How to Treat And Understand PTSD After War

After the war

I had my first experience as a psychologist with PTSD at a psychiatric clinic in Trondheim, Norway at the end of the 1960’s. We had men admitted with anxiety, depression, alcoholism, sleeping problems and related ailments. The one thing they had in common was that they had participated in World War II in various ways.

They had fought in the resistance movement, been tortured or imprisoned in concentration camps, participated in active duty or worked in the Norwegian merchant fleet. I was amazed at how these men had managed to live with these traumatic experiences for nearly 20 years before the symptoms manifested themselves in full.

There are probably many men and women in our country who felt so healthy and strong in their best years that they decided to commit themselves to a service that they believed to be worthwhile and exciting. They were in good physical shape as well as emotionally strong and healthy without any difficulties from their childhood.

Arnfinn T. Berg, Clinical Psychologist

Heroes of war

At the time there existed very little systematic knowledge about or understanding of the treatment of reactions to trauma. Neither were there any effective treatment methods for the long-term, negative effects of trauma. Many countries had participated in the two world wars, but it was during the U.S.A.’s war in Vietnam that focus was gradually directed toward long-term psychological reactions to traumatic events.

All these men who were admitted to the hospitals were heroes after the war, and their actions were something to be proud of. Others admired them and ascribed almost supernatural powers to them. Therefore, it was even more difficult for them to admit to others, not to mention to themselves, that they struggled with inner symptoms such as fear and depression, which our culture defines as weakness.

What does Trauma mean?

    For the sake of clarification, the word “trauma” comes from the Latin word for injury, but it can also be used about experiences in which the injury is the psychological experience. It should also be pointed out here that because people are different, exactly what constitutes a traumatic experience will vary.

    What may be enjoyable for one person may be terrible for another, so that it is futile to judge the experiences of others according to one’s own perceptions. Doing so often leads to insensitive comments and negative remarks from others such as, “It couldn’t have been so bad!” or “He couldn’t handle that?” 

What is PTSD and what defines it?

    The medical diagnosis referred to with the four capital letters PTSD (Post Traumatic Stress Disorder) has therefore become common knowledge.

    All psychiatric conditions are defined by typical symptoms. Below is a simplified list of symptoms for PTSD:

A: The person has been subjected to a traumatic event in which:

  1. He/she experienced, witnessed, or was confronted with one or more situations that resulted in an actual injury or in the threat of injury or loss of life. Or a threat of the same to others
  2.  The person’s reaction was characterized by intense fear or helplessness.

B: The event(s) are continually relived afterward in the following way(s):

  1. Memories return often and in disturbing ways, such as through mental images, sounds, feelings and physical reactions.
  2. Continual repetition in dreams, often as nightmares.
  3. The person acts or reacts as if he/she were still experiencing the event, he/she relives the experience, has hallucinations, delusional experiences and flashbacks, sometimes upon waking or when intoxicated.
  4. Intense discomfort when talking about the event(s), thinking about them or experiencing situations that serve as reminders or symbolize the situation (e.g. TV).
  5. Strong physical reaction to reminders of the situation, both external and within one’s own thoughts.

C: Continual avoidance of situations that can serve as reminders; do not experience the same pleasure from things as before:

  1. Strive to avoid conversations, thoughts and feelings that activate the memories.
  2. Strive to avoid events, places and people who activate the memories.
  3. Not capable of remembering vital elements of the traumatic event.
  4. Considerably reduced interest in participating in otherwise important events.
  5. Feel like an outsider or distanced from other people. Other people who knew them before the traumatic event think that they have changed, become different.
  6. Limited ability to feel, both negative and positive.
  7. Feeling that the future has been shortened; life has no purpose, nothing to look forward to.

D: Continual perception of increased preparedness that was not present before.

  1. Difficulties falling asleep or disturbed sleep.
  2. Irritability and/or emotional outbursts.
  3. Lack of concentration.
  4. Chronically elevated level of alertness.
  5. Extreme sweating reaction.

E: Duration of more than 3 months.

    The list above is simplified, and in reality there are innumerable variations of these and other combinations of symptoms and afflictions. In reality, reactions like these can last years and in many cases become more pronounced over time. In some cases, the reactions are so problematic that they affect the person’s work, enjoyment of life and relationships with other people.

