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Army moving away from traditional PTSD definitions


This news story was published on April 25, 2012.
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By Kim Murphy, Los Angeles Times –

SEATTLE — In a move to improve treatments for post-traumatic stress disorder, the U.S. Army is discouraging the use of traditional definitions such as feelings of fear, helplessness and horror — symptoms that may not be in a trained warrior’s vocabulary. It also is recommending against the use of anti-anxiety and antipsychotic medications for such combat stress in favor of more proven drugs.

The changes are reflected in a new policy document released this month, one that reflects a growing understanding of the “occupational” nature of the condition for many soldiers. For them, the symptoms often associated with combat stress — hyperarousal, anger, numbness and sleeplessness — may be signs of illness at home but also a lifesaving response crucial to survival in a war zone.

Doctors who adhere strictly to traditional PTSD definitions could withhold lifesaving treatment for those who need it most, Army doctors warn, by passing over soldiers or accusing them of faking problems.

“There is considerable new evidence that certain aspects of the definition are not adequate for individuals working in the military and other first-responder occupations,” such as firefighting and police work, according to the policy, developed by the U.S. Army Medical Command.

“They often do not endorse ‘fear, helplessness or horror,’ the typical response of civilian victims to traumatic events. Although they may experience fear internally, they are trained to fall back on their training skills (and) may have other responses, such as anger.”

Charles Hoge of the Walter Reed Army Institute of Research, who for seven years oversaw the institute’s research on the psychological consequences of the wars in Iraq and Afghanistan, said the document reflects work already under way by a committee of the American Psychiatric Association to refine the standards for treating PTSD based on an abundance of new research.

Clinicians will continue to use an algorithm of symptoms to help screen for combat stress, but PTSD should no longer be summarily ruled out if a soldier meets most of the definitions simply because he or she fails to exhibit classic signs of fear or helplessness, he said.

“There is greater recognition now of the occupational context,” Hoge said in an interview. “For me as a clinician, this can change how I talk about the condition with my clients. It kind of normalizes a lot of their experiences and helps them understand why they’re reacting and experiencing things in certain ways.”

U.S. Sen. Patty Murray, D-Wash., chairwoman of the Senate Veterans Affairs Committee, called the new policy “an overdue but very welcome step toward improving the diagnosis of the invisible wounds of war … (that) will help standardize Army mental health care through the use of proven treatments and assessments.”

The new Army policy document estimates that up to a fourth of all service members who have deployed to combat zones come back with full-fledged PTSD but that only about 20 percent complete a full course of treatment.

The new policy addresses growing concerns over soldiers’ use of powerful psychiatric drugs for the condition, finding that anti-anxiety drugs such as Ativan, Klonopin and Valium may do more harm than good and “should be avoided” unless specific cases warrant their use. Likewise, the new policy advises against the “off-label” use of second-generation antipsychotics, especially Risperidone, for PTSD because of potential long-term health effects.

On the other hand, the policy endorses both antidepressants such as Prozac and psychotherapy as equally valid methods of treating PTSD.

While there has been criticism of the use of these drugs among young adults because they can in some cases encourage suicidal thoughts, Army officials have said the benefits outweigh the risks.

“There are a lot of instances when individuals need to talk through these events,” Hoge said. “So in a lot of cases, individuals get a combination of medications and psychotherapies.”

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