WHEN THE MIND STAYS BEHIND: AN OVERVIEW OF PTSD ON SERVICEMEN RETURNING FROM WAR

ptsd

Introduction

Since the fall of man, war has been part and parcel of the human experience. From the moment two brothers, Cain and Abel, warred against each other the earth has been saturated with the blood of mankind. The fall had greater consequences than what Adam and Eve had gambled on that fateful day. Moreover, war not only brought death, but also Post Traumatic Stress Disorder (PTSD). I have often wondered if–from a theological perspective—PTSD is the result of a fallen/imperfect brain failing to be resilient at times when most needed, or were our brains simply not created to suffer trauma to such an extent. One would argue the former is more likely. Whatever the theological implications of PTSD, the fact is that it remains with us for the time being as part of the human reality, and current military chaplains would do well in understanding this phenomenon.

Military Chaplains are more likely to be approached by someone with trauma injury, than a military counselor or psychologist. In current military culture, anything that may resemble a “shrink” carries the stigma of “crazy people’s doctor”, and thus creates mistrust within the ranks; especially when the client is a senior leader. Unfortunately, chaplains are not well equipped to deal with men and women who experience symptoms of PTSD. Most can’t even recognized the signs and symptoms of PTSD. The few who are able to manage these clients with care have acquired these skills through trial and error, have a background in counseling and/or psychology, or they have simply sought the extra education necessary to help survivors of trauma. To this aim one will discuss PTSD from the perspective of an unapologetically Christian military chaplain with a laymen’s understanding of current works of PTSD. This work will discuss symptomology, differential diagnosis, latest research, etiology, and treatment.

Description of Symptomology—Physical, Emotional, Behavioral, Indicators

Dr. Glenn Schiraldi offered a great definition of PTSD in his book entitled The Post-Traumatic Stress Disorder Sourcebook. He defined it as a “normal response by normal people to an abnormal situation.” However, during the course of one’s research few definitions of PTSD have surfaced. Most scholars are concerned mainly with defining PTSD in terms of signs and symptoms, than conceptualizing it into a broad definition; a practical approach which is beneficial to the discussion at hand.

According to the Diagnostic and Statistical Manual IV (DSM-IV) PTSD is classified as an anxiety disorder and diagnosis of PTSD must meet six criteria. First, there must be a stressor which is an exposure to a traumatic event with a serious threat to life or physical integrity to the victim or someone nearby. This criterion is easily met by all veterans of military conflicts. The question has been raised whether there should be a distinction between actual threat and perceived threat. However, in light of the DSM-IV lack of defining and distinction, “the US Department of Veterans Affairs has recently liberalized the evidentiary requirements of Criterion A to include a fear of hostile military or terrorist activity.”

The second criterion for PTSD is intrusive recollection. This condition is the one most often depicted in Hollywood and the most popularly associated with the condition. Intrusive recollection comes in the form of nightmares, flashbacks, dissociation, or severe distress on reminders. These intrusions occur due to triggers, which can be internal or external. These triggers lead to the third criterion for PTSD which is avoiding of stimuli associated with the trauma. This is when the victims begin to avoid people, places, and activities which may remind them in some form, of the trauma. This will also include avoiding certain feelings, thoughts, lack of interest in sexual activities, and avoidance of conversations which may have some loose connection to the trauma.

The fourth criterion is hyperarousal. Hyperarousal is the body’s continued response as if the threat of the trauma is present. In essence, the body continues to react as if in a fight or flight mode. The client may have increase pulse and blood pressure, accompanied by sweating and rapid-shallow breathing. A client with PTSD may have sleep disturbances, may be easily irritated, unable to concentrate, and may be impulsive. Furthermore, the client might demonstrate hyper vigilance, exaggerated hyper response, and outbursts of anger.

The last two criteria for PTSD are duration and functional significance. Proper identification of PTSD requires that symptoms of intrusive recollection, avoidance, and hyperarousal have lasted longer than one month.Moreover, clients with PTSD will have severe disruption in their social and occupational lives. In essence, they are unable to function in society as they once did. These last two criteria are often the culprit in the disruption of marital and family relationships.

By way of example, one can turn to Shakespeare’s famous play Henry IV’s iambic pentameter uttered by Lady Percy to her husband Hotspur. These lines are filled with symptoms of PTSD, which Lady Percy finds difficult to understand.