    Many try to live with it by withdrawing from participation in normal life. Others try to alleviate the symptoms with alcohol or other drugs to reduce pain or provide escape. Still others find no other way to relieve the pain than to consider suicide, and some make the drastic decision to end their own lives.

What is Stress?

    A Canadian researcher, Selye, was one of the first who began to be interested in stress. He described the stages of stress, the physical and mental changes that occur at the different stages, and the consequences of stress. Selye distinguished between good stress: EUSTRESS and bad stress: DISTRESS.

     He believed that good stress is something we experience when we experience something intensely, become excited about something or work hard to accomplish something. The organism is mobilized, such as by increasing adrenalin production, and we feel strong and infused with extra energy. After the situation is over, the organism becomes calm again, and we put the experience behind us, but we remember it later as a positive experience.

     Bad stress also mobilizes the organism on all levels, but the condition is characterized by negative feelings, such as fear. The person feels threatened, and the resulting reaction is often anxiety and despair. Even though Selye used two different concepts, these have since gone out of use, and today we use the concept of stress only in its negative form. Stress is therefore a physical reaction to an unexpected or threatening situation, called the alarm stage, and in the worst case ends with fatigue as the last stage.

    The stressful situation itself is called a trauma and can be a single event, such as an attack, fire, car accident, rape or a dangerous, threatening situation that is ongoing. A difficult childhood with a brutal father, continual bullying at school, living with a psychopathic husband, participating in war, being tortured or imprisoned, or a dangerous and strenuous flight from safe living conditions are all examples of ongoing traumatic life situations.

There are enormous individual differences as to how we experience and deal with these situations, and everyone is affected in different ways. 

Traumatic Reaction I

      It is normal to react to trauma. Not to react is abnormal and, in the worst case, fatal. To understand this phenomenon, it must be viewed in the context of the development of the human being over thousands, even millions of years. All living creatures have a survival instinct that directs the basic mechanism for ways in which creatures react. No animal (or plant?) could have survived if it had not developed methods of survival.

    But what we don’t think about or even realize is that these methods are automated. It is as if nature does not trust us to think for ourselves and decide what to do. No, instinct takes over in a threatening situation and does what is necessary to get us to safety without asking our permission. And we should be thankful for that.

    These mechanisms for survival lie deep within us, in our brains, and from there they direct the heart and blood supply, breathing, internal organs, senses and various hormones. We have this part of our brain in common with other, more primitive animals, and some call it the “reptile brain” because this is the type of brain that reptiles have.

      Above this part of the brain we have the “feeling brain”, which we have in common with other animals that give birth to live offspring. Only humans have developed the cortex, which we use to think.

    The cortex works continually to understand and have an overview of the entire situation, but it cannot understand what the other parts of the brain are doing. The cortex makes it possible for us to know that we exist. It gives us an experience of who we are, what we are, what we can and cannot do, etc., but the survival reactions, which are automatic, do not tell what is happening.

They do not send reports to the system above. All we can do is notice that something is happening, and we try to understand and find meaning and logic in it, but we usually are not able to do so completely.

    When the basis brain has increased the adrenalin to prepare the organism to react quickly and powerfully to get us to safety, we notice this and call it distress, tension or anxiety. We become worried about what is happening to us, which is something we do not understand, and this worry is registered “down” in the system as new information about danger, and the adrenalin is turned up even higher. Some call this a self-reinforcing mechanism, and in simplified form it is the basis for the development of what we experience as fear of the fear.

Traumatic Reaction II

      When we find ourselves in a situation that automatically activates the survival mechanisms, there are two primary reactions: The organism is mobilized either to fight or defend oneself and we are prepared to use aggression, or we are mobilized to get ourselves ready for escaping to safety.

   This second form of reaction is flight, and we are prepared to jump/climb as fast and as well as we can; we are prepared for escape. Again, no detailed report is sent “upward” through the system. The cortex realizes that something is happening, understands very little and becomes worried because this condition does not fit in with one’s usual perception of oneself. We become worried and wonder what it can be. (Am I sick? Am I going crazy? And so forth.)

   The distress is perceived as a new danger signal in the “*lifeguard cellar” where the adrenalin flow is increased to create more energy and power for the imminent event of either fight or flight – we give more “gas.” The overall result is that the prehistoric ability to increase our preparedness to meet danger becomes even greater. This functions just fine in the jungle, where we fight or flee according to the need, but in a more “modern” civilization this does not always serve us well. Instead, we are equipped with an ongoing increased preparedness to meet danger.

