PTSD: A SILENT AND NOT RECOGNISED EVIL

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PTSD: A SILENT AND NOT RECOGNISED EVIL

Authors: Rachele M. Magro*, Flavia Moretti **

Psychologist of the Local Health Unit – Viterbo (Italy) 

** Postgraduate trainee in Psychology– Viterbo  (Italy)

Abstract

The present work is first of all a narration that tries to give meaning to life stories: stories of Italian soldiers who fight a battle not only on a mission with the colors of the flag on their arm but also and above all an inner one. Behind these stories there are people who have long tried to maintain a balance with their own resources, in solitude until they were no longer able to contain the disabling symptomatology. This study confirms that the onset of PTSD can occur even years after the critical triggering event. In the cases that will be presented, however, the clear symptomatologic expression, which emerged only months or years later, led to the denial, by the competent Italian Ministry of Defence, of the causal link of the disorder with the traumatic event. Many of the soldiers we are going to talk about are still fighting a battle not made of weapons but of legal documents, expert reports and legal disputes. An element common to many of them, which in part holds back the resolution of the problem and impedes the treatment process, is the fear of losing their jobs or being redeployed in civilian assignments. Some of them attempt even suicide because they feel alone  in the face of a disabling disorder or worse by being unfit to serve their Country as soldiers any longer.

The clinical aspects

The acronym PTSD stands for “Post Traumatic Stress Disorder”, refers to stress reactions that persist over time and that arise from exposure to a traumatic event. The negative effects that being directly or indirectly involved in a traumatic event can cause on a psychological level have been known for some time. The war events that marked the first decades of the twentieth century contributed greatly to gather interest around the traumatic phenomenon. Since the First World War, the symptoms of stress such as anxiety, depression, aggressive behavior, nightmares, flashbacks and relationship problems were grouped in a syndrome called “shell shock” to refer to the brain effects due to bombing. This theory lost its value, however, when the symptoms occurred even in soldiers who had not directly experienced the bombing. During the Second World War, the depressive aspects began to have a significant weight and began to speak of “combat fatigue” which then became the most widespread and known “war neurosis”. Soldiers, in order to escape from combat, developed somatoform or hysterical symptoms, (i.e., they showed physical symptoms, classifiable in diseases of organic origin, but for which there was no medical evidence).

Soldiers with psychic symptoms are now considered unfit, incapable and unreliable. Today, the biggest problem for our soldiers is institutional stigmatization; despite the great strides forward in research, definitions and diagnosis, after a decade there is still difficulty in treating this disorder in the field of defense and security and in finding an internal space for treatment. Precisely, in the stigmatization is must to be found the cause of failure to report to protect themselves, their families, their work, it follows therefore a chronic disorder due to a dissimulation of discomfort protracted over time. In 2015, in Italy, the Defense Administration set up a scientific technical committee (Board)for the study of mental disorders in military personnel, which represented the first inter-forces body of observation, monitoring and management of mental disorders and which was supposed to facilitate, among other things, the evaluation of the processes of real incidence of PTSD in the Italian military. To date, no epidemiological data have been published in our country, but there are only internal guidelines, inspired by the DSM V (Diagnostic and Statistical Manual of Mental Disorders ), as a tool for the detection of the incidence of the disorder in the territory. However, it is to be considered a guiding tool. Not to be underestimated is also the lack of data on the assessment of mental health of Italian soldiers returning from missions abroad, which explains the absence in our health system of support systems for veterans.

Therefore, although the civilian world can be defined as clinically ready to accept and treat disorders arising from trauma related to critical events, in the military world, where, among other things, it is easy to assume a prevalence of this disorder due to the presence of more critical events, this preparation is not sufficient to support our soldiers, who are forced to seek help, on their own expenses. outside their inner working places, when their defenses begin to fail.

