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With the recent wars in Afghanistan and Iraq, once again America's men and women who have seen war close-up are suddenly expected to return seamlessly to civilian life. In Flashback, Penny Coleman tells the cautionary and timely story of posttraumatic stress disorder in the hope that we can sensitively assist those veterans who return from combat in need of help, and the families struggling to support them.
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Posttraumatic Stress Disorder, Suicide, and the Lessons of War
By Penny Coleman Beacon Press
Copyright © 2007 Penny Coleman
All right reserved.
FROM IRRITABLE HEART TO SHELL SHOCK
DURING THE AMERICAN CIVIL WAR, it was called "irritable heart" or "nostalgia." In the First World War, it became "shell shock," "hysteria," or "neurasthenia." During World War II and the war in Korea, it was "war neurosis," "battle fatigue," or simply "exhaustion." When veterans started coming home from Vietnam, it was at first called "Post-Vietnam syndrome." Then, in 1980, with the publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), "posttraumatic stress disorder" (PTSD) entered the official lexicon. The names have changed over time, but the phenomenon they describe has remained distressingly constant: war causes mental illness that is life-altering and, in far too many cases, fatal.
Bullets and bombs are destructive to human beings in fairly predictable and immediately apparent ways. Terror and horror work more mysteriously, but the psychic wounds they inflict are no less real or incapacitating. Such wounds are more difficult to see, to categorize, or to measure. They have been less well understood and so have been more vulnerableto prejudice and superstition. Jonathan Shay, who has written two of the most important books about combat-induced trauma, champions the idea that PTSD is a legitimate war wound and that the veterans who suffer its injury "[carry] the burdens of sacrifice for the rest of us as surely as the amputees, the burned, the blind, and the paralyzed carry them."
Over time, perhaps the most intractable prejudice has been that those who fall victim to the mental illness caused by war are somehow inherently weak in body or character. That belief has had, and continues to have, many adherents, in spite of evidence that some of the most famous and admired heroes of war, from Ulysses to Audie Murphy, have suffered from symptoms that meet the diagnostic criteria of PTSD. The parallel misconception, that a warrior's success is ensured if his body is strong and his character firm, has likewise plagued and inconvenienced military organizations. If such ideal warriors could be reliably identified, it would certainly make the maintenance of armies more straightforward and the subsequent cost of disability pensions less daunting. Not for lack of trying, no such correlation has been discovered. After 150 years of study, there are still no reliable predictors for who will be affected by their combat experience and under what circumstances. Once affected, there is still no cure. All that is really known is that war is a disease that affects the minds of many who get close to its horrors. The disease can be so painful and debilitating that those afflicted often lose their health, their sanity, their dreams, their families, and often their lives.
The most recent DSM, the fourth edition, published in 1994, describes the circumstances in which PTSD is likely to occur as "a traumatic event in which ... the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, [and] the person's response involved intense fear, helplessness, or horror."
That description pointedly includes traumatic situations that might occur in either civilian or military contexts. It reflects the priorities of the two groups most instrumental in agitating for the official recognition and inclusion of PTSD in the DSM-and perhaps most affected by that recognition. Those two groups were the returning Vietnam veterans and the resurgent or second-wave women's movement. The posttrauma symptoms experienced by veterans eerily mirrored those experienced by victims of sexual abuse. In the early '70s, the women's movement had made violent crimes against women a central issue of its activist agenda and, as veterans and women came to recognize the commonality of their cause, they joined forces to lobby for official recognition of the disease from the medical community. It is poignant to note that since the original inclusion of PTSD in the DSM-III in 1980, the criteria have changed. In the original, the traumatic event was described as falling "outside the range of usual human experience." That criterion was dropped in later editions. As Judith Herman so appropriately points out in Trauma and Recovery, "Rape, battery, and other forms of sexual and domestic violence are so common a part of women's lives that they can hardly be described as outside the range of ordinary experience. And in view of the number of people killed in war over the past century, military trauma, too, must be considered a common part of human experience; only the fortunate find it unusual."
The symptoms that are typically manifested following such a trauma can be divided into three clusters. The first, the intrusive cluster, includes recurrent, uncontrollable recollections of the traumatic event, such as frightening dreams or flashbacks. Those flashbacks are often so convincingly "real" that the sufferer behaves as though he or she were actually in the remembered moment. The experience can be both terrifying and dangerous, not just for the one who experiences the intrusion, but for anyone else who happens to be present. The second, the avoidance cluster, includes attempts to avoid circumstances that might trigger such recollections or flashbacks. To that end, many sufferers withdraw from social contact. They experience a protective emotional numbing and a restricted range of emotions that suck the joy from life and the vitality from relationships. The third, or hyper-arousal cluster, involves difficulty sleeping, violent outbursts, and an exaggerated startle response. Individuals affected by this set of symptoms act as though they were still in immediate danger, leading to inappropriate, socially unacceptable behaviors. To officially fall within the diagnostic guidelines, the symptoms must last for at least a month. A duration of less than three months is considered "acute," three months or more is considered "chronic," and "delayed" refers to an onset of symptoms at least six months after the traumatic experience.
