Psych

Wolters Kluwer Health, Inc.
PTSD in the World War II Combat Veteran

Author(s): Charles Kaiman
Source: The American Journal of Nursing, Vol. 103, No. 11 (Nov., 2003), pp. 32-42
Published by: Lippincott Williams & Wilkins
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On
Kyle Jones's
last mission as an Air Force
navigator
in World
War
H,
his
plane
was hit in the skies over
Germany
and
caught
fire. Mr.
Jones grabbed
another crew member and
they jumped
from the
plane.
Seconds
later,
it
exploded; everyone
left
inside,
including
the
pilot,
was killed. As Mr,
Jones
hurtled toward the
ground,
he found that his
parachute
was defective. He was in
free fall for
22,000
feet before he
managed
to
open
it.
Upon
landing,
both he and his crew mate were
captured by Germans;
he
spent
the next 18 months in a
prison camp.
When he was
released,
Mn
Jones
had lost one-third of his
body weight.
Haunted
by
a fear of fire and intrusive memories of combat and
confinement,
Mr.
Jones
wandered the streets of his hometown for
nearly
three
years
after the
war. As his fear and memories
subsided,
he made efforts to
conquer
his anxi?
eties?by becoming
a
firefighter
in order to overcome his fear of
fire,
for instance.
Although
a
highly
successful
firefighter,
he never married and was
estranged
from
his
family.
At 77
years
of
age,
55
years
after the
trauma,
Mr.
Jones
was
living
alone and had few friends. Dreams of the crash
plagued
his
nights,
and
thoughts
of combat flooded his
days.
In a
panic,
he
sought
treatment.
In World War I it was called "shell
shock";
in World War
II,
"combat
fatigue."
Although
the difficulties combat veterans
experience
have
long
been
recognized,
it wasn't until
1980,
the
year posttraumatic
stress disorder
(PTSD)
was added to
the
Diagnostic
and Statistical Manual
of
Mental
Disorders,
third
edition,
that
symptoms
such as Mr.
Jones's
were understood:
they
were a
psychological
reac?
tion to extreme
trauma,
not a result of weakness.1 Classified as one
of the anxi?
ety disorders,
PTSD is a
syndrome
of
responses
to
extremely disturbing,
often
life-threatening events?combat,
natural
disaster, torture,
or
rape?that
fall out?
side of usual
experience.
While not all combat veterans
develop PTSD,
there's a
correlation between it and combat
exposure.
In
fact,
PTSD occurs in as
many
as
three out of five combat veterans.2
Charles Kaiman is a clinical nurse
specialist
in
psychiatric
mental health
nursing
at the New Mexico Veterans
Affairs
Health Care
System, Albuquerque.
Contact author: ckaiman@comcast.net.
32
AJN
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Vol.
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No. 11
http://www.nursingcenter.com
Many years
after the
war,
some
aging
veterans find themselves
fighting
a new
battle?coping
with
delayed-onset
or exacerbated
posttraumatic
stress disorder.
A nurse describes the
psychotherapy
group
he initiated to treat them.
Combat Veteran
By
Charles
Kaiman, MSN, NP, RN,
CS
? 2003 Charles Kaiman, MSN, NP, RN, CS. Past and Present /,
12" x
16",
watercolor and
pen
and ink.
Author Charles Kaiman also illustrated this article.
During
one session of his
therapy group,
he used
pen
and ink to
capture
his
impressions,
while
preserving
the
anonymity
of the men. He later
superimposed
watercolor images of war, such as the
corpses
shown
above,
on the
drawings.
"I had so
many ?mages
in
my
head after
drawing
that
day andlistening
to their
stories,"
Kaiman
said. "I tried to
imagine
what
they
must have
gone through
and what
they
must be
feeling
after all these
years."
ajnmww.com AJN
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Vol. 103, No. 1 1 33
Assessing
PTSD
A
primer
on
identifying symptoms.
The
key
to
assessing
for
posttraumatic
stress
disorder
(PTSD)
is
establishing
whether a
primary psychological
trauma occured.
(A
brief
military history
should establish whether a vet?
eran was
directly
involved in
combat.)
Once the
episode
of trauma is
confirmed,
the mnemonic
RAN can
help
in the
patient
assessment.
R?
Reexperiencing
?
intense memories of a traumatic event
?
recurrent
nightmares
of the
event,
thrashing
in
sleep, diaphoresis upon awakening
?
reliving
of the trauma as if it were
happen?
ing
now
(flashback),
with
possible auditory,
visual,
olfactory,
or even tactile
hallucinations
?
intense distress induced
by
reminders of
the event
A? Autonomie
hyperarousal
?
outbursts of
anger,
irritability
for little reason,
extreme
impatience
?
an
inability
to be in crowds or use
public
transportation
?
poor
concentration
?
exaggerated
startle
response (for
instance,
taking
cover if a car
backfires,
avoiding
fireworks)
?
hyperawareness
of
surroundings
and
poten?
tial
dangers, sitting
with back to walls with
the room in full
view,
scouting
all entrances
and
exits,
patrolling
the house at
night
N:
Numbing
and avoidance
?
avoidance of
thoughts, feelings, people,
and
places
associated with the
trauma,
such as
military holidays, low-flying aircraft,
and
war movies
?
a lack of interest in activities
?
emotional numbness and detachment
from
life,
inability
to have
strong
emotional
reactions
?
a sense of a foreshortened future
Patients with trauma who have
any
of these
symptoms
that interfere with their
functioning
should be referred to PTSD treatment.
