A survey of American soldiers deployed to Somalia supports this clinical observation. When the original mission of the U.S. troops in Mogadishu shifted through mission creep from humanitarian peacekeeping to the more familiar battlefield assignment of subduing a Somali warlord, there was an increase in the incidence of PTSD among those U.S. troops, with the greatest incidence in those exposed to both the physical dangers and the psychological trauma of actual combat.
The importance of combat in the development of PTSD became clear in a 1995 study involving veterans of the First Persian Gulf War. Deaths and combat casualties were blissfully light, but the prevalence rate for PTSD was 10.1 percent among those who experienced actual combat, compared with 4.2 percent in a matched cohort of troopers who remained in support units. It is expected that, with the ever-increasing exposure to combat situations among all the troops currently being sent to Afghanistan, there will be substantial increases in rates of PTSD similar to those seen in Somalia—especially as the campaign shifts from an occupation to the expected increases in combat as the Marines and Army units go after the bad guys as part of the new counter-insurgency doctrine.
All military data up to the present time, every meta-analysis of studies on wartime stress, collectively points out the critical issue of time on the battlefield as well as in combat as a precondition for the development of PTSD. That fact is already becoming evident in the most recent evaluations. The exposure to combat is significantly higher among troops currently deployed to Afghanistan than similar units now doing garrison duty in Iraq. Even in the oldest and more reviewed studies, more than 90 percent of those diagnosed with Post Traumatic Stress Disorder reported having been shot at, attacked by enemy combatants, or involved in some kind of deadly firefight.
Charles W. Hoge, M.D., in his article, “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care,” reported a prevalence of PTSD of 12.7 percent among U.S. troops after they had been in three to five firefights, and of 19.3 percent after more than five. The author admits these are conservative estimates that do not take into account those most severely wounded. The incidence of the disorder can only be expected to increase as the number of troops fighting in Afghanistan and the desperateness of the battles and severity of the fighting continues to escalate.
The numbers injured, the severity of the current injuries, as well as the survival of those troops who would have been killed has only added to the incidence of PTSD among soldiers and marines deployed. A recent review of the psychological damage to our troops in Iraq and Afghanistan published in the Journal of Massachusetts General Hospital summarizes the problem:
Though the battle deaths for the current wars have been sharply lower than during past conflicts, the conditions of warfare in which troops must be on constant alert for roadside bombs and suicide bombers put soldiers at high risk of stress-related trauma. Moreover, many of the estimated 1.9 million troops who have been deployed to Iraq and Afghanistan are called back on multiple tours of duty. And with better gear and (better) medical treatment, they are more than likely to survive grievous injuries, with only one out of sixteen wounded dying, compared with a third of the casualties who succumbed in Vietnam and about two out of five in World War II.
Matthew Friedman, the director of the Center for PTSD, recently added to the discussion of the reason for the higher incidence of PTSD in our current wars:
Because of fantastic logistical support, med-evac capabilities, and medical advances, people who would have died in past wars are surviving their wounds, but they are at very high risk for psychological difficulties.
Despite documented increasing rates of PTSD, the true incidence may still be underreported. A retrospective report on PTSD documents what most in the military and those in the VA medical system already know. Of those whose evaluations are undeniably positive for a mental disorder, only 23 to 40 percent complained of or sought help for mental health problems while still on active duty. And those soldiers reporting the most severe symptoms were the least likely to seek treatment, for fear it would harm careers, cause difficulty with peers, be an admission of weakness, and worse, of cowardice in the face of the enemy. Soldiers trained to be tough and self-reliant are loathe to admit they have a problem, much less run the risk of asking for help. Experts estimate that no more than half of the veterans who would clearly meet the clinical threshold for PTSD ever seek treatment.
There remains the widely-held notion on the part of both active-duty personnel as well as those on career officer tracks that anyone who seeks help or counseling—even when they or their colleagues clearly recognize the severity of their psychiatric problems—will be stigmatized and jeopardize their own military careers.
In the military culture, “succumbing” to PTSD continues to be seen as a failure, a weakness, as well as evidence of not having the right stuff. It is a view that the present leaders in the Pentagon appear reluctant to challenge even while PTSD remains the most frequently reported problem noted in anonymous surveys among those soldiers returning from active duty in both Iraq and Afghanistan.
There is little doubt that those with PTSD who remain undiagnosed and so untreated, upon their return to civilian life, will fail at reintegration. It has been clear for some time that veterans who are diagnosed with PTSD have more divorces, more marital problems, and more occupational instability, along with the associated social dysfunctions, including higher levels of homelessness, more criminal arrests, and more acts of violence than do veterans without a diagnosis of PTSD. Without diagnosis and effective treatments, the psychological stresses of war never really end. With PTSD you can run, but you can’t hide.
There are real future consequences of ignoring or delaying treatment. As late as 1993, a study of World War II Dutch resistance fighters indicated a sub-acute form of PTSD that had gradually become chronic: a delayed form of the disorder with onset five to thirty-five years after the end of the conflict. Israeli psychiatrists observed reactivation of PTSD among veterans of the 1967 Yom Kippur War when exposed to the news broadcasts of the 1982 Lebanon war.
