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.

source site: click here

The psychotropic drugs are a bow to a little-discussed truth fraught with implications:

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 professionals fear 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. 

I'd hope that those with major depression wouldn't be sent.

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.

The antidepressants work by elevating the level of the neurotransmitter serotonin. Researchers believe that low serotonin levels in the brain could be a biological cause of depression and certain anxiety disorders.

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

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 ¹³ suggests 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”).

Training in coping skills

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 ⁹ for a useful manual of trauma-related coping skills).

Exposure therapy.

Exposure therapy is among the best-supported treatments for PTSD. ¹⁴ It 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 ¹⁵ for 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, ¹⁴ is 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, ¹⁶ which 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 ¹⁷ work on trauma-related guilt may be helpful in addressing veterans’ concerns about harming or causing death to civilians.

Family counseling

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 ²⁰ noted 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. ²¹ In 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.” ²³ Factors 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 ²⁴ outlined some simple principles of patient management that may be useful in the context of veteran care:

• Focus communication around patients’ concerns
• Organize information coherently
• Give risks as numbers
• Acknowledge scientific uncertainty
• Use universally understood language
• Focus on relieving symptoms

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. ²⁵ reported 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.

• your proximity to ground zero during the terrorist attacks

• your emotional attachment to anyone killed or injured

• your personal support systems

• 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:

• Feeling detached or emotionally numb.
• Constant Anxiety or Panic.
• Irritable & more aggressive.
• Easily startled.
• Hyperactive or hyperstressed.
• Sleep problems & nightmares.

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.

Depression & Thoughts of Suicide
The 2 prime reasons that a person becomes depressed, are a loss of control, over their life situation & of their emotions & secondly a loss of a positive sense of their future (loss of hope).

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.

3. Don't try & hide or mask your symptoms by using alcohol & drugs, it'll do no good & may hasten the depressive response.

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.

Either way I hope that the professional & governmental mental health communities are prepared & take some action before things get out of hand.

© Stephen L. Bernhardt - 2001
steveb@frii.com

source: selfgrowth.com

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.

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.

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.

• rape
• military combat
• natural disasters
• beatings
• neighborhood violence

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 anticipated threat.

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

• 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%.

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.