Post-Traumatic Stress Disorder in Demobilized Army Reserve and National Guard Soldiers

By Ronald A. Maul, DO
Colonel, Medical Corps, U.S. Army

ABSTRACT: With the protracted Global War on Terrorism, and combat operations in Iraq and Afghanistan in support of Operation Iraqi Freedom and Operation Enduring Freedom, there has been an increase in the number of returning soldiers showing signs and symptoms of Post-Traumatic Stress Disorder. Included in this population are demobilized Army Reserve and National Guard members who are returning to their communities and former civilian lives. This paper serves to increase the awareness of family physicians, and other primary care providers who may come in contact with PTSD patients, to enhance diagnostic and treatment skills. Review of pertinent literature provides a clear description of historical perspectives, review of typical presenting symptoms, and discussion of the importance of timely diagnosis and treatment in the primary care setting.

PTSD is well-known and prevalent in the American society with several million citizens affected. About 30 percent of Vietnam War veterans are included in that number but 31 percent of Iraqi Freedom veterans have already sough mental health care (some cases involving PTSD) within the first year after returning from combat. Family physicians often play an important role in properly identifying, diagnosing and treating this disorder.

In the years to come, more Americans will fall victim to Post-Traumatic Stress Disorder, many of whom will be returning combat veterans from Iraq and Afghanistan. Since a primary care provider will very likely be consulted initially for evaluation of these issues, the development of increased awareness, keen diagnostic techniques and knowledgeable therapeutics will rightfully keep family physicians as important members of the care and management team.

Post-Traumatic Stress Disorder has been well-described by many. It affects hundreds of thousands of people who have survived terrorist bombings, war and other disasters, both natural and man-made. Previously called shell shock or battle fatigue syndrome when associated with combat operations, it has often been misunderstood or misdiagnosed, even though the disorder has very specific symptons.1

An estimated 5.2 million American adults (ages 18 to 54) currently have PTSD, and among those who may experience PTSD are military troops who previously served in the Vietnam and Persian Gulf Wars. About 30 percent of Vietnam veterans developed PTSD while estimates approach eight percent in the Gulf.2 However, it has become more evident in U.S. military service members in recent years from participation in combat operations in Afghanistan and Iraq, in response to the Global War on Terrorism(GWOT).

The U.S. Department of Veterans Affairs reports that about 63,767 GWOT veterans have gone to Veterans Affairs facilities with possible behavioral health problems and 29,041 have been preliminarily diagnosed as having PTSD.3 To date, tens of thousands of Army Reserve and National Guard forces have been mobilized to active duty and have served extensively in these two conflicts producing a significant incremental rise in the presence of PTSD. Following their respective deployments, release from active duty and re-integration into their civilian lives, many of these citizen soldiers once again rely on the civilian health care system.

A review of the literature and multiple case studies shows that primary care providers may play a key role in early diagnosis and appropriate management of PTSD and that they must remain alert for the presentation of this malady, maintaining maximum awareness of the diagnostic and various treatment modalities available. This paper presents a review of the signs, symptoms, diagnosis, treatment and disposition necessary for the primary care management of this increasingly prevalent condition.

Background
Stress is a normal response of the body and mind, and traumatic stress reactions are normal responses to abnormal events. Many possible reactions to a traumatic situation can be described as emotional, cognitive, physical and/or interpersonal effects.4

The most recent revision of PTSD diagnostic criteria is found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders – Trauma (2000).5 The Manual identifies six distinct criteria:

1. “The person has been exposed to a traumatic or catastrophic event in which both of the following have been present: the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others; and, the person’s response involved intense fear, helplessness, or horror.” [Exposure to a traumatic event]
2. “The traumatic event is persistently re-experienced in at least one of the following ways: recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated); intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The intrusive recollection criterion describes symptoms that are arguably the most distinctive and readily identifiable indications of PTSD.” [Persistent re-experience]
3. “Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect; and, sense of foreshortened future.” [Persistent avoidance of stimuli associated with the trauma]
4. “Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hyper-vigilance; or, exaggerated startle response (which may be the most pathognomonic PTSD symptom).” [Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep or hyper vigilance]
5. “Duration of the disturbance is more than one month. Acute is defined as duration of symptoms of more than one month but less than three months, chronic as duration of symptoms of three months or more, and delayed as onset of symptoms at least six months after the traumatic event.” [Duration of symptoms more than 1 month]
6. “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” [Significant impairment in social, occupational, or other important areas of functioning]

Multiple therapeutic approaches are available to PTSD patients. The most successful interventions are cognitive-behavioral therapy and medication. Selective serotonin reuptake inhibitors such as sertraline and paroxetine, among the first to have gained approval as indicated treatments for PTSD, are particularly useful. However, in more extreme cases, PTSD may be a chronic and severely debilitating psychiatric disorder that is refractory to available treatments.6

Results
Several governmental agencies, among them the U.S. Department of Defense, the U.S. Department of Veterans Affairs and the National Institute of Mental Health, have conducted considerable research on PTSD, in part based on previous experiences in past armed conflicts in which the United States has been involved. However, more recent comprehensive studies have examined the mental health impact of the wars in Afghanistan and Iraq.

