PTSD
Post-traumatic stress disorder, the long-misunderstood
condition once known as shell shock, felled a Canadian
general who witnessed the horrors of Rwanda. But it's
not just soldiers who are at risk.
THE SMELL OF fresh fruit can pitch Roméo Dallaire into
a state of profound depression. Bushes can suddenly
mutate into piles of corpses.
``I can't sleep. I can't stand the loudness of silence,''
says the retired Canadian general who commanded the
United Nations mission to Rwanda during the 1994 genocide,
when up to a million Tutsis were butchered by the ruling
Hutus.
``You cannot put these things behind you,'' Dallaire,
54, says from his home in Quebec city. ``And the more
people say that, the more you get mad because you know
these things will not disappear. Time does not help.''
Two years after he returned to Canada, he could no longer
suppress his memories of the sounds, sights and smells of
the horrors he witnessed in Africa. He tried to kill
himself. But he didn't accept treatment until 1998.
Dallaire's illness used to be called shell shock, a
term coined in 1940 by British psychologist Charles
Myers, who attributed the symptoms of mental breakdown
to the concussive effects of exploding shells.
Now, it's called post-traumatic stress disorder (PTSD).
But until the soft-spoken Dallaire announced in April
that the ailment was forcing him to retire, few Canadians
knew much about it.
It was American war veterans who politicized shell shock.
Before the 1970s, doctors treating the emotional disturbance,
even in soldiers never exposed to gunfire, found shell shock
(or war hysteria, as it was sometimes called) extremely
difficult to distinguish from cowardice, historians say.
`I can't sleep. I can't stand the loudness of silence . . .
Time does not help' - Lt.-Gen. Roméo Dallaire, retired due
to PTSD Then, activists and psychiatric workers concerned
about the lack of recognition of the effects of the Vietnam
War on returning veterans' psychological health revived
interest in U.S. combat psychiatrist Abram Kardiner's largely
forgotten The Traumatic Neuroses Of War, published in 1941.
Dr. Kardiner, now credited with defining PTSD for the
remainder of the 20th century, characterized chronic
irritability, startle reactions, explosive aggression
and an atypical dream life as war-related trauma, even
though such phobic behaviour made the veterans in his care
look as if they were suffering from long-standing neuroses.
``The subject acts as if the original traumatic situation
were still in existence and engages in protective devices
which failed on the original occasion,'' Kardiner writes.
``This means in effect that his conception of the outer
world and his conception of himself have been permanently
altered.''
About the same time as Vietnam veterans' support groups
were agitating for an official diagnosis so sufferers
would have access to treatment and compensation, others
were documenting that the terrifying flashbacks and
nightmares of abused women and children, historically
dismissed as hysteria, resembled the traumatic neuroses
of war.
``There is a war between the sexes. Rape victims, battered
women and sexually abused children are its casualties,''
wrote Judith Herman, clinical professor of psychiatry at
Harvard Medical School, in Trauma And Recovery. ``Hysteria
is the combat neurosis of the sex war.''
But it was not until 1980 that the American Psychiatric
Association accepted PTSD - including ``rape trauma
syndrome,'' ``battered woman syndrome,'' ``Vietnam veterans'
syndrome'' and ``abused child syndrome'' - as a bona fide
medical diagnosis in its Diagnostic And Statistical Manual
Of Mental Disorders (DSM).
That step was controversial: PTSD was then and is now the
only psychiatric illness in which the cause is clearly
acknowledged as originating outside the individual rather
than inside as an inherent weakness or flaw.
``Without the context of a political movement, it has never
been possible to advance the study of psychological trauma,''
says Dr. Herman, who served on the medical committee
developing the DSM criteria and is active in the women's
movement.
Now, Lt.-Gen. Dallaire, who issued directives for four new
military-related PTSD clinics when he was a human-resources
manager for the military in 1998, is defining 21st-century
PTSD in this country.
Despite his ill health, the father of three strives to focus
national attention on what he calls the most common
mental-health problem among military personnel.
He says he has ``bullied'' his way back on to the Canadian
Forces mental-health committee in hopes of pushing ahead
the PTSD program he proposed before his retirement.
