From the TORONTO STAR September 24, 2000
By Sarah Jane Growe
Toronto Star Staff Reporter

Post-traumatic stress disorder, the long-misunderstood 
condition once known as shell shock, felled a Canadian 
general who witnessed the horrors of Rwanda. But it's 
not just soldiers who are at risk. 

THE SMELL OF fresh fruit can pitch Roméo Dallaire into 
a state of profound depression. Bushes can suddenly 
mutate into piles of corpses. 

``I can't sleep. I can't stand the loudness of silence,'' 
says the retired Canadian general who commanded the 
United Nations mission to Rwanda during the 1994 genocide, 
when up to a million Tutsis were butchered by the ruling 

``You cannot put these things behind you,'' Dallaire, 
54, says from his home in Quebec city. ``And the more 
people say that, the more you get mad because you know 
these things will not disappear. Time does not help.'' 

Two years after he returned to Canada, he could no longer 
suppress his memories of the sounds, sights and smells of 
the horrors he witnessed in Africa. He tried to kill 
himself. But he didn't accept treatment until 1998. 

Dallaire's illness used to be called shell shock, a 
term coined in 1940 by British psychologist Charles 
Myers, who attributed the symptoms of mental breakdown 
to the concussive effects of exploding shells. 

Now, it's called post-traumatic stress disorder (PTSD). 
But until the soft-spoken Dallaire announced in April 
that the ailment was forcing him to retire, few Canadians 
knew much about it. 

It was American war veterans who politicized shell shock. 
Before the 1970s, doctors treating the emotional disturbance, 
even in soldiers never exposed to gunfire, found shell shock 
(or war hysteria, as it was sometimes called) extremely 
difficult to distinguish from cowardice, historians say. 
`I can't sleep. I can't stand the loudness of silence . . . 
Time does not help' - Lt.-Gen. Roméo Dallaire, retired due 
to PTSD  Then, activists and psychiatric workers concerned 
about the lack of recognition of the effects of the Vietnam 
War on returning veterans' psychological health revived 
interest in U.S. combat psychiatrist Abram Kardiner's largely 
forgotten The Traumatic Neuroses Of War, published in 1941. 

Dr. Kardiner, now credited with defining PTSD for the 
remainder of the 20th century, characterized chronic 
irritability, startle reactions, explosive aggression 
and an atypical dream life as war-related trauma, even 
though such phobic behaviour made the veterans in his care 
look as if they were suffering from long-standing neuroses. 

``The subject acts as if the original traumatic situation 
were still in existence and engages in protective devices 
which failed on the original occasion,'' Kardiner writes. 

``This means in effect that his conception of the outer 
world and his conception of himself have been permanently 

About the same time as Vietnam veterans' support groups 
were agitating for an official diagnosis so sufferers 
would have access to treatment and compensation, others 
were documenting that the terrifying flashbacks and 
nightmares of abused women and children, historically 
dismissed as hysteria, resembled the traumatic neuroses 
of war. 

``There is a war between the sexes. Rape victims, battered 
women and sexually abused children are its casualties,'' 
wrote Judith Herman, clinical professor of psychiatry at 
Harvard Medical School, in Trauma And Recovery. ``Hysteria 
is the combat neurosis of the sex war.'' 

But it was not until 1980 that the American Psychiatric 
Association accepted PTSD - including ``rape trauma 
syndrome,'' ``battered woman syndrome,'' ``Vietnam veterans'
syndrome'' and ``abused child syndrome'' - as a bona fide 
medical diagnosis in its Diagnostic And Statistical Manual 
Of Mental Disorders (DSM). 

That step was controversial: PTSD was then and is now the 
only psychiatric illness in which the cause is clearly 
acknowledged as originating outside the individual rather 
than inside as an inherent weakness or flaw. 

``Without the context of a political movement, it has never 
been possible to advance the study of psychological trauma,'' 
says Dr. Herman, who served on the medical committee 
developing the DSM criteria and is active in the women's 

Now, Lt.-Gen. Dallaire, who issued directives for four new 
military-related PTSD clinics when he was a human-resources 
manager for the military in 1998, is defining 21st-century 
PTSD in this country. 

Despite his ill health, the father of three strives to focus 
national attention on what he calls the most common 
mental-health problem among military personnel. 

He says he has ``bullied'' his way back on to the Canadian 
Forces mental-health committee in hopes of pushing ahead 
the PTSD program he proposed before his retirement. 

