Military Psychiatry

Delirium

In combat or following terrorism that leads to major illness or injuries, volume depletion and metabolic derangements as well as resuscitative efforts can cause delirium (manifest by clouded consciousness, agitation or diminished responsiveness, and disorientation) ( Box 90-1 ). Pharmacological agents (such as neuroleptics and benzodiazepines) used to manage agitation can further complicate medical assessment and management, especially surrounding combat-related injuries. Symptomatic management of behavioral problems with sedating agents should be initially reserved to protect the life or safety of the patient and other patients or staff. Resolution of the etiology of the delirium should be the primary goal; resolution requires attention to metabolic sequelae of the injury. Common causes of delirium in combat or in disaster settings include hypovolemia, hypoxemia, central nervous system mass effects (e.g., hemorrhage, foreign bodies), infection, and adverse effects of resuscitative medications.

Depression

Depressed mood or resignation in the aftermath of combat or a terrorist event may be difficult to distinguish from the malaise and lassitude common among the prodromes to exposure to many chemical and bioterrorism agents. When depressed mood and associated depressive symptoms disrupt social and occupational function, a depressive disorder (e.g., MDD) is diagnosed.

Acute Stress Disorder and Post-traumatic Stress Disorder

Symptoms of acute stress disorder (ASD) and PTSD include intrusive re-experiencing phenomena (such as distressing dreams and flashbacks), hyperarousal, avoidance of events or situations that resemble—even symbolically—the original trauma, negative alterations in cognition and mood (such as diminished interest in significant activities), and dissociative phenomena (such as derealization or numbing). When symptoms persist for more than 1 month, PTSD is diagnosed. Both ASD and PTSD have high rates of co-morbidities (see Box 90-1 ), the most frequent of which are MDD, other anxiety disorders (such as panic disorder), and substance use disorders. For those who suffer a concomitant physical injury during exposure to trauma, the risk of both ASD and PTSD increases.

Somatic Symptom Disorder and Illness Anxiety Disorder (Formerly Hypochondriasis)

The fear or belief that one has a serious disease based on the misinterpretation of bodily symptoms or environmental exposure has traditionally been termed “hypochondriasis.” The DSM-5 divides the symptom complex into somatic symptom disorder (fear or belief that one has serious illness accompanied by significant bodily symptoms) and illness anxiety disorder (similar fear or belief despite the lack of significant bodily symptoms). In either case anxiety and fear about the somatic symptom and/or disease persist despite normal medical evaluations and reassurance. In the chaos and uncertainty following combat or terrorist events, patients with these two disorders may have particular problems managing their anxiety and health-related beliefs. Persons without a documented diagnosis of either may seek treatment for the first time in this environment. Chronic symptoms (e.g., of at least 6 months) are typical for both of these disorders and are required for a diagnosis of illness anxiety disorder. However, subsyndromal somatic fears may be widespread following a terrorist event or potential combat-related toxic exposure. In contrast, these transient symptoms generally respond favorably to reassurance and a degree of tolerance for appointments/examination requests.

Unexplained Physical Symptoms and Conversion Symptoms

Unexplained physical symptoms are common after combat and disasters. Not all unexplained physical symptoms are conversion symptoms, although anecdotal reports of conversion are well documented after terrorist and combat events. Unfortunately, there is little scientific basis for prevention and care of unexplained physical symptoms. Nonetheless, it is important that persons with unexplained symptoms be identified in the triage process so that inappropriate and potentially harmful treatments (that could also draw resources away from victims who need treatment) are not initiated.

Use of biological or chemical agents presents a challenging differential diagnosis and contagion problem. During World War I “gas hysteria” was common and threatened the integrity of entire military units. Psychological casualties in chemical and biological threat scenarios may outnumber and prove more costly in terms of personnel losses than physical casualties. Acute symptoms of gas hysteria may mimic symptoms (e.g., dyspnea, coughing, aphonia, burning of the skin) of poison gas exposure. Patients may have air hunger and other symptoms that are consistent with anxiety and panic. The factors that predispose a patient to psychological contagion include rates of wounding/exposure in the unit, lack of sleep, and lack of prior experience with this type of phenomena/attack. Therefore, it is important to know what substances a patient has not been exposed to. Following a faked chemical or biological agent threat, there may be a large number of individuals who fear that they have been exposed and will have realistic symptoms based on their knowledge of the alleged agent and the vital sign abnormalities produced by anxiety/fear.

Dissociation and Dissociative Disorders

The essential feature of dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The centerpiece of the diagnosis, to discriminate it from situational dissociation, is the presence of significant distress, or significant disruption in social or occupational function. Situational dissociation is common in the context of any traumatic or terrorist event. Dissociation may be adaptive in the immediate aftermath of a trauma—dissociation may prevent the eruption of intolerable affect or the unleashing of potentially dangerous impulses or behaviors (e.g., fleeing the scene).

It is important not to confuse dissociation and diminished neurological responsiveness. A key role of a psychiatrist in the immediate aftermath of a disaster is to help identify dissociation. One should gently tap the patient on the shoulder, ask if there is anything the patient needs, and ask if the patient knows where he or she is and what day it is. Watching for a muted, but appropriate, response in a dissociating person should indicate his or her level of consciousness and suggest that orientation is grossly intact. Identification of otherwise uninjured disaster victims who are simply dissociating may free up medical resources for other patients.