Advances in Psychiatric Treatment (1998), vol. 4, pp. 211-218

Second World War veterans withchronic post-traumatic stress disorder

Roderick J. 0rner & Wolter S. de Loos

The present case study describes a typically complexclinical presentation of chronic post-traumatic stress

disorder (PTSD) suffered by a Second World Warveteran and advises on multi-disciplinary out

patient management extending to acute hospitalcare. Limited symptomatic impact of psychologicaland psychopharmacological therapies is discussed,and related to patient reports of satisfaction withtherapeutic outcome.

general practitioner (GP) to a specialist PTSD clinic.The referral mentioned regular recurrent traumaticnightmares of attacks by German fighters while beingpursued by dogs. Prior to referral he had driven hiscar into a ditch because he thought an aircraft flyingoverhead was going to 'shoot him up'. To help him

sleep fluoxetine had been prescribed but had notbeen taken. The GP had not been consultedspecifically about war sequelae, but had concludedthat the patient would benefit from some counselling.

Prevalence and presentation Personal history

In January 1997 approximately 170 000 UK SecondWorld War veterans received a service-relateddisability pension, this being 7% of themale population aged 70 years and above. Thepopulation-specific prevalence of war-inducedPTSD is not documented. Case-by-case morbidity isa function of each individual's particular war

experiences (intensity and duration of combat,exposure to traumatic bereavements) and post-war

coping strategies (Lindy, 1988; Shay, 1995). Clinicians taking histories from patients in this agegroup should be alert to a possible link between theircurrent physical and psychological status andtraumatic war experiences.

Case study

Referral details

A 71-year-old combat veteran, with a previouslyunremarkable medical history, was referred by his

At the first interview the patient's grief was evident

when he spoke about colleagues killed in action.During his late teens he witnessed devastation andsuffering caused by strategic bombing of England's

industrial cities. It was then that he resolved tovolunteer for active military service. During trainingfor bomber command he was injured in a crashrequiring six months' hospitalisation. Active

military service comprised 30 bombing missions toGermany and on three occasions he found himselfthe sole survivor. On the final mission in December1944, he was taken prisoner of war (POW) havingparachuted from a burning bomber. He escaped froma POW camp, was hunted by uniformed men withdogs and killed his pursuers in hand-to-hand

fighting before meeting allied invasion forces inApril 1945.

Unable to settle to civilian life after demobilisation, he re-enlisted to pursue a military career,but medical discharge was effected upon developinganxiety and panic reactions that were irreconcilablewith his assigned operational role. A period ofemployment as an administrator in a largepublic company ensued until he experienced an

Roderick J. 0rner (Department of Clinical Psychology, Baverstock House, StAnnes Road, Lincoln LN2 5RA) has maintained a clinicaland research interest in war veterans since the mid-1980s. He also heads a pioneering initiative for clinical incident stress managementservices for emergency services personnel. He is President of the European Society for Traumatic Stress Studies. Wolter S. de Loos servesas a physician to care for severely traumatised war survivors and refugees. His expertise includes the interaction of psychiatric andmedical disorders and the management of functional bodily complaints.

APT(1998),vol.4,p.212 Orner & de Loos/Neal

overwhelming flashback to a traumatic warexperience after an argument with a colleague. Hereported that:

"It was as if it happened again. I was in the combat

zone again. After that I could not do regular workagain and was given a permanent disability pension."

None the less, he stressed that he had succeededin living an active, fulfilling life.

His wife confirmed the history given and addedthat they had shared an unusually eventful life inspite of limited financial means and her husband's

propensity to leave jobs after short periods ofemployment. Often these jobs involved dangerousactivities and high personal risk. To accommodatean unsettled lifestyle her husband insisted on thefamily showing exceptional flexibility as well asmeeting his exacting standards of order and control.Prior to referral, however, he had been unable tomaintain habitual levels of order and control, towhich he reacted with increasing rage and despair.His wife reported recent deterioration in herhusband's physical health and growing difficulties

in his psychological adjustment as evidenced by:social withdrawal; being drawn to a secluded fieldin the countryside where he reported hearing voicesof dead comrades; intense phobia of open fires; andnight-time restlessness so extreme that he would fallout of bed. To reduce risk of injury he had placedmattresses round his bed to cushion the impact offalling.

