Our country was confronted with the problems of postcombat adjustment while the Vietnam conflict was still winding down. Concerns centered on the disruptive impact of returning drug-dependent veterans, the overall problems of readjustment, and assessment of public attitudes. As is the case with each major conflict, health-care-delivery systems were forced to assess and react to the aftermath of combat. This took place within the framework of the disciplines of program evaluation, quality assurance, and clinically applied research. Out of this has evolved a determined attempt to understand the interaction between combat and psychiatric disorders including alcoholism. This chapter demonstrates the existence of a posttraumatic stress syndrome compounded by alcoholism in World War II and Korean Conflict veterans. These comorbidities have resulted in chronic maladjustment over a prolonged period of time. Recommendations suggest early detection and triage of a posttraumatic syndrome and co-related substance use disorder in people who experience any catastrophic stressor.
In 1971 top management at Coatesville Veterans Administration Medical Center committed itself to the development of an aggressive treatment network that would meet the needs of veterans with drug and alcohol dependency problems. As the needs of this group have changed or as we have become aware of new opportunities, programs have been changed or developed. Management had demanded that these needs be clearly demonstrated based on specifically defined needs assessment. A series of studies outlined below highlights an opportunity for programmatic change and raises some critical questions as to the interaction of combat and resulting psychiatric disorders, including alcoholism. Our original clinical impressions suggested that this patient population offered a unique opportunity to assess the relationship of a significant stressor (i.e., combat) and resulting failures to adapt (i.e., psychiatric disorders and alcohol/drug dependency).
World War II and Korean combat veterans were studied. This subgroup was chosen in order to avoid the many confounding issues related to studying Vietnam combat veterans, posttraumatic stress disorder (PTSD), and substance dependence.
Clinical interviews suggested that Korean and World War II veterans with undiagnosed posttraumatic stress disorder have used psychoactive drugs to treat related symptoms. This has resulted in many hospitalizations through the development of chronic addictive disorders and related medical problems. The professional community responsible for treatment largely failed to connect the addictive disorder to PTSD. Consequently, these veterans have seldom discussed their traumatic combat experiences with professionals. Typically, veteran responses to questions about combat experience and possible posttraumatic stress disorder symptoms has been evasive and minimizing. When pressed these veterans frequently became hostile and refused to discuss issues. Once these defenses were relaxed, their responses were emotionally charged with feelings of grief and guilt accompanied by tears. Clinical interviews also suggested that a number of our alcohol-dependent veterans have experienced considerable combat but they did not report posttraumatic stress disorder symptoms. This group discussed combat experience with great ease. They were proud of their performance under severe stress. They were saddened by the loss of many buddies, but view this as the price they had to pay.
We designed the study below to validate these clinical impressions and to discriminate differences between these two unique subgroups.
Robins’ benchmark study of returning Vietnam veterans set in motion a dynamic inquiry into the relationship of combat to postcombat psychiatric disorders, including alcoholism and drug abuse. Articles by Helzer et al. concluded that there was evidence for an association between combat and later, but short-lived, depressive syndromes. As defined, depressive syndromes included depressed mood, insomnia, weight loss, concern about sanity, crying spells, and suicidal thoughts. Robins’ paper and the first Helzer study also indicated that in addition to the depressive symptoms, Vietnam combat veterans reported significant psychosocial problems. These included marital discord, unemployment, bereavement for buddies killed in action, traffic and nontraffic arrests, illicit drug usage, and excessive drinking. Onset of the symptom complex occurred within 2 months after returning home. Forty-four percent of combat veterans reported problem drinking.
The relationship of postservice discharge psychiatric disorders, including alcohol abuse/dependency, to combat is now a high-priority item in the Veterans Administration. Recent articles have clustered together two interesting subgroups of veterans. The first is made up of alcohol-dependent combat veterans with few if any serious postcombat stress symptoms. The second is composed of combat veterans reporting serious and multiple postcombat stress symptoms combined with alcohol dependency. The majority of the studies did not evaluate the magnitude of combat as it related to postcombat adjustment. Other previous research has suggested a significant relationship between level and type of combat and psychiatric symptomatology. In the latter articles, only acute reactions to the stressor were generally studied. Finally, the majority of studies cited have focused on Vietnam combat veterans.
Finney and Moos, in discussing the role of major and minor stressors in problem drinking, suggest that a “strong etiology” position is not tenable. They conclude that major and minor stressors are neither necessary nor sufficient to produce drinking problems among people. Rather they suggest that a set of factors (some known and some postulated) make up the necessary and sufficient condition for problems of adaptation. They further suggest that research should focus on the mediators of stress and a resultant failure to adapt.
In an attempt to address the issues outlined above, the subjects chosen for this study were all 49 years of age or older. Only veterans claiming both passive (being fired on, shelled, mortared) and active combat (assaulting/ firing on enemy troops and/or civilians) levels were included. Combat veterans were further divided on the claimed presence or absence of stress symptoms either during service or within a year after. Focusing attention on veteran patients from World War II and Korea is not a new idea. However, to our knowledge, this is the first attempt to assess the interactions between levels of combat, levels of stress symptoms experienced during the service and within the first year after, alcohol dependency, long-term adjustment problems, and current psychiatric symptoms. Further, the project was originally designed to highlight some of the mediators related to combat experience and failures of adaptation. These failures of adaptation include alcohol dependency, behavior disorders, and psychiatric problems, which may include PTSD. Patient groups were matched based on level of stressor (combat), age, and conflict period. They are also matched in that alcohol dependency is common to all subjects, the severity of this disorder requiring inpatient detoxification and rehabilitation for all participants.