In members of the Army and Marine Corps participating in combat operations in Iraq and Afghanistan, there has been a considerable risk of mental health problems. Further, rates of PTSD have been significantly higher after than before deployment to these war areas. There has not only been a strong reported relation between combat experiences and the frequency of PTSD, but also the prevalence has increased linearly with the number of enemy engagements.7 It also has been associated with high utilization of mental health services after deployment. Among Operation Iraqi Freedom veterans, 31 percent have had at least one outpatient mental health care visit within the first year after deployment. Clearly, this rate of mental health outcomes and, equally important, high mental health care utilization raises concern for estimating the magnitude of the services that might be needed, not only in military and Veterans Affairs facilities, but in civilian practice settings as well.8

Discussion
Primary health care providers should be knowledgeable about traumatic stress, as many victims present with physical rather than mental or emotional symptoms. Further and most importantly, in the private sector, nearly half of all visits involving mentally-related health disorders are to a medical clinic, of which 80 – 90 percent are to primary care providers.9 PTSD can have a direct biological effect on health. Physical disorders may include vulnerability to hypertension and atherosclerotic heart disease, abnormalities in thyroid and hormone functions, increased susceptibility to infections and immunologic disorders, and problems with pain perception, pain tolerance and chronic pain. PTSD is also associated with significant behavioral risks such as smoking, poor nutrition, and misuse/abuse of alcohol and drugs. These physical symptoms and other psychosocial problems may cause difficulty in provider-patient communication, reduce patients’ active collaboration in evaluation and treatment, increase the likelihood of somatization, and reduce patient adherence to medical treatment programs.10 People with PTSD often seek medical care for a range of physical problems for which past trauma may be the underlying cause. As such, primary care providers should have a raised index of suspicion and learn to incorporate simple screening techniques for past trauma into their routine history-taking.11

The Primary Care PTSD (PC-PTSD) screen can be used to detect PTSD. Endorsement of any three items is diagnostically accurate and indicates the need for additional assessment.

“In your life, 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?”12

Other tools have been developed for the diagnosis and management of behavioral health disorders in the primary care setting, such as depression, and may be adapted to specific cases of PTSD.13

Successful management of the PTSD patient by family medicine physicians include: 1) index of suspicion, 2) familiarity with the signs, symptoms and diagnostic criteria, 3) use of the PC-PTSD screen, 4) early intervention, and 5) in extreme or refractory cases, appropriate behavioral health referral.

Conclusion
The wars in Afghanistan and Iraq have produced a new generation of veterans at risk for the behavioral health disorders (particularly PTSD) that may result, in part, from exposure to the stress, adversity, and trauma of combat experiences.14 As a result, civilian sector primary care providers may notice changes in their patient population with an increased number of demobilized Army Reserve or National Guard veterans who have returned seeking care for a multitude of symptoms. These patients may be experiencing some form of PTSD. These types of stress reactions often lead to increased medical utilization and, because far fewer people experiencing traumatic stress reactions seek mental health services, primary care providers are the health professionals with whom individuals with PTSD are most likely to come into contact. PTSD can be detected and effectively managed in primary care settings.12 Interestingly, most patients with behavioral health disorders (including PTSD) receive treatment for their disorders exclusively or predominantly in the primary care setting. Therefore, efficient methods of detecting PTSD as well as newer treatment modalities may effectively facilitate the evaluation and management of this malady in the primary care setting.15 

COL (Dr.) Maul is a 1976 graduate of the University of Medicine and Biosciences, College of Osteopathic Medicine in Kansas City, Missouri. He first received his certification in family medicine in 1988, and is currently the Commanding Officer of the 44th Medical Command at Fort Bragg, North Carolina.

Acknowledgements:
The author wishes to acknowledge the assistance of the following individuals in the preparation of this paper.
Edward O. Crandall, PhD, Colonel, Medical Service Corps, U.S. Army Chief, Department of Behavior Health, Womack Army Medical Center, Fort Bragg, North Carolina and former psychology consultant to the Army Surgeon General.

Dean A. Inouye, MD, Colonel, Medical Corps, U.S. Army Chief, Psychiatry Service, Womack Army Medical Center, Fort Bragg, North Carolina

References:

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