It was not until World War I that specific clinical syndromes came to be associated with combat duty. In prior wars, it was assumed that such casualties were merely manifestations of poor discipline and cowardice. However, with the protracted artillery barrages commonplace during "The Great War", the concept evolved that the high air pressure of the exploding shells caused actual physiological damage, precipitating the numerous symptoms that were subsequently labeled "shell shock". By the end of the war, further evolution accounted for the syndrome being labeled a "war neurosis" (Glass, 1969). During the early years of World War II, psychiatric casualties had increased some 300 percent when compared with World War I, even though the pre induction psychiatric rejection rate was three to four times higher than World War I (Figley, 1978 a). At one point in the war, the number of men being discharged from the service for psychiatric reasons exceeded the total number of men being newly drafted (Tiffany and Allerton, 1967).

During the Korean War, the approach to combat stress became even more pragmatic. Due to the work of Albert Glass (1945), individual breakdowns in combat effectiveness were dealt with in a very situational manner. Clinicians provided immediate onsite treatment to affected individuals, always with the expectation that the combatant would return to duty as soon as possible. The results were gratifying. During World War II, 23 percent of the evacuations were for psychiatric reasons.

But in Korea, psychiatric evacuations dropped to only six percent (Bourne, 1970). It finally became clear that the situational stresses of the combatant were the primary factors leading to psychological casualty. Surprisingly, with American involvement in the Vietnam War, psychological battlefield casualties evolved in a new direction. What was expected from past war experiences and what was prepared for - did not materialize. Battlefield psychological breakdown was at an all-time low, 12 per one thousand (Bourne, 1970). It was decided that use of preventative measured learned in Korea and some added situational manipulation which will be discussed later had solved the age-old problem of psychological breakdown in combat.

As the war continued for a number of years, some interesting additional trends were noted. Although the behavior of some combatants in Vietnam undermined fighting efficiency, the symptoms presented rare but very well documented phenomenon of World War II began to be re observed. After the end of World War II, some men suffering from acute combat reaction, as well as some of their peers with no such symptoms at war's end, began to complain of common symptoms. These included intense anxiety, battle dreams, depression, explosive aggressive behavior and problems with interpersonal relationships, to name a few. These were found in a five-year follow-up (Fut terman and Pump ian- Mind lin, 1951) and in a 20-year follow-up (Archibald and Tud denham, 1965). A similar trend was once more observed in Vietnam veterans as the war wore on.

Both those who experienced acute combat reaction and many who did not began to complain of the above symptoms long after their combatant role had ceased. What was so unusual was the large numbers of veterans being affected after Vietnam. The pattern of neuropsychiatric disorder for combatants of World War II and Korea was quite different than for Vietnam. For both World War II and the Korean War, the incidence of neuropsychiatric disorder among combatants increased as the intensity of the wars increased. As these wars wore down, there was a corresponding decrease in these disorders until the incidence closely resembled the particular prewar periods. The prolonged or delayed symptoms noticed during the postwar periods were noted to be somewhat obscure and few in numbers; therefore, no great significance was attached to them.

However, the Vietnam experience proved different. As the war in Vietnam progressed in intensity, there was no corresponding increase in neuropsychiatric casualties among combatants. It was not until the early 1970's, when the war was winding down, that neuropsychiatric disorders began to increase. With the end of direct American troop involvement in Vietnam in 1973, th During the same period in the 1970's, many other people were experiencing varying traumatic episodes other than combat.

There were large numbers of plane crashes, natural disasters, fires, acts of terrorism on civilian populations and other catastrophic events. The picture presented to many mental health professionals working with victims of these events, helping them adjust after traumatic experiences, was quite similar to the phenomenon of the troubled Vietnam veteran. The symptoms were almost identical. Finally, after much research (Figley, 1978 a) by various veterans' task forces and recommendations by those involved in treatment of civilian post-trauma clients, the DSM (1980) was published with a new category: post-traumatic stress disorder, acute, chronic and / or delayed. e number of veterans presenting neuropsychiatric disorders began to increase tremendously (President's Commission on Mental Healt More than 8.5 million individuals served in the U.S. Armed Forces during the Vietnam era, 1964-1973. Approximately 2.8 million served in Southeast Asia. Of the latter number, almost one million saw active combat or were exposed to hostile, life- threatening situations (President's Commission on Mental Health, 1978).

