Chapter 63: Combat-Related Posttraumatic Stress Disorder & Traumatic Brain Injury

General Considerations

In the newly released DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), posttraumatic stress disorder (PTSD) is classified as a trauma and stressor-related disorder, not a disorder primarily of anxiety alone. The criterion for the diagnosis conceptualizes trauma as the precipitating event where the person experiences, witnesses, or is confronted with an event or events that threaten death or serious injury or posed a threat to the physical integrity of self or others, and the person’s response must have involved fear, helplessness, or horror. The events are beyond the realm of usual and normal human experience and include traumatic events such as war or the Holocaust; natural disasters such as earthquakes and tsunamis, ­hurricanes, and volcanic eruptions; and anthropogenic disasters, including factory explosions, automobile crashes, and airplane crashes. Critical to understanding the diagnosis is the idea that the cause of the illness was a traumatic event that occurred outside of the individual and was not due to an inherent character or personality weakness of that person.

While this condition has likely existed since human beings have endured trauma, PTSD entered the medical diagnostic realm with the publication of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) in 1980. It was first brought to public attention in relation to war veterans and, depending on the name of the war, has been known by a number of different terms to include combat fatigue, gross stress reaction, post-Vietnam syndrome, shell shock, and battle fatigue. Currently, PTSD is described as a disorder of persistent reactivity in all areas of self-regulation, not just troubling memories and chronic anxiety. Distressing memories of past traumatic events and intense stress reactions to reminders of those events that occur in the person’s current life continue to serve as the cornerstone of PTSD.

Essentially, the brain is a control system that regulates the body functions. Trauma forces the brain to make profound biological adaptations in how it operates. When the body is safe and working well, the brain extends its efforts to the “higher” functions that enable you to not only survive but also become a conscious individual. However, when the brain detects serious threats to body survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and takes control of the rest of the brain’s operations, putting all systems in emergency mode until the threat is overcome. In most cases, with nontraumatic threats as well as traumatic survival threats, the alarm reaction in the brain quickly subsides and resets automatically to its normal mode. However, when the brain’s alarm system doesn’t automatically or rapidly reset itself and alarm continues to signal danger, even though safety has been restored (ie, the person is no longer engaged in combat), the overall functioning remains in an altered state that is the chronic stress response.

Posttraumatic stress disorder and traumatic brain injury (TBI) are the largest represented diagnoses from the wars in Iraq and Afghanistan. Understanding the diagnosis and treatment of these conditions is important for healthcare providers, many of whom may not have experience with war casualties, in either civilian or military settings. Many obstacles to the timely and proper diagnosis and treatment are present in this population of veterans, including the overlap of symptoms present in both conditions as well as cultural factors in eliciting a diagnosis. Family practice physicians, both military and civilian, are likely to encounter PTSD patients in their practices, and a knowledge of military culture, traditions, and knowledge of war-related injuries and illnesses is important to master.

Various forms of traumatic brain injury have been described, and all can be understood by the injury caused when the brain is moved violently within its usual protected and physiologically stable environment. TBI was first described in antiquity. It can be divided into several categories, as listed in Table 63-1.

Additionally, an important characteristic of TBI is the cumulative nature of the injury. In the recent wars in Iraq and Afghanistan, blast injuries played a major role in the development of TBI. Service members were exposed to blast injuries from mortars and improvised explosive device (IED) explosions, and some have sustained at many as 5–10 blasts. While some blast injuries do not result in loss of consciousness, other TBI victims experience nausea and vomiting, are dazed, and suffer other consequences of a concussion. The simplest way to understand this type of cumulative injury is to compare it to the damage produced from repetitive boxing injuries to the head.

Most cases of mild TBI improve with time, but more sophisticated testing indicates that although performance on neuropsychological testing is not abnormal, pathophysiologic and anatomic damage is created, which may result in deficits in cognitive functioning in later years. The actual mechanism of damage from the TBI is multifactorial and probably includes one of the following mechanisms:

• Focal injury

• Diffuse axonal injury

• Superimposed hypoxia or ischemia

• Diffuse microvascular injury with loss of autoregulation

These mechanisms are described in more detail in Table 63-2.

