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Stress Takes its Toll on Combat Veterans

By Shannon Hanson

"In an honest assessment of threats to this new generation of veterans, PTSD and emotional or mental problems are at the top of the list," said Paul Rieckhoff, Iraq War vet and founder of veterans advocacy group Operation Truth. "PTSD is a real threat that can lead to multiple issues--unemployment, homelessness, suicide. It's important because history repeats itself, and we still haven't learned our lesson."

Throughout history's patterns, only the names have changed. After the Civil War, they called it soldier's heart or nostalgia--the emotional and psychological symptoms experienced by war veterans. In WWI it was shellshock, and in WWII and Korea it was battle fatigue. Today we know it by the name it was given after Vietnam--PTSD.

Post-traumatic stress disorder was officially designated by the American Psychiatric Association in 1980. The most common symptoms are emotional numbing, hyperarousal (irritability, vigilance) and re-experiencing traumatic situations through flashbacks and emotions. Symptoms may take months or even years to surface. People with acute PTSD generally recover in three to six months, but chronic PTSD can go on for decades.

Combat situations in Afghanistan and Iraq are already producing a host of psychological casualties, including PTSD. A study by the Walter Reed Army Institute of Research conducted in 2003 and published in the New England Journal of Medicine in July 2004 found that 15% to 17% of returning Iraq veterans showed symptoms of PTSD, anxiety or depression. Some 11% of Afghanistan vets showed the same symptoms.

The 6,201 GIs surveyed were from infantry brigades of the 82nd Airborne and 3rd Infantry divisions, plus two battalions of the 1st Marine Expedi-tionary Force. According to study authors, most of those surveyed were vets of the combat arms, though they did include some forward support personnel.

The study also found that of those showing signs of emotional trauma, only 23% to 40% had sought medical care. GIs cited a variety of reasons they had not or would not seek care: They would be seen as weak (65%); their unit leadership might see them differently (63%); unit members might have less confidence in them (59%); and it would be difficult getting time off work (55%). Respondents also indicated their combat experiences (see box below), which are telling of the conditions for combat troops, and clearly show why such high numbers are reporting psychological problems.

Starting with Stress
When GIs in Iraq or Afghanistan experience something traumatic, such as being ambushed, being attacked or seeing a dead body, they may experience combat stress. Characterized by agitation, the inability to sit still or sleep, refusal to carry out orders and getting in fights, this type of stress can disrupt daily activities.

Army Capt. Dale Murray, serving in Iraq, told ABC News he knows the signs when a soldier starts struggling: "Withdrawing, talking again and again about the episode, saying things like 'I don't know if I can do that again.'"

Those most at risk for experiencing these symptoms include older members of National Guard units who had never been mobilized before; younger troops who signed up for the extra cash or college money and never expected to be called up; and troops who have been extended beyond their redeployment date. With Reserve and National Guard members making up 40% of the fighting force in Iraq and frequent redeployment extensions, stress has become a concern for troops and medical personnel.

By the end of September 2004, nearly 900 troops had been sent home because of psychological issues since the start of the war. Research shows that doing this can prevent them from dealing with the situation and can add guilt for abandoning their unit. But, left untreated, their symptoms could develop into PTSD down the line. So medical personnel believe the best course of action is to help soldiers process and diffuse stress as it happens.

Both the Army and Marine Corps have taken steps to improve treatment in the war zone. Each major combat unit has its own combat-stress team to provide troops with counseling and advice. Main bases in Iraq and one base in Kuwait host 72-hour "restoration zones," where GIs experiencing too much stress can take a break and sleep, have good meals, watch movies, relax and attend counseling and group sessions for three days before heading back to the front line.

Unit leaders help troops cope with stress as well, by scheduling downtime for them, hosting informal "rap" sessions and holding memorial services for fallen comrades. Many troops say they cope through denial and dissociation.

"You have to get over your feelings and keep on pushing, just for the simple reason that you have another 170 Marines to take care of and make sure they come back," Capt. Patrick Rapicault with the 2nd Bn., 5th Marine Regt., 1st Marine Div., told Time. (Rapi-cault was KIA in Ramadi, Iraq, in November 2004.)

