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Addendum - PTSD in Military Veterans
Symptoms, Treatment, and the Road to Recovery
for Post-Traumatic Stress Disorder

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Are you having a hard time readjusting to life outside the military? Are you always on edge, always on the verge of panicking or exploding, or, on the flip side, do you feel emotionally numb and disconnected from your loved ones? Do you believe that you’ll never feel normal again? For all too many veterans, these are common experiences—lingering symptoms of post-traumatic stress disorder (PTSD). It’s hard living with untreated PTSD and, with long V.A. wait times, it’s easy to get discouraged. But you can feel better, and you can start today, even while you’re waiting for professional treatment. There are things you can do to help yourself overcome PTSD and come out the other side even stronger than before.
What is PTSD?

After experiencing a severe trauma or life-threatening event, many military veterans develop symptoms of post-traumatic stress disorder (PTSD), sometimes known as shell shock or combat stress. Close to 30 percent of Afghanistan and Iraq War veterans treated at V.A. hospitals and clinics have been diagnosed with PTSD. For veterans who saw combat, the numbers are even higher, with one Pew Research Center report showing a 49% rate of PTSD. However isolated or emotionally cut off from others you feel, it’s important to know that you’re not alone.

We don’t know why some military personnel develop PTSD and others don’t, but we do know that the incidence goes up with the number of tours and the amount of combat you experienced. This isn’t surprising, considering many symptoms of PTSD—like hypervigilance, hyperawareness, and adrenaline-quick reflexes—helped you survive when you were deployed. It’s only now that you’re back home that these responses are inappropriate.
What are the symptoms of PTSD in veterans?

PTSD develops differently from person to person but there are four symptom clusters in veterans:

Recurrent, intrusive reminders of the traumatic event, including distressing thoughts, nightmares, and flashbacks where you feel like it’s happening again. Experiencing extreme emotional and physical reactions to reminders of the trauma (panic attacks, uncontrollable shaking, heart palpitations, etc.).
Extreme avoidance of things that remind you of the traumatic event, including people, places, people, thoughts, or situations you associate with the bad memories. Withdrawing from friends and family and losing interest in everyday activities.
Negative changes in thoughts and mood, such as exaggerated negative beliefs about yourself or the world and persistent feelings of fear, guilt, or shame. Diminished ability to experience positive emotions and feeling detached from others.
Being on guard all the time, jumpy, and emotionally reactive, as indicated by irritability, angry outbursts, reckless behavior, difficulty sleeping, trouble concentrating, hypervigilance, and an exaggerated start response.

Sometimes these symptoms don’t surface for months or years after the event or returning from deployment. They may also come and go. If these problems won’t go away or are getting worse—or they are disrupting your daily life—you may have PTSD. For more on the signs and symptoms of PTSD, see Post-Traumatic Stress Disorder (PTSD).
Treatment and self-help for PTSD in veterans

PTSD is not a sign of weakness and there’s no reason to blame yourself. The only way to overcome it is to confront what happened to you and learn to accept it as a part of your past. This process is much easier with the guidance and support of an experienced therapist or doctor.

There are several different types of treatment for PTSD including:

Cognitive-behavioral therapy or "counselling" involves carefully and gradually "exposing" yourself to thoughts and feelings that remind you of the event. Therapy also involves identifying distorted and irrational thoughts about the event—and replacing them with more balanced picture.
Medication, such as antidepressants, is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression or anxiety. While antidepressants may help you feel less sad, worried, or on edge, they do not treat the causes of PTSD.
EMDR (Eye Movement Desensitization and Reprocessing) incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. These are thought to work by "unfreezing" the brain’s information processing system, which is interrupted in times of extreme stress.

Helping yourself on the road to PTSD recovery

Many veterans suffering from PTSD have to endure long waits for professional treatment at the VA. But there are things you can do for yourself to start feeling better.

As a veteran with PTSD, the job of recovery is to transition out of the mental and emotional war zone you’re still living in. It won’t happen overnight, but if you take it day by day, you’ll soon see progress. And as you learn how to deal with your combat stress, you’ll also be learning skills that will translate into success in the rest of your post-war life—tools you can use for much more than overcoming PTSD.

The following recovery steps can show you how to feel safe again, reconnect with others, deal with nightmares and flashbacks, cope with feelings of depression, anxiety, or guilt, and restore your sense of control.

The road to PTSD recovery step 1: Connect with others

PTSD can leave you feeling disconnected and withdrawn. But instead of isolating yourself, make an effort to invest in your personal relationships. Social interaction with people who care about you is a great stress reliever and one of the most effective ways to calm your nervous system when you’re in a state of hyperarousal or feeling anxious, irritable, or on edge.

