Clinical Presentation of PTSD in World War II Combat Veterans Robert
J an
Hierholzer,
Munson,
M.D.
D.O.
Carol
Peabody,
R.N.
John
Rosenberg,
L.C.S.W.
Clinicians have increasingly recognizedposttraumatic stress disorder (PTSD) among Vietnam veterans, but the disorder may be easily overlookedamong World War ii combat veterans. The authors review recent studies of PTSD in older veterans and describe five cases that illustrate the diverse clinical presentations ofPTSD in this population. Symptoms included anxiety, cognitive and somatic complaints, depression, akohol dependence, and amnestic periods. Despite the variedpresentations, a fairly consistent patient profile emerged. Patients avoided reminders of war, showed an exaggerated startle response, and experienced restless sleep and chronic anxiety. Factors associated with exacerbations of symptoms were retirement and reminders of war experiences. Although past studies have emphasized resuppression of the trauma, the authors encourage a flexible approach to treatment, including exploratory techniques.
Dr.
Hierhoizer
trist
in the
is senior
emergency
psychiapsychiatric
Medical Center, Avenue, Fresno, California 93702. He is also assistant professor ofpsychiatry at the service
445
at
South
Valley Cedar
University Francisco, Munson
of in
California, Fresno, where
is a resident
try. Ms. Peabody berg are affiliated erans
Fresno,
816
Affairs
where
in
and with
San Dr.
psychia-
Mr. Rosen-
Medical
the VetCenter in
this work
was done.
Over the past several years, interest in traumatically induced psychiatric disturbances has increased (1). It is our impression that while notable efforts have been made toward identifying and treating Vietnam veterans with posttraumatic stress disorder (PTSD), the disorder has been poorly recognized in World Wan II veterans, many of whom do not seek treatment in Veterans Affairs hospitals (2). In working with veterans, we have noted diverse presentations of PTSD among those who served in World Wan II. It seems likely that the diversity of the presentations, coupled with the reluctance of these veterans to talk about their war expeniences, have made recognition of PTSD in this group difficult. In this paper, we review recent studies of PTSD among older veterans. We then describe five cases of PTSD in older veterans that highlight its diverse presentations and responses to treatment.
(POWs), have found evidence of PTSD in 3 to 56 percent of combat veterans (4-7). Speed and associates (4), for example, found a 50 percent prevalence of retrospectively diagnosed PTSD during the year after repatriation in a sample of former POWs, and a 29 percent prevalence 40 years after the war. Clinicians may find that patients with PTSD have been diagnosed otherwise. Rosen and associates (8) looked for evidence of PTSD among psychiatric inpatients admitted for diagnoses other than PTSD. At the time ofthe study, more than 40 years after the end of the war, 50 percent showed evidence of partial PTSD, and 27 percent met full criteria for PTSD. While these veterans presented with a variety of diagnoses, the authors found a particular association between current PTSD and generalized Kluznik
anxiety
disorder.
Previous studies This review focuses on more recent, post-DSM-III studies of PTSD in older veterans. A recent review noted that several pre-DSM-III studies in the 1950s and 1960s demonstrated a significant prevalence among World War II combat veterans of PTSDlike symptoms such as an increased startle response, sleep disturbances, and avoidance of war reminders (3). These studies also revealed continued impaired functioning in a significant number of combat veterans 1 5 to 20 years after the war. More recently, those who have looked systematically for evidence of PTSD in World War II combat veterans have had little difficulty finding it. Several studies, mainly cxamining former prisoners of war
and associates (6) found a high incidence of non-PTSD diagnoses, such as generalized anxiety disorder, alcohol abuse or dependence, and major depression among a group of POWs, but did not find an association between PTSD and these other diagnoses. Dent and colleagues (9) reported a high postwar prevalence ofdepnessive illness (dysthymia or major depression) among World War II combatants studied 40 years after the war: 44.7 percent among POWs and 22.7 percent among nonPOWs. Davidson and associates (10) found a temporal progression of diagnoses in both Vietnam veterans and World War II veterans from generalized anxiety disorder to panic disorder to major depression and intermittent depression. Rather than a progression of diagnoses, other investigators have noted a nonstatic, fluctuating course (4,5,
August
Hospital
1992
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43
No.
8
and
Community
Psychiatry
8). Symptoms fluctuate with stressors, and many subjects who retrospectively appear to have had PTSD immediately after repatriation recoven or improve significantly. Some have suggested a link between later alcohol consumption and prior combat exposure (1 1), although not all have found such a connection (6). The literature suggests that PTSD in World War II veterans may look somewhat different than PTSD in Vietnam veterans. World War II veterans more often experience anxiely, feelings of estrangement, withdrawal, and sleep disturbance (8) than nightmares or dissociative phenomena (denealization or flashbacks), which are more commonly seen in Vietnam veterans (10). Whether the symptoms ofPTSD actually differ in this group or whether this finding is due to sampling veterans at different times in the course of their PTSD is unclear. In addition, it has been noted that World War II veterans retnospectively viewed their trauma as being related to events that threatened their own physical integrity on freedom, such as physical injury, incapacity, or captivity, as opposed to Vietnam veterans who saw their trauma as being related to brutality, mutilated bodies, the death of children, on loss of a friend (10). Investigating personality in chronic PTSD, Davidson and associates (12) found increased scores on the intro-
raise intriguing questions about the potential benefits of adversity, and the conditions that are necessary to transform adversity into an opportunity
for growth.
Little research has been done on treatment of PTSD in World War II veterans (3). A wide range of treatments from psychotherapy to pharmacotherapy have been tried (14). Many previously published case reports have emphasized resuppnession of the trauma by reinvolvement in routine, j udicious use of pharmacotherapy, and avoidance of exploratory techniques, alcohol, and war neminders (1 5-17). Black and Keene (18) found implosive techniques useful. A variety ofpsychotropic agents, including benzodiazepines, tnicyclic antidepressants, monoamine oxidase inhibitors, lithium carbonate, beta blockers, clonidine, carbamazepine, and antipsychotics, have been used to treat PTSD, with none universally successful
(19,20).
