265

Psychiatric Intervention With the Orthopaedically Injured

Chapter 12

PSYCHIATRIC INTERVENTION WITH 

THE ORTHOPAEDICALLY INJURED

HAROLD J. WAIN, PhD*; ANDREE BOUTERIE, MD†; MARVIN OLESHANSKY, MD‡; and JOHN C. BRADLEY, MD§

INTRODUCTION

TRAUMA AS A RISK FACTOR FOR PSYCHIATRIC DISORDERS

TRADITIONAL RESPONSES TO COMBAT AND INJURY

CONCERNS OF THE SERVICE MEMBER WITH POLYTRAUMA AND LIMB LOSS 

FACTORS INTERFERING WITH RECOVERY

A PSYCHIATRIC APPROACH TO SERVICE MEMBERS WHO HAVE SUSTAINED 

TRAUMA OR COMBAT-RELATED INJURIES

THERAPEUTIC INTERVENTION FOR PREVENTING PSYCHIATRIC STRESS 

DISORDERS 

PHARMACOLOGY AND OTHER TREATMENT INTERVENTIONS FOR ANXIETY, 

DEPRESSION, AND PAIN

HYPNOSIS

TRAUMATIC BRAIN INJURY ASSOCIATED WITH POLYTRAUMA AND AMPUTATION

TREATING THE TRAUMA PATIENT’S FAMILY

FOLLOW-UP

SUMMARY

*

Chief, Psychiatry Consultation Liaison Service, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Building 2, 

Room 6238, Washington, DC 20307

†

Staff Psychiatrist, Psychiatry Consultation Liaison Service, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, 

Building 2, Room 6237, Washington, DC 20307

‡

Staff Psychiatrist, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett Hite Road, Honolulu, Hawaii 96859

§

Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Building 2, Room 

6237, Washington, DC 20307
266

Care of the Combat Amputee

INTRODUCTION

Injuries that result from disasters, whether natural or human made, have a deleterious impact not 

only on the injured, but also on their families and 

caregivers. The psychological trauma of combat may 

be overwhelming, especially when combined with 

physical injuries. Freud suggested that trauma is an 

extraordinary stimulus that disrupts homeostasis 

and can be too powerful to be worked through in a 

normal way. Variables contributing to this disruption include the physical injuries, recovery from and 

long-term adjustment to the injuries, and associated 

losses and psychiatric sequelae. This is most obvious 

in the polytrauma patient, who may have orthopaedic 

injuries combined with other injuries, such as burns; 

traumatic brain injury (TBI); spinal cord, peripheral 

nerve, and genital injuries; internal organ damage; 

poor wound healing; blindness; deafness; or facial 

disfigurement.

TRAUMA AS A RISK FACTOR FOR PSYCHIATRIC DISORDERS

Morgan et al stated that nearly all survivors exposed to traumatic events briefly exhibit one or more 

stress-related symptoms.1 In many instances, these 

symptoms dissipate within a reasonable period of 

time. However, O’Donnell et al reported that 20% to 

40% of patients followed 1 year after trauma had a 

psychiatric disorder.2 Hoge et al reported that 18% to 

20% of soldiers met screening criteria for psychiatric 

diagnoses 3 to 4 months after duty in Iraq, where 

combat exposure was deemed high.3 Injury appears 

to increase the risk of developing psychiatric disorders above that of exposure to combat alone. Koren 

et al suggested that in the combat-injured, rates of 

posttraumatic stress disorder (PTSD) are more than 

5-fold higher (16.7% vs 2.5%) than in similarly combatexposed soldiers 15 months following injury.4

 A study 

by Grieger et al shows that injured soldiers at Walter 

Reed Army Medical Center (WRAMC) had posttraumatic rates of psychiatric disorders equivalent to 

rates found in the combat-exposed soldiers in Hoge’s 

study, suggesting that early interventions during the 

acute medical–surgical care of combat casualties as 

WRAMC reduces the impact of injury as a risk factor 

for developing psychiatric sequelae.3,5 

Although most survivors of trauma will not manifest severe psychiatric disturbances, some appear more 

susceptible than others. Research demonstrates that 

low intelligence, low education level, poor vocational 

endeavors or achievement, absence of social support 

following the event, and female gender are risk factors for psychiatric sequelae to occur subsequent to 

trauma.6 Severity of the traumatic event, prior traumatic exposure, and additional life stressors may also 

contribute to psychiatric morbidity. Premorbid psychiatric disorders and personality disorders are thought 

to predispose individuals to posttraumatic psychiatric 

disorders. Smells, heat, light, sand, the backfiring of 

a car, and holiday fireworks are just some of the environmental stimuli that can trigger thoughts of past 

trauma and psychiatric symptomatology.

TRADITIONAL RESPONSES TO COMBAT AND INJURY

Service members have traditional fears as they 

engage in battle. Psychological responses to combat 

include the normal fear of injury or death, constant 

threats of being attacked, and existential worries about 

life. While in theater, sleep deprivation is an almost 

universal problem, as is the need for alertness in case 

of attack and a sense of vulnerability. These behaviors 

are all components of what is frequently described as 

the “battle-mind mentality,” which may prevail for a 

long period of time even after a soldier returns home. 