Formulation

The patient's presentation conforms to diagnosticcriteria for chronic PTSD with delayed onset (DSM-IV 309.81; American Psychiatric Association, 1994);all criteria (A-F) were fully met (see Box 1). Hecontinued to respond to his intrusive memories withfear, even horror, and he could only partly mitigatethis by his efforts to avoid reminders of wartimememories. His chronic hypervigilance and psycho-

physiological hyperarousal predicated his toleranceof environmental Stressors. His precarious post-waradjustment was manifest in his significant personaldistress with impaired affect modulation, poorimpulse control and consequent impairment ofsocial, occupational and family functioning. Strikingfeatures not mentioned among the diagnostic criteriaof the DSM-IV but important in this patient andmany others are: survivor guilt, somatic complaints,specific phobias and sensation-seeking throughcompulsive pursuit of danger and risk in which heseemed to re-enact his war traumas (Lindy et al,

1992).

Treatment plan

Outcome studies with war veteran populationsindicate that the disorder is chronic with afluctuating course over time (Op den Velde et al,1990; Solomon, 1995). Some symptomatic change ispossible by focal interventions (Greenwald, 1994).A contract of one session per week of open-ended,action-oriented treatment was agreed with thesubject. Although no specific outcomes wereanticipated, the patient hoped that psychologicaltherapy would re-establish a sense of order andcontrol in his life (see Box 1). His decision to starttherapy was conditional on not being pressurisedto take medication or be compulsorily admitted forpsychiatric treatment.

Summary of psychologicaltherapy

Initially, treatment set out to link contemporaneousreactions to past experiences and develop newrepertoires of coping strategies. To this effect a lifereview generated material amenable to psycho-dynamic interpretation and cognitive-behaviouraltreatment. Reactions to repeated traumatic bereavements were addressed pragmatically. He compliedwith advice to engage his dead comrades in'imaginary dialogue' about pervasive survivor guilt,

his longing for the intense bonds formed withinservice units, his grief at their deaths and theunrelenting miseries resulting from being alive whenothers perished. This adjustment strategy persistedbeyond the closure of therapy, the principal benefitbeing normalisation of what he had previouslyexperienced.

The distinguishing feature of every therapysession was the patient's accounts of recurrent

traumatic nightmares. One was of parachuting froma burning plane, which had in fact happened tohim in the war. Narratives encompassed all sensorymodalities with behavioural re-enactment throughjumping out of bed. These accounts and recreationslost none of their intensity on being told and re-toldin therapy. By contrast, a recurrent dream of slidingand falling off a roof ceased when he could make alink to an actual but hitherto 'forgotten' childhood

event. At the age of seven years he had slid off a roofwith a friend who was killed by this incident; thesubject had survived by falling on top of hisplaymate (see Box 1).

The patient's narrative style when recounting

developmental experiences and war trauma wasremarkable for its lack of detail. Therapeutic

PTSD in Second World War veterans APT(1998),vol.4,f).213

endeavour, therefore, sought to improve recall andarticulation which enabled him to understand thelogical links between events, persons and feelings.Formative experiences were thus recognisedthrough their impact on the subsequent course ofhis life. He is now conversant with the pervasiveinfluence the repetition compulsion has had in hislife,especiallywith respect to sensation-seekingand'addiction to danger'.

