For information on the book explaining PITS in more detail (Perpetration-Induced Traumatic Stress: The
Psychological Consequences of Killing),
or for a DVD of a workshop presentation on Killing as Trauma, click here.
The best price on individual copies of the paperback version of the book can be found at Barnes & Noble.

   There is also a page on PITS in world literature, a page on PITS in personal stories, notes on therapy, and a
bibliography.

PITS -- What is it?

 Many people have heard of Posttraumatic Stress Disorder (PTSD). This is the professional term for a pattern of
symptoms that used to be called combat fatigue, battle fatigue, or shell shock. In the Civil War of the United States it was
noticed, regarded as cowardice, and treated with contempt. In World War I, it was commonly thought to be due to the
sound of shells, and its origin was thought to be physical. German psychiatrists treated it as being caused by a desire
for compensation and treated it very cruelly, by putting men back in battle immediately.

  By the time of World War II, its origin was finally recognized to be psychological , due to suffering a trauma, and
treated accordingly. With the American war in Vietnam, the number of cases grew, and so did the lobby for treating the
veterans more seriously. In 1980, the official psychiatric manual finally recognized it as a disorder and gave it its current
name.

  Even so, people were still thinking in terms of PTSD being caused entirely by being a victim of a trauma. The soldier
was scared of being shot, the soldier was grieved over buddies being shot. The idea that the act of shooting could be
traumatizing to the soldier rarely occurred to people. When it did, it was mainly the "atrocities" -- killing civilians or
prisoners in gory ways -- that got the attention, not the ordinary killing of traditional combat.

   More recently, some research has been done on this. From U.S. government data on its Vietnam veterans, those who
say they killed have more severe PTSD than those who say they did not. It was not just that they were in more intense
battle, because those who killed in light combat had heavier PTSD scores than those who did not kill even though in
heavy combat. The form of PTSD shows those who say they killed had much more by way of intrusive imagery --
nightmares, flashbacks, unwanted thoughts that just will not go away -- and also much more by way of irritable outbursts.
They also tended to have higher scores on measures of alienation, hypervigilance, and feelings of disintegration. But
those who had not killed were more likely to have the pattern of concentration and memory problems. (This is detailed in
the
full book).

    The American war in Vietnam had a higher percentage of soldiers actually engaged in killing from previous wars.
Several studies of different wars show that throughout history, only 15-25% of soldiers have worked against the natural
inclination against killing. Vietnam was different because the U.S. military was aware of this problem and solved it by
better training. Bull's-eye targets don't commonly fly around battlefields, so they used more realistic human-shaped
targets that went down when they were hit. With this conditioning, the firing rate in soldiers went way up.[2] If the act of
killing is not only traumatic, but more traumatic than just being a victim of trauma, then it would make sense that the
PTSD rate among American veterans of the war in Vietnam would be much higher than in previous wars.

    I have called the form of PTSD which is caused by being active in causing the trauma Perpetration-Induced
Traumatic Stress (PITS). This term is not used in the official psychiatric manual and has barely been studied. Some
people have instead referred it as "Participation-Induced Traumatic Stress."

    
World literature shows evidence of the idea of PITS. This will be of interest to students of literature and to students of
history. It will be of interest to psychologists who want to see expressions of the experience, not just look at numbers of
how people answer scales or get classified by psychiatrists ("qualitative" as opposed to "quantitative" data). I'm hoping it
will also be of interest to member of the general public. There are many people who take an interest in the idea, but
don't want to wade through the complications and caveats and nuances that are necessary for technical research
writing. Understanding the idea through poems and stories that were originally written for the general public can be a
better way of understanding.

   Of course, there is no diagnosis to be made of historical characters long dead, and even less to be made of fictional
characters. Psychiatrists and clinical psychologists pay close attention to the definition and decide whether a person in
their care does or doesn't fit it, so that if someone almost fits it but not quite, they may be counted as "sub-clinical" or
they may not be counted at all. But someone could easily suffer from just one symptom and nothing more, and not be at
the level of a "disorder."

  There is a lot of thought that it shouldn't be regarded as a
disorder at all, but as an injury -- it's so clearly caused by a
situation. Many of those treating it feel strongly that this way of looking at it helps in the healing, but for the latest version
of the American psychiatric manual (June, 2013), they decided to keep the wording of a disorder.

   A lot of people will never go to seek treatment because their condition isn't bad enough to seek treatment. I have met
several veterans like this, and they were grateful for the information I had because it let them know that what was
happening to them was in fact normal. For every person with a severe case of PITS, after all, it would make sense that
there are several people with milder cases.



Symptoms of Posttraumatic Stress Disorder - American version

paraphrased from DSM-5, the manual of the American Psychiatric Association (June, 2013)


A.  TRAUMATIC EVENT

Actual or threatened death, serious injury, or sexual violence.

It can be directly experienced, witnessed in others, learned about for violence or accident to family members, or it can
be constantly dealing with nasty details, such as first responders collecting body parts.

Seeing violence in the media doesn't count.  


