I survived, but it’s not a happy ending. – Tim O’Brien, TTTC

Infection in the sentence breeds / we may inhale despair / at distances of centuries.… – Emily Dickinson


I haven’t been writing any fiction.  I’ve been dealing with personal shit (having just hit a fairly noticeable wall, or bump, or tangle of “stuff,” where DBT tactics are not helping and nothing but meds gets me through those bits, and Lord do I hate these meds) and doing day job writing.  But the “mental illness and creativity” post gets more hits than anything else anyway, so I’m using this as a place to dump some stats and figures and sources.

A study of 2525 US Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq showed that of those reporting an episode of mild TBI with loss of consciousness or altered mental status (eg, dazed or confused), 43.9% of those with loss of consciousness and 27.3% of those with altered mental status met criteria for PTSD. (Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358:453-463.)

In a 1992 survey of 8169 veterans of the Vietnam conflict, approximately 72% of respondents reported a lifetime history and 36% reported a 12-month history of at least 1 psychiatric disorder. (Eisen GA, Griffith KH, Xian H, et al. Lifetime and 12-month prevalence of psychiatric disorders in 8169 male Vietnam War era veterans. Mil Med. 2004; 169:896-902.)

Veterans of the first Gulf War reported a significantly higher prevalence of current anxiety disorders (PTSD, panic disorder, and generalized anxiety disorder) than nondeployed military personnel (5.9% vs 2.8%; odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 – 3.1).  (Black DW, Carney CP, Peloso PM, et al. Gulf War veterans with anxiety: prevalence, comorbidity, and risk factors. Epidemiology. 2004;15:135-142.)

The military and the VA have both gotten smarter about PTSD since the first Gulf War.  If you are a first-Gulf-War era vet (or pre-Gulf War era), and you are still holding your shit together with beer, bootlaces, and 55o cord, it’s not easy to get help – but it’s easier than it probably was when you got out. The problem is, it’s not always easy to see you could use some help, since military training tends to produce people who are pretty damned good at holding an amazing amount of shit together with beer, bootlaces, and 550 cord.  And at producing a belief that “invisible injuries” = malingering.  Suck it up and drive on, right?

In fact, when I was actively losing my ability to hold it together with 55o cord and beer at one point in the late 90s, I even went to a counselor on base.  I was told to relax, perhaps by taking a bubble bath, and to stop feeling sorry for myself.  Basically, suck it up and drive on, but have a bubble bath first if you want.  The experience with that (sorry, inept, incompetent) counselor kept me from seeking treatment for ten years – because it convinced me of what I’d suspected anyway, that there was nothing wrong with me except my own weakness, my own inability to always, thoroughly, suck it up.  It wasn’t until I crashed and burned in a fairly spectacular manner in 2008 – a manner which very nearly tore my family apart and cost me my daughter – that I tried again.  I got a better (civilian) doc this time, but she was young and inexperienced, fresh out of residency, and had zero experience with people with my kind of background.  She was, frankly, not helpful at all, and she put me on meds that made me worse.   The moral of the story is “keep trying.”  Please.  Please keep trying.  I’m working with “Mental Health Professionals Number 10, 11, 12, and 13” simultaneously right now (a p-doc, a t-doc, and two group therapy t-docs) and I have finally, finally gotten some actual help.  It took a really long time and it has been very disheartening.  But it’s helping.  Finally.

New PTSD rules relax definition (military.com)

On “complex PTSD” (which not everybody agrees on):

I realize from the comments [from an earlier filtered post] that I didn’t give an accurate picture of where some therapists are coming from nor where I’m coming from on the PTSD issue (about which I do have some fairly strong opinions in some cases, as a military veteran), so I thought I’d post this to lay out some of the issues (or what I perceive to be some of the issues).  The following fine print applies: I am not a medical nor psych professional, and while I have spent a lot of time thinking about some of this stuff, I should not necessarily be taken any more seriously than other random, unattested stuff on any other blog or non-professional website out there.

First off, when I talk about therapists “looking for the trauma,” what I mean is this: when you do psych intake or take some test or answer some inventory for PTSD, the typical question are looking for criteria something like this:

– a traumatic event
– unwanted memories or reminders of that event intruding into your life
– a decreased ability to function and/or handled stressors as a result

This one’s fairly typical of intake inventories:

Have you experienced a traumatic event which was out of the ordinary realm of experience?
Do you have any of the following problems?

