Like this mouse, I tried to run and hide from the ghosts of my past for 33 years. I tried it all; drugs, alcohol, sex, work, and even religion. I thought flashbacks, panic attacks, hallucinations, inability to fall or stay asleep, nightmares, depression, outbursts of anger, and failed relationships where just part of life.

In April of 2000, I went to my local VA Medical Center to see if they could " fix " my right leg. The pain had become unbearable, and I didn't have insurance. It was service connected and that was the main reason I went. This was my first visit to a VA since 1985, when I "attended" a 30 day drug and alcohol rehab program in Lincoln Nebraska. During my visit I was sent to see a vocational rehabilitation councelor. After a short conversation, he told me to re-open my leg claim, and also open a claim for a "mental disorder". I thought this guy was f*%##* Nuts !!! I saw a VSO, re-opened my claim and left. Before I could get off the property, I was crying uncontrollably as vivid images flashed before my eyes, I could hear the sounds of combat as faces of fallen brothers, raced through my mind. Every emotion of guilt, remorse, fear and anger raged within me till my body felt it would explode.The situation grew worst over the next six days, and I had come to a place that I had only two choices; I could just "check out" (I had a very creative way that would involve a very large explosion), or I could get help. They always tell you to save the last bullet for yourself, and I figured I had two left. I chose to seek help. It was the best decision I have ever made in my life. I went to the mental health Crisis team, was immediately placed on several medications, and my long journey home, which continues today, had begun. It was April 16, 2000. It was the first time I had heard the term PTSD.

Many of us here are already in treatment, while many more are not. This page is designed to give information, help, support and hope to both. There is an abundance of information here, all of which will help us to deal with our ghosts.

I have learned two very important things thru therapy. 1) no matter where you go, there you are. And 2) we did the BEST we could with what we had.

What if you think you might be among those who have PTSD from your combat
experiences? (I understand that your unit went through some highly stressful combat.) How can you recognize it? Perhaps the best sign is combat-related nightmares. However, these nightmares don't need to be exact replays of the actual combat experiences. Often they're weird take-offs on those experiences, and may involve, for example, the presence of family members or acquaintances you didn't even know in Vietnam. But nightmares aren't essential. Unwanted, intrusive daydreams often signal PTSD. At their most severe, these may involve a sense of loss of contact with reality, in which case they're called flashbacks.

Other PTSD features include becoming very emotionally or physically upset when reminded of combat experiences, trying to put such memories out of ones mind, and trying to avoid being reminded of combat experiences. There are also other features that a qualified diagnostician can explain to you.

The good news about PTSD is that the natural course in most cases is progressive improvement. However, relapses are possible indefinitely, and it's not uncommon that veterans who initially had PTSD but then became symptom-free for years, start having their symptoms again when they encounter another stressful life experience. The other good news is that effective treatments are available, including various kinds of therapy and medication.

What should you do if you think you might have PTSD related to your Vietnam or other war service? The first thing I recommend is filing a claim with the Department of Veterans Benefits. Persons who do this are usually helped by the DVA, VFW, American Legion, or other veterans' service organizations. One important reason to file a claim is to stand up and be counted. It's important that society recognize the detrimental effects, both physical and psychological, of war on people's health. (This is not to say that war is always bad. It's only to say that a nation that is contemplating war, and persons who are thinking of enlisting in it, should be informed of the risks.) A second reason for filing a claim is that if granted, it entitles you to free care in the VA for your service-connected condition. In some cases, the VA will even pay for outside care. A third reason for filing a claim is to receive compensation payments if you are disabled. Persons who find this thought objectionable should be aware that it's possible to have a 0% service-connection. This means being recognized as having the condition and being entitled to free medical care, but not receiving any monthly payments if you are not disabled.

What if you have filed for service connection and been turned down, and you continue to think your case is legitimate? The answer here is persistence. In some VA Regional Offices, turning down a first application is almost a knee-jerk reaction, and meritorious cases may need to be appealed once, twice, or even more before they are recognized.

If you can't stomach the thought of going to a VA Medical Center for treatment, and some vets who are not very fond of the Federal Government can't, you might consider trying a Vet Center near you (formerly called Vietnam Veterans Outreach Centers, these are now open to vets of all wars.) The environment is often more friendly there. Most Vet Centers provide their own treatment and are even authorized to pay for private treatment in certain circumstances.

Finding good psychiatric treatment isn't always easy. Like all other walks of life, some therapists and doctors are more competent than others. If you need treatment, don't settle for a therapist or a setting that doesn't feel right to you. Ask for a change. Keep trying until you get what you need. Again, in dealing with the VA, patience and persistence are paramount. But keep in mind that there are many highly capable professionals in the VA. Also keep in mind that the rate of alcoholism is very high among Vietnam veterans with PTSD. If you have a drinking problem, help is also available. Like PTSD, the VA is a leader in the research and treatment of alcoholism.

Finally, if the above information doesn't apply to you, count your blessings, and support those among you who are less fortunate.

Roger K. Pitman, M.D.
Assoc. Prof. of Psychiatry
Harvard Medical School

Below is a list of information currently available from the National Center for PTSD about the nature of trauma, PTSD, and the consequences of trauma. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

Fact sheets for the public

Answers basic questions about the signs and symptoms of PTSD, who gets it, how common it is, and what treatments are available

A revised version of an overview of the subject from the Encyclopedia of Psychology

A brief guide to recognizing the symptoms of stress and managing traumatic stress

Below is a list of information currently available from the National Center for PTSD specific to PTSD and trauma-related disorders in veteran populations. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

Fact sheets

General Information

Answers to some questions about PTSD and service-connected disability that are frequently asked by veterans and their families

Information for veterans and caregivers on how veterans may be particularly sensitive to the effects of terroristic acts and war

A brief guide to recognizing the symptoms of stress and managing traumatic stress

Brief information about the Department of Veterans Affairs' network of more than 100 specialized programs for veterans with PTSD, including the Vet Centers operated by VA's Readjustment Counseling Service

Female Veterans

Non-white Veterans

Possible Reactions:All of these feelings and reactions are normal and natural even though they may seem unusual and even though some are very different from others. We are all individuals. We all respond in our own unique way. The incident cannot be erased. The memory will always be a part of your life. Everyone moves at their own pace through the stages of crisis and healing. Everyone has their own clock. For some people, there may be ongoing problems.

Traumatic war experiences often cause many of the following kinds of (often temporary) reactions in veterans:

1. Unwanted remembering or re-experiencing Almost all veterans experience difficulty controlling distressing memories of war. Although these memories are upsetting, on the positive side, the memories provide an opportunity for the person to make sense of what happened and gain mastery over the event. The experience of these memories can include:

· Unwanted distressing memories as images or other thoughts

· Feeling like it is happening again (flashbacks)

· Dreams and nightmares

· Distress and physical reactions (e.g., heart pounding, shaking) when reminded of the trauma

2. Physical activation or arousal The body's fight-or-flight reaction to a life-threatening situation continues long after the event is over. It is upsetting to feel like your body is overreacting or out of control. However, on the positive side, these fight-or-flight reactions help prepare a person in a dangerous situation for quick response and emergency action. Signs of continuing physical activation, common following participation in war, can include:

· Difficulty falling or staying asleep

· Irritability, anger, and rage

· Difficulty concentrating

· Being constantly on the lookout for danger (hyper-vigilance)

· Being startled easily for example, when hearing a loud noise (exaggerated startle response)

· Anxiety and panic

3. Shutting down: Emotional numbing

When overwhelmed by strong emotions, the body and mind sometimes react by shutting down and becoming numb. As a result, veterans may have difficulty experiencing loving feelings or feeling some emotions, especially when upset by traumatic memories. Like many of the other reactions to trauma, this emotional numbing reaction is not something the veteran is doing on purpose.

4. Active avoidance of trauma-related thoughts and feelings

Painful memories and physical sensations of fear can be frightening, so it is only natural to try to find ways to prevent them from happening. One way that most veterans do this is by avoiding anything people, places, conversations, thoughts, emotions and feelings, physical sensations that might act as a reminder of the trauma. This can be very helpful if it is used once in a while (e.g., avoiding upsetting news or television programs). But when avoidance is used too much, it can have two big negative effects. First, it can reduce veterans abilities to live their lives and enjoy themselves, because they can become isolated and limited in where they go and what they do. Second, avoiding thoughts and emotions connected with the trauma may reduce veterans abilities to recover from it. It is through thinking about what happened, and particularly through talking about it with trusted others, that survivors may best deal with what has happened. By constantly avoiding thoughts, feelings, and discussions about the trauma, this potentially helpful process can be short-circuited.

5. Depression

Most persons who have been traumatized experience depression. Feelings of depression then lead a person to think very negatively and feel hopeless. There is a sense of having lost things: one's previous self (I'm not the same person I was), a sense of optimism and hope, self-esteem, and self-confidence. With time, and sometimes with the help of counseling, the trauma survivor can regain self-esteem, self-confidence, and hope. It is important to let others know about feelings of depression and, of course, about any suicidal thoughts and feelings, which are sometimes a part of feeling depressed.

6. Self-blame, guilt, and shame

Many veterans, in trying to make sense of their traumatic war experiences, blame themselves or feel guilty in some way. They may feel bad about some thing(s) they did or didn't do in the war zone. Feelings of guilt or self-blame cause much distress and can prevent a person from reaching out for help. Therefore, even thought it is hard, it is very important to talk about guilt feelings with a counselor or doctor.

7. Interpersonal problems

Not surprisingly, the many changes noted above can affect relationships with other people. Trauma may cause difficulties between a veteran and his or her partner, family, friends, or co-workers.

Particularly in close relationships, the emotional numbing and feeling of disconnection that are common after traumatic events may create distress and drive a wedge between the survivor and his or her family or close friends.

The survivor's avoidance of different kinds of social activities may frustrate family members. Sometimes, this avoidance results in social isolation that hurts relationships.

Others may respond in ways that worsen the problem rather than help recovery. They may have difficulty understanding, become angry with the veteran, communicate poorly, and fail to provide support. Partners and families need to participate in treatment; by learning more about traumatic stress, they can often become more understanding of the veteran and feel more able to help.

Some kinds of traumatic experiences (e.g., sexual assault) can make it hard to trust other people.

These problems in relationships are upsetting. Just as the veteran needs to learn about trauma and its effects, people who are important to him or her also need to learn more. As the survivor becomes more aware of trauma reactions and how to cope with them, he or she will be able to reduce the harm they cause to relationships.

8. Physical symptoms and health problems

Because many traumas result in physical injury, pain is often part of the experience of survivors. This physical pain often causes emotional distress, because in addition to causing pain and discomfort, the injury also reminds them of their trauma. Because traumas stress the body, they can sometimes affect physical health, and survivors may experience stress-related physical symptoms such as headaches, nausea or other stomach problems, and skin problems. The veteran with PTSD will need to care for his or her health, seek medical care when appropriate, and inform the doctor or nurse about his or her traumas, in order to limit the effects of the trauma.

Anniversary Reactions

Many people with PTSD notice that their symptoms seem to get worse at certain times of the year. Often these times of the year are anniversaries of particularly traumatic experiences - getting wounded, being shot down, or the death of a friend for example. During these times, feelings about the trauma can come up and be almost as strong as they were right after the event. Depression, anxiety, guilt, anger, intrusive thoughts, nightmares and other symptoms may all get worse, which can be particularly discouraging if your PTSD seemed to be improving. This is called an "anniversary reaction" and is very common in people who have been traumatized.

You may notice that your symptoms seem to come and go but may not notice that there is a yearly or monthly pattern to this. Or, you may notice that your symptoms get worse at certain times of the year but not understand why. Often veterans with PTSD are not aware of connections between changes in their symptoms and traumatic events in their past. This can often worry people and cause them to feel out of control of their PTSD and hopeless about their recovery.

It can be helpful to keep track of times when your symptoms seem to get worse and notice if there is any pattern to these changes. Do you tend to feel more depressed and have more nightmares around the end of the month, for example, or do you have more panic attacks and intrusive thoughts in the summer? If so, think back over your trauma and see if there are any connections. Were you wounded, attacked, or assaulted on the 28th of the month? Was a friend killed in July? If there are any connections there, you may be experiencing anniversary reactions.

If you are someone who has anniversary reactions, there are things you can do to cope. Simply establishing the relationship between your trauma and your current symptoms can be a relief because you can then better understand your PTSD, predict when your symptoms are likely to get worse, and prepare for this in whatever ways work for you. Some suggestions for preparing for anniversary reactions are:

Start going to support groups or 12-step meetings, or, if you already go, go more often.
Make sure you do not isolate during this time.
Try planning a fun distraction, such as a weekend away or a visit with your children or grandchildren.
If you are in individual counseling, you may want to see your therapist more often during the difficult period.
Telling family members your anniversary dates can also be helpful because then they can understand what is happening if your symptoms suddenly get worse.
Simply reminding yourself that anniversary reactions are temporary, are normal and do not mean that your recovery from PTSD is back at "square one" can be very helpful.

In general, by recognizing anniversary reactions and taking steps to cope, you can feel more in control of your PTSD rather than feeling like your symptoms are controlling you.

Below is a list of information currently available from the National Center for PTSD on anniversary reactions. For more information click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

By Sean Bennick,
President of Get Mental Help, Inc.
Webmaster of Mental Health Matters
Consumer
DID, PTSD, Depression
Mental Health Matters

What Are Your Options?

When dealing with flashbacks, there are actually three possible options. At the first sign of an oncoming flashback, you need to quickly determine which option you are choosing.

The techniques used for each of these options are the same, but how you combine these techniques and the intensity with which you use them will vary to bring about each of the three. It is important to note that not all flashbacks can or will be Controlled or Escaped. If the triggering event is strong enough, the flashback may overwhelm every attempt made at Control or Escape. During these times, get yourself to the safest place you can and keep using the techniques to manage the Acceptance of the flashback.

Accept

The first option is to Accept the flashback at full intensity, and everything that comes with it. At first glance this looks like a ridiculous choice, but one of the reasons you have flashbacks in the first place is to help your mind process the information contained in the flashback. There are times that this is the best option because the information is going to come forward at some time anyway. So if the time and place are right, prepare yourself and try to control the flashback only enough to keep yourself safe.

How do you know if the time and place are right? Well, there are several factors that may help indicate when it is safe enough to Accept a flashback at full force. The first of these is a safe environment, by safe I mean comfortable and comforting. This may be your bedroom, living room, or even your therapist's office. The second is the existence of a support person, or someone you can talk to afterwards if you need to. This could be a significant other, close friend or therapist.

