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Chronic Vietnam PTSD and acute civilian PTSD a comparison of treatment experiences
Chronic Vietnam PTSD and Acute Civilian PTSD A Comparison of Treatment Experiences Allan Burstein, M.D., Patrick E. Ciccone, M.D., Robert A. Greenstein, M.D., Neal Daniels, Ph.D., Katherine Olsen, MSN, R.N., C.S., Anthony Mazarek, M.D., Randolph Decatur, M.H.T., and Norman Johnson, ACSW Abstract: Many types of external trauma have been linked to the genesis of posttraumatic stress disorder (PTSD) and yet recent reports have focused almost exclusively on PTSD occurring in the Vietnam veteran (PTSDlveteran). The extent to which treatment experiences with PTSDlveteran can be generalized to other traumatized patients, for example, acute civilian populations, has not been investigated. Clinical observations comparing PTSD precipitated by a motor vehicle accident with PTSDlveteran suggested there were major differences between these two groups on the following variables: source of referral, age, sex, socioeconomic level, nature of stressor, timing of the stressor, character of the intrusive and avoidance symptoms, and treatment noncompliance behavior. These differences were of sufficient magnitude to call into question the feasibility, at this time, of constructing generalizations regarding PTSD utilizing only the PTSDlveteran population.
Since the Vietnam War, there has been renewed interest in post traumatic stress disorder (PTSD) as manifested by Vietnam veterans (PTSD/veteran). For many clinicians their only exposure to PTSD is through the military-related PTSD literature [ 11. Despite a paucity of data, chronic PTSD/veteran has been synonymous with PTSD in general. Understanding the relationship between the chronic M’SD/veteran and acute PTSD becomes urgent when one realizes that the PTSD/veteran population is finite and aging. Combat in Vietnam ceased in 1973, so that at least 14 years, often more, have From the Department of Psychiatry, University of Pennsylvania (P. E. C.; R. A. G.) and the Psychiatry Service (R. A. G.) andMentalHygieneClinic(P. E. C.;N. D.;K. O.;A. M.;R. D.; N. J.), Veterans Administration Medical Center, Philadelphia, Pennsylvania. Address reprint requests to: Dr. Allan Burstein, 505 Stillwells Corner Road, Freehold, NJ 07728.
passed since the conclusion of the trauma and the onset of symptoms. Establishing formal multicentered academic units, securing grant monies, and assembling research teams can take years. By then, this veteran group will be appreciably older, more chronic and facing different life tasks. It is estimated that as many as 550,000 individuals yearly experience an acute PTSD precipitated by a motor accident. [Burstein, A: Posttraumatic stress disorder in motor vehicle accident victims (M’SD/mva). Submitted for publication]. One of the authors (A. B.) has performed published research based upon the evaluation and treatment of over 70 such patients (DSM-III criteria) in a private practice setting [2]. Over a several-month period, he participated in a Veterans Administration MSD Clinic evaluation and treatment program. This program, which has been in existence for 6 years, is located in a large urban setting and maintains a MSD census of more than 150 veterans. In order to be admitted to the treatment program, patients must meet DSM-III criteria for PTSD. The clinic is staffed by two psychiatrists, a psychologist, social worker, nurse practitioner, and mental health technician. Clinical work and discussions with the staff led to the observation that there were striking differences between the PTSD/mva and PTSD /veteran patients, including demographics, symptomatology, and treatment behavior. The differences observed were pervasive and of sufficient magnitude to call into question the feasibility of constructing generalizations regarding PTSD utilizing the PTSD/veteran population. Because a formal study regarding a comparison
GeneralHospital Psychiaty 10, 245-249,
1988 0 1988 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017
245 ISSN 0163~8.343/88/$3.50
A. Burstein et al.
of the two groups would take years and ultimately lead to the study of an older, different PTSD/veteran group, we decided to report our observations now. The following presentation will consist of two case reports, each deemed representative by the clinicians of the PTSD population from which they are drawn. The case reports, in addition to familiarizing the reader with the two different MSD forms, will serve as a basis for a discussion comparing the groups. For discussion purposes, three categories will be established: (1) clear differences, (2) possible differences, and (3) similarities. Although the similarities noted are not major observations, they supplement the criteria included in the DSM-III diagnostic category. Published formal studies that are supportive of the clinicians’ impressions have been included as references in the discussion.
