Military Veterans PTSD Reference Manual - Chapter 1

Veterans PTSD Reference Manual


Chapter 1 (Complete Chapter)

History and Definitions of PTSD

Section I. GENERAL

01-01. General. Since you are reading this manual one of the followings things is probably taking place:

a. You think you may have Post Traumatic Stress Disorder (PTSD).

b. You are being treated for PTSD.

c. You know someone who has PTSD.

Before you begin this journey you need to know what Post Traumatic Stress Disorder (PTSD) is.

Less than a year ago I did not know what PTSD was and I believed that Veterans who claimed to have PTSD were using their claims to shield them from the consequences of their own stupidity or alcohol/drug abuse. Boy was I wrong.

In this chapter I will present a brief history of PTSD and define PTSD in language you can understand so that;

a. You can determine whether or not you may be afflicted with PTSD.

b. When the time comes you will be better equipped to express your symptoms to your doctor, justify your claim in your stress letter, and explain your condition to your interviewer.

Section II. HISTORY

01-02. General. Prior to the studies done on Vietnam veterans, there were very few scientific studies of what we today call Post Traumatic Stress Disorder (PTSD).

01-03. The 1800ís. During the early 1800ís military doctors began diagnosing soldiers with "exhaustion" following the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Like today, soldiers during the 1800ís were not supposed to be afraid or show any fear in the heat of battle. The only treatment for this "exhaustion" was to bring the afflicted soldiers to the rear for a while then send them back into battle. Through extreme and often repeated stress, the soldiers became fatigued as a part of their bodyís natural shock reaction.

During that time, in England, there was a syndrome know as "railway spine" or "railway hysteria" that bore a remarkable resemblance to what we call PTSD today, exhibited by people who had been in the catastrophic railway accidents of the period. In 1876 DR. Mendez DaCosta published a paper diagnosing Civil War combat veterans with "Soldiers Heart": The symptoms included startle responses, hyper-vigilance, and heart arrhythmiaís.

01-04. The 1900ís. During WWI overwhelming mental fatigue was diagnosed as "soldierís heart" and "the effort syndrome". An article published on a now restricted Internet web site maintained by Med. Access entitled "Chronic Fatigue Syndrome" states that "...some 60,000 of the British forces were diagnosed with the problem and 44,000 of these were retired from the military because they could no longer function in combat". (www.medaccess.com/cfs/cfs_02.htm (this page is no longer accessible without a password))

The term "shell shock" emerged during WWI followed in WWII by the term "combat fatigue." These terms were used to describe those veterans who exhibited stress and anxiety as the result of combat trauma. The official designation of "Post Traumatic Stress Disorder" did not come about until 1980 when the Third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published.

01-05. The Diagnostic and Statistical Manual of Mental Disorders (DSM). This "bible", published by the American Psychiatric Association (APA) provides the "official" definition of all mental illnesses. When first published in 1952 what we now know as PTSD was called "stress response syndrome" and was caused by "gross stress reaction".

In the second edition (DSM-II), 1968, trauma-related disorders were lumped together in an area called "situational disorders". Mrs. Patience Mason, author of Recovering From The War: A womanís Guide to Helping Your Vietnam Veteran, Your Family, And Yourself, points out that those Vietnam Veterans treated for the disorder during that period were informed that if their symptoms lasted more than 6 months after their return from Vietnam they had a "pre-existing" condition, making it a "transient situational disorder", and the problem was not service connected. This resulted in a lot of "walking wounded" and I am certain attributed to the high suicide rate suffered by Vietnam Veterans of that time.

Finally, in the third edition, 1980, DSM-III the title "Post-traumatic Stress disorder" was used and placed under a sub-category of "anxiety disorders". In the current edition, 1994, DSM-IV, "Post-traumatic Stress Disorder" is again used but has been placed under a new "stress response" category and remains in the "anxiety disorder" category.

You may have noticed above that what started out as a "syndrome" turned into a "disorder". According to Taberís Cyclopedic Medical Dictionary a "syndrome" is "a group of signs and symptoms that collectively characterize or indicate a particular disease or abnormal condition" and a "disorder" is an illness. PTSD changed from being part of a collective indicator to a singular illness, a significant medical distinction.

With few exceptions, up until DSM-IV, most combat veterans were diagnosed with "shell shock", which didnít warrant long term treatment. Other combat veterans were merely diagnosed with "bad nerves" which not only didnít warrant long term treatment, but also induced a "get over it" attitude from the military and medical communities. This type attitude was personified in the movie "Patton" when General Patton, played by George C. Scott, threatened apparently uninjured military hospital patients with malingering.