For nurses
caring
for older
adults,
the
impor?
tance of
recognizing
PTSD is
clear;
after
all,
WWII
veterans are now
reaching
their
90s,
veterans of the
Korean War are
hitting
their
70s,
and Vietnam vet
erans are
marching just
12 to 15
years
behind. But
recognizing
PTSD is
important
for all nurses. The
disorder can affect
anyone
who has
undergone
extreme
trauma;
in one
study,
Breslau and col?
leagues
found an overall rate of PTSD of 9.2% in
those who had been
exposed
to extreme trauma.2
Indeed,
reactions to
psychological
trauma can be
even more destructive and
persistent
than effects of
physical
trauma.
Undiagnosed
and untreated PTSD
may
increase risk factors for cardiovascular disease
and cause suicidal ideation and
physically damag?
ing changes
in the function of the endocrine
system,
the immune
system,
and the autonomie nervous
system.3,4 Moreover,
as in a
major depression,
PTSD can lead to
difficulty
in
merely getting
through
one's
day.
Treatment of PTSD seeks not
only
to decrease
psychological distress;
it
may help
to resolve
problems
in the
patient's physical health,
as well.46 A basic
understanding
of PTSD will
help
nurses to
identify patients
in need of
specialized
care and will enable them to
provide
immediate
and
compassionate support.
DIAGNOSING THE DISORDER
PTSD can be
diagnosed only
after
exposure
to a
traumatic event has been established. Because reac?
tions to trauma are
diverse,
how "traumatic event"
is defined will
vary
as well. In one
person,
trauma
would have to be
personally
life
threatening
to
result in PTSD
symptoms;
in
another, exposure
to
others' trauma would do so. Some veterans of
Operation
Desert Storm who have
PTSD,
for
instance, experienced
direct threats to their own
lives;
in
others, symptoms
are the result of
seeing
the
charred bodies of the
enemy
lined
up
for
disposal.
Symptoms. Diagnostic
criteria established in the
Diagnostic
and Statistical Manual
of
Mental
Disorders,
fourth
edition,
text revision
(DSM-IV
TR)
include the
following2:
?
intrusive
reexperiencing
of the trauma: this often
involves memories and
nightmares
of the trauma
and,
less
frequently,
dissociative states
(flash?
backs), during
which the trauma is relived
?
autonomie
hyperarousal:
this includes
insomnia,
irritability,
outbursts of
anger, poor
concentra?
tion, hypervigilance,
and an
exaggerated
startle
response
?
emotional
numbing, coupled
with avoidance of
stimuli associated with the trauma: this
may
manifest as emotional detachment and
unrespon
siveness or as deliberate efforts to avoid
feelings,
thoughts,
or situations associated with the
trauma
All of these
symptoms
must be
present
for more
than one month to confirm a
diagnosis
of
PTSD;
a
patient
who exhibits most but not all of these
symp?
toms receives the
diagnosis
of
"posttraumatic
stress
syndrome,"
also known as "subclinical PTSD."6
34
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Anxiety
and behavioral disturbances
occurring
within the first month of extreme trauma are cate?
gorized
as
symptoms
of acute stress disorder. If
these
symptoms
continue for more than one month
and less than
three,
the
syndrome
is deemed acute
PTSD. After three months it's chronic.
Symptoms
that first occur later than six months after the
trauma are
categorized
as
delayed-onset
PTSD.2
PTSD
may
seem to resolve within three
months,
only
to
reemerge many years
later.79
Alternatively,
patients
with
chronic,
mild PTSD
may suddenly
experience
exacerbated
symptoms
later in life.10
Combat
exposure
can be a
significant
Stressor that
causes
symptoms
decades later.8,9 In
fact,
events that
occur
normally
with
aging?the
deaths of loved
ones,
the loss of a
job,
or diminished
health?may
rekindle wartime
memories,
survivor
guilt,
and
unresolved
grief.11,12
Such events can also erode
important, long-standing coping mechanisms;
for
example, many
WWII veterans
suppressed symp?
toms and memories of trauma
by immersing
them?
selves in work. At
retirement,
a veteran
may
find
himself
suddenly
without
long-practiced
means of
escape.
Dissociation?a
"perceived
detachment of
the mind from the emotional state or even the
body"?may
be used to defend
against
overwhelm?
ing anxiety.7,13 Finally, biology may play
a
part
in
the exacerbation of PTSD in
elderly
veterans;
it's
thought
that neurotransmitter
dysregulation
caused
by aging may
be linked to an increased
psychologi?
cal
vulnerability
in the
elderly.14
Whatever the
causes?and
they
are
likely multiple?exacerbation
of PTSD in
elderly
veterans is common.15,16
Screening
can discern trauma much as labora?
tory
tests can discern blood abnormalities.17 Two
clinically
sensitive PTSD
screenings
used
by
the Vet?
erans Administration are the Clinician Adminis?
tered PTSD Scale and the
Mississippi
Scale for
Combat-Related PTSD. Yet a drawback of these
screenings
is that
they
view the
patient
in a
passive
role,
as a
specimen
to be studied.
