Under extreme circumstances, the human body can respond in the most extraordinary of ways. There are numerous credible reports of people who have actually had the hair on their heads turn gray overnight as a result of frightful experiences. (cf. “Journey through the Maelstrom“, by Edgar Allan Poe). Under extremely stressful circumstances, the loss of body fluids through perspiration is sometimes reported to be measurable in pints, quarts, or even gallons per minute (The Jakarta Incident, British Airways Flight 9, 24 June 1982, Captain Eric Moody). An apocryphal story from the 1960s claims that an otherwise petite woman, in a rush of adrenaline, lifted the front end of an automobile from atop her injured child’s body. These stories represent the body’s response to stress.
There is a great deal of confusion in the media, the courts and the medical community as to just what PTSD really is and how it comes about. The often-misused phrase: Post Traumatic Stress Disorder is certainly a mouthful. In describing this condition some would emphasize the ‘Post’ part and say that PTSD is a delayed reaction to trauma. Others emphasize the ‘Trauma’ part and say that the victim has witnessed or endured a ‘traumatic event’ and is having a ‘stress reaction’ however delayed. In order to clarify just what PTSD really is, one ought to add parenthesis, so: P (TS) D. The emphasis, then, is on ‘traumatic stress’.
We all endure some levels of stress in our daily lives and some of us must endure trauma; but stress and ‘traumatic stress’ are worlds apart. Linguists and moralists would very much like to reclaim the term ‘gay’ from the homosexuals (gay used to mean light-hearted and happy). And likewise, the acronym and syndrome PTSD ought to be reclaimed for those to whom it exclusively and rightfully belongs: Combat Veterans. While stress can wear you down to a breaking point and trauma can be life altering, one bad day won’t give you PTSD – no matter how bad that day is. It has been found that wounded soldiers, even amputees, do not suffer PTSD. How is this possible? Because PTSD is more about stress then it is about trauma.
Some people are just plain unlucky. Their lives are a series of traumatic events: A hit on the head (with a safe, perhaps), run down by a truck, a tie caught in machinery, etc., but none of these unfortunate events are related. In war a soldier endures a series of events, and all are traumatic and all are related. There exists a span of time between two or more of these horrendous experiences. There is trauma with the expectation of more trauma. The Indians don’t always attack at dawn. In war, deadly attacks come at you intermittently, unpredictably and at very irregular intervals; but you do know they are coming, you just don’t know when. For the combat soldier the stress of waiting for the next attack becomes traumatic.
Call it waiting.
Call it suspense
Call it expectation.
Call it being on guard.
Call it vigilance.
Call it terror.
Call it fear.
Call it anxiety.
Call it apprehension.
Call it doubt.
None of these terms describe the physical trauma of an attack, an explosion, a death or dismemberment. They all have to do with time. The time between the traumatic events. Psychologists speak of the ‘fight or flight’ response to danger.1 Traumatic stress is neither flight nor fight. It is the infinite ‘or’ in between. The physiological responses to danger are well cataloged and commonly known: the rush of adrenaline, the quickened pulse, the rapid rise in blood pressure, the dilation of blood vessels, rapid, shallow breathing, the tightening of muscles, the sharpening of the senses, etc.2 When the danger passes the body returns to a state of homeostasis: normal pulse, normal blood pressure, normal breathing. Homeostasis can be roughly defined as the status or state of ‘being at home’. Homeostasis and home are intimately related as they depict quite the same ‘feeling’. On the battlefield and in the trenches endless talk of and pining for ‘home’ goes on. We may include the phenomenon of ‘homesickness’ in our understanding of PTSD, as homesickness is that uneasy feeling one gets when away from home. There is ease, and there is dis-ease. If homeostasis is ease, then PTSD is dis-ease. Among veterans, and especially among Viet Nam veterans, there is endless talk of ‘coming home’ or not receiving a ‘welcome home’. More than a quarter century after the fact some people will still shake your hand and say guiltily: ‘Welcome Home’. In war homeostasis is a luxury one can ill afford. The body seems to know better than the mind when it can relax. Relaxing your vigilance or lowering your guard could very well cost you your life. If homeostasis is 1 (on a scale of 1 to 10) and sheer terror is 10, at what level does the mind/body operate in the interim, in that period of time between the traumatic events? At a Level 4? Level 6? Level 8?