The initial definition of PTSD described a psychological condition experienced by a person who had faced a traumatic event which caused a catastrophic stressor outside the range of usual human experience (an event such as war, torture, rape, or natural disaster). This definition separated PTSD stressors from the "ordinary stressors" that were characterized in DSM-III as "Adjustment Disorders", such as divorce, failure, rejection and financial problems.

Section III. DEFINITIONS

01-06. American Psychiatric Definition. The following is a quote, references to children excluded, from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Washington, DC, American Psychiatric Association, 1994, section 309.81, beginning on page 427. All supplemental information, in parenthesis and bold, is from The Post-Traumatic Gazette, edited by Mrs. Patience Mason:

This disorder is described as occurring when:

"A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self (i.e. combat, friendly fire, being mortared or rocketed, wounded, captured, driving a truck on a mined road, flying in a helicopter that was shot at, jumping our of a helicopter into a hot LT) or others (if you had a buddy who was wounded or lost squad members, family member, or seeing anyone who has recently been killed or injured such as being a medic or nurse on a trauma ward, body bagging, seeing someone you didnít know killed, seeing kids, women or other Americans or civilians who had been killed, or wounded, etc.)

(2) the person's response involved intense fear, helplessness or horror."

According to the DSM-IV, " B. The traumatic event is persistently reexperinced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

(2) recurrent distressing dreams of the event.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three (or more) of the following:

(1) efforts to avoid thoughts, feelings or conversations associated with the trauma (If you try not to think about the war or if you try not to feel love because you lost a beloved buddy, try never to feel guilt because you think you fucked up over there, try never to be happy because you were ambushed when you were feeling fine, trying never to get angry because youíre afraid of what you might do)

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma (never watch war movies, donít hunt, donít go to veterans day parades or associate with other vets, canít stand authority figures because of the REMFís or the lifers, etc.)

(3) inability to recall an important aspect of the trauma (particular battles or periods of time that you canít remember or whether those guys were killed or just wounded)

(4) markedly diminished interest or participation in significant activities (what did you used to do that you donít since your PTSD came on? Lots of guys with PTSD stay home watching TV which is this symptom. Others still get out but theyíve given up hunting, or going places where there are crowds or whatever)

(5) feelings of detachment or estrangement from others (No one can understand what itís like. Iím on the outside looking in at all these people who havenít a clue. I donít care about things or people the way I used to)

(6) restricted range of affect (e.g., unable to have loving feelings) (unable to cry when parent dies or kid dies, told you have no feelings, canít feel love for wife, etc.)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or even a long life span)." (may be still driving drunk or stoned, still jumping out of airplanes or taking other risks, afraid to commit to anyone or anything, etc.)

The Diagnostic criteria in section 309.81, DSM-IV, goes on the state:

"D. Persistent symptoms of increased arousal (not present before the trauma), as

indicated by two (or more) of the following:

(1) difficulty falling or staying asleep;

(2) irritability or outbursts of anger;

(3) difficulty concentrating (Read a page and canít remember it? Forget what your wife just told you or constantly hear "I told you that yesterday!" Feel dumb because you donít follow a lot of conversations, etc., or just canít focus because part of you is scanning for danger all the time?)

(4) hypervigilance (always looking for danger, worrying about people getting hurt, still looking for tripwires and sitting with your back to the wall, avoiding crowds, etc.)

(5) exaggerated startle response (hit the dirt at the sound of a backfire, canít be touched when asleep, etc.)

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:

With Delayed Onset: if onset of symptoms is at lease 6 months after the stresssor"

(Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association.

Experiencing any or all of these symptoms does not mean you are "crazy," but that you are suffering the normal effects of trauma brought on by an abnormal event.

01-07. Department of Veterans Affairs Definition, The Short Version. The VA Home Page on the Internet says:

In order to establish service connection for PTSD, the evidence must establish that during active duty a veteran was subjected to a stressor or stressors that would cause characteristic symptoms in almost anyone. Evidence of combat or having been a prisoner of war may be accepted as conclusive evidence of a stressor incurred during active duty. Evidence of combat includes receipt of the Purple Heart, the CIB, or other similar citation. The medical evidence must establish a clear diagnosis of PTSD and must link the current symptoms to the claimed stressor. (www.va.gov/benefits/ptsdwhat.htm)

01-08. Department of Veterans Affairs (VA) Definition, The Technical Versions. The following, issued by the Department of Veterans Affairs (VA) in the Code of Federal Regulation (CFR), part 38, offers the "official" definition you will be most concerned with:

a. "Post-Traumatic Stress Disorder. 3.304 (f) Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. Additionally, if the claimed stressor is related to the claimant having been a prisoner-of-war, prisoner-of-war experience which satisfies the requirements of 3.1(y) of this part will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor."

