A new Army policy document says symptoms often associated with combat stress… (Carolyn Cole / Los Angeles…)
SEATTLE — In a move to improve treatments for post-traumatic stress disorder, the 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 troops. For them, the symptoms often associated with combat stress — hyperarousal, anger, numbness and sleeplessness — may be signs of illness at home but also responses 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 now warn, 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 reflected work already underway by a committee of the American Psychiatric Assn. 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 but 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."
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 healthcare 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% complete a full course of treatment.
The 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.
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 long said the benefits outweigh the risks. Hoge said it was not possible to know for sure whether the two forms of therapy were equally effective because not enough studies had been done.
"There are a lot of instances when individuals need to talk through these events," he said. "So in a lot of cases, individuals get a combination of medications and psychotherapies."
The new policy on diagnosing PTSD could shed light on an investigation underway at the Madigan Army Medical Center near Seattle. There, about 300 combat stress cases are being reviewed after a number of PTSD diagnoses were set aside by a local Army forensic review team. Some soldiers were accused of faking PTSD symptoms, presumably to receive disability payments.
The new policy says clearly that faking PTSD is not something doctors see often.
"Although there has been debate on the role of symptom exaggeration or malingering for secondary gain … there is considerable evidence that this is rare and unlikely to be a major factor in the vast majority of disability determinations," the policy says.