Treatments that have been used to date include those that ameliorate and reverse the damage caused by the mechanisms listed above (see also Table 63-3). Some agents are described below.

Additionally complicating the diagnosis is the sense that the individual may not believe that there is an illness or injury; this impaired perception of illness is termed anosognosia. The deficits may be quite apparent to others in the social and occupational circle of the injured, and these other people should be routinely questioned about functioning. Writing in the Textbook of Military Medicine, Dr. Edwin Weinsten, a neurologist who treated World War II veterans, noted: “Caution should be exercised in sending patients with a great deal of denial back to duty or accepting their statements about their condition at face value.”

His advice was prophetic and portended the difficulties that practitioners face in dealing with TBI.

Moreover, some cultural factors may impede admission of blast exposures and actual deficits in cognitive functioning. For example, service members may not want to be removed from battle for evaluation and are likely to continue serving with their units and not disrupt the unit stability during combat. Returning Veterans may be loathe to admit a disability as they try to re-adjust to family life and continued service or a civilian life. Some helpful website are listed here:

Prevalence

The rates of PTSD after trauma or disaster have shown considerable variation. The lifetime prevalence of PTSD is 7–30%, and affects approximately 5–7.7 million American adults in any one year. For example, in instances where the trauma is more severe, where it has less meaning, where people believe that they have carried out acts of commission or omission and blame themselves for the trauma, or where they believe others have “let the side down,” as in problems of friendly fire, rates are noted to be higher.

High rates of PTSD in veterans can be found regardless of which conflict is examined. In fact, as noted previously, the diagnosis of PTSD historically originates from observations of the effect of combat on soldiers. Rates of PTSD in Vietnam veterans, Persian Gulf War veterans, and Iraq War veterans are provided below.

Vietnam Veterans

Following a congressional mandate in 1983, the US government conducted the National Vietnam Veterans Readjustment Study (NVVRS) to better understand the psychological effects of participating in the Vietnam War. While approximately 15% of men and 9% of women were found to have PTSD at the time of the study, approximately 30% of men and 27% of women had PTSD at some point in their lives following Vietnam. As one might suspect, these rates were much higher than those found among non-Vietnam veterans and civilians. The rates are alarming since they indicate that at the time of the study, there were approximately 479,000 cases of PTSD and 1 million lifetime PTSD cases as a result of the Vietnam War.

Persian Gulf War

Studies examining the mental health of Persian Gulf War veterans found that rates of PTSD ranged anywhere from almost 9% to approximately 24%. Although the Persian Gulf War was brief, the rates of PTSD were higher than what was found among veterans not deployed to the Persian Gulf. In addition, veterans have reported significant numbers of physical health problems.

Iraq War and Afghanistan

Although the war in Iraq has somewhat subsided, the conflict in Afghanistan is ongoing. Therefore the full the impact on the mental and behavioral health of US soldiers is not yet known. However, the results of one study were obtained for members of four United States combat infantry units (three army and one marine) that served in Iraq and Afghanistan. The majority of soldiers were exposed to some kind of traumatic, combat-related situations, such as being attacked or ambushed (92%), seeking dead bodies (94.5%), being shot at (95%), and/or knowing someone who was seriously injured or killed (86.5%). After deployment, approximately 12.5% had PTSD, a rate greater than that found among these soldiers before deployment.

PTSD Risk

Posttraumatic stress disorder can occur in people of all ages. However, some factors more than others render a person more prone to develop PTSD after a traumatic event:

• Experiencing other types of trauma, particularly early in life

• Being female

• Experiencing intense or longlasting trauma

• Having other mental health problems, such as anxiety or depression

• Lacking a good support system of family and friends

• First-degree relatives with mental health problems, including PTSD

• First-degree relatives with depression

• Childhood neglect and physical abuse

Women are at a twofold increase risk of PTSD because they are more likely to have experienced the types of trauma that trigger the condition. This gender difference is due primarily to a women’s greater vulnerability to PTSD following events that involved sexually assaultive violence. The probability of PTSD in women versus men exposed to assaultive violence was 36% versus 6%.

