Doctors and mental health professionals finally understand PTSD well enough to treat it. Explaining this mental illness, how it differs from combat stress, and how it affects not only war veterans, are Dr. Matthew Friedman, executive director of the VA National Center for PTSD; VA psychiatrist Andrew Pomerantz; retired Navy psychologist Dennis Reeves; Col. Thomas Burke, director of mental health policy for the Dept. of Defense; and Fred Gusman, a director of the VA's National Center for PTSD. These excerpts are from their extended FRONTLINE interviews.
Exec. Dir., VA National Center for Post-Traumatic Stress Disorder
…PTSD is a recognition that if you've been in the wrong place at the wrong time or have been in a place where you've had to commit acts such as shooting other combatants or civilians or driven a car that you weren't in control of and killed people or things of that sort, that these events can change the way you feel about yourself and feel about the world. What's distinct about PTSD from almost all other psychiatric disorders is the fact that there is a historical event that sets this off.
You had to be at Hiroshima; you had to be at Auschwitz; you had to be in Iraq; you had to be raped, mugged, in a plane crash or what have you. That, however, alone is not sufficient. Having been there, you also had to react to that situation with an extreme emotional reaction, what the American Psychiatric Association calls "fear, helplessness or horror." We now think that maybe other strong emotional reactions might also qualify.
So to be traumatized, there are two components: One is having been in an extremely stressful situation, and secondly, having reacted to it with an intense emotional reaction.
Now, what's interesting about this is that when PTSD was first defined back in 1980, the belief was that these events were unusual; that being a war veteran or being a rape victim, being a concentration camp survivor, that these were very, very unusual events. And in fact, the terminology back in 1980 describes a catastrophic stressor as "beyond the range of normal human experience." Now we have [had] 24 years to explore that, and we discovered, unfortunately, that that's incorrect; that unfortunately, trauma is a part of life.
In [the] pre-9/11 United States, more than half of all adult men and women -- 50 percent of women, 60 percent of men -- would have been exposed to at least one traumatic event in the course of their lives. If you go to countries where there's much more civil unrest, the rates are higher. For example, in Algeria, 90 percent of all adult men and women will have been exposed to at least one traumatic event. Same is true in Palestine, Cambodia, other places.
So the lesson from this is that traumatic exposure is not unusual, and we as a society need to be prepared for that. This is not just something that happens to war veterans, to police, to firefighters, to emergency medical personnel; it's something that can happen to almost anybody, and there's at least a 50 percent chance that it's going to happen. And this is before 9/1l.
Now, having been traumatized, there are then three different symptom clusters that characterize PTSD. The first one is the most unique and is what sets PTSD apart from other anxiety disorders, and that is that the traumatic event has a life of its own. It continues to intrude. And we call these intrusive recollections, that someone is trying to listen to this interview, and they can't because they can't get it out of their mind what happened last night with an abusive partner or the traffic accident or the convoy that was attacked or what have you. These recollections are not invited; they're not welcome guests, but they won't go away, and you can't not think about them. They also intrude at night, the traumatic nightmares -- again, another way that these recollections intrude upon sleep. They intrude so badly that many PTSD people don't want to go to sleep because they know there's a nightmare waiting for them.
The most unique manifestation of an intrusive recollection is what we call the PTSD flashback: For a brief or extended period, the person with PTSD believes that he or she is back in the traumatic episode. They believe they're back in Iraq; they believe they're back fending off the rapist; they believe that they're in the train wreck. Often, when you examine these, you find that there were certain situations or stimuli that were reminiscent of the original event.
And that brings us to the last two intrusive recollection symptoms, and that is that events or situations that are reminiscent of the traumatic event can evoke thoughts of the trauma or can evoke physiological changes such as increased pulse rate or increased heart rate, or changes in the way the brain is processing information. Now, this last finding is very important both for research and for treatment, because unlike most other psychiatric disorders, we can reproduce PTSD in the laboratory by exposing -- obviously with their consent -- people with PTSD to traumatic reminders, whether these be auditory cues on an audiotape or videotape cues, or even exposing them to narratives that reenact their own traumatic experience, whether it's child abuse, rape, war-related trauma. And then we can measure a variety of things, whether it's brain function or physiology or psychological thoughts.
