Author(s): Charles Kaiman Source: The American Journal of Nursing, Vol. 103, No. 11 (Nov., 2003), pp. 32-42 Published by: Lippincott Williams & Wilkins Stable URL: http://www.jstor.org/stable/29745429 . Accessed: 07/04/2014 19:32 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. . Lippincott Williams & Wilkins and Wolters Kluwer Health, Inc. are collaborating with JSTOR to digitize, preserve and extend access to The American Journal of Nursing. http://www.jstor.org This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions On Kyle Jones's last mission as an Air Force navigator in World War H, his plane was hit in the skies over Germany and caught fire. Mr. Jones grabbed another crew member and they jumped from the plane. Seconds later, it exploded; everyone left inside, including the pilot, was killed. As Mr, Jones hurtled toward the ground, he found that his parachute was defective. He was in free fall for 22,000 feet before he managed to open it. Upon landing, both he and his crew mate were captured by Germans; he spent the next 18 months in a prison camp. When he was released, Mn Jones had lost one-third of his body weight. Haunted by a fear of fire and intrusive memories of combat and confinement, Mr. Jones wandered the streets of his hometown for nearly three years after the war. As his fear and memories subsided, he made efforts to conquer his anxi? eties?by becoming a firefighter in order to overcome his fear of fire, for instance. Although a highly successful firefighter, he never married and was estranged from his family. At 77 years of age, 55 years after the trauma, Mr. Jones was living alone and had few friends. Dreams of the crash plagued his nights, and thoughts of combat flooded his days. In a panic, he sought treatment. In World War I it was called "shell shock"; in World War II, "combat fatigue." Although the difficulties combat veterans experience have long been recognized, it wasn't until 1980, the year posttraumatic stress disorder (PTSD) was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition, that symptoms such as Mr. Jones's were understood: they were a psychological reac? tion to extreme trauma, not a result of weakness.1 Classified as one of the anxi? ety disorders, PTSD is a syndrome of responses to extremely disturbing, often life-threatening events?combat, natural disaster, torture, or rape?that fall out? side of usual experience. While not all combat veterans develop PTSD, there's a correlation between it and combat exposure. In fact, PTSD occurs in as many as three out of five combat veterans.2 Charles Kaiman is a clinical nurse specialist in psychiatric mental health nursing at the New Mexico Veterans Affairs Health Care System, Albuquerque. Contact author: ckaiman@comcast.net. 32 AJN ? November 2003 ? Vol. 103, No. 11 http://www.nursingcenter.com This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Many years after the war, some aging veterans find themselves fighting a new battle?coping with delayed-onset or exacerbated posttraumatic stress disorder. A nurse describes the psychotherapy group he initiated to treat them. Combat Veteran By Charles Kaiman, MSN, NP, RN, CS ? 2003 Charles Kaiman, MSN, NP, RN, CS. Past and Present /, 12" x 16", watercolor and pen and ink. Author Charles Kaiman also illustrated this article. During one session of his therapy group, he used pen and ink to capture his impressions, while preserving the anonymity of the men. He later superimposed watercolor images of war, such as the corpses shown above, on the drawings. "I had so many ?mages in my head after drawing that day andlistening to their stories," Kaiman said. "I tried to imagine what they must have gone through and what they must be feeling after all these years." ajnmww.com AJN ? November 2003 ? Vol. 103, No. 1 1 33 This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Assessing PTSD A primer on identifying symptoms. The key to assessing for posttraumatic stress disorder (PTSD) is establishing whether a primary psychological trauma occured. (A brief military history should establish whether a vet? eran was directly involved in combat.) Once the episode of trauma is confirmed, the mnemonic RAN can help in the patient assessment. R? Reexperiencing ? intense memories of a traumatic event ? recurrent nightmares of the event, thrashing in sleep, diaphoresis upon awakening ? reliving of the trauma as if it were happen? ing now (flashback), with possible auditory, visual, olfactory, or even tactile hallucinations ? intense distress induced by reminders of the event A? Autonomie hyperarousal ? outbursts of anger, irritability for little reason, extreme impatience ? an inability to be in crowds or use public transportation ? poor concentration ? exaggerated startle response (for instance, taking cover if a car backfires, avoiding fireworks) ? hyperawareness of surroundings and poten? tial dangers, sitting with back to walls with the room in full view, scouting all entrances and exits, patrolling the house at night N: Numbing and avoidance ? avoidance of thoughts, feelings, people, and places associated with the trauma, such as military holidays, low-flying aircraft, and war movies ? a lack of interest in activities ? emotional numbness and detachment from life, inability