Risk factors for military personnel developing PTSD include combat experience, being wounded, witnessing death, serving on graves registration duty or handling human remains, being captured or tortured, being exposed to unpredictable and uncontrollable stress, and experiencing sexual harassment or assault. Higher rates of PTSD and depression are associated with longer deployments, multiple deployments, and greater time away from base camp. Car and suicide bombs, improvised explosive devices (IEDs), and rocket-propelled grenades—all elements of the recent Iraq and Afghanistan conflicts—can exacerbate the intense stress of combat.

Ethnic minorities (African Americans, Hispanics, and Native Americans) are more likely to develop the disorder than men, boys, and Caucasians, and there is some evidence that it may run in families. Some of that difference is attributed to higher rates of dissociation soon before and after the traumatic event (peritraumatic), a tendency for ethnic minorities to harbor self blame, less social support, and an increased perception of racial prejudice, as well as differences in how ethnic minorities may express distress. Roughly 30% of Vietnam veterans developed PTSD. The disorder also has been detected in as many as 10% of Gulf War (Desert Storm) veterans, ~6–11% of veterans of the Afghanistan war, and 12–20% of veterans of the Iraq war.

Potential Preventive Interventions

Prevention of PTSD can potentially reduce a significant burden of individual and societal suffering. Potential ­preventive interventions span various psychological and pharmacological domains and include emerging interventions from complementary and alternative medicine (CAM). These interventions have been used both separately and in combination with one another. Specific psychological interventions that have been studied for the prevention of adult PTSD and include the following:

• Psychological debriefing interventions

• Critical incident stress debriefing (CISD)

• Critical incident stress management (CISM)

• Psychological first aid (PFA)

• Trauma-focused cognitive behavioral therapy (CBT)

• Cognitive restructuring therapy

• Cognitive processing therapy

• Exposure-based therapies

• Coping skills therapy (including stress inoculation therapy)

• Psychoeducation

• Normalization

• Eye movement desensitization and reprocessing (EMDR).

These therapies are designed to prevent the onset of PTSD and development of trauma-related stress symptoms soon after exposure to a traumatic event.

Various neurobiological pathways have been implicated in the development of PTSD. Consequently, pharmacotherapy has been tried as a preventive intervention for PTSD. Several drugs have been studied for PTSD prevention, including propranolol, morphine, glucocorticoids, and selective serotonin reuptake inhibitors (SSRIs). These therapies are designed to prevent the onset of PTSD and development of trauma-related stress symptoms soon after exposure to a traumatic event.

Clinical Findings

A. Signs and Symptoms

Posttraumatic stress disorder symptoms typically start within 3 months of a traumatic event. However, in a small number of cases, symptoms may not appear until years after the event. The symptoms of PTSD are also known to appear and disappear sporadically. They may be more plentiful or severe when life in general is more stressful, or when reminders of the event are encountered. For example, hearing a car backfire may result in reliving combat experiences, or a news report about a rape may bring back memories of the assault. There are four categories or types of PTSD symptoms:

• Reexperiencing the events: Memories of the traumatic event can return at any time (spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress).

• Heightened arousal: You may be anxious, jittery, and constantly on the lookout for danger. Sudden anger or irritability is not uncommon (aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance or related problems).

• Avoidance: You attempt to avoid situations, things, or people that bring back memories of the trauma (distressing memories, thoughts, feelings, or external reminders of the event).

• Negative alterations in thoughts and mood or feelings: Feelings may vary from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event).

In addition to these symptoms, a patient must also meet the following criteria for at least a month:

• At least one recurring symptom

• At least three avoidance symptoms

• At least two hyperarousal symptoms

• Symptoms that make it complicate daily life, going to school or work, social contacts, and performing important tasks.

