Psychiatric Annals

Psychiatric Focus 

War-Related Mental Health Problems of Today's Veterans

Roy R. Reeves, DO, PhD; Jefferson D. Parker, PhD; Deborah J. Konkle-Parker, PhD, FNP

Abstract

With the increasing involvement of the United States in military actions in Afghanistan and Iraq, the number of veterans of these conflicts can be expected to rise steadily. Veterans of these actions and of the first Gulf War are unlike veterans of previous wars in many ways, and may experience different etiologies of illnesses related to their exposure to war. Health care professionals caring for these veterans must be aware of their potential problems if they are to treat them effectively.

The armed forces of the current era differ from those of the Vietnam and previous eras. In 1973, the all-male draft initiated as the Selective Service Act of 1948 was terminated. Since that time, the military has been composed of a much smaller, all-volunteer force. Today, the US military is a diverse and complex population. Ethnic minorities make up significant portions of the armed forces, ranging from 24% in the Air Force to 40% in the Army.1 Approximately 16% of the active US armed forces are women, and more than 50% of service members are married.2

A significant number of active duty personnel are drawn from National Guard and Reserve components. Such personnel may be exposed to significant stress related to deployment. Dates of their deployment are often unpredictable, and the duration of their active duty may not be known when they are deployed, creating an unstable environment for service members and their families.

Environmental and endemic hazards of the regions to which troops are deployed often determine the illnesses experienced later. During tours of duty in Southwest Asia, veterans may have been exposed to unusual pathogens and hazards, including tuberculosis, malaria, leishmaniasis, anthrax, plague, and tularemia, as well as a variety of viral and chemical agents used in warfare and not common in the United States. These topics are beyond the scope of this article, which focuses on mental health issues resulting from participating in war for this group of veterans.

War is an extremely stressful event that creates an atmosphere of confusion and uncertainty, and forces participants to face possible injury, loss, and death. The combat environment, with its violence, physical demands, and separation from loved ones, may precipitate a wide range of emotional distress or psychiatric disorders. For example, as evidence of the emotional effects of the current war, 19.5% of an Army study group returning from Iraq reported perceiving they had a moderate or severe mental health problem.2

The psychiatric differential diagnoses for military patients at war is broad. The clinical picture will vary over the course of a war, depending on several factors, including individual patient characteristics, available social supports, and the time elapsed since the precipitating event. It is useful to consider the range of emotional responses in the context of the multiphasic traumatic stress response, dividing the course of mental health issues into three phases based on the length of time since the event(s) precipitating emotional distress:1

Various aspects and diagnostic considerations during each of the three phases are detailed in Table 1 (see page 933). Veteran patients seeking service in the civilian sector will usually be in the chronic phase of illness. In the following section, we will discuss the most common mental health problem expected to occur in veterans returning from the conflicts in Afghanistan and Iraq — posttraumatic stress disorder (PTSD).

Both acute stress disorder and PTSD are characterized by the onset of psychiatric symptoms immediately following exposure to a traumatic event. Traumatic stress can vary considerably in different people. Given enough stress, anyone can “break.” Time-limited posttraumatic stress responses that do not persist or disorganize functioning are normal…

With the increasing involvement of the United States in military actions in Afghanistan and Iraq, the number of veterans of these conflicts can be expected to rise steadily. Veterans of these actions and of the first Gulf War are unlike veterans of previous wars in many ways, and may experience different etiologies of illnesses related to their exposure to war. Health care professionals caring for these veterans must be aware of their potential problems if they are to treat them effectively.

Wartime Differences

The armed forces of the current era differ from those of the Vietnam and previous eras. In 1973, the all-male draft initiated as the Selective Service Act of 1948 was terminated. Since that time, the military has been composed of a much smaller, all-volunteer force. Today, the US military is a diverse and complex population. Ethnic minorities make up significant portions of the armed forces, ranging from 24% in the Air Force to 40% in the Army.1 Approximately 16% of the active US armed forces are women, and more than 50% of service members are married.2

A significant number of active duty personnel are drawn from National Guard and Reserve components. Such personnel may be exposed to significant stress related to deployment. Dates of their deployment are often unpredictable, and the duration of their active duty may not be known when they are deployed, creating an unstable environment for service members and their families.