A recent study with amitnipryline involving veterans of World War II, Vietnam, and Korea found “overall modest benefit” for amitniptyline (21). The drug reduced the avoidance symptoms of PTSD and improved symptoms of anxiety and depression; the benefit, however, was reduced among veterans with comorbid diagnoses of major depression, panic disorder, and alcohol abuse.
Inventory. The latter finding was felt to reflect a measure of denial and conformity in these aging veterans, rather than any attempt to deceive. Studies have found that not all effects of war trauma are negative. While a long-term longitudinal study found the expected ill effects of heavy-combat exposure (13), the heavy-combat veterans reported positive effects of their war expeniences, notably an ability to cope with adversity, self-discipline, and an appreciation for the value oflife. These veterans, who had been psychologically assessed before the war and who were reassessed at midlife, were felt to have become more assertive and resilient than veterans with less or no combat experience. These findings
Case reports In general, previously published case reports of World Wan II veterans with PTSD depicted individuals who had mild, chronic PTSD symptoms (if any symptoms at all) and who had no history of psychiatric treatment until the emergence of clear PTSD symptoms many years after the war (15-17,22). Factors associated with the onset of fulminant PTSD symptoms included ingestion of alcohol (1 5 ,22), retirement (16), medical problems (16,17), wan movies (1 5), and life situations paralleling wan experiences (22). From these reports emerges a picture of veterans who have been occupationally functional to the point ofworkaholism. Symptoms of PTSD resolved ftirly quickly with medications or brief therapies that em-
Hospital
August
version
and
lie scales
and Community
of the
Eysenck
Psychiatry
1992
Vol. 43
No.8
phasized resuppression ofthe trauma rather than uncovering, exploration, or abreaction. Similarly, our patients have generally been occupationally functional, although some had prior psychiatnic treatment and most had clear evidence of chronic PTSD. We have not found that symptoms have resolved so readily, nor have we necessanily seen problems with exploratory therapy that encourages the veteran to discuss his war experiences in detail. Case 1 In this case, PTSD presented as anxiety and cognitive cornplaints. Mr. A, a 69-year-old married retired postal worker, had longstanding diagnoses of “dementia, .
etiology
undetermined,
and
general-
ized anxiety disorder.” Although he complained offorgetfulness and anxiety, he accurately pointed out that he remained active with bowling and volunteer work. A neurology consultation 1 2 years earlier indicated that Mr. A had an “anxiety disorder with secondary cognitive problems.” IQ tests showed no significant changes over the past 1 2 years. Mr. A had been given trials of antidepressants and buspirone. For the past several years, he had been taking hydroxyzine
and
diphenhydramine,
with a modest reduction in his anxiely. His wife reported that he had been “nervous” even since the war and that the condition had significantly worsened in 1984 after he visited European battlefields. At that time he was frightened to discover that he could not recall what he had done during battle on how he had earned a Bronze Star. Mr. A had been a restless sleeper for years and had war-related nightmares until the early l960s. He startled easily, and once accidently broke his wife’s jaw when she startled him from behind. After he retired, he spent increasing amounts of time perusing scrapbooks from the war, partly in an effort to recall his role in battle. He was initially reluctant to talk about his wan experiences, but after a few individual sessions he recalled that he accidently killed a friend in battle. He was reluctant to acknowledge any connection between his wan experiences and his
817
He experienced significant relief of his depressive symptoms with the nortniptyline and psychotherapy. He has continued to maintain sobriety, has less need to isolate himself, and no longer has the rage episodes. The easy startling persists, and the nightmares continue, although they are not as frequent. Case 4. In this case PTSD presented with somatic complaints. Mn.
chronic PTSD such as intrusive thoughts of combat, survivor guilt, and guilt about killing German soldiers. All the symptoms were exacerbated on anniversary dates. A few months before Mr. B came to the clinic, he began having combat-related nightmares about the fighting that occurred immediately before his capture. Mr. B was initially treated for major depression with trials of six weeks each of nortniptyline and trazadone along with weekly mdividual psychotherapy. He made no improvernent with either antidepressant but ultimately showed a favorable response to clonazepam (.25 rng twice a day). He felt calmer and less depressed, and he slept betten. His wife commented that he was the best she had seen him in 40 years. This patient demonstrated cvidence ofPTSD and dysthymia with a
major depression. Although symptoms of chronic PTSD persisted, he felt less depressed and better able to cope with the symptoms. Whether this improvement was due to medication, psychotherapy, or the passage of time nemains unclean. Case 3. In this case PTSD presented with alcohol dependence and major depression. Mr. C, a 65-yearold World War II veteran with no prior psychiatric treatment, came to the hospital with complaints of severe depression, crying spells, and suicidal ideation about which he was embarrassed. His depression had started after his retirement two years previously. Most alarming to him, however, were “fits of rage” during which he would “lose control and start breaking furniture” at the slightest provocation. These episodes began in 1989 after his son in the military was deployed in Panama. Mr. C worried that he might hurt his wife. Increasingly feeling a need to be alone, he would go to a nearby creek and “sit and stare at the sky. He also began to experience intrusive wartime recollections and nightmares. Since the war he startled easily and avoided war movies or photographs. He had begun to drink alcohol heavily during the previous year, and tial treatment was directed at this problem. When he successfully completed an inpatient alcohol program, Mr. C felt that his depression was relieved. However, after three months of abstinence, his wife contacted us stating that his depression had returned. On several occasions he had taken a shotgun with him to the nearby creek. Mr. C was started on nontriptyline and weekly individual therapy. In therapy, he revealed more about his traumatic war experiences as an aircraft gunner. His aircraft was shot down over Germany, and two crewman were killed and two seriously wounded. The rest were immediately captured except for Mn. C and a friend, who evaded capture for 11 days. He expressed remorse that he had been spared and shame that he had hidden and watched as his buddies were captured.
