B0038M1ADS EBOK (5 page)

This book intends to help bring clarity and understanding to the transition period after a wide range of deployment experiences, both anticipated and unanticipated. Although most of the examples cited in this
book have to do with direct combat in the deployed environment, trauma
can take many forms. All personnel working in the war zone are in danger from indirect fire. Noncombat trauma, including accidents, assault, or
rape, can be just as debilitating as trauma experienced during direct combat. Whether or not there were serious traumatic experiences, most people change as a result of wartime deployment, and this book is intended
for anyone who wants a greater understanding of these possible changes
and how to effectively navigate them.

Although I often address the writing directly to the warrior, this book
is intended for spouses, partners, and family members as well. It can provide you with a greater understanding of your warrior's perspective, and
they will likely appreciate the effort on your part. Chapter 10 is specifically
written for you, but all the exercises in this book can be useful.

A disclaimer: This book is not intended to serve as a substitute for
therapy or treatment of any specific disorder. This book includes information and advice for consideration, but ultimately, each warrior (and
spouse, partner, or family member) needs to seek out and find whatever
works best for them. This book is no substitute for professional help
when it's needed.

WHAT IS COMBAT STRESS AND PTSD?

Mental health professionals define post-traumatic stress disorder (PTSD)
according to a specific list of symptoms. However, the medical definition
does not provide any understanding of what PTSD is from the perspective
of someone who has gone through combat. It does not capture the full
spectrum of reactions to war, or distinguish between what is normal and
abnormal in a military context. PTSD has become part of the vocabulary
of modern warriors, but is sometimes misused as a catchall term for any
postwar behavioral problem, such as getting in fights, driving under the
influence of alcohol, or having failed relationships. The terms combat stress,
post-traumatic stress, combat stress reaction, and acute stress reaction are often
used interchangeably with PTSD, even by medical professionals, creating
confusion over the meaning of all of these terms.

Combat stress and post-traumatic stress are general terms that are used
to refer to any distress or symptoms, less severe than PTSD, which have
resulted from stressful or traumatic events in the war zone. They are not
particularly useful terms because they lack a clear definition. A "combat stress reaction" (also called "acute stress reaction" and "operational
stress reaction") has a specific meaning on the battlefield, and refers to
an immediate reaction to severe stress, trauma, or exhaustion. It reflects
the moment when a warrior reaches a "breaking point" and needs to shut
down for a while. A combat stress reaction can manifest as virtually any
physical symptom (e.g., fatigue, chest pain, shortness of breath, muscle
shaking, headaches, neurological symptoms) or behavioral reaction (e.g.,
rage, agitation, fear, panic, restlessness, bizarre behavior, inability to think clearly). A combat stress reaction is not a mental disorder. It's treated with
rest and reassurance as close to the unit as possible, and almost all warriors
who receive this care are back in the fight within two or three days.

The disorder of PTSD is defined according to a specific set of symptoms that have gone on for at least one month (usually much longer). If
the symptoms have lasted more than a month but less than three, the disorder is called "acute"; if more than three months, it's called "chronic."
If the symptoms didn't begin until at least six months after the combat
trauma, this is referred to as "delayed onset," although in most cases
warriors with "delayed onset" PTSD did experience some reactions close
to the time of the trauma that they suppressed or avoided dealing with.
The distinction between these three categories of PTSD has not proven
very helpful.

PTSD has gained a much higher level of importance during the
wars in Iraq and Afghanistan than in any prior conflict-not because the
problem is greater in veterans of these wars, but because there is greater
political interest and public awareness of the mental health effects of war.
The attention on PTSD has been combined with increased attention on
mild traumatic brain injury (mTBI), also known as concussion. PTSD and
mTBI have been labeled the "signature injuries" of the wars in Iraq and
Afghanistan, but this has unfortunately created confusion over the nature
of both of these conditions.

Although PTSD is considered a mental disorder, it's actually a physical condition that affects the entire body, and is best understood through
the emerging science of stress physiology, which describes how the body
normally responds to extreme stress. Physiology is the science of how the
body works, including how the brain and the rest of the nervous system
functions (also called "neurophysiology" or "neurobiology"). PTSD is a
contradiction, a paradox-a collection of reactions that are both normal
and abnormal depending on the situation-and there is debate as to
where to draw the line.

