Post-Traumatic Stress Disorder (PTSD) was first described as a psychiatric syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (American Psychiatric Association, 1981), but symptoms of the disorder had been found among soldiers in every war, even the Revolutionary and Civil Wars (Herman, 1992). The syndrome manifests itself in very specific ways. A traumatic event or events that a person has experienced leaves such a strong psychic impression that the person later experiences recurrent, painful, and intrusive recollections. These may take the form of unwanted thoughts, images, or even hallucinations, called flashbacks, during which components of the event are actually relived. Many traumatized persons, to avoid re-experiencing the anxiety and pain of the trauma, will arduously avoid activities that may cause them to remember the traumatic events. Consequently, emotional numbing and psychological amnesia to parts or all of an event may occur. Other symptoms that may develop include nightmares, sleep disturbance, hyper-alertness, exaggerated startle response, impaired memory, and reduced ability to concentrate (Falk, Hersen, & Van Hasselt, 1994).
As geriatric nurses care for an increasing number of older veterans seeking medical intervention, they are in an important position to identify this often overlooked disorder and provide appropriate care and referral for mental health treatment. Often, elderly veterans who otherwise are functioning well may experience an onset of PTSD symptoms or a worsening of current symptoms secondary to the stress of physical deterioration, changes in environment, or medical interventions. This is of great importance to the geriatric nurse because there are over 9 million veterans living today who served in World War II and the Korean War, and it is estimated that as many as 12% of these veterans may have symptoms related to PTSD (DVA Office of Public Affairs, 1993; Zeiss & Dickman, 1989). This translates to almost 1 million elders. Also, there is evidence that late-onset PTSD in formerly well-functioning individuals is an increasing phenomenon (Christenson, Walker, Ross, & Malthie, 1981; Schnurr, Aldwin, Spiro, Stukel, &Keane, 1993).
This article seeks to provide a framework for understanding how war-related PTSD may manifest itself in elderly veterans and also to illustrate how unresolved memories may resurface when these veterans experience situational Stressors such as changes in living environment; losses of spouse, family members, or friends; and engagement with health care facilities. In addition, the article seeks to describe some intervention strategies useful with combat veterans and former prisoners of war (POWs) who are experiencing symptoms of PTSD. Case studies from veterans treated at the DVA Medical Center, Cleveland, Ohio will help illustrate our points.
PTSD: A HIDDEN SYNDROME
Mr. Boyd, a 74-year-old diabetic, illustrates how symptoms which may have been suppressed for many years can "flare up" and create diagnostic issues for nurses and physicians. This patient had been admitted to the intensive care unit at approximately 10:00 a.m. for gastrointestinal bleeding. As the day progressed, his primary nurse noticed that he was becoming more agitated. His speech was rapid and pressured, and he had made several attempts to leave the bed; but when asked how he was doing, he would merely reply, "fine." At 2:30 a.m. the following morning, however, he began shouting and thrashing about wildly in bed. He no longer responded to the staff at his bedside, but rather seemed engaged in some imperceptible confrontation. The staff worked furiously to reassure and restrain him, but this seemed to make his agitation worse. What was the cause of the patient's progressive anxiety and acting out? Mr. Boyd had a history of alcohol abuse - was this delirium tremens? Was he experiencing a psychotic episode, a metabolic imbalance, or acute confusion? Was the problem hypoxia? A series of laboratory tests were ordered, but came up negative. It seemed to be none of these syndromes.
The following day, in an interview with a staff nurse, the patient's wife related that Mr. Boyd, a former POW, had reacted in a similar way following cardiac surgery. She further related that for many years this man had been restless, tense, and unable to allow himself to be attended to medically except under great duress. It was a result of his war service, but he had never wanted to talk about it. Now, she added, it seemed that as he was beginning to need more and more medical care, problems with war-related memories were beginning to resurface. A psychiatric consult revealed that this patient, like numerous elderly combat veterans and former POWs, had been suppressing the symptoms of PTSD for almost 50 years. PTSD therapy was initiated concurrent with a medical regimen for his gastrointestinal problems. As the veteran began to see how he had connected his fears of being vulnerable with traumatic events he had experienced as a POW, he was better able to acknowledge his health problems and accept medical help.