to have strong emotional reactions ? a sense of a foreshortened future Patients with trauma who have any of these symptoms that interfere with their functioning should be referred to PTSD treatment. For nurses caring for older adults, the impor? tance of recognizing PTSD is clear; after all, WWII veterans are now reaching their 90s, veterans of the Korean War are hitting their 70s, and Vietnam vet erans are marching just 12 to 15 years behind. But recognizing PTSD is important for all nurses. The disorder can affect anyone who has undergone extreme trauma; in one study, Breslau and col? leagues found an overall rate of PTSD of 9.2% in those who had been exposed to extreme trauma.2 Indeed, reactions to psychological trauma can be even more destructive and persistent than effects of physical trauma. Undiagnosed and untreated PTSD may increase risk factors for cardiovascular disease and cause suicidal ideation and physically damag? ing changes in the function of the endocrine system, the immune system, and the autonomie nervous system.3,4 Moreover, as in a major depression, PTSD can lead to difficulty in merely getting through one's day. Treatment of PTSD seeks not only to decrease psychological distress; it may help to resolve problems in the patient's physical health, as well.46 A basic understanding of PTSD will help nurses to identify patients in need of specialized care and will enable them to provide immediate and compassionate support. DIAGNOSING THE DISORDER PTSD can be diagnosed only after exposure to a traumatic event has been established. Because reac? tions to trauma are diverse, how "traumatic event" is defined will vary as well. In one person, trauma would have to be personally life threatening to result in PTSD symptoms; in another, exposure to others' trauma would do so. Some veterans of Operation Desert Storm who have PTSD, for instance, experienced direct threats to their own lives; in others, symptoms are the result of seeing the charred bodies of the enemy lined up for disposal. Symptoms. Diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV TR) include the following2: ? intrusive reexperiencing of the trauma: this often involves memories and nightmares of the trauma and, less frequently, dissociative states (flash? backs), during which the trauma is relived ? autonomie hyperarousal: this includes insomnia, irritability, outbursts of anger, poor concentra? tion, hypervigilance, and an exaggerated startle response ? emotional numbing, coupled with avoidance of stimuli associated with the trauma: this may manifest as emotional detachment and unrespon siveness or as deliberate efforts to avoid feelings, thoughts, or situations associated with the trauma All of these symptoms must be present for more than one month to confirm a diagnosis of PTSD; a patient who exhibits most but not all of these symp? toms receives the diagnosis of "posttraumatic stress syndrome," also known as "subclinical PTSD."6 34 AJN ? November 2003 ? Vol. 103, No. 1 1 http://www.nursingcenter.com This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Anxiety and behavioral disturbances occurring within the first month of extreme trauma are cate? gorized as symptoms of acute stress disorder. If these symptoms continue for more than one month and less than three, the syndrome is deemed acute PTSD. After three months it's chronic. Symptoms that first occur later than six months after the trauma are categorized as delayed-onset PTSD.2 PTSD may seem to resolve within three months, only to reemerge many years later.79 Alternatively, patients with chronic, mild PTSD may suddenly experience exacerbated symptoms later in life.10 Combat exposure can be a significant Stressor that causes symptoms decades later.8,9 In fact, events that occur normally with aging?the deaths of loved ones, the loss of a job, or diminished health?may rekindle wartime memories, survivor guilt, and unresolved grief.11,12 Such events can also erode important, long-standing coping mechanisms; for example, many WWII veterans suppressed symp? toms and memories of trauma by immersing them? selves in work. At retirement, a veteran may find himself suddenly without long-practiced means of escape. Dissociation?a "perceived detachment of the mind from the emotional state or even the body"?may be used to defend against overwhelm? ing anxiety.7,13 Finally, biology may play a part in the exacerbation of PTSD in elderly veterans; it's thought that neurotransmitter dysregulation caused by aging may be linked to an increased psychologi? cal vulnerability in the elderly.14 Whatever the causes?and they are likely multiple?exacerbation of PTSD in elderly veterans is common.15,16 Screening can discern trauma much as labora? tory tests can discern blood abnormalities.17 Two clinically sensitive PTSD screenings used by the Vet? erans Administration are the Clinician Adminis? tered PTSD Scale and the Mississippi Scale for Combat-Related PTSD. Yet a drawback of these screenings is that they view the patient in a passive role, as a specimen to be studied. Seng has introduced the concept of the acknowl? edgment of trauma.6 She says, "Acknowledging that trauma and posttraumatic stress may affect patients' lives and their health throughout their lifespans may allow