Many people think PTSD is the root of all mental health problems among veterans. This oversimplification is often reinforced by behaviors considered abnormal. One veteran I spoke with claimed to have stopped a dangerous driver, thrown him out of the car, and “gave him a life lesson.” Most people would accuse the veteran of needing anger management […]
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This is how we feel after coming back from the war.
“We are all just actors trying to control and manage our public image, we act based on how others might see us.” ―Erving Goffman Recently, I’ve been thinking quite a bit about what it means t…
Source: How We Mask Our Authenticity
Suicide among military veterans is especially high in the western U.S. and rural areas, according to new government data that show wide state-by-state disparities and suggest social isolation, gun ownership and access to health care may be factors.
The figures released Friday are the first-ever Department of Veterans Affairs data on suicide by state. It shows Montana, Utah, Nevada and New Mexico had the highest rates of veteran suicide as of 2014, the most current VA data available. Veterans in big chunks of those states must drive 70 miles or more to reach the nearest VA medical center.
The suicide rates in those four states stood at 60 per 100,000 individuals or higher, far above the national veteran suicide rate of 38.4.
The overall rate in the West was 45.5. All other regions of the country had rates below the national rate.
Other states with high veteran suicide rates, including West Virginia, Oklahoma and Kentucky, had greater levels of prescription drug use, including opioids. A VA study last year found veterans who received the highest doses of opioid painkillers were more than twice as likely to die by suicide compared to those receiving the lowest doses.
The latest VA data also reaffirmed sharp demographic differences: Women veterans are at much greater risk, with their suicide rate 2.5 times higher than for female civilians. Among men, the risk was 19 percent higher among veterans compared to civilians. As a whole, older veterans make up most military suicides — roughly 65 percent were age 50 or older.
“This report is huge,” said Rajeev Ramchand, an epidemiologist who studies suicide for the RAND Corp. He noted that the suicide rate is higher for veterans than non-veterans in every single state by at least 1.5 times, suggesting unique problems faced by former service members. “No state is immune.”
Ramchand said it was hard to pinpoint specific causes behind veteran suicide but likely involved factors more prevalent in rural areas, such as social isolation, limited health care access, gun ownership and opioid addiction. Nationally, 70 percent of the veterans who take their lives had not previously been connected to VA care.
“This requires closer investigation into why suicide rates by veteran status are higher, including the role that opiates play,” Ramchand said.
The dataset offers more detailed breakdowns on national figures released last year, which found that 20 veterans a day committed suicide. The numbers come from the largest study undertaken of veterans’ records by the VA, part of a government effort to uncover fresh information about where to direct resources and identify veterans most at-risk.
The department has been examining ways to boost suicide prevention efforts.
“These findings are deeply concerning, which is why I made suicide prevention my top clinical priority,” said VA Secretary David Shulkin. “This is a national public health issue.”
Shulkin, who has worked to provide same-day mental health care at VA medical centers, recently expanded emergency mental care to veterans with other than honorable discharges. The department is also boosting its suicide hotline and expanding telehealth options.
Ret. Army Sgt. Shawn Jones, executive director of Stop Soldier Suicide, said veterans suicide is an issue that needs greater awareness to provide community support for those in need. Transitioning back to civilian life can be difficult for active-duty members who may return home with physical and mental conditions and feel unable to open up to friends or families. As a result, some veterans can feel overwhelmed by daily challenges of finding a job, buying a home and supporting a family.
“It can be tough because the military is a close-knit community and you have that familial feel,” Jones said. “As you transition out, you tend to lose that a little bit and feel like an island onto yourself.”
The attention on veteran suicide comes at a time when the VA has reported a huge upswing in veterans seeking medical care as they have returned from conflicts in Afghanistan and Iraq.
Veterans’ groups say the latest data may raise questions about the department’s push to expand private-sector care.
“Veterans often have more complex injuries,” said Allison Jaslow, executive director of Iraq and Afghanistan Veterans of America, citing limitations if civilian doctors don’t understand the unique challenges of the veterans’ population. If doctors don’t ask the right questions to a veteran complaining of back pain, for instance, they may prescribe opioids not realizing the veteran was also suffering PTSD or brain injury after being blown up in a humvee, said Jaslow, a former Army captain.
Expanding private-sector care and stemming veterans’ suicide are priorities of President Donald Trump. In a statement this week as part of Suicide Prevention Month, Trump said the U.S. “must do more” to help mentally troubled veterans.
Perl’s findings, published in the scientific journal The Lancet Neurology, may represent the key to a medical mystery first glimpsed a century ago in the trenches of World War I. It was first known as shell shock, then combat fatigue and finally PTSD, and in each case, it was almost universally understood as a psychic rather than a physical affliction. Only in the past decade or so did an elite group of neurologists, physicists and senior officers begin pushing back at a military leadership that had long told recruits with these wounds to “deal with it,” fed them pills and sent them back into battle.
If Perl’s discovery is confirmed by other scientists — and if one of blast’s short-term signatures is indeed a pattern of scarring in the brain — then the implications for the military and for society at large could be vast. Much of what has passed for emotional trauma may be reinterpreted, and many veterans may step forward to demand recognition of an injury that cannot be definitively diagnosed until after death. There will be calls for more research, for drug trials, for better helmets and for expanded veteran care. But these palliatives are unlikely to erase the crude message that lurks, unavoidable, behind Perl’s discovery: Modern warfare destroys your brain.
The physics behind blast forces was almost unknown until the modern era, and it remains so mysterious and terrifying that scientists sometimes invoke the word “magic” when talking about it. A blast begins simply: A detonator turns a lump of solid matter into a deadly fireball. Within that moment, three distinct things happen. The first is the blast wave, a wall of static pressure traveling outward in all directions faster than the speed of sound. Next, a blast wind fills the void and carries with it any objects it encounters. This is the most manifestly destructive part of the blast, capable of hurling cars, people and shrapnel against buildings and roadsides. The remaining effects include fire and toxic gases, which can sear, poison and asphyxiate anyone within range.
The effects of all of this on the human body are myriad and more complicated than the blast itself. People who have been exposed to blasts at close range usually describe it as an overpowering, full-body experience unlike anything they have ever known. Many soldiers do not recall the moment of impact: it gets lost in the flash of light, the deafening sound or unconsciousness. Those who do remember it often speak of a simultaneous punching and squeezing effect, a feeling at once generalized and intensely violent, as if someone had put a board against your body and then struck it with dozens of hammers. From a distance, a blast makes a distinctive thump, the sound of air pressure clapping outward. When I lived in Baghdad, reporting for this newspaper, I would sometimes be awakened by that sound early in the morning. I would sit up in bed, instantly alert, with a surreal and awful realization: Someone who was just as healthy as me 30 seconds ago has been shredded to pieces.
Credit Greg Kahn for The New York Time.
Trinitrotoluene, or TNT, was first used in artillery shells by the German Army in 1902. Soon after the First World War started in 1914, a rain of these devices was falling on the hapless men on each side of the front. It was a level of violence and horror far beyond the cavalry charges of earlier wars. Very quickly, soldiers began emerging with bizarre symptoms; they shuddered and gibbered or became unable to speak at all. Many observers were struck by the apparent capacity of these blasts to kill and maim without leaving any visible trace. The British journalist Ellis Ashmead-Bartlett famously described the sight of seven Turks at Gallipoli in 1915, sitting together with their rifles across their knees: “One man has his arm across the neck of his friend and a smile on his face as if they had been cracking a joke when death overwhelmed them. All now have the appearance of being merely asleep; for of the several I can only see one who shows any outward injury.”
