Understanding PTSD: An Overview

On this Veterans Day, I wanted to thank all the Veterans who are currently serving or have served in the past for their service. It takes a great deal of courage to sign up for the Armed Forces and allow the military to place you in whatever job and whatever country that you are needed to protect our country. Today I also wanted to talk openly about some problems treating PTSD and a simplified overview of the nature of this most dangerous but also most misunderstood diagnosis.

The words PTSD or Post Traumatic Stress Disorder have become a part of our present American culture. I hear it frequently mentioned in the news, especially regarding Veterans, and it is often mentioned as a significant contributor the Veterans the very high suicide rate which is currently quoted as approximately 20 per day. These are Veterans who often take their lives out of a desperate futility that they cannot take the emotional pain and have finally given up trying to find any meaningful solution for their chronic suffering. There are several reasons for this stunning and terribly sad phenomenon. The first is the ambivalence on the part of the Veteran to seek help. Most Vets have been told that they were weak if they sought the help of a psychologist or other behavior health professional. This is true to all branches of the service and especially true for those Veterans who want to be make the military their career. I have talked to many "Lifers" who have stayed in the service for 20+ years and asked them when they come in for an evaluation "What took you so long to come in and get help?" The answer, almost universally is the same, "Doc, if I had come in earlier in my career I would never have been allowed to advance to the next rank!" So an initial problem for Veterans is allowing themselves to ask for an evaluation and then possible treatment for whatever is emotionally distressing them (whether it be PTSD, Anxiety or Depression). So problem number 1 is that Vets are discouraged from seeking help and then they are often embarrassed when they do show up because they have been taught that it is a sign of weakness to need help and shameful to be sitting in a psychologist's office.

A second problem for Veterans is that they come back from deployment and the life they had before they went overseas later feels very different upon their return to civilian life. What makes their perception so different is that they have been exposed to a dangerous situation or even combat. This experience of being exposed to a serious threat to their lives or to those around them is that it has activated what has come to be called "The Fight, Flight, or Freeze Response".

When they see real and present danger that is a serious threat to their lives (i.e. a terrorist with a gun, RPG, or a grenade) something in their brain mobilizes an extremely rapid and powerful response that initiates a chain reaction of events that equips them to survive the threat. This response increase hear rate, tenses muscles, and pumps adrenaline almost immediately. The Veteran is suddenly aware of imminent death and prepared to do whatever it takes to live through it. In addition to the sudden physical changes in the body, the Veteran's perception also makes a immediate change to start identifying anything around them in their five senses that might be an additional threat. Every sight, sound, smell, touch or taste becomes acutely analyzed as a potential source of threat. This sudden shift in every body system means that the Veteran will never again be comfortable with deep relaxation that my have been normal before deployment. This is a life changing moment that can never be fully reversed. For the Veteran, life has suddenly changed and everything in their awareness must now be analyzed to determine if it is an important trigger of a potential ambush by deadly enemy. This shift, although it is felt as a dramatic increase in tension at every level is actually meant by the primal brain defenses (Limbic System) as a good thing. This is the ultimate act of protection. This elevated level of alertness and tension (like a coiled snake) is meant to provide the maximum protection to keep the Veteran alive least they be caught off guard. The problem is that once this shift from relaxation to Fight, Flight or Freeze takes place it is very difficult to turn off. For the Veteran it may feel like a fuse to a bomb has been lit and there is no way to turn it off. Nothing will ever be the same and all five senses will now be assigned a new task of constantly analyzing every bit of information to see if it is in any way an incoming threat or even the hint of a threat.

What seemed normal to them in their everyday lives now feels strange and even scary. There are a number of reasons for this but simply stated it is because a part of their brain has been activated by the realization that they could be killed and this realization sets off a chain reaction in their brain that changes the way they react to situations for the rest of their lives. This change is dramatic and feels irreversible (although it is quite reversible) because most Veterans do not know what is happening to their thoughts, feelings, or bodily sensations. Whereas before deployment they may have had a fun loving, carefree attitude and enjoyed socializing without a care in the world. After they return from deployment they often have great difficulty relaxing and turn to excessive alcohol or drug intake to try to calm themselves. Whereas before deployment, they could meet people easily and form trusting relationships, but after deployment, they are often very suspicious of others intentions or behaviors. As a result, the post deployment Veterans become socially isolated even to the point that they only shop for essentials at Walmart at 2 am so that they can avoid crowds of shoppers. Veterans often stop keeping in touch with long time friends because they don't feel they have much in common with them anymore because their friends have never been in combat or faced dangerous situations as the Veterans have. The Vets who make friends during their deployment look to those same friends later on (AKA "Battle Buddies) for understanding and support. This may leave out their spouses and their children who do not understand what the Veterans have been through and are therefore in a sense "Outsiders" to the special experience of being under fire together. This closed group of "Battle Buddies" becomes a lifeline of hope and understanding for the Veterans. Unfortunately the rest of their social circle gets left out and this leads to a high divorce rate among military families which can range as high as 85%.

