IRAQ WAR CLINICIAN GUIDE 2nd EDITION Written and Compiled by National Center for Post-Traumatic Stress Disorder Contributing authors include (in alphabetical order): Eve B. Carlson, Ph.D., Erika Curran, L.C.S.W., Matthew J. Friedman, M.D., Ph.D., Fred Gusman, M.S.W., Jessica Hamblen, Ph.D., Rachel Kimerling, Ph.D., Gregory Leskin, Ph.D., Brett Litz, Ph.D., Barbara L. Niles, Ph.D., Susan M. Orsillo, Ph.D., Ilona Pivar, Ph.D., Annabel Prins, Ph.D., Robert Rosenheck, M.D., Josef I. Ruzek, Ph.D., Paula P. Schnurr, Ph.D., Steve Southwick, M.D., Jane Stafford, Ph.D., Amy Street, Ph.D., Pamela J. Swales, Ph.D., Casey T. Taft, Ph.D., Robyn D. Walser, Ph.D., Patricia J. Watson, Ph.D., Julia Whealin, Ph.D.; and Harold Kudler, M.D., from the Durham VA Medical Center. Editorial Assistant: Sherry E. Wilcox. Walter Reed Army Medical Center Contributing authors include (in alphabetical order): LTC John C. Bradley, MC, USA, LTC David M. Benedek, MC, USA, COL Ryo Sook Chun, MC, USA, COL Dermot M. Cotter, COL Stephen J. Cozza, MC, USA, Catherine M. DeBoer, MAJ Geoffrey G. Grammer, CAPT Thomas A. Grieger, MC, USN, Rosalie M. Kogan, L.C.S.W., COL (Ret) R. Gregory Lande, DO FACN, Barbara A. Marin, Ph.D., COL (Ret) Patricia E. Martinez, MAJ Erin C. McLaughlin, Corina M. Miller, L.C.S.W., COL Theodore S. Nam, MC, USA, COL (Ret) Marvin A. Oleshansky, M.D., MAJ Mark F. Owens, LTC (Ret) Harold J. Wain, Ph.D., COL Douglas A. Waldrep, MC, USA. June 2004 DEPARTMENT OF VETERANS AFFAIRS NATIONAL CENTER FOR PTSD Iraq War Clinician Guide ii Table of Contents IRAQ WAR CLINICIAN GUIDE Table of Contents I. Executive Summary ........................................................................................1 Key Topics II. Topics Specific to the Psychiatric Treatment of Military Personnel ....................4 III. The Returning Veteran of the Iraq War: Background Issues and Assessment Guidelines .................................................................................21 IV. Treatment of the Returning Iraq War Veteran.................................................33 Special Topics V. Treatment of Medical Casualty Evacuees .......................................................46 VI. Treating the Traumatized Amputee ...............................................................50 VII. PTSD in Iraq War Veterans: Implications for Primary Care..............................58 VIII. Caring for the Clinicians Who Care for Traumatically Injured Patients ............62 IX. Military Sexual Trauma: Issues in Caring for Veterans.....................................66 X. Assessment and Treatment of Anger in Combat-Related PTSD ........................70 XI. Traumatic Grief: Symptomatology and Treatment for the Iraq War Veteran..........................................................................................75 XII. Substance Abuse in the Deployment Environment .........................................79 XIII. The Impact of Deployment on the Military Family .........................................83 Appendices A. Case Examples from Operation Iraqi Freedom ...............................................87 B. VA/DoD PTSD Practice Guideline ................................................................92 C. VA Documents on Service Provision .............................................................93 D. Assessment of Iraq War Veterans: Selecting Assessment Instruments and Interpreting Results ..............................................................................108 E. Program Evaluation ....................................................................................126 F. Litz, B. T., Gray, M. J., Bryant, R. A., & Adler, A. B. (2002). Early interventions for trauma: Current status and future directions. Clinical Psychology: Science and Practice, 9, 112-134. ............................................128 G. Keane, T. M., Street, A. E., & Orcutt, H. K. (2000). Posttraumatic stress disorder. In M. Hersen & M. Biaggio (Eds.), Effective brief therapies: A clinician’s guide (pp. 140-155). New York: Academic Press..........................151 H. Friedman, M. J., Donnelly, C. L., & Mellman, T. A. (2003). Pharmacotherapy for PTSD. Psychiatric Annals, 33, 57-62. ..........................169 I. Friedman, M. J., Schnurr, P. P., & McDonagh-Coyle, A. (1994). Post­ traumatic stress disorder in the military veteran. Psychiatric Clinics of North America, 17, 265-277.......................................................................175 J. Educational Handouts for Iraq War Veterans and Their Families...................188 DEPARTMENT OF VETERANS AFFAIRS NATIONAL CENTER FOR PTSD Iraq War Clinician Guide 1 Executive Summary PP - -- I. Executive Summary The medical, surgical, and psychiatric casualties of Operation lraqi Freedom will receive