For those who survived a blast and suffered the mysterious symptoms, soldiers quickly coined their own phrase: shell shock. One period lyric went like this:
Perhaps you’re broke and paralyzed
Perhaps your memory goes
But it’s only just called shell shock
For you’ve nothing there that shows.
One British doctor, Frederick Mott, believed the shock was caused by a physical wound and proposed dissecting the brains of men who suffered from it. He even had some prescient hunches about the mechanism of blast’s effects: the compression wave, the concussion and the toxic gases. In a paper published in The Lancet in February 1916, he posited a “physical or chemical change and a break in the links of the chain of neurons which subserve a particular function.” Mott might not have seen anything abnormal in the soldiers’ brains, even if he had examined them under a microscope; neuropathology was still in its infancy. But his prophetic intuitions made him something of a hero to Perl.
Mott’s views were soon eclipsed by those of other doctors who saw shell shock more as a matter of emotional trauma. This was partly a function of the intellectual climate; Freud and other early psychologists had recently begun sketching provocative new ideas about how the mind responds to stress. Soldiers suffering from shell shock were often described as possessing “a neuropathic tendency or inheritance” or even a lack of manly vigor and patriotic spirit. Many shell-shock victims were derided as shirkers; some were even sentenced to death by firing squad after fleeing the field in a state of mental confusion.
This consensus held sway for decades, even as the terminology shifted, settling in 1980 on “post-traumatic stress disorder,” a coinage tailored to the unique social and emotional strain of returning veterans of the war in Vietnam. No one doubted that blasts had powerful and mysterious effects on the body, and starting in 1951, the U.S. government established the Blast Overpressure Program to observe the effects of large explosions, including atomic bombs, on living tissue. One of my uncles recalls standing in the Nevada desert as an Army private in 1955, taking photographs of a nuclear blast amid a weird landscape of test objects: cars, houses and mannequins in Chinese and Soviet military uniforms. At the time, scientists believed blasts would mainly affect air pockets in the body like the lungs, the digestive system and the ears. Few asked what it would mean for the body’s most complex and vulnerable organ.
Only after yet another European war broke out did scientists begin looking again at blast’s effects on the brain. When the Balkans collapsed into fratricidal violence in the early 1990s, Ibolja Cernak, a small, tenacious woman who grew up in the countryside of what is now Serbia, was working as a doctor and researcher at a military hospital in Belgrade. She soon began seeing large numbers of soldiers with blast trauma, usually from mortars and artillery fire, a common feature of that war. As in World War I, the men often suffered from striking mental impairments but few visible wounds. Cernak, whose colleagues call her Ibi, has an appealing blend of briskness and warmth, along with a clinician’s conviction that you must listen to your patients. It is easy to imagine her running around the battlefields of Bosnia and Serbia, collecting blood samples from soldiers. That is what she did for several years, at no small risk to her life, for a study cataloging the neurological effects of blast on 1,300 recruits. “The blast covers the entire body,” she told me. “It has a squeezing effect. Ask soldiers what they felt: The first thing they say is that their ears were popped out, they were gasping for air, like some huge fist is squeezing them. The entire body is involved in that interaction.”
Cernak became convinced that blast ripples through the body like rings on a pond’s surface. Its speed changes when it encounters materials of different density, like air pockets or the border between the brain’s gray and white matter, and can inflict greater damage in those places. As it happens, physicists would later theorize some very similar models for how blast damages the brain. Several possibilities have now been explored, including surges of blood upward from the chest; shearing loads on brain tissue; and the brain bouncing back and forth inside the skull, as happens with concussion. Charles Needham, a renowned authority on blast physics, told me post-mortems on blast injuries have lent some support to all of those theories, and the truth may be that several are at play simultaneously.
A decade after her initial battlefield surveys in the Balkans, Cernak took a position at Johns Hopkins University in Baltimore, where she did animal research that bolstered her conviction about blast’s full-body effects. She found that even if an animal’s head is protected during a blast, the brain can sustain damage, because the blast wave transfers through the body via blood and tissue. Cernak also came to believe that blast injuries to the brain were cumulative and that even small explosions with no discernible effects could, if repeated, produce terrible and irreversible damage. Much of this would later be confirmed by other scientists.
Even Cernak’s limited conclusions about blast injuries were heresy to much of the military-medical establishment at the time. She presented some of her findings at a conference in Vienna in the late 1990s, and before she was even finished, “an older gentleman stood up, a military doctor from the U.S.A.,” she recalled. “He said: ‘Stop with this nonsense. If you give soldiers fluid replacement, they’ll do fine after 24 hours, so it’s not this.’ … I was taken aback. It’s been an uphill battle.”
Credit Australian War Memorial
It was not until 2001, when America embarked on what became an era of constant warfare, that doctors began to move slowly toward Cernak’s way of thinking. A new generation of more powerful roadside bombs — improvised explosive devices, or I.E.D.s, in military parlance — became a signature of the fighting in Iraq and Afghanistan, yielding an epidemic of blast injury. Medics soon noticed an oddity of blast: It reflects off hard surfaces and multiplies, so that people who appear to be protected inside an enclosed space like a Humvee often suffer much worse brain injuries than those outside. Military and civilian researchers began focusing their work on the brain rather than just the body. But it was still very difficult to isolate blast from all the other physical and mental effects of being exposed to an explosion in a combat zone.
A landmark advance came in 2007, when an engineering firm called Applied Research Associates received a call from the SWAT team of the Arapahoe County Sheriff’s Office in Colorado. The officers were worried about possible neurological effects from breaching, the practice of blowing open doors with small explosive charges. Almost every major city in the United States has breacher teams, as do militaries in war zones. The Applied Research team quickly recognized that monitoring breachers would allow them to observe blast in its pure form, because the charges are too small to knock soldiers over or give them concussions; they are subject to the blast wave only. Plus, the researchers could bypass any ethical concerns about running tests on human subjects, because the breachers were doing it anyway.
The Applied Research team quickly designed and led a study on military breachers, rigging its own blast gauges and subjecting the recruits and trainers to neuropsychological tests at the beginning and end of a two-week breaching course. The resulting report, circulated in 2008, found a small but distinct decline in performance among the instructors, who are exposed to far more blasts than students. It was only a pilot study, but one author, Leanne Young, told me it added to “converging evidence that there is a cumulative effect with chronic exposure to blast,” even at relatively low levels.
The military was still reluctant to take blast seriously or even to concede that the symptoms it caused were a matter of physical harm. As late as 2008, researchers at the Walter Reed Army Institute of Research published a paper suggesting that the symptoms of traumatic brain injury could be caused in large part by PTSD and brushing off “theoretical concern” about neurological effects of the blast wave. By that time, American doctors who had gained Cernak’s unusual blend of medical expertise and battle experience were starting to draw their own conclusions.
One of the first to challenge the military from within was a 44-year-old Army lieutenant colonel named Christian Macedonia. In March 2008, Macedonia was in Arlington, Va., listening to a group of scientists and government bureaucrats talk about roadside bombs. The talk was dry and technical, and finally Macedonia, a square-jawed man with an air of urgent candor, could no longer contain himself. He lashed out against the military’s inaction on brain injury, using what he recalls as “some pretty salty language” to make his point. “I see no movement, and I’m kind of sick of it,” he concluded. As the meeting broke up, Macedonia expected other participants to politely avoid him. Instead, a younger aide approached, gave him a business card and urged him to get in touch with Adm. Michael Mullen, then chairman of the Joint Chiefs of Staff. Macedonia contacted Mullen and repeated his pitch. To his surprise, Mullen hired him.
