Serving veterans and their families for over 28 years

Post-Traumatic Stress Disorder (PTSD)

ABOUT PTSD

Readjustment problems among veterans are not a new phenomenon. Such problems are traced back as far as the Civil War, when the disorder was labeled "soldier's heart." It was subsequently referred to as "shell shock" in World War I, "combat neurosis" in World War II, and "combat fatigue" in Korea. (Stern & Smith, 1988) Frequently, veterans were suffering from disorders which were misdiagnosed as paranoia, paranoid schizophrenia, or borderline personality disorders. More often than not the veterans were dismissed as cowardly or personally weak.

What inevitably evolved was the realization that there were distinct differences among Vietnam veterans and veterans of other wars. The reasons for these differences soon became starkly evident.

The Causes and the Nature of the Differences Between the Vietnam War and Previous Wars.

The war in Vietnam was significantly different from previous wars and it was these same differences which contributed to the psychological traumas and their resulting problems in the returning veteran. They became the hallmark of what was to be a continuing struggle to survive.

Age

The Vietnam war could be called our first war fought by adolescents. The average age of World War II soldiers was 26 years. In contrast, the boys who left for Southeast Asia averaged 19.2 years of age. They were still in their formative years and most susceptible to the imprinting of the terrors of combat. The morals and values the boy learned at home were soon stripped and the ego structure so carefully built through his childhood often became impaired. Amid the insanity of combat, he experienced a psychological "snap", perhaps as the result of a first kill, or seeing a buddy killed. (B. Goderez, 1985) In essence, he was robbed of the opportunity to finish his teenage years as his maturing process came to an abrupt halt. Many veterans still today appear to be scrambling to complete that process in an attempt to "make up for lost time".

In addition, the example of their parent role model was replaced by the role models of superior officers. The admonition to "go out and kill" was in sharp contrast to "Thou shalt not kill" and the result was a mind ripe for psychiatric disturbances.

Political/Social Climate

The unpopularity of the conflict in Southeast Asia created an atmosphere of national unrest and divisiveness. Campus demonstrations, draft card burnings, riots, and draft evaders was the tenor of the times.

The negative reactions to the war were not confined to the United States. American troops arriving in Southeast Asia were not welcomed enthusiastically, and U.S. soldiers soon began to wonder why they were laying down their lives for a seemingly ungrateful populace. (S. Huppenbauer, 1982)

Combat Characteristics

For possibly the first time, there were no defined battlefields or "front lines". There was confusion as to whether land was to be taken and/or held. "Search and destroy" became a familiar phrase as soldiers searched for an enemy who was often unseen. Frequently the enemy included women and children, creating a situation in which there was no certainty as to who was the enemy. Boundaries for battle inevitably became unclear. The dense jungle also became the enemy with its searing heat and monsoon rains. Moral confusion reigned as atrocities were either performed or witnessed by GI's.

Individual Rotations

In previous wars, soldiers traveled to the war zone and 'home again in groups. This allowed a socialization to develop which did not occur in the Vietnam war. The group journeys home allowed for a debriefing, a chance to process the experience, and re assimilate into civilian life.

In an effort to reduce psychiatric and readjustment difficulties, a new system known as DEROS (Date of Expected Return From Overseas) was introduced. DEROS allowed for each GI to know when he was scheduled to return home. The average tour of duty was 12 months, except for Marines who had a 13 month tour. Because in previous wars, those combatants with the greatest duration of combat had the highest incidences of breakdowns, it was felt that the Vietnam soldier could hang on for his 12 or 13 month tour, he would be less exposed to psychological problems; thus the DEROS system.

What the system created however, was an individualized experience. The soldier arrived in Vietnam alone, and because of the continuing rotations in and out of the country, he was denied the opportunity to participate in unit cohesiveness. Subsequently, unit morale was lacking along with the support systems necessary for a soldier in combat. Upon completion of his tour, he frequently endured a solitary plane ride home and no one with whom to share the mass of mixed emotions he was experiencing. What should have been a return trip filled with joy and anticipation was instead one filled with a barrage of anxiety and confusion.

