Psychiatric Annals

Post-Traumatic Stress Disorder

Harry A Wilmer, MD, PhD

Abstract

1. Wilmer HA: Social Psychiatry in Action. Springfield. Illinois. Charles C Thomas Pub. 1958.

2. Wilmer HA: Dream seminar for schizophrenic patients. Psychiatry, to be published.

3. Wilmer HA: Vietnamand madness, dreams of schizophrenic veterans. J Am Acad Psychoanal 1982; 10:47-65.

4. Lund M. Strachan A: Paper presented at the American Psychological Association Convention, Los Angeles, California, 1981.

TABLE

THE FOUR STAGES OF VIETNAM VETERANS' NIGHTMARES…

My observations of combat experience are limited to treating patients in hospitals in this country. During the Korean Emergency I directeé a therapeutic community at the U.S. Naval Hospital in Oakland, California.1 Almost all psychological work on the ward was carried out in groups. This gave me valuable experience in understanding the rich unconscious life in acute psychoses.

During a study of combat Vietnam veterans at the Audie Murphy Veterans Hospital and referrals from the Veterans Center, it became obvious that there was a particular kind of schizophrenic patient who, recovering from his hallucinations and delusions, was still at the mercy of unconscious forces: Vietnam veterans with combat nightmares. The clinical records of these patients contained neither a summary of their military experiences, nor a description of their combat nightmares which were often the patient's greatest apprehension and the reason for insomnia. Instead of relying on medication for their symptoms a "Dream Seminar" was developed that met for one hour a week, focusing exclusively on the manifest content of one or two dreams.' All patients were encouraged to participate, to appreciate and understand the dream world. It was a very popular ward activity. If dream awareness was facilitated, patients would be on better terms with their unconscious, and less at its mercy.

In these Dream Seminars, combat Vietnam nightmares were heard firsthand. There exists a wide gulf between the Vietnam veteran and the non-Vietnam veteran and the staff. Anyone who has worked with combat soldiers sees that the need to deny and to avoid reliving and reactivating war trauma is powerful. Countertransference factors are often astronomical in significance and at the same time t herapists are often blind to them. The silence is not only from the negative attitudes of the non-veterans, and their abhorrence of what had happened, but is equally a consequence of the inability of the soldier to articulate his experiences, his heavy burden of guilt and his encounters with slaughter and death. At home, television brought instantaneous playbacks of Vietnam battlefield action into the living room each night. Unfortunately, this led not to compassion or understanding, but to callousness and antipathy. This was probably related to the fact that Americans, for the first time, saw that there was a "collective American shadow" that could not be projected only onto the enemy. Americans, were now more directly involved in individual torture and killing of women and children than ever before. This seems to have had much to do with the fact that we were fighting in the Far East and had little comprehension of the culture, the simplicity and the brutality of that life. The American shadow is the dark side of our psyche, the forces of evil and inhumanity. The war evoked ethical and moral problems of unprecedented proportions. The entire "conflict" was obscured by this shadow.

In no place was this more evident than in the situations where American soldiers killed civilians. The silence that surrounded the returning warriors was the inarticulate nature of this experience. People at home were not prepared to listen or understand that in order to survive it was often necessary to kill women and children - that children were commonly boobytrapped. In all wars there has been a vast amount of killing of civilians, but in this instance there was no way for the returning veterans to "work through" the transition from war to peace. There were no rites de sorte, no rites of passage. This had a devastating effect, which to a measure is now being seen in the delayed stress disorders surfacing many years after Vietnam. My own work with these veterans is a kind of archeology of that silence. How can we most easily dig to these depths in a healing manner?'

First, it was necessary to work with Vietnam veterans exclusively. Over a one-year period, 120 in-depth interviews were conducted with combat veterans. The interviews, averaging three hours each, ranged from one hour to 20 hours. Detailed studies of combat nightmares were an essential part of this study because in nightmares the war is relived as if it were still being fought, and the re-experience is undistorted by conscious attitudes and reflections. In a manner of speaking I was accumulating data for an oral unconscious history of Vietnam war experiences. This was undertaken in the belief that the ventilation of combat experience to an attentive, nonjudgmental listener who was convinced that there was some explanation for what was plaguing the patient would be therapeutic. This latter attitude cannot be overemphasized, because it also contained an element of hope and justification for talking to these men, over and above the accumulation of clinical research data.

