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Other common complaints
 

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Other common complaints
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Sleep difficulties

  • Disturbed sleep is a common complaint among veterans. It can be caused by illness, stress or by poor sleep habits.
  • Sleep problems can also be related to mental health problems. Given that depression, generalised anxiety, PTSD and alcohol misuse are relatively common in the veteran population, it is important to screen for these disorders if chronic sleep problems are detected.

Self-management strategies are the first line intervention. If insomnia persists, it may be necessary to consider more formal interventions.  Cognitive behavioural therapy (CBT) is the recommended psychological intervention.

Learn more about the key elements of CBT for insomnia

 The key components of CBT for the treatment of insomnia include:

  • Sleep hygiene and stimulus control strategies: this includes removing stimuli from the bedroom that is not related to sleep, avoiding caffeine, and ensuring that the bed is only associated with sleep.
  • Cognitive therapy: this helps identify and challenge negative thoughts or cognitions which can play a role in maintaining and perpetuating sleep disturbance e.g., worry about the consequences of loss of sleep and unrealistic expectations about how much sleep is actually required.

Further information on recommended treatments is available in the Mental Health Advice Book that was developed for clinicians who work with veterans.

Non-benzodiazepine hypnotic agents are the preferred pharmacotherapy. When possible, prescribe medications in conjunction with self-management advice or CBT.

Problem gambling

  • Problem gambling is characterised by difficulty in controlling gambling impulses. This includes difficulty in limiting the money and/or time spent gambling which then leads to negative consequences for the veteran and his or her friends, family or community.
  • Comorbid mental health problems are common in people with problem gambling.
  • Problem gambling is slightly more common in veterans than the general population, with around 4% of Australian Vietnam veterans experiencing problem gambling, compared to 1-2% of the general population.  Review full article by O'Toole et al. (1996) (PDF) .

The recommended psychological treatment for problem gambling is cognitive behavioural therapy (CBT).

Learn more about the key elements of CBT for problem gambling

The key components of CBT for the treatment of problem gambling include:

  • Motivational interviewing: This approach increases the readiness for making changes to gambling behaviours.
  • Cognitive therapy: this helps identify and challenge any cognitive errors related to gambling (e.g., misunderstanding of randomness and the odds of winning).
  • Exposure therapy: this includes imaginal desensitisation, in vivo exposure and response prevention.
  • Activity scheduling: this encourages the veteran to schedule enjoyable activities as an alternative to gambling.
  • Identification of triggers and high-risk situations for gambling, and coping strategies to use in these situations.

Further information on recommended treatments is available in the Mental Health Advice Book that was developed for clinicians who work with veterans.

There is limited evidence supporting the effectiveness of pharmacological treatments for problem gambling.

  •  Gambling Help: provides free face-to-face gambling counselling throughout Australia. They also provide financial counselling. Refer to their website for information on service locations and/or call 1800 858 858 for referral information.

Problematic anger and aggression

  • Problematic anger and aggression are common problems for veterans and present a potential risk to others.
  • For example, just over one in ten US veterans of Iraq and Afghanistan report having problems controlling violent behaviour.  Review article by Elbogen et al. (2010).

Cognitive behavioural therapy (CBT) interventions can be effective. If family violence is involved, referral to a practitioner with expertise in this area or to a family violence program is recommended.

Learn more about the key elements of CBT for problematic anger

The key components of CBT for the treatment of problematic anger:

  • Arousal management: this includes breathing and distraction techniques.
  • Cognitive therapy: this assists in identifying and challenging unhelpful beliefs including, when appropriate, addressing beliefs about gender and exploring how these beliefs are related to the presence of abuse and violence.
  • Self-instruction training: this provides skills to manage situations where anger is a problem.
  • Exposure for anger: this includes imagining anger-triggering events and practicing skills of anger management in response.
  • Behavioural techniques: this includes problem solving, assertion techniques, and negotiation and conflict resolution skills.

 Further information on recommended treatments is available in the Mental Health Advice Book that was developed for clinicians who work with veterans.