The Sample

The small sample of subjects who approached the Association “l’Altra Metà della Divisa” is limited by the specificity of the study. All those who participated in the evaluation are included in a technical consultation process for the request of the cause of service (for the work-related illness request) and the evaluation of the damage (injury level).The 5 subjects sampled are members of the Armed Forces and all have been exposed to one or more traumatic events during their employment in the service (service of duty in both in homeland and overseas).

The assessment procedure presented herein examines cases of soldiers with PTSD seeking appeal for cause of service denied (for their denied work-related illness request). By cause of service (work-related illness) we mean the recognition of the dependence of an illness or physical injuries contracted as a result of duty service, provided for personnel of public administration (PA) belonging to the Police Force, the Armed Forces . In any case, in order (to be recognized as work-related) for the dependence of cause of service to be recognized, it is mandatory that the illness or injuries derive from events occurred while in service or from causes inherent to the service itself such as, for example, the environment and working conditions. The causal link, in the field of defense, is based on the connection between the psychotraumatic event and the psychopathology found that must take place through the so-called “finding of compatibility” that is the time elapsed between  the event and the clinical appearance of psychological symptoms and subsequent chronic stabilization. The late onset of PTSD makes it complex to identify the target event that triggers it. In the presentation of the data, we try to build the process of evaluation of the causal link between the manifested symptomatology, the consequent diagnosis and the trauma reported and described. To elaborate it, it was necessary to refer to the guidelines for the diagnostic and medico-legal framing of mental disorders related to traumatic and stressful events (Stato Maggiore della Difesa ed. 2016 – Italian Defence Staff ).

Assessment system  

For the diagnosis of PTSD there are many assessment tools, however, it has been found useful to use appropriate tools combined to assess the incidence of PTSD. The rationale for this approach is based on the fact that no single instrument taken individually is able to function as a definitive indicator of PTSD; the psychometric limitations of each of the instruments used can be compensated for by their combined use, as well as giving us a more complex assessment in the analysis of the various aspects associated with the disorder. This multimodal assessment makes use of structured and semi-structured diagnostic interviews, self-descriptive lists, empirically derived psychometric measurements, not formally based on the diagnostic criteria for PTSD, psychometric measurement of exposure to potentially traumatic events, and psychophysiological and collateral assessment. The latter involve any information that spouses, family partners, or friends can offer to the clinician.

The first phase involves the examination of the complete documentation reported by the soldier, which usually includes the reports prepared by the Military Hospital Medical Commission (CMO) and the certifications of private physicians and ASL (local health company). Through the clinical interview an exhaustive case history is carried out (i.e. the global analysis of the patient’s life that includes the investigation of interpersonal and family relationships, work and the description of his current clinical status). Another fundamental point is represented by the collection of information more specifically related to the critical event that is supported by the compilation of a “diary of triggers”, in which the soldier is led to transcribe all those environmental stimuli that go to activate the present clinical picture.

