This study looks to establish a relationship between the intensity of a veteran’s pain score and their ability to cope with stress. It is hypothesized that higher pain scores will reflect greater maladaptive coping behaviors (Otis, 2009). Maladaptive coping will be defined as missed appointments, noncompliance with treatment regimens, continued substance abuse, and increased reports of pain to name a few. Presently, there is no central, easily identifiable location for recording pain status in the patient record. The collection of pain assessment data would allow for continuous quality improvement and allocation of resources. Military veterans report pain at more than double the rate of non-enlisted patients. U.S. service members may see lifetime treatment for diseases associated with polytrauma or increasing disability. Without less costly and effective pain management solutions, it is estimated that costs related to care and disability will approach $5 trillion (Levy, 2015).
Keywords: Posttraumatic stress, trauma, catastrophes.
Post-traumatic stress disorder (PTSD) is a disease linked from its origins to psycho-traumatic events such as war, although not exclusive of these situations, which makes it one of the so-called parallel syndromes it can and should be used for the preparation of medical officers for war. PTSD was classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as an anxiety disorder, with a relatively frequent lifetime prevalence, representing the late response to an extreme or catastrophic event that produces alterations psychological problems of such magnitude that anguish ceases to be a danger signal to become a source of it (1). This disorder offers a clinical picture articulated by 3 basic symptoms: The repeated and involuntary evocation of the traumatic event. The reduction of the general level of response to daily stimuli and an increase of the waking state. Symptoms begin after a latency period, which varies from a week to months (rarely more than six). The course is fluctuating, but recovery can be expected in most cases (2). It is often noticed that war veterans and survivors of civil disasters, who apparently had no symptoms for many years, may develop a post-traumatic flowered syndrome after the occurrence of stressful events (3). It has also been described in veterans with PTSD a higher frequency of other disorders, such as the consumption of psychoactive substances, anxiety disorders, somatization, and depression when compared with the general population (4). Groups of symptoms of this syndrome are present in a significant percentage of veterans of Operation Desert Shield, those who have suffered from a condition called Gulf syndrome.
In 1666, Samuel Pepys, following the great fire in London, described a picture similar to what we now call PTSD. Erichsen in 1866 described a syndrome with psychosomatic and cognitive symptoms in victims of railway disasters (5). In 1889 Herman Oppenheim, introduced the term traumatic neurosis, the concept that maintains its validity. The Swiss Edouard Stierlin published investigations, one about the Messina earthquake and another one about a serious mining accident (6). Sigmund Freud modified his ideas regarding the relationship trauma-psychopathology over the years, to finally ignore the effect of real traumas, which replaced the fantasized traumas (7). However, it is the war experience that offers more complete and abundant descriptions, with clinical characteristics similar to that offered by civil catastrophes. In war, people are exposed to a large number of psycho traumatizing agents, which go beyond the usual human experience.
n the First World War, traumatic neurosis was of great interest, and the so-called "trench shock" was deeply debated, which was also related to physical causes, this time with brain injuries (8). At that time, residual symptoms associated with combat stress were classified as "war neurosis". Nevertheless, although its relationship with war events was known, it was believed that the fundamental causes were in previous predispositions, such as alterations of the personality and underestimated the traumatic effect of the battle (9). The investigations on the psychic consequences of the war increased in World War II, in the course of which an increase in the incidence of "traumatic neurosis" was reported. This diagnosis was significant among the troops dislocated in the Pacific, where the worst conditions and greatest isolation existed, despite the fact that the number of recruits rejected by psychic causes had been greater, compared to the previous world war (10). At that time, the syndrome was called "battle exhaustion", despite the fact that many soldiers without previous mental illness had been affected by exposure to the environmental stress of war. According to Menninger, if they were treated close to the battle line, they recovered better than those treated in rear-guard hospitals.
A lifetime prevalence has been reported in Vietnam veterans between 20 and 30%, a figure similar to that found in other wars3 and other armies, as well as in civilian victims of attacks, threats, and abuses, which is between 10 and 30%. In accidents and natural catastrophes also occurs although with lower figures. The violations represent the events of civil life where higher rates of PTSD are reported, some authors suggest that more than 50% of raped women have PTSD (12). The estimated prevalence in the general population is 3-6%, which is supported by the findings of a group of studies. It has been described that in situations of war the individuals who are evacuated tend to present greater persistence of post-traumatic symptoms than those who present them are treated in hospitals, near the line of fire, those who most often recover and do not cause sanitary loss (13). In this case, the evacuation would work in a similar way to indemnities in civil life, which are associated with income neuroses that have been described as perpetuating factors of the symptoms.
