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What is normal and abnormal when it comes to reactions to combat? When
do normal "reactions" become "symptoms" of a disorder? (Note that in
this book, the terms reaction and symptom are often used interchangeably.)

The answers are both complicated and simple. Making the distinction
between normal and abnormal based on the level of impairment in work
or personal relationships isn't sufficient. Many warriors experience high levels of symptoms that they would rather get rid of, but learn to cope with
them and continue to function relatively well in their work and/or home
lives. Other warriors are severely debilitated by "normal" (expected) reactions to particularly severe wartime experiences.

The simplest answer is that when reactions interfere with your happiness or your ability to do the things you want to do, then they're undesirable
(you can say that they are "symptoms"), and you've identified something
that you want to change or learn to dial up or down. You deserve to be
happy and enjoy life. The focus here isn't on deciding what's normal or
abnormal, but on identifying what it is that interferes with your life in such
a way that change is warranted. You may have all the symptoms listed in the
DSM after combat, or exhibit other behaviors that don't match with societal norms, but if they're not interfering seriously with your life or the lives
of others, then they shouldn't be considered abnormal. An example is a
combat veteran who develops a passion for gun collecting up to the limit
of what the law will allow. Some people may consider that "abnormal," but
if it's something that the veteran enjoys, and he isn't intending to use these
weapons dishonorably, then it's not "abnormal." On the other hand, if he's
barricading himself in his house, suspicious of anyone who approaches,
threatening people, unable to have any close personal relationships or
hold a job, then this behavior is not serving the veteran well.

DECONSTRUCTING AND UNDERSTANDING THE PTSD
DEFINITION

If we take each component of the DSM definition of PTSD and break it down,
we discover some of the problems with how PTSD is conceptualized from the
perspective of warriors. Every "symptom" of PTSD stems from things your
body normally does in response to severe danger or stress. PTSD symptoms
can be manifestations of normal stress reactions to threatening situations, as
well as a disorder that requires treatment. That's the paradox of it.

When mental health professionals assess PTSD, the DSM definition
requires that they ask about six different criteria, A through F, all of which
must be fulfilled to make the diagnosis "true."

Criterion A defines a trauma exposure as witnessing or experiencing
an event involving serious injury or death. This may be an actual injury or
a threat to the physical integrity of self or others. Clearly, many combat scenarios would fulfill this definition, as well as assault, rape, and other serious events. In addition, the DSM requires that the response to this trauma
at the time included intense fear, horror, or helplessness.

If the person (in this case, a warrior) meets criterion A and develops
symptoms as a result of the traumatic event, then the mental health professional would determine if there are a sufficient number of symptoms
present according to the list contained in the DSM. The DSM diagnosis
for PTSD includes seventeen total symptoms divided into three groups:
Criterion B includes five symptoms related to re-experiencing the traumatic event; criterion C includes seven symptoms related to avoidance;
and criterion D includes five symptoms related to hyperarousal (revvedup, hypervigilance).

The following survey will help you understand the seventeen symptoms a mental health professional looks for. This is one of the most common surveys given to veterans to identify PTSD, and you may have taken
this or a similar one at some point during your service. This is not a "test";
there are no right or wrong answers. The survey will do two things: First, it
will familiarize you with the definition according to DSM-IV, and second,
it will allow you to assess your own level of current symptoms.

(If you're a spouse, partner, family member, or friend who has experienced a traumatic experience and want to take this survey, simply remove
the words "military" or "veteran." The scale can be used to refer to any
traumatic experience.)

To score this, first look at questions 1-5. If you marked a "3" (moderately) or higher on any of these first five questions, then this fulfills the
DSM criterion B requirement for re-experiencing the traumatic event.
Next, look at questions 6-12. If you marked a "3" or higher on any three
(or more) of these seven questions, then this fulfills the criterion C
requirement for avoidance symptoms. (At least three of these seven questions must be present to fulfill criterion C, but only one of the criterion
B symptoms is required.) Finally, if you marked a "3"or higher on any two of questions 13-17, this fulfills the DSM requirement for criterion D
hyperarousal symptoms.

This may be confusing, but follows the way the definition is written.
The DSM-IV requires that there are symptoms in all three categories of
criteria B-D; again, at least one of the first five questions, three of questions
6-12, and two of questions 13-17. If after taking the survey yourself, you
discover that you meet this definition, don't panic. This is only a prelimi nary screening tool designed to give you information for consideration,
and we'll discuss this in more detail.

Using another scoring method, add up the total score from the
seventeen questions you already marked. For example, if you marked
all seventeen questions "1" ("not at all"), your total score would be 17,
the minimum value possible; if you marked all seventeen questions "5"
("extremely"), you would have the highest possible score of 85. If you
marked three questions at the level of "l," six questions at the level of
"2" ("a little bit"), five at the level of "3" ("moderately"), two at the level
of "4" ("quite a bit"), and one at the level of "5," this would add up to a
total score of 43 (3+12+15+8+5).

