Veterans: PTSD & combat stress

The military calls the reactions people have to combat and operational stress “combat and operational stress reactions”. They are considered a normal response, and having them does not mean you have a mental health disorder.

They can include

• Feeling tired or worn out
• Hypervigilance: always scanning for danger
• Pulling away from others
• Sleep problems
• Trouble paying attention

Combat stress reactions and PTSD can share signs, but they are not the same thing. VA says stress reactions after trauma are normal and ease over time for most people. If they don’t ease, or they get in the way of relationships, work or daily life, that is the time to talk with a counselor or doctor.

PTSD symptoms usually start soon after a trauma, but they can appear months or years later.

A review of studies that followed people over time found that about 1 in 4 cases of PTSD were “delayed”, meaning full PTSD appeared later. Military combat was linked with delayed PTSD. The authors described most delayed cases as earlier, milder symptoms that got worse, rather than something that came out of nowhere.

Things that can bring it to the surface

• A new loss, illness or injury
• Leaving the military or retiring from work
• News of war, or an anniversary
• More quiet time to think, with fewer distractions

VA says PTSD can last for years, return after earlier treatment, or appear for the first time in later life. Retirement and doing fewer activities can leave more unstructured time, which can make symptoms more noticeable. Looking back on life during quieter years can also bring memories back.

Health problems, pain or limited mobility can add to the load. So can a smaller circle of people, after losing a spouse, family members or friends.

What helps

• Talk therapy works for older adults, whether PTSD began early in life or later
• Ask your provider whether video visits are an option
• Stay connected: groups, volunteering, faith communities
• Tell your provider about other health conditions, so care fits all of you

Some trauma is not one bad day. It goes on for a long time, happens again and again, or comes from a person who should have kept you safe. VA says this kind of trauma can bring PTSD symptoms plus extra struggles: trouble managing strong feelings, feeling worthless, feeling distant from others, and trouble trusting people.

For some veterans, service was not the only trauma. Hard childhoods, abuse, or long stretches of danger can all add up. That can help explain why some reactions feel deeper than “just” PTSD.

The World Health Organization’s ICD-11 (2022) lists complex PTSD as its own diagnosis. The U.S. system does not list it separately, because its PTSD diagnosis already covers these extra symptoms. Some providers use the two names almost the same way.

VA says trauma-focused therapies, like CPT, PE and EMDR, work well whether you have PTSD or complex PTSD. They usually take about 3 to 4 months. Some programs first build skills for handling feelings and relationships, then work on the trauma. Other struggles, like low mood or relationship problems, can be worked on afterwards with your provider.

Memories of the trauma can push their way in, even when you do not want to think about it. A sound, a smell, a news report or fireworks can suddenly bring it all back, as if it were happening again.

It can look like

• Flashbacks: feeling like you are back in the moment
• Nightmares about the event
• Strong body reactions (racing heart, sweating) to reminders
• Upsetting memories that pop up out of nowhere

What can help in the moment

• Keep your eyes open and look around. Name where you are and the date.
• Remind yourself: “This is a memory. I am safe now.”
• Move your body: stand up, walk, feel your feet on the floor.
• Call or sit with someone you trust.

It is natural to want to stay away from painful reminders. But the more we avoid, the bigger the fear can grow, and the smaller life can become. Avoidance is one of the main things that keeps PTSD going.

It can look like

• Avoiding crowds, driving or certain places
• Refusing to talk or think about what happened
• Skipping events, family gatherings or appointments
• Staying busy all the time so memories cannot catch up

What can help

• Notice what you avoid and write it down
• Talk with a trusted person or counselor about it at your own pace
• With support, take small steps back toward safe things you have been avoiding

Trauma can change how you see yourself, other people and the world. You might think “I should have done something”, “No one can be trusted” or “The world is completely dangerous.” Feelings may go numb, making it hard to feel love or joy.