What used to be a disability best ``kept in a drawer,'' 
as Dallaire once described his shame, is becoming a public 
rather than a private problem, not only for combat veterans 
and abused women and children but also for emergency 
services personnel and victims of and witnesses to violent 
crimes or natural disasters. 

It was not until 1980 that the American Psychiatric Association accepted PTSD - including ``rape trauma syndrome,'' ``battered woman syndrome,'' ``Vietnam veterans' syndrome'' and ``abused child syndrome'' - as a bona fide medical diagnosis

The hard-won DSM diagnostic criteria (revised in 1987 and 
1994) are being used now on both sides of the border to 
help raise awareness of the syndrome in both professional 
and lay communities. 

The trauma must be grave, the manual says, an experience 
of or witness to an ``actual or threatened death or 
serious injury, or a threat to the physical integrity of 
self or others.'' 

The exception is any childhood sexual abuse, which qualifies 
even without threatened or actual violence or injury. Response 
to the trauma must ``involve intense fear, hopelessness or 
horror,'' although children can be simply disorganized or 

The catastrophic event must be persistently re-experienced, 
either by recurrent nightmares, flashbacks, hallucinations, 
intrusive recollections or by physical or psychological 
reactions to cues that remind the sufferer of his past 

``PTSD is a disease of time,'' explains McGill University 
anthropology professor Allan Young, who did field research 
in the United States from 1986 to 1988. 

``The disorder's distinctive pathology is that it permits 
the past (memory) to relive in the present, in the form of 
intrusive images and thoughts and in the patient's compulsion 
to replay old events,'' Young writes in The Harmony Of 
Illusions: Inventing Post-Traumatic Stress Disorder. 

Cpl. Chris Cassavoy served with Dallaire in Rwanda.
``The worst thing about being a Canadian soldier is that
a weakness is frowned upon, so the easiest thing to do 
is take everything and push it to the side and pretend 
it was a movie,'' he says in Witness The Evil, a Canadian 
Forces' educational video made in 1998. 

``That is, until you get the smells. The smells are the 
worst things that trigger a memory. It's like a film 
starting up in your head. 

``There are foods I can't eat any more. Grilled chicken. 
Can't eat it. It looks like a dead body. Rusted vehicles. 
Can't go near them. Children. I have a hell of a time, a 
hell of a time, looking at little kids, especially newborns 
because they were a plaything with the Hutus.'' 

Cassavoy can no longer hold back his tears. 

``They really liked killing kids.'' 

As a medic, Cpl. Darrell Daines thought he could take it. 

``But I couldn't. They had all the children lined up,'' 
he says, his voice shaking as he recalls a Rwandan school 
he inspected. ``It looked like they played a game with 
the children.'' 

Daines must pause to collect himself. 

``Like they chopped their heads off and then they signed 
their names. It was a game.'' 

Not everyone exposed to catastrophe reacts in the same 
way, says psychiatrist Randy Boddam, a major acting as 
clinical adviser on PTSD to the Canadian Forces' surgeon 

``Some may have no stress. Others may have post-traumatic 
stress. But simply feeling upset after a trauma is not a 

``We must be careful not to pathologize stress.'' 

Canadian Forces does not know exactly how many military 
personnel have been diagnosed, Boddam goes on to say. 
Epidemiological studies are expensive, and the first 
one is not slated until next year. 

The U.S. Department of Veterans' Affairs reports that 
30.9 per cent of the 3,140,000 men who served in the 
Vietnam War have had full-blown PTSD at some point in 
their lives. A 1990 study showed that, 20 years after 
the war, 15.9 per cent of those veterans, about 500,000 
men, still suffered from full-blown PTSD and another 11.1 
per cent from partial PTSD. 

One of four Vietnam-era combat veterans was arrested within 
two years of discharge, according to studies, and 200,000 
are thought to be addicted to drugs or alcohol, an associated 
feature of PTSD. Their divorce rate is twice that of the 
general population and their suicide rate is 23 per cent higher. 

Among America's homeless, one-third are said to be veterans 
of the Vietnam War. 

The majority of PTSD sufferers, however, are civilians. Dr. 
Herman says it is one of the most common of all psychiatric 
illnesses; the lifetime incidence among all Americans is 7 
to 8 per cent.

In 1987, the American Psychiatric Association expanded its 
definition of trauma to include events ``not outside the range 
of usual human experience'' such as automobile accidents. 