Environmental and endemic hazards of the regions to which troops are deployed often determine the illnesses experienced later. During tours of duty in Southwest Asia, veterans may have been exposed to unusual pathogens and hazards, including tuberculosis, malaria, leishmaniasis, anthrax, plague, and tularemia, as well as a variety of viral and chemical agents used in warfare and not common in the United States. These topics are beyond the scope of this article, which focuses on mental health issues resulting from participating in war for this group of veterans.

Psychiatric Disorders Seen During Wartime

War is an extremely stressful event that creates an atmosphere of confusion and uncertainty, and forces participants to face possible injury, loss, and death. The combat environment, with its violence, physical demands, and separation from loved ones, may precipitate a wide range of emotional distress or psychiatric disorders. For example, as evidence of the emotional effects of the current war, 19.5% of an Army study group returning from Iraq reported perceiving they had a moderate or severe mental health problem.2

The psychiatric differential diagnoses for military patients at war is broad. The clinical picture will vary over the course of a war, depending on several factors, including individual patient characteristics, available social supports, and the time elapsed since the precipitating event. It is useful to consider the range of emotional responses in the context of the multiphasic traumatic stress response, dividing the course of mental health issues into three phases based on the length of time since the event(s) precipitating emotional distress:1

  • An immediate phase, during or immediately after a traumatic event.
  • A delayed phase, in the aftermath of combat.
  • A chronic phase, months to years after a precipitating event.

Various aspects and diagnostic considerations during each of the three phases are detailed in Table 1 (see page 933). Veteran patients seeking service in the civilian sector will usually be in the chronic phase of illness. In the following section, we will discuss the most common mental health problem expected to occur in veterans returning from the conflicts in Afghanistan and Iraq — posttraumatic stress disorder (PTSD).

War-related Emotional Responses and Diagnostic Considerations in the Context of Multiphasic Traumatic Stress Response1

Table 1:

War-related Emotional Responses and Diagnostic Considerations in the Context of Multiphasic Traumatic Stress Response1

Posttraumatic Stress Disorder

Both acute stress disorder and PTSD are characterized by the onset of psychiatric symptoms immediately following exposure to a traumatic event. Traumatic stress can vary considerably in different people. Given enough stress, anyone can “break.” Time-limited posttraumatic stress responses that do not persist or disorganize functioning are normal reactions to external threat, much like normal grief reactions, and are often necessary for survival. However, when catastrophic stress overwhelms individuals' adaptive biological and coping responses, posttraumatic psychiatric disorders result. In the acute phase of traumatic reactivity (less than 4 weeks after the event), the symptomatology is referred to as acute stress disorder. When the disturbance lasts more than 4 weeks, it is referred to as PTSD.

Patients with PTSD develop symptoms in three domains: reexperiencing the trauma, avoiding stimuli associated with the trauma, and increased autonomic arousal. Trauma may be re-experienced in flashbacks (in which the person may feel and act as if the trauma were recurring), distressing recollections and dreams, and psychological or physiological stress reactions on exposure to stimuli associated with the trauma. Symptoms of avoidance include efforts to avoid thoughts or activities related to the trauma, anhedonia, reduced capacity to remember events related to the trauma, blunted affect, feelings of detachment or derealization, and a sense of a foreshortened future. Symptoms of increased arousal include insomnia, hypervigilance, exaggerated startle response, and irritability or outbursts of anger. To be diagnosed with PTSD, based on criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision,3 patients must exhibit at least one symptom of reexperiencing, three symptoms of avoidance, and two symptoms of increased arousal, and the symptoms must persist for at least 1 month.

Stressors Faced by Today's War Zone Soldiers

American soldiers face a number of stressors that may contribute to the development of PTSD, many of them unique to modern warfare. The best available data suggest that 10% of combat veterans of the first Gulf War have PTSD,4 as opposed to a lifetime prevalence of the disorder in 5% of men and 7.8% of the general population.5 It is important to appreciate the types of stressors and demands today's soldiers face in order to facilitate communication between clinicians and patients, and enhance empathy and understanding. Described below are a number of stressful war zone experiences reported by veterans of the first Gulf War.6

Lack of preparedness. Some veterans reported anger about feeling they were not sufficiently prepared or trained for what they experienced in the war.

