American College of Physicians: Internal Medicine — Doctors for Adults ®


Facing new challenges of PTSD

As combat veterans seek care, internists need to know how to screen and treat

From the July-August ACP Observer, copyright 2006 by the American College of Physicians.

By Bonnie Darves

Veterans Affairs facilities across the country are gearing up for what experts say will be an enduring legacy of the wars in Iraq and Afghanistan: patients with complicated post-traumatic stress disorder (PTSD) symptoms.

The perilous conditions under which deployed service members are living—with suicide bombings, constant ambushes, the absence of a “frontline” and the catastrophic injuries wrought by improvised explosive devices—have created an inordinately stressful environment, especially in Iraq.

"Many of these returning veterans have experienced tragedy and they're having trouble reintegrating," said Chirag Raval, MD, a psychiatrist at the Edward Hines Jr. VA Hospital near Chicago. Dr. Raval helped create a clinic at the hospital to address post-deployment stress and PTSD.

Given the fact that many who serve today are not career soldiers, the task of diagnosing and treating PTSD in veterans will fall increasingly on community internists, who frequently are the first to see patients with mental health concerns. The good news is that PTSD, if detected and treated early, can be resolved—but physicians face many challenges in diagnosing the disorder.

Need for community care

A landmark study published in the July 1, 2004, issue of New England Journal of Medicine found that 28% of returning Iraq War veterans had symptoms often associated with PTSD, depression or generalized anxiety. (When stricter definitions were employed, said psychiatrist Col. Charles Engel, MD, MPH, director of the deployment health clinical center at Washington's Walter Reed Army Medical Center, that figure dropped to 17%.)

A social worker conducts a support group for veterans with PTSD at a VA hospital.

Yet only 26% of study respondents who informally acknowledged mental health symptoms reported receiving formal care. The study also found that a significant number of returning personnel who might benefit from mental health services experienced barriers to care, ranging from a lack of confidence in mental health treatment to personal career concerns and fears of stigmatization.

While most cases of PTSD usually surface within six months, PTSD or other mental health problems can arise years later. San Diego internist Paul F. Speckart, MACP, for example, now wonders if delayed PTSD is afflicting some of his patients who are veterans—of World War II.

"Now that they’re facing their own mortality or have lost their spouses, [these veterans] are falling apart because of things that happened in 1943,” Dr. Speckart said. “I’ve seen patients I’ve known for 30 years suddenly start to drink a lot and have sleep disturbances—things not explained by the severity of what’s happening to them [medically] now.”

Internists who cared for veterans of the Vietnam War or Operation Desert Storm may be familiar with PTSD, but the disorder may be new turf for many. And much of the available literature on PTSD may not apply to today's returning veterans.

“The literature can be difficult to interpret because much of it is based on Vietnam veterans who were looked at years after the fact—so it really was chronic PTSD,” explained Michael E. Kilpatrick, FACP, deputy director of force health protection and readiness in the office of health affairs in the Department of Defense in Washington.

The Defense Department has intensified its focus on early PTSD detection and intervention post-deployment. In addition to an initial screening soldiers receive on leaving the combat zone, health screenings are being conducted again three to six months later on military installations.

And the Defense Department has implemented an online mental health screening program that promises anonymity, to encourage more veterans who need help to seek services.

But given the configuration of returning troops, community physicians increasingly may be the ones to initially see and screen these patients. Of the 1.2 million service members deployed to Afghanistan or Iraq since 2001, the reserve component has exceeded 40% at times, according to military sources.

Although that level is currently 17%, virtually all reservists and guard members—especially those who access health benefits through employers or an employed spouse—will eventually receive care from civilian providers.

In addition, only one-third of troops who have left the military since deployment have sought care in VA facilities to date. And the recent expansion of the TRICARE benefit--eligible reservists may now remain in TRICARE, the Defense Department's managed care-style insurance program, by paying a monthly premium--likely will boost the number of veterans looking to the civilian sector for treatment.

Difficult diagnosis

Complicating diagnosis is the changing profile of today's military. For instance, 15% of service members now are women.

And many guard members and reservists are in their 30s or 40s, making it harder to discern if new (or returning) patients have served in Iraq or Afghanistan. Col. Elspeth Cameron Ritchie, MD, MPH, psychiatry consultant to the U.S. Army Surgeon General, urged internists to include in their history a question about military service. “Up front, ask the question, 'Are you a veteran?'", she advised.

Another major diagnostic challenge: Certain PTSD signs and symptoms are common among service members returning from combat zones who do not have PTSD, and tend to resolve over time, she noted.

For example, irritability and memory and cognition problems also show up in veterans with traumatic brain injury as a result of exposure to blasts—a frequent occurrence in Iraq and, Dr. Ritchie said, "the signature wound of this war."

