Depression and PTSD in Veterans

Albert Patterson arrived in Vietnam on his 21st birthday, an eager young man fairly bursting with ideals. For his tour of duty in the late 1960's, the U.S. war veteran was showered with medals of honor. "I was doing my duty for my country as an American," recalls Patterson. Yet, when the soldier returned to his hometown in Northern California after a year in the Vietnam war, he came back a changed man, disillusioned and withdrawn.

Patterson was haunted by images of horror: buddies killed in front of him, body parts blown up by grenades and land mines, heads flying off bodies, the shrapnel that burned its way into his skin. Although he had been decorated as a hero by his government, Patterson felt anything but heroic. In fact, he began to see himself as a freak. "During the day, I slept under a bed. I wouldn't sleep at night," he recalls. Any sudden noise tended to startle him. Out in the streets, his heart would start pounding uncontrollably and his body stiffen at the mere sight of individuals of Asian descent, since their faces reminded him of Vietnam.

To escape the encroaching dread, Patterson began to rely more and more on the comfort afforded by alcohol and drugs. After failing to hold down a series of jobs, he finally landed a swing shift schedule at a grocery store that provided him with the isolation he craved. "I didn't want to get close to anyone," recalls Patterson. "Because you lose people if you get close to them."

More than three decades after serving in Vietnam, Patterson was finally diagnosed with post-traumatic stress disorder (PTSD), a condition that afflicts many men and women who have served their country in foreign or domestic wars. But for those 30 long years that Patterson inhabited the imaginary bunker he had constructed to fend off attacks, he wasn't even aware that his condition had a name. "I didn't know that a lot of people had it. We got no debriefing after getting back from Vietnam, so for 30 years I just thought I was weird," explains Patterson. Then, on a day when Patterson says he was "ready to explode with anger," a chance meeting with a counselor changed his life. With the aid of therapy, he initiated the slow process of healing himself.

While PTSD is better understood and treated today than ever before, many people who suffer from the disorder go without getting the help they need. Estimates of PTSD for military personnel that have served in Iraq range from 12 to 20 percent, yet little more than a third of soldiers returning from Iraq with mental health problems say they plan to get help; Afghanistan vets also suffer from the disorder. Many soldiers cite fear of what others might think should they get treatment and worry that a diagnosis of PTSD could hurt their military careers.

What is post-traumatic stress disorder (PTSD)?

In the past, post-traumatic stress disorder was known as "shell shock" or "combat stress." Cases of this particular anxiety disorder have been documented as far back as World War I. Those involved in armed conflict or caught in a natural disaster are most susceptible to its ravages, although any severe trauma -- a rape, assault, molestation, incest, physical abuse, or a natural disaster -- can trigger symptoms as well. Indeed, any event or situation that inspires fear, helplessness, and threat of annihilation can lead to the development of PTSD.

It has been calculated that a surprisingly high percentage of Vietnam vets -- about half of male and female vets alike -- have experienced symptoms of PTSD in their lifetime, according to the National Center for Post-Traumatic Stress Disorder. In fact, studies show that the prevalence of PTSD grows dramatically just after veterans return from combat. In one study, of Gulf War veterans from New England, rates of PTSD more than doubled for men and women two years out from their initial assessment upon return from combat. With time, other studies suggest that veterans can experience considerable recovery from PTSD.

Overall in the general population, women experience PTSD at more than twice the rate of men. Female veterans who have served in the U.S. military at home or overseas may be vulnerable to the condition for a reason other than the trauma of war: sexual harassment or assault in the line of duty. "Women's exposure to sexual stress in the military is particularly toxic for the development of PTSD," concluded a report in the journal Psychiatric Services. (However not all researchers believe these gender differences can be attributed only to traumatic events. Across studies, women are more likely than men to report trauma, and men are more likely to respond to trauma in ways that do not fit into the diagnostic criteria for PTSD. For example, men are more likely to report substance abuse and conduct disorders and less likely to report anxiety and depression.)

For war veterans, PTSD can be so excruciating that it's been likened to carrying the battlefield around inside. Often a victim will relive the action of the combat theater over and over again in dreams and hallucinations. Any unexpected or loud noise may be mistaken for gunfire, causing him to panic and dive for cover. He may feel he has to be constantly on the alert for imagined threats, and will devise multiple strategies for waylaying disaster. In this way, his world may gradually grow ever narrower because safety has become the first order of the day, one that subsumes everything else.

As was true for Albert Patterson before he started down the road of personal recovery, many vets with PTSD frequently find themselves reliving the horrors of war and trying to escape them all over again. Some survivors also feel overwhelming guilt that they were able to survive a situation in which so many of their buddies met a premature death. A PTSD victim may inexplicably swing from feeling powerful surges of raw emotion, as if still in the midst of combat, to a complete emotional shutdown. Many veterans who suffer the long-term effects of PTSD will eventually fall prey to depression and/or substance abuse.

What are the symptoms of combat-related PTSD?

Generally, these symptoms include recurrent recollections or dreams about war, flashbacks that cause you to relive various traumas, and avoidance of any reminders of combat. The condition can also result in emotional numbing (diminished responsiveness to the world around you), intense distress when confronted with reminders of battle, and hyperarousal, a feeling of frequently being on edge and on the alert for new threats.

If you've been involved in a war and have experienced fear, helplessness, or horror during your time in that country and at least one of the above symptoms for more than a month after you returned from combat, you should see a medical professional for help. If you are close to a vet, or you yourself have served in the Armed Forces, you should be reassured that PTSD is a treatable disorder and that help is available.