Case 1 Mr. A is a 40-year-old bus driver who has been seen at the VA clinic intermittently for several years. The patient was involved in combat during his 1967-1968 experience in Vietnam. It appears that he first began to experience posttrauma symptoms at that time. Currently he is experiencing the following major symptoms: forced thoughts of his war experience, images of Vietnam battles, dream disturbances, sleep disturbances, and an exaggerated startle reaction. For years he has felt as if he were drifting in and out of Vietnam. During these periods, he felt as though he were back in Vietnam, and, as a consequence, he pursued Vietnam-related activities. He continues to be very worried about intruders in his home, but keeps no weapons in the house for fear he might use them. Temper outbursts are frequent. He avoids activity outside of his home or place of employment for fear of becoming “upset” and losing control. Occasionally he becomes tearful but does not seem to be clinically depressed or suicidal. He remains guilty about his activities in Vietnam, which involved killing a number of enemy soldiers and civilians who were assisting them. Alcohol abuse has been common since his discharge and he currently reports periodic cannabis use. The patient has a high school equivalency diploma. Prior to his army experience, his history is unremarkable. Since discharge from the service, he has had two failed marriages but has been able to sustain his current relationship for 7 years. There have been lengthy periods of unemployment during the past 15 years, but he has been functioning well as a bus driver for 4 years.
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Mr. A usually attends the clinic when he is in crisis. During these times, he receives psychotropic medication (tricyclic antidepressant) and psychotherapy. After a several-month period, he stabilizes and drops out, only to return during the next crisis.
Case 2 Mrs. B is a 40-year-old mother of four and housewife who was referred by her orthopedic surgeon. Three months prior to the initial psychiatric interview she was involved in a motor vehicle accident. She reported that within 24 hours of the accident she began to experience a variety of sleep and dream disturbances and repetitive thoughts and images of the accident. During the following 3 months posttrauma, she experienced two episodes of revisualizations. After seeing cars reminescent of the one that struck her, she had brief (less than a few seconds) visualizations of lifelike intensity of the accident. Driving was impossible for her during these initial months. Her anxiety became overwhelming when in a car. Even as a passenger, she misjudged the cars driving around her and continually acted as if her car were about to collide with them. She withdrew from her husband and family. After initially being sympathetic, her family became frustrated and irritated with her. They often teased her about her behavior in a car. The patient was unable to explain her symptoms to them or herself. Mrs. B’s past history was unremarkable. She graduated from high school and, at the age of 18, married her husband. Since then, she lived in a pleasant suburb, caring for her children, while her husband pursued his successful career as the owner of a small real estate firm. Upon entering treatment, she was placed on a tricyclic antidepressant. Her PTSD-anxiety related symptoms decreased. With encouragement, she was able to drive her car limited distances. During the next 3-4 years of treatment, exacerbations and remissions, in response to intercurrent stressors, were frequent. These stressors were either related to her motor vehicle accident or family tensions. Four years after treatment began, she remains on medication and continues to experience exacerbations of symptoms. Themes during sessions deal with problems coping with her increased volatility. The accident, even with encouragement, is not discussed. She is able to drive longer distances, but not with the calm and efficiency that existed prior to her motor vehicle accident. Family-related stress persists, but with decreased intensity.
Chronic Vietnam M’SD
Discussion Clear Differences 1. Almost all of the patients seeking treatment at
2.
3.
4.
5.
6.
