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WHEN WAR WON'T LET GO One lesson learned: identify and treat post-traumatic stress

THE BALTIMORE SUN

When Johnny and Jane come marching home again, the hurrahs will be a lot more helpful than the unfriendly welcome was the last time around.

In fact, the probability that Persian Gulf veterans will get hurrahs should be part of the healing process for those who come back primed for the nightmares, flashbacks, hyper-vigilance or, alternatively, the emotional shut-down now recognized as symptoms of post-traumatic stress disorder (PSTD).

"Right now the people in Desert Storm are heroes. I hope it stays that way," said psychologist Aphrodite Matsakis, clinical coordinator of the Silver Spring Vet Center.

A nationwide project of the Department of Veterans Affairs, Vet Centers provide counseling for Vietnam veterans. About 15 percent of Vietnam vets have PTSD and are hurting from the brickbats of abuse they received when they returned from the war as well as from the physical and emotional wounds of the war itself.

With knowledge gained from their experience, and from a decade in which PTSD has been recognized in civilians, too, mental health experts are already planning to deal with it in this war's combatants.

Already extra mental health workers were been assigned to the troops in the desert, according to a recent article in the Journal of the American Medical Association. And the Department of Veterans Affairs is also gearing up for their return.

"We are planning to educate them, to say, 'This is what it is,' because when you name the monster it isn't so frightening. We can say, 'This is predictable; of course you have nightmares, of course you get anxious,' " said Dr. Matsakis.

Defined as a reaction to a physical or emotional trauma that is outside the range of normal human experience, PTSD can strike anyone who has been threatened or wounded, or who has witnessed something sufficiently threatening.

"These are people whose basic assumptions of safety are gone," said Sheppard Pratt psychologist Sally Winston, who counsels civilians with PTSD. "Anybody, given enough trauma, can develop PTSD, and it doesn't mean anything about their prior strength. The traumatized state has to do with the trauma, not the individual."

However, she added, while most people who undergo trauma have a reaction in the following weeks and then recover, people who "are behind the eight ball in the first place" are more vulnerable to chronic symptoms.

That means people who are substance abusers, people with prior psychiatric illnesses and people for whom the most recent disaster caps a history of misery and makes the whole load just too heavy to bear.

Research also shows that horrors imposed by other people are more likely to precipitate PTSD than are natural disasters; that younger people are more vulnerable than older people; that being held prisoner, being tortured, being involved in atrocities are more traumatic than involvement in conventional combat. Inability to unload the grief and dammed-up feelings of self-blame make it worse.

"It's not just that a person goes through a wounding, but that they are stigmatized for it," Dr. Matsakis said. "Those [Vietnam] vets who had some kind of support system, at least one human being to whom they

could turn and who accepted them -- it made all the difference in the world. Those whose families rejected them, who had no human bond -- that made healing impossible."

All trauma survivors do not have PTSD, of course. And those who do have it suffer in different degrees and at different times.

Some people with PTSD have occasional nightmares or depressive episodes, but seem otherwise OK. In some generally OK Vietnam vets, the war in the gulf has triggered "more nightmares, more intrusive thoughts, more shutdown of feelings, more emotional pain," Dr. Matsakis has found.

"It's like, if you were a rape victim and go to a movie about rape, it's going to do something to you," Dr. Matsakis said. "Or if your father got killed in a car crash on the corner, and now another old man is killed in a car crash on the corner."

At its worst, PTSD makes people paranoid, irritable, intolerant of the real or supposed errors of others. They're easily startled, unable to sleep peacefully, unable to establish intimate relationships, unable to remember large chunks of the traumatic experience and unwilling to face even the remotest reminders of it.

Periodically, however, the pain breaks through, erupting sometimes in rage or warlike aggressiveness.

Whether violence following trauma is necessarily caused by PTSD is, however, open to question. In Jacksonville, Fla., a few weeks ago, a young sailor was convicted of deliberately murdering a woman and her 3-year-old daughter in 1987, despite his claim that he did it in a flashback to an Iraqi missile attack while he was aboard the USS Stark in the Persian Gulf a few months before.

The reaction is more than just emotional. "There's a major change in neurochemicals," said Baltimore psychiatrist Alan Peck. "The brain is overproducing energizing chemicals like epinephrine, and these people are on guard, wound up, on fire; they can't turn it off."

Patients may, therefore, need drugs to calm them down and help them sleep. Some require individual therapy, and others do well in groups, where they can talk to other people who are having similar reactions after similar traumas.

Women often do so intuitively, Dr. Winston said. Women now serving in Saudi Arabia may be able to talk one another through their acute reactions and avoid the disorder.

On the other hand, Dr. Matsakis and Dr. Winston both noted, military women often feel the need to act in a more manly, stoic manner than they do in civilian life, which could have a contrary effect.

Other factors, peculiar to this war, raise other questions:

The volunteer servicemen and women in the Persian Gulf are generally older, presumably wiser, and possibly less vulnerable than the teen-age draftees of the Vietnam war. They are also less likely to be using drugs and alcohol, which are forbidden in Saudi Arabia. The war itself appears to be coming to a quicker conclusion, with fewer troops facing personal threat.

And it appears now that they will also be coming home to flag-waving and yellow-ribboned compatriots who learned, after Vietnam, to appreciate the warrior if not the war.

To learn more . . .

*The Baltimore Vet Center, at 777 Washington Blvd., provides outpatient services to Vietnam-era veterans. Call 539-5511.

*The Department of Veterans Affairs provides outpatient counseling to all veterans with PTSD at 31 Hopkins Plaza. Call 962-3319.

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