Jeremy and Post Traumatic Stress Disorder

Today there are countless veterans living with PTSD who have returned from wartime situations and are attempting to acclimate to the civilian lifestyle. Many of these also populate the streets of the cities of our nation. Veterans represent 23% of the homeless population in the United States. 96% of homeless veterans are male. There were reported 192 sheltered and unsheltered veterans in Cincinnati/Hamilton area in January of 2011.

What do veterans with PTSD face when coming back to the United States, let alone when they are homeless?

First, the direct symptoms of PTSD are burdensome and affect an individual immensely. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition- Text Revision) provides descriptions of the symptoms one must present with to be diagnosed with PTSD:

There is persistent reexperiencing of the traumatic event in memories, images, emotions, thoughts (Criterion B1), dreams (Criterion B2), acting or feeling as if the event is actually happening again (Criterion B3), intense psychological distress at exposure to cues that may be relevant to the experience (Criterion B4), or physiological distress to the same cues (Criterion B5).

The individual must also persistently avoid those stimuli associated with the trauma and they will experience numbing of general responsiveness that had not appeared before the traumatic event. This symptom can manifest as efforts to avoid mental processed associated with the trauma as in thoughts, feelings, and conversations (Criterion C1), efforts to avoid concrete items like people, places, or activities that remind the individual of the trauma (Criterion C2), an inability to remember or recollect a significant portion of the trauma (Criterion C3), disinterest or less interest in common activities enjoyed before the trauma (Criterion C4), antisocial behavior or feelings of detachment or estrangement from others (Criterion C5), a general restriction of emotions (Criterion C6), or a belief that they will not have a full lifespan or will not complete major life goals (Criterion C7) (DSM–IV–TR).

Often times, flashbacks are caused by this intense aversion to threat or danger, and can play a significant role in maintaining this symptom by constantly reminding the survivor of the danger or threat. This creates a vicious cycle, from which it is difficult for the survivor to remove him or herself (Brewin, p. 185).

Finally, there must be a state of increased arousal which can emerge as difficulty falling or staying asleep (Criterion D1), angry outbursts or general irritability (Criterion D2), difficulty focusing or concentrating (Criterion D3), hypervigilance (Criterion D4), or an exaggerated startle response. These symptoms, after the traumatic event, must be present in the individual for over a month to be considered PTSD (Criterion E); acute PTSD is diagnosed when the symptoms are present less than three months, while chronic PTSD lasts longer than the three month period. These symptoms must also cause significant distress and disorder within the normal functioning of the individual through any important aspect of their life (Criterion F) (DSM—IV—TR).

These though, are simply the fundamentals of the disorder; the dynamic condition of PTSD can influence varying people in varying manners, creating large varieties of manifestations that could be considered within the PTSD spectrum. Many soldiers, returning from and with a war torn experience who show symptoms of PTSD, seem to have some trends in their reentry experience.

These symptoms create many obstacles for returning veterans and often lead to outcomes that severely affect their everyday lives.  Jeremy's experiences with these obstacles ultimately had a strong influence in facilitating his current situation.

If you have not already, I would recommend reading these two (1) (2) posts so that you know who the fictional character Jeremy is and why I am talking about him.

When Jeremy returned from war, his parents used to tell him that he seemed "changed". He was less enthusiastic about the activities he once enjoyed: motorbikes, fast cars, and ATVs. He often avoided driving in general and refused to drive on highways or other long stretches of road without exits because this was a factor that had caused the tragedy that occurred overseas. He had told his parents that he wanted to stay in Cincinnati for the job opportunities and cheaper rent, but he alluded to being uncomfortable with driving the distance to return home as well.

He became distant and irritable with his family first and then generally everyone around him, he began to calm his anxiety and penetrating headaches with copious amounts of alcohol. His personal relationships disintegrated along with his perception of his personal worth. He was conflicted in his identity because his personal worldview and moral system did not coordinate well with the things that had occurred during combat. His most overwhelming guilt came from surviving the tragedy that killed the three other members in the vehicle, because he had been the one driving. He felt like he had no control over his life anymore and that he was not capable of functioning properly. The combination of these factors led him to, as was described before, lose his job and ultimately facilitate his chronic homelessness.

Once Jeremy first became homeless, his PTSD was in many ways exacerbated by the environment in which he was living. His already hyper-vigilant mind and frequent bouts of paranoia preventing him from sleeping. With each attack from other homeless people or simply inhumane citizens, more experiences began to fill the memory banks to which his mind would flashback. His temper was uncontrollable and his emotions were even more sporadic. With every honk of a horn or screech of tires, Jeremy would be thrown into a panic attack or flood of anger. This continued until he found his camp near the river, where he was able to leave the populated areas of the city.

Over the next few years, Jeremy was able to remedy some of the severity of the PTSD symptoms by creating some structure in his life. He has specific places within his camp for certain activities, while not always enforced they are still considered important. He continuously works to construct a more elaborate and luxurious structure for his cats to live in, while only sometimes improving his own. He is mostly consistent in waking up early in the morning and walking to find work in downtown.

At this point Jeremy refuses to drive, is very skeptical of anyone who enters his camp, avoids large social situation unless absolutely necessary, and spends most of his time alone. When he is social he says little and listens less, only freely interacting with Will and Terry. He often reports that he is awoken from sleeping by nightmares and flashbacks which leave him in an alerted anxiety preventing him from sleeping well.

He believes the system he has created is the only solution to the way he feels and stubbornly argues with anyone who believes he could live in society in a more traditional manner. He has begun to exhibit a sense of pride in the new life that he lives day by day, with nothing and no one other than himself on which to depend. However, on many occasions he expresses strong self-deprecation and shame due to his homelessness and mental status.

His sentements are well put in his quote "Who would want to help a lazy, crazy bum like me anyway? We're all lookin' out for number one here aren't we. That's what I'm doin'... lookin' out for numero uno."

References:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
 (4th ed., text rev.). Washington, DC: Author.

Brewin, C. R. (2003). Post traumatic stress disorder: Malady or myth?. New Haven: Yale Unniversity Press.

Paulson, D. S., & Krippner, S. (2007). Haunted by combat: Understanding PTSD in war veterans including women, reservists, and those coming back from Iraq. Westport, Connecticut: Praeger Security International.