Research Term paper on military PTSD: final version

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Simon Marc

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Hey people,
I have finished my term paper on military PTSD. I would like to thank every member of the community that helped to improve it. I got 10 out of 15 points (german grade system), which is ok but not very satisfying when taking into account the amount of work.
I couldn't find out how to attach a microsoft word file (does anyone here know?), so I just copied the text. I couldn't insert the polls , but nevertheless you will understand my message.
Please post your opinions on the paper and let me know whether I could do justice to the issue or not.
With best regards,
Simon


Term paper in English
2018/2019

Topic: War makes men mad – The effects of Post-Traumatic Stress Disorder on the soldier and how to overcome them

Mentoring Teacher: Dr. Karina Schröder

Author: Simon Marc Schewes

Abstract
“Shell Shock”, ”Vietnam Stress”, “Post-Traumatic Stress Disorder (PTSD)” - These are the names for an abnormal human reaction to enormous pressure in combat. Significant awareness for this particular phenomenon was first raised during World War I. Soldiers who were suffering from PTSD and refused to redeploy to the front were shot for cowardice at that time. Today, the problem is far bigger than it ever was and veterans have severe trouble to come home and reintegrate into society.

The findings of this term paper mainly consist of unconfirmed information I compiled in forums. That means that the veracity of the information can’t be proven. Why am I doing this? Because this term paper is dedicated to the veterans who are physically at home but are mentally still fighting the battle in their minds. Some of them might get along after a couple of years, others keep struggling their whole life with the experiences they made during deployment. I want to tell their personal view of things, their opinion. That is why the reader of this paper will not find much information drawn from the field of psychology or from governmental sources. The intention is to give civilians an overview on military PTSD and to provide initial orientation about this complicated issue. Furthermore I would like to remark that I mainly focus on the United States’ military because it is one of the biggest in the world. The situation in Germany is also featured in a subsection in which I point out what our armed forces can learn from the USA. By doing so, I hope to raise attention for this issue in the framework of my possibilities, for military PTSD has to be present in everyone’s mind.

Table of contents


1. Introduction in prehistorical context 3

2. Military PTSD 3

2.1 Definition 4

2.2 Possible contributing factors 5

2.3 Terminology 6

3. Treatment 9

3.1 Methods 9

3.2 Governmental treatment 10

3.3 Situation in Germany 11

4. Conclusion 12

5. Acknowledgements 13

6. Bibliography 14

7. Annex 16




1. Introduction in prehistorical context
For thousands of years, there has been conflict in our world. Conflicts between two or more parties led to hostility and hostility eventually led to war. Every kind of society, from a little tribe to an empire required warriors to fight against the enemy. The kind of warfare was brutal, merciless and it deadened the sensitivity for the value of human life. However, life itself was a hardship back in the days and when going to war the soldier was more hardened than an individual of today’s western society. When returning home, many of them who experienced direct combat had to deal with the transition back into civilian life. How easy or hard this period of processing the experiences is often depended on the kind of society the soldier is put back into. Let’s take an Indian tribe as an example: The community the warrior fought for was everything he had. It provided him with safety, nutrition and also was a kind of old-age provision. In a nutshell: It satisfied his human needs. The community took care of the homecomers and as a logical consequence, even severe combat stress healed very fast.

When comparing a tribe to modern western society, there are countless differences. The most negative result of our civilization is an enormous lack of solidarity. Real social bonds only exist at best within a family and the inner circle of friends. Now imagine for example a U.S. marine who deployed for eight months in Afghanistan, working, sleeping and eating with the same platoon the whole time. No running water, no direct connection to the beloved ones, firefights almost every day. He comes back to a society beyond daily mortal danger, extraordinary fast-paced and full of possibilities and decisions in every field of life. But he also comes back to a society that does not look after him, does not appreciate his efforts for the community and does not honor him for the sacrifices he made like his comrades in the war zone. This can be toxic for every human being and may be another frightening reason why depression becomes a growing problem in the US[1].

