Treating Men In The Aftermath Of War: Posttraumatic Stress Disorder

Dr. Clyde Flanagan (left) and Dr. Eugene Kaplan Are intrigued by posttraumatic stress disorder in war. Special thanks to the Celebrate Freedom Foundation for the use of facilities in this photo.

There was no tank that afternoon in Vermont some thirty years ago. The noise was actually a bulldozer, the reaction by Dr. Kaplan a flashback to his military service in World War II. For a few moments in time he believed he was an infantryman back in Germany, surrounded by gunfire and imminent danger. While Dr. Kaplan’s flashback was an isolated incident, some men who return from combat suffer from flashbacks on a disturbingly regular basis. Life-after-war can also be plagued with irritability; outbursts of unprovoked anger; and struggles with anxiety, depression, or withdrawal that make it increasingly difficult to manage everyday life. Following the Vietnam War, these adjustment problems experienced by thousands of soldiers were formally recognized as posttraumatic stress disorder.

Dr. Clyde Flanagan, a professor of Neuropsychiatry and Behavioral Science, has a special interest in individuals with PTSD. Whether related to war or another destructive event, posttraumatic stress disorder occurs after a terrifying experience with a threat of death or serious injury. Coping with constant danger of loss of life in a battle situation can result in a sense of helplessness. Fear or rage become directed indiscriminately towards the person or situation that put the solider in this position. “In Vietnam it was hard to sort out who the enemy was. Ordinarily you wouldn’t want to think about shooting a woman, yet a Vietnamese woman could set off a grenade and kill you, so you had to be on guard,” Dr. Flanagan said.

Although PTSD wasn’t identified as such until the 1980’s, the psychiatric disorder wasn’t new to the men who fought the Vietcong. During Dr. Kaplan’s service in World War II, it was referred to as combat fatigue. In World War I, the term used was shell shock. Even as far back as the Civil War, soldiers returning from battle struggled with what they called “the blues.” Unfortunately the very strategies that help a soldier cope in a combat setting can create severe problems once he is back home. “He remains in a state of hyperarousal. While he is no longer being threatened, he may still behave as if he is, having an explosive outburst to a minor stimulus or even when not provoked,” Dr. Flanagan said. Individuals with PTSD can also have trouble concentrating, memory difficulties, nightmares, and feelings of detachment. Related anxiety and depressive disorders are not uncommon, along with alcohol and drug abuse.

Sometimes a simple sound, smell or other sensation can trigger a memory, hurling the solider back into combat mode, like Dr. Kaplan’s experience in Vermont. Over time, the veteran may start avoiding places or situations that served as triggers to these terrifying war experiences. “The world becomes a frightening place and he begins to stay in the place that seems relatively safe,” Dr. Kaplan said.

As troops head back to the United States from Iraq, psychiatrists are finding a new generation of soldiers struggling with PTSD. Dr. Flanagan noted that the conditions in Iraq present daily threats to U.S. military personnel. “Many of the enemy are not dressed as the enemy, and some of them are going to kill you or your buddies. This is a tremendous amount of daily, unremitting stress,” he said.

Treatment for PTSD has effectively used cognitive-behavioral therapy, focusing on intrusive thoughts and behavior patterns and teaching patients how to replace them.  Relaxation techniques and biofeedback are incorporated in the process, and medication can be used to help with depression and anxiety. In some cases, conscious or unconscious guilt is the source of a soldier’s depression and anxiety, and psychoanalytic psychotherapy is the appropriate treatment Group therapy sessions can provide a controlled setting for veterans to share their experiences, though Dr. Flanagan notes that, “Many men tend to not want to talk about what they have been through, except with other soldiers. Otherwise, they just don’t see any good in talking about it,” he said.

Goals for treatment are set on an individualized basis. “You look at how dysfunctional the patient is and what symptoms he is experiencing,” Dr. Flanagan said. After a thorough diagnostic assessment, a course of treatment is planned. While symptoms may not disappear completely, treatment can reduce their frequency of occurrence and degree of intensity, thus helping the patient manage better on a day-to-day basis. 

As Dr. Kaplan will attest some six decades after his combat duty in Europe, a soldier’s experiences remain with him throughout his life. “War leaves indelible imprints, and makes you think about death up front and close. It changed my perspective on life: You never know when it’s going to end. Make the best of it and the most of it,” he said.

Reprinted from Connections newsletter, October 2006.

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