I have found that limiting the times I Accept a flashback at full force can significantly improve how I deal with the more devastating memories.

Control

The second option is to Control the flashback, or rather to make an attempt to diminish the effects of the flashback. In order to Control the flashback, you need to increase the effort you put into the coping techniques you have (or those listed at the bottom of this article). I find it useful to also continue to remind myself that I am safe and that I cannot be hurt.

Controlling and Escaping flashbacks work by interrupting the thought processes involved in the flashback. Since flashbacks are basically electrical impulses within the brain, I look at this as short-circuiting the flashback process. When you have a song you don't particularly like stuck in your head, the only way to get rid of it is to hear a song you like and replace the thought that is keeping that song in your head. Short-circuiting a flashback is the same thing you are attempting to replace one thought process with another.

Controlling is not the full replacement of a flashback but a redirection of the flashback onto a different and safer circuit. To do this, you will be using your coping tools to interrupt the thought process. You may need to interrupt the flashback several times to Control the impact, and it may take several efforts to cause a single interruption. Mixing your coping methods around and using them in combination are ways of intensifying the attempt at interruption.

If your environment is familiar and you can feel safe, or if you are with someone who can give you a measure of safety, then Controlling the flashback may be the best option.

Escape

The final option is the Escape of the flashback. Again, remember that this may not always be possible, but never give up your attempts. Mix up your coping methods and combine them, try the more intense methods and try new methods. Escape is both tiring and difficult for me, but it can be done.

One thing that you need to be aware of is that Escape is not permanent. By Escaping the flashback, you are simply putting it off until it is safe to process the information. You won't get to select when that reprocessing happens either. Once you Escape, get yourself to a safer place and calm yourself down.

Taking Notes

Whether you simply make mental notes or write down every detail about the flashback and what you did to cope, this is an important part of the process. The more information you have about your flashbacks, the better.

What triggered the flashback?
What was your goal? (Accept, Control or Escape)
Did you accomplish your goal?
What coping techniques did you use?
Which of these techniques helped, which didn't?

Having these notes can help create a better plan for flashback management. They can also help your therapist in helping you.

Coping Techniques

Nearly anything you can do to help cope with your flashbacks is a good thing. I say nearly everything because anything that does harm to yourself or another person is simply inexcusable in my opinion. I feel I have a right to say this because like many out there with PTSD, I resorted to self-injury in an attempt to deal with some of the memory I recovered. Not only was self-injury ineffective, it put me in a very dangerous position.

Resorting to causing yourself pain to cover other pain simply amplifies your agony. You may temporarily feel what you believe to be relief but once things return to normal and the flashback is gone, there is additional pain to deal with and at times, serious injury as well. I view Alcohol and Drugs the same way (with the exception of drugs prescribed by my own doctor or therapist). They may not do visible harm like cutting yourself, but the damage is done and the problems are compounded.

Having said that, remember that if something works to help you cope and it is not harmful, then use it as often as you can. If this means that you need to hum the theme from Gilligan's Island over and over in public (which was surprisingly effective because I was attempting to recall the words as I was humming), then do so.

Keep in mind that my explanations about why the techniques below work for me are based on my own understanding and may not be accurate. I can tell you that each of the ideas I suggest have worked for me and helped me cope with my own flashbacks for the past 5 years.

When You Are Alone

Memory Games

One of the easiest ways to cope or manage a flashback is by distraction. Try to remember something challenging such as the lyrics to a particular song, or a favorite poem. This can help interrupt the flashback by redirecting the activity in your brain.

For some reason, memory games work well when I am having flashbacks that involved my hearing and balance.

Some of the more effective memory games I have used are:

Humming songs or remembering the lyrics to songs
Naming facts I learned in school

Ice Cube

This has been my most important tool in dealing with physically oriented flashbacks. The technique was actually taught to me by a Viet Nam Veteran who said he used it for every single flashback, adding "usually it helps, but sometimes it can't." I have found it to be effective to some degree almost every time I have tried it.

The idea is simple, take a fairly large ice cube and hold it tight in one of your hands throughout the flashback. The cold feeling keeps that part of you grounded to some degree and the physical sensation gives you something solid to focus on besides the memory you are reliving. It is important to hold the ice cube fairly tight and in the same hand for the duration of the flashback. I experimented with switching hands and holding it lightly and the technique lost much of its effectiveness.

I always use this technique in addition to some of the others when attempting to Escape or Control.

Wall Spotting

This technique involves selecting 4 or 5 brightly colored items in the room that are easily within vision and moving your focus between them. Make sure to vary the order and allow yourself to lock onto the items briefly before shifting to the next item. Keep this up throughout the flashback and continue for a short time afterwards.

Following the same pattern can actually cause you to become more involved in the flashback because your mind becomes used to the pattern and builds on it. By varying the pattern, you disrupt the thought processes involved in the flashback.

I suggest continuing the eye movements for a while after the flashback ends to allow yourself to get more focused on the present since I use this technique mostly for flashbacks with a visual element.

Cold Water on Your Face

This one is simple and can help with any type of flashback. This idea is one of the first ones any of us find that helps. Remember that it can continue to help. Try and use water cold enough to give yourself a good shock. There is a bit more evidence on why this works, it is called the "Mammalian Diving Reflex" or simply the "Diving Reflex" and relies on the fact that our bodies want to survive.

Sudden immersion in very cold water (below 70 degrees) triggers the Diving Reflex. The body reacts by lowering the heart rate, increasing blood pressure, and shutting down circulation to all but the body's core. The result is a lowered metabolism that conserves energy, which helps cold water survival. This is also why near-drowning victims in cold water have a much higher survival rate.

The effect on a flashback is fairly drastic. In short, the brain is shocked and interrupts the flashback to survive what may be a life-threatening immersion in freezing water. For this reason, make sure you use the coldest water available and use a good amount of it.

When A Friend Is Available

Counting

This is a technique I came up with while assisting a friend with a panic attack. I call this Counting for lack of a better term. The idea, like most of the techniques above, is to confuse the mind and disrupt the thought processes. To do this, remember that random is good.

Basically, your friend would make you repeat whatever they are saying and would start by following a predictable pattern. Throwing in random words breaks the pattern up and causes a brief disruption in the flashback. This can be very powerful against the more intense flashbacks and I tend to use it only when I am in great need.

The sample below is meant to illustrate both why I call it counting and how it can work.

One
Two
Three
Eight
Five
Six
Seven
Green
Forty-seven
Nine
Ten
Eleven
Cow

I am unsure why this has been effective, but I do know it will not work alone. If you are selecting the order, than the order is not random, there are no surprises. The surprises catch us off guard and our reaction of "One, Two, Three, Eight?" is often enough to lessen the impact of fairly intense flashbacks.

Biology

Below is a list of information currently available from the National Center for PTSD about the psychophysiological and biological aspects of PTSD and trauma-related disorders. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

Abuse) Laboratory of the Clinical Neursosciences Division in West Haven, CT.

PTSD and Physical Health

A National Center for PTSD Fact Sheet

By Kay Jankowsi, Ph.D.

Exposure to traumatic events such as military combat, physical and sexual abuse, and natural disaster, can be related to poor physical health. Posttraumatic Stress Disorder (PTSD) is also related to health problems. This fact sheet provides information on the relationships between trauma, PTSD, and physical health; specific health problems associated with PTSD; health-risk behaviors and PTSD; mechanisms that help explain how PTSD and physical health could be related; and a clinical agenda to address PTSD and health.

Before addressing these topics, it is necessary to provide some basic information about how existing studies have measured physical health. The most common way to measure physical health is by having people report about their own health conditions, symptoms, and overall physical health. Self-report measures of physical health can be valid indicators of actual illness, but they should be interpreted with caution because they may be influenced by psychological health. The most reliable measure of physical health involves a physician’s diagnosis or laboratory tests.

Is psychological trauma related to physical health?

A considerable amount of research has found that trauma has negative effects on physical health. The relationship is clearest when examining self-report of physical health problems and trauma experienced as a result of time in the military, sexual assault, childhood abuse, and motor vehicle accidents. Greater self-report of military trauma, sexual assault, childhood abuse, and motor vehicle accidents is related to greater self-report of health problems. However, when health status is measured by physician diagnosis, associations are not as consistent for military trauma and sexual assault in adulthood. There is, however, a probable association for survivors of natural disaster. Two recent studies found that reports of childhood abuse and neglect were related to an increase in physician diagnosed disorders including cancer, ischemic heart disease, and chronic lung disease. It is also likely that a relationship exists between the experience of a trauma and an increase in utilization of medical services for physical health problems. In addition, health care costs have been found to be higher among women who report a history of childhood abuse or neglect than among women who report no history of maltreatment as a child.

What is the relationship between physical health and PTSD?

A growing body of literature has found a link between PTSD and physical health. Some studies have found that PTSD explains the association between exposure to trauma and poor physical health. In other words, trauma may lead to poor health outcomes because of PTSD. When health problems are measured by self-report, there is a clear association with PTSD for veterans and active duty personnel, civilian men and women, firefighters, and adolescents. Those who report that they have PTSD symptoms are more likely to have a greater number of physical health problems than those who do not have PTSD. Similar results are found when physical health is measured by physician report or by laboratory tests. PTSD also has been found to be associated with greater medical service utilization for physical health problems. At present, however, an association between PTSD and illness via physician diagnosis and medical service utilization has only been examined in veteran populations. Further research is indicated to examine PTSD, physical illness, and medical service utilization in both veteran and other traumatized populations.

Existing research has not been able to determine conclusively that PTSD causes poor health. Thus, caution is warranted in making a causal interpretation of what is presented here. It may be the case that something associated with PTSD is actually the cause of greater health problems. For example, it could be that a factor associated with PTSD, such as smoking, is the actual cause of the increased health problems. This is not likely, however, given that we know that PTSD is associated with poor physical health even when behavioral factors such as smoking are controlled.

PTSD may promote poor health through a complex interaction between biological and psychological mechanisms. The National Center for PTSD and other laboratories around the world are studying these mechanisms. Current thinking is that the experience of trauma brings about neurochemical changes in the brain. These changes may have biological, as well as psychological and behavioral, effects on one’s health. For example, these neurochemical changes may create a vulnerability to hypertension and atherosclerotic heart disease that could explain in part the association with cardiovascular disorders. Research also shows that these neurochemical changes may relate to abnormalities in thyroid and other hormone functions, and to increased susceptibility to infections and immunologic disorders associated with PTSD.

The psychological and behavioral effects of PTSD on health may be accounted for in part by comorbid depressive and anxiety disorders. Many people with PTSD also experience depressive disorders or other disorders. Depressed individuals report a greater number of physical symptoms and use more medical treatment than do individuals who are not depressed. Depression also has been linked to cardiovascular disease in previously healthy populations and to additional illness and mortality among patients with serious medical illness. PTSD also may be related to poor health through symptoms of comorbid anxiety or panic. The evidence linking anxiety to cardiovascular morbidity and mortality is quite strong, but the mechanisms are largely unknown.

Hostility, or anger, is another possible mediator of the relationship between PTSD and physical health. It is commonly associated with PTSD and decades of research on the health risks associated with the Type A behavior pattern have isolated hostility as a crucial factor in cardiovascular disease. PTSD and poor health also may be mediated in part by behavioral risk factors for disease such as smoking, substance abuse, diet, and lack of exercise.

Little is known about how coping and social support relate to health in PTSD, but it is likely that both play important roles. Further research is needed to better understand these potential protective factors.

What specific health problems are related to PTSD?

There is not a lot of information about what specific health problems are associated with PTSD. Many studies have not looked at specific health problems but instead report only the number of overall health problems associated with PTSD. Some studies have examined specific health problems, but these problems have been primarily self-reported. However, there is some evidence to indicate PTSD is related to cardiovascular, gastrointestinal, and musculoskeletal disorders. There is also one study with similar findings that evaluated physician diagnosed disorders and PTSD in relation to specific body systems.

A number of studies have found an association between PTSD and poor cardiovascular health. These studies found that self-report of circulatory disorders and symptoms of cardiovascular trouble were each associated with PTSD in veteran populations, civilian men and women, and male firefighters. Among studies that have examined PTSD in relation to cardiovascular illness via physician diagnosis or laboratory findings, PTSD has been consistently associated with a greater likelihood of cardiovascular morbidity. In a recent study, researchers used electrocardiogram (ECG) findings to compare the cardiovascular function of Vietnam veterans with PTSD to the cardiovascular function of veterans without PTSD. After controlling for risk factors such as alcohol consumption, weight, current substance abuse, and smoking, in addition to controlling for current medication use, PTSD was found to be associated with nonspecific ECG abnormalities, atrioventricular conduction defects, and infarctions. Because the PTSD group in this study included only those veterans with severe PTSD, it is important to interpret this study with caution. It is unknown whether men with less severe PTSD would show the same ECG abnormalities. It is also important to be cautious about generalizing the findings in this study since there have been no studies specifically evaluating cardiovascular morbidity and PTSD in women.

The gastrointestinal and musculoskeletal systems have also been shown to be associated with PTSD, but the relationship of PTSD to these two systems has not been as extensively researched as the relationship between PTSD and the cardiovascular system. The majority of the studies that have been conducted have gathered information about veterans, but a study of civilian young men and women found that there is a relationship between gastrointestinal symptoms and PTSD. Similarly, researchers found that PTSD was related to musculoskeletal symptoms among male firefighters. Additional research is needed to learn more about how these and other bodily system troubles may be related to PTSD.

What is the agenda for clinical practice?

One agenda for clinical practice is for mental-health workers to increase collaboration with primary and specialty medical care professionals in order to better address this relationship between PTSD and health problems. Medical personnel need to become more aware of the potential harmful effects trauma and PTSD can have on health. Specifically, it is important to screen for PTSD in medical settings. Studies of patients seeking physical-health care show that many have been exposed to trauma and experience posttraumatic stress but have not received appropriate mental-health care. In answer to this problem, it might be useful to integrate PTSD treatment services with medical care services.

Spiritual Healing And PTSD

By Philip G. Salois, M.S.

NCP Clinical Quarterly 5(1): Winter 1995

Twenty-five years ago, I was drafted and sent to Fort Ord to train as a combat infantry soldier. It certainly was no mystery to me or anyone else that I would end up in the jungles of Viet Nam. I served with a Light Infantry Brigade experiencing combat, the loss of a few friends, and the earning of a Silver Star for leading a rescue mission. I never sustained physical injury, but the war impacted my psyche and my soul.

