Today’s combat veterans with PTSD are different from previous generations of combat veterans with PTSD

DEAR EDITOR:
Our veteran population is remarkably different from those we have served in the past. Although this generation of veterans, like other generations, avoids interaction with others, they uniquely isolate themselves using technology, such as computers, MP3 players, and video games. They often deny numbing, avoidance, and isolation, the key identifiers of the posttraumatic stress disorder (PTSD) diagnosis, but are doing just that by using their technologies. The technology allows the user to remain removed or isolated from direct contact with others through the elimination of environmental sounds, noise, and cues that can trigger unpleasant memories and intrusive thoughts.

It is speculated that PTSD will be one of the primary disorders of the current war. If this is true, then making a correct diagnosis of PTSD will be a critical component of care for this generation of veterans. The burden to correctly identify combat trauma is placed on the shoulders of all providers. As the global war on terrorism continues, we will be providing care and treatment to veterans who have long periods of deployment and two or more tours of duty in the combat theater. More often than not, these veterans report constant exposure to trauma, chronic stress, and repeated traumatic episodes, in addition to the general horror forged by war. Often these veterans do not report traditional numbing and avoidance behaviors or activities.

As defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the numbing and avoidance are key identifiers of PTSD.[1] Specifically, strong effort is put forth to avoid triggers associated to the traumatic event. A majority of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) veterans report several common issues or themes when interviewed. One of the most common themes is the use of technology to manage and repress feelings. Another common theme is the use of video gaming as a way of calming nightmares and anxiety related to PTSD. After completing numerous interviews with combat veterans from OEF and OIF, video gaming is often reported as providing a calming effect similar to meditation, which appears to slow breathing, thus reducing the physical response most associated with anxiety.

The OIF/OEF veterans report decompressing through the escape offered in video games. Repeatedly, there is the description of feeling “zoned out,” where pervasive thoughts involving the death of friends or fear of personal safety are easily pushed back from conscious thought. It would appear from these reports that video gaming provides a similar effect to cognitive behavioral techniques for PTSD involving the “here and now,” where we instruct our combat veterans to reassure their safety by reinforcing the perceived danger is in the past.[2] Researchers have shown that mental reflection gained in meditation might be a useful technique for managing PTSD.3 Exploration of meditation and the younger veteran’s self-description of feeling “zoned out” may warrant further study.

Additionally, these combat veterans appear to find great comfort in this faux electronic world where control belongs to the gamer. The electronic environment is a familiar one without a real threat of danger or death. Our newest combat veterans have a persistent drive to replace the emotional and physical control necessary to survive in the combat theater. Video gaming provides an excellent opportunity to build a faux world where the gamer has full knowledge of the rules and personalities of all characters, including the enemy in the game. The patient is provided with a full disclosure of the “rules of engagement,” thereby providing the ultimate controlled safe environment. This crystal clear world is accessed repeatedly. After lengthy discussions with these veterans, a similar theme comes to the forefront in that the veteran feels a part of the electronic world, an integral part of the occurrences unfolding on the screen.

The link we may be missing is that these young men and women have grown up in a world of technology. Serving in today’s military does not remove a soldier from technology. Today’s soldiers are prepared for combat through the use of video graphics, computer simulations of terrain within the areas of conflict, and simulated equipment training allowing for improved performance in combat.4–6 Technology is utilized by the military to simulate combat in order to prepare and train these soldiers for combat service. This simulated combat training is provided in a protected environment without the threat of personal injury or harm. Now that these soldiers are veterans, the intense emotional reaction reported after combat is neatly removed in the gaming world. The veteran soldier is able to avoid events that invoke feelings of helplessness, terror, panic, and grief experienced in the combat theater.