But there is something more going on here that has added to the increasing incidence of PTSD among our troops, and that is the increased ages of those that we have rather indifferently sent and continue to send to Iraq and now Afghanistan. I recently interviewed a Norwegian Special Forces officer from the NATO Command. He was on active duty so he couldn’t say very much, but he did say that he was surprised by the age of the soldiers that we sent to Iraq and Afghanistan. In short, he said that many were too old to take on the much younger and more nimble Taliban. He was obviously talking about our National Guard, which has always made up over 40 percent of the forces that have been deployed to the Middle East and are continuing to be deployed to both Iraq and now Afghanistan.
Not only are these National Guard troops older than the typical active duty soldier or marine, few if any are making or considering the military as a career. And yet, for many, the extended, as well as the second and third, deployments have not only exposed these soldiers to continuing combat situations, but have added to the burdens of combat, the stresses of families to worry about, and careers left on hold. War is always more difficult for those who are older and have personal commitments and responsibilities that go beyond their unit, their comrades, and even their own sense of patriotism.
The nasty little secret about the constant deployments to Iraq and Afghanistan is that the highest percentages of soldiers whose responses meet the screening criteria for PTSD are among members of the National Guard and Reserve units, and that those screening results are decidedly higher with each additional deployment.
Dr. Dewey recently wrote, “When you talk to many of these guys and gals who are constantly being sent back, particularly the older ones, you get an ever-increasing sense of hopelessness and doom with each additional deployment.”
The constant danger, along with the so-called collateral damage of these wars, the deaths of women and ch
ildren killed in bombing, during the large sweeps through towns and villages and at road blocks, have all taken their own unique and unexpected psychological toll on the older U.S. troops, particularly those who are themselves parents. It is this group who most experience flashbacks and late episodes of PTSD, after being confronted with the mangled bodies of civilians caught either in the cross hairs of the insurgents or their own weapons. But that was to be expected. War is always more difficult when you understand what dying and death really mean. It is in reality the old story about all wars. “If you keep going back, sooner or later they will kill you.” Only now they can add PTSD.
What Dewey offers in War and Redemption is just that— both war and redemption. But in the process of dealing with these patients, he also offers a possible connection between the brain and the mind. He acknowledges what the Greeks and certainly the Romans acknowledged. The work of war is in the end, the work of death. And that the necessary killing is made immeasurably easier by the dehumanization of the enemy, whether it is as infidels, the gooks of Vietnam, the skinnes of Mogadishu, the terrorists of the world, the Nazis, the Japs, or the Ragheads. Yet in a very real way, killing is so difficult that the country has to work very hard to keep up dehumanization in order to get our troops to go back, again and again and day after day, to kill the bad guys.
The problem is that as time goes on and our troops continue to live and work in the lands of our enemies, these adversaries morph from the bad guys into insurgents and even freedom fighters. Some even become respected enemies, and as if that doesn’t become confusing enough, there is the whole issue of collateral damage, the carnage brought about by that “Fog of War” itself. No one signed up to kill women and children, and yet these grim deaths become a nightmarish burden and even deep spiritual wounds, that can fester as much as those contaminated physical wounds. It is those deaths as well as the deaths of comrades that become the content of dreams, nightmares, and intrusive thoughts that can and do haunt many of our own returning warriors.
One of the major factors in the persistence of PTSD was missed in Vietnam, but is clearly understood today as a key contributor to the differing symptoms of the disorder. Recent clinical studies indicate that close to 50 percent of those deployed and returning home are not getting adequate sleep. They awaken involuntarily in the midst of the most disturbing battle dreams and nightmares. If they return to sleep they are only awakened again by the same nightmares. In the daytime, images of the grisly scenes of war intrude into their thoughts, making it hard to concentrate and focus, along with that creeping exhaustion of persistent sleep deprivation. Months and years of these symptoms predispose our troops to not just a full spectrum of PTSD symptoms, but depression and then substance abuse, as they self-medicate to try to find some relief from what more than one soldier or marine calls, “these warcursed thoughts.”
The question with all of this is whether these problems are physical or mental. Military and VA psychiatrists like Dewey lean towards the mind rather than the brain, but even they are beginning to understand that the mental has something physical to it. We remember things, which means that somehow those remembered memories have become fixed within the neuro-networks of our brains. Something physical has to happen to keep these memories current. After all, they are not happening again. They are being remembered. The idea is that if you can get beyond the nightmares you can get to the more deep-seated mental issues. And that is happening.
The work of Murray Raskind, published in the Journal of Biological Psychiatry, deals with a study of the use of an old blood pressure medication Prazosin, off patent now and so incredibly cheap, that easily crosses the blood-brain barrier to accumulate in the brain, and that, in the study of PTSD patients, can quiet the nightmares of these patients even as it improves sleep patterns and reduces intrusive thoughts.