As a result of a battlefield promise made to God on March 1, 1970, I am an ordained Priest. Curiously, I had forgotten that promise made during intense battle, until two years into my seminary training four years later. And though I went into the seminary on my own free will and not under the obligation of fulfilling a promise, I have come to believe that God rescued me from the war for some special work or mission. This realization has not made the on-going work any easier, but it did provide the quiet strength I needed to begin my own long and painful pilgrimage of healing.

I have been ordained 10 years now and as I hoped, I have had the opportunity to work with veterans. After five years of working with Vietnam veterans, I increasingly understand spirituality's significant role in the holistic picture of healing. The majority of Vietnam veterans were raised in Judeo-Christian families with a view of God as a father-image, that is, the strong, stern disciplinarian capable of inflicting severe punishment. In these families, the difference between right and wrong was clearly defined for children and it was defined within religious parameters. Adolescents going to war brought with them their adolescent concept of God. For many young soldiers, their concept of God was tested, challenged and potentially destroyed by the magnitude of evil all around them. In Vietnam, soldiers discovered that their concept of God did not provide answers or explanations for what they were going through. For many, the experience of the war shattered their religious concept of right and wrong. For many, the exposure to evil resulted in deep feelings of guilt and shame.

The approach to spiritual healing with Vietnam veterans requires much care, and even caution, as many of these veterans view God as a helpless, non-caring outsider watching it all from His heavenly throne.

Refounding Of The Sacred Story

My work is to help the veteran to refound his or her sacred story. I make deliberate use of that word re-founding because for many their sacred story was lost on the battlefield. The process of re-founding of one's sacred story is one of a journey away from an adolescent view of God toward a more mature understanding of faith and God's role in the course of humanity. It begins with helping the veteran to discover where and when the connection was lost. This encounter is pre-requisite to any authentic reconciliation with God as knowledge and understanding must precede forgiveness and reconciliation.

To help the process of reconnection, I have developed two interfaith healing services: one for male Vietnam veterans entitled "WELCOME HOME SERVICE," and one for women. The women' service, entitled "WOMEN OF FAITH/ WOMEN OF VALOR" has included veteran and civilian women who served in Vietnam, Vietnamese women, as well as wives, widows, and mothers of veterans. In each service the altar holds various artifacts to reflect aspects of the Vietnam experience. In the past I have used The Book of Names (on The Wall), a replica of the The Wall; a replica of the Three Service Men Statue; an actual piece of the Hanoi Hilton, framed pictures of the Eight Viet Nam Nurses whose names are on The Wall and other religious and patriotic symbols as well.

Combining the power of ritual and symbol, there are many activities that can aid veterans spiritual healing process. My own personal healing has included visits to the Vietnam Veterans Memorial "The Wall' in Washington, DC bringing flowers, letters and taking a rubbing of a name; a return to Vietnam with other veterans for the purpose of healing; a visit to the parents and grave of my buddy who was killed in 'Nam (recounting the events of his death proved healing for his parents as well). I am not recommending that other veterans pursue this same path. There are hundreds of creative ways for veterans to receive healing from writing to participating in Sweat Lodges. Every veteran must find the form of healing appropriate to their experience and ability. My role is to help them discover the options available to them.

It is crucial that something in the form of a spiritual healing take place. Disillusioned veterans need to regain the capacity to hope- - HOPE IN THEMSELVES - IN LIFE - IN OTHERS - IN GOD. As someone said - we might have to hope for the Vet until he or she can begin to hope for himself.

FATHER PHILIP G. SALOIS, M.S. is the Chief, Chaplain Service at Boston VAMC. President, National Conference of Vietnam Veteran Ministers, National Chaplain, Vietnam Veterans of America. Fr. Salois served in the US Army in Vietnam from 1969-1970 as a combat infantryman with the 199^th Light Infantry Brigade-earning many decorations including the Silver Star.

Trauma And Dissociation
Charles R. Marmar M.D.
Department of Psychiatry,
University of California, San Francisco and
Department of Veterans Affairs Medical
Center, San Francisco

The past decade has witnessed an intense reawakening of interest in the study of trauma and dissociation. In particular, the contributions of Janet, which had been largely eclipsed by developments within modern ego psychology and cognitive behav-ioral therapy, have enjoyed a resurgence of interest. Putnam (1989) and van der Kolk and van der Hart (1989) have provided a contemporary reinterpreta-tion of the contributions of Janet to the understanding of traumatic stress and dissociation. Recent research on the interrelations among trauma, memory, and dissociation is presented in a forthcoming book by Bremner and Marmar. Paralleling the resurgence of interest in theoretical studies of trauma and dissociation, there has been a proliferation of research studies addressing the rela-tionship of trauma and general dissociative tenden-cies. Chu and Dill (1990) reported that psychiatric patients with a history of childhood abuse reported higher levels of dissociative symptoms than those without histories of child abuse. Carlson and Rosser-Hogan (1991), in a study of Cambodian refugees, reported a strong relat ionship between the amount of trauma the refugees had experienced and the severity of both traumatic stress response and dissociative reactions. Spiegel and colleagues (1988) compared the hynotizability of Vietnam combat veterans with PTSD to patients with generalized anxiety disorders, affective disorders, and schizophrenia, as well as to the normal comparison group. The group with PTSD was found to have hypnotizability scores that were higher than both the psychopathological and normal controls.

Recent empirical studies have supported a strong relationship among trauma, dissociation, and per-sonality disturbances. Herman and colleagues (1989) found a high prevalence of traumatic histories in patients with borderline personality disorder. A pro-found relationship has been reported for childhood trauma and multiple personality disorder (MPD). Kluft (1993) proposes that the dissociative processes that underlie multiple personality development con-tinue to serve a defense function for individuals who have neither the external nor internal resources to cope with traumatic experiences. Coons and Milstein (1986) reported that 85% of a series of 20 MPD patients had documented allegations of childhood abuse. Simi-lar observations have been made by Frischholz (1985) and Putnam and colleagues (1986), who reported rates of severe childhood abuse as high as 90% in patients with MPD. The nature of the childhood trauma in many of these cases is notable for its severity, multiple elements of physical and sexual abuse, threats to life, bizarre elements, and profound rupture of the sense of safety and trust when the perpetrator is a primary caretaker or other close relationship.

Peritraumatic Dissociation. The studies reviewed clearly demonstrate the relationship between trau-matic life experience and general dissociative response. One fundamental aspect of the dissociative response to trauma concerns immediate dissociation at the time the traumatic event is unfolding. Trauma victims not uncommonly will report alterations in the experience of time, place, and person, which confers a sense of unreality of the event as it is occurring. Dissociation during trauma may take the form of altered time sense, with time being experienced as slowing down or rapidly accelerated; profound feelings of unreality that the event is occurring, or that the individual is the victim of the event; experiences of depersonalization; out-of-body experiences; bewilderment, confusion, and disorientation; altered pain perception; altered body image or feelings of disconnection from one¹s body; tunnel vision; and other experiences reflecting immediate dissociative responses to trauma. We have designated these acute dissociative responses to trauma as peritraumatic dissociation.

Although actual clinical reports of peritraumatic dissociation date back nearly a century, systematic investigation has occurred more recently. Wilkinson (1983) investigated the psychological reponses of sur-vivors of the Hyatt Regency Hotel skywalk collapse in which 114 people died and 200 were injured. Survi-vors commonly reported depersonalization and derealization experiences at the time of the structural collapse. Holen (1993), in a long-term prospective study of survivors of a North Sea oil rig disaster, found that the level of reported dissociation during the trauma was a predictor of subsequent PTSD. Koopman and colleagues (1994) investigated predic-tors of posttraumatic stress symptoms among survi-vors of the 1991 Oakland Hills firestorm. In a study of 187 participants, dissociative symptoms at the time the firestorm was occurring more strongly predicted subsequent posttraumatic symptoms than did anxi-ety and the subjective experience of loss of personal autonomy.

Peritraumatic Dissociative Experiences Questionnaire. Based on the important clinical and early research observations on peritraumatic dissociation as a risk factor for chronic PTSD, we embarked on a series of studies to develop a reliable and valid measure of peritraumatic dissociation. We designated this measure the Peritraumatic Dissociative Experiences Questionnaire (Marmar et al., 1996).In a first study with the PDEQ, the relationship of peritraumatic dissociation and posttraumatic stress was investigated in male Vietnam theater veterans (Marmar et al.1994). In a first replication of this finding, the relationship of peritraumatic dissociation with symptomatic distress was determined in emergency services personnel exposed to traumatic critical incidents (Weiss et al., 1995; Marmar et al., 1996). In a second replication, the relationship of peritraumatic dissociation and posttraumatic stress was investigated in female Vietnam theater veterans (Tichenor et al., 1994). Across the four studies, the PDEQ has been demonstrated to be internally consistent, strongly associated with measures of traumatic stress response, strongly associated with a measure of general dissociative tendencies, strongly associated with level of stress exposure, and unassociated with measures of general psychopathology. These studies support the reliability and convergent, discriminant, and predictive validity of the PDEQ. Strengthening these findings are two independent studies utilizing the PDEQ by investigators in other PTSD research programs. Bremner and colleagues (1992), utilizing selective items from the PDEQ as part of a measure of peritraumatic dissociation, reported a strong relationship of peritraumatic dissociation with posttraumatic stress response in an independent sample of Vietnam War veterans. In the first prospective study with the PDEQ, Shalev and colleagues (1996) examined the relationship of PDEQ ratings gathered in the first week following trauma exposure to posttraumatic stress symptomatology at 5 months. In this study of acute-physical-trauma victims admitted to an Israeli teaching hospital emergency room, PDEQ ratings at 1 week predicted stress symptomatology at 5 months, over and above exposure levels, social supports, and Impact of Event scores in the first week. This study is noteworthy in that it is the first finding with the PDEQ in which ratings were gathered prospectively. Mechanisms for Peritraumatic Dissociation. The strong replicated findings relating peritraumatic dissociation to subsequent PTSD raise theoretically important questions concerning the mechanisms that underlie peritraumatic dissociation. Speculation concerning psychological factors underlying trauma-related dissociation date back to the early contributions of Breuer and Freud (1895/1955). In their formulation,traumatic events are actively split off from conscious experience but return in the disguised form of symptoms. The dissociated complexes have an underground psychological life, causing hysterics to "suffer mainly from reminiscences." Janet (1889) proposed that trauma-related dissociation occurred in individuals with a fundamental constitutional defect in psychological functioning, which he designated la misere psychologique. Janet proposed that normal individuals have sufficient psychological energy to bind together their
mental experiences, including memories, cognitions, sensations, feelings, and volition, into an integrated synthetic whole under the control of a single personal self with access to conscious experience (Nemiah, in press). From Janet's perspective, peritraumatic dissociation results in the coexistence within a single individual of two or more discrete,
dissociative streams of consciousness, each existing independently from the others, each with rich mental contents,including feelings, memories, and bodily sensations, and each with access to conscious experience at different times. Contemporary psychological studies of peritraumatic dissociation have focused on individual differences in the threshold for dissociation. It is also possible that the threshold for
peritraumatic dissociation or generalized dissociative vulnerability is a heritable trait, aggravated by early trauma exposure and correlated with hypnotizability, as suggested by Spiegel and colleagues (1988).
A second line of investigation concerning the underlying mechanisms for peritraumatic dissociation focuses on the neurobiology and neuropharmacology of anxiety. A yohimbine challenge study by Southwick and colleagues (1993) suggests that, in individuals with PTSD, flashbacks occur in the context of high-threat arousal states. It is also significant that panic-disordered patients frequently report dissociative reactions at the height of their anxiety attacks. The effects of yohimbine in triggering flashbacks in PTSD patients and panic attacks in patients with panic disorder is mediated by a central catecholamine mechanism, as yohimbine serves as an alpha-adrenergic receptor antagonist, resulting in increased firing of locus ceruleus neurons. These observations suggest that the relationship between peritraumatic disso-
ciation and PTSD may, for some individuals, be mediated by high levels of anxiety during the trauma. Marmar et al. (1996) reported on individual differences in the level of peritraumatic dissociation during critical-incident exposure in emergency services personnel. They found the following factors to be associated with greater levels of peritraumatic dissociation: younger age; higher levels of exposure during critical incident; greater subjective perceived threat at the time of critical incident; poorer general psychological adjustment; poorer identity formation; lower levels of ambition and prudence, as defined by the Hogan Personality Inventory; greater external locus of control; and
greater use of escape/avoidance and emotional self-control coping. Taken together these findings suggest that emergency services personnel with less work experience, more vulnerable personality structures, higher subjective levels of perceived threat and anxiety at the time of incidence occurrence, greater reliance on the external world for an internal sense of safety and security, and greater use of maladaptive
coping strategies are more vulnerable to peritraumatic dissociation.
Treatment for Trauma Related Dissociation. To date, no controlled clinical trials have been reported of psychosocial or pharmacological intervention specifically targeting trauma-related dissociation. Kluft (1993), in an overview of clinical reports on treatment approaches for trauma-related dissociation,recommendsindividual,supportive-expressive
psychodynamic psychotherapy, augmented as needed with hypnosis or drug-facilitated interviews.