for more effective interventions and better health outcomes." In fact, Seng posits, "acknowledging can be an intervention in itself." And the patient's "health status can improve by acknowledging trauma as a contributing factor in the health problem." This acknowledgment by the patient represents a tacit agreement to begin healing. Depression, anxiety, anger, guilt, and alcohol and drug abuse may afflict combat veterans as well. Alcoholism in elderly patients with PTSD com? pounds maladjustment, while anger has been shown to hinder treatment in combat veterans with PTSD, possibly by interfering with the patient's ability to When PTSD Is Diagnosed Protect yourself and your patients. ? Approach the patient calmly and slowly, remaining in his field of vision. ? Don't startle the patient with loud noises or by touching him unexpectedly. If the patient is sleeping, awaken him verbally not by touch. ? Don't box a patient into an office with no easy way out; he may feel trapped and his anxiety may increase. ? Recovery room and ICU nurses should be especially alert to the possibility of postanesthesia flashbacks. A combat veter? an having a flashback is psychologically in a war zone and may misidentify people or places as threats. Remove sharp, loose, or heavy objects and decrease noise in the area. Gently try to reorient the patient, but don't force it; keep trying periodically. ? Don't drive the patient away from treatment by telling him, "Get over it; the war was 60 years ago/ Remember, his symptoms may be emerging for the first time since the war. engage with either therapist or family and friends.18,19 Finally, when compared with elderly patients with? out PTSD, the incidence and severity of physical illness are disproportionately high.3'5 CASE STUDY: GROUP THERAPY WITH WWII VETERANS In 1993, while working as part of an interdiscipli? nary treatment team at the Veterans Administration Hospital in New York City, I initiated a weekly psy? chotherapy group for WWII combat veterans with PTSD. Two attended the first meeting. Nine years later, the group had grown to 29 men, ranging in age from 75 to 88. Three were African American, five were Filipino American, and the others were European American. Group members included offi? cers and enlisted men representing all four branches of the U.S. military. Five had been prisoners of war. All of the men met the DSM-IV diagnostic crite? ria for PTSD. Although some had experienced symptoms of full-blown PTSD since the war, most had latent or mild PTSD until their 60s or 70s, at which time their symptoms worsened. All received treatment for other medical conditions from the Veterans Administration or at private facilities. The 90-minute meetings were scheduled in the early afternoon, to allow time for commuting ajn@lww.com AJN ? November 2003 ? Vol. 103, No. 1 1 35 This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Reliving the Terror September 1 1 was 'Pearl Harbor, all over again. 1 On its Web site, the National Center for Post-Traumatic Stress Disorder warns that acts of terrorism and war may be particularly disturbing for people who have already survived traumatic events (www.ncptsd.org/ facts/disasters/fs_screen_disaster.html). This proved true in my group of WWII veterans. The terrorist attacks of September 11, 2001, taxed their emotional resilience as well as my skills as a therapist. Although none of us lost loved ones, more than half of the members living in Manhattan witnessed the attack, as did I. At our first meeting nearly a week after the attacks, the most com? mon remark was, "It's Pearl Harbor, all over again." Many of the men expressed fear that their "defense of the free world" had been undone by the attacks. And like most people across the country, they felt shock and disbe? lief. But in this group, the attacks also resulted in increases in out? bursts of anger, isolation, hypervigi lance, anxiety, nightmares, and intrusive memories of combat. These exacerbated symptoms of posttrau matic stress disorder (PTSD) affected , , the group dynamic. Verbal and Chartes Kaiman ? ? _i_i i physical aggression suddenly became part of our group. For example, one member, angry with another, who was wheelchair bound, ripped off his shirt and walked over to him. With his chest bared, he was an extremely threatening presence. I had to get between them to break it up. Before September 11, this type of behavior was rare. I found myself adjusting my therapeutic style. I began standing during meetings to better maintain control of the group. I directed conversation away from topics such as politics and religion. I even took a few intractable members out of the group far a couple of sessions and counseled them individually. Even with these efforts, several meetings ended early because the level of anger was such that I was concerned that the men could become physically ill. It was a difficult time personally as well, as I needed to restrain my own anxiety in order to handle the patients' anxieties. Reestablishing equilibrium in the group involved setting strict limits. Instead of a free-flowing, interactive group, we set a predetermined topic at the beginning of each meeting. The group took on a more formal tone, as I disallowed cross talk and began calling on