Combat exposure. The recent wars in the Gulf appear to entail stereotypical exposure to warfare experiences, such as firing weapons, being fired on, witnessing injury and death, and going on missions that involve such experiences.

Aftermath of battle. Many veterans may experience the consequences of combat, such as observing the dead bodies of enemy and American soldiers, dealing with prisoners of war, seeing destroyed villages and homeless refugees, and being exposed to the sights, sounds, and smells of dying or dead men and women.

Perceived threat. Veterans may experience fear and sustained anticipatory anxiety about exposure to combat and other perceptions of life-threatening events.

Difficult living and working environment. Soldiers may face personal discomfort and deprivation, including lack of desirable food, lack of privacy, poor living arrangements, uncomfortable climate, cultural differences, boredom, inadequate equipment, and long work hours. These conditions tax individuals' available coping resources.

Concerns about life and family disruptions. Soldiers may worry about how their deployment may negatively affect their careers, families, and other personal concerns. National Guard and Reserve troops may be particularly vulnerable because of the unpredictability of their length of deployment and its possible recurrence.

Sexual and gender harassment. Participation of an increasing number of female soldiers in the war zone may increase the incidence of sexual or gender harassment.

Ethnocultural stressors. Minority soldiers may, in some cases, be subjected to stressors related to their ethnicity. Of particular concern are those who may appear to be of Arabic background, descent, or faith.

Perceived exposure to radiological, biological, and chemical weapons. Modern warfare poses the risk of previously unused weaponry and concomitant concerns about its dangers and long-term effects on individuals' health.

Other stressors. In addition to these factors, soldiers in Iraq face new stressors, including terrorist tactics such as suicide bombings, the potential of severe abuse or execution if captured, and possible mutilation and desecration if killed and their bodies fall into enemy hands. Current warfare involves situations in which one may have difficulty determining whether apparent civilians are actually enemy combatants. Finally, military occupations that were relatively safe in past wars (eg, truck drivers, mechanics, medical personnel) now face serious threats just as frontline soldiers do.

Assessment of Returning Veterans

Screening in Primary Care Settings

Returning veterans often will be seen by primary care providers who are not mental health professionals. Any of these patients may be experiencing symptoms of PTSD, so it is important to be able to detect the disorder in the primary care setting. Although some patients may exhibit obvious symptoms, many symptoms will not be apparent unless specifically looked for. A four-question Primary Care PTSD screening tool has been developed (Sidebar 1, see page 935) to quickly assess for the likelihood of PTSD. Endorsement of any two items of the tool is associated with a diagnostic accuracy of 0.82; sensitivity (the probability that a person having a disease will be identified) of 0.93; specificity (the probability that a person who does not have a disease will be correctly identified) of 0.79; and indicates the need for additional assessment.7

Sidebar 1.

Screening Questions for Posttraumatic Stress Disorder7

Have you had any experiences that were so frightening, horrible, or upsetting that, in the past month, you:

  1. Have had nightmares about it or thought about it when you did not want to?

  2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

  3. Were constantly on guard, watchful, or easily startled?

  4. Felt numb or detached from others, activities, or your surroundings?

Initial Approach to Patients with Possible PTSD

Veteran patients returning from the Gulf may demonstrate symptoms in a variety of ways. While some will be emotional and need to share their stories, most will find it difficult to discuss their thoughts and feelings about their experiences during the war. It is important not to press traumatized patients too soon or too intensely to talk about their experiences, but rather to allow them to do so when they are ready. The assessment process should begin by focusing on patients' current psychosocial functioning and immediate needs, and health care professionals should be ready to explore the traumatic exposure, as necessary, later in the assessment process. Therefore, according to Litz and Orsillo, assessment should occur in stages,6 as does triage, and proceed in the following sequence:

  • Address symptoms that require emergency intervention, such as suicidal or homicidal ideation or acute psychotic symptoms.
  • Address symptoms that are most disruptive to the patient (ie, those that interfere with psychosocial functioning).
  • Develop a case formulation to functionally explain the potential relationship among the symptoms to create a comprehensive treatment plan.