818
August
Hospital
current symptoms. After attending one group therapy session, he cornplained that he felt more anxious. He then declined further therapy except for medication visits. Although Mr. A’s symptomsamnesia, sleep disturbance, trouble concentrating , chronic anxiety, and an exaggerated startle response-did not meet all criteria for PTSD, they were most consistent with a diagnosis of PTSD. His symptoms markedly worsened with retirement and with neexposure to the site of his trauma. We found no convincing cvidence that he was demented. His medical work-up was unremarkable. Rather, anxiety made it difficult for him to concentrate, with consequent forgetfulness, perhaps exacerbated by the anticholinergic effects of his medications. Case 2. In the second case, PTSD presented as dysthymia with superimposed major depression. Mr. B was a 70-year-old retired former POW who had been held in a European prison. He complained of depressed mood, insomnia with frequent waking, poor appetite, tearfulness, and suicidal ideations. He was chronically anxious and depressed, startled easily, and was upset by reminders of the war. Further evaluation revealed not only his traumatic combat and
POW
experiences
but other signs
of
superimposed
“
mi-
1992
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No.
8
D, a 66-year-old
ex-Marmne
with
cx-
tensive combat exposure, was admitted to the cardiac care unit for the third time in two months because of chest pain. When no cardiac abnormalities were found, a psychiatric consultation was requested. Mr. D revealed little during the interview until his military experiences were explored. Suddenly, he started crying uncontrollably, which embarrassed him. Since the Persian GulfWar, Mr. D had experienced crying spells that he found frightening. A few months before the wan he had attended a reunion of his Marine buddies. He also revealed that he had begun to isolate himself more and to avoid watching any newscasts about the Persian GulfWar. Nightmares of his World Wan II combat experiences began occurring frequently; they had previously been rare. He expressed particular remorse about a picture of himself and his buddies that found its way into newspapers and that showed them holding the severed heads of their enemies. Mr. D recollected that Eleanor Roosevelt had commented to the press that these men should not be allowed to return immediately to civilian life. The patient received individual psychotherapy at a vet center specializing in the treatment oIPTSD. The treatment allowed him to discuss his wartime trauma, which he thought he had “buried” when he burned his military uniform in 1947. While finding it exceedingly painful to cxpose his emotional wounds, he cxpressed relief that his symptoms were normal for his experiences and not indicative of some other psychiatric disorder. Since he began visiting the vet center six months ago, Mr. D has had neither chest pain non fears of having a heart attack, al-
and
Community
Psychiatry
though therapy has been stormy and difficult at times. Case 5. In this case, PTSD presented with complaints of anxiety and “blackout spells.” Mn. E, age 65, complained that ever since World War II he experienced extreme ncrvousness that was somewhat alleviated by chewing tobacco. He also complained ofamnestic periods lasting from seconds to minutes that he called blackout spells. He had expenienced about eight such episodes in the month before he came to the hospital. Mr. E stated that others would not tell him what happened during the blackout episodes, but family members reported that sometimes he would take his clothes off, pull at his hair, and scream. He was amnestic for a six-week period of his military service, during which he had been told that he was “crazy” and unfit for duty. After this wartime episode, his nervousness-consisting of sub jective feelings ofanxiety, itching, and shaking-developed. Mr. E soon discovered that tobacco, smoked or chewed, offered partial relief. Keeping busy with work helped control his anxiety, but he found that working even 1 6 hours a day did not entirely control it. Since his retirement in 1984, he had been unable to stay as busy as when he was employed, and his symptoms of nervousness worsened.
Medical work-up including an electroencephalogram, a 24-hour Holter monitor, and a computed tomognaphy scan of the head showed no abnormalities. Further evaluation revealed that Mn. E had a history of avoidance of war reminders such as war movies. He experienced combatrelated nightmares and “daydreams” that he described as “real.” He had chronic difficulty expressing feelings to those he was close to and had trouble concentrating. During the war Mr. E manned a landing craft that transported soldiers to the beaches. He was particulanly distraught about an experience in which he felt something underfoot on a sandy beach and discovered that he was stepping on the ftce ofa dead
GI. He also described which
Hospital
his
ship
had
and Community
Discussion A fairly consistent patient profile emerges from these cases, although there are cleanly a wide variety of symptomatic presentations. These are men who held jobs, raised families, and thought that they had put the war behind them. Careful cxamination, however, revealed that the war was not entirely behind them. They consistently avoided reminders of wan, showed an exaggerated startle response, and expenienced restless sleep and chronic anxicty. They worked hand, in some cases extremely long hours, apparently to deal with chronic anxicry.
None liked to talk about his war experiences, which supports earlier descriptions ofdenial (12). Most saw little point in talking about these cxpeniences. They did not parade into sessions in military attire, nor talk in heroic terms oftheir exploits. It is as if the constant activity of work and family and the avoidance of wan reminders were successful in preventing the more disabling aspects of PTSD. Factors associated with cxacerbations
ofPTSD
were
retirement
torpedoed
and reminders of war experiences such as visits to battlefields, military reunions, and the recent conflicts in Panama and the Persian Gulf. The initial clinical presentations and complaints of these patients were diverse: chest pain, amnesia, cognitive deficits, and depression. We feel that in each case the diagnosis of PTSD most fully explained
Psychiatry
August
an incident been
and several crewmen killed. He cxpenienced intense survivor guilt about this incident, and it was the precipitant for his six-week amnestic episode. Mr. E was not treated with mcdications but derived much benefit from group therapy with other World War II combat veterans. At one session, after relating the two traumatic incidents, Mr. E became nonresponsive for two to three mmutes. He reacted with a startle when the group therapist walked oven and touched his shoulder. Since that mcident in the group almost a year ago, Mr. E has felt markedly less nervous and has experienced no further blackout episodes.