Find someone you can connect with face to face—someone you can talk to for an uninterrupted period of time, someone who will listen to you without judging, criticizing, or continually being distracted by the phone or other people. That person may be your significant other, a family member, one of your buddies from the service, or a civilian friend.

You may feel like the civilians in your life can’t understand you since they don't know what it's like to be in the military or to have seen the things you did. But people don't have to have gone through the exact same experiences to understand and relate to painful emotions and be able to offer support. What matters is that the person you're turning to cares about you, is a good listener, and is able to be there for you as a source of strength and comfort.

If you're not ready to open up about the details of what happened, that's perfectly okay. You can talk about how you feel without going into a blow-by-blow account of events.
You can also tell the other person what you need or what they can do to help, whether it's just sitting with you, listening, or doing something practical. Comfort comes from someone else understanding your emotional experience. You’ll also find that people who care about you welcome the opportunity to help. Listening is not a burden for them but an opportunity.

Don't...

Keep quiet because you don’t want to upset others
Keep quiet because you’re worried about being a burden
Assume that others don’t want to listen
Wait until you’re so stressed and exhausted that you can’t benefit from help

Source: National Center for PTSD

Other ways to connect with others

Many veterans find it helpful to join a PTSD support group or to connect with other veterans or trauma survivors. Listening to others' stories and struggles may help you feel less isolated.
You can also volunteer in the community, which can help you feel more connected and useful, especially if you’re not currently working.

The road to PTSD recovery step 2: Calm your overstimulated nervous system
The benefits of the great outdoors

Spending time in nature and pursuing outdoor activities like hiking, camping, mountain biking, rock climbing, whitewater rafting, and skiing can help veterans cope with PTSD symptoms and transition back into civilian life.

Focusing on strenuous outdoor activities can also help challenge your sense of vulnerability and help your nervous system become "unstuck" and move on from the traumatic event you experienced. Seek out local organizations that offer outdoor recreation or teambuilding opportunities or, in the U.S., check out Sierra Club Military Outdoors. This program provides service members, veterans, and their families with opportunities to get out into nature.

PTSD overstimulates your nervous system, leaving you amped up and on high alert all the time. While connecting with people close to you is a great way to calm yourself, it’s not always practical to have a buddy close by. In these cases, you can use your senses to quickly calm your nervous system. Just as loud noises, certain smells, or the feel of sand in your clothes, for example, can instantly transport you back to the trauma of a combat zone, so too can sensory input—sights, sounds, tastes, smells, etc.—quickly calm you down. The key is to find the sensory input that works for you.

Think back to your time on deployment: what brought you comfort at the end of the day? Perhaps it was looking at photos of your family? Or maybe it was the taste of candy in a care package from home, or listening to a favorite song, or smelling a certain brand of soap or cologne? Or maybe petting an animal or the sound of wind chimes works quickly to make you feel calm and centered? Everyone responds to sensory input a little differently, so experiment to find what works best for you.

For more ways to quickly calm yourself, see Stress Relief in the Moment.
Reestablish safety

As a survivor of a war zone, you already know that the world can be a dangerous place at times. The problem with PTSD is that it makes you feel as if you’re still in danger, even when you’re not. That’s why it’s important to reestablish safety.

One of the most helpful things you can do is create your own safe place (ideally someplace close and convenient). Your safe place is where you can sit and think, relax or meditate, or work through your traumatic memories. The safe place should be a secure, private location with limited access—somewhere you don’t have to worry about outside dangers or others intruding. Maybe it’s your bedroom or your office. Or it could be a corner of your back yard or an isolated spot outdoors. When you’re feeling unsafe, you can retreat to this safe place and calm your overstimulated nervous system.
The road to PTSD recovery step 3: Take care of your body

The symptoms of PTSD can be hard on your body. The effects include insomnia, fatigue, irritability, angry outbursts, concentration problems, and jumpiness. Eventually, your health will suffer. That’s why, if you have PTSD, one of the best things you can do is care for your body. That means putting a priority on sleep, exercise, healthy food, and relaxing activities.

