BASIC OVERVIEW / PTSD LINKS

BASIC OVERVIEW OF POST TRAUMATIC STRESS DISORDER

BY: JIM LOUGHREY

Histories of the Vietnam War are beginning to abound more than two decades after our nation's involvement in the conflict officially ended. Historical analysis is most often subjective to some extent -- and always dependent on available information. History, as it is recorded, may change when new facts come to light. It also may change more subjectively when the times change and the opinions involved in the writing reflect a different view-point.

Think for a moment about how the veterans of the Vietnam War have been portrayed. The picture depends on who does the writing and when. Every Vietnam Veteran is a part of history -- as nameless as any of us may always be, we did have a part in the making of this part of history. But as a group, how were and are we being pictured?

I think most people will agree that for years we were not portrayed very favorably at all. In movies and books and on television the initial, main role of the Vietnam Veteran was that of a psychopath and social misfit -- a man brutalized and warped by a war most Americans had little use or respect for. When the writers needed a character who was insane, completely antisocial, dangerous to society, drug and/or alcohol addicted, guilt-ridden and vengeful, etc. ad nauseam, the Vietnam Veteran filled the need. If one needed a character who would evoke pity, the beaten, weak, suffering Vietnam Vet served once more --because our song was, many agreed, "When Johnny Comes Slinking Home". Like the new guy in Hollywood, we had to start at the bottom with all the bad guy roles.

Why? Why wasn't it like it was with our World War II and Korean War brothers? How come we weren't allowed to start out playing the good guy, the hero, the indomitable spirit? The roles we were given in fiction were the same ones we played in reality as far as our news media were concerned, and hence, as far as our people were given to know. Headlines reporting Vietnam Vets shooting from rooftops were more saleable than those which would tell of veterans of our era forming businesses, getting professional degrees, or otherwise benefiting themselves and society. It was as if the World War II Veteran was one who went off to the terrible task of war and took along with him morality and honor, while the veteran of the Vietnam War was somehow something less who went off to war and brought back immorality and dishonor. In any event, if despicable or pitiful, we had become, at least, interesting. But while some people who write the news might be given to exploitation and a certain degree of selective myopia, there usually is at least something of truth or reality in the reporting as an element of justification. Wasn't it true that some of us did, indeed, do some of the things we as a group became famous for?

Certainly. But few asked why. It is apparent that very few people wished to know what caused the difference in behavior, compared to that of veterans of other wars, or wondered if such behavior might be attributable to only a very small segment of the Vietnam Veteran populous. A very tired and disillusioned America was not yet recovered enough from Vietnam to deal with the problems of its youngest war veterans; or countrymen felt they had difficulties enough of'their own, perhaps, or they simply were not aware that the problem was any more complex than it seemed. The result was that the seemingly obvious was taken as explanation enough. Hence, when anyone needed an explanation at all, we were known to suffer what became known as Post-Vietnam Syndrome. The term -- which had no scientific meaning -- was adopted by both veterans and the public.

Today we speak of PTSD in Vietnam Veterans. Today veterans are getting help and getting better, all because they suffer from a medically recognized condition: PTSD. But for far too many people -- veterans and non-veterans of the Vietnam War -- "PTSDII is nothing more than a substitute for IIPVS". The problem has been given the legitimacy of official and professional recognition, but that has not necessarily led to any more understanding -- either by veterans of Vietnam or by their countrymen. As in the days of IIPVS", many veterans do not know what their problem is or what they need or can do to solve it, nor do other Americans understand what PTSD really means and why it exists. Consequently, too many veterans are still blamed for things that are not at all their doing or fault. They are still sometimes looked down upon when in reality they deserve to be praised and honored. And America cheats itself as long as it erroneously and unjustly rejects a part of itself.

We need to concern ourselves with PTSD for everyone's ultimate benefit. But first it is necessary to know and comprehend what PTSD is, means, and does. Following is a brief discussion of PTSD that does not require a professional degree to understand. It only demands one care enough to read it and do so with an open mind, not with comfortable bias.

And what's required of the Vietnam Vet who is having serious emotional and mental problems is something even greater: courage. The courage many of us already know he had in his war. To heal will demand courage because healing is change. Sometimes even hell can get to be comfortable and change will look like just too much to ask. Too much to try. But that is what is necessary and there is no other way.