Seng
has introduced the
concept
of the acknowl?
edgment
of trauma.6 She
says, "Acknowledging
that
trauma and
posttraumatic
stress
may
affect
patients'
lives and their health
throughout
their
lifespans may
allow for more effective interventions
and better health outcomes." In
fact, Seng posits,
"acknowledging
can be an intervention in itself."
And the
patient's
"health status can
improve by
acknowledging
trauma as a
contributing
factor in
the health
problem."
This
acknowledgment by
the
patient represents
a tacit
agreement
to
begin healing.
Depression, anxiety, anger, guilt,
and alcohol and
drug
abuse
may
afflict combat veterans as well.
Alcoholism in
elderly patients
with PTSD com?
pounds maladjustment,
while
anger
has been shown
to hinder treatment in combat veterans with
PTSD,
possibly by interfering
with the
patient's ability
to
When PTSD Is
Diagnosed
Protect
yourself
and
your patients.
?
Approach
the
patient calmly
and
slowly,
remaining
in his field of vision.
?
Don't startle the
patient
with loud noises or
by touching
him
unexpectedly.
If the
patient
is
sleeping,
awaken him
verbally
not
by
touch.
?
Don't box a
patient
into an office with no
easy way out;
he
may
feel
trapped
and his
anxiety may
increase.
?
Recovery
room and ICU nurses should be
especially
alert to the
possibility
of
postanesthesia
flashbacks. A combat veter?
an
having
a flashback is
psychologically
in
a war zone and
may misidentify people
or
places
as threats. Remove
sharp, loose,
or
heavy objects
and decrease noise in the
area.
Gently try
to reorient the
patient,
but
don't force
it;
keep trying periodically.
?
Don't drive the
patient away
from treatment
by telling
him,
"Get over
it;
the war was
60
years ago/ Remember,
his
symptoms
may
be
emerging
for the first time since
the war.
engage
with either
therapist
or
family
and friends.18,19
Finally,
when
compared
with
elderly patients
with?
out
PTSD,
the incidence and
severity
of
physical
illness are
disproportionately high.3'5
CASE STUDY: GROUP THERAPY WITH WWII VETERANS
In
1993,
while
working
as
part
of an
interdiscipli?
nary
treatment team at the Veterans Administration
Hospital
in New York
City,
I initiated a
weekly psy?
chotherapy group
for WWII combat veterans with
PTSD. Two attended the first
meeting.
Nine
years
later,
the
group
had
grown
to 29
men,
ranging
in
age
from 75 to 88. Three were African
American,
five were
Filipino American,
and the others were
European
American.
Group
members included offi?
cers and enlisted men
representing
all four branches
of the U.S.
military.
Five had been
prisoners
of war.
All of the men met the DSM-IV
diagnostic
crite?
ria for PTSD.
Although
some had
experienced
symptoms
of full-blown PTSD since the
war,
most
had latent or mild PTSD until their 60s or
70s,
at
which time their
symptoms
worsened. All received
treatment for other medical conditions from the
Veterans Administration or at
private
facilities.
The 90-minute
meetings
were scheduled in the
early afternoon,
to allow time for
commuting
ajn@lww.com AJN
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Vol. 103,
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Reliving
the Terror
September
1 1 was 'Pearl
Harbor,
all over
again.
1
On
its Web
site,
the National Center for Post-Traumatic
Stress Disorder warns that acts of terrorism and war
may
be
particularly disturbing
for
people
who have
already
survived traumatic events
(www.ncptsd.org/
facts/disasters/fs_screen_disaster.html).
This
proved
true
in
my group
of WWII veterans. The terrorist attacks of
September
11, 2001,
taxed their emotional resilience as
well
as
my
skills as a
therapist. Although
none of us lost
loved ones,
more than half of the members
living
in
Manhattan witnessed the
attack,
as did I. At our first
meeting nearly
a week after the
attacks,
the most com?
mon remark was,
"It's Pearl
Harbor,
all over
again."
Many
of the men
expressed
fear
that their "defense of the free world"
had been undone
by
the attacks.
And like most
people
across the
country, they
felt shock and disbe?
lief. But in this
group,
the attacks
also resulted in increases in out?
bursts of
anger, isolation,
hypervigi
lance, anxiety,
nightmares,
and
intrusive memories of combat. These
exacerbated
symptoms
of
posttrau
matic stress disorder
(PTSD)
affected
, , the
group dynamic.
Verbal and
Chartes Kaiman
? ?
_i_i i
physical aggression suddenly
became
part
of
our
group.
For
example,
one
member,
angry
with
another,
who was wheelchair
bound,
ripped
off
his shirt and walked over to him. With his chest
bared,
he
was an
extremely threatening presence.
I had to
get
between them to break it
up.
Before
September
11,
this
type
of behavior was rare.
