Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan

by Ronald Glasser M. D.

  With the successes of Freud and the psychoanalytical movement, the diagnosis of “combat neurosis” began to creep into the military vocabulary, having replaced “combat exhaustion” by the time of Vietnam. There were now concerns about personality disorders, deep-seated anxieties, and unresolved childhood conflicts.

  The conviction grew that there was something more complicated going on here than mere fatigue or exhaustion. It was believed that the routine short-term evacuation of these “stressed” patients from the front lines was not part of the cure, but a large part of maintaining, as well as adding to, the symptoms.

  Guilt at evacuation, of not doing one’s duty, of leaving friends and colleagues to fight on alone, was believed to play a major role in fixing the physical, and what were finally realized to be the psychological, signs and symptoms of the disorder.

  The psychoanalysts proposed that soldiers surviving, while others died, could and did turn a few minutes of doubt, panic, and finally guilt into lifelong disabilities. It was considered best to treat these soldiers as far forward on the battlefield as possible, to maintain unit identifications and that, above all else, treatment was always to include the unwavering expectation, no matter how apparently tragic or disabling the symptoms, that these soldiers would be returned to duty as soon as possible.

  The emphasis was to be placed on the previous health of the patient and not on the symptoms, on the soldier’s ability to ultimately cope, and when appropriate, to acknowledge that for everyone the battlefield was indeed a difficult and scary place. There was clearly a mind to be considered now, as well as the brain.

  By the time troops began moving into Vietnam in large numbers, the use of tranquilizers had become available. The basic treatment for battlefield depression, hysteria, and anxiety became the use of large dosages of the newly available psychopharmacological agent, Thorazine.

  It made some sense. Neurotic behaviors deserved the new psychological medications. The idea was to drug these troopers, in essence to tranquilize them, in order to force them to rest, to let them sleep off their problems, and then gradually allow them to wake up, take a deep breath and, supposedly healthy once again, go back to their units.

  Everyone quickly learned the drill. No matter what the symptoms, the treatment was always large dosages of Thorazine, rest, and being sent back to the unit. Whatever else might be going on, these patients were still members of their units, with the expectation that sooner rather than later they would all be going back to combat duty.

  For the most part, it worked. At least the Army thought so. The more resistant cases, where even after they woke up from their drug-induced sleep soldiers couldn’t function normally or remained truly disoriented, were sent to the military hospitals in Japan, Okinawa, or the Philippines. If necessary, from there they went back to the States.

  But those troopers removed from combat were a decidedly small percentage of the large number of soldiers diagnosed with the newest combination of “combat fatigue” along with the new diagnosis of “combat neurosis” and all were treated with both rest and huge dosages of drugs. It appeared to work.

  During the Vietnam War, the majority of patients with psychiatric diagnoses did go back to duty. During the whole of the war, 100 percent of soldiers with an initial diagnosis of “combat exhaustion,” 90 percent with a primary diagnosis of “combat neurosis,” 98 percent of the alcoholic and drug problems, 56 percent of the supposed psychotics, and 85 percent of the supposed exhausted and diagnosed neurotics, went back to their units with a bland, final nonjudgmental impression or diagnosis on their record of “Acute Situation Reaction.” There were no ominous-sounding medical or psychiatric terms to disturb these patients, their units, their families, or the country.

  And of course out of all of this, the military got what they wanted. The vast majority of those soldiers and marines were not lost to the fight. But there were also no follow-ups for those troopers after they were returned to duty. No one knew if they were the ones who died in the next firefight or, distracted and confused, called in the wrong artillery coordinates and killed their buddies with friendly fire. No one knew if they were the ones who missed the trip wire stretched across the path and, ignoring or not seeing the flattened area along the trail, tripped the mine or bouncing-betty and killed themselves and the trooper in front or behind them.

  No one ever checked to see if these were the soldiers whose weapons jammed or went on to gun down unarmed civilians. And no one knew how many of these soldiers and marines who did make it back to the States would end up over the next ten, twenty, and thirty years in the country’s different VA PTSD clinics, if they were lucky enough even to seek treatment.

  But pain is pain. Once the Genie of the Mind is out of the bottle, there is no easy way of putting it back. Agitation, depression, guilt, mistrust, anger, thoughts of suicide, and emotional anesthesia, along with personal and social dysfunctions, are complicated multi-dimensional affairs. They can be persistent and, by themselves, can be more devastating than the loss of a limb, and as permanent as being blind or having a transected spinal cord.

  What had always troubled the physicians and psychologists dealing with the emotional trauma of war was that these same symptoms occurred in civilian life—abused spouses who continually remembered and relived previous beatings, rape victims, abused children, and those involved in traumatic events like airline crashes and train accidents. They all had similar symptoms. It wasn’t just war and it certainly had nothing to do with exhaustion or neurotic tendencies. All of it finally came together under the new and definitive psychiatric diagnosis of Post Traumatic Stress Disorder. But even with the diagnosis, it would take another thirty years and three more wars to finally begin to sort it all out.