the clinic were self-referred, whereas all the PTSD/mva patients were referred by physicians, usually within the first 6 months posttrauma [2]. The clinic population is all male whereas the majority of PTSD/mva patients seeking treatment are women [2]. As with many veterans seen at the clinic, Mr. A would be considered to belong to Class IV (semi-skilled factory workers with high school education) in the Hollingshead-Redlich Scale [3]. Like Mrs. B, almost all of the PTSD/mva patients would belong to Class III (small proprietors, white-collar office workers, with high school education). This difference in socioeconomic status involves more than a clinic-private Tractice difference. The Vietnam War, for many years, was fought by individuals drawn from lower socioeconomic levels. The Veterans Administration’s delay in recognizing PTSD problems in the returning veterans has been well-noted in the literature [4]. In recent years, much has been done by the VA and the media to increase the veterans’ and the public’s awareness of the problems of the PTSD/veteran. At their initial interviews, most of the veterans had some awareness of PTSD. However, the PTSD/mva patients rarely have any knowledge of PTSD and often have trouble relating their problems to their accident. The PTSD/veteran group experienced a lengthy period of combat that involved physical deprivation, multiple losses, and physical trauma. Their experiences occurred during their adolescence or early adulthood. The PTSD/mva patients experienced one brief moment of trauma at varying ages. The ages of patients in the M’SDlmva group ranged from 16 through 72. In terms of intrusive symptoms, PTSD/veteran imagery involves war-related violence and is grotesque. As such, it is more disturbing to the patient and the therapist than that occurring in the M’SD/mva patient. Among PTSDlmva patients, reexperiencing events are typified by illusions in which cars seem closer than they are in reality. Consequently, patients feel that cars in which they are traveling are frequently on the verge of colliding. To a much lesser extent, PTSD/mva patients
report hallucinatory experiences or revisualization in which they see the original traumatic collision occurring with lifelike intensity before them. Such experiences are brief (less than 1 minute) and usually require an anxiety provoking trigger (a thought or reminder). The reexperiencing events, then, are focused around the driving situation and may interfere with the ability of the patient to drive efficiently. Reexperiencing events among PTSD/veterans range from recurrent intrusive thoughts or dreams to more intensive experiences typified by dissociative episodes. During these episodes the patients feel as though they are in Vietnam. They may act upon this feeling and recreate a Vietnam scenario. During these periods they are not aware of their current circumstances. Such episodes can last for only minutes or can be hours in duration. Patients report such episodes with minimal provocative stimuli. Such dissociative episodes are not reported by PTSD/mva patients. 7. Avoidance behaviors can occur on two levels: general or specific. On a general level both groups will avoid any situation that might arouse overwhelming emotions. On a specific level, the PTSD/veteran will avoid situations that remind him of Vietnam. Such reminders are varied in type and number and can be quite subtle. For example, the patient may cross the street to avoid a man of Asian ethnicity coming toward him. For the PTSD/mva, specific avoidance behavior is focused on the driving situation and is quite intense. The patient may refuse to enter a car or drive more than a few miles from home. 8. The overwhelming majority of patients in both groups received treatment consisting of a combination of medication (usually a tricyclic antidepressant) [5,6] and psychotherapy. In psychotherapy, the veterans can be encouraged to relate their combat experiences whereas PTSD/mva patients will usually not discuss the trauma. Indeed, they repeat that they have nothing to discuss. It should be noted that the veterans struggled with their PTSD symptoms for many years and, by the time they finally entered treatment, many were relieved to share their combat related experiences with an emphatic therapist. “Cures” in the PTSD/veteran group were, at best, a rare occurrence. However, a substantial
247
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proportion of the PTSD/mva patients will terminate treatment, asymptomatic, within 4 months posttrauma [7]. Of the remaining group, a small proportion will terminate within 1-2 years posttrauma, either asymptomatic or with symptom distress at a tolerable level. Follow-up observations for those, like Mrs. B, who have been in treatment for 2 years or longer are not yet available. At present, these patients continue to experience active posttrauma symptoms. 9. The noncompliance phenomenon was significantly different in both groups. Among the MSDlveteran group, a substantial number dropped out before the third professional contact. Among those remaining, a substantial proportion used the clinic only during periods of crisis. Among the I’TSD/mva patients, noncompliance was clearly related to the passage of time since the trauma. In one formal study [3] dealing with an acute MSD population, the majority of whom were PTSD/mva patients, the dropout rate for those entering treatment during the first 9 weeks posttrauma was 26.9%. The dropout rate increased over time so that 81.8% of those entering treatment during the 40th week posttrauma and beyond dropped out.