I found
myself adjusting
my therapeutic style.
I
began
standing during meetings
to better maintain control of the
group.
I directed conversation
away
from
topics
such as
politics
and
religion.
I even took a few intractable members
out of the
group
far a
couple
of sessions and counseled
them
individually.
Even with these
efforts,
several
meetings
ended
early
because the level of
anger
was such that I was
concerned that the men could become
physically
ill. It was
a difficult time
personally
as
well,
as I needed to restrain
my
own
anxiety
in order to handle the
patients'
anxieties.
Reestablishing equilibrium
in the
group
involved
setting
strict limits. Instead of a
free-flowing,
interactive
group,
we
set a
predetermined topic
at the
beginning
of each
meeting.
The
group
took on a more formal
tone,
as I disallowed cross
talk and
began calling
on
people
to
speak.
Yet I continued to
encourage
mutual
support among
members. Even with the
group's history
of mutual
empathy
and
unity,
it was several
months before the
group
was the
strong
source of social
sup?
port
it had once been. After about
a
year,
the
intensity
of
PTSD
symptoms
subsided to
nearly
the level
they
had been
at before the attack.?Charles
Kaiman, MSN, NP, RN,
CS
I before rush-hour traffic.
They
are run as an
ongo?
ing,
interactive
psychotherapy group using "experi?
ential
learning,"
which
gives patients,
over
time,
the
opportunity
to discuss their
grief
with other
group
members,
decrease their
isolation,
and
apply
this
experience
in communication to their relations with
others in their lives
(as opposed
to a didactic
approach,
in which
patients
are
merely
told that dis?
cussing feelings
of loss and
grief
with
family
and
friends is
helpful
to mental
health). Although
the
meetings
have no set
agenda,
the focus remains on
the
members,
with the
goal
of
decreasing depres?
sion,
intrusive
memories, nightmares, rage,
isola?
tion,
and
anxiety.
The
following descriptions
of
group
members
will
convey
a sense of the men who
participate
in
this
group. (Names
have been
changed
and
descrip?
tions modified to maintain
confidentiality.)
None of
the
patients
was in
therapy
before
joining my group,
and none identified instances of trauma before or
after WWII.
My participation
in the
group
ended
recently,
when I moved to New Mexico.
Howard
Jameson, 84,
was an
Army infantry?
man from 1940 to 1945. He
joined
the
group
two
years ago. During prolonged,
intense combat in
North
Africa, Sicily,
and
Normandy,
he sustained
multiple shrapnel
wounds to his
hands, neck,
and
legs.
Over the last five
years,
the
pain
from these
wounds has increased and has become a constant
reminder of wartime service. Married for 52
years,
Mr.
Jameson
has six children and 12
grandchildren;
he claims to have
enjoyed
a
fairly happy family life,
although
he admits his children sometimes criticize
his "short
temper."
Before
retiring
six
years ago,
he
had a successful career in sales and
says
he never
abused
drugs
or alcohol. He had a
myocardial
infarction 11
years ago.
He has no
cognitive
deficits
or
psychological
comorbidities.
Except
for occa?
sional outbursts of
anger,
he was not bothered
by
PTSD
symptoms
until
eight years ago. Upon
retir?
ing,
his
symptoms
intensified and now include out?
bursts of
anger,
an
exaggerated
startle
response,
and
daily
intrusive memories of combat and lost buddies
("just
like it was
yesterday").
He has severe insom?
nia, sleeping just
two to three hours a
night,
and he
suffers
nightmares
about combat five times a
month.
However,
since
joining
the
group
he has dis?
cussed his war trauma with his
family,
and he's feel?
ing
less
emotionally
isolated.
Marion
Westerfeld, 80,
would have been
respon?
sible for
dropping
the atomic bomb on
Nagasaki,
had last-minute
scheduling changes
not occurred.
As it
was,
the B-29
pilot
flew over the
city
the
day
after it was bombed and witnessed the devastation
from the air. He was
emotionally
detached from
what he
saw,
calling
it "dreamlike and unreal." After
the
war,
he went on to a successful business career.
I But he had a
tendency
toward
isolation,
and he
36
AJN
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November 2003
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Vol.
103,
No. 1 1
? 2003 Charles Kaiman, MSN, NP, RN,
CS. Pair and Pressnr
ff,
12" x
14",
watercolor and
pen
and ink.
non?
drive the
patient away
by telling
him,
'Get over
it;
the
war was 60
years ago/
divorced twice.
Through
his
highly
visible
job
in
architecture,
he entered the world of the
"jet
set"?
once even
dancing
a fox-trot with Eva Per?n. He
joined
the
group
in 1994 because of a
sharp
in?
crease in intrusive
thoughts
about his war
experi?
ences. Several months after
joining,
Mr.
Westerfeld,
who has suffered from alcoholism since his time in
the
service, stopped drinking.
He
began
to bond
with others.
Morris
Aronson, 81,
flew 44
bombing
missions
over the Pacific as a
flight engineer.
He crashed
once. He witnessed six buddies burn to death in an
explosion
and felt tremendous survivor
guilt
because his brother drowned while in the
military,
also in WWII. His turbulent
marriage
ended in
divorce,
and he's
estranged
from two of his four
children.
