Military troop deployment for the United States has historically extended to 130 countries. For the past 50 years, deployments in Japan, Germany, South Korea, and, more recently, Iraq and Afghanistan have included troops from the Army, Air Force, Navy, Marine Corps, Coast Guard, National Guard, and Reserves (Deployments and conflicts, 2011; Military Hub, 2011). The Department of Defense (DOD) estimates of military troop deployment in past wars and current deployments are presented in Table 39-1 (Sayer et al, 2010; Deployments and Conflicts, 2011).

Multiple illnesses, health risks, and concerns have been identified in military service personnel during past and current wars. For veterans of wars in Iraq and Afghanistan, the incidence of mental health issues has become one of the leading health problems, second only to orthopedic issues (Rosenberg, 2008; Walker, 2010). Veterans and their families are confronted with many mental health issues that range from coping with initial and multiple deployments to depression, substance abuse, anxiety, family dissolution, homelessness, violence, and incarceration (Seal et al, 2007; Snell and Tusaie, 2008; Vietnam Veterans of America 2008).

Military culture is complex and separate from civilian life. Deployment can adversely affect one’s health and psychological well-being. The toll of combat experiences can be substantial and not readily evident to health care providers and the public (Capps, 2010). The most pervasive and disabling experiences to military troops, families, and survivors are threats to psychological health and well-being. Examples of health risks and illnesses dating from the Vietnam War to the present global war on terror are identified in Table 39-2 (Vietnam Veterans of America 2008; U.S. Department of Veterans Affairs [VA] Office of Academic Affiliations, 2009).

Medical Disorders of Veterans

Military personnel are exposed to conditions that make them vulnerable to developing a variety of medical problems. Soldiers may be exposed to illnesses such as malaria, tuberculosis, and hepatitis A, B, and C. Another exposure-linked illness, leishmaniasis, has been found in 88 countries of the Middle East, Central and South America, Africa, Asia, and southern Europe. This condition is transmitted by the sand fly and can cause skin lesions or even damage to bone marrow, liver, and spleen.

Exposure to various adverse conditions also contributes to the development of a variety of neurological problems. Many military personnel who returned from the Persian Gulf War developed conditions such as chronic fatigue, idiopathic migraines, fibromyalgia, and irritable bowel syndrome. These illnesses were originally referred to as Gulf War Syndrome but are now more commonly referred to as Medically Unexplained Symptoms (MUS).

Hearing problems are a common condition afflicting military personnel, accounting for 10% of all service-connected disabilities. Hearing problems may develop as the result of traumatic injury or repeated exposure to noise hazards including gunfire, explosions, and loud equipment. Examples of hearing problems include partial or total hearing loss and tinnitus (ringing in the ears). Each of these may be temporary or permanent.

Returning veterans may experience cognitive difficulties such as concentration problems and memory loss. Other complications can include physical illness, traumatic injury, sleep deprivation, stress, migraine headaches, and psychiatric conditions. Veterans commonly experience sleep disorders including insomnia, sleep apnea, restless legs syndrome, and narcolepsy. These conditions, if left untreated, can contribute to other medical problems such as obesity and heart disease, as well as lethargy, fatigue, increased trauma from accidents, and decreased quality of life.

Traumatic Brain Injury

There has been a significant increase in the number of veterans with traumatic brain injury (TBI) during recent military conflicts. The increase in number of identified cases may be related to more sophisticated diagnostic capabilities. TBI is a complex injury with a broad spectrum of symptoms and disabilities that can be disabling and can adversely impact quality of life (Snell and Halter 2010). It is discussed in Chapter 22.

Advances in technology have led to improvements in protective gear, which have increased survival rates from traumatic injury. The style of current warfare contributes to the increase in the number of TBI cases. Improvised explosive devices (IEDs) are the typical weapons of choice used by the opposing forces in Iraq and Afghanistan, and multiple blast injuries including TBIs have occurred as the result of these explosive devices. In spite of advances in protective equipment, the head, face, eyes, ears, and brain often remain vulnerable to blast injuries.

Many cases of TBI are overlooked because the symptoms are diffuse and may not initially suggest any specific brain injury as the primary cause. Often symptoms do not surface until well after the initial injury, which can further complicate accurate diagnosis of TBI. Also, mild TBI may not be the primary or most urgent injury that occurs in the field, and it may be missed during triage.

TBI can be classified based on intensity (i.e., mild, moderate, or severe) or on the actual type of blast injury:

• Primary blast injuries occur as a direct injury from changes in atmospheric pressure.

• Secondary injuries are caused by shrapnel or missiles that are propelled by the blast.

• Tertiary injuries are caused when the individual is propelled by the blast and strikes the ground or other object.

• Quaternary injuries result from the sequelae of the blast, such as burns, inhalation injuries, or even posttraumatic stress disorder (PTSD).

Cognitive symptoms associated with TBI include problems with memory, concentration, language, and executive function. Emotional and behavioral problems may include depression, anxiety, increased mood lability, apathy, anger, irritability, impulsivity, and personality changes. Physiological problems related to TBI can include headache, pain, vision and hearing problems, dizziness, seizures, insomnia, appetite and weight changes, fatigue, and sexual dysfunction (Zeitzer and Brooks, 2008).

Effectiveness of treatment is dependent on early and accurate diagnosis of symptoms. A useful three-question TBI self-report instrument for detecting TBI in troops returning from deployment in Iraq and Afghanistan is presented in Figure 39-1.