Insights attained in therapy made the patient feelrelieved and reassured. He was able to order and

Box 1. Psychological aspects of PTSD inveterans

PTSD tends to be very persistent and canstill be active in old age after more than50 years

It can remain unrecognised for years ordecades and should be consideredexplicitly in the diagnostic phase

Very often, psychodynamic roots for sensitivity to traumatisation can be retrievedin early life

Reactivation of traumatisation during thecourse of life can be expected at randomby seemingly normal events or by inter-current illnesses, operation with generalanaesthesia and other intrusive medicaltreatments

Psychophysiological manifestations generally precede behavioural and psychological expressions of PTSD and aremore resistant to psychotherapy of anykind

Post-traumatic nightmares are intrusivememories comparable to daytime flashbacks

Psychotherapy for PTSD is important foracceptance of the condition and to findnew balance living with a disability, butoften does not eliminate disturbingsymptoms

No type of psychotherapy has ever beenfound to be specific for PTSD

Reduction of symptoms, although unimpressive on psychometric assessment,may be and often is experienced as animportant therapeutic success

Being in control is a core issue in the needsof any traumatised person, as loss ofcontrol is essential in the experience ofbeing traumatised

structure his life to a large extent where previouslyhe thought only chaoscould prevail. However, theseintellectual insights attained in therapy did notbring about greater affect control. He continued toreport overwhelming emotions in responseto contemporaneous reminders of war. If anytherapeutic gain was made at this level, it was toextend his awareness of the vast array of seeminglyneutral stimuli that, by reason of their associations,repeatedly aggravated his chronic PTSD. Forinstance, the evocative potential of the number 'six'

was explained through a link to the number ofcolleagues killed on a particular mission. Aversivereactions to Easter celebrations were linked toinvolvement in an operation behind enemy lines inwhich civilians were killed while celebrating thisreligiousday.Aprofound suspicion ofpoliceofficersand traffic wardens was accounted for in terms ofthe threat uniformed personnel presented to hissafety when he was on the run from a POW camp inGermany. Avoidance strategies were developedfrom this increased understanding but totalprotection from stimulus exposure was impossible.Consequently, fears rooted in not knowing whatmight elicit these aversive reactions or when theymight occur were reduced rather than eliminated.

During the course of psychological therapy thesubject required hospital admission for removal ofa cataract and, predictably, he was terrified by theprospect of being submitted to anaesthesia andsurgery (see Box 1). To minimise the disruptivepotential of this reaction steps were taken to allowhim a sense of control. The therapist advisedhospital staff of the reasons for his fearfulness ofsubmitting to hospital regimes and how to managesuch a patient in the hospital environment. Wardstaff were warned to expect extreme night-timerestlessness associated with traumatic nightmares.The care team decided that he could choose the dateof admission, that local rather than generalanaesthesia would be used (in keeping with hisexpressed preference) and that his insistence onbeing taken to the operating theatre in a wheelchairinstead of lying in a bed was complied with. In spiteof these anticipatory measures the patient reportedrunning out of the operating theatre in panic andwaking up on the ward floor during the night (seeBox1).Hospital records indicate routine admission,treatment and discharge.

Psychometric assessment

At approximately weekly intervals the patientcompleted the Symptom Checklist (SCL-90-R;

APT(1998),vol.4,p.214 Orner & de Loos/Neal

Derogatis, 1983). This self-report scale is well

validated with large population norms and isextensively used in clinical and research settings.The SCL-90-R Global Severity Index (GSI)provides the most sensitive numerical indicator ofpsychological distress. From a 10th percentilebaseline (probably due to under-reporting) at onsetof psychological therapy, GSI increased to andoscillated about the 70th percentile throughout.When reviewing personal trauma or being otherwisereminded of the war, 'spikes' in the GSI profile peak

beyond the 90th percentile occurred. With thissubject the process of psychotherapeutic 'workingthrough' intensified psychological distress in the

short-term. A distinctive effect of psychologicaltherapy with this subject is demonstrated by theSCL-90-R Positive Symptom Distress Index (PSDI)profile. Psychotherapeutic change occurred at thelevel of symptom intensity rather than symptomelimination.