    -One way to understand this is to look at what happens when we drink alcohol. We touched on this topic once when I lectured on stress and stress management for employees of an organization. I explained that alcohol has the effect of gradually “funnelling” down through the brain so that the first effect of drinking alcohol is to turn off the cortex. Regard for others, manners and inhibitions are “loosened up” so that feelings such as happiness, joy, anger, melancholy and aggression are no longer held back, but have freer reign.

As the alcohol “funnels” down even farther, the ”feeling brain” is loosened up, and the most primitive part of the brain is released. In this case, we become disagreeable and stubborn, we argue and fight, we become more sexually aggressive, and it is impossible to talk sense into us. When I talked about this, the group I was lecturing nodded in unison – even one participant raised his hand and commented that this was absolutely true. As he said, “That’s right. We have a real reptile party every now and then!”

      To understand what happens during and after a traumatic threat to our person, it is important to be aware of what happens to our organism when preparedness increases dramatically.

Traumatic Reaction III

      Increased preparedness results in massive changes in the body’s functioning, and we mention the most important ones here:

  1. Immediately upon a traumatic threat, adrenalin production increases dramatically to obtain more energy. 
  2. The body eliminates extra weight; we urinate or move our bowels. In a milder version, we all have felt the need to urinate when we feel distressed, or unsettled in our stomachs when we are anxious. 
  3. The heart beats harder and faster to provide nutrients and oxygen to the muscles. 
  4. We hold our breath or hyperventilate (short and quick).
  5. We sweat. (cold sweats)
  6. Our eyesight changes, pupils become larger, and we use our peripheral vision more. Sometimes this results in tunnel vision, and we can even lose our ability to see colours. This may be explained because peripheral vision is better for observing movements. (*There is contrast vision for black/white, and it is very effective. This is the reason for using blinders on horses.)
  7. Our hearing is sharpened, and we “scan” for new and unfamiliar sounds that may be a sign of danger. (This is often the reason for disturbed sleep. We awaken at the slightest noise.)
  8. We have reduced production of mucus in our mouth and stomach; the organism does not have a need to consume food when in danger. Dryness of the mouth and discomfort in the stomach is the result.
  9. Our breathing locks up. We tense our diaphragm, the primary breathing muscle, which can give a feeling of tension and tingling down the arm. This, as well as pains in the chest, can lead to the fear that there is something wrong with our heart, which further accelerates the reaction. 
  10. Some of our senses are turned off, first and foremost our hearing and feeling on our skin. We do not notice scratches, injuries and pain.
  11. Our skin becomes cold, known as cold sweats, because the blood is diverted from the skin’s surface and sent to the lungs, muscles and head. One may experience numbing and prickling of the skin, especially on the arms and around the mouth.
  12. The brain draws on its best abilities to evaluate the situation, and all possible negative consequences are conjured up. A sort of creative brainstorming takes place in order to be prepared for the worst case scenario. Unfortunately, this is sent up to the cortex as information, often as pictures, which in turn increases the negative cycle. 
  13. All kinds of thoughts race through the mind, and if the situation is so serious that thoughts like “Now I’m going to die” or “I’m going to be injured” come to mind, then the alarm really goes off.

      In almost all cases this response is useful. We fight and win, or we flee and manage to escape to safety. Our organism also can take other measures as well, most importantly an ability to paralyze or become immobilized. We completely lock up and “freeze,” and we cannot move or say anything.

      This may seem like an absurd reaction, but this is most likely a reaction we have carried with us from prehistoric times. Some animals have a similar reaction. “Playing dead” is a survival mechanism because most predators want living prey; dead animals are uninteresting. Other mechanisms may be fainting (which gives the allusion of being dead) or acting strangely (the attacker becomes uncertain because we do not act as expected). 

  1. During the trauma, everything is registered by the *basis brain. Where we were, what we saw, how it smelled, what sounds we heard, etc. This is actually useful since the brain needs this information for later use to protect us against similar threats. Unfortunately, this information is used automatically outside our conscious control. It is as if we have built up a good, super-effective database of elements in dangerous situations.


