➣ Post-traumatic Stress Disorder (PTSD): An Overview and Commentary
by Deborah Grassman
PTSD is not limited to those who’ve been traumatized by combat. Victims of crime, abuse, natural disasters, serious motor vehicle accidents, marital affairs, life-threatening illnesses, etc. might suffer PTSD; policeman, firefighters, emergency room responders, and other people who witness trauma are also vulnerable for experiencing PTSD symptoms. These traumatic experiences are sometimes not integrated into a person’s consciousness. Instead, the trauma is left compartmentalized, stored in unconscious experience, sabotaging personal peace.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the fundamental reference for defining mental health. It identifies a constellation of symptoms that must be present for the diagnosis of Post-traumatic Stress Disorder. These include: exposure to a traumatic event experienced with fear, helplessness, or horror; after the original trauma is over, the trauma is re-experienced through recollections, dreams, flashbacks, hallucinations, illusions, distress at cues that symbolize the trauma, or physiologic responses when confronted with cues reminiscent of the trauma. The distress of the re-experienced trauma causes people to exhibit avoidance behaviors and utilize emotional numbing in order to block out the trauma. But in spite of their best efforts, there are times when the trauma is re-experienced anyway and the person exhibits symptoms of arousal such as: difficult sleep patterns, irritability or outbursts of anger, difficulty concentrating, hypervigilance (staying on guard and unable to calm down or relax), exaggerated startle response to noises, being touched, etc. When this constellation of symptoms lasts for at least a month and causes significant impairment, a diagnosis of PTSD is made.
Many people with PTSD have successfully suffered their traumatic experiences by learning lessons that help them live their lives, deal with trauma, and reckon with PTSD. If they have received PTSD treatment, they can often say what helps them feel better. They might already have a PTSD network of friends who can provide support. Family members usually know how to respond to breakthrough episodes of PTSD because it’s familiar territory.
Other people with PTSD have not had this experience. They’ve compartmentalized the trauma, banishing it into unconsciousness. They might have increased difficulty as death approaches – haunted by residual memories or corroding guilts. Others seem less affected.
When patients with PTSD are admitted to a Hospice unit, they are sometimes anxious, suspicious, or angry. Leaving their home to enter an unknown hospital environment is threatening, increasing their feelings of danger. The hospital environment itself can act as a trigger with its militarized processes. Their own anticipated death can act as a PTSD trigger. PTSD, especially when combined with alcohol abuse, has often taken its toll on their relationships, leaving much unfinished business to be resolved so a peaceful death can ensue. Sometimes they arrive at the end of their lives broken, bitterness poisoning their souls. However, it is never too late. Opportunities for growth abound when death approaches and many people – even those who are bitter – avail themselves of the lessons.
Raymond was a veteran in a local hospital with end-stage liver disease, the result of excessive alcohol usage used to self-medicate his PTSD he sustained with the Vietnam War. His doctor phoned me, requesting admission for the patient to our Hospice and Palliative Care unit.
I had a mental image of what Raymond probably looked like based on his diagnosis: swollen abdomen due to accumulated fluid, mentally dull from built-up toxins, and the ruddy, disheveled appearance of a man who no longer took pride in himself.
That night, I dreamed I went to meet Raymond, and he arose from his hospital bed, tall, handsome and well-groomed, in a three-piece business suit. Then I awoke, puzzled by my dream. Raymond arrived later that day; he looked sick and ungroomed like I had expected.
The Hospice team held a meeting at his bedside to learn more about Raymond. He told us he had PTSD and had been a drifter since Vietnam, finding it difficult to establish relationships or maintain a job for long periods. “I don’t know what got into me. I wasn’t raised like that. I should have done something with my life,” he told us. I asked him if there was anything from the war that might still be troubling him.
“I try not to think about it,” he said. “But what keeps coming back is the eyes of my comrades. I saw peace in the eyes of the dead; I saw fear in the eyes of the living.” Our team sat in stunned silence as we let ourselves experience war vicariously.
Later in my office, I kept reflecting on the profundity of this casual comment and the detachedness with which it was said. I let its chilling truth penetrate my illusory, warless world. Now I understood the meaning of my dream. It was not this Raymond I had seen, but the Raymond he might have been. I had met the Raymond who had not gone to Vietnam. That’s when I realized that war robs people of many things; but possibly the most significant is a young person’s hope and dreams.
