CHAPTER 89 Military Psychiatry
The discipline of military psychiatry extends psychiatric practice beyond the boundaries of traditional environments of care. The United States military has established—within the United States and on its bases abroad—an extensive network of community mental health clinics, combat stress centers, ambulatory care facilities, hospitals, and tertiary medical centers to address the wide range of psychiatric illnesses observed in the civilian setting. The stresses of military life—frequent moves, prolonged separations between service members and their families, repetitive deployments, and often hazardous duty in a variety of humanitarian assistance, peacekeeping, and battlefield settings—create unique challenges for the military psychiatrist.
In the theater of war, there is the terror of unanticipated injury, loss, and death. During military operations psychological injury may occur in conjunction with physical injury, exposure to the injury and death of others, potential exposure to biological or chemical agents, disruption of one’s physical environment, or as a consequence of the terror and helplessness that these events combine to evoke. Therefore, the knowledge base, skills, and professional attitudes required of a military psychiatrist must include more than those associated with traditional clinic or hospital-based practice.
Negative effects of combat exposure can persist for decades, as Prigerson and colleagues1 demonstrated in a study of 2,583 men ages 18 to 54 who received standardized psychiatric interviews in the National Comorbidity Survey. They found that combat exposure resulted in high prevalence rates of psychiatric diagnoses and psychosocial problems: 28% had posttraumatic stress disorder (PTSD); 21% engaged in spousal or partner abuse; 12% experienced job loss; 9% were currently unemployed; 8% had 12-month substance abuse problems within 1 year; 8% underwent divorce or separation; and 7% sustained major depressive disorder (MDD).
In combat or following terrorism that leads to major illness or injuries, volume depletion and metabolic derangements can cause delirium (manifest by clouded consciousness, agitation or diminished responsiveness, and disorientation) (Table 89-1). Pharmacological agents (such as neuroleptics and benzodiazepines) used to manage agitation can further complicate medical assessment and management, especially surrounding combat-related injuries. Symptomatic management of behavioral problems with sedating agents should be initially reserved to protect the life or safety of the patient and other patients or staff. Resolution of the etiology of the delirium should be the primary goal; resolution requires attention to metabolic sequelae of the injury. Common causes of delirium in combat or in disaster settings include hypovolemia, hypoxemia, central nervous system mass effects, infection, and adverse effects of resuscitative medications.
Depressed mood or resignation in the aftermath of combat or a terrorist event may be difficult to distinguish from the malaise and lassitude common among the prodromes to exposure to many chemical and bioterrorism agents. When depressed mood and associated depressive symptoms disrupt social and occupational function, MDD is diagnosed.
Symptoms of acute stress disorder (ASD) and PTSD include reexperiencing phenomena (such as dreams and flashbacks), hyperarousal, avoidance of events or situations that resemble—even symbolically—the original trauma, and dissociative phenomena (such as derealization or numbing).2 When symptoms persist for more than 1 month, PTSD is diagnosed. ASD and PTSD do not occur in a vacuum. When one of these disorders exists, it is highly probable that another psychiatric condition (see Table 89-1) exists as well, especially MDD, panic attacks, panic disorder, substance use disorders, and generalized anxiety disorder. Having a physical injury increases the risk of both ASD and PTSD.3
Hypochondriasis is the fear or belief that one has a serious disease based on the misinterpretation of bodily symptoms. Anxiety and fear about the disease persist despite normal medical evaluations and reassurance. In the generally anxious atmosphere and uncertainty following combat and terrorist events, patients with hypochondriasis may have particular problems managing their anxiety and beliefs, and people without a documented diagnosis of hypochondriasis may seek treatment for the first time. Six months of symptoms are required before making this diagnosis. Hypochondriasis is a chronic condition with a poor prognosis. However, subsyndromal hypochondriacal fears may be widespread following a terrorist event or potential combat-related toxic exposure, and should be managed with reassurance and with a degree of tolerance for a patient’s requests for appointments and examinations by his or her primary care provider.
Unexplained physical symptoms are common after combat and disasters. Not all unexplained physical symptoms are conversion symptoms, although anecdotal reports of conversion are well documented after terrorist and combat events. Unfortunately, there is little scientific basis for prevention and care of unexplained physical symptoms. Nonetheless, it is important that persons with unexplained symptoms be identified in the triage process so that inappropriate and potentially harmful treatments (that could also draw resources away from victims who need treatment) are not initiated.
Use of biological or chemical agents presents a challenging differential diagnosis and contagion problem. During World War I “gas hysteria” was common and threatened the integrity of entire military units. Psychological casualties in chemical and biological threat scenarios may outnumber and prove more costly in terms of personnel losses than physical casualties. Acute symptoms of gas hysteria may mimic symptoms (e.g., dyspnea, coughing, aphonia, and burning of the skin) of poison gas exposure. Patients may have air hunger and other symptoms that are consistent with anxiety and panic. Factors that predispose to psychological contagion include rates of wounding/exposure in the unit, lack of sleep, and lack of prior experience with these phenomena/attacks.4 Therefore, it is important to know what substances a patient has not been exposed to. Following a faked chemical or biological agent threat, there may be a large number of individuals who fear that they have been exposed and will have realistic symptoms based on their knowledge of the alleged agent and the vital sign abnormalities produced by anxiety/fear.
The essential feature of dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The centerpiece of the diagnosis, to discriminate it from situational dissociation, is the presence of significant distress, or significant disruption in social or occupational function. Situational dissociation is common in the context of any traumatic or terrorist event. Dissociation may be adaptive in the immediate aftermath of a trauma—dissociation may prevent the eruption of intolerable affect or the unleashing of potentially dangerous impulses or behaviors (e.g., fleeing the scene).
It is important not to confuse dissociation and diminished neurological responsiveness. A key role of a psychiatrist in the immediate aftermath of a disaster is to help identify dissociation. One should gently tap the patient on the shoulder, ask if there is anything the patient needs, and ask if the patient knows where he or she is and what day it is. Watching for a muted, but appropriate, response in a dissociating person should indicate his or her level of consciousness and suggest that orientation is grossly intact. Identification of otherwise uninjured disaster victims who are simply dissociating frees up medical resources for other patients.
Beyond traditional psychiatric disorders, “battle fatigue” and “operational stress” are also important practical concepts in military psychiatry. Symptoms such as gastrointestinal distress, tremulousness, and transient perceptual disturbances (including depersonalization and derealization) occur in response to the traumatic exposure, to sleep deprivation, to loss of social supports, or to any combination of these stressful factors associated with military operations. Minor injury, parasitic infection, starvation, heat exhaustion, or cold injury may also deplete adaptive homeostatic mechanisms and contribute to operational stress symptoms.