Invisible Wounds

The Army defines collateral damage as “unintentional or incidental damage” occurring as a result of military action.

“War means something different to those of us that have looked through the sights of a rifle at another human being’s face. Collateral damage means something different to those of us that have seen the lifeless body of a 9-year-old girl caught in the crossfire. Or for those of us that have struggled to save the life of a 7-year-old boy. I’ve only mentioned a fraction of what still haunts me from Iraq. I’ve been diagnosed with PTSD.” These are the words of an Iraq veteran from New Jersey, quoted in “Collateral Damage,” by Col. Rich O’Connor.

It was soldier’s heart in the Civil War, shell shock in World War I, combat fatigue in World War II, Post Traumatic Stress Disorder (PTSD) in the Vietnam War. What do all of these terms have in common?  They all describe the same thing, a condition brought on by traumatic events that threaten or cause great physical harm.

The condition can also be described as a severe and ongoing emotional reaction to an extreme psychological trauma. Stressors can be someone’s actual death, a threat to the individual (or someone else’s life), serious physical injury; or threat to psychological integrity, overwhelming psychological defenses. It’s as old as time, having been the inevitable result of continuous stress and combat for warriors down through the ages.

Some common symptoms include flashbacks and/or nightmares, avoidance of stimuli associated with the original trauma (this can manifest itself by the individual isolating themselves from their friends and family, for example), and increased arousal,which can interfere with sleep and manifest itself in anger and hypervigilance.  Others include self-medication (drugs or alcohol), suicidal thoughts, confusion, anxiety/panic attacks, self-absorbed behavior, and rejecting affection.

The Rand Corporation conducted a comprehensive study of post-deployment health-related needs related to PTSD, major depression, and traumatic brain injury (TBI). “All three conditions affect mood, thoughts, and behavior; yet these wounds often go unrecognized and unacknowledged.”

Rand issued a report on this study in April 2008, which it called “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.” They found that of the over 1.64 million U.S. troops that have been deployed in Operation Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq, over 300,000 or about 20 percent of the OEF/OIF veterans report symptoms of these conditions, but only half of those seek treatment, and of those that do, only half of them receive treatment that the researchers felt could be considered “minimally adequate” for their illnesses. 

There is a great need to get the word out to the public at large, and to those veterans who may read this, that there IS help out there –- evidence-based care –- and it is available for them. Delivery of such care, according to the Rand study, would pay for itself within two years, even saving money, by improving productivity and reducing medical and mortality costs.

Some say the study is in part responsible for recent changes in policy, funding, and attitude at the DoD and VA on addressing PTSD treatment, since the study concluded that to ensure delivery of such care would require “system-level changes across the Department of Defense, the Department of Veterans Affairs, and the U.S. health care system.”

Another influential paper on PTSD was written by U.S. Army Colonel Richard O’Connor. Entitled “Collateral Damage:  How Can the Army Best Serve a Soldier with Post-Traumatic Stress Disorder,” it was published in February 2009. In a recent article, Col. O’Connor didn’t mince words about the amount of mental health training he had before taking a squadron of the 3rd Armored Cavalry Regiment to war in Iraq’s Diyalah province in 2006 – “What kind of training did I receive on post-traumatic stress?” he said. “Zero.  How much did our soldiers receive?  None.” 

An ongoing study of the University of Texas has been following 160 soldiers before, during, and after deployment. Dr. Michael Telch has been working with troops from Fort Hood in his Texas Combat PTSD Risk Project for the past few years. The three-phase study assesses the participants using clinical interviews, validated questionnaires, an eye tracking assessment, and a carbon dioxide stress test.

“We assess their reactions subjectively, and their hormonal response – their cortisol and testosterone responses to the challenge – and we ultimately want to link their reactions to their risk of developing combat stress problems in theater,” Telch said. 

Deployed, soldiers access a web-based system filling out online questionnaires every 30 days.  Once home, they return to the lab and do full day assessments similar to pre-deployment, and also do one-on-one interviews conducted by Dr. Telch. One early inference that was not expected is that access to the Internet has caused added stress for combatants. An example: one soldier tried to commit suicide because he learned through email that while he was deployed, his wife had moved in a boyfriend.

Warriors – veterans and active duty alike – often suffer severe anxiety from the effects of PTSD, which in turn affect their work, sometimes leading to negative behaviors such as self-medication using alcohol or drugs (street and/or prescription).
What is it like for them?  Here is one Warrior reflecting on his PTSD…

“This has been a rought week for sleep. What little sleep I’ve had has been uneven and very light. For some reason my hypervigilance has come back with a vengeance recently.

“I think we all go through a renewal process when we come home from war. It’s a process where we reconnect with ourselves and those around us. We learn how to be the person that we are now, not the one we used to be.

“Sometimes I feel like you can take the warrior out of the war, but you can never take the war out of the warrior. This means you can still find the strength that combat forget within you.

“A perfect example of the changes within is my ‘fight or flight’ response. In conflict or combat, you have three responses: fight, flight, or freeze. In Iraq I hardwired my brain, like any infantry guy, to forget the flight and freeze responses. It just wasn’t an option at any time for me. My response to everything was fight. It didn’t matter how big the problem was (a firefight) or how little (some Iraqi upset me at a checkpoint). Force and firepower became my preferred response. And no matter which I chose, it was always overwhelming. I never wanted a fair fight. Sometimes we got hurt in the process, but generally I won.

“You can only imagine the effect this has had at home. It was the same here. For four years, my response, no matter what the issue, was to fight. It was to overwhelm and it was to win, no matter the cost.

“Then about a year ago the light bulb went on, admittedly with some help from my wife. Taking the war out of me was impossible. First, I can see the consequences each day when I look in the mirror. Some days it’s not as obvious and I glance over it, but each day it is there. It is a scar from one day in Iraq. A day I wish I could have back. God, I wish I could have that day back.”

Family and friends suffer, too. When individuals suffering from PTSD isolate themselves, or react out of fear via rage or explosive anger, relationships suffer. In turn, the spouses, partners, and children can suffer secondary PTSD, developing very similar symptoms. Communication breaks down, and it is unfortunately all too common for relationships to fail.
When you care for a Warrior with PTSD, you soon learn that their wanting to sit facing an entrance in a restaurant so they can watch the exits, or their lying in bed at night with eyes wide open staring at the ceiling, unable to sleep (partly because deep down they might dread sleep and the nightmares it brings), is just how it is for them. There may be days when they avoid you, coping with anxiety you cannot imagine in the only way they can, by isolating themselves. You learn to give them space and respect it even as you feel the pain of being shut out. If you’re lucky, they might reach out for help, talk to someone. If they are lucky, it might help. You may need to reach out yourself and find support.

And where do you find it? While there is the traditional route of counseling and talk therapy, there are also newer resources—many of them online—that are springing up all the time.  A couple of great ones for both Warriors and family/friends, is NOTALONE.COM.  Another one is OperationPTSD.org, created by two Veterans FOR Veterans.

Resources: http://www.ptsd.va.gov, http://www.notalone.com, tinyurl.com/hpr-veterans, http://www.rand.org/news/press/2008/04/17/, tinyurl.com/hpr-giveanhour, http://www.studentveterans.org/ndsu/
Questions and comments: http://hpr1.com/member/90/