Case 19: A veteran who asks only for sleeping pills

01The case

A 46-year-old man who served on military missions in the Middle East comes to an outpatient clinic with persistent insomnia and asks firmly for sleeping pills. As the interview goes on he admits, reluctantly, that since his early discharge he has struggled to find work and to keep in touch with old friends. Often, especially when alone, a vivid memory comes over him of a patrol jeep being blown up, sometimes with clear pictures of his colleagues' torn bodies, "as if in a film". He drinks heavily every day and has become more irritable. He avoids conversations and programmes about the conflicts in the region, and twice became short of breath while watching one.

02Summary

Diagnosis

Post-traumatic stress disorder, one of the stress-related disorders, with heavy alcohol use.

What points to it

• An extremely threatening, horrific event, of a kind that would distress almost anyone.
• Re-experiencing: vivid intrusive images that feel as if they are happening again (flashbacks).
• Avoidance of reminders: conversations and broadcasts about the war.
• Hyperarousal: poor sleep, irritability, breathlessness when reminded.
• Poorer functioning at work and with friends. Alcohol is a common attempt to dull the symptoms.

What else it could be

Depression, which often comes with it. An alcohol use disorder in its own right. Complex PTSD in ICD-11, if he also has lasting problems controlling emotion, a deeply negative view of himself and difficulty in relationships. Ask about head injury from blasts, which can add cognitive and mood symptoms.

Management

• Ask about suicidal thoughts: PTSD, heavy drinking, isolation and loss of work all raise the risk.
• Trauma-focused CBT or EMDR, the treatments of first choice.
• Assess the drinking (the AUDIT helps). If he is dependent, plan reduction or assisted withdrawal, since stopping abruptly can bring dangerous withdrawal.
• Medication if he prefers it or cannot yet engage in therapy: an SSRI, an antidepressant such as sertraline, or venlafaxine.
• Do not give him what he came for: benzodiazepines and other sleeping pills are not a treatment for PTSD, and with alcohol they are dangerous. Sleep improves as the PTSD is treated.
• Support with work and contact with veterans' services.

Outlook

Variable. About half of people with PTSD recover within a year and about a third have a chronic course. Heavy drinking, isolation and further stress make the outlook worse.