CHAPTER 1
What is PTSD?
Key points
• PTSD is caused by exposure to a traumatic event or series of events
• The symptom picture lasts for more than one month
• PTSD can affect anyone in society, not just combatants
• PTSD is a normal reaction to an abnormal event(s)
Todd: There has been a slow evolution of names and diagnoses for soldiers with Post-Traumatic Stress Disorder (PTSD) since World War I; initially combatants were diagnosed with 'shell shock', so named as it was believed to have been a result of concussion from the impact of artillery shells. During the modern conflicts of the 20th Century the symptom picture progressed along with the change in designation, with terms such as 'battle fatigue', 'combat stress' and the more general 1950s definition of 'gross stress reaction'.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the go-to manual for most psychiatrists, psychologists, and general practitioners when diagnosing mental health disorders. The manual is currently in its Fifth Edition and each edition is designated by Roman Numerals, such as DSM II or DSM IV. In between publishing new editions, the American Psychiatric Association has also printed Text Revisions (TR) – as an example, DSM III TR. However, the current edition is designated by numerals: DSM 5. This rationale sounds a lot like something the Army would do. This is not an attempt to teach you to suck eggs, but I feel it is important to be on the same page as our treating clinical support team. Therefore the majority of statements referenced within this chapter will be from the extant DSM 5.
Before we tackle PTSD, it is pertinent to identify what encompasses trauma from a clinical perspective. A traumatic stressor is defined within the DSM 5 as any event (or events) that may cause or threaten death, serious injury, or sexual violence to an individual, a close family member, or a close friend. Traumatic events include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault, threatened or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, natural or man-made disasters, and severe motor accidents. This is only a part of the diagnostic definition, in addition there are eight criteria that incorporate the symptom picture and lead to a formal diagnosis. Each element will be discussed in turn.
The essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation varies. In some individuals, fear-based re-experiencing, emotional, and behavioural symptoms may predominate. The DSM refers to a few mood states of which you may not be familiar with: anhedonia and dysphoria. Anhedonia is defined as the inability to experience pleasure or have any fun. Dysphoria is regarded as a feeling of uneasiness, discomfort, anxiety, or anguish. It is at this point that it should be noted that in previous editions of the DSM, PTSD was characterised as an anxiety disorder, however it is now placed between trauma and stress-related disorders.
Before we start analysing the diagnostic features and criteria, I want to reinforce that it is not just service personnel who may develop PTSD, indeed it can affect anyone from every walk of life. My personal experience is one of a military background, which has a unique organisational culture and operating environment. Similarly, so do the emergency services, first responders, and the personnel of border protection agencies. Hence, my focus within the handbook will be upon the effects of PTSD within the service culture.
The initial part of the definition of a traumatic stressor is quite clear: exposure to actual or threatened death, serious injury, or sexual violence. It is easy for one to identify or acknowledge triggers from the previous statement, particularly for military personnel during their operational service. However, with first responders these waters are somewhat muddied and it may not be easy to identify one specific trigger. Indeed, the PTSD may have developed as a result of an accumulation of numerous traumatic incidents that led to the development of the disorder.
The last part of the initial descriptor is something that requires further discussion: to an individual, a close family member, or a close friend. Having previously mentioned that the service culture is unique, I would now suggest that in terms of relationships it is akin to family. The majority of my military tenure was within infantry and special operations units; very close-knit teams particularly at lower levels, where groups comprised a small number of personnel. As with most families, these men and women may not all like each other, but they know the most intimate details about their team members, and the bond between them is extremely strong. These bonds are forged during initial training, mission rehearsal exercises, and reinforced during operational deployments. Notably, it is the latter part of the aforementioned definition that may often be overlooked with regard to the development of PTSD: exposure of a traumatic event to a close family member, or a close friend.
Diagnostic Criteria
In the section below, I have summarised the eight diagnostic criteria (A-H) that describe the full symptom picture. Some are quite detailed and others are very simple. Further, some of the elements require two or more of a specific criterion to be present before a diagnosis is confirmed. Leaving this part to the clinicians, I will describe or extrapolate upon the statements within the DSM 5 to give you a greater understanding of the components within the criteria as they have affected me.
A) Exposure to trauma
While deployed to Malaysia, I was involved in a fatal motor vehicle accident. Five of my soldiers were killed and many others seriously injured. My ultimate task was recovery of the bodies back to Australia, which included spending an evening at the morgue and witnessing all five autopsies. Five years later, I was posted back to Malaysia on exchange and the apartment I lived in overlooked the same morgue where I'd spent time with the bodies of my friends. For the next two years, I had no choice but to drive past the accident site every day on the way to and from work.
B) Intrusive symptoms associated with the trauma
My experiences have taken the form of an out of body experience and flashbacks; involuntary memories pop in and out of my consciousness without thought or choice. With the out of body experience I felt like I was floating above myself and looking down upon my body. It was very weird. I have no idea of the trigger for this reaction apart from being overwhelmed by the situation. Flashbacks are common and are usually triggered by one of our senses. In an instant we are taken back to the traumatic event(s): although rationally we know we are in the present, it nonetheless feels like we are back in the moment of a traumatic event and the feelings are extremely real. The most powerful triggers for me are smell and taste, as sight and sound have been desensitised to trauma through movies, TV programs and daily news broadcasts. Further, my understanding is that due to brain anatomy, smell and taste are more closely linked with emotion and memories than vision or hearing, as the olfactory bulb is next to or closely associated with those brain regions. These symptoms can be experienced psychologically or physiologically. My experiences have been feelings of anxiety, depression, helplessness, fear and variations in mood. The physiological symptoms I have felt are increased heart rate, sweating and shaking hands.