My curiosity about PTSD was stimulated because I wanted to better understand the impact that combat experiences made on my patients. Thus, when I went to graduate school to become a Nurse Practitioner, I decided to focus on psychiatric nursing. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was the fundamental reference for the courses I took. Used as the handbook for defining mental health, the DSM identifies characteristics for each mental disorder. I wasted no time looking up Posttraumatic Stress Disorder (PTSD) in the DSM. I read about the six criteria that must be present for the diagnosis:
Exposure to a traumatic event experienced with fear, helplessness, or horror
The traumatic event is persistently reexperienced through one or more of the following symptoms:
- Flashbacks, hallucinations, or illusions
- Distress at cues that symbolize the trauma
- Physiologic responses when confronted with cues reminiscent of the trauma
Avoidance behaviors and emotional numbing exhibited by three or more of the following:
- Avoidance of thoughts, feelings, or conversations related to the trauma
- Avoidance of activities, places, or people that arouse recollection
- Inability to recall certain critical aspects of the trauma
- Lack of interest in significant activities formerly enjoyed
- Feelings of detachment or emotional distancing from others
- Restricted range of affect (limited emotional expression)
- Sense of a foreshortened future (inability to accomplish cherished life goals)
Persistent symptoms of increased arousal manifested by two or more symptoms that include:
- Difficult sleep patterns
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance (staying on guard and unable to calm down or relax)
- Exaggerated startle response to noises, being touched, etc.
Symptoms persist for at least one month
The disturbance of symptoms causes significant distress or impairment
Because PTSD had only recently been added to the DSM, I assumed it was a new disorder. Then one day, I heard a sermon about Job, a man in the Old Testament; I was intrigued enough to read more about him in the Bible. When I did, I realized I was reading a description of PTSD centuries before it was given a name. After experiencing the deaths of his 10 children, failing health, and the loss of his wealth, Job understandably became angry with God, questioning what he had done to deserve his fate. Job thinks he can gain reprieve from his torment while he’s asleep, but he’s wrong. He graphically describes the nightmares of PTSD: “My bed shall comfort me, my couch shall ease my complaint. Then, God, you affright me with dreams and visions terrify me, so that I should prefer choking and death rather than my pains.”
Though its victims preferred choking and death over the affliction, PTSD was not included in the psychiatric disorders curriculum at my university. My graduate school professor told me PTSD was not important for us to learn since most students didn’t work with veterans. I reminded her that PTSD was not a uniquely military experience. “Victims of crime, abuse, natural disasters, and violence commonly experience PTSD,” I told her. “Even policemen, ambulance drivers, and trauma counselors experience what is called ‘vicarious trauma’.” I added that the bereavement literature identifies complicated grief as PTSD.
My pleas fell on deaf ears. My professor said PTSD had only recently been recognized by the psychiatric community. I resisted the urge to read the Bible to her, and kept it in military terms. “But that doesn’t mean it wasn’t around. It just means we didn’t recognize it. Civil War soldiers called it ‘soldier’s heart,’ World War I soldiers called it ‘shell shock’ or ‘battle fatigue’.”
She remained unconvinced. I did gain consent from a different professor in another course to focus on PTSD for a group assignment. Three of us who worked for the VA provided a classroom dramatization reflecting a composite experience of the suffering we often witnessed with our combat veterans. Afterward, one pensive student responded, “My boyfriend was killed in Vietnam. I’ve never gotten over it. Now that I realize how PTSD might have affected his life, maybe death wasn’t the worst outcome he could have suffered.”
When my classmate said this, I thought about some of the things I’d heard my patients say that made me think she might be right: “Ninety percent of me died in that war” or “I lost my soul in that war,” are statements I’ve sometimes heard. Often veterans speak of survivor’s guilt. “If only I would have done ______, he’d still be here today. It should have been me who died.”
As often as not, however, silence about war experiences enshrouds PTSD. While they were in the military, they kept silent because of the attached stigma and loss of promotion opportunities if anyone knew they had PTSD. After discharge from service, their silence was often a way to protect their families from the trauma they experienced. Others kept silent because “it’s impossible to explain; no one who hasn’t been there can understand what it’s like.” Some weren’t allowed to talk about it; they were on secret missions and signed a contract stating they wouldn’t divulge their experiences. Some have said they kept quiet because when they did speak up “I wasn’t believed;” this attitude only added insult to injury. Many veterans don’t talk about their experiences because they don’t know who they can trust with their stories; many people don’t want to hear about the ugly things they saw or did.
