Click on the new page - the network guide - to introduce yourself to what this self help network of websites has to offer you.
Post Traumatic Stress Disorder
(PTSD) Quote from Jonathan
Davidson, M.D. director of the Anxiety & Traumatic Stress Programs at Duke Univ. Medical Ctr.
"If symptoms from a
traumatic event linger for more than 3 months, the chance of them improving on their own becomes less likely. PTSD affects 13 million Americans at any one time 1/2 of all adults will experience
a trauma and 20 % of them will develop PTSD."
"Faith can have a profound impact on health. It only requires that one fully embrace possibility, and the ultimate value is in the depth of the embrace."
Patch Adams, M.D.
Additional Information at the
newest mental health site in the emotional feelings network of sites! A new site - anxieties 102... it's being constructed just for you. Hang in there & you'll be delighted to find the page links at the top & bottom
of each of these pages within the site as soon as they become available for you!
Military personnel and their families - click here - to read some information I've received.
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and you can help support me in my writing ventures by visiting my health and happiness column for the Dayton,
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After clicking on the above link - look at
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War vets find peace in fly-fishing
How fly fishing helps veterans recover from the war
Fishing as a way of recovering
PTSD Ignored on Active Duty
Thurs. July 16, 2009
by Maya Schenwar
Neglect, mistreatment and abuse are the norm for active-duty soldiers suffering from post-traumatic stress disorder (PTSD).
The wars in Iraq and Afghanistan
have thrown post-traumatic stress disorder into stark public light. As of the end of March,
346,393 US veterans were being treated for PTSD; 115,000 of those served in Iraq or Afghanistan.
That number continues to grow rapidly.
However, PTSD symptoms don't always wait to emerge until soldiers return home. For active-duty soldiers like Airman Steven
Flowers, stationed in Aviano, Italy, it can take years to receive even minimal care. And once treatment begins, the soldiers
are often punished for revealing their problems.
Diagnosed with PTSD in 2007, Flowers receives only a 15-minute monthly session with a military psychiatrist - mostly to prescribe
medications - and a brief monthly or bimonthly session with a psychologist. Since his diagnosis, Flowers has endured "constant
harassment" within his unit, and incurs harsh punishment from his commanders for even the "slightest perceived inadequacies."
"Though I have had suicidal ideations, I am not considered a risk," Flowers told Truthout.
Flowers's case is not unique.
Active-duty PTSD sufferers are subject to neglect and ridicule, according to Tim Huber, director of the Military Counseling Network.
"PTSD is a great scapegoat
for the military to trot out when veterans face discrimination or have a difficult time securing jobs and making a new life
in the civilian world, but while those troops are on active duty, they're supposed to simply 'soldier on' and get over it,"
Huber told Truthout.
This mentality leads many
soldiers to conceal their symptoms for years. It also means that military leaders are resistant to signs of PTSD in the ranks. In fact, Huber considers Flowers's case lucky.
"I am actually impressed Flowers
was able to receive a PTSD diagnosis," Huber said. "We work with many service members who
can't even get that much recognition, and are instead simply criticized for being soft, and/or trying to get out."
The trend toward disregarding
or silencing PTSD sufferers even extends to military psychiatrists, according to Chris Capps-Schubert,
the Europe coordinator for Iraq Veterans Against the War, who is following Flowers's situation closely.
"In the summary of Flowers's
case, his military psychologist said it's a difficult position for him as a doctor, because he has conflicting interests in
his role as a medical provider and his role as a soldier," Capps-Schubert told Truthout.
Flowers was experiencing PTSD symptoms well before 2007, but says he was afraid of the consequences of seeking help.
Many soldiers suffer for long
periods before coming forward with their symptoms; others speak out about their condition but are denied treatment.
Army Sgt. Selena Coppa was
recently diagnosed with military sexual trauma, a form of PTSD resulting from sexual harassment, assault or rape, years after her symptoms
began.
"I think that the lack of
initial treatment has severely impacted my life," Coppa, who served in Iraq and is now stationed in Germany, told Truthout.
"I was told by my therapist that my PTSD had gone from simple to complex as a result of the military environment and
lack of real treatment. Military practitioners tend to be extremely unwilling to diagnose PTSD
in active-duty soldiers, and thus make it more difficult for individuals to have access to treatment and care."
Retention at All Costs
Both Flowers and Coppa protested
the military's neglect of their problems, but found little recourse for their grievances.
"I complained about what I
felt was inadequate treatment, but was told there was simply no better treatment to offer me outside of the States, and they would not consider
transferring me to the better treatment until I had already 'run the full course' with the less-effective treatment," Coppa
said.
The military's reluctance
to diagnose or treat PTSD is linked to its primary goal: retaining soldiers on the ground.
Even if a soldier is only marginally able to perform, military authorities may make a strategic decision to delay diagnosis and treatment, which could lead to a discharge.
"For Flowers to be discharge-worthy,
the military must feel it is better off without him," Huber said. "But there's a wrinkle. The military has to cultivate a
culture of commitment. If it were easy to skip the enlistment contract and get out early, retention would plummet and America's ability to maintain
the military status quo would vanish. That's why so many squeaky wheels don't get greased, and eventually crack and crumble....
I guess one could say brute retention is more important than mission readiness."
Soldiers diagnosed with psychological
disorders may be reassigned to alternate duties, in place of receiving adequate treatment or a discharge. Flowers, for example,
is now relegated to "meter maid" duty. He walks the Air Force base looking for parking violations, though he suffers from
serious knee and back problems.
By the end of his daily nine-hour
shift, he is in excruciating pain.
Coppa, who is now stationed
in Germany, notes that her treatment - or lack thereof - was determined almost solely based on the "wishes of the command,"
not on her medical needs. Even after her diagnosis was recognized, she repeatedly met with resistance and indifference.
She also discovered that the
military has startlingly few resources to deal with military sexual trauma.
"There are no domestic violence groups here in Germany, and no military sexual trauma groups," Coppa said. "They are ill-equipped to treat this form of PTSD in anything but a solo
setting, which is not as helpful. Though they acknowledged I would benefit medically from a transfer to the States, one was refused."
Coppa's experience is widespread:
support groups and alternative treatments are very rare. Typically, PTSD-diagnosed soldiers are prescribed medication at the outset, often with little explanation or accompanying talk therapy.
Drugs are seen as the quickest, most efficient route to retaining a soldier on duty, regardless of the consequences, according
to Huber.
"The main strategy is to prescribe
the problems away with pills, and as long as someone can remain upright under their own power and perform the base elements of their MOS [military occupation specialty],
the military is adequately 'treating' the problem," Huber said. "If someone refuses to medicate, for fear of what they might do with live ammunition under the influence of three, four, five or more mind-altering drugs, they are simply written off as refusing the military's 'help' and not wanting to get better."
Recently, after a long fight,
Steven Flowers was able to form a support group for PTSD sufferers in his unit. The group was created against the wishes of the military
mental health staff, and Flowers's psychiatrist initially refused to consider the idea. Such groups are almost unheard of for soldiers on active duty.
For many service members with
PTSD, the best they can hope for is the strength and luck to hold out until they return home.
"The help can be a little
better after people get out and start seeing civilian psychologists, who care more about the individual then retaining a soldier who fills a slot in a unit," Capps-Schubert said.
Military personnel and their families - click here - to read some information I've received.
"I've had many horrible things happen to me in my lifetime, but none as serious
or extreme as going to war. I can hardly comprehend the extent of the intensity of fear that these soldiers, whether they
be men or women must endure. And when I think that their families are so stressed, so fearful, so "on edge" that I can hardly
believe that they themselves aren't developing their own case of PTSD. How can they not?
I pray that the world will begin to embrace those who are affected by mental illness. For those who are denying it so pervasively
are mostly those who are in denial concerning their own well being."
June 30, 2004 - About 1 in
7 soldiers returning from combat duty in Iraq have major depression, posttraumatic stress disorder, or other serious mental health issues.
Yet those most in need of treatment are least likely to seek it, according to the first study to explore the mental health of returning Army and
Marine personnel fighting the war on terrorism in either Iraq or Afghanistan.
"Most often, it's due to a
perception they have that they'll be stigmatized if they do receive care," lead study researcher Col. Charles W. Hoge, MD, of Walter Reed Army Institute of Research, tells WebMD. "Among soldiers
who screen positive (for mental healthproblems), about
65% have the perception they will be seen as weak if they sought care."
For his study, published in
this week's New England Journal of Medicine, Hoge and colleagues surveyed 2,530 members of the armed services prior
to their deployment in Iraq and 3,670 within 4 months of returning from combat in either Iraq or Afghanistan.
Most Experience Trauma
Most returned having experienced
traumatic events such as being shot at, killing someone, seeing bodies, or witnessing civilian injuries they could do nothing about.
Generally, those in Iraq were
up to twice as likely to engage in a firefight compared with those fighting in Afghanistan.
Hoge finds that some 17% serving
in Iraq met the criteria for mental health disorders requiring treatment - twice as many as before deployment.
That compares with only 11% of those serving in Afghanistan. Iraq veterans were also significantly more likely as those serving
in Afghanistan to develop posttraumatic stress disorder (PTSD).
"We think the difference results from a greater frequency and intensity of combat in Iraq," says Hoge, chief of psychiatry and behavior
sciences at the Bethesda, Md.- based medical research facility.
But what's especially worrisome to Hoge and other experts is that even though the armed forces
offers several programs to offer counseling and other assistance to returning veterans, those who need them are reluctant to use them.
His study
indicates that as few as 1 in 4 soldiers who need mental health treatment are seeking it - largely because of the belief it'll hurt their military careers.
'Not Just a Military Issue'
"Eventually, all of these
soldiers will be returning to civilian life, so this isn't just a military issue," Hoge tells WebMD. "Hopefully, this article
will raise public awareness in general about psychiatric manifestations of combat duty. This is something the entire medical system needs to look at."
Of particular concern is PTSD, which first came to light following the Vietnam War. This type of anxiety disorder
usually develops within months of a traumatic event, but may not manifest until years or even decades later.
Overall, PSTD
affects about 5% of American men some time in their life. The rate in members of the armed services returning from Iraq is
at least 3 times as high.
"And these are early returns,"
says Matthew J. Freidman, MD, PhD, Dartmouth Medical School psychiatrist and executive director of the National Center for
PSTD in Vermont.
"The men and women surveyed
in this study have been back in the states for 8 to 12 months already. So while the duty they saw was quite considerable,
most of them were in Iraq before the war really changed in character," he tells WebMD. "At their time, it was still primarily
a war of liberation and we were welcome by the Iraqis. It was very different than it is now.
"Tours are now being extended
& we have data back from World War I that suggest the longer you're in a war zone, the greater the
likelihood you'll have psychiatric problems. And those surveyed in this very important study were on active duty and
evidence suggests that National Guard Reserve units are more vulnerable because they're less well-prepared and they also have deployment stressors like being uprooted from their families and economic hardships. This may be the tip of the iceberg."
While returning soldiers may
be hesitant to seek help, at least one stigma has changed in this war.
"Despite the fact there are
major disagreements about this war and justification for it, what's fortunate is that the American public isn't making the same mistake as in Vietnam and we're now supportive to these veterans," adds Freidman, who says tells WebMD he "cut his teeth" in psychiatry treating PTSD
in Vietnam veterans who came home to hostility from fellow Americans.
"At least now we've now learned to separate the war from the warrior."
What is the best treatment of PTSD?
Therapy is a
very important component of the treatment of PTSD; in particular, a structured form of psychotherapy
know as cognitive-behavioral therapy (CBT) is the most widely accepted as effective for PTSD. Sometimes it is useful to work
one-on-one with a therapist through individual therapy.
Working together with others who have also suffered
traumatic experiences in a group therapy setting may also be helpful. Certain medications may also be very useful in reducing
many of the symptoms of PTSD.
Military personnel and their families - click here - to read some information I've received.
