Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment (2012) / Chapter Skim
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8 Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities
8 Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities
Pages 293-338
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From page 293... ...
Three major categories of co-occurring conditions are considered: psychiatric (including depression and substance use disorders) , medical (including chronic pain, TBI, and spinal cord injury)
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. Three-fourths of male Vietnam veterans who had PTSD also had a lifetime diagnosis of alcohol abuse or dependence, 44% had a lifetime diagnosis of generalized anxiety disorder, and at least 20% had a lifetime diagnosis of depression or dysthymia.
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. Collaborative stepped-care approaches and rehabilitative interventions that simultaneously target PTSD and comorbid conditions and psychosocial complexities have been proposed as an essential treatment delivery model for active-duty military and veteran populations (Engel and Katon, 1999; Engel et al., 2008; Gilbody et al., 2006; Zatzick et al., 2004, 2011, 2012)
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; the results have been mixed. In a recent RCT of 98 male veterans who had both substance use disorder and PTSD symptoms and who were recruited from an outpatient VA substance use disorders clinic, substituting Seeking Safety for part of the usual treatment was associated with better drug use outcomes than in the controls.
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. A review of medical records of OEF and OIF veterans who were seeking treatment at a VA polytrauma clinic found that 82% of them had documented chronic pain (Lew et al., 2009)
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Originally developed for use in sports medicine, this musculoskeletal pain management approach is individually tailored to the patient (on the basis of self-reported pain, medical history, structural measures, and functional-capacity measurements) with the goal of returning him or her to activity rather than focusing on pain symptoms (Mayer et al., 2003)
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to evaluate the effectiveness of combined PE for PTSD and chronic pain treatment in active-duty orthopedic-trauma patients. The STRONG STAR RCT will compare outcomes in four study arms: a combined abbreviated PE and FORT-based pain approach, a PE group, a FORT group, and a treatment-as-usual group assessed immediately after treatment and at 6-month and 12-month follow-ups.
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Traumatic Brain Injury TBI is defined by the DoD and the VA (DCoE and DVBIC, 2009) as a traumatically induced structural injury and/or physiological disruption of brain function as a result of external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: • Any period of loss of or a decreased level of consciousness; • Any loss of memory for events immediately before or after the injury;
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. Falls, motor vehicle incidents, and assault also cause TBIs in this population.
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. Co-Occurrence of TBI and PTSD Symptoms of PTSD and mTBI may have considerable overlap, and this presents a diagnostic challenge.
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, 97% reported chronic pain, and 71% met the criteria for PTSD. In a comprehensive review of medical records of 340 OEF and OIF veterans seen at a level-2 polytrauma network site, Lew et al.
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. Treatment for Co-Occurring TBI and PTSD Few empirical studies have examined treatment protocols that specifically targeted co-occurring TBI and PTSD symptoms in civilian populations (Bryant et al., 2003; McAllister, 2009; McMillan et al., 2003)
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The Co-occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health (DCoE, 2011) evolved from a 2009 VA conference
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Adoption of body armor and armored vehicles has improved battlefield injury survival rates; however, the enhanced protection from injuries to vital organs has meant that a number of service members have survived catastrophic spinal cord injury, amputation, and burns (in addition to TBI)
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(2010) examined the effect of mental health diagnoses on cardiovascular risk factors -- including hypertension, dyslipidemia, and diabetes -- in a sample of approximately 303,000 OEF and OIF veterans who received care at VA facilities from 2001 through 2008.
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found that after adjustment for coronary risk factors and depression, a diagnosis of PTSD more than doubled the risk of death from early-age heart disease. The third prospective study, which sampled 1,059 civilian women, found that after adjustment for coronary risk factors and depression, participants who had five or more PTSD symptoms were at significantly higher risk of incident coronary heart disease than participants who had no PTSD symptoms (Kubzansky et al., 2009)
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, including one that used a sample of 2,490 male Vietnam veterans, were negative. Using a large sample from the Millennium Cohort Study, Boyko et al.
