1. Chapter 39: The Military and Their Families

2. Introduction
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.
Deployment can adversely affect one’s health and psychological well-being
The most pervasive and disabling experiences to military troops, families, and survivors are threats to psychological health and well-being.

3. Medical Disorders of Veterans Vietnam War
Military personnel are exposed to conditions that make them vulnerable to developing a variety of medical conditions
Vietnam War PTSD, Agent Orange, Birth defects, Hepatitis B & C, HIV & Aids, Substance Abuse, Military sexual trauma

4. Persian Gulf War
Persian Gulf War 1990 – not determined: PTSD, Gulf War illnesses, Leishmaniasis, ALS, exposure to chemical smoke, biological agents & depleted uranium, immunizations, substance abuse and military sexual trauma.

5. Global War on Terror
Global War on Terror 2001 to present: PTSD, TBI, Multidrug resistant Acinetobacter, Leishmaniasis, Vision loss, hearing loss, tinnitus, traumatic amputation, exposure to depleted uranium, substance abuse and military sexual trauma.

6. Traumatic Brain Injury
TBI is a complex injury with a broad spectrum of symptoms and disabilities that can adversely impact quality of life. Classifications based on intensity: Primary blast injuries (direct injury from atmospheric pressure), Secondary injuries (shrapnel or missiles), Tertiary injuries (propelled by the blast and hit something), Quaternary (sequelae of the blast such as burns, PTSD)

7. Posttraumatic Stress Disorder
PTSD: 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.
Results 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.

8. Three Groups of PTSD Symptoms
Re-experiencing symptoms (1 or more): recurrent intrusive thoughts, disturbing dreams, flashbacks, emotional distress from reminders, and physical reaction from reminders. Avoidance symptoms (3 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 and sense of foreshortened future. Hyperarousal symptoms (2 or more): sleep disturbance, increased anger/irritability, decreased concentration, hypervigilance, and hyperactive startle.

9. Pharmacological Treatment of PTSD
SSRIs are considered the first line of pharmacological treatment for individuals diagnosed with PTSD. This med helps with depression, irritability, anxiety and intrusive thoughts
SNRI, venlafaxine, also helpful.
Atypical antipsychotics used alone or in combination with antidepressants
Benzodiazepines may be helpful in anxiety, insomnia, and hyperarousal but use with caution d/t abuse.
The alpha-blocker Minipress has been effective in managing hyperarousal and re-experiencing symptoms by decreasing nightmares and normalizing sleep.
Mood stabilizers have not been demonstrated to be helpful.

10. Nonpharmacological Treatment of PTSD
Cognitive behavioral therapy (CBT)
Be nonjudgmental and supportive
Assure client that his or her feelings and behaviors are normal reactions
Encourage client to express feelings; provide individual therapy that addresses loss of control or anger issues
Assist client to develop adaptive coping mechanisms and to use relaxation techniques
Encourage support groups
Prolonged exposure (PE) Interventions include:
Facilitate a progressive review of the trauma experience
Encourage client to establish and reestablish relationships.
Inform client that hypnotherapy or systematic desensitization may be used as a form of treatment.

11. Other Psych Disorders
Suicide: It has been estimated that as many as 20% of all suicides in this country are documented among veterans. In the first half of 2009, more American soldiers committed suicide than died in combat.
Substance Use Disorders: It is estimated that one in four deaths among veterans is attributable to use of alcohol, tobacco, or hallucinogens and that more than 7% of veterans meet criteria for substance abuse problem.
Military Sexual Trauma: Approximately 1:5 women and 1:100 men seeking treatment from the VA respond “yes” when screened for MST. Survivors of MST may be reluctant to report abuse.
Women are more likely to be victims of physical and domestic abuse and 10x more likely than their male counterparts of being victims of MST.

12. Challenges to Care
The five challenges to care are psychological health, access to services and support, communication challenges, deployment, and frequent relocation.
Education, debriefing, and supportive therapy are essential to ensure smooth reintegration for these veterans.
Although the rates of those suffering physical and psychological injuries may be fairly high, the percentage who actually seek treatment is disproportionately low.
Efforts must be increased to change the culture and educate veterans about the potential benefits of services including mental health services to make it more likely that these services will be utilized.

13. Impact on Families and Clinicians
Deployment for military families can produce many issues and hardships
Creating avenues and opportunities for family members to cope with deployment and healthy reintegration in routines prior to deployment is a key supportive intervention for the psychiatric nurse.
Mental health providers working with PTSD may become vulnerable to the effects of trauma by proxy called vicarious traumatization.
Compassion fatigue and burnout are very high in health care workers.
It is critical that providers working with survivors of trauma be aware of their personal feelings and vulnerabilities to provide quality clinical care.

14. It’s Going to be OK with our help!