PTSD is a disease characterized by the victims’ inability to achieve homeostasis. The disease is brought on by exposure to homicidal, mortal danger punctuated with intermittent traumatic events over a protracted period of time.
How long is too long?
In order to shed more light on this disease, one might consider the effects produced by the infamous Chinese Water Torture. The victim is placed on his back and bound and the head pinioned in such a way so as to preclude any movement at all. Water is then dripped, a drop at a time, in the juncture of the eyebrows. Since the victim cannot move he simply waits in helpless anticipation of the next drop. Over time, the minute electrical currents produced by the spasmodic blink reflex so overwhelms the circuitry of the brain that it erases memory and reduces the victim to a helpless idiot. Inflicted long enough, these little drops of water can eventually kill the victim. The brain is an electrochemical device. Over-use and abuse can unbalance the brains’ chemistry and completely burn out the circuits. People often use the expression:
“The suspense is killing me.”
It can, and does, kill.
Varied lists of PTSD symptoms exist. Some of these lists include an exaggerated startle reflex as one of the more obvious and readily observable symptoms.
In the popular media one often reads stories of people who have undergone some truly horrendous experiences. They often claim to have PTSD as a result. But if you closely examine their story you will note the absence of any precursory anxiety. They had no idea this event would overtake them. Also absent is the idea that the event could be expected to happen again. There is absolutely no protracted suspense.
I found myself put off and to be honest, really quite angry and frustrated at the service I received at the VA for even the most ordinary treatments. I spent literally hour upon hour in that damnable waiting room because Service Connected Veterans (veterans with Purple Hearts) were given priority of service. They even had special I.D. cards with a big purple triangle and the word PRIORITY on it. They were WW II veterans whose wounds that got them their Purple Hearts had long since scarred over and they were there for other medical reasons. But they were still given priority and I sometimes spent the better part of a day in the waiting room. (I once spent 9 hours waiting for treatment for an excruciatingly painful sinus infection I contracted from a sick dog). This was not triage. The idea of prioritization on the basis of wounding is illogical and chauvinistic; and to think that a man with a Purple Heart is more of a hero than one without is utterly ludicrous.
I am a Viet Nam veteran. Do you know the difference a veteran with a Purple Heart and one without? Inches or seconds. You can even call it dumb luck. Do you feel more compassion for the wounded veteran than the veteran who was not? It is important.
In “Post Traumatic Stress Disorders Among Vietnam Veterans”† Jim Goodwin (1980) writes:
Finally, it is important to note an interesting trend. My interviews have all been with the Disabled American Veterans Vietnam Veterans Outreach Program. Yet it has only been on rare occasions that we have interviewed significantly disabled veterans, suffering loss of a limb or another wound that required months or even years of hospitalization. After many rap sessions with the director of our office, we have concluded that significant numbers of severely disabled veterans received much more comprehensive care after their combat experiences. In particular, this included close emotional support from other veterans on the hospital wards regarding their combat experiences. This, in turn, helped the seriously disabled veterans find some final resolution of their feelings about Vietnam. It also included a more empathetic understanding of the physically wounded veteran by the VA, which had learned about wounds and their concomitant psychological problems in World War II. Subsequent support and training to help these veterans to readjust to their losses was also provided. The veteran who was not seriously wounded had no such resources, hence the apparently smaller incidence of post-traumatic stress, chronic and/or delayed, in severely disabled veterans of Vietnam.