O, my good lord, why are you thus alone?

For what offence have I this fortnight been

A banish’d woman from my Harry’s bed? (lower sexual drive/interest)

Tell me, sweet lord, what is’t that takes from thee

Thy stomach, pleasure (lack of interest in pleasures) and thy golden sleep? (Trouble sleeping)[…]

[…]Thy spirit within thee hath been so at war

And thus hath so bestirr’d thee in thy sleep, (Nightmares)

That beads of sweat have stood upon thy brow (Sweating)

Like bubbles in a late-disturbed stream;

And in thy face strange motions have appear’d,

Such as we see when men restrain their breath (Possible flashback expressed in his face)

On some great sudden hest. O, what portents are these?

Some heavy business hath my lord in hand,

And I must know it, else he loves me not. (Causing relationship problems)

Symptoms of PTSD affect all areas of the client’s life; emotional, behavioral, psychological, spiritual, relational or interpersonal effects, and physical effects. A military chaplain would do well to become familiarized with these signs and symptoms:

Significant Factors in Differential Diagnosis

Many disorders have similar signs and symptoms as PTSD, and as a result, many combat veterans who have PTSD are misdiagnosed. For this reason, it is essential to recognize the differentiating characteristics found among these conditions. A combat veteran may either be misdiagnosed, or may actually have a comorbid condition alongside PTSD. Knowledge of these differential diagnoses will benefit a military chaplain to approach a counselee appropriately, and effectively.

Antisocial Personality

Victims of combat PTSD often have difficulty adjusting, and reintegrating once again into society. Some who are married become serial divorcees, and some who never married have difficulty in keeping a stable relationship. In fact, according to a study done by George Mason University, “PTSD-related numbing/withdrawal is particularly associated with interpersonal problems in combat veterans and other trauma survivors…. and suggests that this pattern also extends to individual psychological distress in partners.”

Moreover, many upon discharge from the military are unable to maintain employment, and have long periods of unemployment. All of these features can be misconstrued as antisocial personality at face value. The differing factor between PTSD and antisocial personality lies in the onset of behavior. All personality disorders begin at childhood, and a proper interview on a client’s background may provide information on whether the pattern of behavior occurred prior to the trauma. Only when the behavior began after the trauma, can it be attributed to PTSD.

Borderline Personality Disorder

Survivors who struggle with PTSD at times display overt behaviors which may be attributed to borderline personality disorder (BPD). Uncontrolled anger, self-injury, suicide attempts, mood swings, and even regression to adolescent behavior can persuade a clinician to diagnose a client with BPD. However, an essential element of BPD is an inability to tolerate being alone. Those suffering from PTSD in the other hand prefer to be alone, and are often intolerant to interaction with others. Contrary to BPD, PTSD survivors do not have dependence on feedback from others. In fact, BPD patients appear to have a need to have their very existence verified by others.

Substance Use Disorders-Abuse, and Dependence (SUD)

Substance use disorders are co-morbid disorders to PTSD. According to the National Center for PTSD website, 80% of people with PTSD have a co-occurring disorder which substance abuse is most prominent, and from a different perspective out of those people with substance abuse disorder, 60% of them have a co-occurring disorders of which PTSD is the most prominent. Due to this level of co-morbidity many veterans suffering from PTSD, often are diagnosed only with either substance abuse disorder or substance dependence disorder. It is important to gather enough history from the client during the exploration stage to avoid overlooking PTSD.

Traumatic Brain Injury (TBI)

According to the Department of Veterans Affairs, “The primary causes of TBI in Veterans of Iraq and Afghanistan are blasts, blast plus motor vehicle accidents (MVA’s), MVA’s alone, and gunshot wounds.” The close connection between TBI, PTSD, and SUD makes it difficult for a clinician to diagnose accurately. In fact, according to the National Center for PTSD, patients with TBI often meet criteria for PTSD on screening instruments for TBI and vice versa. Some of these positive screens may represent false positives, but many Iraq-war Veterans have experienced a mild traumatic brain injury and also have PTSD related to their combat experience.

Military chaplains who recognize these dynamics will be able to appropriately direct those who seek their help. These complex arenas of seemingly related disorders can be confusing, but a working knowledge of them allows the chaplain to raise flags when survivors have diagnosed conditions that can be confused with PTSD and vise versa. A caring chaplain always seeks to be an advocate to those whom he or she serves.