in
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the clinical picture, although specific inquiry had to be made to elicit the traumatic history and characteristic symptoms of PTSD. The reemergence of dramatic, disabling symptoms of PTSD in individuals who have been functional and relatively asymptomatic has profound implications. It accords with the view that PTSD is a chronic condition marked by exacerbations and remissions (4,5,8). Ifthis view is correct, we may expect a second wave ofPTSD in seemingly well-adjusted veterans ofother conflicts as they age and experience the kinds of stressors, losses, and life changes shared by these aging World War II veterans. Apparently no treatment for PTSD is uniformly effective. Like others, we have sometimes found pharmacotherapy useful. Unlike previous investigators who emphasized the resuppression of symptoms and the avoidance of exploratory techniqucs in therapy, we found exploration and ventilation frequently of great help. Although some veterans, such as Mn. A, are not good candidates for this type of therapy, others, such as those in cases 2, 4, and 5, have derived benefit. In previously published case reports, the World War II veterans were still of working age, and thus it was easier to reimmerse them in routine. With an older population, reinvolvement in the work routine is often not feasible, and health problems are harder to ignone. In addition, it seems impossible-and undesirable-to inhibit the age-appropriate review and consideration ofone’s life experiences. We urge mental health professionals to inquire carefully about past combat and traumatic expeniences no matter what diagnostic label is attached to the patient. We also suggest that clinicians remain flexible in their choice of therapies for this group ofpaticnts and not immediately discount the value of cxploratory therapy.
References 1. Van der Kolk BA: Psychological Trauma, 1st ed. Washington, DC, American Psychiatric Press, 1987 2. Beebe GW: Follow-up studies of World
819
War II and Korean prisoners. American Journal ofEpidemiology 101:400-422, 1975 3. Schnurr PP: PTSD and combat-related psychiatric symptoms in older veterans. PTSD Research Quarterly 2: 1-2, 1991 4. Speed N, Engdahl B, Schwartz J, et al: Posttraumatic stress disorder as a consequence of the POW experience. Journal of Nervous and Mental Disease 177: 147-153, 1989 5. Zeiss RA, Dickman HR: PTSD 40 years later: incidence and person-situation correlates informerPOWs.Joumal ofClinical Psychology
45:80-86,
6. KluznikJC,Speed Ct al: Forty-year States prisoners
ofPsychiatry 7.
8.
1989
N, VanValkenburg C, fullow-up of United ofwar.
AmericanJoumal
143:1443-1446,
and emotional
1986
Hamilton JD, Canteen W: Posttraumatic stress disorder in World War II naval veterans. Hospital and Community Psychiatry 38:197-198, 1987 Rosen J, Fields RB, Hand AM, et al: Concurrent posttraumatic stress disorder in
psychogeriatric
Geriatric 65-69,
patients.
Psychiatry
and
of Nervous and Mental Disease 175: 486-490, 1987 10. Davidson JRT, Kudler HS, Saunders WB, et al: Symptoms and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress disorder. Comprehensive Psychiatry 31:162170, 1990 1 1 . Parette HP, Farrow BJ, FarrowJM, et al: The aging war veteran and alcohol abuse: an emerging relationship? Perceptual and Motor Skills 68:985-986, 1989 12. DavidsonJ, Kudler H, Smith R: Personaliry in chronic post-traumatic stress disorder: a study of the Eysenck Inventory. Journal of Anxiety Disorders 1:295300, 1987 13. ElderGH, Clipp EC: Combat experience
Journal
of
Neurology
2:
1989
9. Dent
OF, Tennant CC, Goulston KJ: Precursors of depression in World War II veterans 40 years after the war.Journal
14.
impairment
Sadock
BJ.
Baltimore,
Williams
stress in a World
American
Journal
1070-1073, Richmond
1985
18.
disorder:
a thirty-
War
II veteran.
of Psychiatry
Beck
JS,
stress disorder
JC:
in a World
(ltr). American 143:1485-1486, BlackJL, Keene in the treatment in a World
19.
20.
Journal of Psychiatry 1986 TM: Implosive therapy ofcombat-related fears
War
II veteran.
Journal
1982 BA: The drug treatment stress disorder.Journal
of
Disorders
Affective
1987 Birkhimer
U,
teristics
DeVane
stress
CL, Muniz
disorder:
population.
Psychiatry Davidson
26:304-3
response
in
Comprehensive
ofposttraumatic
der with amitriptyline
CE:
charac-
10, 1985 H, Smith
J, Kudler
Treatment
R, et al:
stress
disor-
and placebo. ArPsychiatry 47:259-
chives of General 266, 1990 Hamilton JW: Unusual long-term sequelae of a traumatic war experience. Bulletin
NJ, McKinnonJA:
13:203-213,
and pharmacological
the veteran
22.
of
Experi-
Van der Kolk ofpost-traumatic
Posttraumatic
21.
142:
Posttraumatic War II veteran
Behavioral Therapeutics and mental Psychiatry 1 3:163-165,
&
Wilkins, 1989 Brockway 5: Case report: flashback as a post-traumatic stress disorder (PTSD) symptom in a World War II veteran. Military Medicine 1 53:372-373, 1988
16. Van DykeC,Zilberg
17.
and
resilience in later life. Journal of Personality 57:311-341, 1989 Kinzie JD: Post-traumatic stress disorder, in Comprehensive Textbook of Psychiatry, 5th ed, vol 1. Edited by Kaplan HI,
15.
health:
Posttraumatic
year delay
of
539-541,
the
Menninger
Clinic
46:
1982
CultUral Influences in Psychotherapy With Refugee Survivors of Torture and Trauma Patrick Derrick
Morris, Silove,
M.B.B.S. M.B., Ch.B.
A sekctive review of the literature describing treatment of refugee survivors oftorture and trauma reveakd that approaches to psychotherapy used in treating South American patients differed from those used in treating Indochinese patients. South American patients
Dr.
Morris
psychiatric Hospital,
town,
New
Australia.
psychiatrist
Wales and
820
is deputy services Eldridge
director
of
at Bankstown Road, BanksWales, 2200,
Service
subcommittee.
Dr.