The purpose of this glossary is to provide definitions for the frequently used terms in the field of traumatic stress disorders. The anticipated audience is diverse, ranging from mental health professionals to consumers of mental health services and their families. Because of this diversity, we have included general mental health terms for those unfamiliar with psychological literature. The goal is to provide a common vocabulary and common meanings for both general psychiatric and trauma disorder terms

http://www.compassionpower.com/ is where you can find out about compassion treatments for abuse. the usual shaming and blaming treatment for abusive men is 28% effective, and that is based on the man not getting arrested again in the same precinct in the next yr, which is pathetic. Dr. Stosny's compassion treatment for abusive guys is 87% effective by VICTIM report on court ordered batterers. Anyone who lashes out can use it. I use his HEALS technique myself on bad feelings so that I don't lash out or get superior. It hurts to be put down, but the way to heal it is to develop compassion for myself, and then for others. It is empowering to feel compassion, and it helps me not be a victim. Here is my article on HEALS from Vol 2, No 1 (Issue 7) of the Post Traumatic Gazette (Solace for the Self) copyright 1996 by Patience H C Mason reprinted with permission: Please visitwww.patiencepress.comHEALS: A Useful Acronym for Self-Soothing by Patience Mason Steven Stosny’s HEALS acronym is a valuable resource for anyone who has been traumatized. Developed to help violent men replace the temporary high of violence with something that feels better: compassion, it was first used it in a maximum security prison with men who had each killed more that four people. It is currently used in programs for batterers. People who go through this program are 87% violence free after a year by victim report. It is also very helpful to victims who are not good at having compassion for themselves. He’s given me permission to use it in the newsletter, so here goes: "H" is for HEALING. Visualize this word in flashing neon letters as a thought stopper when you start to feel the first prickles of painful emotional arousal whether it is anger or another emotion. Stosny developed this with anger in mind, but it can also work for paralyzing waves of shame and despair. I’ve flashed HEALING many times in the last month when I realized the March/April issue would come out in May! Late again. The image of the word stimulates the natural healing capacity of the body and is “incompatible...[with] shame, anxiety, anger, hostility, and aggression. Since the brain cannot think ‘healing’ while hurting, it must switch programs to respond to your command to heal.” "E" stands for Explain to yourself. Here you acknowledge the lowest of the painful feelings you are experiencing using a list Dr. Stosny developed: disregarded unimportant accused: guilty or mistrusted devalued rejected powerless unlovable Say “I feel disregarded (or whatever).” Say it slowly and feel it for about 20 seconds. If you don’t feel it, you can’t heal it! Each time you feel this feeling, your sensitivity to its pain will go down and your tolerance for it will go up. It is like a vaccination against the power of painful feelings. Instead of controlling you, you can deal with them. "A" stands for Applying self compassion to change the meaning of having that feeling. This is the most important part because you train yourself to change patterns which you have internalized over a lifetime, patterns that tell you you really are no good unless you feel good, that you are no good unless someone else validates you. This is false information. Nothing someone else does or doesn’t do makes you unimportant, unlovable, unacceptable, or unworthy. This is particularly important for trauma survivors because they tend to assume responsibility for what happened to them, whether it’s a veteran saying I should have known about the ambush or an incest survivor believing s/he caused the abuse. [or a wife thinking she caused or deserves verbal abuse--(new addition to the article for this post. P.M.)--which is caused by a veteran's efforts to avoid thoughts or feelings associated with the trauma, usually shame and guilt, by blaming her! It has a momentary effect, but it doesn't last.] Here you learn to question the validity of the negative meaning your mind habitually supplies you with. HEALS also strengthens your boundaries. Say to yourself, “Does this external event or the behavior of that person mean that I’m unimportant, not valuable, unlovable?” Don’t question the feeling which is valid, question the meaning that attaches itself to that feeling, question whether feeling bad means you are bad. Feelings are real, but they don’t necessarily reflect reality. ”As you heal these feelings by rejecting false meaning about yourself, you will no longer need anger, anxiety and obsessions to avoid them.” YES! Stosny says the worst an external event can mean about you is that you made a mistake. That doesn’t mean you are a mistake! [And someone calling you names means they are having a bad day and have no other resources to feel better, and isn't that pathetic...P M] "L" stands for LOVE YOURSELF. Give yourself compassion. Feel compassion for yourself and others. Stosny writes: “To make yourself invulnerable to the core hurts, make yourself feel compassion.” Say to yourself: “I feel disregarded, but I am regarding myself, so the fact that whoever is not regarding me is okay. I can give myself the attention I need, the importance I need, the acceptance I need, the love I need, [The respect I need--PM] whichever of the emotions in the list applies. I suggest going through the whole list at first because they all seem to apply to me. Stosny suggests finding the lowest one on the list that applies and that works for me, too. It’s a good way to learn about and experience feelings in small bursts. Experiencing bad feelings and changing what they mean about you is preferable to avoiding them (ie emotional numbing), because it is so empowering. Being able to tolerate the pain means you have a pause button and can choose how to act instead of reacting in old patterns. I think HEALS parallels what happens when an understanding parent comforts a small child and leads him or her through handling a feeling: H= There, there. E= Johnny hit you and it hurt. A=When someone hits you, you don’t deserve to be hit. You didn’t make him hit you. L=You are a good kid. S= Solution: we’ll go play somewhere else till Johnny can control himself. When a caregiver gives you compassion, you develop it yourself. When you get ‘shut up or I’ll give you something to cry about,’ you don’t learn how to handle feelings, you learn to stuff them. "S" stands for SOLVE THE PROBLEM. Stosny believes “the skill of using self-compassion to heal the hurt that causes anger and anxiety must be learned before you are able to employ your full potential to solve problems...your concerns, opinions, and desires about a problem are...valid and important, but you will not be able to communicate their validity and importance until you have regulated anger and anxiety. Otherwise you will tend to blame, accuse, and attack, which is the surest way to get people to disagree with you and disregard you, no matter how valid and important the content of your opinions.” Ironically, that’s exactly how batterers respond to victims and their advocates in the battered women’s movement. They dismiss valid concerns because of the way they are expressed. Would you rather be right or effective? Once you have learned HEALS, anyone can learn to make classic non-blaming I statements, calmly and compassionately, and work through problems. “With repetition and practice, connections between the core hurts and higher healing thought processes replaces [the earlier learned] connections to hurts, anger, guilt, shame, obsessions and depression.” Stosny recommends practicing this system every day, many times a day (twelve or more) till it is automatic. Don’t wait till you’re in a rage or in the depths of despair to practice it. It works like pushups or shooting baskets or any other skill. Practice makes it work.

By Jeffrey Brandsma, Ph.D. and Lee Hyer, Ph.D. NCP Clinical Quarterly 5(2/3): Summer 1995

Among the many mysteries of PTSD, especially the chronic combat-related type, the construct of grief has few equals. There is no universally accepted definition of grief, no widely used grief measures, and seemingly little interest in even basic questions (e.g., how is grief related to PTSD?). The absence of attention to the association of traumatic events with loss and bereavement process is a puzzle. In this brief article we address the "necessary" commingling of grief and PTSD, and propose a model of the processes and steps involved in grief treatment. Traumatic Grief
Traumatic grief is a fitting term used by van der Hart et al (1) to straddle the clinical construct of pathological grief and the diagnostic category of PTSD. It represents the complicated side of loss in PTSD, a state reflective of the "biphasic symptom swings from symptoms of arousal, intrusive traumatic imagery, and anxiety, to defensive numbing and avoidance" (p.264). We have previously argued that states of grief and PTSD are descriptively and conceptually overlapping; they share many features in common (2). Just as most war veterans with PTSD experience guilt (3) and depression (4), most also feel the pain of loss (grief) initially as a result of combat experience (5), and later from other losses and experiences.
The stages of grief (6) are helpful in understanding the PTSD/grief connection. One key feature of combat is the attempted prevention of the third stage --disorganization--which is part of the natural process of psychological survival and crucial to the initiation and integration of the grieving reorganization. In a combat context, this reaction is rarely allowed for legitimate internal (e.g., maintenance of psychological integrity) and external reasons (e.g., safety from combat-related danger). Since this crucial step (disorganization) cannot be tolerated, the person reverts back to other stages, i.e., numbness, anger, and/or acting out in an effort to gain completion of the short-circuited process. This process and repeated exposure to other trauma result in becoming "stuck." Clinicians are familiar with this "defensive" pattern -- finding it to be more difficult to have a combat veteran experience loss and pain in therapy than other PTSD victims. Treatment
Grief therapy has been outlined by theoretical orientation, such psychodynamic (7), cognitive-behavioral approaches (8), by components of the grief process (9), by stages of grief (6), and by grief work tasks (10,11). When PTSD is chronic and unrelenting, however, these methods have only loose clinical application. After all, grieving in PTSD is "traumatic," having resulted in an alteration of basic physiological responses as well as enduring dysfunction in basic character structure (5). In working with the soul sick, chronic PTSD client, the healing of the human personality extends beyond that required by the curing of the patient's presenting problem. The work is too often done in a piece meal fashion.
Some curative components of treatment are evident in grief therapy with veterans diagnosed with PTSD. First, veterans with traumatic grief benefit from talk and exposure to the event. Exposure, however, may be done in a gradual (12) and even non-systematic way (13). Second, affect and cognition are the key ingredients in the healing process. The "white heat of relevance" from affect is the omnipresent governor in this effort; the often inflexible state of cognition being the homeostatic resistance mechanism in the personality. Both require the therapist's interest (9). Third, the life span of the grief reaction in the Both require the therapist's interest. survivor appears set during the first few weeks -- bad start, bad finish (14). Perhaps as a result of the early adjustment to trauma, the pathological types of complicated grief take form (6). Fourth, the chronic grief reaction of PTSD is individually expressed but tends to follow two paths: numbing and intrusion. The grief reaction tends to either get stuck in the intensity of the experience (unsuccessful avoidance) or in suppressing the response, i.e., being numb to feelings, but more likely acting out (9). The therapeutic goal is to find a balance and modulate more smoothly between these reactions with some observing ego. Steps Of Treatment With War Veterans
Step 1: Verbalization of loss
The verbalization of loss is a stated recognition that sense of loss was or is being experienced. Two emotion ascend to the question of "What are the emotional residuals of you experience?" First, there is often an angry or guilt-ridden symptom presentation related to loss, often similar to those responses seen at the time of the trauma. The task here is to work through anger, reframing much of it into protest, and to look into the "softer side" of the equation, i.e., the felt loss and dependency. Second, the problem of memories retraumatizing the veteran is present. Here the task is to give cognitive structure --words, concepts, and descriptive processes -- to allow some understanding and then mastery regarding what they are going through in order to clarify and objectify their experience.
Step 2: Psychoeducation
Psychoeducation of the grief process is the delicate interplay of normalization and empathy. Issues related to the stuck affect and cognitions as well as the stages, blockages, and tasks of grief therapy are "taught," anchored to the experience of the veteran. As in few other therapies, the role of teaching about grief processes help the clarify and extend the veteran's experience. Often the veteran has intense feelings as he has over-identified with the lost object (or function) and feels that has lost part of his own personhood; with some veterans, the relationship is more complex and a great deal of ambivalence is encountered. Anger, in particular may need to be reframed during this time. Also, the fear of being overwhelmed again by feelings requires addressing as the result of interlocking grief reactions from various levels of development and history. To counter this fear, it is important to restate the main losses, organizing these into categories, and focusing on each sequentially until there is an acceptable degree of resolution.
Step 3: Talking through loss
The therapist must be sensitive to exposing the positive and negative aspects of the loss -- guided by the affect connected to the various contents expressed. The greater the affect, the better (within personal limits). Done well, an increasing understanding of the "grief strength" of the veteran becomes clear as well as issues that remain unresolved. A tutored catharsis addressing the emotional reasoning of the loss is a needed reflective component of this process.
Step 4: Use of guided imagery
Although not always utilized, guided imagery is often a necessary part of grief work. In some cases, it is the grief work. The veteran closes his eyes and accesses the scene, overlapping as many senses as possible. At times, resolution unfolds as in the imagination of a burial and/or funeral service. During this process, there will be several blocks to the "affective flow." Common blockages include the inability to express "softer" emotions such as affection, love, guilt, and caring. Others will "numb out" during the process as this is their habitual pattern. Patience is required, pointing out that the patient is expressing feeling -- in their voice or body. Often the therapist can note that is not "all or nothing." Also as noted above, some disorganization must occur as part of the process. The phobic response of the combat veteran to this disorganization requires negotiation to obtain a level that is bearable.
Step 5: Saying Good-bye
A public ritual (funeral, memorial) can offer powerful closure to a traumatic memory (14). Other approaches include letter writing to the deceased person and/or empty chair work. Several useful procedures revolve around the concept of forgiveness for both self and others (15).
Step 6: Orienting toward the future
Ideally as the grief processes resolve, the veteran will assume an orientation toward the future imbued with energy, hope, and planning. Imagery may be used to help the individual construct his/her future in terms that recognize the finality of the loss and the need to continue in life. This makes the cycle complete -- acceptance of the reality of the loss, (re)experiencing the emotional pain, a digestion of the life that was lived, and a commitment to self and the future.
Despite good work or treatment gains, it will be necessary to remind the patient that grief is pervasive and may reoccur. The purpose of this reminder is to make the continual allowance for the incorporation of future affective reactions necessary for healing and growing. As Heidegger observed, "Life is suffering." Grief is the natural and appropriate human response.

