Combat-Related Posttraumatic Stress Disorder (PTSD): A Basic Primer
Suffering posttraumatic stress is not a sign of weakness but rather an expected consequence of war. With that said, the degree and nature of the impact of trauma varies wildly from person to person and experience to experience. For some, the impact is immediate and sometimes requires removal from combat settings. For the majority of combatants, the signs and symptoms of PTSD slowly emerge over the course of many years.
PTSD is a “for life” condition with no cure, as the memories of combat will always exist and will always be emotionally charged. On a positive note, PTSD is very manageable and is known to respond to psychoeducation and therapy. Medications and other treatments are often employed, but these treatments are not considered first line treatments except with some severe cases or cases that involve multiple mental health conditions.
Before getting into the standard signs, symptoms, and treatment of PTSD, it is important to know a little more about the opening stages of PTSD and common functional complications. One aspect that is often overlooked in the literature is the utility of the emotional numbing and detachment associated with the condition.
PTSD: A Friend?
PTSD starts out as a friend to combatants. Why? It begins with the trauma itself and an emotional separation from the horrific event that is occurring. The experience is best described as surreal. When faced with death and/or serious injury to self or others, people often feel fear or horror. That said, they are often able to separate themselves enough and avoid processing what they are witnessing in order to maintain control of their behavior. This allows them to complete the job they are there to perform without an overt emotional response that could endanger the lives of themselves and others in the engagement zone. They should be scared beyond definition, but there is no time for that in combat.
This is why military personnel are asked to repeat drills and exercises at their stateside bases on a non-stop basis. I hated these drills when I served, and I never appreciated the rationale… until I did. The goal of the military machine is to prepare individuals to perform their duties even when injured and/or discombobulated. This is known as achieving “fingertip knowledge” of each person’s identified role which is achieved through repetitive learning. The machine needs everyone to know their duties without having to think too much while taking on enemy fire.
Standard Operating Procedure: The Black Box and Post Combat Life
During months of combat deployment, the ability to detach from combat experiences and related emotions becomes second nature. Even after leaving the danger zone, the combat veteran often maintains that detachment, as reliving the memories and horror of military trauma is just too much. However, those curbed experiences are not discarded from memory. In fact, all details of the traumatic experience - the sights, sounds, smells, and other sensations - are recorded in such detail. These in-theater experiences are stored in the “black box” of traumatic memories in the dark net of the veteran’s mind, often outside conscious awareness. One could say that the veteran’s mind is protecting him or her from that trauma.
As the veteran returns from combat and are asked to complete a PDHA (Post Deployment Health Assessments) during post-deployment processing (back stateside), medical and behavioral health staff hope to get a jump on the eventual stress. These efforts are often thwarted, however, as the trauma suffered APPEARS to be safely tucked away in that black box. Still more, keeping things in that box seems prudent, as the contents are understood as horrific events best left in country. Matters are not helped by the unspoken understanding that behavioral health referrals are considered career killers by service members.
Once stateside, the combat veteran begins to re-engage in his or her community. This is where the timing and severity of post-combat stress symptoms varies dramatically from person to person. With that said, most service members report a noticeable change in their experience of life after war. Small things in their daily routine, once benign, suddenly trigger a new experience of internal discomfort, anxiety, fear, depression, and/or anger. This continued difficulty in re-engagement is often accompanied by impairments in social, marital, and familial relations and occupational functioning.
Consider the following example:
Sgt. Tucker and his wife are headed to a nearby lake on a beautiful weekend day and decide to stop at a gas station for a drink. Sgt. Tucker walks into the store in a happy, relaxed mood. He returns to the car with his drink but begins to curse at his wife because of a napkin on the floor in the car. Perplexed, his wife stares at him wondering what just happened. This only serves to enrage Sgt. Tucker who begins saying things to his wife he never imagined he would. He observes himself acting irrationally and out of control and slips into a shame spiral. There are feelings of humiliation, decreased self-worth, and depression.