Dr. and Si-
love is also professor and director of mental health services at the South Western Sydney Area
for the Treatment ofSurvivors
Torture and Trauma, where Siove is chair of the clinical research
South He is also consultant at the New South
Rehabilitation
were receptive to psychodynamic psychotherapeutic approaches that focused on detaikd recolkction of past trauma. lndocbinese patients responded to a broader-based rehabiitation approach that could indudepsychotropic medication, supportive psychotherapy, and assistance in meeting practical needs. The authors suggest that many of the differences in treatment of the two groups may be attributed to
Health
of
Service
in
Sydney,
1992
Vol. 43
Aus-
tralia.
August
No. 8
culturalfactors, with South American patients reflecting an affinity for the Western philosophical assumptions in which psychodymimic therapy is rted and indochinese patients reflecting a cultural background that values responsibiity to the group, deference to authority, and restrained modes ofemotional expression. The number of displaced persons throughout the world was estimated in 1989 to be more than 15 million (1). Due to rapidly changing political situations, that number may have become considerably larger in the past three years. Many of these pensons are survivors of severe trauma, including torture, although not all of them would meet DSM-iIi-R cnite-
Hospital
and
Community
Psychiatry
J an
Hierholzer,
Munson,
M.D.
D.O.
Carol
Peabody,
R.N.
John
Rosenberg,
L.C.S.W.
Clinicians have increasingly recognizedposttraumatic stress disorder (PTSD) among Vietnam veterans, but the disorder may be easily overlookedamong World War ii combat veterans. The authors review recent studies of PTSD in older veterans and describe five cases that illustrate the diverse clinical presentations ofPTSD in this population. Symptoms included anxiety, cognitive and somatic complaints, depression, akohol dependence, and amnestic periods. Despite the variedpresentations, a fairly consistent patient profile emerged. Patients avoided reminders of war, showed an exaggerated startle response, and experienced restless sleep and chronic anxiety. Factors associated with exacerbations of symptoms were retirement and reminders of war experiences. Although past studies have emphasized resuppression of the trauma, the authors encourage a flexible approach to treatment, including exploratory techniques.
Dr.
Hierhoizer
trist
in the
is senior
emergency
psychiapsychiatric
Medical Center, Avenue, Fresno, California 93702. He is also assistant professor ofpsychiatry at the service
445
at
South
Valley Cedar
University Francisco, Munson
of in
California, Fresno, where
is a resident
try. Ms. Peabody berg are affiliated erans
Fresno,
816
Affairs
where
in
and with
San Dr.
psychia-
Mr. Rosen-
Medical
the VetCenter in
this work
was done.
Over the past several years, interest in traumatically induced psychiatric disturbances has increased (1). It is our impression that while notable efforts have been made toward identifying and treating Vietnam veterans with posttraumatic stress disorder (PTSD), the disorder has been poorly recognized in World Wan II veterans, many of whom do not seek treatment in Veterans Affairs hospitals (2). In working with veterans, we have noted diverse presentations of PTSD among those who served in World Wan II. It seems likely that the diversity of the presentations, coupled with the reluctance of these veterans to talk about their war expeniences, have made recognition of PTSD in this group difficult. In this paper, we review recent studies of PTSD among older veterans. We then describe five cases of PTSD in older veterans that highlight its diverse presentations and responses to treatment.
(POWs), have found evidence of PTSD in 3 to 56 percent of combat veterans (4-7). Speed and associates (4), for example, found a 50 percent prevalence of retrospectively diagnosed PTSD during the year after repatriation in a sample of former POWs, and a 29 percent prevalence 40 years after the war. Clinicians may find that patients with PTSD have been diagnosed otherwise. Rosen and associates (8) looked for evidence of PTSD among psychiatric inpatients admitted for diagnoses other than PTSD. At the time ofthe study, more than 40 years after the end of the war, 50 percent showed evidence of partial PTSD, and 27 percent met full criteria for PTSD. While these veterans presented with a variety of diagnoses, the authors found a particular association between current PTSD and generalized Kluznik
anxiety
disorder.
Previous studies This review focuses on more recent, post-DSM-III studies of PTSD in older veterans. A recent review noted that several pre-DSM-III studies in the 1950s and 1960s demonstrated a significant prevalence among World War II combat veterans of PTSDlike symptoms such as an increased startle response, sleep disturbances, and avoidance of war reminders (3). These studies also revealed continued impaired functioning in a significant number of combat veterans 1 5 to 20 years after the war. More recently, those who have looked systematically for evidence of PTSD in World War II combat veterans have had little difficulty finding it. Several studies, mainly cxamining former prisoners of war
and associates (6) found a high incidence of non-PTSD diagnoses, such as generalized anxiety disorder, alcohol abuse or dependence, and major depression among a group of POWs, but did not find an association between PTSD and these other diagnoses. Dent and colleagues (9) reported a high postwar prevalence ofdepnessive illness (dysthymia or major depression) among World War II combatants studied 40 years after the war: 44.7 percent among POWs and 22.7 percent among nonPOWs. Davidson and associates (10) found a temporal progression of diagnoses in both Vietnam veterans and World War II veterans from generalized anxiety disorder to panic disorder to major depression and intermittent depression. Rather than a progression of diagnoses, other investigators have noted a nonstatic, fluctuating course (4,5,
August
Hospital
1992
Vol.
43
No.
8
and
Community
Psychiatry
8). Symptoms fluctuate with stressors, and many subjects who retrospectively appear to have had PTSD immediately after repatriation recoven or improve significantly. Some have suggested a link between later alcohol consumption and prior combat exposure (1 1), although not all have found such a connection (6). The literature suggests that PTSD in World War II veterans may look somewhat different than PTSD in Vietnam veterans. World War II veterans more often experience anxiely, feelings of estrangement, withdrawal, and sleep disturbance (8) than nightmares or dissociative phenomena (denealization or flashbacks), which are more commonly seen in Vietnam veterans (10). Whether the symptoms ofPTSD actually differ in this group or whether this finding is due to sampling veterans at different times in the course of their PTSD is unclear. In addition, it has been noted that World War II veterans retnospectively viewed their trauma as being related to events that threatened their own physical integrity on freedom, such as physical injury, incapacity, or captivity, as opposed to Vietnam veterans who saw their trauma as being related to brutality, mutilated bodies, the death of children, on loss of a friend (10). Investigating personality in chronic PTSD, Davidson and associates (12) found increased scores on the intro-
raise intriguing questions about the potential benefits of adversity, and the conditions that are necessary to transform adversity into an opportunity
for growth.
