IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide 181 Appendix
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two extremes are a number of disease patterns. Blank" bas concluded that acute,
delayed, chronic, and intermittent or recurrent forms of PTSD have been well
documented. OP den Velde et aP1 described three life-suan develoomental
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courses among i~orld War I1 Dutch resistance fighters: a ;ubacutcform that
gradually becomes chronic, a delayed form rvitll onset 5 to 35 years after the end
of World War 11, and an intermittent subtype with relapses and rcmisrions.
individuals who appear to have recovered conipletely from FED may relapse
when sukquetrtly exposed to stimuli and situations that resemble the
initial trauma. Solomon'sw studies have emphasized the vulnerability of Israeli
conrbat veterans to reactivationof PTSD symptonrs if they had previously exhibited
combat stress reactions. Solomon and mlleagues observed reactivation of
I'TSD among asymptomatic veterans of the 1967 Yom Kippar War wlre~t reexposed
to tl~e war-zone stress of the 1982 Lebanon War. An example of reactivation
of PTSD among American veteransoccurred during the Persian Gulf War,
!vhen there was a marked increase in PTSD symptoms anlong male and fcmale
Vietnam veterans apparently in respolrse to the massive array of war-related
stimuli that flooded American print and bmadcast n~ediil!*" PrSD also niay
recur following life evens associated with aging, such as retire~nent!."
Finally, it is worth noting that pple with PTSD often find it difficult to
cope with the vicissitudes and ordinary hassles of life. Interpersonal conflicts,
parenting problems, vocational setbacks, and the like may sometln~es produce
reactivationor exacerbation of mSD symptoms. The niechanism for such a wellknown
clinical phenomenon may be that hassle-provoked autonomic arousal
precipitates trauma-related symptoms through response genenliwtion.
PREVENTION
Of course. the best primary prevention for war-related FED is the prevention
of war. Many psychiatrists view such work as beyond their professional
puwiew, although some have stated that social action is a responsibility of
psychiatric professionals. For example, Friedman" has argued that from n public
health perspective, pmventionof war (and other traumas) is a valid professional
mncern. Another primary preventive method is to %men out wdully military
recruits rvha are at greatest risk for developing PTSD.Such a strategy is unlikely
to succeed for reasons outlined by Oei et aLWA.third stralegy is a psychoeducational
approach to basic training that would equip new milihry recruits with
tools for coping with anticipated war-zone strcssarsP 'illis could be nlled a
stress inoculationapproach.
Secondary preventiot~, the minimizing of long-term psychological sequelae
following war-zone exposure, consists of interventions based on the treatment
principles of proximity, immediacy, expectancy. and sinrplicity.*" Szlnranu list
dclincated these principles during World War I, and they have proved successful
in reducing the number of psychological casualties, at least in the short-term.
Soldiers arc treated close to the frontline, quite soon after initial symptoms
appear. Caregisws communinte the mnsage that they are having a normal arid
lemporary reaction and should be able to resume their dutie alter a brief period
of rest and support. They are given opporhrnities to discuss the traumatic experiences
in daily group critical incident stress debriefing sessions." &cause of the
principle of positive expectancy and the desire to lrormalize the soldier's responses,
ppharrnacothcrapy is often avoided during frontline treatment of acute
CSRs. Under appropriate conditions, i!owever, pharmacotherapy can be used
effecli!:ely for recently evacuated nlilihry casi~alties!~ in a thought-provoking
DEPARTMENT OF VETERANS AFFAIRS
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NATIONAL CENTER FOR PTSD