Homecoming

If we were to choose one overriding contributing factor to PTSD, it might well be the homecoming. Never before has this country so effectively turned its back on her returning soldiers. An angry and frustrated American populace left no welcome mat on its floors for the returning Vietnam veteran. As opposed to his World War II father who received cheers, tumultuous welcomes and ticker tape parades, the Vietnam veteran arrived home alone amid continuing antiwar protests. He was frequently spat upon or was the recipient of such epithets as "baby killer". There was little or no debriefing by the Veterans Administration. When he went to the VA for help, he was often misdiagnosed and chemically restrained. In the face of such adversity, the veteran was left on his own to try to retrieve what was left of his shattered life. He was not the same boy who had left home to fight for his country. He was confused and soon became enraged. He had done his duty, lost buddies, lost his own sense of self in the insanity of the war and was rejected at home. Many veterans still express a desire to be back in Vietnam; "At least there I know I was good at my job, did my duty, and knew who I was. I was accepted. I may have come back, but I never came home."

MAJOR FACTORS ASSOCIATED WITH PTSD

1. Depression and Suicidal Syndrome

The individual suffers from feelings of helplessness, depression, dejection, and severe grief with frequent thoughts of suicide. In 1986, a study published in the New England Journal of Medicine found that men who served in Vietnam were nearly twice as likely to commit suicide as men who did not serve. This study reveals that the number who died since returning home from Vietnam is close to the number who died in Vietnam itself--around 59,000. (Veteran, September, 1988)

Many veterans are enveloped in a death immersion; they remember it, they dream it, and the thoughts are ever present. It is not uncommon for them to possess and carry weapons.

In the veteran's mind, there was no resolution to the conflict in Vietnam, and with support lacking at home, there has been no resolution in their own lives; thus the accompanying depression and feelings of helplessness.

When pressed to discuss his war experiences and resulting feelings, the veteran invariably cries. There is an overwhelming feeling of sadness which accompanies the memories.

2. Isolation and Withdrawal

The veteran tends to withdraw from society, avoids groups of people, prefers to live alone, and sometimes retreats to remote or wooded areas typical of Vietnam. Traditionally he has few friends. Having lost buddies in combat, and harboring a deep-seated suspicion towards a populace who rejected him, he finds it easier to retreat.

The isolation is not limited to the veteran alone. His family is also subjected to frequent moves and/or alienation from other people. They are indeed expected to endure the lack of interaction with friends and extended families, creating an enormously stressful lifestyle.

3. Sensation Seeking Syndrome

There is a driving need for the veteran to be involved in high risk, thrilling, or dangerous activities in order to feel that he is truly "alive". It is not uncommon for those veterans seeking to bring some manner of order to their lives to seek careers as firemen or policemen, both high risk occupations.

According to Wayne Smith, (Veteran, October 1988) "some statistically small--but significant--number of PTSD sufferers relive their wartime experiences, suffering episodes of violence ... those who suffer from PTSD as a result of a wartime experience are subject to continual bouts of these symptoms that cannot, of themselves, be alleviated".

Smith continues, "A recent study indicated that fully 29,000 Vietnam veterans now reside in state and federal prisons; 37,500 have been paroled; 250,000 remain under probationary supervision; and 87,000 are awaiting trial. All told, 400,000 Vietnam veterans are in trouble with the law--a rate of some 20 percent of all Vietnam veterans, therefore, have failed to adjust to civilian life as a result of their experiences in Vietnam".

4. Paranoid State Syndrome

Explosive rage, anger, hostility, and suspicion, particularly toward authority figures, are also hallmarks of a PTSD sufferer. These emotions are often as frightening to the veteran as to those who come in contact with him. His family is not immune to his rage.

Often the outbursts are a result of flashbacks or fantasies in which he envisions himself confronted by the Vietnamese enemy. It is a frightening situation for anyone who tries to restrain him. Once again he finds himself in a struggle for survival. (Goodwin, Readjustment Problems Among Vietnam Veterans)

The veteran will often leave the scene when he feels his rage emerging. His fear of hurting someone is more overwhelming than the rage.

There are a myriad of reasons for the all encompassing rage, however, the primary ones appear to be leftover, violent impulses incurred in Vietnam, a general mistrust in the government which sent him there, and again in the society which rejected and often continues to reject him.

5. Profound Psychic Numbing

The veteran has lost all sense of self and feels completely hopeless; he may suffer extreme anxiety or show no expression at all; a loss of affect. It is not unusual for him to report that he feels dead inside. In the combat situation, numbing was an effective adaptive mechanism to avoid a breakdown. He would then be less susceptible to the feelings associated with loss. (S. Huppenbauer, November, 1982) He very effectively learned to hold back his feelings, and he continues to employ the same mechanisms today.