Little research has been done on treatment of PTSD in World War II veterans (3). A wide range of treatments from psychotherapy to pharmacotherapy have been tried (14). Many previously published case reports have emphasized resuppnession of the trauma by reinvolvement in routine, j udicious use of pharmacotherapy, and avoidance of exploratory techniques, alcohol, and war neminders (1 5-17). Black and Keene (18) found implosive techniques useful. A variety ofpsychotropic agents, including benzodiazepines, tnicyclic antidepressants, monoamine oxidase inhibitors, lithium carbonate, beta blockers, clonidine, carbamazepine, and antipsychotics, have been used to treat PTSD, with none universally successful
(19,20).
A recent study with amitnipryline involving veterans of World War II, Vietnam, and Korea found “overall modest benefit” for amitniptyline (21). The drug reduced the avoidance symptoms of PTSD and improved symptoms of anxiety and depression; the benefit, however, was reduced among veterans with comorbid diagnoses of major depression, panic disorder, and alcohol abuse.
Inventory. The latter finding was felt to reflect a measure of denial and conformity in these aging veterans, rather than any attempt to deceive. Studies have found that not all effects of war trauma are negative. While a long-term longitudinal study found the expected ill effects of heavy-combat exposure (13), the heavy-combat veterans reported positive effects of their war expeniences, notably an ability to cope with adversity, self-discipline, and an appreciation for the value oflife. These veterans, who had been psychologically assessed before the war and who were reassessed at midlife, were felt to have become more assertive and resilient than veterans with less or no combat experience. These findings
Case reports In general, previously published case reports of World Wan II veterans with PTSD depicted individuals who had mild, chronic PTSD symptoms (if any symptoms at all) and who had no history of psychiatric treatment until the emergence of clear PTSD symptoms many years after the war (15-17,22). Factors associated with the onset of fulminant PTSD symptoms included ingestion of alcohol (1 5 ,22), retirement (16), medical problems (16,17), wan movies (1 5), and life situations paralleling wan experiences (22). From these reports emerges a picture of veterans who have been occupationally functional to the point ofworkaholism. Symptoms of PTSD resolved ftirly quickly with medications or brief therapies that em-
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version
and
lie scales
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of the
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phasized resuppression ofthe trauma rather than uncovering, exploration, or abreaction. Similarly, our patients have generally been occupationally functional, although some had prior psychiatnic treatment and most had clear evidence of chronic PTSD. We have not found that symptoms have resolved so readily, nor have we necessanily seen problems with exploratory therapy that encourages the veteran to discuss his war experiences in detail. Case 1 In this case, PTSD presented as anxiety and cognitive cornplaints. Mr. A, a 69-year-old married retired postal worker, had longstanding diagnoses of “dementia, .
etiology
undetermined,
and
general-
ized anxiety disorder.” Although he complained offorgetfulness and anxiety, he accurately pointed out that he remained active with bowling and volunteer work. A neurology consultation 1 2 years earlier indicated that Mr. A had an “anxiety disorder with secondary cognitive problems.” IQ tests showed no significant changes over the past 1 2 years. Mr. A had been given trials of antidepressants and buspirone. For the past several years, he had been taking hydroxyzine
and
diphenhydramine,
with a modest reduction in his anxiely. His wife reported that he had been “nervous” even since the war and that the condition had significantly worsened in 1984 after he visited European battlefields. At that time he was frightened to discover that he could not recall what he had done during battle on how he had earned a Bronze Star. Mr. A had been a restless sleeper for years and had war-related nightmares until the early l960s. He startled easily, and once accidently broke his wife’s jaw when she startled him from behind. After he retired, he spent increasing amounts of time perusing scrapbooks from the war, partly in an effort to recall his role in battle. He was initially reluctant to talk about his wan experiences, but after a few individual sessions he recalled that he accidently killed a friend in battle. He was reluctant to acknowledge any connection between his wan experiences and his
817
He experienced significant relief of his depressive symptoms with the nortniptyline and psychotherapy. He has continued to maintain sobriety, has less need to isolate himself, and no longer has the rage episodes. The easy startling persists, and the nightmares continue, although they are not as frequent. Case 4. In this case PTSD presented with somatic complaints. Mn.
chronic PTSD such as intrusive thoughts of combat, survivor guilt, and guilt about killing German soldiers. All the symptoms were exacerbated on anniversary dates. A few months before Mr. B came to the clinic, he began having combat-related nightmares about the fighting that occurred immediately before his capture. Mr. B was initially treated for major depression with trials of six weeks each of nortniptyline and trazadone along with weekly mdividual psychotherapy. He made no improvernent with either antidepressant but ultimately showed a favorable response to clonazepam (.25 rng twice a day). He felt calmer and less depressed, and he slept betten. His wife commented that he was the best she had seen him in 40 years. This patient demonstrated cvidence ofPTSD and dysthymia with a
major depression. Although symptoms of chronic PTSD persisted, he felt less depressed and better able to cope with the symptoms. Whether this improvement was due to medication, psychotherapy, or the passage of time nemains unclean. Case 3. In this case PTSD presented with alcohol dependence and major depression. Mr. C, a 65-yearold World War II veteran with no prior psychiatric treatment, came to the hospital with complaints of severe depression, crying spells, and suicidal ideation about which he was embarrassed. His depression had started after his retirement two years previously. Most alarming to him, however, were “fits of rage” during which he would “lose control and start breaking furniture” at the slightest provocation. These episodes began in 1989 after his son in the military was deployed in Panama. Mr. C worried that he might hurt his wife. Increasingly feeling a need to be alone, he would go to a nearby creek and “sit and stare at the sky. He also began to experience intrusive wartime recollections and nightmares. Since the war he startled easily and avoided war movies or photographs. He had begun to drink alcohol heavily during the previous year, and tial treatment was directed at this problem. When he successfully completed an inpatient alcohol program, Mr. C felt that his depression was relieved. However, after three months of abstinence, his wife contacted us stating that his depression had returned. On several occasions he had taken a shotgun with him to the nearby creek. Mr. C was started on nontriptyline and weekly individual therapy. In therapy, he revealed more about his traumatic war experiences as an aircraft gunner. His aircraft was shot down over Germany, and two crewman were killed and two seriously wounded. The rest were immediately captured except for Mn. C and a friend, who evaded capture for 11 days. He expressed remorse that he had been spared and shame that he had hidden and watched as his buddies were captured.