people to speak. Yet I continued to encourage mutual support among members. Even with the group's history of mutual empathy and unity, it was several months before the group was the strong source of social sup? port it had once been. After about a year, the intensity of PTSD symptoms subsided to nearly the level they had been at before the attack.?Charles Kaiman, MSN, NP, RN, CS I before rush-hour traffic. They are run as an ongo? ing, interactive psychotherapy group using "experi? ential learning," which gives patients, over time, the opportunity to discuss their grief with other group members, decrease their isolation, and apply this experience in communication to their relations with others in their lives (as opposed to a didactic approach, in which patients are merely told that dis? cussing feelings of loss and grief with family and friends is helpful to mental health). Although the meetings have no set agenda, the focus remains on the members, with the goal of decreasing depres? sion, intrusive memories, nightmares, rage, isola? tion, and anxiety. The following descriptions of group members will convey a sense of the men who participate in this group. (Names have been changed and descrip? tions modified to maintain confidentiality.) None of the patients was in therapy before joining my group, and none identified instances of trauma before or after WWII. My participation in the group ended recently, when I moved to New Mexico. Howard Jameson, 84, was an Army infantry? man from 1940 to 1945. He joined the group two years ago. During prolonged, intense combat in North Africa, Sicily, and Normandy, he sustained multiple shrapnel wounds to his hands, neck, and legs. Over the last five years, the pain from these wounds has increased and has become a constant reminder of wartime service. Married for 52 years, Mr. Jameson has six children and 12 grandchildren; he claims to have enjoyed a fairly happy family life, although he admits his children sometimes criticize his "short temper." Before retiring six years ago, he had a successful career in sales and says he never abused drugs or alcohol. He had a myocardial infarction 11 years ago. He has no cognitive deficits or psychological comorbidities. Except for occa? sional outbursts of anger, he was not bothered by PTSD symptoms until eight years ago. Upon retir? ing, his symptoms intensified and now include out? bursts of anger, an exaggerated startle response, and daily intrusive memories of combat and lost buddies ("just like it was yesterday"). He has severe insom? nia, sleeping just two to three hours a night, and he suffers nightmares about combat five times a month. However, since joining the group he has dis? cussed his war trauma with his family, and he's feel? ing less emotionally isolated. Marion Westerfeld, 80, would have been respon? sible for dropping the atomic bomb on Nagasaki, had last-minute scheduling changes not occurred. As it was, the B-29 pilot flew over the city the day after it was bombed and witnessed the devastation from the air. He was emotionally detached from what he saw, calling it "dreamlike and unreal." After the war, he went on to a successful business career. I But he had a tendency toward isolation, and he 36 AJN ? November 2003 ? Vol. 103, No. 1 1 http://www.nursingcenter.com This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions ? 2003 Charles Kaiman, MSN, NP, RN, CS. Pair and Pressnr ff, 12" x 14", watercolor and pen and ink. non? drive the patient away by telling him, 'Get over it; the war was 60 years ago/ divorced twice. Through his highly visible job in architecture, he entered the world of the "jet set"? once even dancing a fox-trot with Eva Per?n. He joined the group in 1994 because of a sharp in? crease in intrusive thoughts about his war experi? ences. Several months after joining, Mr. Westerfeld, who has suffered from alcoholism since his time in the service, stopped drinking. He began to bond with others. Morris Aronson, 81, flew 44 bombing missions over the Pacific as a flight engineer. He crashed once. He witnessed six buddies burn to death in an explosion and felt tremendous survivor guilt because his brother drowned while in the military, also in WWII. His turbulent marriage ended in divorce, and he's estranged from two of his four children. Quadruple coronary artery bypass graft surgery forced him to retire five years ago. A heavy drinker since his time in the service, he quit drink? ing without joining a support group after he retired. In the years following the war, he was prone to out? bursts of anger. But since his health began to dimin? ish and he was forced into retirement, other PTSD symptoms emerged, including frequent intrusive thoughts, nightmares, insomnia, and an exagger? ated startle response. He joined the group about 18 months after symptom onset. Since then, he's felt less anxiety and survivor guilt, he's grown closer to his family, and he's become a volunteer tutor to chil? dren in his community. Don Dinato, 85, was buried alive during the Battle of the Bulge by dirt thrown by an exploding bomb. He was rescued 10 hours later. Also, as a company commander, Mr. Dinato had to decide which of his men would be in the front lines?men who in most cases became casualties. After the