The Role Of Comorbid Social Phoibia By Susan M. Orsillo, Ph.D. NCP Clinical Quarterly 7(3): Summer 1997
Individuals with PTSD often experience significant interpersonal problems including fear of intimacy, diminished social support, and impairment in occupational functioning (1). Traumatic events, particularly those of an interpersonal nature such as combat, rape, and incest, can threaten basic assumptions about relationships and disrupt an individual’s sense of connection with their community (2). Some have argued that social disconnectedness may in fact be one of the most profound consequences of trauma (3).
Relatedly, social support may play an important role in the recovery of trauma victims (4). Herman argues that recovery from traumatic experiences can only occur within the context of intimate relationships (3). Therefore a major focus of therapy for individuals with PTSD must be increasing the frequency of their positive social contacts. Choosing the optimum way in which to accomplish this goal requires that we understand the etiology and function of social avoidant behavior among individuals with PTSD. Although social avoidance as a symptom can look similar across individuals, there can be idiographic differences in the function of the behavior that may have important implications for treatment. What Does Social Avoidance Represent?
Several possibilities exist to explain the cause and function of the socially avoidant behavior that so frequently presents with PTSD. Some individuals with PTSD may limit their social contacts to avoid encountering cues that could trigger a conditioned emotional response related to the traumatic event. For example, a rape victim may avoid parties for fear that interacting with men will bring back memories of the rape. A second possibility is that the hyperarousal symptoms of PTSD, such as irritability and hypervigilance, may adversely impact upon an individual’s family members and friends, decreasing the probability of fulfilling social contact. For instance, friends may be driven away from the Vietnam veteran who is constantly verbally abusive. Further, some patients may experience emotional numbing and anhedonia to the extent that they no longer experience pleasure in the context of social interactions. Thus, an incest survivor may decline social invitations because she does not expect that they will be enjoyable. Alternatively, social avoidance displayed by an individual with PTSD may in some cases be best conceptualized as reflecting social anxiety, or in more severe cases an actual comorbid diagnosis of social phobia.
Social phobia is defined in DSM-IV as "a marked and persistent fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others" (5). The specifier "generalized" can be used when the fears are pervasive across most social situations such as informal conversations, dating situations, and work-related interactions. An individual with true comorbid PTSD and social phobia would avoid at least some social situations for fear of social evaluation. For instance, a crime victim who avoids crowds both because she fears for her safety and because she is embarrassed about being evaluated and scrutinized would likely meet criteria for both diagnoses.
On the surface it may seem unimportant to determine whether or not social avoidance is a product of social phobia. Some may feel that this is a nosological distinction lacking in clinical significance. However, ignoring the hypothesized function of avoidance behavior could negatively impact treatment decisions. For instance, encouraging an individual to engage in more frequent activities with their family may not be efficacious if family members are irritated and annoyed by the patient’s symptoms. Further, prescribing a trauma-related in vivo exposure assignment, such as asking a rape victim to spend 30 minutes in shopping mall, may result in non-compliance if she also has social fears that have not been addressed. Thus, a careful functional analysis of social avoidant behavior will provide the clinician with the best information regarding treatment choices. Social Phobia As A Comorbid Condition
The remainder of this paper will focus specifically on the presentation and impact of social phobia on PTSD. I will first present a rationale for why social phobia may be a common complaint among individuals with PTSD. Next, I will discuss assessment and treatment implications regarding this potential comorbidity. Why Might Social Phobia And PTSD Co-Occur ?
There is a small, but growing, body of literature suggesting that PTSD and social phobia may frequently co-occur. The overall comorbidity of anxiety disorders has been shown to range from 50 to 70%, with social phobia being one of the most common co-occurring anxiety disorders (6-7). Unfortunately, few well designed studies have directly assessed the comorbidity of social phobia and PTSD. However, current prevalence estimates of social phobia among Vietnam veterans with PTSD appear to be approximately 15% which is significantly higher than the rate of social phobia among a non-PTSD comparison group (8).
Two major theories regarding the development of social phobia have etiological components that underscore the potential role of traumatic events in the development of social anxiety and avoidance. Buss (9) proposed four distinct emotional-behavioral patterns associated with social anxiety: embarrassment, shame, audience anxiety and shyness. Most relevant to this paper is the proposal that shame is associated with the development of social anxiety. Thus, the other components of social anxiety will not be discussed here.
Shame is characterized by self-disgust or self-abasement. As compared to embarrassment (which is a more personal, temporary state), shame is conceptualized as a more serious, enduring, and public emotional state often associated with judgments of morality.
Buss described several causes of shame. Most relevant to this paper is that shame can be caused by failure at a task that is highly valued by society or by engagement in a task that is deemed immoral by society. For example, a soldier may feel shame as a direct result of losing a firefight, or in response to harming a civilian. Or, a child sexual abuse survivor may feel shame because she engaged in a taboo sexual act.
Shame endures because the failure or immoral act comes to represent a stigma. A stigma can be viewed as a "black mark" on an individual’s identity or character which directly impacts upon social functioning in two important ways. If a stigma is revealed, the individual risks ongoing negative appraisal from society. For instance, if a Vietnam veteran discloses his combat history he risks reproachment and rejection as a result of his behavior. However, even if the stigma is unrevealed, the individual may experience private shame concerning his or her shortcomings and fear of future, public disclosure. For example, a rape victim may withdraw from intimate relationships because she is unwilling to risk the reaction her partner might have upon learning about the sexual assault. Thus, she may avoid all social contact and appear inhibited in interpersonal contexts as a result of her feelings of shame.
Barlow (10) has also advanced a theory of social phobia. He proposed three pathways through which an individual could develop social phobia. Most relevant to this paper is the "true alarm" pathway. Barlow’s model suggests that social phobics inherit a biological vulnerability to states of generalized autonomic arousal and/or social inhibition. Given this biological predisposition, an individual would be more likely to experience a "true alarm" or a panic-like reaction in response to a socially threatening event. After this alarm, the individual is at risk to experience heightened anticipatory anxiety at the prospect of experiencing similar reactions in social situations. Barlow proposes that this anxiety interferes with the individual's ability to focus in a social situation and thus leads to poor task performance (e.g., stumbling over one’s words). Inevitably, this poor performance reinforces the individuals concern about social situations and leads to avoidance, which paradoxically decreases the opportunities to have successful social encounters and to break this vicious cycle.
Unfortunately, true alarms or direct experience with socially traumatic events are likely to be quite common among individuals with PTSD. The social psychology literature suggests that we have a motivated cognitive style by which we tend to blame victims for their own misfortunes. Victims are perceived as responsible for their own fate, a cognitive strategy that allows nonvictims to maintain their own sense of invulnerability, safety and justice (11). Examples of how this victim blaming stance can lead to socially traumatic experiences are plentiful in the area of trauma and PTSD (e.g., denial of acquaintance rape, labeling and discrimination toward Vietnam veterans).
A preliminary study in this area demonstrated the contributions of both shame and direct experiences with socially traumatic events to the development of social phobia among trauma victims. My colleagues and I (12) examined the impact of the shame Vietnam veterans felt about their military service and the perceived adversity of their homecoming on their current level of social anxiety. Controlling for premorbid social anxiety and severity of combat exposure, shame and adversity of homecoming experiences together accounted for a significant proportion of the variance in current level of social anxiety. How Can Social Phobia Be Assessed In A Patient With PTSD?
Thus, social phobia is likely to be a co-occurring problem for some individuals with PTSD. Fortunately, there appear to be some promising treatments for social phobia (13) that may be applicable for patients with PTSD. However, as discussed earlier, before initiating treatment, the first step must be to determine whether or not a patient’s social avoidance actually reflects social anxiety/ phobia rather than representing a lack of social opportunities or interest.
Traditional self-report measures of social anxiety may not be sufficient to address this issue. Questionnaires focused on social phobia often include items that tap into both the behavioral component of social phobia (e.g., "I avoid parties.") and the affective component (e.g., "I get nervous at parties."). For instance, although approximately half of the items comprising the Social Interactional Anxiety Scale (14) include an affective component of social behavior (e.g., embarrassment), the remaining items are worded such that a given social situation is described as being difficult (or for reverse scored items easy) such as "I have difficulty making eye-contact with others". The latter set of items could be endorsed by a rape victim who is fearful of making eye contact because it reminds her of aggressive behavior, a PTSD-related symptom, or because she perceives negatively evaluated, which is more likely related to social phobia. Given the complexity of this issue, both interview and questionnaire data should always be utilized when assigning a diagnosis.
Relatedly, clinical experience suggests that the validity of an individual's ability to predict his or her level of social anxiety in a given situation may be questionable. If a patient has avoided social situations for a long period of time, his or her ability to accurately predict an emotional response in a given social situation may be severely limited. Furthermore, social anxiety can be masked by anger in individuals who have suffered prolonged social rejection. For example, a veteran who reports that he "doesn't give a shit" what others think may be covering up the anxiousness and hurt he feels about being rejected. One way to better assess social anxiety in this population may be to have subjects participate in a behavioral assessment or role-play of a potentially anxiety-provoking situation and to have physiological and behavioral ratings obtained in addition to self-report. The Impact Of Social Phobia On Trauma-Related Treatment
The implications of the high rate of comorbidity of PTSD and social phobia for treatment need to be empirically addressed. Currently, cognitive-behavioral therapies, including exposure therapy, show the most promise as effective treatments for PTSD (15). However, it is unclear how a comorbid diagnosis of social phobia may impact on the efficacy of these approaches. Although research in this area is clearly needed, it is possible that supplemental treatments could be useful to address related social deficits.
Further, although there have been fewer studies examining the effectiveness of trauma-related group therapy, this approach may be quite helpful in resolving PTSD symptomatology and associated features. Herman (3), based on extensive clinical experience, discussed group treatment as an advanced stage of healing. She proposed that where traumatic events destroy the sustaining bonds between an individual and the community, a group can recreate a sense of belonging. Groups may allow a trauma victim to discover the commonality of his or her traumatic experience that has been previously hidden away as a "shameful secret".
Given these theoretical considerations, as well as the current economic atmosphere which supports the development of cost-effective delivery of services, group therapy may prove to be a viable option for many patients with PTSD. However, it may be more difficult for an individual with comorbid social phobia and PTSD to accept referral into a therapy group. By definition, individuals with social phobia fear and avoid situations that are inherent in group psychotherapy, such as being exposed to the scrutiny of others and speaking in front of a group. In addition to refusing referral, social phobic patients may attend but not actively participate in a trauma group, or they may prematurely drop out of therapy. Suggestions For Treatment
Although there is no research on treating social phobia as a comorbid diagnosis to PTSD, several suggestions can be made based on the existing social phobia literature (13, 16). In vivo exposure, which requires the patient to enter and remain in a feared situation until their fear level subsides, can be extremely useful in treating phobic conditions. An example of an in vivo assignment would be to have a social phobic patient invite a co-worker to lunch.
Although this method is effective in reducing anxiety, it can be very difficult to adequately conduct with social phobics. Social situations are often unpredictable and uncontrollable (17). An individual with a specific phobia, such as a fear of dogs, can be systematically exposed to their feared object for a scheduled period of time. However, social situations are difficult to schedule and they may vary in context and content depending on the actions of the other party. Further, in vivo exposure is typically conducted in a prolonged manner. Unfortunately, many social interactions are fleeting (e.g., asking a question in class) and they do not allow sufficient time for habituation (17). Further, social situations are not always easily available (13). Unlike the height phobic who can gain easy access to exposure situations, a Vietnam veteran who has become completely isolated due to his hypervigilance and anger control problems may not have many opportunities for social interaction.
In order to address these issues, Heimberg (13) incorporates within session exposure simulations or role-plays into his treatment. Simulations can be set up to emulate reading a prepared speech to an audience, making small talk at a party, or refusing an unreasonable request from a co-worker. Heimberg emphasizes the use of simulations because unlike in vivo assignments, they are always available, schedulable, controllable, "moldable" to the needs of a specific client, open to therapist observation, and less subject to avoidance and non-compliance. In Heimberg’s protocol, these simulations occur in the context of a group therapy program in which other patients both can serve as "role-players" and maximize their opportunities for exposure to social situations. Nonetheless, with adequate creativity and resources, simulations can also be conducted in the context of individual therapy.
Another technique often used in the treatment of social phobia is cognitive restructuring. Heimberg (13) outlines a systematic approach to cognitive restructuring which includes several steps. First, the patient is encouraged to anticipate a feared social situation and report experienced automatic thoughts (e.g., "She will think I am a fool."). Next, the patient is instructed to review his or her thoughts looking for cognitive errors using a list of common cognitive distortions (e.g., mind reading; all or nothing thinking). Patients are then encouraged to question their automatic thoughts ("How do I know what they are thinking? What is the probability that my feared consequence will occur?") and develop a rational response that they can use to cope with their fear (e.g., "A conversation is not all my responsibility"). Heimberg incorporates cognitive restructuring into each exposure simulation.
Recent meta-analytic studies evaluating treatment programs for social phobia suggest that the cognitive component may not be essential (16). However, more research is needed before definitive conclusions can be made about the exact agent of change in the current treatment packages for social phobia. Nevertheless, Heimberg’s (13) manual provides an excellent starting point for the clinician who is confronted with a patient with comorbid PTSD and social phobia. Conclusions
Several recent advances in the field have resulted in the development of efficacious treatments focused on alleviating symptoms of re-experiencing, avoidance, and hyperarousal expressed by our patients. However, we need to continue to make progress in improving their quality of life. One potential approach is to focus our treatment efforts on the social isolation that continues to be a problem for many trauma patients. As suggested in this paper, social phobia may be one comorbid condition that can be targeted in some patients to improve their daily functioning. Although more research is needed to adequately assess the needs of PTSD patients with comorbid social phobia, clinicians can use the guidelines delineated in this paper to begin to think about the function of their patients’ social avoidance and to determine adequate treatment strategies.

DSM-IV SUMMARY TABLE

Axis 1:

Clinical disorders

Axis 2:

Personality/ developmental disorders

Axis 3:

Relevant physical disorders

Axis 4:

Psychosocial and Environmental problems

Axis 5:

Global Assessment of Functioning

Examples:

· Anxiety disorders

· Mood disorders

· Dissociative disorders

· Substance-related disorders

· Schizophrenia

· Sexual & gender-identity disorders

· Eating disorders

Examples:

· Paranoid personality disorder

· Antisocial personality disorder

· Narcissistic personality disorder

· Borderline personality disorder

· Dependent personality disorder

Examples:

· Infectious & parasitic diseases

· Endocrine, nutrional, metabolic, immune diseases

· Diseases of nervous system & sense organs

· Congenital anomalies

Examples:

· Problems with primary support group

· Problems related to social environment

· Educational problems

· Occupational problems

· Housing or economic problems

Examples:

100 = Superior functioning in a wide range of activities

50 = Serious symptoms or impairment in social, occupational, or school functioning

10 = Persistent danger of severely hurting self or others

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Identifying Information:

age
ethnic background
era of military service
reason for referral (original exam to establish PTSD diagnosis and related psychosocial impairment; re-evaluation of status of existing service-connected PTSD condition)

B. Sources of Information:

records reviewed (C-file, DD-214, medical records, other documentation)
review of social-industrial survey completed by social worker
statements from collaterals
administration of psychometric tests and questionnaires (identify here)

C. Review of Medical Records:

Past Medical History:

Previous hospitalizations and outpatient care.
Complete medical history is required, including history since discharge from military service.
Review of Claims Folder is required on initial exams to establish or rule out the diagnosis.

Present Medical History - over the past one year.

Frequency, severity and duration of medical and psychiatric symptoms.
Length of remissions, to include capacity for adjustment during periods of remissions.

D. Examination (Objective Findings):

Address each of the following and fully describe:
History (Subjective Complaints):
Comment on:
Premilitary History (refer to social-industrial survey if completed)

describe family structure and environment where raised (identify constellation of family members and quality of relationships)
quality of peer relationships and social adjustment (e.g., activities, achievements, athletic and/or extracurricular involvement, sexual involvements, etc.)
education obtained and performance in school · employment
legal infractions
delinquency or behavior conduct disturbances
substance use patterns
significant medical problems and treatments obtained
family psychiatric history
exposure to traumatic stressors (see CAPS trauma assessment checklist)
summary assessment of psychosocial adjustment and progression through developmental milestones (performance in employment or schooling, routine responsibilities of self-care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits).

Military History

branch of service (enlisted or drafted)
dates of service
dates and location of war zone duty and number of months stationed in war zone
Military Occupational Specialty (describe nature and duration of job(s) in war zone
highest rank obtained during service (rank at discharge if different)
type of discharge from military
describe routine combat stressors veterans was exposed to (refer to Combat Scale)
combat wounds sustained (describe)
clearly describe specific stressor event(s) veteran considered particularly traumatic. Clearly describe the stressor. Particularly if the stressor is a type of personal assault, including sexual assault, provide information, with examples, if possible.
indicate overall level of traumatic stress exposure (high, moderate, low) based on frequency and severity of incident exposure (refer to trauma assessment scale scores described in Appendix B).
citations or medals received
disciplinary infractions or other adjustment problems during military

NOTE: Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. Crucial in this description are specific details of the stressor, with names, dates, and places linked to the stressor, so that the rating specialist can confirm that the cited stressor occurred during active duty.

