Late Breaking News
Young Adults Often Begin Military Service at an Age When Schizophrenia Symptoms Begin to Manifest
- Categorized in: August 2009 Issue
WASHINGTON, DC—In a war in which PTSD and TBI are of great concern, it can be easy to forget that young adults beginning military service are often at an age where schizophrenia symptoms first become apparent.
For Army Lt Col Geoffrey Grammer, chief of inpatient psychiatry at Walter Reed Army Medical Center, it is a fact that he does not overlook. “I am reminded on a daily basis that it is not all PTSD and TBI,” he said. “A lot of attention and focus and resources are poured into things like PTSD and TBI with the current climate and war going on, but I think it is easy to forget that the bulk of our active duty fighting population is in their late teens and early 20s, which is the point where a lot of first-break psychosis occurs in our young men. Women break a little later,” Dr Grammer said.
Schizophrenia is a chronic, severe, and disabling brain disorder that affects about 1.1% of the US population age 18 and older. In men, symptoms usually start in their late teens and early 20s. For women, symptoms start in their mid-20s to early 30s. While no one is sure what causes schizophrenia, genetic makeup and brain chemistry probably play a role, according to the NIH.
An individual cannot enter the military with schizophrenia, but it is a condition that can manifest itself during the course of military service. Symptoms of schizophrenia are often caught early in military patients because of the military work structure. “In the civilian community, the time from onset symptoms to presentation for psychiatric care can be in the order of 12 or more months…there are estimates as high as 18 months,” Dr Grammer said. “But within the military, because there is such strong oversight and such an immersion within the workplace, most patients that we see have symptoms that have only been present for a few weeks, or up to six weeks.”
Symptoms of schizophrenia include unusual thoughts or perceptions, disorders of movement, hallucinations, difficulty speaking and expressing emotion, and problems with attention, memory and organization. While there is no cure for the condition, medications can relieve many of the disorder’s symptoms.
Because schizophrenia symptoms are often caught so early in patients in the military, the challenge is that their symptoms may not yet meet the diagnostic criteria for schizophrenia. “We catch psychosis so early that it often presents atypically,” he said. “Many times, patients will come in and technically meet diagnostic criteria for delusional disorder—which is a rare disorder particularly in younger folks—but over time, as the disease becomes fully entrenched and manifests itself, it becomes more like schizophrenia, with the full criteria of symptoms that we need for a definitive diagnosis.”
It is hoped that by catching schizophrenia symptoms early, the long-term prognosis of patients will be improved, Dr Grammer said. “With each psychotic episode, there is some loss of function that is not fully recoverable in schizophrenic patients,” he said. “We may be able to, in the military, help offset some of that by catching them early and getting them into treatment early, and then keeping them in a healthy social environment, where they are not going to drift downward into drug or alcohol use, homelessness, and so forth, while they are undergoing their medical evaluation.”
Doctor Grammer said that he does not believe that military service brings on schizophrenia, based on studies that have been conducted. “Their [first] break can occur in a variety of environments. Some initial research that we have done didn’t necessarily correlate well with environmental stress in first break psychosis,” he said. “In other words, people tend to break more because of where they are within their timeline in life.”
Care for Schizophrenia
At WRAMC, there are specific inpatient and outpatient programs tailored to those with conditions like schizophrenia.
Most patients with acute psychotic breaks initially arrive to the medical center and are admitted to the inpatient unit. “Last year, we had roughly 900 inpatient admissions at Walter Reed. The incidence of psychosis has varied somewhere between 15% and 30%, depending on the month. If you begin to think about that, that is several hundred patients with some psychotic process occurring,” Dr Grammer said.
When these patients arrive, the medical center has a multidisciplinary treatment team to care for these patients, including staff psychiatrists, psychiatry residents, medical interns, medical students, art therapists, recreational therapists, occupational therapists, nurse practitioners, social workers, psychiatric nurses, and psychiatric nurse technicians.
In addition, the medical center recently hired an exercise therapist to work on lifestyle modifications with patients. This can be particularly helpful in the treatment of schizophrenia. “One of the problems that we have is that the medications we put people on have lasting metabolic effects,” he said. “There is some research to show that if you actually help them with diet and exercise at the initiation of those pharmacologic interventions, you can offset some of the long-term morbidity of that kind of metabolic syndrome.”
One unique aspect that helps in the treatment of military patients with schizophrenia is that they have often had less opportunity to use illicit substances, since drug use is incompatible with military service. In addition, they would not have likely been on any prior schizophrenia therapy. “They tend to be less involved with illicit substance use,” he said. “They are often drug naïve, because you can’t come into the service with schizophrenia. They haven’t been treated with a drugs in the past. Because of that, anecdotally, the patients we have had the opportunity to treat tend to respond very well to our treatment measures.”