Treatment of PTSD

After emergency and disruptive issues have been addressed, and assessment for other disorders in the differential diagnosis have been performed, treatment of PTSD can be initiated. A variety of psychological and pharmacological options may be considered and are discussed below.

Psychosocial Interventions

General Considerations

As with all mental health counseling, the relationship between the patient and the health care professional is the starting point for care. Health care professionals should work from a patient-centered perspective and determine the patient's current concerns. Practical help with specific issues can then be offered.8

Referral to a Veterans Affairs (VA) Medical Center may be an early consideration for many patients. The Department of Veterans Affairs has many clinicians with treatment expertise in PTSD, and virtually all veterans returning from the current conflict will be eligible for VA treatment. Because PTSD interferes with social functioning, it is important to help patients avoid withdrawal from others and isolation.8 Veterans often report that the opportunity to connect with and be supported by other veterans is a valued experience. This may be difficult to accomplish outside a VA or Veterans Center setting.8

The comorbidity of PTSD with substance abuse is high, so it is important to regularly assess for and prevent drug and alcohol abuse.8 Attention to other issues commonly causing difficulties for patients with PTSD should also be considered, including maintaining stable family relationships and preventing employment problems. A broad range of physical health concerns may be reported by patients with PTSD; these should be appropriately assessed and never assumed to be exclusively psychogenic in origin.8

Education About PTSD

Education is intended to improve patients' understanding and recognition of symptoms, reduce fear and shame about symptoms, and provide patients with knowledge of what will happen in treatment and how recovery is thought to occur. This education should include the concept that many symptoms are the result of reactions to stress; such reactions should be interpreted as responses to overwhelming stress, rather than as a personal weakness.8 This approach lessens patients' fears about long-term treatment and helps them understand the etiology of the symptoms.

Training in Coping Skills

Training in coping skills helps patients learn to cope with the intense problems they may be experiencing. Coping skills that may be effective in combat veterans include anxiety management, anger management, emotional “grounding,” and improved communication.8 Training focuses on helping patients restore a sense of control of emotional feelings and physical symptoms, such as hyperventilation.

Exposure Therapy

Exposure therapy can be used when patients are ready to confront their trauma-related emotions and painful memories. It emphasizes repeated verbalization of traumatic memories; patients are exposed to their own individualized fear stimuli repetitively until the fear responses are consistently diminished.9 Exposure therapy can help correct faulty perceptions, improve perceived self-control of memories and negative emotions, and strengthen adaptive coping responses under conditions of stress. It is important that the health care professionals providing this treatment be properly trained, qualified, and have experience working with combat trauma.

Cognitive Restructuring

Cognitive restructuring is designed to help patients review and challenge distressing trauma-related beliefs. It focuses on providing education about the relationships between thoughts and emotions, exploring common negative thoughts held by traumatized patients, identifying personal negative beliefs, developing alternative interpretations, and practicing new thinking.9 Cognitive restructuring involves individual assessments, self-monitoring of thoughts, homework assignments, and practice of learned techniques in real-life settings. This therapy may help veterans cope with fear, guilt, shame, anger, and other emotions, and recognize changed perceptions of personal identity caused by participation in combat.

Family Counseling

Families are intricately involved in the lives of traumatized patients and are profoundly affected by their loved ones. Both families and patients can benefit from family counseling, workshops, and education, as well as couples counseling, parenting classes, and training in conflict resolution. In addition, families, especially significant others, may provide significant history (eg, sleep habits, emotionality, socialization, drug abuse) that the patients themselves are unable or unwilling to report.

Pharmacologic Interventions

Posttraumatic stress disorder involves not only psychological disruptions but also biological and physiological responses to trauma. Biological alterations found among patients with PTSD include adrenergic hyperresponsiveness, increased thyroid activity, increased levels of corticotrophin-releasing factor, and possibly low cortisol levels.10,11 Therefore, it is logical that pharmacological interventions could be beneficial. It is important to note that pharmacotherapy should not be considered the primary method for treating PTSD but should be considered an option among the other psychological methods discussed above. The most effective interventions for PTSD probably involve a combination of pharmacotherapeutic and psychotherapeutic methods. Several classes of medications have been used to treat PTSD, including antidepressant, antipsychotic, anti-convulsant, and adrenergic-inhibiting agents, and benzodiazepines.12 Their use for PTSD is discussed below.