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current symptoms. After attending one group therapy session, he cornplained that he felt more anxious. He then declined further therapy except for medication visits. Although Mr. A’s symptomsamnesia, sleep disturbance, trouble concentrating , chronic anxiety, and an exaggerated startle response-did not meet all criteria for PTSD, they were most consistent with a diagnosis of PTSD. His symptoms markedly worsened with retirement and with neexposure to the site of his trauma. We found no convincing cvidence that he was demented. His medical work-up was unremarkable. Rather, anxiety made it difficult for him to concentrate, with consequent forgetfulness, perhaps exacerbated by the anticholinergic effects of his medications. Case 2. In the second case, PTSD presented as dysthymia with superimposed major depression. Mr. B was a 70-year-old retired former POW who had been held in a European prison. He complained of depressed mood, insomnia with frequent waking, poor appetite, tearfulness, and suicidal ideations. He was chronically anxious and depressed, startled easily, and was upset by reminders of the war. Further evaluation revealed not only his traumatic combat and
POW
experiences
but other signs
of
superimposed
“
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D, a 66-year-old
ex-Marmne
with
cx-
tensive combat exposure, was admitted to the cardiac care unit for the third time in two months because of chest pain. When no cardiac abnormalities were found, a psychiatric consultation was requested. Mr. D revealed little during the interview until his military experiences were explored. Suddenly, he started crying uncontrollably, which embarrassed him. Since the Persian GulfWar, Mr. D had experienced crying spells that he found frightening. A few months before the wan he had attended a reunion of his Marine buddies. He also revealed that he had begun to isolate himself more and to avoid watching any newscasts about the Persian GulfWar. Nightmares of his World Wan II combat experiences began occurring frequently; they had previously been rare. He expressed particular remorse about a picture of himself and his buddies that found its way into newspapers and that showed them holding the severed heads of their enemies. Mr. D recollected that Eleanor Roosevelt had commented to the press that these men should not be allowed to return immediately to civilian life. The patient received individual psychotherapy at a vet center specializing in the treatment oIPTSD. The treatment allowed him to discuss his wartime trauma, which he thought he had “buried” when he burned his military uniform in 1947. While finding it exceedingly painful to cxpose his emotional wounds, he cxpressed relief that his symptoms were normal for his experiences and not indicative of some other psychiatric disorder. Since he began visiting the vet center six months ago, Mr. D has had neither chest pain non fears of having a heart attack, al-
and
Community
Psychiatry
though therapy has been stormy and difficult at times. Case 5. In this case, PTSD presented with complaints of anxiety and “blackout spells.” Mn. E, age 65, complained that ever since World War II he experienced extreme ncrvousness that was somewhat alleviated by chewing tobacco. He also complained ofamnestic periods lasting from seconds to minutes that he called blackout spells. He had expenienced about eight such episodes in the month before he came to the hospital. Mr. E stated that others would not tell him what happened during the blackout episodes, but family members reported that sometimes he would take his clothes off, pull at his hair, and scream. He was amnestic for a six-week period of his military service, during which he had been told that he was “crazy” and unfit for duty. After this wartime episode, his nervousness-consisting of sub jective feelings ofanxiety, itching, and shaking-developed. Mr. E soon discovered that tobacco, smoked or chewed, offered partial relief. Keeping busy with work helped control his anxiety, but he found that working even 1 6 hours a day did not entirely control it. Since his retirement in 1984, he had been unable to stay as busy as when he was employed, and his symptoms of nervousness worsened.
Medical work-up including an electroencephalogram, a 24-hour Holter monitor, and a computed tomognaphy scan of the head showed no abnormalities. Further evaluation revealed that Mn. E had a history of avoidance of war reminders such as war movies. He experienced combatrelated nightmares and “daydreams” that he described as “real.” He had chronic difficulty expressing feelings to those he was close to and had trouble concentrating. During the war Mr. E manned a landing craft that transported soldiers to the beaches. He was particulanly distraught about an experience in which he felt something underfoot on a sandy beach and discovered that he was stepping on the ftce ofa dead
GI. He also described which
Hospital
his
ship
had
and Community
Discussion A fairly consistent patient profile emerges from these cases, although there are cleanly a wide variety of symptomatic presentations. These are men who held jobs, raised families, and thought that they had put the war behind them. Careful cxamination, however, revealed that the war was not entirely behind them. They consistently avoided reminders of wan, showed an exaggerated startle response, and expenienced restless sleep and chronic anxicty. They worked hand, in some cases extremely long hours, apparently to deal with chronic anxicry.