Sending mentally ill soldiers back to Iraq: Reckless disregard for soldiers' welfare and for Iraqi lives
by Stephan Soldz / March 26, 2006
As the US military has difficulties recruiting and retaining soldiers for its never-ending war
of occupation in Iraq, the armed services are resorting to increasingly desperate means of coping.
The Stop-Loss option in soldiers' contracts
has allowed soldiers to be kept in uniform months or years after their term of service has expired.
The National Guard has
been sent overseas to a previously unprecedented extent. And military standards have been lowered, so that drug or alcohol abuse, pregnancy and poor fitness no longer necessarily lead to dismissal of new recruits.
Now word comes that "mentally ill" troops are being sent
back to Iraq. [See: Some troops
headed back to Iraq are mentally ill] This article refers
to "a little-discussed truth fraught with implications," but the implications discussed all have to do with the effects on the soldiers being returned
& these soldiers' "effectiveness in combat."
In many instances, being returned to combat
and to a state of constant tension, will exacerbate the soldiers' problems, the article - correctly - suggests.
The article indicates that the military is putting pressure on mental health professionals treating these soldiers to minimize the extent of their problems and to declare them fit for return to Iraq and combat.
i.e., some Army doctors are reporting that they're being
told to diagnose combat-stress reaction instead of the more serious post-traumatic stress disorder (PTSD).
I've written about the moral issues involved in mental health treatment of soldiers in Iraq [To Heal or To
Patch: Military Mental Health Workers in Iraq]. The issues are similar for those treating the soldiers
when they return if the professionals play any role in deciding whether or not the soldiers should return to combat.
The mental health professionals aren't in a position to make unbiased judgments as to a soldier's readiness to return to combat when their own status and advancement in the military may depend upon how
they exercise that judgment.
One "implication" not even mentioned in the article is that sending "mentally
ill" soldiers back into combat puts not only the soldiers' own mental health at risk, but endangers Iraqis as well.
What's the quality of decision-making by highly stressed soldiers, whether they suffer from "PTSD" or only from "combat-stress
reaction"?
These soldiers are armed with lethal weapons
and are often in a position to make split-second life-or-death decisions. After all, "stress" is often used as a defense when other armed authorities, such as police, are caught engaging in abusive or even murderous behavior.
Surely the effects of stress can only be magnified on soldiers who spend a year or more being assigned to a country where they can never feel entirely safe.
We know from the memoirs of US soldiers in Iraq how alienated from Iraqis they feel. Thus, Colby Buzzell, in his My War: Killing Time in Iraq,
describes being "hit with the realization that I'm on the other side of the planet far away from home and that I'm a stranger
in a really strange land" (p. 297).
These strangers feel so alienated from Iraqis that they have a number of names for them. As Kayla Williams tells us in Love
My Rifle More Than You: Young and Female in the US Army:
"[W]e called them hajjis, but
we also called them sadiqis... or habibis....
We called them towelheads. Ragheads.
Camel jockeys. The fucking locals. Words
that didn't see our enemy as people - as somebody's father or son or brother or uncle" (p. 200; emphasis in original).
Of course, it isn't only "the enemy" that
terms like these describe and who aren't seen as people. Ordinary Iraqis of all stripes are characterized as the "hajjis"
or "the fucking locals."
Not surprisingly, in such a climate of alienation combined with pervasive never-ending danger, even mentally "healthy" soldiers have emotional difficulties.
i.e., Jason Christopher Hartley, author of the memoir Just Another Soldier: A Year on the Ground in Iraq, describes attempting to refuse leave:
"[I]n all honesty, I did it because I didn't want to leave Iraq. One of the ways to cope with being in combat is to go crazy just a tiny bit and learn to enjoy the work... I was afraid that if I left, it would be difficult to get back into the 'combat is fun' way of thinking when I returned" (p. 279).
If Hartley, by all indications a mentally
healthy soldier, was only able to survive by going a bit crazy and in his case, cultivating a love of combat, what happens
to an emotionally disturbed soldier returned to that crazy-making environment?
Does (s)he cower in terror, perhaps shooting
at stimuli little more dangerous than his or her shadow, even if those stimuli happen to be Iraqi civilians?
Or does (s)he perhaps cultivate an even
greater love for combat, shooting at Iraqis as an expression of a game necessary to transform the pervasive fear?
Undoubtedly each
of these paths is chosen by some. Either possibility will increase the odds of adding to the massive Iraqi civilian casualties
being generated by this war of occupation, estimated at about 100,000 in September 2004 and considerably higher at this point.
To deploy mentally unstable soldiers
[not to mention those with drug or alcohol problems] likely will increase these horrific numbers. This policy of returning potentially unstable soldiers to combat in
Iraq is, thus, not only a serious threat to the mental health of the soldiers, but a threat to occupied Iraqis.
This policy, already reprehensible
because of the danger it poses to the long-term mental health of the US troops, is also in its reckless disregard for Iraqi
lives yet another example of the innumerable war crimes being committed against the Iraqi people.
Could
it be that the United States Armed Forces don't take the issues of mental illness seriously enough? Doesn't it simply come
back around to bite them in the butt when soldiers who are in Iraq and other countries suddenly make rash, irrational decisions
to kill, rape or incur violence upon innocent civilians while in anticipation of being bombed at any time by the insurgency?
Our government had better get their ducks in a row, for once their personnel get professional advice concerning being sent
back into warfare although being diagnosed with PTSD or other mental illness, they must not be held responsible for the outcome
should there be an unfortunate incident concerning bad judgments!
kathleen
"Where are the people who thrive in their states of emotional wellbeing? Where
are they in our communities? Do we need to beg for these fortunate people to reach out and share their experiences of well
being with those who are so hopelessly searching for that same state of mind? What about the children affected by war? What
about our soldiers wives and children? It's the responsibility of every American in the United States to reach out in some
way to help those in need. It's what they used to refer to as, 'the heart of America.'"
Mentally ill service members are being returned
to combat.
The redeployments are legal
and the service members are often eager to go. But veterans groups, lawmakers and mental-health professionalsfear that the practice lacks adequate civilian oversight. They also worry that such redeployments are becoming more frequent as
multiple combat tours become the norm and traumatized service members are retained out of loyalty or wartime pressures to maintain troop numbers.
Sen. Barbara Boxer hopes to
address the controversy thru the Dept. of Defense Task Force on Mental Health, which is expected to start work next month.
The California Democrat wrote the legislation that created the panel. She wants the task force to examine deployment policies
and the quality and availability of mental-health care for the military.
We’ve also heard reports
that doctors are being encouraged not to identify mental-health illness in our troops. I'm asking for a lot of answers, Boxer
said during a March 8 telephone interview. If people are suffering from mental-health problems, they shouldn't be sent on
the battlefield.
Stress reduces a person’s
chances of functioning well in combat, said Frank M. Ochberg, a psychiatrist for 40 years and a founding member of the International
Society for Traumatic Stress Studies.
I haven't seen anything that
says this is a good thing to use these drugs in high-stress situations. But if you're going to be going (into combat) anyway, you're
better off on the meds, said Ochberg, a former consultant to the Secret Service and the National Security Council.
About 25,000 Marines and sailors
based in San Diego County are undergoing a major combat rotation that began in January. Their deployments are expected to
last 7 months.
Officials from the Defense
Dept. and Camp Pendleton, where some units have been to Iraq 3 times, said they don’t track personnel deployed while
taking mental-health medication or the number diagnosed with mental illness.
But medical officers for the
Army and Marine Corps acknowledge that medicated service members and those suffering combat-induced psychological problems are
returning to War. And anecdotal evidence, bolstered by the government’s own
studies, suggest that the number could be significant.
A 2004 Army report found that
up to 17% of combat-seasoned infantrymen experienced major depression, anxiety or post-traumatic stress disorder after one combat tour to Iraq.
Less than 40% of them had
sought mental-health care.
A Pentagon survey released
last month found that 35% of the troops returning from Iraq had received psychological counseling during their first year home.
That survey echoed statistics
collected by the San Diego Veterans Affairs Healthcare System. The system has found that about 33% of Iraq and Afghanistan
veterans suffer from schizophrenia, depression and post-traumatic stress disorder.
The various studies apparently
didn’t consider the effects of multiple combat tours, though psychiatrists agree that the greater people’s exposure
to combat, generally the higher their risk of suffering mental illness.
More than 435,000 U.S. personnel
have served in Iraq and Afghanistan combined. It's unclear how many have served in that region more than once.
Joe Costello, a mental-health counselor at the Vista Veterans Center, said emotionally scarred troops are routinely redeployed and that most want to go back to the
War zone.
I see it every day, said Costello,
who mainly treats reservists.
Buttressing the idea that
large numbers of service members are medicated, more than 200,000 prescriptions for the most common types of antidepressants were written in the past 14 months for service members and their families, said Sydney Hickey, a spokeswoman for the National
Military Family Association.
Hicks said a Defense Dept.
official gave her the information during a December briefing. She said the official didn't distinguish between prescriptions for the troops and those for their family members.
In addition,
the Defense Dept. hasn't provided prescription totals for such antidepressants from before and after the United States invaded Iraq in 2003.
The prescriptions were for
selective serotonin reuptake inhibitors, commonly called SSRIs. These drugs are used to treat depression, anxiety disorders, some personality disorders and post-traumatic stress disorder.
They include brand names such as Paxil, Cymbalta and Wellbutrin.
Mental-health
care for service members and the Defense Dept.’s efforts to keep the mentally ill in uniform are becoming national issues,
said Steve Robinson, director of the National Gulf War Resource Center in Silver Spring, Md.
Robinson said 3 Army doctors
have told him about being pressured by their commanders not to identify mental conditions that would prevent personnel from being deployed.
They're being told to diagnose
combat-stress reaction instead of PTSD, he said. That
does 2 things:
It keeps the troops deployable
It makes it hard for them to collect disability claims once
they get out of the military
Robinson contends that the
Pentagon is trying to control its spending on mental-health disabilities.
Between 1999 and 2004, disability
payments to veterans with post-traumatic stress disorder rose to $4.3 billion from $1.7
billion nationwide, according to a report by the Dept. of Veterans Affairs’ inspector general.
Overall,
service members’ mental health is a hot-button subject because it goes to the cost of the War in dollars and lives, said Joy Ilem, an assistant national legislative
director for the organization Disabled American Veterans.
The (Dept.
of Veterans Affairs) is very worried about the political implications of PTSD and
other mental issues arising from the War, Ilem said. They're talking about early outreach and treatment,
but they're really trying to tamp down the discussion.
Cmdr. Paul S. Hammer deals
with such issues daily.
Hammer, a psychiatrist, is responsible for the Marine Corps’ mental-health programs during this deployment
rotation. He confirmed that Marines with post-traumatic stress disorder and combat
stress are returning to Iraq, though he wouldn't say how many.
Hammer said deciding who is
deployed is often anguishing.
Sometimes he has to tell Marine
commanders that personnel they had counted on will not be deploying. In other instances, he said, We’ll hold some guy’s
feet to the fire and say, ‘This is what you signed up for and you have to go.’
Marines are amazingly resilient,
Hammer added. You’ve got people exposed to incredible violence, but they do entirely well.
It’s the tough calls
that worry Adrian Atizado, a legislative director for Disabled American Veterans.
Currently, the services will deploy a service member if the person is medically stable and it's determined that
the deployment won’t aggravate (his) condition, Atizado said. How does one gauge that?
This a
gray area; this is asking a medical provider to make a decision based on the future. The medical providers are
human beings. I have no doubt that they're looking out for the best interest of the service members, but they're under pressure to check off on their deployment.
Ultimately,
much is unknown about the rates of post-traumatic stress disorder among Iraq veterans, especially
those who have been through more than 1 combat tour, said Matt Friedman, executive director of the U.S. Dept. of Veterans
Affairs National Center for PTSD in White River Junction, Vt.
Friedman said that with time,
one of the things we're going to find out is how well people function who might have been on medication (during combat). This is a very important question and has all kinds of implications.
But remember, they're all volunteers. This isn’t Vietnam, where people were drafted and sent to fight. Think of the ethical questions that would arise from sending draftees back to War on medications.