It is this writer's opinion that the vast majority of Vietnam era veterans have had a much more problematic readjustment to civilian life than did their World War II and Korean War counterparts. This was due to the issues already discussed in this chapter, as well as to the state of the economy and the inadequacy of the GI Bill in the early 1970's. In addition, the combat veterans of Vietnam, many of whom immediately tried to become assimilated back into the peacetime culture, discovered that their outlook and feelings about their relationships and future life experiences had changed immensely. According to the fantasy, all was to be well again when they returned from Vietnam. The reality for many was quite different. A number of studies point out that those veterans subjected to more extensive combat show more problematic symptoms during the period of readjustment (Wilson, 1978; Strayer & Ellen horn, 1975; Kosmos, 1978; Shatan, 1978; Figley, 1978 b).

The usual pattern has been that of a combat veteran in Vietnam who held on until his D EROS date. He was largely asymptomatic at the point of his rotation back to the U.S. for the reasons previously discussed; on his return home, the joy of surviving continued to suppress any problematic symptoms. However, after a year or more, the veteran would begin to notice some changes in his outlook (Shatan, 1978). But, because there was a time limit of one year after which the Veterans Administration would not recognize neuropsychiatric problems as service-connected, the veteran was unable to get service-connected disability compensation. Treatment from the VA was very difficult to obtain. The veteran began to feel depressed, mistrustful, cynical and restless.

He experienced problems with sleep and with his temper. Strangely, he became somewhat obsessed with his combat experiences in Vietnam. He would also begin to question why he survived when others did not. For approximately 500,000 veterans (Wilson, 1978) of the combat in Southeast Asia, this problematic outlook has become a chronic lifestyle affecting not only the veterans but countless millions of persons who are in contact with these veterans. The symptoms described below are experienced by all Vietnam combat veterans to varying degrees.

However, for some with the most extensive combat histories and other variables which have yet to be enumerated, Vietnam-related problems have persisted in disrupting all areas of life experience. According to Wilson (1978), the number of veterans experiencing these symptoms will climb until 1985, based on his belief of Erickson's psychosocial developmental stages and how far along in these stages most combat veterans will be by 1985. Furthermore, without any intervention, what was once a reaction to a traumatic episode may for many become an almost unchangeable personality characteristic. THE SYMPTOMS OF PTSD: Depression The vast majority of the Vietnam combat veterans I have interviewed are depressed.

Many have been continually depressed since their experiences in Vietnam. They have the classic symptoms (DSM, 1980) of sleep disturbance, psychomotor retardation, feelings of worthlessness, difficulty in concentrating, etc. Many of these veterans have weapons in their possession, and they are no strangers to death. In treatment, it is especially important to find out if the veteran keeps a weapon in close proximity, because the possibility of suicide is always present.

When recalling various combat episodes during an interview, the veteran with a post-traumatic stress disorder almost invariably cries. He usually has had one or more episodes in which one of his buddies was killed. When asked how he handled these death when in Vietnam, he will often answer, "in the shortest amount of time possible" (Howard, 1975). Due to circumstances of war, extended grieving on the battlefield is very unproductive and could become a liability. Hence, grief was handled as quickly as possible, allowing little or no time for the grieving process. Many men reported feeling numb when this happened.

When asked how they are now dealing with the deaths of their buddies in Vietnam, they invariable answer that they are not. They feel depressed; "How can I tell my wife, she'd never understand" they ask. "How can anyone who hasn't been there understand" (Howard, 1975). Accompanying the depression is a very well developed sense of helplessness about one's condition. Vietnam-style combat held no final resolution of conflict for anyone. Regardless of how one might respond, t he overall outcome seemed to be just an endless production of casualties with no perceivable goals attained.