Symptoms of PTSD (American Psychiatric Association, 1994) are categorized into three broad areas. First is the set of re-experiencing symptoms. The traumatized person may have the experience of reliving the event or events in thoughts, dreams or dissociative flashbacks. Also, he may incur great anxiety when exposed to things that remind him of elements of a traumatic scene. These may include loud noises, confinement, the loss of a close person, and even movies or songs reminiscent of the time period in which the trauma occurred.
The second broad area is the set of avoidance symptoms. The person may purposely avoid places, people, or discussions that are reminders of the trauma. He or she may behave with a purpose of affectively "tuning out" things that might cause a resurfacing of feelings or thoughts associated with the trauma. There is usually also concurrent symptoms of depression, emotional numbing, and disinterest in life.
Finally, the third broad area is arousal symptoms. These indicate a seemingly permanently aroused physiological state. They can be seen in patients who are chronically irritable or angry, cannot sleep, have trouble concentrating, are hyperalert to usually unknown dangers, and who exhibit an exaggerated startle response. The presence of a single symptom is not sufficient to diagnose PTSD, but if a patient displays one or two symptoms from each broad category and has experienced a traumatic event, caregivers should be alert to the possibility of the disorder being present.
It is only in the last 15 years that PTSD has been studied intensively as an anxiety disorder. Since that time, the majority of veterans receiving treatment for PTSD have been those who fought in Vietnam (Friedman, Schnurr, & McDonaghCoyle, 1994). Many health care workers learned about the disorder through exposure to this younger group of veterans, and may have developed expectations about how a veteran with PTSD might look based on stereotypes drawn from their behaviors and symptom presentation. Hence, veterans with PTSD are characteristically thought to be loners who exhibit explosive emotions, are easily angered, and use an array of drugs to quell feelings associated with the war.
The older veteran with PTSD, however, has a very different presentation. In fact, studies comparing World War II and Vietnam combat veterans, have found that the older veterans with PTSD display fewer and less dramatic symptoms and associated problems such as overt hostility, work impairment, panic disorder, and suicide attempts than their diagnostically similar Vietnam War counterparts (Davidson, Kudler, Saunders, & Smith, 1990).
Consequently, while the incidence of PTSD among older veterans may be as high as that among Vietnam veterans, the presence of the disorder in an elderly veteran may be more likely to be missed. Because of this, some writers have suggested that PTSD may be a hidden syndrome in older combat veterans (Lyons & McCiendon, 1990; Nichois & Czirr, 1986). In part this may be a consequence of clinical inattention, because elder veterans do display less dramatic manifestations of the disorder and are less disposed to ask for psychological help. Also, somatic complaints and depression often mask PTSD; and thus, the symptoms that could lead to a clearer diagnostic picture will often be missed by uninitiated clinicians.
Further complicating this picture is the observation by Christenson and colleagues (1981) that this generation of veterans is very reluctant to discuss the emotional effects of combat. They also often deny symptoms of PTSD or downplay the intensity and frequency of symptoms the first time that they are approached (Kluznik, Speed, Van Valkenburg, & Magraw, 1986). Because they came to adulthood in a culture which was not accepting of psychological problems, they are more likely to emphasize their physical problems rather than psychological distress, even if they originate from chronic emotional conflicts. When they do seek help, they often present with non-specific complaints that are not explicitly attributable to their war experience. If asked how their war experience may have affected them, these older men tend not to voice distress or dramatic material, but rather are quick to report that they have experienced nothing out of the ordinary.
Dick C. is a case in point. He was referred for psychiatric assessment after numerous tests failed to identify a medical cause for his chronic pain and weakness in both legs. This problem seemed to worsen when he was in a crowd from which he could not escape. The problem became a crisis during his 50th wedding anniversary party, where he had a panic attack which was initially thought to be a heart attack. After a series of negative medical tests, he was referred for psychiatric counseling. Over time and after some education about PTSD, he was able to discuss what had been troubling him for over 50 years. In therapy he related how he was plagued by vivid images of being captured by the Germans and pinned against others in a crowded boxcar as the Americans bombed the train yard. Until recently, he had never talked about this event, but had always suspected that the overwhelming anxiety he experienced whenever in a large group of people was related to his "hard times" in the war. Yet, Dick had maintained this suffering in silence, not knowing anything could be done to help him, and fearful of saying anything that might label him "crazy" or "weak." He explained that he never accurately reported his level of distress because of his fear of being locked up. He had seen soldiers who had "lost it" during the war and felt that if he told the truth about his experiences others would confirm his fear of being crazy.