  • A standardised assessment tool that can help you develop a treatment plan, or assess severity and outcomes, is the Dimensions of Anger Reactions 5 (DAR5) scale.
  • It is important to include the patient’s partner and where appropriate, other family members, in the assessment in order to address the family’s safety needs and risk of harm.  It is recommended that partners or family members be interviewed separately to ensure that information received is given without any sense of threat or coercion when family violence is suspected.
  • In order to assess family violence it is important to ask direct questions about potential violent behaviour.  Review the following video that demonstrates how to assess violence with a veteran.
  • Other measures of psychosocial functioning include:
  • Anger online course:  part of PTSD 101 training series, this course reviews literature on anger and PTSD and discusses clinical implications.
  • Anger in PTSD article.
  • Anger, hostility and aggression among veterans article.
  • Australia's National Research Organisation for Women's Safety: provides evidence-based information and resources relevant to reducing the incidence and impact of violence against women and their children.
  • Family Violence Risk Assessment, Risk Management Framework and Practice Guides: Provide an Australian framework for assessing and managing family violence, background information and assessment templates.
  • Anger and trauma chapter: Novaco, R. W., & Chemtob, C. M. (1998). Anger and trauma: Conceptualization,assessment, and treatment. In V. M. Follette, J. L. Ruzek & F. R. Abueg (Eds.),Cognitive-behavioral therapies for trauma (pp. 162-190). New York: Guilford Press.
  • Anger and combat-related PTSD: Forbes, D., McHugh, T. & Chemtob, C. (2013).  Regulating anger in combat-related posttraumatic stress disorder.  In Fernandez, E. (Ed), Treatment for anger in specific populations: Theory, application and outcome.
  • DVA Evidence Compass: Summarises recent research on effective interventions for adults suffering from problematic anger.

Complicated grief

Losing a loved one or friend requires a period of adjustment, during which people grieve for the loss and re-establish their lives without the loved one’s presence. For most people, the intensity of their grief recedes with time as they adjust to life without their loved one.

Some indications that the normal grieving process has been derailed, and that complicated grief may be present, include:

  • preoccupation with the decesased or circumstances of the death
  • persistent yearning or longing for the deceased
  • difficulty making sense of the loss
  • misinterpretation of aspects of the loss (e.g., excessive self-blame)
  • avoidance of reminders of the loss
  • feeling that life is meaningless without the deceased
  • prolonged experience of grief, e.g., for more than one year

Complicated grief is associated with more prolonged distress and disability, as well as greater negative health outcomes and suicidality, than normal grief. It is important to note that complicated grief is distinct from anxiety and depression, although there are some common features across these disorders.

Approximately one in ten bereaved people experience complicated grief, with higher rates amongst those bereaved by disaster or violent death, or parents who lose a child (Shear et al., 2011).

Cognitive behavioural therapy (CBT) is an effective treatment for complicated grief.

Learn more about the key elements of CBT for complicated grief

The key components of CBT for the treatment of complicated grief:

  • Cognitive therapy: this assists in identifying unhelpful beliefs relating to the loss and finding more helpful ways of thinking about it.
  • Behavioural techniques: These assist the veteran to re-engage with the world, undertake positive activities, and set goals for the future.
  • Exposure therapy: this can be particularly useful for those whose loss occurred in traumatic circumstances. This involves repeatedly telling the story of the loss or confronting places, activities or people associated with the loss that have been avoided.
  • CBT may include having imagined conversations with the deceased, evoking happy memories, and exploring regrets and resentment.

 Further information on recommended treatments is available in the Mental Health Advice Book that was developed for clinicians who work with veterans.

Where medication is required, newer antidepressants should be considered as the first choice and should be delivered as an adjunct to psychological intervention.

Traumatic brain injury (TBI)

  • A traumatic brain injury (TBI) can occur when something outside the body hits the head with significant force, e.g., a penetrating injury when a piece of shrapnel enters the brain, a blast injury, or blunt force as a head hits the windscreen during a car accident.
  • The Australian Institute of Health and Welfare report a rate of 107 TBI-related hospital stays per 100,000 people in the population.
  • TBIs in veterans from recent conflicts rarely occur in isolation, but have high comorbidity with pain and PTSD. For more information please refer to the Article by Otis, McGlinchey, Vasterling, & Kerns (2011) (PDF) .

It is not uncommon for mental health disorders and cognitive impairment to co-occur (whatever the underlying cause of the impairment). Psychological therapy can still be effective with veterans with cognitive impairment, although it is important to accommodate for the veteran’s cognitive difficulties.

Principles for adapting CBT for people with TBI.

Clinical practice mTBI guidelines: includes detailed information on assessment and management of mTBIs.

  • TBI information: includes information on understanding and managing traumatic brain injury.
  • TBI training: self-study modules on understanding cognitive and behavioural changes following TBI, and managing related mental health problems.
  • mTBI Pocket Guide mobile device app: provides a quick-reference guide on improving care for mTBI veterans.

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