A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.
Post-Military Trauma History (refer to social-industrial survey if completed)

describe post-military traumatic events (see CAPS trauma assessment checklist)
describe psychosocial consequences of post-military trauma exposure(s) (treatment received, disruption to work, adverse health consequences)

Post-Military Psychosocial Adjustment (refer to social-industrial survey if completed) · legal history (DWIs, arrests, time spent in jail)

educational accomplishment
employment history (describe periods of employment and reasons)
marital and family relationships (including quality of relationships with children)
degree and quality of social relationships
activities and leisure pursuits
problematic substance abuse (lifetime and current)
significant medical disorders (resulting pain or disability; current medications)
treatment history for significant medical conditions, including hospitalizations
history of inpatient and/or outpatient psychiatric care (dates and conditions treated)
history of assaultiveness
history of suicide attempts
summary statement of current psychosocial functional status (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits)

E. Mental Status Examination

Conduct a brief mental status examination aimed at screening for DSM-IV mental disorders. Describe and fully explain the existence, frequency and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

Impairment of thought process or communication.
Delusions, hallucinations and their persistence.
Eye Contact, interaction in session, and inappropriate behavior cited with examples.
Suicidal or homicidal thoughts, ideations or plans or intent.
Ability to maintain minimal personal hygiene and other basic activities of daily living.
Orientation to person, place and time.
Memory loss, or impairment (both short and long-term).
Obsessive or ritualistic behavior which interferes with routine activities and describe any found.
Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent.
Panic attacks noting the severity, duration, frequency and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation is shown.
Depression, depressed mood or anxiety.
Impaired impulse control and its effect on motivation or mood.
Sleep impairment and describe extent it interferes with daytime activities.
Other disorders or symptoms and the extent they interfere with activities, particularly:

mood disorders (especially major depression and dysthymia)
substance use disorders (especially alcohol use disorders)
anxiety disorders (especially panic disorder, obsessive-compulsive disorder, generalized anxiety disorder)
somatoform disorders
personality disorders (especially antisocial personality disorder and borderline personality disorder)

Specify onset and duration of symptoms as acute, chronic, or with delayed onset.

F. Assessment of PTSD

state whether or not the veteran meets the DSM-IV stressor criterion
identify behavioral, cognitive, social, affective, or somatic change veteran attributes to stress exposure
describe specific PTSD symptoms present (symptoms of trauma re-experiencing, avoidance/numbing, heightened physiological arousal, and associated features [e.g., disillusionment and demoralization])
specify onset, duration, typical frequency, and severity of symptoms

G. Psychometric Testing Results

provide psychological testing if deemed necessary
provide specific evaluation information required by the rating board or on a BVA Remand.
comment on validity of psychological test results
provide scores for PTSD psychometric assessments administered
state whether PTSD psychometric measures are consistent or inconsistent with a diagnosis of PTSD, based on normative data and established "cutting scores" (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL > 50; Mississippi Scale > 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-8)
state degree of severity of PTSD symptoms based on psychometric data (mild, moderate, or severe)
describe findings from psychological tests measuring problems other than PTSD (MMPI, etc.)

H. Diagnosis:

The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.
If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.
Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or is caused or aggravated by another mental disorder, you should separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects in such cases, please explain why.

I. Diagnostic Status

Axis I disorders
Axis II disorders
Axis III disorders
Axis IV (psychosocial and environmental problems)
Axis V (GAF score - current)

J. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.)

DSM-IV is only for application from 11/7/96 on. Therefore, when applicable note whether the diagnosis of PTSD was supportable under DSM-III-R prior to that date. The prior criteria under DSM-III-R are provided as an attachment.

K. Capacity to Manage Financial Affairs: Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest. In order to assist raters in making a legal determination as to competency, please address the following:

What is the impact of injury or disease on the veteran's ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently? Does the veteran handle the money and pay the bills himself or herself?

Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion.

If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran's ability to manage his or her financial affairs, please explain why.

L. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand (furnish the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken). If the requested opinion is medically not ascertainable on exam or testing please state why. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks " ... is it at least as likely as not ... ", fully explain the clinical findings and rationale for the opinion. M. Integrated Summary and Conclusions

Describe changes in psychosocial functional status and quality of life following trauma exposure (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits)
Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important.
If possible, describe extent to which disorders other than PTSD (e.g., substance use disorders) are independently responsible for impairment in psychosocial adjustment and quality of life. If this is not possible, explain why (e.g., substance use had onset after PTSD and clearly is a means of coping with PTSD symptoms).
If possible, describe pre-trauma risk factors or characteristics than may have rendered the veteran vulnerable to developing PTSD subsequent to trauma exposure.
If possible, state prognosis for improvement of psychiatric condition and impairments in functional status.
Comment on whether veteran is capable of managing his or her financial affairs.

Understanding the C & P Examination Process

The following videos were developed for professionals; however you may find it helpful in knowing what adjudicators are looking for in a claim.

Purpose:
To assist mental health professionals and claims raters to better understand and improve the C&P PTSD examination process.

Objectives:
For VHA/RCS Clinicians:
Illustrate what is needed to translate clinical findings into a form that is usable for VBA raters. Explain how to use the "Best Practice Manual for PTSD C&P Examinations".

For VBA Claims Raters: Determine when an examination should be returned for further documentation.

A panel discussion, moderated by Doris McMillon, about the Compensation and Pension process at the department of Veterans Affairs. The purpose of this video is to assist mental health professionals and claims raters to better understand and improve the C&P PTSD examination process.

Writting Your Stressor Letter
Please contact one the individuals listed at the end of the page for more information and any questions you have There are two basic steps to receive a disability from the Veterans Administration for PTSD. The first step is filing a claim with the VA for PTSD. The second, and most Important, is submitting a stressor letter. Most combat veterans do not trust the government or the VA. This is understandable considering the treatment most veterans received during and after the Vietnam War. But the VA has improved in most places, and the benefits are there for the combat veterans. The VA does not go looking for the combat veteran with PTSD. You mush push aside any bad feelings and make the effort to receive the earned benefits.
As ridiculous at it may seem, all combat veterans must not only prove that they were in combat, they must also prove that they were in the military. This process screens out the phony combat veterans. It is surprising how many combat veterans have surfaced who were on top secret missions, and of course, there is no record of their even being in the military because their missions were so secret.
You can file a claim on your own, but there are several veteran’s organizations who will represent you on a disability claim. You will need to sign a power of attorney. You sign this paper and send it back through the mail. This gives the Service Officer your permission to represent you in your claim. Please be aware that there are many poor Service Officers. If you are not offered immediate help, with eagerness, move on until you find a Service Officer who is eager to help you. All Veterans Groups have Service Officers, so shop alll of them until you find a person your are comfortable with or contact us and we will try to help you.
This is the single most important factor in obtaining disability for the combat veteran. After your claim has been filed, usually within 30 to 60 days, you will receive a letter from the VA stating that they have received your claim for PTSD. Then you will be asked to submit a stressor letter. This is a written record of combat experiences which you felt were life threatening or have caused you to display symptoms of PTSD. They will also note that they understand how difficult this can be for some veterans (thinking about war experiences and writing them down). And for many this is difficult. Some can't write well. Some are too terrified to think in detail about their war experience.
Chances are the average veteran cannot write a stressor letter that will pass the rating board. Once a stressor letter has been rejected by the rating board, the process to receive disability can be long and discouraging. Many veterans give up and never receive the disability they deserve. The VA will tell-you how to write the letter or what details to include. If the letter is rejected, many combat veterans will give up before appealing the rating board decision. So a veteran must submit a solid stressor letter to pass the rating board. This is my area of expertise. I know what to put in the letter and how to present it so that the rating board will grant any where from 10% to 50% disability just from your stressor letter without rejection and VA appeal hearings. It will be impossible to receive a 100% rating from a stressor letter, but once the VA agrees you are disabled, you can appeal for a higher percentage.
PTSD IS A RECOGNIZED DISORDER WHICH DOES NOT GO AWAY. THE REACTIONS TO COMBAT STRESS OFTEN BECOMES A PERMANENT PART OF THE VETERAN'S PERSONALITY.
COMP EXAM
At some point after you file for disability, either before or after you have submitted your stressor letter, you will receive a letter asking you to come to the nearest VA Hospital in your area for a Compensation Examination. This just means that you are going to speak to a VA psychiatrist. The psychiatrist will ask you many questions about your background (including your childhood and current social life) and your war service. The meeting with the doctor will probably last anywhere from 20 to 45 minutes. The VA will also reimburse you with a small travel allowance for coming.
You must show up for this comp exam. If for some reason you can't make it, then call the VA and they will schedule you again. Most of all, relax. This psychiatrist is not your enemy, and it is his or her job to send a report to the VA regional office as to whether you show symptoms of PTSD. The psychiatrist Is Impartial. If you show symptoms of PTSD, it will be reported without any favor toward the VA. So relax and answer questions to the best of your knowledge. Always stress the negative side of your life...never the positive. Just like at the close of the stressor letter. You can do this and still tell the truth just by avoiding the positive.
Here are some things not to say at a Comp Exam
1. My life is okay. It's not or you wouldn't be there.
2. I sometimes hear voices. Hearing voices can lead to a diagnosis of schizophrenia, and your PTSD claim may be rejected.
3. I am happily married. It has often been decided that having PTSD automatically means an unhappy marriage. It can but not always.
4. I love my job. I have been there twenty years. If you have managed to keep one job, it may be determined that you interact normally and do not have PTSD. You can have one job and still be miserable. It's a matter of survival.
5. I have lots of friends. Never admit you have lots of friends. Chances are you don't anyway. At least, not like the friends you made in combat situations who you can trust with your life.
6. Don't threaten the doctor. Some veterans scream, yell, and threaten to kill the doctor in an attempt to show symptoms of PTSD. 99% of the time this is an act and won't help your claim. The main thing is to stress the negative side of your life, just as in the end of the stressor letter. If you have had a substance abuse problem since before your war service, it would be best not to mention it. Stress the fact that you are depressed and have nightmares and feel that the war has altered your life. Just remember to stress the negative instead of anything positive in your life.
For aditional information and help with writing a stressor letter please go to: http://silverrose.org/ptsd.html

Coping with PTSD and Recommended Lifestyle Changes for PTSD Patients

A National Center for PTSD Fact Sheet

By Joe Ruzek, Ph.D.

Coping with PTSD

Because PTSD symptoms seldom disappear completely, it is usually a continuing challenge for survivors of trauma to cope with PTSD symptoms and the problems they cause. Survivors often learn through treatment how to cope more effectively.

Recovery from PTSD is an ongoing, daily, gradual process. It doesn't happen through sudden insight or "cure." Healing doesn't mean that a survivor will forget war experiences or have no emotional pain when remembering them. Some level of continuing reaction to memories is normal and reflects a normal body and mind. Recovery may lead to fewer reactions and reactions that are less intense. It may also lead to a greater ability to manage trauma-related emotions and to greater confidence in one's ability to cope.

When a trauma survivor takes direct action to cope with problems, he or she often gains a sense of personal power and control. Active coping means recognizing and accepting the impact of traumatic experiences and then taking concrete action to improve things.

Positive coping actions are those that help to reduce anxiety and lessen other distressing reactions. Positive coping actions also improve the situation in a way that does not harm the survivor further and in a way that lasts into the future. Positive coping methods include:

Learning about trauma and PTSD-It is useful for trauma survivors to learn more about PTSD and how it affects them. By learning that PTSD is common and that their problems are shared by hundreds of thousands of others, survivors recognize that they are not alone, weak, or crazy. When a survivor seeks treatment and learns to recognize and understand what upsets him or her, he or she is in a better position to cope with the symptoms of PTSD.

Talking to another person for support-When survivors are able to talk about their problems with others, something helpful often results. Of course, survivors must choose their support people carefully and clearly ask for what they need. With support from others, survivors may feel less alone, feel supported or understood, or receive concrete help with a problem situation. Often, it is best to talk to professional counselors about issues related to the traumatic experience itself; they are more likely than friends or family to understand trauma and its effects. It is also helpful to seek support from a support group. Being in a group with others who have PTSD may help reduce one's sense of isolation, rebuild trust in others, and provide an important opportunity to contribute to the recovery of other survivors of trauma.

Talking to your doctor about trauma and PTSD-Part of taking care of yourself means mobilizing the helping resources around you. Your doctor can take care of your physical health better if he or she knows about your PTSD, and doctors can often refer you to more specialized and expert help.

Practicing relaxation methods-These can include muscular relaxation exercises, breathing exercises, meditation, swimming, stretching, yoga, prayer, listening to quiet music, spending time in nature, and so on. While relaxation techniques can be helpful, they can sometimes increase distress by focusing attention on disturbing physical sensations or by reducing contact with the external environment. Be aware that while uncomfortable physical sensations may become more apparent when you are relaxed, in the long run, continuing with relaxation in a way that is tolerable (i.e., interspersed with music, walking, or other activities) helps reduce negative reactions to thoughts, feelings, and perceptions.

Increasing positive distracting activities-Positive recreational or work activities help distract a person from his or her memories and reactions. Artistic endeavors have also been a way for many trauma survivors to express their feelings in a positive, creative way. This can improve your mood, limit the harm caused by PTSD, and help you rebuild your life. It is important to emphasize that distraction alone is unlikely to facilitate recovery; active, direct coping with traumatic events and their impact is also important.

Calling a counselor for help-Sometimes PTSD symptoms worsen and ordinary efforts at coping don't seem to work. Survivors may feel fearful or depressed. At these times, it is important to reach out and telephone a counselor, who can help turn things around.

Taking prescribed medications to tackle PTSD-One tool that many with PTSD have found helpful is medication treatment. By taking medications, some survivors of trauma are able to improve their sleep, anxiety, irritability, anger, and urges to drink or use drugs.

