Thursday, December 13, 2007

Disadvantages of Nurses Strategies That Would Assist the Military With Post-Traumatic Stress Disorder (PTSD) In Veterans of Foreign Wars.

“Among American Vietnam theater veterans 31% of the men and 27% of the women
have had PTSD in their lifetime. Preliminary findings suggest that PTSD will be present in at least 18% of those serving in Iraq and 11% of those serving in Afghanistan,” (National Center for PTSD, 2005, p.4). As troops return from deployments in Iraq and Afghanistan, the need for post-traumatic stress disorder treatment is expected to increase.
Due to the ongoing war in Iraq and conflict in Afghanistan, nurses needs to implement strategies that assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans.
Combat linked trauma has existed as long as humans have made war. In the U.S., the problem was first identified among World War I, World War II, and Korean War vets (National Center for PTSD, 2005, p.4). According to American Journal of Nursing, in World War I it was called “shell shock”; in World War II, “combat fatigue.” Although the difficulties combat veterans experience have long been recognized, it wasn’t until 1980, the year posttraumatic stress disorder (PTSD) was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition ( Kaiman, 2003, ¶ 3). Families welcoming soldiers home encountered profoundly damaged men: chronically tense, clinically paranoid, and often unable to maintain jobs or carry on social relations—some prone to violence (National Center for PTSD, 2006). In today’s era of global conflict, the number of patients with war related trauma has soared. Their wounds are not just physical, but mental. Despite the soaring numbers of war related trauma among veterans returning from Iraq and Afghanistan, there are not near enough programs that effectively identify and treat Post Traumatic Stress Disorder among these veterans after deployment. Such programs are an important part of identifying the mental health burden of the current war and ensuring that there are adequate resources to meet the mental health care needs of veterans returning from Iraq and Afghanistan. Unfortunately, individuals with PTSD are often undiagnosed, which highlights the importance of proper recognition, assessment, and diagnosis. Providers need a quick, readable, accessible reference guide and annual education (Guess, 2006, ¶1).
There is current evidence determining what prerequisites are necessary to provide a firm basis for implementing a military psychological screening program. “Screening programs need to be acceptable: clinically, ethically, and socially, to the soldiers being screened. Screening programs also need to be simple, precise and validated in order to accurately identify psychological problems such as Post Traumatic Stress Disorder. Unlike anonymous surveys, it is likely that current pre-deployment and post-deployment questionnaires under identify psychological problems,” (Rona, 2005, ¶ 7). Nurses can play a critical role in determining that program prerequisites are met by organizing an active committee that will validate current screening programs. Nurses must take into account that surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments (National Center for PTSD, 2005, p.8). Early recognition of PTSD signs and symptoms are important for the most effective treatment (Guess, 2006).
To be diagnosed with Post Traumatic Stress Disorder, patients must meet four criteria: a history of “reexperiencing” the trauma (with associated panic symptoms such as dyspnea and palpitations) along with chronic social avoidance and withdrawal, emotional numbness, and hyperarousal (amplified startle reflexes or hypervigilance in anticipation of flight or fight) (Hoge, 2006). Although written psychological questionnaires have not been proven to be an effective tool on determining Post Traumatic Stress Disorder, it is the primary tool being used. “The Fort Lewis Soldier’s Wellness Assessment Pilot Program (SWAPP) has been developed to identify the susceptibility of returning troops to mental health ailments through questionnaires and face-to-face on-site interviews with nursing staff. This pilot program is giving nurses the ability to identify soldiers that are at risk of having Post Traumatic Stress disorder. Nurses are scheduling follow-up appointments immediately if a soldier is identified as at risk of having Post Traumatic Stress Disorder. Although this is a test site for such a program, on-site SWAPP assessments have helped improve access to health care and are working to breakdown the fear of soldiers not wanting to ask for help,” (Cantwell, 2006). By nurses having the proper education and access to more programs like SWAPP, nurses can continue to work together with each other, other health care professional and soldiers to deteriorate this fear that soldiers have developed.
Treatment for Post Traumatic Stress Disorder starts with education. Knowledgeable nurses can play a major role in the recognition and treatment of Post Traumatic Stress Disorder while in primary care settings or in such programs as SWAPP. Soldiers and their family members need to be educated by nurses on the development of the disorder, effects that Post Traumatic Stress Disorder has on the soldier and family, and effective treatments available. Nurse can provide patients and their family members with educational materials that help them understand that their effected family member’s feelings are related to the Iraq war and its consequences (Schnurr, P., 2004, p.59). Treatment for PTSD is really very practical and involves common sense. Soldiers have regular conversations with a trained counselor, in order to think about their situation and how the soldier wants to change it (National Center for PTSD, 2005, p.8). Through this form of psychotherapy the soldier learns more about what PTSD is and how it affects them . Although psychotherapy along with medication seems to work best for most, there are many other treatments available. While in a safe environment exposure therapy helps patients confront trauma-related situations, people, objects, memories, or emotions that evoke intense fear. Cognitive therapy helps patients identify and change assumptions, beliefs, and thoughts that lead to disturbing emotions and impaired functioning. Anxiety management, also called stress inoculation training, teaches patients skills they can use to reduce both the distress and the intensity of PTSD symptoms. In hypnotherapy, also know as eye movement desensitize and reprocessing (EMDR), the patient recalls traumatic memories while the therapist elicits eye movements that are similar to those that occur naturally during REM sleep. (Neason, 2006)
As returning PTSD-affected soldiers face their ghosts, RNs across the country will be involved in their struggle to regain their lives. “By recognizing patients with PTSD and other trauma related symptoms nurses can validate patients’ distress, and help them know that their feelings are not unusual” (Schnurr, P., 2004, p.59). Since there seems to be no ending to the current war in Iraq, implementing strategies that will assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans is a crucial need of nurses. If we are lucky, as a nation, we will not lose quite the generation like we have in the past to Post Traumatic Stress Disorder.