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. That finding is similar to the significantly higher divorce rate in Vietnam veterans than in the general population; rates of divorce are even higher in Vietnam veterans who have PTSD (Kulka, 1990)
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When age was controlled for, odds ratios showed that male OEF and OIF veterans who had PTSD were 1.9–3.1 times more likely to perpetrate aggression toward their female partners and 1.6–6.0 times more likely to report experiencing female-perpetrated aggression than OEF and OIF veterans who did not have PTSD and Vietnam veterans who had PTSD. Typically, deployment and reintegration stressors weigh heavily on service members or veterans and their partners as they navigate complicated adjustments and transitions back into the community.
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. A small study that examined IPV in a sample of mainly OEF and OIF veterans (84% who had PTSD)
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In 2009, FOCUS services were made available to Army and Air Force families at selected installations throughout the United States. The preventive interventions in the program use psychoeducation, emotional regulation skills, problem solving skills, communication skills, and management of traumatic stress reactions (Lester et al., 2011)
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. In general, the rates of child maltreatment in military families decreased through the 1990s, increased to 5.2 per 1,000 children in 2000 and 6.2 per 1,000 children in 2004, and decreased to 5.0 per 1,000 children in 2007, the latest year for which data are available (Robichaux and McCarroll, 2011)
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One RCT found child–parent psychotherapy to be more efficacious than case management plus treatment-as-usual for preschool children exposed to IPV. Children in the child–parent psychotherapy group had decreased total behavior problems and PTSD symptoms, and their mothers (most of whom had PTSD)
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. Women who received PE experienced a significantly greater reduction of PTSD symptoms and were significantly less likely to meet PTSD diagnostic criteria than women who received present-centered therapy.
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(2005) found that the severity of PTSD symptoms correlated with work performance.
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Patients had high rates of co-occurring other psychiatric conditions, including alcohol dependence (42%) , alcohol abuse (21%)
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Although OEF and OIF veterans did not differ significantly with regard to PTSD symptoms, OIF veterans reported significantly more depression, alcohol use, and substance use than OEF veterans (Eisen et al., 2012)
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For example, alcohol misuse was recently shown to be related to PTSD symptoms in OEF and OIF veterans (Jakupcak, 2010)
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, and several studies have corroborated the significant association between PTSD and problem gambling in veteran populations. Lifetime PTSD was related to current pathologic gambling in Vietnam twin-study veterans, and active PTSD symptoms predicted gambling problems in older veterans (Levens et al., 2005; Scherrer et al., 2007)
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Overall, 23% had been incarcerated at some time in their lives. Veterans of the 1990–1991 Gulf War who had been incarcerated were three times more likely to report PTSD symptoms and depression and twice as likely to report alcohol abuse and anxiety.
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These programs have demonstrated through program evaluations that they are effective in reducing homelessness. A recent uncontrolled study of three residential care programs, the most intensive interventions, indicated that of 1,003 participating veterans, all but 11% had a serious mental health or substance abuse disorder.
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1997. Inter personal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder.
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2010. Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from Iraq.
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2009b. Posttraumatic stress disorder and health-related quality of life in patients with coronary heart disease: Findings from the heart and soul study.
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2001. Posttraumatic stress disorder and depression symptomatology in a sample of Gulf War veterans: A prospective analysis.
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2011. Symptoms of posttraumatic stress disorder in men who sustain intimate partner violence: A study of helpseeking and community samples.
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1992. Problems in families of male Vietnam veterans with posttraumatic stress disorder.
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2009. A prospective study of posttraumatic stress disorder symptoms and coronary heart disease in women.
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2009. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad.
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2008. Acute stress disorder and posttraumatic stress disorder: A prospective study of prevalence, course, and predictors in a sample with major burn injuries.
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2011. Complicating factors associated with mild traumatic brain injury: Impact on pain and posttraumatic stress disorder treatment.
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2008. Understanding sequelae of in jury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder.
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2009. Exploring the convergence of posttraumatic stress dis order and mild traumatic brain injury.
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2010. Intimate partner aggression perpetrated and sustained by male Afghanistan, Iraq, and Vietnam veterans with and without posttraumatic stress disorder.
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1997. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans.
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2010. Multisite investigation of traumatic brain injuries, posttraumatic stress disorder, and self-reported health and cognitive impair ments.
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