Download Click here to HCP Final Joseph Kapcia III

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Joseph Kapcia III
Writing 39C
Instructor Annie
5 May 2016
Combat-induced Post-Traumatic Stress Disorder: The Humanitarian Crisis
Human consciousness and emotion is an incredibly complex and fragile
existence. For years the mind can be healthy and well, but one traumatic event
can destroy that tranquility. When the behavior of the person is radically
changed by such trauma for a long enough time, the person has developed PostTraumatic Stress Disorder (PTSD). PTSD is a disorder characterized by a
traumatic experience that constantly terrorizes the victim in the form of vivid
flashbacks, resulting in the victim becoming unable to function normally in society
for at least one month (Friedman). There are many different subtypes of PTSD,
but we will focus on combat-induced PTSD in veterans. PTSD has likely been
around since humankind could experience trauma, but it was not officially defined
until 1980 (Friedman). As a result, combat-induced PTSD has very old roots that
beget different treatments and opinions on it as time progressed. In modern
times, treatment and awareness of PTSD has become much better and more
widespread, but it is still a prevalent and serious problem in society that results in
needless suffering, death, and the large loss of money.
The first mention of symptoms similar to PTSD has roots as far back as
1700 B.C., mainly in literature such as epics and poems. Marc-Antoine and
Louis Croqc provide a thorough summary of many documentations of PTSD-like
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syndromes. The oldest mention of PTSD-like symptoms comes from the first
major epic written, the Epic of Gilgamesh, dating to at least 1700 B.C. (Abusch
614) Gilgamesh loses his friend and experiences grief as expected, but his grief
radically changes his personality, culminating in him searching for a way to die
(Croqc 47). Lucretius’ poem De Rerum Natura (50 B.C.) describes a battle
dream, a nightmare about re-experiencing a battle, with horrifying imagery
including “a wild cry as if their throats were cut” while the survivors of the battle
go on to “groan with pains, and fill all regions round with mighty cries and wild…”
(Croqc 48) A final example is a man named Pierre de Beam, a veteran from the
Hundred Year’s War in Europe. Sometime in 1388, Beam’s symptom was
described as being unable to sleep near his family because of “his habit of
getting up at night and seizing a sword to fight oneiric enemies.” (Croqc 48) At
the very least, PTSD-like symptoms had been recognized to exist as a
debilitating syndrome for soldiers and people very far back in time.
More detailed descriptions of the symptoms of battle trauma and some
mentions of treatments arose during and after the Industrial Revolution. During
the French Revolutionary Wars (1792-1800) and the Napoleonic Wars (18001815), French Army physicians took note of soldiers falling into an extensive
stupor when cannonballs flew close by without physically harming the
soldier. This stupor was dubbed the “vent du boulet” syndrome because the
soldiers became terrified of flying cannonballs (Croqc 48). The syndrome was
among the first ones to be named by physicians, and many more different name
variations were to come. In America, a man named De Costa detailed a war
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syndrome from the American Civil War that he termed “irritable heart”. He
describes symptoms such as shortness of breath, burning or sharp chest pains,
fatigue, headaches, and disturbed sleep. However, De Costa’s account is
different from previous ones because he attempted a treatment: prescribing
several drugs, which all seemed to have a beneficial effect on the soldiers
(Hyams 398-399). The success of drug treatment is important because it would
become a very common treatment for soldiers in the future.
Figure 1: This is a table of common symptoms of some war syndromes, just as the table
title says. Notice common symptoms such as headache, fatigue or exhaustion, and disturbed
sleep. Source: Hyams page 399
With the advent of World War I (WWI) in 1914, PTSD-like syndromes
came about in unprecedented numbers that demanded new approaches to the
syndrome. Dr. Edgar Jones of the American Psychological Association details
the history of one particular syndrome from the viewpoint of British Army head
physician Charles Myers. The British Army was extremely surprised by the
hundreds upon hundreds of cases of a war syndrome termed shell shock by the
soldiers (Jones). In response, the British decided to hire Myers as the head
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physician to investigate shell shock. He detailed symptoms similar to those
found in previous war syndromes, such as headaches, fatigue, tremors, and loss
of sensation. After studying his first cases, he came to an important conclusion:
the shell shock is a psychiatric issue that can be resolved through forward
treatment. On an individual basis, his treatment method worked well for the
time. Unfortunately, he and the four specialist hospital units he set up were
overwhelmed by the sheer number of shell shock cases (Jones). Myer’s
important contribution was discovering and making widespread the use of
forward treatment, which would evolve into modern day therapy treatments.