For the total score, less than 30 is considered low ("normal"), 30-39
indicates some symptoms, 40-49 indicates moderate symptoms, and 50 or
more is considered a high score for PTSD. The higher the score, the more
likely you would be considered to have PTSD by a medical professional,
although this is not a perfect measure. Most warriors who experienced
direct combat will have some of these symptoms. For warriors who have
moderate or high scores, some continue to function very well, while others experience serious problems with relationships or work. The level of
symptoms isn't as important as whether they are interfering with your happiness or ability to do the things you want to do. However, when this survey
is used in a medical or mental health clinic setting, any person who has a
moderate or high score or meets the DSM definition would be evaluated
further by the health professional.

The last two criteria necessary to fulfill the DSM-IV definition is criterion E, which requires that symptoms have been present for at least one
month; and criterion F, which requires that there is significant distress or
impairment in work or relationships as a result of the symptoms.

This survey, along with my description, provides you with detailed
information about how mental health professionals define PTSD, as well
as information regarding your own level of reactions that you can monitor over time. If you have a moderate or high score on this survey, most
mental health professionals would agree that further evaluation is warranted. There is information on how to do this in chapter 8, as well as many skills throughout the book to help you address specific reactions
you may be experiencing.

The next section provides additional detail about each criterion of the
PTSD definition from the perspective of being a warrior. Warriors are professionals trained in how to respond to traumatic events. There are many
unique factors regarding how well (or poorly) this definition describes the
experience for warriors.

Criterion A. The Traumatic Event

Criterion A concerns the definition of a traumatic event, and has two parts,
A-1 and A-2. A-1 defines what type of traumatic event is considered necessary to cause PTSD, and A-2 defines an "abnormal" response to this event.
The irony is that the "abnormal" reaction from the standpoint of fulfilling
the PTSD definition may be a perfectly normal, expected response to a
serious life-threatening event, a normal reaction to an extremely abnormal circumstance. In essence, in order to be defined as having PTSD, your
normal response has to be considered "abnormal," which really makes no
sense when you think about it.

More important, the medical definition of a traumatic event doesn't
really capture the horrific nature of many events, nor explain why some
warriors exposed to combat develop serious symptoms of PTSD, while
others exposed to the same or similar events do not. This is one of the
most fundamental questions, and a tremendous amount of research
spurred on by the Iraq and Afghanistan (OIF and OEF) wars is being
devoted to answering it.

Criterion A-1. The Definition of Trauma

The A-1 definition of a traumatic event is quite broad. Almost any event
that is perceived as life-threatening can meet the definition, although lawyers or disability specialists might disagree. However, this doesn't mean
that all traumas are equal. The definition doesn't speak to what a traumatic event is, but rather whether the trauma-whatever it is-is perceived
to be threatening to life or personal integrity. For example, working in a
war zone but remaining inside the "wire" (the protective perimeter of the base camp) for the duration of the rotation and never seeing direct combat could be sufficiently traumatic if one is constantly threatened from
enemy mortars landing inside. Line or transport folks working constantly
outside the wire might roll their eyes at this notion, but the fact remains
that a threat is a threat, whether it involves episodic mortar attacks or constant ambushes and firefights.

The VA has traditionally required that veterans seeking disability for
PTSD prove that they actually experienced a seriously life-threatening
direct-combat event, through military records or affidavits. This policy was
designed to prevent fraudulent claims. Lying about military service to gain
compensation (called "malingering") does occur, but is infrequent, and
the policy ended up being a significant barrier and source of frustration
for thousands of veterans with legitimate claims. Change in this policy was
finally initiated several years into the OIF and OEF wars to make it sufficient to have been in the war zone to qualify. This change was long overdue. Mental health professionals should not be put in a position of having
to judge how much threat is sufficient for each individual. We should be
meeting each of our clients where they are.

We need to appreciate that the experiences of infantry warriors operating in hostile territory 24/7 are different than warriors who mostly work
inside a protective perimeter. Personnel working inside the wire (pejoratively dubbed in the current wars "Fobbits," from "FOB" or "Forward
Operating Base") often don't live with the same level of day-to-day threat
from direct combat as line infantry personnel. Yet, it's also important to
appreciate that these warriors in support roles can experience substantial
stress from indirect fire and other deployment stressors. They may also
be at higher risk than line infantry warriors when they do go on support
missions outside the wire (as most do), because of a lower level of experience dealing with unexpected combat scenarios, such as ambushes. Combat teams often have higher cohesion and combat readiness than support
teams, and are therefore better equipped to handle unexpected enemy
engagement. This can actually translate into lower rates of PTSD for some
line units, despite much higher levels of combat, compared with some
support units. Personnel in support units may also feel a sense of guilt that they are stuck in a support role when they would rather be out directly
engaging the enemy, and this can take a toll. The guilt may lead them to
resist seeking help for serious war-related problems because they feel that
they shouldn't be having these problems in light of the relative security of
their assignment.