The author and his colleagues naively believed that the ministrations and attention ladled out upon wounded veterans by the VA spelled the difference in whether or not they suffered the symptoms of PTSD. How is it possible for a man to have his legs blown off and yet not suffer PTSD? And how is it possible for a man to survive the terrors of war, coming home without so much as a scratch, yet still suffer PTSD to the point of suicide?
The answer lies in suspense as the culprit producing anxiety. While most combat veterans suffer the high anxiety of waiting for the next attack, not all are killed or wounded. Most of us witnessed and waited our turn. But our turn never came. In contrast, those who were wounded suffered the physical trauma and lived. The suspense built up in them was broken. There is a vast difference between intellectual knowledge and carnal knowledge. We all know intellectually that the war is long over and the danger has passed. But have our bodies heard the news? Those who were wounded however severely have received the blow we all anticipated. But those of us with PTSD are still waiting for the blow that never comes. While I have witnessed the violent injury and death of others I still don’t really know (carnally) what it feels like. I imagine it hurts.
There is an infamous film from the Viet Nam War depicting the summary execution of a bound VC prisoner by the Saigon Police Chief during Tet. (The still photograph seen in magazines is one frame of a movie clip). The still photographic image depicts this man with a pistol aimed at his head a split second before he is shot. His face is distorted in terrified anticipation of the mortal blow about to be struck. His face is frozen in mid-flinch. We who suffer PTSD live out our lives in mid-flinch. We live in an unshakable state of anticipation, waiting for the blow that we know is coming.
In the absence of Homicidal Mortal Danger, PTSD is falsely claimed. While an individual may undergo an event that involves catastrophic destruction of property, the death of others, great personal bodily harm, and even extreme violence on the part of others, it still falls far short of the Homicidal Mortal Danger criterion.
Homicidal Mortal Danger involves the cunning mind. While it may be said to be dangerous to drive on a busy highway – no one is plotting your death. When you are in a homicidal type of mortal danger there is someone out there planning and plotting and conspiring to kill you. Someone is out to take your life. In attempt after attempt they try to kill you and the only thing that prevents them from succeeding is your own diligence; your own vigilance. (Stay Awake!)
Perhaps it is possible to graphically illustrate the pattern that brings about PTSD:
– and so on.
How long is too long? How long before the nervous system of a man of normal constitution is permanently damaged? How long before he suffers a nervous breakdown?
While every man is unique in his response to anxiety, the actual amount of time “the average man” can withstand the stress induced by mortal danger and repeated homicidal attack is, statistically at least, quantifiable and has long been known:
Chapter 7: The Stress of Combat ‡ (an excerpt):
“…reliable soldiers …were observed to fail at a …predictable rate ….
… the breaking point … in most …was about 200 aggregate days. Each moment of [ combat ] … imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot or shrapnel wounds in warfare. A single near miss could use up more of a soldiers’ limited allowance of days than a long period without traumatic happenings. Many officers in the combat arms felt that the limit was only 180 or even 140 days. The stress of modern war … set limits to human endurance.”
— Albert E. Cowdrey
I was issued two ‘overseas bars’, which are small stripes one wears on the lower sleeve of the dress uniform. Each, I was told, represents six months of overseas duty. In WW II they were known as combat bars and sometimes referred to as ‘Hershey Bars’ after the man who invented them, who happened to be head of the family that manufactured the chocolate bar of the same name. Back then each bar represented 180 days of combat ( I am authorized two, although in reality I served precisely 337 days in Viet Nam).
This number, 180 days, takes on even greater significance when one considers the nominal length of a Tour of Duty during the Viet Nam War. For the typical Army soldier it was 1 year and for the Marines (for the sake of bravado) it was 13 months. But for Field Grade Officers (those above the rank of Captain) the normal Tour of Duty was 180 days.