Regardless of how well one worked, sweated, bled and even died, the outcome was the same. Our GIs gained no ground; they were constantly rocketed or mortared. They found little support from their "friends and neighbors" back home, the people in whose name so many were drafted into military service. They felt helpless. They returned to the United States, trying to put together some positive resolution of this episode in their lives, but the atmosphere at home was hopeless. They were still helpless.

Why even bother anymore Many veterans report becoming extremely isolated when they are especially depressed. Substance abuse is often exaggerated during depressive periods. Self medication was an easily learned coping response in Vietnam; alcohol appears to be the drug of choice. Isolation Combat veterans have few friends. Many veterans who witnessed traumatic experiences complain of feeling like old men in young men's bodies.

They feel isolated and distant from their peers. The veterans feel that most of their non-veteran peers would rather not hear what the combat experience was like; therefore, they feel rejected. Much of what many of these veterans had done during the war would seem like horrible crimes to their civilian peers. But, in the reality faced by Vietnam combatants, such actions were frequently the only means of survival. Many veterans find it difficult to forget the lack of positive support they received from the American public during the war. This was especially brought home to them on the return from the combat zone to the United States.

Many were met by screaming crowds and the media calling them "depraved fiends" and "psychopathic killers" (DeFazio, 1978). Many personally confronted hostility from friends and family, as well as strangers. After their return home, some veterans found that the only defense was to search for a safe place. These veterans found themselves crisscrossing the continent, always searching for that place where they might feel accepted. Many veterans cling to the hope that they can move away from their problems.

It is not unusual to interview a veteran who, either alone or with his family, has effectively isolated himself from others by repeatedly moving from one geographical location to another. The stress on his family is immense. The fantasy of living the life of a hermit plays a central role in many veterans' daydreams. Many admit to extended periods of isolation in the mountains, on the road, or just behind a closed door in the city. Some veterans have actually taken a weapon and attempted to live off the land. It is not rare to find a combat veteran who has not had a social contact with a woman for years - other than with a prostitute, which is an accepted military procedure in the combat setting.

If the veteran does marry, his wife will often complain about the isolation he imposes on the marital situation. The veteran will often stay in the house and avoid any interactions with others. He also resents any interactions that his spouse may initiate. Many times, the wife is the source of financial stability.

Rage The veterans' rage is frightening to them and to others around them. For no apparent reason, many will strike out at whomever is near. Frequently, this includes their wives and children. Some of these veterans can be quite violent. This behavior generally frightens the veterans, apparently leading many to question their sanity; they are horrified at their behavior. However, regardless of their afterthoughts, the rage reactions occur with frightening frequency.

Often veterans will recount episodes in which they became inebriated and had fantasies that they were surrounded or confronted by enemy Vietnamese. This can prove to be an especially frightening situation when others confront the veteran forcibly. For many combat veterans, it is once again a life-and- death struggle, a fight for survival. Some veterans have been able to sublimate their rage, breaking inanimate objects or putting fists through walls. Many of them display bruises and cuts on their hands. Often, when these veterans feel the rage emerging, they will immediately leave the scene before somebody or something gets hurt; subsequently, they drive about aimlessly.

Quite often, their behavior behind the wheel reflects their mood. A number of veterans have described to me the verbal catharsis they " ve achieved in explosions of expletives directed at any other drivers who may wrong them. There are many reasons for the rage. Military training equated rage with masculine identity in the performance of military duty (Eisen hart, 1975). Whether one was in combat or not, the military experience stirred up more resentment and rage than most had ever felt (Egendorf, 1975).

Finally, when combat in Vietnam was experienced, the combatants were often left with wild, violent impulses and no one upon whom to level them. The nature of guerrilla warfare - with its use of such tactics as booby trap land mines and surprise ambushes with the enemy's quick retreat - left the combatants feeling like time bombs; the veterans wanted to fight back, but their antagonists had long since disappeared. Often they unleashed their rage at indiscriminate targets for want of more suitable targets (Shatan, 1978). On return from Vietnam, the rage that had been tapped in combat was displaced against those in authority.