Quadruple coronary artery bypass graft
surgery
forced him to retire five
years ago.
A
heavy
drinker since his time in the
service,
he
quit
drink?
ing
without
joining
a
support group
after he retired.
In the
years following
the
war,
he was
prone
to out?
bursts of
anger.
But since his health
began
to dimin?
ish and he was forced into
retirement,
other PTSD
symptoms emerged, including frequent
intrusive
thoughts, nightmares, insomnia,
and an
exagger?
ated startle
response.
He
joined
the
group
about 18
months after
symptom
onset. Since
then,
he's felt
less
anxiety
and survivor
guilt,
he's
grown
closer to
his
family,
and he's become a volunteer tutor to chil?
dren in his
community.
Don
Dinato, 85,
was buried alive
during
the
Battle of the
Bulge by
dirt thrown
by
an
exploding
bomb. He was rescued 10 hours later.
Also,
as a
company commander,
Mr. Dinato had to decide
which of his men would be in the front lines?men
who in most cases became casualties. After the
war,
ajn@lww.com AJN
?
November 2003 ?Vol.
103,
No. 1 1 37
Combating
PTSD
The or
my
works to soften emotional Stressors
in
Iraq
and at home.
Since
the war in
Iraq began
earlier this
year,
the U.S.
Army
has modified
practices
to ease
the stress of combat and has initiated a
plan
to
help
those
returning
to the United States
readjust
to life back home.
Experts agree
that the
potential
for trauma for soldiers in
Iraq
is
great.
It's been
warned that the
controversy surrounding
the war,
the
prolonged deployments,
and the "no
place
to
hide" nature of the conflict will lead to trauma lev?
els as
high
as those in Vietnam veterans.
The
army currently
relies
heavily
on reserve
forces and
requires frequent
reinforcements.
Furthermore,
more than 50% of enlisted soldiers are
married,
and statistics show that (or
many,
reunions
can be as difficult as
separations:
the divorce rate
among deployed troops
was 27%
higher
than that
among nondeployed troops
in the 21 months after
the 1991 Gulf
War,
according
to a
study by
the
Department
of Defense. If s also believed that com?
bat stress
played
a
part
in the deaths of four women
killed in 2002
by
their husbands who had
recently
returned from
fighting
in
Afghanistan.
On the
front,
early
interventions include
?
battlefield rites for fallen soldiers.
?
encouraging troops
to discuss fears and
feelings
after combat.
?
stress and
anger management
classes.
?
a
"tip
card" used
by
unit leaders to
help
screen soldiers for
problems
such as suicidal
thoughts
and strained
relationships.
Before
returning home,
?
soldiers remain with their units for
physical
and mental health
screening
and "reunion
training" designed
to
prepare
them for the
return home.
Once
home,
?
before
being given leave,
soldiers remain with
their units until
everyone
has
completed
fur?
ther evaluations and
integration training (up
to
10
days).
?
those identified as
having specific problems
are connected with an
appropriate
official or
agency
for
follow-up.
For
example,
financial
counselors are
provided
to those with
money
problems.
?
a
telephone-based employee
assistance
pro?
gram
is available to veterans and their fami?
lies for a
year
after their return.?Lisa
Santandrea,
senior editor
I he
adjusted
well to civilian life. Married for more
than 50
years,
he had a successful career as an auto?
motive executive. Aside from
long
absences from
home while
traveling
for business
(which may
have
indicated a
propensity
toward
isolation),
Mr.
Dinato had no PTSD
symptoms.
But since he was
forced to retire two
years ago,
when
problems
resulting
from wartime
leg injuries
hindered his
ability
to
travel,
he
began having nightmares,
intru?
sive
thoughts,
and insomnia. He
joined
the
group
a
year
after it
began.
THERAPEUTIC GOALS
Like those described
above,
most members of the
group
have been
strong,
survival-oriented
men who
were able to
readjust
to and even thrive in civilian
life after
enduring profound
combat trauma. Yet
many years
after
returning home, they
found them?
selves
fighting
a new
battle?coping
with
delayed
onset or exacerbated PTSD. Some of the
group's
initial
goals
were to
help
members break
patterns
of
isolation,
to
replicate
the combat unit and the fam?
ily
within the
group,
and to aid them in
coming
to
terms with
tragedy.
Breaking patterns
of isolation. As the men discuss
their
experiences
in the war and how their combat
memories and
nightmares
have
increased, they
look
to one another for comfort and
support, just
as
they
did in combat.15,20 Yalom considered
universality?
the
patient's understanding
that he's not alone with
his
feelings?to
be an
important
factor in
group
therapy.21
In this
specialized group,
the sense of uni?
versality provided
almost immediate relief. Most
members had little
understanding
of PTSD and
thought they
were alone in
having
their intrusive
and
painful
memories.
Finding
out that
they
weren't
gave
them a tremendous sense of validation. Mr.
Aronson,
for
example,
had
expressed
his doubt that
anyone
could understand his
difficulty
in
adjusting
to life after the
war;
when the
group responded
to
his
story
with boisterous
offerings
of
support
and
empathy,
his relief was
palpable.