Figure 2: Many soldiers after a battle in WWI wait to be treated. The man in the bottom
left hand corner has shell shock, as evidenced by his piercing and dissociated stare often dubbed
the “Thousand Yard Stare.” Source: Wikipedia Public Domain
In general, the public felt sorrow and pity for soldiers afflicted by shell
shock until a massive number of soldiers became afflicted. For example, “war-
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shakers” were soldiers affected by a war syndrome, and they received a lot of
money when they drew attention to themselves on street corners (Croqc
51). However, after some time, society began treating the war syndromes with
disdain when the number of cases grew too high. For instance, Myer’s critics
criticized his failures based on the belief that shell shock was simply cowardice or
malingering (Jones). Other Europeans wondered if soldiers were just trying to
get out of fighting a war or believed that the syndrome is not related to mental
issues. These beliefs were held strongly enough to elicit the awful treatment of
soldiers, including the British army executing 346 afflicted soldiers on the
grounds of cowardice, the British discouraging diagnoses of shell shock in order
to reduce the number of cases, and the Austrians using an experimental
treatment named faradization, where an electrical current is applied to stop
tremoring (Crocq 51). With the influx of war syndromes came treatments for
soldiers and more attention from the public, but the attention became a double
edged sword for these soldiers during this time.
https://www.youtube.com/watch?v=IWHbF5jGJY0
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Figure 3: A video of several soldiers afflicted by shell shock/war neuroses. Their physical
symptoms made it difficult for them to live a normal life. The effects of treatment can also be
seen on some of the soldiers. The picture comes from the video and shows a man afflicted by
hyperthyroidism and Von Graefe’s Sign, the latter of which is responsible for the man’s wide open
eyes.
PTSD finally became an official term in 1980 after the Vietnam
War. During the Vietnam War, about 700,000 American soldiers suffered from
another war syndrome labeled post-Vietnam syndrome (Hyams 400). This, like
all the other syndromes before it, was a short-term stress disorder found in some
soldiers after a battle. The difference between this war and those before it was
the presence of more data. Europeans collected tons of data on the survivors of
WWII, which happened over a decade before the Vietnam War. Meanwhile,
Americans had been collecting information on survivors of the Korean War,
which happened between WWII and the Vietnam War (Croqc 52-53; Hyams
400). The most important information gathered from all these studies is how the
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syndrome still persisted in some individuals long after the war ended. As a
result, Americans created a new term in 1980 that would become the official term
for persistent war syndromes throughout the world: Post-Traumatic Stress
Disorder.
The definition for PTSD evolved through time, starting from 1980 until as
recently as 2013. Doctor Matthew Friedman from the Department of Veteran
Affairs provides an extensive summary of the evolution of PTSD’s definition
through a few versions of the Diagnostic and Statistical Manual for Mental
Disorders (DSM) written by the American Psychiatric Association (APA).. The
APA first created PTSD in the third edition of DSM in response to observations
from WWII, the Korean War, and the Vietnam War.
The most obvious
importance is the creation of the term, but the next most important aspect was
recognizing that the victim must have been exposed to a traumatic event “outside
the range of usual human experience,” with examples such as war, torture, and
rape (Friedman). Then, in 1994, the APA released the fourth edition of DSM,
which revised the definition of PTSD to include a few more criterion: exposure to
traumatic events, intrusive memories of the event, avoiding anything related to
the event, hyperarousal symptoms, and details on stress and the duration of
these symptoms. Finally, the fifth edition of DSM was released in 2013, which
included the same criterion as DSM-IV but with more specifics. In particular, the
duration of the symptoms must be at least one month long, the symptoms must
not be caused by medication, the victim must experience many negative
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emotions and thoughts, and the victim must be in some type of distress
(Friedman). Thus, the fully modern definition of PTSD was created.
Through the evolution of the definition of PTSD, it is apparent that human
society has become more educated about PTSD. When large numbers of war
syndromes first appeared in WWI, society became suspicious of the soldiers as
people accused the soldiers of being cowards and trying to skirt their
duties.
Now, society has an official definition for these syndromes and
recognizes that PTSD is a traumatic disorder that causes undue suffering in
soldiers. Some countries thought that this disorder could be treated with
something as simple as milk, chocolate, and some rest, or just some electricity
applied to the person (Crocq 50,52). Now, we recognize that it takes a lot of
therapy, possibly some medication, and rest over a long period of time
(Friedman). All this research and information about PTSD is evidence of how
much more educated society has become about combat-induced PTSD.