You may find it very difficult to relax at first. In fact, it’s common for veterans to be drawn to activities and behaviors that pump up adrenaline. After being in a combat zone, that’s what feels normal. Without the rush, you feel strange or even dead inside. Things you may turn to for that familiar adrenaline rush include energy drinks, coffee, stimulant drugs, cigarettes (even if you’ve never smoked before), violent video games, action and horror movies, and daredevil sports. If you recognize these urges for what they are, you can make better choices that will calm and care for your body and mind.
Healthy habits for veterans with PTSD

Here are some active steps you can take to improve your PTSD symptoms:

Exercise to burn off adrenaline. Good choices include activities that involve the large muscles, such as running, walking, swimming, weight lifting, and basketball. The benefits of exercise include reducing physical tension and stress, increasing energy, and decreasing symptoms of depression and anxiety. All in all, regular exercise will make you feel better, both mentally and physically.
Take time to rest and restore your body’s balance. That means taking a break when you’re tired and avoiding the temptation to lose yourself by throwing yourself into activities. Avoid doing anything compulsively, including exercising and working.
Avoid alcohol and drugs (including nicotine). It can be tempting to turn to drugs and alcohol to numb painful feelings and memories and get to sleep. But substance abuse can make the symptoms of PTSD worse and compound your problems. The same goes for cigarettes. If at all possible, stop smoking, and seek help for drinking and drug problems.
Find safe ways to blow off steam. Pound on a punching bag, pummel a pillow, go for a hard run, sing along to loud music, head to the gym for a vigorous workout, go somewhere private where you can scream at the top of your lungs, or vent in your journal or to someone you trust.
Support your body with a healthy diet. Eat plenty of complex carbohydrates, such as potatoes and whole grains, to support mental clarity and physical stamina. Limit processed sugars, which can exacerbate mood swings and energy fluctuations.
Get plenty of sleep. Sleep deprivation exacerbates anger, irritability, and moodiness. Aim for somewhere between 7 to 9 hours of sleep each night. Develop a relaxing bedtime ritual (listen to calming music, take a hot shower, watch a funny show, or read something light and entertaining) and make your bedroom as soothing as possible. Use curtains to block outside light and avoid digital clocks or electronic devices that emit light. If noise is a problem, try using a sound machine.

Take advantage of relaxation techniques

Relaxation techniques such as mindfulness meditation, tai chi, deep breathing, and progressive muscle relaxation are powerful defensive weapons against the symptoms of PTSD. Among their many benefits, they reduce stress, ease the symptoms of anxiety and depression, help you sleep better, and increase your feelings of peace and well-being. The only catch is that you need to practice your relaxation technique of choice regularly. It’s like military training. You practice until it’s second nature, so when the crisis comes, you’re able to act quickly and decisively. To learn more, see Relaxation Techniques for Stress Relief.
The road to PTSD recovery step 4: Reconnect to what you feel

If you’re a veteran with PTSD, it’s normal to want to avoid remembering or re-experiencing what you went through. But the problem is that avoiding those memories doesn’t make them go away. You can try to escape through fantasies, daydreams, excessive TV, video games, pornography, or drugs and alcohol, but the feelings associated with the trauma are still inside you. When you try to suppress them, the thoughts, images, and dreams can actually become more threatening and intrusive.
It’s not helpful to obsess over disturbing thoughts and feelings. Sometimes you’ll need to take a step back in order to take care of yourself, get through your day, and avoid retraumatizing yourself. But to heal and move on, you’ll need to reconnect to what you feel. While this may seem like a terrifying step, reconnecting to your feelings is the only way you’ll be able to experience joy in life again.
Safely reconnect to what you feel

As you stop trying to numb yourself and avoid traumatic reminders, you’ll need to pay attention to your feelings. Your body and emotions give you clues when you’re starting to feel stressed and unsafe. These clues include:

feeling tense anywhere in your body
holding your breath
racing thoughts
nervous behaviors (pacing, nail biting, picking at your skin)
shortness of breath
pounding heart
sweating, hot flashes
dizziness, nausea

When you pick up on these symptoms of stress, take steps to calm down before they spiral out of control. These are the times when you can take advantage of the relaxation techniques and quick stress relief strategies you have in your arsenal.
A powerful program for reconnecting to your feelings

There are many ways for you to start reconnecting to your feelings, including increasing your contact with other people and working through the trauma in therapy. Helpguide also offers a free, online program that teaches you how to reconnect to uncomfortable or disturbing emotions without becoming overwhelmed. Over time, it can make a huge difference in your ability to manage stress, balance your moods and emotions, and take back control of your life.
The road to PTSD recovery step 5: Deal with flashbacks, nightmares, and intrusive thoughts

Flashbacks usually involve visual and auditory memories of the trauma you experienced. It feels as if the trauma is happening all over again so it’s very important for you to accept and reassure yourself that your traumatic experience is not occurring in the present. Trauma specialists call this "dual awareness."