6. Alienation and Cynicism Syndrome

The veteran is extremely cynical about society in general, but particularly concerning the law and authority figures. Even though he may be highly moral, he thinks in terms of how to "get back at" the system, particularly in confrontations with police.

7. Problem of Intimacy Syndrome

Although the veteran longs for intimacy and strong relationships, he resists getting close for fear of losing those he loves (as in Vietnam).

Many veterans hold themselves accountable as individuals for combat killings. Their divorce and suicide rate exceeds that of their civilian peers and also that of non-combat Vietnam veterans. (S. Haley, 1979)

Upon his return home, the veteran was frequently rebuffed in his efforts to discuss his experiences with his wife or family. They, along with the rest of society, wanted to forget the war. The forgetting and the refusal to listen, only served to heighten his numbing process.

Another factor to consider once again is the guerrilla nature of the war, in which even women and children were the enemy. Consequently, veterans who have feared or killed women and children in combat may find it difficult to make the transition to the role of husband, protector and nurturing parent. (S. Haley, 1979)

Associated/Related Symptoms

Guilt

Many veterans are consumed by overwhelming feelings of guilt; feelings which take several forms:

  1. Guilt for acts which they have committed, albeit necessary acts.
  2. Guilt for things he did not do, which his conscience would not allow him to do.
  3. Guilt more appropriately referred to as Survivor Guilt, perhaps the most devastating of all. Survivor guilt has created an intense conflict within the veteran. "Why am I here? Why did I survive when others did not?", are frequently asked questions. Such questions and doubts invariably led him down a path of self destruction and/or violence, and inevitably fashioned for him a painful and guilt-ridden existence.

Sleep Disorders

Inability to sleep, or brief intermittent periods of sleep is a common secondary symptom of PTSD. Intrusive nightmares may interrupt and bring an abrupt halt to a brief but sound sleep.

The sleep disorders are also not surprising when one considers how necessary it was for the GI in combat to remain alert and vigilant, catching a few hours of sleep while someone else stood guard. He now feels the need to be always on guard for the unexpected. He learned his survival techniques well; so well that they continue to disrupt his daily living and sleeping patterns.

Hyper vigilance

Ever on the alert, ever surveying his surroundings, the veteran never lets down his guard, a skill so necessary in combat. One veteran described an incident in which a buddy was killed because he felt he let down his guard. He has vowed never to allow that to happen again and remains constantly vigilant and on guard. (CBS Reports, The Wall Within, 1988)

When venturing into public places such as restaurants, a quick surveillance is always necessary to insure a seat with his back against the wall, giving him the ability to "check out" everyone in the establishment. His hyper vigilance is a pervasive and constant companion.

Exaggerated Startle Response

A sudden clap of thunder, a backfiring car, or any sudden noise may send the veteran scrambling for cover. His startle response is the result of memories relating to the persistent and often unexpected sounds of mortar, artillery, or small arms fire. The responses may be frightening and embarrassing and are yet another reason for isolation.

Flashbacks/Intrusive Thoughts

A traumatic event associated with Vietnam may be re experienced; such experiences are commonly referred to as flashbacks and involve intrusive recollections of the event or recurrent disturbing dreams. There may also be occasions in which the veteran becomes disassociated from reality, an occurrence which may last anywhere from several seconds to several hours, or in extreme cases even days. The veteran firmly feels he is reliving the original trauma or experiencing the event. Many times these events are exacerbated by anniversary dates. (R. Lifton, 1973)

Such episodes may typically be triggered by the all too familiar sounds of a helicopter flying overhead, by familiar smells, or even a rainy day, a reminder of the prolonged monsoon rains in Vietnam. Some, unable to cope with the intrusive thoughts, leave their familiar surroundings and escape to a safer place, often the woods. There they can be alone, without the risk of hurting others.

For many veterans, flashbacks are a reminder that they were once in Vietnam, but a constant reminder none the less.

Alcohol/Substance Abuse

Perhaps the most difficult symptom to separate from PTSD is alcohol/substance abuse. In fact, for many, it is inseparable. "It isn't just substance abuse. It isn't just PTSD. It's both, insidiously wrapped up in one another," says Steve Bently, Chairman of the VVA PTSD and Substance Abuse Committee. "Alcohol and other drugs have successfully aided Vietnam veterans in covering their feelings for years. The biggest problem ... is that alcohol quits working after a while".

"The trauma tries to surface, though the individual suffering the trauma tries to keep it submerged," he continues.