  But it is not only the increasing numbers of deployed military personnel being diagnosed with PTSD who have to be treated, the number of suicides among active duty personnel is also increasing. There have been a number of months since the invasion of Iraq and the surge in Afghanistan where deaths from suicide have exceeded the numbers of deaths from actual combat. It is not that the military does not understand or that they are confused about the cause of these deaths. The Pentagon’s own data indicates that these suicides are the result of disrupted love relationships; that simply being apart, or worse, having someone pull the plug through a “Dear John” letter, can cause a soldier or a marine, away from home for months and sometimes a year or more at a time, to quickly spiral out of control.

  What is known is that the majority of these suicides are best correlated to the lengths and the numbers of deployments, having little if any contributing factors due to combat. Suicides can and should be considered to be PTSD on steroids. But there is also the issue of prescription drugs.

  The military medical system, both within the Department of Defense and the VA, has struggled to meet the demands of our two wars, and yet to this day still reports shortages of therapists, psychologists, and psychiatrists. But medications are available, and in that treatment gap the military has turned in ever-increasing numbers and in evermore complicated combinations to prescription drugs.

  Across all branches of the military, spending on psychiatric drugs has doubled since 2001. Literally tens of thousands of troops struggling with insomnia, anxiety, alcoholism, flashbacks, irritability, chronic pain, and survivor’s guilt have received prescriptions for sleeping aids, narcotics, anti-depressants, tranquilizers, and mood-stabilizers. The New York Times recently documented that many of these medications used together can cause severe and deadly complications. An Army report published in 2009 admitted the problem by reporting that one third of all troops deployed have been on one prescription medication, and of the 162 documented suicides of all active duty personal in 2009 over a third involved the use of one of these prescription medications.

  Five times as many troops claim to have abused prescribed medications than admit to using illegal drugs like cocaine and marijuana. The truth about the actual numbers of suicide
s due to prescribed drugs may never be known, since those who are autopsied and are found to have multiple drugs in their system are usually given a diagnosis of “accident” as the official “Manner of Death.” Whatever else might be said about our current wars, we are, as a nation and as a military, simply wearing down those few we keep sending back again and again to make the fight that is supposedly for all of us.

  11.

  THE WARS WITHIN

  Post Traumatic Stress Disorder was officially recognized as a definitive psychiatric diagnosis by the American Psychiatric Association in 1980, when it was included for the first time in the Diagnostic and Statistical Manual of Mental Disorders. An official mental health diagnosis was an important step in finding unified answers for a condition that seems to arise from multiple and disparate causes. All the nonsense was to end. It was like when germ theory finally came to the study of infectious diseases.

  The Army’s goal though, has always been to keep its troops up on the lines, and where necessary, at the tip of the spear, while medicine’s goal has always been to cure disease and relieve suffering. That on the surface the two would seem incompatible is only reasonable, but it doesn’t have to be.

  Larry Dewey, the former Chief of Psychiatry at the Boise, Idaho Veterans Affairs Medical Center and Clinical Associate Professor at the University of Washington School of Medicine, in his book War and Redemption: Treatment and Recovery in Combat-related Posttraumatic Stress Disorder, explains that it is the power of group solidarity, the love of comrades forged in the life-and-death crucible of combat, the binding and saving esprit de corps that keep the weak, as well as the strong, integrated within combat units, while keeping the majority of troops fighting on effectively whatever the circumstances and the ferocity of the fighting. There is a reason that the marines on their way to Iwo Jima already thought of themselves as dead and yet none gave up or refused to go.

  Dewey points out that a study on bomber pilots published in the medical literature in 1943 documented that 95 percent of the 150 men who had completed their twenty-five combat missions over Germany and were headed home were suffering from what at the time was called “operational fatigue,” and today would have been called PTSD.

  Dewey’s own clinical experience documents the large numbers of combat troops in recent wars coming home to experience intrusive thoughts of wars, nightmares, flashbacks, and hyper-alert states, with little if any tolerance for anything that reminds them of battle or their former enemies. The issues of PTSD arise not out on the battlefield, but rather when these men and women come home.

  While there are relatively few female veterans in the VA’s PTSD clinics, Dewey and other VA psychiatrists are convinced that those numbers will increase over the next few years. Dewey has made it clear that the women in the military are strong personalities and strong people. You would have to be, to survive basic training and be deployed in combat areas doing combat duty. You were strong or became strong. “They will try to work through the problems on their own and right now that’s what they’re doing. But that kind of thing never works. The symptoms of PTSD do not get better and they do not go away. They will finally understand that much and will need to go into therapy. That’s just the way it is.”

  Here is what Dr. Dewey writes in the beginning section of War and Redemption called “Descent into Hell.” It is what everyone experiences who has been in combat and what all of us see in many of those who have made the fight and managed to get home alive and supposedly intact.

  In this section, we explore the deep pain and burden of killing. We explore the role of propaganda in starting the killing and the role love plays in helping combatants wage war to its end. I portray through my patients’ stories what the personal war of the ordinary combatant is like and the burden of guilt, grief, and pain that is carried afterwards. I present the deeper misery of killing civilians and other friendly combatants. Finally, we look at the forces that cause men (and women) to break down in war and afterward— overwhelming grief, exhaustion, guilt, and fear, in that relative order. We finish by clarifying some of the misconceptions that have arisen over the role of fear in combat breakdown and in prolonging the combatant’s suffering through the rest of their lives.