As a result of more advanced research on PTSD, its effects upon the
afflicted veteran and people related to him or her have become more
apparent.
According to Jitender Sareen, a professor of psychiatry and
psychology, the individual veteran can be plagued by a large variety of
detrimental effects. These effects include comorbidity with alcohol dependence,
major depressive disorder, and sleep disturbances. Then, these effects cause
more major problems for the veteran, such as interpersonal problems, parenting
difficulties, and suicidal tendencies (Sareen). These directly affect the veteran,
but there are also indirect effects on the family and friends of the
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veteran. Depression, suicide, and parenting difficulties indirectly affect family
and friends of the veteran through grief and stress, especially if the veteran
commits suicide. Thus, one case of PTSD can jeopardize the welfare of the
veteran
and
at
least
one
person
related
to
that
veteran.
Figure 4: Vietnam, like many other wars, had a lot of harsh fighting that resulted in a massive
number of soldiers wounded, maimed, and/or killed, events more than traumatic enough to cause
PTSD. This picture by war photographer Henri Huet shows an injured medic tending to another
soldier. Source: Huet
One example that showcases the far-reaching effects of PTSD and
reveals the hypocrisy of society can be found through Vietnam veterans. An
extremely long study named the National Vietnam Veterans Longitudinal Study
concluded in 2015 after 25 years of research. It found that, over 40 years after
the end of the Vietnam War, 271,000 veterans, or about 26% of veterans still
alive from the war, still have full PTSD. About one-third of those with PTSD are
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also suffering from comorbid major depression (Marmar 875). The study also
found that there is a near 20% death rate in this group because of PTSD. On top
of that, two times the veterans with PTSD are deteriorating in condition when
compared to those improving (Marmar 880). The war caused what is turning out
to be a lifelong crippling trauma for almost 300,000 veterans, with an alarmingly
large percentage of these veterans’ lives worsening to the point of
death. Society’s failure to properly treat these veterans is basically inhumane
because society has failed to prevent a lifetime of suffering and thousands of
early deaths. The inhumane inaction of society is made more apparent when the
context of the Vietnam war is considered: that is, during the Vietnam war and
towards the end, anti-war sentiments were extraordinarily high to the point of
men burning their draft cards and the war being dubbed the “most unpopular war
in the nation’s history.” (American Pageant 935-936) The hypocrisy should be
apparent as US society showed vehement opposition to the war, yet a significant
percent of the afflicted veterans did not receive the maximum care possible.
The Iraq war, which ended in 2014, is a more
modern example of the problems associated with
PTSD. According to an article by the RAND corporation
summarizing a small portion of its own 500-page study,
300,000 veterans of the Iraq War reported symptoms of
PTSD, yet only 53% sought treatment. Then, among
those who sought treatment, only half received what is
considered the minimum adequate treatment (One in
Figure 5: This soldier has
been maimed by a bullet through his
eye. He was only 28 years old at the
time of this photograph. Injuries as
severe as this are more than capable
of causing PTSD in veterans. Source:
Adams
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Five). After the veterans’ sacrifices to protect the United State’s interests and
freedom, the least society can do is take care of the veterans. Instead, only
about 75,000 of afflicted veterans received the bare minimum care, leaving at
least 200,000 veterans to suffer. This is another display of inhumanity by our
society because the majority of these veterans are suffering with little to no
additional effort put forward by society. It is even more atrocious that society
allowed almost 150,000 veterans to deal with PTSD on their own instead of
seeking them out and giving them the tools to heal from their wounds.
A common treatment method for PTSD is mass prescribing medication;
however, this practice can cause serious problems for society. According to a
report by the Citizens Commission on Human Rights International, 80% of
veterans with PTSD in 2011 were prescribed medication, and 89% of those
veterans were prescribed antidepressants (Citizens Commission 15).
The
evidence points to a mass prescription of medication and antidepressants to
thousands upon thousands of veterans. The antidepressants are a strange
choice, given that less than 89% of veterans will develop comorbid
depression. Additionally, between the years of 2001-2012, the government spent
billions of dollars on medication (Citizens Commission 16-18), with almost $2
billion used by the VA and resulting in no fewer hospitalization rates for mental
disorders (Citizens Commission 17). The same report also featured the Food
and Drug Administration’s MedWatch system, which collected 14,733 reports
between 2004 and 2012 on violent side effects of psychiatric drugs (Citizens
Commission 7). These reports reveal a potentially bleak future for society
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because not only are billions of dollars being used on a single treatment method
that may not be successful in treating every veteran, but some of the drugs may
actually
cause
veterans
to
become
more
aggressive
towards
other
citizens. PTSD is therefore a serious problem everyone should care about
because there will inevitably be more veterans with PTSD as more wars occur,
which will only make these money and violence problems become worse.