B.  RE-EXPERIENCING THE TRAUMA

1.  Constant, unwanted and intrusive memories of the event

2.  Many dreams where content or feeling is related to the event

3.  Flashbacks -- like dreams while awake, feeling the event is happening again

4.  Intense distress at cues that resemble the trauma

5.  Physical stress reactions -- being especially jumpy -- at reminders of the event


C.  AVOIDING

1. Avoiding memories & thoughts about the trauma

2. Avoiding all kinds of people, places, and situations that might arouse those memories.


D. NEGATIVE THOUGHTS AND MOODS

1. Can't remember something important about the trauma

2. Overblown negative beliefs

3. Distorted thoughts about the cause or consequence of the event - unfairly blaming self or others

4. Persistent negative emotions like fear, horror, anger, guilt or shame

5. Being seriously uninterested in activities

6. Feeling detached or estranged from others

7. Can't feel positive emotions


E.  INCREASED AROUSAL

1.  Irritable behavior, unprovoked angry outbursts

2. Reckless or self-destructive behavior

3. Hypervigilance

4. Exaggerated startle response

5. Problems concentrating

6. Sleep disturbance


F. DURATION

The problems have to last more than one month, or else it's just an acute reaction (which is a different diagnosis)


G. DISTRESS

It has to cause enough problems to be worth going to a clinic for. That's what makes it a "disorder" and gets the
insurance money.


H. NOT SOMETHING ELSE

If it's actually a problem with drugs, alcohol, or some other medical condition, then it's not PTSD.


ADD-ONS

Can specify if there are also "Dissociative Symptoms":

Depersonalization - feeling detached from or feel like seeing from outside from one's own thoughts or body; feeling as
if in a dream, or the self isn't real, or time is moving slowly

Derealization - feeling the world is unreal, dreamlike, distant, distorted


Can specify if there is also "Delayed Expression":

This means the full problems don't all come until at least 6 months after the event, though some of the symptoms could
have shown up earlier.

    The DSM-5, in contrast to previous versions, does address the idea of
perpetration as a cause of trauma in a less than thorough way, since it's
limited to the military. It is under the discussion accompanying the definition,
and adds to the list of causal factors: “for military personnel, being a
perpetrator, witnessing atrocities, or killing the enemy.”


Symptoms of Posttraumatic Stress Disorder - International version

from the ICD-10 of the World Health Organization: [4]

  "Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an
exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may
lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor
sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive
memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness"
and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance
of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with
hypervigilance, and enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the
above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period
that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of
cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition
to an enduring personality change."



This is what PTSD is not:

*   It's not the same as an acute reaction to trauma -- the negative feelings a person can have right away. Over the
course of time, these can subside. It's when they don't subside, when time and loving care has not been enough, that
PTSD might be a possibility.

*   It's not grief. Again, grief lasts a while but subsides over time.

*   It's not panic attacks, though such attacks can be associated with it.

*   It's not guilt. Though obviously guilt can be associated with post-traumatic stress if it was caused by killing, these are
different things.

*   It's not just acting crazy. Though irritable outbursts and flashbacks are among the symptoms, paranoia is something
different and delusions are something different.

*   It doesn't come from an imaginary trauma. Though symptoms could be similar, if the event never actually happened,
this is a different problem.

*   It doesn't come from things that most people would not regard as traumatic. Over-reacting to things most people
would regard as mild irritants at most is a different psychological problem from  PTSD.


  Hollywood movies have treated PTSD in various ways. The term is used in the movie Antz, but was used incorrectly --
the veteran was acting crazy, but not with this disorder, according to the definition. This was just a folk mis-diagnosis. On
the other hand, PTSD was never mentioned but clearly portrayed in
The Legend of Bagger Vance,  complete with one
flashback where the young captain could hear the guns of the war. The symptoms were also clear in the protaganist in
The Master.

  There was a remark in "Almost Famous" which indicated a minor symptom of PTSD, which could be regarded as PITS
since it involved a man being involved in a hit-and run accident. In the scene, everyone is making confessions as an
airplane is going down and apparently about to crash. This fellow mentions running away from the accident when the
other was injured and says "I see his face every day." That sounds like an expression of the intrusive imagery.

  Similarly, an episode of Star Trek Voyager (broadcast the week of January 29, 2001) had a line from a man who had
committed a murder. He expressed distress and still being able to see the sight and hear the sound of his victim.

  As some of the symptoms, if not the full disorder, show up on rare occasions in Hollywood fiction, they have also
shown up in the
world's literature and many biographies and autobiographies. There are differences across cultures in
how these things are perceived and expressed, but the same underlying set of symptoms can be seen. PTSD, and
therefore PITS, to be well-founded as psychological categories, must be found in different times and places. There is
quite a bit of variety in expressions.


                                                                          *               *               *


  For information on the book explaining PITS in more detail (
Perpetration-Induced Traumatic Stress: The Psychological
Consequences of Killing),
or for a DVD of a workshop presentation on Killing as Trauma, click here.
The best price on individual copies of the paperback version of the book can be found at Barnes & Noble.
There is also a page on PITS in world literature and a page on PITS in personal stories.

The author is available for
teaching and speaking.

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