Dual awareness is the recognition that there is a difference between your "experiencing self" and your "observing self." On the one hand there is your internal emotional reality: you feel as if the trauma is currently happening. On the other hand, you can look to your external environment and recognize that you’re safe. You’re aware that despite what you’re experiencing, the trauma happened in the past. It is not happening now.
Tips for strengthening dual awareness

One effective technique for strengthening dual awareness is to state to yourself (either out loud or in your head) the reality of both selves. Here’s a simple script you can use when you awaken from a nightmare or start to experience a flashback or intrusive thought:

"I am feeling [panicked, frightened, overwhelmed, etc.] because I am remembering [traumatic event], but as I look around I can see that [traumatic event] isn’t happening right now and I’m not actually in danger."

Other techniques that can be helpful in bringing you back to the present include tapping or touching your arms or describing your actual environment and what you see when look around (for example, name the place where you are, the current date, and three things you see when you look around).
Tips for grounding yourself during a flashback

If you’re starting to disassociate or experience a flashback, try using your senses to bring you back to the present and "ground" yourself. Experiment to find what works best for you.
Movement Touch

Move around vigorously (run in place, jump up and down, etc.); change the position of your body; rub your hands together; shake your head

Splash cold water on your face; grip a piece of ice; touch or grab on to a safe object; pinch yourself; play with a Slinky, worry beads, or a stress ball
Sight Sound

Blink rapidly and firmly; visit your safe place; look around and take an inventory of what you see

Turn on loud music; clap your hands or stomp your feet; talk to yourself (tell yourself you’re safe, that you’ll be okay)
Smell Taste

Smell something that links you to the present (coffee, mouthwash, your wife’s perfume) or a scent that has good memories

Suck on a strong mint or chew a piece of gum; bite into something tart or spicy; drink a glass of cold water, soda, or juice
The road to PTSD recovery step 6: Work through survivor's guilt

Many veterans with PTSD struggle with difficult emotions, including survivor’s guilt. You may have seen people injured or killed, often your friends and comrades. In the heat of the moment, you don’t have time to fully process these things as they happen. But later—often when you’ve returned home—these experiences come back to haunt you. You may ask yourself questions such as:

Why didn’t I get hurt?
Why did I survive when others didn’t?
Could I have done something differently to save them?

You may end up blaming yourself for what happened and believing that your actions (or inability to act) led to someone else’s death. You may feel like others deserved to live more than you—that you’re the one who should have died. This is survivor’s guilt.
Healing from survivor's guilt

Feelings of guilt are very common among veterans. Healing from it doesn’t mean that you’ll forget what happened or those who died. And it doesn’t mean you’ll have no regrets. What it does mean is that you’ll look at your role more realistically. Remember, you are only human.

The following questions can help you "reality test" your guilty feelings:

Is the amount of responsibility you’re assuming for the event reasonable?
Could you really have prevented or stopped what happened?
Could you really have reacted differently?
Are you judging your decisions based on full information about the event, or just your emotions?
Did you do your best at the time, under challenging circumstances?
Do you truly believe that if you had died, someone else would have survived?

Honestly assessing your responsibility and role can free you to move on and grieve your losses. Instead of punishing yourself, you can redirect your energy into honoring those you lost and finding ways to keep their memory alive. And in those cases where you truly believe you did something wrong, you can make amends. Even when you can’t make amends directly, there is always something you can do (such as volunteering for a cause that’s connected in some way to one of the friends you lost). The goal is to put your guilt to positive use, and thus transform tragedy, even in a small way, into something good.
More help for PTSD in veterans

PTSD and trauma
Emotional and Psychological Trauma: Symptoms, Treatment, and Recovery
PTSD in the Family: Helping a Loved One or Family Member with Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder (PTSD): Symptoms, Treatment and Self-Help for PTSD
Coping with Grief and Loss: Understanding the Grieving Process
Related issues
Depression Symptoms and Warning Signs: How to Recognize Depression Symptoms and Get Effective Help
Anger Management: Tips and Techniques for Getting Anger Under Control
Alcoholism and Alcohol Abuse: Signs, Symptoms, and Help for Drinking Problems
Overcoming Drug Addiction: Drug or Substance Abuse Treatment, Recovery, and Help

Smith, M.A., Melinda Lawrence Robinson, and Jeanne Segal, Ph.D. PTSD in Military Veterans Symptoms, Treatment, and the Road to Recovery for Post-Traumatic Stress Disorder, Helpguide.org, December 2014.

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