At the time, “you had an entrenched military-medical community that did not want to go down that road,” Macedonia told me. “They didn’t want to give any credence to the idea that these symptoms were anything other than emotional difficulty.” Macedonia, an obstetrician as well as a soldier, knew otherwise. He did a tour in Anbar province in Iraq in 2004 and 2005 with soldiers who were being targeted frequently by mortars and roadside bombs. As an officer and doctor, he felt responsible for younger soldiers and their injuries. “Kids exposed to explosions were asking for help, and I was mouthing the party line: ‘You’ll be O.K.’ I was part of the machine that didn’t help. That’s what haunts me.”
Like Macedonia, some senior officers, including Gen. Peter Chiarelli of the Army and Gen. James Amos of the Marines, were also frustrated. They had seen too many soldiers discharged for disciplinary issues that were related to brain injury. Mullen hired several other experts to join Macedonia, asking them to monitor and improve the treatment of brain injury across the entire military. They called it the “Gray Team” — partly a play on gray matter and partly because the men were mostly in their 40s and going gray. They were an extraordinary group: mostly military officers, all of them had advanced degrees in medicine or science. And almost all of them had seen combat.
One of them was Jim Hancock, an emergency physician and Navy captain whose main qualification, he told me, was that he had suffered a traumatic brain injury himself, in southern Afghanistan. He also suffered concussions twice as a college athlete, so he had a basis for comparison. “The theory at the time was, it was a concussive event,” Hancock told me. “I said, ‘B.S.’ I’ve been concussed. I’ve never had anything like blast.” Like other members of the team, Hancock had noticed that soldiers exposed to blasts often had memory and focus problems that did not go away and that seemed distinct from battlefield trauma. If the blasts were repeated, the lapses sometimes devolved into career-ending mental and behavioral struggles. The Gray Team shared a gut-level belief that a blast wave’s effects on the body were far more extreme, and more complex, than the concussion model could account for. But their main task was to push the military to take brain injury more seriously, whatever its causes.
In early 2009, the Gray Team’s first five members traveled to military bases in Iraq and Afghanistan, meeting with trauma surgeons and other doctors to see how they handled brain injury. They found a wildly inconsistent picture. There were three extraordinary doctors who understood brain trauma and how to handle it. But “our fear was, those three rotate out, and it disappears,” said Dr. Geoffrey Ling, another member of the Gray Team.
Credit Nick Oza for The New York Times
When they got home, the team identified the most valuable practices and, along with Chiarelli and Amos, had them codified. Any soldier who was within 50 meters of a blast or who was in a vehicle behind or ahead of one struck by a bomb would have to be screened for brain injury. Anyone who suffered a concussion would have to be pulled out of combat. The Gray Team used a checklist to help identify concussed soldiers, although they were soon forced to write six different versions of it, because so many Marines memorized the correct answers to avoid being pulled out of combat. They also found a civilian contractor to build blast gauges, like the ones used in the breacher study. Every recruit or officer in a combat zone now wears three of these tiny devices, which weigh 20 grams each. The gauges are designed to turn red if they register a force of more than 12 pounds per square inch, the lower limit indicating a possible concussion or brain injury. The soldiers can no longer brush it off: If your sensor is red, you must be screened for brain injury.
The military has taken the new rules seriously. Less than a year after its first tour, the Gray Team went out to the field again and found that 90 percent of the bases they visited were in compliance. Still, the larger question of blast’s residue inside the skull remained a mystery.
Brandon Matthews is built like a tank, with huge humps of muscle outlining his back and shoulders. Ugly scars run down his biceps and forearms, cutting deep creases into the muscle. Others line his legs and sides, the legacy of an 11-year career as an Army Ranger. Matthews, registered with the military as Brandon Matthew Sipp, was exposed to so many blasts, in Iraq and other places, that he cannot count them all. The worst was a suicide bombing that sent him flying down a corridor and left him in a coma. He was hospitalized for months, and his military career was over. But his struggles with brain injury were only starting.
“I have moments when I forget everything: who I am, where I am, what I’m doing,” he told me. “It happens almost every day,” sometimes while he is driving. Decisions, once easy, have become impossible. He turns the kitchen burner on and then walks out, returning to discover a fire raging.
Matthews has 24 names tattooed down the center of his back. Eighteen are former war buddies who were killed in action. The more painful losses, in a sense, are five others: friends who have killed themselves since returning from the war. One of them, another Special Operations veteran with an undiagnosed traumatic brain injury, threatened his wife and children with a gun six months ago, Matthews told me, then shot himself in the head. Matthews spoke at the funeral. Undiagnosed blast injuries are common among the Special Operations soldiers, he said, because members of this military elite prize their toughness and do not want to risk losing their careers. “Here’s the harsh reality,” another veteran told me. “In the Special Forces especially, if I fail my physical, I’m done. That’s all there is to it. My cool-guy stuff is done.” So they keep their heads down, say nothing and suffer more blasts. Until one day, like Brandon Matthews, they are too damaged to fight.
I met Matthews at a hotel in Scottsdale, Ariz., where he now lives, and within an hour he had consumed several vodka-and-waters. He was warm and talkative, but every now and then he got a lost, plaintive look in his green eyes; I had the impression of a man who is clinging to a precipice. Before I could turn in, he insisted on steering me to a series of nightclubs, where he drank round after round and regaled strangers with his war stories. I asked him about friends, and he told me that almost all of them were dead. He lives on his military pension, and at 33, seems to have given up on holding down a job.
All this is fairly typical of service members and veterans who have suffered serious or repeated blast injuries, I was told by Susan Ullman, who runs an outreach network called Warrior2Warrior. (Ullman’s own husband, a Green Beret who suffered a traumatic brain injury, killed himself in 2013.) When I asked Matthews about other veterans and suicide, he grimaced and unleashed a string of obscenities about the cowardice of taking your own life. It felt cruel, and a little unnecessary, to ask if he had been tempted that way himself. (He has his own name tattooed on his back after those of friends who have killed themselves.)
Even if the underlying wounds of men like Matthews cannot be treated, the symptoms of brain injury, like those of trauma, can often be alleviated. The distinction between organic and emotional injury can be very blurry; trauma changes neuronal patterns, and therapy can alter a brain that has been physically damaged. “Everything we know suggests that people with structural lesion will also respond to pharmacological and psychological treatment,” said David Brody, a neurologist who has worked extensively with the military. Finding the right treatment is the key. Many veterans told me that they had gone to the V.A. and been handed pills indiscriminately. A number of mostly untested treatments have gained traction in the past few years, from hyperbaric chambers to ergonomic mouth guards, and some veterans swear by them.
For all his mental confusion, Matthews told me that he thinks he can now distinguish between the emotional wounds he suffered — the survivor’s guilt, the bad dreams and night terrors — and the more concrete cognitive problems that he traces to his blast exposure. A number of Special Operations soldiers said the same thing. They also said it makes a big difference to be told they have a physical wound rather than a mental one, even if it is incurable. Some brain injuries can now be seen on M.R.I.-type brain scans of living people, though precise diagnoses remain elusive. Matthews told me he would find some solace in simply being able to see what was going on inside his head.
Daniel Perl is continuing to examine the brains of blast-injured soldiers. After five years of working with the military, he feels sure, he told me, that many blast injuries have not been identified. “We could be talking many thousands,” he said. “And what scares me is that what we’re seeing now might just be the first round. If they survive the initial injuries, many of them may develop C.T.E. years or decades later.”