None liked to talk about his war experiences, which supports earlier descriptions ofdenial (12). Most saw little point in talking about these cxpeniences. They did not parade into sessions in military attire, nor talk in heroic terms oftheir exploits. It is as if the constant activity of work and family and the avoidance of wan reminders were successful in preventing the more disabling aspects of PTSD. Factors associated with cxacerbations
ofPTSD
were
retirement
torpedoed
and reminders of war experiences such as visits to battlefields, military reunions, and the recent conflicts in Panama and the Persian Gulf. The initial clinical presentations and complaints of these patients were diverse: chest pain, amnesia, cognitive deficits, and depression. We feel that in each case the diagnosis of PTSD most fully explained
Psychiatry
August
an incident been
and several crewmen killed. He cxpenienced intense survivor guilt about this incident, and it was the precipitant for his six-week amnestic episode. Mr. E was not treated with mcdications but derived much benefit from group therapy with other World War II combat veterans. At one session, after relating the two traumatic incidents, Mr. E became nonresponsive for two to three mmutes. He reacted with a startle when the group therapist walked oven and touched his shoulder. Since that mcident in the group almost a year ago, Mr. E has felt markedly less nervous and has experienced no further blackout episodes.
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the clinical picture, although specific inquiry had to be made to elicit the traumatic history and characteristic symptoms of PTSD. The reemergence of dramatic, disabling symptoms of PTSD in individuals who have been functional and relatively asymptomatic has profound implications. It accords with the view that PTSD is a chronic condition marked by exacerbations and remissions (4,5,8). Ifthis view is correct, we may expect a second wave ofPTSD in seemingly well-adjusted veterans ofother conflicts as they age and experience the kinds of stressors, losses, and life changes shared by these aging World War II veterans. Apparently no treatment for PTSD is uniformly effective. Like others, we have sometimes found pharmacotherapy useful. Unlike previous investigators who emphasized the resuppression of symptoms and the avoidance of exploratory techniqucs in therapy, we found exploration and ventilation frequently of great help. Although some veterans, such as Mn. A, are not good candidates for this type of therapy, others, such as those in cases 2, 4, and 5, have derived benefit. In previously published case reports, the World War II veterans were still of working age, and thus it was easier to reimmerse them in routine. With an older population, reinvolvement in the work routine is often not feasible, and health problems are harder to ignone. In addition, it seems impossible-and undesirable-to inhibit the age-appropriate review and consideration ofone’s life experiences. We urge mental health professionals to inquire carefully about past combat and traumatic expeniences no matter what diagnostic label is attached to the patient. We also suggest that clinicians remain flexible in their choice of therapies for this group ofpaticnts and not immediately discount the value of cxploratory therapy.
References 1. Van der Kolk BA: Psychological Trauma, 1st ed. Washington, DC, American Psychiatric Press, 1987 2. Beebe GW: Follow-up studies of World
819
War II and Korean prisoners. American Journal ofEpidemiology 101:400-422, 1975 3. Schnurr PP: PTSD and combat-related psychiatric symptoms in older veterans. PTSD Research Quarterly 2: 1-2, 1991 4. Speed N, Engdahl B, Schwartz J, et al: Posttraumatic stress disorder as a consequence of the POW experience. Journal of Nervous and Mental Disease 177: 147-153, 1989 5. Zeiss RA, Dickman HR: PTSD 40 years later: incidence and person-situation correlates informerPOWs.Joumal ofClinical Psychology
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6. KluznikJC,Speed Ct al: Forty-year States prisoners
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Hamilton JD, Canteen W: Posttraumatic stress disorder in World War II naval veterans. Hospital and Community Psychiatry 38:197-198, 1987 Rosen J, Fields RB, Hand AM, et al: Concurrent posttraumatic stress disorder in
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of Nervous and Mental Disease 175: 486-490, 1987 10. Davidson JRT, Kudler HS, Saunders WB, et al: Symptoms and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress disorder. Comprehensive Psychiatry 31:162170, 1990 1 1 . Parette HP, Farrow BJ, FarrowJM, et al: The aging war veteran and alcohol abuse: an emerging relationship? Perceptual and Motor Skills 68:985-986, 1989 12. DavidsonJ, Kudler H, Smith R: Personaliry in chronic post-traumatic stress disorder: a study of the Eysenck Inventory. Journal of Anxiety Disorders 1:295300, 1987 13. ElderGH, Clipp EC: Combat experience
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OF, Tennant CC, Goulston KJ: Precursors of depression in World War II veterans 40 years after the war.Journal
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10, 1985 H, Smith
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chives of General 266, 1990 Hamilton JW: Unusual long-term sequelae of a traumatic war experience. Bulletin
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CultUral Influences in Psychotherapy With Refugee Survivors of Torture and Trauma Patrick Derrick
Morris, Silove,
M.B.B.S. M.B., Ch.B.
A sekctive review of the literature describing treatment of refugee survivors oftorture and trauma reveakd that approaches to psychotherapy used in treating South American patients differed from those used in treating Indochinese patients. South American patients
Dr.
Morris
psychiatric Hospital,
town,
New
Australia.
psychiatrist
Wales and
820
is deputy services Eldridge
director
of
at Bankstown Road, BanksWales, 2200,
Service
subcommittee.
Dr.
Dr. and Si-
love is also professor and director of mental health services at the South Western Sydney Area
for the Treatment ofSurvivors
Torture and Trauma, where Siove is chair of the clinical research
South He is also consultant at the New South
Rehabilitation
were receptive to psychodynamic psychotherapeutic approaches that focused on detaikd recolkction of past trauma. lndocbinese patients responded to a broader-based rehabiitation approach that could indudepsychotropic medication, supportive psychotherapy, and assistance in meeting practical needs. The authors suggest that many of the differences in treatment of the two groups may be attributed to
Health
of
Service
in
Sydney,
1992
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tralia.
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culturalfactors, with South American patients reflecting an affinity for the Western philosophical assumptions in which psychodymimic therapy is rted and indochinese patients reflecting a cultural background that values responsibiity to the group, deference to authority, and restrained modes ofemotional expression. The number of displaced persons throughout the world was estimated in 1989 to be more than 15 million (1). Due to rapidly changing political situations, that number may have become considerably larger in the past three years. Many of these pensons are survivors of severe trauma, including torture, although not all of them would meet DSM-iIi-R cnite-
Hospital
and
Community
Psychiatry