Today, the most common causes of PTSD in the general 
population are rape, witnessing a murder and violent car 

Each year, Toronto psychologist Rex Collins and his 
colleagues see from 30 to 50 people - many of them 
children - who have PTSD as the result of a motor vehicle 
accident. What happens in hospital after an accident is 
also part of the trauma, Collins says, and the hope is 
to develop a sense of trust so that victims can talk about 

Some symptoms can be calmed just by understanding them, 
he says, adding that he believes psychotherapy itself, 
without drugs, can change the damaged brain chemistry by 
providing nurturing. 

``I can't ever make the nightmares and intrusive reactions 
go away,'' he says, ``but I may be able to help people put 
them in perspective and carry on with their lives.'' 

Unfortunately, Collins says, because of legal entanglements 
and problems with insurance payments, he often doesn't get 
to see children until two or three years after an accident, 
when their symptoms are already entrenched, increasing the 
likelihood of the pathological responses to the traumatic 
memories becoming chronic. 

That delay makes treatment more difficult. 

``It's easier to stabilize victims of more-recent trauma,'' 
says David Lingley, a Maple Ridge, B.C., psychologist who 
specializes in treating PTSD in emergency-services workers. 

``Adult survivors of childhood trauma have already found 
their own ways to function in a crisis mode, which may not 
always be healthy.'' 

Gary Denomme, now 39, knows about childhood trauma that 
goes untreated. 

Sexually abused at St. John's School for Boys, a former 
reform school in Uxbridge, Ont., run by the Christian Brothers, 
Denomme has suffered from depression, an associated feature 
of PTSD, all of his adult life. 

But he never knew why; he never associated his depression 
with the trauma. 

``I get really down and I never knew what it was,'' says 
Denomme from Vancouver, where he has lived since 1977. 

``I thought it was normal. I didn't know how to cope with l
ife. I tried to commit suicide a couple of years back. I 
know I've had it for a long time. I didn't know what it was.'' 

Three years ago, his general practitioner, David Lai, made 
the diagnosis: PTSD. 

Dr. Lai says Denomme, who was part of a high-profile 
class-action settlement in Ontario, is doing better now 
that he knows what's wrong with him. But in addition to 
therapy, Denomme is on medication for depression. 

``I am afraid to go off it,'' he says. 

Separating the idea from consciousness, which is called 
dissociation, at the moment of trauma seems to be the 
single most important predictor for chronic PTSD, according 
to the psychiatric association's DSM. And once it is chronic, 
it is a subliminal part of a person's history. 

As Collins explains it, trauma doesn't happen in isolation. 
Some victims of accidents not considered serious develop 
PTSD and others who have fairly serious injuries are all 
right - perhaps their families are able to help them.

Although the insurance industry likes to classify earlier 
post-traumatic stress as a pre-existing injury and thus 
ineligible for compensation, accidents don't happen to blank 
screens, Collins says. They happen to people with a history, 
with a particular way of dealing with things or not dealing 
with things. 

``People who have been sexually abused, for example, seem 
to suffer more severe reactions to motor vehicle accidents,'' 
Collins says.

American psychologist John Briere writes in Psychological 
Assessment Of Post-Traumatic Stress that studies indicate 
childhood abuse is a significant risk factor for victimization 
as an adult. Individuals with a history of child abuse are 
more likely to develop PTSD in response to adult combat 
experiences than those without a history of abuse, he writes.  

Childhood abuse puts a person at greater risk of a PTSD response 
to a catastrophe in the way that a high-cholesterol diet means a 
greater risk of heart disease, says Dr. Matthew Friedman, a 
Vermont psychiatrist and Dartmouth Medical School professor 
who acts as executive director of the National Center for 
Post-Traumatic Stress Disorder. 

California child psychiatrist and author Lenore Terr specializes 
in childhood trauma. 

Decades after the infamous 1976 Chowchilla, Calif. school-bus 
kidnapping, she still keeps track of 25 of the victims, then 
age 5 to 14, who'd spent 27 hours in a state of terror. She 
says none of them was spared the traumatic effects of the 

In early 1987, Terr was struck by the images of adolescent 
terror in the movie Stand By Me, based on horror writer Stephen 
King's novella, The Body. 

At the moment when a train appears and almost runs down four 
boys on a narrow trestle high above a gorge, ``the scene is 
so scary, so monstrous, so unexpected that it reproduces the 
feeling of childhood trauma right then and there,'' Terr 
writes in ``Terror Writing By The Formerly Terrified: A Look 
At Stephen King,'' published in The Psychoanalytic Study Of 
The Child in 1989. 