<input … > I think about it even when I try not to.
<input … > I have strong waves of feeling about it, especially if something reminds me of it.
<input … > I have trouble falling asleep or staying asleep because pictures of it or thoughts about it come into my mind.
<input … > I have nightmares about it.
<input … > I stay away from reminders of it.
<input … >I try not to talk about it.
<input … >I don’t let myself get upset if I think about it.
<input … >Pictures about it pop into my mind.
<input … > My feelings are kind of numb.
<input … > I don’t enjoy life the way I used to.
<input … >I feel like life has passed me by.
<input … >I am jumpy if I hear a loud noise.
<input … > I am always aware of potential danger.
<input … >I have trouble concentrating and my memory is shot.
<input … > Little things bother me that didn’t used to bother me.
<input … > I get irritated or angry a lot.

You’ll note the reference to “an event” and symptoms associated with that event.


And here’s what NIMH says about PTSD:

“Post-Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.”

“People with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. They may experience sleep problems, feel detached or numb, or be easily startled.”

And a useful list of symptoms etc you should look at if you’re interested in this.

You’ll note symptoms falling into three categories: 1. reexperiencing the event, 2. avoidance of reminders, 3. hyperarousal.


Finally, the DSM-IV Diagnosis and Criteria bit:

309.81    DSM-IV Criteria for Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.



So you can see that according to the “psych manual,” there has to be some sort of traumatic event, and symptoms have to be associated with said event.

Now, I know people with textbook PTSD, many military veterans though by no means all vets, and in some cases, PTSD is a clear fit for a diagnosis, and getting the diagnosis helps with treatment, and the treatment helps them with their lives.  I’m not complaining about that.

However, I know a lot of people who don’t meet the criteria for textbook PTSD for any number of reasons, and many of these don’t because there is no one, single “event” which continues to irrupt into their lives and diminish their ability to function.  This group includes non-combat veterans (and law enforcement and medical personnel) in whom hyperarousal was cultivated, but who find themselves unable to simply turn it off when they aren’t in uniform or on duty any more (many turning to drugs or alcohol to “turn it off” temporarily); victims of child- or relationship abuse and assault, for whom there was no particular single event but instead a drawn out experience; children of alcoholics for whom hyperarousal/hypervigilance is a survival mechanism when living with people whose behavior is unpredictable or violent; etc.  Or there may be various types of avoidance, but they aren’t quite textbook PTSD symptoms, though they make a lot of sense in context – for instance, reacting negatively to a certain smell that reminds them of an abuser; avoiding situations that remind them of a person or type of person they feel uncomfortable about; etc.  They might have a lot of bad dreams or anxiety dreams but with no particular content that links them to any single event or even any long-term situation like abuse or assault.

If there is no “one event,” then people are unlikely to have symptoms in the first two categories and in fact are unlikely to score high enough on any general intake inventory to merit further exploration or discussion.  (At my last intake appointment, for a new group therapy to which my p-doc referred me, I was asked “Were you exposed to combat during your military service?”  At my reply of “no,” that line of inquiry was discontinued.  But as any convoy driver can tell you, you don’t need to be exposed to combat proper to get your ass blown off, or watch your buddy get his ass blown off.  In the modern military,  in our recent “conflicts,” you can be a cook, or a mechanic, or a linguist, or [fill in the blank] and still get your ass blown off by an IED.

You can see how it would be difficult to find the “one event” that the DSM manual needs when the person in question grew up in an abusive home, or was in a relationship with an abusive person, or who ran into many burning buildings and pulled many burning children out of them, or was deployed somewhere nasty for a while. The preceding examples have this in common: a bunch of nasty shit was happening all the time.  Grew up with an abusive parent?  Is there one particular broken bone or one particular outburst or one particular bad night to point to?  Spent six months in Somalia, or three years in Vietnam, or five minutes with an IED, or a year in Iraq?  Is there one particular night of guard duty or one particular chopper full of incoming wounded or one battle (or non-battle) injury, or one particular sleep-deprived maneuver with lots of live ammo to point to?  Probably not.  Hence, not PTSD. Maybe something else, but not PTSD.

Furthermore – what did the person’s psychological landscape “before the trauma” even look like? How do you help a kid who grew up in a civil war (or on the streets, or in a crackhouse, or in a refugee camp) “return” to a way of being in the world that is something he never knew in the first place?  How can you say an event intruded when that event is the only thing they’ve ever known? It can’t really intrude, then, can it?