Possible Differences The PTSD/veteran group was more likely to report a delayed onset of symptoms [8]. Such a latency period could last for years. Among the PTSD/mva patients, a delayed onset was rare and, even then, the latency period was several months duration [9]. These observations are similar to the formal findings of a recent epidemiologic study in which reports of delayed onset PTSD were found among Vietnam combat soldiers but not among civilian PTSD participants [lo]. The coexistence of alcohol/substance abuse, major affective disorder, and violent thoughts and behavior have been reported in the FED/veteran literature [11,12] and applies to our MSD/veteran group. However, such behavior has been found in non-PTSD veterans, calling into question the specificity of these findings [13,14]. In addition, a small subgroup of patients exhibited both schizophrenic and PTSD symptoms. This is a phenomenon not examined in the literature. 248
Such coexisting problems were not found in the PTSD/mva group. Mild depressive symptoms were evident in the MSD/mva group and appeared after a prolonged period of PTSD-related impairments in the work and social spheres. Problems related to cerebral concussions, usually mild, were quite prevalent [2]. 3. PTSD/veteran patients often reported periods of unemployment and frequent job changes since their discharge from the service. Similarly, a history of one or more divorces was common. However, again, these problems also have been reported in non-FED veterans [13]. By comparison, PTSD/mva patients reported stable work and marital histories. Once the PTSD process began, their ability to perform in both areas was impaired, with secondary problems developing at that time.
Similarities In addition to meeting DSM-III criteria, a striking clinical similarity between these two groups was their inability to tolerate reasonable levels of stress. Such stressors involve the expectable difficulties of daily living as well as direct reminders of the trauma. This stress intolerance manifests itself as affective instability that often overwhelms the individual. It is this precipitate that leads many of the PTSD/veterans to seek assistance. Similarly, affective instability is often the ongoing focus of the treatment for the PTSD/mva patients. Both groups of patients were eligible for financial compensation. The structure of the compensation process is substantially different for each group. VA clinic staff members felt that, at this point, malingering was not a significant phenomenon among those PTSD/veteran patients who entered treatment. Similarly, malingering was not noted among PTSD/mva patients [15].
Conclusion In conclusion, clear differences in the treatment experiences involving PSTD/veteran and PSTD/mva patients were clinically evident in the following areas: source of referral, age, sex, socioeconomic level, nature and timing of stressor, character of intrusive and avoidance symptoms, and noncompliance behavior. Possible differences
Chronic Vietnam PTSD
were noted in the areas of aggressivity, concurrent psychiatric entities, and work and marital histories. The etiologic, phenomenologic, and treatment implications of differences in these variables and the ways in which they might interact have not been studied. We conclude that any generalizations made from chronic PTSD/veteran to acute PTSD/mva patients must be cautiously made and highly focused. This article has dealt only with the limitations involved in generalizing from PTSD/veteran to PTSD/mva. However, there are other major groups of PTSD. For example, 1,467,531 Americans were victims of violent crimes (rapes, assaults, robberies) in 1986 (161. As many as 44,026 (3%) may have experienced a subsequent acute PTSD [lo]. One suspects that any generalizations from chronic PTSD/veterans to any of these other PTSD groups would also have to be made carefully. With this major cautionary note in mind, two similarities between both groups are worth repeating. Affective instability, that is, the inability to tolerate stress from any source, was seen in both groups and warrants further investigation. Secondly, both groups experienced similar treatment approaches, with partial responses occurring in both cases. Despite the multitude of differences between these two groups, there is the clear potential for a lengthy, disabling illness even with available treatment in both instances. This study is clearly impressionistic, although attempts were made to reach group consensus through repeated discussions, joint interviews, and review of the manuscript. Indeed, some of the observations have been reported in the literature in other ways and from other sources. More formal studies are clearly warranted but, as stated in the introduction, may not be feasible.