Negative coping actions help to perpetuate problems. They may reduce distress immediately but short-circuit more permanent change. Some actions that may be immediately effective may also cause later problems, like smoking or drug use. These habits can become difficult to change. Negative coping methods can include isolation, use of drugs or alcohol, workaholism, violent behavior, angry intimidation of others, unhealthy eating, and different types of self-destructive behavior (e.g., attempting suicide). Before learning more effective and healthy coping methods, most people with PTSD try to cope with their distress and other reactions in ways that lead to more problems. The following are negative coping actions:

Use of alcohol or drugs-This may help wash away memories, increase social confidence, or induce sleep, but it causes more problems than it cures. Using alcohol or drugs can create a dependence on alcohol, harm one's judgment, harm one's mental abilities, cause problems in relationships with family and friends, and sometimes place a person at risk for suicide, violence, or accidents.

Social isolation-By reducing contact with the outside world, a trauma survivor may avoid many situations that cause him or her to feel afraid, irritable, or angry. However, isolation will also cause major problems. It will result in the loss of social support, friendships, and intimacy. It may breed further depression and fear. Less participation in positive activities leads to fewer opportunities for positive emotions and achievements.

Anger-Like isolation, anger can get rid of many upsetting situations by keeping people away. However, it also keeps away positive connections and help, and it can gradually drive away the important people in a person's life. It may lead to job problems, marital or relationship problems, and the loss of friendships.

Continuous avoidance-If you avoid thinking about the trauma or if you avoid seeking help, you may keep distress at bay, but this behavior also prevents you from making progress in how you cope with trauma and its consequences.

Recommended Lifestyle Changes – Taking Control

Those with PTSD need to take active steps to deal with their PTSD symptoms. Often, these steps involve making a series of thoughtful changes in one's lifestyle to reduce symptoms and improve quality of life. Positive lifestyle changes include:

Calling about treatment and joining a PTSD support group-It may be difficult to take the first step and join a PTSD treatment group. Survivors say to themselves, "What will happen there? Nobody can help me anyway." In addition, people with PTSD find it hard to meet new people and trust them enough to open up. However, it can also be a great relief to feel that you have taken positive action. You may also be able to eventually develop a friendship with another survivor.

Increasing contact with other survivors of trauma-Other survivors of trauma are probably the best source of understanding and support. By joining a survivors organization (e.g., veterans may want to join a veteran's organization) or by otherwise increasing contact with other survivors, it is possible to reverse the process of isolation and distrust of others.

Reinvesting in personal relationships with family and friends-Most survivors of trauma have some kind of a relationship with a son or daughter, a wife or partner, or an old friend or work acquaintance. If you make the effort to reestablish or increase contact with that person, it can help you reconnect with others.

Changing neighborhoods-Survivors with PTSD usually feel that the world is a very dangerous place and that it is likely that they will be harmed again. It is not a good idea for people with PTSD to live in a high-crime area because it only makes those feelings worse and confirms their beliefs. If it is possible to move to a safer neighborhood, it is likely that fewer things will set off traumatic memories. This will allow the person to reconsider his or her personal beliefs about danger.

Refraining from alcohol and drug abuse-Many trauma survivors turn to alcohol and drugs to help them cope with PTSD. Although these substances may distract a person from his or her painful feelings and, therefore, may appear to help deal with symptoms, relying on alcohol and drugs always makes things worse in the end. These substances often hinder PTSD treatment and recovery. Rather than trying to beat an addiction by yourself, it is often easier to deal with addictions by joining a treatment program where you can be around others who are working on similar issues.

Starting an exercise program-It is important to see a doctor before starting to exercise. However, if the physician gives the OK, exercise in moderation can benefit those with PTSD. Walking, jogging, swimming, weight lifting, and other forms of exercise may reduce physical tension. They may distract the person from painful memories or worries and give him or her a break from difficult emotions. Perhaps most important, exercise can improve self-esteem and create feelings of personal control.

Starting to volunteer in the community-It is important to feel as though you are contributing to your community. When you are not working, you may not feel you have anything to offer others. One way survivors can reconnect with their communities is to volunteer. You can help with youth programs, medical services, literacy programs, community sporting activities, etc.

But here we're focusing on talking to other people - your partner, family members, friends, work or volunteer colleagues.

There are many possible benefits to telling others that you have PTSD. They can come to understand you better and support you more. They may realize that when you're angry or need to leave a situation, it's not because you dislike them but more about your symptoms and struggles. They can come to be more accepting of your fears, irritability, withdrawal, or other PTSD symptoms.

Partners and family members have a special need to learn about PTSD. In fact, good care for you will often mean that those close to you need to become better educated about PTSD: what it is, how it can result from traumas like combat or sexual assault, what happens in treatment, what happens in the process of recovery, what things trigger your symptoms, and what they can do to help support your recovery.

On a case-by-case basis, it may also be important to tell people you work, volunteer, or socialize with about your PTSD. If they know about PTSD, they will be more likely to react in a helpful way when your PTSD worsens or you have problems related to PTSD.

Here are some things to consider as you decide if, when, and how to tell another person about your PTSD:

Talk about this with your counselor before telling others and think together about the pro's and con's of talking.
Choose carefully whom you tell. There should be a good reason to tell them, and there are times when it will not be necessary or wise to tell a particular person.
Think about their possible reactions. Will they be understanding; will they listen?
Think about and prepare what you are going to say.
Test the water a little. Try a brief conversation and see how they react.
When doing this for the first or second time, choose someone that you are confident will be understanding and supportive.
Don't tell them about your traumatic experiences, unless you and your counselor decide there is some reason to do so. Other people need to understand what your experience is now, not what happened to you. You can tell them, briefly and generally, what happened, if you choose ("I saw people die" or "I almost died" or "I saw terrible things"). But there is no reason to go into the details.
Tell them why you are explaining about your PTSD: that part of your recovery means letting people important to you know what's going on with you, discussing what problems you might occasionally experience, and making some plans for how to deal with problems if they arise.

Very occasionally, someone might react badly when you tell them about your PTSD. They might be scared of you ("crazy Vietnam vet") or they might appear uncomfortable. Usually, this will be due to ignorance, a lack of understanding of war and other trauma, and of trauma reactions. Commonly, they will not know what to say. Most people don't know much about the impact of trauma on human beings, and they have not had the opportunity to talk about emotional problems with someone who is experiencing them.

What do you want to tell them about your PTSD? It may be especially helpful to tell them about the parts of your PTSD reactions that might affect them: your difficulty in expressing positive feelings, your difficulty in getting close to another person, your irritability or anger, your difficulty in going into busy or crowded places, your occasional social isolation, your difficulties in being in social situations, and so on. Also tell them about the basic symptoms of PTSD.

You can explain things in a positive and prideful way. You can say (in your own words, expanding on what you want) that war (or other trauma) affects many people in very powerful ways that continue long past the trauma itself, that you are actively working at self-care by learning coping tools and getting counseling and other forms of regular support, and that part of your self-care action is to talk to people that are important to you about what PTSD is and how it can affect you.

As you strengthen your recovery and become more skilled in using your coping tools, you will gradually become more comfortable in talking to others about what is going on with you.

www.patiencepress.com e deals with all kinds of trauma. Her book "Recovering from the War" is a great pla

What would happen if there was a disease in this country that had killed hundreds of thousands over the decades and inhibits the lives or disables thousands of people in this country?

The corporation will serve as a mechanism for people involved with PTSD to band together and provide support not only to the victims of PTSD, but also to all those who love the victims.

TO ADVOCATE: To help victims and those who who love them find the help they need to lead a more normal life. To work with the VA and other agencies who can provide assistance to the victims.

TO ASSIST: Provide a network where victims and those who love them can talk to someone who understands them. The best help is from someone who has been there. This must be a 24 hour help line, because crises can happen at any time and intervention can save a life. Help the victim find professional help.

TO INFORM: To provide information to victims and those that love them. Too many know something is wrong but do not know what. Also, the male ego does not want to admit to any kind of weakness. This includes a monthly opt in newsletter with contributions from people who have been there.

TO EDUCATE: To educate the public at large about PTSD, how it affects people, its affect on families and society, and the help the general public can provide to the victims.

WHY DOES THIS ORGANIZATION NEED FUNDS? Contributions are needed for maintaining this web site, promotion, office equipment, database maintenance, travel for lectures, etc. The corporation will develop grant proposals, but the primary support is from individuals. It is amazing how fast even $5 contributions can add up and allow the organization to accomplish its stated purpose.

The Ex-Services Mental WelfareSociety, COMBAT STRESS, exists toserve ex service personnel. For over 80 years, they have been the only services charity specialising inhelping those of all ranks from the
Armed Forces and the Merchant Navy suffering from psychological disability as a result of their service.Through their national network of welfare officers, they visit clients athome in order to establish how best
we can improve their quality of life.Through out their three treatment centres, we provide rehabilitative treatment which aims to help the victim cope with his or her disabilitiesand to enjoy a better quality of life.
In over 80 years of operation, theSociety has provided some 75,000 veterans of the two World Wars and the many conflicts since with a unique lifeline. Currently, the Societytakes about 600 veterans onto its
books each year, the youngest intheir early twenties, the oldest in their seventies. There are people inreceipt of help who between them represent service in every campaignwhich the British Armed services has
been engaged from the start of WorldWar 2 to the present day. Should you wish to contact CombatStress please speak to Keith Hudson
(NIVA Welfare Officer) onTel: 07880535314.
Or alternativley contact CombatStress directly:-
Head Office
Tyrwhitt House, Oaklawn Road
Leatherhead, Surrey KT22 0BX
Telephone Number: 01372 841600
Email Address:
contactus@combatstress.org.uk
Notes taken from Combat Stress

Active Duty Military

Below is a list of information currently available from the National Center for PTSD about active duty military. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

Author of Recovering from the War: A Guide for all Veterans, Family Members, Friends,and Therapists

http://www.patiencepress.com/ ©2007 Patience H. C. Mason All rights reserved. No portion of this publication may be reprinted without expresswritten permission of the author, which you have if you are a veteran, family member, friend or therapist. Please print, copy, and give to anyone it will help. .

My husband, Bob, spent the second year of our marriage flying a Huey slick in the First Cavalry Division in Vietnam 1965-66. His book, Chickenhawk, tells the story of that year. When he got back, I saw how skinny he was, but I was so glad to have him back, I didn’t notice the thousand yard stare. I had no idea what he had been through. I was just so glad he was alive. Neither of us had any idea that the war was, quite naturally and normally, going to affect both of us for the rest of our lives. We didn’t know any of what you will read in this pamphlet. They told Bob he would be fine in a few weeks. When he wasn’t, he thought he was nuts. I thought I was a bad wife, or he would not be having problems. He often agreed. Our life was not very happy for the next fifteen years, until we found out about Post-Traumatic Stress Disorder. We still deal with it, but today our dealings are informed, which makes things easier.

Stage 1: I’m fine: Most soldiers come back believing it’s all over. Young, strong, proud, even if you are having some odd moments, you are not about to tell the doctors because you will be kept from going home. The changes that helped you survive war don’t seem that big a deal, and who is going to tell some guy in a white coat that you are seeing dead people? You may not know how much you have changed till you’re home.

Life here is flat. People have petty problems. You can’t sleep, have bad dreams, get furious at everything, and keep looking for roadside bombs. When a car backfires, you hit the dirt. Still, you probably think the people around you have problems. Not you. Any comments about how you’ve changed may really piss you off. You’re fine! You survived a war! What kind of help could you possibly need after that? If you don’t know that it is normal to be affected, what else can you do but deny that you are? That’s what everyone else does. Denial can make your family feel nuts. You may be telling them they are nuts.

This usually does not improve relationships. Furthermore, in today’s military, you probably will have to go back, so denial may seem necessary..

Stage 2: I’m not fine, but I’m not telling you: You notice some problems. You get angry too fast, you are yelling at people instead of talking to them, you keep seeing your friends die. When civilian things go wrong, you don’t care. (Is anyone shooting?) You may be shocked to feel nothing when a beloved relative gets sick or dies, or you may think you don’t love your spouse anymore because you can’t feel it. You hate civilians or Arabs. You are not fine, but you are not going to tell anyone, especially not anyone who wasn’t there and has been telling you that you have problems. You start to think that you can’t talk to anyone who wasn’t there. You begin isolating so no one will see how nuts you feel. You are pissed off about being affected. You also fear going for help because it may dull your edge, which you will need when you go back. It might also affect your career, and you don’t want people to think you are nuts. You exclude your spouse. He or she gets angry at you a lot.

Stage 3: I can’t talk to people who weren’t there: Since you can talk to other vets, you feel that no one understands unless they were there. This unfortunately is true. Most people make this clear by saying insensitive things like, “So what’s your problem? Get over it!” “Did you kill anyone?” “You’re a hero.” and the inevitable, “But why aren’t you over it?” So you increase your isolation from family and friends. This however tends to make spouses angry, because we are supposed to be understanding. Your sense of humor has become very black, and you laugh at things that would have horrified you once. You may even wonder if your spouse would still love you if they knew what happened over there. You might feel that everyone around you is spoiled and insensitive and it pisses you off. You have to stay so numb that your spouse feels you don’t love him or her anymore.

Stage 4: What’s wrong with me? The term “Post-Traumatic Stress Disorder” is a good description of the effects of war on normal people. The skills of war create a lot of disorder in your life. Shrinks and family members tend to see the symptoms of PTSD as the problem. Not me. I see war as the problem and the symptoms of PTSD as solutions to the problem of war, something right with you, not something wrong with you. Each symptom begins as part of your body’s hard-wired survival responses to danger, which your training has been designed to intensify and strengthen. They worked. You are alive. That is the bottom line. You have been through something that killed others. Having PTSD is proof of survival. I also believe that the people who get PTSD are the ones who care the most. You may feel like you don’t care, but if you didn’t care, you would not have to develop the symptom of emotional numbing to survive. Although PTSD symptoms originate in hard-wired survival skills built into all of us, unhealed, they can become your biggest problems over time.

Stage 5: I’m screwed up and no one can help. Deciding that no one can help is pretty human, but it is not true. I don’t think you are screwed up, either. You are in survival mode. What helped you survive one deployment will probably help you during the next one, unless your symptoms become debilitating. What you will need, when you are finally haome for good, and decide you want to change, is information and tools, someone to talk to, and hope. So will your family. You can get treatment without diagnosis at the Vet Centers and for two years after you get back at the VA. This can be a problem since it might be two years before you realize you have problems.

Admitting you have a problem and asking for help is hard, but you survived the war, and you can survive getting help and healing. If you don’t get help, you can be stuck in any one of these stages for the rest of your life, losing friends and family in the process, like so many veterans of previous wars. War affects people who live through it. There is evidence of PTSD throughout written history. People not affected by war are usually actors in war movies. It’s worse when it’s real. You may have noticed this.