2. Military PTSD
2.1 Definition

The best way to gain first understanding of PTSD (Post-Traumatic Stress Disorder[2]) is to look up the term in a renowned dictionary. According to the Cambridge Dictionary, PTSD is “a mental condition in which a person suffers severe anxiety and illness after a very frightening or shocking experience, such as a war or an accident”[3].

This “mental condition” is a disordered state of mind. “Severe anxiety and illness” include hypervigilance, insomnia, intrusive thoughts or numbness[4]. The prerequisite for this state is a traumatic event experienced by the sufferer that led to psychological instability. It is of vital importance to distinguish Post-Traumatic Stress from the Post-Traumatic Stress Disorder, because the former is a normal response of the human to stressful events and its symptoms decline within a month, while PTSD can last decades.[5]

The first example cited in the quote is also the most known: War. Without trivializing other experiences like accidents, sexual abuse or natural disasters, I would like to point out the special challenges that a soldier has to rise to in a warzone in the chapter “Possible contributing factors”.

2.2 Possible contributing factors
To answer this question, I consulted military members on the forum “MyPTSD”[6]. By creating a poll, I was able to find out main reasons and also learned about options I have never been aware of. Of course I cannot prove neither the identity of the contributors nor the authenticity of their assertions. Nevertheless, their statements are plausible and provide more insight than an external research. My findings are listed below.

Essential for the understanding of this chapter is to differentiate between causes of PTSD and contributing factors. Causes only include death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, according to criterion A of the DSM-5.[7] By contrast, contributing factors are conditions which are not related to the trauma itself, i.e. “family problems”.

In addition, contributing factors and their significance for PTSD depend on each individual case and the veteran’s personal assessment.

Although Military Sexual Trauma is a different type of mental illness, I was made aware that one trauma can cause another one.

For a better understanding of the factor “lack of excitement/thrill after discharge/return home” I would like to quote a member of the forum:

“... and the only event that stands out as the first time everything changed? Was the first time I was in the field. Not in training, but actually working. Everything just clicked. Snapped into place. I felt alive. Like for the very first time. Like I had found my place in the world, where I was meant to be, where I belonged, where I was right ... and it was f*cking amazing. Coming back after that? Was just surreal. Like the world had lost its color, and I lost my place in the world.”

Unfortunately, the website limited the maximum amount of answers to ten options. There are several factors missing, like problems during childhood, lack of comradeship, firefights with the enemy, poor social support within the deployed unit and our society’s indifference towards veterans.

2.3 Terminology
“Post-traumatic Stress Disorder” seems to be a quite modern term which contains an advanced knowledge of psychology. However, this syndrome is much older than it seems. Let’s take a look at the history of combat related PTSD.

If we wanted to roll off the complete history, we would probably have to look at biblical times. For example, Deuteronomy 20: 1-9 advises military leaders to remove soldiers who are troubled by personal problems (like concerns about harvest at home or fear of the enemy) from the frontline. This could be a hint for their knowledge about psychological breakdowns during combat[8].

In order to not exceed the limits, I skip some centuries until scientists first examined the psychological phenomenon and tried to name the nameless.

In the 17th century, Swiss Physicians identify “nostalgia”. This term, normally a synonym for homesickness, was used beyond the American Civil War to describe "... a species of melancholy, or mild type of insanity, caused by disappointment and a continuous longing for the home . . . and is daily met with in its worst form in our military hospitals and prisons, and is especially marked in young subjects"[9]. As we know today, the numerous cases of nostalgia were not affected by those sentiments but surely by the cruelties and the violence they had to bear.

Now we take a big step forward to the beginning of the 20th century. After the outbreak of WW1, the world experiences the brutality of a limitless warfare, driven by industrialization. The soldiers are fighting in trenches and the artillery is firing without mercy. The so-called “shell shock” is a common “disease” but it is not yet recognized by the doctors. Due to frequent detonations and the shock wave, the sufferers are sometimes trembling at the whole body and are incapable to fight. Nevertheless, they are accused of being malingerers who want to escape the combat zone. They have to pay with their lives for their “cowardice”.2

After the war, more and more attention was paid to the returning soldiers. In 1920, Sigmund Freund published a memorandum against the brutal treatment of mentally disordered veterans[10].