    For example, if a person has been robbed on a bridge and it was foggy, this may result in the person feeling distress related to bridges and fog. The person begins to avoid these situations without knowing why. Our brain helps us to handle situations all the time. It always runs a “program” that functions as “feed forward.” It is as if the brain is always asking, “Is this familiar? Have we been in a situation like this before? Do we have experience with this, with what could happen?”

    Sometimes the brain finds an example of a bridge or fog in the “folder,” and the alarm sounds. If both the bridge and fog are present at the same time, the probability of danger is even greater. We do not notice this process ourselves. We do not understand it ourselves. The only thing we notice is the distress, internal tension or anxiety that means nothing more than that our brain has increased our preparedness to meet danger, and it therefore tries to stop us from going farther (over the bridge in the fog). 

      We walk around with a fantastic warning system and an incredibly effective ability to survive. Unfortunately, this is ill-suited to a modern society, and it creates some problems for us, both because it is automatic and because it is not easily turned off. And unfortunately, some people discover that alcohol can dampen it for a short time. 

      This was a short description of reactions which actually are normal, but which can frighten us when experienced for the first time.

Traumatic Reaction IV

      Another survival mechanism during the trauma itself may be to pretend that one is not present. This is called disassociation and is experienced as being outside oneself, outside one’s own body. The person may think that this is not happening or it is not me it is happening to. The person shuts off all feelings, not just fear and pain. The person becomes numb and feels like the “living dead” without senses or feelings.

     Shutting out everything is one way to survive. Sometimes this can last long after the traumatic experience itself. The world seems flat and colourless. Nothing means anything or makes an impact. The person is not affected by anything. If this reaction lasts a long time, it can be problematic for other people in the person’s life and negatively affect his/her quality of life. Some people lose all feeling and will dare to do anything because nothing matters anymore. Still others may live dramatic lives because they have to go to extreme lengths to feel that they are alive. 

      This is one of the so-called personality changes that can occur after a traumatic event. The person’s character often changes. The person’s relatives and friends think that he/she has changed, and the person’s interests, values and way of thinking are different from before. The person in question will usually deny this, or agree but conceal the reasons. Women who are mistreated over a period of time by a partner will also often be criticized for the changes in him that has caused the mistreatment. (*Note: I don’t really understand this point, or perhaps I have misunderstood the entire sentence?)

Traumatic Reaction V

 

      As described earlier, the brain notices and registers everything that happens during the traumatic event. But when the event is extreme, safety and survival are prioritized. The first message is to resolve the situation so that the situation is safe or that the person has found safety. One does not have time to evaluate, reflect upon or process all the data that one perceives. Everything is quick saved in a “temporary file,” to use a term from the IT world. Survival is the first, most important and only message in such a situation.

Post-Reaction I

      Only when the situation is over and the person is safe can he/she begin to think about and reflect upon what happened. This reaction usually comes later and is often surprising. The person may tremble, cry, become angry, have difficulty sleeping and experience terrible nightmares about the situation.

     Unfortunately, many people experience these things all alone and feel miserable. They have nobody to talk to or share their experiences with. They may have received an offer of crisis help immediately after the event, but at the time they were glad that the experience was over and they refused help because it did not seem necessary.

     “As long as I can go home and relax or sleep, I’ll be fine,” is a common response. It is even worse when the person cannot go home, but must go back to or continue to live with a threatening, dangerous and continually traumatic situation. Norwegian merchant sailors who were shot at and torpedoed during the war experienced exactly this, and some lived with this threat for several years.

Immediate Treatment Measures
     The past few years have seen the development of expertise in crisis help. In this type of work, two principles are paramount.

      First, a great deal of time is spent on providing as thorough information as possible about the situation the person has just experienced. All information given is as detailed as possible. The person has the opportunity to talk and ask all types of questions in this debriefing phase. This helps the person understand what has happened and place his/her own experiences in the context of the entire event. The blast they heard was a tank that exploded, the screaming came from a woman on the fourth floor, etc. 

      The second principle of crisis help is that everyone has the opportunity to feel, talk about and express the feelings they have inside. This releases the pressure, and the person gains acceptance for and understanding of the fact that it is normal and appropriate to have these feelings. People who have similar experiences can offer each other support, understanding, closeness and respect for person, who reacted like others and not abnormally. The greater the trauma, the more crisis help over a long period of time is needed to re-establish emotional balance, put the event in the past and move on with life.