Where this becomes really important treatment-wise is that the most powerful treatments that have been developed for treatment of PTSD -- and they're even more powerful than medication treatments -- are what we call cognitive behavioral treatments. And one of them is called prolonged exposure, where the individual with PTSD is reexposed to the traumatic information and by a continual reexposure in the safety of a therapist's office is able to free themselves from the toxic effects of the traumatic memories [that] cause these intrusive recollections, the physiological arousal and the avoidant behaviors that are maladaptive.
The other cognitive behavioral treatment was developed by Patricia Resick, who now runs the Women's [Health Sciences] Division of the National Center for PTSD, which includes some of the exposure elements that Dr. [Edna] Foa developed in a somewhat different way, with written autobiographical narratives, but also has a technique called cognitive restructuring.
But the bottom line [in PTSD symptoms] is that the first cluster of symptoms are these intrusive recollections, and they can be evoked by stimuli that the person either chances upon in the course of his or her life or are deliberately exposed to in the course of treatment or research.
The second cluster are what we call the avoidant numbing symptoms. And what this is about is that these reexperiencing symptoms, and also the arousal symptoms that I'll talk about later, are so distressing, are so upsetting, are so intolerable that people will do whatever they can to avoid them. And there are two strategies. There are behavioral strategies so that, for example, a person who may have been in an automobile accident at the main intersection in this town will stay away from that because it will remind them. People that have come back from Iraq won't watch the newscasts because the film clips of the latest carnage will re-evoke these memories.
And then there are other psychological strategies: psychic numbing to shut down their emotional capacity so they can't feel upset; they can't feel terrified; they can't feel afraid. But when you do that, you also shut down your capacity to feel pleasure, to feel love, and that's why marriages and family life are such a casualty in PTSD. Other avoidant symptoms are just being not antisocial but asocial, just trying to avoid people, trying to be off by yourself, etc.
So the first cluster is reexperiencing symptoms. The second cluster are the avoidant numbing symptoms. And the third are the arousal symptoms. People with PTSD can't sleep; they can't think; they can't concentrate because this traumatic material is in their minds. They may be irritable, even aggressive. They have the startle reflex to unexpected noises, which is what Dr. Kardiner first discovered back in the late '30s and early '40s. And they're hypervigilant; they're on guard all the time. They have security locks on their doors. They don't want another traumatic episode to sneak up on them by surprise. ...
Can you talk about the difference between PTSD and Acute Stress Disorder?
Post-Traumatic Stress Disorder cannot be diagnosed until a month has elapsed after exposure to the traumatic event. And this definition was from the very beginning, back in 1980 when PTSD was first conceptualized. And the wisdom behind this stipulation is the recognition that most people exposed to traumatic events don't develop PTSD; most people exposed to these traumatic events have the normal, natural resilience to recover from these events. And somewhat arbitrarily, they're given a month. So you've got a month to get over it essentially, and you can't make a PTSD diagnosis.
Well, around 1994, there was a recognition that what are you going to do with people that are really bent out of shape in that first four weeks before you can make a PTSD diagnosis? So the American Psychiatric Association came up with something called Acute Stress Disorder, and this is a severe psychiatric disturbance that occurs only in the first four weeks. Last year, the Department of Defense and the Department of Veterans Affairs convened about 20 of us to come up with practice guidelines. What are you going to do when someone with these symptoms comes into your office or comes into your tent in a war zone or in a VA hospital or in a military hospital with these kinds of symptoms, and how should you proceed in terms of diagnosis, treatment, etc.?
And we spent months developing these guidelines which are now available on a VA Web site and in print form, but in that process we had to invent a new syndrome, Acute Stress Disorder, which is a severe psychiatric disturbance which can only last four weeks. But we coined something we called acute stress reaction, and what this gave credence to was the fact that people can be completely bent out of shape immediately after their exposure, but they're going to recover, and they're going to be OK, and they're not going to have any psychiatric sequelae, and they're not going to have any problems.
Getting back to your staff sergeant, this is a crucial piece of the puzzle, because he shouldn't be sending people out that are having an acute stress reaction that they're going to recover from in a couple days. But under the present situation, sending people with Acute Stress Disorder out, you know, given the lack of information, probably makes some sense. So this is an important piece of that puzzle, and I just wanted to emphasize that.
