“My head is ﬁlled with garbage—all these images, sounds, smells I can’t cut out. It’s like there’s another skin beneath this skin and I can’t shed it. I’m not like you. You have one vision of life. I have two. My ‘other’ life must not interfere with the one that’s safe and good. It must not become so overwhelming, it will make me unable to function in my normal life.”
This is a statement from an Auschwitz Holocaust survivor, but it’s similar to those who have grown up in, or are continuing to experience chronic traumatic situations, including post traumatic stress disorder (PTSD). It is an example of the ‘split-brain phenomenon’ that occurs in suﬀerers of complex trauma, like military service members. They have a higher rate of addiction, suicide ideation, and PTSD compared to the general population because of the demands of their profession.
Active duty personnel abide by strict protocol and a rigid hierarchy where vets are obliged to follow orders, no matter what. Even if the directives bring to the fore questions of morality, active duty soldiers have to comply.
Exposure to combat, violence, harsh training, premature deployment, physical danger (including contact with hazardous chemicals), physical/sexual/psychological abuse, crime, illness, harrowing living situations, hostile territory, separation from family, friends, and the comforts of home, loss of intimacy all contribute to extreme stress, which gives rise to physical and mental health issues. Having the threat of illness, permanent injury, or death hanging over them on a daily basis doesn’t help.
While military members have specialized training, they are still human beings. Greater exposure to the above situations results in a higher risk for the triad conditions of PTSD, suicidal ideation, and addiction. Active service members whose tours of duty have ended often have diﬃculty transitioning to civilian life.
Negative eﬀects of PTSD, addiction, and suicidal ideation
Triad patients suﬀer from panic attacks, severe anxiety, depression, nightmares, insomnia, reliving of traumatic experiences, or substance use disorders (SUDs). Risk factors for suicide attempts include owning weapons, lack of moral support, being male, and a family history of suicide.
Triad ailments adversely impact physical and psychological health, work, and relationships. They often give rise to mistrust, isolation, and loss of control of emotions and actions. Going through trauma—whether or not PTSD develops—can also lead to alcohol use problems.
PTSD suﬀerers have a greater risk of developing other mental health issues, such as anxiety, depression, eating disorders, and SUDs. They are about six times as likely as someone without PTSD to develop depression and attempt suicide, and about ﬁve times as likely to develop another anxiety disorder .
The US Department of Veteran Aﬀairs (VA) cites the main cause of PTSD as trauma, which is an experience that threatens a person’s life. Symptoms include:
- Reliving the traumatic event
- Avoidance of reminders of the event
- Increase in negative emotions and thoughts. Inability to sustain positivity. Diﬃculty in expressing oneself. Sadness or numbness. Loss of interest in previously enjoyed activities. Feelings of mistrust, guilt, blame, and shame.
- Hyperarousal (nervousness), anger, and irritability. Patients get easily startled, are super vigilant, and may have diﬃculty sleeping, concentrating, or relaxing. They act out, engaging in binges, drug/alcohol abuse, or impulsive behaviour.
This screening questionnaire from VA is a useful tool for ﬁnding out if you have PTSD. In the past month, have you…
- Had nightmares about the traumatic event(s) or thought about the event(s) when you didn’t want to?
- Tried hard not to think about the event(s) or gone out of your way to avoid situations that reminded you of the event(s)?
- Been constantly on guard, watchful, or easily startled?
- Felt numb or detached from people, activities, or your surroundings?
- Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
If you answered ‘yes’ to three or more questions, it’s possible you may have PTSD. Regardless of the result, if you feel bothered by an event, consult a mental health professional for a proper diagnosis. This is especially true if you have suicidal thoughts, your symptoms last longer than a few months, and these are interfering with daily life.
People with multiple disorders have higher suicide rates. “Suicidal behaviour is associated with severe and persistent mental disorders. But this doesn’t mean everyone who wants to kill himself has a mental illness, as many who commit suicide are not diagnosed with it,” says Marsha Linehan, professor and director, Behavioural Research and Therapy Clinics, Department of Psychology, University of Washington. She is a treatment development researcher whose specialty is mental health disorders and suicide.
According to Edwin Shneidman, the father of suicidology, perturbation is the major motivator for suicide. Perturbation means anguish and the inability to solve problems . In 1958, he founded the Los Angeles Suicide Prevention Center with Norman Farberow and Robert Litman. Apart from researching suicide, they developed a crisis medical centre and suicide prevention treatments.
Statistics on suicide
The World Health Organization’s 2002 data showed global suicide rates increased from 5% to more than 15% from 1950 to 2000.
According to the Centers for Disease Control and Prevention (CDC), in the US, there are:
- 31,647 deaths by suicide annually
- 500,000 ER visits due to suicide attempts in 1997
- 1.7 times more deaths by suicide than homicide
The CDC’s 2006 report on 2004 data states that suicide is the 11th leading cause of death in the US. In terms of age groups, it is the third for ages 15-24, fourth for ages 25-44, eighth for ages 45-64, eighth for men, and 17th for women.
