Post-traumatic stress disorder
Post-traumatic stress disorder is diagnosed from a traumatic exposure together with lasting symptoms that cause distress or impairment. It is often accompanied by other problems, is linked to changes in two brain structures that process memories, and is treated with psychotherapy and medication within a relationship of trust. Among soldiers it can follow blast injury, after months lived under conditions of fear, within a military culture that one army psychiatrist describes as embracing suicide.
Diagnostic criteria and symptoms
The diagnostic criteria for the disorder, as described in 2010, are exposure to a traumatic event; symptoms of re-experience, avoidance and arousal; a duration of symptoms of more than one month; and clinically significant distress or impairment caused by the symptoms.
Patients experience nightmares that place them back in the scene they lived through, have triggers that can bring on symptoms, and show hypervigilance and heightened startle reactions.
Associated problems
The disorder is often associated with other difficulties, including alcohol and drug problems, suicidal ideation, distancing, problems at work and with marriage, and homelessness.
Memory and brain structures
In one psychiatrist's account, humans have two types of memory, narrative and sensory-motor. Narrative memories are factual or textual, accessible at will, and enable learning and communication. Sensory-motor memories are precise and detailed but inaccessible unless triggered.
In the disorder, the hippocampus, a brain structure thought to be very active in processing narrative memories, shrinks, while the amygdala, a brain structure thought to be active in processing fearful memories, enlarges.
Treatment
The same psychiatrist emphasized that in treatment a relationship of trust and empathy is essential and that psychotherapies are at least as important as pharmacotherapies. As he described it in 2010, patients often derive significant benefits from treatment with selective serotonin reuptake inhibitors, and prazosin can be beneficial for the nightmares associated with the disorder.
Deployment and blast injury among soldiers
For one army psychiatrist deployed to Iraq, soldier readiness processing provoked anxiety. He was given a 9-mm Beretta, told to have it on him at all times and warned not to lose it. He walked an improvised explosive device training lane with multiple things exploding around him. He was told to wear one set of dog tags around his neck and another tied to his boot straps, so that his body could be identified if his top half were separated from his bottom half. He was also told always to carry his Geneva Convention card, a document that was supposed to protect him if captured, although in reality, he acknowledged, capture would end with him on television with his head cut off. These preparations induced fear and a feeling of complete lack of safety and security. Soldiers live under such conditions for months at a time.
A patient the psychiatrist treated in Iraq was part of a unit that was sent out to patrol the streets and whose HUM-V was hit by a 500 lb improvised explosive device. All of the soldiers in the unit survived the explosion, but each was wounded in some way, some with traumatic brain injuries and many with post-traumatic stress disorder.
Suicide in military culture
The same psychiatrist described military culture as one that embraces and embodies suicide. Shortly after joining the military he was told to "save the last round for himself". Suicide Charley is the mascot of the 1st Battalion, 7th Marines. The poem Fiddler's Green ends "and the hostiles come to get your scalp, just empty your canteen, and put your pistol to your head, and go to Fiddler's Green."