The personal story of Army Specialist Scott Barber, a veteran of the Iraq
War with PTSD, illustrates another danger of mass medication prescriptions:
sudden death. According to him, he had been taking medication and felt worse
than before. In response, the VA prescribed him more until he was taking a
combination of seven drugs, including antipsychotics. Then, sometime around
Christmas, he suddenly died from having too many drugs in his body at once
(Costello). Luckily for him, he was revived in the back of an ambulance to tell his
story. However, not all veterans are as lucky as he was. In Barber’s case, he
actually felt worse when he used the medication. This should have been a red
flag to stop the medication, but the VA gave him more types of medication
instead of looking deeper into his case. This falls under not meeting the
minimum adequate treatment because he actually died from the efforts put forth
by the VA. Fortunately, he is hopeful for the first time since he has been
discharged from duty because he joined what is essentially a support and
therapy group. His story is one of many that reveals how all the money being
spent on medication may not be necessarily treating veterans.
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Combat-induced PTSD is only one of many types of PTSD, yet it poses a
potentially large financial problem and a significant humanitarian issue for us
all. Money will continuously be thrown at the problem, but more surgical uses of
money and compassion will be needed to truly curb the problem. As more wars
are fought, more veterans will inevitably be created along with tens of thousands
of additional cases of PTSD. As society reaps the benefits of freedom and
safety, many veterans are still stuck in the chains of PTSD. As the people who
benefit from their work, we have an obligation to bring them a better future or we
risk leaving behind our humanity and living at the expense of other people’s
suffering once again.
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Bibliography
Abusch, Tzvi. "The Development and Meaning of the Epic of Gilgamesh: An
Interpretive Essay." Journal of the American Oriental Society, vol. 121,
no.4, Winter 2001, pp. 614-22.
Adams, Bryan. “We must always honour our dead. But today let’s also
remember war heroes who can never forget: Rock legend Bryan Adams,
who took this powerful image, argues it has a vital message for us all.”
Daily Mail, 9 Nov. 2013.
Citizens Commission on Human Rights International. A REVIEW OF HOW
PRESCRIBED PSYCHIATRIC MEDICATIONS COULD BE DRIVING
MEMBERS OF THE ARMED FORCES AND VETS TO ACTS OF
VIOLENCE & SUICIDE. Rep. Department of Veteran Affairs, Apr. 2014.
The report created by the nonprofit organization Citizens Commission on
Human Rights International is a collection of statistics on medication
prescriptions and violent tendencies in the 21st century. The statistics
generally come from the Department of Veteran Affairs, so the data is
trustworthy. It also features numerous expert opinions ranging from the
effectiveness of certain drugs to accusations of the DSM handbook
defining PTSD in such a way that implies medication can solve the
problem. There are also other quotes explaining things such as that
PTSD is not a mental disorder based on chemical imbalances, or that the
definition is based on a biological model of disease. The usefulness of
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this source is through the statistics on violence and the amount of
medication prescribed because they tell a story of unintended harm. The
recent statistics is also vital to my argument that PTSD is still a prevalent
problem. The only problem is that there is no counterargument in the form
of statistics that go against the trend.
Costello, Carol. "Costello: Are We Treating PTSD Veterans the Right Way?"
CNN. Cable News Network, 23 July 2015.
Croqc, Marc-Antoine, and Lous Croqc. "From Shell Shock and War Neurosis to
Posttraumatic Stress Disorder: A History of Psychotraumatology."
Dialogues in Clinical Neuroscience, vol. 2, no.1, March 2000, pp. 47-55.
This article is written by two psychiatrists, and it provides a timeline and
history of many war syndromes that were the precursors to combatinduced PTSD, such as shell shock and war neurosis. The article starts
off with the oldest potential form of a PTSD-like syndrome and makes its
way to the Vietnam war. It also goes over some of the methods doctors
used back then in attempts to treat the PTSD-like syndromes. Throughout
the article are pieces of information that explain society’s general feeling
towards the war syndromes and those affected by it. This is the most
important historical artifact here because not only does it contain the
history of PTSD, it contains the opinions of society from the past. The
timeline and opinions show the evolution of views on PTSD up to relatively
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modern day, and it also tells the story of how humankind came to
recognize PTSD as an important issue to face.