In the 1940s, the symptoms associated with battle fatigue (an early name for PTSD) were thought to originate from vulnerabilities in a soldier's character or from personal weakness rather than a normal predictable response to being involved in one or more horrific experiences (Herman, 1992; Wilson, 1994). Men who were bothered by distressing memories or dreams often did not consider psychological treatment because of the stigma of being in an asylum, or as another veteran put it, the fear of being "put into a rubber room." One veteran stated, "I wanted to talk about what I had gone through, but I was afraid that someone would think I was somehow damaged or cracked-up." Other veterans have reported that when they did talk about their war experiences, the advice offered, by both lay persons and professionals was, "the war is over," "be a man, forget it," and "get a job, raise a family, put it behind you."
How did these men, traumatized by the war, go on to raise families, maintain stable employment, and, in many other ways, sustain the appearance of easy adjustment? The answer lies in a repertoire of highly stylized and often rigid coping behaviors. A look at American culture after World War II gives an indication of why and how these men began to hide or suppress their problems immediately on entering civilian life. The period of the 1940s and 1950s placed great emphasis on masculine-role behaviors, and these roles provided little leeway for men to explore conflicting emotions about their war duty. To many of that era, emotional problems as a result of war experiences were a sign of character weakness. In addition, the cultural ideology of the time embedded in many of these veterans the idea of taking pride in selfsufficiency and the ability to overcome problems through individual will. In essence, societal demands for conformity and negative stereotypes about mental illness pushed many veterans to hide their post-war trauma conflicts, maintain secrecy, or suppress anxiety and depressive symptoms through a variety of means, not the least of which were psychological mechanisms of repression and denial (Tennant, Goulston, & Dent, 1986; Van Dyke, Zilbert, & McKinnon, 1985).
Senior Veteran's PTSD Screening Instrument
One frequently reponed coping behavior is overwork. Not only have most of these veterans worked extremely hard at one job for the majority of their working life, but many of them report it was imperative they focus on work as a way to avoid distressing memories of the war. Paul N. related, "I worked furiously to keep my mind occupied. I hated to go on vacation, and couldn't wait to get back to work." Charles T. worked a full time job and two part time jobs at the same time for most of his work history. He reported coming home long enough to eat and clean up before going to his next job. He would return home after his family was asleep. When asked about this behavior, he replied that he discovered if he kept busy he could not think about the war. Keeping busy also served to isolate him from those who would seek a close relationship.
Other veterans have reported seeking jobs where they would be alone all or most of the time. One job held by several men was that of a long distance truck driver. This vocation permitted isolation not only from co-workers and bosses, but also wives and children. One patient, Mr. H., related, "I didn't trust myself to be around people because I knew the violence of which I was capable." He further explained that when alone, he would not experience his anger so intensely and would feel somewhat at peace as long as he kept busy.
Even outside of work, many veterans preferred hobbies or activities that allowed them to be busy and alone. One veteran explained, "I would get out my tools and work myself into a sweat in an effort to get away from everyone and lock out the war." His wife said, "He would always find a project to do around the house and became nervous when the project was close to being completed. He might tear apart something that he built for no other reason than to keep busy."
Other veterans coped with memories of the war by using mind- or emotion- altering substances such as alcohol. Glen H., for instance, was able to "hold it together" by getting drunk when something reminded him of certain events in the war or when images or dreams surfaced spontaneously. "When I drank the alcohol it effectively numbed the pain that came with the memories." Roger F. began drinking heavily following early medical retirement. He felt that alcohol helped erase the memories and numb the distressing feelings that arose as he experienced long periods of idle time. But by age 65, he was not able to tolerate alcohol and felt unable to deal with his memories. Once he stopped drinking, he attempted suicide and was admitted to a psychiatric ward with a diagnosis of major depression. He was referred for PTSD treatment with complaints of intrusive thoughts, nightmares, difficulty managing anger, isolation, and depression. In therapy he came to understand that these were symptoms of war trauma which he had been treating with alcohol for over 4 decades.