Suicide is a major unmet public health problem. In a review of 83 mortality studies, the following suicide rates were found in people with these mental disorders:
- Schizophrenia: 4%
- Depression/bipolar disorder: 6%
- Addiction disorder: 7%
- Borderline personality disorder (BPD): 8-10%
BPD overlaps with major depression (about 87-90%) and addiction disorders. When the CDC researched impulsive suicide attempters, they found that one-third of them had not considered suicide before they attempted it.
Obstacles to suicide research and treatment development
According to Linehan, up to two-thirds of studies on new treatments for suicide and depression exclude individuals at high risk of suicide —except for ﬁve medication trials. Although out of these, only one had reasonably signiﬁcant ﬁndings. It was a comparison between two antipsychotic drugs for high suicide risk schizophrenics. The study found that suicidal behaviour was lower with one antipsychotic drug.
Psychology departments across the United States, including Linehan’s, are not allowed to take in high-risk suicide cases because their inclusion was thought to be unethical, unsafe, or too diﬃcult to manage clinically. Linehan says that clinicians’ prevailing “belief that they know how to reduce suicide risk”—and “their fears of trying anything new”—is keeping them from learning how to treat suicidal individuals eﬀectively. These aspects impact research and outcomes, and discriminate against patients who need help the most.
She explains, “The medical model stipulates that the current standard of care (hospitalization and medication) should treat suicidal behaviour as a symptom of a mental disorder. The belief is that if you treat the mental disorder, you reduce the risk of suicide. There is no single study, however, that demonstrates inpatient treatment keeps anyone alive. But don’t mistake ‘no data’ for ‘it doesn’t work’. It just means we have no data. The association of suicidal behaviour with mental disorders is just that: an association. It does not say that the disorder causes it. We don’t know why they’re associated. We simply know they are.”
Most US therapists work in extremely stressful environments, often juggling 30 to 50 caseloads at a time. They have some training, but very little continuing education and not a lot of supervision. Linehan laments: “Mental health is the only area where the more educated you are, the less severe your clients are. So the people dealing with severe suicide cases are those with low education. They treat people psychologists refuse to take because (their cases) are too serious for students—except for psychiatrists who take them in because they’re required to. In contrast, in oncology, the more serious the cancer case, the better trained the physician.”
Challenging the status quo
So Linehan embarked on her own study sponsored by the University of Washington. Her methodology is in contrast to the current standard. She proposes constant monitoring of behaviour, urges, and thoughts of suicide and intentional self-injury, then looking for the disorder (or other cause) associated with these. A new model of care arose: “Suicidal behaviour is disordered behaviour—best viewed as a problem itself, rather than a symptom of a diﬀerent problem.” She recommends treating the behaviour instead.
The solution, says Linehan, is for clinicians to put high-risk individuals into a treatment eﬀective for depression, then see if suicide rates go down, citing Dr. Jerome Motto, who conducted the only eﬀective suicide study in 1976 . Motto got some suicidal patients out of treatment facilities for his study, then divided them into two groups. He then sent non-demanding, supportive ‘how are you doing?’ letters—which didn’t require a response—to one group over two years. Then he tracked the suicide rates in that group. They had signiﬁcantly fewer deaths by suicide.
Linehan concludes: “The lesson here is: ‘Reach out and touch someone’.” To follow up on Motto’s success, she started a strategic planning group on suicide intervention research by investigators from the USA and Europe.
Eﬀective ways of dealing with the triad include: reaching out to others for support; getting regular exercise, sleep and a balanced diet; avoiding addictive substances; socializing; counselling; integrative medicine (mindfulness techniques, yoga, Ayurveda, qigong, martial arts); bodywork (massage, physical therapy, acupuncture, acupressure); lifestyle changes; expressive therapies (music/art/dance therapy, journaling); and distraction tools (Zen garden, needlework).
Apps for every occasion
Sobriety/recovery apps that help manage addiction include VetChange, Sober Grid, SoberTool, recoveryBox, Nomo, and Pear reSET. Most are free. Even if they’re much cheaper than rehab programs, they’re not meant to replace traditional treatment. Rather, these medically approved digital tools supplement post-treatment aftercare, examples of which are support groups like Alcoholics Anonymous. Apps give 24/7 mobile access to support networks. For those interested in complementary therapies, there are apps for mindfulness, meditation, yoga, and suchlike.
