GETTYSBURG MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
20, September 2001

Anxiety  II: Posttraumatic Stress Disorder

Tom was a 22-year-old college graduate in 1967. He had played football at a major university and was a big strong athletic individual. Upon graduation from college, he was drafted into the United States Army and eventually completed ranger training joining the Special Forces in Vietnam in early 1968.

His duty involved frequent raids into unsecured areas. One night when his group was returning to their home base, his group found it necessary to dig foxholes and try to remain hidden for the night. Tom recalls that it was very, very hot that night and he took off his flack jacket because it was too hot to wear. He fell asleep in his foxhole and awakened with a bayonet stabbing into his abdomen. He recalls very little of the next few minutes but does know that he was able to kill his attacker. After a brief skirmish, he and the men with him were able to escape. When they reached home base, Tom was evacuated to a hospital in Japan and then back to the United States. After a brief hospitalization, he was returned to duty with a training unit for the Special Forces. It was at this time that he began to manifest disturbing and disabling symptoms.

He had been married prior to going to Vietnam. His wife was a very loving and understanding individual but Tom’s behavior became frightening. If someone touched Tom from behind simply tapping him on the shoulder, the person was very likely to be attacked and harmed by this very strong capable United States Army Ranger. On one occasion, he knocked his wife unconscious when she unexpectedly caressed his shoulder. He could not sleep at night with the lights out. All of the lights in the bedroom had to be on. His training tactics with the Rangers were so brutal that he was reprimanded and given a desk job. Alcohol became a significant problem especially every night. After he injured another individual in a physical altercation while on duty, he was hospitalized and eventually diagnosed with having posttraumatic stress disorder. Soon thereafter, he was given a medical discharge from the army.

I met him for the first time four years later because of alcohol-related problems. He had been unable to hold a job and volunteered that he had no skills other than killing people and he remained suspicious of everyone. His physical condition deteriorated substantially, and he was admitted to my hospital with gastrointestinal bleeding from alcohol-related ulcers. I met Tom as an attending physician in 1975 seven years after his original ordeal. He had been prescribed various medications through the Veteran’s Hospital System but had not been seen in their clinic for eight months and abandoned the medications as “not useful.” He insisted that alcohol worked better for him than those silly medications. He volunteered that he had been diagnosed as having “posttraumatic stress disorder” which in 1975 was not even a recognized diagnosis. I was warned, “Don’t touch him from behind unless he is watching and he knows who you are and what you are doing.”

Posttraumatic stress disorder is a mental illness of variable duration from months to years. It is characterized by an event or series of events that are catastrophic and overwhelming. The individual suffering from this problem has the feeling of helplessness and loss of control leading to severe insecurity. The problem may be accentuated if the individual feels they were a cause of the catastrophe. If they broke the rules such as Tom did in taking off his flack jacket, the person seems to ruminate on that event and how they might have avoided it if they had just obeyed the rules. Sometimes the person will flaunt all rules as not useful and other times they will become so compulsive that rules are followed even though they do not apply. Anxiety, fear and overreaction to minor stimuli may occur. Alternatively, the individual may feel helpless and simply stop trying because they fear that nothing will work. Distrust of everyone becomes a way of life.

The concept of posttraumatic stress disorder grew out of many Veterans who returned from the Vietnam War. It was then recognized that it occurs in many other individuals in our society after they have experienced a traumatic event. Other cases I have seen include a wealthy businessman who drank to excess resulting in a fatal automobile accident in which a pedestrian was killed and he was charged with hit and run driving. Over the next several years, in addition to the legal considerations, his previously very successful business failed and his family virtually unraveled. A third and tragic case was that of a mother whose diabetic child died of complications that the mother felt she should have recognized and dealt with. In spite of all reassurances she received from her family and others, she was unable to forgive herself resulting in divorce and tragic consequences for her family.

To get back to the story of Tom, I helped him obtain psychiatric care. He was started on several medications to help with the anxiety that he was feeling and went through an alcohol treatment program. With his GI Bill of Rights, he was able to return to school, obtained a teaching certificate and eventually became a counselor at a local high school in the inner city. A very highly skilled counselor was able to help him deal with his fears and distrust. I last heard from him in 1988. He remained married to his wife and they now have two children. He was working as a counselor at a local high school and his alcohol habit had been stopped. He was off all medication at that time.

I asked him then how he thought his posttraumatic stress disorder had been dealt with. He said that perhaps it was just time after seven years but that more importantly he was finally willing to accept help and place his trust in the healthcare professionals who were working with him. Pivotal in his recovery had been the unwavering support from his wife and one brother-in-law who had supported him with many hours of conversation and support. He felt the bottom line was that he was finally willing to accept help when it was offered.

With the grotesque events in New York City this week there will undoubtedly be many more cases of posttraumatic stress disorder. In South Dakota, it can result from terrible farm accidents or fires or very traumatic interpersonal relationships such as a divorce. The healthcare professionals at your local clinics often have to weed through very real medical problems such as a bleeding ulcer before they recognize the basic problem is posttraumatic stress disorder. Referrals to appropriate healthcare professionals under those circumstances are highly beneficial leading to recovery if the individual is willing to accept help.