“Many soldiers wounded in Afghanistan or Iraq who would have died in prior wars now survive. However, they may sustain lasting injuries resulting in disfigurement or loss of function.
A recent study of combat troops following return from deployment to Afghanistan or Iraq found postwar rates of posttraumatic stress disorder (PTSD) ranging from 12.2% to 12.9% and rates of depression from 7.1% to 7.9%. Higher rates of PTSD were associated with higher levels of direct combat exposure and minor wounds or injury,” (Grieger, 2006). These are the type of statistic that one may come across when researching posttraumatic stress disorder, also known as PTSD. There are studies that show that posttraumatic stress disorder is nothing more than an attempt to medicalize a response to trauma. Further research also debates the usefulness of certain treatments that are meant to help victims of posttraumatic stress disorder.
“The predominant view in psychiatric publications is that post-traumatic stress disorder is a medical disorder, characterized by particular psychobiological dysfunction. Although the question of what constitutes a medical disorder is still debated, the identification of both psychobiological dysfunctions and medical interventions that can reverse dysfunctions, provide an important basis to legitimize the medicalization of a disorder (Stein, 2007). Studies show that post traumatic stress disorder may not be a medical disorder after all but an increasing medicalization of a problem that has been brought into the limelight by recent events such as the terror attacks on 9/11 and the ongoing war in Iraq. A more radical view is that post-traumatic stress disorder is merely a social construction, a label that has been applied to distress, for particular sociopolitical reasons. (Stein, 2007)
“Veterans may resist attempts to participate in treatment because they may associate authority figures with distrust. Angry veterans may also become impatient during the treatment process due to their desire to gain relief from their anger problems and their general heightened level of hostility and frustration. They may become easily frustrated when changes do not immediately occur as a result of therapy, and may become hostile or otherwise resistant to therapy,” (National Center for PTSD, 2005). This is a situation that clinicians might find themselves facing when treating service members returning from a combat zone. This is only a few disadvantages that come up when treating service members with therapy alone. Posttraumatic stress disorder therapies include psychotherapy, cognitive therapy, anxiety management, and hypnotherapy. Surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened are other disadvantages that effect a service member’s treatment. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments. It has also been discussed that therapy alone may not help victims of posttraumatic stress disorder.
“There is a strong rationale from laboratory research to consider antiadrenergic agents. It is hoped that more extensive testing will establish their usefulness for PTSD patients. Hypotension and sedation needs to be monitored. Patients should not be abruptly discontinued from antiadrenergics. Despite suggestive theoretical considerations and clinical findings, there is only a small amount of evidence to support the use of carbamazepine or valproate with PTSD patients. Further, the complexities of clinical management with these effective anticonvulsants have shifted current attention to newer agents (e.g., gabapentin, lamotrigine, and topirimate), which have yet to be tested systematically with PTSD patients,” (National Center for PTSD, 2005). There have not been enough studies on successful treatment of posttraumatic stress disorder with only pharmaceuticals. There are many disadvantages for the pharmaceutical treatment. Side effects and improper dosage for such a disorder are those that are brought up most often.
Despite the ongoing war in Iraq and service members returning with symptoms of PTSD, there is a lack of studies on posttraumatic stress disorder. Further studies need to be conducted in order to determine whether posttraumatic stress disorder is in fact a medical disorder. Once this is established than proper treatment is than needed to treat service members that are returning from the combat zone that have posttraumatic stress disorder symptoms.