Many of us suffer from a disease that perpetuates itself with a vicious cycle effect: the disease is one of a lack of change and part of the disease itself is an unwillingness to seek change. There is a similarity between this disease and the disease of alcoholism. Alcoholics, many believe, suffer from a type of insanity; the insanity makes them drink and the drinking affects the brain, hence the mind, and causes insanity. The disease we're discussing here is called PTSD.

PTSD stands for Post-Traumatic Stress Disorders. Put simply, this is a set of disorders common in people who are reacting to severe trauma with the reactions occurring or continuing after the stressful event. PTSD is not, therefore, a set of mental disorders found only in Vietnam Veterans. Who suffers from the disease is determined by what was the stressful event or trauma. Survivors of rape or a life of child-abuse or some catastrophe as well as veterans of combat and associated experiences all may well eventually experience PTSD.

Our concern here, though, is PTSD as it relates to us, the veterans of the Vietnam War. And it's only been in recent years that the term PTSD has been applied to the mental disorders many of us have been suffering. PTSD has been applied to us only since 1980 when the disorders were first included in the American Psychiatric Association's DSM III -- "Diagnostic and Statistical Manual III".

The DSM serves as the text, the bible, for American psychiatrists and psychologists. The first Manual appeared in 1952; the DSM II with its new entries and revisions was available in 1968. PTSD as a term and a concept wasn't documented until the DSM III.

There's an old joke in chemistry: If Lavoisier discovered oxygen, what did people breathe before he discovered it? Similarly, from what did veterans of combat suffer before PTSD was discovered? Before Lavoisier, of course, people were breathing oxygen but just didn't know what it is or what to call it. The history of combat veterans' illnesses and maladjustments reflects a similar situation. One difference is that many labels have been used to describe the effects of combat on men and women over decades. Also, oxygen was, is and always will be just oxygen no matter what it is called. However, what was "wrong" with veterans of combat has been a matter of who judged the problem and when.

At first there were no specific explanations for Vietnam Veterans' having the myriad problems they did; problems like a suicide rate described as 33% greater than the national average, disproportionately high incidences of chemical abuse and criminal convictions.

People who were against the war could point to the returning veteran who suffered such problems as proof of the veracity of their viewpoint: the Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people. The nature of the war was created by the nature of those who waged it. But more often we encountered antiwar sentiment that reversed this so that the immoral and disgusting war was the creator of immoral and disgusting people.

Likewise, supporters of the war used our condition to further their aims. We were proof positive of the Communist brutality and dirty tactics -- all the more reason for our country to believe in the morality of its position. The war was disgusting because the enemy made it so and we were its gallant victims.

Sociopolitical motivations aside, people began to label us as sufferers of "Post-Vietnam Syndrome". This label seems to have appeared sometime during the late sixties to early seventies.

PVS was more or less a term of convenience. It was a nebulous concept that purported to describe the ailments of the combat veterans of only this particular conflict. It was unique to us as if our behavior had never been seen in other veterans. As the war dragged on and this country wearied of the internal strife and lack of a victory, PVS began to be a derogatory term, especially as younger veterans and counterparts from other wars became less and less able to identify with each other.

The term Post-Traumatic Stress Disorders came about only after the effects of combat were truly studied scientifically and for the first time. So, before analyzing the nature of PTSD as it relates to combat veterans, a little history of its evolution would be informative.

Jim Goodwin, PhD reported in POST-TRAUMATIC STRESS DISORDERS OF THE VIETNAM VETERAN (Disabled American Veterans, 1980): "It was not until World War I that specific clinical syndromes came to be associated with combat duty. In prior wars, it was assumed that such casualties were merely manifestations of poor discipline and cowardice. However... during 'The Great War', the concept evolved that... exploding shells caused actual physiological damage, precipitating the numerous symptoms that were subsequently labeled -shell shock'. By the end of the war, further evolution accounted for the syndrome being labeled a 'war neurosis'.

Until World War I, then, any soldier negatively responding to the stresses of combat would have been labeled just a coward. The studies done during that war, though, did not do much to alter opinion that it was somehow the fault of the soldiers that they ended up displaying mental disorders. Even though psychiatrists began to recognize combat as capable of producing such symptoms, it was still assumed that something had to be wrong with the soldiers character before combat stresses could have adversely affected him. Even though we'd moved from basic cowardice to "shell shock" and then on to "war neuroses", the thinking continued on into World War II that a soldier had to have been "predisposed" toward such reactions ... in other words, had to have had basic character defects.

