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Since returning from active duty overseas, my husband is having nightmares, is afraid to go out, and is quieter than his usual self. Is this posttraumatic stress? Will it go away?

Posttraumatic stress disorder is a common combat casualty for many soldiers returning from war. It is associated with three primary symptoms that persist for longer than a month after a traumatic event: (1) reexperiencing[1], such as flashbacks or nightmares or intense memories; (2) hyperarousal[2], such as jumping at noises one used to ignore; and (3) numbing[3], such as an inability to feel pleasure and a tendency to isolate.

After the intensity of combat where life is "black and white," civilian life appears drab and overly complicated, further adding to the distress and isolation. There is a strong possibility that posttraumatic stress disorder will lead to substance abuse and depression if left untreated. In some studies, as many as 52% develop alcohol abuse or dependence and 47% develop depression. In a recent study of U.S. soldiers returning from Iraq, approximately 16% said they were experiencing symptoms of depression and anxiety associated with posttraumatic stress disorder. The highest rates of symptoms result from being shot at, being ambushed, receiving artillery, shooting or directing fire at the enemy, or seeing human remains. Natural disasters are less prone to result in posttraumatic stress disorder than man-made disasters.

There is no absolutely clear understanding of why some soldiers are at greater risk for developing post-traumatic stress disorder than others. Aside from the type of exposure as mentioned previously, it appears that reservists are more prone than careerists. Additionally, premorbid personality and mental health factors may play a role, as well as prior exposure to traumatic incidents. Finally, cultural and political factors as well as social supports have impact on the soldiers. The lack of clear identification of friend from foe during their tour of duty, their sense of society's attitude toward them and the war after returning from their tour, and the support system available to them after return have significant influence on soldiers' vulnerability to mental illness. Unfortunately, many, if not most, soldiers will not admit to having a problem or seek help. They have been trained to "suck it up," and any admission of emotional problems related to their duty is an admission of weakness in the face of their responsibility. Those who usually do admit to the problems are ostracized and accused of weakness. As noted in Question 71, the earlier your spouse gets into treatment, the better the chance for a positive outcome.

I am not getting any better despite numerous medication trials. My doctor says I have a personality disorder that medication will not treat and recommends more intensive therapy. What does she mean by that?

As mentioned in previous questions concerning the DSM-IV-TR, the diagnosis of a personality disorder is a complicated and controversial issue. As noted in Question 4, the DSM-IV-TR divides different diagnoses into Axis I, or major mental illnesses, and Axis II, or personality disorders. Axis III is for coding of medical conditions. The notion that personality disorders are separate from major mental illnesses partly stems from an understanding that there is a difference between the changing states of mood and thinking over time and those personality traits that seem a part of what makes a person who he or she is. For example, there are people who are naturally outgoing, gregarious, and quick to try new things. And as well there are those who are shy, reserved, and uncomfortable in new and unfamiliar situations and environments. Most people have some elements of both traits that vary with particular situations, but the traits are generally of an enduring quality. But whether or not one is shy or outgoing by nature, depression can plague both types.

The DSM-IV-TR defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment"

Consider some well-known celebrities who have recently spoken in public of their struggles with depression. These celebrities are generally gregarious people who seem to have everything going for them so it comes as a surprise when they speak of their depression and its treatment. One naturally thinks of a depressive personality when one thinks of someone struggling with depression. But depression can affect anyone. The treatment fortunately restores one back to his or her "old self," which can include all the idiosyncratic behaviors or "quirks" of personality that define who one is as a person.

The attempt to classify personality has a rich and complicated history that remains unfinished, including psychoanalysis, with its narrative approach, as well as psychometrics, with various paper and pencil tests. But personality has been difficult to classify because most people have personalities that do vary somewhat with their circumstances and the people around them. The DSM-III and its various editions since, as a manual of psychopathology, has attempted to classify personality when it goes wrong or when it leads to distress or disability. The Diagnostic and Statistical Manual of Mental Health Disorders-IV-TR (American Psychiatric Association, 2000) defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment."

Medication has traditionally not been an effective treatment for personality disorders. Instead, intensive psychotherapy has been the recommended intervention. Although this rule generally remains in effect, recently, particularly with the introduction of SSRIs, some personality traits have appeared to respond to medication. This has been particularly true for traits that involve extremely shy, reserved individuals traditionally known as having avoidant personality disorders but are now often diagnosed under Axis I with social phobia. As a result, the boundary between Axis I and Axis II has become blurred, offering new hope for individuals previously thought to benefit only from intensive outpatient therapy. There are now, however, challenging ethical questions regarding the use of medications to alter personality "cosmetically" along the same lines that plastic surgery cosmetically alters physical appearance.

Although this example illustrates the advancement psychopharmacology has made in the past decade, unfortunately, most personality disorders are not as responsive to medication interventions as therapy. In particular, for a condition known as borderline personality disorder, dialectical behavior therapy in addition to medication remains the standard of care. Borderline personality disorder remains one of the most difficult and devastating personality disorders to diagnose and treat. It is accompanied by inner feelings of rejection sensitivity; rapidly shifting moods, which are extreme and directly related to good or bad news received; and severe self-injurious behavior with frequent impulsive suicide attempts. Even with mood-stabilizing and antidepressant medication, the behaviors can continue to plague individuals and their families with frequent hospitalizations and an increased frustration for everyone involved. Many times these individuals have multiple psychiatric diagnoses that can be as much an attempt to stabilize them with medication as a sense of frustration regarding lack of response to multiple treatment interventions. Although such a patient may view recommendations for intensive therapy as another example of abandonment, it is exactly what is required to have a chance at getting better. Often, more than one care provider working in a team that provides both medication and therapy is a useful treatment approach, and any recommendation short of including intensive therapy would not be in the patient's best interest.

  • [1] the phenomenon of having a previous lived experience vividly recalled and accompanied by the same strong emotions one originally experienced.
  • [2] a heightened state of alertness to external and internal stimuli, often resulting in sleep disturbance, problems concentrating, hypervigilance, and exaggerated startle response. This is typically seen in posttraumatic conditions.
  • [3] the psychologic process of becoming resistant to external stimuli so that previously pleasurable activities become less desirable.
 
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