Post-Traumatic Stress Disorder (PTSD), which more enlightened advocates and treatment providers refer to as Post-Traumatic Stress (PTS) or Combat Operational Stress (COS), is the most common of all military-related mental health conditions. It is a diagnosable condition described in the Diagnostic and Statistical Manual of Mental Disorders (IV Edition) of the American Psychiatric Association as “the development of characteristic symptoms following exposure to an extreme stressor”…something which involves “actual or threatened death or serious injury or other threat to one’s physical integrity”. What is not as well known is that it is also possible to develop PTS by proxy, either as a witness to a traumatic event or among family members of one who has survived a life-threatening episode. Trauma events in combat may also be layered upon each other as the combat experience continues. This repeated trauma causes challenges in treatment and in discovery as each additional episode buries the earlier one in distant memory and requires special considerations in treatment to uncover.
In the early and mid-20th century, PTS was studied only for its effect upon military performance. Later, focus shifted to include issues associated with explosive behavior which became the cultural hallmark of the Vietnam-era veteran. In recent history, research began in earnest to understand the broader effects of PTS, both on the individual and within society as a whole. Three decades of exhaustive studies has led to a much more fundamental understanding of the condition and to the development of guidelines to aid with diagnosis and establish treatment regimens.
As a mental health condition, PTS has become so widely accepted within American society that legislation has been adopted in some states and localities which permit police to turn a veteran over to a treatment facility or veteran representative who will help them get treatment instead of filing formal charges. In January 2011, California lawmakers ordered the Commission on Peace Officer Standards and Training (POST) to assess officers’ expertise regarding Post Traumatic Stress and Traumatic Brain Injury and make recommendations for training them in how to cope with veterans who may have psychological war wounds. (See Cal. Penal Code §13515.36). Police are being trained to deal with the minority of veterans who are psychologically impacted by trauma, and who might be having episodes of combat-related stress or attempting “suicide-by-cop.” In the courts, judges have become educated about the benefits to public safety that result from sentencing veterans to appropriate treatment instead of putting them behind bars.
General PTS Statistics
Among all Americans, about 6.6% of the population will suffer from PTS at some point in their lives; 3.6% of men and 9.7% of women. By contrast, PTS among male veterans of the Vietnam conflict is estimated at nearly 31%. In the wars in Iraq and Afghanistan, some research has discovered that up to 1 in 5 combat veterans who were deployed in areas once described as “front-line” meet the criteria for PTS. In contemporary theatres of warfare, the “front line” is often ever-present. In Vietnam, Iraq and Afghanistan, enemy combatants were not in uniform, not easily identified; a consistent existential threat.
Some Basic Statistics about Veterans Combat Experience:
36.7% Received small arms fire
56.9% Received incoming artillery, rocket or mortar fire
18.1% Handled or uncovered human remains
34.1% Saw dead or seriously injured Americans
57.1% Knew someone seriously injured or killed
47.4% Saw dead bodies or human remains
45.4% Had a member of their unit become a casualty
The Stigma of PTS
The stigma of admitting that a veteran has a psychological problem is a significant barrier to getting treatment both prior to involvement in criminality and during the disposition of these veterans’ cases. While those without these traumatic conditions might well intellectually understand that treatment can help, veterans with these conditions are cognitively affected by them. This often prevents them from seeking treatment on their own. And even those who are unaffected by trauma may be affected by the stigma.
A case can be made that treatment options such as veterans treatment courts, available to the newer generations of veterans, may counteract these affects in ways not available to older veterans. The chronic nature of anti-social and criminal behavior among older veterans may not be repeated among this newer generation if they receive early treatment, before their PTS symptomology becomes incorporated fully into their daily environment and character. Once PTS has incorporated, it is much more resistant to treatment. Thus, persons serving multiple tours in combat may have layer upon layer of symptomology which left untreated becomes resistant to recovery.
In reliving the trauma of the events which have brought on the condition, many veterans suffering from PTS will look for ways to escape from or alleviate the affects of these memories. The chronic anxiety produced by these affects can be completely debilitating. Alcohol and drug use are common methods used to counteract it. They begin as essentially efforts at self-medication and, in most instances, substance use develops into abuse and compounds the problem.
At the other end of the stress-spectrum, emotional numbness can lead the veteran to become a thrill-seeker in an often futile effort to reconnect with his emotions. For some veterans, thrill-seeking is an effort to reconnect with “the high,” the emotional rush they experienced during combat. Still others find themselves feeling the need to be on guard at every moment, seeing in every action around them a threat and a reason to lash out. Some veterans experience unbearable guilt, either for surviving an event which others did not, or in perceiving some effort they might have taken to protect others but didn’t. These veterans may go looking for trouble, committing acts for which they will be caught and punished or even killed. Every symptom of PTS can lead to violent behavior or other criminal activity.
PTS among veterans can be exhibited in ways quite different than PTS within the general population. First, military training and combat essentially reinforce some of the symptoms associated with PTS - most notably hyper-vigilance, a behavior which is critical under combat conditions and even rewarded during military training. Second, while civilians suffering from PTS are almost always passive victims, veterans are usually unwilling but nevertheless active participants within their trauma. Finally, the extended nature of deployment and combat also create conditions which are likely to deepen and expand the symptoms associated with PTS among veterans.
The most undeniable difference in PTS symptomology among veterans is that it may remain dormant for years, and therefore go untreated. A civilian in a violent traffic accident most often experiences PTS immediately, and can obtain immediate treatment as well. Untreated dormant military-related PTS may fester, which can lead to more serious consequences when it finally surfaces. Dormancy may be another reason that lower levels of PTS have been observed in veterans from the Iraq and Afghanistan conflicts than among Vietnam-era veterans. With the passage of time, more veterans from later wars may yet develop PTS.
Perhaps the greatest contrast between civilian PTS and the form suffered by veterans is aggression. Nearly every individual with PTS experiences anger, but veterans are far more likely to develop patterns of aggressive, anti-social behavior. Some veterans exhibiting aggression as a PTS symptom will become openly hostile. However, the majority of hostile acts committed by veterans suffering from PTS are impulsive, not pre-meditated; they are irrational acts, not rational ones pursued with an actual objective in mind. And what is perhaps more important to acknowledge here is that PTS is treatable. With timely and appropriate treatment, evidence-based therapies yield a high rate of success.
PTS and Confinement
PTS is often aggravated by imprisonment. A veteran released after completing a sentence may be more of a risk leaving jail than he was at sentencing. Sentences tend to be short for veterans because in their pre-military civilian lives most had never been in trouble with the law, and their offenses are often not serious enough to warrant long periods in detention. But if they are suffering from PTS or another serious mental health condition brought on by military service, confinement instead of treatment creates the potential for repeat offenses. Delays in onset of treatment cause the condition to become more treatment-resistant as the symptomology is integrated into one’s character and self image. Early diagnoses and timely treatment yield the best results.