Upon being injured, a soldier may initially exhibit 

disbelief (denial), begin prayer (taking a bargaining 

approach with religion), show anger or rage, and 

eventually express grief or depression. Emotional 

reactions resulting from physical injuries may persist 

even after evacuation to safety. Negative reactions may 

complicate recovery and rehabilitation and may lead 

to poor interactions with family members and staff. 

Unit cohesion reportedly helps decrease the incidence 

of PTSD. It is therefore important to consider the 

impact of removing injured soldiers from their units 

and understand the importance of finding a strong 

environmental support structure for them. 

Separation anxiety and “survivor guilt” may also 

play a significant role in a service member’s psychological adjustment after an injury. The service member 

may experience overwhelming guilt for surviving a 

wartime experience that led to the death of a battle 

buddy. Survivor guilt may also extend beyond the injured soldier, adversely affecting many of the members 

within the unit. This may play a role in the subsequent 

interactions between injured service members and 

their units and may impact the support they receive. 

Although most patients deal with feelings of survivor 

guilt effectively, professional intervention is sometimes 

necessary to help reframe a patient’s perceptions in an 
267

Psychiatric Intervention With the Orthopaedically Injured

appropriate manner. Surviving service members often 

feel their fallen comrades’ families expect to hear comforting words about their loved ones’ last moments. 

Whenever possible, service members are encouraged 

to attend their colleagues’ funerals or military unit 

reunions because these events are often helpful during 

the recovery process. Most wounded warriors want 

to rejoin their former units when they are redeployed 

and every effort should be made to advocate for this 

reunion. Service members should be encouraged to let 

go of grief to maximize their own life potentials and 

thereby honor the fallen and their sacrifices.

Trauma victims employ various psychological defenses in an attempt to maintain homeostasis. Some 

of the more common defense mechanisms include 

dissociation, regression, intellectualization, rationalization, and denial. Dissociation may occur during or 

subsequent to trauma and is an attempt to delay the 

impact of the trauma. Regression occurs when a person 

temporarily reverts to an earlier stage of psychological 

development. For example, an adult who is hospitalized may become more dependent and act several 

years younger. In the early stages of hospitalization, 

dependency can be helpful. It can become pathological, however, if it lasts too long or is too extreme. 

Intellectualization is a mental mechanism in which 

the person engages in excessive abstract thinking or 

extreme reasoning to avoid confronting conflicts or 

disturbing feelings. Rationalization is a similar defense mechanism in which patients develop elaborate 

explanations for their behavior that appear logical 

only to themselves, allowing them to escape anxiety 

about their actions and continue with the behavior. 

Denial can also be a healthy defense because it allows 

patients to distance themselves from the impact of the 

injury and perhaps decrease the immediate likelihood 

of being overwhelmed. However, it too can become a 

hindrance if prolonged.

When psychological defenses are overwhelmed, 

normal coping mechanisms may become dysfunctional. Generally, psychiatric disorders that emerge 

soon after injury are best characterized as adjustment 

disorders or acute stress disorders. More prolonged 

reactions include various anxiety and depressive 

disorders, such as generalized anxiety disorder, panic 

disorder, social phobia, agoraphobia, major depressive disorder, and other mood disorders, which may 

also be associated with more chronic forms of PTSD. 

Somatoform disorders and volitional symptoms are 

also observed in some service members returning 

from combat. Psychotic disorders are rarely observed 

in injured service members. Cognitive disorders may 

result from a comorbid TBI or from postconcussive 

sequelae. 

CONCERNS OF THE SERVICE MEMBER WITH POLYTRAUMA AND LIMB LOSS

Service members who have sustained traumatic 

injuries, including amputation, present with myriad issues. In addition to physical limitations, they may fear 

failure, rejection, loss of military careers, and future 

under-employability. Orthopaedically and neurologically injured service members must also deal with pain 

and loss of body integrity and function. Psychological 

responses to this state include the classic symptoms of 

acute and chronic PTSD, such as emotional numbing, 

flashbacks, avoidance of reminders of the experience, 

and hyperarousal. They may express resentment, frustration, helplessness, hopelessness, and self-pity. Body 

image concerns may also be prominent (eg, one of the 

earliest concerns of many service members is fear they 

have sustained physical injury to or loss of their genitals). As recovery progresses, many service members 

wonder if they are going to be the same men or women 

that they were before they were injured. Those who 

are single may focus negatively on the future prospects 

of dating; all may question whether they will be able 

to play with children or partake in physical activities, 

such as athletics, recreational events, hobbies, and, in 

particular, sexual activities. The latter concern may be 

exacerbated by the lack of opportunity to test out sexual 

functioning in the earlier stages of rehabilitation. Later, 

medication-related problems may decrease libido and 

impair performance, further increasing these concerns.

Service members who have lost one or more limbs or 

other body parts experience a host of additional concerns. 

They often struggle with a severely altered body image, 

and low self-esteem may ensue. They frequently worry 

about the impact of further surgical revisions, which may 

come to be seen as cutting them down in size. They may 

particularly fear rejection by loved ones and social stigma. 