Almost all Vietnam veterans were eager to talk about their experiences, not as war stories, but as existential phenomena. The tenuous hold on violent impulses, the fall back into alcoholism, the self-destructive lifestyles, the withdrawal into painful introverted isolation and the nebulous touch between people were all obvious and threatening.

Figure 1. A pathway of post-traumatic stress disorder.

Figure 1. A pathway of post-traumatic stress disorder.

Figure 2. Recognizable catastrophic stressor.

Figure 2. Recognizable catastrophic stressor.

While it might have been better had I been a Vietnam veteran, the fact that I was a retired Navy captain, and old enough to be seen as father/ grandfather with a genuine interest in being told what Vietnam was like, made the results highly satisfactory. Many patients seen only four or five times made dramatic improvements. Many of these soldiers had never before talked to anyone about these experiences. All interviews were recorded on audiotape and transcribed for study.

It was impressive to note that grunts did not dream in Vietnam, and when asked about dreams in Nam, they almost invariably responded: "Dream in Nam? No, I slept with one eye open." There were prolonged periods of sleep and dream deprivation. Hardly any veterans reported combat dreams while in Nam, but when they returned home it was different. The veterans felt that there was an urgent need for their voices to be heard since many felt that another war was coming. If we fail to learn from our stress casualties of Vietnam we may never have another chance to learn.

The following figures and descriptions help me to conceptualize the phenomena of the Vietnam veteran's psychological stress. They related both to psychiatric patients and non-patients as well.

A PATHWAY OF POST-TRAUMATIC STRESS DISORDER (Figure 1)

The sequential realms are: early life, military indoctrination, combat and combat trauma and re-entry home. This is followed by a continuum of experiences of self-image, intercurrent life events including change factors and the residuals of the Vietnam trauma. At some point there may be a re-emergence of the Nam-related disorder. The realm of concerted effort for healing is Helper-Healing in the hie et nunc or here and now. The HelperHealer is within the individual's psyche. It is the activation of this part of the personality which may integrate and heal inner turmoil.

The question always comes to mind, why the delay of years for symptoms of post-traumatic stress disorders? That can be understood in individual cases, the birth or death of a child for example, and by more universal factors such as the approaching mid-life crises of the Vietnam veterans which may precipitate the disorder. There will be a predictable resurgence of symptoms in another 20 to 25 years with the problems of aging and approaching death. Dr. Einar Johnson of the Modum Bad's Nerve Sanatorium in Vikersund, Norway, reports that he is seeing an increasing number of men who were at sea during World War II who are only now decompensating psychologically.

RECOGNIZABLE CATASTROPHIC STRESSOR (Figure 2)

What are the criteria for identifying the post-traumatic stress disorder cases? An individual must have experienced a recognizable catastrophic trauma or stressor. It is not enough to have seen people die or be killed. There must be personally experienced trauma of an overwhelming nature. In terms of psychiatric nomenclature (DSM-IIl) following this event a set of characteristic symptoms may develop which re-experience the trauma: there is a numbing of responsiveness to, or reduced involvement with the external world; and a variety of autonomic, dysphoric or cognitive symptoms.

RE-EXPERIENCE OF TRAUMA (Figure 3)

The traumatic event is re-experienced in painful. intrusive recollections or recurrent dreams, nightmares, or flashbacks (dissociative state) lasting from a few minutes to hours, or even days, during which time components of the event are relived, and the individual behaves as though he is experiencing the event at that moment. This may be set off by a stimulus from the outer world such as fire, a helicopter, a car backfire, gun shot, fireworks explosion - or by an inner world ideational stimulus, memory, etc. To each of these causes the veteran may recoil, trying to separate himself from the evoked feelings, but since the dreams, flashbacks or intrusive thoughts are unconsciously activated, an associated panic or fear of loss of control or actual violence may occur.

Figure 3. Re-experience of trauma.

Figure 3. Re-experience of trauma.

Figure 4. Numbing of responsiveness.

Figure 4. Numbing of responsiveness.

NUMBING OF RESPONSIVENESS (Figure 4)

Diminished responsiveness to the outside world referred to as "psychic numbing" or "emotional anesthesia" usually begins soon after the event. A person usually becomes estranged or detached from other people, losing the ability to become interested in previously enjoyed significant activities or even the ability to feel emotions of any type, especially those associated with intimacy, tenderness and sexuality.

Figure 5. Two or more of these symptoms.

Figure 5. Two or more of these symptoms.