How do you quantify PTSD along with other very severe, painful stresses? Are they sort of on a continuum?
The short answer is no, we don't look at them as on a continuum. The way we look at them now is traumatic events are considered different. Where there's a threat of life or loss of limb or loss of a loved one is different. That's not to say that going through a divorce, flunking out of medical school, going into bankruptcy, that these are not very, very painful events that people will lose sleep over -- relationships may be destroyed; other kinds of things can happen. I'm not minimizing the terrible impact that these events can have on people, but we believe that they're different than post-traumatic events. It's an empirical question.
Now, there's something that has been around for a long time, at least in a medical context, and that's called Chronic Stress Syndrome. And we know that chronic stress can be related; it can cause medical illness and can have psychological components. There seem to be some differences -- a lot of similarities, but there seem to be some differences between chronic stress and chronic PTSD, at least in terms of the medical consequences. Now, what I believe is that these events can be functionally distressing if not incapacitating, and that we need a diagnostic language that does justice to the severe impact that this can sometimes happen. But we should not confuse it with PTSD, because I do think that there are some important differences.
There appears to be a high rate of suicides among Iraq war troops. Can you talk about this and how suicide relates to PTSD?
…I was at a meeting last July where they talked about the suicide data. And these were high-ranking military mental health personnel, and they felt that there had been a blip in suicide, but that it had evened out. I don't know what the latest data are. One thing that we do know, and this is from research with civilians, is that the greater the number of traumatic events one has been exposed to, the greater the suicide risk.
I'm not trying to draw an association between PTSD and suicide; I'm just citing the data that's there. Suicidal behavior is not one of the diagnostic criteria for PTSD; it is for depression. So that raises another question, since you're talking to me about PTSD. ... Let me make the point right now that although PTSD is perhaps the best defined post-traumatic psychiatric disorder, it's by no means the only [one]. And some of the best research on this has been done by Arik Shalev and his colleagues at Hadassah [University] Hospital Jerusalem.
As you can imagine, the emergency room at Hadassah Hospital is a busy place, full of all kinds of problems -- and not just terrorist attacks, but motor vehicle accidents, domestic violence and the other kinds of things that can happen. And what Shalev has shown is that some people who have been in traumatic episodes may not develop PTSD but may develop depression.
So that's another point I want to make. ... All roads don't necessarily point to PTSD, and it's important, I think, that when we have these discussions about the post-traumatic psychiatric problems that PTSD is by no means the only kid on the block. Another kid on the block is alcoholism and substance abuse. In many ways, we were more aware of that in Vietnam because there was better access in country, but when folks come home, the access is there as well. And we know from civilian situations as well, and even the post-9/11 data showed increases in alcohol behavior, smoking, marijuana use.
So the problem with suicide is a very important problem. I would not like to see it bundled into a PTSD question. It's an important question that needs to be thought through, in all the complexity, in all the clinical demand that it creates. …
Chief of mental health services for the VA in Vermont
…What is the ideal window for treatment?
I wish we knew for certain exactly what the best time period is for treatment. We think we know, but we've been wrong before, and I'm hoping that we get it right this time. To the best of anyone's knowledge, giving people [a] little time to readjust after they get back -- I mean, that's a big adjustment, coming back from a war. It's hard enough if you've been over on the front for six months or so and you're an 18-year-old who got drafted and so on, but if, let's say, you're a National Guard person who has got a family, a job, little kids, you come back after a year, everything is different; your family has actually adjusted to being without you. That's a tough blow to people. Spouse is handling the checkbook. Pick up your kid, [he] screams, "Who is this man?" "Well, that's Daddy; he's back." So there are a lot of general adjustment problems that are going to take place when people come home. ...
We don't want to rush in and disrupt the normal process. At the same time, you want to be able to intervene early enough to prevent it from becoming a chronic illness. And it's one of the things that we know about all psychiatric disorders, that the longer they go without treatment, the more difficult they are to treat, and there are probably a lot of very good mechanisms in the brain that account for that. So we don't want to be waiting six months; we don't want to be waiting six years.