Rybarczyk et al showed that a negative body image is 

correlated with an increase in adjustment problems following amputation.7

 Phantom pain, though troublesome, 

may later exacerbate psychological sequelae by delaying 

focus on the emotional trauma.8,9 Others suggest that 

phantom pain may have nothing to do with psychological concerns, emphasizing that each individual’s needs 

must be addressed independently.10

The loss of a body part is similar to the loss of a loved 

one and may be associated with a prolonged grieving 

process. The reintegration of self for the amputee 

has been described as occurring in three phases. The 

first phase involves shock, with feelings of cold and 

numbness; being dazed and confused; and feeling 

empty.11 This manifests as the service member feeling 

overwhelmed and immobilized by daily tasks. The 
268

Care of the Combat Amputee

second phase is the period of mourning, in which internal focus leaves little energy for others. In this phase, 

the service member’s internal body image awareness 

comes in line with external awareness, but the patient 

still does not give up the past.12 A prolonged period of 

mourning may hamper eventual adjustment. Following the mourning phase, an adjustment phase ensues.13

As the patient deals with the demands of life, present 

resources and abilities are reorganized. Through a 

gradual increase in satisfying experiences and newfound competencies, the patient finally emerges with 

a new sense of self and worth.14

FACTORS INTERFERING WITH RECOVERY

There are many factors that interfere with physical 

and psychological recovery after injury. Lack of support from family, caregivers, and even the general public can be detrimental and can impede recovery. The 

Department of Defense provides travel and housing 

allowances to nonmedical attendants who stay with 

service members during recovery. The nonmedical 

attendants, who are often family members, can help 

with activities of daily living, dressing changes, and 

medication administration. Nonmedical attendants 

also provide companionship and often serve as advocates for the service member. 

Feelings of low self-esteem, loss of wholeness, and 

fear of the future are common early in the recovery 

phase for combat-related trauma. Frierson and Lippmann describe social isolation as a common occurrence after amputation that needs to be addressed.15

Similarly, social discomfort and body image anxiety 

must be addressed and overcome with appropriate 

support and therapy.16 Some amputees may exhibit 

initial discomfort with their prostheses, which may 

represent rejection of themselves and their ongoing 

mourning. It is not uncommon for severely injured 

service members to believe that their injuries have left 

them less than human. Additionally, grief and sorrow 

over their personal loss may be complicated by grief 

over the loss of combat buddies injured in the same 

incident. Survivor guilt can contribute to depressive 

symptoms. Grief and sorrow are often expressed as 

anger, which may threaten relationships with spouses 

and families. Anger may eventually lead to emotional 

withdrawal.

A significant stressor in the orthopaedically injured 

service member is the need for frequent washouts of the 

affected limbs. Service members are often apprehensive of these procedures, which usually require general 

anesthesia and may be associated with significant pain. 

Service members also fear additional surgeries that 

may result from poor healing of the affected tissues. A 

significant number of service members without initial 

limb loss may ultimately require amputation. Some 

service members fear losing a limb and plead for its 

preservation, while others seek elective amputation to 

minimize pain and shorten recovery and rehabilitation 

time. Before elective amputation, however, a thorough 

psychological evaluation is performed to assess capacity, ascertain secondary gain, and address underlying 

issues. Some injured service members who are hesitant 

to return to the community or who fear limited access 

to healthcare upon discharge may seek to prolong their 

hospital stays. A small number of service members 

may be motivated to extend their hospital stays because they believe (incorrectly) that will enhance their 

disability benefits. 

It is important that professionals caring for injured service members believe in a positive outcome 

for their patients because their expectations will be 

reflected in their interactions and resultant care. 

However, this may be problematic in situations 

where the service member is not likely to return to 

full physical function. Providers must be aware that 

their verbal and nonverbal interactions are keenly 

observed by their patients and their patients’ families. Providers often feel the need to correct their 

patients’ overly negative and overly positive appraisals for recovery; however, hope and determination 

are important motivators for recovery and need to 

be encouraged. Providers should keep in mind that 

during the initial inpatient hospitalization, it is often 

too early to understand the full extent of even the 

most severe injuries and the impact they will have 

on the service member. 

A PSYCHIATRIC APPROACH TO SERVICE MEMBERS WHO HAVE SUSTAINED TRAUMA OR 

COMBAT-RELATED INJURIES

A major concern in providing mental health care to 

service members is their reluctance to seek treatment 

because of a fear of stigmatization.3 To address this 

issue at WRAMC, the psychiatric consultation-liaison 

service developed a preventive medical psychiatry 

(PMP) service.9 This service performs, without formal 

consult, routine initial screening evaluations of every 

service member admitted to the hospital for medical or 

surgical sequelae of the global war on terror. The goal 

of the PMP service is to foster acceptance of mental 
269

Psychiatric Intervention With the Orthopaedically Injured

health issues and decrease stigmatization, thereby 

preventing or decreasing chronic disabling psychiatric 

disorders following trauma. 

The approach to psychiatric intervention with 

injured service members has evolved over the years. 

The contemporary model of intervention has been 

developed based on lessons learned from past conflicts 

and events.17 For example, after the Pentagon attack on 

September 11, 2001, WRAMC staff were deployed to 

local hospitals to meet with injured survivors where, 

instead of using classic debriefing techniques that 

had not proven effective in the past, caregivers practiced empathic exposure (see below) and provided 

ongoing follow-up. Anecdotally, this technique was 

well perceived by those who were contacted, so the 

practice was continued with the casualties returning 

to WRAMC from Iraq and Afghanistan. While it has 

been reported that prolonged exposure may be a more 

efficacious treatment than cognitive restructuring 

for patients with acute stress disorder,18 the experience of the WRAMC staff has shown that injured 

service members may not be able to tolerate the stress 

of more aggressive psychotherapies while dealing 

with physical loss, pain, and profound life change. 

