IRAQ WAR CLINICIAN GUIDE

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-Iraq War Clinician Guide 183 Appendix I - I'OST-ntAUMATICSTRCS5 DIK1RDER INTHE MILITARY VmERAN 273 As already noted, military personnel with PTSD oftcn have comorbid substanceabuse problems. Neurobiologic factors that are cl~aracteristic of chronic PTSD may increase a PTSD patient's risk for alcoholism or substance abuse." 111 addition, the adrenergic hyperarousal associated with withdrawal from abused substances may exacerbate PTSD symptoms. Furthermore, the dual diagnosis lileratur? stro~ielv ", suceests ." that the best trcatrnenk outcomes resull when two mprin~ary illnnsn are treated simu.la~,cnusly. Tor all these reawlns, Kofotd el 31'' nrgw that mSD jnd subslance al~t!sc/llepc~ndc~~cc must be trr~tcd bimulw- oeousiy rvhe11 they co.occur Eelore leaving the topic ol treartae~it, nicnliu~r must be made ol longrr icrtn. ~nslitulion;ll trcatrncnt of mSD. There are s11eciali7.ed i~ivatlcnt ircatnlclrt uniils at several VA hosuitals in the United ~tates.'~he . vroeranis - arc desiencd " to helv veterans locus on intensive. Ir~u~~ia.rclated therapy a, well as rehabilitation therspy. The Isr~el Defetw Forces hlediral Corps developed a variation on Illis type ol i,ls~ii~ttiot~al care, Ihe pilot tcst of svhich is known as the Ko.rc11 Project!' program borrowed heaviiy from the principles of treatment of acute co~nbat stress reactions in that vositive exveclancv and similarilv of the heatment settine. - IU the tmum,+tic setting wcru clnpl,3si~cd Alrhougll ps)cl,otnelra oulcocnc data failed to dcam,nstr>re thc pnlgram'i elf~c>cy. Ilir appro.~ch is worthy ol l~~rllwr study." PHYSICAL HEALTH Lilerature suggesting that exposure to combat trauma may alter thebody's normal physiology and health dales back to reports on cardiovascular abnormalities among Civil War veterans. Over the years, Ihese problenrs have been variously labeled soldier's Benrl, Dn Corfn's syndrome, irrilnblc be~~rt, elfart syndros~e, and ncrrrocirc,tlolory nsfheriin." Studies have confirmed that exposure to war-zone stress is associated with poorer health and more chronic medical problenrs in diverse strata of the \,etemn population, e.g.. male and female Vieham velcr- \ am,= male Australian World War I1 prisoners of war.'" Despite this extensive literature, there is little research that has addressed the question whether PTSD rather than traumatic exposure per se is associated with ooor liealtl~ amone militan, veterans. In the NVVRS. both n~ale and female \'.ctnLn rcwus s v ~ tutr~ntI'ISD ~ t r~p~r1i.d .r.u:r' ~plrysiial 11calt11 pr~'JIeln;. poorer health status, snd more medical scwicc ttl~lizalton': Afler controlling for war-zone exposure, Wolfe ct al" found among 109 female Vieham theater veterans that hither PTSD scores were associated with increased likelihood of neu- rologic, cardLvascular, gastrointestinal, gynecologic, dcrmatologic, and ophthal- moloeic/otolarvneolo~ic ," " comolainls. Israeli combat veterans with PTSD had hlglr; rates of somatic compl~ints than a "on-PTSD compari~n group." When tested on a treadmill, lsrael~ combat veterdns with PTSD exhibited lorv effort tolemnce atid dc~rc2sed cardlac ~~:cIYc." Finally, prelilninary data collected by IVollr 2nd coll:agtles (\Yolfc I. uopublisl\ed d~la. 1993) on rcler.~ns ol Operation Dcjcrt Storm i~idlr.ite a slwcw asso:i.,!iun b
, ~ -Iraq War Clinician Guide 184 Appendix I associated with PTSD" (seealso the article by Southwick el a1 in this issue) might increase biologic susceptibility to cardiovascular, gastrointestinal, endocrine, autoimmune, and other medical disorders. Adverse health beliaviors (smoking, drinking, ealiig disorders. sexual behavior) associated with 1TSD might affect health risk. Comorbid deoression. anxiehr disorders. and alcoholismlsubstance ~ .~ ~~ abusc might increase discox sus~e~tibili;~. and h~i~litened vigilance or perceptions of autonomic cbnges might increase rates of hc2lth complaints SALUTARY EFFECTS OF <strong>WAR</strong>-ZONE EXPOSURE The significant problems associated with MSD among military veterans have overshadorved the fact that some veterans who have extensive combat exposure are rvell adiusted and hieh function in^.^^" Moreouer. war-zone exoosuie can have ~0ter;tiallv saluta; effects. alt6ououeh - these effects .