Unknown to both Sgt. Tucker and his wife is the fact that he was triggered by something in the gas station that caused his mood shift, anxiety, and meltdown. The word “trigger” is a formal way of saying that the black box, the one tucked away in the subconscious, gets plucked from time to time by various things in stateside environments. Let’s say that the trigger in this example was a child wearing a Pittsburgh Steelers shirt in the gas station. Although Sgt. Tucker had no idea at the time, his black box was plucked (triggered) by remembering Joey from Ohio. Joey was a soldier with whom Sgt. Tucker served. Joey was a big Steelers fan and would talk about his team to anyone who would listen until an IED cut him into pieces. Sgt. Tucker’s unit was tasked with collecting his body parts. Sgt. Tucker’s conscious mind does not recall that trauma at the time because he has that black box of traumatic memories in lockdown. Outside of his conscious awareness, Sgt. Tucker recalls Joey’s death which stimulates activation of psychological and biological systems associated with PTSD.
PTSD: The Psychological Fueled by a Hard-Wired Biological
The psychological component of PTSD is best conceptualized as an anxiety condition on steroids. PTSD is an anxiety condition, and anxiety is a fear-based condition. A chronic fear of unknown threats lurking nearby is fueled by combat experiences that leave most veterans believing that this is a dangerous world. In terms of the psychological seed of PTSD, it can be described as a mushroom that thrives in darkness. Knowledge is the antidote.
To understand the biological part, it is important to know what happens to your brain and body when faced with danger. When your brain perceives danger, a series of events very quickly occurs. To summarize, your store of adrenaline is dumped into your body, and this also triggers the release of another hormone, cortisol. Nearly immediately, you perceive a jolt of energy, your heart rate increases, your pupils dilate, digestion slows, and blood is quickly pumped into your large muscle groups. Other effects also occur, and these events effectively prepare your body to fight or run. As a result, you become temporarily more focused, strong, and able to defend yourself or flee. It is a beautiful process that we share with most other animal groups and helps us survive. Emotionally, this can feel like fear or even anger.
Humans have another process that often occurs shortly after the fight-or-flight response is triggered. Our frontal lobe, which is the “smart” part of our brain involved in decision-making and other executive processes, helps us to make decisions about the danger. For example, you might become enraged at someone at a bar, causing you to puff up and triggering the fight-or-flight response. Fortunately, your frontal lobe kicks in, you reason out the situation, and you ultimately decide that a bar fight tonight just is not worth it.
The biological part of PTSD/anxiety is most simply understood as the outcomes of communication between the frontal lobe (our smart brain also known as the executive processor) and those parts of the brain involved in the fight-or-flight response (we’ll call this our “ape brain”). Combat veterans trust their ape brain, because listening to it meant life or death in warzones. There was no time for reasoning, only action. The problem is that, in individuals with PTSD, the fight-or-flight response is easily triggered by things that are not objectively dangerous but subconsciously remind them of a prior traumatic experience. While this fight-or-flight reaction is quite helpful in country, these sudden unexplained biological responses at their son’s little league game or at Walmart are exhausting and psychologically stressful. Many veterans find themselves avoiding going out because of these reactions.
Remember when I mentioned that memories of trauma are stored in detail, even if the combat veteran cannot actively recall the experience? There is a good survival reason we keep those memories – so that we can instantly identify similar danger in the future and act even more quickly. If a deer is attacked by a coyote and survives, that deer becomes hyper-aware of any sign a coyote is near and can avoid it more quickly. It may be a certain scent, a pattern of rustling in the leaves, or movement detected in the periphery. That’s just survival. In PTSD, however, these “signs” extend to things that trigger traumatic memories and result in fear but are not objectively dangerous, such as the sound of a firecracker on July 4 or even a heavy rainstorm.
Without treatment, Sgt. Tucker’s life becomes a scattered series of odd mood swings and biologically fueled anxiety attacks with no clear rhyme or reason. As he encounters more and more triggers leading to more outbursts, shame spirals, and fear of the world around him, Sgt. Tucker begins to feel hopeless. Left untreated, the onset of another condition, depression, is common as persons feel powerless to control their symptoms and life. Furthermore, the use of alcohol is a common self-treatment that is more acceptable in military culture than seeking behavioral health treatment. Substance abuse risk is high for PTSD populations.