Moreover, PTSD and depression often present similarly or occur concurrently in combat veterans. “Sometimes it’s hard to tell the difference," Dr. Kilpatrick noted, "because the symptoms overlap.”

To help physicians overcome such barriers, experts offered these tips for effective screening:

  • Look for PTSD "red flags." Internists should look for what are frequent PTSD indicators: substance abuse; visibly high irritability, which may present as anger or anxiety; and unexplained, persistent horrific thoughts about the war that interfere with work or home life.
  • Expect multiple physical symptoms. As with patients who have depression, PTSD patients are less likely to cite mental health concerns than physical symptoms such as headache, gastrointestinal complaints, dizziness, immune system problems, chest pain and discomfort in other parts of the body. Sleep difficulties are also common as individuals with PTSD often relive the traumatic experience in nightmares and daytime flashbacks.
  • Choose screening questions. Experts say there are several alternative approaches to screening questions.

According to Scott A. Pawlikowski, ACP Member, a Hines VA staff physician, VA physicians use a series of screening questions. Physicians begin by asking if veterans have had any experience that was so frightening or upsetting that in the past month it has:

  • led to nightmares or thoughts that they didn't want to have;
  • caused them to try not to think about it or to go out of their way to avoid situations that remind them of it;
  • caused them to be constantly on guard, watchful or easily startled; or
  • caused them to feel numb or detached from other people, activities or surroundings.

If patients answer affirmatively to three or more questions, PTSD may be present, Dr. Pawlikowski said, and treatment or referral for confirmative diagnosis and treatment is indicated.

If soldiers balk at sharing details of their combat experience, Walter Reed's Dr. Engel recommended using “exposure-type questions”—asking whether patients were injured, saw dead bodies, came under direct fire, or witnessed someone they knew being hurt or killed.

He also said that his group has been evaluating a new single question as a “short route” to screening for PTSD: Are you currently bothered by a past event in which you thought you would be injured or killed?

"We have found that if they answer 'yes' and say they are 'bothered a lot,' about half have PTSD," Dr. Engel said. If the answer is negative, the likelihood of PTSD drops to about 3%.

And internists who aren’t comfortable using such questions might probe more generally, said Dr. Raval, asking, "How do you feel you are adjusting since you got back?"

  • Enlist family members. When he encounters patients with suspected PTSD who don't want to talk, Maher A. Roman, FACP, primary care team leader at the Loma Linda VA Healthcare System in Loma Linda, Calif., tries to involve a spouse or family member. "That can be very delicate, of course," Dr. Roman said, "but it can be very helpful to get a perspective the patient may not be able to express." In fact, family members are often the ones pushing the patient to get treated.
  • Destigmatize the disorder. In discussing PTSD, physicians should emphasize the medical model of the disorder: that it is a valid medical problem associated with central nervous system changes, Dr. Engel said, not a matter of personal weakness.
  • Consider serial screening. And finally, keep in mind that—as Dr. Speckart suspects with some of his older patients—PTSD symptoms that may have been manageable for many years may worsen, inexplicably, long after the event.

As a result, some experts say the answer is serial screening. “We’re learning that there is no magical time to screen," Dr. Engel said, "so the optimal time to keep screening is ‘all along the way.’ ”

How to treat, when to refer

Research shows that patients with PTSD tend to seek a lot of medical care. Consequently, deciding who to work up and when can be a challenge.

“Internists might need to be a bit more tolerant of these patients’ health concerns, yet perhaps not quite so quick to order extensive workups,” Dr. Engel said. He recommended "watchful waiting" with regard to physical symptoms, and symptomatic treatment if objective signs are not present.

The most effective treatment for PTSD is pharmacotherapy, particularly with selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy—either individually or in combination. Studies show that PTSD patients in whom SSRIs are effective achieve substantial improvement within 10 weeks, Dr. Engel said.

Internists uncomfortable with diagnosing or managing the disorder or prescribing SSRIs should refer early on to a psychiatrist or mental health practitioner with direct experience treating PTSD in veterans. And they should make an emergent referral for any patient expressing thoughts of harming himself or others. According to Dr. Engel, VA studies show that about half of primary care patients with PTSD report thoughts of suicide.

When in doubt, internists should consult with a mental health professional, Dr. Engel advised, and encourage the patient to tap into plentiful resources from the Defense Department and the VA. (See "PTSD resources".) The VA now offers two years of health care for reservists and guard members who served in a combat zone.

Early intervention and treatment are “very helpful in reducing the signs and symptoms of PTSD,” Dr. Ritchie said, noting that limited data on new veterans makes it hard to give an exact recovery time.

Dr. Raval is likewise optimistic: “The prognosis for these veterans, if they’re getting treatment, staying sober and have family support, is very good.”

Bonnie Darves is a freelance writer in Lake Oswego, Ore.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.


PTSD resources

Resources for physicians as well as for patients and families dealing with post-traumatic stress disorder (PTSD) include:


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