by Fermin Sarabia, MD LFAPA
There is nothing new about post-traumatic stress disorder.
Since creation, natural catastrophes, other human beings and other circumstances have emotionally traumatized people through events that threaten their lives or physical integrity, or those of others. Thus, it is possibly the oldest recognizable emotional disorder.
The different labels attributed to the emotional consequences of these happenings include combat fatigue, traumatic neurosis, war neurosis, emotional shock, war trauma, etc.
It was not until 1980 that the American Psychiatric Association introduced the term post-traumatic stress disorder in its Diagnostic and Statistical Manual (DSM III) and described its clinical components.
Although the condition has always existed, it was after the Vietnam War when psychiatrists identified it as a major and well-defined psychiatric condition developed as a consequence of an event in which the life or physical integrity of self or others is seriously threatened. The clinical manifestations are very complex, and the symptoms may follow an acute or chronic process, with an immediate or delayed onset.
Perhaps I should also mention that for a period of several years I myself suffered from symptoms of PTSD in connection with my experiences in escaping from communist Cuba. My wife is the only witness of those days.
The traumatic event in my case was the series of acts by the communist regime of Castro that was designed to destroy the economy, security, productivity, freedom and happiness of a prosperous, law-abiding and honest society by destroying everything built in slightly more than half a century
of being a republic. His means were expropriation, humiliation, intimidation, incarceration without legal proceedings, torture of the most cruel type and ultimately death – not always by means of the infamous and popular, but quick, firing squads.
The terror became an epidemic that prompted the massive migration of one million Cubans – nearly 20 percent of the population – from a country that previously attracted and welcomed a large number of immigrants, especially Americans, due to its beauty, wealth and opportunities.
I witnessed many tragedies and horrors perpetrated by Castro’s regime, many of them very close to me. Of course, my family and I would eventually appear on the list of potential enemies to be eliminated, due to our history of productivity and religiosity.
My traumatic events were multiple. Although we were finally able to flee Cuba and immigrate to the United States, I continued to experience those events in horrible nightmares that transported me back to those hellish events. In those nightmares I re-enacted my emotional reactions, talking, yelling, crying and making abrupt gestures that alarmed my wife who slept next to me. The day following the nightmares was always a very sad one. I avoided gatherings in which the subject could arise.
With that purpose, I chose Oklahoma for my residency because I thought that no other Cubans would go there. I was wrong. In fact, there were Cuban physicians even within my residency program who would continue to bring up our recent tragedy.
My professional interest in PTSD became prominent in the early 1960s during my psychiatry residency, when Albert Glass, MD, who was both our professor and state commissioner for mental health and mental retardation, lectured us about “war neurosis” and “combat fatigue.” Dr. Glass was a retired U.S. Army Colonel and a veteran of the Korean War.
In 1987 I took a seminar with C.B. Scrignar, MD at Tulane Medical Center. Dr. Scrignar is the author of the book, “Post-Traumatic Stress Disorder, Diagnosis, Treatment and Legal Issues.”
Since the 1980s, I have had the opportunity to work with some Vietnam veterans, and lately I have been seeing veterans from the Gulf War, Afghanistan and Iraq conflicts.
The severity of PTSD’s symptoms varies, depending on the circumstances and intensity of the trauma and the emotional predisposition of the subject, as well as other contributing or aggravating factors occurring with the trauma or following it.
These include but are not limited to humiliation, scorn, insult, rejection by significant ones, abandonment, contemptuous attitudes, etc.
A good example is the reception that some of our Vietnam veterans received. That reception included vicious accusations that left deep emotional scars in most of them, the consequences of which we continue to confront. Inflicting that damage were people who had no idea of the horrible circumstances that our servicemen had to endure day by day.
Unquestionably, such unfair treatment by others and biased publicity by the media contributed significantly to the severity and chronicity of the condition in Vietnam veterans.
Survival guilt is another aggravating factor. Although acts of war are the most frequent cause of PTSD, other circumstances may trigger the condition, such as acts of extreme violence and natural disasters. The latter may include events like earthquakes, tsunamis, floods, etc., in which one’s life or physical safety feels threatened, as well as circumstances in which the individual feels he or she has no control and responds with intense fear, helplessness or horror.
The symptoms characteristic of PTSD (per DSM-IV, 1994) last more than a month and include:
• Persistent re-experiencing of the traumatic event in one or more of the following ways:
~ Recurrent and intrusive recollections of the event including images, thoughts or perceptions
~ Recurrent distressing dreams of
the events
~ Acting or feeling as if the traumatic event is recurring (including a sense of reliving the experience, illusions, hallucinations and disassociate flashback episodes including those that occur on awakening or when intoxicated)
~ Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
~ Physiological activities or exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (absent before the trauma), as indicated by three or more of the following:
~ Efforts to avoid thoughts, feelings, or conversations associated with the trauma
~ Efforts to avoid people, activities or places that arouse recollections of the trauma
~ Inability to recall important aspects of the trauma
~ Markedly diminished interest or participation in significant activities
~ Feelings of detachment or estrangement from others
~ Restricted range of affect (e.g. loving feelings)
~ Sense of foreshortened future (e.g. does not expect to have a career, marriage, children or a normal
life span)
• Persistent symptoms of increased arousal (absent before the trauma), as indicated by two or more of
the following:
~ Difficulty falling or staying asleep
~ Irritability or outbursts of anger
~ Difficulty concentrating
~ Hypervigilance
~ Exaggerated startle response
The disturbance causes clinically significant distress or impairment in social, occupational or other areas of functioning. It could be classified as acute if duration is less than three months, or chronic if duration is three months or more. The onset could be delayed when the symptoms take six months or more to appear.
Not everyone exposed to the same circumstances will develop PTSD. Among the contributing factors are emotional predisposition, previous experiences, character strength, emotional stability or maturity, intensity of the trauma and other vulnerabilities of the individual.
Also playing a role are aggravating factors like humiliation and a lack of understanding or compassion and cruelty, or detractive attitudes by others who seek to inflict shame rather than provide emotional support to the victim. Again, the case of the Vietnam veterans is a clear example. Fortunately, the Veterans Administration now espouses a very receptive, positive and understanding attitude toward our war veterans, not only from Vietnam but also from World War II, Korea, the Gulf War, Afghanistan and Iraq, who now receive more adequate professional assistance.
PTSD can be a severe, complicated psychiatric condition. The treatment includes psychotherapy, antidepressants, anxiolytics, antipsychotics and social and family support. Prompt intervention, as prescribed by our medical and civil authorities in cases of conflicts or cata-strophes, could prevent a great deal
of suffering.
My own personality did not suffer any transformation, and I continued to do the same things I had always done – study and work hard. That, and the kindness and understanding of my wife, helped me a great deal.
Possibly, had I sought experienced professional help, my recovery would have taken less time. There is no question, however, that staying very active in my profession helped me considerably. I like to believe that I made a good adjustment, as now my family and I are good and grateful Americans.
My nightmares, although very sporadic, have not totally gone away – not even after 45 years.
Dr. Sarabia is a diplomate of the American Board of Psychiatry and Neurology and a clinical professor of psychiatry at UTHSCSA. He also maintains a private psychiatry practice.