According to Dr. Goodwin: "During the early years of World War II, psychiatric casualties had increased some 300 percent when compared with World War I, even though the preinduction psychiatric rejection rate was three to four times higher than WW I. At one point in the war, the number of men being discharged from the service for psychiatric reasons exceeded the total number of men being newly drafted-"

World War II thinking suggested that, if we're going to assume that men had to possess "predispositional factors" in order to break down in combat, then we had better expect not too many to be immune. According to a 1944 Inspector Generalls report: "If screening is to weed out all those likely to develop a psychiatric disorder, all should be weeded out.,,

Therefore, the belief that war neurosis could only grow in the fertile ground of a defective character had outlived its usefulness. Psychiatrists now began to look into the "intrinsic qualities of the combat situation" for the reasons for the breakdown and the blame was beginning to shift from the shoulders of the fighting men to the conditions of battle themselves. Basically, war itself held the capacity to exhaust anyone.

What changed during the Korean War was the way the men were treated. Terminology had now progressed from "war neurosis" to "combat exhaustion". But soldiers were no longer so readily discharged from service when they showed signs of mental disorders attributable to combat. Rather, doctors began treating men immediately and close to the front. A very good rate of return to duty was achieved.

Vietnam, however, was a vast surprise for everyone. Military psychiatrists were prepared for the same situations as seen in past wars, but these did not develop. Battlefield breakdown in Vietnam was "at an all-time low: 12 per one thousand".

Were the men fighting in Vietnam staunchier than their predecessors? If so, why then were Vietnam Veterans so severely criticized? How could they have been statistically so much better able to endure combat than their predecessors and yet have been at some points nearly universally considered inferior and the reason the war was lost?

The answer is that the basic package was really the same; it was the wrapping that differed....

Most of our problems surfaced after our return from combat. We succumbed as did our older brothers, but we did so alone and thus did not lend ourselves as much to being battle statistics. Furthermore, the differences in our respective homecomings contributed to the apparent disparity.

By virtue of their coming home together and on long journeys that allowed for mutual sharing of the war experience, older veterans were able to lay to rest much of their horror. We were forced thereby to carry ours with us into life after our war. Additionally, the initial recovery of WW II veterans was greatly aided by their country's reception: very warm and appreciative. The negative homecoming we received -- the rebuke, disdain, criticism, blame, and forced silence and isolation -- not only helped retard recovery but actually very severely added to the stress we had to overcome.

Another characteristic difference between Vietnam and other wars was the personal involvement and ability to understand and relate to the public.

Our countrymen were bludgeoned daily with the horror of our war, which received mostly negative and biased press. Our war's purpose was not clear-cut and our people at home were not encouraged to feel a part of it. And despite the vast coverage graphically displayed to them, the American people were really not made privy to the actual experience of their soldiers on the battlefield.

During the second World War, conversely, it had been unthinkable to present the fighting men's efforts in anything but a positive light and the nation received primarily reports which cultivated a sense of unity, purpose, conviction and optimism. Our soldiers were aware of the nation's constant sacrifices and the people were made aware of the soldier's sacrifices -- and each shared the other's respect as well as experiences.

Ultimately, then, our nation and its servicemen suffered together during World War II, bled together and healed together. Vietnam? --The factors created an environment socially that demanded veterans recover on their own and with fewer of the tools required for such recovery.

Hence PTSD.

Post-Traumatic Stress is a consequence of extreme or severe trauma. The reactions to it do not often appear until after the fact. The victim may have come through the traumatic situation apparently relatively intact only to ultimately exhibit the symptoms that characterized the PTSD condition.

PTSD is diagnosed according to two categories. These, according to Dr. Erwin R. Parson, are:

ACUTE PTSD -- The onset of symptoms occurs within six months of the trauma and the symptoms last for less than six months.

CHRONIC or (a) The onset is at least six months DELAYED PTSD -- after the trauma (DEIAYED).

(b) Duration of the symptoms is more than six months (CHRONIC).

