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Kapcia 1 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 Kapcia 2 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 Kapcia 3 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 Kapcia 4 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- Kapcia 5 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 Kapcia 6 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 Kapcia 7 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 Kapcia 8 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 Kapcia 9 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 Kapcia 10 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 Kapcia 11 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 Kapcia 12 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. Kapcia 13 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. Kapcia 14 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 Kapcia 15 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 Kapcia 16 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." Kapcia 17 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. Kapcia 18 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. Kapcia 19 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.