Perl takes some solace from the past. He has read a great deal about the men who suffered from shell shock during World War I and the doctors who struggled to treat them. He mentioned a monument in central England called “Shot at Dawn,” dedicated to British and Commonwealth soldiers who were executed by a firing squad after being convicted of cowardice or desertion. It is a stone figure of a blindfolded man in a military storm coat, his hands bound behind him. At his back is a field of thin stakes, each of them bearing a name, rank, age and date of execution. Some of these men, Perl believes, probably had traumatic brain injuries from blasts and should not have been held responsible for their actions. He has begun looking into the possibility of obtaining brain samples of shellshocked soldiers from that war. He hopes to examine them under the microscope, and perhaps, a century later, grant them and their descendants the diagnoses they deserve.
The support of friends and family members is critical for servicemembers experiencing symptoms of posttraumatic stress disorder (PTSD), especially when many service members choose not to get the help they need because of the stigma that surrounds psychological health care. Paul Rose, the author of this Navy Medicine Live blog post knows this firsthand. Read about how he helped his brother, a U.S. Army veteran, get the help he needed for his combat-related PTSD. And then explore the resources identified at the end of this post to support military members and those who support them.
When my kid brother left for Iraq he was just that — a kid. He returned home shattered inside. The “dark pit,” as he calls it, was hidden underneath his gruff, infantry-tattooed exterior. No one in our family could have predicted what he would experience or the after-effects that continue to haunt him today.
Many sailors, soldiers, Marines and airmen return from deployments with posttraumatic stress disorder. As a family member of a person suffering from PTSD, we must be strong for them in a variety of ways to help them combat the disorder. I received an up-close and personal look at how it can affect a person, when my younger brother came to live with me after separating from the U.S. Army.
Shortly after graduating from the U.S. Army Infantry School at Fort Benning, Ga., my younger brother found his newly-issued boots on the sandy ground in Mosul, Iraq — during a time that would turn out to be one of the bloodiest during the war. His main duties were to provide infantry support to convoys, security detail, and to locate and apprehend insurgents.
He came home with an inescapable burden on his back. He continually woke up, drenched in sweat, with nightmares so real he could still see the terrifying images in his dark room. His mind was filled with the lives he had to take, the friends he lost — some to the enemy, some to suicide — and the near-misses of death’s cold, bony grip on his own neck.
He talked to no one about the sleepless nights and the recurring feelings of depression and hopelessness. The stigma associated with being diagnosed with PTSD kept him from seeking help. The disorder eventually caused him to exit the Army before his enlistment was up. A short time later he’d be living in my finished basement, as my wife and I adjusted to life with our two kids and a newly discharged war veteran.
My brother would continually become overwhelmed with routine things like paying his bills, getting up for work or dealing with relationships. PTSD was winning the battle against him, and he did not know how to fight back. Even after he hung up his uniform, he still carried himself like an invincible infantry soldier. Deep down he knew he needed help, but was still too afraid, ashamed and overwhelmed to seek it.
The year he spent with us was an extremely trying time. As he was learning how to get better, we were learning how to help him. Being a family member of someone who has been diagnosed with combat-related PTSD can be difficult, but the most important thing we did was to provide a stable support system for him.
There were times my brother could be so frustrating that we would get into screaming matches. He would peel out of the neighborhood, the screech of his car tires echoing through the house, and I would pray he came home that night. His behavior became more erratic. I helped him apply for jobs. He would hold one for a short time and then quit, normally after losing his temper or becoming fed-up with it. All of these actions are a correlation to the internal fight he was struggling with.
After much convincing by my wife and I, he finally overcame his fear of the stigma associated with the disorder and went to the local Department of Veterans Affairs (VA) medical center, where he was evaluated and given a service-connected disability for PTSD, as well as for injuring his back while deployed, but most importantly access to the tools and programs to fight it.
The nightmares still remained. We continued our support. I gathered research on the subject, finding that a mix of therapy, medication and a healthy lifestyle could decrease the effects. He started taking a prescribed medication and spoke with social workers at the VA hospital regularly. I dragged him to workouts with me and created healthy athletic competition for us, including intramural sports, which was something he enjoyed and looked forward to all week. We made sure he remembered his appointments, encouraged him in his work and most importantly, ensured that he knew he was a valuable part of our family dynamic. I tried to keep him from getting overwhelmed by telling him to take things “one day at a time.” It became a mantra for us.
It’s been a few years since my brother was in Iraq with an M4 slung over his shoulder. And he’s a long way from the 8-year-old who dug foxholes in my mother’s backyard while dreaming of being a soldier. He would never take back his time in the Army and believes very much in his mission in Iraq. When he eventually made me one of the few people he shared his experiences with, he confessed with tear-filled eyes of times he came close to taking his own life. He assured me that war is not glorious or heroic. He did what he had to do because the soldiers serving beside him needed him, and each one of them would have done the same thing, he said.
After a year with us, he had gotten his PTSD under control, with help from the VA and support from his family. He continues to maintain his appointments, take his medication, work out on a regular basis and has a steady job. He is living on his own and is still fighting hard.
While there is no clear cut route to helping a family member with combat-related PTSD, the one thing we can do for those close to us who are suffering, is to offer support. Without his family, I don’t know where my brother would be today — if he would even be alive. But I do know that he is winning the war — one day at a time.
From Chapter 4, Iraq War Clinician Guide.
In this section from the Iraq War Clinician Guide, we discuss treatment of Veterans recently evacuated due to combat or war stress who are brought to the VA for mental health care, and Iraq War Veterans seeking mental health care at VA medical centers and Vet Centers.
This section complements discussion of special topics (e.g., treatment of medical casualties, identification and management of PTSD in the primary care setting, issues in caring for Veterans who have been sexually assaulted, traumatic bereavement) that are addressed in other sections of this Guide.
It is important that VA and Vet Center clinicians recognize that the skills and experience that they have developed in working with Veterans with chronic PTSD will serve them well with those returning from the Iraq War. Their experience in talking about trauma, educating patients and families about traumatic stress reactions, teaching skills of anxiety and anger management, facilitating mutual support among groups of Veterans, and working with trauma-related guilt, will all be useful and applicable. Here, we highlight some challenges for clinicians, discuss ways in which care of these Veterans may differ from our usual contexts of care, and direct attention to particular methods and materials that may be relevant to the care of the Veteran recently traumatized in war.
The helping context: active duty vs. Veterans seeking health care
There are a variety of differences between the contexts of care for active duty military personnel and Veterans normally being served in VA that may affect the way practitioners go about their business. First, many Iraq War patients will not be seeking mental health treatment. Some will have been evacuated for mental health or medical reasons and brought to VA, perhaps reluctant to acknowledge their emotional distress and almost certainly reluctant to consider themselves as having a mental health disorder (e.g., post-traumatic stress disorder). Second, emphasis on diagnosis as an organizing principle of mental health care is common in VA. Patients are given DSM-IV diagnoses, and diagnoses drive treatment. This approach may be contrasted with that of frontline psychiatry, in which pathologization of combat stress reactions is strenuously avoided. The strong assumption is that most soldiers will recover, and that their responses represent a severe reaction to the traumatic stress of war rather than a mental illness or disorder. According to this thinking, the “labeling” process may be counterproductive in the context of early care for Iraq War Veterans. As Koshes (1) noted, “labeling a person with an illness can reinforce the “sick” role and delay or prevent the soldier’s return to the unit or to a useful role in military or civilian life” (p. 401).