The optimum length of time as far as we know -- and some of this is educated guesswork based on a lot of studies -- is probably about 30 days or so. Somebody's 30 days back, been back with the family and is still having trouble sleeping, having nightmares, easily startled, avoiding watching the news, staying away from anything that might remind him of the war or just reexperiencing it in any one of a number of ways, or still seems remarkably different and on edge and irritable with a spouse, then it's probably time to get into treatment.…
What are the newest therapies?
Number one, there are the new cognitive therapies. ... Cognitive therapies are psychotherapies that are based on looking at how a person understands an event, how they process it in their own minds at that time. We know that when you're in the middle of a trauma, particularly combat trauma, you're not thinking in the same way that you might be thinking if you're sitting in a chair reading about a trauma. So memories get laid down in a certain way, and they may be in a way that is very negative for the individual. They may prevent his or her recovery. So cognitive therapies tend to be based on re-looking at those events, so all of them require some amount of getting back to what actually happened, most of them by either talking about it or writing about it and then reviewing what you've written with the therapist, who can then help you look at how this might not make as much sense as it did at the time. ...
The older psychotherapies, the exploratory psychotherapies, the insight-oriented psychoanalytic therapy, the stuff from the mid-20th century and early 20th century, those were based on the opposite kind of reasoning: that it starts in here with the feeling, and if you work on that, then the thoughts will change. Cognitive therapy kind of reversed that. And cognitive therapy, for a lot of different things, has shown a lot of value. It actually works, which is a good thing.
The brain is a wonderful organ. I mean, it works miracles. It changes reality; it makes reality; and it develops comfortable pathways, like an old shoe. And memories work the same way. You might have a certain memory, a belief about it, and the longer you have that, the more comfortable and the more part of you it becomes, no matter how dysfunctional it may make you. It is burned in, if you will. We used to use the analogies to software and hardware, that you keep running the same software over and over again, [and] eventually it becomes part of the hardware, and it's very difficult to reassemble it in a different way. It's just now that we're doing some of the studies with cognitive therapy for people who had their trauma 30, 35 years ago. ... …
Back when we were saying that World War II veterans didn't have so much trouble with PTSD -- or that's what was apparent at the time -- one of the reasons given [was] they were older and more mature. What I've come to understand, from at least the reports that I've been getting from people coming back from Iraq, is that age does not protect you from getting PTSD, that a 19-year-old can get it [and a] 28-year-old can get it just as easily.
Is it hard to come back to the civilian population?
The best book every written about PTSD is Slaughterhouse-Five [by] Kurt Vonnegut. [It's a] wonderful, wonderful description. It was one of the books that I reread to prepare for this wave of people coming back. [I] also reread [Stephen Crane's] The Red Badge of Courage not too long ago so that I could try to get some sense of things. …
Do most soldiers you meet have PTSD or some other kind of psychological effects from combat?
…I've yet to meet any veteran who has said he was not affected by combat, or who was not affected by combat. It affects everybody in different ways. To say that everybody who has been affected has been somewhat changed by it, looks at the world differently as a result of it, to say that everyone like that has PTSD is ridiculous. …
Some people do go on to develop PTSD. I don't think we know exactly why. There may be some individual vulnerabilities. We know that people with other serious mental illnesses have the highest incidence of PTSD, higher than any other subgroup of the population. We know that certain groups of people are more susceptible to it.
We also know that some of the defining characteristics of a particular trauma have a lot to do with the development of PTSD. It's quite different to be sitting in a modern bomber pushing buttons and looking at a video screen than it is to be low over the skies watching people running and fleeing from your bombs, and yet again quite different to be actually involved in direct confrontation on the ground with somebody else.
Combat is an experience that changes people. It gives their life a different meaning, a new meaning, but [they] may not have PTSD. We just have to be careful with all of our psychiatric disorders, all of the phenomena that we deal with in mental health, to know when is something pathological and dysfunctional and when is it part of the normal human experience.
Retired Navy psychologist
… If you take a look at the statistics now that we're seeing in terms of the prevalence of formal, diagnosed PTSD [Post-Traumatic Stress Disorder], we're [seeing] 16 percent to 17 percent, sometimes up to 20 percent. But what? That means 80 percent of the individuals have really readjusted, and they're doing well.