Chronic/Delayed PTSD would, thus, be the condition of those of us now exhibiting the symptoms. Following are the generally accepted symptoms of PTSD:

Depression Isolation Rage Intrusive thoughts Alienation Survivor guilt Sleep disturbances and nightmares Anxiety reactions

Depression may include feelings of worthlessness, feelings of helplessness, suicidal thoughts, etc. Isolation is the inability to get close to others (veterans of combat often have very few friends and tend to feel they cannot relate to most people and vice versa). Others often see such a veteran as "cold" due to the symptom of Alienation in which the veteran does feel "emotionally dead". Anxiety Reactions include the tendency to overreact to certain stimuli -- being acutely startled by loud noises or feeling extreme discomfort in the open or when people are behind the veteran (there is a tendency to identify the stimulus with combat and/or to react to it as one would have to combat). Rage is an uncontrolable urge to lash out at people, often suddenly and without apparent reason, with the veteran being himself frightened by the rage response. Survivor Guilt causes the veteran to recount the death of comrades with a sense of guilt over not having been able to do anything about it; the "why wasn't it me" attitude can drive some to self-destructive behavior. Sleep Disturbances & Nightmares -- the sufferer has much difficulty in falling asleep and maintaining sleep; there is a tendency even to avoid and postpone sleep or the use of drugs or alcohol where the veteran feels he needs sleep; and the nightmares are often of a recurring nature with the same scenery, events and situations.

The above symptoms may also be indicative of other conditions and that a veteran may be suffering from one or two of the above is by no moans to be taken as a sign that he does indeed suffer from PTSD. Only a competent, professionally-made determination should be sought; and it should be noted that not all veterans suffering PTSD exhibit all of the given symptoms.

But who does suffer from PTSD and how is the determination made?

Determination of PTSD cases is something that should be done only by the professionally qualified who also have specialized experience with and knowledge of PTSD in combat veterans. Any veteran presenting himself for such a determination should fully be aware of the fact that the process must necessarily be lengthy and involved.

One reason is this: PTSD as an ailment of combat veterans qualifies the sufferer for compensation from the government. There are, unfortunately, some who may not really need treatment and who merely want to exploit the system for personal gain. Dr. Jim Goodwin states this: "When a veteran appears in an interview wanting something from us (the VA) other than treatment, there is a manipulative flavor to the interview. I am then immediately alerted that issues other than PostTraumatic Stress may be involved."

Some time must be spent by the psychologist in ascertaining the honesty of a prospective sufferer not to save the government money. The main reason is a seriously practical one: The number of qualified doctors available to veterans is limited and dishonest and undeserving veterans who are permitted to undergo counseling and treatment detract from the total available help for those having serious problems.

Even more critical is that the initial interviews and exams must attempt to distinguish possible PTSD-sufferers from those afflicted with other mental ailments whose symptoms often may be confused with those of PTSD.

Schizophrenia is not uncommon and the disorder is one often confused at first with PTSD. For example, decreased productivity, certain types of amnesia, and hallucinations are common to both disorders. On the other hand, many aspects of each disorder are completely different, some even opposite. Medication indicated for schizophrenia will do no good for the PTSD-sufferer and vice versa. Schizophrenics respond well to the phenothiazines, which have no effect on PTSD patients. Conversely, tricyclic antidepressants work well in PTSD cases, but have no effect at all on schizophrenics.

Veterans who finally present themselves for evaluation and treatment often become impatient with the evaluation process. They see no need for the psychologist or psychiatrist to "waste time" with tests and questions that do not readily seem pertinent to their service experiences. The veteran usually is convinced from the start that he suffers from his combat experiences and wants only to discuss war-related matters, all else in his opinion being irrelevant. What has the doctor's question concerning his grade school years got to do with the time he had to crawl into a VC tunnel in Vietnam? Why should he submit to hundreds of questions on the Minnesota Multiphastic Personality Inventory -- which seem to be designed more to determine if he's lying than to determine if there's anything abnormal about him -- when he knows that the only thing wrong with his personality is whatever was changed by war experiences?

This attitude of some of-us is quite understandable. Many or most of us do not seek help until we've essentially reached the end of our rope -- either just unable to endure it alone anymore or are in some sort of serious trouble. So, there is a deep sense of urgency and we are in no frame of mind to sit back and let someone drag us down those "dead-end roads". Moreover, many veterans have developed a tendency to distrust authority and, should we be seeking aid at the VA, some of us might even assume that the doctor is looking for ways to deny that we have any war-related problem.