Like acid, anxiety eats away at the mind. The brain is an electrochemical device. Anxiety produces chemicals intended as short-term responses to emergencies. Anxiety eats away hopes, dreams, aspirations, plans, values, discipline, courage, self-esteem, appetite, sexual desire, the ability to sleep, etc. The high anxiety that produces PTSD destroys even denial. Psychiatrists have cataloged and described a long list called ‘The Mechanisms of Denial’. These mechanisms are the plots, ploys, gambits and really, mental gymnastics we all use every day to stave off the knowledge of our own impending death and the death of others.
Psychologically we are rarely if ever in touch with the reality of death.
One of our helicopters had crashed (while I was on guard duty) and one of the men drove up and announced “ Jones and Young are dead”. My denial response was
“That’s impossible. I talked to Jones yesterday.”
(I felt stupid immediately after I said those words.)
As another example:
I knew a woman who was doing some file work at home for her boss. She consulted with him over the telephone; 15 minutes later she called him again, only this time his mother answered. His mother informed her that he was dead. Her denial response was
“That’s impossible. I just talked to him fifteen minutes ago.”
Death can occur at any moment but we function as though it doesn’t exist or, if it does, it only happens to the old or someone else, not me.
I had every intention of attending a funeral for a sweet little two-year-old girl. I had shaved, showered and dressed to go to the funeral. I picked up the obituary I had clipped from the newspaper and discovered that I was a full day too late. I subsequently discovered I was not the only one who became dyslexic in reading the obituary of this two-year-old child. People simply could not deal with it and stayed away in droves.
Denial might be described as the self-generated and self-delusional presumption that we have time between now and death. Anxiety eats away this mental time to the point where we stand in the very shadow of death – and the Presence of Almighty God.
War veterans with PTSD are not in denial – just waiting for death. We see the world with a new set of eyes – survival is just wishful thinking. The world – life – this plane of existence – becomes utterly absurd and altogether meaningless. The things that seem to matter most to people are worthless: what is a gold coin in the hand of a dead man?
Comparisons are often made between the role of the combat soldier and police work. When a police officer dons his uniform and sets out to report for duty he might well reflect on the possibility of injury or death in the course of his workday. Police work is sometimes dangerous and officers do die in the line of duty; but, on any given day, on any given morning, there is no one within a hundred-mile radius that has so much as formulated in his mind, a homicidal intent toward him or any other police officer. A police officer is well-trained, armed, assertive, confrontational and legitimately authoritative; and in the eyes of good citizens, welcome. While comparisons can be drawn between the training and even armament of soldiers and police, the police officers are never subjected to the Homicidal Mortal Danger PTSD criterion on a constant, around-the-clock basis as is the soldier in a war zone.
A statistical analysis might reveal the most dangerous jobs in the world by mortality rate but if we use homicide as the sole criterion, first place always belongs to the combat soldier and second place belongs to the cab driver, while police work actually falls into third place. In terms of homicidal danger a taxi driver is untrained, unarmed, trusting and exposed; turned as he is with his back to complete strangers in close proximity hour by hour. This is part and parcel of his job. A cabbie is utterly defenseless and vulnerable to attack. Being a cab driver is, in terms of homicidal violence, the most dangerous civilian job. A taxi driver is subject to random acts of violence by junkies, desperadoes and other guilty spawn of society who are willing to kill for the twelve dollars in the driver’s pocket. But where is the genius behind such an attack? Where is the conspiracy or forethought? Where is the secret society plotting and planning how to successfully attack and kill a cabbie? While truly, something should be done to protect cab drivers from homicidal assault – and I would urge production of a vehicle designed and dedicated soly and specifically to the safety of the driver – the lot of the taxi driver falls short of the imminent and constant threat faced by the soldier in a combat zone.
In accepting or rejecting a diagnosis of PTSD the Homicidal Mortal Danger criterion must be met. In other words: Was the threat truly homicidal? Was it man-made? Was it repeated again and again and over what period of time? A tiger can kill a man but it is not homicidal and heat is in fact a physical stressor, but nothing can make you sweat like a confrontation with men bound and determined to kill you – to take your very life.