Unlike
many therapy groups,
in which outside
contact
among
members is
discouraged,
this one
encourages
members to interact with one another
outside the
group;
I believe the
group
also serves as
a social
support
for men who are isolated
by
the
loss of loved ones or because of the emotional dis?
tancing
caused
by
PTSD. In order to
encourage
members to
socialize,
I never arrived
early
for the
group
and
always
left
immediately
afterward.
Most of the members have
exchanged phone
num?
bers,
and several see one another
socially
outside
the
group.
Replication
of the combat unit and
family.
I've
I been
leading
interactive
therapy groups
for 20
38
AJN
?
November 2003
?
Vol.
103,
No. 1 1
Mn
order to
encourage
members to
socialize,
I never
arrived
early
for the
group
and
always
left
immediately
afterward. Most of the
members have
exchanged
phone
numbers,
and several
see one another
socially
outside the
group.
? 2003 Charles Kaiman, MSN, NP, RN,
CS. Past and Present
III,
12" x
6",
watercolor and
pen
and ink.
years.
This
group
was
unusual,
in that
cohesiveness,
which
usually
takes at least several
meetings
to
establish,
formed almost
instantly.
For
example,
after
attending
his first
group meeting,
Mr.
Westerfeld missed the next three
meetings
because
of
unexpected surgery.
The
group
members sent
him a
get-well card,
and some visited
him;
when he
returned, they
welcomed him back like a
long-lost
friend. Before
joining
the
group,
Mr. Westerfeld had
few friends and had
significant problems
with inti?
macy, yet
he now feels comfortable
talking
in the
group
and finds it a
significant
source of
support.
This ease of
bonding
that exists in the
group may
be a
replication
of the camaraderie of soldiers in
combat.
Indeed,
some members even took on their
former
military personas.
Mr.
Dinato,
for
example,
a former
company commander,
became the
group's
negotiator
and an
authority figure,
which
helped
create the sense of the
group
as a
company.
The
downside to this
bonding
is that the "rest of the
world"?anyone
who was never in combat?is
excluded from this intimate
circle,
and this includes
spouses
and
children,
whom the men often
kept
at
an emotional distance.
Members felt that those who haven't seen com?
bat "would never
understand"; many
also remain
quiet
in an
attempt
to
"protect"
loved ones. For
example,
Mr.
Jameson
had never told his wartime
story
to
family
or friends. After first
telling
the
group,
he was able to tell a
friend,
then his
wife,
and
finally
his children. He recalls
being
comforted
by
the
discovery
that
they
weren't made of
"fragile
glass."
Like Mr.
Jameson, many
of the other mem?
bers had never discussed their
experiences
with their
children before
joining
the
group, seeing
them as
too
vulnerable,
even
though
most of their children
now have their own children. In
fact,
children of a
veteran with PTSD often exhibit emotional re?
sponses
similar to but less severe than their
father's,
even if
they
are unaware of his trauma. When the
phenomenon
of PTSD is
explained
to
them,
chil?
dren are relieved
by
the
discovery
that
they
and their
a?n@lww.com AJN
?
November 2003
?
Vol.
103,
No. 11 39
International
Society
of Traumatic
Stress Studies
www.istss.org; (847) 480-9028; istss@istss.org
National Center for Post-Traumatic
Stress Disorder
www.ncptsd.org; (802) 2966300;
ncptsd@ncptsd.oiig
Office of the
Special
Assistant for Gulf
War Illnesses
www.gulflink.osd.mil;
special.assistant@deploymenthealth.osd.mil
Posttraumatic Stress Disorder Alliance
www.ptsdalliance.org; (877) 507-PTSD;
infb@pl5dalliance.0rg
Deportment
of Veterans Affairs
www.va.gov
family
weren't the cause of their father's distress.22
Transference,
the
projection
of
feelings
about
people
from the
past
onto those in the
present,
is an
essential
aspect
of the
group.
Because I'm about the
same
age
as
many
of the members'
children,
I used
father-child transference as a
way
of
encouraging
them to discuss their
experiences.
When
they
shared
their stories with
me,
they
were
rehearsing
a discus?
sion with their own children. One
group member,
for
example, helped
liberate the concentration
camp
at Dachau. When he first told me this
story,
one he
hadn't told in more than half a
century,
I sobbed
right along
with him. And I
encouraged
him to con?
tinue
talking, demonstrating
that his
story
was not
too
painful
to hear and
empathize
with. This is an
example
of
Peplau's
idea of the
"therapeutic
use of
self."21,23 It
proved extremely
effective for this
patient,
who shared his
story
with his son soon
after.
Ultimately,
his
symptom frequency
and inten?
sity
decreased more than
anyone
else's in the
group.
Coming
to terms with
tragedy.
The
aging
veteran
has
heightened susceptibility
to survivor
guilt.24
A
useful intervention is
encouraging
a search for
sig?
nificance in
past
events. This search is in accord
with Erikson's last
developmental stage, ego
integrity
versus
ego despair.25 Ego integrity
refers to
a
person's
sense of his life as
having meaning
and
significance;
in
contrast, ego despair
results from a
sense that one's life has been
insignificant,
that
opportunities
were
squandered,
that all was for
nothing.