war, ajn@lww.com AJN ? November 2003 ?Vol. 103, No. 1 1 37 This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Combating PTSD The or my works to soften emotional Stressors in Iraq and at home. Since the war in Iraq began earlier this year, the U.S. Army has modified practices to ease the stress of combat and has initiated a plan to help those returning to the United States readjust to life back home. Experts agree that the potential for trauma for soldiers in Iraq is great. It's been warned that the controversy surrounding the war, the prolonged deployments, and the "no place to hide" nature of the conflict will lead to trauma lev? els as high as those in Vietnam veterans. The army currently relies heavily on reserve forces and requires frequent reinforcements. Furthermore, more than 50% of enlisted soldiers are married, and statistics show that (or many, reunions can be as difficult as separations: the divorce rate among deployed troops was 27% higher than that among nondeployed troops in the 21 months after the 1991 Gulf War, according to a study by the Department of Defense. If s also believed that com? bat stress played a part in the deaths of four women killed in 2002 by their husbands who had recently returned from fighting in Afghanistan. On the front, early interventions include ? battlefield rites for fallen soldiers. ? encouraging troops to discuss fears and feelings after combat. ? stress and anger management classes. ? a "tip card" used by unit leaders to help screen soldiers for problems such as suicidal thoughts and strained relationships. Before returning home, ? soldiers remain with their units for physical and mental health screening and "reunion training" designed to prepare them for the return home. Once home, ? before being given leave, soldiers remain with their units until everyone has completed fur? ther evaluations and integration training (up to 10 days). ? those identified as having specific problems are connected with an appropriate official or agency for follow-up. For example, financial counselors are provided to those with money problems. ? a telephone-based employee assistance pro? gram is available to veterans and their fami? lies for a year after their return.?Lisa Santandrea, senior editor I he adjusted well to civilian life. Married for more than 50 years, he had a successful career as an auto? motive executive. Aside from long absences from home while traveling for business (which may have indicated a propensity toward isolation), Mr. Dinato had no PTSD symptoms. But since he was forced to retire two years ago, when problems resulting from wartime leg injuries hindered his ability to travel, he began having nightmares, intru? sive thoughts, and insomnia. He joined the group a year after it began. THERAPEUTIC GOALS Like those described above, most members of the group have been strong, survival-oriented men who were able to readjust to and even thrive in civilian life after enduring profound combat trauma. Yet many years after returning home, they found them? selves fighting a new battle?coping with delayed onset or exacerbated PTSD. Some of the group's initial goals were to help members break patterns of isolation, to replicate the combat unit and the fam? ily within the group, and to aid them in coming to terms with tragedy. Breaking patterns of isolation. As the men discuss their experiences in the war and how their combat memories and nightmares have increased, they look to one another for comfort and support, just as they did in combat.15,20 Yalom considered universality? the patient's understanding that he's not alone with his feelings?to be an important factor in group therapy.21 In this specialized group, the sense of uni? versality provided almost immediate relief. Most members had little understanding of PTSD and thought they were alone in having their intrusive and painful memories. Finding out that they weren't gave them a tremendous sense of validation. Mr. Aronson, for example, had expressed his doubt that anyone could understand his difficulty in adjusting to life after the war; when the group responded to his story with boisterous offerings of support and empathy, his relief was palpable. Unlike many therapy groups, in which outside contact among members is discouraged, this one encourages members to interact with one another outside the group; I believe the group also serves as a social support for men who are isolated by the loss of loved ones or because of the emotional dis? tancing caused by PTSD. In order to encourage members to socialize, I never arrived early for the group and always left immediately afterward. Most of the members have exchanged phone num? bers, and several see one another socially outside the group. Replication of the combat unit and family. I've I been leading interactive therapy groups for 20 38 AJN ? November 2003 ? Vol. 103, No. 1 1 http://www.nursingcenter.com This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions Mn order to encourage members to socialize, I never arrived early for the group and always left immediately afterward. Most of the members have exchanged phone numbers, and several see one another socially outside the group. ? 