Now, whether or not that had something to do with our Warrior Conservation program and our intervention before they came home and their ability to do a close-to-the-event processing of what had happened to them, I don't really [know]. I can't tell you that we have evidence-based [medical] data to prove that yet. We're working on that. But I do know that about 80 percent of our guys are doing quite well, and then the other 16 to 17 percent do come home, and it depends on what their prior history was and what kind of environment they moved back into. That, too, plays a major role in terms of whether or not they regress and start thinking about what had happened to them. ...
Some events were extremely traumatic to some individuals and no big deal to others. Some had been exposed to things like that before, and others had not. First time around, it makes a major impression on you which is hard to erase. So just a few debriefing sessions and a little bit of talking about it is not going to erase that. So that's why we have some pretty serious follow-up programs now to treat PTSD. …
What exactly is PTSD?
During briefings, we had to explain what Post-Traumatic Stress Disorder, or PTSD, is. There are several major symptoms that occur. First of all, you have to have experienced a psychologically traumatic event -- and again, what's traumatic to individuals is highly individual -- but an event so powerful that it actually changes biochemistry in your brain. PTSD is a biological disorder, and it is a trauma that actually changes brain anatomy and causes distortion in parts of the brain. And the effects of those changes happen to be things like recurring nightmares, major nightmares, night terrors every single night, usually a very similar theme. Then, if you are walking around and something kind of catches your eye, or you get a whiff of something that was similar to what you had experienced during the trauma, you will actually lose the sense of reality about time and place and where you are, and you have what we call a flashback, and you believe that you're actually back in the environment.
So you have nightmares; you have flashbacks; you have spontaneous anxiety or panic attacks. Your heart starts racing; your breathing becomes very rapid; you get very sweaty and clammy and lightheaded, and you think that you're going to die. And that's a panic attack. Those are the major things. You have nausea; you have headaches and outbursts of anger.
And as a result, if you don't know what's going on, frequently what happens is individuals start self-medicating, and you get alcohol and substance abuse. Also, with the anger outbursts and substance abuse, you end up with family violence, so it tears apart family units, [child] abuse, spousal abuse. ...
One of the problems with having PTSD, or Post-Traumatic Stress Disorder, is that you can't see the injury, and a lot of people believe that it's a sign of weakness, and it's just something in their head. ... We know that one area that affects memories and things of that nature, the hippocampus, is damaged, and the wiring or connections within the neural networks is distorted, and the biochemical interactions where the nerve cells are communicating are also altered. Now, the good news is that it's treatable. [But] if you don't treat PTSD, it never goes away. It's a lifetime illness. ...
Actually, before the war started coming on, individuals from Vietnam started arriving at the hospital again, ... [because] the occurrences that they were seeing on TV from Iraq brought up everything and exacerbated what they were already experiencing and had experienced for over 30 years. [They] made it to the point where they finally broke down and started asking for help. And we've educated the public, I hope, enough now so that they know that it's truly an illness and it is not a sign of weakness. …
How do you know if soldiers have PTSD or are just very stoic? And why are they so stoic to begin with?
… A lot of that has to do with training. ... When they finally get to war, mainly the reaction is, "OK, I've been trained to do this; I'm going to do my job." And another common reaction was "Wow, this is cool; we finally get to do what we've been trained to do." So when they did see and experience things that would just horrify somebody that has not been in the military before, for a Marine it's like "Whatever," or "Oh, that was kind of cool." ...
[In support groups,] they are able to in a very matter-of-fact, unemotional fashion talk about some very horrifying things, including thoughts about suicide. This is a very common experience, and that's why you have to have highly trained mental health professionals running the groups that can hopefully determine when an individual that's talking about thoughts of suicide versus thinking about actually acting on those suicidal thoughts. There's a big difference between just thoughts about "I might be better off dead" or "I've been thinking about it" versus "I've got a plan, and I'm getting pretty serious about it."
So that's one of the things that mental health professionals deal with every day, which is not what the general public sees. And so it can be pretty disturbing unless [you can identify] the difference between what's a real threat and what is just passing thoughts, which is not unexpected given the situation.
