Post-Traumatic Stress at the End of Life
CATEGORY: Medical and Clinical
BY: Edgardo Padin-Rivera, Ph.D.
PUBLICATION: Clinical Connections
The symptoms of post-traumatic stress disorder (PTSD) have been found among soldiers in every war. The syndrome begins when a traumatic event or events that a person has experienced leaves such a strong psychic impression that the person later suffers from recurrent, painful, and intrusive recollections. These may take the form of unwanted thoughts, images, or even hallucinations, called flashbacks, during which components of the event are actually relived.
Many traumatized persons, to avoid re-experiencing the anxiety and pain of a trauma, will avoid activities that activate emotions or thoughts about the events. Consequently, emotional numbing and psychological amnesia to parts or all of an experience may occur. Other symptoms that may develop include nightmares, sleep disturbance, hyper-alertness, survivor guilt, exaggerated startle and unresolved mourning.
There is evidence that late-onset PTSD in formerly well-functioning individuals now facing end-of-life issues is an increasing phenomenon. As nurses and other providers care for veterans encountering medical intervention or end-of-life issues, they are in an important position to identify this often overlooked disorder and provide appropriate care and referral for mental health treatment.
Often, veterans facing the prospect of death may experience an onset of PTSD symptoms in response to changes in environment, medical interventions or loss of family members. It is also reasonable to expect that the veteran who suffered war traumas may be faced in late life with re-activation of symptoms in reaction to the developmental imperative to reflect upon and integrate his life history.
In unfamiliar and new environments, a veteran may suffer great anxiety when exposed to sudden loud noises, confinement and even movies or songs reminiscent of the period when the trauma occurred. In response, the veteran may purposely avoid discussions that are reminders or try to emotionally “tune out” things that might cause a resurfacing of feelings or thoughts associated with the trauma. Also, staff should be aware that any noxious stimuli such as surgery or an unknown medical procedure may trigger PTSD symptoms.
The aging process itself can cause symptoms to surface as serious health issues force limits on driving, working and walking. Subsequent feelings of vulnerability and powerlessness can mimic emotions similar to those experienced during combat. All people have common experiences as death approaches. Among these is a life review that allows the person to reassess significant experiences in their lives. This life review may be more complex for combat veterans who have faced the chaos, destruction and death that are signature components of war.
Clinicians at residential facilities can assist veterans with some short and immediate interventions. These include initiating conversations about their military service, without going into traumatic experiences. Intensive trauma processing may worsen depression and anxiety. Pushing for details of traumatic events is best left for an expert in PTSD.
Showing respect and gratefulness for their service goes a long way. Discuss with family members how the veteran has coped with symptoms over the years; this will give the clinician a better picture of how to approach symptoms and what to expect. Doing PTSD symptom education with the veteran can help normalize the fearful imagery and emotions associated with memories. Thought distracting can also help manage intrusive thoughts and reorienting the veteran to present day can help contain overwhelming imagery or sensory illusions.
Sudden anxiety and depression might be clues to an activation of symptoms. Intense anger may also be a sign. It is worth noting that soldiers learned during war that allowing intense feelings of vulnerability, loneliness and helplessness were a threat to survival while expressing anger or aggression was more apt to help in survival. Often, this lesson has been carried and ingrained in behaviors for decades after the war.
Editor’s Note: Dr. Padin-Rivera is Chief, Psychological Services, and Chairman of the Mental Health Council for the Louis Stokes Cleveland VA Medical Center.