2003 Charles Kaiman, MSN, NP, RN, CS. Past and Present III, 12" x 6", watercolor and pen and ink. years. This group was unusual, in that cohesiveness, which usually takes at least several meetings to establish, formed almost instantly. For example, after attending his first group meeting, Mr. Westerfeld missed the next three meetings because of unexpected surgery. The group members sent him a get-well card, and some visited him; when he returned, they welcomed him back like a long-lost friend. Before joining the group, Mr. Westerfeld had few friends and had significant problems with inti? macy, yet he now feels comfortable talking in the group and finds it a significant source of support. This ease of bonding that exists in the group may be a replication of the camaraderie of soldiers in combat. Indeed, some members even took on their former military personas. Mr. Dinato, for example, a former company commander, became the group's negotiator and an authority figure, which helped create the sense of the group as a company. The downside to this bonding is that the "rest of the world"?anyone who was never in combat?is excluded from this intimate circle, and this includes spouses and children, whom the men often kept at an emotional distance. Members felt that those who haven't seen com? bat "would never understand"; many also remain quiet in an attempt to "protect" loved ones. For example, Mr. Jameson had never told his wartime story to family or friends. After first telling the group, he was able to tell a friend, then his wife, and finally his children. He recalls being comforted by the discovery that they weren't made of "fragile glass." Like Mr. Jameson, many of the other mem? bers had never discussed their experiences with their children before joining the group, seeing them as too vulnerable, even though most of their children now have their own children. In fact, children of a veteran with PTSD often exhibit emotional re? sponses similar to but less severe than their father's, even if they are unaware of his trauma. When the phenomenon of PTSD is explained to them, chil? dren are relieved by the discovery that they and their a?n@lww.com AJN ? November 2003 ? Vol. 103, No. 11 39 This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions International Society of Traumatic Stress Studies www.istss.org; (847) 480-9028; istss@istss.org National Center for Post-Traumatic Stress Disorder www.ncptsd.org; (802) 2966300; ncptsd@ncptsd.oiig Office of the Special Assistant for Gulf War Illnesses www.gulflink.osd.mil; special.assistant@deploymenthealth.osd.mil Posttraumatic Stress Disorder Alliance www.ptsdalliance.org; (877) 507-PTSD; infb@pl5dalliance.0rg Deportment of Veterans Affairs www.va.gov family weren't the cause of their father's distress.22 Transference, the projection of feelings about people from the past onto those in the present, is an essential aspect of the group. Because I'm about the same age as many of the members' children, I used father-child transference as a way of encouraging them to discuss their experiences. When they shared their stories with me, they were rehearsing a discus? sion with their own children. One group member, for example, helped liberate the concentration camp at Dachau. When he first told me this story, one he hadn't told in more than half a century, I sobbed right along with him. And I encouraged him to con? tinue talking, demonstrating that his story was not too painful to hear and empathize with. This is an example of Peplau's idea of the "therapeutic use of self."21,23 It proved extremely effective for this patient, who shared his story with his son soon after. Ultimately, his symptom frequency and inten? sity decreased more than anyone else's in the group. Coming to terms with tragedy. The aging veteran has heightened susceptibility to survivor guilt.24 A useful intervention is encouraging a search for sig? nificance in past events. This search is in accord with Erikson's last developmental stage, ego integrity versus ego despair.25 Ego integrity refers to a person's sense of his life as having meaning and significance; in contrast, ego despair results from a sense that one's life has been insignificant, that opportunities were squandered, that all was for nothing. In order to avoid despair, the task is to see one's life in a greater context. Mr. Jones undertook such a task when he sought to find the family of the pilot killed in the explosion of the plane he'd bailed out of. Previous efforts to do so had been unsuc? cessful. Yet about the same time he joined our group, he met somebody who was able to help him trace them. When he finally met them, the pilot's widow embraced him, and the entire family accepted, thanked, and honored him. When he told us this in a group session, there wasn't a dry eye in the room. The group has helped all members achieve a feel? ing of belonging and has given them opportunities to disclose painful memories in a safe arena. Many have noticed improvement in their physical health and in their enjoyment of life. And many have begun sharing their traumatic experiences and feel? ings with their families and have expressed satisfac? tion and relief in having done so. What's left to be expressed is the gratitude I feel for having had the chance to work with these extraordinary human beings. ? Complete the CE test for this article by using the mail-in form available in this issue or by going to Online CE at www.ajnonline.com. REFERENCES 1. National Center for Post-Traumatic Stress Disorder. Posttraumatic Stress Disorder: An Overview [Web site]. 