We simply have to understand that no competent psychologist can make snap decisions or diagnoses if the intention is to provide proper help. Misdiagnosis of mental/emotional disorders can be just as dangerous and detrimental as misdiagnosis of physical ailments. It isn't merely a question of whether the wrong medication will help or do no good at all; the wrong medication in some cases can do severe harm. Medication aside, the course of treatment for various mental disorders is to be considered. The incorrect approach here may also do damage, not just be ineffectual.

Complicating the situation for the doctor and the patient is the fact that a veteran may not be suffering from only a single condition. PTSD does not necessarily push aside other possible problems by its presence. one patient may suffer PTSD and have a tendency to drink too heavily because of it -- without being an alcoholic. Yet, another veteran may suffer from both conditions. Still a third may be purely alcoholic and characteristically blaming his troubles on a condition he does not actually possess, in this instance PTSD.

The course of treatment for PTSD is not identical to that preferable for alcoholism. In fact, treatment of the veteran's PTSD may have little or no effect on his alcoholic tendencies -- but if the veteran should join Alcoholics Anonymous and truly embrace its Twelve Steps program for recovery, the new way of life and advantages available to one dedicatedly working this program may actually alleviate the PTSD symptoms considerably.

But let's consider medication within the same scenario-: A PTSD sufferer may indeed benefit from the use of prescribed antidepressants or, for the anxiety-ridden, tranquilizers. Suppose that the PTSD sufferer is also alcoholic. Alcoholism is a disease involving an addictive personality. Therefore, it may be dangerously inappropriate to treat one drug addition as if it were some sort of "Valium deficiency" -- prescription of tranquilizers may only serve to feed the inherent need for drugs.

During the evaluation stage, the patient will also be classified according to veteran status: non-veteran, V.E.V (Vietnam Era Veteran -- one who served during the conflict period, but not in Vietnam), or V.V. (Vietnam Veteran). The likelihood of the patient's suffering from PTSD is obviously greater if he did serve in the war zone. It is still greater if he did actually see combat.

As Dr. Goodwin states: "One proven indicator of the intensity of the disruptive symptoms is the extent to which the veteran was exposed to actual combat." Thus VV's,are further classified as "noncombat" and "combat" veterans... and as we'll see, combat veterans are still further assessed as low- and high-combat veterans.

Combat -- and the degree to which it was experienced -- is a major factor in the diagnosis of PTSD. Dr. Woodwin says, "In developing a diagnosis of PTSD, chronic and/or delayed, it is particularly important to be empathetic to the horrors of the combat situation. Many veterans have struggled endlessly to suppress these feelings, in part because of the refusal of society to even acknowledge their existence."

Many of us who saw heavy and prolonged combat never had the opportunity to rid ourselves of the concomitant and associated emotions as did veterans of the other wars. It is generally acknowledged now that the Vietnam Veterans endured the same and similar hardships that other veterans did. Why we fell prey to resultant disturbances to a greater degree is at least in part due to major differences in the homecoming experiences.

The Vietnam Veteran came home to a vastly different climate. He went from battlefield to Main Street in less than 48 hours and did not receive the distinct and recognized advantage of long weeks aboard troopships with the chance to share experiences with others who had endured the same things. Further to his detriment, he found himself rejected and severely criticized -- even blamed for what people saw as wrong with his war. Veterans benefits were often much less and more difficult to obtain. Society was in turmoil and many veterans found themselves the object of ridicule by fellow citizens in their own age group. And so on.

Dr. Goodwin maintains this: "When the (Vietnam) veteran finally returned home, his fantasy about his DEROS date was replaced by a rather harsh reality. As previously stated, WW II veterans took weeks, sometimes months, to return home with their buddies. Vietnam vets returned home alone. Many made the transition in less than 36 hours. Most made it in under a week. The civilian population of the WW II Era had been treated to movies about the struggles of readjustment for veterans (i.e., THE MAN IN THE GREY FLANNEL SUIT, ... PPIDE OF THE MARINES, etc.) to prepare them to help the veteran. The civilian population of the Vietnam Era was treated to the horrors of the war on the six o'clock news. They were tired and numb to the whole experience ... some were even fighting mad ... WW II veterans came home to victory parades. Vietnam Veterans witnessed protests. For WW II veterans resort hotels were taken over and made into redistribution centers to which the veterans could bring their wives and devote two weeks to the initial homecoming. For Vietnam Veterans there were screaming antiwar crowds and locked military bases where they processed back into civilian life in two or three days.