TWO OR MORE OF THESE SYMPTOMS (Figure 5)

Many people develop symptoms of excessive autonomic arousal, such as hyper-alertness, excessive startle reaction, and difficulty falling asleep. Some complain of impaired memory or difficulty in concentrating or completing tasks. In the case of life-threatening trauma shared with others, as in combat, survivors often describe guilt feelings about surviving when others did not, and about the things they had to do to survive. They may avoid activities or situations which remind them of the traumatic event. Some or all of these symptoms may be intensified when the individual is exposed to situations or activities that resemble the original trauma.

REALM OF VIETNAM NIGHTMARES (Figure 6)

Most Vietnam combat veterans are not subject to this psychological syndrome. There were 5,964,000 military personnel who were not actually in Vietnam at any time. There were 2,769,000 soldiers who served in Vietnam. Some of them were in no combat and experienced no intense, traumatic event. The remaining troops can be divided into low and high combat experience. This makes a great difference because the psychiatric casualties were far greater after high combat exposure. Some high combat experience soldiers do not seek help, and if they have no residual problems they should not seek help (Figure 6). However, many others avoid reaching out for the help they should seek. If the help is found and is not adequate or does not seem right to the patient, he should reject it and try some other help. Many soldiers have been turned off by the attitudes of therapist and physician or some VA experiences; unfortunately these can have lifelong consequences. On the other hand many veterans who suffer do seek help. They may not have nightmares. Those who do have nightmares can be classified into one of four dream categories (Table). When the therapists do not ask the patient about or listen to combat nightmares they may miss the crucial symptom. Dreams not only reveal critical combat experiences but also represent how it is perceived by the psyche and may have prognostic value.

Figure 6. Realm of Vietnam nightmares.

Figure 6. Realm of Vietnam nightmares.

VIETNAM STRESS: CAUSE AND EFFECT (Figure 7)

There is a cause and effect phenomena of war: high combat exposure yields serious suffering. One of the most disturbing causes is the killing and wounding of enemy civilians, particularly women and children. There are currently two theories as to the cause and effect of war: one, the Residual Stress Model, maintains that the combat experience itself explains the long-term disorder. The other, the Evaporation Model, postulates that the pre-military experiences, rather than military stress, explain the disorder. The Residual Stress Model is the most important, though some casualties (such as schizophrenia) do not seem to be precipitated by war stress that is not severe and acute. There are genetic and developmental events that are often equally as important and sometimes more important than war experience. Severe personality disorders are usually lifelong and symptoms may be related to the continued manifestation of this disorder. In some of these cases of personality disorders, the war experience is the cause of a posttraumatic stress disorder. One does not, however, exclude the others.

Figure 7. Vietnam stress: Cause and effect.

Figure 7. Vietnam stress: Cause and effect.

Figure 7. Realms of increasing stress magnitude.

Figure 7. Realms of increasing stress magnitude.

REALMS OF INCREASING STRESS MAGNITUDE (Figure 8)

Lund and Strachan4 devised a Vietnam Combat Exposure Scale created through a Guttman scalagram analysis based on response patterns to questions about events experienced in Vietnam. The events are unidirectional and cumulative. The veteran is assigned a score according to the highest event passed. The events are:

1. Whether he went to Vietnam during the time of the war.

Figure 9. Vietnam realms: Soldier returns.

Figure 9. Vietnam realms: Soldier returns.

2. Whether he saw the death or injury of a friend or other U.S. soldier.

3. Whether he fired a weapon or was directly under fire in a combat situation.

4. Whether he was personally responsible for the death of enemy military personnel.

5. Whether he was wounded in combat.

6. Whether he was personally responsible for the death of a Vietnamese civilian.

7. Whether he served a third tour of duty in Nam.

VIETNAM REALMS: SOLDIER RETURNS (Figure9)

The Realms of the Soldier's Return (Figure 9) emphasizes territoriality, a much neglected element of the guerrilla warfare in Vietnam. Not only was the war fought on the homeland of the enemy but also from underground tunnels. The relationship of aggression and territoriality are of considerable importance in understanding the attitudes of American soldiers to the war and to the enemy. The significant realms in the soldier's return are: home and adjusted; nightmares and flashbacks and symptoms; group (social) help; no help or inadequate help. The arrows indicate the directions and connections between these different realms. Group experience is most helpful since only a few veterans are able to avail themselves of individual treatment. No help or inadequate help is a dead end, there being no arrows flowing back into the system because it is conceptualized that if there is no help available the patient will sink or swim depending on many interrelated factors. If inadequate help is experienced for any length of time, this is likely to be destructive and is always counterproductive. Adequate genuine help might repair what the misbegotten therapy begot.