2003. www.ncptsd.org/facts/general/fs_overview.html. 2. American Psychiatric Association, et al. Diagnostic and sta? tistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. p. 463-72. 3. Falger PR, et al. Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch Resistance veter? ans from World War II. Psychother Psychosom 1992;57(4):164-71. 4. National Center for Post-Traumatic Stress Disorder. Screening for PTSD in a primary care setting [Web site]. 2003. http://www.ncptsd.org/facts/disasters/fs_screen_ disastenhtml. 5. Lipton MI, Schaffer WR. Physical symptoms related to post-traumatic stress disorder (PTSD) in an aging popula? tion. MilMed 1988;153(6):316-8. 6. Seng JS. Acknowledging posttraumatic stress effects on health. A nursing intervention model. Clin Nurse Spec 2003;17(1):34-41; quiz 2-3. 7. Sullivan HS. The interpersonal theory of psychiatry. New York,: Norton; 1953: 139-61. 8. Rosen J, et al. Concurrent posttraumatic stress disorder in psychogeriatric patients. / Geriatr Psychiatry Neurol 1989; 2(2):65-9. 9. Engdahl B, et al. Posttraumatic stress disorder in a commu? nity group of former prisoners of war: a normative response to severe trauma. Am J Psychiatry 1997;154(11):1576-81. 10. Ni?ois B, Czirr R. Post-traumatic stress disorder: hidden syn? drome in elders. Clinical Gerontologist 1986;5(3/4):417-33. 11. Boehnlein JK, Sparr LF. Group therapy with WWII ex POW's: long-term posttraumatic adjustment in a geriatric population. Am J Psychother 1993;47(2):273-82. 12. Hierholzer R, et al. Clinical presentation of PTSD in World War II combat veterans. Hosp Community Psychiatry 1992;43(8):816-20. 40 AJN ? November 2003 ?Vol. 103, No. 1 1 http://www.nursingcenter.com This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions 13. Substance Abuse and Mental Health Services Administration, National Institute of Mental Health. Mental health: a report of the Surgeon General Anxiety disorders. [Web site], http://www.surgeongeneral.gov/library/ mentalhealth/chapter4/sec2.html. 14. Allen A, Blazer D. Mood disorders. In: Sadavoy J, Lazarus L, Jarvik L, editors. Comprehensive review of geriatric psy? chiatry. Washington, DC: American Psychiatric Press; 1991. 15. Snell FI, Padin-Rivera E. Group treatment for older veterans with post-traumatic stress disorder. / Psychosoc Nurs Ment Health Sew 1997;35(2):10-6. 16. National Center for Post-Traumatic Stress Disorder. PTSD and Older Veterans [Web site]. 2003. http://www.ncptsd.org/ facts/veterans/fs_older_veterans.html. 17. Franklin CL, et al. Screening for trauma histories, posttrau matic stress disorder (PTSD), and subthreshold PTSD in psy? chiatric outpatients. Psychol Assess 2002;14(4):467-71. 18. Druley KA, Pashko S. Posttraumatic stress disorder in World War O and Korean combat veterans with alcohol depen? dency. Recent Dev Alcohol 1988;6:89-101. 19. Forbes D, et al. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. / Nerv Ment Dis 2003;191(2):93-9. 20. Elder GH, Jr., Clipp EC. Wartime losses and social bonding: influences across 40 years in men's lives. Psychiatry 1988;51 (2):177-98. 21. Yalom ID. The theory and practice of group psychotherapy. New York: Basic Books; 1985. p. 3-19. 22. Rosenheck R. Impact of posttraumatic stress disorder of World War II on the next generation. / New Ment Dis 1986; 174(6):319-27. 23. Peplau H. Professional closeness. In: Toole A, Welt S, edi? tors. Interpersonal theory in nursing practice. New York: Springer; 1989. p. 230-43. 24. Miller T. W. Long-term effects of torture in former prisoners of war. In: Basoglu M, editor. Torture and its consequences: current treatment approaches. New York: Cambridge University Press; 1992. p. 107-34. 25. Erikson EH. Childhood and society. 2d ed. New York: Norton; 1963. p. 268-9. ce2 Continuing Education GENERAL PURPOSE: To present registered professional nurses with a detailed review of posttraumatic stress disorder in combat veterans, including case studies and treatment approaches. LEARNING OBJECTIVES: After reading this article and taking the test on the next page, you will be able to ? discuss the origins, etiology, and classification of posttraumatic stress disorder. ? describe the diagnostic criteria (or diagnosing and therapeutic approaches to treating posttraumatic stress disorder. ? outline a plan for a group therapy approach to helping elderly combat veterans cope with posttrau? matic stress disorder. To own continuing oducation (CE) croon, follow those instructions: 1? After reading this article, darken the appropriate boxes (numbers 1-17) on the answer card between pages 40 and 41 (or a photocopy). Each question has only one correct answer. 2. Complete the registration information (Box A) and help us evaluate this offering (Box C).* 3? Send the card with your registration lee to: Continuing Education Department, Uppincott Williams & Wilkins, 345 Hudson Street, New York, NY 10014. 