The issue was later left on one side until Germany was once again at daggers drawn with other European countries. During the global conflict, military medicine introduced a new term: “combat exhaustion”. British doctors described it as the “post-concussion syndrome”[11]. Subsequently, those two terms were called “Gross stress reaction” and included in DSM-I, a system created for classification of mental disorders[12].

Only one decade later, Vietnam War influenced psychology to an enormous extent: Today’s PTSD was given the name “Post-Vietnam syndrome”. Initially a medical term, its meaning was later changed to describe a sociological phenomenon[13].

The term “Post-traumatic Stress Disorder” was first mentioned in 1980 in the DSM-III (third revision of the DSM). Until today, the term remains to be controversial. Particularly the definition “disorder” is avoided even by officials as a measure against stigma towards the soldiers[14].

All in all, we can conclude that the development of the terminology led to an ascending grade of euphemisation, but equally to a more precise explanation which is able to distinguish similar syndromes from each other. This allows us today to improve the methods and to employ treatment suited to each patient.

Treatment
3.1 Methods

There are countless methods which promise to cure the patient from his/her mental illness. They can be categorized in terms of psychological therapy, medication, social interaction, creativity, meditation and distraction.

By using a poll, veterans were asked about the most effective measures, according to their personal opinion...Due to the low number of participants the results do not represent a general opinion. Nevertheless, the method “hobbies” turns out to be impactful. The statement of Adam C. (cf. 7. Annex: “Another huge part of my healing process has been nutrition and exercise.”) supports this conclusion.

3.2 Governmental treatment
The governmental treatment in the USA is organized by the U.S. Department of Veteran’s Affairs (hereinafter called “VA”). It was established to offer special benefits and support for the ones who served their country.

Benefits include financial and personal support by providing…
  • health care (surgeries, acute care, preventive care services, etc.)[15]
  • care for mentally and physically disabled vets [16]
  • education benefits (payment for college or training programs, etc.)[17]
  • career and employment assistance[18]
  • pension for veterans of certain age and disability grade[19]
  • etc.
Of course there are certain criteria to prove the vet’s eligibility for each benefit like age, disability grade, income or the type of discharge.

During the research I made contact with an employee of the VA and beneficiaries. I asked them about their opinion on this institution and summed up the arguments to show both positive and negative aspects of governmental treatment.

On the one hand, veterans receive free benefits when they meet certain criteria.

On the other hand, the VA sometimes has a bad reputation when it comes to eligibility. Adam C., for example, mentions that he has to pay privately for his EMDR-therapy (cf. 7. Annex). Another person told that she receives free EMDR. This shows that the criteria not always correspond to the veterans’ needs. Moreover, a community member confirmed the claim that the VA is fast at prescribing medication instead of psychological therapy, even when not needed. Antidepressants, for example, can become a serious issue when side effects occur, for instance sexual dysfunction[20]. A reason for the vast amount of prescribed medication could be staff shortage[21] which does not allow the doctors to spend enough time on one patient. Another contributor emphasized his wish for privacy as well as the difference between working for the government and letting it into personal life or relationships.

Indubitably, it depends on the individual therapist and the criteria a patient meets to have access to benefits. However, an underfunded institution will not solve the veterans’ crisis. To conclude it can be advised that the government should consider raising the budget of the U.S. Department of Veterans Affairs.

3.3 Situation in Germany
What can we deduce for our own nation when looking at the United States’ Veterans Care? I researched which special information the Bundeswehr delivers and how we can learn from the Americans.

I started off with the official website of the German military[22] and found a link relating to a webpage especially created for PTSD sufferers[23]. The website provided information about the disorder, how family, comrades and supervisors should cope with it and an online test. Furthermore a 24-hour hotline is offered. Unlike the VA’s official online presence, it does not inform about entitlements to or prerequisites for health care, disability support or pension. In comparison, the VA’s website has a more modern design, a better structure and a more detailed FAQ section. What stood out was an application called “CoachPTBS”, available for Android and iOS[24]. I tested this app and remarked certain analogies to the apps developed by the VA. The imprint revealed that the app was mainly inspired by the Department of Veterans’ Affairs of the USA and Australia.