Even with the assistance of the descriptive symptoms listed above, the assessment of PTSD can often be difficult for practitioners to make since most patients present with complaints other than the anxiety associated with a traumatic experience. Those symptoms tend to include expression of mental conditions as disturbed body functions (somatization), depression, or substance misuse. Most studies of Iraq war veterans tend to display more of the physical symptoms as opposed to describing the associated emotional problems. Many of the cases describe individuals with PTSD who present with a history of suicide attempts, depression, and substance abuse disorders. In addition, the diagnosis of PTSD often occurs comorbidly with bipolar disorder (manic depression), eating disorders, and other anxiety disorders such as obsessive-compulsive disorder (OCD), panic disorders, social anxiety disorder, and generalized anxiety disorder.

B. Neuroanatomic Features

Through the use of brain imaging, characteristic changes in brain structure in PTSD patients have been identified. Regions typically altered in these patients include the hippocampus, amygdala, and cortical regions (anterior cingulate, insula, and orbitofrontal region). The interconnectivity of these regions forms a circuit that mediates adaptation to stress and fear conditioning. It is the change in this circuitry that has been proposed to have a direct link to the development of PTSD.

Hyppocampus

As mentioned above, the hippocampus is implicated in the control of stress responses, declarative memory, and contextual aspects of fear conditioning. It is one of the most plastic regions of the brain, which is why a reduction in hippocampal volume is considered by many to be a hallmark of PTSD. Smaller hippocampal size has been demonstrated with magnetic resonance imaging (MRI) in Vietnam veterans with PTSD and associated with trauma severity and memory impairment. It is important to note that hippocampal atrophy and functional deficits exhibit considerable reversal after treatment with SSRIs, which have been demonstrated to increase neurogenic factors and neurogenesis in some preclinical studies.

Amygdala

A limbic structure critical for the acquisition of fear response is the amygdala. It mediates both the stress response and emotional learning, thereby implicating its role in the pathophysiology of PTSD. Given the linkage between increased reactivity and genetic traits that moderate risk for PTSD, increased amygdala reactivity may signify a biological risk factor in the development of PTSD.

Cortex

Because of its partial connections to the amygdala, the medial prefrontal cortex exhibits inhibitory control over stress responses and emotional reactivity. In PTSD patients, decreased volumes of the frontal cortex and reduction in anterior cingulate cortex (ACC) have been associated with PTSD symptom severity in some studies. Contrary to the volume loss of the hippocampus, ACC volume loss is ­secondary to the development of PTSD; therefore, it is not considered a preexisting risk factor.

C. Imaging Studies

Traumatic stress has a broad range of effects on brain function. The areas implicated in the response of the brain to stress include the amygdala, hippocampus, and prefrontal cortex. Studies of the brain in PTSD patients replicated findings in animal studies by demonstrating alterations in these brain areas. The key alterations noted included support for the hypothesis that the amygdala is hyperresponsive in PTSD while rostral and ventral portions of the medial prefrontal cortex are hyporesponsive. Although the dorsal anterior cingulate cortex and insula appear to be hyperresponsive in numerous anxiety disorders, it is also found in PTSD. In addition, the hippocampus also appears to function abnormally in PTSD, although the direction of the abnormality tends to vary depending on the methods used in the study.

In a more recent study case subjects were identified from a group of male US veterans previously deployed to Iraq or Afghanistan. There were 29 participants; 15 of the veteran case subjects met DSM-IV criteria and were essentially free of psychotropic drugs except for two who were receiving the antidepressant trazodone for insomnia and 14 veterans without PTSD who participated in the MRI study. When the PTSD subjects were compared to the controls, three differences were identified: (1) greater connectivity between the amygdala and brain insular cortex, (2) reduced connectivity between the amygdala and the hippocampus, and (3) reduction of the negative correlation between the amygdala and two regions of the anterior cingulate cortex. It is important to understand that in the normal control brains, there is typically a negative correlation between signaling in the amygdala and the ­cingulate cortex. In the study referenced above, a reduction in the level of this typical negative correlation was noted.