And (and this probably gets into the difference between “trauma” in a more general sense and “PTSD,” but I can only type for so long), there’s the issue of “retraumatization” (and the “originary event” adherents will see child abuse or an abusive marriage as long series of repetitions of some originary traumatic event – an adherence to a model that I’m not sure is worth adhering to so strictly as to cause some of the contortions it produces in its adherents).  Events or images that are not clearly related to some earlier traumatic event may “trigger” someone – and if that someone can’t express what is going on, and can’t see the connection to the earlier event(s), then = not PTSD.  For instance, children of concentration camp survivors have presented with real, acute symptoms that have interfered with their lives – symptoms that meet the criteria for PTSD with the exception of the “experiencing life-threatening event.”  I know people who get extremely distressed around images and reminders of wars they were  never in.  There are such lives in which a “death immersion experience”* is so prolonged, or is somehow or other such a strong shaping factor in the “narrative” of that life (as with family structures in which concentration camp survival affects all of them, not just the survivor), that debilitating reactions as a result of that death-immersion experience can come about without the individual having experienced that “short, sharp shock, for which they were unprepared, and to which they keep returning,” which is how I personally characterize textbook PTSD.**

There is a name for this non-“event”-dependent type of PTSD: complex PTSD.  Not everybody agrees about it, and some people think it should have a different name, and the DSM hasn’t caught up with the debates.  But here is a bit of info:

Types of long-term traumas associated with complex PTSD:

  • Concentration camps.
  • Prisoner of War camps.
  • Prostitution brothels.
  • Long-term domestic violence.
  • Long-term child physical abuse.
  • Long-term child sexual abuse.
  • Organized child exploitation rings

Symptoms that may result from living in chronic stress:

  • Alterations in emotional regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
  • Alterations in consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one’s mental processes or body.
  • Changes in self-perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
  • Alterations in how the perpetrator is perceived. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
  • Alterations in relations with others. Examples include isolation, distrust, or a repeated search for a rescuer.
  • Changes in one’s system of meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.

As many people who are suffering from this type of thing engage in self-medication as a survival mechanism, develop self-destructive coping mechanisms or responses, and/or repeat patterns in abusive relationships, they are often misdiagnosed as having Borderline Personality Disorder, Dependent Personality Disorder, Masochistic Personality Disorder, Type II Bipolar Disorder, etc.


For more info, see any of the links on this post, and/or the following:

Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.

Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.


Now.  I have a lot more to say about this, esp. when it comes to treatment models and the motherfucking military, but I have to go to work. More later maybe.  For now I’ll stop with this: not every traumatic event produces PTSD.  Not every person who survives a fucked up childhood or relationship, or an armed conflict, or a natural disaster, develops PTSD. And I’m aware there’s a whole host of other shit out there besides PTSD that people can suffer with.  But the psych profession has a tendency to run down a list of things (and holy mother of God, don’t get me started on the VA) and tot up a list of scores and tickboxes, producing a “diagnosis” and moving forward accordingly, and while I’m glad somebody out there can do stuff like that and some people get the help they need, shit is very often just not that simple.  Maybe the diagnostic model should change.  Or maybe it shouldn’t, and these “other things” should have their own diagnosis. I don’t really know.  I also know that some in the psych profession are aware of the limitations of the DSM model and are working on what to do with “what we have and what we know” in their own practices.  But the way the textbook treats this stuff just doesn’t “fit” a lot of cases of trauma survivors. And it seems to me there is enough overlap with the “other cases” I’ve talked about here, and the “textbook PTSD” cases, to warrant further thinking and discussion.

* This is Robert J. Lifton’s phrase; I find his model of trauma infinitely more useful for talking about war and abuse survivors, or for any type of event that does not fit the “my whole squad got taken out in an explosion one night” model.  See for instance “A Short History of PTSD,” and Post-Traumatic Stress Disorder: A Bibliographic Essay, for starting points.

** This is my paraphrasing/summation of (most of) where Freud eventually arrived in his theories of what they used to call “shell shock.”

In case I do come back to this, this is a reminder to talk about how some reactions to traumatic events are evolutionary and protective, and are in fact healthy in the short-term.  In some cases they can be healthy or strengthening in the long term.  In others, they are damaging or limiting.  Sometimes the damaging/limiting stuff can be grokked and changed and integrated and the survivor of trauma becomes an incredibly resilient person who is in fact innoculated against further traumatization and is therefore wonderful to have around in an emergency.  A lot of this is why I HATE to use the word “victim” when talking about this stuff, though it’s sometimes hard to avoid.


My page on PTSD resources

National Center for PTSD home

VA Mental Health

Get Help for PTSD