Lilly, a fictitious soldier, was corporal in the Canadian Forces (CF) when she was deployed to Afghanistan. Early in her deployment, she was attacked by another soldier as she was returning to her barracks one evening. As he groped her he whispered, "You know you want this," and tore at her clothes. She managed to escape. "He didn't hurt me so I didn't report it. I didn't want to be a problem. I tried to forget about it and do my job," she recalled.
Months later, a close friend died when she was ambushed while on patrol. Lilly was usually part of that patrol group, but she had been sick and stayed behind. When she learned of her friend's fate, she recalled feeling numb. "I was going through the motions after that, putting my time in, but I didn't really care what happened to me."
Following her deployment, Lilly returned to Canada but no longer felt she belonged. "My friends were back in Afghanistan. I needed to go back and make things right." Unable to re-deploy, Lilly requested a release from the CF, much to the surprise of her superiors who saw her as a rising star.
Lilly couldn't stop thinking about her experiences in Afghanistan. The little time she did sleep was broken by terrifying nightmares. She became isolated, avoided friends and asked her husband to leave. He refused and told her he was worried she was ill. She ignored him. She was certain everyone would be relieved if she were no longer a burden. One day, Lilly took an overdose while her husband was at work.
When I worked as a psychiatrist at a military post-traumatic stress disorder (PTSD) clinic, I heard stories like Lilly's every day.
The diagnosis of PTSD requires that a person has "...experienced, witnessed or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The traumatic event must provoke intense fear, helplessness, or horror.
PTSD symptoms include "re-experiencing" the trauma, through intrusive, disturbing memories and nightmares, "hyperarousal" symptoms like irritability, anger and insomnia, and "avoidance" of all reminders of the trauma.
I didn't learn about PTSD in medical school or during my residency. I learned through my patient's experiences, and some of what I learned challenged my own beliefs about how people react when faced with a horrible, terrifying event.
I have learned from my experience with soldiers and survivors of torture and sexual violence, that the vast majority of PTSD patients experienced previous trauma.
1. Most people exposed to trauma do not develop PTSD.
By some estimates, up to 90 per cent of us will have a traumatic experience that is severe enough to meet the criteria for PTSD. However, only about seven to eight per cent will ever develop PTSD.
2. The type of trauma matters
Trauma that is personal (perpetrator known to victim), protracted (repeated over an extended period), violent, or sexual heightens the risk of PTSD. This underscores the staggering impact of childhood physical or sexual abuse, which is often perpetrated by a friend or family member and may occur repeatedly, sometimes over many years.
3. PTSD often results from accumulated trauma
Sometimes patients describe what many would consider a relatively minor incident, yet it provoked severe PTSD. I have learned from my experience with soldiers and survivors of torture and sexual violence, that the vast majority of PTSD patients experienced previous trauma. The event that provoked the onset of PTSD was "the straw that broke the camel's back," but the previous trauma in many cases was much more "severe."
I have learned that trauma is subjective.
My military patients were usually model soldiers with bright futures. When the severity of their impairment and suffering seemed out of keeping with the incident, I invariably learned they had experienced earlier trauma, often childhood abuse or the loss a parent at an early age, which made them more vulnerable to PTSD.
I learned to ask patients gently but repeatedly about previous trauma. Patients with PTSD struggle to trust, so it can take years for them to disclose past trauma, often due to a sense of guilt and shame and the fear of being judged.
4. What is traumatic to one person might not be traumatic to another.
Soon after I finished my psychiatry residency, Swiss Air flight 111 crashed off the coast of Nova Scotia. Like many helpful Maritimers, a family friend who lived nearby helped to pick up debris along the shoreline. Months later, he told me he was struggling with distressing memories of finding human flesh amongst the debris. My response was, "But it's just body parts."
My callous response was inexcusable. As a new doctor, I had recently dissected a human cadaver and was exposed to all manner of human suffering. I didn't consider that my friend was a plumber. He'd never seen a dead body, let alone pieces of a person being washed ashore. I have learned that trauma is subjective.
5. The patients I have diagnosed with PTSD usually have additional diagnoses, most commonly depression and substance abuse.
6. Lack of control is a risk factor
Some CF peacekeepers were highly trained for combat, deployed to a zone of conflict, and then were not allowed to intervene. They were equipped with weapons they were not authorized to use. Unable to control their situation, some were forced to witness intolerable atrocities and human suffering. For some it was soul-destroying.
7. "Critical stress debriefing" (CSD) may cause PTSD
CSD involves teams of caring nurturers descending on victims to help them cope with trauma. It has ultimately been found to provoke more PTSD than it prevents. There are several theories to explain this finding, but the lesson is clear: what seems like a good idea still requires scientific proof.
8. Social support is protective
A solid social support network will not immunize every person from PTSD, but supportive family and friends offer tremendous benefits, before and after exposure to trauma.
9. I am a better psychiatrist because of the trust and patience of my many brave and inspiring patients.
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