In STRESSES OF WAR: THE EXAMPLE OF VIETNAM by Arthur Blank, MD (1981, THE FREE PRESS, MacMillian Pub. Co.), there is this assessment of wars and how Vietnam compared:

I. Stresses Typical for All Wars:

A. Miserable living conditions B. Fatigue C. Sensory assault D. The fighting itself E. Wounds F. Special stresses of the combat situation:

1. Capture and torture 2. Isolation 3. Acute survivorship (only narrowly escaping death when others were killed) 4. Authoritarian organization 5. Command incompetence 6. The observers (fighting while others merely watched)

II. Unusual Stresses Peculiar to the Vietnam War:

A. Guerilla warfare B. Lack of clear objectives C. Limitations on offensive actions D. Terrorism ("All of Vietnam was a combat zone; what varied was only degree." E. Climate and topography F. Miscellaneous bizarre physical dangers G. Tropical diseases H. Immersion in an extraordinarily poor Third World society I. Chaos and confusion

III. Psychological Stresses Secondary to the General Political Character of the War:

A. Experience of absurd waste B. Government deceit and misjudgment C. Massive national conflict D. Defeat

From the above it is evident that stresses were much greater for those who actually participated in the fighting. Those who treat PTSD cases are well aware of this, but many veterans assume a need to explain more than they need to. That may have been necessary or a good idea several years ago but much has been gained by the professional since -- via the enlightenment provided by the many veterans who have been so far treated.

In the beginning of evaluation and treatment, this might be important for the veteran of heavy combat, since he is the least likely to want to recall bad experiences. It does take time for proper rapport with the psychologist to develop. As Joel Osler Brende, MD states in COMBINED GROUP THERAPY FOR VIETNAM VETERANS, "Even though every combat soldier has been traumatized and harbors the residual effects of that trauma within him, he will be unable to disclose his pain until the right circumstances allow,'and then only gradually."

Therefore, a determination of the degree of combat a patient has seen not only makes the psychologist aware of the degree of probability that this patient may suffer PTSD but helps him design his approach to dealing with that veteran. Some doctors may choose to employ what is known as The 13-Point Combat Scale.

The scale is a set of ten questions designed to determine how extensive the veteran's combat experience were. The test/scale was prepared by Drs. Mark Gallop, Robert Laufer, and Thomas Yeager. Although the test is called The 13-Point Combat Scale, a total score of 14 is actually possible. It is, however, highly unlikely that a given veteran would score 14, unless he happened to have been in combat with both the artillery and another combat arm, primarily the infantry. (When the scale was being tested, no veteran scored more than 13 points.)

The test, shown below, simply requires a YES or NO answer to each question. Each question has been assigned a certain numerical weight.

THE 13-POINT COMBAT SCALE

COMBAT EXPERIENCE WEIGHT

1. Served in an artillery unit which fired on the enemy 1 2. Flew over Vietnam in an aircraft 1 3. Was stationed at a forward observation post 1 4. Received incoming fire 1 5. Encountered mines and boobytraps 1 6. Received sniper or sapper fire 1 7. Unit patrol was ambushed 2 8. Engaged VC in a firefight and/or engaged NVA in a firefight 2 9. Saw Americans killed and/or saw Vietnamese killed 2 10. Was wounded 2

MAXIMUM SCORE 14

An answer of NO to all questions results in a "noncombat" classification of the veteran. A score of 1 through 6 is rated as "low combat" while one of 7 through 14 is regarded as "high combat". A linear, graphic scale may be drawn to visualize where one places according to his combat-experience rating:

---high combat-----

7 8 9 10 11 12 13

0-- /-- /-- /-- /-- /-- /-- /-- /-- /-- /-- /-- /-- /-- 14

1 2 3 4 5 6

---low combat ------

(The 13-Point Combat Scale is taken from LEGACIES OF VIETNAM: COMPARATIVE ADJUSTMENT OF VETERANS AND THEIR PEERS. This study was done for the Veterans Administration by the Center for Policy Research, Inc. of New York and is copyrighted 1981. The text consists of five volumes with two appendices.)

A high score on the scale does not always indicate that a given veteran will suffer PTSD, nor does a low score rule out that possibility. In general, the more combat, the greater the probability of PTSD and the higher one places may predict a greater severity of the disorders.