Following injury, all means must be taken to help the 

patient overcome losses and facilitate recovery. Initially, patients must believe the staff is there to protect 

them from further harm. Care providers should work 

to facilitate sleep and rest and reduce physiological 

arousal and pain. This may be accomplished through 

medical and surgical means or through pharmacological interventions, hypnotic techniques, and psychological support. Care providers and family members 

of injured service members must strive to reduce unnecessary stressors. 

It is important for caregivers to connect with their 

patients so patients can see providers as a healthy 

adjunct to their recovery. At times, patients may only 

need basic information as to what services or treatment options are available; other times, they may 

need guidance toward more direct coping strategies, such as distracting themselves and reframing 

conflicts. Negative appraisals by patients or their 

families must also be corrected; however, providers must take care to remind patients that although 

they will not be returned to their premorbid states, 

they can still achieve their goals and have satisfying lives. As patients join in a therapeutic alliance 

with their caregivers, they become more open to 

discussing complex issues, fears, and concerns about 

the future. This is facilitated with a flexible evaluation and treatment approach. Patient assets and 

strengths should be recognized and reinforced. The 

PMP service acts as a patient advocate and serves as 

a liaison between families and medical and support 

staff (Exhibit 12-1). 

EXHIBIT 12-1

CASE STUDY 1: AN EXPERIENCE OF THE PREVENTIVE MEDICAL PSYCHIATRY SERVICE

A 36-year-old soldier with a soft tissue injury to right eye, left femur and tibia fractures, and a right below-the-knee 

amputation responded in a sullen manner to his orthopaedic and physical therapy teams. Upon the initial visit, he 

denied any psychiatric problems had resulted from the improvised explosive device blast that had resulted in his 

injuries. He claimed he did not need psychiatric intervention and was concerned that the team referred him. The 

team reported poor compliance with treatment and disrupted sleep. When the soldier became aware that the psychiatric approach was routine and preventive, he began describing his concerns about his decision-making process 

while in theater that may have led to his unit receiving the blast it sustained. The preventive medical psychiatry 

service worked to reframe his experiences while advocating for him. As he accepted the routine of the approach, the 

soldier began to respond more favorably, appeared to assimilate the intervention, and cooperated more fully with 

his rehabilitation.

THERAPEUTIC INTERVENTION FOR PREVENTING PSYCHIATRIC STRESS DISORDERS 

At WRAMC, the PMP service employs an approach known as the “Therapeutic Intervention for 

the Prevention of Psychiatric Stress Disorders.” This 

program was developed to address the psychological 

needs of trauma victims, provide support to the individuals and their families, assess psychiatric status, 

provide early intervention (when needed) without 

stigmatization, and support the medical and surgical 

staff. The major components of the approach include 

making mental health a routine part of trauma care, 

using a biopsychosocial approach to care, developing a strong therapeutic alliance with the patient 
270

Care of the Combat Amputee

EXHIBIT 12-2

CASE STUDY 2: USING REFRAMING AND 

AFFIRMING TECHNIQUES 

Following the blast from an improvised explosive 

device, the right ankle of a 22-year-old male was 

severed such that he could not stand to run. He 

described seeing his driver bleeding from a gunshot 

wound and he crawled to the driver’s side, applied 

a tourniquet to his fellow soldier, and pulled him 

to safety. The caregiver focused positively on the 

soldier’s actions, asking how he had the strength to 

assist the driver and help save his life.

and family, normalizing the patient’s experience 

and psychological response to the trauma, providing 

education, using pharmacology and hypnosis when 

appropriate, providing empathic exposure therapy 

(see below), treating identified psychiatric symptoms, reinforcing resiliency, and promoting positive 

coping behaviors. Traditional psychotherapeutic and 

psychodynamic perspectives are also employed to 

help conceptualize specific patient problems and 

find solutions.19

Intervention timing is particularly important to the 

success of the approach. Following trauma, victims are 

less likely to attend to internal psychological distress 

until they are medically stabilized. Maslow described 

a hierarchy of needs, with a specific time and place 

for all interventions.20 He suggested that patients’ 

physiological needs have to be met first, followed 

by their needs for safety, belongingness, esteem, and 

self-actualization. Ultimately, therapy for resilience is 

ineffective while the patient is struggling for life or 

feels unsafe. 

Horvath and Symonds found that the therapeutic 

alliance is meaningfully correlated with treatment outcomes,21 and Crits-Christoph et al found the therapeutic alliance is important in developing interactions that 

repair problematic ones.22 Marmar et al reported that 

addressing feelings leads to positive outcomes only 

after the therapeutic alliance has been established.23

Therapeutic alliances with injured service members are used to help the injured process their ordeals 

EXHIBIT 12-3

CASE STUDY 3: USE OF EMPATHIC EXPOSURE

Following the blast from an improvised explosive 

device, a 41-year-old service member with a soft tissue injury to the left eye and bilateral lower extremity fractures was hospitalized with an external fixator 

on his leg. The patient began having episodic tremors and seizure-like behavior without any explanation (his electroencephalography result was normal). 