Patients themselves may have a number of incentives to minimize their distress: to hasten discharge, to accelerate a return to the family, to avoid compromising their military career or retirement. Fears about possible impact on career prospects are based in reality; indeed, some will be judged medically unfit to return to duty. Veterans may be concerned that a diagnosis of PTSD, or even Acute Stress Disorder, in their medical record may harm their chances of future promotion, lead to a decision to not be retained, or affect type of discharge received. Some may think that the information obtained if they receive mental health treatment will be shared with their unit commanders, as is sometimes the case in the military.
To avoid legitimate concerns about possible pathologization of common traumatic stress reactions, clinicians may wish to consider avoiding, where possible, the assignment of diagnostic labels such as ASD or PTSD, and instead focus on assessing and documenting symptoms and behaviors. Diagnoses of acute or adjustment disorders may apply if symptoms warrant labeling. Concerns about confidentiality must be acknowledged and steps taken to create the conditions in which patients will feel able to talk openly about their experiences, which may include difficulties with commanders, misgivings about military operations or policies, or possible moral concerns about having participated in the war. It will be helpful for clinicians to know who will be privy to information obtained in an assessment. The role of the assessment and who will have access to what information should be discussed with concerned patients.
Active duty service members may have the option to remain on active duty or to return to the war zone. Some evidence suggests that returning to work with one’s cohort group during wartime can facilitate improvement of symptoms. Although their wishes may or may not be granted, service members often have strong feelings about wanting or not wanting to return to war. For recently activated National Guard and Reservists, issues may be somewhat different. (2) Many in this population never planned to go to war and so may be faced with obstacles to picking up the life they “left.” Whether active duty, National Guard, or Reservist, listening to and acknowledging their concerns will help empower them and inform treatment planning.
Iraq War patients entering residential mental health care will have come to the VA through a process different from that experienced by “traditional” patients. If they have been evacuated from the war zone, they will have been rapidly moved through several levels of medical triage and treatment, and treated by a variety of health care providers. (3) Many will have received some mental health care in the war zone (e.g., stress debriefing) that will have been judged unsuccessful. Some Veterans will perceive their need for continuing care as a sign of personal failure. Understanding their path to the VA will help the building of a relationship and the design of care.
More generally, the returning soldier is in a state of transition from war zone to home, and clinicians must seek to understand the expectations and consequences of returning home for the Veteran. Is the Veteran returning to an established place in society, to an economically deprived community, to a supportive spouse or cohesive military unit, to a large impersonal city, to unemployment, to financial stress, to an American public thankful for his or her sacrifice? Whatever the circumstances, things are unlikely to be as they were:
“The deployment of the family member creates a painful void within the family system that is eventually filled (or denied) so that life can go on…The family assumes that their experiences at home and the soldier’s activities on the battlefield will be easily assimilated by each other at the time of reunion and that the pre-war roles will be resumed. The fact that new roles and responsibilities may not be given up quickly upon homecoming is not anticipated.”(p.31). (4)
Learning from Vietnam Veterans with chronic PTSD
From the perspective of work with Vietnam Veterans whose lives have been greatly disrupted by their disorder, the chance to work with combat Veterans soon after their war experiences represents a real opportunity to prevent the development of a disastrous life course. We have the opportunity to directly focus on traumatic stress reactions and PTSD symptom reduction (e.g., by helping Veterans process their traumatic experiences, by prescribing medications) and thereby reduce the degree to which PTSD, depression, alcohol/substance misuse, or other psychological problems interfere with quality of life. We also have the opportunity to intervene directly in key areas of life functioning, to reduce the harm associated with continuing post-traumatic stress symptoms and depression if those prove resistant to treatment. The latter may possibly be accomplished via interventions focused on actively supporting family functioning in order to minimize family problems, reducing social alienation and isolation, supporting workplace functioning, and preventing use of alcohol and drugs as self-medication (a different focus than addressing chronic alcohol or drug problems).
Prevent family breakdown
At time of return to civilian life, soldiers can face a variety of challenges in re-entering their families, and the contrast between the fantasies and realities of homecoming (4) can be distressing. Families themselves have been stressed and experienced problems as a result of the deployment. (5,6) Partners have made role adjustments while the soldier was away, and these need to be renegotiated, especially given the possible irritability and tension of the Veteran. (7) The possibility exists that mental health providers can reduce long term family problems by helping Veterans and their families anticipate and prepare for family challenges, involving families in treatment, providing skills training for patients (and where possible, their families) in family-relevant skills (e.g., communication, anger management, conflict resolution, parenting), providing short-term support for family members, and linking families together for mutual support.
Prevent social withdrawal and isolation
PTSD also interferes with social functioning. Here the challenge is to help the Veteran avoid withdrawal from others by supporting re-entry into existing relationships with friends, work colleagues, and relatives, or where appropriate, assisting in development of new social relationships. The latter may be especially relevant with individuals who leave military service and transition back into civilian life. Social functioning should be routinely discussed with patients and made a target for intervention. Skills training focusing on the concrete management of specific difficult social situations may be very helpful. Also, as indicated below, clinicians should try to connect Veterans with other Veterans in order to facilitate the development of social networks.
Prevent problems with employment
Associated with chronic combat-related PTSD have been high rates of job turnover and general difficulty in maintaining employment, often attributed by Veterans themselves to anger and irritability, difficulties with authority, PTSD symptoms, and substance abuse. Steady employment, however, is likely to be one predictor of better long term functioning, as it can reduce financial stresses, provide a source of meaningful activity and self-esteem, and give opportunities for companionship and friendship. In some cases, clinicians can provide valuable help by supporting the military or civilian work functioning of Veterans, by teaching skills of maintaining or, in the case of those leaving the military, finding of employment, or facilitating job-related support groups.
Prevent alcohol and drug abuse
The co-morbidity of PTSD with alcohol and drug problems in Veterans is well established. (8) Substance abuse adds to the problems caused by PTSD and interferes with key roles and relationships, impairs coping, and impairs entry into and ongoing participation in treatment. PTSD providers are aware of the need to routinely screen and assess for alcohol and drug use, and are knowledgeable about alcohol and drug (especially 12-Step) treatment. Many are learning, as well, about the potential usefulness of integrated PTSD-substance abuse treatment, and the availability of manualized treatments for this dual disorder. “Seeking Safety,” a structured group protocol for trauma-relevant coping skills training, (9) is seeing increased use in VA and should be considered as a treatment option for Iraq War Veterans who have substance use disorders along with problematic traumatic stress responses. In addition, for many newly returning Iraq War Veterans, it will be important to supplement traditional abstinence-oriented treatments with attention to milder alcohol problems, and in particular to initiate preventive interventions to reduce drinking or prevent acceleration of alcohol consumption as a response to PTSD symptoms. (10) For allreturning Veterans, it will be useful to provide education about safe drinking practices and the relationship between traumatic stress reactions and substance abuse.
Connect with the returning Veteran
As with all mental health counseling, the relationship between Veteran and helper will be the starting point for care. Forming a working alliance with some returnees may be challenging, however, because most newly-returned Veterans may be, as Litz (this Guide) notes, “defended, formal, respectful, laconic, and cautious” and reluctant to work with the mental health professional. Especially in the context of recent exposure to war, validation (7) of the Veteran’s experiences and concerns will be crucial. Discussion of “war zone”, not “combat,” stress may be warranted because some traumatic stressors (e.g., body handling, sexual assault) may not involve war fighting as such. Thought needs to be given to making the male-centric hospital system hospitable for women, especially for women who have experienced sexual assault in the war zone (see Special Topic VI, this Guide), for whom simply walking onto the grounds of a VA hospital with the ubiquitous presence of men may create feelings of vulnerability and anxiety.