Antidepressant Agents

Antidepressant agents are the most frequently prescribed and most carefully studied agents used to treat PTSD. Several categories of antidepressant agents have been used with the results described below.

Tricyclic antidepressant agents. Tricyclic antidepressant agents (TCAs) are known to have anti-panic effects, suggesting they may be of value for treating PTSD. In small clinical trials, imipramine showed modest improvement in PTSD symptoms, amitriptyline showed moderate improvement, and desipramine showed no improvement.12 No effect on avoidance or numbing occurred. Tricyclic antidepressant agents are no longer commonly used because of the risk of cardiac conduction disturbances, sedation, and dangers related to overdose.

Monoamine oxidase inhibitors. Monoamine oxidase inhibitors (MAOIs) have antipanic effects and have been used to treat mixed states of anxiety and depression. Overall, MAOIs have been found to be more effective than TCAs for the treatment of PTSD, particularly for intrusive/reexperiencing symptoms.13 However, MAOIs can only be used with caution because of the risk of hypertensive crisis, and currently are rarely prescribed.

Selective serotonin reuptake inhibitors. Selective serotonin reuptake inhibitors (SSRIs) inhibit serotonin reuptake, resulting in the presence of increased serotonin in synapses and increased serotonin functioning in the central nervous system. Serotonin helps modulate excessive external stimuli and can thereby reduce feelings of fear. These agents have been shown to be effective for treating panic attacks, anxiety, and depression. Trials have shown sertraline, paroxetine, fluoxetine, fluvoxamine, and citalopram all to be effective in the treatment of PTSD.12 In addition, sertraline and paroxetine have completed the rigorous process of obtaining approval through the US Food and Drug Administration (FDA) for the treatment of PTSD. Both drugs are effective in treating each of the major symptom clusters of PTSD. The side effects of SSRIs are generally more tolerable than those of other categories of antidepressant agents.12

Novel antidepressant agents. This group contains antidepressant medication that work by mechanisms other than those described above. Nefazodone and trazodone increase serotonin activity, but not selectively. Nefazodone has been found to reduce nightmares, anxiety, and global ratings of PTSD, and may be helpful for PTSD-related sleep disturbance. However, some clinicians have recently become concerned about prescribing nefazodone because it has received a black-box warning by the United States Food and Drug Administration because of the risk of hepatotoxicity and even liver failure. Trazodone has not proven significantly effective in the treatment of the core symptoms of PTSD and causes some sedation.

Other available antidepressant agents include mirtazapine, venlafaxine, and bupropion. Although effective for treatment of depression, these drugs have not yet been tested in clinical trials for PTSD.

Adrenergic-Inhibiting Agents

Autonomic dysregulation is common in patients with PTSD who have elevated levels of plasma norepinephrine at rest and experience significant increases when exposed to trauma-related stimuli.14 Sustained periods of increased norepinephrine levels are thought to increase the risk of PTSD by a process in which overconsolidation of memories of the traumatic event occurs.15 Therefore, drugs that decrease the effect of norepinephrine can decrease PTSD symptoms. By modulating central and peripheral adrenergic (a term for the part of the nervous system mediating the action of norepinephrine) activity, adrenergic blockers (eg, propranolol) may reduce anxious arousal in patients with PTSD. The same is true for drugs that effectively reduce the release of brain norepinephrine, such as clonidine and guanfacine. Prazosin, another medication that blocks the effect of norepinephrine, appears to have promise as a treatment for PTSD-related sleep disturbance and nightmares, as well as overall PTSD symptoms.

Benzodiazepines

Although benzodiazepines are frequently used, they cannot be recommended for patients with PTSD. In addition to the potential for addiction, benzodiazepines do not appear to be effective against core PTSD symptoms. No studies have demonstrated their efficacy for PTSD-specific symptoms.

Buspirone

Buspirone is used widely to treat anxiety and does not have the addiction risk of benzodiazepines. However, its effectiveness for treating PTSD has not yet been established.

