, but follow-up appointment scheduling depends on clinician and patient availability and the urgency of the symptoms. Since authorities said Lopez showed no signs he might be a threat to either himself or others, a longer time frame seems "reasonable," Ritchie said.
According to officials, Lopez was undergoing treatments for other, often related conditions including depression, anxiety, and sleep disturbances. But Ritchie said she wouldn't be surprised if Lopez had been eventually diagnosed with something more severe, like schizophrenia. She referred to infamous Navy Yard shooter Aaron Alexis, who denied having suicidal or homicidal thoughts three weeks before killing 12 people in last year's rampage but told Veterans Affairs doctors he had insomnia. "It's important to note that PTSD comes in a spectrum of severity, as do mental disorders in general," she said.
There are reasons why soldiers would both under- and over-report PTSD, which may lead to stretched-out diagnoses, Ritchie said. Veterans who report PTSD usually receive more disability compensation than those diagnosed with depression or anxiety. On the other hand, soldiers who want to hold on to their career — and their weapons — might feel pressure to under-report.
"Soldiers by and large in this difficult economy don't want to be discharged from service, so they are more likely to minimize their symptoms because they don't want their weapons to be taken away," Ritchie said, adding that it's "fairly routine" when someone is in stress to briefly limit access to military weapons, although the military has little to no ability to control a service member's access to private weapons.
Given the known incentives, "you can see why it would take a whole month to diagnose," she said.
How is PTSD treated?
There are two main types of treatment for PTSD: psychotherapy and medication.
As outlined by the U.S. Dept of Veteran's Affairs, psychotherapy entails Cognitive Processing Therapy (CPT), where you "learn skills to understand how trauma changed your thoughts and feelings," and Prolonged Exposure (PE) therapy, "where you talk about your trauma repeatedly until memories are no longer upsetting. You also go to places that are safe, but that you have been staying away from because they are related to the trauma."
Veterans often try group therapy because "soldiers are used to focusing on cohesion and group morale," Ritchie said.
Selective serotonin reuptake inhibitors (SSRI), also used for depression, are the most common medications prescribed for PTSD.
Alternative treatments include yoga, service dog programs, acupuncture, and medical marijuana.
What about Lopez's self-reported head injury?
Although Lopez served for four months as a truck driver in Iraq in 2011, his records "show no wounds, no direct involvement in combat ... or any injury that might lead us to further investigate battle-related [traumatic brain injury]," Army Secretary John McHugh told the Senate Armed Services Committee on Thursday. However, Lopez had self-reported a traumatic brain injury.
Since Lopez was not in combat, Williams said the likelihood of his injury being battle related seemed unlikely.
Ritchie said based on what she knows about Lopez's case, she doubted that he had suffered a traumatic concussion, which can result in impulsive decision-making.
Is there a correlation between PTSD and violence?
Although there's a statistical correlation between PTSD and violence, the vast majority of people with PTSD are not violent, Schnurr said. There are no studies that provide definitive information about the prevalence of aggression or violence among veterans or civilians with PTSD, and those that have explored the relationship are often inconsistent in their definitions and measures of aggression and violence.
According to the Department of Veterans Affairs, most behaviors associated with PTSD are mild — think yelling instead of hitting.
Since individuals with PTSD have a higher prevalence of other risk factors that are associated with increased aggression and violence, findings regarding the relationship between PTSD and aggression or violence are sometimes based on analyses that do not take risk factors other than PTSD into account, like substance abuse and depression, youth, witnessing or being the victim of violence in childhood, committing crimes before military service, and experiencing higher levels of combat exposure. According to the National Center for PTSD, a number of protective factors are associated with lower risk of aggression and violence in veterans, including meeting basic financial needs, having stable housing, perceiving self-determination, reporting higher resilience, and indicating superior social support.
It's a grave misconception that veterans with PTSD are typically anything other than "productive members of society," Schnurr said.
Katie Baker is an investigative reporter for BuzzFeed News and is based in New York.
Contact Katie J.M. Baker at firstname.lastname@example.org.
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