What used to be a disability best ``kept in a drawer,''
as Dallaire once described his shame, is becoming a public
rather than a private problem, not only for combat veterans
and abused women and children but also for emergency
services personnel and victims of and witnesses to violent
crimes or natural disasters.
The hard-won DSM diagnostic criteria (revised in 1987 and
1994) are being used now on both sides of the border to
help raise awareness of the syndrome in both professional
and lay communities.
The trauma must be grave, the manual says, an experience
of or witness to an ``actual or threatened death or
serious injury, or a threat to the physical integrity of
self or others.''
The exception is any childhood sexual abuse, which qualifies
even without threatened or actual violence or injury. Response
to the trauma must ``involve intense fear, hopelessness or
horror,'' although children can be simply disorganized or
agitated.
The catastrophic event must be persistently re-experienced,
either by recurrent nightmares, flashbacks, hallucinations,
intrusive recollections or by physical or psychological
reactions to cues that remind the sufferer of his past
terror.
``PTSD is a disease of time,'' explains McGill University
anthropology professor Allan Young, who did field research
in the United States from 1986 to 1988.
``The disorder's distinctive pathology is that it permits
the past (memory) to relive in the present, in the form of
intrusive images and thoughts and in the patient's compulsion
to replay old events,'' Young writes in The Harmony Of
Illusions: Inventing Post-Traumatic Stress Disorder.
Cpl. Chris Cassavoy served with Dallaire in Rwanda.
``The worst thing about being a Canadian soldier is that
a weakness is frowned upon, so the easiest thing to do
is take everything and push it to the side and pretend
it was a movie,'' he says in Witness The Evil, a Canadian
Forces' educational video made in 1998.
``That is, until you get the smells. The smells are the
worst things that trigger a memory. It's like a film
starting up in your head.
``There are foods I can't eat any more. Grilled chicken.
Can't eat it. It looks like a dead body. Rusted vehicles.
Can't go near them. Children. I have a hell of a time, a
hell of a time, looking at little kids, especially newborns
because they were a plaything with the Hutus.''
Cassavoy can no longer hold back his tears.
``They really liked killing kids.''
As a medic, Cpl. Darrell Daines thought he could take it.
``But I couldn't. They had all the children lined up,''
he says, his voice shaking as he recalls a Rwandan school
he inspected. ``It looked like they played a game with
the children.''
Daines must pause to collect himself.
``Like they chopped their heads off and then they signed
their names. It was a game.''
Not everyone exposed to catastrophe reacts in the same
way, says psychiatrist Randy Boddam, a major acting as
clinical adviser on PTSD to the Canadian Forces' surgeon
general.
``Some may have no stress. Others may have post-traumatic
stress. But simply feeling upset after a trauma is not a
disorder.
``We must be careful not to pathologize stress.''
Canadian Forces does not know exactly how many military
personnel have been diagnosed, Boddam goes on to say.
Epidemiological studies are expensive, and the first
one is not slated until next year.
The U.S. Department of Veterans' Affairs reports that
30.9 per cent of the 3,140,000 men who served in the
Vietnam War have had full-blown PTSD at some point in
their lives. A 1990 study showed that, 20 years after
the war, 15.9 per cent of those veterans, about 500,000
men, still suffered from full-blown PTSD and another 11.1
per cent from partial PTSD.
One of four Vietnam-era combat veterans was arrested within
two years of discharge, according to studies, and 200,000
are thought to be addicted to drugs or alcohol, an associated
feature of PTSD. Their divorce rate is twice that of the
general population and their suicide rate is 23 per cent higher.
Among America's homeless, one-third are said to be veterans
of the Vietnam War.
The majority of PTSD sufferers, however, are civilians. Dr.
Herman says it is one of the most common of all psychiatric
illnesses; the lifetime incidence among all Americans is 7
to 8 per cent.
In 1987, the American Psychiatric Association expanded its
definition of trauma to include events ``not outside the range
of usual human experience'' such as automobile accidents.
Today, the most common causes of PTSD in the general
population are rape, witnessing a murder and violent car
accidents.
Each year, Toronto psychologist Rex Collins and his
colleagues see from 30 to 50 people - many of them
children - who have PTSD as the result of a motor vehicle
accident. What happens in hospital after an accident is
also part of the trauma, Collins says, and the hope is
to develop a sense of trust so that victims can talk about
it.
