As General William Tecumseh Sherman famously noted during the Civil War, “War is hell.” It’s hell for civilians caught in the cross-fire and can be hell for the political powers that petition for it. But most especially war can become an exceptionally cruel and lasting hell for the soldiers tasked with waging it.
Once called shell-shock, then Vietnam Veteran’s Disorder, a condition now referred to as post-traumatic stress disorder is common among military personnel who have served, and it, too, is considered a hellish condition by many people who have it. Though PTSD occurs at higher rates among military personnel than the general population, we now understand that it can develop in anyone who has experienced or witnessed a traumatic event.
What Is PTSD?
Dr. Freda C. Lewis-Hall, chief patient officer at Pfizer and co-editor of the book “Psychiatric Illness in Women: Emerging Treatments and Research,” says PTSD is an overexpression of normal mental and physiological processes, namely the fight-or-flight response. “If you think about what happens when you’re in significant danger, your body has a whole host of reactions.” These reactions ready you to either fight or flee a hazard and include a flood of hormones that set you on high alert and prepare your body for a fight or to run. These responses can save your life in a life-threatening situation, but too much of a good thing can be bad. “PTSD is really those reactions gone rogue,” Lewis-Hall says.
Symptoms of PTSD may include:
— Re-experiencing the initial trauma via intrusive thoughts, unwanted recollections and memories, nightmares and flashbacks.
— Avoidance of certain activities, particularly difficult emotions and places that remind the individual of the trauma.
— Increased arousal, such as feeling anxious or on edge all the time, being jumpy, having difficulty sleeping, being irritable, having angry outbursts or engaging in self-destructive behaviors.
— Negative changes in mood and thinking that can include mood swings, difficulty focusing or concentrating, depression, isolation from friends and family and apathy.
Symptoms must endure for at least a month before a diagnosis can be made, and not every patient with PTSD will experience all the symptoms. Symptoms may not surface immediately after a traumatic event, but rather may develop months or even years after the initial trauma.
Although PTSD is often thought of as a problem only for certain people who’ve been to war or who’ve lived through a massive trauma, Ken Yeager, director of the Stress, Trauma and Resilience (STAR) Program at The Ohio State University Wexner Medical Center, notes that in 2013 — as part of a larger update to its diagnostic manual for psychological disorders called the DSM — the American Psychological Association expanded the definition of PTSD to include people who have witnessed events. The DSM-5 “changed the definition of PTSD to include vicarious traumatization, which means that previous editions suggested that you had to be traumatized and it had to include life-threatening risks to you. The current revised DSM acknowledges that you don’t have to be the person who’s threatened. You can witness (a trauma) — you can see it or you can hear about it and be traumatized by what you’re hearing.” This change in the diagnostic criteria reflects an improved understanding of what PTSD is and the many ways it can manifest in different individuals.
He says this change is likely at least in part attributable to observations of mental health made after the September 11 terrorist attacks and omnipresent school shooting events that have increased in frequency since the late 1990s. “I don’t know about you, but I still look up when I see a jet flying over that’s perceivably louder or lower than it should be, and I’m at a University where we’ve had an active attack on students. It’s one of those things that’s always on our minds, and it’s changed the way we think about the impact of those kinds of situations. If it changes your behavior even though you weren’t directly involved with it, it probably is a form of traumatic stress,” he says.
How Common Is PTSD Among Veterans?
The U.S. Department of Veterans Affairs reports that incidence of post-traumatic stress disorder among veteran varies depending on which conflict a service member was involved with.
— About 11 to 20 out of every 100 veterans (or between 11 and 20%) who served in operations Iraqi Freedom and Enduring Freedom have PTSD in a given year.
— About 12 out of every 100 Gulf War Veterans (or 12%) have PTSD in a given year.
— About 15 out of every 100 Vietnam veterans (15%) were currently diagnosed with PTSD when the most recent study of them (the National Vietnam Veteran Readjustment Study) was conducted in the late 1980s. It’s believed that 30% of Vietnam veterans have had PTSD in their lifetime.
Yeager says that these statistics tell us a lot about the conflicts they come from. For example, these populations may have higher rates of PTSD than veterans returning from World War I and World War II in part because the nature of warfare has changed significantly since the mid-20th century, and there are new pressures and challenges more recent veterans experience. “They aren’t retuning with a unanimous victory,” such as WWI and WWII vets did, “and with each subsequent group — Korea, Vietnam, the Gulf war, OEF, OIF — there were fewer and fewer individuals who experienced active combat.” This means a smaller pool of people who can relate to the returning veterans’ experiences. “We have a volunteer army, which is a good thing, but it’s also a bad thing in that people don’t have a lot of people to relate to. They don’t have many people to speak to about their experiences, and so when they come back, they’re more hyper-vigilant, they have trouble trusting, they attempt to control situations, they shut down and become less open and have less intimacy just in conversations with others, because others can’t really understand what they’ve been through,” Yeager explains.
In addition, simple speed of travel these days may also be working against some veterans’ natural resiliency — after the World Wars, it just plain took longer to get home. “A lot of these soldiers returned on ships, and they had more time to decompress from where they had been to their return home. They had time to write letters. They had time to process through things,” and they were likely surrounded by other soldiers who’d had very similar experiences. They could spend time talking to each other and working through what they’d witnessed. “I don’t know if that makes a remarkable difference or not, but I think it’s a very different situation from the OEF and the OIF veterans who get on a plane and are back in the US within 48 to 72 hours. It’s pretty remarkable.”
