WHY DO SOME PEOPLE DEVELOP PTSD AND OTHERS GET STRONGER AND HOW CAN WE HELP?
Senator Bob Dole stands in sharp contrast to the many veterans who suffer from chronic Post Traumatic Stress Disorder. What made him different? Why was he resilient – able to live life by Nietzsche’s words, “what doesn’t destroy me makes me strong”? Was it his genetics? Both of his parents were hard working Midwesterners that were successful though not prosperous despite neither having graduated from high school. Was it the example his father set of going to work at his store every day in his overalls? Or was it his close relationship with his mother who contributed to the family’s support by selling sewing machines and teaching sewing? His mother’s love for him can be pictured as he tells of her holding his cigarettes for him while both his arms were paralyzed from his severe war injury – even though smoking was disgusting to her. He certainly wasn’t spoiled growing up living in the basement since his parents rented out the main house to help make ends meet. Was it because he’s a man? In general, men genetically are more resistant to stress for better and worse. Women suffer more symptoms in response to stress or trauma and women are generally more emotional, sensitive and reactive. Maybe it was because he was in WW II and not Viet Nam.
What made Viet Nam so different from WW I and II and even the Korean War? Arguably it was not just that we lost but that our returning soldiers weren’t received as heroes. It was more like they were co-conspirators in an immoral, politically motivated war. We didn’t ask, “why are they so traumatized?? We did ask, “why don’t they all have PTSD?” By researching this question we started a new chapter in the understanding of PTSD. Studies found that it was the young men/women who had abusive childhoods or who had suffered early life trauma or major losses that were vulnerable to the trauma of war. We learned that these experiences early in life – even the experience of being a fetus in a mother suffering from clinical depression or abusing drugs sensitized the brain to react much more powerfully to later experience.
Post Traumatic Stress Disorder is one of the most challenging disorders that I treat. A physician came up to me after a recent presentation in El Paso and told me that a lot of the soldiers returning from Iraq were suffering from the classic triad of PTSD symptoms:
• Flashbacks
• Hyperarousal
• Emotional numbness
He knew that I had been an Air Force psychiatrist during the war in Viet Nam when the symptoms of PTSD were first clearly recognized. He was looking for any suggestions on how to help these people.
I was an Air Force psychiatrist during the last part of the Viet Nam war and its immediate aftermath from 1972-74. I worked in the largest Air Force inpatient psychiatric facility in the world at Sheppard Air Force Base in Wichita Falls, Texas. We were sent almost daily admissions from Viet Nam and other bases around the world. At the end of the war we received over 40 just released POW’s. Many of them had spent over 10 years in solitary confinement. Many of the POW’s survived mainly by thinking about their families only to return to find their wives had remarried and they had no family to return to. Of course many of them had been assumed dead and it was understandable that their wives had moved on. It’s impossible for most of us to truly know the pain of their trauma. They survived with the hope to be freed and reunited with their families only to be retraumatized by loss.
I tell doctors that PTSD does to the brain what being run over by a truck does to the body. It messes up everything! In our Diagnostic and Statistical Manual or DSM IV (the “bible” of psychiatry) the diagnosis of PTSD is included as one of the anxiety disorders. I have always believed that anxiety is only one of the components of PTSD. I write down each patient’s diagnosis in the upper left hand corner of their patient information sheet. Then later I add other diagnoses in the same place above with the date that I add it. I noticed a common pattern for patients that I would later realize were actually PTSD. They would initially come in with a mood disorder, an anxiety disorder, an eating disorder, or substance abuse, etc. Over time I would keep adding one diagnosis after another until they would usually have one or more from each category. Eventually the trauma or abuse would come out and the underlying condition that was the primary cause of all the others was PTSD. It is certainly not just an anxiety disorder. PTSD affects every area of mental functioning.
Childhood histories of repeated physical or sexual abuse are often not initially revealed. Guilt, shame, and embarrassment are frequently the strongest legacies of abuse. Men with a history of sexual assault are especially reluctant to bring it up because of severe shame that they have as a result. Women will often choose abusive relationships as though they don’t deserve better because they are “damaged.” This is usually a subconscious decision.