A thorough psychological evaluation also appeared 

to be normal. After the development of a therapeutic 

alliance and applying techniques such as hypnosis 

and pharmacological management of sleep, it was 

discovered that the noise that was being generated 

multiple times a day from the patient’s external 

fixator was similar to that created by the blast that 

had caused his injury; the sound was contributing to 

his symptom manifestation. As he was empathically 

exposed to his trauma, his symptoms dissipated. 

through empathic exposure therapy. During this 

therapy, service members are usually seen for 15 to 

20 minutes several times per week. They are asked to 

reflect on their traumatic experiences, with the suggestion that talking about them at the present will 

be helpful in the future. Empathic exposure allows 

patients to normalize their experiences and consolidate 

them in their memory, and may help them integrate 

the past trauma into a normal stream of consciousness. 

Providers are trained to offer rapid empathic responses 

to the patient’s recall of the trauma and injury. Caregivers avoid confrontational approaches and instead 

employ nonthreatening techniques, responding in 

ways that emphasize patients’ positive assets, such 

as, “How did you know to do that?” and “Where did 

you learn that?” Clinicians are encouraged to display 

acceptance, respect, empathy, warmth, advice, praise, 

affirmation, and a sense of hope while working with 

these patients. It is critical that providers are viewed 

as genuine in their concern and support of the patient 

while encouraging patients to elaborate on reactions 

relevant to the trauma and offering empathic validation (Exhibits 12-2 and 12-3).

PHARMACOLOGY AND OTHER TREATMENT INTERVENTIONS FOR ANXIETY, DEPRESSION, 

AND PAIN

 In addition to the psychotherapeutic interventions 

discussed above, medications can be used to address 

patient needs and psychiatric symptoms. Although it is 

beyond the scope of this chapter to present a detailed 

medication or other treatment approach to combattrauma–injured patients, an overview of symptoms 
271

Psychiatric Intervention With the Orthopaedically Injured

and disorders most frequently encountered and general treatment approaches are discussed below. 

 In order to address the combat-injured patient’s 

most urgent needs and to provide comfort (barring 

frank delirium), the primary focus should be on 

encouraging sleep, controlling pain, and alleviating 

anxiety symptoms, which most prominently present 

in the form of nightmares, hyperarousal, intrusive 

thoughts, and flashbacks. Before recommending 

medication, it is important to consider the patient’s 

underlying medical condition, current medications, 

and allergies. Potential interactions should be reviewed because most psychoactive medications have 

the propensity to interact with other medications 

and antibiotics. Sleeping agents are recommended 

as needed, according to the patient’s preference and 

medical situation. Hypnotic agents, such as zolpidem, 

may be helpful for problems with sleep initiation, 

but may not be as efficacious for problems with sleep 

maintenance, early morning wakefulness, or nightmares. Sedating antidepressants, such as trazodone 

and mirtazapine (both of which are fairly well tolerated, have few medication interactions, and may help 

address comorbid anxiety or depressive symptoms), 

are frequently used. Atypical antipsychotics have 

also been successfully employed to treat sleep disturbances with nightmares, and may be indicated 

in the presence of flashbacks or disorientation and 

emotional dysregulation due to multiple or high 

doses of pain medications or other medical issues. 

Quetiapine is used in low doses (25–75 mg) to capitalize on its sedative properties in this dose range and 

to minimize potential, although rare, adverse side 

effects. In this dose range, quetiapine appears to work 

largely by blocking histamine receptors, an action that 

has been associated with a decrease in the rapid eye 

movement stage of sleep. Prazosin has also proven 

effective for reducing nightmares in outpatients with 

PTSD,24 but has not been studied in the inpatient 

polytrauma setting, in part because of concern over 

its cardiovascular effects. 

Pain control is an important consideration for 

patients in all stages of recovery, but is particularly 

important in the earlier stages of treatment because 

proper management can set the stage for future 

adequate responses. Conversely, poor pain control 

may heighten a patient’s anticipatory anxiety for all 

procedures, interfere with sleep, and may eventually 

lead to problems with chronic pain. The psychiatric 

consultation-liaison service at WRAMC works closely 

with the medical, surgical, and pain services to achieve 

maximum patient comfort. Hypnotic techniques are 

frequently employed to help in this area.

 More specific treatments for anxiety and depression depend on the associated disorder (if present), 

the severity of symptoms, and the patient’s stage of 

medical recovery. Early during the course of medical 

treatment, anxiety may be associated with delirium 

because of the underlying medical condition, in which 

case a neuroleptic medication may be used to address 

anxiety, agitation, and disorientation. As the patient 

stabilizes, anxiety symptoms tend to ameliorate or 

consolidate into more recognizable disorders. As the 

service member physically heals and develops more 

cognitive reserve, more standardized treatment strategies may be used for the particular disorder identified 

(eg, more formalized cognitive behavioral therapy for 

anxiety or depression). Service members may then 

participate in supportive group or psychodynamic 

therapy, particularly if more developmental and interpersonal concerns appear to be impacting the current 

condition. 