Latest Research on Disorder.

In the past years, many studies have come to the forefront in regards to PTSD on military personnel. However, since the military chaplain is a pastor to the whole family, one will look at studies done in regards to parenting and family relationship among veterans with PTSD. According to the National Center for PTSD families with one spouse affected by PTSD are 1.6 times more likely to divorce than those with unaffected spouses.The University of Minnesota conducted a one-year study on 468 Army National Guard fathers returning from Iraq. The findings suggested that symptoms of PTSD influence family structure on multiple levels increasing the difficulty of adjustment. Furthermore, the study demonstrated that, “PTSD symptoms of emotional numbing/avoidance may manifest in detachment from family activities and reduced monitoring of, and involvement with children, and hyperarousal symptoms may spark volatile ore emotionally dysregulated parent-child interactions, particularly in stressful situations (such as those around discipline or conflict).”

Another research conducted by University of Utah on forty nine wives of the Utah Army National Guard revealed some interesting findings. The aim of the research was to identify the psychological vulnerability of spouses of military men suffering with PTSD. The study revealed that spouses were more likely to report having psychological symptoms of either depression or PTSD when they perceived their military partner to have PTSD symptoms, which the military partners did not acknowledge themselves. Furthermore, the study revealed that spouses who knew that their husbands have faced high levels of combat were more resilient. Conversely, those who perceived that their husbands had faced low levels of combat had an increased marital dissatisfaction. Perhaps they felt that they could not identify an understandable cause for their husbands PTSD.

One final note worthy study was conducted by Tel Aviv University in conjunction with Ariel University Center of Samaria. The study examined the correlation between PTSD and parental attachment. They were able to gather 504 participants with 286 of them being part of the control group. The participants were asked a series of inventories and questionnaires. The findings revealed, “veterans who suffered from PTSD…reported lower levels of both parental functioning and parental satisfaction, compared to veterans who did not suffer from PTSD.” The researchers suggest that when the family members witness the father’s difficulty readjusting to his former role in the family, they react with “resentment and destabilization of familial borders. This, in turn, may further undermine father’s perception of their parental functioning and the satisfaction from their role as a parent.”

In recent years, the military has begun to look into improving resiliency. The chaplaincy corp. is at the head of this campaign, and as such a good understanding of the latest research on PTSD and family relationship can only be beneficial. In a culture where divorce is already at an extremely high rate, the preservation of the integrity of the family ought to be a major goal of the chaplaincy ministry. A chaplain who understands the dynamics of PTSD and how it affects the family relationships is more capable of guiding a family into a healthier and more sympathetic environment.

Possible Etiological Factors and Assessment Issues.

The complexity of PTSD and the various areas in the client’s life, which are affected by it, leads to making a distinction between diagnosis and assessment. The diagnosis looks at the various signs and symptoms while assessment looks at the larger picture; that is behavioral history, relationships, and other areas of psychological function. In fact, some researchers will argue that a decision of PTSD on purely diagnosis gives an incomplete picture of the client. Three reasons are given for this position. First, a diagnosis of PTSD does not contribute much to choice of a treatment method. Second, the information gathered in the diagnostic does not say much about other areas of the patient’s life; areas which are more likely affected by PTSD. Third, the diagnosis for PTSD has changed so much since the inception of the DSM that it would be very easy to overlook some important characteristics of PTSD. In light of this rationale, it is important that a thorough history is taken in the exploration stage.

According to Alexander C. Mcfarlane, “the inclusion of PTSD in DSM-III arose from a consensus that the nature and intensity of the stressor was the primary etiologic factor determining the symptoms that people develop in the presence of extreme adversity.”These stressors, in the case of military personnel, are usually combat related, although according to recent studies sexual trauma has become more prevalent especially among female veterans. In fact, national surveys have suggested that 13%-30% of women veterans experienced rape during their military career. In the face of such disconcerting statistics, a military chaplain has to think in broader terms than just combat related PTSD.

Beyond the stressors there are other etiological factors that ought to be considered, such as family history and concurrent psychiatric disorders. A study conducted in 1985 found that 66% of the PTSD veterans had a family history of psychiatric disorders. Moreover, the study also found that 50% were suffering from another psychiatric disorder. Dr. McFarlane deduced, “these data suggested that PTSD probably shares common etiologic processes with both the anxiety disorders and depression and hence may share some of the same vulnerabilities.”