Psychopharmacologicalmanagement

After 18 months of psychological therapy thepatient's condition revealed traumatic nightmares,

anger, violent temper, irritability and startleresponses to be the most persistent and disturbinglegacy of war experiences. These reactions had notbeen significantly changed by psychotherapy norhad the associated feelings of shame and guilt.Although extremely reluctant to submit to drugtreatment, he accepted advice given by both authorsin this respect. The patient was advised to takefluoxetine at a starting dose of 2.5 mg for 16 days,5 mg for another 16 days, 10 mg for 30 days andthen to re-evaluate and decide whether to increaseto 20 mg/day (see Box 2). The dose range advisedfor elderly chronic PTSD patients is 5-20 mg. Furtherincrease to 40 mg rarely enhances the effect onimpulse control and self-efficacy. The dose wouldbe reduced on the subject's reporting of unacceptable

loss of impulsiveness (for example, falling asleepduring the day, anorgasmia or general loss ofinitiative or energy).

Psychometric assessment duringpharmacological treatment

Psychotherapy had ended when pharmacologicaltreatment started. The decision to take fluoxetineevoked a marked GSI spike well above the 90thpercentile, because the subject felt that he was

Box 2. Pharmacotherapeutic aspects of PTSDin veterans

Selective serotonin reuptake inhibitors(SSRIs) make sense as a first choice inthe medical support for integratedtreatment of PTSD

Pharmacology of SSRIs, in causing theirinitial side-effects and the therapeuticgain, can be described by receptor down-regulation

PTSD patients may be more sensitive toSSRIs than subjects with depression, bothregarding the initial side-effects and thetherapeutic level of the drug

As urgency is less imperative than indepression, gradual increase of a lowstarting dose is acceptable and preventsadverse reactions, which are a commoncause of therapeutic failure

SSRIs seem to be particularly effective indecreasing impulsiveness and anger andenhancing introspection

SSRIs have a favourable effect on post-traumatic nightmares and dissociation inmany PTSD patients

Other pharmacotherapeutic possibilitiesinclude monoamine oxidase inhibitors,buspirone and anti-kindling substanceslike carbamazepine and valproate

Anti-opioids, such as naltrexone, may beuseful to treat numbing and dissociation

"handing over control to someone else". Active

treatment reduced GSI scores to a level comparableto that in late-stage psychotherapy. Subsequentmonthly monitoring sessions revealed a period ofdrug regimen non-compliance. The non-compliancephase resulted in rapid increases in GSI, which,when he resumed medication, promptly reverted tothe level at start of drug treatment. PSDI scores againindicate that changes typically occurred at the levelof symptom intensity, but examination of individualsymptom dimension scores reveals a distinctand clinically significant treatment effect forhostility (90th decreasing to 1st percentile) and paranoid ideation (55th to 1st percentile; see Box 2).Consequently, the re-emergence of hostile andparanoid symptoms during drug non-compliancewas resolved on resuming medication. Leastsymptomatic impact was effected on phobic anxiety,which remained at the 90th percentile as it hadduring psychotherapy. Somatisation, obsessive-compulsive, interpersonal sensitivity, depression

PTSD in Second World War veterans APT (1998), vol. 4, p. 215

and anxiety scores fluctuated seemingly independently of any treatment with, medians aroundthe 55th percentile.

Discussion

Second World War veterans, among other intenselytraumatised persons, can suffer from severelydisabling, chronic PTSD(Op den Veldeet al, 1990).Notwithstanding flexible care planning anddelivery, lasting cures are rarely, if ever, effectedfor this chronically disabled group, both in our andothers' experience (Solomon, 1995). Therapeutic

dogmatism is to be eschewed in such cases. In thecase of the subject of our study, the primary taskwas to constitute a therapeutic alliance, to helphim to establish new order and regain control overhis life. It also implied structuring and reassuranceduring intercurrent illness and hospitalisation.However, a number of symptoms remained unaffected during the initial phase of psychotherapy.Then, it was suggested to resort to pharmacotherapyas an adjuvant.

