Tuesday, November 11, 2008

Veterans Day

Take time out and thank a Veteran today.

As we remember our Veterans today, those who served, those who fought, and those who died in the service of their country, let us also remember that many of our Veterans are carrying physical and emotional scars. To that end, this bit of historical and educational information is dedicated to the walking wounded....

Today we call it Post-traumatic Stress Disorder (PTSD). It has gone by many names. In the U.S. Civil War, it was "nostalgia," "soldier's heart," and "Swiss disease." Its symptoms are not new. The ancient Egyptians, Greeks and Romans all write of severe anxiety attacks, and physical symptoms associated with battle. Herodotus, writing in the 5th century BCE, tells of somatic symptoms of blindness of a soldier who witnesses the death of a comrade. Herodotus also tells of a Spartan who was so anxious as to be nicknamed "The Trembler;" a soldier who later hanged himself, presumably in shame.

As the 19th century approached, psychology was beginning to gain acceptance in the medical community, and terms like "traumatic neurasthenia" became known in the doctor's offices. World War I gave us "shell shock," a term specifically for those with neurological/physical symptoms, but without overt physical injury. Contrary to the image created by the term, most cases were not due to any actual explosions, but just exposure to the trauma of the battlefield. This was not always diagnosis of understanding: Frederick Parsons, a commanding officer at U.S. military hospital Number 117, said "a war neurosis which persists is not a creditable disease to have ... as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies." And that "no one should be permitted to glorify himself as a case of 'shell shock.'"

By World War II, the diagnosis of "combat fatigue" was given to those with a set of symptoms most similar to our current diagnosis. The numbers from WWII are quite impressive. Of the 800,000 or so direct combat troops, greater than 35% required discharge due to psychiatric reasons. Over 1 million American Soldiers suffered some psychiatric debilitation for some period of time, and over 500,000 were discharged or hospitalized due to psychiatric reasons.

Somewhere between the Korean and Vietnam War, the term "Combat Stress Reaction" gradually made its way into the medical parlance. This description was used somewhat interchangeably with Combat Fatigue, and PTSD, although it became further defined as a more acute process, rather than a persistent and recurrent anxiety state. It was Vietnam, though, that ushered in the PTSD diagnosis. Some studies have shown estimates of 400,000+, out of 2.8 million who served, as having PTSD. PTSD was added to the DSM-III in 1980. The wars in Iraq and Afghanistan have brought a new generation of service personnel affected with PTSD.

The DSM-IV criteria for PTSD are quoted as follows:
A. Exposure to a traumatic event
B. Persistent reexperience (e.g. flashbacks, nightmares)
C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience, avoidance of things and discussions that trigger flashbacks and re-experiencing symptoms fear of losing control)
D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilence )
E. Duration of symptoms more than 1 month
F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)
For many veterans, PTSD is only part of the picture. Depression, other psychiatric conditions, and substance abuse often present as comorbid and contributory conditions, making for a very difficult to treat cluster of symptoms. Many veterans have difficulties with getting help, in part due to their own reluctance to address the painful issue, and sometimes due to the limitations of the health care and military systems. Stigma continues to be a significant problem; many veterans that I have seen professionally often confide that it took a great deal of courage, support, (and severe symptoms), in order to get them to see a psychiatrist.

Medication and therapy are common treatments for PTSD. Our local VA (like many others) has therapy groups specifically designed for veterans with PTSD. These are mostly in the "support group" modality, and often coincide with other treatments, such as individual therapy.

From an analytic point of view, I have always thought of PTSD as being a very dichotomous state. The cognitive component of the anxiety appears to be definable in two opposite areas: "Destroy" or "Be Destroyed." Both components are often present in the veteran with PTSD. They have not only the fear of harm, but a fear of loss of control, and with that, the potential harm they present to others. This often differentiates (from a therapy standpoint) the PTSD of the veteran from other traumatic sources, such as those who have been in severe car accidents.

Families and friends are often dramatically affected by the chaos that PTSD presents. It is important to be consistent, calm, patient, and supportive of loved ones as they go through the symptoms. Encouragement to seek help, and educating veterans that they are not alone in their struggle is what usually has led most veterans on their path of recovery. Many programs for veterans support exist. Now, more than anytime in the past, the Department of Veterans Affairs has taken a proactive approach to PTSD treatment.

For the rest of us, again, if you know a Veteran, call them, see them, thank them.


Geoffrey Kruse-Safford said...

On combat PTSD, I once overheard a couple WWII vets talking about an incident on Guam? Wake? Some island in the Pacific the Japanese repeatedly attacked. The old men talking (this was about, I don't know, 20 years ago) had been Marines in the PTO. One of the men spoke of a man who had been an anti-aircraft gunner near the beach. The gun had been encased in cement and reinforced - and had been at the point where many of the Japanese planes had come in for attack.

After the attack, it took other Marines over an hour to get the unresponsive man to literally pry his hands off the gun. Around the outside of the casement were shell holes and bullet holes; inside his other three comrades who had helped with aiming, etc. were all dead from a lucky strafing run. The guy telling the story had said that no one ever heard this man speak again.

Such is what we bring about through war. Not just bodies, but minds as well, get mangled by the horrors.

Amanda said...

this is great. i bet it will inspire a lot of people.

i suffer from ptsd but not from a war or anything like that. either way, its awful and it gives me so much more respect for these men and women. i know soldiers personally and i cannot even imagine seeing what they have seen and going through what they've gone through. every one of us should realize... great post. :)

Doc said...

Thanks for the comments.
PTSD suffered by those in wars is very similar to those in other forms of trauma. There is no diagnostic difference, although I do usually find the fear of being retraumatized (being harmed) greater in the non-veteran with PTSD, than in the veteran, who usually has both the fear of being harmed and harming others.

Amanda, thanks for stopping by, do feel free to drop in again.