C) Avoidance
Certain songs, music or movies summon distressing memories for me. As such, I often change the station or make a conscious decision not to see a specific movie or TV program in order to evade the potential trigger. The smell of fuel plus aromas that are similar to the sickly sweet smell of decaying flesh such as some flowers or perfumes are also odours that I try to avoid. Some of the avoidance techniques I have used at one time or another include staying away from loud noises, congested traffic, public transport and densely populated venues such as shopping centres, sporting events and concerts.
D) Negative thoughts and mood
We all have expectations about others and ourselves; however since I was diagnosed with PTSD I have noticed a heightened view of my expectations and get upset when they aren't met. It can be demoralising when I can't complete activities or tasks that I used to be able to perform with ease. When strangers in particular are not courteous or respectful as I would expect them to be, this will raise feelings of anger within me that are out of proportion to the situation.
Anger is a common emotion following a traumatic event and can become a chronic ailment if not addressed – it certainly did for me. Guilt manifested within me as I questioned why I survived the accident yet several of my colleagues did not. This was often accompanied by shame, where I questioned everything I did during the incident and severely underestimated my effectiveness at the scene and during the recovery of the bodies back to Australia. For example, I constantly asked myself, 'Why didn't I do this? If only I had thought of that.' I also blamed myself for the accident, which was completely irrational. Blaming or second-guessing ourselves doesn't help anyone, least of all ourselves.
I have already mentioned anhedonia, which refers to activities that you used to enjoy that no longer give you pleasure. For me it was no longer playing or watching sport. Sometimes I just couldn't be fucked. It was almost like a sense of martyring myself or even punishing myself, as I didn't deserve to be happy.
Something that did not affect me directly but I did observe in a colleague following our accident in Malaysia, was amnesia. We were in a team of three performing CPR on one of our mates injured in the accident. My colleague has no recollection of me working side by side with him or even being at the scene. To this day he swears I was not there, yet my participation has been validated by many sources.
For members of the services there is a massive rift between 'us' and 'them' (the wider community). No one understands me; they don't 'get' what I've been through. These feelings extend to our close friendships and family members, often as a defensive measure to prevent ourselves from being hurt by failed relationships. The irony here is that it is this action that directly erodes connectedness and leads to relationship breakdowns. I believe there are two elements to this emotional flaw: firstly, I was unable to experience these emotions; and secondly, I would often punish myself as I considered myself unworthy of happiness, fun or enjoyment.
E) Changes in reactions and response
Most of you will recognise this within yourself or a loved one. I would fly off the handle for no apparent reason with the intensity and frequency of these outbursts being significantly exaggerated. Impulsive and loud noise was the most common element to cause me to lose control with my anger. I also became self-destructive in a number of ways, such as spending money like there was no tomorrow, self-harming, abusing alcohol and sabotaging relationships. Other common behaviours that others might experience include risk-taking, such as speeding in a vehicle or gambling.
I was hyper-vigilant, always scanning for threats even though there weren't any. I could be in a safe environment but I was constantly on the lookout and ready to combat a threat if it presented itself. I would sit with my back to the wall in a café or restaurant in order to see the entry/exit and to ensure no one could approach me from behind. At the movies or theatre I always tried to position myself near the exit so I could make a quick departure, while continually developing plans for all types of 'what if' scenarios. This constant searching, assessing and responding became tiring and psychologically draining. I would overreact to unexpected noises such as a motor vehicle backfiring, an unfamiliar noise at night or someone sneaking up on me. My heart rate would increase and it felt as though my heart was in my throat. In severe cases I would sweat profusely and my hands would tremble.
I also had difficulty concentrating when reading and especially when trying to study. I struggled during conversation, finding it difficult to maintain eye contact as I was forever scanning a room and then losing track of what was being said. This was frustrating for everyone involved. I had difficulty falling asleep or staying asleep if awakened during the night, especially after a nightmare but even if I just had to use the bathroom. This became a vicious cycle where I slept less and less each night but more during the day. I was constantly tired and unable to face the most minute challenges of the day.
F) Symptoms persist longer than one month
This period of one month post the event is what differentiates between Acute Stress Disorder and Post-Traumatic Stress Disorder.
G) Significant distress and impaired functioning
I was unable to maintain a job and I always felt like the odd one out at social gatherings. When with others in a social setting I really didn't want to be there – everyone else would appear happy but I didn't know how to be like that anymore. Over time, my friends and extended family stopped inviting me to social get-togethers. This didn't affect me at the time but it did impact upon my spouse and children. When I was at my worst, I found it difficult to complete simple tasks such as grocery shopping, paying bills, banking, cooking meals, domestic duties or even maintaining my personal hygiene.
H) Symptoms are not caused by substances
No need for expansion here.
A couple of other points to take into consideration are that the disorder may be long lasting if the stressor or trauma is at the hands of another human, such as in the case of murder or sexual assault. Further, the prospect of developing the disorder may increase when one is located within close proximity to the stressor or if an individual is repeatedly exposed to trauma.
This chapter has contained some technical information and clinical definitions that you may not have been familiar with previously. However, I feel it is important to be comfortable with these terms so you can consult effectively with your clinical support team and contribute towards your treatment plan. The following chapters will be much easier to read as they are based on personal experiences with less reliance upon psychological texts.
Comorbid Conditions
Key Points
• The most common comorbid conditions are depression, anxiety, substance abuse, and suicide
• Substance abuse is only a Band-Aid fix
• Self-medication is never a wise move
• Suicide is not the answer
Todd: Comorbid conditions are a fancy way to describe the other symptoms you may experience while combatting PTSD. It is important to understand the term, not only for your own benefit but also when conversing with clinicians. This chapter will examine some of the most common comorbid conditions associated with PTSD, namely depression, anxiety, anger, substance abuse, and suicide. There is a fair bit to cover with each of these conditions, so I will break it down respectively.