~. mav no< be ~ -~ obervcd imniediatcty afier war at;d may not involve all a>pects of function. For e~aniple, Elder and Clipp" studied pvrsonality change from ndolmence to mid. life in male Korean Waiand World War Ilveteraos. Veterans with heavy combat exposun! had the greatest gains in resilience and decreases in helpless6ess relative to less-exposed veterans but at a price-the heavy exposure group also had the most painfulmemories and en~otional distress. SUMMARY 1. Military personnel exposed to war-zone tmuma are at risk lor developing PTSD. Those at greatest risk are those exposed to the highes! levels ol war-zone stress, those wounded in action, those incarcemtcd as prisoners of war, and those who nlanifest acute war-zone teactionr, such as CSR. 2. In addition to problems directly attributable to PlSD symptoms per se, individuals witli this disorder frequently suffer from other comorbid psychiatric disorders, such as depression, other anxiety disorders, and alcohol or substance abuselde~~endence:le mulling constellation of psychiatric syrnpto~ns f~~quelllly impairs matital, vontional, and social function. 3. Vie likelihood of developing chronic I'TSD depends on prc~nilitary and poslnrilitary factors in addition to features of the trauma itsell. Prcmilitary (actors include negative environmental factors in childhood, econotnic deprivation, family psycliiatric history, age of enhy into the military, premilitary edr~calional attainment, and pe~sonality characteristin. I'ostmilitary factors include social support and the veteran's coping skills. 4. Among Allrentan military personnel, there nre three populations at risk lor unique problenis that may amplify the psychological impact of warzone stress. 3iey are women whose tr2ar-zone experiences may be complicated by sexual assault and harassment; rronrvhite ethnic minority individuals ~vhose premilitary, postmilitary, and nrilitary experience is affected by the many manifestations of racism; and those with war-related physical disabilities, rvhose PTSD and niedical problems often exacerbate each other. (Ither panems include delayfd. chronic, &d intermittent k15D.' P DEPARTMENT OF VETERANS AFFAIRS - -- w--- NATIONAL CENTER FOR PTSD
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IRAQ WAR CLINICIAN GUIDE 2 nd EDITI
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Iraq War Clinician Guide 3 Executiv
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Iraq War Clinician Guide 5 Military
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Iraq War Clinician Guide 7 Military
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-Iraq War Clinician Guide 9 Militar
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Iraq War Clinician Guide 11 Militar
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Iraq War Clinician Guide 21 Backgro
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Iraq War Clinician Guide 33 Treatme
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Iraq War Clinician Guide 47 Medical
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Iraq War Clinician Guide 49 Medical
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Iraq War Clinician Guide 51 Traumat
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-Iraq War Clinician Guide 53 Trauma
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Iraq War Clinician Guide 59 Im~lica
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Iraq War Clinician Guide 61 Implica
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Iraq War Clinician Guide 63 Caringf
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Iraq War Clinician Guide 65 Caring
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Iraq War Clinician Guide 71 Assessm
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-Iraq War Clinician Guide - - 73 As
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Iraq War Clinician Guide 79 Substan
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Iraq War Clinician Guide 81 Substan
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Iraq War Clinician Guide 83 Impact
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Iraq War Clinician Guide 85 Impact
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Iraq War Clinician Guide 87 Appendi
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Iraq War Clinician Guide 104 Append
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Iraq War Clinician Guide - 106 Appe
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Iraq War Clinician Guide 108 A~~end
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IRAQ WAR CLINICIAN GUIDE

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