Challenges in the treatment of PTSD
> 4/22/2006 9:17:06 PM

A recent article in the American Journal of Psychiatry highlights the issues that need addressing in the treatment of PTSD with Vets returning home from Afghanistan and Iraq. The article by Matthew Friedman M.D. thoroughly highlights the complex factors that clinician and veterans face when it comes to unraveling the trauma of modern combat. The article presents a compelling composite case history which I present here in its entirety:

Mr. K, a 38-year-old National Guard soldier, was assessed in an outpatient psychiatric clinic several months after he returned home from a 12-month deployment to the Sunni Triangle in Iraq, where he had his first exposure to combat in his 10 years of National Guard duty. Before deployment, he worked successfully as an automobile salesman, was a happily married father with children ages 10 and 12 years, and was socially outgoing with a large circle of friends and active in civic and church activities. While in Iraq, he had extensive combat exposure. His platoon was heavily shelled and was ambushed on many occasions, often resulting in death or injury to his buddies. He was a passenger on patrols and convoys in which roadside bombs destroyed vehicles and wounded or killed people with whom he had become close. He was aware that he had killed a number of enemy combatants, and he feared that he may also have been responsible for the deaths of civilian bystanders. He blamed himself for being unable to prevent the death of his best friend, who was shot by a sniper. When asked about the worst moment during his deployment, he readily stated that it occurred when he was unable to intercede, but only to watch helplessly, while a small group of Iraqi women and children were killed in the crossfire during a particularly bloody assault. Since returning home, he has been anxious, irritable, and on edge most of the time. He has become preoccupied with concerns about the personal safety of his family, keeping a loaded 9-mm pistol with him at all times and under his pillow at night. Sleep has been difficult, and when sleep occurs, it has often been interrupted by vivid nightmares during which he thrashes about, kicks his wife, or jumps out of bed to turn on the lights. His children complained that he has become so overprotective that he will not let them out of his sight. His wife reported that he has been emotionally distant since his return. She also believed that driving the car had become dangerous when he is a passenger because he has sometimes reached over suddenly to grab the steering wheel because he thinks he has seen a roadside bomb. His friends have wearied of inviting him to social gatherings because he has consistently turned down all invitations to get together. His employer, who has patiently supported him, has reported that his work has suffered dramatically, that he seems preoccupied with his own thoughts and irritable with customers, that he often makes mistakes, and that he has not functioned effectively at the automobile dealership where he was previously a top salesman. Mr. K acknowledged that he has changed since his deployment. He reported that he sometimes experiences strong surges of fear, panic, guilt, and despair and that at other times he has felt emotionally dead, unable to return the love and warmth of family and friends. Life has become a terrible burden. Although he has not been actively suicidal, he reported that he sometimes thinks everyone would be better off if he had not survived his tour in Iraq.

 The author goes on to further review the Behavioral models involved in the development of PTSD as well as highlighting the Neurobiological models that mediate hypervigilence in the PTSD patient.

A common denominator for many returnees is the experience of having sustained anticipatory anxiety about potential threats to life and limb at any hour of the day and at any place within the theater of operations. For many, such a sustained combat-ready orientation to the environment results in a pervasive and uncontrollable sense of danger. In Mr. K’s case, this has resulted in a preoccupation with concerns about the personal safety of his family, manifested by being hypervigilant, overprotective parenting, grabbing the steering wheel from his wife because of a perceived threat, and keeping a loaded firearm within reach at all times.

Such behavior has been explicated in terms of psychological models such as classic Pavlovian fear conditioning, two-factor theory, emotional processing theory, and other models. The traumatic (unconditioned) stimulus—such as the explosion of a roadside bomb, direct assault by insurgents, or a suicide bomb attack—automatically evokes the posttraumatic (unconditioned) emotional response, such as fear, helplessness, and/or horror. The intensity of this emotional reaction provokes avoidant or protective behaviors that reduce the emotional impact of the stimulus. Stimuli reminiscent of such traumatic events (conditioned stimuli)—such as driving along a highway or experiencing a perceived threat to one’s family or oneself—evoke similar conditioned responses manifested as fear-induced avoidant and protective behaviors.

Such psychological models can also be explicated within the context of neurocircuitry that mediates the processing of threatening or fearful stimuli. In short, traumatic stimuli activate the amygdala, which in turn produces outputs to the hippocampus, medial prefrontal cortex, locus ceruleus, thalamus, hypothalamus, and dorsal/ventral striatum. In posttraumatic stress disorder (PTSD), the normal restraint on the amygdala exerted by the medial prefrontal cortex, especially by the anterior cingulate gyrus and orbitofrontal cortex, is severely disrupted. Such disinhibition of the amygdala creates an abnormal psychobiological state of hypervigilence in which innocuous or ambiguous stimuli are more likely to be misinterpreted as threatening. In a war zone, it is adaptive to be hypervigilent. At home it is not.