One of the most unfair consequences of victimization is that it is only the victims who suffer all the emotional consequences. I can’t remember a patient ever telling me “I abused someone and I feel a lot of guilt.” The perpetrator invariably rationalizes past behavior. I remember asking a DSM committee member who helped formulate the PTSD criteria a question about the trauma of childhood sexual abuse. Amazingly, he said that it is not included in the causes for PTSD because it is too common. I said, “I guess the victims of the holocaust are not included because there are so many of them too.”
How is trauma different from normal loss or stress?
Normal losses are like the death of a parent or grandparent, or loss of a job. Divorce is unfortunately very common and is not usually considered to be a trauma. However, some divorces are handled in such a way that they can be traumatic to one or more of the parties involved. Murder, suicide, or death of a child are never normal and therefore always traumatic.
There are 3 clusters of symptoms that are found with PTSD.
The first cluster is re-experiencing phenomena, including flashbacks, nightmares, and panic attacks. Traumatic memories are different than normal memories. They are recorded deep in the emotional brain (amygdala) and are like a videotape or DVD recording. They retain all the associations and feelings. These memories are often induced by a reminder in the immediate environment or especially watching TV or a movie. I remember one Viet Nam veteran who stopped for gas along the highway. The station’s bathroom smelled like urine. He immediately felt like he was back in Viet Nam on the battlefield holding his buddy who had just been killed and had urinated on himself. He felt the pain of loss and guilt because he had talked his friend into joining the army with him. Worse yet his friend’s parents would later blame him for their son’s death. The sound of a helicopter would also cause panic attacks.
The second cluster of symptoms is all the problems associated with hyperarousal including constant vigilance, anxiety, nervousness, and insomnia. It is as though they are always in an acute danger situation. They are easily startled and are in a 24/7 state of fight or flight. Sometimes after months or years there is total burnout causing exhaustion and fatigue.
The third cluster of symptoms is emotional numbing. There is a general lack of even normal feelings. It is as though they are under emotional anesthesia.
All three clusters of symptoms can lead to general withdrawal from normal life.
What can we do to help?
It helps for them to talk about the trauma – but not necessarily right away. Studies of relatively immediate debriefing have been shown to actually increase symptoms. Later it helps to talk about it and ventilate. Processing any loss means going through all the stages of grief including anger, sadness, guilt, bargaining, and eventually acceptance. It’s very hard to resolve feelings without knowing what happened and who/what was responsible or to blame. Some traumatic events like the recent tsunami are “acts of God.” Others aren’t really anyone’s fault and fall under the category of “shit happens.”
Medication can be very helpful in not only easing the immediate pain of trauma but actually protecting the brain from some of the negative impact. Propranolol (Inderal) if given within hours of a traumatic event can decrease the impact and actually reduce the intensity of the memory of the event. Medications that provide normal sleep, (Sonata, Ambien, Lunesta) can be helpful immediately for insomnia associated with acute or chronic PTSD. Anxiety medications like Xanax or Klonopin can be helpful for acute symptoms or in some cases stronger mood stabilizers like Abilify or Seroquel are required.
For chronic PTSD most patients need an antidepressant (almost all suffer from clinical depression) like Effexor XR, Lexapro, Wellbutrin, Zoloft, Paxil, or Prozac. Many require long-term anxiety medications. Most of these patients also have poor concentration and loss of interest/motivation and many times adding a stimulant like Adderall XR or Concerta, or Provigil can be very helpful. It is not uncommon to also need a mood stabilizer.
Processing traumatic events and working toward resolution, while at the same time being able to work and have healthy relationships requires that the mind be working well. This means getting good sleep and not being overwhelmed with anxiety, having panic attacks or being emotionally disconnected. The right medications at the right doses can facilitate the recovery process and help those suffering with PTSD to get back their life.
Senator Bob Dole apparently did not suffer from PTSD – at least not on a long term chronic basis in spite of very severe trauma. Part of the explanation is his strength of character but he also had loving parents and a good support system. He could have felt sorry for himself and become chronically disabled. Instead he has given more than 60 years of public service. He has appeared on Meet the Press, more times than any other individual (63). Even in his 80’s he continues to contribute. What does he want people to get out of his new book, One Soldiers? Story? It is hope for those with PTSD, handicaps, and encouragement for seniors to be productive and keep giving.
Vulnerability to PTSD after trauma is much higher in those that had abuse or trauma in childhood – all the more reason that sufferers deserve our compassion, understanding and support.