This appears to be one of the biggest unidentified barriers for this generation of combat veterans to overcome—the overly safe, artificially secure world provided by the video games and computers. Certainly, we need to stay true to the diagnostic criteria for PTSD, while gaining a greater understanding of how focusing on role-playing electronic games, movies, and music are what set this generation of soldiers apart from their combat brothers. Technology allows one to pass vast amounts of time and report feelings of involvement and belongingness without truly encountering the real world. We, as providers of healthcare services, need to center our questions and assessments to better embrace the technically savvy youth we are trying to help. Because if we do not truly identify the differences between this generation of combat veterans and other age groups, we might end up with a large group of young men who build relationships and life only in artificially created worlds of the computer, who isolate themselves in groups by using MP3 players, or who interact only in the neat, tidy world of high graphic video games.

References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington, DC: American Psychiatric Press Inc., 2004.
2. Tiet QT, Rosen C, Cavella S, et al. Coping, symptoms, and functioning outcomes of patients with posttraumatic stress disorder. J Trauma Stress 2006;19:799–811.
3. Simpson TL, Kaysen D, Bowen S, et al. PTSD symptoms, substance use, and vipassana meditation among incarcerated individuals. J Trauma Stress 2006;20:239–49.
4. Strassman M. Uncle Sam wants video gamers: Playing games could help build careers in the US military. Orlando, February 8, 2005. Available at: www.cbsnews.com/stories/2005/02/08/eveningnews/main672455.shtml. Access date: October 26, 2007.
5. Sieberg D. War Games: Military training goes high-tech. November 23, 2001. Available at: http://archives.cnn.com/2001/TECH/ptech/11/22/war.games/index.html. Access date: October 26, 2007.
6. Erwin S. Video games gaining clout as military training tools. National Defense. November 2006. Available at: www.nationaldefensemagazine.org/issues/2000/Nov/Video_Games.htm. Access date: October 26, 2007.

With regards,

Rob Kirkhart, PhD, PA-C
Clinical Professor, Marrietta College, Department of Veterans Affairs Medical Center, Chillicothe, Ohio

Charlene Crace, MSW/LSW, OIF/OEF
Outreach Case Manager, Department of Veterans Affairs Medical Center, Chillicothe, Ohio

Rebecca Talbert, PharmD
Clinical Pharmacy Specialist, Riverside Methodist Hospital, Columbus, Ohio

Brendan T. Carroll, MD
Acting Chief of Staff, Department of Veterans Affairs Medical Center, Chillicothe, Ohio

Rich Pulice, MPAS, PA-C, MD
Department of Veterans Affairs Medical Center, Chillicothe, Ohio

Response to Article, “Five Ethical Questions Involving Alzheimer’s Disease (AD)”

DEAR EDITOR:
As a neuropsychiatrist who evaluates and treats patients with cognitive disorders, I found the advice regarding patients with suspected mild cognitive impairment (MCI) in Dr. Howe’s article, “Five Ethical Questions Involving Alzheimer’s Disease (AD),”[1] to be quite perplexing. He suggests that the psychiatrist collude with the patient’s denial about his or her cognitive deficits by having a colleague (rather than the treating psychiatrist himself) perform periodic cognitive testing of the patient and to inform the psychiatrist only when the diagnosis of AD is more definitive.

Dr. Howe states that then the psychiatrist and patient can continue to “interact” (unclear if this means psychotherapy or any therapeutic relationship) without either of them knowing whether the patient has MCI, and thus alleviating the burden on the psychiatrist to keep the MCI diagnosis a secret from the patient.

What is particularly baffling is why any treating physician would want to be “kept in the dark” about any of his or her patients’ medical conditions, cognitive or otherwise. Would Dr. Howe suggest that the psychiatrist also collude in this way if the patient were in denial about symptoms that could represent a malignancy for which there may be no definitive treatment or cure? With Engel’s[2] biopsychosocial model in mind, it would seem more prudent that knowing a patient’s complete medical history would be a physician’s priority in order to effectively treat him. Furthermore, does the doctor really believe that he can deceive himself about the MCI diagnosis if he remains in a continued relationship with this patient? With time, it will soon become apparent that the patient is having difficulty retaining new information due to his or her memory deficits, thus forcing the doctor to acknowledge the patient’s cognitive difficulties even before his or her colleague performs formal testing. Since one’s cognitive competence is vital to quality of life issues, these deficits would pose a formidable obstacle in the “interaction” between the psychiatrist and patient, hampering the achievement of any proposed therapeutic goals. Finally, to encourage an aura of dishonesty to prevail in the doctor/patient relationship hardly seems ethical.