Selective serotonin reuptake inhibitors remain the 

medications of first choice to treat PTSD25 and depression. Of these, sertraline and citalopram are generally 

preferred because of their tolerability and relatively 

decreased potential for drug-to-drug interactions. 

Benzodiazepines are generally avoided where possible, particularly in PTSD, because data that supports 

their use is lacking and they may result in addiction 

and worsen PTSD in the long term.1 However, benzodiazepines are occasionally used to temporarily 

relieve severe anxiety and panic attacks. Patients are 

frequently already prescribed benzodiazepines for 

conditions such as muscle spasms or phantom limb 

pain. In this case, patients should be educated on the 

impact benzodiazepines have on anxiety, and the effects should be monitored. Treatment for persistent 

conditions may ultimately extend beyond the period 

of hospitalization. 

HYPNOSIS

Absorption, focused attention, decreased vigilance, 

suggestion, dissociation, trance logic, rapid data assimilation, and time distortion are all components of 

hypnosis.26 Patients often tend to be self-absorbed and 

focused on their somatic complaints in the presence of 

medical or surgical illness, and many psychologically 

healthy individuals may have a hypnotic gift.27 These 

individuals can constructively employ dissociation 

to distract themselves from physical and emotional 

trauma. When appropriate, they can weave dissociative elements into a normal stream of consciousness. By 

capitalizing on the rapid assimilation of data, they can 
272

Care of the Combat Amputee

also learn new techniques at a faster pace. Hypnotic 

techniques that guide constructive thought processes 

help individuals cope with pain, insomnia, and injuries by allowing them to distance themselves from 

their treatment, feel safe, rapidly learn new coping 

techniques, and become productively engaged in the 

healing process.28–30 Experience at WRAMC has shown 

that service members can use hypnosis to control pain 

from surgery, wounds, washouts, burns, and phantom sensations, as well as to assist with medication 

augmentation. Hypnosis can provide a safe place for 

patients to work through or restructure their emotional 

conflicts (Exhibit 12-4).

EXHIBIT 12-4

CASE STUDY 4: USE OF HYPNOSIS IN 

TREATING PHANTOM LIMB PAIN

A 28-year-old male with a left below-the-knee amputation complained of phantom limb pain, which 

was described as the painful curling of his missing 

toes. He was taught to envision relaxing his foot and 

uncurling his toes. Using this hypnotic technique, 

he was able to reduce pain from an 8 to a 0 on a 

10-point pain scale.

TRAUMATIC BRAIN INJURY ASSOCIATED WITH POLYTRAUMA AND AMPUTATION

Approximately one third of the service members 

injured in Iraq who require medical evacuation to 

WRAMC have been found to have TBI. Of these, 

about 50% are classified as having mild TBI, with 

the remaining half having moderate or severe TBI. 

Most TBIs occur with polytrauma and are common 

in service members with traumatic amputations. All 

service members with an injury history that may be 

associated with TBI (eg, blast exposures, motor vehicle 

accidents, falls, etc) are screened during the initial 

phase of their hospitalization by a specialized team 

from the Defense Veterans Brain Injury Center (this 

screen is in addition to the routine screening performed 

by the PMP service). A multidisciplinary team from the 

departments of neurology, neuropsychology, physical medicine and rehabilitation, psychiatry, physical 

therapy, occupational therapy, and speech language 

pathology provides ongoing assessment and treatment 

of these patients. 

The PMP service provides clinical assessment of 

TBI and treats associated behavioral sequelae. This 

begins in the intensive care unit (ICU) for more severely injured service members, who generally arrive 

at WRAMC on ventilator support. In addition to the 

common problems of disorientation and frank delirium seen in patients with polytrauma as they are 

weaned from sedation, patients with TBI take considerably longer to become alert, are often agitated and 

disorganized, and are generally less able to participate 

in their own care. Families of service members with 

TBI are provided support and made aware that the 

prognosis for moderate to severe TBI is hard to predict 

and may be frightening and upsetting. In addition, 

staff members treating patients with more severe 

TBI can be nihilistic—a disposition that needs to be 

addressed by the consultation-liaison psychiatrist. 

Treatment of delirium and agitation often involves 

modifying the intravenous pain regimen, minimizing 

external stimulation, adding neuroleptic medication, 

and, when other modalities fail, restraining the patient. 

Symptoms of hyperarousal, such as sleep disturbances, 

nightmares, and flashbacks, are common in service 

members in the ICU, and they can be worse with 

existing TBI. Preemptive treatment of hyperarousal 

with low-dose, atypical neuroleptics has proven to be 

especially effective in improving sleep and decreasing 

nightmares and flashbacks.

TBI in amputees often complicates rehabilitation. Significant deficits in cognition, memory, and 

awareness may preclude prosthetic fitting and training. Additionally, patients with TBI may manifest 

problems with impulse control. Their disinhibition 

and impulsivity may interfere with their care as well 

as disrupt others in treatment. Similarly, problems 

with mood and emotional regulation can manifest as 

anxiety, depression, and emotional liability and can 

complicate recovery. Behavioral problems, including 

apathy, lack of motivation, dependency, and passive 

childlike behavior, are also commonly seen in this 

patient population. Somatic symptoms, such as sleep 

disturbances, fatigue, slowness, dizziness, headaches, 

and noise sensitivity, are likely to be magnified in 

patients with TBI. 

