PTSD in Iraq War Veterans: Implications for Primary Care

Annabel Prins, PhD, Rachel Kimerling, PhD, and Gregory Leskin, PhD

From Chapter 7, Iraq War Clinician Guide

During and after the Iraq War, primary care providers may notice changes in their patient population. There may be an increased number of veterans or active duty military personnel returning from the war. There also may be increased contact with family members of active duty personnel, including family members who have lost a loved one in the war or family members of individuals missing in action (MIA) or taken prisoner of war (POW). In addition, there may be increased distress in veterans of other wars, conflicts, and peacekeeping missions. All of these patients may be experiencing symptoms of posttraumatic stress disorder (PTSD):

• Veterans and active duty military personnel may have witnessed or participated in frightening and upsetting aspects of combat.
• Veterans and active duty military personnel may have experienced military-related sexual trauma during their service.
• Family members may suffer traumatic stress by hearing about frightening or upsetting events that happened to loved ones, or from the loss or fears of loss related to family members missing or deceased.
• Other veterans may be reminded of frightening and upsetting experiences from past wars, which can exacerbate traumatic stress responses.
  

These types of stress reactions often lead people to increase their medical utilization. Because far fewer people experiencing traumatic stress reactions seek mental health services, primary care providers are the health professionals with whom individuals with PTSD are most likely to come into contact.

What do primary care practitioners need to know about PTSD?

Patients want primary care providers to acknowledge their traumatic experiences and responses

• Over 90% of patients indicate that traumatic experiences and responses are important and relevant to their primary care.
• Over 90% of patients in VA primary care settings will have experienced at least one traumatic event in their life. Most will have experienced 4 or more.
• The relationship between trauma exposure and increased health care utilization appears to be mediated by the diagnosis of PTSD.

Thus, primary care practitioners should be aware of the essential features of PTSD: re-experiencing symptoms (e.g., nightmares, intrusive thoughts), avoidance of trauma cues, numbing/ detachment from others, and hyperarousal (e.g., increased startle, hypervigilance).

PTSD can be detected in primary care settings

• The Primary Care PTSD (PC-PTSD) screen can be used to detect PTSD in primary care.
• Endorsement of any three items is associated with a diagnostic accuracy of .82 (sensitivity .93; specificity .79) and indicates the need for additional assessment.

PC-PTSD

In your life, have you had any experiences that were so frightening, horrible, or upsetting that, in the past month, you….. Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings?

PTSD can be effectively managed in primary care settings

By recognizing patients with PTSD and other trauma-related symptoms you can:

• Provide patients and their family members with educational materials that help them understand that their feelings are connected to the Iraq War and its consequences.
• Validate patients’ distress, and help them know that their feelings are not unusual in these circumstances.
• When appropriate, initiate treatment for PTSD or mental health consultation.

What can primary care providers do for their patients?

Determine the patient’s status in relationship to the war

By assessing the patient’s status in relation to the war, primary care providers acknowledge the relevance and importance of this event. Example questions include:

• Have you recently returned from the Persian Gulf? How has your adjustment been?
• Do you have family members or friends who are currently in the Persian Gulf? How are you dealing with their absence?
• How has the war in Iraq affected your functioning?

Acknowledge the patient’s struggles

Regardless of their specific relationship to the war, primary care providers should recognize and normalize distress associated with war. Example statements include:

• I am so sorry that you are struggling with this.
• I can appreciate how difficult this is for you.
• You are not the only patient I have who is struggling with this.
• It’s not easy, is it?

Assess for PTSD symptoms

The PC-PTSD can be used either as a self-report measure or through interview. It can be a standard part of a patient information form or introduced as follows:

I would like to know if you are experiencing any specific symptoms It is not uncommon for people to have certain types of reactions.

Be aware of how trauma may impact on medical care

The specific health problems associated with PTSD are varied and suggest multiple etiologies; neurobiological, psychological, and behavioral factors are likely explanations. Research has increasingly demonstrated that PTSD can lead to neurobiological dysregulation, altering the functioning of catecholamine, hypothalamic-pituitary-adrenocorticoid, endogenous opioid, thyroid, immune, and neurotransmitter systems. Exposure to traumatic stress is associated with increased health complaints, health service utilization, morbidity, and mortality

• PTSD appears to be a key mechanism that accounts for the association between trauma and poor health.
• PTSD and exposure to traumatic experiences are associated with a variety of health-threatening behaviors, such as alcohol and drug use, risky sexual practices, and suicidal ideation and gestures.
• PTSD is associated with an increased number of both lifetime and current physical symptoms, and PTSD severity is positively related to self-reports of physical conditions.

Determine if and how trauma responses can be managed in Primary Care

The delivery of mental health care is possible in the general or primary care setting. According to this approach, brief psychotherapeutic, psychoeducational, and pharmacological services are delivered as a “first line” intervention to primary care patients. If a patient fails to respond to this level of intervention, or obviously needs specialized treatment (e.g., presence of psychotic symptoms or severe dissociative symptoms), the patient is referred to mental health emergency, outpatient mental health intake coordinator, or PTSD program. Procedures to follow if patient demonstrates PTSD symptoms during medical examinations: Medical examinations or procedures may cause the patient to feel anxious or panicky. The following techniques may help in addressing trauma-related symptoms that arise in the medical setting:

• Speak in a calm, matter of fact voice.
• Reassure the patient that everything is okay.
• Remind the patient that they are in a safe place and their care and well being are a top priority.
• Explain medical procedures and check with the patient (e.g., “Are you ok?”).
• Ask (or remind) the patient where he or she is right now.
• If the patient is experiencing flashbacks, remind him or her that they are in a doctor’s office at a specific time in a specific place (grounding).
• Offer the patient a drink of water, an extra gown, or a warm or cold wash cloth for the face, anything that will make the patient feel more like his or her usual self.

Any assistance and sensitivity on the part of the primary care provider can help reinforce an effective and positive alliance with the patient.

Additional resources

To learn more about screening and treatment for PTSD in primary care settings, see: PTSD Screening and Referral: For Health Care Providers. Discusses the importance of screening for traumatic stress symptoms, with specific steps for screening and referral.