Whether they speak about it or not, an expression in their eyes gives it away, a kind of deadness as they detach from themselves or others. Dissociation from feelings is often the only way they can get through horror. The DSM describes this as “psychic numbing” or “emotional anesthesia.” Coupled with military training that taught them stoicism, this numbness can leave veterans isolated physically, mentally, emotionally, and spiritually. Isolation is a common way for traumatized veterans to deal with their experiences. This can cause serious impairments of emotional intimacy in relationships.
Alcohol abuse can cause further detachment for some veterans. Alcohol usage was encouraged in military service. It was easily available and accessible in places on base without under-age limitations. It was a convenient way to numb feelings of loneliness when away from home. It shouldn’t be surprising that soldiers excessively used alcohol or drugs after discharge from military service to “flight” unwanted feelings stuck behind stoic walls or to numb traumatic war memories. On the other hand, drinking sometimes allows hidden stories to surface, though it often accomplishes little. Poignantly, a veteran’s daughter told me, “He only wanted to tell his war stories when he was drinking, but when he was drinking, we didn’t want to be around him.”
Despite veterans’ best efforts to remain disconnected from their trauma, there are times when their walled-off self emerges anyway. When it does, it sometimes comes out angrily, like hurled grenades. With traumatic memories intruding and interrupting, it’s not surprising that people with PTSD might struggle with irritability and anger. Driving habits might become reckless; career patterns might disintegrate into job-hopping. Frustrations, disagreements, or disappointments incite aggression; anger often masks pain.
In this state, veterans can overreact to otherwise innocuous stimuli. A car backfires triggering a veteran with PTSD to “hit the deck.” A helicopter flies overhead and a Vietnam veteran seeks cover. A balloon pops at a birthday party and a veteran with PTSD decides he won’t go to parties again. A veteran, ambushed in the woods or jungle, no longer enjoys wooded environments. Rain triggers memories of monsoons. Hunting takes on new, no-longer-enjoyable meanings. Open fields (that made combat veterans vulnerable to attack) mean inability to enjoy the expanse of open areas anymore. If a vet experienced a bridge blowing up, he may no longer be able to drive over bridges, altering driving patterns extensively. News reports of current wars or mass traumas trigger memories. If children were crying when a village was invaded, a child’s cry now, even their own child’s, sets off panic and anger.
I’ve seen how sounds or suspicious actions precipitate hypervigilance (staying on guard) because trust in the world has been violated and adrenalin stays on call for rescue from the next threat. I’ve heard accounts of veterans repeatedly getting up through the night to look out the windows to assure themselves that no enemy threats lurk in their civilian neighborhoods. In restaurants, they find a seat against the wall to make sure that nothing is behind their back and that they are in position to survey the environment. Hypervigilant behaviors can become extreme, developing into paranoia. Paranoia helps save lives in combat zones, but it can destroy personal relationships.
One of my patients had been a World War II prisoner-of-war (POW). He became extremely agitated with flashbacks of the POW camp; he believed he was actually there. We treated him with high doses of sedatives and provided one-on-one nursing care, but nothing seemed to help. Though the patient had been urinating regularly, one of the nurses checked to see if the patient’s bladder was emptying incompletely because full bladders can cause agitation. A bladder scan revealed six times the normal amount of urine! We inserted a urinary catheter; he immediately calmed down and returned from the POW camp. It was a graphic reminder that any noxious stimuli (like a full bladder) can trigger noxious combat memories.
Not surprisingly, PTSD often surfaces at night. Nightmares have freedom to rise from unconsciousness. The kind of nightmares my patients describe are unlike any I’ve ever had. They are anguishing nightmares that wreak havoc to rest and slumber. Many wives of patients have told me about trying to awaken her husband to rescue him from torment only to be mistaken for the enemy and then to be struck or restrained. Many people with PTSD become unable to fall to sleep, knowing these nightmares are awaiting them.
In my work at the VA, I’ve seen that some veterans with PTSD seem to age prematurely. Often they look 10 years older than they are. With the adrenalin of the autonomic nervous system turned to the “on” position much of the time and the restorative power of sleep interrupted with nightmares, this phenomenon is not surprising.