References 1. Burstein A: Posttraumatic stress disorder in general hospital psychiatric consultations. (Letter). Am J Psychiatr 141:722-723, 1984 2. Burstein A: Treatment non-compliance in patients with posttraumatic stress disorder. Psychosomatics 27:37-40, 1986 3. Hollingshead AB, Redlich PC: Social stratification and psychiatric disorders. In Proshansky, H, Seidenberg, B (eds), Basic Studies in Social Psychology. New York, Holt Rinehart, and Winston, 1966, p 368 4. Figley CR: Introduction. In Figley CR (ed), Stress Disorders among Vietnam Veterans. New York, BrunnerlMazel, 1978 5. Burstein A: Treatment of posttraumatic stress disorder with imipramine. Psychosomatics 25:683-687, 1984 6. Falcon S, Ryan C, Chamberlaink, et al: Tricyclics: Possible treatment for posttraumatic stress disorder. J Clin Psychiatry 46:385-388, 1985 7. Burstein A: Treatment length in posttraumatic stress disorder. Psychosomatics 27:632-636, 1986 8. Horowitz MJ, Solomon GF: Delayed stress response syndromes in Vietnam veterans. In Figley CR (ed), Stress Disorders Among Vietnam Veterans. New York, BrunnerlMazel, 1978 9. Burstein A: How common is delayed posttraumatic stress disorder? Am J Psychiatry 142:887, 1985 10. Helzer JE, Robins LN, McEvoy L: Post-traumatic stress disorder in the general population. N Engl J Med 317:1630-1634, 1987 11. Sierles FS, Chen JJ, McFarland RE, et al: Posttraumatic stress disorder and concurrent psychiatric illness: A preliminary report. Am J Psychiatry 140:1177-1179, 1983 12. Atkinson RM, Sparr LF, Sheff AG, et al: Diagnosis of posttraumatic stress disorder in Vietnam veterans: Preliminary findings. Am J Psychiatry 141:694-696, 1984 13. Boman B: Combat stress, posttraumatic stress disorder and associated psychiatric disturbance. Psychosomatics 27:567-573, 1986 14. Sparr LF, Atkinson RM: Posttraumatic stress disorder as an insanity defense: Medico-legal quicksand. Am J Psychiatry 143:608-612, 1986 15. Burstein A. Can monetary compensation influence the course of a disorder? Am J Psychiatry 143:112, 1986 16. Uniform Crime Reports: Crime in the United States. Washington, D.C., U.S. Government Printing Office, 1987
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Since the Vietnam War, there has been renewed interest in post traumatic stress disorder (PTSD) as manifested by Vietnam veterans (PTSD/veteran). For many clinicians their only exposure to PTSD is through the military-related PTSD literature [ 11. Despite a paucity of data, chronic PTSD/veteran has been synonymous with PTSD in general. Understanding the relationship between the chronic M’SD/veteran and acute PTSD becomes urgent when one realizes that the PTSD/veteran population is finite and aging. Combat in Vietnam ceased in 1973, so that at least 14 years, often more, have From the Department of Psychiatry, University of Pennsylvania (P. E. C.; R. A. G.) and the Psychiatry Service (R. A. G.) andMentalHygieneClinic(P. E. C.;N. D.;K. O.;A. M.;R. D.; N. J.), Veterans Administration Medical Center, Philadelphia, Pennsylvania. Address reprint requests to: Dr. Allan Burstein, 505 Stillwells Corner Road, Freehold, NJ 07728.
passed since the conclusion of the trauma and the onset of symptoms. Establishing formal multicentered academic units, securing grant monies, and assembling research teams can take years. By then, this veteran group will be appreciably older, more chronic and facing different life tasks. It is estimated that as many as 550,000 individuals yearly experience an acute PTSD precipitated by a motor accident. [Burstein, A: Posttraumatic stress disorder in motor vehicle accident victims (M’SD/mva). Submitted for publication]. One of the authors (A. B.) has performed published research based upon the evaluation and treatment of over 70 such patients (DSM-III criteria) in a private practice setting [2]. Over a several-month period, he participated in a Veterans Administration MSD Clinic evaluation and treatment program. This program, which has been in existence for 6 years, is located in a large urban setting and maintains a MSD census of more than 150 veterans. In order to be admitted to the treatment program, patients must meet DSM-III criteria for PTSD. The clinic is staffed by two psychiatrists, a psychologist, social worker, nurse practitioner, and mental health technician. Clinical work and discussions with the staff led to the observation that there were striking differences between the PTSD/mva and PTSD /veteran patients, including demographics, symptomatology, and treatment behavior. The differences observed were pervasive and of sufficient magnitude to call into question the feasibility of constructing generalizations regarding PTSD utilizing the PTSD/veteran population. Because a formal study regarding a comparison