T. Grieger, S. Cozza, R. Ursano, & C. Hoge. (2006). Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers. The American Journal of Psychiatry, 163(10), 1777-83. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

D. Stein, S. Seedat, A. Iversen, & S. Wessely. (2007). Post-traumatic stress disorder: medicine and politics. The Lancet, 369(9556), 139-144. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf



Cantwell, M. (2006). Cantwell Calls for Extensive Mental Health Screenings for Soldiers Returning from Iraq. Retrieved on May 01, 2007 from http://cantwell.senate.gov/news/record.cfm?id=262201

Guess, K. (2006). Posttraumatic Stress Disorder: Early Detection is Key. The Nurse Practitioner: The American Journal of Primary Health Care, 31(3), 26-33. Retrieved on May 26 2007 from http://www.nursingcenter.com/pdf.asp

Hoge, C., Authterlonie, J., & Milliken, C. (2006). Mental Health Problems, Use of Mental Health Services, and attrition From Military Service After Returning From Deployment to Iraq or Afghanistan. The Journal of the American Medical Association, 295(9), 1023-. Retrieved on November 7, 2006 from
http://jama.ama-assn.org/cgi/content/full/295/9/1023?eaf

Kaiman, C. (2003) PTSD in the World War II Combat Veteran. American Journal of Nursing, 103(11), 32-40. Retrieved on May 26, 2007 from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=429109

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf


National Center for PTSD. (2006). Returning from the War Zone: A Guide for Families of Military Members. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforFamilies.pdf

Neason, K. (2006). PTSD: Help patients break free. RN Professional Journal, RN/AHC Media Home Study Program CE CENTER. Retrieved on October 1, 2006, from
http://www.rnweb.com/rnweb/article/articleDetail.jsp?id=375524

Rona, R., Hyams, K., Wessely, S. (2005). Screening for Psychological Illness in Military Personnel. The Journal of American Medical Association, 293(10), 1257-. Retrieved on November 7, 2006 from http://jama.ama-assn.org/cgi/content/full/293/10/1257?eaf

Schnurr, P. & Cuzza, S. (Eds). (2004). Iraq War Clinician Guide (2nd ed.) (pp. 58-61). Retrieved November 7, 2006 from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_clinician_guide_v2.p

39 comments:

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