Post-traumatic stress disorder

“ That’s why we’ve already made one of the largest increases in funding for veterans in decades. We’re treating the signature wounds of today’s wars -- post-traumatic stress disorder and traumatic brain injury -- while providing the health care and benefits that all of our veterans have earned. ”

“ Approximately 2.2 million American adults age 18 and older, or about 1.0 percent of people in this age group in a given year, have OCD. [1] The first symptoms of OCD often begin during childhood or adolescence, however, the median age of onset is 19.5 Post-Traumatic Stress Disorder (PTSD) Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD. [1] PTSD can develop at any age, including childhood, but research shows that the median age of onset is 23 years. ”

“ Taking into account the “many faces” of male depression (aggression, alcohol abuse, poor social functioning) leading to male vulnerability and gender related public health paradoxes [ [56] , this idea looks very attractive. Logically the model of suicidal behavior in war veterans with PTMD has been proposed by L. Sher which consists of the following components: (1) genetic factors; (2) prenatal development; (3) biological and psychosocial influences from birth to mobilization/deployment; (4) mobilization/pre-deployment stress; (5) combat stress, traumatic brain injury, and physical injury ”

“ It should be noted that this contingent has many risk factors, such as stressful exposures, wounds, brain trauma and pain syndrome. Most recent observations confirm that veterans are really more likely to die of suicide as compared to the general population; they are also more likely to experience suicidal ideation and suffer from mental health problems. Suicides are more frequent in those who develop PTSD, depression and comorbid states due to war exposure. Combat stress and its’ frequency may be an important factor leading to suicide within the frame of the stress-vulnerability model. ”

“ On the other hand, the development of a mental disorder such as posttraumatic stress disorder, which can last months or even years, or even chronic depression, which can also last for a considerable period of time is untreated, might satisfy the prolonged hard requirement. ”

“ Studies among veterans from the Vietnam War have shown that there is a direct causal link between traumatic stress exposure and subsequent PTSD [ [26] . Moreover, those Vietnam veterans who had a diagnosis of PTSD were shown to have a significantly (~4-fold) increased standardised mortality rate of suicide [ [27] ; those who had been wounded were also at higher suicide risk [ [28] . In other studies, Vietnam veterans were shown to have increased levels of suicidal ideation and a history of suicide attempts ”

“ Recent evidence has also underscored the importance of PTSD as an underlying risk factor of suicide. This raises the question on what may be the reasons behind the recent reports on the association between PTSD diagnoses and suicide rates. Do young military personnel have higher risks and vulnerabilities which are further exacerbated by military service or is it specifically connected with the changing military situation? ”

“ These data provide an explanation for many veteran suicides; however, suicide cannot be explicated as the result of one particular mental disorder. Moreover, as can be seen from Table 1 some studies do not confirm that those war veterans who suffer PTSD are more likely to commit suicide. Notwithstanding, depression is considered the leading underlying disorder for suicide and recent studies suggest that PTSD has a pronounced effect on risk mostly if comorbid with depression. ”

“ Disturbance from explosion without external injury presupposes an emotional state, and it is from this state that it derives its causal efficacy; whatever the etiological complex found as the cause of a condition of shock, whether the explosion of a shell, bomb or mine, the sight of the dead, burial in a trench, wound from an explosion or a missile, there is only one factor of importance, the emotional factor, which is essentially responsible for all the neuropsychic disorders that together make up the shock syndrome. ”

“ The process of repression does not cease when some shock or strain has removed the soldier from the scene of warfare, but it may take an active part in the maintenance of the neurosis. New symptoms often arise in hospital or at home which are not the immediate and necessary consequence of the war experience, but are due to repression of painful memories and thoughts, or of unpleasant affective states arising out of reflection concerning this experience. ”

“ When the most courageous persons are wounded in parts essential to life, there is more or less alarm or shock created by the injury; although it has been gravely argued that a man does not always know when he is actually shot or run through the body. A continued state of anxiety and depression after an accident of this kind is a disagreeable accompaniment of the injury, during which little should be done beyond the giving a little cordial, and quieting the apprehensions of the patient, leaving him to rest, if possible, after the necessary applications have been made. ”

“ Veterans who commit suicide are a heterogeneous group, wherein they are differentially exposed to social, psychological or psychopathological risks. Combat stress and direct experiences of war may be the unifying factor though this factor is valid only for the part of the released military. On the other hand this particular exposure may be the main contributing risk factor that influences suicide rates in a more general contingent. This again emphasises that stress is potentially the main mechanism exacerbating existing vulnerabilities and may serve as the main component for inducing suicide. ”

“ It was always the emotions first developed in military service that were revived in the disease. In the third phase, the physical condition of the patient had grown much better pari passu with disappearance of the obsessions and the onset of the personality disorder. The adrenalin raised arterial tension, and going down to the sympathetic caused the anxiety and war emotions linked therewith to disappear; but the adrenalin treatment, [231] according to Laignel-Lavastine and Courbon, disturbed the organic sensations so suddenly that there was a break between the new conscious status and the old. ”

“ The vast majority of cases studied had a neuropathic or psychopathic taint, as shown in the family history in fourteen per cent of the total. A previous neuropathic constitution in the patient was found in [192] seventy-two per cent. "A gradual psychic shock from long-continued fear, together with the sudden change from quiet, peaceful environment to the extraordinary stress and strain of trench fighting, is the chief predisposing cause of war psychoneurosis in soldiers with neuropathic predisposition.... Wounded soldiers do not suffer from war neuroses except in rare instances." ”

