Veteran in an Acute Dissociative State

(Acknowledgments: The author would like to thank Alan Maiers, PsyD, Brenda Mayne PhD, and Thea Schneider, CNS, for their helpful review of the article. Dr Geppert is associate professor of psychiatry and director of ethics education at the New Mexico School of Medicine in Albuquerque. She is also chief of consultation psychiatry and ethics at the New Mexico Veterans Affairs Health Care System in Albuquerque. Alan Maiers, PsyD, assistant chief of the COPE Division at the Warrior Resiliency Program in San Antonio, Tex, coauthored the case vignettes that appear in this article. ) Cynthia M. A. Geppert, MD, PhD

October 6, 2009
Psychiatric Times. Vol. 26 No. 10
CASE VIGNETTE

A 24-year-old veteran of Operation Iraqi Freedom (OIF) presents to the ED mid-morning on a weekday. While the veteran is waiting to be triaged, other patients alert staff that he appears to be talking to himself and pacing around the waiting room. A nurse tries to escort the veteran to an ED examination room. Multiple attempts by the ED staff and hospital police—several of whom are themselves OIF veterans—are unsuccessful in calming the patient or persuading him to enter a room.

The increased attention escalates the patient’s behavior and he begins to run around the ED. At one point he hides under instrument trays, yelling out “Incoming! We have to get them before they get us! The enemy is coming for us!” He then runs to another location, as if taking fire.

A quick general status evaluation shows a young man with several days’ growth of beard in jeans and T-shirt who looks sleep-deprived. The veteran’s speech is rapid and staccato; he displays hyperactive movements, with frequent scanning of the environment, terrified affect, and loss of contact with the immediate hospital reality.

An experienced female emergency psychiatrist quickly arrives but is unable to orient the patient or convince him to accept medical intervention. All questions regarding his current status are answered with phrases indicating the patient is re-experiencing combat in Iraq. His behavior is increasingly unpredictable and aggressive, leading the ED physician and psychiatrist to be concerned about the safety not only of the veteran but also of other patients and staff. All involved wish to avoid use of force if at all possible, certain this will retraumatize the patient and reinforce his dissociative state.

The ED physician, an older man, tells the psychiatrist that he is an Army veteran and a colonel in the Reserves....

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