Different experiential, psychophysiological, and neurobiological responses to traumatic symptom provocation in PTSD have been reported in the literature. Two subtypes of trauma response have been hypothesized, one characterized predominantly by hyperarousal and the other primarily dissociative, each one representing unique pathways to chronic stress-related psychopathology.

D. Screening Tests

Screening tests or measures for PTSD vary in a number of ways. One of the most important differences is in format (Table 63-4).

Measures range from a 17-item self-report measure with a single rating for each item to a structured interview with detailed inquiries about each symptom and interviewer ratings regarding the validity of reports. Structured interviews vary in format as well. Some interviews have a single gatekeeping item, some have many, and in certain interviews, the ratings reflect symptom severity and/or frequency. It is important to note that the best PTSD measure really depends on what is needed. Important elements to consider when selecting a measure include the following:

• Time required to administer the measure

• Reading level of the population being sampled

• Whether it is necessary to assess symptoms related to a single traumatic event

  or to assess symptoms related to multiple traumatic events (or to assess symptoms when the trauma history is unknown)

• Whether the measure needs to correspond to DSM criteria for PTSD

• Psychometric strengths and weaknesses of the measure

• Cost of using the measure

• Whether complexity and language of the measure is appropriate to the population being sampled

With the release of DSM-5, the National Center for PTSD is developing the following measures based on the following new criteria:

• Clinician-Administered PTSD Scale (CAPS), which includes new combined ratings of symptom frequency and intensity

• PTSD checklist (PCL)

• The Primary Care PTSD Screen (PC-PTSD), which will also be available in Spanish

Of particular note is the PC-PTSD. It is a four-item screen that was designed for use in primary care as well as other medical settings and is currently used to screen for PTSD in Veterans Administration (VA) veterans. The first item on the screen is an introductory sentence that cues respondents to traumatic events (Table 63-5).

In most circumstances the results of the PC-PTSD should be considered “positive” if a patient answers yes to any three items. Those screening positive should then be assessed with a structured interview for PTSD. The screen does not include a list of potentially traumatic events.

Differential Diagnosis

Clinicians may have difficulty making the diagnosis of PTSD because the patient may have other disorders as well. In particular, major depression and substance abuse are common in people with PTSD. There may also be an increased risk of panic disorder agoraphobia, obsessive-compulsive disorder, social phobia, and somatization disorder. It is not clear to whether these concomitant disorders occur before or after the traumatic event and the development of PTSD.

Complications

Persons with posttraumatic stress disorder (PTSD) most often present to their primary care physician with physical symptoms rather than psychological concerns. Studies have also shown that people with PTSD are at increased risk for a number of medical conditions, such as hypertension, diabetes, cardiovascular disease, and asthma.

When there is prolonged exposure to trauma, certain persons may develop certain long-term patterns of behavior. These include difficulty in trusting others, irregular moods, impulsive behavior, shame, decreased self-esteem, and unstable relationships. Many of these traits are also seen in persons with borderline personality disorder, and people with this disorder often have histories of childhood physical and sexual abuse, which are possible causes for PTSD.

Significant interpersonal difficulties are common in persons with PTSD. Symptoms of estrangement, irritability, and anger, or associated depression, may take their toll on a person’s relationships. Persons with PTSD may find it difficult to discuss their symptoms with those who did not go through the same trauma. Sometimes, guilt about surviving or about acts done in order to survive can also cause increased isolation and tension in interpersonal relationships.

Treatment

The main treatments for PTSD typically include psychological and medical interventions, which are often used in combination. Everyone is unique; therefore, any treatment intervention should be well formulated and culturally appropriate to optimize clinical and functional outcomes. Providing information about the illness usually involves teaching individuals about what PTSD is, how it impacts others, that it is caused by extraordinary stress rather than inherent personal weakness, that there is effective treatment available, and what to expect in treatment; this information helps to dispel inaccuracies and minimize any shame. This is particularly important in populations such as military personnel, who are frequently disadvantaged by the perceived and real stigma associated with seeing a mental health professional.