Practitioners should work from a patient-centered perspective, and take care to find out the current concerns of the patient (e.g., fear of returning to the war zone, concerns about having been evacuated and what this means, worries about reactions of unit, fear of career ramifications, concern about reactions of family, concerns about returning to active duty). One advantage of such an orientation is that it will assist with the development of a helping relationship.
Connect Veterans with each other
In treatment of chronic PTSD, Veterans often report that perhaps their most valued experience was the opportunity to connect in friendship and support with other vets. This is unlikely to be different for returning Iraq War soldiers, who may benefit greatly from connection both with each other and with Veterans of other conflicts. Fortunately, this is a real strength of VA and Vet Center professionals, who routinely and skillfully bring Veterans together.
Offer practical help with specific problems
Returning Veterans are likely to feel overwhelmed with problems, related to workplace, family and friends, finances, physical health, and so on. These problems will be drawing much of their attention away from the tasks of therapy, and may create a climate of continuing stress that interferes with resolution of symptoms. The presence of continuing negative consequences of war deployment may help maintain post-traumatic stress reactions. Rather than treating these issues as distractions from the task at hand, clinicians can provide a valuable service by helping Veterans identify, prioritize, and execute action steps to address their specific problems.
Attend to broad needs of the person
Wolfe, Keane, and Young (11) put forward several suggestions for clinicians serving Persian Gulf War Veterans that are also important in the context of the Iraq War. They recommended attention to the broad range of traumatic experience (see Section I of this Guide). They similarly recommended broad clinical attention to the impact of both pre-military and post-military stressors on adjustment. For example, history of trauma places those exposed to trauma in the war zone at risk for development of PTSD, and in some cases war experiences will activate emotions experienced during earlier events. Finally, recognition and referral for assessment of the broad range of physical health concerns and complaints that may be reported by returning Veterans is important. Mental health providers must remember that increased health symptom reporting is unlikely to be exclusively psychogenic in origin. (12)
Methods of care overview
Management of acute stress reactions and problems faced by recently returned Veterans are highlighted below. Methods of care for the Iraq War Veteran with PTSD will be similar to those provided to Veterans with chronic PTSD.
Education about post-traumatic stress reactions
Education is a key component of care for the Veteran returning from war experience and is intended to improve understanding and recognition of symptoms, reduce fear and shame about symptoms, and, generally, “normalize” his or her experience. It should also provide the Veteran with a clear understanding of how recovery is thought to take place, what will happen in treatment, and, as appropriate, the role of medication. With such understanding, stress reactions may seem more predictable and fears about long-term effects can be reduced. Education in the context of relatively recent traumatization (weeks or months) should include the conception that many symptoms are the result of psychobiological reactions to extreme stress and that, with time, these reactions, in most cases, will diminish. Reactions should be interpreted as responses to overwhelming stress rather than as personal weakness or inadequacy. In fact, some recent research (13) suggests that survivors’ own responses to their stress symptoms will in part determine the degree of distress associated with those symptoms and whether they will remit. Whether, for example, post-trauma intrusions cause distress may depend in part on their meaning for the person (e.g., “I’m going crazy”).
Training in coping skills
Returning Veterans experiencing recurrent intrusive thoughts and images, anxiety and panic in response to trauma cues, and feelings of guilt or intense anger are likely to feel relatively powerless to control their emotions and thoughts. This helpless feeling is in itself a trauma reminder. Because loss of control is so central to trauma and its attendant emotions, interventions that restore self-efficacy are especially useful.
Coping skills training is a core element in the repertoire of many VA and Vet Center mental health providers. Some skills that may be effective in treating Iraq War Veterans include: anxiety management (breathing retraining and relaxation), emotional “grounding,” anger management, and communication. However, the days, weeks, and months following return home may pose specific situational challenges; therefore, a careful assessment of the Veteran’s current experience must guide selection of skills. For example, training in communication skills might focus on the problem experienced by a Veteran in expressing positive feelings towards a partner (often associated with emotional numbing); anger management could help the Veteran better respond to others in the immediate environment who do not support the war.
Whereas education helps survivors understand their experience and know what to do about it, coping skills training should focus on helping them know how to do the things that will support recovery. It relies on a cycle of instruction that includes education, demonstration, rehearsal with feedback and coaching, and repeated practice. It includes regular between-session task assignments with diary self-monitoring and real-world practice of skills. It is this repeated practice and real world experience that begins to empower the Veteran to better manage his or her challenges (see Najavits (9) for a useful manual of trauma-related coping skills).
Exposure therapy is among the best-supported treatments for PTSD. (14) It is designed to help Veterans effectively confront their trauma-related emotions and painful memories, and can be distinguished from simple discussion of traumatic experience in that it emphasizes repeated verbalization of traumatic memories (see Foa & Rothbaum (15) for a detailed exposition of the treatment). Patients are exposed to their own individualized fear stimuli repetitively, until fear responses are consistently diminished. Often, in-session exposure is supplemented by therapist-assigned and monitored self-exposure to the memories or situations associated with traumatization. In most treatment settings, exposure is delivered as part of a more comprehensive “package” treatment; it is usually combined with traumatic stress education, coping skills training, and, especially, cognitive restructuring (see below). Exposure therapy can help correct faulty perceptions of danger, improve perceived self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of distress.
Cognitive therapy or restructuring, one of the best-validated PTSD treatments, (14) is designed to help the patient review and challenge distressing trauma-related beliefs. It focuses on educating participants about the relationships between thoughts and emotions, exploring common negative thoughts held by trauma survivors, identifying personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking. This is a systematic approach that goes well beyond simple discussion of beliefs to include individual assessment, self-monitoring of thoughts, homework assignments, and real-world practice. In particular, it may be a most helpful approach to a range of emotions other than fear – guilt, shame, anger, depression – that may trouble Veterans. For example, anger may be fueled by negative beliefs (e.g., about perceived lack of preparation or training for war experiences, about harm done to their civilian career, about perceived lack of support from civilians). Cognitive therapy may also be helpful in helping Veterans cope with distressing changed perceptions of personal identity that may be associated with participation in war or loss of wartime identity upon return. (4)
For those wishing to learn more about the approach, a useful resource is the Cognitive Processing Therapy manual developed by Resick and Schnicke, (16) which incorporates extensive cognitive restructuring and limited exposure. Although designed for application to rape-related PTSD, the methods can be easily adapted for use with Veterans. Kubany’s (17) work on trauma-related guilt may be helpful in addressing Veterans’ concerns about harming or causing death to civilians.
Mental health professionals within VA and Vet Centers have a long tradition of working with family members of Veterans with PTSD. This same work, including family education, weekend family workshops, couples counseling, family therapy, parenting classes, or training in conflict resolution, will be very important with Iraq War Veterans. Some issues in family work are discussed in more detail below.
Early interventions for ASD or PTSD
If Iraq War Veterans arrive at VA medical centers very soon (i.e., within several days or several weeks) following their trauma exposure, the possibility for early intervention to prevent development of PTSD will exist. Although cognitive-behavioral early interventions have only been developed recently and have not yet been tried with war-related acute stress disorder, they should be considered as a treatment option for some returning Veterans, given their impact with other traumas and consistency with what is known about treatment of more chronic PTSD. In civilian populations, several randomized controlled trials have demonstrated that brief (i.e., 4-5 session) individually-administered cognitive-behavioral treatment, delivered around two weeks after a trauma, can prevent PTSD in some survivors of motor vehicle accidents, industrial accidents, and assault (18,19) who meet criteria for Acute Stress Disorder and are therefore at risk for development of PTSD.