  Having to kill can leave emotional, moral, and spiritual wounds, that for many become the most troubling and most problematical results of war. The Wall Street Journal in 2005 got some of all this right. It was in an article above the fold published in October of that year titled “I’m not the Same Person.” The Journal described what was happening to so many by documenting what had happened to one. That no one has appeared to listen is understandable; that no one seems to care is almost unbelievable.

  This summer, Nate Self’s wife caught him staring at his old Army uniforms, hung neatly in his closet.

  “What was all this for?” the twenty-eight-year-old former Army Ranger asked. His wife Julie tried to reassure him. “Nathan, you did great, great things in the Army,” she recalls telling him.

  In January 2003, the Army Ranger captain sat in the Capitol as the President’s guest while Mr. Bush gave his State of Union address. To the White House, Mr. Self was a symbol of American strength, resolve, and success in the war on terror. Badly outgunned, the young officer led his men through a bloody fifteen-hour firefight against al Qaeda fighters atop a remote mountain in Afghanistan.

  After the battle, the Army awarded him the Silver Star, heaped praise on him, and assumed he would move swiftly onto the next war. He did. In the spring of 2003, he deployed to Iraq. There, Mr. Self began to suffer from grisly nightmares, anxiety, and depression. Last year the war hero came home. In November, he quietly—and inexplicably, to his Army friends—left the military. A few months later, he was diagnosed with severe post-traumatic stress disorder.

  Today, Mr. Self presents a different sort of model for the Army. He’s a striking example of the emotional toll the wars in Iraq and Afghanistan are taking on soldiers and the U.S. Government’s incomplete efforts to respond. Just as the U.S. military underestimated many things in Iraq—the insurgency, the need for better body armor and stronger vehicles—it didn’t anticipate the levels of emotional stress soldiers have faced.

  The medical path to the military aspects of PTSD began in 1947 with a paper by Kardiner and Spiegel, “War Stress and Neurotic Illness,” that described a persistent, chronic and disabling war-induced neurosis consisting of nightmares, irritability, and a tendency toward angry outbursts, along with a general impairment of overall cognitive functions.

  Half a dozen years later, an article dealing with a follow-up study of some 200 psychiatric patients who became symptomatic during the Second World War was published in The American Journal of Psychiatry. It reported the prevalence as well as the persistence of what, at the time, was still called “Traumatic War Neurosis.” Physicians involved in the study continued to observe significant symptoms in these war veterans up to ten years after the end of combat.

  A fifteen-year follow-up of these same Second World War veterans, along with the addition of Korean War servicemen, continued to document severe and persistent problems including startle reactions, significant sleep disturbances, and the avoidance of activities even slightly reminiscent of combat.

  The Korean War veterans showed the same initial psychological profile as the World War II servicemen, with an increase in both the number and severity of symptoms in combat controls compared with the noncombatant veterans.

  All the symptoms are treatable with group or individual therapy.

  As Dewey points out, death or illness of close family members can activate war-related symptoms, the loss being too close to the pain of having lost beloved comrades in battle. Most veterans hate to get angry and try to avoid anger because it is so closely linked to many of their combat experiences and can trigger those intrusive war memories and feelings. But there are also those thoughts that keep veterans cautious about their relationships, always some version of the question, “If I really told
them what I had done what would they think of me?” or “What type of man could do that?” The answer is usually self-condemning. All of this becomes more intense and more acute the older the soldier, particularly those with families and children of their own, and with over 40 percent of those being deployed to Iraq and Afghanistan being National Guard troops, that incidence, along with the severity of PTSD, has skyrocketed. Dewey has seen, in his own clinics, the hopelessness and concern of these National Guard troops increase with each new deployment.

  And there is the whole issue of grief and shame itself. Those not in combat are forever embarrassed that others have had to make the fight, while those who have fought, and are wounded, know that others have been killed. There is no way out. This terrible parsing of combat can become a vicious and never-ending cycle where nobody wins no matter what happens. There is no easy way on a battlefield, where a few seconds of terror can lead to a lifetime of confusion and heartache.

  But this is not just an American problem. PTSD is not restricted to any war or to any specific nationality. Symptoms and percentages of PTSD among Israeli soldiers who fought in the 1982 Lebanon war proved similar to those of U.S. troops in Vietnam, Mogadishu, and now Afghanistan and Iraq. PTSD is now viewed as a long-term, and in many cases, particularly if undiagnosed, untreated, or under-treated, a persistent and crippling reaction to the stresses of battle at any time or any place by anyone who pulls a trigger or sees someone else killed or wounded.

  It is true that pre-existing psychiatric and psychological conditions, such as depression, antisocial personality, and alcohol and substance abuse, can be associated with an increased diagnosis of PTSD. But a high incidence of war-zone as well as battlefield exposures dramatically increases the risk of developing the condition in soldiers and marines without any pre-existing psychological conditions or anti-social personalities.