The author provides excellent advice to clinicians who encounter the returning Vet:

Clinicians confronted by patients who have had a difficult reentry need to be aware of the complicated nature of readjustment. On the one hand, they must consider the likelihood that postdeployment difficulties for a particular patient may be par for the course and simply a minor setback in an otherwise normal readjustment trajectory. On the other hand, they must consider the possibility that reentry problems are manifestations of a clinically significant problem (such as anger/aggressive behavior, depression, self-blame, guilt, shame, suicidal thoughts, and alcohol/drug use) or a psychiatric disorder (PTSD, major depressive disorder, other anxiety disorders, or alcohol/drug abuse/dependence). The subsequent discussion is focused on PTSD, with the understanding that the clinician should make a comprehensive assessment that includes inquiry about other posttraumatic disorders that may be expressed alone or in combination with PTSD. Because people with PTSD often hesitate to seek care on their own due to avoidant behavior or because of the stigma associated with seeking mental health care, the window to PTSD may be provided through the problems expressed by other family members as a result of marital discord, domestic violence, or children’s difficulties at school.

The author further highlights the risk factors clinicians need to consider when treating returning veterans:

Risk Factors and Protective Factors
Suicidal risk
Assessment of suicidal risk is important. There is evidence of a positive association between the number of previous traumatic events and the likelihood of a suicide attempt. Furthermore, PTSD is often comorbid with other conditions that are associated with suicidal behavior such as depression, substance use, panic attacks, and severe anxiety.

Danger to others
There are no data to suggest that PTSD, per se, is associated with harm to others. As in the assessment of any other patient, the clinician should inquire about access to firearms or other lethal weapons, the prominence of aggressive impulses, and the comorbid presence of persecutory delusions.

Ongoing stressors
After the euphoria of a safe return from the war zone has worn off, returnees may be faced with new problems (such as changes that occurred at home during their absence) or, more likely, with home-front problems that preceded their deployment to Iraq or Afghanistan. Most typically, such stressors include marital or familial discord but may also extend to workplace or social settings. Ongoing or secondary stressors are risk factors for the development of PTSD. In addition, people with PTSD often have impaired capacity to cope with the ordinary stressors of daily life.

Risky behaviors
As with other psychiatric disorders, clinical assessment must address alcohol/drug abuse and dependence, impulsivity, potential for further exposure to violence, risky sexual behavior, and nonadherence to treatment.

Personal characteristics
People exposed to extremely stressful events exhibit a wide spectrum of posttraumatic reactions, from extreme vulnerability to strong resilience. Indeed, most people exposed to such events never develop PTSD. Personal characteristics that appear relevant in this regard include coping skills, interpersonal relatedness, attachment, shame, stigma sensitivity, past trauma history, and motivation for treatment.

Social support
Social support is a powerful protective factor. The protective aspect is influenced by the capacity of an individual to accept or utilize social support when it is made available. Acceptance of social support may be especially problematic in PTSD, where symptoms such as avoidance, alienation, and detachment impair the affected individual’s ability to benefit from available marital, family, and social support. This impairment was certainly apparent in the case of Mr. K.

The likelihood that a patient with PTSD will meet diagnostic criteria for at least one other psychiatric disorder is 80%. Such individuals are also at higher risk for medical illnesses. Therefore, any assessment of overall clinical risk must consider the contribution of comorbid psychiatric and medical disorders. In Mr. K’s case, assessment of depressive symptoms would be a high priority.

Special Assessment Issues
The current wars have unique aspects that should be addressed during assessment. They include stigma, deployment with a National Guard or military reserve unit, military sexual trauma, and survival after serious injury.

It has been shown that recent military returnees experience a strong stigma against disclosure of PTSD and other psychiatric problems. Furthermore, those who are most symptomatic are most sensitive to such stigma and, consequently, least likely to seek mental health treatment. It appears that one barrier to seeking treatment for PTSD within a Veterans Affairs or Department of Defense setting is fear that documentation in the medical record of PTSD-related problems might have an adverse effect on advancement in a military career. As a result, many men and women with PTSD and other war-related mental health problems may prefer to seek treatment from civilian psychiatrists where confidentiality can be ensured.

National Guard or military reserve service
A large proportion of troops on current deployments are members of the National Guard or military reserve. They are civilians who are neither embedded within full-time military culture nor residing on military bases alongside families who are similarly affected by repeated deployments, and they have much less access to the social support and family services available to full-time active-duty troops. Thus, deployment stress itself (e.g., separation from family, loss of income) may exacerbate the traumatic stress of dangerous service in a war zone. This factor may explain why National Guard and reserve troops in the Persian Gulf War had a higher prevalence of PTSD and depression than active-duty personnel. The sudden displacement from a military to a postdeployment domestic environment posed a significant problem for Mr. K.

Military sexual trauma
Although military sexual trauma has a higher prevalence among women, the same number of men are affected, despite a lower prevalence, given the substantially higher number of male military personnel. Because group cohesion, interdependence, and mutual support are critically important within a military unit, sexual trauma is a betrayal, a blatant breach of trust and security that can precipitate a sense of apprehension and vulnerability.

Survival after serious injury
Most troops wounded in the war zone are surviving their injuries. Thanks to remarkable protective gear, medical advances, and evacuation procedures, 90% of wounded troops now survive serious injuries, sometimes with loss of limb(s), eyesight, or other permanent physical disability. Previous research with Vietnam veterans has shown that those wounded in battle are at greatest risk for PTSD. As a result, mental health status should be assessed routinely as part of any postinjury rehabilitation.

The usefulness of this article in treating the PTSD Veteran is obvious and we discuss further here and here and here other details about PTSD. I particularly think the section on identifying the Risks of treatment in this population to be critical and essential to review in anyone suffering from PTSD.

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