In 1988, the Centers for Disease Control concluded that Vietnam veterans were far more likely to suffer from depression, anxiety, and alcoholism with nearly 500,000 having experienced severe PTSD symptoms. (Veteran, September 1988)

Drinking and drugging appear to compound the symptoms of PTSD, which compound the symptoms of addiction, resulting in increasingly painful readjustment problems and progressively worse addiction ... Unless both conditions are appropriately dealt with, there will be little lasting relief from either condition. (Brinson and Treanor, Veteran, September 1988)

A sad commentary is that those veterans seeking treatment for alcoholism and PTSD at Veterans Administration hospitals were given treatment for either one or the other. Perhaps sadder is the fact that treatment in the VA hospitals has consisted primarily of chemical restraints. More often than not those restraints were addictive drugs which intensified rather than alleviated the symptoms. As stated by Steve Bently, "Alcohol treatment that denies a veteran his or her experience of Vietnam is unpardonable." To deny his experiences is tantamount to denying his existence.

Substance abuse is also a major factor of homelessness among veterans. The numbers of homeless Vietnam veterans is estimated to be between 82,000 and 110,000. (Veteran, September 1988)

The Family Experience

On the opposite end of the vast spectrum which comprises PTSD is the least mentioned and oft times forgotten segment--the family.

It has often been said that the women who live with Vietnam veterans are the "forgotten wounded" of the Vietnam war. Too infrequently is their plight given adequate attention partly due to their own reluctance to discuss their family problems; either from fear of retaliation from their veteran husbands, or guilt, feeling that something must be wrong with them when confronted by their spouse's anger or alienation. At worst, the wife has little or no understanding of her husband's behavior; at best she does not know how to deal with what she understands.

The Vietnam veteran who is suffering from PTSD typically has a family which is a dysfunctional one, however there are distinct characteristics which sets the family apart from other dysfunctional family units. (T. Scarano, Family Therapy: A Viable Approach for Treating Troubled Vietnam Veterans) Rigid family patterns are set by the veteran, closely interwoven with alternating periods of denial and intrusive thoughts. The family members allow the patterns to continue in order to prevent disruptive behavior by the veteran. They see him as ill, reinforcing his own identification as ill. If this life style continues, the family members adopt complimentary roles resulting in a MORE rigid pattern.

A comment typically stated by a family member is, "We don't talk about Vietnam, he says I don't understand." Additionally, family members may sometimes receive information concerning his war experiences by the veteran who may be under the influence of alcohol or drugs. Such experiences may thus be exaggerated. These myths are perpetuated by family members, and offers an acceptable explanation for them when his behavior is unacceptable. (A. Ferreira, 1960) Naturally the rationale is that his behavior must then be a result of his experiences in Vietnam. This in turn again allows his behavior to continue. In actuality, the continuing cycle is a huge disservice to the whole family unit because it allows for maintenance of distorted interactions.

The roles of children during the war were confusing to the veteran and as a result he has difficulty interacting with his own. He may be overly involved in their protection or welfare, or completely incapable of emotional involvement of any kind. Thus the child begins to emulate his/her parent by isolating or feeling he is responsible for the destructive behaviors.

Most importantly perhaps is the veteran's fear of loss, whether real or expected. Many veterans have not yet mourned their losses in Vietnam and have suppressed the related grief. The overwhelming fear of loss prevents him from closely aligning to family members and in effect leaves them without a viable husband and/or father. What results among the entire family is alternating feelings of sadness and hostility. When there is PTSD present in a Vietnam veteran, it is undoubtedly present in family members. The same symptoms are frequently displayed by them and the cycle continues unless they seek help or intervention.

Treatment

The primary objective when considering treatment for PTSD is to create an atmosphere which will allow the veteran to work through the traumatic event. Also essential is an atmosphere of trust and caring. Because of the degree of survival guilt, and because of the continuing battle between the combat and civilian selves, it is first of all essential to "support an attitude, of pride at having survived and done a good job in an extreme situation...One must re frame the destructive attributes as having been positive and adaptive in the insanity of the combat situation." (B. Goderez, 1985) In essence, the veteran needs to be reminded that abnormal behavior in an abnormal situation is normal. War was an abnormal situation. Given that information, it is necessary for him to know that indeed his behavior was normal. He needs also to see himself not as a victim, not as an executioner, but as a survivor. (R. Lifton, 1976) "It is important to remember that time, rather than healing all wounds may actually see them intensify ... symptoms may show a greater frequency now than when originally diagnosed." (M. Friedmann, 1981)

In many cases therapy must continue indefinitely, and this often means periods of hospitalization. Even after prolonged periods of change, there may be some unexpected stress, an anniversary reaction, or periodic depressions which will create the need for further or continued treatment.