This treatment is comprised of education, breathing training/relaxation, imaginal and in vivo exposure, and cognitive restructuring. The exposure and cognitive restructuring elements of the treatment are thought to be most helpful. A recent unpublished trial conducted by the same team compared cognitive therapy and exposure in early treatment of those with ASD, with results indicating that both treatments were effective with fewer patients dropping out of cognitive therapy. Bryant and Harvey (20) noted that prolonged exposure is not appropriate for everyone (e.g., those experiencing acute bereavement, extreme anxiety, severe depression, those experiencing marked ongoing stressors or at-risk for suicide). Cognitive restructuring may have wider applicability in that it may be expected to produce less distress than exposure.
Toxic exposure, physical health concerns, and mental health
War syndromes have involved fundamental, unanswered questions about chronic somatic symptoms in armed conflicts since the U.S. civil war. (21) In recent history, unexplained symptoms have been reported by Dutch peacekeepers in Lebanon, Bosnia, and Cambodia, Russian soldiers in Afghanistan and Chechnya, Canadian peacekeepers in Croatia, soldiers in the Balkan war, individuals exposed to the El Al airliner crash, individuals given the anthrax vaccine, individuals exposed to the World Trade Center following 9/11, and soldiers in the Gulf War. Seventeen percent of Gulf War Veterans believe they have “Gulf War Syndrome”. (22)
Besides PTSD, modern Veterans may experience a range of “amorphous stress outcomes.” (23) Factors contributing to these more amorphous syndromes include suspected toxic exposures, and ongoing chronic exhaustion and uncertainty. Belief in exposure to toxic contaminants has a strong effect on symptoms. Added to this, mistrust of military and industry, intense and contradictory media focus, confusing scientific debates, and stigma and medicalization can contribute to increased anxiety and symptoms related to feared exposure to contaminants.
When working with a recent Veteran, the clinician needs to address a full range of potentially disabling factors, to include: harmful illness beliefs, weight and conditioning, diagnostic labeling, misinformation, unnecessary testing, over-medication, all or nothing rehabilitation approaches, medical system rejection, social support, and workplace competition. The provider needs to be familiar with side effects of suspected toxins so that he or she can educate the Veteran, as well as being familiar with the potential somatic symptoms that are related to prolonged exposure to combat stressors, and the side effects of common medications. The provider should take a collaborative approach with the patient, identifying the full range of contributing problems, patient goals and motivation, social support, and self-management strategies. A sustained follow-up is recommended.
For those with inexplicable health problems, Fischoff and Wessely (24) outlined some simple principles of patient management that may be useful in the context of Veteran care:
- Focus communication around patients’ concerns
- Organize information coherently
- Give risks as numbers
- Acknowledge scientific uncertainty
- Use universally understood language
- Focus on relieving symptoms
There is evidence that both cognitive-behavioral group therapy (CBGT) and exercise are effective for treating Gulf War illness. In a recent clinical trial, Donata et al. (25) reported that CBGT improved physical function whereas exercise led to improvement in many of the symptoms of Gulf War Veterans’ illnesses. Both treatments improved cognitive symptoms and mental health functioning, but neither improved pain. In this study, CBGT was specifically targeted at physical functioning, and included time-contingent activity pacing, pleasant activity scheduling, sleep hygiene, assertiveness skills, confrontation of negative thinking and affect, and structured problem solving skills. The low-intensity aerobic exercise intervention was designed to increase activity level by having Veterans exercise once per week for one hour in the presence of an exercise therapist, and independently 2-3 times per week. These findings are important because they demonstrate that such treatments can be feasibly and successfully implemented in the VA health care system, and thus should be considered for the treatment of Iraq War Veterans who present with unexplained physical symptoms.
Family involvement in care
The primary source of support for the returning soldier is likely to be his or her family. We know from Veterans of the Vietnam War that there can be a risk of disengagement from family at the time of return from a war zone. We also know that emerging problems with ASD and PTSD can wreak havoc with the competency and comfort the returning soldier experiences as a partner and parent. While the returning soldier clearly needs the clinician’s attention and concern, that help can be extended to include his or her family as well. Support for the Veteran and family can increase the potential for the Veteran’s smooth immediate or eventual reintegration back into family life, and reduce the likelihood of future more damaging problems.
If the Veteran is living at home, the clinician can meet with the family and assess with them their strengths and challenges and identify any potential risks. The “Transitioning Family Questionnaire” (see Appendix A: Assessment Instrumentation) can be used to assess to what extent the family is reorganizing to once again fully include the family member who has been in the war zone. Family and clinician can work together to identify goals and develop a treatment plan to support the family’s reorganization and return to stability in coordination with the Veteran’s work on his or her own personal treatment goals. The Transitioning Family Questionnaire can be used again at a later date to assess progress and/or need for continuing work.
If one or both partners are identifying high tension or levels of disagreement, or the clinician is observing that their goals are markedly incompatible, then issues related to safety need to be assessed and plans might need to be made that support safety for all family members. Couples who have experienced domestic violence and/or infidelity are at particularly high risk and in need of more immediate support. When couples can be offered a safe forum for discussing, negotiating, and possibly resolving conflicts, that kind of clinical support can potentially help to reduce the intensity of the feelings that can become dangerous for a family. Even support for issues to be addressed by separating couples can be critically valuable, especially if children are involved and the parents anticipate future co-parenting.
Residential rehabilitation treatment
Inpatient hospitalization could lengthen the time returning personnel are away from their families, or it could be an additional absence from the family for the Veteran who has recently returned home. It is important to the ongoing support of the reuniting family that clinicians remain aware that their patient is a partner and/or parent. Family therapy sessions, in person or by phone if geographical distance is too great, can offer the family a forum for working toward meeting their goals. The potential for the involvement of the soldier’s family in treatment will depend greatly on their geographic proximity to the treatment facility. Distance can be a barrier, but the family can still be engaged through conference phone calls, or visits as can be arranged.
Pharmacologic treatment of acute stress reactions
Pharmacological treatment for acute stress reactions (within one month of the trauma) is generally reserved for individuals who remain symptomatic after having already received brief crisis-oriented psychotherapy. This philosophy and approach is in line with the deliberate attempt by military professionals to avoid medicalizing stress-related symptoms and to adhere to a strategy of immediacy, proximity, and positive expectancy.
Prior to receiving medication for stress-related symptoms, the war zone survivor should have a thorough psychiatric and medical examination, with special emphasis on medical disorders that can manifest with psychiatric symptoms (e.g., subdural hematoma, hyperthyroidism), potential psychiatric disorders (e.g., acute stress disorder, depression, psychotic disorders, panic disorder), use of alcohol and substances of abuse, use of prescribed and over-the-counter medication, and possible drug allergies. It is important to assess the full range of potential psychiatric disorders, and not just PTSD, since many symptomatic soldiers will be at an age when first episodes of schizophrenia, mania, depression, and panic disorder are often seen.
In some cases a clinician may need to prescribe psychotropic medications even before he or she has completed the medical or psychiatric examination. The acute use of medications may be necessary when the survivor is dangerous, extremely agitated, or psychotic. In such circumstances the individual should be taken to an emergency room where short acting benzodiazepines (e.g., lorazepam) or high potency neuroleptics (e.g., haldol) with minimal sedative, anticholinergic, and orthostatic side effects may prove effective. Atypical neuroleptics (e.g., risperidone) may also be useful for treating aggression.