Friedman, Matthew J. "PTSD History and Overview." PTSD: National Center for
PTSD. U.S. Department of Veteran Affairs, 23 Feb. 2016.
This informational page from the Department of Veteran Affair’s website is
written by Dr. Matthew Friedman. The page is mainly the summary and
history of when PTSD was officially recognized in the Diagnostic and
Statistical Manual of Mental Disorders, a widely trusted source of
information on mental disorders. The article describes the evolution of
PTSD to encompass more than just the version obtained from combat
exposure. It also details the evolving criteria for defining types of PTSD,
revealing the increase in knowledge and interest on the disorder. The end
of the page has many shallow dives into different topics related to PTSD,
such as the most effective treatments for it and pressing questions that
have yet to be answered. The most significant detail on the page is a very
trustworthy and lengthy definition on PTSD. The next most important
aspect is the recent history of the term PTSD since it shows the increasing
knowledge of society on the subject.
Huet, Henri. “ID 6601010827.” Associated Press, 30 Jan. 1966, Vietnam.
Hyams, Kenneth C., Robert Roswell, and Stephen F. Wignall. "War Syndromes
and Their Evaluation: From the U.S. Civil War to the Persian Gulf War."
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War Syndromes and Their Evaluation: From the U.S. Civil War to the
Persian Gulf War, vol. 125, no. 5, pp. 398-405. 1 Sept. 1996.
This is another history and timeline of the disorders before PTSD was
formally defined. It is very similar to the article written by Croqc, except
that this one includes the American Civil War and the Persian Gulf War
and excludes the thoughts of scholars from before the 1800s. It also
compares and contrasts each disorder in its own section, and there is a
conclusion and some commentary by the author at the end. Hyam and
Croqc’s articles have very similar information, but Hyam’s is more focused
on searching for the similarities between the numerous war syndromes
and a war syndrome prominent during the time the article was
written. The important aspect used here was the table of war syndromes
because it visually showcases the similarities between each war
syndrome and PTSD. The similarities between the syndromes explains
one reason why PTSD was invented as a term: because there are too
many terms with very similar circumstances and effects, all of which could
be congregated under one term. The only downside is the age of the
article because there was not as much research on PTSD than there is
now.
Jones, Edgar. “Shell shocked.” American Psychological Association, vol. 43, no.
6, June 2012, pp. 18.
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Kennedy, David M., Lizabeth Cohen, and Thomas A. Bailey. The American
Pageant: A History of the Republic. 12th ed. Boston: Houghton Mifflin
Company, 2001.
Marmar, Charles R, et al. "Course of Posttraumatic Stress Disorder 40 Years
After the Vietnam War." Jama Psychiatry, vol. 79, no. 9, pp. 875-81. 22
July 2015.
This longitudinal study done by a huge number of psychiatrists follows up
on Vietnam War veterans 40 years after the war and determined that
those with PTSD from the war generally got worse. The article is mostly
spent detailing the methods used to find the very specific statistics of
specific groups of veterans regarding PTSD rates and comorbidities. In
the end, the article urges for policy changes for the current treatment
system in order to account for the minority of veterans like this group who
become worse over time instead of getting better. The study is concrete
evidence that PTSD can last a lifetime since these veterans, who would
be at least 58 years old, still have PTSD 40 years later. The statistics
here are used as evidence to show that combat-induced PTSD in soldiers
is a problem for society’s humanity because society’s failure to treat PTSD
fully after four decades is a massive disservice to the veterans, especially
after everything the veterans did for the country.
"One In Five Iraq and Afghanistan Veterans Suffer from PTSD or Major
Depression." Rand Corporation, 17 Apr. 2008.
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The article is a small summary of certain aspects of the first
comprehensive study on PTSD from Iraq War veterans by the Rand
Corporation. The article is written by the Rand Corporation itself. The
article contains very important statistics, notably that 300,000 soldiers
from the very recent Iraq war reported PTSD, about half sought treatment,
and half of those got what is considered adequate treatment. It also
quantifies the cost of PTSD in terms of money and includes an expert’s
opinion on what may happen if PTSD isn’t treated efficiently. The
information above is used to describe the potentially serious problems that
can arrive from not efficiently treating afflicted veterans. It is also proof of
how inefficient our current system is, although it is much better than the
past. Finally, it is a more quantitative approach to the problem posed by
PTSD.
Sareen, Jitender. "Posttraumatic Stress Disorder in Adults: Impact, Comorbidity,
Risk Factors, and Treatment." The Canadian Journal of Psychiatry, vol.
59, no. 2, May 2014, pp. 460-67.