Central issues in post-traumatic states of longduration are impulsiveness, hostility and paranoidreactions,which are not typicallydescribed in DSM-IVbut have been proposed by others (Jongedijkefal,1996;Pelcovitz et al, 1997;Chemtob et al, 1997).Inour patient the strong resistance against medicationwas clearly reflected in the GSI,but the impact onhis general well-being was best reflected in thehostility and paranoid ideation scales.

The gradually increasing dose scheme describedfor fluoxetine reflectsexperience gained by W.de L.in treating elderly Dutch veterans and civiliansurvivors of the Second World War suffering fromchronic PTSD. These patients are typically moresensitive to selective serotonin reuptake inhibitors(SSRIs)than those suffering from major depression.Occasionally, starting doses as low as 2.5 or even1 mg have provoked serotonin syndromes, and thefluoxetine has had to be discontinued. Thisdifferential sensitivity is clinically significant withrespect to initial reactions to medication, possibleside-effects in the short term and ultimatetherapeutic outcome. As observed with the subjectin our study, serotonin-mediated responses suchas anxiety, restlessness, sleeplessness, tension,sweating, as well as known gastro-intestinalserotonin effects,subside with continued treatmentthrough the involvement of receptor down-regulation (see Box 2). Being predictable, thesereactionscan be explained to patients as a proof thatmedicationwill have its intended therapeuticeffect.

As stated above, impulsiveness is a pervasivetrait of chronic PTSD patients encompassingmany behavioural expressions like irritability,anger outbursts or physical violence, but alsopsychological expressions like withheld angeraccompanied by guilt and shame. These may bedifficult to discriminate from numbing andmay in part account for the comorbid diagnosisof depression. It is probably the diversity ofbehavioural manifestations of impulsiveness thathas impeded its recognition as a core symptom inthis chronic disorder. A therapeutic implication isthat a decrease in impulsiveness may be beneficialfor the therapeutic process (seeBox2).Byconferringbetter control over feelingsand reactions, a patient's

ability for reflectionand introspection may improve.From a biological point of view the trait of

impulsiveness can be understood as a function ofthe amygdaloid complex and the central grey in thelimbic system or paleocortex of the brain. Inparticular, the amygdala seems to play a pivotal rolein the organisation ofwhat isessentiallythe 'defencereaction' (Cannon, 1915;Hilton & Zbrozyna, 1963)

common to all mammals including Homosapiens.Inthis formulation may lie an important clue to thetarget of pharmacological approaches to PTSD.Whether psychoactive drugs can exert differentialclinical and therapeutic effects through thesestructures, as it appears to have done withour subject, depends on their 'cleanness' and

directedness. Modern SSRIs, with their narrowpharmacological spectrum, have this distinctadvantage over conventional antidepressantswhich have many compromising effects that makethem less tolerable to patients and may impedepsychotherapy through sedation and altered self-perception.

The pharmacotherapy of PTSDhas been investigated far less than for some other major psychiatricdisorders - a pharmacological 'breakthrough' is still

awaited. Reviews of the literature reveal that manykinds of drug treatments ventured (Friedman &Southwick, 1995;Shalevef al, 1996)have producedrather unimpressive effects on PTSD symptomswhen measured with the usual psychometricinstruments. This is especially the case in patientspresenting with very long-term reactions to severe,lifethreatening trauma (DeBoerefal,1992);however,such subjects can feel substantially relieved byseemingly modest treatment effects.This is equallytrue forpsychotherapy,which has not demonstrateda capacity for effectively reducing typical post-traumatic symptoms in SecondWorldWarveterans.As suggested for this patient, the process of talkingabout traumatic events and reactions evoked bythese experiences may intensify symptoms ofdefence or hyperarousal. Conceivably, this may

APT(1998),vol.4,p.216 Orner & de Loos/Neal

prove harmful to some patients, but generally, itis likely to deter them from regular attendance andthe establishment of a constructive workingalliance. Much to the surprise of many clinicians,promising evidence has recently emerged oftherapeutic effects achieved by the new focalintervention of eye movement desensitisation andreprocessing (Greenwald, 1994). The persistenceof this patient's post-traumatic nightmares

illustrates that they are different from dreams andnightmares during rapid eye movement sleep(Schreuder, 1996). They are night-time post-traumatic re-enactments or memories, or flashbacksof actual events, which occur during sleep stages(see Box 1). Psychotherapists should have this inmind when focusing on dream material presentedby patients. Interpretation helped the subject ofour study stop one recurrent dream of sliding offa roof, but reliving war trauma continuedunabated in dreams, nightmares and re-enactments,even after accepting the need for medication.