When a decision has been made to use medication for acute stress reactions, rational choices may include benzodiazepines, antiadrenergics, or antidepressants. Shortly after traumatic exposure, the brief prescription of benzodiazepines (4 days or less) has been shown to reduce extreme arousal and anxiety and to improve sleep. However, early and prolonged use of benzodiazepines is contraindicated, since benzodiazepine use for two weeks or longer has actually has been associated with a higher rate of subsequent PTSD.
Although antiadrenergic agents including clonidine, guanfacine, prazosin, and propranolol have been recommended (primarily through open non-placebo controlled treatment trials) for the treatment of hyperarousal, irritable aggression, intrusive memories, nightmares, and insomnia in survivors with chronic PTSD, there is only suggestive preliminary evidence of their efficacy as an acute treatment. Of importance, antiadrenergic agents should be prescribed judiciously for trauma survivors with cardiovascular disease due to potential hypotensive effects and these agents should also be tapered, rather than discontinued abruptly, in order to avoid rebound hypertension. Further, because antiadrenergic agents might interfere with counterregulatory hormone responses to hypoglycemia, they should not be prescribed to survivors with diabetes.
Finally, the use of antidepressants may make sense within four weeks of war, particularly when trauma-related depressive symptoms are prominent and debilitating. To date, there has been one published report on the use of antidepressants for the treatment of Acute Stress Disorder. Recently-traumatized children meeting criteria for Acute Stress Disorder, who were treated with imipramine for two weeks, experienced significantly greater symptom reduction than children who were prescribed chloral hydrate.
Pharmacologic treatment of post-traumatic stress disorder
Pharmacotherapy is rarely used as a stand-alone treatment for PTSD and is usually combined with psychological treatment. The following text briefly presents recommendations for the pharmaco-therapeutic treatment of PTSD, and then the article by Friedman, Donnelly, and Mellman (26) in the Appendix provides more detailed information. Findings from subsequent large-scale trials with paroxetine have demonstrated that SSRI treatment is clearly effective both for men in general and for combat Veterans suffering with PTSD.
We recommend SSRIs as first line medications for PTSD pharmacotherapy in men and women with military-related PTSD. SSRIs appear to be effective for all three PTSD symptom clusters in both men and women who have experienced a variety of severe traumas and they are also effective in treating a variety of co-morbid psychiatric disorders, such as major depression and panic disorder, which are commonly seen in individuals suffering with PTSD. Additionally, the side effect profile with SSRIs is relatively benign (compared to most psychotropic medications) although arousal and insomnia may be experienced early on for some patients with PTSD.
Second line medications include nefazadone, TCAs, and MAOIs. Evidence favoring the use of these agents is not as compelling as for SSRIs because many fewer subjects have been tested at this point. The best evidence from open trials supports the use of nefazadone, which like SSRIs promotes serotonergic actions and is less likely than SSRIs to cause insomnia or sexual dysfunction. Trazadone, which has limited efficacy as a stand-alone treatment, has proven very useful as augmentation therapy with SSRIs; its sedating properties make it a useful bedtime medication that can antagonize SSRI-induced insomnia. Despite some favorable evidence of the efficacy of MAOIs, these compounds have received little experimental attention since 1990. Venlafaxine and buproprion cannot be recommended because they have not been tested systematically in clinical trials.
There is a strong rationale from laboratory research to consider antiadrenergic agents and it is hoped that more extensive testing will establish their usefulness for PTSD patients. The best research on this class of agents has focused on prazosin, which has produced marked reduction in traumatic nightmares, improved sleep, and global improvement among Veterans with PTSD. Hypotension and sedation need to be monitored and patients should not be abruptly discontinued from antiadrenergics.
Despite suggestive theoretical considerations and clinical findings, there is only a small amount of evidence to support the use of carbamazepine or valproate with PTSD patients. Further, the complexities of clinical management with these effective anticonvulsants have shifted current attention to newer agents (e.g., gabapentin, lamotrigine, and topirimate), which have yet to be tested systematically with PTSD patients.
Benzodiazepines cannot be recommended for patients with PTSD. They do not appear to have efficacy against core PTSD patients. No studies have demonstrated efficacy for PTSD-specific symptoms.
Conventional antipsychotics cannot be recommended for PTSD patients. Preliminary results suggest, however, that atypical antipsychotics may be useful, especially to augment treatment with first or second line medications, especially for patients with intense hypervigilance/paranoia, agitation, dissociation, or brief psychotic reactions associated with their PTSD. As for side effects, all atypicals may produce weight gain and olanzapine treatment has been linked to the onset of Type II diabetes mellitus.
Pharmacotherapy should be initiated with SSRI agents. Patients who cannot tolerate SSRIs or who show no improvement might benefit from nefazadone, MAOIs, or TCAs.
For patients who exhibit a partial response to SSRIs, one should consider continuation or augmentation. A recent trial with sertraline showed that approximately half of all patients who failed to exhibit a successful clinical response after 12 weeks of sertraline treatment, did respond when SSRI treatment was extended for another 24 weeks. Practically speaking, clinicians and patients usually will be reluctant to stick with an ineffective medication for 36 weeks, as in this experiment. Therefore, augmentation strategies seem to make sense. Here are a few suggestions based on clinical experience and pharmacological “guesstimates,” rather than on hard evidence:
- Excessively aroused, hyperreactive, or dissociating patients might be helped by augmentation with an antiadrenergic agent
- Labile, impulsive, and/or aggressive patients might benefit from augmentation with an anticonvulsant
- Fearful, hypervigilant, paranoid, and psychotic patients might benefit from an atypical antipsychotic
Integrating Iraq War soldiers into existing specialized PTSD services
Iraq War service members with stress-related problems may need to be integrated into existing VA PTSD Residential Rehabilitation Programs or other VA mental health programs. Approaches to this integration of psychiatric evacuees will vary and each receiving site will need to determine its own “best fit” model for provision of services and integration of Veterans. At the National Center for PTSD’s PTSD Residential Rehabilitation Program in the VA Palo Alto Health Care System, it is anticipated that Iraq War patients will generally be integrated with the rest of the milieu (e.g., for community meetings, affect management classes, conflict resolution, communication skills training), with the exception of identified treatment components. The latter elements of treatment, in which Iraq War Veterans will work together, will include process, case management, and acute stress/PTSD education groups (and, if delivered in groups, exposure therapy, cognitive restructuring, and family/couples counseling). The thoughtful mixing of returning Veterans with Veterans from other wars/conflicts is likely, in general, to enhance the treatment experience of both groups.
Working with Iraq War Veterans affected by war zone trauma is likely to be emotionally difficult for therapists. It is likely to bring up many feelings and concerns – reactions to stories of death and great suffering, judgments about the morality of the war, reactions to patients who have killed, feelings of personal vulnerability, feelings of therapeutic inadequacy, perceptions of a lack of preparation for acute care – that may affect ability to listen empathically to the patient and maintain the therapeutic relationship. (27) Koshes (1) suggested that those at greatest risk for strong personal reactions might be young, inexperienced staff who are close in age to patients and more likely to identify with them, and technicians or paraprofessional workers who may have less formal education about the challenges associated with treating these patients but who actually spend the most time with patients. Regardless of degree of experience, all mental health workers must monitor themselves and practice active self-care, and managers must ensure that training, support, and supervision are part of the environment in which care is offered.