Figure 10. Images.

Figure 10. Images.

IMAGES (Figure 10)

The essential symbolic elements in healing are demonstrated in Figure 10. So long as the shield of silence separates the unconscious from the conscious world the energy and drain is into the unconscious and these constellate nightmares, flashbacks and intrusive thoughts. The process of three related phenomena is mediated unconsciously so that by and large, cognitive therapy will not undo the repetition compulsion or phenomenon of these symptoms. The shield of silence makes I-Thou relationships impossible. The image flow to work and creative acts is possible only when one is liberated from the autonomous power of the unconscious. This can happen under favorable circumstances that facilitate long-term relationships with a few people and nature. The images seen in consciousness will otherwise remain black and heavy.

NIGHTMARES: CLASS I (Figure 11)

The first class of combat nightmares is the most frequent and the most difficult to treat psychologically or pharmaceutically. Category I (or Class I) dreams are replications of the dominant traumatic event. They recur with a periodicity or rhythm. They appear as on/ off, yes/ no phenomena, that is, the dreams are finite images that are turned on as if by a switch. They are not contaminated by other images. There is a similarity of content, marked by constancy, predictability and precision. Very often the re-emergence of the dream out of darkness is described by an analogy to film. Psychologically it is like an engram experienced as a vision. Because of these qualities. Class I dreams seem to be organic. It is as if a stimulus to a locus of the image storage sets it off and sets this one thing and nothing else off. This kind of phenomena may be related to archaic mechanisms of survival.

Figure 11. Nightmares (Class 1}.

Figure 11. Nightmares (Class 1}.

CLASSIFICATION OF VIETNAM DREAMS (Table)

In a random sample of 44 cases of combat veterans, 64% reported nightmares, and 36% did not. The dreams were divided into four categories. Class I nightmares consisted of dreams images of the actual combat situations, so realistic that the veterans recognized all aspects as the way the combat actually was. No new element is introduced in the dream. The dream ego is usually central and the dream images vivid, often with color, smell and sound. These dreams are usually recurrent; they began after the veterans had returned to the United States, starting anywhere from a few weeks to ten years later. They are memorable. The veterans will at once usually reveal Class I nightmares when dreams are asked for. This is his war dream. The dream continues as often as every night, but usually from several times a week to once or twice a month or less. Class I accounted for 46% of reported dreams.

Table

TABLETHE FOUR STAGES OF VIETNAM VETERANS' NIGHTMARES

TABLE

THE FOUR STAGES OF VIETNAM VETERANS' NIGHTMARES

Class II dreams are nightmares of events that were untrue in the dreamer's experience, but that could have happened in the war. Class III are metaphorical dreams that portray events highly improbable in reality. Class IV are nightmares of impossible events completely divorced from reality.

Therapists deal with or interpret these dreams according to their own orientation of the dream.

The phenomena of combat nightmares and the psychological study of the unconscious manifestations of combat soldiers offer unique opportunities to understand how the human psyche copes with the catastrophic stress of war. It also might lead to understanding about the treatment of war trauma and give important prognostic clues. Such dreams are characteristic of all wars of all times.

In ancient Greece, Virgil wrote in the Aeneid:

Behold, the Fate's infernal minister!

War, death, destructible, in my hand I fear.

Thus having said, her smokTring torch impressed

With her full forces, she plung'd into his breast.

Aghast, he wak'd; and stirring from his bed.

Cold sweat, in clammy drops, his limbs o'erspread.

"Arms! Arms! he cries; "My sword and shield prepare."

He breaths defiance, biood and mortal war.

REFERENCES

1. Wilmer HA: Social Psychiatry in Action. Springfield. Illinois. Charles C Thomas Pub. 1958.

2. Wilmer HA: Dream seminar for schizophrenic patients. Psychiatry, to be published.

3. Wilmer HA: Vietnamand madness, dreams of schizophrenic veterans. J Am Acad Psychoanal 1982; 10:47-65.

4. Lund M. Strachan A: Paper presented at the American Psychological Association Convention, Los Angeles, California, 1981.

TABLE

THE FOUR STAGES OF VIETNAM VETERANS' NIGHTMARES

10.3928/0048-5713-19821101-08

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