Negative effects of combat exposure can persist for decades, as Prigerson and colleagues ¹ 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).

PSYCHIATRIC SYNDROMES IN THE IMMEDIATE AFTERMATH OF MILITARY OPERATIONS AND TERRORIST EVENTS

Delirium

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.

Table 89-1 Common Psychiatric Syndromes and Phenomena in the Immediate Aftermath of Military Operations and Terrorist Events

Depression

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.

Acute Stress Disorder and Posttraumatic Stress Disorder

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

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 and Conversion Symptoms

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.

Dissociation and Dissociative Disorders

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.

Battle Fatigue and Operational Stress

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.

EFFECTS OF RESUSCITATIVE MEDICATIONS

Resuscitative medications are crucial to effective management of acutely injured patients. Unfortunately, many of them can cause neuropsychiatric or autonomic symptoms (Table 89-2). It is important to find out which medications an injured patient has received, in what amounts, and over what time period. Agents such as intravenous (IV) fluids (e.g., water), epinephrine, lidocaine, atropine, sedatives, nitroglycerin, and morphine are commonly used and have significant psychiatric or autonomic effects. These effects can resemble symptoms of primary psychiatric disorders. For example, atropine causes significant anxiety and anticholinergic effects. Epinephrine causes elevations in blood pressure and heart rate, and stimulates patients to feel anxious or panicky. Morphine causes sedation and impairs orientation and responsiveness.

Table 89-2 Resuscitative Medications That Can Cause or Mimic Psychiatric or Neurological Syndromes

Medications	Signs/Symptoms
Intravenous fluids (water)	Delirium/hyponatremia
Epinephrine	Blood pressure/heart rate elevations, anxiety
Lidocaine	Delirium, psychosis
Atropine	Delirium, anticholinergic effects, anxiety
Sedatives	Depressed consciousness/responsiveness
Nitroglycerin	Dizziness
Morphine	Sedation, delirium

CONFIDENCE IN A POTENTIALLY TOXIC ENVIRONMENT

Training and confidence in combat, rules of engagement, and containment procedures following toxic exposures may be important factors in limiting psychological contagion and unexplained physical symptoms. Military experience reveals that the risk of contagion and psychiatric conditions (such as conversion disorder) is lessened when potentially exposed personnel have received effective training. This allows personnel to feel confident in their odds of survival in a scenario involving chemical or biological threats. In addition to training, the military services place a high priority on the vaccination of groups at highest risk of coming into contact with biological agents or with persons (including health care workers) exposed to them. This also increases confidence in the ability to survive and to operate in toxic environments.

LEVELS OF CLINICAL PREVENTION AND INTERVENTION: SYMPTOMS VERSUS FUNCTION

Distress and highly emotional responses are nearly universal during combat. Therefore, initial psychiatric interventions must focus on the mobilization of effective function to allow the military mission to continue. Military psychiatric theory and doctrine have long operated on the principle that transient and near-universal symptoms (that represent normal responses) can become “medicalized” if physicians reinforce a view that these symptoms constitute a disease. Levels of clinical intervention are conceptualized and deployed according to this doctrine (Table 89-3).

Table 89-3 Levels of Psychiatric Intervention and Care following Combat or Terrorist Attack

Intervention Level	Indication
Support during combat	Consultations with leaders to mobilize effective function, to allow the military mission to continue
Combat stress control teams	Manage distress and acute psychiatric syndromes (as closely as possible to the area of operations) to maximize chances of a rapid return to effective function; use a mobile “holding environment”
Traditional psychiatric clinics	In the theater of operations, at aeromedical evacuation staging areas, or at fixed military bases in the United States, traditional psychiatric assessment and treatment can be provided at different times following one’s departure from the theater of operations
Inpatient psychiatric clinics	For patients with severe psychiatric illness or those with safety issues
Consultation-liaison services	For physically injured patients who need psychiatric care in military hospitals and rehabilitation units
Veterans Administration and community medical facilities	For veterans returned to their communities with ongoing mental health needs

Combat stress centers assist in the management of clinically significant distress or psychiatric syndromes; these centers are located as close to the area of operations as possible. This further helps to avoid pathologizing the service member and possibly setting the stage for longer-term disability. Sometimes, service members who are exposed to combat or terrorist attacks develop pathological states that require evacuation from the theater of operations. In these cases, more traditional psychiatric settings, such as outpatient clinics and inpatient psychiatric units, are called on for definitive treatment.