It seems likely that as World War II and Korean War veterans enter their sixth, seventh, and eighth decades and experience the life transitions, medical problems, and losses that characterize normal aging, conflicts and memories of traumatic events long held at bay may intensify into clinically acute symptoms of PTSD. Davidson and colleagues (1990) noted at the conclusion of their study that "later life constitutes an important risk period for the emergence of new disorders in veterans of combat who are already diagnosed with PTSD. Friedman and colleagues (1994) report on studies that show the incidence of PTSD among veterans seeking medical treatment to be as high as 27%. Elder and CUpp (1989) describe how a traumatic experience may be initially contained but resurface at a later time due to "situational correspondence." These authors note that when a person goes through a current event that is similar in content or in emotional impact to a past traumatic experience, he or she will sometimes to go into acute exacerbation of PTSD symptoms. They proposed that certain events or even certain persons in a veteran's life may serve as triggers of the experience of helplessness and loss of control the veteran felt during war trauma experiences. A small set of published clinical observations of World War II veterans provide supportive evidence for this phenomenon (Christenson, Walker, Ross, & Maltbie, 1981; Hamilton, 1982; Van Dyke, Zilberg, &: McKinnon, 1985). Our experiences at the Cleveland DVA Medical Center also provide some dramatic case studies of this occurrence.
One particularly instructive case was that of Samuel W, whose first indication of a problem was during magnetic resonance imaging. At the start of the test, he began sweating profusely and had a panic stricken look on his face. No amount of comforting or support seemed to calm him. In the middle of the procedure he panicked and ran from the room. He did not stop running until he reached the hospital parking lot. On further questioning, Samuel related that being in the closed space resurrected feelings from 50 years ago when he was trapped under a small porch during a nonstop bombing blitz. At that time he thought that he would die like his friend next to him, who was hit by shrapnel. Later, in therapy, he related that he could actually feel the blood of his friend on his body.
In addition to having to face the results of suppressing PTSD symptoms for decades, World War II and Korean War veterans in their later years must also confront normal, but often stressful, developmental tasks inherent to later life. Older persons in our society face numerous problems as the vigor and status of youth gradually diminish and as arenas of mastery and instrumentality become fewer. Deaths of friends and decreased personal vigor may precipitate an intensified awareness of aging and mortality. Loneliness, physical impairments, and real or threatened cumulative losses can also place older persons at great risk for emotional disturbances. Life-span development theory points to the tasks of late life as introspective exploration, realistic life review and, ultimately, acceptance of one's personal history (Erickson, 1963). Life review, an internally focused, selfevaluative process, is likely to be triggered by normative life transitions (i.e., retirement, remarriage) and life crises (i.e., chronic illness, loss of loved ones). It is a process of taking inventory of one's life experiences, both the good and bad. In doing this, veterans may face once again some of their behaviors during the war, and some of the guilt, anger, or helplessness they have suppressed for many years. As these intense feelings surface, and the familiar ways of coping with them are no longer available, veterans are often at a loss as to what to do.
Nurses are likely to encounter symptomatic elders in all health care settings, but the chances increase in inpatient settings where patients experience acute physical and psychological Stressors. See Box on page 15 for interventions to assist nurses who find they must intervene with older patients who have PTSD in addition to other acute illnesses.
Contrary to common wisdom, the prevalence of PTSD among World War II and Korean War veterans may well be as high as that among Vietnam veterans. However, the former may display less dramatic manifestations of the disorder, be less disposed to seek psychological treatment, and may thus be diagnosed with the disorder less often. Because this population is reluctant to discuss war-related psychological conflicts, treatment settings that serve veterans need to be attentive to the often unspoken psychological needs of elderly veterans. It is crucial to note that elderly veterans present a different clinical picture than younger veterans with PTSD.
Interventions which may be helpful in detecting PTSD among the older veteran population include short screening for symptoms and discussion with family members. It may also be important for health care workers to be able to intervene in helping these veterans when symptoms arise. Among the short interventions found useful are education about PTSD to help normalize the sometimes fearful imagery and affect associated with memories, thought stopping to help the veteran master intrusive thoughts, and reorienting strategies to help them contain overwhelming imagery or sensory illusions.
Note: Names in this article have been changed for anonymity purposes.
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Senior Veteran's PTSD Screening Instrument