How common is depression among war vets?

In some studies, nearly half of the veterans who had PTSD were also depressed. The two conditions often go hand in hand, often with some overlap in symptoms. "In the group who have PTSD, depression is quite prominent, about 45 percent," reports Frank Schoenfeld, MD, the director of the PTSD program at the Veterans Affairs Hospital in San Francisco.

Depressed veterans often feel worthless and profoundly sad, but other typical symptoms include poor concentration, lack of interest in social activities, feeling of hopelessness and helplessness, changes in appetite, difficulty sleeping, or oversleeping, unusual irritability, apathy and listlessness, and suicidal thoughts or attempts. If you or someone you know has been feeling depressed and have had four or more of the above symptoms for more than two weeks, call a health professional: depression is a serious and even life-threatening disease. If a vet is talking about or threatening suicide, get help immediately. Most communities have suicide prevention hotlines, or you can also call a crisis center, hospital, and 911.

How can I come to terms with PTSD and depression?

Seek treatment. The Veterans Affairs administration has PTSD programs and psychiatric services all over the country (look in your phone book or on the Internet for the local office). In addition to hospitals, there are 200 community-based veterans centers in the United States that provide counseling and referrals for veterans in an informal, non-clinical atmosphere.

How are depression and PTSD treated?

After a doctor evaluates you, he or she will work with you to determine what treatment would be most appropriate. For example, if you have a substance abuse problem, a doctor would likely refer you to a program to help you overcome it, in addition to treating your symptoms.

Since people with PTSD often feel out of control and unsafe, the initial goal of treatment is to help you feel safe and stable. A doctor may prescribe medication such as an antidepressant, which can alleviate anxiety and depression and make it easier to sleep. You may be referred to a counselor for individual therapy who will help you feel safe rather than caught in a cycle of crisis. The therapist may spend some time educating you about PTSD, so you'll better understand how the disorder works and how to control it.

You may also be enrolled in cognitive behavioral therapy, a form of talk therapy that helps take away the power of the active memories that come rushing back against your will. By talking about these traumatic memories, instead of avoiding them, "the veterans can feel that the experience is a part of them and not outside of them oppressing them," says Schoenfeld. Part of the process, he adds, is recognizing that the memories are often distorted.

At least one therapist is using groups of veterans with PTSD to role play different characters involved in a trauma, expressing forgiveness, love, and validation, according to the New York Times Magazine. One veteran, "forgiven" by a participant playing the mother of a young man he had killed in Iraq ("You were both young and in hell"), experienced some relief from the session and said he felt more hopeful about the future.

If you need help in other areas of your life, such as finding a good job or getting better housing, some veterans centers are also set up to do this. Since you've been under considerable stress, your counselor may recommend relaxation exercises that use body imaging to help you get rid of tension. Finally, the VA or veterans centers may offer group therapy, which can help you examine your behavior and ways of coping with difficult situations, as well as sharing your experiences with other vets who are also working to patch their lives back together.

For Albert Patterson, who is currently employed as a manager of PBX operators in San Francisco, group therapy was a turning point. "The healing began when I realized I wasn't alone. That's when the door opened up for me." Patterson still looks forward to the weekly sessions with his fellow veterans. Some days are better than others, Patterson admits, but in general, the quality of his life has improved immeasurably since he began treatment for PTSD. "My life is bordering on becoming manageable. I still have my rough days, but it's manageable," he says. And he implores other vets to do what he did -- even if it's 30 years after the fact. "They need to know there's hope for them. If nothing more, there's someone who can get you through this."

Further Resources

Veterans Affairs Administration can direct you to your local vet center or VA hospital 800-827-1000 National Center for PTSD http://www.ncptsd.org

References

National Institute of Mental Health, Reliving Trauma http://www.nimh.nih.gov

Herman, Judith, MD Trauma and Recovery, Basic Books, 1992/1997, New York

Interland, J. A Revolutionary Approach to Treating PTSD. New York Times Magazine, May 22, 2014.

Wilkeson, A., et al, "Posttraumatic stress disorder, dissociation and trauma exposure in depressed and nondepressed veterans," J Nerv Ment Dis;188(8):505-9

National Center for Post-Traumatic Stress Disorder. What is Posttraumatic Stress Disorder? http://www.ncptsd.va.gov/facts/general/fs_what_is_ptsd.html

National Center for PTSD. What Is Post-Traumatic Stress Disorder? http://www.ncptsd.va.gov/facts/general/fs_what_is_ptsd.html

Quyen QT et al. Recent Sexual Abuse, Physical Abuse, and Suicide Attempts Among Male Veterans Seeking Psychiatric Treatment. January 2006. http://psychservices.psychiatryonline.org/cgi/content/abstract/57/1/107

National Center for PTSD. PTSD in Iraq War Veterans: Implications for Primary Care. http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_clinician_guide_ch_7.pdf

Acknowledging the Psychiatric Cost of War. Matthew J. Friedman, MD, PhD. New England Journal of Medicine. Volume 351:75-77. http://content.nejm.org/cgi/content/full/351/1/75

Tolin, DF et al. Sex Differences in Risk of PTSD. National Center for Post-Traumatic Stress Disorder PTSD Research Quarterly. Volume 18, Number 2. Spring 2007. http://www.ncptsd.va.gov/ncmain/nc_archives/rsch_qtly/V18N2.pdf

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