The National Institute on Drug Abuse recommends these treatments used for multiple disorders, but which are also eﬀective in dealing with the triad:
- Evidence-based prevention interventions—minimize risk factors and increase resilience
- Multi-systemic therapy (MST)—targets antisocial behaviour
- Multi-dimensional Family Therapy (MDFT)—a comprehensive intervention that addresses interpersonal and relationship issues, parental behaviours, and family environment
- Brief Strategic Family Therapy (BSFT)—highlights family interactions that ‘enable’ SUDs (including alcohol problems) and unhealthy behaviours
- Behavioural therapy—cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT), and stress inoculation training (SIT). CBT, eﬀective with anxiety and mood disorders, replaces thoughts and behaviours leading to substance abuse and harmful actions with productive alternatives. Eﬀective for treating borderline personality disorder, DBT reduces depression, hopelessness, anger, impulsiveness, and self-harm behaviours (drug abuse and suicidal attempts, thoughts, or urges). SIT is PTSD-speciﬁc psychotherapy that teaches patients to identify triggers and skills to cope with them.
- Assertive Community Treatment (ACT)—encourages relationship-building and community involvement
- Therapeutic Communities (TCs)—a group-based approach to mental illness, personality disorders, and drug addiction
- Contingency management (CM) or motivational enhancement therapy (MET)— encourages behaviour change by using rewards
- Integrated Group Therapy (IGT)—developed for bipolar disorder and SUDs
- Seeking Safety (SS)—present-focused therapy for trauma-related problems and SUDs
- Mobile Medical Application—a device that treats SUDs and delivers CBT to outpatients
These are the most eﬀective PTSD treatments (according to VA and the National Center for PTSD):
- Prolonged Exposure Therapy (PE). This involves repeated exposure (in a controlled therapeutic environment) to a feared situation, object, traumatic event, or memory to desensitize patients and develop coping mechanisms.
- Virtual reality exposure therapy (VRET) is a type of exposure therapy that addresses avoidance and other behaviours PTSD and phobia patients engage in, in response to upsetting situations or thoughts. Patients are transported to a computer-generated virtual space using a headset where they can practise confronting their fears—something most trauma patients can’t do in real life.
- Cognitive Processing Therapy (CPT)—teaches patients how to make sense of traumatic thoughts.
- Eye Movement Desensitization and Reprocessing (EMDR) Patients recall distressing events while the therapist submits them to outside stimuli like eye movements or ﬁnger taps.
- Medication. More eﬀective if combined with one of the above therapies. PTSD depletes the brain of feel-good chemicals that handle stress. Medicine called SSRIs (selective serotonin reuptake inhibitors) and SNRIs (selective norepinephrine reuptake inhibitors) increase the level of these chemicals.
- Medical marijuana. Clinical research involving placebo-controlled larger studies suggests that smoking cannabis reduces symptoms of PTSD in some patients. In May 2016, the US Congress lifted a federal ban that previously prevented military veterans’ access to medical marijuana. Now they can get it through VA in states that allow it.
- Getting Results in Transition (GRIT). IBM’s mobile app was developed to address the rates of suicide among military service members. It’s a resiliency-building tool that uses neuro-scientiﬁc tests to assess brain function —including identifying traumatic brain injury (TBI)—and evaluate war veterans’ emotions, cognition, and self-control. Games enhance memory, focus, planning, and optimism. It has built-in scientiﬁc screening tests for depression, anxiety, attention deﬁcit disorder, addiction, PTSD, social phobia, and sleep apnea .
To decide which PTSD treatment is appropriate, check out this online treatment decision aid, consult the comparison chart, and watch informational videos to know what’s involved in each method.
Where to get help
Phone: 800-273-8255 (press 1)
TTY (for those with hearing loss): 800-799-4889
Conﬁdential chat: https://www.veteranscrisisline.net/get-help/chat
http://www.va.gov/directory/guide/PTSD.asp. Also visit submenu links.
For other mental health issues and veteran substance abuse
For homeless military personnel
For help outside the VA
Consult the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the US Department of Health and Human Services: https://ﬁndtreatment.samhsa. gov/
A note of urgency
There is hope. One can still reclaim a normal life and regain a sense of renewal. It’s important to get treated for PSTD, suicide ideation, and addiction right away because symptoms may get worse if ignored. Note that one PTSD symptom is not wanting to deal with the trauma, so some suﬀerers feel that they’ll never be ready for treatment. But one has to seek help in spite of this. Just think about how your quality of life will vastly improve when your condition is properly managed— and hopefully, eliminated.
PSTD can be treated even if the traumatic event happened years ago. If the treatment you’ve had before didn’t work, try other methods. Many medical improvements have arisen over the last decade that are eﬀective for triad conditions. The key is to ﬁnd out which ones are appropriate for you with the help of a mental health care provider.
 Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. “Post-traumatic stress disorder in the National Comorbidity Survey”. Archives of General Psychiatry 52(12):1048-60. 1995.
 Shneidman, Edwin S. “Perturbation and Lethality as Precursors of Suicide in a Gifted Group”. 1971.
 Allen L. Edwards psychology lectures, College of Arts and Sciences, University of Washington. 2007.
 Dr. Motto, Jerome A. “Suicide Prevention for High‐Risk Persons Who Refuse Treatment”. 1976.
 Total Brain CEO Louis Gagnon’s pitch through Nextgov: https://www.nextgov.com/? oref=ng-nav.