When I consider the question, "What is PTSD?" I don't mean only how
doctors define it. What I'm considering is how each person experiences
the condition, or what they perceive the condition to be. For warriors, PTSD can be a day-to-day experience of living with memories they want to
forget, staying constantly alert to dangers others don't pay any attention
to, enduring sleepless nights, and reacting to things at home as if still in
the war zone. It's very difficult (if not impossible) for anyone who has not
been in a war zone to understand what these experiences are like. These
reactions may help a warrior survive in combat, and may be needed again
if they return to the war zone or any other situation where there's danger.
What "normal" is in this context can't be precisely defined.

The DoD and VA acknowledged at the beginning of the wars in
Afghanistan and Iraq that there would be substantial psychological costs.
No prior war has had as much research conducted on the mental health
impact while the war is going on. Congress and news organizations took
special interest in PTSD in part because of a paper my research team and
I wrote that was published in the New England Journal of Medicine in 2004,
showing that 12 to 20 percent of soldiers and marines who had participated in the initial ground invasion of Iraq had serious symptoms of PTSD
three to four months after coming home.

GOOD NEWS AND BAD NEWS ABOUT PTSD

Enormous advances have occurred in the understanding of PTSD over
the last two decades, including characterizing the neurobiology, and how
to diagnose, evaluate, and treat the condition. Neurobiology is the study
of nerve functioning and chemical processes in the nervous system. Neurobiological research related to PTSD has included many experiments
using animals subjected to stress and studies of humans who have suffered
trauma. Neurobiological research has helped us to understand that PTSD
is not an "emotional" or "psychological" disorder, but a physiological condition that affects the entire body, including cardiovascular functioning,
hormone system balance, and immune functioning. PTSD can result in
physical, cognitive, psychological, emotional, and behavioral reactions
that all have a physiological basis. These studies have led to new treatments
of PTSD, including psychotherapy (talk therapy) and medications that target specific areas of the brain and body responses. Successful treatment with psychotherapy and medications lead to chemical changes in the brain
and nervous system, and some of these changes can actually be seen on
brain-imaging studies. Numerous new types of treatment are being evaluated and will be reviewed later in this book.

The wars in Iraq and Afghanistan have led to a greater understanding of the stigma of mental health problems, not only in the military, but
also in society in general. The word stigma literally means to be stained or
marked by a shameful disease. Our article in the New England Journal of
Medicine showed that less than half of the soldiers and marines who were
experiencing serious symptoms of PTSD or depression received any help,
including counseling by a chaplain. The stigma was the main reason they
avoided getting help. Warriors expressed concern that they would be perceived as weak or treated differently by their leaders and buddies if they
sought assistance for their problems. They also expressed distrust that
mental health professionals could help them, a topic that will be discussed
further in later chapters. The findings from this study contributed to new
programs in the DoD and VA to encourage service members and veterans
to seek help early, before problems become serious. These programs have
involved screening after returning from deployment (post-deployment
health assessments), resiliency training, and increased training of mental health professionals in how to treat combat-related problems. Many of
these services were unavailable during prior wars.

The increased attention on PTSD in the military has had a positive
effect on the way that society views mental illness. Society has often viewed
mental disorders as a personal failure of character. People with these conditions have felt shame and have been stigmatized socially and occupationally. The advances in research and increased awareness of the mental
health impact of war have helped to bring about a shift in the way mental illnesses are viewed. PTSD and other mental disorders are now being
regarded as medical problems. Mental disorders are slowly being accepted
as medical conditions that are not the "fault" of the person who acquires
them, and which can be treated like any other physical illness, not something to be ashamed of.

So that was the good news; now for the bad.

The bad news is that we still have a long way to go. It's a step forward
that mental health problems, including PTSD, are beginning to be viewed
like other physical health problems (and PTSD is a physical health problem). However, we can take it a step further, especially for combat veterans, and that is to view PTSD and many other mental health problems
as part of the normal range of human responses to extremely stressful
experiences. Society still tends to perceive mental illness as something that
you get if you're unfortunate or don't have the right genes, not something
that everyone can expect to encounter in one form or another during the
course of a normal life. However, the reality is that mental health problems
touch everyone to one degree or another, either directly or indirectly, and
are thus part of the human experience. By considering PTSD within the
framework of normal reactions, it doesn't mean that we don't also consider it a disorder. PTSD is both, and the more we become aware of this
contradiction, the further our understanding will evolve in how best to
help each other get through difficult experiences.