The second phase focuses on the psychodiagnostic assessment, which begins with the evaluation of personality through the MMPI-2. Of this instrument were taken into account mainly the levels of three scales out of the total ten (Hs (hypochondria), D (depression) and Hy (hysteria) and the additional scale Pk (Keane’s Post-traumatic Stress). Correlations were also studied in specific subscales. (ANX, Dep, Hy4. Pal and Sc2-Sc3). The Wartegg Reactive Drawing Test (WZT) was added to the personality test, useful to complete and confirm the clinical picture of personality and to evaluate the examination of reality, planning, problem solving, adherence to collective thinking and affectivity. The IES- R (Event Impact Scale -Revised) is a self-assessment scale that allows to identify the ways of response to stressful life events that are avoidance, intrusiveness and hyperarousal. The inventory of traumatic and stressful life events (Giannantonio 2009) helps to highlight previous traumatic events or in concourse with the critical event under investigation, which could justify the symptomatology related to post-trauma. It therefore allows to meet the criterion necessary for the definition of the causal link to exclude other possible causes. The PCL- Military (PCL??) is a self-report scale commonly used in America, still not standardized in Italy, specifically built for military experiences that on average are accustomed to a presence of greater criticality in their lives and that relies on the diagnostic criteria of the DSM V. A final result of 44 is considered indicative of PTSD in ordinary people, while an overall result of 50 is considered positive for PTSD in the military. DES (Test Dissociative Experience Scale) is a self-report scale that measures the level and type of dissociative experience grouped into 3 clusters: dissociative amnesia, dissociative functioning, depersonalization and de-realization. This test is essential to investigate dissociative phenomena caused by traumatic experiences that interfere with the integration of the functions of the psyche, also represent an index of the severity of the clinical picture and to allow a differentiation in Complex PTSD. Revised ABC-X Model (adapted from McCubbin and Patterson, 1983): through the structured interview on this model, it is possible to investigate the set of characteristics, dimensions and properties that allow families to resist stress in coping with change and to overcome the crisis situation. It therefore allows us to evaluate the internal and external resources to which the subject refers and relies by accessing an important area such as the incidence of family support and how stressors have determined those unmetabolized changes that define part of the existential prejudice. Another data of analysis are the blood tests with the finding of alterations in the biological response through the elevation of cortisolemia and the level of urinary catecholamines in 24 hours. This data was not present in the documentation submitted by all cases because these examinations must be carried out after the traumatic event. However, it is an important datum to consider.

Global analysis of data 

The collection of data through interviews and the administration of tests has allowed the elaboration of a theory that confirms and reinforces the causal relationship between the traumatic event experienced during the mission and the onset of PTSD, which can also occur at a distance due to the greater capacity for containment and resilience due to military training.

In conclusion, the following section will focus on the test results obtained from the cases bringing a brief analysis (table I; figure 1) 

Tab . I. 

MMPI-2 scoresPkHsHyAnx DepHy4Pa1Sc2Sc3AverageDs
CASE 18670726977777367928977,2+8,84
CASE 27669727075696074728972,6+7,30
CASE 38472717472738067728975,4+6,76
CASE 4 7378838872728052798075,7+9,74
CASE 56859504854614755446655,2+7,75

Figure 1  

The profiles are all valid and interpretable and high, with a significant number of self-reported symptoms and several indices of a general emotional maladjustment associated with stress. The disorders appear relevant and exceed the subjects’ ability to defend themselves. Psychological balance and relationship life are reduced by the intensity or persistence of the symptoms. The most representative scores also confirm the presence of depressive traits and ego dyscontrol.  

The detection of the Pk, D and Sc3 scale shows a significance for the diagnosis of PTSD in soldiers. In all reported cases the diagnosis confirms a PTSD with severe injuries. 

Tab.II 

IES-R SCORES AVOIDANCEIPERAROUSALINTRUSIVENESS TOTALAverageDs
CASE 12027216822,66+ 3,78
CASE 21824287023,33+ 5,03
CASE  32523317926,33+ 4,16
CASE 4 2821328127+ 5,56
CASE 5 2319236521,66+4,61

Figure.2 

Casella di testo: IES-R SUB-SCALES CHARTFigure 3  

Case 1 is characterized by reporting a lower total score than the others, in detail within the sub-scales it is easy to deduce how the symptoms of hyperarousal are the most predominant in this clinical picture. In all other cases, the most significant scale is represented by that of intrusiveness as also supported by a more significant score in the MMPI-2 in the scale Sc3 (ego control, cognitivity). The intrusiveness of thoughts and emotions is the most disturbing part of the trauma, resulting in a picture of greater severity. Case 4 shows the most significant total score of the sample (81) and therefore a higher standard deviation equal to 5.56 and an average score of 27. (table II). In this subject the symptomatology of avoidance assumes a greater incidence. In the case 5, although a pathological incidence emerges with predominance of avoidance and intrusiveness symptoms, the global picture appears lower than average. (Figure 3)

Tab III: 