The other thing that you may see is that individuals may describe a horrible experience or something that they saw and be very frank and almost bland and unfeeling about it. Well, that's one of the symptoms of PTSD -- numbness, emotional numbing. ... The numbness is a survival mechanism. It keeps them alive; it keeps them from being suicidal. And you will witness that in the early phase of counseling. And so guys with PTSD are not crazy, and they're not falling apart, and they're not sitting around crying, and they're not sitting around just mute. They're still real, live, functioning individuals who happen to be experiencing spontaneous panic attacks, which is very disruptive, nightmares and flashbacks and things of that nature. ...
I'll guarantee you, they are hurting on the inside, and that is just their system kicking in and keeping them alive until they really can come to the point where they can emotionally deal with the trauma that they're describing. …
Director of Mental Health Policy, U.S. Dept. of Defense
…How has our understanding and treatment of PTSD changed since it was first identified in the Vietnam veterans?
Well, after Vietnam, the soldiers [began] coming home in the late '60s, early to mid-70s. The amount of change that has gone on in our understanding of how the brain works, how the mind works, the medications that we have available and treatments that we have available for the whole spectrum of mental illnesses is vastly different. So in that aspect, the soldiers in this war are coming home to a mental health system that has much more to offer them than did the system that was waiting for the Vietnam veterans to come home.
The Vietnam veterans came home, many times, to a society that was deeply divided and was very angry with them and saw them as a target for their anger and their outrage. And so they took out a lot of their bad feelings on the soldiers as they came home, and they weren't well accepted. [But in] this war, the support for the soldiers has just been phenomenal, so they're coming home to a completely different society.
Do you think the positive public reaction will lessen the current veterans' experience of PTSD?
I don't know whether it will help them to have less extreme reactions, because I don't think that PTSD and the level of the symptoms that a soldier's going to get depends as much on what they're coming home to as what they've seen and what they've been exposed to. But I think that their recovery from whatever they come with is going to be much better, much easier and faster, because the society accepts them, because the society is more understanding of mental illness. They're just generally more aware. ... I mean, they're not completely accepting. There's still a great deal of stigma attached to mental illness and getting treatment for mental illness in the society at large, but I think that they're much further along in that they're much more familiar with what treatments are available. Treatment is more acceptable now than it was in the '70s. …
Director, education and clinical laboratory division, VA National Center for Post-Traumatic Stress Disorder
…Is there anything that can be done to prevent chronic PTSD? Tell me about the "treatment window" theory.
One of the things that we've learned over the last five years is that early intervention is crucial to prevent a chronic problem. It's actually not rocket science if you think about it: If you take care of an injury and don't just let it go, if you go to the doctor and take care of it and he puts you in physical therapy and you're attentive to the physical therapy, generally, you get better. But if you sort of halfheartedly attend to the doctor's treatment, you don't get better.
The same thing is true when people are experiencing stress. If you can intervene early, give them the basic principles of self-care, then you have a much better opportunity to prevent potential chronic long-term problems.
Let me give you a concrete example: Somebody's feeling stress, anxiety, because of what just happened to [him] in a combat situation. The tendency might be to want to suppress that feeling, the emotion attached to it. You don't want to start thinking about it and dwelling about it, because if you start dwelling about it, you can end up putting yourself in harm's way.
But maybe when things are quiet, or maybe when you're post-deployment, those memories come back. You might start drinking to make them go away, temporarily. They never really go away, but what you're doing [is] you're numbing yourself out.
Had that individual had an opportunity to talk about that in the field, soon after that incident occurred, there's a good possibility that that individual could understand what's happening to him. [But] the reality is that no matter what treatment we can provide, there [are] no real magic bullets out there. One has to take responsibility for himself at some point. And so when you understand how your mind and your body [are] working, you have a better chance of taking care of yourself -- of course [with] the assistance of the professionals that you might need help from. But really it's the individual's inner strength.
So when you talk about people in the military, they have something that's special and unique, and that's a resiliency. It takes a special person to face death, to be in harm's way, 24/7. And what we've learned is that we need to learn how, as mental health providers, to use that positive strength to help them understand that they still have [resiliency]. Yes, something terrible just happened, but it didn't totally take it away from them.
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posted march 1, 2005
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