It was directed against those the veterans felt were responsible for getting them involved in the war in the first place - and against those who would not support the veterans while they were in Vietnam or when they returned home (Howard, 1975). Fantasies of retaliation against political leaders, the military services, the Veterans Administration and antiwar protesters were present in the minds of many of these Vietnam combat veterans. These fantasies are still alive and generalized to many in the present era. Along with the rage at authority figures from the Vietnam era, these veterans today often feel a generalized mistrust of anyone in authority and the "system" in the present era. Many combat veterans with stress disorders have a long history of constantly changing their jobs. It is not unusual to interview a veteran who has had 30 to 40 jobs during the past 10 years.

One veteran I interview had nearly 80 jobs in a 10-year span. The rationale quite often given by the veterans is that they became bored or the work was beneath them. However, after I made some extended searched into their work backgrounds, it became apparent that they felt deep mistrust for their employers and coworkers; they felt used and exploited; at times, such was the case. Many have had some uncomfortable confrontations with their employers and job peers, and many have been fired or have resigned on their own. Survival Guilt When others have died and some have not, the survivors often ask, "How is it that I survived when others more worthy than I did not" (Lift on, 1973). Survival guilt is an especially guilt- invoking symptom.

It is not based on anything hypothetical. Rather, it is based on the harshest of realities, the actual death of comrades and the struggle of the survivor to live. Often the survivor has had to compromise himself or the life of someone else in order to live. The guilt that such an act invokes or guilt over simply surviving may eventually end in self-destructive behavior by the survivor. Many veterans, who have survived when comrades were lost in surprise ambushes, protracted battles or even normal battlefield attrition, exhibit self-destructive behavior. It is common for them to recount the combat death of someone they held in esteem; and, invariably, the questions comes up, "Why wasn't it me" It is not unusual for these men to set themselves up for hopeless physical fights with insurmountable odds.

"I don't know why, but I always pick the biggest guy", said the veteran in the transcript at the beginning of this chapter. Shatan (1973) notes that some of these men become involved in repeated single-car accidents. This writer interviewed one surviving veteran, whose company suffered over 80% casualties in one ambush. The veteran had had three single-car accidents during the previous week, two the day before he came in for the interview. He was wondering if he were trying to kill himself. I have also found that those veterans who suffer the most painful survival guilt are primarily those who served as corpsmen or medics.

These unfortunate veterans were trained for a few months to render first aid on the actual field of battle. The services they individually performed were heroic. With a bare amount of medical knowledge and large amounts of courage and determination, they saved countless lives. However, many of the men they tried to save died. Many of these casualties were beyond all medical help, yet many corpsmen and medics suffer extremely painful memories to this day, blaming their "incompetence" for these deaths.

Listening to these veterans describe their anguish and torment... seeing the heroin tracks up and down their arms or the bones that have been broken in numerous barroom fights... is, in itself, a very painful experience. Another less destructive trend that I have noticed exists among a small number of Vietnam combat veterans who have become compulsive blood donors. One very isolated and alienated individual I interviewed actually drives some 80 miles round-trip once every other month to make his donation. His military history reveals that he was one of 13 men out of a 60-man platoon who survived the battle of Hue. He was the only survivor who was not wounded. this veteran and similar vets talk openly about their guilt, and they find some relief today in giving their blood that others may live.

Anxiety Reactions Many Vietnam veterans describe themselves as very vigilant human beings; their autonomic senses are tuned to anything out of the ordinary. A loud discharge will cause many of them to start. A few will actually take such evasive action as falling to their knees or to the ground. Many veterans become very uncomfortable when people walk closely behind them. One veteran described his discomfort when people drive directly behind him. He would pull off the road, letting others pass, when they got within a few car lengths of him.