Anticonvulsant Agents

It has been postulated that PTSD may develop as a result of sensitization and kindling of the limbic system by traumatic stimuli, and that anticonvulsant medications, which stabilize mood, could help alleviate this. Despite these suggestive theoretical considerations and clinical findings, only a small amount of evidence exists to support the use of carbamazepine or valproate for patients with PTSD. In addition, because of the side effect profiles and potential interactions with other drugs of these medications, attention has shifted to new agents (eg, gabapentin, lamotrigine, topiramate); however, these have not yet been systematically tested with PTSD patients.

Antipsychotic Agents

Antipsychotic agents are not routinely used to treat patients with PTSD, but are useful in the treatment of PTSD with co-occurring psychosis. Conventional anti-psychotic agents (eg, haloperidol, chlorpromazine) cannot be recommended for patients with PTSD because of the risk of side effects. However, preliminary results suggest that atypical antipsychotic agents (eg, risperidone, olanzapine, quetiapine) may be useful to augment treatment with first-line or second-line medications, especially for patients with intense paranoia or hypervigilance, agitation, dissociation, or brief psychotic reactions associated with their PTSD. All atypical antipsychotic agents may produce weight gain.

General Guidelines for Use of Medications in PTSD

Table 2 (see page 936) summarizes some of the medications used for the treatment of PTSD. Pharmacotherapy should be initially begun with SSRIs, given the extensive data available to document their effectiveness for PTSD. If patients cannot tolerate SSRIs or experience no improvement, second-line medications such as TCAs, nefazodone, or MAOIs could be considered.8

Some Medications Used to Treat Posttraumatic Stress Disorder12

Table 2:

Some Medications Used to Treat Posttraumatic Stress Disorder12

Augmentation should be considered for patients who exhibit a partial response to SSRIs.8 Patients experiencing excessive arousal, hyperactivity, or dissociation may be helped by augmentation with an adrenergic-inhibiting agent. Patients exhibiting lability, impulsivity, or aggressiveness may benefit from augmentation with an anticonvulsant agent. Patients who are paranoid, hypervigilant, and psychotic could benefit from an augmentation with an atypical antipsychotic drug.

In all cases, health care professionals should be aware of potential side effects of the medications used and monitor patients appropriately.8 Pharmacotherapy should be used in combination with other methods to provide a comprehensive approach to patient care.

Other War-Related Mental Disorders

Posttraumatic stress disorder is the primary war-related mental disorder seen in veterans returning from the Gulf. However, other mental disorders may also occur and should be given appropriate consideration. Prior to receiving a conclusive diagnosis of PTSD, patients should receive a thorough psychiatric and medical examination to rule out other possible causes of the reported symptoms. Evaluation should include assessment for medical problems that can manifest with psychiatric symptoms (eg, hyperthyroidism) and other potential psychiatric disorders.

Many soldiers reporting psychological symptoms will be at an age when first episodes of depression, mania, panic disorder, and schizophrenia also occur. It is easily conceivable that, in a person susceptible to a certain disorder, that disorder could be precipitated or exacerbated by the stresses of war. In addition, mental disorders such as depression may occur or worsen as a result of the effects of PTSD. Therefore, it is important to consider the full range of psychiatric disorders, not just PTSD.

Evaluation should also include assessment for substance abuse. Clinicians in Iraq report that alcohol is easily accessible and black-market diazepam is cheap and readily available.16 In addition, opium poppies and marijuana remain the two largest cash crops in Afghanistan.17

Summary

When treating veterans returning from the current military conflicts in Iraq and Afghanistan, health care professionals should keep in mind the effects of the war on patients and the possible contributions of wartime events to patients' symptoms. It is essential to listen to the patients for signs of problems developing as a result of exposure to war and to initiate necessary treatment. For health care professionals treating these patients, several excellent sources of additional information on a variety of topics pertinent to PTSD are available on the Internet (Sidebar 2, see page 940). In addition, the Department of Veterans Affairs remains an important resource for treatment of postcombat problems and is readily available for consultation and treatment of eligible veterans.

Sidebar 2.

Selected Internet Sources from the Department of Veterans Affairs for Information on Posttraumatic Stress Disorder and Other War-related Topics

Selected Internet Sources from the Department of Veterans Affairs for Information on Posttraumatic Stress Disorder and Other War-related Topics

Editor's note: This is a reprint of the Article of the Year from the Journal of Psychosocial Nursing and Mental Health Services, a sister SLACK Incorporated publication. The award was instituted this year to recognize and mentor new authors in the field. Articles published in the Journal of Psychosocial Nursing and Mental Health Services between October 2004 and September 2005 were eligible. This article was originally published in July 2005.