It has been pointed out that a group of subjects after experiencing extreme situations present incomplete forms of PTSD. After the terrorist attack of September 11 in New York, it is estimated that more than 50% of people who were directly involved in it, had post-traumatic symptoms even if they did not have the complete syndrome (14). It has been suggested that the presence of partial PTSD could interfere, as well as the complete disorder, in the rehabilitation of the individual after a traumatic event (15). High levels of combat have been associated with the presence of the disorder in veterans of Operation Desert Storm, and in Vietnam veterans.
With respect to the causal relationship between premorbid factors and the development of PTSD, there is no agreement in the literature. McFarlane argued that the severity of exposure to a disaster was the main determinant of early morbidity, whereas previous psychological disorders were those that best predicted the chronic evolution of PTSD (16). In a study of Vietnam veterans, it was observed that good premorbid social adjustment was a predictor of PTSD. Other research supports the fact that the presence of anxiety disorders and some personality traits increase the risk of suffering PTSD after a traumatic event (17). Participation in military actions has been linked to the presence of long-term PTSD and other psychiatric disorders. Among veterans, mood disorders, obsessive-compulsive disorder, anxiety disorders, drug addiction, and individuals who have suffered PTSD have been associated with an increased risk of other psychiatric disorders (18). PTSD has not yet been accepted as a classification with a pathogenic basis, although it is recognized that trauma is an essential component of the definition of the disorder. To relate a causal factor to disease requires that 2 essential factors be met (22).
The first factor involves the concept of validity, or the ability to recognize the disorder as a discrete diagnostic entity. This means that the disease appears after exposure to the proposed causative factor. Prospective investigations reflect an increase in PTSD compared to other diagnoses that also appear in response to a traumatic event.
The second factor consists in the possibility of isolating and replicating the proposed causal agent. For example, scarlet fever is recognized as a discrete diagnostic entity with an association with a recognized agent, Staphylococcus aureus.
The forced question here is what kind of trauma can be considered sufficient to incur a causal designation? The disagreement is based on the opinion of some researchers who state that trauma represents a non-specific trigger factor of various syndromes, such as major depression, panic disorder, somatic problems, and addiction. These disorders also increase their incidence after the trauma (23). Issues such as intensity of the stressor, risk factors in the event, the vulnerability of the individual, and subjective evaluation of the event are still considered mediating factors in the development of the disorder. In addition to other causal factors have been proposed as genetic factors (24). Comorbidity with problems related to alcohol consumption is variable in the literature consulted. Some studies report a lifelong prevalence of drug addiction between 25 and 75% in ex-combatants with PTSD.
A single traumatic episode can have an influence for a lifetime, despite the fact that the subject does not get sick with a complete PTSD, that is, with all the necessary criteria to be diagnosed. Some works suggest that the affectation in the work areas and social is similar in patients with total PTSD and in those who have incomplete PTSD (25). This situation is often misunderstood by the authorities in charge of health insurance, and reinforced by the vision that these patients sometimes have. Some think that it is people who seek economic and social support in all ways and are stigmatized with the approach of simulating the disease and the tests applied to them (26). This negatively influences the development of plans to care for those affected by the disease. The disappearance of symptoms can be facilitated thanks to what are called social containment variables, which include reintegration into social and working life, the understanding of society for what happened, and the image of the ex-combatant community, among other factors (27). It is also important the appreciation that the individual has about their quality of life.
Definition and Diagnostic Aspects
From its primary origin in emotional reactions to combat experience, the modern nosological approach to PTSD has expanded to the consideration of other types of events characterized as "extreme" or catastrophic (28). A long list of such events is now accepted: violent attacks of a sexual nature, domestic or by criminals, kidnappings, acts of terrorism, natural or technological disasters, domestic or industrial accidents, torture, serious medical diagnoses or terminal illnesses, sudden losses of beings dear ones, to be witnesses of massacres, massacres or mutilations, etc.
The diagnostic criteria for PTSD make it clear that: a) The traumatic event constitutes a threat to the physical integrity of the victim or others close to her and generates intense fear, helplessness, or horror, b) The patient lives or re-experience the event either through memories "intruders" in the field of consciousness, nightmares, "flashbacks", discomfort before internal or external perceptions that remind him of the event (in the case of veterans, for example, the noise of helicopters or airplanes, smel...
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