Some symptoms can be calmed just by understanding them,
he says, adding that he believes psychotherapy itself,
without drugs, can change the damaged brain chemistry by
providing nurturing.
``I can't ever make the nightmares and intrusive reactions
go away,'' he says, ``but I may be able to help people put
them in perspective and carry on with their lives.''
Unfortunately, Collins says, because of legal entanglements
and problems with insurance payments, he often doesn't get
to see children until two or three years after an accident,
when their symptoms are already entrenched, increasing the
likelihood of the pathological responses to the traumatic
memories becoming chronic.
That delay makes treatment more difficult.
``It's easier to stabilize victims of more-recent trauma,''
says David Lingley, a Maple Ridge, B.C., psychologist who
specializes in treating PTSD in emergency-services workers.
``Adult survivors of childhood trauma have already found
their own ways to function in a crisis mode, which may not
always be healthy.''
Gary Denomme, now 39, knows about childhood trauma that
goes untreated.
Sexually abused at St. John's School for Boys, a former
reform school in Uxbridge, Ont., run by the Christian Brothers,
Denomme has suffered from depression, an associated feature
of PTSD, all of his adult life.
But he never knew why; he never associated his depression
with the trauma.
``I get really down and I never knew what it was,'' says
Denomme from Vancouver, where he has lived since 1977.
``I thought it was normal. I didn't know how to cope with l
ife. I tried to commit suicide a couple of years back. I
know I've had it for a long time. I didn't know what it was.''
Three years ago, his general practitioner, David Lai, made
the diagnosis: PTSD.
Dr. Lai says Denomme, who was part of a high-profile
class-action settlement in Ontario, is doing better now
that he knows what's wrong with him. But in addition to
therapy, Denomme is on medication for depression.
``I am afraid to go off it,'' he says.
Separating the idea from consciousness, which is called
dissociation, at the moment of trauma seems to be the
single most important predictor for chronic PTSD, according
to the psychiatric association's DSM. And once it is chronic,
it is a subliminal part of a person's history.
As Collins explains it, trauma doesn't happen in isolation.
Some victims of accidents not considered serious develop
PTSD and others who have fairly serious injuries are all
right - perhaps their families are able to help them.
Although the insurance industry likes to classify earlier
post-traumatic stress as a pre-existing injury and thus
ineligible for compensation, accidents don't happen to blank
screens, Collins says. They happen to people with a history,
with a particular way of dealing with things or not dealing
with things.
``People who have been sexually abused, for example, seem
to suffer more severe reactions to motor vehicle accidents,''
Collins says.
American psychologist John Briere writes in Psychological
Assessment Of Post-Traumatic Stress that studies indicate
childhood abuse is a significant risk factor for victimization
as an adult. Individuals with a history of child abuse are
more likely to develop PTSD in response to adult combat
experiences than those without a history of abuse, he writes.
Childhood abuse puts a person at greater risk of a PTSD response
to a catastrophe in the way that a high-cholesterol diet means a
greater risk of heart disease, says Dr. Matthew Friedman, a
Vermont psychiatrist and Dartmouth Medical School professor
who acts as executive director of the National Center for
Post-Traumatic Stress Disorder.
California child psychiatrist and author Lenore Terr specializes
in childhood trauma.
Decades after the infamous 1976 Chowchilla, Calif. school-bus
kidnapping, she still keeps track of 25 of the victims, then
age 5 to 14, who'd spent 27 hours in a state of terror. She
says none of them was spared the traumatic effects of the
experience.
In early 1987, Terr was struck by the images of adolescent
terror in the movie Stand By Me, based on horror writer Stephen
King's novella, The Body.
At the moment when a train appears and almost runs down four
boys on a narrow trestle high above a gorge, ``the scene is
so scary, so monstrous, so unexpected that it reproduces the
feeling of childhood trauma right then and there,'' Terr
writes in ``Terror Writing By The Formerly Terrified: A Look
At Stephen King,'' published in The Psychoanalytic Study Of
The Child in 1989.
``I remember saying to myself, `Whoever wrote this movie is
playing post-traumatic games with me.' ''
Dipping into accounts of interviews with King, Terr discovered
that, when the author and screenwriter was 4 in 1951, a friend
he was playing with on at a rail crossing was run over by a
freight train. The young King returned home white as a ghost,
unable to speak for the rest of the day. Years later, his mother
told him pieces of the boy had been collected in a wicker
basket. But King has no memory of the incident.