There are, in fact, some indications that veterans scoring in the "low combat" grouping may be better adjusted than not only high-combat veterans but also noncombat veterans. In LEGACIES a study of arrests shows that, of men of the same age group, 24% of high-combat veterans and 17% of Vietnam Era Veterans were arrested after service, while only 10% of those in the low-combat group were arrested. As a matter of fact, 14% of nonveteran men of the same age had been arrested -- still more than the low-combat veterans.

Some studies reflect another phenomenon: some veterans who served in Vietnam, but saw no combat, apparently returned with more guilt feelings than they who had seen combat because they felt they "didn't do their part".

Possibly more surprising is the report that some former war protesters today experience guilt-feelings over not having served. Some admit to admiration for those who served in Vietnam. An example is given by Myra MacPherson in her excellent book, LONG TIME PASSING: VIETNAM AND THE HAUNTED GENERATION (Doubleday, 1984).

She reports that one protestor evaded induction by the inhalation of canvas dust "to revive a childhood case of bronchial asthma." Years later he is haunted by ambivalence: " ... as I survey my friends and acquaintances who have served, I notice something disturbing that makes me want to rethink the issue. To put it bluntly, they have something we haven't got. It is, to be sure, something vague, but nonetheless real, and can be embraced under several headings: realism, discipline, masculinity (kind of a dirty word these days), resilience, tenacity, resourcefulness ... I'm not at all sure they didn't turn out to be better men -- in the best sense of the word."

Post-Traumatic Stress Disorders, like most other illness, are not only to be found in veterans of this or that station in life. PTSD is no respecter of education, intelligence, race, creed, socioeconomic level or whatever. Tom Williams, Psy. D. by his experience can represent those veterans who went to war with better-than-average intellect and the attainment of or potential for advanced education, for example. From his case history: he ' attended the US Naval Academy and served as a Marine Officer for eleven years, which includes two tours of duty in Vietnam. He has been married and divorced and has remarried. He obtained his master degree, worked in mental health for five years and then obtained his doctorate.

One experience with PTSD symptoms that Dr. Williams had was reported in POST-TRAUMATIC STRESS DISORDERS OF THE VIETNAM VETERAN:

" ... (in the winter) of 1979, I was overcome by a wave of poor judgment and saw the movie, THE DEER HUNTER. It was hard to watch the movie, but I white-knuckled it through. The sound of helicopters and the realistic battle scenes were disturbing, but not as disturbing as the metaphor of Russian roulette used to symbolize the constant stresses of combat in Vietnam. I was reminded of the guerilla nature of the war, especially of the continued and heavy use of booby traps by the enemy. The movie brought up more memories and overwhelming emotions than I could handle. At the end of the movie, I was unable to talk. As I walked out, I hoped that someone would jostle me or some kid usher would tell me to go out a different exit than I intended so I could express my rage at him.

"When my wife and I arrived at the car, I got in the passenger side, knowing full well I couldn't drive, and cried deeply and uncontrollably. All I could say was 'those poor fucking kids' over and over again between my sobs. My wife made an excellent therapeutic inter-vention by taking me to a loud bar and buying me a taco and a beer. We talked. It helped, but I remained confused about being so completely overwhelmed by such a multitude of emotions."

The date of the quotation tells us that Dr. Williams' reaction to war stresses is delayed. His reaction was, typically, brought on by war related stimuli: the sound of helicopters, realism in battle scenes (and sounds), and even the symbolism of the guerrilla warfare. He experienced rage. His emotions became unmanageable. There is probably survivor guilt evidenced by his feelings about the children. He also experienced the common temporary loss of the ability to function (couldn't drive).

Dr. Williams could not be classified as an average person, yet he does share the common experience of PTSD symptoms as described. But the doctor who evaluates the prospective sufferer of PTSD will also concern himself with differences as well as similarities his patient exhibits with relation to other veterans.

Again, a big difference among us is whether or not a veteran has seen combat and this difference has certain implications. From page 43 of LEGACIES: "Our findings demonstrate that Viet Vets exposed to combat generally feel the war had a negative psychological effect. Of the majority who feel the war had a positive effect on their lives (a mating effect, for example), many still emphasize traumatic wartime experiences. Most important, we find that combat vets continue to have significantly more psychological and behavioral difficulties than Vietnam Era Vets, Vietnam Vets not exposed to combat, or nonveterans."

The same source also states that "only one-quarter of Vietnam Vets believe the war had little,or no effect on them. Vietnam Veterans not involved in combat are much more likely to make this assessment."