THE EARLY HISTORY OF PTSD
Official recognition of PTSD may be relatively new, but the history of combat-related distress is an old one. Jonathan Shay is both a psychiatrist who treats Vietnam combat veterans and a classics scholar. He believes that Achilles, as described in The Iliad, would almost certainly be diagnosed as having PTSD today. In his book Achilles in Vietnam, Shay parallels the behaviors and symptoms of the Greek hero in Homer's 2,700-year-old story with those of American veterans of the war in Vietnam, and finds them to be strikingly similar. The vulnerability of Achilles' heel is a symbol for the vulnerability of his mind. His grief and rage at the death of his friend Patroclus, and his sense of betrayal at the hands of his commander, Agamemnon, are such that he suffers a breakdown and has to be restrained so he cannot harm himself. He then directs his pain outward, committing atrocities against the living and the dead until the gods and even the ghost of Patroclus are appalled and intervene.
Agamemnon's betrayal of Achilles may seem tame to a modern audience, when compared to the systemic leadership betrayals suffered by American soldiers who fought in Vietnam, but it is from that betrayal, Shay argues, that "the catastrophic operational failure that the Greek army suffered in the first fifteen books of the Iliad" directly flowed. And, he adds, it was that betrayal from leadership, coupled with the death of Patroclus, that was responsible for Achilles' personal collapse. Shay uses the term themis, a word he translates from the Greek as "what's right" to describe the "trustworthy structure" that should characterize a soldier's relationships within the military. The horizontal, or peer, relationships, the vertical relationships along the chain of command, and the personal relationships that soldiers have with their branch of the service all must be grounded in the belief that they have been appropriately trained and supplied. In the absence of such a trustworthy structure, soldiers are exposed to the combination of moral grievance and combat stress. Shay believes it is that combination that is central to lasting psychological injury. "Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as 'what's right' has not been violated."
PTSD AND THE AMERICAN CIVIL WAR
George Washington's Continental Army, which became the U.S. Army, was plagued with mental health disorders that are recognizably similar to those seen today. Labels of "melancholia" and "insanity" were loosely applied to the most extreme cases, the psychoses, the paralyses, or to those who suffered from invasive flashbacks. "Nostalgia" referred to chronic situational depressions, which were thought to stem primarily from homesickness. "Drunkenness," according to Joseph Lovell (surgeon general, 1817-1828), was responsible for half of the deaths in the U.S. Army during the period of his tenure. Lovell was a temperance advocate who succeeded in abolishing the daily rum ration, which probably makes him a questionable primary source, but it does seem likely that some of the excess consumption, not unlike the self-medication so frequently noted among today's vets, was an attempt to keep demons at bay.
The psychic distress of soldiers was a serious but relatively uncomplicated issue for nineteenth-century commanders. During the years of the American Civil War, it was assumed by commanders on both sides that men of strength and character would maintain a "manly" attitude in battle. There was little sympathy in either army for those who did not. Both armies made discharge for psychiatric complaints virtually impossible. If a soldier was beyond masking his traumatic symptoms, he had few options. If he tried to desert and was caught, his comrades would be forced to stand at attention to witness his execution. He would be buried where he fell, and the ground smoothed over his unmarked grave to symbolically erase his existence. He otherwise might apply for a psychiatric discharge and, in some cases, a sympathetic commanding officer would reassign him to light duty. But in applying for relief, he risked calling attention to his distress. If his application was rejected and he could not manage to mask his symptoms, he would be officially labeled a coward or a malingerer. The penalty for cowardice or malingering was the same as that for desertion. He might just as well have run off in the first place. Executions were intended both to eliminate the contagion of weakness and to terrify the ranks into obedience. Such severe consequences must have discouraged many from seeking help. They certainly encouraged many others to resort to flight.
At the outset, the social and economic issues over which the war was fought had inspired passion on both sides. Romantic notions of heroism, glory, and honor fed a short-lived frenzy of voluntarism in both the North and the South. By 1862, however, as word of battlefield carnage, rampant disease, and intense hardships became known, the enthusiastic rush to enlist was seriously slowed. The Confederate army was forced to pass a draft law in 1862. The Union followed suit the next year. The laws were unpopular, unwieldy, and patently unfair. They exempted most professionals, and included commutation and substitution clauses, which allowed a draftee to buy his way out of service altogether or pay to send someone else in his place. Pundits North and South began calling it "a rich man's war and a poor man's fight." Shay would have called it a betrayal of what's right. The injustice of the draft provoked draft riots in several cities, most notably in New York.