b. "Mental Disorders - 4.125 General considerations. The field of mental disorders represents the greatest possible variety of etiology, chronicity and disabling effects, and requires differential consideration in these respects. These sections under mental disorders are concerned with the rating of psychiatric conditions, specifically psychotic and psychoneurotic disorders and psychological factors affecting physical conditions as well as organic mental disorders. Advances in modern psychiatry during and since World War II have been rapid and profound and have extended to the entire medical profession a better understanding of and deeper insight into the etiological factors, psychodynamics, and psychopathological changes which occur in mental disease and emotional disturbances. The psychiatric nomenclature employed is based upon the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM - III), American Psychiatric Association. This nomenclature has been adopted by the Veterans Health Services and Research Administration of the Department of Veterans Affairs. It limits itself to the classification of disturbances of mental functioning. To comply with the fundamental requirements for rating psychiatric conditions, it is imperative that rating personnel familiarize themselves thoroughly with this manual (American Psychiatric Association Manual, 1980 Edition) which will be hereinafter referred to as the APA manual.

4.126 Substantiation of diagnosis. It must be established first that a true mental disorder exists. The disorder will be diagnosed in accordance with the APA manual. A diagnosis not in accord with this manual is not acceptable for rating purposes and will be returned through channels to the examiner. Normal reactions of discouragement, anxiety, depression, and self-concern in the presence of physical disability, dissatisfaction with work environment, difficulties in securing employment, etc., must not be accepted by the rating board as indicative of psychoneurosis. Moreover, mere failure of social or industrial adjustment or the presence of numerous complaints should not, in the absence of definite symptomatology typical of a psychoneurotic or psychological factor affecting physical condition, become the acceptable basis of a diagnosis in this field. It is the responsibility of rating boards to accept or reject diagnoses shown on reports of examination. If a diagnosis is not supported by the findings shown on the examination report, it is incumbent upon the board to return the report for clarification. (CFR 38)."

01-09. The European Description. If you are not confused enough have a look at the description offered by the World Health Organization in Geneva. The good part is that PTSD is now recognized world-wide as a "real" disorder. The bad part is found in their "Diagnostic Guidelines". What follows is an exact from their Internet Home Page:

"Post-Traumatic Stress Disorder

F43.1 This arises as a delayed and/or protracted response to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or other crime)Ö.

Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks") or dreams, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to itÖ.

The onset follows the trauma with a latency period which may range from a few weeks to months (but rarely exceeds 6 months). The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of patients the condition may show a chronic course over many years and a transition to an enduring personality change.

Diagnostic Guidelines

This disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. A "probable" diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder (e.g. as an anxiety or obsessive-compulsive disorder or depressive episode) is plausibleÖ.."

ICD-10 copyright 1992 by World Health Organization

Internet Mental Health (www.mentalhealth.com) copyright 1995-1997 by Phillip W. Long, M.D.

Section IV. PERSONAL EXPERIENCE

01-10. The Eye Opener. When I finally forced myself to go to a VA Clinic I was in a very high state of anxiety and depression had already begun to set in. I had had a bout with depression shortly after retirement so I was aware of some of the signs. I had never experienced a high state of anxiety before and did not even know what PTSD was. Some of you will have the same symptoms, most will not. Since my diagnosis I have been talking to more of my veteran friends about PTSD and finding out that most, if not all , of them have it to some degree and many of them have been under counseling for some time but had not spoken to me, or anyone else, about it because they thought their friends would think they were feigning illness.

SITREP- WWII Era (1939):

The cyclotron of John Ray Dunning splits an atom for the first time in America; The first commercial transatlantic passenger air service begins; New Yorkís La Guardia Airport opens; The first American made helicopter is flown; Hewlett-Packard is founded; FM radio receivers go on sale for the first time; "Batman" is launched by DC Comics; the books The Grapes of Wrath and How Green Was My Valley are released; the movies "Gone With The Wind" and "Drums Along the Mohawk" are released; the songs "Iíll Never Smile Again" and "South of the Border (Down Mexico Way)" are released; the New York Yankees win the World Series by defeating the Cincinnati Reds 4 games to 0.

SITREP - WW II Era (1940):

Winston Churchill succeeds Neville Chamberlain as Britainís prime minister; the first peacetime military draft in U.S. history begins October 29; President Roosevelt wins reelection to third term with 54 percent of popular vote; the first Social Security checks go out January 30; the new Chevrolet coupe sells for $659; the book For Whom the Bell Tolls, is written by Ernest Hemingway; the Broadway play Pal Joey opens at the Barrymore theater; the songs "The Last Time I saw Paris" and "You Are My Sunshine" were released; the Cincinnati Reds win the World Series by defeating the Detroit Tigers 4 games to 3.

This page last updated on 06-01


© Msg. I. S. Parrish, USA Retired