By Rick Rogers UNION-TRIBUNE STAFF WRITER
Treatment of the Returning Iraq War Veteran
Josef I. Ruzek, Ph.D.,
Erika Curran, M.S.W., Matthew J. Friedman, M.D., Ph.D., Fred D. Gusman, M.S.W., Steven M. Southwick, M.D., Pamela Swales,
Ph.D., Robyn D. Walser, Ph.D., Patricia J. Watson, Ph.D., and Julia Whealin, Ph.D.
In this section
from the Iraq War Clinician Guide, we discuss treatment of veterans recently evacuated due to combat
or war stress who are brought to the VA for mental health care & Iraq War veterans seeking mental health care at VA medical centers & Vet Centers.
This section complements discussion of special topics (e.g., treatment of medical casualties, identification & management of PTSD
in the primary care setting, issues in caring for veterans who've been sexually assaulted, traumatic bereavement) that are addressed in other sections of this Guide.
It's important that VA & Vet Center clinicians recognize that the skills & experience that they've developed in working with veterans with chronic PTSD
will serve them well with those returning from the Iraq War.
Their experience in talking about trauma, educating patients & families about traumatic stress reactions, teaching skills of
anxiety & anger management, facilitating mutual support among groups of veterans & working with trauma-related guilt, will all be useful & applicable.
Here, we highlight some challenges for clinicians, discuss ways in which care of these veterans may differ from our usual contexts of care & direct attention to particular methods & materials
that may be relevant to the care of the veteran recently traumatized in war.
The Helping Context: Active Duty vs. Veterans Seeking
Health Care
There are a variety of
differences between the contexts of care for active duty military personnel & veterans normally being served in
VA that may affect the way practitioners go about their business.
1st, many Iraq
War patients will not be seeking mental health treatment. Some will have been evacuated for mental health or medical reasons
& brought to VA, perhaps reluctant to acknowledge their emotional distress & almost certainly reluctant to consider
themselves as having a mental health disorder (e.g., post-traumatic stress disorder).
2nd,
emphasis on diagnosis as an organizing principle of mental health care is common in VA. Patients are given DSM-IV diagnoses
& diagnoses drive treatment. This approach may be contrasted with that of frontline psychiatry, in which pathologization of combat stress reactions is strenuously avoided.
The strong assumption
is that most soldiers will recover & that their responses represent a severe reaction to the traumatic stress of war rather
than a mental illness or disorder.
According to this thinking, the “labeling” process may be counterproductive in the context of early care for Iraq War veterans. As Koshes 1noted, “labeling a person with an illness can reinforce the “sick” role & delay or prevent the
soldier’s return to the unit or to a useful role in military or civilian life” (p.
401).
Patients themselves
may have a number of incentives to minimize their distress:
to hasten discharge
to accelerate a return to the family
to avoid compromising their military career or
retirement
Fears about possible impact on career prospects are based in reality; indeed, some will be judged medically unfit to return to
duty. Veterans may be concerned that a diagnosis of PTSD, or even Acute
Stress Disorder, in their medical record may harm their chances of future promotion, lead to a decision to not be retained,
or affect type of discharge received.
Some may think that the information obtained if they receive mental health treatment will be shared with their unit commanders, as
is sometimes the case in the military.
To avoid legitimate concerns about possible pathologization of common traumatic stress reactions, clinicians
may wish to consider avoiding, where possible, the assignment of diagnostic labels such as ASD
or PTSD, and instead focus on assessing and documenting symptoms and behaviors.
Diagnoses of acute or
adjustment disorders may apply if symptoms warrant labeling. Concerns about confidentiality must be acknowledged and
steps taken to create the conditions in which patients will feel able to talk openly about their experiences, which may include:
difficulties with commanders
misgivings about military operations or policies,
possible moral concerns about having participated
in the war
It will be helpful
for clinicians to know who will be privy to information obtained in an assessment. The role of the assessment and who will
have access to what information should be discussed with concerned patients.
Active duty service members
may have the option to remain on active duty or to return to the war zone. Some evidence suggests that returning to work with
one’s cohort group during wartime can facilitate improvement of symptoms. Although their wishes may or may not be granted,
service members often have strong feelings about wanting or not wanting to return to war.
For recently activated
National Guard and Reservists, issues may be somewhat different. 2Many in this population never planned to go to war and so may be faced with obstacles to picking up the life they “left.”
Whether active duty, National Guard, or Reservist, listening to and acknowledging their concerns will help empower them and inform treatment planning.
Iraq War patients
entering residential mental health care will have come to the VA through a process different from that experienced by “traditional”
patients. If they have been evacuated from the war zone, they will have been rapidly moved through several levels of medical
triage and treatment, and treated by a variety of health care providers. 3
Many will have received
some mental health care in the war zone (e.g., stress debriefing)
that will have been judged unsuccessful. Some veterans will perceive their need for continuing care as a sign of personal failure.Understanding their path to the VA will help the building of a relationship and the design
of care.
More generally,
the returning soldier is in a state of transition from war zone to home, and clinicians must seek to understand the expectations
and consequences of returning home for the veteran. Is the veteran returning to an established place in society, to an economically
deprived community, to a supportive spouse or cohesive military unit, to a large impersonal city, to unemployment, to financial
stress, to an American public thankful for his or her sacrifice? Whatever the circumstances, things are unlikely to be as they were:
“The
deployment of the family member creates a painful void within the family system that is eventually filled (or denied) so that life can go on…The family assumes that their experiences at home and the soldier’s activities
on the battlefield will be easily assimilated by each other at the time of reunion and that the pre-war roles will be resumed. The
fact that new roles and responsibilities may not be given up quickly upon homecoming is not anticipated.”(p.31). 4
Learning from Vietnam Veterans with Chronic
PTSD
From the perspective of
work with Vietnam veterans whose lives have been greatly disrupted by their disorder, the chance to work with combat
veterans soon after their war experiences represents a real opportunity to prevent the development of a disastrous life course.
We have the opportunity
to directly focus on traumatic stress reactions and PTSD symptom reduction (e.g., by helping veterans process their traumatic experiences, by prescribing medications)
and thereby reduce the degree to which PTSD, depression, alcohol/substance misuse, or other
psychological problems interfere with quality of life. We also have the opportunity to intervene directly in key areas of
life functioning, to reduce the harm associated with continuing post-traumatic stress symptoms
and depression if those prove resistant to treatment.
The latter may possibly
be accomplished via interventions focused on actively supporting family functioning in order to minimize family problems,
reducing social alienation and isolation, supporting workplace functioning, and preventing use of alcohol and drugs as self-medication
(a different focus than addressing chronic alcohol or drug problems).
Prevent family breakdown
At time of return to civilian
life, soldiers can face a variety of challenges in re-entering their families, and the contrast between the fantasies
and realities of homecoming 4can be distressing.
Families themselves have
been stressed and experienced problems as a result of the deployment. 5, 6 Partners have made role adjustments while the soldier was away, and these need to be renegotiated, especially given
the possible irritability and tension of the veteran. 7
The possibility exists
that mental health providers can reduce long term family problems by:
helping veterans and their families anticipate
and prepare for family challenges
involving families in treatment
providing skills training for patients (& where
possible, their families) in family-relevant skills (e.g., communication, anger management, conflict resolution, parenting)
providing short-term support for family members
linking families together for mutual support
Prevent social withdrawal and isolation
PTSD also interferes
with social functioning. Here the challenge is to help the veteran avoid withdrawal from others by supporting re-entry
into existing relationships with friends, work colleagues, and relatives, or where appropriate, assisting in development of
new social relationships.
The latter may be especially
relevant with individuals who leave military service and transition back into civilian life. Social functioning should
be routinely discussed with patients and made a target for intervention. Skills training focusing on the concrete management
of specific difficult social situations may be very helpful. Also, as indicated below, clinicians should try to connect veterans
with other veterans in order to facilitate the development of social networks.
Prevent problems with employment
Associated with chronic
combat-related PTSD have been high rates of job turnover and general difficulty in maintaining
employment, often attributed by veterans themselves to anger and irritability, difficulties with authority, PTSD symptoms, and substance abuse.
Steady employment,
however, is likely to be one predictor of better long term functioning, as it can reduce financial stresses, provide a source
of meaningful activity and self-esteem, and give opportunities for companionship and friendship.
In some cases,
clinicians can provide valuable help by supporting the military or civilian work functioning of veterans, by teaching skills
of maintaining or, in the case of those leaving the military, finding of employment, or facilitating job-related support groups.
Prevent alcohol and drug abuse
The co-morbidity
of PTSD with alcohol and drug problems in veterans is well established. 8Substance abuse adds to the problems caused by PTSD and interferes with key roles
and relationships, impairs coping, and impairs entry into and ongoing participation in treatment. PTSD
providers are aware of the need to routinely screen and assess for alcohol and drug use, and are knowledgeable about alcohol
and drug (especially 12-Step) treatment.
Many are learning,
as well, about the potential usefulness of integrated PTSD-substance abuse treatment, and
the availability of manualized treatments for this dual disorder. “Seeking Safety,” a structured group protocol
for trauma-relevant coping skills training, 9is seeing increased use in VA and should be considered as a treatment option for Iraq War veterans who have substance
use disorders along with problematic traumatic stress responses.
In addition,
for many newly returning Iraq War veterans, it will be important to supplement traditional abstinence-oriented treatments
with attention to milder alcohol problems, and in particular to initiate preventive interventions to reduce drinking or prevent
acceleration of alcohol consumption as a response to PTSD symptoms. 10
For allreturning veterans, it
will be useful to provide education about safe drinking practices and the relationship between traumatic stress reactions
and substance abuse.
As with all mental health counseling, the relationship between veteran and helper will be the starting point for care. Forming a working alliance with some returnees may be challenging, however, because most newly-returned veterans may be,
as Litz (this Guide) notes, “defended, formal, respectful, laconic,
and cautious” and reluctant to work with the mental health professional.
Especially in the
context of recent exposure to war, validation 7of the veteran’s experiences and concerns will be crucial. Discussion of “war zone”, not “combat,”
stress may be warranted because some traumatic stressors (e.g., body handling, sexual assault)
may not involve war fighting as such.
Thoughtneeds to be given to making the male-centric hospital system hospitable for women, especially for women who have experienced
sexual assault in the war zone (see Special Topic VI, this Guide), for
whom simply walking onto the grounds of a VA hospital with the ubiquitous presence of men may create feelings of vulnerability
and anxiety.
Practitioners should
work from a patient-centered perspective, and take care to find out the current concerns of the patient (e.g., fear of returning to the war zone,
concerns about having been evacuated and what this means, worries about reactions of unit, fear of career ramifications, concern
about reactions of family, concerns about returning to active duty).
One advantage of
such an orientation is that it will assist with the development of a helping relationship.
Connect veterans with each other
In treatment of chronic PTSD, veterans often report that perhaps their most valued experience was the opportunity
to connect in friendship and support with other vets. This is unlikely to be different for returning Iraq War soldiers, who
may benefit greatly from connection both with each other and with veterans of other conflicts.
Fortunately, this
is a real strength of VA and Vet Center professionals, who routinely and skillfully bring veterans together.
Offer practical help with specific problems
Returning veterans
are likely to feel overwhelmed with problems, related to workplace, family and friends, finances, physical health, and so
on. These problems will be drawing much of their attention away from the tasks of therapy, and may create a climate of continuing stress that interferes with resolution of symptoms.
The presence of
continuing negative consequences of war deployment may help maintain post-traumatic stress reactions.
Rather than treating these issues as distractions from the task at hand, clinicians can provide a valuable service by helping
veterans identify, prioritize, and execute action steps to address their specific problems.
Attend to broad needs of the person
Wolfe, Keane,
and Young 11put forward several suggestions for clinicians serving Persian Gulf War veterans that are also important in the context
of the Iraq War. They recommended attention to the broad range of traumatic experience (see Section
I of this Guide). They similarly recommended broad clinical attention to the impact of both pre-military and post-military
stressors on adjustment.