4* Your registration foe for Ais coring is $13.95. If you take two or more tests in any nursing journal published by Uppincott Williams & Wilkins and send in your answers to all tests together, you may deduct $0.75 from the price of each test. Within six weeks after Uppincott Williams & Wilkins receives your answer card, you'll be notified of your test results. A passing score for this test is 13 correct answers (76%). If you pass, Uppincott Williams & Wilkins will send you a CE certificate indicating the number of contact hours you've earned. If you fail, Uppincott Williams & Wilkins gives you the option of taking the test again at no additional cost. All answer cards for this toaonPlSDmeeWMWrMConeattotonnmuau* received bv November 30.2005. This continuing education activity for 2 contact hours is provided by Uppincott Williams & Wilkins, which is accredited as a provider of continuing nursing educa? tion (CNE) by the American Nurses Credentialing Center's Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 11?96, category O). This activity is also provider approved by the California Board of Registered Nursing, provider number CEP 11749 for 2 contact hours. Uppincott Williams & Wilkins is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA ?75. All of its home study activities are classified for Texas nursing continu? ing education requirements as Type 1. */n accordance wie Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of ?is CNE offering may be submitted to the Iowa Board of Nursing. ajn@lww.com AJN ? November 2003 ? Vol. 103, No. 1 1 41 This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions CE Continuing Educ ntion TEST 9 HOURS || PTSD in the World War II Combat Veteran 1. In World War II, the term used to describe a reaction to extreme trauma experienced during military service was a. anxiety disorder. b. reactive neurosis. c. combat fatigue. d. battle neurosis. 2. Posttraumatic stress disorder (PTSD) a. develops in about 40% of combat veterans. b. is a term that came into use around 1990. c. is often a result of weakness. d. is classified as an anxiety disorder. 3? Diagnostic criteria for PTSD Include a. emotional numbing. b. physiologic distress. c. suicidal ideation. d. survivor guilt. 4. Dissociative states are a mani? festation of a. behavioral disturbances. b. emotional detachment. c. autonomie hyperarousai. d. intrusive reexperiencing of the trauma. 5. Insomnia is a manifestation of a. behavioral disturbances. b. emotional detachment. c. autonomie hyperarousai. d. intrusive reexperiencing of the trauma. 6? PTSD is confirmed when a per? son experiences a. most of the diagnostic criteria for more than one month. b. most of the diagnostic criteria for at least one year. c. all of the diagnostic criteria for more than one month. d. all of the diagnostic criteria for at least one year. 7. When symptoms appear than six months after the initial trauma/ the person is said to have a. posttraumatic stress syndrome. b. delayed-onset PTSD. c. acute PTSD. d. acute stress disorder. 8? Symptoms that continue for longer than one month but less than three months are considered manifestations of a. posttraumatic stress syndrome. b. delayed-onset PTSD. c. acute PTSD. d. acute stress disorder. 9. Symptoms such as anxiety that appear within one month of an extreme trauma are considered manifestations of a. posttraumatic stress syndrome. b. delayed-onset PTSD. c. acute PTSD. d. acute stress disorder. 10? One cause of the exacerbation of PTSD in elderly veterans may be a. neurotransmitter dysregulation. b. well-developed coping mechanisms. c. avoidance of environmental stimuli. d. good health and a rewarding work life. 11. Which of the following does Seng propose to allow for more effective interventions for patients with PTSD? a. identifying comorbidities b. using the Clinician Administered PTSD Scale c. acknowledgment of trauma d. using the Mississippi Scale for Combat-Related PTSD 12. Which of the following has been identified as a deterrent to treatment in combat veterans with PTSD, probably because it hinders engagement with the therapist? a. guilt b. anger c. depression d. anxiety 13. The therapeutic approach the author used in his group is a. didactic teaching. b. individual discussion. c. experiential learning. d. behavioral correction. 14. The author's group experienced an almost immediate sense of relief as a result of which of the follow? ing factors, described by Yalom as an essential factor in successful group therapy? a. catharsis b. cohesion c. reflection d. universality 15? In contrast with other types of therapy groups, the veterans in the author's group were encouraged to a. form their own smaller therapy groups. b. bring their spouses and children to meetings. c. socialize outside group meetings. d. attend meetings for a limited period. 16. Veterans search for significance in past events to achieve the devel? opmental stage of a. ego integrity. b. self-actualization. c. generativity. d. self-esteem. 17? When awakening a veteran who has PTSD, the best approach is to a. gently shake his shoulder. b. awaken him verbally. c. softly clap your hands a few times. d. take his hand and call his name in a soothing tone of voice. ? 42 AJN ? November 2003 ? Vol. 103, No. 11 http://www.nursingcenlBr.CQm This content downloaded from 67.239.64.253 on Mon, 7 Apr 2014 19:32:59 PM All use subject to JSTOR Terms and Conditions