A. Psychotherapy

Posttraumatic stress disorder can be effectively treated with psychotherapy, and while there are several types of psychotherapies available, they all share common elements:

• Therapy should always is individualized to meet the specific concerns and needs of each unique trauma survivor.

• Trauma therapy is performed only when the patient is not currently in crisis.

• A shared plan of therapy should be developed within an atmosphere of trust and open discussion by the patient and therapist.

• One goal is to enable the survivor to gain a realistic sense of self-esteem and self-confidence in managing bad memories.

• Trauma exploration can be done in several ways, depending on the type of posttraumatic problems that a survivor is experiencing (Table 63-6).

Several types of effective psychotherapy are employed to treat PTSD, including

• Group psychotherapy

  • - Likely the most beneficial psychotherapy method for PTSD, especially for military personnel and veterans. This treatment is practiced in VA PTSD clinics and medical centers for military veterans.

  • - This peer-to-peer exchange is an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material with the safety, cohesion, and empathy provided by other survivors.

  • - This builds confidence and ability to trust. This allows the patient to work through trauma-related shame, guilt, rage, fear, doubt, and self-condemnation by sharing the “trauma narrative.”

• Cognitive behavioral therapy

  • - Most widely accepted as useful for PTSD is cognitive behavioral psychotherapy (CBT), which is a relatively structured psychotherapy that involves teaching specific techniques (ie, exposure and cognitive restructuring, relaxation, self-talk, and assertiveness training) within a limited number of sessions.

  • - Exposure therapy targets assistance with facing the fear and gaining control of the accompanying distress. Some care is needed to avoid retraumatizing the patient.

  • - Cognitive restructuring involves identifying irrational patterns of thought, feeling, and behavior gradually teaches the subject how to substitute new thoughts for the old and develop new emotional and behavioral patterns.

• Eye movement desensitization and reprocessing (EMDR)

  • - EMDR provides an avenue for patients to view their memories of the trauma (including all of the negative thoughts, feelings, and sensations experienced at the time of the event) in an effort to change those feelings.

B. Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) approaches to the treatment of many medical and mental health diagnoses, including PTSD, employ a range of therapies that are not or may not be considered standard to the practice of medicine. Although the research base to support the effectiveness is not complete, there is little evidence that these interventions are harmful. Nonetheless, patients who are reluctant to accept mental health labels or interventions may be more accepting of these innovative treatment approaches. Many CAM interventions are practiced in a manner that could increase social support and reduce stress for the patient and family members. These CAM interventions promote greater resilience through an increased sense of control.

The CAM modalities are typically grouped by categories reflecting their mechanism of action. However, many of the modalities cross several categories. The CAM modality categories as delineated by the National Center for Complementary and Alternative Medicine include

• Natural products: Include biologically based practices that include herbs, dietary supplements, vitamins, foods, and homeopathic remedies.

• Mind-body medicine: Seeks to harmonize mind body function to promote health and wellness. If the focus is primarily on mental activity, it will include prayer and guided imagery. If the emphasis is on the integration of mind and body, then yoga, meditation, tai chi, expressive art therapies, and breath-oriented therapies are the focus.

• Manipulation and body-based practices (exercise and movement): These modalities are based on manipulation of body parts or systems of the body. This includes disciplines such as chiropractic spinal and joint manipulation, osteopathic manipulation, massage therapy, reflexology, and acupuncture

• Energy medicine: Practices that focus on energy medicine look to balance energetic fields that surround and penetrate the human body (qi gong, reiki, and therapeutic touch).

It has been estimated that 41% of service members and veterans rely on one or more CAM treatments, a rate very similar to estimates in civilian populations. Furthermore, CAM is more often used by those who have a greater number of health symptoms, that is, comorbid conditions. In one study, more than two-thirds of service members and veterans with a history of PTSD reported using one or more CAM treatments. Because many of the CAM modalities relate to particular cultural backgrounds, physicians and allied health professionals should pay particular attention to the desires of the patient and the family.