For example,
history of trauma places those exposed to trauma in the war zone at risk for development of PTSD,
and in some cases war experiences will activate emotions experienced during earlier events. Finally, recognition and referral
for assessment of the broad range of physical health concerns and complaints that may be reported by returning veterans is
important. Mental health providers must remember that increased health symptom reporting is unlikely to be exclusively psychogenic
in origin. 12
Management of acute
stress reactions and problems faced by recently returned veterans are highlighted below. Methods of care for
the Iraq War veteran with PTSD will be similar to those provided to veterans with chronic
PTSD.
Education about post-traumatic
stress reactions
Education is a key component
of care for the veteran returning from war experience and is intended to improve understanding and recognition of symptoms, reduce fear and shame about symptoms, and, generally, “normalize” his or her experience.
It should also provide the veteran with a clear understanding of how recovery is thought to take place, what will happen in treatment, and, as appropriate, the role of medication.
With such understanding, stress reactions may seem more predictable and fears about long-term effects can be reduced. Education in the context
of relatively recent traumatization (weeks or months) should include the
conception that many symptoms are the result of psycho-biological reactions to extreme stress and that, with time, these reactions,
in most cases, will diminish.
Reactions should be interpreted
as responses to overwhelming stress rather than as personal weakness or inadequacy. In fact, some recent research 13suggests that survivors’ own responses to their stress symptoms will in part determine the degree of distress
associated with those symptoms and whether they will remit. Whether, for example, post-trauma intrusions cause distress may
depend in part on their meaning for the person (e.g., “I’m going crazy”).
Returning veterans
experiencing recurrent intrusive thoughts and images, anxiety and panic in response to trauma cues, and feelings of guilt
or intense anger are likely to feel relatively powerless to control their emotions and thoughts. This helpless feeling is
in itself a trauma reminder. Because loss of control is so central to trauma and its attendant emotions, interventions that
restore self-efficacy are especially useful.
Coping skills training is a core element in the repertoire of many VA and Vet Center mental health providers. Some skills that
may be effective in treating Iraq War veterans include:
anxiety management (breathing
retraining and relaxation)
emotional “grounding”
anger management
communication
However, the days,
weeks, and months following return home may pose specific situational challenges; therefore, a careful assessment of the veteran’s
current experience must guide selection of skills.
For example, training
in communication skills might focus on the problem experienced by a veteran in expressing positive feelings towards a partner
(often associated with emotional numbing); anger management could help
the veteran better respond to others in the immediate environment who do not support the war.
Whereas education helps
survivors understand their experience and know what to do about it, coping skills training should focus on helping them know how to do the things
that will support recovery. It relies on a cycle of instruction that includes education, demonstration, rehearsal with feedback
and coaching, and repeated practice.
It includes regular
between-session task assignments with diary self-monitoring and real-world practice of skills. It is this repeated practice
and real world experience that begins to empower the veteran to better manage his or her challenges (see
Najavits 9for a useful manual of trauma-related coping skills).
Exposure therapy
is among the best-supported treatments for PTSD. 14It is designed to help veterans effectively confront their trauma-related emotions and painful memories, and can be
distinguished from simple discussion of traumatic experience in that it emphasizes repeated verbalization of traumatic memories
(see Foa & Rothbaum 15for a detailed exposition of the treatment).
Patients are exposed
to their own individualized fear stimuli repetitively, until fear responses are consistently diminished. Often, in-session
exposure is supplemented by therapist-assigned and monitored self-exposure to the memories or situations associated with traumatization.
In most treatment
settings, exposure is delivered as part of a more comprehensive “package” treatment; it is usually
combined with traumatic stress education, coping skills training, and, especially, cognitive restructuring (see below). Exposure therapy can help correct faulty perceptions of danger, improve perceived
self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of
distress.
Cognitive restructuring
Cognitive therapy or restructuring, one of the best-validated PTSD treatments, 14is designed to help the patient review and challenge distressing trauma-related beliefs. It focuses on educating participants
about the relationships between thoughts and emotions, exploring common negative thoughts held by trauma survivors, identifying
personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking.
This is a
systematic approach that goes well beyond simple discussion of beliefs to include individual assessment, self-monitoring
of thoughts, homework assignments, and real-world practice. In particular, it may be a most helpful approach to a range of
emotions other than fear – guilt, shame, anger, depression – that may trouble veterans.
For example,
anger may be fueled by negative beliefs (e.g., about perceived lack of preparation or training
for war experiences, about harm done to their civilian career, about perceived lack of support from civilians).
Cognitive therapy may also be helpful in helping veterans cope with distressing changed perceptions of personal identity that
may be associated with participation in war or loss of wartime identity upon return. 4
For those wishing to learn
more about the approach, a useful resource is the Cognitive Processing Therapy manual developed by Resick and Schnicke,
16which incorporates extensive cognitive restructuring and limited exposure. Although designed for application to rape-related
PTSD, the methods can be easily adapted for use with veterans. Kubany’s 17work on trauma-related guilt may be helpful in addressing veterans’ concerns about harming or causing death to
civilians.
Mental health professionals within VA and Vet Centers have a long tradition of working with family members of veterans with PTSD. This same work, including
family education, weekend family workshops, couples counseling, family therapy, parenting classes, or training in conflict
resolution, will be very important with Iraq War veterans. Some issues in family work are discussed in more detail below.
Early Interventions for ASD or PTSD
If Iraq War veterans
arrive at VA medical centers very soon (i.e., within several days or several weeks)
following their trauma exposure, the possibility for early intervention to prevent development of PTSD will exist. Although
cognitive-behavioral early interventions have only been developed recently and have not yet been tried with war-related acute
stress disorder, they should be considered as a treatment option for some returning veterans, given their impact with other
traumas and consistency with what is known about treatment of more chronic PTSD.
In civilian populations,
several randomized controlled trials have demonstrated that brief (i.e., 4-5 session)
individually-administered cognitive-behavioral treatment, delivered around two weeks after a trauma, can prevent PTSD in some
survivors of motor vehicle accidents, industrial accidents, and assault 18, 19 who meet criteria for Acute Stress Disorder and are therefore at risk for development of PTSD.
This treatment
is comprised of education, breathing training/relaxation, imaginal and in vivo exposure, and cognitive restructuring. The
exposure and cognitive restructuring elements of the treatment are thought to be most helpful.
A recent unpublished trial
conducted by the same team compared cognitive therapy and exposure in early treatment of those with ASD, with results indicating
that both treatments were effective with fewer patients dropping out of cognitive therapy. Bryant and Harvey 20noted that prolonged exposure is not appropriate for everyone (e.g., those experiencing
acute bereavement, extreme anxiety, severe depression, those experiencing marked ongoing stressors or at-risk for suicide).
Cognitive restructuring may have wider applicability in that it may be expected to produce less distress than exposure.
Toxic Exposure, Physical Health Concerns, and Mental
Health
War syndromes
have involved fundamental, unanswered questions about chronic somatic symptoms in armed conflicts since the U.S. civil war.
21In recent history, unexplained symptoms have been reported by Dutch peace keepers in Lebanon, Bosnia, and Cambodia,
Russian soldiers in Afghanistan and Chechnya, Canadian peace keepers in Croatia, soldiers in the Balkan war, individuals exposed
to the El Al airliner crash, individuals given the anthrax vaccine, individuals exposed to the World Trade Center following
9/11, and soldiers in the Gulf War. 17% of Gulf War veterans believe they have “Gulf War Syndrome”. 22
Besides PTSD,
modern veterans may experience a range of “amorphous stress outcomes.” 23Factors contributing to these more amorphous syndromes include suspected toxic exposures, and ongoing chronic exhaustion
and uncertainty. Belief in exposure to toxic contaminants has a strong effect on symptoms. Added to this, mistrust of military
and industry, intense and contradictory media focus, confusing scientific debates, and stigma and medicalization can contribute
to increased anxiety and symptoms related to feared exposure to contaminants.
When working with a recent
veteran, the clinician needs to address a full range of potentially disabling factors, to include:
harmful illness beliefs
weight & conditioning
diagnostic labeling
misinformation
unnecessary testing
over-medication
all or nothing rehabilitation approaches
medical system rejection
social support
workplace competition
The provider needs to
be familiar with side effects of suspected toxins so that he or she can educate the veteran, as well as being familiar
with the potential somatic symptoms that are related to prolonged exposure to combat stressors, and the side effects of common
medications.
The provider should
take a collaborative approach with the patient, identifying the full range of contributing problems, patient goals and motivation,
social support, and self-management strategies. A sustained follow-up is recommended.
For those with inexplicable
health problems, Fischoff and Wessely 24outlined some simple principles of patient management that may be useful in the context of veteran care:
There is evidence
that both cognitive-behavioral group therapy (CBGT) and exercise are effective for treating Gulf War illness.
In a recent clinical trial,
Donata et al. 25reported that CBGT improved physical function whereas exercise led to improvement in many of the symptoms of Gulf War
veterans’ illnesses.
Both treatments
improved cognitive symptoms and mental health functioning, but neither improved pain. In this study, CBGT was specifically
targeted at physical functioning, and included:
time-contingent activity pacing
pleasant activity scheduling
sleep hygiene
assertiveness skills
confrontation of negative thinking & affect
structured problem solving skills
The low-intensity aerobic exercise
intervention was designed to increase activity level by having veterans exercise once per week for one hour in the
presence of an exercise therapist, and independently 2-3 times per week. These findings are important because they demonstrate
that such treatments can be feasibly and successfully implemented in the VA health care system, and thus should be considered
for the treatment of Iraq War veterans who present with unexplained physical symptoms.
Family Involvement in Care
The primary source
of support for the returning soldier is likely to be his or her family. We know from veterans of the Vietnam War that there
can be a risk of disengagement from family at the time of return from a war zone. We also know that emerging problems with
ASD and PTSD can wreak havoc with the competency and comfort the returning soldier experiences as a partner and parent.
While the returning soldier
clearly needs the clinician’s attention and concern, that help can be extended to include his or her family as well.
Support for the veteran and family can increase the potential for the veteran's smooth immediate or eventual reintegration
back into family life, and reduce the likelihood of future more damaging problems.
Outpatient treatment
If the veteran is living
at home, the clinician can meet with the family and assess with them their strengths and challenges and identify any
potential risks. The "Transitioning Family Questionnaire" (see Appendix A: Assessment
Instrumentation) can be used to assess to what extent the family is reorganizing to once again fully include
the family member who has been in the war zone.
Family and clinician
can work together to identify goals and develop a treatment plan to support the family's reorganization and return to stability
in coordination with the veteran's work on his or her own personal treatment goals. The Transitioning Family Questionnaire
can be used again at a later date to assess progress and/or need for continuing work.
If one or both partners
are identifying high tension or levels of disagreement, or the clinician is observing that their goals are markedly incompatible,
then issues related to safety need to be assessed and plans might need to be made that support safety for all family members.
Couples who have
experienced domestic violence and/or infidelity are at particularly high risk and in need of more immediate support. When
couples can be offered a safe forum for discussing, negotiating, and possibly resolving conflicts, that kind of clinical support
can potentially help to reduce the intensity of the feelings that can become dangerous for a family. Even support for issues
to be addressed by separating couples can be critically valuable, especially if children are involved and the parents anticipate
future co-parenting.
Residential rehabilitation treatment
Inpatient hospitalization
could lengthen the time returning personnel are away from their families, or it could be an additional absence from the family
for the veteran who has recently returned home. It is important to the ongoing support of the reuniting family that clinicians
remain aware that their patient is a partner and/or parent.
Family therapy sessions, in person or by phone if geographical distance is too great, can offer the family a forum for working toward meeting their
goals. The potential for the involvement of the soldier’s family in treatment will depend greatly on their geographic
proximity to the treatment facility. Distance can be a barrier, but the family can still be engaged through conference phone
calls, or visits as can be arranged.
Pharmacotherapy
Pharmacologic treatment of acute
stress reactions
Pharmacological treatment for acute stress reactions (within one month of the
trauma) is generally reserved for individuals who remain symptomatic after having already received brief crisis-oriented
psychotherapy. This philosophy and approach is in line with the deliberate attempt by military professionals to avoid medicalizing
stress-related symptoms and to adhere to a strategy of immediacy, proximity, and positive expectancy.