The train trauma and the loss of his father, who abandoned the
family when King was 2, are clues to the writer's psyche, Terr
says. He never believed in his own personal future; until age
20 he thought he'd never reach 20 and he now frets that one of
his children will die.
``I think it is clear that Stephen King currently suffers
many of the symptoms and signs of post-traumatic stress
disorder of childhood,'' Terr says. ``He suffers nightmares,
fears, headaches, insomnia, a sense of futurelessness and
active denial. He has never seen a psychiatrist.
``Stephen King says he believes he could write, if he wanted
to, non-horror fiction. But he does not. And he has not. His
writing is devoted to one emotion - terror.''
On June 19, 1999, King was struck by a van as he walked along
the shoulder of a road against traffic near his country home
in Maine.
He was thrown 4 metres in the near-fatal accident and suffered
a collapsed lung and multiple broken bones. (His surgeon described
the bones below his right knee as ``reduced to so many marbles
in a sock.'')
A graphic account of his post-traumatic stress and his efforts
to return to writing appeared in the June 19/26 issue of The
New Yorker.
``I didn't want to go back to work,'' King wrote. ``I couldn't
imagine sitting behind a desk for long, even in a wheelchair...
Yet, at the same time, I felt I was all out of choices...
For me, there have been times when the act of writing has
been an act of faith, a spit in the eye of despair.''
According to the psychiatric association's manual, PTSD can
develop in individuals without predisposing conditions,
particularly if the stress is extreme.
Severity, proximity and duration of the exposure to trauma
are the most important factors in developing a PTSD response,
the manual says, although there is some evidence that social
supports, family history and nurturing childhood experiences
decrease its likelihood.
The disorder may be especially severe or long-lasting, it says,
when the stress is of human design, i.e., torture or rape or
childhood sexual abuse.
``The trauma that causes post-traumatic stress disorder is
a life-changing moment,'' says Lingley, who conducts workshops
for B.C. rescue workers. ``It alters a person's belief in the
components of the world, in safety and predictability, in the
faith that bad things don't happen to good people.
``It alters the way people view the world and themselves in
it. They are faced with reconstructing the beliefs they once
held.''
Dallaire kept his faith.
``When I was there in the field, and I was alone as the
commander in that mess, and having negotiated with the devil
himself, it became for me a reality that there was another
being above all else,'' he says. ``What hit me was reinforcing
the values and the faith I had over the years.''
Now taking 12 pills a day and in weekly therapy, he says he
doesn't need an extended social structure. In fact, he tends
not to want to talk to people. He avoids social gatherings:
Since being surrounded by massive crowds in Africa, they make
him nervous. He can't stay in a movie theatre that's full.
He needs a family that's been specifically educated about PTSD,
he says. Including families of military members is one of the
most important innovative dimensions of the military's new PTSD
clinics.
``What you absolutely also need is an âme soeur - a `sister
soul' - someone who doesn't give you all the platitudes and
so on that just make you more mad,'' he says. ``They just
listen. They cry with you. They stay with you. And they don't
run away when you start into some of the horrific stuff.''
Despite the horrors and the toll they've taken on him, Dallaire
last week agreed to return to the world's war zones - as a
special adviser to federal International Co-operation Minister
Maria Minna - when his therapy permits it.
Social support enhances therapy and medication, Dr. Herman
says, by helping sufferers disconnect with the trauma and
reconnect with family, friends and society. Dr. Friedman
says public-health prevention is also in the early stages
south of the border, where professionals are learning to
identify situations likely to cause PTSD and where, since
the Gulf war, there has been an increasing recognition of
the kinds of catastrophes that result in PTSD.
But that's secondary prevention, he adds. Primary prevention
is altering the social structures that lead to war, rape and
child abuse.
``History has shown that social reform is the best medicine,''
British psychiatrist Derek Summerfield writes in the July 22
issue of the British Medical Journal.
``For victims of war and atrocity, this means public recognition
and justice.
``Health and illness have social and political roots:
post-traumatic reactions are not just a private problem, with
the onus on the individual to recover, but an indictment of
the sociopolitical forces that produced them.''
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