References

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  2. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22. doi:10.1056/NEJMoa040603 [CrossRef]15229303
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publisihing; 2000.
  4. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141–148. doi:10.1093/aje/kwf187 [CrossRef]12522021
  5. Kessler RC, McGonagle KA, Zhao S, et al. Posttraumatic stress disorder in the National Comorbidity Study. Arch Gen Psychiatry. 1995;52(12):1048–1059. doi:10.1001/archpsyc.1995.03950240066012 [CrossRef]7492257
  6. Litz B, Orsillo S. The returning veteran of the Iraq War: background issues and assessment guidelines. In: Schnurr PP, Cozza SJ, eds. Iraq War Clinician Guide. 2nd ed. White River Junction, VT: National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs; 2004:21–32.
  7. Prins A, Kimerling R, Leskin G. PTSD in Iraq War veterans: implications for primary care. In: Schnurr PP, Cozza SJ, eds. Iraq War Clinician Guide. 2nd ed. White River Junction, VT: National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs; 2004:58–61.
  8. Ruzek JI, Curran E, Friedman MJ, et al. Treatment of the returning Iraq War veteran. In: Schnurr PP, Cozza SJ, eds. Iraq War Clinician Guide. 2nd ed. White River Junction, VT: National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs; 2004:33–45.
  9. Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: The Guilford Press; 2000.
  10. Southwick SM, Paige S, Morgan CA 3rd, et al. Neurotransmitter alterations in PTSD: catecholamines and serotonin. Semin Clin Neuropsychiatry. 1999;4(4):242–248.10553029
  11. Wang S, Mason J, Southwick S, et al. Relationships between thyroid hormones and symptoms in combat-related post-traumatic stress disorder. Psychosom Med. 1995;57(4):398–402. doi:10.1097/00006842-199507000-00012 [CrossRef]7480570
  12. Schoenfeld FB, Marmar CR, Neylan TC. Current concepts on pharmacology for posttraumatic stress disorder. Psychiatr Serv. 2004;55(5):519–531. doi:10.1176/appi.ps.55.5.519 [CrossRef]15128960
  13. Pearlstein T. Antidepressant treatment of posttraumatic stress disorder. J Clin Psychiatry. 2000;61(Suppl 7):40–43.10795608
  14. Yehuda R, Siever LJ, Teicher MH, et al. Plasma norepinephrine and 3-methoxy-4-hydroxyphenylglycol concentrations and severity of depression in posttraumatic stress disorder and major depressive disorder. Biol Psychiatry. 1998;44(1):56–63. doi:10.1016/S0006-3223(98)80007-3 [CrossRef]9646884
  15. Pitman RK. Post-traumatic stress disorder, hormones, and memory. Biol Psychiatry. 1989;26(3):221–223. doi:10.1016/0006-3223(89)90033-4 [CrossRef]2545287
  16. Lande RG, Marin BA, Ruzek JI. Substance abuse in the deployment environment. In: Schnurr PP, Cozza SJ, eds. Iraq War Clinician Guide. 2nd ed. White River Junction, VT: National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs; 2004:79–82.
  17. Sorenson G. Afghanistan veteran returns. Vet Center Voice. 2004;25(2):6–15.

War-related Emotional Responses and Diagnostic Considerations in the Context of Multiphasic Traumatic Stress Response1

PhaseEmotional ResponsesDiagnostic Considerations
Immediate (during or immediately after the traumatic event)Strong emotions, disbelief, numbness, fear, confusion, anxiety, autonomic arousalAcute stress disorder; adjustment disorders; brief psychotic disorder; delirium from toxic exposures; exacerbation of substance abuse, personality disorders, or premorbid mood; anxiety or thought disorders
Delayed (approximately 1 week after the traumatic event or in the aftermath of battle)Intrusive thoughts, autonomic arousal (eg, insomnia, nightmares, startle response, irritability), somatic symptoms, grief and mourning, apathy, social withdrawalPosttraumatic stress disorder (PTSD), substance abuse, depression, other mood and anxiety disorders, bereavement, somatoform disorders
Chronic (months to years after the traumatic event)Disappointment or resentment, sadness, persistent intrusive symptoms, refocusing on the rebuilding of lifePTSD, substance abuse, dysthymic disorder, other mood disorders, chronic effects of toxic exposure

