Traumatic experiences, combat stress and PTSD in serving military members and veterans

Combat stress is an expected and predictable reaction to combat experiences. After being in a combat zone under constant physiological stress (poor diet, extreme temperatures, little opportunity for good personal hygiene, etc.) and psychological stress (concerns about improvised explosive devices, snipers or the death of fellow service members), it is not surprizing that many are impacted by traumatic experiences. Whilst combat reactions are actually considered adaptive, some individuals may develop PTSD as a result of their experiences and their difficulties in coping with what they have gone through.

Although there s some overlap between combat stress responses and PTSD symptoms, theyre not addressed in the same way. Combat stress isnt considered a medical problem or something that requires treatment. For many war veterans, combat stress wears off after their period of service has ended, being back in their day to day environment. for a few weeks to months. However, if combat stress persists then the individual may be suffering with PTSD.

PTSD refers to a psychological disorder which impairs functioning. Its considered very serious whereas combat stress is considered to be a normal reaction to traumatic circumstances.

During the First World War PTSD was referred to as "shell shock", in WW11 as "war neurosis" and as "combat stress reaction" during the Vietnam War. In the 1980s the term Post Traumatic Stress Disorder (PTSD) was introduced. PTSD can affect every part of someones life and can be a complex and debilitating condition.

PTSD put simply is a memory filing error. PTSD can occur when individuals are exposed to an extraordinary life-threatening situations which is experienced with intense fear, horror and helplessness.

When exposed to intensely fearful situations, the mind 'suspends' normal operations and copes as well as it can in order to survive. This might involve reactions such as 'freezing or instead the opposite a 'flight' response from the danger. Usually the individual is aware of coping in an automated manner. Many Veterans following the traumatic event will say later that their 'training took over' and they survived.

The mind does not lay a memory for the frightening event or events in a normal way because it has delayed this until the danger passes. Once the danger has passed, the mind will try to file away the memory. This means it tries to file the facts of what happened, the emotions associated with the trauma and the sensations (eg: touch, taste, sound, vision, movement, and smell).
The problem is that when the mind presents the memory for filing it can be very distressing. The mind repeatedly and automatically presents the memory in the form of nightmares, flashbacks and intrusive unwanted memories. These "re-experiencing" phenomena are the mind's way of trying to file away the distressing memory. The re-experiencing can be very unpleasant and distressing because of the nature of the traumatic experience it exposes the sufferer to.

The individual finds that their levels of arousal (awareness) change. People can become hyper-aroused and suffer intense symptoms of anxiety (both physical: with shortness of breath and a racing heart, as well as emotional: feeling on edge, looking out for signs of danger and being 'on patrol' all the time or feeling panicky).

Many individuals also report feeling emotionally numb and have trouble communicating with others without feeling numb, irritable or both.

Hyper-arousal and emotional numbness symptoms can become so unpleasant that the individual then starts to avoid anything linked to the original trauma. The person avoids anything that causes upset or irritation or that might represent danger. Avoidance can become the main coping mechanism for most situations.

The more the individual avoids things, including confronting what happened, the less likely is it that any memory processing will occur, and the more likely it is that further attempts at filing a memory will occur automatically. This leads to further re-experiencing nightmares, flashbacks and intrusive memories. These re-experiencing symptoms then lead to further hyper-arousal and emotional numbing, and this in turn, leads on to more avoidance and so on. It becomes a vicious cycle.

In the majority of individuals, the three symptom clusters (which represent the immediate psychological reaction to a traumatic experience) settles down. In some people it can remain problematic and become chronic. When this occurs, PTSD may be said to be present.

For treatment to be successful, information processing must be completed, which is why therapies aimed at helping the individual to process and work through the traumatic material are extremely beneficial.

PTSD comprises three symptom clusters:

Re-experiencing of the traumatic experience
Hyper-arousal and emotional numbing
Avoidance.

1. Re-experiencing symptoms
Veterans with PTSD repeatedly relive the event in at least one of the following ways:

*Intrusive unwanted memories of the traumatic event.
*Unpleasant nightmares which comprise replays of what happened.
*Flashbacks where they may suddenly act or feel as if they are reliving the event.
*They become emotionally upset if something reminds them of the traumatic experience.
*Palpitations, panicked, high anxiety levels, sweating, feeling tense or shaky if they are reminded about their traumatic experience.

2. Avoidance symptoms

Veterans with PTSD try to avoid thoughts and feelings related to the traumatic event. They find it extremely difficult at times, as the traumatic images and memories intrude spontaneously. Symptoms include:

*Avoidance of activities, places or people which remind them of their trauma.
*Difficulty remembering exactly what happened during exposure to their traumatic event (this reflects the intense fear at the time of exposure).
*Becoming less interested in hobbies and activities that they used to enjoy before the traumatic event.
*Feeling detached and estranged from people, and feeling that nobody understands them - a tendency to isolate themselves.
*Becoming emotionally numb, and having trouble experiencing their feelings.
*A sense of futility in relation to their future and feeling that somehow they will be stuck down by yet another disaster or tragedy.

3. Hyper-arousal symptoms

Hyper-arousal symptoms cause problems with relationships, especially problems generated by irritability and anger. They include:

*Great difficulty falling or staying asleep.

*A tendency to being irritable and angry at the slightest provocation and for trivial reasons.
*A tendency to become aggressive, verbally or physically, or to become violent towards themselves or others.
*Great difficulty concentrating, and concentration usually requires effort.
*Remaining especially alert and watchful (hyper-vigilant).
*Looking for signs of danger in their environment and in an exaggerated way; they are tuned in to any sign that they might perceive as threatening.

Other commonly associated symptoms

The other symptoms that are commonly associated with PTSD relate to feelings of guilt, and difficulty relating to authority figures.
Guilt can take two forms:

*Guilt in relation to what one should or should not have done during the traumatic exposure.
*Survivor guilt: while the individual survived relatively intact (physically, at least), others involved in the traumatic experience did not.

Feelings of guilt are very common among veterans with PTSD. They may have seen people injured or killed, often their friends and comrades. Veterans may question why they survived when others didnt, they may end up blaming themselves for what happened, believing it was their actions or lack of that led to others dying. They may feel they should have died themselves, instead of others - This is survivor guilt.

Anger and hostility can also be a major factor in the presentation of PTSD in veterans.

The more individuals try to use avoidance as their main coping mechanism, the more likely it will be that they will isolate themselves and become depressed.

Many individuals may also turn to drinking alcohol, as a means to avoid unpleasant irritability and hyperarousal. Others may turn to drugs, medications or other substances to 'feel alive'; and to counteract the emotional numbing they feel.

In Veterans the commonest co-morbid clinical presentation of PTSD, is PTSD presenting with depression and alcohol misuse disorders. Co-morbid illness needs to be addressed and treated alongside PTSD.

There are issues of stigma associated with Veterans asking for help. Many Veterans would never admit they have a mental health problem, a dependency issue to others, including to a medical practitioner who has not served in the military. This means that unless they asked directly, medical practitioners, supportive others find it difficult to identify who is a Veteran and what his or her needs might be. Equally lack of knowledge of services to help those affected by their experiences of serving in the military can be a contributory factor in whether or not someone receives support. Additionally some veterans have reported very negative experiences with accessing mainstream services such as the NHS, or that civilian organisations do not understand the unique nature of their traumatic experiences.

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