PTSD: Severity Levels
The severity of each person’s PTSD varies as does the progression of PTSD. Without treatment, PTSD may remain mild for the remainder of one’s life or it may progress from mild to moderate to severe. Severity levels are commonly determined by the depth and breadth of symptoms and understood impact on social, marital, familial, and occupational functioning. My more informal definition is as follows: With mild PTSD, persons attack or vent against safe targets such as spouses and family. With moderate PTSD, persons act aggressively against bosses, co-workers, and strangers. Maintaining employment can become difficult. With severe PTSD, persons cuss out police officers and judges, commonly suffer co-occurring conditions, and are often unemployable.
PTSD Signs and Symptoms
PTSD includes a broad range of symptoms across many criteria but is best identified as follows: combat or some form of trauma is present and is persistently re-experienced via nightmares, flashbacks, or other internal/external triggers. Post-trauma symptoms result in a fundamental change in psychological and emotional functioning such as emotional detachment, depression, suicidal thoughts, anxiety, survivor’s guilt, and anger. There is also a presence of hyperarousal symptoms which includes impaired sleep, always scanning one’s environments for threats (hypervigilance), exaggerated startle responses, and extreme irritability.
Many treatments for PTSD are evidence-based. This means that various treatments have been measured and scientifically determined to be effective in managing PTSD. When seeking treatment, people should inquire about evidence-based practices. The primary treatment tool is psychoeducation, which is a component of cognitive behavioral therapy or CBT. Other common techniques include cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR) therapy, group therapy, and medication management. With CBT and CPT, clinicians help the veteran open that black box so they can unmask the boogey man by identifying the things in their environment that trigger their symptoms. Proper treatment teaches combat veterans how to neutralize threats (and associated anxiety) by identifying the environmental cues that are linking to prior experiences. From a psycho-babble standpoint, our smart brain disarms our ape brain with knowledge, which results in reduction of anxiety, depression, and related PTSD symptoms.
In Sgt. Tucker’s case, therapy would help him to unload the Joey experience from the black box. Bringing this to his conscious mind would allow Sgt. Tucker to identify the child in the Steelers jersey as the trigger to the sudden anxiety he felt walking into the store. He would then be able to engage his frontal lobe to tell himself that he is not currently in danger, it’s just that the child triggered the fear he felt when his friend was killed in combat. The psychological fear and biological response is neutralized by knowledge. He could then employ skills, such as relaxation techniques and self-talk, to help himself calm down and enjoy the day with his wife.
Treatment Cautions and Advice
Service members and veterans are often funneled to psychiatry and group therapy treatments by the VA due to staffing shortages. Individual therapy may not be offered, but it is a crucial part of treatment. The best course of action is to begin with individual therapy to determine the breadth and severity of the symptoms. After multiple sessions, the veteran and therapist are better informed as to the need for medication. In my experience, when combat veterans finally muster the courage to seek help, the last thing they want is to be in a room full of other patients. Group therapy is an excellent adjunct to treatment; however, it may be best to wait until after the groundwork has been laid down in individual therapy. In summary, when starting the treatment process, begin with individual therapy. You should use this modality to map further treatment.
A Note to Family
Spouses and family should understand that many of the behaviors observed after combat are products of a deeply ingrained fear-based anxiety. As the symptomatic experiences described above unfold, veterans may begin to struggle with social anxiety, decreased self-confidence, and increased irritability. This is followed by relational conflict and suffering anxiety about anxiety which is followed by feelings of decreased empowerment and impaired ability to emotionally connect to others.
Wives/Husbands/Partners and family that offer unconditional love become safe targets for venting. Please do not take these events personally. Another common complaint from spouses/partners I work with is combat veterans’ refusal to discuss combat experiences. They feel like their loved ones are not trusting them with this life experience, and it ushers in feelings of resentment and hurt. The truth is, it can be difficult for combat veterans to begin dialogue about their experiences due to a lack of shared experience and a desire to keep the black box welded shut. Still more, most veterans do not know where or how to begin. A common example I offer to families is as follows: asking veterans to describe their combat experiences and feelings is like asking a mother to describe childbirth to a man. While one mother describing child birth to another mother can be accomplished with a few words and a nod, a man can never really know what that event is like. Bottom line; be patient and rest assure that your spouse/partner is not purposefully withholding or withdrawing.
If you are a combat veteran and in need of immediate help, please call the VA’s Veterans Crisis Line at 1-800-273-8255 and Press 1 for free, confidential support 24 hours a day. Families and loved ones may also call this number.