Prior to receiving medication for stress-related symptoms, the war zone survivor should have a thorough psychiatric and medical examination, with
special emphasis on medical disorders that can manifest with psychiatric symptoms (e.g.,
subdural hematoma, hyperthyroidism), potential psychiatric disorders (e.g.,acute stress disorder, depression, psychotic disorders, panic disorder),
use of alcohol and substances of abuse, use of prescribed and over-the-counter medication, and possible drug allergies.
It is important
to assess the full range of potential psychiatric disorders, and not just PTSD, since many
symptomatic soldiers will be at an age when first episodes of schizophrenia, mania, depression, and panic disorder are often
seen.
In some cases a
clinician may need to prescribe psychotropic medications even before he or she has completed the medical or psychiatric examination.
The acute use of medications may be necessary when the survivor is dangerous, extremely agitated, or psychotic.
In such circumstances
the individual should be taken to an emergency room where short acting benzodiazepines (e.g.,
lorazepam) or high potency neuroleptics (e.g.,haldol) with minimal sedative, anticholinergic, and orthostatic side effects may prove effective.
Atypical neuroleptics (e.g., risperidone) may also be useful for treating
aggression.
When a decision has been
made to use medication for acute stress reactions, rational choices may include benzodiazepines, antiadrenergics, or
antidepressants. Shortly after traumatic exposure, the brief prescription of benzodiazepines (4
days or less) has been shown to reduce extreme arousal and anxiety and
to improve sleep.
However, early
and prolonged use of benzodiazepines is contraindicated, since benzodiazepine use for two weeks or longer has actually has
been associated with a higher rate of subsequent PTSD.
Although antiadrenergic
agents including clonidine, guanfacine, prazosin, and propranolol have been recommended (primarily
through open non-placebo controlled treatment trials) for the treatment of hyper-arousal, irritable aggression,
intrusive memories, nightmares, and insomnia in survivors with chronic PTSD, there is only
suggestive preliminary evidence of their efficacy as an acute treatment.
Of importance,
anti-adrenergic agents should be prescribed judiciously for trauma survivors with cardiovascular disease due to potential
hypo-tensive effects and these agents should also be tapered, rather than discontinued abruptly, in order to avoid rebound
hypertension.
Further, because
anti-adrenergic agents might interfere with counter-regulatory hormone responses to hypoglycemia, they should not be prescribed
to survivors with diabetes.
Finally, the use
of antidepressants may make sense within 4 weeks of war, particularly when trauma-related depressive symptoms are prominent and debilitating.
To date, there
has been one published report on the use of antidepressants for the treatment of Acute Stress
Disorder. Recently-traumatized children meeting criteria for Acute
Stress Disorder, who were treated with imipramine for two weeks, experienced significantly greater symptom reduction
than children who were prescribed chloral hydrate.
Pharmacologic treatment of post-traumatic
stress disorder
Pharmaco-therapy
is rarely used as a stand-alone treatment for PTSD and is usually combined with psychological treatment.
The following text
briefly presents recommendations for the pharmaco-therapeutic treatment of PTSD, and then
the article by Friedman, Donnelly, and Mellman 26in the Appendix provides more detailed information.
Findings from subsequent
large-scale trials with paroxetine have demonstrated that SSRI treatment is clearly effective both for men in general and
for combat veterans suffering with PTSD.
We recommend SSRIs
as first line medications for PTSD pharmaco-therapy in men and women with military-related PTSD.
SSRIs appear to be effective for all three PTSD symptom clusters in both men and women who
have experienced a variety of severe traumas and they are also effective in treating a variety of co-morbid psychiatric disorders, such as:
which are commonly seen in individuals suffering
with PTSD.
Additionally, the
side effect profile with SSRIs is relatively benign (compared to most psychotropic medications) although arousal and insomnia may be experienced early on for some patients with PTSD.
Second line medications include nefazadone, TCAs, and MAOIs. Evidence favoring the use of these agents is not as compelling as for SSRIs because
many fewer subjects have been tested at this point.
The best evidence
from open trials supports the use of nefazadone, which like SSRIs promotes serotonergic actions and is less likely than SSRIs
to cause insomnia or sexual dysfunction. Trazadone, which has limited efficacy as a stand-alone treatment, has proven very
useful as augmentation therapy with SSRIs; its sedating properties make it a useful bedtime medication that can antagonize
SSRI-induced insomnia.
Despite some favorable
evidence of the efficacy of MAOIs, these compounds have received little experimental attention since 1990. Venlafaxine
and buproprion cannot be recommended because they have not been tested systematically in clinical trials.
There is a strong rationale
from laboratory research to consider antiadrenergic agents and it is hoped that more extensive testing will establish their
usefulness for PTSD patients. The best research on this class of agents has focused on prazosin,
which has produced marked reduction in traumatic nightmares, improved sleep, and global improvement among veterans with PTSD. Hypotension and sedation need to be monitored and patients should not be abruptly discontinued
from antiadrenergics.
Despite suggestive theoretical
considerations and clinical findings, there is only a small amount of evidence to support the use of carbamazepine
or valproate with PTSD patients. Further, the complexities
of clinical management with these effective anticonvulsants have shifted current attention to newer agents (e.g., gabapentin, lamotrigine, and topirimate), which have yet to be tested systematically
with PTSD patients.
Benzodiazepines
cannot be recommended for patients with PTSD. They do not appear to have efficacy against
core PTSD patients. No studies have demonstrated efficacy for PTSD-specific
symptoms.
Conventional antipsychotics
cannot be recommended for PTSD patients. Preliminary results suggest, however, that atypical
antipsychotics may be useful, especially to augment treatment with first or second line medications, especially for patients
with intense hypervigilance/paranoia, agitation, dissociation, or brief psychotic reactions associated with their PTSD.
As for side effects,
all atypicals may produce weight gain and olanzapine treatment has been linked to the onset of Type II diabetes mellitus.
General guidelines
Pharmacotherapy
should be initiated with SSRI agents. Patients who cannot tolerate SSRIs or who show no improvement might benefit from nefazadone,
MAOIs, or TCAs.
For patients who
exhibit a partial response to SSRIs, one should consider continuation or augmentation. A recent trial with sertraline showed
that approximately half of all patients who failed to exhibit a successful clinical response after 12 weeks of sertraline
treatment, did respond when SSRI treatment was extended for another 24 weeks.
Practically speaking,
clinicians and patients usually will be reluctant to stick with an ineffective medication for 36 weeks, as in this experiment.
Therefore, augmentation strategies seem to make sense. Here are a few suggestions based on clinical experience and pharmacological
“guesstimates,” rather than on hard evidence:
Excessively aroused, hyper-reactive, or dissociating
patients might be helped by augmentation with an anti-adrenergic agent;
Labile, impulsive, and/or aggressive patients might benefit from augmentation with an anti-convulsant;
Fearful, hypervigilant, paranoid,
and psychotic patients might benefit from an atypical antipsychotic.
Integrating Iraq War Soldiers into Existing Specialized
PTSD Services
Iraq War service members
with stress-related problems may need to be integrated into existing VA PTSD Residential Rehabilitation Programs or other
VA mental health programs.
Approaches to this integration
of psychiatric evacuees will vary and each receiving site will need to determine its own “best fit” model for
provision of services and integration of veterans.
At the National Center’s
PTSD Residential Rehabilitation Program in the VA Palo Alto Health Care System, it is anticipated that Iraq War patients will
generally be integrated with the rest of the milieu (e.g., for community meetings, affect
management classes, conflict resolution, communication skills training), with the exception of identified
treatment components.
The latter elements of
treatment, in which Iraq War veterans will work together, will include process, case management, and acute stress/PTSD education groups (and, if delivered in groups, exposure
therapy, cognitive restructuring, and family/couples counseling).
The thoughtful mixing
of returning veterans with veterans from other wars/conflicts is likely, in general, to enhance the treatment experience of
both groups.
Practitioner Issues
Working with Iraq War
veterans affected by war zone trauma is likely to be emotionally difficult for therapists. It is likely to bring up many feelings and concerns - reactions to stories of death and great suffering, judgments about the morality of the war, reactions to patients who have killed, feelings of personal vulnerability, feelings of therapeutic inadequacy, perceptions of a lack of preparation for acute care - that may affect ability to listen empathically to the patient and maintain the therapeutic relationship. 27
Koshes 1suggested that those at greatest risk for strong personal reactions might be young, inexperienced staff who
are close in age to patients and more likely to identify with them, and technicians or paraprofessional workers who may have
less formal education about the challenges associated with treating these patients but who actually spend the most time with
patients.
Regardless of degree of
experience, all mental health workers must monitor themselves and practice active self-care, and managers must ensure
that training, support, and supervision are part of the environment in which care is offered.
My view of Post Traumatic Stress Disorder is where a witnessed
event or series of events is so traumatic (foreign to what we're used to & extremely
severe) so that an emotional & possible autonomic response is implicitly embedded into our unconscious
mind regardless of our cognitive input.
The horrendous sight of those two airplanes slamming into the World Trade Center Towers on September 11, 2001
was implicitly embedded into our unconscious minds. What's even more traumatic was our view of the towers each collapsing
in succession, as this in an instant dashed our hopes of rescuing those remaining in the towers.
Make no mistake, there will be many
cases of Acute Stress Disorder (short term)
& Post Traumatic Stress Disorder - PTSD (long term
& more severe) as a result of these attacks, it may even reach national epidemic proportions.
The incidence & severity of possible Post Traumatic Stress will
be directly related to several factors including:
your
proximity to ground zero during the terrorist attacks
the
ability of our people to sustain the renewed patriotism felt after the attacks
possible
unjust reprisals against like ethnic groups in our country
the
national & your individual economic health, subsequent terrorist attacks in this country or against our allies
the success or failure of our political & military operations in reprisal of these dastardly acts
Symptoms of Post Traumatic Stress Traumatic
memories are stored in the emotional unconscious in the implicit form & are less influenced by cognitive thought or reason & logic.
The triggers that will cause a flashback (see below about flashbacks) are anything which reminds us of the traumatic event, yet these
triggers may be seemingly unrelated events such as a child jumping off a playground gym where the posture of the arms &
body in flight trigger the emotional memory of someone jumping off a building.
In addition
to the emotional flashback (see below about flashbacks)
many people experience autonomic responses which may include:
Some may tend to avoid activities (avoidance behavior) which remind them of the event, deny the event or its effect on them, or are unable to recall some aspect of the traumatic event.
Most people will have some of these
symptoms for a few weeks, maybe up to 2 months & that'll be the end of it, except possibly on the anniversary of the event.
Others may experience flashbacks (see below about flashbacks)
even years after the event.
The fact that our emotional & autonomic responses to trauma are independent of our cognitive input places undue stress on our conscious mind & we begin to feel a loss of control. We don't understand why this is happening to us & negative ruminations about our inability to control this process causes further loss of control of our emotions.
We begin to lose hope that we will ever gain control of our emotional & autonomic responses.
It's the genetic responsibility of the unconscious mind to maintain control of our being in order insure our survival & procreation as a species. As we begin to lose control of our emotional response the unconscious mind will initiate a protective depressive response so that our lack of emotional
control will not destroy us.
Yet the protection afforded us by the depressive response is short lived if our conscious mind can't solve the problem & alleviate the stress. In that case the depression itself becomes debilitating & we are at risk of becoming suicidal in order to escape from the pain of depression & lack of control.
Those people who were already suffering from depression when the New York World Trade Center & Pentagon were attacked by terrorists are especially at risk of becoming further
depressed & of triggering suicidal thoughts.
The depressed will tend to personalize the terrorist attack to the point of it confirming that they aren't in control & there's no hope left in their future.
Combating Post Traumatic Stress Carol S. North, MD, MPE, a Washington University psychiatrist authored a study of survivors of
the Oklahoma City bombing. 1 in 3 developed PTSD & almost 1/2 suffered depression or alcoholism.