In order to avoid
despair,
the task is to see
one's life in a
greater
context. Mr.
Jones
undertook
such a task when he
sought
to find the
family
of the
pilot
killed in the
explosion
of the
plane
he'd bailed
out of. Previous efforts to do so had been unsuc?
cessful. Yet about the same time he
joined
our
group,
he met
somebody
who was able to
help
him
trace them. When he
finally
met
them,
the
pilot's
widow embraced
him,
and the entire
family accepted,
thanked,
and honored him. When he told us this in a
group session,
there wasn't a
dry eye
in the room.
The
group
has
helped
all members achieve a feel?
ing
of
belonging
and has
given
them
opportunities
to disclose
painful
memories in a safe arena.
Many
have noticed
improvement
in their
physical
health
and in their
enjoyment
of life. And
many
have
begun sharing
their traumatic
experiences
and feel?
ings
with their families and have
expressed
satisfac?
tion and relief in
having
done so. What's left to be
expressed
is the
gratitude
I feel for
having
had the
chance to work with these
extraordinary
human
beings.
?
Complete
the CE test for this article
by
using
the mail-in form available in this
issue or
by going
to Online CE at
www.ajnonline.com.
REFERENCES
1. National Center for Post-Traumatic Stress Disorder.
Posttraumatic Stress Disorder: An Overview
[Web site].
2003.
www.ncptsd.org/facts/general/fs_overview.html.
2. American
Psychiatric Association,
et al.
Diagnostic
and sta?
tistical manual
of
mental disorders. 4th ed.
Washington,
DC:
American
Psychiatric Association;
1994.
p.
463-72.
3.
Falger PR,
et al. Current
posttraumatic
stress disorder and
cardiovascular disease risk factors in Dutch Resistance veter?
ans from World War II.
Psychother Psychosom
1992;57(4):164-71.
4. National Center for Post-Traumatic Stress Disorder.
Screening for
PTSD in a
primary
care
setting [Web site].
2003.
http://www.ncptsd.org/facts/disasters/fs_screen_
disastenhtml.
5.
Lipton MI,
Schaffer WR.
Physical symptoms
related to
post-traumatic
stress disorder
(PTSD)
in an
aging popula?
tion. MilMed
1988;153(6):316-8.
6.
Seng JS. Acknowledging posttraumatic
stress effects on
health. A
nursing
intervention model. Clin Nurse
Spec
2003;17(1):34-41; quiz
2-3.
7. Sullivan HS. The
interpersonal theory of psychiatry.
New
York,: Norton;
1953: 139-61.
8. Rosen
J,
et al. Concurrent
posttraumatic
stress disorder in
psychogeriatric patients. /
Geriatr
Psychiatry
Neurol
1989;
2(2):65-9.
9.
Engdahl B,
et al. Posttraumatic stress disorder in a commu?
nity group
of former
prisoners
of war: a normative
response
to severe trauma. Am
J Psychiatry 1997;154(11):1576-81.
10. Ni?ois
B,
Czirr R. Post-traumatic stress disorder: hidden
syn?
drome in elders. Clinical
Gerontologist 1986;5(3/4):417-33.
11. Boehnlein
JK, Sparr
LF.
Group therapy
with WWII ex
POW's:
long-term posttraumatic adjustment
in a
geriatric
population.
Am
J Psychother 1993;47(2):273-82.
12. Hierholzer
R,
et al. Clinical
presentation
of PTSD in World
War II combat veterans.
Hosp Community Psychiatry
1992;43(8):816-20.
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No. 1 1
13. Substance Abuse and Mental Health Services
Administration,
National Institute of Mental Health. Mental
health: a
report of
the
Surgeon
General
Anxiety
disorders.
[Web site], http://www.surgeongeneral.gov/library/
mentalhealth/chapter4/sec2.html.
14. Allen
A,
Blazer D. Mood disorders. In:
Sadavoy J,
Lazarus
L, Jarvik L,
editors.
Comprehensive
review
of geriatric psy?
chiatry. Washington,
DC: American
Psychiatric Press;
1991.
15. Snell
FI,
Padin-Rivera E.
Group
treatment for older veterans
with
post-traumatic
stress disorder.
/ Psychosoc
Nurs Ment
Health Sew
1997;35(2):10-6.
16. National Center for Post-Traumatic Stress Disorder. PTSD
and Older Veterans
[Web site].
2003.
http://www.ncptsd.org/
facts/veterans/fs_older_veterans.html.
17. Franklin
CL,
et al.
Screening
for trauma
histories, posttrau
matic stress disorder
(PTSD),
and subthreshold PTSD in
psy?
chiatric
outpatients. Psychol
Assess
2002;14(4):467-71.
18.
Druley KA,
Pashko S. Posttraumatic stress disorder in World
War O and Korean combat veterans with alcohol
depen?
dency.
Recent Dev Alcohol
1988;6:89-101.
19. Forbes
D,
et al.
Comorbidity
as a
predictor
of
symptom
change
after treatment in combat-related
posttraumatic
stress disorder.