Some veterans are uncomfortable when standing out in the open. Many are uneasy when sitting with others behind them, often opting to sit up against something solid, such as a wall. The bigger the object is, the better. Many combat veterans are most comfortable when sitting in the corner in a room, where they can see everyone about them. Needless to say, all of these behaviors are learned survival techniques. If a veteran feels continuously threatened, it is difficult for him to give such behavior up.

A large number of veterans possess weapons. This also is a learned survival technique. Many still sleep with weapons in easy reach. The uneasy feeling of being caught asleep is apparently very difficult to master once having left the combat zone. Sleep Disturbance and Nightmares Few veterans struggling with post-traumatic stress disorders find the hours immediately before sleep very comfortable. In fact, many will stay awake as long as possible.

They will often have a drink or smoke some cannabis to dull any uncomfortable cognition that may enter during this vulnerable time period. Many report that they have nothing to occupy their minds at the end of the day's activities, and their thoughts wander. For many of them, it is a trip back to the battle zone. Very often they will watch TV late into the mornings. Finally, with sleep, many veterans report having dreams about being shot at or being pursued and left with an empty weapon, , unable to run anymore.

Recurrent dreams of specific traumatic episodes are frequently reported. It is not unusual for a veteran to reexperience, night after night, the death of a close friend or a death that he caused as a combatant. Dreams of everyday, common experiences in Vietnam are also frequently reported. For many, just the fear that they might actually be back in Vietnam is very disquieting. Some veterans report being unable to remember their specific dreams, yet they feel dread about them. Wives and partners report that the men sleep fitfully, and some call out in agitation.

A very few actually grab their partners and attempt to do them harm before they have fully awakened. Finally, maintaining sleep has proven to be a problem for many of these veterans. They report waking up often during the night for no apparent reason. Many rise quite early in the morning, still feeling very tired. Intrusive Thoughts Traumatic memories of the battlefield and other less affect- laden combat experiences often play a role in the daytime cognition's of combat veterans. Frequently, these veterans report replaying especially problematic combat experiences over and over again.

Many search for possible alternative outcomes to what actually happened in Vietnam. Many castigate themselves for what they might have done to change the situation, suffering subsequent guilt feelings today because they were unable to do so in combat. The vast majority report that these thoughts are very uncomfortable, yet they are unable to put them to rest. Many of the obsessive episodes are triggered by common, everyday experiences that remind the veteran of the war zone: helicopters flying overhead, the smell of urine (corpses have no muscle tone, and the bladder evacuates at the moment of death), the smell of diesel fuel (the commodes and latrines contained diesel fuel and were burned when filled with human excrement), green tree lines (these were searched for any irregularity which often meant the presence of enemy movement), the sound of popcorn popping (the sound is very close to that of small arms gunfire in the distance), any loud discharge, a rainy day (it rains for months during the monsoons in Vietnam) and finally the sight of Vietnamese refugees.

A few combat veterans find the memories invoked by some of these and other stimuli so uncomfortable that they will actually go out of their way to avoid them. When exposed to one of the above or similar stimuli, a very small number of combat veterans undergo a short period of time in a dissociative-like state in which they actually reexperience past events in Vietnam. These flashbacks can last anywhere from a few seconds to a few hours. One veteran described an episode to me in which he had seen some armed men and felt he was back in Vietnam. The armed men were police officers. Not having a weapon to protect himself and others, he grabbed a passerby and forcefully sheltered this person in his home to protect him from what he felt were the "gooks".

He was medicated and hospitalized for a week. Such experiences among Vietnam veterans are rare, but not as uncommon as many may believe. Many veterans report flashback episodes that last only a few seconds. For many, the sound of a helicopter flying overhead is a cue to forget reality for a few seconds and remember Vietnam, re experiencing feelings they had there.

It is especially troublesome for those veterans who are still "numb" and specifically attempting to avoid these feelings. For others, it is just a constant reminder of their time in Vietnam, something they will never forget..