**2. Psychiatric management**

### **2.1 Assessment**

52 Post Traumatic Stress Disorders in a Global Context

Kaloupek, 1997, Keane and Wolfe, 1990, Forbes et al., 2003, Kulka et al., 1990, Gradus et al., 2010, Nepon et al., 2010, Sareen et al., 2005) and chronic disability contributing to impaired

Military personnel are more likely to be exposed to trauma than the general public (Breslau et al., 1991). Potentially traumatic events can include combat, imprisonment, torture, witnessing atrocities, comrades being wounded or killed, or rescue missions following natural disasters. Peacekeeping missions to Bosnia, Somalia and Rwanda have also involved complex rules of engagement that prevented immediate and active intervention, with a resultant sense of intense vulnerability to attack (Litz et al., 1997b, Litz et al., 1997a, American Psychiatric Association, 2004, Litz, 1996). However military members can also be exposed to non-military specific trauma including rape, motor vehicle accidents, assault and

Risk factors for the development of PTSD have been extensively studied in the military and veteran population. Pre-trauma risk factors for PTSD include a family and/or personal history of psychiatric illness, past trauma including history of childhood abuse (Brewin et al., 2000, Ozer et al., 2003a, Sandweiss et al., 2011). Women are twice as likely to develop PTSD, although men are more likely to be exposed to a traumatic events (Kessler et al., 1995, Breslau et al., 1998). In the military, men still vastly outnumber women, especially in trades that involved combat. Other proposed pre-trauma risk factors from community studies include: younger age, single marital status and lower socioeconomic status (Breslau et al.,

Suggested peri-traumatic risk factors include: trauma severity and life threat, (Brewin et al., 2000, Hoge et al., 2004a, Richardson et al., 2007) bodily injury (Koren et al., 2005) and the number of operational deployments (Richardson et al., 2007, Statistics Canada, 2002). The dose-response effect between number of operational deployments was confirmed in a recent re-analysis of PTSD's prevalence among U.S. male Vietnam veterans (Dohrenwend et al., 2006)and in American soldiers deployed in Afghanistan (Hoge et al., 2004b). The emotional response at the time of the trauma, such as feeling unable to control a situation and peritraumatic dissociation, (Brewin et al., 2000, Yehuda, 1999, Ozer et al., 2003a) has also been identified as significant peri-traumatic risk factors. Although more recent studies have cast some doubt on the vailidity of the importance of peri-traumatic dissociation (Candel et al., 2003). More recent studies have demonstrated that pain control in trauma care was significantly associated with a lower risk of PTSD after injury (Holbrook et al., 2010), and both increase heart rate at the time of the trauma (Bryant et al., 2011) and intensive care admission following traumatic injury (O'Donnell et al., 2010) were associated with increased

Post-traumatic risk factors may include: lack of access to treatment, stigmatization, ongoing life stressors and lack of social support (Brewin et al., 2000, Ozer et al., 2003b, Yehuda et al., 1998). Access to treatment is important, as there is a significant association between soldiers diagnosed with a psychiatric conditions and high attrition rates from the military (Hoge et al., 2002). Deployed members are frequently exposed to long separations from their families and friends and ongoing financial strain might add to the distress a deployed member might face after they return home. Shame and guilt are also posttraumatic risk factors

Formal psychometric instruments have been developed to assess deployment risk and resiliency factors in relation to mental health outcomes, such as the Deployment Risk and

(Yehuda et al., 1998) that military members frequently often face.

quality of life (Mills et al., 2006, Richardson et al., 2008 , Richardson et al., 2010).

natural disasters.

2006, Richardson et al., 2007).

risk of developing PTSD.

Resilience Inventory (King et al., 2006).

The presentations of military-related PTSD is often complex. Military members and veterans may initially present indirectly with an emotional, behavioural or addiction concern or an unrelated, less stigmatizing somatic problem such as a physical complaint (Australian Centre for Post Traumatic Mental Health and National Health and Medical Research

Psychiatric Management of Military-Related PTSD: Focus on Psychopharmacology 55

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, *in the past month*, you...

1. Have had nightmares about it or thought about it when you

2. Tried hard not to think about it or went out of your way to

3. Were constantly on guard, watchful, or easily startled? *Yes/No* 4. Felt numb or detached from others, activities, or your

*Screen is positive if patient answers "yes" to any three items.*

avoid situations that reminded you of it? *Yes/No*

Enquiry should also be made into family functioning, the health of spouse and children, social functioning and vocational issues (American Psychiatric Association, 2004). Family, friends and peers can also provide valuable collateral information as to the current and past functioning of the military member or veteran and eliciting their support at the initial