A single catastrophic event, even with homicidal intent, will not produce PTSD. In New York City after the suicidal attack on The World Trade Center of September 11, 2001, many claims of PTSD were made. There were in fact two terrorist attacks on The World Trade Center, the first on February 26, 1993 – some eight-and-a-half years before. 8½ years is a long time between attacks; long enough for the human body to return to a condition of homeostasis – long enough to forget. In war the next attack might come in the next 8½ minutes, 8½ hours, or 8½ days. And you know it’s coming.
There are dilettantes among us, unschooled in psychiatry, who bandy about the term PTSD loosely as opinionated pop psychologists, even some malingerers and frauds, all throwing pity parties for themselves. Yes, there are the purely ignorant who really don’t know what they’re talking about. But there are also politicians with personal or party agendas, churning lawyers out for a buck, deliberately abusing the diagnosis. Clueless doctors. Would I had the resources to collect all the stories – the false claims of PTSD.
An unfinished wall falls and buries a construction worker who claims PTSD. A politician garners some bad press and claims PTSD. An Australian woman claimed PTSD for an unsolicited kiss that also left her paralyzed and wheelchair-bound. Dear Abby is a notorious abuser of the diagnosis.
To all those who misuse or abuse the diagnosis of PTSD and it’s attendant jargon, I would send a letter of stern reprimand, stating quite flatly that, if it’s not about war; if it’s not about a soldier in mortal danger, it’s just not PTSD, and you are seriously disrespecting combat veterans.
† Goodwin, Jim, Post-Traumatic Stress Disorders Among Vietnam Veterans, p.19, Edited by Tom Williams, Cincinnati, Ohio, Disabled American Veterans (DAV), 1980
‡ Cowdrey, Albert E., “Fighting for Life” American Military Medicine in World War II, 151 (New York, The Free Press, Macmillan, 1994)
Full text: Chapter 7: The Stress of Combat p.151
“[Instead, the re-] lentless grind of combat had begun to produce a type of psychiatric breakdown that seemed to have little to do with childhood repressions, individual weakness, malingering, simple exhaustion, or the initial shock of combat. Over the course of time, reliable soldiers, well led and adequately supplied, were observed to fail at a fairly predictable rate. Even in Africa, medics had begun to talk about the breaking point-the time when combat service would produce psychiatric breakdown in most fighting men. Italy tended to confirm their observations. Viewing the reports from the theater, the surgeon general in September 1944 concluded that the limit was about two hundred aggregate days. Beyond that point, “the ‘worn out’ soldier . . . is through.” The reason was the cumulative effect produced by the peril of death. “Each moment of [combat],” General Kirk declared, “imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot or shrapnel wounds in warfare.” Some medical officers denied that any quantitative limit could be set, arguing that the quality of service was the determining factor: A single near miss could use up more of a soldier’s limited allowance of days than a long period without traumatic happenings. Others accepted the surgeon general’s idea of a time limit but argued over its length. Many officers in the combat arms felt that the limit was only 180 or even 140 days. Some studies suggested that units that fought much beyond 80-90 days were able to endure only because so many men became casualties of wounds or disease before they had time to crack up psychologically. Whatever viewpoint was adopted, the stress of modern war appeared to set limits to human endurance. Those who succumbed to its attrition could not be made effective combat soldiers again. The only hope was prevention. The British practice of systematic rotation, Kirk claimed, doubled the period of combat effectiveness to about four hundred days. Some form of rotation was essential to keep effective troops on the line in modern war. But American commitments were heavy, and the surgeon general was far down the chain of command. The army recommended the rotation of combat units for periods of rest but left compliance up to [theater commanders, who in turn left the matter to field armies, whose commanders might be too pressed to consider it.]”
2 In Viet Nam there was much talk concerning ‘The Pucker Factor’. When in extreme danger, the anal sphincter tightens and retracts into the rectum. Your ass actually puckers. The Pucker Factor then was seen as a 1 to 10 scale by which the men would compare and describe moments of terror.