GeneralHospital Psychiaty 10, 245-249,
1988 0 1988 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017
245 ISSN 0163~8.343/88/$3.50
A. Burstein et al.
of the two groups would take years and ultimately lead to the study of an older, different PTSD/veteran group, we decided to report our observations now. The following presentation will consist of two case reports, each deemed representative by the clinicians of the PTSD population from which they are drawn. The case reports, in addition to familiarizing the reader with the two different MSD forms, will serve as a basis for a discussion comparing the groups. For discussion purposes, three categories will be established: (1) clear differences, (2) possible differences, and (3) similarities. Although the similarities noted are not major observations, they supplement the criteria included in the DSM-III diagnostic category. Published formal studies that are supportive of the clinicians’ impressions have been included as references in the discussion.
Case 1 Mr. A is a 40-year-old bus driver who has been seen at the VA clinic intermittently for several years. The patient was involved in combat during his 1967-1968 experience in Vietnam. It appears that he first began to experience posttrauma symptoms at that time. Currently he is experiencing the following major symptoms: forced thoughts of his war experience, images of Vietnam battles, dream disturbances, sleep disturbances, and an exaggerated startle reaction. For years he has felt as if he were drifting in and out of Vietnam. During these periods, he felt as though he were back in Vietnam, and, as a consequence, he pursued Vietnam-related activities. He continues to be very worried about intruders in his home, but keeps no weapons in the house for fear he might use them. Temper outbursts are frequent. He avoids activity outside of his home or place of employment for fear of becoming “upset” and losing control. Occasionally he becomes tearful but does not seem to be clinically depressed or suicidal. He remains guilty about his activities in Vietnam, which involved killing a number of enemy soldiers and civilians who were assisting them. Alcohol abuse has been common since his discharge and he currently reports periodic cannabis use. The patient has a high school equivalency diploma. Prior to his army experience, his history is unremarkable. Since discharge from the service, he has had two failed marriages but has been able to sustain his current relationship for 7 years. There have been lengthy periods of unemployment during the past 15 years, but he has been functioning well as a bus driver for 4 years.
246
Mr. A usually attends the clinic when he is in crisis. During these times, he receives psychotropic medication (tricyclic antidepressant) and psychotherapy. After a several-month period, he stabilizes and drops out, only to return during the next crisis.
Case 2 Mrs. B is a 40-year-old mother of four and housewife who was referred by her orthopedic surgeon. Three months prior to the initial psychiatric interview she was involved in a motor vehicle accident. She reported that within 24 hours of the accident she began to experience a variety of sleep and dream disturbances and repetitive thoughts and images of the accident. During the following 3 months posttrauma, she experienced two episodes of revisualizations. After seeing cars reminescent of the one that struck her, she had brief (less than a few seconds) visualizations of lifelike intensity of the accident. Driving was impossible for her during these initial months. Her anxiety became overwhelming when in a car. Even as a passenger, she misjudged the cars driving around her and continually acted as if her car were about to collide with them. She withdrew from her husband and family. After initially being sympathetic, her family became frustrated and irritated with her. They often teased her about her behavior in a car. The patient was unable to explain her symptoms to them or herself. Mrs. B’s past history was unremarkable. She graduated from high school and, at the age of 18, married her husband. Since then, she lived in a pleasant suburb, caring for her children, while her husband pursued his successful career as the owner of a small real estate firm. Upon entering treatment, she was placed on a tricyclic antidepressant. Her PTSD-anxiety related symptoms decreased. With encouragement, she was able to drive her car limited distances. During the next 3-4 years of treatment, exacerbations and remissions, in response to intercurrent stressors, were frequent. These stressors were either related to her motor vehicle accident or family tensions. Four years after treatment began, she remains on medication and continues to experience exacerbations of symptoms. Themes during sessions deal with problems coping with her increased volatility. The accident, even with encouragement, is not discussed. She is able to drive longer distances, but not with the calm and efficiency that existed prior to her motor vehicle accident. Family-related stress persists, but with decreased intensity.
Chronic Vietnam M’SD
Discussion Clear Differences 1. Almost all of the patients seeking treatment at
2.
3.
4.
5.