It can look like

• Feeling hopeless about the future
• Feeling numb or detached from loved ones
• Losing interest in hobbies or activities
• Strong guilt, shame or blame
• Trouble remembering parts of the event

What can help

• Ask: “Is this thought 100% true? What would I say to a buddy who thought this?”
• Keep doing small things you used to enjoy, even if the joy is not there yet
• Let loved ones know you care, even when it is hard to feel it

This is sometimes called hypervigilance or hyperarousal. In a war zone, staying alert kept you alive. At home, the same alertness can be exhausting. You may scan every room, sit with your back to the wall, or jump at small noises.

It can look like

• Always watching for danger
• Being easily startled
• Irritability or sudden anger
• Risky behavior, like heavy drinking or reckless driving
• Trouble focusing

What can help

• Daily exercise to burn off tension
• Learning anger-management skills with a counselor
• Slow breathing to tell your body it is safe
• Taking a time-out before reacting

Almost everyone who has PTSD also has trouble sleeping. Both insomnia and nightmares are PTSD symptoms, and nightmares are often a replay of the traumatic event. The body stays on alert at night, and bedtime can start to feel unsafe. Poor sleep then makes mood, focus and anger harder to manage.

What can help

• After a nightmare, remind yourself it was a dream, get up and reorient
• Cut back on caffeine, alcohol and screens before bed
• If you cannot sleep, get up and do something calm, then try again
• Keep a regular bedtime and wake time

A short talk therapy called Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended treatment for long-lasting sleep problems. It usually takes about six sessions and improves sleep for about 7 in 10 people who complete it. Research shows it also reduces how many nightmares people have. It is offered in person, by video, online and through the free CBT-I Coach app.

There are also talk therapies made just for nightmares, sometimes called cognitive behavioral therapy for nightmares. VA notes they show promise for nightmares and may also help with insomnia, PTSD and low mood.

Sudden loud sounds can set off the body’s alarm before you have time to think. Holidays with fireworks can be especially hard, and the startle can leave you shaky and on edge for hours.

What helps

• After a startle, breathe out slowly and name where you are and today’s date
• Check local fireworks schedules and plan where you will be
• Tell neighbors or family ahead of time; many are glad to help
• Use noise-reducing headphones or stay indoors with music on

In a crowd, it can be hard to keep track of exits and people, which keeps a trained brain on high alert. Many veterans choose seats facing the door or avoid busy places entirely. The VA notes that veteran gatherings and emotionally powerful symbols can also bring symptoms back.

What helps

• Bring a trusted person, and agree on a signal to leave
• Go at quieter times, and build up slowly
• Pick a seat where you feel comfortable, and know it’s okay to do that
• Use grounding: feel your feet, name five things you can see

For veterans who served where roadside dangers were real, driving can bring back that state of alert: watching for debris, tensing under bridges, or feeling trapped in traffic. Some find themselves driving fast or aggressively without meaning to.

What helps

• If driving often brings strong reactions, raise it with your provider; therapies for PTSD can help with this
• Keep a lane with an easy way out when possible
• Plan routes ahead, and allow extra time so you aren’t rushed
• Use calming music or a podcast

The VA describes anniversary reactions: distress or stronger symptoms around the date of a past trauma, such as Memorial Day for someone who lost a battle buddy. Most people feel better within a week or two after the date, and the distress usually becomes less frequent and less intense over time.

What helps

• Cut back on news and social media coverage if it’s upsetting
• Do something meaningful: visit a grave, volunteer, donate blood, spend time with family
• Plan ahead for the date rather than hoping it passes unnoticed
• Spend time with veterans who understand
• Try the VA’s free PTSD Coach app before the date

News coverage of war can bring back your own military experiences, and symptoms may worsen when the news closely mirrors what you went through. The VA suggests limiting how much TV news you watch and taking breaks when you notice anger, worry or low mood.

What helps

• Choose one or two set times a day to check the news
• Read instead of watching graphic footage
• Talk it through with another veteran or write in a journal
• Turn anger into action, like volunteering, rather than blame

Smells are powerful memory triggers. Diesel fumes, burning, gunpowder or certain foods can bring a flood of memories. So can inside signals, like heat, exhaustion or a pounding heart after exercise.

