Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The "soldier’s heart" of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3
Yet, there are also unique aspects of the combat experience of these veterans that influence their psychiatric presentations in acute settings.
First, far more of the troops (up to 45%) are reserve or National Guard rather than active duty compared with earlier wars.4 Their combat exposure, severity of PTSD, and impairments in interpersonal functioning are more similar to those experienced by career military.5 These individuals are most likely to appear in crises in community emergency departments (EDs); they may present with problems that may be different from veterans of previous wars or from soldiers in active military duty.
Typical presenting symptoms are marital stress from unexpectedly long deployments of 15 months (rather than the standard 12), employment concerns, financial stresses, and overall difficulty in reintegrating into civilian life. The absence of a strong military identity and cohesion, geographical separation from comrades, greater stigma, and misunderstanding from communities without exposure to the military or combat trauma serve as formidable barriers to care for these citizen-soldiers.
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