This pamphlet is meant to explain the normal effects of war. Today, you don’t have to feel crazy, weak or defective, or blame each other, like Bob and I did. You can find ways to heal.

2. When people are trying to kill or injure those you are close to (and many soldiers are closer to their buddies than to anyone in their lives.)

3. When you suddenly lose your home or community, which happens to soldiers who are wounded and medevacked or when they lose a lot of buddies to an IED or firefight.

4. Seeing anyone who has recently been seriously injured or killed (stranger, enemy, civilian).

Most soldiers have hundreds if not thousands of traumatic events during a deployment. Traumatic events are cumulative, starting in childhood.

Traumatic events are made worse by human cruelty, neglect, and betrayal. Suicide bombing and the constant killing of civilian men, women, and children by factions in Iraq and Afghanistan make this war very cruel. What an incident means to you may also make it more traumatic. If your friends were “wasted”, it is worse than if they were killed doing something that was noble and important. It’s worse if the deaths were because they had no armor (betrayal). If you shot a car that was full of women and kids, it is a lot worse than if you shot guys with guns. Such incidents can destroy your sense of who you are.

Three other things also cause PTSD: Your brain is designed to keep you alive, so built in systems are activated by war. You care about other people or you would not have to get and stay numb. And finally, you lived. Dead people do not get PTSD.

Given enough trauma, everyone gets PTSD. Most people have allthe symptoms right after, but some of them seem to heal better than others. The peoplewho develop PTSD have the most exposure to war, the greatest losses (not only friends,mental health and body parts, but trust, faith in the government or God or the military),the greatest number of previous traumas, the fewest resources [not just family and friends, but also the capacity to know what you feel or sit with a bad feeling and let it peak and fade (emotional intelligence), to let other people think differently, etc.] , the greatest vulnerabilities, and the least social support. PTSD seems to be a disorder of healing. That’s why it is important to be informed about post-traumatic reactions and about different kinds of help. There is no one-size-fits-all treatment for PTSD and no drug that makes it all go away, although research continues. Individuals need different things to heal. However healing seems to be dependant on being able to talk about the war, feel the pain, learn to moderate your reactions, and stay present in the present instead of being stuck back in the war.

Many people think of PTSD as “the problem.” To me war is the problem, and PTSD is actually a solution to the problem of surviving war. All the symptoms start out as skills that help you survive

Watch for these three categories. They grow outof the fight-flight-or-freeze survival mechanisms hard-wired into us all.

Set 1: Hyperarousal: Your brain is designed to pay attention to anything new, especially to threats, so you can survive. Hyper-alertness is a capacity that keeps you alive. Under the hammer of war constant watchfulness and expectation of danger (hypervigilance) become ingrained. Extremely effective startle responses [the shrrinks call it exaggerated] keep you alive and moving (fight or flight). Irritability and outbursts of anger, keep you alive and fighting instead of giving up. The inability to fall or stay asleep keeps you from being killed in your sleep. Shrinks also mention the inability to concentrate, but that is not exactly what is going on. It is the inability to concentrate on regular everyday stuff like picking up diapers at the store on your way home. Believe me you are concentrating on safety and on survival information. These hyperarousal symptoms are appropriate and effective in a war zone, where you have to do whatever it takes to survive, including things you may regret later. You have developed rapid responses, faster than thought, which can move your body before you know what you are doing. Keeping this edge is very important if you face redeployment. At the same time, at home these can become some of your biggest problems.

Numbing: The brain has a natural capacity to rapidly adapt to circumstances, especially danger. This is so we can be in control. It enables warriors to numb their feelings automatically so they can do whatever it takes to survive and to help others survive. It’s called professionalism, part of your training. Among the numbing symptoms are feeling like you have no feelings anymore, feeling like there is no future (so why worry when you could be killed tomorrow?), and feeling like no one can understand you unless they were there. Trauma happens so fast that you also may not remember all or part of some incidents. Our brains are also capable of dissociating. When this happens it is like being an observer of what is happening, as if you weren’t there.

Avoidance: We use avoidance to keep from feeling the painful emotions we have numbed. You maintain professionalism through numbness. You must not lose control. Avoiding emotions, thoughts, situations and activities that remind you of the war is easier if you are using substances, like alcohol, or behaviors, like workaholism, TV watching, the internet, or creating chaos (affairs, gambling, fighting). If you think you should be over it and your family and some of your outfit think only weaklings get post-traumatic reactions, avoidance seems like the perfect answer.

Set 3: Re-experiencing: Re-experiencing symptoms make you feel nuts. They include intrusive thoughts of the war, which you can’t stop having, dreams, nightmares, acting/feeling as if you were back in the war, blasts of adrenaline when thing that remind you of the war, and anniversary reactions (see PTSD and Holidays . Your brain is a better-safe-than-sorry system designed to keep you alert and alive. Trauma happens so fast and is so overwhelming that the more primitive parts of the brain don’t know it is over. They do not speak English, nor can they tell time. They want you to spend the rest of your life looking for roadside bombs and ambushes, so you won’t die.You know you are home, but your brain doesn’t seem to. Although this part of your brainis trying to keep you alive, the effect of re-experiencing can be the opposite. Acting as if today were the past can get you killed or get other people killed. You have to be reacting to today to stay alive and not harm those around you. Many people have horrible flashes of non-verbal memory burnt into them by the war. They may be triggered by situations like confrontation, sounds like a backfire, emotions like guilt or shame or fear (many people turn these big three into anger so fast that they don’t know they are feeling them), thoughts like “I should/shouldn’t have…, sights like a car at the side of the road, or smells like cooking meat on a grill. Triggers can remind you of incidents of which you have no coherent memory. Further complicating your life, some sights, smells, emotions, sounds, etc., that are going on around you if you are triggered back home can become second or third generation triggers. This will make you feel even crazier when something with no connection to the war starts to trigger you. Oddly enough, moving a non-verbal memory up into your frontal lobes, which do speak English and can tell time, either by writing and re-writing or telling and re-telling the story, often stops the re-experiencing. There are several forms of short term exposure therapy that can help with intrusive re-experiencing so you can keep your edge for the next deployment.

Why don’t they just get over it? Avoidance is very understandable, but it is also the main factor in perpetuating PTSD symptoms. By avoiding thinking about the traumatic events, you can’t make sense of it. Part of you is still back in the war zone trying to figure out what happened, going over and over it, hoping for a better ending. Avoiding triggers leads to isolation, which means you don’t get the help you need to heal. Avoiding bad feelings means you suppress them all, which can lead to depression and family problems. People can tell you are not feeling what you once felt, and rather than ascribe it correctly to PTSD, they think you don’t love them any more. You may think that, too.

The symptoms of PTSD can reinforce each other, too. Perhaps you are so numb, the only time you feel alive is when you are filled with adrenaline. You may unconsciously create arguments at home or do dangerous things that anger your spouse so you can feel alive. Then you start remembering and feeling, so you have to clamp back down to numbness, and they feel unloved as well as angry.

What you tell yourself can also perpetuate the problem. “I shouldn’t feel like this,” “I should be over it,” “What’s wrong with me?” “I must be crazy!” all can serve to keep you stuck. You are having normal reactions to war, reactions which John Wayne and Rambo never had because they were never in a war.

Although you may need your hypervigilance and emotional numbing in your next deployment, if you have significant re-experiencing it may endanger you and your buddies. Once you are home for good, PTSD symptoms can become your biggest problems if you simply ignore them and expect them to go away. Although some people seem to heal, a large percentage of veterans exposed to high war-zone stress develop chronic cases. This is partly because of the lack of treatment available before the ‘80’s, but it is also due to the stigma people attach to “being affected”. I hope to reverse some of that, since normal people are affected by what they live through. Since PTSD can also be triggered by subsequent events throughout the rest of your life, it is wise to learn how to heal. Many older veterans have lost their friends and families because of the struggle to hide symptoms and seem fine. The current war has also re-triggered PTSD symptoms in many older veterans because they remember. They know what you’re facing. If this has happened to you, don’t think treatment didn’t work. It worked before and it will work again. Go back for more.

Getting Better: Each symptom of PTSD develops from a bodily-based, God-or evolution- given built-in survival mechanism, designed to keep you alive. We all have these survival mechanisms, and if we had been through what you have been through, would also be affected. You learned these survival mechanisms under the hammer of war. When you are ready to get better, you have to learn what they are, when and how they are useful, and new skills for when they are not. Each met a need, usually for survival, and finding other ways to meet your natural needs for safety and security is the job of recovery.

We also have built-in healing mechanisms. Attention (eye contact, being listened to, receiving empathy and respect), telling your story, safe touch, acceptance (bad things happen; they are painful), crying, making a contribution (working for the common good [altruism] and to support your family), justice, and spirituality are some of our built-in healing mechanisms. Our culture finds some of them awkward.

While avoidance strengthens and perpetuates PTSD symptoms, it is much less painful than the work of healing, especially if you have lost buddies, your sense of yourself as good or competent, and/or have shame or guilt or despair associated with the trauma as most people seem to. Somehow feeling like it is your fault, and if only you had done something, it wouldn’t have happened, makes you feel less powerless. The essential ingredient of trauma, however, is that it is overwhelming and you are powerless. No one can stop bombs or bullets with if-onlys. Many people spend their lives after trauma waiting and wishing for a better past, instead of working through the pain and anxiety for a better future.

Exposure is the basic task for healing PTSD. It teaches the parts of your brain that don’t speak English and can’t tell time that it is over. Exposure to what you are avoiding in small safe doses with a trained trauma therapist makes a huge difference. Often this is telling parts of your story again and again so that details come back and you can comprehend the whole experience. If you want to avoid these details because you think whatever happened was your fault, talking can help with that, too. Most vets feel that if they ever let themselves feel, it would destroy them, but numbing bad feelings means the good ones are gone, too. Healing means you learn how to sit with a feeling and let it peak and fade, so you can process your memories. You went through hell. The feelings will hurt, but they will also pass eventually. Your therapist can teach you how to identify your feelings, that you are not your feelings, and that otherpeople can have different feelings without either of you being wrong.

You can even learn to go in and out of numbing, since it can be handy, as can many of these survival skills. If you have developed an addiction to help you maintain numbness, you probably need to get clean, sober or abstinent from the substance or behavior.

The best way to deal with non-verbal memories is to move them from the non-verbal parts of the brain up to the frontal lobes and turn them into narrative memories, in other words: remember. Writing and rewriting something that happened to you is one way of doing it. Talk therapy is another. You get to tell your story. This is painful but you made it through the event, and you can make it through the memory.

For hyper-arousal, I always suggest basic un-training. Every soldier I’ve ever met thinks the military taught him to take care of himself. “Oh, really?” I often say, “So you used to say to your drill instructor, ‘Sorry Sergeant, I can’t do that. I need a nap.’” This usually gets a big laugh, but that is the kind of self-care you need to learn. After you have been to war, there are some things you simply can’t do. Sometimes it’s parties (don’t bunch up), cookouts (burning flesh), family fights. Sometimes it’s “Don’t ever come up behind me and grab me.” Whatever it is, learning to speak up is important.

You have to learn self-soothing methods, so you’re not always yelling and angry.

You have to expose yourself to triggers in small safe doses, too, so they lose the power to trigger you. Learning that what triggers you is not necessarily dangerous here is also important, so your family doesn’t have to avoid your triggers.

Learning to meditate helps with these tasks and keeps you present in the present. The book Wherever You Go, There You Are, by Jon Kabat-Zinn helped Bob a lot. He also reads Thich Nhat Hanh. You may also find ways to heal your body’s constant state of tension through somatic therapies or yoga.

You may have to heal your beliefs. During extremely traumatic events, such as having a buddy die in your arms, or get killed when you weren’t there, people often decide “I will never love anyone again” or “I should never have left” or “It’s my fault.” Other beliefs that can interfere with healing and with everyday life include ideas like “Don’t talk about it,” “Only weaklings and whiners ask for help,” “You can’t trust anyone who wasn’t there,” and it’s converse, “You can (and must) trust anyone who was there.”

PTSD can make you feel totally out of control. By choosing to take new actions which have worked for others, you can regain that sense that you are in charge of your life. Home life problems: The final topic I want to cover are some of the things I noticed in my family. Bob did things that really made me mad and I told him so a lot. Family members, friends, and even therapists can believe if you just did what they told you, you would be over it. Since the essence of trauma is your powerlessness to prevent it, most veterans need to regain a sense of control in their lives. This makes telling them what to do, even if you are right, counter-productive and ineffective, especially if you are constantly doing it. How do I know? I did it for years. Suggestions, on the other hand, can be quite useful, especially if explained as, “This has helped others. It might be awkward at first, but you might try it?”

For veterans of war, home life also creates triggers which cause major problems in the family without anyone realizing why. Being asked to do things can get you killed in war, yet not doing common everyday things that your spouse asks you to do can cause a lot of resentment. Ask yourself, “Will taking out the garbage get me killed?” If not, maybe you can help out. Bob also says that common everyday things seem so unimportant when you come home from war, why bother? (Is the garbage shooting? No. Then don’t worry about it.)

Taking orders can also get you killed, so if your spouse gets demanding or bossy, resistance may become even stronger. Spouses resent this, too, because they usually get bossy when they are desperate for help. Not following orders can also get you killed. Since you have the experience of war, you may find yourself ordering your family around and expecting instant obedience as if you were in the field. This can cause problems and resentments. No one likes to be ordered around. Lateness can get you killed, so you may react strongly to it.

Mistakes can get you killed, but the way children (and grownups) learn is through mistakes, so they are not all fatal. You can remind yourself of this.

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Fact sheets

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Female Veterans

Non-white Veterans

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Brief Introduction to Flashbacks

Introduction:

Categorizing Flashbacks:

Dangerous Memories:

Anniversary Reactions

What Are Your Options?

Accept

Control

Escape

Taking Notes

Coping Techniques

When You Are Alone

When A Friend Is Available

Biology

PTSD and Physical Health

A National Center for PTSD Fact Sheet

By Kay Jankowsi, Ph.D.

Is psychological trauma related to physical health?

What is the relationship between physical health and PTSD?

What specific health problems are related to PTSD?

What is the agenda for clinical practice?

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By Philip G. Salois, M.S.

NCP Clinical Quarterly 5(1): Winter 1995

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DSM-IV SUMMARY TABLE

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Understanding the C & P Examination Process

Coping with PTSD and Recommended Lifestyle Changes for PTSD Patients

A National Center for PTSD Fact Sheet

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Active Duty Military

Below is a list of information currently available from the National Center for PTSD about active duty military. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.