In a nutshell: The VA should serve as a role model and copying certain designs, structures or applications would heavily improve the intuitiveness of German PTSD-related websites.

Conclusion
What are the main findings of this term paper and what should the reader remember when engaging with a veteran? First and foremost, one does not have to kill or lose a comrade in combat to have PTSD. There are several causes and contributing factors, some of them even date from the early childhood of the sufferer.

Furthermore, it seems to be an established tradition in the USA to thank vets for their service. If we really want to show them our gratitude, the first measure is to stop using empty phrases like this.

The topic of this term paper maybe implicated to find an absolute solution to “overcome” PTSD completely. My conversations with the veterans led me always to the same conclusion. Perhaps it’s never possible to overcome the mental illness entirely. However, governmental support can be improved by treating the causes in therapy rather than treating symptoms like depression with medication.

Ultimately, I would like to draw attention to a matter beyond the topic of this term paper. PTSD is more a civilian than a military issue, unlike the depiction of the mainstream media. My urgent appeal is therefore to raise attention for every type of PTSD and to fight against society’s indifference about this issue.

Acknowledgements
I would especially like to thank the MyPTSD community members. Both, civilians and veterans provided useful information and clarified difficult topics. They continued to question my approaches and statements to prove their veracity. Thank you for making my term paper possible.

Another big thanks goes out to Adam C., a former member of the Navy, who answered my questions in detail as a case example.

I am also indebted to my mentoring teacher, Ms. Schröder. She helped me especially in questions of references and expressions.



Bibliography
Internet sources

Oxford English Dictionary. 2019 Oxford University Press. Retrieved April 26, 2019, from disorder | Definition of disorder in US English by Oxford Dictionaries.
2019, San Diego Union-Tribune. Retrieved April 28, 2019, from Young vets: Trouble in the bedroom.
2019 WETA. Retrieved April 29, 2019, from Link Removed what-are-differences-between-pts-and-ptsd.
2019 WETA. Retrieved April 29, 2019, from BrainLine article/dsm-5-criteria-ptsd.
Anderson, D. L. & Anderson, G. T. (1984). Nostalgia and Malingering in the Military During the Civil War. Perspectives in Biology and Medicine 28(1), 156-166. Johns Hopkins University Press. Retrieved April 30, 2019, from Project MUSE database.
Cambridge Dictionary.Cambridge University Press 2019. Retrieved April 6,2019, from POST-TRAUMATIC STRESS DISORDER | Bedeutung im Cambridge Englisch Wörterbuch.
Crocq, Marc-Antoine ; Crocq, Louis. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. Dialogues in Clinical Neuroscience. Retrieved April 23, 2019, from Dead Link Removed. gov/pmc/articles/PMC3181586/.
ÖSTA 2014. Retrieved April 23, 2019, from Sigmund Freud Gutachten zu Elektroschocks =artefactgroup264.
U.S. Department of Veterans Affairs. Retrieved April 21,2019, from VA.gov.
Verizon Media 2019. VA Mental Health Care Delays, Staff Shortages, Plague Veterans. Retrieved April 28, 2019, from VA Mental Health Care Delays, Staff Shortages, Plague Veterans | HuffPost.
bundeswehr.de: Startseite Bundeswehr (Retrieved April 22, 2019).
Dead Link Removed (Retrieved April 22, 2019).

Print media
Jones; Fear; Wessely: Shell shock and mild traumatic brain injury: a historical review. London: King’s Centre for Military Health Research, 2007.
Junger, Sebastian: Tribe. On homecoming and belonging. London: 4th Estate, 2016.

Annex
The objective of this term paper is also to convey a notion of how it feels to have military PTSD and what treatment is effective to civilians. In order to achieve this, I conducted an interview with Adam C., a former member of the Navy. His answers are only edited in terms of punctuation as a measure to not change the meaning and the effect it has on the reader.