Because of the magnitude of complications associated with TBI and their disruption of amputee rehabilitation, service members with significant cognitive, 

emotional, or behavioral problems related to TBI are 

best managed in a TBI center of excellence, such as 

those that have been established in the Veterans Affairs 

polytrauma centers. For this reason, nearly all service 

members with severe TBI are rapidly transferred from 

the military healthcare system to a Veterans Affairs 

polytrauma center. Once brain injury has recovered 

to the point where the patient can begin learning new 

tasks and attend therapy training, those with amputation are typically returned to one of the Department 

of Defense amputee centers of excellence for amputeespecific rehabilitation.
273

Psychiatric Intervention With the Orthopaedically Injured

TREATING THE TRAUMA PATIENT’S FAMILY

Initially, it is important that the families of injured 

service members have access to food, clothing, and 

shelter. Many spouses of injured service members 

communicate a sense of hopelessness and helplessness 

in the face of their loved one’s injuries. They worry 

about lack of information, support, and control in the 

injured service member’s care and rehabilitation. This 

experience may be very traumatic.31–34 It is also often 

difficult for families to absorb the amount of information presented to them from the multiple healthcare 

providers treating their loved one. Uncertainty within 

the healthcare team adds to the family members’ feelings of anxiety and helplessness.35 Conflicts between 

family members may cause some members to be unwilling to share information with others, exacerbating 

the challenges of information exchange. It is difficult to 

predict how family members will react to the injuries 

sustained by the service member or to the “trauma” 

with which they themselves are faced. Helping these 

families cope with the traumatic event may lessen 

their chances of developing secondary PTSD.33 Family members are often better than the medical staff 

at providing emotional support and reassurance to 

trauma patients.32

Preexisting conflicts between family members or 

between the injured service member and the family may 

be exaggerated with the added stress of the injury. At 

times, having a severely injured family member may 

exacerbate family malfunctioning,35 and the family’s 

built-in support system may need to be augmented 

with professional help.33 Effective therapeutic family 

interventions may not only help family members cope 

with the traumatic events, but may help the patient 

as well. Support group therapy sessions can help the 

families of trauma victims address their needs and 

feelings.36 Harvey at al found that families were more 

willing to attend group therapy sessions when the focus 

was on education and families sharing their stories with 

one another.36 Families attending these support groups 

realized that they were not alone and were able to offer support to each other. They were able to share their 

feelings, reduce their anxiety, garner hope, and gain a 

better understanding of their family member’s injuries, 

medical treatments, and hospital procedures. Many 

support groups are run by social workers and allow for 

empathetic sharing and support. Session topics may include issues such as fear, frustration, the need to protect 

the injured patient, depression, anger, education, coping 

with disabled spouses, and feelings of alienation and 

disappointment. The purpose of family intervention is 

to build up the family’s coping skills and resolve symptoms associated with psychological trauma. Further 

activities, such as sharing meals with other families of 

trauma patients, may provide the family with additional 

support.33 Brief supportive counseling has also proven 

effective at reducing anxiety in individual family members of trauma victims (Exhibit 12-5).37

EXHIBIT 12-5

CASE STUDY 5: FAMILY INTERVENTION

A 28-year-old male with a right above-the-knee 

amputation and left below-the-knee amputation was 

injured in Afghanistan. The patient was flown to 

Germany, where his wife and mother met him. His 

wife began having difficulty adjusting to his injury. 

Problems with her and her in-laws were prominent. 

The patient’s wife and mother frequently argued 

about what care was appropriate for the patient, 

causing more stress for the family, service member, 

and medical staff. The service member’s mother was 

particularly angry that her daughter-in-law of 1 year 

was taking charge of her son, whom she had raised 

by herself since he was 5 years old. Upon arrival 

at Walter Reed Army Medical Center, the family 

and patient were assessed by the preventive medical psychiatry team and interventions were initiated. The problems were eventually resolved and 

continued therapy was established upon hospital 

discharge.

FOLLOW-UP

The PMP service continues to support those 

who need help and attempts to reach out to those 

screened as inpatients. At discharge, each patient is 

given a contact number and is encouraged to call 

the PMP service office if concerns develop. The PMP 

service at WRAMC calls patients at 30, 90, and 180 

days following discharge. If crises occur, patients 

appear more willing to accept referral recommendations from behavioral health providers they have 

known previously or whom they perceive as allies. 

Additionally, they may find it easier to receive and 

respond to psychiatric interventions once they have 

returned home. In general, patients who need treatment upon leaving WRAMC are referred to resources 

within the military, Veterans Health System, or civilian community.
274

Care of the Combat Amputee

SUMMARY

The impact of a traumatic event resulting in physical injuries frequently extends beyond the bodily 

disruptions sustained by the victim to encompass the 

psychological realm. Although medical trauma teams 

are designed to respond to physical injuries, equal 

emphasis needs to be placed on the mental health interventions necessary to assist these victims and their 

families. The WRAMC PMP service is the first mental 

health service to see every hospitalized, traumatically 

injured patient without a formal consult. This approach 

appears to have reduced the need for emergent psychiatric services in this population. 

REFERENCES

1. Morgan CA, Krystal JH, Southwick SM. Toward early pharmacological posttraumatic stress intervention. Biol Psychiatry. 2003;53(9):834–843.