Other service members complete their combat tours of duty, but then develop mental health concerns or impaired function after returning home. In 2004 an anonymous survey ⁵ administered to United States servicemen either before, or 3 to 4 months after, deployment to Iraq (n = 2,530) or Afghanistan (n = 3,671) suggested that a significantly higher percentage met screening criteria for major depression, generalized anxiety, or PTSD (15.6% to 17.1%) after deployment to Iraq than they did after duty in Afghanistan (11.2%) or before deployment (9.3%). Over one-third of Iraq war veterans accessed mental health services in the year after returning home, and 12% were diagnosed with a mental disorder. These data highlight the importance of making mental health resources available to meet the needs of returning veterans, and not just to those recently exposed to combat or to terrorist attack.

FACTORS RELATED TO DEVELOPMENT OF PSYCHIATRIC DISORDERS AMONG SERVICE MEMBERS EXPOSED TO COMBAT OR TERRORIST ATTACK

Neurobiological Factors

The emotional and behavioral responses to trauma are rooted in a combination of social, autonomic, and voluntary mechanisms that are increasingly being understood at the molecular level (Table 89-4). In the immediate phase of the stress response, the release of corticotropin-releasing factor (CRF), the secretion of adrenocorticotropic hormone (ACTH), the surge of peripheral catecholamines, and the activation of cortical brain areas related to perception of threat accompany extremes of environmental stress. Changes in behavior and cognition correlate with these noradrenergic phenomena. The immediate impact of acute stress under most conditions is improved performance. However, as the capacity to act becomes inadequate to meet continued demands, the risk for cognitive dysfunction increases and behavior often becomes too narrowly focused. An aroused, but focused, state may result in a difficulty with shifting sets or changing plans of action (e.g., adapting). If extreme distress disrupts cognition and creates chaotic thinking, the overfocused fight-or-flight response may result in immobility.

Table 89-4 Factors Related to Development of Psychiatric Disorders among Service Members Exposed to Combat or Terrorist Attack

Factor Type	Observations
Neurobiological factors	Corticotropin-releasing factor release
	Adrenocorticotropin hormone release
	Peripheral catecholamine surge
	Amygdala activation
Predisposing factors	Women are at higher risk for postcombat PTSD, anxiety disorder, depression
	Men are at higher risk for substance use disorder, antisocial/violent behaviors
	Preexposure level of function
	Past traumatic exposure history and experience
Protective factors	Unit cohesion
	Unit loyalty and interpersonal trust
	Strong leadership
Precipitating factors	Intensity and duration of combat exposure
	Physical injury
	Witnessing death or atrocities
	Sexual assault
Mitigating and perpetuating factors	Safety and security of recovery environment
	Degree of secondary traumatization
	Rotation schedules
	Recognition and rewards
	Quality of medical and psychological assistance provided
	Psychosocial situation at home

PTSD, Posttraumatic stress disorder.

The immediate alarm response is followed by a cascade of neuronal and intracellular events that lead to elevated levels of CRF, increased synthesis of cortisol-related receptors, and activation of protein synthesis in subcortical nuclei of the amygdala that are responsible for the encoding of emotionally laden memories and the development of conditioned responses or habits. Hypersecretion of epinephrine also seems to exaggerate and consolidate fear-related memories. These changes may provide the molecular foundation for intrusive thoughts, exaggerated startle responses, and a general state of hyperarousal that is observed as clinically significant pathology in PTSD and ASD ⁶ (Figure 89-1).

Figure 89-1 Noradrenergic circuitry in the traumatic stress response.