How one recalls military life is also dependent, in general, on the category to which the veteran belongs. From page 30, vol. 1 of LEGACIES: I'VEVs recall service primarily in terms of pleasant experience (78.8%), while 70% of Vietnam Veterans recall the negative primarily, especially combat, and the greater the involvement in combat, the more likely memories of battle would be cited."

No veteran is a perfect "classic" PTSD case. Whether one will suffer PTSD experiences and to what degree is dependent on many factors --basic personality and life experiences must be taken into account as well as combat service and its intensity. Because of factors other than combat, then, it is possible for the veteran of extreme combat to survive the war and the aftermath with even fewer adjustment difficulties than will some veterans who saw much less action. The reverse is also true. Family histories do enter the picture.

LEGACIES reports (p. 47, vol. 1): "Men from the most stable families are likely to develop stress reactions in response to heavy combat. Men from average families are more likely to develop stress reactions after exposure to even low amounts of combat. Men from the least stable families may develop stress reactions simply in response to daily life stressors, exposure to combat does not greatly affect their level of stress reaction."

Further (p. 48, vol. 4 of LEGACIES): "We have found consistently that men who were sent to Vietnam, but were not involved in combat at all, score lower on the Stress Scales than any other men in our sample. This holds true regardless of race, most levels of family stability, and parental class. We reason that such men found clerical and bureau-cratic positions well removed from the possibility of being subjected to hostile fire. In their terms -- though perhaps not in the terms of the military -- they were a 'success'. Further, when they compared their distress to that of other men they knew in Vietnam, they had to judge themselves as being much better off. Similar findings with respect to 'relative deprivation' were reported in the classic study of World War II troops in THE AMERICAN SOLDIER (Stouffer et al, 1949)."

There is this with regard to race: Myra MacPherson reports, "By the mid-sixties the racial and class inequities of the Vietnam war were scandalous. Gen. S. L. A. Marshall... commented, 'In the average rifle company the strength was 50% composed of Negroes, Southwestern Mexicans, Puerto Ricans, Guamanians, Nisei and so on. But a real. cross-section of American youth? Almost never."'

MacPherson goes on to say, "In 1965 blacks accounted for 24% of.all Army combat deaths. As black leaders publicized the plight of blacks in Vietnam, the Department of Defense reduced the minorities' share of the fighting -- to 16% in 1966 and 13% in 1968.11

Some psychologists have established that blacks who experienced a degree of combat equal to that of whites tend to suffer fewer PTSD-type problems or possess them to a lesser degree. The explanation offered is that blacks who came from more deprived areas and lives were most accustomed to handling trauma. Yet this seems incompatible with the findings which deal with family stability.

Another finding that seems to run contrary to the common sense expectation is the prevalence and severity of PTSD in the severely wounded and disabled of the Vietnam War. These men tend, as a group, to suffer less from PTSD.

This is the finding offered by Dr. Goodwin: "It is important to note an interesting trend... it has only been on rare occasions that we have interviewed significantly disabled veterans, suffering the loss of a limb or another wound that required months or even years of hospitalization. ... We have concluded that significant numbers of severely disabled veterans received much more comprehensive care after their combat experiences. In particular, this included close emotional support from other veterans on the hospital wards regarding their own combat emotional experiences. This, in turn, helped the seriously disabled veterans find some final solution to their feelings about Vietnam. It also included a more empathetic understanding of the physically wounded veteran by the VA, which had learned about wounds and their concomitant psychological problems in WW II. Subsequent support and training to help these veterans to readjust,to their losses was also provided. The veteran who was not seriously physically wounded had no such resources, hence the apparently smaller incidence of post-traumatic stress, chronic and/or delayed, in severely disabled veterans of Vietnam."

This last finding does seem to encapsulate the conditions that made PTSD so rampant among our returning combat veterans of Vietnam. Very simply put, the lack of caring coupled with the inability of the veterans to rid themselves of their emotions at an early date provided very fertile soil for the growth of severe problems.

With this understanding comes a solution. Proper treatment in light of the causes. Such assistance is available in several forms. But it is up to each veteran to recognize his situation and acutely seek help, whatever program he may eventually choose.

Copyright 1986

VVNW, Inc. Not to be reprinted without written permission from The Veterans of the Vietnam War, Inc. All rights reserved.

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