So let me try to simplify the dynamics of PTSD in the hope that just understanding how it works may be very helpful in reducing the mystery of the PSTD diagnosis and its many ramifications. The Limbic System is a small portion of the brain between the spinal cord and the neocortex (the wrinkly gray stuff just under the skull) that is extremely specialized in detecting a possible fatal threat from the environment around us. As I stated previously once this has been activated by a perceived threat it is very difficult to turn off. It's like a smoke alarm that is loudly alerting you to "Do Something" with a disturbing message that Vet's cannot ignore. This "Fight, Flee, Or Freeze" response is accompanied by a searching mental inquiry as to the nature of the threat. Often Vets begin to ask themselves things like, "I know that guy I just saw looked harmless but he might have been packing a weapon so I will just turn around and follow him." Or "I know I am awake in the middle of the night in my own home, but what if someone is outside just waiting for the lights to go out. I think I will just get out my gun and walk the perimeter of my home one more time, just to make sure everything is OK." These kinds of thoughts may be perceived as paranoia by the Veteran's family or friends; however, for the Vet it makes sense to them to be extra precautious and act on their fears anyway. Just to make sure. Some Vets carry a gun all the time and keep extras in their car, closet, or even in every room in the house. Does this seem insane? Not if the Vet has been in combat themselves or seen other friends get killed while deployed. For them, no behavior is outrageous or unnecessary because in their mind it is a matter of life or death. This over abundance of caution by the Vet's sometimes unusual behavior is easy to understand once it is clear that the Limbic System and not the neocortex or logical part of the brain is running the show. In some ways it is like a overprotective helicopter parent who, in their deep concern for their child, runs interference for them by over reacting to anything they perceive could be a threat to their life. For the helicopter parent, even normal developmental tasks like major tests or seeing their child go on their first date, are cause for the parent to find ways to protect their child from pain even to the point of interfering with the child's ability to manage stress and as a result inadvertently crippling emotionally crippling their children.

So the bottom line for Vets is this: the symptoms of PTSD which include hypervigialnce (always scanning for threats), nightmares (visually reliving the threatening event), obsessive thoughts, and intrusive thought triggered by those things that remind you of the traumatic event are all attempts by your Limbic system to make some sense of what happened to you by keeping the memory alive in your mind. This is the Limbic's systems way of saying "Hey don't forget what happened to you and stay aware that it might happen again anytime you become apathetic to the possibilty".

Here are some ideas for Vets that often work well to understand and then eventually change theirsymptoms:

1. Read what is available to understand what is going on with you. Knowlege is power and if you gain an understanding of what is happening within your then you may be able to lessen the intensity of your symptoms a great deal. In my own life, I reduced by symptoms of anxiety by 30-40 percent just by reading about anxiety in general and PTSD in particular. Here's a short list of books that I personally have found helpful: "The Body Keeps Score" by Bessel Van Der Kolk M.D. Dr. Van Der Kolk is an expert in the field of trauma and bases his writing on research done in PTSD over the past 20 years. A second book I highly recommend is entitled "The Anxiety and Phobia Workbook" by Edmund Bourne, Ph. D. Dr. Bourne has written extensively on anxiety and provides a large number of coping skills so you can try several until you find the ones that fit you best. There is no single coping skill that universally works well for everyone. The reality is that recovery from PTSD is a matter of trial and error so that each person finds the combination that uniquely works well for them. The Third book is entitled" The PTSD Workbook" by Mary Beth Williams and Soili Poijula.This is an excellent workbook designed specifically for those with a PTSD diagnosis and has some excellent self-help exercies. The fourth and final book that I will recommend is entitled, "Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families".

2. Find a VA Clinic and get involved in doing individual and group therapy. There are many VA Clinics in the Southwest Missour and Northwest Arkansas area that offer behavior health assistance either face-to-face or over the internet using Telepsycholgy as a means of deliversing service. If you don't have a computer and want to do therapy at home you can often use your cell phone for Facetime or just a telephone conversation. Don'tt hesitate to do this now. The VA has been overhauled recently and is ready to serve you. You earned this service so please use it. By the way, if you don't feel your VA therapist is being helpful to you then ask for another one. The comfort you feel with your therapist is extremely important in how quickly you recover from PTSD.

3. Finally, please take pride in your service. When I say to you thank you for your sevice I mean it and so do many others. It isn't just a ritual like "How are you doing? Oh just fine thanks for asking". No, we mean it. Anyone who is courageous enough to enlist in the military knowing that they could be sent to the front lines of a battlefield and suddenly lose their life is a patriot and we certainly need more citizens like that . For the past 245 years we have relied on people just like you to go out and fight for our country even to the point of giving up your precious life for all of us. For that I give you my heartfelt thanks.