My second year psychiatric residency occurred at Letterman Army Hospital in San Francisco in 1968-1969. The Vietnam War was raging and so the injured soldiers were returning there and elsewhere for treatment both medical and psychiatric. The army’s basic attitude about emotional traumas was to treat traumatized soldiers as close to the front lines as possible and to return them to duty as quickly as possible with the hope/expectation that most of the soldiers would recover. If the soldiers in the front lines had an emotional decompensation, he was often given an intravenous drip of an antipsychotic medication and the person rested for two or three days, sedated, and then was returned to the front lines if possible. If not, the individual was then medevaced for more intensive treatment and if this did not permit a return to duty in Vietnam, the individual was sent to a hospital such as Letterman for more extensive inpatient treatment and either reassignment or medical discharge. My clinical experience at Letterman was with soldiers who were not so resilient that they were able to recover in a short period of time and instead needed more intensive treatment, sometimes medical discharge.
Treating such patients led me to wonder why some individuals who have exposure to horrific experiences are resilient whereas others are not. Most soldiers in front-line situations were being emotionally traumatized and feeling helpless at times, often greatly frightened, but it seemed that only a percentage of those soldiers were not able to handle the stress. On a related level, I also was consulting with soldiers who suffered major orthopedic injuries in warfare, often limb amputations, and I wondered about the same question, i.e., why were many of these soldiers not suffering from a Post-Traumatic Stress Disordersyndrome? In a manner of speaking, I had a built-in group of controls against which I could compare my PTSD psychiatric patients.
In almost all of the cases I examined, and this was not a statistical study, the common thread which ran through the explanations given by the orthopedic/non-PTSD patients was an attitude of resignation and release “to fate.” Before combat each of these soldiers assumed the attitude that either a bullet or grenade “had their name on it” or did not. When I asked one amputee why he was not continuing to have nightmares and other responses to his tragedy, his answer was “it just was not my time.” This seemed to sum up the defensive mechanism used by most of the soldiers I spoke with who only had orthopedic injuries. One may ask why I was speaking with them at all if they were not having any reactive problems. The reason is that certain of the orthopedists thought that given the extent of the injuries there might be something wrong with their patients, which they were not able to see. They wanted to make sure nothing emotional was going to interfere with recovery. I was the designated evaluator since I had been assigned to the orthopedic unit by my chief of psychiatry.
There were occasions when I did find PTSD in orthopedic patients, but in those cases, as with the PTSDpsychiatric cases in the psych ward, the soldiers had thought they were “different” and relatively invulnerable to injury. The common psychological defense mechanism used by these soldiers was denial. Either as a result of injury or as a result of overwhelming personal experiences, the denial defense broke down and the soldier was then flooded with an emotional overload leading to feelings of helplessness, vulnerability, and fear, which lead to the development of the collection of symptoms called Post-Traumatic Stress Disorder.
Recovery from the symptoms was helped by a medication. In those days the approach to the treatment of PTSD was catharsis, that is to say an emotional purging of the feelings about the events which would lead to relief. This treatment strategy unfortunately was often not successful. Subsequent clinical experience and investigation indicates that the better treatment strategy is to help the person repair their emotions by talking about the symptoms when they want to talk about them and not opening up the symptom complex if they are able to repress the symptoms. Reconciliation of trauma takes time and cannot be rushed with catharsis. If anything, the catharsis seems to keep the psychological wounds open and prevent the mind’s healing process to occur.
My conclusion was that when an individual is prepared for a catastrophic situation in advance and has “dealt with it” in an anticipatory way, then this person is much less likely to subsequently develop a Post-Traumatic Stress Disorder because he is not caught unaware. Conversely, if the danger of a situation is unrecognized or denied, then the individual is more likely to be blind-sided by a catastrophe and overwhelmed by it.
Neurosciences have looked more into emotional traumas in the recent past, particularly at the creation of long-term memories out of short-term memories. Epinephrine neuro receptors seem to be instrumental in the laying down of long-term memories. Theoretically, the immediate treatment of a person who has been traumatized with an epinephrine blocking medication such as Atenolol should diminish the person’s likelihood of laying down a permanent memory and the traumatic emotions associated with the traumatic event. Research about this is underway, but no final result has been obtained.
The SSRIs (Selective Serotonin Reuptake Inhibitors), particularly Zoloft and Prozac, have also been shown to be beneficial in the treatment of Post-Traumatic Stress Disorder as has Effexor. These medications seem to interrupt the ruminations that are characteristic of this condition. The effect of these drugs is incomplete, but often very helpful.