While it is true that there is not a definitive treatment for MCI, taking the stance that it is better not to know about it is unnecessarily nihilistic when it need not be. One pertinent example in this regard is the Alzheimer’s Disease Cooperative Study involving 769 subjects with MCI randomized to treatment with an acetylcholinesterase inhibitor (donepezil), which demonstrated the reduced risk of progression to AD for the first 12 months of the study in all patients, and up to 24 months in a subgroup of patients who carried the APOE4 allele.[3] Using this “borrowed time” can be critical for such patients to make financial or end-of-life decisions while they are still cognitively intact enough.

Since MCI appears to be the prodromal stage of a dementing condition and because it is not yet definitive what factors predict which patients will progress more rapidly to AD than others, encouraging patients to participate in exercise and diverse cognitive activities that may reduce the risk of dementia[4] seems to be reasonable clinical advice; it will not hurt the patient and gives him an opportunity to participate in his or her treatment rather than “waiting around helplessly.” Finally, exploring the possibility that a patient consider participation in an experimental protocol for MCI treatment at an early stage in his or her illness may allow the patient to feel some mastery over his or her condition. I would suggest to Dr. Howe that referring these patients to subspecialists who are comfortable in dealing with this patient population might be a wiser therapeutic decision than trying to pretend that the problem may not exist.

References
1. Howe E. Five ethical questions involving Alzheimer’s disease. Psychiatry 2007;8:31–4.
2. Engel GL. The need for a new medical model. Science 1977;196:129–36.
3. Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med 2005;352:2379–88.
4. Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurol 2004;3:343–53.

With regards,

Angela Scicutella, MD, PhD
Attending Neuropsychiatrist, Associate Professor of Clinical Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine, Long Island Jewish Medical Center/Zucker Hillside Hospital, Glen Oaks, New York

AUTHOR RESPONSE
I very much appreciate Dr. Scicutella’s questions and responses to my article, “Five Ethical Questions Involving Alzheimer’s Disease (AD),” which appeared in the August issue of Psychiatry 2007.[1] Her comments give me an opportunity to clarify the underlying ethical rationales I discussed in that article, and more importantly to discuss an additional, critical consideration I did not previously discuss.

The specific clinical interaction she questions involves psychiatrists seeing patients who have memory problems but who, after being fully informed about both mild cognitive impairment (MCI) and AD, do not want to know if they “only” have MCI. These patients may want to be informed only if and when they have AD. Then and only then they may, on the basis of empirical data, want to be treated.[2]

These patients may not want to know whether or not they have MCI for two reasons: First, they might get better,[3] and then they feel they may needlessly have worried about developing AD, which may negatively affect their quality of life. Second, if they do go on to develop AD, they may be better able to enjoy their lives before this time without carrying a greater burden of potential diagnosis. This rationale is not so different from that of patients who do not want to know if they are at greater risk of developing cancer or Huntington’s disease.

In my previous article, I raised the possibility that among these patients, there may be some who would prefer that their psychiatrists, like themselves, not know whether or not they have MCI until or unless they develop AD. I suggested that psychiatrists respect these patients’ wishes by referring their initial basic screening (for MCI or AD) to a colleague. Subsequently, the colleague would continue to oversee the screening on a regular basis and if or when the patient met a certain criterion for AD would then notify the psychiatrist.