1. General information on deployment (where and when; aspects of deployment): Years in the Navy: 12. Occupation: Navy Explosive Ordnance Disposal Technician[25]. Number of deployments: 5. Three Carrier deployments: Supporting flight deck ordnance operations and force protection diving operations prior to ships pulling into port. Force protection diving deployment: Searching tugs and piers for explosives prior to ships pulling into port. Iraq deployment: Counter IED[26] operations, route clearance of explosives and post blast analysis & intelligence gathering.

2. How did PTSD influence your everyday life (during and after deployment)?: When I thought of PTSD I always thought of someone being angry, distrustful and in a state of constant high alert. That really wasn’t me. For a very long time I had no idea that I had a clue I was suffering from PTSD. The human brain is amazing at masking and numbing symptoms. I didn’t really even understand the extent of my numbness until after going through EMDR[27] where I was free up many of those repressed feeling / emotions and recover feelings again. I was in a constant state of numbness to the point that I had very few thoughts going through my head. I was unable to feel happiness, excitement, or pleasure. I turned to alcohol for many years which just made things worse. I felt like an empty shell of a person. The very few thoughts I did have were constantly negative. My mind and body were so disconnected that I couldn’t perceive the world properly. I lived in this constant state of emptiness for many, many years after the war. It affected my marriage. When my wife and I got into arguments my mind would go blank to the point of not even being able to form sentences so I would just stop speaking.

3. What kind of treatment for PTSD did you try (psychologists; medication; workbooks; etc.)?:
Therapies: Talk therapy, EMDR therapy, CBT[28]
Medications: Welbutrin, Zoloft, Cymbalta[29]

4. Which of these approaches did work for you?: EMDR therapy has been by far the most beneficial of any of the therapies I have experience with. CBT has also been helpful. Talk therapy in my opinion has been the least helpful. Another huge part of my healing process has been nutrition and exercise. These two things have been stronger than any form of medication. Fasting and exercise has helped me reconnect my mind and body. I am now able to feel and perceive my surroundings in a new positive way which was impossible with the imbalances I was dealing with.

5. Your opinion on official treatment (VA; private institutions; medication)?: The VA is quick to throw medication at every problem, including PTSD. I believe that the VA is way behind when it comes to therapy. My VA doesn’t even offer EMDR as an option which means I pay out of pocket for my EMDR therapy.

6. Do you have any ideas for a successful treatment?: Successful treatment starts with an individual that has decided to truly fix their problems. If they are not ready, they will probably not be willing to truly look inside themselves and start the healing process. In my opinion EMDR is by far the most effective therapy for treating PTSD. It allows you to effectively tap into the memories of the past and process them in a safe and effective manner. I believe that individuals that struggle the most with PTSD have had issues in their lives long before the war. My problems started in my early childhood. Those problems drove me to the military which exacerbated my problems because I had never learned to deal with those problems. If I personally got into helping veterans with therapy I would have my therapy revolve around these things:
  • EMDR therapy
  • Nutrition & fasting
  • Exercise
  • Volunteering
  • Creativity / Art
  • Breathing / Meditation
  • Socialization vs Isolation
7. How to treat a soldier as a civilian (how to help; questions to ask; questions that should be avoided by a civilian)?: This again depends on the person. Forcing people to talk about triggering things can be very bad for someone who doesn’t know how to deal with their emotions. I think it is best to get an understanding of the person’s background, emotional state and their willingness to be open about the things that are going on.

8. What is your opinion on Veterans Day[30]?: I personally do not like attention. I don’t really like when people thank me for my service. It makes me feel awkward. I have never gone out for a free meal on Veterans Day or anything like that. Sometimes I feel like Veterans Day is more for the civilians than it is for the veterans, but that is just my opinion. I am sure there are veterans out there that love it, but that isn’t me.

Adam set up a website where he tells about his experiences, his life and the treatment methods he tried (Battling PTSD and depression - A military veteran's blog). The website itself, but also opening up to a larger community could be another way to process a trauma and maybe overcome it one day.