``I remember saying to myself, `Whoever wrote this movie is 
playing post-traumatic games with me.' '' 

Dipping into accounts of interviews with King, Terr discovered 
that, when the author and screenwriter was 4 in 1951, a friend 
he was playing with on at a rail crossing was run over by a 
freight train. The young King returned home white as a ghost, 
unable to speak for the rest of the day. Years later, his mother 
told him pieces of the boy had been collected in a wicker 
basket. But King has no memory of the incident. 

The train trauma and the loss of his father, who abandoned the 
family when King was 2, are clues to the writer's psyche, Terr 
says. He never believed in his own personal future; until age 
20 he thought he'd never reach 20 and he now frets that one of 
his children will die. 

``I think it is clear that Stephen King currently suffers 
many of the symptoms and signs of post-traumatic stress 
disorder of childhood,'' Terr says. ``He suffers nightmares, 
fears, headaches, insomnia, a sense of futurelessness and 
active denial. He has never seen a psychiatrist. 

``Stephen King says he believes he could write, if he wanted 
to, non-horror fiction. But he does not. And he has not. His 
writing is devoted to one emotion - terror.'' 

On June 19, 1999, King was struck by a van as he walked along 
the shoulder of a road against traffic near his country home 
in Maine. 

He was thrown 4 metres in the near-fatal accident and suffered 
a collapsed lung and multiple broken bones. (His surgeon described 
the bones below his right knee as ``reduced to so many marbles 
in a sock.'') 

A graphic account of his post-traumatic stress and his efforts 
to return to writing appeared in the June 19/26 issue of The 
New Yorker. 

``I didn't want to go back to work,'' King wrote. ``I couldn't 
imagine sitting behind a desk for long, even in a wheelchair...
Yet, at the same time, I felt I was all out of choices...
For me, there have been times when the act of writing has 
been an act of faith, a spit in the eye of despair.'' 

According to the psychiatric association's manual, PTSD can 
develop in individuals without predisposing conditions, 
particularly if the stress is extreme. 

Severity, proximity and duration of the exposure to trauma 
are the most important factors in developing a PTSD response, 
the manual says, although there is some evidence that social 
supports, family history and nurturing childhood experiences 
decrease its likelihood. 

The disorder may be especially severe or long-lasting, it says, 
when the stress is of human design, i.e., torture or rape or 
childhood sexual abuse. 

``The trauma that causes post-traumatic stress disorder is 
a life-changing moment,'' says Lingley, who conducts workshops 
for B.C. rescue workers. ``It alters a person's belief in the 
components of the world, in safety and predictability, in the 
faith that bad things don't happen to good people. 

``It alters the way people view the world and themselves in 
it. They are faced with reconstructing the beliefs they once 

Dallaire kept his faith.
``When I was there in the field, and I was alone as the 
commander in that mess, and having negotiated with the devil 
himself, it became for me a reality that there was another 
being above all else,'' he says. ``What hit me was reinforcing 
the values and the faith I had over the years.'' 

Now taking 12 pills a day and in weekly therapy, he says he 
doesn't need an extended social structure. In fact, he tends 
not to want to talk to people. He avoids social gatherings: 
Since being surrounded by massive crowds in Africa, they make 
him nervous. He can't stay in a movie theatre that's full. 

He needs a family that's been specifically educated about PTSD, 
he says. Including families of military members is one of the 
most important innovative dimensions of the military's new PTSD 

``What you absolutely also need is an âme soeur - a `sister 
soul' - someone who doesn't give you all the platitudes and 
so on that just make you more mad,'' he says. ``They just 
listen. They cry with you. They stay with you. And they don't 
run away when you start into some of the horrific stuff.'' 

Despite the horrors and the toll they've taken on him, Dallaire 
last week agreed to return to the world's war zones - as a 
special adviser to federal International Co-operation Minister 
Maria Minna - when his therapy permits it. 

Social support enhances therapy and medication, Dr. Herman says, by helping sufferers disconnect with the trauma and reconnect with family, friends and society. Dr. Friedman says public-health prevention is also in the early stages south of the border, where professionals are learning to identify situations likely to cause PTSD and where, since the Gulf war, there has been an increasing recognition of the kinds of catastrophes that result in PTSD. But that's secondary prevention, he adds. Primary prevention is altering the social structures that lead to war, rape and child abuse. ``History has shown that social reform is the best medicine,'' British psychiatrist Derek Summerfield writes in the July 22 issue of the British Medical Journal. ``For victims of war and atrocity, this means public recognition and justice. ``Health and illness have social and political roots: post-traumatic reactions are not just a private problem, with the onus on the individual to recover, but an indictment of the sociopolitical forces that produced them.''

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