What helps

• Carry a calming scent, like mint or a favorite lotion, to “reset” your senses
• Notice which body states set you off, and pace yourself
• Remind yourself: “This is a smell, not the place.”
• Use the “My trigger map” worksheet to spot patterns

• Checking exits, hands and faces when you walk into a room
• Checking over your shoulder, or locks and windows, again and again
• Jumping at small noises or sudden movements
• Jumping to the worst case, like a missed call meaning something terrible
• Reading every tone of voice or text message for signs of trouble
• Sitting with your back to the wall so no one can come up behind you

Staying on alert keeps the body’s stress system running. Over time this can bring exhaustion, poor sleep, stomach trouble, trouble focusing and irritability. Some people use alcohol to switch off, which usually makes things worse.

When tension becomes your normal, anger is easier to trigger, and everyday stress can feel like a threat.

If your brain is scanning for danger, other people can look careless: a partner who leaves the door unlocked, kids who run ahead in a parking lot, a friend who sits with their back to the door. It can feel like you are the only one on watch, and that is lonely and frustrating.

Your family isn’t being careless. Their brains were never trained to treat ordinary places as dangerous. VA notes that loved ones may not understand symptoms and get frustrated too, which leads to conflict.

VA explains that PTSD can leave people feeling they need to control their surroundings and that others can’t be trusted. At home, that can look like snapping about safety, checking up on people or making strict rules. Family may feel criticized or controlled, and start to pull back.

Hypervigilance can also make it hard to trust or feel close to people, and needing constant reassurance can wear partners out.

Arguments are more likely when one or both partners have PTSD. Partners often report more stress and less happiness, and may feel like they are walking on eggshells.

Most people with PTSD have never been violent. But there is a higher risk of partner conflict or violence when one or both partners have PTSD.

If anyone at home feels unsafe, safety comes first. The National Domestic Violence Hotline is free, confidential and open 24/7 at 800-799-7233. If anyone is in danger, call 911.

Emotional numbness means feeling flat, shut down or cut off from your feelings. Cleveland Clinic describes it as a protective response: after trauma, the brain dims feelings so you can get through. It is not a diagnosis, but it is a sign that something needs care.

In service, shutting feelings off may have helped you do the job. The trouble is that the switch doesn’t only turn off fear and grief. It can turn off love, joy and closeness too.

It can feel like

• Being in a heavy fog, going through the motions
• Doing risky things, or drinking, just to feel something
• Not feeling what you “should” at a wedding, a birth or a funeral
• People telling you that you seem distant or cold
• Struggling to feel connected to your partner or kids

What can help

• Keep doing things with loved ones, even before the feelings come back
• Move your body every day; exercise can help you feel present
• Notice small sensations: warm water, music, the taste of food
• Talk with a provider; trauma-focused therapy can help feelings return
• Tell your family it’s numbness, not a lack of love

In a study of 249 male veterans and their partners, emotional numbing was the PTSD symptom most linked to partners wanting changes in intimacy.

PTSD can affect sex and sexual satisfaction. People who experienced sexual assault are more likely to have problems with sex, but anyone with PTSD can be affected. Avoidance and numbness can make being close hard.

It can look like

• Feeling far away during closeness
• Less interest in sex, or avoiding it
• Sleeping apart because of nightmares or restless nights
• Touch or certain positions bringing back memories
• Worry about how your body responds

VA suggests setting regular times to talk, planning together for hard days, staying flexible about shared activities and considering couples or family therapy.

Ways to start

• “Can we agree on a word for when I need a break?”
• “I want to be close. I just need to go slower.”
• “What do you miss most about us? I miss it too.”
• “When I go quiet, it isn’t about you. My brain shuts down.”

A traumatic brain injury happens after a sudden blow or jolt to the head, or when the brain is shaken inside the skull, as can happen in a blast. Mild TBI (often called a concussion) is the most common type, and most symptoms of a mild TBI go away.

The same event, like a blast, a crash or an assault, can cause both TBI and PTSD. They share some signs, such as poor sleep, irritability, memory trouble and trouble concentrating. Together, they can make it harder to recover on your own. TBI can also bring headaches, dizziness, nausea, vision problems and sensitivity to light or noise.