What appears to be a most successful treatment is the traditional "rap" group which allows for the necessary social supports from his peers. The "rap" groups are comprised of other Vietnam veterans, with similar feelings and experiences. Often the groups offer the first opportunity toward personal and social recovery.

In conjunction with treatment for PTSD must be treatment for an alcohol/substance abuse problem. The two are too closely aligned to be treated separately.

The 700,000 member Disabled American Veterans (DAV) was the first to recognize the enormity of PTSD associated problems. It funded and founded research which in turn resulted in the Vietnam Veterans Outreach Program in 1978. These programs provide much needed counseling, both individual and group, for not only the veteran but significant others as well.

The Outreach Centers are not bound by traditional systems, and the autonomous program was developed because the VA was not able to handle the special needs and sensitivity of these young warriors' experiences. When considering treatment of the veteran, we must also consider treating the entire family unit, both through education and therapy.

Conclusion

"Boys with a normal viewpoint were taken out of the fields and offices and factories and classrooms and put into the ranks. There they were remolded; they were made over; they were made to "about face"; to regard murder as the order of the day. They were put shoulder to shoulder and, through mass psychology, they were entirely changed. We used them for a couple of years and trained them to think nothing at all of killing or of being killed.

Then, suddenly, we discharged them and told them to make another "about face!" This time they had to do their own readjusting, sans mass psychology, sans officers' aid and advice, sans nation-wide propaganda. We didn't need them anymore. So we scattered them about without any speeches or parades.

Many, too many, of these fine young boys are eventually destroyed, mentally, because they could not make that final "about face" alone."

Smedley D. Butler, 1936
Major General, United States Marine Corps
Two-time recipient, Congressional Medal of Honor
(Veteran, September 1988)

Etched on the black granite wall which is the Vietnam Veterans Memorial in Washington, D.C. are the words, "Our nation honors the courage, sacrifice, and devotion to duty of its Vietnam veterans". Having said that, we need to continue to honor them by providing for them and their families the help, treatment and understanding so necessary to bring them home and end their inner wars.

References

CBS 1988. CBS Reports, The Wall Within.

Diagnostic and Statistical Manual, Edition III 1980. Washington D.C.: American Psychiatric Association.

Ferreira, A., Family Myths and Homeostasis. Archives Of General Psychiatry, 1960, 9: 457-463.

Figley, Charles R. 1978. Stress Disorder Among Vietnam Veterans. New York: Brunner/Mazel.

Friedman, M.J. 1981. Post-Vietnam Syndrome: Recognition and Management. The Academy of Psychosomatic Medicine 22, no. 11: 931-943.

Giglia, Paul 1983. A Time for Heroes.

Goderez, Bruce. 1985. Massive Trauma and Post-traumatic Stress Disorder: the Survivor Syndrome. VA Medical Ctr., Northampton, MA.

Goodwin, Jim. Readjustment Problems Among Vietnam Veterans. Cincinnati: Disabled American Veterans.

Haley, Sarah A. 1982. The Vietnam Veteran and His Pre-school Child. Symposium. Dublin.

Helzer, John E.; Robins, Lee N.; and McEvoy, Larry. 1987. Post traumatic Stress Disorder in the General Population. The New England Journal of Medicine 317, no. 26: 1630-1634.

Huppenbauer, Sandra L. November 1982. PTSD: A Portrait of the Problem. American Journal of Nursing 82, no. 11: 1699-1703.

Lifton, R.J. 1973. Home from the War. New York: Simon and Schuster.

Melanson, Joseph & Dech, Gerry, eds. 1988. i magazine Division of Humanities, Mount Wachusett Community College, Gardner, MA.

Scarano, Thomas P. Family Therapy: A Viable Approach for Treating Troubled Vietnam Veterans. Academic paper. Date & place unknown.

Skodwek, Richard P. Post Traumatic Stress Disorder and Vietnam Veterans. Incoming 21-26.

Stern, Gary M., and Smith, Wayne. October 1988. War and Memory. Veteran 8, no.10: 21-23.

VVA Staff September 1988. War and Memory. Veteran 8, no. 9: 11 - 14, 28.