Predisposing Factors

The level of functional impairment in the aftermath of combat or disaster is related to pretrauma function. Individuals who function marginally in social, or in their occupational, roles before combat or exposure to disaster are at increased risk of poor function after exposure to trauma. The extent to which past traumatic experiences may produce future resilience or vulnerability is unclear. If a person has successfully negotiated combat or disaster situations in the past, he or she may be less traumatized by subsequent exposures. On the other hand, if past traumatic experiences have produced PTSD or other psychiatric syndromes, further traumatic exposures may trigger exacerbations, or emergence, of new psychiatric disorders.

Protective Factors

In groups (such as exist in the military, police or firefighters, and paramedics) certain factors may diminish the potential sequelae of trauma. Loyalty and interpersonal cohesion within such organizations provide ready access to social supports during the acute phase of a disaster and its aftermath. When organizations possess effective leaders, an environment embodied by strong loyalty, mutual trust, and respect is more likely to exist. Such an environment may facilitate voluntary participation in high-risk rescue/recovery or combat missions and facilitate the synchronization of individual efforts necessary for success in these types of operations.

Precipitating Factors

The high intensity and long duration of a disaster or combat situation increases the likelihood of psychiatric casualties. Specific experiences, such as physical injury, or the witnessing of grotesque deaths, torture, or other atrocities, place individuals at increased risk for adverse mental health consequences. Deployments and peacekeeping missions disrupt families and are often poorly timed with regard to other life events. Exposure to multiple simultaneous stressors and to traumatic events increases the risk of pathological outcomes.

Mitigating or Perpetuating Factors

Ongoing factors (including the security and safety of recovery environments, the extent of secondary traumatization, rotation schedules, the degree of recognition or compensation for efforts, and one’s belief in the mission) all affect the rate and severity of psychiatric illness and symptoms of distress. Personal attributes or behaviors (such as “overdedication” to the task at hand) may further contribute to the development of dysfunction. Symptoms in civilian victims of war or the aftermath of disaster may be mitigated or exacerbated by several factors (e.g., by perceptions of community’s leadership, preparedness for disaster, response to crisis, recognition of heroes, and provision of medical, financial, or emotional assistance) both immediately after the crisis and over time.

MANAGEMENT AND CARE DELIVERY

General Principles

Secondary prevention (i.e., early intervention) begins with the initial triage and treatment of victims. It is important to create a “holding environment”—a location or locations where persons demonstrating such symptoms can be observed and monitored. This area should be sufficiently removed so as not to disrupt the ongoing triage and stabilization of life-threatening physical injuries, but close enough to allow reevaluation and further medical intervention should symptoms worsen. A holding environment may also prove to be a location where affected individuals attend to basic needs (such as food, shelter, and personal hygiene) that are critical to restoration of a sense of normalcy after engagement in prolonged or intense combat. In military psychiatry—particularly within United States Army doctrine—the Medical Detachment for Combat Stress Control (CSC) provides a mechanism for establishing just such a “mobile holding environment,” which can be rapidly relocated as the battlefront moves.

The United States military has attempted to decrease the incidence and severity of combat- and operations-induced psychiatric disorders through a number of mechanisms. Mental health teams are now routinely assigned to United States forces in combat and are deployed in operations other than war. Each branch of the United States military services has specialized rapid intervention teams to provide consultative assistance and acute treatment as necessary to units that have experienced traumatic events. These teams educate unit commanders on likely behavioral responses to stressful events and recommend leadership interventions that may reduce negative stress responses.

Therapeutic Interventions in Psychiatric Casualties

Neuropsychiatric symptoms may be manifest as an emotional response, may occur as a consequence of a neurological injury from a blast or other blunt trauma, or may occur—in the case of terrorist attack—from the neurotoxic effects of specific chemical or biological agents. Rapid identification of the underlying infectious, chemical, or physical insults to the brain will direct the treatment strategy. Regardless of etiology, delirium must be addressed rapidly, because the mortality rate from all underlying causes increases when symptoms of delirium go unaddressed.

Antipsychotics and anxiolytics used in the acute management of delirium or psychosis may alter levels of antimicrobial agents and acetylcholinesterase inhibitors used in the treatment of biological or chemical terrorist attack victims. Dose-related side effects (e.g., akathisia and somnolence) of antipsychotic agents may be mistaken for primary symptoms of an infectious, a post–physical-trauma, or a chemically mediated encephalopathy. Therefore, a conservative approach that minimizes the initial use of psychotropics is warranted. Short-acting hypnotics may be used to restore normal sleep patterns in cases where insomnia appears as the primary cause of dysfunction.