By the usual criterion of symptom status asassessed by clinical interview and psychometricquestionnaire, treatment outcome for this SecondWorld War veteran is disappointing. The severityand chronicity of his PTSD suggests that therapeuticeffectiveness should be assessed using othermeasures. The patient expressed this in his ownwords as follows:

"Before I decided to attend for therapy I had decided

to take my life. Too many memories of the war andmy dead colleagues made life unbearable for me.Talking in therapy helped me realise I do not have tokeep it all to myself. Others can understand and attimes of crisis there is someone to turn to withoutburdening my family. The medication has helped memore than anything else to control anger and violenttemper outbursts. Because of my memories of thewar many reactions continue as before, but now Ifeel for the first time, I have learnt to be a survivor".

References

American Psychiatric Association (1994) Diagnostic andStatistical Manual of Mental Disorders (4th edn). Washington,DC: APA.

Cannon, W. B. (1915) Bodily Changes in Pain, Hunger, Fearand Rage:An Account of Recent Researchesinto the Function ofEmotional Excitement. New York: Appleton.

Chemtob, C. M., Novaco, R. W., Hamada, R. S., et al (1997)Anger regulation deficits in combat-related post-traumatic stress disorder, Journal of Traumatic Stress, 10,17-36.

Derogatis, L. R. (1983) SCL-90-R. Administration, Scoringand Procedures Manual (2nd edn). Towson, MD: ClinicalPsychometric Research.

De Boer, M., Op den Velde, W., Falger, P. R. }., et al (1992)Fluvoxamine treatment for chronic PTSD: a pilot study.Psychotherapy and Psychosomatic^, 57,158-163.

Friedman, M. J. & Southwick, S. M. (1995) Towardspharmacotherapy for post-traumatic stress disorder. InNeurohiologicaland Clinical Consequencesof Stress from NormalAdaptation to PTSD (eds M. J. Friedman, D. S. Charny &A. Y. Deutch), pp. 465^181. Philadelphia, PA: Lippincott-Raven.

Greenwald, R. A. (1994) Eye movement desensitisation andreprocessing (EMDR): an overview. Journal of ContemporaryPsychotherapy, 24, 15-34.

Hilton, S. M. & Zbrozyna, A. W. (1963) Amygdaloid region fordefence reactions and its efferent pathway to the brain stem.Journal of Physiology, 165, 160-173.

Jongedijk, R. A., Carlier, 1. V. E., Schreuder, J. N., et al (1996)Complex post-traumatic stress disorder: an exploratoryinvestigation of PTSD and DESNOS among Dutch warveterans. Journal of Traumatic Stress, 9,577-586.

Lindy, J. D. (1988) Vietnam: A Casebook. New York: BrunnerMazel.

—, Green, B. L. & Grace, M. (1992) Somatic reenactment in thetreatment of post-traumatic stress disorder. PsychotherapyandPsychosomatics, 57,180-186.

Op den Velde, W., Falger, P. R., De Groen, J. H. M., et al(1990) Current psychiatric complaints of Dutch resistanceveterans from World War II. Journal of Traumatic Stress, 3,351-358.

Pelcovitz, D., Van der Kolk, B. A., Roth, S., et al (1997)Development of a criteria set and a structured interview fordisorders of extreme stress (SIDES). Journal of TraumaticStress,10, 3-16.

Schreuder, J. N. (1996) Post-traumatic re-experiencing in olderpeople: working through or covering up? American Journal ofPsychotherapy, 50, 231-242.