Preferred Therapeutic Interventions of Treatment

As a military chaplain endeavors to be a helper to those who are struggling with PTSD, a working knowledge of current treatment methods may be of help. The purpose is not to for chaplains to become counselors and clinicians themselves, for this falls outside of the scope of practice of a chaplain. However, knowledge never harmed anyone, only ignorance. The goal is to have enough knowledge to avoid saying or doing something that may trigger a counselee, or worse re-victimizing him or her.

The consensus among researchers that one has encountered in the course of this research seems to indicate that cognitive-behavior therapy is the preferred treatment for PTSD. This seems to be closely followed by psychopharmacology therapy and eye movement desensitization and reprocessing (EMDR). A brief description of each one of these treatments should suffice to inform a military chaplain.

Cognitive Behavior Therapy

Cognitive behavior therapy embraces a variety of techniques that are at a therapist’s disposal. These techniques include exposure therapy, stress inoculation training, cognitive processing therapy, and cognitive therapy. Exposure therapy confronts the client with frightening but realistically safe stimuli continuing until the anxiety is diminished. Stress inoculation training educates and gives a client the tools necessary to manage his or her anxiety. These may include self-dialogue, role-playing, muscle relaxation training, and breathing retraining. In cognitive processing therapy, the client is challenged to deal with troubled cognitions acquired during trauma, to include self-blame and false beliefs. Cognitive therapy is based on the theory that an interpretation of an event, rather than the event itself, causes different emotional states. In regards to PTSD, counselors’ focus on the survivals appraisal of safety/danger, trust and views of themselves, which serve to maintain a continued sense of a current threat.

Psychopharmacology

Psychopharmacotherapy recognizes that PTSD is involved with specific neurotransmitters, neurohormonal, and neuroendocrine systems. It also recognizes that a great number of PTSD clients have co-morbid psychiatric disorders; therefore, it is no surprise that some of the medications used to reduce PTSD symptoms are helpful in some of these co-morbid disorders. Based on current studies selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRI’s and SNRI’s) are currently the best established drug treatments for PTSD, and they are often used as first line of treatment.

EMDR-Eye movement Desensitization and Reprocessing

Since trauma is stored in a set of related and unprocessed thoughts, images, and emotions, practitioners of EMDR theorize that the application of either eye movement or bilateral stimulation helps the client process and/or desensitize the traumatic thoughts or emotions. EMDR has become more popular in past years and its effectiveness cannot be denied. Often EMDR treatment is combined with other treatments, especially cognitive-behavior therapy.

Conclusion and Prognosis for Recovery

The prognosis for recovering from PTSD is very encouraging for those who seek and finish the treatments available to him or her. Unfortunately, recent studies have indicated that 68% of military personnel that seek help for PTSD abandon the process and never finish.  According to this study, the reason behind this trend is the stigma found among young military men in regards to seeking psychological or psychiatric help. Furthermore, Survivors of PTSD who are discharge from the military often lack the financial resources to seek treatment, and the Department of Veterans Affair does not have adequate resources to help them. A recent study found that the current cost for PTSD treatment in a five-year period (2003-2008) totaled $1,097,312,949, a drop in the bucket when the actual need according to current deployment is around $200 million annually. The study concludes that the main culprit behind this statistic is the inadequacy of Veterans Health administration and Department of Defense institutions in dealing with this crisis, and the scarcity of resources available to treat PTSD in these health care institutions.

Indeed the prognosis is encouraging, yet there a variety of dynamics that hinder the process to a healthy mind. The military chaplain can be a catalyst in the life of someone who is thinking about seeking help for his or her psychological wellbeing. The Chaplain can be harmful to a survivor of PTSD, and even re-victimize them by making ignorant statements. Conversely, the Chaplain can be a therapeutic person, and even encourage the survivor to seek help for the sake of their family and their sanity. The deciding factor on whether a chaplain harms or helps a survivor is knowledge. An inform chaplain, well acquainted with the dynamics of PTSD will change a survivor’s life for the better. An inform Chaplain Corp can change the military culture to be more open to psychological/counseling help. It is one’s hope that the Chaplaincy ministry becomes the leadership in targeting the current emergency, for the sake of Airmen, Soldiers, Marines, Sailors, and their families.

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