Non-organic Vision Loss in the Afghanistan and Iraq Conflicts.

Non-organic visual loss (NOVL), defined as a decrease in visual acuity or field without an identifiable organic cause, can be challenging to diagnose, especially in patients whose NOVL is superimposed on some component of true organic pathology. Exposure to combat puts soldiers at risk of emotional distress and physical trauma, which can contribute to the development of NOVL with conversion disorder or malingering. This case series describes six patients with NOVL who sustained ocular or non-ocular injuries while serving in combat operations in Iraq and Afghanistan, and highlights diagnostic pearls and components of inter-disciplinary management in the unique military context.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A dissociative episode following stage hypnosis in a combat-injured soldier: implications, treatment and reflections.

Significant data to suggest the need for more appropriate precautions for volunteers participating in stage hypnosis is presented. This paper is a case report of a soldier previously injured in battle who, due to participating in stage hypnosis one year after his injury, experienced a dissociative episode wherein post-traumatic stress symptoms were prominent. During this episode, which lasted over three hours, the service member assaulted an acquaintance, subsequently believed he was a prisoner of war, experienced amnesia for some of the events, and was eventually psychiatrically hospitalized. The diagnosis of acute psychotic reaction was rendered. Fortunately for this service member, upon his return to his treating hospital center, his primary medical team made an appropriate referral. Psychotherapeutic treatment allowed this individual to integrate his traumatic experiences, gain control and understanding of his behavior, and extinguish his pain and suffering, returning to his successful career.

Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries.

The psychological issues facing medical and surgical patients suffering from traumatic injuries are numerous and varied. These injuries may occur in the settings of armed conflict, terrorist attack, natural disaster, or accident. The goal of preventing or decreasing significant and disabling psychiatric comorbidity can be the objective and assignment of a Psychiatry Consultation Liaison Service (PCLS) within the hospital setting. A comprehensive trauma consultation service could be designed to assist the entire medical complex in its response to various events. The needs of the patient, the patient's primary support group, and the medical staff must be considered in the development of a treatment strategy for the setting of a traumatic event. This article describes the integration of a Preventive Medical Psychiatry Service (PMP) at Walter Reed Army Medical Center (WRAMC) into a traditional PCLS. The PMP model is built upon the biopsychosocial model and psychodynamic developmental concepts.

Posttraumatic stress disorder and depression in battle-injured soldiers.

OBJECTIVE: This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. METHOD: The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed. RESULTS: At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length. CONCLUSIONS: Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.

Meeting the patients where they are: consultation-liaison response to trauma victims of the Pentagon attack.

The Psychiatry Consultation-Liaison Service at Walter Reed Army Medical Center provided an immediate mental health response to hospitalized victims of the Pentagon attack on September 11. This article reviews our experience with this population and the lessons learned. Successful intervention required a flexible and innovative approach that included export of our services to the patient's location, liaison with involved facilities and treatment teams, and modification of therapeutic contact. Our debriefing approach was adapted to accommodate the victims' vulnerable psychological state in the wake of the trauma. Clinically effective interventions were implemented with the goals of reducing psychological symptoms, facilitating compliance with medical care, supporting rapid recovery of social and occupational functioning, and integrating social supports. This unique method, which we call "therapeutic debriefing," can serve as a model for future interventions after catastrophic events.

Reflections on hypnotizability and its impact on successful surgical hypnosis: a sole anesthetic for septoplasty.

While hypnosis has been a significant medical tool through the ages, its use has been, at best, capricious. After the development and widespread use of ether, hypnosis has been mostly relegated to the role of an adjunct to chemical anesthesia. The present paper describes a case where hypnosis was used as the sole anesthetic for a septoplasty. The chronology of the surgery, hypnotic suggestion and strategies used as well as the clinician's responses are described. The paper highlights relevant clinical issues such as the hypnotic capacity of the patient, associated hypnotic phenomena, enhancing trance, and maximizing the hypnotic capacity by "meeting them where they are."

The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma.

BACKGROUND: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. METHODS: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. RESULTS: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. CONCLUSIONS: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.