TBI can be hard to diagnose because there may be no physical signs of injury. VA screens all veterans who served in combat for TBI. The screen is not a diagnosis; a positive result means a specialist should take a closer look.

Good news

• People usually get better after a head injury, not worse, and recovery is often gradual.
• The best PTSD therapies work even if you have TBI symptoms.
• Completing CPT or PE may also ease some TBI symptoms.
• VA’s Polytrauma System of Care treats veterans with TBI and other injuries.

Depression is more than a bad day. In a large national survey, people with PTSD were about 3 to 5 times more likely to have depression than people without PTSD. The two share many signs, so they can be easy to mix up.

Signs of depression

• Feeling sad or down most days for at least two weeks
• Feeling worthless or hopeless
• Losing interest in things you used to enjoy
• Sleeping or eating much more or less than usual
• Thoughts of hurting or killing yourself
• Trouble focusing

Alcohol or drugs can feel like a quick way to quiet memories, calm nerves or get to sleep. Over time, they usually make sleep, mood and PTSD worse. Veterans who have had PTSD are about 2 times more likely to have alcohol problems and 3 times more likely to have drug problems than veterans without PTSD.

Signs it might be a problem

• Drinking more than you planned
• Family or friends worry about it
• Needing a drink or drug to sleep or get through the day
• Problems at work, home or with the law

What can help

• Be honest with yourself and one trusted person
• Look at the Mentally United “Substance Use” guide for more support
• Talk to your doctor or VA provider; they can help with both PTSD and substance use

In 2024, the suicide rate was higher for veterans than for non-veteran adults, even after taking age into account. VA reviews found that pain, sleep problems, health problems, relationship problems, hopelessness, money loss and unsecured firearms at home were among the most common risk factors. These numbers are hard to read, but they also show why reaching out matters so much.

Warning signs to take seriously

• Giving away prized possessions or getting affairs in order
• Hopelessness, or heavy guilt, shame or a sense of failure
• Rage, risky actions without thinking, or drinking and drug use going up
• Talking about death, dying or suicide, or feeling there is no reason to live
• Withdrawing from family and friends, or losing interest in everything

How you can help someone

• Show you care. You don’t need to be an expert.
• Ask directly: “Are you thinking about taking your own life?” Asking does not raise the risk.
• Listen more than you talk, without judging.
• Offer to call the Veterans Crisis Line together (dial 988 then press 1), and stay on the line.
• Help put time and distance between them and anything they could use to hurt themselves, such as making sure firearms are locked up.

VA suggests setting a specific time to talk, so your loved one can prepare. Share your concerns, then plan another talk rather than trying to solve everything at once. You don’t need to ask about their military experiences to offer support.

Things you could say

• “I know it’s your call whether you go to see somebody, but if there’s something I can do to help, let me know.”
• “I know things are hard right now, and I’d like to help.”
• “I may not understand what service was like, but a Vet Center counselor might.”

What to avoid

• Demanding that they get help, which can backfire
• Threats or ultimatums, like “Get help, or else”

Families often feel rejected or helpless when they don’t realize the behavior comes from PTSD. Some feel they must be careful all the time so they don’t upset their loved one. Others start avoiding things too, like doing all the shopping so their loved one never has to face a crowd.

These reactions are understandable. But some kinds of “helping” can keep avoidance going. Learning about PTSD and its treatments helps families support recovery instead.

A parent’s PTSD can affect children. Kids may not understand why a parent is jumpy, angry or distant, and may think it is their fault. Some children take on extra jobs at home to look after a parent.

What helps

• Explain in simple, age-right words: “Dad has a hurt on the inside from the army. It is not your fault.”
• Keep routines steady
• Let kids be kids, and not caregivers
• Make time for fun one-on-one moments

Living with someone’s PTSD can be tiring and lonely. VA has support built for family members and caregivers.