Whether drafted or enlisted, though, the soldiers who fought for the North or for the South were certainly exposed to "events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others," and there was adequate cause for a response that "involved intense fear, helplessness, or horror." It is impossible to know how many of the almost 400,000 deserters (about 10 percent of both armies) were running from personal demons, but it was the only recourse, short of execution or suicide, available to those most acutely afflicted.
Against that background, Dr. Jacob Mendes DaCosta is credited with conducting the first scientific study of combat-related stress. He called the array of symptoms he identified "the irritable heart of a soldier" because so many of his patients complained of shortness of breath, palpitations, anxiety, and chest pain. But generally, soldiers' complaints varied widely, and so did the diagnoses. William Hammond, who was Lincoln's surgeon general, appropriately called the state of nineteenth-century American medicine "the end of the medical Middle Ages." Unlike their European counterparts, who were becoming familiar with the work of Koch and Pasteur, and who were adopting scientific methodologies to investigate disease, American doctors who served in both armies had virtually no practical training or clinical experience. Their understanding of a soldier's symptoms was therefore based largely on superstition, custom, and a good measure of imagination and the supernatural. What DaCosta diagnosed as irritable heart, another doctor might have called insanity or sunstroke. "Nostalgia," which was a popular diagnostic category at the beginning of the war, implied a weakness of character neither army chose to indulge. After the early years, the diagnosis was firmly discouraged: 5,200 soldiers were hospitalized with "nostalgia" before 1853, but between 1853 and 1865 not a single case was reported. There were, however, 145,000 hospitalizations for constipation, 66,000 for headache, and 58,000 for neuralgia.
The title of Eric Dean's book about the traumatic effects of combat on American Civil War veterans, Shook over Hell, is taken from the medical records of one Jason Roberts, a Union soldier who used this expression when describing his symptoms to doctors. Doctors described Roberts as "sometimes ... raving and excited, at others melancholy.... Very peculiar and eccentric, flying from one Subject to another, and talking incoherently on all Subjects.... The subject of religion and his experiences in the army being paramount in his mind." The core of Dean's book is an analysis of the case histories of 291 Civil War veterans who, between 1861 and 1920, were committed to the Indiana Hospital for the Insane. Using medical records, letters, memoirs, newspaper articles, and pension files, Dean concludes that, whatever nineteenth-century doctors chose to call it, these inmates all suffered from symptoms that would today be diagnosed as PTSD. "Many of these men," Dean writes, "continued to suffer from the aftereffects of the war and, along with their families, often lived in a kind of private hell involving physical pain, the torment of fear, and memories of killing and death."
A tradition of support for disabled veterans dates back to the original colonies. The laws of the Plymouth Colony in 1636 promised soldiers that "if any that shall goe returne maymed [and] hurt he shalbe mayntayned competently by the Colony duringe his life." In 1776, the Continental Congress pensioned veterans who had been disabled in the Revolution. After the Civil War, however, activist veterans organized and lobbied for a pension system that would cover not only those who had been disabled, but all Union Army veterans and their dependents. (Veterans of the Confederate army were not eligible for any federal benefits and had to rely on relatively modest state entitlement programs.) By 1891, fully one-third of the federal budget went to military pensions, and eventually, more money was paid out in pensions than the $8 billion spent on prosecuting the war itself.
Excerpted from Flashback by Penny Coleman Copyright © 2007 by Penny Coleman. Excerpted by permission.
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What People are Saying About This
This book is long overdue and should be mandatory reading for all those who have seen combat, including in Iraq, and for those who love them and live with them.—Margaret Ferguson, national board chair of the Gold Star Wives of America
"A tautly argued study…Coleman chillingly reveals the hidden cost of war. Further, with force and conviction, she shows how the U.S. military has systematically denied and cynically managed the psychic impact of war on its soldiers . . . [Flashback] will surely generate further attention to a sadly timely subject." —Publishers Weekly
"Well-crafted, insightful…With this book, an important subject is hidden no longer."—Marc Leepson, The VVA Veteran
"Flashback is a remarkable combination of painful experience and thoughtful interpretation. The descriptions of suicides of Vietnam veterans by women who loved them, together with a wide-ranging exploration of war and trauma, provide a new and original perspective on Vietnam. Coleman concludes with a moving plea that 'we accept the truth that war itself is an illness that sickens our society as surely and in much the same way as it sickens our citizens and our soldiers.' Few authors have done more to confront that sickness as a step toward cure."—Dr. Robert Jay Lifton, author of Home from the War
"A well-researched and well-documented publication with a uniquely human touch." —Library Journal, starred review