Critical Reasoning

How would you respond if the spouse of your patient, who is a veteran, asks you whether his TBI will have permanent effects?

Psychiatric Disorders of Veterans

Veterans may develop a variety of mental health disorders, including mood disorders, anxiety disorders, thought disorders, and substance abuse disorders. Exposure to certain conditions can exacerbate symptoms of a personality disorder that may have been previously undiagnosed or in remission.

There are often significant physical and mental health co-morbidities in veterans. Symptoms may include pain, somatic problems, neurological problems, memory/cognitive problems, sleep disturbance, anxiety, and mood and behavioral changes. Psychiatric symptoms can have an acute or insidious onset. They often evolve diffusely and with unclear etiology, which can complicate the diagnostic and treatment profile.

Presentation of multiple complex symptoms often requires the use of polypharmacy, which becomes the rule rather than the exception. This in turn can contribute to treatment adherence issues and increase the potential for adverse medication reactions.

Posttraumatic Stress Disorder

PTSD is defined as an anxiety disorder that arises when a person has been exposed to a life-threatening traumatic event that provokes terror, horror, and helplessness, such as combat experiences (American Psychiatric Association, 2000). PTSD involves a range of physical, cognitive, emotional, and behavioral symptoms resulting from psychological trauma (see Chapter 15). The cause of PTSD is complex and involves many factors. There is evidence that the potential to develop PTSD may be influenced by genetics, early life experience, and health disparities as well as the exposure to a traumatic experience.

Like other anxiety disorders, PTSD symptoms result from excessive activity of the sympathetic nervous system. The exaggerated effect of the fight-or-flight response is responsible for physiological symptoms associated with hyperarousal and re-experiencing phenomena. This response also stimulates the limbic system and fear circuitry of the brain, which in turn triggers abnormal emotional and behavioral responses.

PTSD consists primarily of three groups of symptoms:

1. Re-experiencing symptoms (one or more)

• Recurrent intrusive thoughts

• Disturbing dreams

• Flashbacks

• Emotional distress from reminders

• Physical reaction from reminders

2. Avoidance symptoms (three or more)

• Avoids thoughts or feelings reminding them of trauma

• Avoids people, places, or things reminding them of trauma

• Traumatic events blocked from memory

• Decreased interest in activities

• Feeling detached/aloof

• Blunted affect

• Sense of foreshortened future

3. Hyperarousal symptoms (two or more):

• Sleep disturbance

• Increased anger/irritability

• Decreased concentration

• Hypervigilance

• Hyperactive startle

A diagnosis of acute stress disorder is made when criteria for PTSD have been met but symptoms have persisted for less than 30 days since the initial trauma. Early diagnosis and treatment of symptoms have been found to provide better outcomes for individuals with PTSD. A useful tool for diagnosis and screening for PTSD is the PTSD Checklist—Military Version (PCL-M), presented in Figure 39-2.

Persons diagnosed with PTSD have a greater incidence of behavioral health problems and social dysfunction (Nayback, 2008; Jankowski, 2011). Approximately 18% to 20% of returning veterans who were deployed multiple times suffer from PTSD. The number of veterans seeking treatment for PTSD increased an estimated 70% from 2006 to 2007, and mental health treatment is the second largest treatment provided for returnees from Iraq and Afghanistan (National Security Archive, 2006).

Careful attention is needed to distinguish between trauma exposure and PTSD. A measure of trauma exposure examines whether a person has gone through a traumatic event such as combat, an accident, or sexual abuse, identifying when the event occurred and how the experience affected the person. In contrast, a measure of PTSD identifies how a person felt or acted after going through a traumatic event. Some evaluations inquire about other issues, such as depression or relationship problems, but these are not used in making a diagnosis of PTSD.

Critical Reasoning

PTSD can develop after a traumatic event. Do you think responses differ based on whether the event includes physical or psychological trauma?

Pharmacological Treatment of PTSD

Pharmacological interventions have been found to be useful in the treatment of the positive symptoms of PTSD including hyperarousal and re-experiencing phenomena, and to a lesser extent the negative symptoms of PTSD, including avoidance symptoms. Selective serotonin reuptake inhibitors (SSRIs) are considered the first line of pharmacological treatment for individuals diagnosed with PTSD. These medications help with symptoms including depression, irritability, anxiety, and intrusive thoughts. The serotonin-norepinephrine reuptake inhibitor (SNRI), venlafaxine, also has been found to be helpful in the management of this disorder.

Atypical antipsychotics have been used alone or in combination with antidepressants in individuals who have demonstrated a suboptimal response to antidepressants alone. Benzodiazepines may be helpful in managing anxiety, insomnia, and hyperarousal, but they should be used cautiously because of the high degree of co-morbid substance abuse in veterans. Mood stabilizers have not been demonstrated to be effective in the management of PTSD symptoms. The alpha-blocker prazosin (Minipress) has been shown to be effective in managing hyperarousal and re-experiencing symptoms by decreasing nightmares and normalizing sleep.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Policy and Advocacy in Mental Health Care
2. Implementing the Nursing Process: Standards of Practice and Professional Performance
3. Child Psychiatric Nursing
4. Neurobiological Responses and Schizophrenia and Psychotic Disorders

Stay updated, free articles. Join our Telegram channel

Join