Chapter 36: Soldiers & Veterans in Mental Health Care

Historically referred to by terms such as shell shock or battle fatigue, PTSD is now understood as a distinct clinical diagnosis characterized by a triad of symptoms: reexperiencing the trauma through intrusive thoughts and flashbacks, avoidance of reminders of the event, and a state of hyperarousal marked by irritability and insomnia. The neurobiology of PTSD involves significant alterations in brain structure and function, including reduced volume in the hippocampus and prefrontal cortex, which impairs the body's ability to contextualize safety and inhibit emotional overreactions from an overactive amygdala. Chronic activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis leads to prolonged elevations of cortisol and norepinephrine, which can cause long-term neural damage. Parallel to these psychological wounds is the rise of TBI, frequently cited as the "signature wound" of contemporary warfare due to the widespread use of improvised explosive devices. These injuries often result from the intense pressure waves of blasts, causing axonal shearing and microscopic damage that may not be visible on standard medical imaging. Symptoms of TBI span cognitive, physical, and behavioral domains, manifesting as memory loss, executive dysfunction, chronic headaches, and increased aggression. The chapter highlights the frequent comorbidity of these conditions—sometimes referred to as postdeployment multisymptom disorder—which complicates the recovery process. Treatment strategies are typically symptom-based, utilizing selective serotonin reuptake inhibitors (SSRIs) for mood stabilization, prazosin for sleep disturbances, and various psychotherapies like exposure therapy and EMDR. Crucially, the text underscores the impact of these conditions on the veteran's family, noting that loved ones often experience secondary traumatization and require dedicated support and education to navigate the long-term changes in their family member's behavior and personality.