Another issue facing many veterans is that they come home to high-stress jobs that continue to put them in the line of fire. “Many of our current law enforcement and police and fire fighters are veterans. They’re continuing in a wonderful tradition of giving to society and helping society, but also in a way that is remarkably difficult, with its own challenges for PTSD.” The rules of engagement for law enforcement and emergency personnel are different from those of war, and sometimes “it’s very difficult to know what’s appropriate and what’s not. What was appropriate in one setting might not be in another,” and that can lead to further stress for some people.
Sadly, the worst outcome of PTSD, namely suicide, is also increasing among veterans. The VA reports that there were more than 6,000 veteran suicides each year from 2008 through 2016, and from 2005 to 2016, veteran and non-veteran adult suicide rates increased 25.9% and 20.6% respectively. “In 2016, the suicide rate was 1.5 times greater for veterans than for non-veteran adults, after adjusting for age and gender.”
These troubling statistics point to another complication of life after war for veterans — a lack of support and connection to others, Yeager says. “The whole idea of the band of brothers is a very real neurophysiological situation. You never feel more alive or more connected with people than you do when you’re in that combat field and I think for many vets combing back who’ve had their neurotransmitters firing at a very high rate, they struggle with ‘how do I find this again? Where can I get this kind of feeling alive?'”
The heightened danger of living in a combat zone leads to a release of many powerful hormones and chemicals in the brain and body, causing powerful changes to the brain and how people respond to everything. “It’s not just a change to their thought process. It also involves cortisol levels, hormone stress responses, blood pressure responses, heart rate increases and other hormones that are released like oxytocin, which is widely touted as the hug neurotransmitter. When you have oxytocin, dopamine and serotonin all working at very high levels, the individual feels very connected to their combat buddies, which they should be. But when they return home, that’s absent and it’s missed and it can very quickly then lead to issues of depression. It can very quickly lead to feelings of isolation that one doesn’t fit in,” and some people will try to fill that void with fast cars, alcohol, substance abuse or other potentially dangerous or self-destructive activities. “They want that adrenaline rush again,” Yeager explains.
This also may lead some veterans “to go back for recurrent tours of duty, which can further set the spiral and keep it going more and more out of control.”
Treatment Is Available
But it’s not hopeless. People with PTSD don’t have to stay in an endless loop of feeling bad. Connecting with networks, particularly of other people who’ve had similar experiences, can be a powerful antidote to PTSD. Cognitive behavioral therapy is considered the frontline treatment for PTSD and medications can help some individuals as well.
Yeager also recommends considering cures that you might not have thought of, such as practicing meditation, mindfulness and “anything that requires you to slow down and engage in it at a rate that takes you to the next level. Things such as woodworking and sanding the grain, things with repetitive motion to them — sewing, knitting, crocheting, restoring cars, tying fly-fishing flies. That kind of stuff. Don’t rule out that stuff for being really helpful,” especially when combined with “the traditional psychiatric treatment. A lot of the non-traditional treatments like yoga, meditation, acupuncture and acupressure are also very effective tools in managing one’s trauma,” he says. Horseback riding and keeping a service or companion dog can also help some patients.
One treatment approach that’s recently gotten a lot of buzz as being helpful for veterans is ketamine infusions. Ketamine was originally approved by the FDA as an anesthetic, and it’s frequently used in children because it’s considered very safe. Lately, though, it’s been gaining a lot of attention as a novel and very fast-acting therapy for anxiety and PTSD.
Dr. Rand McClain, a regenerative and sports medicine physician in private practice in Santa Monica, California, who also offers ketamine treatment for veterans with PTSD says that although the exact mechanism hasn’t entirely been explained, it seems that ketamine helps alleviate PTSD symptoms more quickly than more traditional antidepressant medications. “We think that SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant medication that boosts levels of the feel-good neurotransmitter serotonin in the brain) have been somewhat good at changing the structure of the brain,” but it can take several weeks for patients to feel the effects. “Ketamine seems to do it right away.” Somehow, ketamine seems to disrupt established pathways in the brain that are associated with PTSD and helps the brain make new pathways that obscure the trauma.
In treating patients with this therapy, McClain says, “you hear a lot of patients after the first treatment describing it as stepping back from your life and being able to look at your problems from a bird’s eye view. It helps you process the trauma.” When used in conjunction with CBT, ketamine can help some patients experience significant relief of symptoms.
The bottom line is despite how lonely PTSD can sometimes feel, you’re not alone and help is available, says Janina Scarlet, a licensed clinical psychologist and lead trauma specialist at the Center for Stress and Anxiety Management in San Diego. “One of the things that I wish for people to understand is that with our mental health struggles — whether it’s PTSD, anxiety or depression — these are not a weakness. These are our survival mechanisms, and these are our greatest strength. In learning to understand our differences and our experiences, we can even help other people. Sometimes by sharing what we’re going through we can help someone else, too.” Reaching out for support, whether that takes the form of a veteran’s support group, a visit to your primary care doctor or more intensive treatment for PTSD can make a world of difference in your post-military service experience.
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