The specific clinical question I address here is three-fold. Is there a way that psychiatrists can (1) respect these patients’ desires to not know whether or not they have MCI, (2) do this in a way that does not negatively affect the long-term course of these patients’ AD (if they go on to develop it), and (3) enable these patients to maintain a trusting patient/psychiatrist relationship?

I answer, “Yes.”

The ethical principle underlying a psychiatrist’s decision to respect the request of his or her patient to not know about a diagnosis is well-acknowledged. When psychiatrists accept this request they respect patient autonomy.

Respecting a patient’s autonomy means also respecting a patient’s request, whether or not the patient makes choices that are best for him or her and whether or not the physician agrees. Dr. Scicutella is quite right that in some contexts, this decision is ethically problematic. When patients have a malignancy that can be treated, for example, the negative consequences of not telling such patients that they have cancer, even when they request this, are much greater.

The underlying, more general ethical principle I refer to here is that psychiatrists should try to tailor their interventions to each patient’s individual needs as much as possible. Some time ago, physicians relied more on paternalism, or on their doing what they believed was best for their patients, regardless of what patients themselves wanted. There is an overwhelming ethical consensus, at least in this country, that in most cases a patient’s autonomy should prevail. This is, in part, because it is the patient, not the physician, who will experience the consequences of the disease or illness.

Clinically, psychiatrists should inform all potential MCI patients about the different meanings their memory problems could have, and psychiatrists should also inform these patients of all their different treatment options. Some patients, after having been fully informed, may not want to find out if they have MCI. They might prefer, instead, to undergo basic screening at usual, regular intervals and be informed only if they have AD. They might want to be treated only if and when they
have AD.

Dr. Scicutella most importantly points out, however, that alternatively patients may improve the quality of their lives if, upon diagnosis of MCI, they are treated with donepezil. They may, she points out, in addition to other short-term benefits, use this “borrowed time” to make critical financial and end-of-life decisions. I agree that psychiatrists should initially fully inform every patient who presents with memory problems about MCI and AD and their treatment options. I believe a fully informed patient who chooses to not know whether he or she has MCI is different from a patient with “unconscious” denial. A fully informed patient makes deliberate choices. The psychological bases of so-called conscious and unconscious “denial” are wholly discrepant. The ethical analysis of what care providers should do in either of these cases likewise wholly differs. When a patient’s denial is unconscious, care providers’ options are more limited and the potential for doing harm is greater. A caregiver’s core concern cannot be, in cases of unconscious denial, whether or not to respect such a patient’s autonomy.

Ethically, if a psychiatrist wants to maximize a patient’s autonomy, he or she must ask the patient what the patient wants. So, why might a patient want his or her psychiatrist to not know whether or not the patient has MCI? I believe the answer is simple: If a psychiatrist knows the patient has MCI but the patient does not know, then this knowledge of the diagnosis by the psychiatrist is kept secret from the patient, and it is now common knowledge in medical ethics that the knowledge that one party is keeping a secret from the other party can have profoundly destructive effects on the patient/psychiatrist relationship. This secret can destroy the relationship this patient and his or her psychiatrist previously had. The one knowing the secret is forced to carry out a “charade.”

In addition to trying to individualize their care, psychiatrists should always try to exercise their moral imagination. I suggest this is the only way in which psychiatrists can consistently have the greatest likelihood of successfully treating their patients. This is especially the case since patients so often have not only diverse but highly idiosyncratic needs.

References
1. Howe E. Five ethical questions involving Alzheimer’s disease. Psychiatry 2007;4:31–4.
2. Rosenberg PB, Johnston D, Lyketson CG. A clinical approach to mild cognitive impairment. Am J Psychiatry 2006;163:1884-90.
3. Mariani E, Monastero R, Mecocci P. Mild cognitive impairment: A systematic review. J Alzheimer’s Dis 2007;12:23-35.

With regards,

Edmund G. Howe, MD, JD
Professor, Department of Psychiatry Uniformed Services University of the Health Sciences, Bethesda, Maryland