“ According to MacCurdy, this case is a typical case of war neurosis of the anxiety type, except that a relapse with depression is somewhat atypical.
Re anxiety, Lépine counts trauma as one of the most important factors. The reduction of morale in physically injured cases may at times require their rapid withdrawal to a safety zone. The delirium of the physically injured sometimes takes on a melancholic tinge. Fatigue, loss of sleep, and cold are other factors of a physical nature. ”

“ It soon became clear, however, that the great majority of the functional nervous disorders of warfare are not traumatic in the strict sense, but occur in pronounced forms either in the complete absence of any physical shock, or after exposure to shell explosions of a kind very unlikely to have caused physical injury. It became evident that the shell-explosion or other event which forms the immediate antecedent of the illness is only the spark which sets into activity a morbid process for which the mental stresses and strains of warfare have long prepared the ground. ”

“ It is a small price to pay if emotional symptoms can be traced to a physical cause.
It is well known that virtually any serious organic illness or injury can produce emotional suffering, either in the form of physical pain or in the form of anxiety and depression. Chronic pain is a chronic stress and can lead to the same emotional problems as prolonged stress of any variety: anxiety or depression. Similarly, prolonged severe anxiety or depression can cause physical deterioration and make the body more susceptible to disease. ”

“ The fatigue, the lack of food and rest, the horror of the suffering, the fear of dying without any care developed among even the bravest soldiers a nervous condition that reduced many to tears. Often when not overcome by pain the dominant thought of the soldier was for his mother, and the fear of what she would suffer when she learned of his death. ”

“ Modern understanding of stress-vulnerability mechanisms based on genetic predispositions, early life development, level of exposure to stress and stress-reactivity together with interpersonal aspects may help to build more effective suicide prevention programs based on universal/selective/indicated prevention principles. ”

“ A door slammed, a thunder-clap, a distant shot, makes the patient break down, and his previously unconscious anxiety idea becomes over-weighted. Terror and dread of death here generally form the primary basis for the dissociation of the psyche and for the attack-like mastery of the conscious by the unconscious.
A soldier who has once been paralysed for a time through the emotion of terror in his conscious ego is in many ways no longer in the position to satisfy consciously the repression which the pressure of discipline demands. ”

“ Examples seem to show that it may occasionally be overpowered for a time, even in most severe injuries, by mental and nervous action of another kind; but this can rarely happen when the injury is a vital one. Panic may lead to similar results when the wound is of a less serious nature. A soldier, having his thoughts carried away from himself—his whole frame stimulated to the utmost height of excitement by the continued scenes and circumstances of the fight—when he feels himself wounded, is suddenly recalled to a sense of personal danger ”

“ It is associated with high blood pressure, hardening of the arteries, strokes, ulcers, colitis, and a host of other physical conditions. And severe stress endured too long leads to emotional breakdown.
All physical materials can be loaded or stressed to a certain point beyond which they distort, snap, fracture, or break. Stress loads human beings physically as well as emotionally. Any change—whether for good or for ill—is a stressor. ”

“ There are in the United States about half a million insane, while the victims of psychopathic, mental maladies may be counted by millions. Now that the war is over, there will come thousands upon thousands of nervous and mental wrecks, under the name of shell shock or war shock, the unfortunate results of nervous exhaustion and fear shock produced by the war. ”

“ If disturbances from explosion and from emotional shock, existing with or without traumatism, produce identical results, it is evident that they have a common factor and this common factor can be only the emotion itself. ”

“ The examination of many cases of war neuroses has shown that there is little if any qualitative difference between the case of those who break down under the abnormal pressure of war conditions and the War-shock case of those who are unable to stand even the relatively mild stresses and difficulties incidental to a time of peace. All persons are, it would appear, liable to suffer nervous breakdown if subjected to emotional strain beyond a certain limit; this limit varying, however, very considerably from one individual to another. ”

“ The fatigue, pains and aches, changes in mood and emotion are born of this reaction, except in those cases where they arise from definite bodily disease, and even here a vicious circle is established. The weakness and fatigue state, the consciousness of impaired power brought about by sickness, are reacted to in a neurasthenic manner. It is not often enough realized by physicians that a physical defect or a physical injury may be reacted to so as to bring about nervous and mental symptoms; may cause the emotions of fear, hopeless anger, and sorrow; may cause an agony of doubt. ”

“ The heaviest bombardments are not in line to produce these disorders when the morale of the troops is good. The bloodiest affairs may leave no single case of nervous disorder when the morale is good. Dide found in a whole year’s work but a single functional case,—an oniric delirium, following a trench mortar explosion. ”

“ In most instances patients reported the attack struck with almost the impact of a physical blow. The prodromal symptoms were usually slight ... a sudden feeling of uneasiness and guilt ... hot and cold flashes ... dizziness ... double vision. Then this ghastly sense of depression coupled with a blind insensate rage at life. One man said he felt as if the world were closing in on him. Another that he felt the people around him were plotting his destruction. One housewife made her husband lock her in her room for fear she would injure the children. ”

“ The case I have just narrated is a straightforward example of anxiety neurosis, which made no real progress as long as the patient tried to keep out of his mind the painful memories and anxieties which had been aroused in his mind by reflection on his past experience, his present state, and the chance of his fitness for duty in the future. When in place of running away from these unpleasant thoughts he faced them boldly and allowed his mind to dwell on them in the day they no longer raced through his thoughts at night and disturbed his sleep by terrifying dreams of warfare. ”

“ Postoperative and traumatic neuroses are at once explained on the ground of noci-association, the resulting strain from which, upon the brain-cells, causes in them physical lesions. If one were placed against a wall and were looking into the gun muzzles of a squad of soldiers, and were told that there were nine chances out of ten that he would not be killed outright when the volley was fired, would it help him to be told that he must not be afraid? ”