C. Medications

Several classes of medications are employed to help improve or eliminate symptoms of posttraumatic stress disorder. They are nearly always used in conjunction with psychotherapy for PTSD, because while medications may treat some of the symptoms commonly associated with the disorder, they will not relieve a person of the flashbacks or feelings associated with the original trauma.

The selective serotonin reuptake inhibitor (SSRI) antidepressants are the most commonly prescribed class of medications for PTSD and the first class approved by the US Food and Drug Administration (FDA). They include medications such as fluoxetine, sertraline, and paroxetine. Research shows that this group of medicines tends to decrease anxiety, depression, and panic associated with PTSD in many people. These types of antidepressants may also help reduce aggression, impulsivity, and suicidal thoughts that can occur in people with PTSD. For combat-related PTSD, there is increasing evidence that prazosin can be particularly helpful. To prevent a relapse, antidepressants should be prescribed for at least a year. Many patients may need to try several types of antidepressants before finding one that meets their needs and relieves their symptoms.

The atypical antipsychotics are the most common class of medications prescribed after antidepressants. They include medications such as risperidone, olanzapine, and quetiapine. These medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness, paranoia, or brief psychotic reactions. Although less effective, the mood stabilizers like lamotrigine, tiagabine, and divalproex sodium can be helpful. Medicines that help decrease the physical symptoms associated with PTSD include drugs such as clonidine, guanfacine, and propranolol. Benzodiazepines are sometimes prescribed for certain symptoms because they provide rapid relief of anxiety. However, their usefulness is limited because of their associated dependence. There is even a small sample of data indicating that over time they can exacerbate PTSD. While other medications such as duloxetine, bupropion, and venlafaxine are sometimes used to treat PTSD, there is little research that has studied their effectiveness in treating this illness.

The current state of evidence suggests that the SSRIs remain as the treatment of first choice for most patients requiring drug therapy for PTSD. Currently there is minimal evidence to support the use of any specific SSRI. Therefore, the differences in pharmacokinetic profile, individual tolerability, and drug interaction potential should be used to guide the selection. In the event that SSRI therapy has not provided adequate benefit, or where adverse effects or drug interactions mean that SSRI treatment is unsuitable, mirtazapine or venlafaxine can be regarded as reasonable alternatives.

Prognosis

Overall, approximately 30% of people eventually recover completely with proper treatment, and another 40% get better, even though less intense symptoms may remain. Treatment with psychotherapy and/or medications, such as SSRIs, has been very helpful. However, the prognosis for PTSD depends primarily on the severity and length of time that a person has suffered from the disorder. The majority of patients with PTSD respond to psychotherapy. Symptom duration is variable and is affected by the proximity, duration, and intensity of the trauma, as well as comorbidity with other psychiatric disorders. The patient’s subjective interpretation of the trauma also influences symptoms. In patients who are receiving treatment, the average duration of symptoms is approximately 36 months. In patients who are not receiving treatment, the average duration of symptoms rises to 64 months. More than one-third of PTSD patients never fully recover. Those who do not receive treatment may remain in a hyperaroused state and cause further damage to their brain, have difficulty maintaining a job, have difficulty developing or retaining relationships, and have a significant risk of suicide.

Both PTSD and TBI will be an ongoing challenge for healthcare providers at every venue of healthcare entry. Family practitioners will surely be involved in the diagnosis and management of these individuals. While PTSD and TBI may not be adequately diagnosed in the service member and veteran, any patient with combat experience should be considered at risk for these conditions both separately and apart. Screening for a history of blast injuries, concussions, and traumatic exposure should be part of the clinical workup of any former service member with deployment and combat experience during the Iraq and Afghanistan wars. Family practice physicians are especially likely to encounter these patients at various stages of their illness progression, and a knowledge of how combat and deployment effects illness and health is essential.