Some Medications Used to Treat Posttraumatic Stress Disorder12

Class/DrugAdult Dosage (mg per day)Common Side Effects and Risks
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Citalopram20 to 60Nausea, drowsiness, dry mouth, sexual dysfunction
Fluoxetine20 to 80Nausea, insomnia, tremor, sexual dysfunction
Fluvoxamine50 to 250Nausea, drowsiness, insomnia, sexual dysfunction
Paroxetine20 to 60Nausea, drowsiness, dry mouth, sexual dysfunction
Sertraline50 to 200Nausea, insomnia, loose stools, sexual dysfunction
TRICYCLIC ANTIDEPRESSANT AGENTS
Amitriptyline50 to 300Drowsiness, weakness, cardiac conduction disturbances
NOVEL ANTIDEPRESSANT AGENTS
Bupropion200 to 450Agitation, tremor, dizziness, insomnia, risk of seizures and hypertension
Mirtazapine15 to 45Somnolence, weight gain, dry mouth, agranulocytosis
Nefazodone200 to 600Nausea, weakness, risk of hepatotoxicity and liver failure
Trazodone50 to 400Drowsiness, postural hypotension, risk of priapism
Venlafaxine75 to 225Insomnia, sedation, sexual dysfunction, hypertension
ADRENERGIC-INHIBITING AGENTS
Clonidine0.2 to 0.6Dry mouth, sedation, dizziness, weakness
Guanfacine0.5 to 3Dry mouth, drowsiness, dizziness, fatigue
Prazosin2 to 10Dizziness, headache, sedation, risk of syncope
Propranolol40 to 160Bradycardia, hypotension, fatigue, insomnia
ANTICONVULSANT AGENTS
Carbamazepine400 to 1,000Nausea, sedation, risk of anemia and agranulocytosis
Gabapentin300 to 2,400Drowsiness, dizziness, ataxia, fatigue
Lamotrigine25 to 400Sedation, ataxia, headache, risk of skin rash (may be serious)
Topiramate50 to 400Drowsiness, dizziness, ataxia, confusion
Valproate250 to 2,000Nausea, weight gain, risk of hepatic failure and pancreatitis
ATYPICAL ANTIPSYCHOTIC AGENTS
Olanzapine5 to 20Sedation, weight gain, extrapyramidal symptoms, risk of diabetes
Quetiapine25 to 300Sedation, weight gain, dizziness, postural hypotension, risk of cataracts
Risperidone0.5 to 0.8Extrapyramidal symptoms, weight gain, agitation, anxiety, insomnia, rhinitis

Sidebar 1.

Screening Questions for Posttraumatic Stress Disorder7

Have you had any experiences that were so frightening, horrible, or upsetting that, in the past month, you:

  1. Have had nightmares about it or thought about it when you did not want to?

  2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

  3. Were constantly on guard, watchful, or easily startled?

  4. Felt numb or detached from others, activities, or your surroundings?

Sidebar 2.

Selected Internet Sources from the Department of Veterans Affairs for Information on Posttraumatic Stress Disorder and Other War-related Topics

Selected Internet Sources from the Department of Veterans Affairs for Information on Posttraumatic Stress Disorder and Other War-related Topics

Authors

Dr. Reeves is chief of mental health, G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS, and professor of psychiatry and neurology, University of Mississippi School of Medicine, Jackson, MS. Dr. Parker is director, Chemical Dependency Program, G.V. (Sonny) Montgomery VA Medical Center, and assistant professor of psychiatry, University of Mississippi School of Medicine. Dr. Konkle-Parker is assistant professor of medicine, University of Mississippi School of Medicine.

Address reprint requests to: Roy R. Reeves, DO, PhD, G.V. (Sonny) Montgomery VA Medical Center, (11M), 1500 E. Woodrow Wilson Dr., Jackson, MS 39216; or e-mail roy.reeves@med.va.gov.

10.3928/00485713-20051101-08

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