Aging and illness, in general, can make it more difficult to reckon with PTSD. Likewise, PTSD can be exacerbated by aging and illness. Memories can no longer be suppressed so easily. More than one veteran’s wife has told me, “He’s talked about that war more in the last year than he has in all the previous years put together.” Even veterans’ end-of-life experience can be influenced by their previous exposure to death. They sometimes come to a Hospice unit associating death with the fear, horror, and helplessness that they had experienced on the battlefield. This fear adds yet another layer of complexity to their end-of-life care. When I try to tell them how peaceful death can be, they don’t believe it.
The DSM states that the severity, duration, and proximity of an individual’s exposure to a traumatic event are the most important factors influencing the likelihood of developing PTSD. Most references cite PTSD incidence among veterans to be around 20%-30% depending on which war they fought in, the branch of service they were in, their role in the war, and other factors. The silence that surrounds PTSD, no doubt, causes underreporting, suggesting that the incidence may be even higher.
Ground troops in face-to-face combat who see the results of their killing are at higher risk than those whose roles distance them from the carnage. For example infantry soldiers are more susceptible to PTSD than pilots; Army and Marine Corps divisions are more susceptible than Air Force or Navy. As one patient told me, “The people I killed with my bayonet are the ones I can’t forget. The killing is much more personal.” I’ve heard similar comments from snipers who saw the result of their killing up close through their rifle scopes.
Some sources say that the act of killing is the single most important factor generating PTSD. It is this soul injury that soldiers sustain that I sometimes see surface as they face their deaths in Hospice years later. Experiencing or witnessing violence can cause PTSD in anyone; but the difference with veterans is that they committed much of the violence. This is a deeper level of traumatization that the literature calls “moral injury.” I call it “soul injury.”
The DSM cites other factors that increase risk of PTSD. These include lack of social supports, family history, childhood experiences, personality variables, and preexisting mental disorders. It also notes the condition can develop “without any predisposing conditions.”
When I do presentations about veterans, I set the tone by playing a recording of war sounds. Inevitably, the audience becomes irritated and asks me to turn it off. “These sounds mean nothing to us except that they are disrupting our safe, comfortable environment,” I tell them. “Imagine if you were in combat. These sounds would mean that death is coming. How would we feel then?”
I don’t know if any of us, who have not experienced war, can fully appreciate its impact. The closest I can imagine is the terrorist attack on the World Trade Center and Pentagon on 9/11 2001. I remember how our whole world stopped. Our lives were suspended as we sat on edge to learn our fate. I think about what it might have been if there had been a 9/12 with the Empire State building bombed or a 9/13 with the White House burned. Maybe there’s not a 9/14, but we didn’t know that, and so we stayed on guard. Meanwhile, the media are saying: “We don’t know where the terrorists are, but we know they’re in your neighborhood.” It’s hard to imagine how we would live day after day under these kinds of circumstances. One thing I do know: there would be a greater appreciation for PTSD because a lot of us would have it.
Other Ramifications of PTSD That Are NOT Listed in the DSM
The DSM does not identify anger, resentment, fear, guilt, and shame as an aftereffect of trauma, but it’s a theme I sometimes observe. It causes suffering and undermines veterans’ goals, even if they don’t realize they have PTSD. “I came back from the war and enrolled in college, but I just couldn’t seem to focus. I wasn’t so sure of my goals anymore,” more than one veteran has told me.
Relationships sometimes suffer. “I can’t believe how I treated my first wife,” different veterans have said. “I don’t know what got into me.”
Family life can be affected. “All I ever wanted was a family, yet the kids got on my nerves, and all I seemed to do was yell. They were scared of me.” Another veteran added, “I tried to run my family like a minimilitary unit. It didn’t work too well.” Sometimes the could-have-been future relationships were not to be. Several veterans have told me they never married because they knew they couldn’t be good husbands or fathers.
Young people 18, 19, and 20 years old often naively think they will give their three or four years to their country to fight a war and then resume their lives unaffected when discharged. In fact, the American public expects them to do that. Guilt and a sense of inadequacy heighten as hopes are dashed or dreams are unable to be achieved in the way society, parents, or the veteran himself had planned. Shame is often a common denominator; they feel like they let others down or could have done better. The self-hate this sometimes generates can result in either fear and isolation or anger and violence. Furthermore, there’s often a lack of awareness about how failure to achieve hopes might relate to combat exposure. I’ve seen this kind of guilt as veterans near the end of their lives. I call it the guilt of unfulfilled longings for the life not lived.