• Caregiver Support Program teams at every VA medical center
• VA Caregiver Support Line: 1-855-260-3274 (Monday to Friday, 8 a.m. to 8 p.m. ET)
• VA’s free PTSD Family Coach app, with tips for loved ones
• Vet Centers: free marriage and family counseling

Trauma can leave you with “stuck points”, beliefs like “It was my fault” or “I can never trust anyone.” CPT helps you look at whether the facts really support those beliefs, and find a more balanced way to see what happened.

How it works

• You learn about PTSD and write about how the trauma has affected you.
• With your therapist, you find unhelpful thoughts and practice other ways of seeing things, using worksheets.
• Some people also write a detailed account of the trauma, if they and their therapist agree.
• Later sessions look at safety, trust, control, self-esteem and closeness.

What to expect

• About 12 weekly sessions (about 3 months)
• 60 minutes alone with a therapist, or 90 minutes in a group
• Practice worksheets between sessions. The more you put in, the more you usually get out.

Avoidance keeps PTSD going. PE helps you face your fears step by step, so your brain learns that the memories and safe situations are not dangerous. Over time, they lose their power.

How it works

• You learn a breathing skill to manage anxiety early on.
• You and your therapist list safe places, people or activities you have been avoiding, and work through them one step at a time.
• You talk through the trauma in sessions, at a pace you and your therapist set, and listen to a recording at home.

What to expect

• Usually 8 to 15 weekly sessions (about 3 months)
• 60 to 90 minutes each, one-on-one
• Practice between sessions, starting with easier steps

EMDR stands for Eye Movement Desensitization and Reprocessing. You hold the upsetting memory in mind while paying attention to a back-and-forth movement or sound, like a moving finger, a light or tones. This helps you stay in the present while your brain processes the past, so the memory becomes less upsetting.

How it works

• You first learn coping skills and get ready.
• You pick a memory to work on, with its thoughts, feelings and body sensations.
• You do short sets of about 30 seconds, then talk about what you noticed.
• Later you focus on a positive belief while holding the memory.

What to expect

• About 3 months of weekly sessions, 50 to 90 minutes each
• You usually do not have to describe the trauma in detail
• No homework, and many people notice improvement after a few sessions

In WET, you write about a traumatic event during each session, then talk about it with your therapist. Later sessions look at how the trauma changed how you see yourself, others and the world.

What to expect

• Just 5 sessions
• Writing happens during sessions with your therapist
• You are encouraged not to avoid the memories between sessions

Trauma can be hard to put into words. Painting, drumming, songwriting, dance or a few lines in a journal can help people express feelings safely, calm the body and reconnect with others. Pleasant activities like art can also lift mood.

Creative Forces: NEA Military Healing Arts Network is run by the National Endowment for the Arts with the Departments of Defense and Veterans Affairs. It brings art, music and dance/movement therapies, and creative writing, into care for service members, veterans and their families, including by telehealth for people in rural areas. Therapists are trained, credentialed professionals, and you do not need any talent.

Try at home

• Doodle or color for 10 minutes when you feel tense
• Drum or tap along to a steady beat to slow your breathing
• Go for a mindful walk and notice each step
• Make a “calm down” playlist and a “get going” playlist
• Stretch slowly to music, or try a beginner yoga or tai chi video
• Write a letter you never send, or list three things that went OK today

According to VA’s National Center for PTSD, two large phase 3 trials found bigger drops in PTSD symptoms with MDMA-assisted therapy than with the same therapy and a placebo. But only about 19% of the people in those trials were veterans, so we know less about how it works for veterans.

The research also has limits: small samples, risk of bias, and the fact that people can often tell whether they got the real substance, which can affect results. In 2024, the FDA declined to approve MDMA for PTSD and said more research was needed on safety and effectiveness.

Psilocybin comes from certain mushrooms. VA’s National Center for PTSD says the evidence for PTSD is much weaker than for MDMA, with very little research so far and no completed clinical trials of psilocybin-assisted therapy for PTSD. Most of the research has looked at depression, anxiety and substance use.

A few places allow supervised use in some settings. That is not the same as FDA approval, and it does not make it safe to use on your own.