/
Nerv Ment Dis
2003;191(2):93-9.
20. Elder
GH, Jr., Clipp
EC. Wartime losses and social
bonding:
influences across 40
years
in men's lives.
Psychiatry 1988;51
(2):177-98.
21. Yalom ID. The
theory
and
practice of group psychotherapy.
New York: Basic
Books;
1985.
p.
3-19.
22. Rosenheck R.
Impact
of
posttraumatic
stress disorder of
World War II on the next
generation. /
New Ment Dis
1986;
174(6):319-27.
23.
Peplau
H. Professional closeness. In: Toole
A,
Welt
S,
edi?
tors.
Interpersonal theory
in
nursing practice.
New York:
Springer;
1989.
p.
230-43.
24. Miller T. W.
Long-term
effects of torture in former
prisoners
of war. In:
Basoglu M,
editor. Torture and its
consequences:
current treatment
approaches.
New York:
Cambridge
University Press;
1992.
p.
107-34.
25. Erikson EH. Childhood and
society.
2d ed. New York:
Norton;
1963.
p.
268-9.
ce2
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CE
Continuing Educ
ntion
TEST
9
HOURS
||
PTSD in
the World War II
Combat Veteran
1. In World War
II,
the term used to
describe a reaction to extreme
trauma
experienced during military
service was
a.
anxiety
disorder.
b. reactive neurosis.
c. combat
fatigue.
d. battle neurosis.
2. Posttraumatic stress disorder
(PTSD)
a.
develops
in about 40% of combat
veterans.
b. is a term that came into use around
1990.
c. is often
a
result of weakness.
d. is classified as an
anxiety
disorder.
3?
Diagnostic
criteria for PTSD
Include
a. emotional
numbing.
b.
physiologic
distress.
c. suicidal ideation.
d. survivor
guilt.
4. Dissociative states are a mani?
festation of
a.
behavioral disturbances.
b. emotional detachment.
c. autonomie
hyperarousai.
d. intrusive
reexperiencing
of the
trauma.
5. Insomnia is a manifestation of
a.
behavioral disturbances.
b. emotional detachment.
c. autonomie
hyperarousai.
d. intrusive
reexperiencing
of the
trauma.
6? PTSD is confirmed when a
per?
son
experiences
a. most of the
diagnostic
criteria for
more than one month.
b. most of the
diagnostic
criteria for at
least one
year.
c. all of the
diagnostic
criteria for
more than one month.
d. all of the
diagnostic
criteria for at
least one
year.
7. When
symptoms
appear
than six months after the initial
trauma/ the
person
is said to have
a.
posttraumatic
stress
syndrome.
b.
delayed-onset
PTSD.
c. acute PTSD.
d. acute stress disorder.
8?
Symptoms
that continue for
longer
than one month but less
than three months are considered
manifestations of
a.
posttraumatic
stress
syndrome.
b.
delayed-onset
PTSD.
c. acute PTSD.
9.
Symptoms
such as
anxiety
that
appear
within one month of an
extreme trauma are considered
manifestations of
a.
posttraumatic
stress
syndrome.
b.
delayed-onset
PTSD.
c. acute PTSD.
10? One cause of the exacerbation
of PTSD in
elderly
veterans
may
be
a. neurotransmitter
dysregulation.
b.
well-developed coping
mechanisms.
c. avoidance of environmental stimuli.
d.
good
health and a
rewarding
work
life.
11. Which of the
following
does
Seng
propose
to allow for more
effective interventions for
patients
with PTSD?
a.
identifying
comorbidities
b.
using
the Clinician Administered
PTSD Scale
c.
acknowledgment
of trauma
d.
using
the
Mississippi
Scale for
Combat-Related PTSD
12. Which of the
following
has
been identified as a deterrent to
treatment in combat veterans with
PTSD,
probably
because it hinders
engagement
with the
therapist?
a.
guilt
b.
anger
c.
depression
d.
anxiety
13. The
therapeutic approach
the
author used in his
group
is
a. didactic
teaching.
b. individual discussion.
c.
experiential
learning.
d. behavioral correction.
14. The author's
group experienced
an almost immediate sense of relief
as a result of which of the follow?
ing
factors,
described
by
Yalom as
an essential factor in successful
group therapy?
a. catharsis
b. cohesion
c.
reflection
d.
universality
15? In contrast with other
types
of
therapy groups,
the veterans in the
author's
group
were
encouraged
to
a. form their own smaller
therapy
groups.
b.
bring
their
spouses
and children to
meetings.
c. socialize outside
group
meetings.
d. attend
meetings
for a limited
period.
16. Veterans search for significance
in
past
events to achieve the devel?
opmental stage
of
a.
ego integrity.
b. self-actualization.
c.
generativity.
d. self-esteem.
17? When
awakening
a veteran
who has
PTSD,
the best
approach
is to
a.
gently
shake his shoulder.
b. awaken him
verbally.
c.
softly clap your
hands a few times.
d. take his hand and call his name in
a
soothing
tone of voice. ?
42
AJN
?
November 2003
?
Vol.
103,
No. 11
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PTSD in the World War II Combat Veteran

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