They found that those who relied most on numbing (alcohol & drugs) & those who avoided thinking or talking about the bombing were most likely to develop long-term problems.
The general population of the USA is more at risk of suffering PTSD
after the New York attack than it was after the Oklahoma City bombing. This is due to the increased scope of the disaster & the fact that many of us witnessed the despicable event live on TV & again & yet, again.
I shall not, nor have I ever, written about personal pain & emotional trauma without, to the best of my ability, attempting to help ease the pain & normalize the emotional trauma. These are my suggestions to help combat our Post Traumatic Stress:
1. First & foremost is to become informed. You should know why you're
having flashbacks (see below about flashbacks),
unusual emotions & unexplained autonomic responses.
These symptoms are natural reactions to trauma. The conscious mind isn't innately aware of how or why the unconscious mind reacts to trauma in order to maintain control of our being.
If our conscious mind over reacts to the symptoms of trauma we risk making it worse & may become depressed.
2. Think about & talk to others about your experience & your feelings. Your thoughts &
talks should be directed. THIS IS VERY IMPORTANT!
If you do nothing but re-hash the horror of that event & leave it at that, you'll reinforce
& strengthen the unconscious response to that trauma. You must end each thought or talk affirming that you'll do everything within your power to regain control & that there's hope in the future, however slight.
Tell the truth, it may be that your only chance to regain control is to seek help & that you failed today but you'll try again tomorrow. If you can't do this then I suggest that you seek professional help.
When you think & talk about the event in this manner, over time it'll help to desenseitize the emotional & autonomic responses
& you will be less likely to become depressed.
4. Exercise, eat right & cleanse your body of toxins by drinking more water & possibly a short one or two day juice fast. This will clear
your mind, strengthen your immune system & help combat negative thoughts.
5. Take a break from thinking about this incident. Right after the terrorist attacks I was glued to the television set for days on end. I had to force
myself to return to work & finally decided to write this article.
I know that this article is about the attacks, but my focus is on presentation & finding solutions
& not on the negative aspects. Of course you need to keep informed & I'm not suggesting hiding from it, but your mind needs a rest, find other things to do.
6. Find ways to help others.
This keeps you from over personalizing the event. Right after the attacks many people donated blood & financial contributions
have been extraordinary.
At the appropriate time you could write letters to the survivors showing your support & later there may be people in the armed services that might appreciate a letter of support.
You also might organize & attend a local support group for people, especially the young, who've been suffering PSTD because of this event.
Conclusion My hope is that this situation is resolved in a timely manner with the least possible loss of life & that very few people suffer
from Post Traumatic Stress. My fear is that further bad news will exacerbate the incidence & severity of PTSD & depression.
From the
time I was a young child until I was 17 years of age, my father & his brother raped me & in other was sexually
abused me. I did tell my parents about my uncle, who started the abuse, but following that, my father started in with the
worst of it.
Then,
when I was 36 years old, my baby girl died & when I was 40, my teen-age son drowned while out with friends. The house
caught fire, my husband & I couldn't get past the deaths of our children & we ended up divorced.
Some months
after the unexpected death of our son, I started into therapy, both individual & group & I was placed on antidepressants
& anti-anxiety medication. I was suicidal & still am occasionally when the stress factors in my life rise too high.
I was diagnosed with major depression, an eating disorder, agoraphobia, generalized anxiety disorder, panic attacks &
some obsessive/compulsive components.
3 years
ago, all of these various disorders were moved under the umbrella heading of post traumatic
stress disorder.
At age
53, I've spent 13 years on various medications & in various group counseling situations & when necessary, in
one-on-one therapy.
When life is calm for the most part,
I get along okay. However, I nursed my mother for 1-1/2 years thru the day of her death, had my house - my “safe place”
- up for sale with strangers walking thru it, purchased another house & had to move to a place where there were no window
coverings to protect me from the outside world, had my daughter move across the United States from me & have been taking
care of my father, all of this at the same time.
My symptoms were exacerbated terribly.
All I could think of was death.
I was very strong in nursing my mother
thru her last months & I'm strong in taking care of my father. The other stressful situations are now over & my medication
seems to be working again, as does my individual therapy sessions.
I've relapsed under heavy circumstances
a number of times & experienced “suicidal ideology.” However, when the brunt of the stress backs off, I'm
then able to cope again for the most point.
Unlike the others, I can't say I
was okay in 3 months, or a short given amount of time. Rather, I’ve lived a roller coaster life & my psychiatrist
& therapist have both informed me that I'm “delicately balanced” on my medications & that they don't believe
that I'll ever be able to give up my medications.
They also state that I will require
therapy “as needed” for particularly stressful times in life. But there are the times when from the outside, my
life looks as normal as any one else’s.
It can develop at any age, including
childhood; there's some evidence that susceptibility to PTSD may run in families.
"I was raped when I was 25 years old. For a long
time, I spoke about the rape as though it was something that happened to someone else. I was very aware
that it had happened to me, but there was just no feeling."
Myths & Facts about PTSD
by Harold Cohen, Ph.D. April 8, 2006
Myth:
PTSD is only seen in people with “weak characters” who are unable to cope with difficult situations in the same
way that most of us do.
Fact:
PTSD is a human response to markedly abnormal situations, and it involves specific chemical changes in the brain that occur
in response to a person experiencing a traumatic event. Many of the symptoms of PTSD seem to be a direct result of such brain
changes.
Myth:
All of us have been through frightening experiences and have at least one symptom of PTSD as a result of that experience.
Fact:
Although memories of frightening experiences may be similar to symptoms of PTSD (e.g., vivid memories), most persons do not
have the severity of symptoms or impairment associated with PTSD. The specific brain-based responses seen in PTSD differ from
those seen in normal anxiety. Similarly, the experiences of normal anxiety and of PTSD are markedly different.
Myth:
Stress reactions to trauma exist, but these should not be considered as a serious medical problem.
Fact:
PTSD is a medical disorder that can sometimes cause serious disability. Persons with PTSD often also have co-occurring mood,
anxiety, and substance-related disorders. In addition, these people may have significant difficulty at their job, in their
personal relationships, or other social interactions.
Post-traumatic stress
disorder is:
A debilitating condition that can develop following a terrifying event
Extreme trauma is: "a terrifying
event or ordeal" that a person has experienced, witnessed or learned about, especially one that's life threatening
or causes physical harm.
The extreme trauma may be a single event or repeated experience.
Research suggests that prolonged trauma may disrupt & alter brain chemistry. This may lead to the development of
PTSD.
3 categories
or "clusters" of symptoms are associated with the determination if PTSD is present.
Many people with PTSD repeatedly re-experience the ordeal in
the form of flashback episodes, memories, nightmares or frightening thoughts, especially when they're exposed to events
or objects reminiscent of the trauma. An individual must experience some of the following symptoms from each cluster described below:
The traumatic event is persistently relived thru:
Recurring nightmares
Intrusive distressing recollections of the event, including images, thoughts or perceptions occurring at any given time
Recurring dreams of the event
"Living in the Moment of the Trauma" by acting or feeling as if the traumatic event were recurring in the
present (includes a sense of reliving the experience, illusions, hallucinations & dissociative
flashback episodes, including those that occur on awakening or when intoxicated).
Note: In young children, repetitive play may occur in
which themes or aspects of the trauma are expressed. There may also be frightening dreams without recognizable content. Trauma-specific re-enactment may occur.
For more information concerning post traumatic stress disorder when experienced by children - click here to visit children 101 - the child specific site within the emotional feelings network of sistes!
What is the prognosis of PTSD?
The prognosis of PTSD differs from individual
to individual. Some people can experience a remarkable return to normal functioning. Others experience persistent, fluctuating
symptoms of the disorder. Fortunately, specific medications and/or psychotherapies may often result in a substantial reduction
in the symptoms of PTSD, and in an improved quality of life.
Sleep &
Posttraumatic Stress Disorder (PTSD)
A National Center for PTSD Fact Sheet By Pamela Swales, Ph.D.
Many
people suffer from problems with their sleep. This can be especially true for those who have witnessed or experienced one or more traumatic events such as:
Some individuals exposed to traumatic physical or psychological events develop a condition known as Posttraumatic Stress Disorder (PTSD).
It's well known that a problem with sleep is one of many problems for those with PTSD. Sleep problems, such as difficulty falling asleep, waking frequently & having distressing dreams or nightmares, are common to those with PTSD. In fact, sleep disturbance can be a normal response to past trauma or anticipatedthreat.
What are the major reasons why people with PTSD have problems with sleep?
Severe psychological or physical trauma can cause changes in a person’s basic biological functioning.
As a result of being traumatized, a person with PTSD may be constantly hyper-vigilant,
or "on the lookout," to protect him or herself from danger. It's difficult to have restful sleep when you feel the need to be always alert.
What are some sleep problems commonly associated with PTSD?
Difficulty falling asleep
Basic Biological Changes:
Actual biological changes may occur as a result of trauma, making it difficult to fall asleep.
In addition, a
continued state of hyper-arousal or watchfulness is usually present. It's very hard for
people to fall asleep if they think & feel that they need to stay awake & alert to protect themselves (& possibly others) from danger.
Medical Problems:
There are medical conditions commonly associated with PTSD. They can make going to sleep
difficult. Such problems include: chronic pain, stomach & intestinal problems & pelvic-area problems (in women).
Your Thoughts: A person’s thoughts can also contribute to problems with sleep; i.e., thinking about the traumatic event, thinking about general worries & problems, or just thinking, "Here we go again, another night, another terrible night’s sleep," may make it difficult to fall asleep.
Use of Drugs or Alcohol: These substances are often associated with difficulty going to sleep.
Difficulty staying asleep
DistressingDreams or Nightmares: Nightmares are typical for people with
PTSD. Usually, the nightmares tend to be about the traumatic event or some aspect of it.
i.e.,
in Vietnam veterans, nightmares are usually about traumatic things that happened in combat. In dreams, the person with PTSD may also attempt to express the dominant emotions of the traumatic event; these are usually fear & terror. i.e., it isn't uncommon to dream about being overwhelmed by a tidal wave or swept up by a whirlwind.
Night Terrors: These are events such as screaming or shaking while asleep.
The person may appear awake to an observer, but he or she isn't responsive.
Thrashing Movements:
Because of overall hyper-arousal, active movements of the arms or legs during bad dreams
or nightmares may cause awakening. i.e., if one were having a dream about fleeing an aggressor, one might wake up because
of the physical movements of trying to run away.
Hearing the Slightest
Sound & Waking Up to Check for Safety: Many people with PTSD , especially combat veterans, wake up frequently
during the night. This can be for various reasons. However, once awake, a "perimeter check," or a check of the area, is often
made. For example, a Vet may get up, check the sleeping area, check the locks on windows & doors & even go outside
& walk around to check for danger. Then the Vet may stay awake & vigilant &
"stand guard;" he (or she) may not return to sleep that night.
What can you do if you
have problems sleeping due to PTSD?
Talk to your doctor
Let
your doctor know that you have trouble sleeping. Tell your doctor exactly what the problems are; he or she can help you best
if you share this information about yourself.
Let your doctor know that you have (or think
you have) PTSD. It isn't your fault that you have these symptoms. Tell your doctor
exactly what they are.
Let your doctor know about any physical problems that you think are contributing
to your sleep problems. i.e., chronic pain associated with traumatic injuries can make it difficult to sleep.
Let
your doctor know about any other emotional problems you have - these may also be contributing to your sleep problems. i.e.,
depression or panic attacks can make it hard to fall asleep or to stay asleep.
There are a number of medications that are helpful for sleep problems
in PTSD. Depending on your sleep symptoms & other factors, your doctor may prescribe
some medication for you.
Psychologists, social workers & psychiatrists fall into this category. They can help you take a closer look at & possibly change,
the variety of factors that may be preventing you from sleeping well. They can help you with PTSD
& other problems.
Don't use alcohol or other drugs
These substances disturb a variety of bodily processes. They impair a person’s ability to get a good night’s sleep. i.e., alcohol may help a person fall asleep, but it interferes with one’s ability to stay asleep.