2. O’Donnell ML, Creamer M, Pattison P, Atkin C. Psychiatric morbidity following injury. Am J Psychiatry. 2004;161:507–514.

3. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental 

health problems, and barriers to care. N Engl J Med. 2004;351:13–21.

4. Koren D, Norman D, Cohen A, Berman J, Klein EM. Increased PTSD risk with combat-related injury: a matched comparison 

study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry. 2005;162(2):276–282.

5. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163:1777–1783.

6. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed 

adults. J Consult Clin Psychol. 2000;68(5):748–766.

7. Rybarczyk B, Nyenhuis DL, Nicholas JJ, Cash SM, Kaiser J. Body image, perceived social stigma, and the prediction 

of psychosocial adjustment to leg amputation. Rehabil Psychol. 1995;40(2):95–110.

8. Lundberg SG, Guggenheim FG. Sequelae of limb amputation. Adv Psychosom Med. 1986;15:199–210.

9. Wain HJ, Grammer G, Stasinos J. Psychiatric intervention for medical and surgical patients following traumatic injuries. 

In: Ritchie EC, Watson PJ, Friedman MJ, eds. Interventions Following Mass Violence and Natural Disasters: Strategies for 

Mental Health Practice. New York, NY: The Guilford Press; 2007: 278–298.

10. Katz J. Reality of phantom limbs. Motiv Emot. 1993;17:147–179.

11. Shontz FC, Fink S. A method for evaluating psychosocial adjustment of the chronically ill. Am J Phys Med. 1961;40:63–69.

12. Parkes CM. Bereavement: Studies of Grief in Adult Life. New York, NY: International Universities Press; 1972.

13. Lazarus RS. Psychological Stress and Coping Process. New York, NY: McGraw-Hill; 1966.

14. Katz S, Florian V. A comprehensive theoretical model of psychological reaction to loss. Int J Psychiatry Med. 1986–

1987;16(4):325–345.

15. Frierson RL, Lippman SR. The Psychological Rehabilitation of the Amputee. Chicago, Ill: Charles Thomas; 1978.

16. Horgan O, MacLachlan M. Psychosocial adjustment to lower-limb amputation: a review. Disabil Rehabil. 2004;26:837–850.

17. Wain HJ, Grammer GG, Stasinos JJ, Miller CM. Meeting the patients where they are: consultation-liaison response to 

trauma victims of the Pentagon attack. Mil Med. 2002;167(Suppl 9):19–21.

18. Bryant RA, Mastrodomenico J, Felmingham KL, et al. Treatment of acute stress disorder: a randomized controlled 

trial. Arch Gen Psychiatry. 2008;65(6):659–667.
275

Psychiatric Intervention With the Orthopaedically Injured

19. Wain HJ, Gabriel G. Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries. J Am 

Acad Psychoanal Dyn Psychiatry. 2007;35(4):555–573.

20. Maslow AH. Toward a Psychology of Being. 2nd ed. Princeton, NJ: Van Nostrand; 1968.

21. Horvath A, Symonds V. Relation between working alliance and outcome in psychotherapy: the meta-analysis. J Couns 

Psychol. 1991;38:139–149.

22. Crits-Christoph P, Barber J, Kurcias J. The accuracy of therapists’ interpretations and the development of the therapeutic 

alliance. Psychother Res. 1993;3:25–35.

23. Marmar CR, Weiss DS, Gaston L. Toward the validation of the California Therapeutic Alliance Rating System. Psychol 

Assess. 1989;1:46–52.

24. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans 

by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160:371–373.

25. Davidson JR, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM. Multicenter, double-blind comparison of sertraline 

and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry. 2001;58:485–492.

26. Wain HJ. Medical hypnosis in medical psychiatric practice. In: Stoudemire A, Fogel BS, eds. Medical Psychiatric Practice. 

Vol 2. Washington, DC: American Psychiatric Press; 1993; 39–66.

27. Wain HJ. Hypnosis on a consultation-liaison service. Psychosomatics. 1979;20:678–689.

28. Beshai JA. Toward a phenomenology of trance logic in posttraumatic stress disorder. Psychol Rep. 2004;94:649–654.

29. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull. 2003;129(4):495–521.

30. Spiegel D, Spiegel H. Hypnosis in psychosomatic medicine. Psychosomatics. 1980;21:35–41.

31. Solursh DS. The family of the trauma victim. Nurs Clin North Am. 1990;25:155–162.

32. Brown V. The family as victim in trauma. Hawaii Med J. 1991;50(4):153–154.

33. Flannery RB Jr. Treating family survivors of mass casualties: a CISM family crisis intervention approach. Int J Emerg 

Ment Health. 1999;1:243–250.

34. Alexander DA. The psychiatric consequences of trauma. Hosp Med. 2002;63:12–15.

35. Landsman IS, Baum CG, Arnkoff DB, et al. The psychosocial consequences of traumatic injury. J Behav Med. 

1990;13(6):561–581.

36. Harvey C, Dixon M, Padberg N. Support group for families of trauma patients: a unique approach. Crit Care Nurse. 

1995;15(4):59–63.

37. Lenehan GP. Emotional impact of trauma. Nurs Clin North Am. 1986;21(4):729–740.