[1] Junger, Sebastian: Tribe. On homecoming and belonging. London: 4th Estate, 2016. pp.20-21.
[2] According to the Oxford American Dictionary, a disorder is “a disruption of normal physical or mental functions” [Oxford English Dictionary. 2019 Oxford University Press. Retrieved April 26, 2019, from disorder | Definition of disorder in US English by Oxford Dictionaries].
[3] Cambridge Dictionary. Cambridge University Press 2019. Retrieved April 6, 2019, from POST-TRAUMATIC STRESS DISORDER | Bedeutung im Cambridge Englisch Wörterbuch.
[4] Those effects are examples of diagnosed PTSD sufferers met during research.
[5] 2019 WETA. Retrieved April 29, 2019, from What Are the Differences Between PTS and PTSD? | BrainLine.
[6] My PTSD Forum (Accessed April 24, 2019).
[7] 2019 WETA. Retrieved April 29, 2019, from DSM-5 Criteria for PTSD | BrainLine.
[8] Crocq, Marc-Antoine ; Crocq, Louis. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. Dialogues in Clinical Neuroscience. Retrieved April 23, 2019, from From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology.
[9] Anderson, D. L. & Anderson, G. T. (1984). Nostalgia and Malingering in the Military During the Civil War. Perspectives in Biology and Medicine 28(1), 156-166. Johns Hopkins University Press. Retrieved April 30, 2019, from Project MUSE database.
[10] ÖSTA 2014. Retrieved April 23, 2019, from Sigmund Freud Gutachten zu Elektroschocks.
[11] Jones; Fear; Wessely: Shell shock and mild traumatic brain injury: a historical review. London: King’s Centre for Military Health Research, 2007. p.1643.
[12] Further information about DSM can be found on the American Psychiatric Association’s website (Home │ psychiatry.org).
[13] In particular the reluctance of the people of America to support or begin any further overseas military conflict.
[14] The word “disorder” implicates that the soldier is suffering from a mental illness, while PTS refers to a normal response of the body to stressful situations.
[15] U.S. Department of Veterans Affairs. Retrieved April 21,2019, from About VA health benefits | Veterans Affairs.
[16] U.S. Department of Veterans Affairs. Retrieved April 21,2019, from VA disability compensation | Veterans Affairs.
[17] U.S. Department of Veterans Affairs. Retrieved April 21,2019, from About GI Bill benefits | Veterans Affairs.
[18] U.S. Department of Veterans Affairs. Retrieved April 21,2019, from Careers And Employment | Veterans Affairs.
[19] U.S. Department of Veterans Affairs. Retrieved April 21,2019, from VA Pension Benefits | Veterans Affairs.
[20] Report of veterans having trouble with intimacy: 2019, San Diego Union-Tribune. Retrieved April 28, 2019, from Young vets: Trouble in the bedroom.
[21] Verizon Media 2019. VA Mental Health Care Delays, Staff Shortages, Plague Veterans. Retrieved April 28, 2019, from Link Removed 5380739.
[22] bundeswehr.de: Startseite Bundeswehr (Accessed April 22, 2019).
[23] Dead Link Removed (Accessed April 22, 2019).
[24] Link for the Android-App: Link Removed. ptbscoach&hl=de (Accessed April 26, 2019).
[25] More information on this career: Explosive Ordnance Disposal Technician (EOD) Jobs - Navy.com (Accessed on April 24, 2019).
[26] IED = Improvised Explosive Device (i.e. bombs or mines).
[27] EMDR = Eye Movement Desensitization and Reprocessing. Further information on the therapy: Dead Link Removed (Accessed on April 24, 2019).
[28] CBT = Cognitive behavioral therapy. Further information on the therapy: What is Cognitive Behavior Therapy | Beck Institute (Accessed on April 24, 2019).
[29] All the medications on the list are antidepressants.
[30] Veterans Day is celebrated annually on November 11 for honoring military veterans of the U.S. Armed Forces. It does not exist in Germany.
 
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shatter eyes

MyPTSD Pro
Thank you for sharing with us and i really appreciate how you diligently compiled the information you received. The references you used will be helpful to many as includes benefits and resources.

Thank you. Will you stay here or go? Now that you finished?
 
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