Limit substances that contain caffeine (e.g., soda, coffee, some over-the-counter medicines).
Try to set a regular sleep/wake schedule:
A consistent sleep schedule helps to regulate & set the body’s "internal clock," which tells us when we are tired & when it's time to sleep, among other things.
Make your sleeping area as free
from distractions as possible:
Aim for quiet surroundings;
keep the room darkened; keep the television out of the bedroom.
Consider a light nighttime snack:
A light snack after
dinner may prevent hunger from waking you up in the middle of the night.
Avoid over-arousal for at least
2-3 hours prior to going to sleep:
Try not to get your body
& mind in "arousal mode." Things that may tend to do this are: heavy meals, strenuous exercise, heated arguments,
paying bills & action-packed movies.
Don’t worry that you can’t
sleep:
Remember, there may
be a number of reasons for your sleep problems. The first step is to talk to your doctor.
Additional Information at the
newest mental health site in the emotional feelings network of sites! A new site - anxieties 102... it's being constructed just for you. Hang in there & you'll be delighted to find the page links at the top & bottom
of each of these pages within the site as soon as they become available for you!
kat's sidebar - Sleep is my main issue
at the present time(august 2006) with my PTSD.
I've never slept well in my whole life. As a child, my parents believed in putting us to bed very early, i.e., 7:30 pm even
in the summer when there was no school. I began to develop a love for being up late and getting up early. Those two times,
early in the morning and after midnight became the times when I functioned the best.
I developed a night time eating disorder which also messed with my sleep.
I became so sleep deprived that I had difficulty thinking straight about anything. I was crying often and unpredictably. Sleep
still eludes me. I stay up most nights until 1:30 am or even 2:00 am and get up at 6:00 am. I told a sleep specialist that
and he asked me how long I'd been doing that. Ten or eleven years... maybe longer.
He didn't believe me. I admitted to night eating for most of those years
which entailed getting up several times within that four hour period I usually tried to sleep to eat. Therefore, I wasn't
getting more than an hour of sleep at one time throughout those years. I was seriously sleep deprived. I had to take naps
in the daytime.
PTSD has interfered in my life with more factors that just sleep. Being
awake, I've been living with movie reels of traumatic experiences going thru my mind at any given moment. I'm not sure what
triggers all of them. The more extreme traumas, I know what triggers those, but they affect every part of my life from the
everyday dentist visit for a cleaning to the paranoid feeling I get when I'm living in a state of hyper-arousal or hypervigilence
because someone has hurt my feelings or been rude to me.
If you think you're experiencing PTSD, look at how your life is being
affected by your disorder's symptoms. Write it down. You'll know.
Feelings of intense guilt are also common, which are probably associated w/the severe feelings of helplessness endured during the trauma. Most people w/ PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than
1 month.
kat's sidebar - i.e., I was living in such a distressed
emotional state due to my memories of trauma that I began to do anything, which mostly included staying emotionally numb -
to get thru any reminders or triggers of traumas.
Not only was I living in complete
avoidance of most of my stressors, I was forming habits such as lying, deceiving and ignoring important factors in
every day life, in my relationships, and in my duties as a mother and a wife. That depressed me again and again, over and
over.... I began to hate myself more and more... it never seemed to end.
Avoiding
reminders of the event including:
Places, people, thoughts or other activities associated w/the
trauma
Have extreme emotional or physical reactions; such as chills,
heart palpitations or panic when faced w/reminders of the event
Persistent avoidance of stimuli associated w/the trauma & numbing of general
responsiveness (not present before the trauma), as indicated by 3 (or
more) of the following:
Efforts to avoid thoughts, feelings or conversations associated w/the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant
activities
Sense of a foreshortened future (e.g.,
doesn't expect to have a career, marriage, children or a normal life span)
Being on guard or being hyper-aroused
at all times, including feeling irritability or sudden anger, having difficulty sleeping or concentrating, or being overly alert or easily startled.
Triggering Events. PTSD is triggered by events that are usually thought to be outside the norm of human experience.
Such events include, but aren't limited to experiencing or even witnessing:
sexual assaults
accidents
combat
unexpected deaths in loved ones
PTSD may also occur in people who have serious
illness & receive aggressive treatments or who have close family members or friends w/such conditions.
Persistent symptoms of increased arousal (not present
before the trauma), as indicated by 2 (or more) of the following:
The disorder is often accompanied by depression, substance abuse, or one or more other anxiety disorders.
In severe
cases, the person may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered
them was deliberately initiated by a person - such as a rape or kidnapping.
Ordinary events can serve as reminders of
the trauma, triggering flashbacks or intrusive images. A person having a flashback, which can come in the
form of images, sounds, smells, or feelings, may lose touch w/reality & believe that the traumatic event is happening
all over again.
Not
every traumatized person gets full-blown PTSD, or experiences PTSD at all.
PTSD
is diagnosed only if the symptoms last more than a month. In those who do develop PTSD, symptoms usually begin w/in 3 months of the trauma & the course of the illness
varies. Some people recover w/in 6 months, others have symptoms that last much longer. In some cases, the condition may be
chronic. Occasionally, the illness doesn't show up until years after the traumatic event.
Determining A Diagnosis of PTSD
A diagnosis of PTSD is determined by knowing that an individual
has been exposed to a traumatic event in which both of the following were present:
Experiencing,
witnessing or confronted w/an event or events involving actual or threatened death or serious injury, or a threat to the physical
integrity of self or others
Note: In children,
this may be expressed instead by disorganized or agitated behavior
Once PTSD symptoms have lasted for 1 month or more & have caused interruptions in one's lifestyle thru
social, occupational or other important areas of functioning, a diagnosis of PTSD can be
determined.
PTSD
symptoms will often occur w/in several weeks of the trauma although some individuals may not experience symptoms for months or years later. The PTSD
is labeled "delayed onset" if symptoms don't occur until at least 6 months after the trauma.
PTSD
may continue for 3 months for some determining the case to be acute, while in others
for longer, making the PTSD a chronic case that could last for years. Understanding that the level of terror or fear that some individuals may experience & be able to cope positively to can be different for other individuals.
While many
people experience PTSD for a short period, then seem to overcome it themselves, others may need counseling, medications &
long-term treatment for their recovery from PTSD. Everyone is different.
Recognizing PTSD symptoms can be just as difficult to determine as a child who is experiencing symptoms
of an anxiety disorder. Because the child is growing & maturing so quickly, it's often
hard to distinguish symptoms of the anxiety from those of quickly
changing behavior growth.
It's critical
to recognize the determining symptoms of PTSD & get treatment as quickly as possible. Left untreated, the individual
may have an escalation of the disorder &/or develop coexisting disorders.
Some
of the reasons there is difficulty in the determination of PTSD being diagnosed are:
People who have experienced an extreme traumatic event may hope, or even expect, to be able to handle it & get over it on their own. Either they may find themselves "expectedt" to believe this or they've simply convinced themselves that the normal thing would be for them to just get over it on their own!
Sometimes people
feel guilty about what happened & may mistakenly believe they're
to blame or deserve the hurt & pain they're experiencing. Sometimes the experience may be too personal, painful or embarrassing to discuss. Those individuals experiencing relationships with domestic violence involved may especially feel this way.
Some people avoid dealing with anything related to the trauma, especially as they try to get back to the normal activities of their daily lives. Some may do this on a unconscious level,
never realizing that they're avoiding the situation.
PTSD can make a person feel isolated or alone, making it difficult to reach out for help. Fear plays a big factor in this & when anxiety is also present, the "what ifs" often get in the way of reaching out for help.
Sometimes people don't know that help is available or don't know where to turn for help.
"The rape happened the week before Thanksgiving,
& I can't believe the anxiety & fear I feel every year around the anniversary date. It's as though I've seen a werewolf.
I can't relax, can't sleep, don't want to be with anyone. I wonder whether I'll ever be free of this terrible problem."
What Consequences are Associated w/PTSD? (This information from the National Center for PTSD website.)
PTSD is associated w/a number of distinctive neurobiological &
physiological changes.
PTSD may be associated w/stable neurobiological alterations in both
the central & autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus &
abnormal activation of the amygdala.
People w/PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important
finding is that the neurohormonal changes seen in PTSD
are distinct from & actually opposite to, those seen in major depression; also, the distinctive profile associated w/PTSD is seen in individuals who have both PTSD & depression.
In a large-scale study:
88 % of
men & 79 % of women w/PTSD met criteria for another psychiatric disorder.
The co-occurring
disorders most prevalent for men w/PTSD were:
PTSD
also makes a significant impact on psychosocial functioning, independent of co-existing conditions.
How common is PTSD?
An estimated 7.8% of Americans will
experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD.
About 3.6% of U.S. adults
aged 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small portion of those who
have experienced at least one traumatic event; 60.7% of men & 51.2% of women reported at least one traumatic event.
The traumatic events most
often associated with PTSD for men are:
rape
combat exposure
childhood neglect
childhood physical abuse
The most traumatic events
for women are rape, sexual molestation, physical attack, being threatened with a weapon & childhood physical abuse.
About 30% of the men & women who have spent time in war
zones experience PTSD. An additional 20 to 25% have had
partial PTSD at some point in their lives.
More than 1/2 of all male Vietnam veterans & almost half of all female Vietnam veterans have experienced "clinically
serious stress reaction symptoms."
PTSD has also been detected
among veterans of the Gulf War, with some estimates running as high as 8%.
"I believe that having PTSD is like living
in a different realm - a realm that feels as though one is always on the brink of severe danger.... it interferes with the
ability to ever feel safe."
kathleen
Vietnam veterans w/PTSD were
found to have profound & pervasive problems in their daily lives. This included problems in:
Those who report
greater perceived threat or danger, suffering or being upset, terror & horror or fear
Those with a social environment, which produces shame, guilt, stigmatization or self-hatred
In a study of individuals who had suffered physical or sexual abuse or neglect as children, about 1/3 developed PTSD. Most didn't; negative family or other influences
in addition to the traumatic conditions contributed to the risk for this disorder.
One study reported that having a pre-existing emotional disorder, particularly depression, before the traumatic event most often predicted PTSD in women.
About 30 % of the men & women who have spent time in war zones experience
PTSD.
An additional 20 to 25 % have had partial PTSD
at some point in their lives.
More than
half of all male Vietnam veterans & almost half of all female Vietnam veterans have experienced "clinically serious stress
reaction symptoms."
PTSD has also been detected among veterans
of the Gulf War, w/some estimates running as high as 8 %.
The one-million children who suffer abuse each year as well as those who have had other previous traumatic experiences are more likely than others to develop PTSD. Other risk factors for developing PTSD include:
type of trauma
severity of the trauma
duration of the event
recurrence of the event
the individual's resiliency & coping skills
availability of support from family, friends & community
A Flight of Mind
The Act of Dissociation Can
Protect Children Emotionally From Trauma, but Repeated Use May Cause Lasting Harm
By
Pamela Oldham Special to The Washington Post Tuesday, February 18, 2003
Rachel Downing, a 58 year-old
therapist in Frederick, often tells her colleagues the true story of a little girl who fell into a deep well while walking alone on her family's farm. After landing on a narrow ledge several feet below ground, she sat patiently, ignoring her scrapes & bruises, waiting to be rescued. A few minutes later, it seemed to the child, a firefighter pulled her to
safety.
In reality, several
hours had passed. The girl had no memory of feeling trapped, afraid or even worried. She didn't recall hearing the sounds of rescuers working frantically overhead
to save her. Instead, the girl separated emotionally from the event, Downing says, because
remembering her feelings of terror or how long she had been inside the well wasn't important. Surviving the ordeal was.
"When you think abou it, this was a very good tactic," Downing said. "Imagine what might have happened if that young child had sat
there all that time, feeling terrified for hours, wondering if she'd be rescued, wondering, 'Am I going to die?' "
Research tells us what children
or, for that matter, adults generally do when exposed to physical violence or other trauma they can't flee from or prevent: They "dissociate."