6.
the clinic were self-referred, whereas all the PTSD/mva patients were referred by physicians, usually within the first 6 months posttrauma [2]. The clinic population is all male whereas the majority of PTSD/mva patients seeking treatment are women [2]. As with many veterans seen at the clinic, Mr. A would be considered to belong to Class IV (semi-skilled factory workers with high school education) in the Hollingshead-Redlich Scale [3]. Like Mrs. B, almost all of the PTSD/mva patients would belong to Class III (small proprietors, white-collar office workers, with high school education). This difference in socioeconomic status involves more than a clinic-private Tractice difference. The Vietnam War, for many years, was fought by individuals drawn from lower socioeconomic levels. The Veterans Administration’s delay in recognizing PTSD problems in the returning veterans has been well-noted in the literature [4]. In recent years, much has been done by the VA and the media to increase the veterans’ and the public’s awareness of the problems of the PTSD/veteran. At their initial interviews, most of the veterans had some awareness of PTSD. However, the PTSD/mva patients rarely have any knowledge of PTSD and often have trouble relating their problems to their accident. The PTSD/veteran group experienced a lengthy period of combat that involved physical deprivation, multiple losses, and physical trauma. Their experiences occurred during their adolescence or early adulthood. The PTSD/mva patients experienced one brief moment of trauma at varying ages. The ages of patients in the M’SDlmva group ranged from 16 through 72. In terms of intrusive symptoms, PTSD/veteran imagery involves war-related violence and is grotesque. As such, it is more disturbing to the patient and the therapist than that occurring in the M’SD/mva patient. Among PTSDlmva patients, reexperiencing events are typified by illusions in which cars seem closer than they are in reality. Consequently, patients feel that cars in which they are traveling are frequently on the verge of colliding. To a much lesser extent, PTSD/mva patients
report hallucinatory experiences or revisualization in which they see the original traumatic collision occurring with lifelike intensity before them. Such experiences are brief (less than 1 minute) and usually require an anxiety provoking trigger (a thought or reminder). The reexperiencing events, then, are focused around the driving situation and may interfere with the ability of the patient to drive efficiently. Reexperiencing events among PTSD/veterans range from recurrent intrusive thoughts or dreams to more intensive experiences typified by dissociative episodes. During these episodes the patients feel as though they are in Vietnam. They may act upon this feeling and recreate a Vietnam scenario. During these periods they are not aware of their current circumstances. Such episodes can last for only minutes or can be hours in duration. Patients report such episodes with minimal provocative stimuli. Such dissociative episodes are not reported by PTSD/mva patients. 7. Avoidance behaviors can occur on two levels: general or specific. On a general level both groups will avoid any situation that might arouse overwhelming emotions. On a specific level, the PTSD/veteran will avoid situations that remind him of Vietnam. Such reminders are varied in type and number and can be quite subtle. For example, the patient may cross the street to avoid a man of Asian ethnicity coming toward him. For the PTSD/mva, specific avoidance behavior is focused on the driving situation and is quite intense. The patient may refuse to enter a car or drive more than a few miles from home. 8. The overwhelming majority of patients in both groups received treatment consisting of a combination of medication (usually a tricyclic antidepressant) [5,6] and psychotherapy. In psychotherapy, the veterans can be encouraged to relate their combat experiences whereas PTSD/mva patients will usually not discuss the trauma. Indeed, they repeat that they have nothing to discuss. It should be noted that the veterans struggled with their PTSD symptoms for many years and, by the time they finally entered treatment, many were relieved to share their combat related experiences with an emphatic therapist. “Cures” in the PTSD/veteran group were, at best, a rare occurrence. However, a substantial
247
A.
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proportion of the PTSD/mva patients will terminate treatment, asymptomatic, within 4 months posttrauma [7]. Of the remaining group, a small proportion will terminate within 1-2 years posttrauma, either asymptomatic or with symptom distress at a tolerable level. Follow-up observations for those, like Mrs. B, who have been in treatment for 2 years or longer are not yet available. At present, these patients continue to experience active posttrauma symptoms. 9. The noncompliance phenomenon was significantly different in both groups. Among the MSDlveteran group, a substantial number dropped out before the third professional contact. Among those remaining, a substantial proportion used the clinic only during periods of crisis. Among the I’TSD/mva patients, noncompliance was clearly related to the passage of time since the trauma. In one formal study [3] dealing with an acute MSD population, the majority of whom were PTSD/mva patients, the dropout rate for those entering treatment during the first 9 weeks posttrauma was 26.9%. The dropout rate increased over time so that 81.8% of those entering treatment during the 40th week posttrauma and beyond dropped out.
