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Introduction: The Complexity of PTSD

Ron, a strong fifth-generation Israeli, volunteered for the parachutists, an elite and demanding corps. During the 1973 Yom Kippur War, he served as a squad commander in a unit he helped train. Ron sustained a combat stress reaction in his first heavy fight in that war. His description of his experiences in the battlefield illustrates the essence of the breakdown—the helplessness he felt in the face of his inability to cope with the threat:

What we went through in Yom Kippur wasn’t pleasant... . I saw a lot of wounded and a lot of guys who died of their wounds because we couldn’t reach them. They cried out for help. The shelling was heavy, and you can’t get to them. And all the while they’re slaughtering, and the wounded are dying like flies. I remembered the feeling of utter impotence. In just another minute, they’ll finish me off. I’ll die. And there’s no way out.

I was waiting for a miracle. I asked myself, “Why the hell did you volunteer for the parachutists, of all things? Who needs it? What am I doing here?” I saw dying men, soldiers of mine, who’d been training for several months, call me to help them. I want to go over, but I can’t! My legs won’t carry me. Even if it might have been possible to reach them, I couldn’t have gone. I wanted to walk, but found myself crying. I was sweating, crying and trembling. I was shaking, shaking like a leaf. A madness of fear ... I was rooted in one spot. I was lying there and couldn’t get up.1

Ron, like many people throughout the world, was experiencing symptoms of PTSD in response to a traumatic event—in this case, war. As has been well-documented, trauma exposure places a major psychological toll on the population. In this chapter, we address one of its most conspicuous outcomes, PTSD, focusing in particular on war-related PTSD. PTSD includes four major symptom clusters: (a) re-experiencing of the traumatic event, (b) avoidance of stimuli that are reminiscent of the traumatic event, (c) negative alterations in cognitions and mood that are associated with the traumatic event, and (d) increased physical arousal.2

Whereas the key factor required for the diagnosis of PTSD is exposure to a traumatic event, PTSD is not the only response to traumatic stress. In fact, research suggests that the human response to trauma varies considerably, and we often observe other psychological effects occurring in addition to or instead of PTSD. These include disorders such as anxiety, depression, substance misuse, and somatization, as well as adaptive responses.3 At the same time, however, most survivors are able to cope with the trauma and resume highly functional lives.1 A complex causal pathway links trauma and PTSD, and individual reactions may change with time. Post-traumatic responses evolve along many different courses, aligning with any number of disorders, comorbidities, or related psychological sequelae.2

In the hours, days, and months following a traumatic event, it is possible to identify acute stress reactions that in some cases might lead to acute or even chronic PTSD, as shown in Figure 11.1. This general classification does not represent the only stress response pathway. For example, PTSD can develop de novo months or years later in the absence of an acute subclinical or clinically diagnosable reaction. In the first 48 hours after a traumatic event, the clinical picture is conceptualized as an acute stress reaction (ASR), a short-lived state that remits on its own. When classical PTSD symptoms are present for 3 days to 1 month after exposure, the person is classified as having acute stress disorder (ASD), which by definition is a short-term symptomatic response. The exact mechanism of ASD and its implications for later acute or chronic PTSD onset are unclear. In many studies, at least half of ASD cases go on to develop PTSD,4 either in its acute form (4-12 weeks post-trauma) or as a chronic condition (lasting 12 weeks or more).2 As noted, PTSD can occur among individuals who did not exhibit ASD in the early period after trauma exposure.

This chapter focuses on combat exposures, which are among the most threatening of all traumatic events. Combat exposes soldier, often in their late teens and early 20s, to a surfeit of stressors, the worst of which are undoubtedly the imminent risks of injury, capture, torture, and death. Other combat-related stressors include the loss of friends, killing or witnessing killing, exposure to ghastly scenes of injury and death, and significant physical discomfort due to lack of sleep, food, water, or temperature extremes. Also common are feelings of loneliness, lack of social support, and lack of privacy. In the anecdote presented earlier, Ron experiences multiple stressors at once, and his extreme immediate response is that of an acute stress reaction.1

Time and course of possible reactions following a traumatic event

Figure 11.1 Time and course of possible reactions following a traumatic event.

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