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Pre-PTSD Combat Stress Disorder design

WASHINGTON- ~ As a Department of Veterans Affairs (VA) and Department of Defense (DoD) working group nears completion of the development of new clinical practice guidelines for the diagnosis, treatment and management of post-traumatic stress disorder (PTSD), a new disorder has been defined to identify soldiers who may be experiencing stress symptoms before PTSD sets in.

"It's unique in that in addition to PTSD, we defined a combat operational stress disorder," said Dr. Harold Kudler, a member of the working group and the VA's VISN 6 mental health coordinator in Durham, N.C.

This is similar to an acute stress disorder that has been identified in a national psychological manual (DSM). Dr. Kudler said the disorder exhibits the same symptoms as PTSD, but within the first month following a traumatic event. He said PTSD can be defined if signs persist for a month. The combat operational stress disorder exhibits PTSD symptoms, such as feelings of disassociation, confusion, amnesia, disturbed thoughts and a glazed over state, according to Dr. Kudler. "It requires a minimum of two days and a maximum of four weeks," he said. "Say you're two hours out [of a trauma experience] and you're mute, having severe anxiety, you're unresponsive, you're all tears or having panic symptoms." This combat and operational stress reaction is being studied by DoD and VA trauma specialists in the working group. "We feel this is a recognizable syndrome," Dr. Kudler said. "We have to train people to recognize it and what to do about it."

This is particularly important in the triage stage and immediate response to trauma exposures for people in military operations. Furthermore, there may be soldiers who are necessary for the immediate operation, such as if they are the only personnel who can operate certain artillery, Dr. Kudler said. They need to be able to overcome trauma right away and continue their focus on the mission. There may be different response treatments that require not just good medical approaches, but good social approaches, he advised.

Although the working group came up with the new definition more than a year ago at a meeting in Alexandria, Va., its development is ongoing and will be part of the soon to be published joint PTSD clinical practice guidelines (CPG). Dr. Kudler said many first responders were chosen to be part of the working group so that they can apply what they learn to their field experience and pass it on to others. At least one member of the group, a Marine psychologist, took the developing CPG to Iraq to apply it to the management of traumatic stress situations there, Dr. Kudler advised. "We picked people who are first responders and some were mobilized," he said. "We will have people who respond to trauma. Our hope is to screen people, knowing that the majority will do just fine, but also knowing that almost anyone will benefit by some sort of counseling. We also want to provide resources and contacts for those who may need help later on, including [for] their families."

Dr. Kudler said he thinks DoD and VA are understanding of the need for attention in the area of PTSD, but a change of culture has to take place over time for it to work. "I think every branch has had running programs, but there is not a lot of DoD/VA transitional assistance," he advised. "We're looking at a whole new generation of combat veterans, some of whom will come to VA. We want to build the infrastructure and take a longitudinal perspective. I think the military has done a good job, but the idea of following them into VA with transitional assistance or a fully orchestrated hand-off [is new]. By creating the guidelines, we create a concentrated hand-off, continuity of care, [and better] records. Until recently we didn't get their [DoD] records. Within the last year or two, we can read some in our system. But it's not universal yet, so it is something that is evolving. As our computerized record systems become able to talk to each other...if we understand each other's positions, it would help."

For instance, Dr. Kudler said some soldiers who experience symptoms of PTSD may have a tendency not to complain. He said he had a chance to work with an active duty unit that had responded to 9/11 in the New York City area and was exposed to horrific sights and situations there. He said there were people in the unit who were suffering, but they did not want to admit it because that would endanger their mission and unit, in their minds. They would not want to leave their unit, he said. "But it's important to ask for help, and if they don't do it, that's what endangers the mission," Dr. Kudler said. "So we want to make it easy, and I believe these guidelines will help. There will be a clear rationale for what's being followed with DoD and VA. People will have a better understanding earlier, rather than waiting 20 years."

Most soldiers will adjust well after combat, but Dr. Kudler said, "we just want to be sure that small group [that does not] can be identified and can get help, and make sure others know [where to go]. A lot of it is education and support for the unit."

2 Dr. Kudler said last month that he was reviewing the final draft of the new PTSD CPG and that the document was in the "late revisions" stage. Once completed, he said it will be posted on DoD and VA Web sites and handouts. He said training will accompany the rollout of the guidelines. There are 15 working group members from VA and 15 from DoD that will help facilitate the distribution of them. The VA's National Center for PTSD and the department's 200-plus disaster and readjustment counseling Vet Centers around the country will also have roles in the implementation of the guidelines. The idea is to have trained trauma specialists working throughout the country to help veterans and others who are exposed to trauma. In addition to having front line trauma specialists working on the joint CPG committee, Dr. Kudler said it will be important to get the word out to primary care providers, many of who provide some mental health care to their patients.

I am greatly concerned about having the VA and DoD working on this project. These concerns should be dealt with by the American Psychiatric Association in expansion of Diagnostic and Statistical Manual of Mental Disorders (DSM).

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