Post Traumatic Stress: A presentation by Dr. Jim Canfield - Pittsfield, MA >Vietnam Veteran< What recently named disorder is commonly referred to by the four first letters of its four-word name? I'll give you a some clues: It affects 100 times more Americans, and has killed ten times more Americans than AIDS. I'm going to tell you about a disorder which over 2-1/2 million Americans are at risk of acquiring in your lifetime; especially at risk are approximately one million individuals who, in surviving their physical involvement in a life- threatening situation which cost over 55,000 American lives, are as much as risk of killing themselves as they were of being killed at the time of their original exposure. I'm going to tell you about a terrible sort of social disease, a disease I know both as a victim and healer, an affliction with more than a 10% fatality rate. Once known as "Post-Vietnam Syndrome", it is properly termed Post Traumatic Stress Disorder ... or P.T.S.D. My goal is to describe to you a set of behavioral characteristics which you might tuck away in some recess not too far back in your mind, right next to the place you remember how you might run across and recognize such an individual, and where you store the memory of how I convinced you of the destructiveness of this disorder as well as its remarkable responsiveness to the right treatment. There are, almost as though "cloned", between 300,000 and 500,000 young Americans who, over the past ten years, have displayed some or all of the following oddly linked behavioral characteristics: * Depression, suicide, drug dependence * Isolation, friendlessness, asexuality, nomadism * Rage, battering, authority intolerance, negativism * Emotional, psychic numbing * Survival guilt, self-destructive or action junkie behavior * Anxiety states, paranoia, phobias * Sleep disorders, insomnia, "sundown syndrome" * Situational intrusive thoughts, obsessions * Compulsive humanitarianism, altruism, over-idealistic self- actualization 95% are men presently aged 32 to 48 years old with symptoms dating back 5 to 15 years. Most have been divorced at least once. The likelihood is that he is above average intelligence, that he enlisted and was not drafted into military service, that he saw combat, that he lost one or more close friends in Vietnam, that he received an honorable discharge and was awarded military decorations. He may likely have been a medic or corpsman, to have been involved in military intelligence operation or graves registry activity. He may well have served more than one tour and likely assumed battlefield leadership responsibilities. You are now prepared to recognize people with PTSD. You may be getting the sinking feeling that you know someone with this disorder. Here are some situations or some presenting behaviors of people who may well represent this disease: * While conducting a job interview, you are impressed with a candidate's qualifications, but notice that he has never held a job more than a year, and has always quit because he wouldn't "play the game", that he was tired of "being used", or that he just couldn't hack "a creep of a boss."; * When that quiet guy next door you've lived next to for years but never really gotten to know is divorced by his wife and you find that he'd been abusing her for years; * When a guy you know can't weight more than 150 pounds is coming home drunk every weekend with his face smashed in from picking fights in bars with guys twice his weight and half his age; * When an ex-Army nurse your wife knew from school commits suicide the night before she was to fly back for her first nursing school class reunion, fifteen years after graduation; * When a quiet guy with a limp at work is awarded a plaque from the Red Cross for having donated more blood in 5 years than anyone at the plant had given over the previous 10 years; * When you spot in the obituaries the name of an old friend from high school you knew had gone into the service after graduating in '67. He died somewhere out in Wyoming in some little town you never heard of -- and his ex-wife and kid hadn't seen him for more than 5 years, you're later told. A critical period in accomplishing young adult maturation - the achievement of ego identity - typically occurs in the late- teens to mid-twenties. It consists of the recognition of one's autonomous self, and often is accompanied by finding sexual fulfillment, choosing a career and acknowledging certain individual features separating one from one's parents and acceptable to one's peers. This period has been described by Erik Ericson as a time of psychosocial self-commitment - and if inhibited or prohibited may result in identity diffusion, an inability to evolve a style of effective self-assertion and a blunted