GLENVILLE, N.Y. – For hundreds of thousands of Americans, mental illness is just a drive down the road. Ask Beth Puglisi.
The 45-year-old mother was out to fill her gas tank on a bitter-cold January day last year. She turned the wheel of her pickup, felt a wrenching jolt, and watched the roadway fly into a spin.
"No!" she heard herself screech. The rubbery aroma of spilled antifreeze filled her nostrils.
In the days after her crash with a car, Puglisi was plagued by flashbacks of the accident and riddled with anxiety. She was eventually diagnosed with Post Traumatic Stress Disorder, a condition mental health experts now say can be triggered by crashes, house fires, a sudden death or severe family illness, witnessing a disaster, or even learning of one. PTSD has broadened the model of mental illness to cover disturbances set off solely by external events, outside of the mind. Almost anyone can be vulnerable.
Research suggests the disorder is now present in 5 percent of Americans, or more than 13 million, according to the PTSD Alliance, which unites professionals and advocates. It is expected to touch 8 percent of adults during their lives. By contrast, just over 3 percent of Americans have cancer.
Puglisi had been in accidents before, but she never felt this way.
She couldn't stop picking over this crash in her mind. It wasn't her fault; it just wasn't. So why did it have to happen? Why?
Her family encouraged her to talk: "Each time I would tell someone about it, I could feel it and smell it -- the whole thing." In a kind of flashback typical of PTSD, she could still smell the antifreeze.
As PTSD's debilitating anxiety took hold, Puglisi started to feel nervous, flushed, even lightheaded when she was driven to a doctor or physical therapist. She would tremble, and her chest would tighten: "Just thinking about it was making me crazy."
When she tried driving again, she'd have to circle around to avoid making the same kind of turn as in the crash. She'd bypass where it happened. Ashamed, she asked her husband to drive the children to their activities.
While television droned war news from Iraq, she felt trapped in her own combat zone: "When you're in the war, you have no idea if you're going to be alive or dead in 10 minutes. That's exactly the way I felt."
Warring soldiers have carried home psychological scars for centuries. The ancient Greeks noticed it.
In American wars, it has been called shell shock, combat fatigue and post-Vietnam syndrome. Though skeptics discounted some cases as shams meant to win compensation, other extreme cases were taken for schizophrenia.
Medical authorities first accepted PTSD as a distinct psychiatric condition in 1980 at the urging of Vietnam veterans and their medical caretakers.
In PTSD, stress hormones like adrenaline scorch a painful event deep into long-term memory, scientists believe. Lab studies show such hormones normally improve memory in animals. They seem to overshoot the mark in PTSD.
People get very edgy and fearful, prone to nightmares or flashbacks. They desperately want to avoid reminders of their shock, even to the point of feeling numb. PTSD happens more often in women, in cases of multiple traumas (Puglisi had another road accident just a couple weeks earlier), and in people with depression.
Once defined, the disease was soon embraced, and insurance coverage expanded. Here was a psychiatric condition touched off by concrete events, not something hidden in the mind's dim recesses. It could theoretically happen to anyone, even the hardiest and soundest of mind. It wasn't your fault.
The federal government established the National Center for Post-Traumatic Stress Disorder. It began researching PTSD and treating hundreds of thousands of veterans. Survivors from rape and car crashes began to seek therapy in greater numbers too. In 1994, the sudden death of a relative, or even learning that one was hurt, joined the expanding list of PTSD traumas in the chief diagnostic manual for psychiatry.
When Dr. Greenbrier Almond was working as a psychiatrist at a West Virginia veterans hospital in the late 1990s, PTSD was its leading diagnosis, above heart disease and diabetes, he says. He now treats PTSD in abused children at a community health clinic.
Research at Henry Ford Health System, Harvard and Georgia State has identified the two leading causes of PTSD as unexpected deaths of relatives and car crashes. Combat ranks far down on the list.
Some bad diagnosticians and purveyors of pop culture have come to consider just about any of life's shocks -- divorcing, losing a job, even failing a test -- as triggers for PTSD.
"Anything that happens to you that's remotely icky now qualifies," says psychologist J. Gayle Beck, at the University at Buffalo-State University of New York. "It's been culturally overdiagnosed."
This psychiatric illness has carried cultural baggage since its birth in the social turmoil over the Vietnam War. The new disorder tied to external events meshed with a Kafkaesque view of society inherited from the 1960s: Outside forces constantly threaten peace of mind.
Since 2001, PTSD has tapped into another source of anxiety: terrorists who can inflict mass death in an instant. A survey found highly elevated rates of PTSD in the New York metropolitan area, where the smoking towers of the World Trade Center could be seen for miles.
Afterward, some companies sent reassuring notices to workers listing PTSD symptoms and saying they were common responses. One compared them to a minor flu.
"It speaks to dangerous times and threats, and that certainly defines our era," says Dr. Robert Jay Lifton, a Harvard University psychiatrist who helped define PTSD as a condition. "There is bound to be widespread PTSD and an awareness of it."
Even so, many people with PTSD still do not come forward for help, caregivers say. And even experts may miss the signs.
"My father dropped dead in front of my mother. She developed PTSD for two years, and I was completely unaware of it. I knew something was wrong, but I didn't know it was PTSD," says psychologist Terence Keane.
Yet he is director of behavioral science at the federal PTSD center.
The good news is this: Even untreated, PTSD goes away in about half of the cases within six months, research indicates.
The bad news: When it doesn't, it can last for decades.
Puglisi had never needed therapy before and didn't think of treating her embarrassing automotive anxiety.
"I would say I'm all right," she recalls. But she wasn't.
Her doctor told her she'd soon get over it, but her physical therapists knew better. After several months, they persuaded her to look for help.
She found Edward Hickling, a former veterans psychologist who now specializes in road-accident PTSD.
"I came to private practice, and I saw motor-vehicle accident victims that looked a lot like ... the post-traumatic stress responses I saw in the veterans hospital," says the therapist based in nearby Albany.
Like many PTSD therapists, he relies on cognitive behavioral therapy. A common psychological treatment, it teaches how to replace negative mental monologues ("I could die on the way to work") with positive, rational ones ("I'll probably get there just fine, as usual"). It can be carried out one-on-one or in groups.
Like many PTSD therapists, Hickling re-exposes participants to memories of the terrifying situation, while desensitizing them over a few months or longer. They start by telling what happened and graduate to driving back to the crash site.
One woman was able to drive back and gaze at the place where her car plunged down a hill, trapping her for more than two hours. Later, she felt as though she had "removed a cloud from her brain," according to Hickling.
The therapy can work in up to 75 percent of road-accident survivors with chronic PTSD, research suggests.
Some patients, though, can't tolerate thoughts of their ordeal. "It's just too painful," says psychologist Charles Figley, at Florida State University. Lesser symptoms persist in many people.
Psychiatrists often treat PTSD with drugs. The federal government has approved two depression medicines, Zoloft and Paxil, for PTSD. Research suggests they help at least a quarter of PTSD patients.
Other researchers are experimenting with potential PTSD drugs like anti-adrenaline agents and the antibiotic D-cycloserine. In theory, they might disrupt the consolidation of long-term PTSD memories or help the brain forget them later.
Psychological therapy alone conquered Puglisi's symptoms, though it took a year.
She still hasn't gone back to work but doesn't feel so alone. Now she knows of many others like her: "The mind does this sometimes."
What happened to her, she has learned, is normal.