Dozens of articles in the psychiatric and medical literature throughout the 1990s and first decade of the Twenty-first Century pointed the way towards a medication to treat the symptoms of PTSD. In 1998 Thomas Neylan, Director of PTSD program at San Francisco VA Affairs, documented in the American Journal of Psychiatry that traumatic nightmares and sleep disturbances were the most treatment-resistant and distressing symptoms among Vietnam PTSD patients. These nighttime PTSD symptoms contributed to alcohol and drug abuse, as well as suicidal thoughts, while precipitating completed suicides. The use of medications were rarely, if ever, effective in treating these nighttime symptoms.
Research studies indicated that specific receptor sites within the brain are associated with the emergence of these nighttime symptoms, suggesting that the medical blockade of these nerve cell receptors could provide relief from these traumatic nightmares and sleep disturbances, along with most, if not all, of the other PTSD symptoms.
Dr. Raskin’s original paper using Prazosin as a specific alpha-receptor antagonist was in a cross-over study of Vietnam combat veterans. The medication clearly reduced PTSD trauma nightmares and sleep disturbances, as well as the persistent symptoms of depression, while improving the overall global clinical status, and in some cases even leading, for the first time in decades, to more typically normal dreams.
Raskind’s clinical research at the Puget Sound VA and the Army’s medical facilities at Fort Lewis, Washington, has been picked up by some of those who, like Dr. Dewey, are dealing with returning soldiers and marines, and like Dewey, are finally beginning to use the drug and reporting positive responses in both restoring normal sleep to today’s returning veterans, while acting as a powerful antidote to the exhausting and increasing dangerous cycle of nightmares and intrusive thoughts. It may be the economic fact that the drug is off patent that is keeping the drug companies from actively promoting or disseminating this new treatment. In short, the drug as a generic is basically free to patients, so why would a generic drug be promoted nationally by the pharmaceutical industry?
But there may be another reason for the overall lack of use. As startling as it may be, the reason for its lack of use, or to put it less diplomatically, the refusal to prescribe it to PTSD patients, as reported by Robert Rosenbeck in the Archives of General Psychiatry in 2009, is that most of the clinical work on Prazosin has been done at VAs on the West Coast. Indeed, that is where Dr. Dewey practices, and medical information very seldom moves across the country from West to East. The influential centers of medical education and research are at the prestigious universities and hospitals in the East and, because of this, medical information moves across America starting in the East and moving West. Still, the published works of Raskind, Rosenheck, and Dewey, as well as the growing databases developing within the PTSD clinics of Oregon and Washington State concerning the therapeutic effects of Prazosin, have come none to soon.
But it is not only the increasing numbers of deployed military personnel being diagnosed with PTSD who have to be treated, the numbers of suicides are also increasing. In September 2010, the Pentagon released information that there had been more deaths in deployed military personnel from suicides than from combat. There have been a number of months since the invasion of Iraq and the surge in Afghanistan where deaths from suicide exceed the numbers of deaths from actual combat. And it is not that the military does not understand or that they are confused about the cause of these deaths.
Across all branches of the military, spending on psychiatric drugs has doubled since 2001 to over 280 million dollars in 2010 alone. The list of medications is extensive and in fact shocking: Prozac, Paxil, Zoloft, Celexa, Effexor, Valium, Klonopin, Wellbutrin, Atavin, Restoril, Xanax, Adderall, Ritalin, Haldol, Risperdal, Seroquel, Ambien, Lunesta, Elavil, and Trazodone. We not only have the most powerful military in the world, but clearly the best medicated.
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. It is well understood within the civilian
medical community that many of these medications, if abused or used together, can cause severe and deadly complications.
12.
MULTIPLE DEPLOYMENTS/BRAINS AT RISK
In Vietnam they would tell you that if you keep going back, they will kill you. In Iraq and Afghanistan, they say that if you keep being deployed, you will be brain-damaged.
—Conversation, PTSD Clinic, 2010
Both of the above comments are accurate. Indeed, the statement “they will kill you” was what Colonel Hackworth, an officer in Korea during the worst of the fighting and a colonel in the 101st Airborne following the Tet Offensive in Vietnam said to Joe Galloway, at the time a young UPI reporter who insisted on being part of many of the major battles of the Vietnam War. It wasn’t said to be dramatic or to even keep the reporter from going back. That would be Galloway’s choice. But it was a knowledgeable combat officer’s professional assessment of the fight going on in Southeast Asia; no more and no less. It was reality.
The newer comment about being brain-damaged is also as accurate as it is insightful, if still lacking some of the overall acceptance of the facts. Again, it is reality—a new reality to say the least, but reality nevertheless. The reasons for these two different outcomes is the difference of forty years, the change in weapons, in strategies and tactics, in military medicine, and the fact that the insurgents in Iraq and the Taliban in Afghanistan, unlike the Viet Cong and North Vietnamese Army in South Vietnam, are not so much shooting our troops as blowing them up.
And all this is happening with a medical profession becoming increasingly aware of how the brain functions, while growing more and more worried about the cumulative concussive damage following what may at first appear to be no more than minor or trivial head injuries. The growing connection between a concussion caused by helmet-to-helmet collisions during high school, college, and professional football games and the young men and women being exposed daily to brain-rattling blast waves from IEDs, suicide bombers, and roadside bombs, is too obvious to ignore. One cannot pretend that the exposures to recurrent blasts are not dangerous and damaging to the brain.
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 12