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Resilience and Military Psychiatry 39

In our experience, trauma-related nightmares are common but oft en
are initially unreported. The relationship between trauma nightmares and

subsequent other symptoms is currently unknown. Th e antihypertensive
prazosin (Minipress) may be helpful in treating trauma-related nightmares
(Raskind et al., 2003). Other pharmacologic approaches such as adrenergic

blockade and the serotonergic antagonistic effects of quetiapine also show
promise but require further study.

Chronic Combat Stress Reactions: Treatment Issues

What the U.S. Army refers to as chronic combat stress reaction is essentially
synonymous with PTSD. It may be treated in theater as described under
anxiety disorders. However, if a soldier is unable to perform eff ectively aft er a
trial period of treatment or if a soldier is deemed dangerous to self or others,

then evacuation from the field may be necessary.
When service members are identifi ed as a psychiatric casualty in need of
evacuation, they are first evacuated from the theater of operations to an inpatient

medical unit such as Landstuhl Army Medical Center in Germany. Very few
who are evacuated to Germany will later return to service. Between 2001 and
2004, only 5% of service members who were evacuated to Germany for psychi-
atric care were able to return to service in Iraq or Afghanistan (Rundell, 2006).
If service members require more than a standard few days of treatment in
Germany, they are transferred to Walter Reed Army Medical Center
(Washington, District of Columbia) or to other hospitals closer to their homes.

There most will spend another week or two receiving inpatient psychiatric
care before they are being transferred to the psychiatric continuity service.
The psychiatric continuity service was developed to serve the needs

of veterans who return from Iraq and Afghanistan suff ering psychiat-

ric disorders or symptoms. The mission of this service is to provide spe-
cialty outpatient care in an interdisciplinary, multimodal, and multilevel
setting designed to address the needs of service members who no longer
need inpatient care but do require intensive outpatient care. Th e treatment
model employed by the psychiatric continuity service attempts to enhance
resilience as a means to improve individual coping and prevent attrition.
Service members’ difficulties are managed until an appropriate and eff ec-

tive disposition can be determined. In some cases, disposition might mean
returning to duty. In most cases, service members may be granted medical
retirement from active or reserve duty.
Because service members who undergo medical evaluation board review
must remain at Walter Reed Army Medical Center for extended periods of
time, the psychiatric continuity service has developed three levels of care
within a tier system of care originally developed by Walter Reed Army

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