The book, “Once a Warrior–Always a Warrior” by Hoge gives an account of post-traumatic stress disorder (PTSD) alongside other war reactions, which veterans, service members, government workers or contractor previously deployed in a war zone endure after coming back home.
Hoge was triggered to write this book so as to bridge the gap that exists between combat veterans, the society and mental health professionals in as far as comprehending PTSD is concerned.
Unfortunately, the medical definition of PTSD does not show any understanding of this disorder in the context of someone who has been through combat. It is misused to refer to any post-war behavioural problem like having failed relationships, being violent and getting in fights, or driving under the influence of alcohol.
PTSD is seen as a mental disorder but in actual sense, it is a physical condition that has a huge toll on the whole body and can be understood well via the developing science of stress physiology (describes the body’s normal response to extreme stress). Each person has a breaking point, which if reached leads to total exhaustion.
Veterans succumb to total physical and metal exhaustions since reaching the breaking point is inevitable in an event such as war. As objectively stated there is not sign of a mental condition in such an instance (xiii).
As Hoge writes, PTSD is associated with different meanings among different people. It is considered to be among the 300 diagnoses described in detail in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.
It is defined based on a specific set of symptoms, which have been present for more than one month. It can be acute if the symptoms have lasted between 1 and 3 months and chronic if more than 3 months. If the symptoms begin six months after combat trauma, then this is known as delayed onset.
However, warriors with delayed onset did experience some reactions that were similar to what the warriors experienced during the time of trauma but apparently suppressed them or avoided dealing with them. The clear-cut between the three categories of PTSD has not proved useful.
PTSD is defined by mental health professionals depending on the particular list of symptoms that prevail. Unfortunately, as earlier stated, it does not capture the full picture with regard to reactions to war. Neither does it distinguish between what is normal and what is abnormal within a military context. This is because PTSD is continuously confused with some normal reactions experienced by warriors/veterans during war.
Combat stress, acute stress reaction, post-traumatic stress and combat stress reaction are some other terms used to refer to PTSD. Medical professional also use these terms thereby creating confusion.
Combat and post-traumatic stresses are used to refer to less severe forms of distress or symptoms as compared with PTSD. They are not essential terms that could be used because they lack a clear definition.
A combat stress reaction/acute stress reaction/operational stress reaction is associated with being on a battlefield. It refers to the direct and immediate reaction to critical stress, exhaustion or trauma. It is a reflection of the point in time when a veteran reaches “breaking point” and requires time to shut down.
It can manifest itself in almost every form of physical symptom such as “chest pain, neurological symptoms, fatigue, shaking of the muscles, headaches, shortness of breath” or as behavioural reaction such as panic, bizarre behaviour, rage, inability to think clearly, agitation” (Hoge 1-2). This kind of stress reaction is not a mental disorder and is easily managed by rest and reassurance.
Some people perceive PTSD as a catchall phrase used to refer to the reactions of post-war veterans upon coming back home like shell shock and battle fatigue. PTSD is mainly closely linked to several reactions, emotions and perceptions, which do not form part of a neat diagnosis.
PTSD has been contraindicated with concussions, being referred to as mild traumatic brain injury (mTBI). Most post-war veterans have been advised that their post-war problems like anger, fatigue, memory issues. PTSD symptoms, sleeplessness and poor concentration ability are due to medically unattended concussions that resulted from exposure to blasts.
PTSD among warriors can be a day-to-day experience where warriors are haunted by memories they eagerly desire to forget. Warriors are always alert as if they expect some form of danger that others are no aware of. They endure lack of sleep at night; react to stimuli as if they were still at war.
It becomes very arduous for a lay person to understand the behaviour of these post-war warriors. These kinds of reactions are very important during survival in combat and may be required later in future hence the title of the book, “Once a Warrior–Always a warrior”.
Therefore, to some extent they are normal in a certain environment. This notion in mind, it becomes difficult to define what is normal and what is not normal in this post-war context.
According to the book, PTSD is diagnosed on the basis of Axis I for DSM-IV. The essence of diagnosis is to enable the medical professional team to communicate in the same language hence, will be more confident while managing and treating a patient. Apparently, it has been easy to diagnose PTSD due to its uniqueness among other DSM disorders.
The uniqueness is attributed to the fact that it is explicitly linked to one or more traumatic event. While assessing for a diagnosis, medical professionals inquire about the nature of the trauma and symptoms.
When the trauma is considered to have resulted into the occurrence of the requisite number and nature of symptoms going for more than one month, then a PTSD diagnosis is made.
I would make a diagnosis of PTSD on the basis of Axis IV for the DSM-IV version. The reason why I make this diagnosis is because it has been attributed to psychosocial and environmental factors in this case war and responses adopted to enhance survival in times of war.
The main difference between the diagnosis made in the book and the one I have made is that the previous one is considered to be a clinical disorder while the later is not.
The diagnosis can be clarified by breaking down DSM definition of PTSD. This way, it will be evident that every symptom of PTSD develops as a result of the body’s response to serious stress or danger. Usually, six different criteria, A via F, and all must be met for the diagnosis to stand true.
Criterion A defines a trauma as an event that involves serious injury or death. The DSM diagnosis requires responses such as horror, intense fear or helplessness to result at the time of the trauma. There should be a sufficient number of symptoms: 17 in number.
Criterion B is where the patient experiences five different kinds of symptoms associated with re-experiencing the traumatic event. Criterion C is associated with symptoms depicting avoidance while criterion D entails five symptoms that suggest hyper-arousal (Hoge 12).
Some aspect of PTSD aroused my attention. Warriors in a war zone area have to develop survival tactics that enable them to make it through the war period. Some behaviours, as long as they are not harming other people cannot be considered to be abnormal.
For example, if a post-war veteran develops a strong desire to collect guns up to the highest acceptable level by law and does not intend to use the weapons in any evil way to harm others, Doctor Hoge does not consider this to be not abnormal despite the fact that other people consider abnormal.
It is no doubt that warriors/veterans have developed some peculiar behaviour while at war which may seem to be a deviation from the normal.
However, it is important for the loved ones and the warriors themselves to acknowledge the changes that have taken place so as to avoid the detrimental repercussions that come along with post-war effects hence avoid unpleasant surprises and shocks (Hoge xiv).
The book was published last year therefore there is no much difference between now and then. However, it has transverse across historic times like when referring to Iraq and Afghanistan battlefields which occurred in the mid twentieth century.
It has incorporated the enormous advances that have occurred to help in understanding PTSD better and this includes neurobiology and diagnosing, evaluating and treating the condition. Neurobiology research in relation to PTSD has involved numerous experiments to study animals upon being subjected to stress, and humans who have suffered trauma.
This advanced research has helped in bringing about a greater understanding of PTSD as a physiological condition rather than an emotional or psychological disorder. Based on this advanced neurobiology research, PTSD affects the whole body; the cardiovascular system, endocrine system as well as the immune system.
PTSD can lead to physical, emotional, behavioural, psychological and cognitive reactions, all of which have a physiological basis. The advanced findings have led to the development of new PTSD treatments like psychotherapy/talk therapy, as well as medications that target particular brain areas and body responses.
Hoge, Charles W. Once a Warrior–Always a Warrior. Guilford, CT: Globe Pequot Press, 2010.