ability to trust one's intimate or idealized revelations. Productive adult societal integration is impaired. The achievement of positive young adult ego identity appears to be facilitated by a certain period of parental and societal "letting go", a moratorium period early in young adulthood when, prior to that time when financial self- sufficiency, marital or career commitment is expected, one is permitted more mobility, autonomy, privacy and freedom of verbal and lifestyle expression than before. What results, should this period of metamorphic benign neglect be replaced instead by a traumatic life experience or involvement in life-threatening risk taking, exposure to inhuman acts or atrocities, the death of close friends? What if, instead of a period of self-paced adult-world exploration one is forced to adhere to a code of behavior not in accordance with one's previously formed religious or political principles, and accept injury and/or physical deprivation sustained in carrying out orders to achieve ends to which one is not morally committed? How does one accept the reality of picking bits of human flesh off one's flack jacket, sole visible remains of what, moments before, had been one's best friend and confidante, that worse of nights out on patrol? How, in surviving such experiences, does one rationalize one's altered self-image, one's world-image? How likely is such an individual to respond upon reentry to the once adolescent world of his family, the educational, societal and commercial world of his birth, when he gratefully emerges annealed from combat experiences and returns to a homeland now grown hostile, guilty and blameful towards this native son who felt he'd responded to his country's highest calling? Picture over a million such young men, bursting at the seams with grief, anger, guilt and pride acquired in a war zone in which he also learned all too well to contain expressing them for his own and his buddies' protection. Imagine plucking them, one at a time, from the battlefields and transporting them in a day or two back to their home towns, where Vietnam was a noxious news item treated by turning off TV sets. Imagine a nation apologetically tucking each of these forgotten warriors back into the folds of its society, admonishing the veteran for any prideful outbursts, patronizingly foregoing any parades, discounting its veterans benefits, and refusing to recognize the need to anticipate reentry maladjustments. A nation which extensively debriefed and quarantined its first moon explorers ignored millions of its sons and daughters returning from much longer explorations of a far more dangerous and hostile foreign soil. Worse, imagine a society which claimed the veteran both criminal and victim in a twenty-year-long national guilt trip down the road of self-deception. Is it any wonder this 1% of Americans who served in Vietnam almost went out of their way to avoid each other? Like telling a couple millions of ostriches to treat their headaches by burying them in the sand, it came to pass that the sand helped some, neither helped nor harmed others, and was the worst possible way to deal with those with the worst headaches. During World War II, 25% of combat zone casualties evacuated were for psychiatric reasons. (At one point in the war, more men were being discharged for psychiatric reasons than were being drafted.) More dishonorable discharges were issued during WWII than any war since. With more selective military induction and more aggressive psychiatric management in the field, only 6% of Korean casualties were for psychiatric reasons. Then, using a method specifically designed to minimize psychiatric breakdown in combat in Vietnam, soldiers left basic training and were assigned and transported individually into their units in-country, never for more than 12 or 13 month tours -- an endurable term if survived -- and resulting in only about 1-1/2% of all casualties evacuated in Vietnam being for psychiatric reasons. Yet, by 1985, 40% of the one million men who served in combat, and nearly 10% of the one and a half million Vietnam veterans not assigned to combat units were demonstrating PTSD symptoms within 15 years of discharge. More tragically, the number of disordered veterans who have taken their own lives after returning to their native soil by most accounts now exceeds the number who died in actual combat! Where does the dying stop? Wherein lies the cure? Post traumatic stress disorder can best be described as a behavioral response pattern seen in normal individuals surviving traumatically abnormal inhuman experiences. It appears to be a characteristic response developing over a significant period of time in individual survivors who underwent severe moral conflict in young adulthood -- situations in which survival was at the price of painful compromise between idealistic and pragmatic rules, never subsequently reconciled. Denied the sanction of eventual resolution -- or spontaneous or induced psychologic catharsis -- and given an ongoing burden of anger, guilt and grief -- the expressively all-too-well contained and self-disciplined former "good soldier" fabricates a progressively unmanageable ponderous framework of ego props, resulting in a dysfunctional, ego-burdened lifestyle presenting quite like a personality disorder in young adults with normal childhoods -- a psychiatric impossibility. It is typically dismissed, misdiagnosed and/or mistreated by classical psychotherapists however. The treatment of PTSD is first, foremost, and finally dependant on its proper diagnosis and management to permit the disordered veteran to see himself through the only eyes that can see his inherent normalcy -- those of his fellow veterans. Only through the common perspective of shared experience does the insight evolve that one may forgive oneself. Only through overt grief, venting of long-repressed fears, anger, and self-blame, statements confiding love and pride among trusted fellow veterans does the emotionally disabled veteran regain self-respect and recover as an adult the ability to productively sense and communicate his deepest feelings. Because of the critical requirement for the perception of commonality in precipitating free and confidential disclosure, the most enlightened of nonveteran therapists one- on-one is less likely to be successful than participation in the most awkward of veteran group sessions. It can be anticipated that the period of intense once or twice weekly group sessions required to fully explore the basis and expression of the veterans' disorder adequate to achieve enough insight to base subsequent recovery will be at least equal to the duration of the veterans' traumatic military experience. If the veteran has a family it will have inevitably been adversely disordered in turn with maladaptive entrenched behaviors. Once the veteran's counseling and recovery are underway therefore, it is important to involve the spouse or family in appropriate therapy. The abnormal behaviors need to be identified, their origins acknowledged, and appropriate replacement behaviors chosen, to serve as common goals within the family dynamics and seen as normal and desirable. Otherwise, the recovering veteran may recover his self-esteem and begin exercising his long-latent expressive powers at the risk of losing his marriage or family. Secondary alcoholism or other substance abuse, spouse or child abuse, criminal or economic issues need to be approached specifically, but never displacing the ongoing context of his veterans group support. There may be no more pervasive, insidious, destructive, misdiagnosed and misunderstood yet treatable a cause of unhappiness, death, family anguish and economic loss in America's young families today than PTSD. I hope that in reminding you of its features -- Depression Isolation Rage Emotional incompetence Survival guilt Anxiety and phobias Sleep disorders Situational flashbacks Compulsive altruism ...in appreciating it as an expectable behavioral syndrome following a normal young adult's traumatic immersion in a sustained dehumanizing experience; ...in realizing that it is an eminently treatable disease once recognized and appropriately referred to a veterans outreach center... ...that YOU might be a factor in helping a disordered veteran and his family understand and recover from their all-too- American tragedy. REFERENCES: Goodwin, Jim, Psy.D. CONTINUING READJUSTMENT PROBLEMS AMONG VIETNAM VETERANS published by Disabled American Veterans, National Headquarters P.O.Box 14301, Cincinnati, OH 45214 DeFazio, V.J. Dynamic Perspectives on the Nature and Effects of Combat Stress in C.R. Figley (Ed.) STRESS DISORDERS IN VIETNAM VETERANS: THEORY, RESEARCH AND TREATMENT New York: Brunner/Mazel 1978 Wilson, J.P. Conflict, Stress and Growth: The Effects of the Vietnam War on Psychosocial Development Among Vietnam Veterans IN C.R. Figley & S. Levantman (Eds.), STRANGERS AT HOME: VIET NAM VETERANS SINCE THE WAR, Praeger Press, 1980 Shatan, C.F. Stress Disorders among Vietnam Veterans: The Emotional Content of Combat Continues, in C.R. Figley (ref above) and, Shatan, C.F. The Grief of Soldiers: Vietnam Combat Veterans Self Help Movement. AMERICAN JOURNAL OF ORTHOPSYCHIATRY, 1973, 43(4): 640-653 Hearst N., Newman TB, Hulley SB. Delayed effect of the military draft on mortality; a randomized natural experiment. N.E.J.M. 1986,; 314: 620-4 Kolb LC The Post-traumatic stress disorders of combat; a subgroup with a conditioned emotional response. MILIT. MED. 1984; 149; 237-43