During and after the Iraq War, primary care providers may notice changes in their patient population. There may be an increased number of veterans or active duty military personnel returning from the war. There also may be increased contact with family
members of active duty personnel, including family members who have lost a loved one in the war or family members of individuals missing in action (MIA) or taken prisoner of war (POW). In addition, there may be increased distress in veterans of other wars, conflicts, and peacekeeping missions.
All of these patients may be experiencing symptoms of
posttraumatic stress disorder (PTSD):
Veterans and active duty military personnel may have
witnessed or participated in frightening and upsetting aspects of
Veterans and active duty military personnel may have
experienced military-related sexual trauma during their
Family members may suffer traumatic stress by hearing about
frightening or upsetting events that happened to loved ones, or
from the loss or fears of loss related to family members missing
Other veterans may be reminded of frightening and upsetting
experiences from past wars, which can exacerbate traumatic stress
These types of stress reactions often lead people to increase
their medical utilization. Because far fewer people
experiencing traumatic stress reactions seek mental health
primary care providers are the health professionals with whom
individuals with PTSD are most likely to come into contact.
What do primary care practitioners need to know about PTSD?
Patients want primary care providers to acknowledge their traumatic experiences and responses
Over 90% of patients indicate that traumatic experiences and
responses are important and relevant to their primary care.
Over 90% of patients in VA primary care settings will have
experienced at least one traumatic event in their life.
Most will have experienced four or more.
The relationship between trauma exposure and increased health care utilization appears to be mediated by the diagnosis of PTSD.
Thus, primary care practitioners should be aware of the
essential features of PTSD: re-experiencing symptoms (e.g.,
nightmares, intrusive thoughts), avoidance of trauma cues, numbing/
detachment from others, and hyperarousal (e.g., increased startle,
PTSD can be detected in primary care settings
The Primary Care PTSD (PC-PTSD) screen can be used to detect
PTSD in primary care.
Endorsement of any three items is associated with a
diagnostic accuracy of .82 (sensitivity .93; specificity .79) and
indicates the need for additional assessment.
In your life, have you had any experiences that were so
frightening, horrible, or upsetting that, in the past month,
Have had nightmares about it or thought about it
when you did not want to?
Tried hard not to think about it or went out of
your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily
Felt numb or detached from others, activities, or
PTSD can be effectively managed in primary care settings
By recognizing patients with PTSD and other trauma-related symptoms
Provide patients and their family members with educational
materials that help them understand that their feelings are
connected to the Iraq War and its consequences.
Validate patients’ distress, and help them know that
their feelings are not unusual in these circumstances.
When appropriate, initiate treatment for PTSD or mental
What can primary care providers do for their
Determine the patient’s status in relationship to the war
By assessing the patient’s status in relation to the war,
primary care providers acknowledge the relevance and importance of
this event. Example questions include:
Have you recently returned from the Persian Gulf? How
has your adjustment been?
Do you have family members or friends who are currently in
the Persian Gulf? How are you dealing with their absence?
How has the war in Iraq affected your functioning?
Acknowledge the patient’s struggles
Regardless of their specific relationship to the war, primary
care providers should recognize and normalize distress associated
with war. Example statements include:
I am so sorry that you are struggling with this.
I can appreciate how difficult this is for you.
You are not the only patient I have who is struggling with
It’s not easy, is it?
Assess for PTSD symptoms
The PC-PTSD can be used either as a self-report measure or
through interview. It can be a standard part of a patient
information form or introduced as follows:
I would like to know if you are experiencing any specific
symptoms It is not uncommon for people to have certain types of
Be aware of how trauma may impact on medical care
The specific health problems associated with PTSD are varied and
suggest multiple etiologies; neurobiological, psychological, and
behavioral factors are likely explanations. Research has
increasingly demonstrated that PTSD can lead to neurobiological
dysregulation, altering the functioning of catecholamine,
hypothalamic-pituitary-adrenocorticoid, endogenous opioid, thyroid,
immune, and neurotransmitter systems. Exposure to traumatic stress
is associated with increased health complaints, health service
utilization, morbidity, and mortality.
PTSD appears to be a key mechanism that accounts for the
association between trauma and poor health.
PTSD and exposure to traumatic experiences are associated
with a variety of health-threatening behaviors, such as alcohol
and drug use, risky sexual practices, and suicidal ideation and
PTSD is associated with an increased number of both lifetime
and current physical symptoms, and PTSD severity is positively
related to self-reports of physical conditions.
Determine if and how trauma responses can be managed in Primary Care
The delivery of mental health care is possible in the general
or primary care setting. According to this approach, brief
psychotherapeutic, psychoeducational, and pharmacological services
are delivered as a “first line” intervention to primary
care patients. If a patient fails to respond to this level of
intervention, or obviously needs specialized treatment (e.g.,
presence of psychotic symptoms or severe dissociative symptoms),
the patient is referred to mental health emergency, outpatient
mental health intake coordinator, or PTSD program. Procedures to
follow if patient demonstrates PTSD symptoms during medical
examinations: Medical examinations or procedures may cause the patient
to feel anxious or panicky. The following techniques may help in
addressing trauma-related symptoms that arise in the medical
Speak in a calm, matter of fact voice.
Reassure the patient that everything is okay.
Remind the patient that they are in a safe place and their
care and well being are a top priority.
Explain medical procedures and check with the patient (e.g.,
“Are you ok?”).
Ask (or remind) the patient where he or she is right
If the patient is experiencing flashbacks, remind him or her
that they are in a doctor’s office at a specific time in a
specific place (grounding).
Offer the patient a drink of water, an extra gown, or a warm
or cold wash cloth for the face, anything that will make the
patient feel more like his or her usual self.
Any assistance and sensitivity on the part of the primary care
provider can help reinforce an effective and positive alliance with