Psychosocial interventions have an important role in secondary prevention in military trauma victims. Group debriefing techniques and critical incident stress debriefings have been used, although there is no convincing evidence that such debriefings reduce the incidence of PTSD; in fact, several studies suggest that these interventions may be harmful.⁷ On the other hand, ongoing and frank discussions among squad members after a critical incident (such as an ambush or a raid) can open lines of communication to coordinate and evaluate the efficacy of actions, while fostering cohesion and group understanding of an event. These discussions, called “After Action Reports,” “Lessons Learned,” or “Historical Debriefings,” may serve to sustain the performance of persons critical to the management of the mission, may decrease individual isolation, and may help identify team members who may require further psychiatric or other mental health attention.

Cognitive-behavioral, as well as psychotherapeutic, approaches to anxiety, social withdrawal, depressive symptomatology, and hyperarousal can be effective; even brief interventions may reduce immediate symptoms of depression, anxiety, and PTSD and may diminish the development of long-term morbidity. Since medical resources may be quickly overwhelmed in combat situations, nonphysicians, provided they are appropriately trained in the delivery of these therapies, will allow for more effective care.

MILITARY PSYCHIATRIC CARE IN PEACETIME

When not directly involved in combat operations, peacekeeping, or humanitarian relief, military psychiatric practice is in many ways similar to civilian practice. In addition to operating a medical school funded by Congress to train military medical officers for medical practice in military operational and peacetime environments, the United States Depart-ment of Defense has tertiary care hospitals and clinics throughout the world. These facilities care for military personnel and their family members, and psychiatric residency training is provided at several of the larger military medical centers. When military medical resources are oversubscribed because of operational commitments, there is a comprehensive civilian network, TRICARE, available to military medical beneficiaries. TRICARE is the tri-service (Army-Navy-Air Force) health insurance program that provides managed health care for all department of defense beneficiaries (active duty, family members, retirees, and survivors) by integrating available care at military treatment facilities with regional partner civilian health care providers and facilities.

Military members who develop psychiatric disorders while on active duty are eligible for medical retirement disability pay, and continued treatment through a system of Veterans Administration hospitals. Individuals may be separated from service (without disability payment or ongoing medical care from the military) due to personality problems. Increasingly, civilian community hospitals provide ongoing psychiatric care to returning veterans, especially those in the National Guard and the Reserves. General psychiatrists must therefore understand the basic principles of military psychiatry and learn about the psychiatric disorders most prevalent in those who have been exposed to combat or terrorist attacks.

ETHICAL CHALLENGES

Unlike earlier United States military experiences in the Persian Gulf, the current conflicts in Iraq and Afghanistan have created a significant population of detainees—prisoners of war, unlawful combatants, third-party nationals, and other persons captured on the battlefield and held for indefinite duration—for whom the United States must assume responsibility for humane medical (and psychiatric) treatment under the provisions of the Geneva Conventions. Providing compassionate treatment for enemy combatants in hospital beds alongside ill or combat-injured United States service members creates obvious challenges associated with dual agency for professionals (who, as they honor the requirements of their medical professional codes of conduct, must make triage decisions involving patients who may resume efforts to kill or injure United States forces once released). Further, released combatants and noncombatants may have uncertain medical follow-up that is limited to the standards of the nation in which further care will be provided.

Physicians, including psychiatrists, may be asked to provide consultative assistance to persons who gather intelligence on detainees. This has created an ethical dilemma. Position statements and reports of a number of professional organizations (including the American Medical Association)⁸ and the Department of Defense indicate that health care professionals who provide treatment to detainees must not assist in interrogations, and that torture, or otherwise inhumane or coercive interrogations, is not acceptable. However, disparities in these reports suggest that the degree to which health professionals not engaged in the treatment of detainees may apply their knowledge and skill sets to assist interrogators in safe, ethical, and humane interrogations remains unsettled.