Possible Differences The PTSD/veteran group was more likely to report a delayed onset of symptoms [8]. Such a latency period could last for years. Among the PTSD/mva patients, a delayed onset was rare and, even then, the latency period was several months duration [9]. These observations are similar to the formal findings of a recent epidemiologic study in which reports of delayed onset PTSD were found among Vietnam combat soldiers but not among civilian PTSD participants [lo]. The coexistence of alcohol/substance abuse, major affective disorder, and violent thoughts and behavior have been reported in the FED/veteran literature [11,12] and applies to our MSD/veteran group. However, such behavior has been found in non-PTSD veterans, calling into question the specificity of these findings [13,14]. In addition, a small subgroup of patients exhibited both schizophrenic and PTSD symptoms. This is a phenomenon not examined in the literature. 248
Such coexisting problems were not found in the PTSD/mva group. Mild depressive symptoms were evident in the MSD/mva group and appeared after a prolonged period of PTSD-related impairments in the work and social spheres. Problems related to cerebral concussions, usually mild, were quite prevalent [2]. 3. PTSD/veteran patients often reported periods of unemployment and frequent job changes since their discharge from the service. Similarly, a history of one or more divorces was common. However, again, these problems also have been reported in non-FED veterans [13]. By comparison, PTSD/mva patients reported stable work and marital histories. Once the PTSD process began, their ability to perform in both areas was impaired, with secondary problems developing at that time.
Similarities In addition to meeting DSM-III criteria, a striking clinical similarity between these two groups was their inability to tolerate reasonable levels of stress. Such stressors involve the expectable difficulties of daily living as well as direct reminders of the trauma. This stress intolerance manifests itself as affective instability that often overwhelms the individual. It is this precipitate that leads many of the PTSD/veterans to seek assistance. Similarly, affective instability is often the ongoing focus of the treatment for the PTSD/mva patients. Both groups of patients were eligible for financial compensation. The structure of the compensation process is substantially different for each group. VA clinic staff members felt that, at this point, malingering was not a significant phenomenon among those PTSD/veteran patients who entered treatment. Similarly, malingering was not noted among PTSD/mva patients [15].
Conclusion In conclusion, clear differences in the treatment experiences involving PSTD/veteran and PSTD/mva patients were clinically evident in the following areas: source of referral, age, sex, socioeconomic level, nature and timing of stressor, character of intrusive and avoidance symptoms, and noncompliance behavior. Possible differences
Chronic Vietnam PTSD
were noted in the areas of aggressivity, concurrent psychiatric entities, and work and marital histories. The etiologic, phenomenologic, and treatment implications of differences in these variables and the ways in which they might interact have not been studied. We conclude that any generalizations made from chronic PTSD/veteran to acute PTSD/mva patients must be cautiously made and highly focused. This article has dealt only with the limitations involved in generalizing from PTSD/veteran to PTSD/mva. However, there are other major groups of PTSD. For example, 1,467,531 Americans were victims of violent crimes (rapes, assaults, robberies) in 1986 (161. As many as 44,026 (3%) may have experienced a subsequent acute PTSD [lo]. One suspects that any generalizations from chronic PTSD/veterans to any of these other PTSD groups would also have to be made carefully. With this major cautionary note in mind, two similarities between both groups are worth repeating. Affective instability, that is, the inability to tolerate stress from any source, was seen in both groups and warrants further investigation. Secondly, both groups experienced similar treatment approaches, with partial responses occurring in both cases. Despite the multitude of differences between these two groups, there is the clear potential for a lengthy, disabling illness even with available treatment in both instances. This study is clearly impressionistic, although attempts were made to reach group consensus through repeated discussions, joint interviews, and review of the manuscript. Indeed, some of the observations have been reported in the literature in other ways and from other sources. More formal studies are clearly warranted but, as stated in the introduction, may not be feasible.
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