Once a firm diagnosis has been established, psychoeducation in group format or individually regarding diagnosis and treatment is critical for both patient and family (American Psychiatric Association, 2004, Turnbull and McFarland, 1996, Van Der Kolk et al., 1996a, Foa et al., 2000). Patient education is a fundamental component of the treatment of as PTSD. Providing psychoeducation can enhance patient satisfaction and improve treatment compliance (Gray et al., 2004). Effective treatment requires that patients understand the treatment plans and return for follow-up assessment and treatment (American Psychiatric Association, 2004). Veterans need information soon after the initial assessment of the different stages of treatment for PTSD (Herman, 1992). The initial phase of treatment focuses on symptom stabilization and the treatment of co-morbid conditions such as depression, addictions and anxiety disorders. Educating patients regarding the phases of treatment reassures those frightened by the notion of psychiatric medication and psychotherapy as well as to set appropriate expectations for treatment. Some patients expect they will be forced to talk about feared traumatic events from the outset and are relieved to know that trauma work comes after their anxiety and distress are more manageable. While symptoms might initially be overwhelming and require pharmacological intervention, early work on mastering anxiety and anger using psychological tools, provides a sense of self- control. Safety in therapy is paramount and only after acute symptoms, particularly suicidality and homicidality, are addressed should the exploration of traumatic events be approached. Once symptoms stabilize, patients are more able to engage in psychotherapy (Van Der Kolk et al.,

Fig. 1. Primary Care PTSD Screen

**2.2 Treatment** 

1996b).

assessment can assist with the treatment process.

did not want to? *Yes/No*

surroundings? *Yes/No*

Council, 2007). The psychiatric assessment should detail the presenting symptoms and elicit a trauma history, including childhood and adolescent trauma, and exposure to military trauma (combat or peacekeeping operations) (Friedman, 2006). The details of the traumatic event should be limited to information that clarifies the diagnosis as the recounting of an extremely traumatic event is often highly triggering and can lead to significant symptom exacerbation.

Clinically, PTSD presents as four symptom clusters: reexperiencing the traumatic events, avoidance of reminders and emotional numbing (which are grouped together as one symptoms cluster in DSM-IV but are seen as distinct and will likely be denoted as such in DSM-5), and hyperarousal symptoms (American Psychiatric Association, 2004, American Psychiatric Association, 2001). Military members with PTSD relive their trauma in intrusive recollections during the day, including flashbacks, or at night as bad dreams or nightmares. Many complain of both physical and emotional symptoms of anxiety when exposed to reminders of their traumatic event. They may avoid reminders of the trauma and describe emotional numbness or an inability to experience a normal range of emotions with family or friends. They may complain of hyperarousal symptoms such as insomnia, irritability, frequent anger outburst, poor concentration and hypervigilance. According to DSM-IV-TR, acute PTSD has a duration of between 1 and 3 months, whilst chronic PTSD has a duration of more than three months (American Psychiatric Association, 2001).

The clinician can screen for PTSD using available short screening instruments such as the four-item yes/no screening instrument—the Primary Care PTSD Screen—designed for use by primary care practitioners. It has a sensitivity of 78% and specificity of 87% for PTSD in patients who endorse three or more items, (Friedman, 2006) figure 1. Patients who screen positive should be assessed for PTSD using the DSM IV diagnostic criteria, figure 2, or using more elaborative screening instruments such as the Clinician Administered PTSD Scale (CAPS)(Blake et al., 1995) or a self-rating scale such as the PTSD Checklist (Military Version) (Weathers et al., 1993). Veterans may also present with some symptoms of PTSD without meeting the full diagnostic criteria (Zlotnick et al., 2002, Schützwohl and Maercker, 1999, Stein et al., 1997, Charney et al., 1986, Weiss et al., 1992). Even if the full criteria are not met, studies indicate that these individuals may experience significant functional impairment (Olfson et al., 2001). In a study of Canadian veterans, Asmundson and colleagues (Asmundson et al., 2002) demonstrated increased psychopathology in veterans with subthreshold PTSD when compared to the non-deployed, non-traumatized veterans.

Assessing suicide risk is also critical. The presence of PTSD symptoms increases the possibility of suicidal ideation (Marshall et al., 2001). PTSD often presents with comorbidities such as depression and addictions (Kessler et al., 1995, Forbes et al., 2003). Studies have estimated that more than 50% of PTSD patients have symptoms of a major depressive disorder (Kessler et al., 1995), but in the veteran population, possibly due to delayed treatment, the percentage may be much higher (Keane and Wolfe, 1990, Southwick et al., 1991, Forbes et al., 2003). Co-morbid depression also significantly increases suicide risk (Kaufman and Charney, 2000). Issues of aggression and anger are also well documented in war veterans, (Lewis, 1990, Forbes et al., 2003, Forbes et al., 2004, Biddle et al., 2002) and during the initial PTSD assessment, male military members may report violent thoughts and aggressive behavior, including homicidal thoughts. Assessing comorbidity, suicidal or homicidal ideations and social support is important in order to determine the need for inpatient treatment or referral for specialist care (American Psychiatric Association, 2004).

In your life, have you ever had any experience that was 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? *Yes/No* 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? *Yes/No* 3. Were constantly on guard, watchful, or easily startled? *Yes/No* 4. Felt numb or detached from others, activities, or your surroundings? *Yes/No Screen is positive if patient answers "yes" to any three items.*

Fig. 1. Primary Care PTSD Screen

Enquiry should also be made into family functioning, the health of spouse and children, social functioning and vocational issues (American Psychiatric Association, 2004). Family, friends and peers can also provide valuable collateral information as to the current and past functioning of the military member or veteran and eliciting their support at the initial assessment can assist with the treatment process.