But when the dissociative response is called on repeatedly, especially in early childhood, the defense can become fixed & ingrained, disrupting normal functioning & undermining emotional & physical well-being. The most common
cause is chronic child maltreatment - physical, emotional or sexual abuse.
Downing knows about this firsthand.
She battled depression & unexplained physical illnesses throughout childhood & early adulthood before she was diagnosed with dissociative identity disorder at age 35 & then treated. The source of her problems, she says:
"Within one 3 month period,
I was taken to the emergency room 17 times for abdominal pain," Downing said. "They even performed surgery & still found
nothing.
What's more, new biological
research has found that repeated triggering of the trauma response early in life visibly injures the brain.
A Complex Process
When our brains perceive danger,
sensory information is diverted from the hippocampus, which is responsible for processing non-intense emotion & committing everyday events
to memory. Instead, the brain zaps the information from the thalamus, the brain's sensory input center, to a tiny almond-shaped nerve center, called the amygdala, in the midsection of the brain, for emergency processing.
At the amygdala's command, orchestrated in milliseconds, the heart rate quickens & respiration &
blood pressure increase. Noncritical sensory information is tuned out & activity in the hippocampus is suppressed so we can concentrate on self-preservation.
When the threat persists beyond a few seconds, other neurophysiological & functional processes kick in to disengage us from the
outside world & routine sensations. Heart rate & blood pressure suddenly drop & we may feel as though we're floating.
We may be unable to speak or scream. We might "blank out," faint or experience phenomena outside the realm of what we consider normal.
Such responses may inhibit the ability to readily retrieve details later.
Automobile accident victims
who dissociate, i.e., are frequently unable to recall the moment of impact while others describe experiencing the crash in slow motion.
Adult rape victims who dissociate during their attacks often report observing the assaults rather than experiencing them.
Survivors of fires may stumble out of a burning building, not knowing how they escaped or realizing the extent of their injuries.
For much of her life, Downing
says, she blocked out memories so well that she couldn't explain some of her own behaviors.
"As a child, I had thoughts that didn't make sense, of animals being killed & people being tied up & sexual things being done," Downing said.
"My diary shows that at the age of 12, I wrote about myself in the third person. During my teenage years, I had irrational fears. I was afraid to date because I feared being raped."
According to Marlene Steinberg,
a Northampton, Mass., psychiatrist who is a leading researcher on dissociation & dissociative disorders, people who dissociate during a traumatic event
will often describe their experience as if they were detached from it.
"They'll say 'I was numb, I didn't feel anything,' 'It was like I wasn't really there,' or 'It was like watching a movie,' " Steinberg said.
Smoking Gun
Martin Teicher, an associate
professor of psychiatry at Harvard Medical School & director of the Developmental Psychopharmacology Laboratory at McLean
Hospital in Belmont, Mass., has been at the forefront of biopsychiatry research on the physiological effects of child maltreatment.
Using brain scans, Teicher
has documented structural changes not attributable to head trauma in the brains of young abuse victims.
"The most readily discernable abnormality," said Teicher, "is the reduced size of the corpus callosum," a normally thick band
of neurofibers that serves as the communications bridge between the left & right cerebral hemispheres, integrating motor,
sensory & cognitive functions.
Teicher's finding may help
explain why abuse victims often have difficulty retrieving memories of early trauma, one hemisphere of the brain stores language-based memories while the other retains sensory-based memories. Other abnormalities
captured by brain imaging include diminished growth in the left hemisphere, atypical amygdala size & reduced hippocampus size & volume.
The nature of the physical changes,
Teicher says, offers a physiological explanation for why early maltreatment increases the risk for development of post-traumatic stress disorder, depression, substance abuse, antisocial behavior & other problems. "This provides scientific evidence that you can't abuse or neglect children & then expect them to simply 'get over it' as adults," Teicher said.
This new research underscores
the importance of early treatment for child abuse victims. Experts theorize that specialized therapy may help restore normal brain function & neurodevelopment in children because
their brains, unlike those of adults, are still malleable.
The 2.5 million children whom the government estimates are maltreated, abused & neglected each year in the US are particularly at risk for developing dissociative of disorders.
At the root of these
difficulties is a collection of 5 conditions known as dissociative disorders, ranging from:
Depersonalization Disorder, the
mildest & most common form
Dissociative Identity Disorder (DID),
formerly known as multiple-personality disorder
With early identification & treatment,
Steinberg & others say these disorders can be effectively treated & in many cases, cured.
Medication is normally prescribed only to manage symptoms of co-existing conditions, such as depression & anxiety.
Therapy often also includes treatment for post-traumatic stress disorder. Since 1990, Baltimore
psychologist Joyanna Silberg has treated about 350 children with dissociative disorders. Dissociative children, she says,
may exhibit stress, appear emotionally inaccessible, dazed & sometimes unresponsive. They may forget their own behavior or events from one
day to the next.
"When abuse takes place outside the family . . . what I see most often are reports of assaultive behavior toward parents, sometimes without
the child's memory of behaving that way," Silberg said. "Or, I hear about kids who deny behavior, even good behavior, that others have observed."
Keeping young victims safe from further harm & helping them to accept anger & other emotions as valid are primary treatment goals. As traumatized children learn that they needn't be ashamed about past trauma & abuse, Silberg says their identities consolidate, memory improves & they become less reliant on dissociation & other coping mechanisms.
Adults with dissociative disorders may face bigger challenges; those who seek professional help typically do so for relief from depression & anxiety. On average, they spend 5 to 7 years after first seeking
treatment before an accurate diagnosis is made. They may undergo a wide variety of therapies. But until the underlying problem, trauma, is addressed, they don't get better.
It wasn't until after the
1976 death of her father, an Episcopal minister, that Downing sought professional help. The immediate trigger:
She became physically ill & doctors were unable to find a cause.
To amass corroborating
evidence, she has interviewed family members & examined school & medical records, diaries & journals, photographs,
old letters exchanged between her parents & her father's calendars, personal papers & records.
Downing's childhood school
records document difficulty in learning & poor attendance. Her 1st grade report card shows she was absent 17 days during
the first 7 weeks of the school year, & written comments by her teacher suggest Downing had a difficult time attending
to classwork "without getting emotionally upset."
Downing says she was absent
from school 1 or 2 days every week throughout grades 1 thru 12.
"My fifth-grade teacher wrote
'emotionally disturbed' on my report card that year," Downing said. "Keep in mind, this was in the 1950's, when people didn't talk or know about
such things."
In junior high school, Downing
says, her IQ measured just 90. But Downing became a serious student despite everything, graduating from college magna cum
laude in 1971 & earning a master's degree in 1973.
Before her father's death,
she says, she had no conscious memories of his abuse, just sketchy recollections. Later, she says, she began to remember & her childhood fears & thoughts began to make sense. According to Downing, her father had repeatedly abused her sexually & killed her pets to punish her. Remembering helped her heal.
"It's like a widow
who's lost her husband in a tragic accident," Downing said. "If she doesn't talk about it, deal with it
& set it aside, she can't move on with life."
Today, Downing says her life
is happy & full. In her practice, she sees clients with a range of mental health needs & says she has a high level of respect for them because she has walked the path to recovery herself.
She teaches fellow clinicians
about dissociative disorders & the power of the human mind to protect & preserve our young when there is no escape from terror.
Pamela Oldham is a Washington-area freelance writer.
Treatment of PTSD
PTSD is treated by a variety of forms of psychotherapy & drug therapy. There is no definitive treatment & no cure, but some treatments seem to be quite promising, especially:
Studies
have also shown that medications help ease associated symptoms of depression & anxiety & help ease sleep. The most widely used drug treatments for PTSD are the selective serotonin reuptake inhibitors, such as Prozac & Zoloft.
At present,
cognitive-behavioral therapy appears to be more effective than drug therapy, but it would be premature to conclude that drug therapy is less effective
overall since drug trials for PTSD are at a very early stage.
Drug therapy definitely appears to be highly effective for some individuals & is helpful for many more. Also, the recent findings
on the biological changes associated with PTSD have spurred new research into drugs that
target these biological changes, which may lead to much increased efficacy.
Acute Stress Disorder
Similar to PTSD,
Acute Stress Disorder was determined as a disorder that didn't fit the extreme classification
of PTSD. Individuals experiencing Acute Stress Disorder
have been exposed to a traumatic event in which both of the following were present:
The individual either experienced, witnessed,
or was confronted w/an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others & the person's response involved intense fear, helplessness or horror.
Either while experiencing or after experiencing the distressing event, the individual has 3, or more of the following dissociative symptoms:
Distress on exposure to reminders of the traumatic event
Marked
avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
There
are marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
More about Acute Stress Disorder
The person
has been exposed to a traumatic event in which both of the following were present:
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
The person's response
involved intense fear, helplessness, or horror
Either while experiencing
or after experiencing the distressing event, the individual has 3 (or more) of the following dissociative symptoms:
A subjective sense of numbing, detachment, or absence of emotional responsiveness
A reduction in awareness of his or her surroundings (e.g., "being in a daze")
Derealization
Depersonalization
Dissociative amnesia (i.e.,
inability to recall an important aspect of the trauma)
The traumatic event is persistently re-experienced in at least 1 of the following ways:
The person experiences
marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
The person experiences marked symptoms of:
anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
The disturbance causes
clinically significant distress or impairment in :
social, occupational, or other important
areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance
or mobilizing personal resources by telling family members about the traumatic experience.
The disturbance
lasts for a minimum of 2 days and a maximum of 4 weeks & occurs w/in 4 weeks of the traumatic event.
The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not
merely an exacerbation of a pre-existing mental disorder
According to two new studies,
there is growing evidence that heavy smoking & substance abuse are prevalent in people with PTSD, however more studies are needed before an association between PTSD & substance abuse can be determined.
Children & Post Traumatic Stress Disorder: What Classroom Teachers Should Know
Susan J. Grosse
Post traumatic stress
disorder: development of characteristic symptoms following exposure to an extreme
traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to ones physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (APA, 1996).
School children may be exposed to trauma in their personal lives or, increasingly, at school. Classroom teachers can help prepare children to cope with trauma by understanding the nature of trauma, teaching children skills for responding to an emergency & learning how to mitigate the after-effects of trauma.
By the very unexpected nature
of trauma, one can never totally prepare for it. Because each individual responds differently to emotional upset, it's impossible to
predict trauma after-effects.
Under certain circumstances, trauma can induce Post Traumatic Stress Disorder (PTSD). Unrecognized / untreated PTSD can have a lifelong negative impact on the affected individual. Teachers, who spend up to 8 hours each day with the children in their charge, can influence the outcome of a childs' response to trauma stress by creating an environment in which PTSD
is less likely to develop to the point of life impact.
Not all emotionally upsetting
experiences will cause PTSD. Trauma sufficient to induce
PTSD has specific characteristics & circumstances, including situations
during which the child experiences a complete loss of control of the outcome
when death is observed
Disasters, violence & accidents are just some of the experiences that can lead to PTSD. Preparing
children for trauma involves giving them skills & knowledge to survive the experience & emerge with as little potential as possible for developing PTSD.
Survival skills for traumatic
experiences are essentially emergency action plans. Carrying out emergency action plans not only helps a child retain some personal control, but increases the potential for a healthy outcome.
Appropriate vs. inappropriate touching (i.e., shoulder vs. genitals)
Appropriate vs. inappropriate information sharing (i.e., who is at home at what times)
Presence of appropriate vs. inappropriate people (i.e., the teacher on playground duty vs. a prowling stranger)
Skills to Mitigate PTSD
While there is no predictability
in who will develop PTSD, it's possible to take steps to prepare children ahead of time & by doing so, lessen the PTSD potential. Children need to be taught lessons about trauma. Learning about people who have experienced trauma & gone on to live healthy lives gives children role models & hope for their own future.
During a traumatic experience, children will survive better if they have a structure to follow & can maintain some sense of control. Learning the survival skills will aid in maintaining this control. Childrenneed accurate & specific information about their immediate safety, about what has happened & about what will happen to them next (James, 1989).