Alcohol Effects on Posttraumatic Stress Disorder Symptoms
Ethanol has been shown to decrease degree of attention or vigilance to auditory stimuli and decrease motor coordination and reaction time. Sensory impairment across olfactory, gustatory, tactile, and visual modalities also occurs with moderate doses of ethanol (0.1-0.7 g/kg), although visual impairment may require higher doses. Under conditions of ethanol intoxication, exaggerated startle and anxiety symptoms are lessened through decreased sensory input as well as decreased motoric output (). Memory and concentration abilities are also diminished by ethanol consumption.
Sleep disturbances have been reviewed in relation to the effects of alcohol. Aside from the sedative/depressant effects alcohol has on sleep initiation, phases of sleep are affected by ethanol. Rapid-eye-movement (REM) sleep is disrupted in quality and frequency. There appears to be a strong relation between REM and dreaming.
Classification of posttraumatic stress disorder indicates that it is an anxiety disorder that is affectively characterized by hyperalertness or exaggerated startle, sleep disturbances, guilt or anxiety over surviving, and avoidance of activities that serve as reminders. Ethanol, along a continuum of concentrations, can decrease the intensity of the above feelings and manage sleep initiation/early termination disturbances that result from anxiety. In addition, sleep disturbances such as night terrors may be managed by ethanol.
The above effects of ethanol can be considered positive in terms of alleviating acute posttraumatic stress disorder symptomatology. When someone with posttraumatic stress disorder searches his coping strategy inventory and finds that alcohol can immediately and dramatically curtail most of his posttraumatic stress disorder symptoms, that person is very likely to continue its use. The magnitude of the reward may also decrease the likelihood that the person will try other means of handling his symptoms. This relationship between posttraumatic stress disorder symptoms and alcohol use may result in alcohol abuse if the posttraumatic stress disorder symptomatology persists.
Incidence and Implications of Combined Substance Abuse and Psychiatric Disorders
The prevalence of substance use disorders among psychiatric admissions not seeking treatment for drug/alcohol dependency has been a key concern of top management at this Medical Center. Three major studies carried out in 1976, 1981, and 1984 have addressed this issue. Patients in the 1976 project were not on substance abuse treatment wards nor had they sought treatment for drug/alcohol dependency. Of the total sampled, 29% felt that use of alcohol had been “serious enough” that they considered it a problem and 22% were using alcohol at least three times a week postadmission. Of the 76 patients feeling that substance dependency/use was a problem, only 26% informed medical staff of the problem. Likewise, only 37% felt the need for drug/alcohol dependency treatment.
Results of the 1981 study indicated 16% of all veterans had a primary and 13% had a secondary substance use disorder, giving a total of 29% of 921 psychiatric patients. Treatment teams indicated that substance abuse was a part of life-style for 23% of veterans hospitalized for psychiatric care other than substance abuse treatment. The 1984 study indicated 17% of all veterans had a primary and 12% had a secondary substance use disorder, giving a total of 28%. Treatment teams indicated that substance abuse was a part of life-style for 27% of patients hospitalized for psychiatric care other than substance abuse. For the 1984 study the percentage of substance abuse problems was 22% in organic patients, 26% in schizophrenic, 33% in affective, and 90% in PTSD.
In the course of another 1984 assessment to determine the number of patients on other psychiatric wards in need of substance abuse care, we found that 94% of those patients on the Medical Center’s posttraumatic stress disorder ward had significant problems with the abuse of substances. This was much higher than the incidence of substance abuse care needed by patients with other psychiatric diagnoses. To get an estimate as to whether the high rate of substance abuse in posttraumatic stress disorder patients was an artifact of a 1-day sample, 50 consecutive posttraumatic stress disorder discharge files were examined. Ninety percent of these posttraumatic stress disorder files showed additional diagnoses of substance dependence.
These data indicated that there was a high correlation between posttraumatic stress disorder and substance abuse. Thus, questions arose regarding the number of patients seeking admission for substance abuse who might also have PTSD. Concerns arose that our treatment staff might be missing an important clinical issue. Often, patients with posttraumatic stress disorder are reluctant or unwilling to talk about their combat experiences. In addition, we had concerns that patients who still experienced posttraumatic stress disorder symptomatology (e.g., insomnia, hyperalertness, anxiety) after discharge might seek to medicate themselves with alcohol and/or drugs of abuse and relapse back into their addiction. We put in place a stress inventory package and began to monitor combat level and self-reported stress symptoms among our patients. Approximately 8% of our monthly admissions had a strong potential for having clinical posttraumatic stress disorder since they had high combat levels and high levels of self-reported stress symptoms. Another 3% had high levels of self-reported stress symptoms with low levels of combat, and 19% had high levels of combat with low self-reported stress symptoms. These percentages generally continue to the present day. Since our Substance Abuse Treatment Unit (SATU) discharges approximately 1200 patients per year, the rate of posttraumatic stress disorder among our patients is between 100 and 350 per year. This includes combat veterans from World War II, Korea, and Vietnam.
Selections from the book: “Recent Developments in Alcoholism. Volume 6: Posttraumatic Stress Disorder. The Workplace. Consequences in Women. Markers for Risk.” Edited by Marc Galanter. An Official Publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism. 1986.