PCL-M SCORESTOTAL
CASE 171
CASE 273
CASE 374
CASE 4 Not tested on the basis of DPTS diagnosis already done 
CASE 5 78
  

Figure 4 

About PCL-M self-report scale, leaving out Case 4, as the administration of this test did not occur for the diagnosis of PTSD already made, this test appears to be more sensitive to the specificity of role and war trauma with an average of sample scores above 70 (table III- figure 5) 

Tab IV 

DES  SCORES TOTAL
CASE 154.64
CASE 236,78
CASE 366.4
CASE 4 Not tested on the basis of DPTS diagnosis already done 
CASE 5 <30

Finally, analysing the results of DES test (table IV and figure 5)  only one case shows a very important score related to dissociative functioning  whereas  the others, despite a slight presence of dissociative symptoms, are illustrative of a chronic but not complicated DPTS.

To summarize the typical features found in the research, the presence of some still points has emerged:

  • Very high MMPI-2 scores, mainly of Pk, D and Sc3 scales;
  • Very homogeneous  IES-R scores with a prevalence of intrusiveness symptoms;
  • Very homogeneous  PCM-L scores >70;
  • Inhomogeneous DES scores, even if all related to dissociative functioning trauma-related and underlining  just one case of complicated chronic DPTS.

Despite the small number of subjects involved in the sample, the battery of tests applied on them can be defined scientifically appropriate for studying the late onset DPTS in the military, in order to detect the damages and define, beyond any doubt, the relative casual link.

Conclusion

The study presented was made possible thanks to the association “L’Altra Metà della Divisa”. This nonprofit and apolitical association created in 2012 by mothers, wives, daughters of military deals with giving psychological support, legal and for all those daily activities that characterize military families. The association has recorded 31% of requests for help specifically for PTSD. In the cases reported it is clear that the absence of support from the institutions is fundamental to trigger a worsening and chronic course. With regard to this, the family has proved to be a fundamental resource to avoid cases of suicide, to detect those warning signs and to encourage them to seek help. Unfortunately, in many other cases, even if the family is valued as a resource, it is not used as such in a protective function. According to statistics we can highlight that 10% of cases are married, 20% single, very often because of the inability to establish a stable relationship due to the effects of the disorder and 70% are separated. On this last point we must specify that very often the separation occurs after the traumatic event because the symptomatology brought by the disorder in particular the traits of irritability and anger have strongly affected family relationships, the family alone cannot support a situation of this type and then separate. Continuing to deny an existing reality determines negative consequences to the men who wear a uniform, to their families and to our country.

 To date, all cases presented and appealed to the Court of Labour have obtained the recognition of the disease and the cause of service demonstrating the veracity of the objective diagnostic evaluation and scientifically proven.

Acknowledgments

The authors sincerely thank L’Altra Metà della Divisa Association that supports military and police personnel and their families. The Association helped make this little research possible. The authors also thank Dr. Tagliavini , psychiatrist and President of the AISTED Association, for his precious reviewing. 

References   

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Breslau N, Davis GC : Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity. American Journal of Psychiatry, 1992, 149, 671-575. 

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M. Sarti, 2017, “lo stress post-traumatico, la malattia silenziosa che colpisce i nostri militari.

Comitato tecnico scientifico (Board) per lo studio dei disturbi mentali nel personale militare, considerazioni sul Disturbo Post-Traumatico da Stress in ambito militare, Giornale di Medicina Militari (Roma, 14 novembre 2013).

Pubblicato in https://www.researchgate.net/publication/350186021_PTSD_A_SILENT_AND_NOT_RECOGNISED_EVIL?utm_source=twitter&rgutm_meta1=eHNsLVd6cXpqRXh1dFNlZnFtbFhHS0tKSnVQL1JCRFN4bG4ycUdDNTRHMkg3TitiQkcvYkpLK3JGUUhlU3VscS9RanRvVUxvMmVhays3TXFId3RuK3Y0RzF3PT0%3D

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