Post-Reaction II

      Traumas often result in some kind of loss, not just of human life or material things, but loss of a psychological nature as well. People may:

  1. Feel that they have lost control over their own lives, own reactions, own thoughts and feelings.
  2. Lose their belief in people or God.
  3. Lose their belief in rationality or justice.
  4. Lose a feeling of strength or invulnerability.
  5. Lose their belief in the future.
  6. Lose their belief in their own autonomy and independence.
  7. Lose belief in themselves, their own worth, abilities, talents and skills.

      Because all loss results in mourning and sadness, this may result in reactions that calcify and become chronic in the form of depression, despair and resignation if not acknowledged, addressed and processed. This requires follow-up over time by professionals outside the person’s own circle. If not processed, the reaction may develop into chronic psychological problems in which the symptoms continue and increase as described in the section above on reactions to trauma.

      Nature has equipped us with the ability to handle different forms of trauma, injury and loss. Our organism needs rest, time to think and to feel. We dream in our sleep, and this is one of the most important methods the organism uses to process experiences. But this assumes that the experiences to be addressed, worked through and filed away are bearable. Intense trauma can be so overwhelming that we push our experiences aside, suppress them or seemingly forget them entirely. People who had a traumatic childhood often remember very little or nothing from their youth.

      Afterward the brain tries to set things right. It tries to get you to remember. It tries to get you to accept that some feelings are not finished being expressed. It reminds you constantly about what has happened through direct or indirect means. It tries to use your night dreams to process the feelings. Sometimes it pushes the experiences down into the body resulting in physical disorders. This can take many different forms, from anorexia nervosa to fibromyalgia.

    Maybe physical symptoms will remind you of something you do not want to remember. Often the temporary files that were saved contain such intense, overwhelming memories that they are too much for dreams. They manifest themselves as nightmares that bite and fragment and disturb the person with the full strength of sound, feelings and physical reactions. In the long run this is so tiring that it becomes a stress factor in itself.

     Sleep, which is supposed to be refreshing and restorative, becomes an added burden. Some people end up being afraid of sleep and resort to alcohol or sleeping pills, which is unfortunate because these substances inhibit dream activity. One of several negative cycles is then set in motion.

Treatment

      Much can be done, even though a good deal of time has elapsed after the trauma and the symptoms are chronic and all-encompassing. Extensive research on this topic has been carried out in the past few years. This knowledge has been passed on to professionals, and expertise in treatment has been developed.

      Several different methods have been developed that seem to have a positive effect on this disorder. The methods are different and must be adapted to the individual and the situation, but common to them all are that the treatment addresses and helps process much of what has been described above. It would be impossible to describe the various treatment methods in detail here, but if you, the reader, recognize yourself in some of what has been described, the first step is to acknowledge it to yourself, then contact someone who can help you or give you information about someone who can help.

Conclusion

      The book, The Long Way Home, written by Knut Braa, is the account of  a 19 year old soldiers traumatic experiences from a war zone in Lebanon and what it resulted in. Some people will recognize themselves to a certain degree; others will have had other reactions. In my opinion, what the author has struggled with is a direct result of providing service to his country.

There are probably many men and women in our country who felt so healthy and strong in their best years that they decided to commit themselves to a service that they believed to be worthwhile and exciting. They were in good physical shape as well as emotionally strong and healthy without any difficulties from their childhood. They received good training and were prepared for most situations. However, the service made demands on them which far exceeded anything that anyone could have foreseen.

Perhaps there are many people who now – years later – are suffering from wounds that will not heal, and something should be done for them. Norway has had thousand of resourceful young people stationed serving in Gaza, Congo, Lebanon, Bosnia, Kosovo and Afghanistan. And perhaps in the future similar contingents will serve in other countries. The first ones received little or no help after they returned home from their tours of duty, and some are probably still suffering today as a result.

Written by: Arnfinn T. Berg (7.october 1942 – 19. december 2002) Clinical Psychologist, Private Practice.
Revised 28. october 2021, by Knut A Braa

Afterwards

My friend and life saver, Arnfinn T Berg, unfortunately died in a traffic accident, during the winter 2002. He was an extraordinary psychologist who helped many people, including me. This article was written for me in my book The Long Way Home. I will focus on this topic in more blogposts to come. Meanwhile you can read these short posts.
Why exercise when you have PTSD?
Living with PTSD

See also archive for more post on this topic

 

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