Shalev, A. Y, Bonne, O. & Eth, S. (1996) Treatment of post-traumatic stress disorder: a review. Psychosomatic Medicine,58, 165-182.

Shay, J. (1995) Achilles in Vietnam. London: Touchstone Books.Solomon, Z. (1995) Coping with War-Induced Stress. London:

Plenum Press.

Multiple choice questions

1. Which of the following is correct? PTSD:a can best be treated by intensive psychotherapyb is generally refractory to treatmentc should be treated by behavioural therapyd is refractory to psychodynamic, but not

desensitisation therapye can be alleviated by combined pharmaco- and

psychotherapy.

2. Core symptoms of chronic PTSD are:a violent behaviour, hallucinations and

paranoid ideationb intrusive thinking, delusions and depressionc somatisation, secondary gain and sleeping

disorderd impulsivity, arousability and anger outburstse always accompanied by depression.

3. Which of the following is true?a physiological phenomena are not so typical

in PTSDb intrusive thoughts are the exclusively

essential symptom of PTSD

PTSD in Second World War veterans APT (1998),vol. 4,p. 217

c PTSD can remain unrecognised in a patientduring several decades

d PTSD does not cause character changese PTSD cannot remain unrecognised for a

long period of time.

4. Which of the following is correct? SSRIs:a should not generally be used during

psychotherapyb are less effective with longer use, like

benzodiazepinesc cause receptor hypersensitivityd may facilitate introspectione are insensitive to dose levels.

5. Post-traumatic nightmares:

a mainly occur during rapid eye movementsleep stages

b are indistinguishable from anxious dreamsc are nightly flashbacksd occur preferentially during slumber sleepe are phenomena of primary process thinking.

MCQanswers1abcdeFFFFT2abcdeFFFTF3abcdeFFTFF4abcdeFFFTF5abcdeFFTFF

CommentaryLeigh A. Neal

It is a sobering fact that the average age of thesurviving veterans of the Second World War is nowclose to 80 years. The available information indicatesthat the prevalence of post-traumatic stress disorder(PTSD) in all Second World War veterans is slightlyhigher than the 15% lifetime prevalence found inVietnam War veterans, although there are fewreliable studies on which to base this conclusion. Itis, however, consistent with the finding that combatstress, based on casualty rates, during periods ofthe Vietnam War was equivalent to the severityof combat stress in the Second World War. Thereare several epidemiological studies (Beebe,1975; Tennant et al, 1986) of more specific SecondWorld War veteran groups such as Far Eastprisoners of war and, predictably, they showhigher PTSD prevalence rates, ranging between30 and 50%.

The case history clearly demonstrates the complexities of managing war veterans presenting

with PTSD over 50 years after the traumatic event.The authors' emphasis on developing a therapeutic

alliance and providing a flexible psychologicalintervention with adjunctive pharmacologicaltreatment is a useful model on which to base atreatment strategy.

Many Second World War veterans, althoughexhibiting post-traumatic symptoms for most of theirlives, have characteristically not allowedtheir symptoms to cause significant social oroccupational impairment. They come from an erawhich encouraged the 'stiff upper lip' and this

distinguishes them from the emotionally lessinhibited veterans of recent conflicts. Patients in theelderly veteran group tend to present withan exacerbation of their symptoms at times ofimportant anniversaries or during the developmentof comorbid psychiatric disorders, when theirfunctional reserves are eroded. In fact, PTSD rarelypresents as a unitary diagnosis and the presence of

Wing Commander Leigh A. Neal is Officer Commanding the Defence Medical Services Psychiatric Centre and the Tri-ServicePTSD Unit, Duchess of Kent's Hospital, Home Road, Catterick Garrison, North Yorkshire DL9 4DR

10.1192/apt.4.4.211Access the most recent version at DOI: 1998, 4:211-217.APT 

Roderick J. Ørner and Wolter S. de LoosDisorderSecond World War Veterans with Chronic Post-Traumatic Stress

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