care from a broad group of clinicians working in diverse clinical settings. Although most service members will initially be treated in military treatment facilities, many may find themselves returning to the United States with conditions that are treated in military facilities, VA Hospitals, civilian treatment centers, or all of these as they move through their recovery. As a result, some clinicians involved in treating casualties returning from lraq may not have an understanding of the experiences of the military patient, the military system in which he or she serves, the military medical services available, or the potential impact of medical decisions on the service member's future military career. It is essential that all health care professionals-civilian or military-who care for casualties from Operation lraqi Freedom have at least rudimentary and relevant military knowledge. A variety of factors including personal and cultural characteristics, orientation toward coping with stressors and painful emotions, pre-deployment training, military-related experiences, and post- deployment environment will shape responses to Operation lraqi Freedom. Furthermore, psychological responses to deployment experiences can be expected to change over time. The absence of immediate symptoms following exposure to a traumatic event is not necessarily predictive of a long-term positive adjustment. Depending on a variety of factors, veterans may appear to be functioning at a reasonable level immediately upon their return home particularly given their relief at having survived the war-zone and returned to family and friends. However, as life circumstances change, symptoms of distress may increase to a level worthy of clinical intervention. Even among those veterans who will need psychological services post-deployment, acute stress disorder and posttraumatic stress disorder (PTSD) represent only two of a myriad of psychological presentations that are likely. Veterans of Operation lraqi Freedom are likely to have been exposed to a wide variety of war-zone related stressors that can impact psychological functioning in a number of ways. It is important for clinicians to recognize that the skills and experience that they have developed in working with veterans with chronic PTSD will serve them well with service members returning from lraq. Clinicians' experience in talking about trauma, educating patients and families about traumatic stress reactions, teaching skills of anxiety and anger management, facilitating mutual support among groups of veterans, and working with trauma-related guilt, will all be useful and applicable. Chapter II provides an overview of several military-specific topics. First, a brief history of the evolution and change in the size and components of the military force is discussed, highlighting the challenges of a highly deployed force that relies on National Guard and Reserve members. Next, the various types and stages of military conflict are described, with a focus on the specific stressors that each of these stages might engender. This is followed by an explanation of the military medical services delivery system, including the different echelons of care of the military evacuation system. The subsequent section provides a review of psychiatric disorders that often present during military conflicts. Available psychiatric services are outlined next. Finally, a section on military decision-making processes focuses on important administrative and medical procedures that are used to facilitate the evaluation, treatment and management of military patients with medical and psychiatric conditions. DEPARTMENT OF VETERANS AFFAIRS NATIONAL CENTER FOR PTSD Iraq War Clinician Guide 2 Executive Summary Chapter Ill provides information that is useful for addressing the following questions: What are the features of the lraq War that may significantly impact the quality of life, well. being, and mental health of returning veterans? What are important areas of functioning to evaluate in returning veterans? What might be beneficial for veterans of the lraq War who request clinical services? Chapter IV provides information about treatment of veterans recently evacuated due to combat or war stress who are brought to the VA for mental health care, and lraq War veterans seeking mental health care at VA medical centers and Vet Centers. This chapter complements discussion of special topics (e.g., treatment of medical casualties, identification and management of PTSD in the primary care setting, issues in caring for veterans who have been sexually assaulted, traumatic bereavement) that are addressed in other sections of this Guide. The authors highlight some challenges for clinicians, discuss ways in which care of these veterans may