A biopsychosocial approach is required when treating the active duty service member or veteran with posttraumatic stress disorder (PTSD) due to the complex integration of medical and psychological elements with ever-evolving social dynamics. Additionally, there are military-specific issues (administrative, cultural, etc.) that must be considered for comprehensive treatment for the active duty military population.

This patient represents a common, multifactorial presentation of service members with combat-related PTSD with comorbid physical conditions, such as chronic pain. Psychologically, she is experiencing extreme survivor’s guilt regarding the IED blast during her second deployment. Biologically, she continues to struggle with opiate dependency for management of chronic pain as well as heavy alcohol use. Socially, her marriage ended in divorce, resulting in a limited support network. The problem list is lengthy and could include anxiety, depression, alcohol use disorder, opiate use disorder vs. physiological dependence for the purpose of pain control; however, the unifying diagnosis is PTSD.

Notable changes to the diagnostic criteria for PTSD were made for the DSM-5 as compared to the DSM-IV-TR. Per DSM-IV-TR, the individual needs to react with horror to the traumatic event; however, the military population is trained to maintain composure when faced with a potentially traumatic event (Table 16.1 ). The DSM-5 removes the requirement of reacting with horror. The symptom triad of reexperiencing, avoidance, and hyperarousal has been expanded to include an additional requirement of negative alteration of mood, such as depression, anger, or irritability [1, 2].

PTSD remains a clinical diagnosis, though multiple assessment tools may be helpful in screening and tracking progression of treatment. The PTSD checklist (PCL) has a military-specific version (PCL-M) for combat-associated PTSD that consists of 17 questions answered by patient self-report [3]. The Department of Veterans Affairs (VA) and Department of Defense (DoD) have now adopted the PCL-5 for screening purposes. Given the push for more objective measures of patient progress in clinical practice, these tools can be helpful in tracking a patient’s response to treatment.

Initial psychiatric evaluations must include a safety assessment which is of noted importance in the military population, where the rate of suicide is higher than the general population [4]. Many service members and veterans own firearms, a known risk factor for suicide [5]. Counter to popular belief, a recent publication noted no association between deployment and suicide rate. Increased suicide risk was associated with early separation from the military (< 4 years) and other-than-honorable discharge from military service [6].

There are inherent challenges in developing rapport between the civilian provider and a military patient due to perceived cultural differences and possible language barriers with regard to military jargon. Examples include the numerous acronyms used in the various services and military slang to refer to individuals, weapons, etc. Identifying these barriers and differences early in the treatment process can aid in developing rapport, potentially leading to improved outcomes [7]. Possible strategies include providers familiarizing themselves with acronyms and military slang specific for their patient’s branch of service as well as open dialogue acknowledging the provider’s deficits regarding military culture.