But most say the biggest help is their commitment to each other. "All of the bigger issues don't exist," one Marine serving in al-Anbar province told Time. "You understand, ultimately, that the mission is about protecting each other."

Preventing PTSD
Unfortunately, for veterans of Iraq and Afghanistan, returning home does not necessarily mean life goes back to normal. Some feel good about the experience. They feel a new self-confidence--that no challenge is beyond them. They have formed deep bonds of friendship and have a renewed appreciation for their loved ones and the comforts of home.

"I'm still glad I went," Cpl. Travis Friedrichsen, who served in Ramadi with the 2nd Bn., 4th Marine Regt., told the Chicago Tribune. "It gives me a better appreciation for the U.S. I love everything here."

But others may struggle. Many may experience common symptoms such as hypervigilance--jumping at noises or automatically reaching for a weapon. Though this can persist for weeks or months after leaving a combat situation, much of it is gone after the first month. Some veterans may experience other mild depressive and anxiety symptoms, such as trouble sleeping or nightmares.

"In the majority of the cases, these symptoms are transient," Army Col. Tom Burke, the Pentagon's director of mental health policy, told the American Forces Press Service. "They are common and diminish with time." They may even come back out of the blue years later, he said, and that's normal.

Some veterans, however, have more intense symptoms that don't go away. They may feel an uneasy restlessness, anger easily or have hair-trigger reactions. Some are troubled by guilt (for killing or surviving) or feel an emotional distance from those around them. Often they are unable to communicate what they've endured with those who weren't there.

"It was hot," says Miguel Escalera, a Navy corpsman who served in Ramadi with the 2nd Bn., 4th Marine Regt., when people ask him about Iraq. He told the Chicago Tribune: "That's pretty much all I say. They're going to go ahead with the rest of their lives, and they won't care about it. Why should I pour my heart into it? Even if I do tell you, you're not going to understand."

Feelings like Escalera's are not uncommon. But if nothing is done about them, these types of symptoms can worsen with time, leading to a higher risk for substance abuse, unemployment, homelessness or suicide.

Several programs are in place to try to prevent that from happening. Officials at Ft. Drum, N.Y. (home of the 10th Mountain Division), created a PTSD task force to educate leadership, soldiers and the community on PTSD, its symptoms and treatment. At Ft. Polk, La. (base of the 2nd Armored Cavalry Regiment), each returning soldier is screened with a detailed questionnaire and meets one-on-one with a mental health technician, with a follow-up screening three months later.

The Marine Corps requires all those returning from Afghanistan and Iraq to attend its Warrior Transition Program, a 4-hour seminar that includes a questionnaire, presentation and discussion. The Army offers Army One Source, a 24-hour-a-day service that helps soldiers deal with a variety of issues. Soldiers can call 1-800-464-8107 to speak with a consultant or set up free sessions with a private counselor.

Many vets will not seek help on their own, for fear of being stigmatized.

"Soldiers are concerned that coming to see us might hurt their careers," said Maj. Paul Morrissey, chief of mental health services at Ft. Drum, to CNN. "I can say to them sincerely, honestly, that not coming to get some assistance will harm their careers."

Some veterans believe that anyone coming home from a war zone should be required to go through two or three counseling sessions, while VA psychologists have suggested peer counseling from volunteer vets.

No matter what method is used, the key is to get these GIs talking. "Soldiers feel a huge sense of relief just realizing they are not the only ones experiencing these symptoms," said Capt. Todd Benham, Ft. Drum chief of Commu-nity Mental Health, in the Ft. Drum Blizzard.

Not All in Your Head
While prevention is the ultimate goal, researchers are always looking for more treatment options. Some traditional methods that have helped veterans include talk therapy, speaking with others who have been in combat, relaxation methods and distraction techniques.

But PTSD is not only a psychological problem, it also is a physiological one. Researchers have used imaging techniques to monitor the brain's reaction to extreme stress. According to Newsweek, they now believe that subtle biological changes in response to extreme stress alter the way memories are stored.

The body responds to stress or trauma by releasing adrenaline, which increases heart rate, raises blood pressure and creates vivid memories. PTSD can develop when, in cases of repeated or severe trauma, that stress response goes into overdrive.

According to Dr. Roger Pitman, a psychiatry professor at Harvard Medical School quoted in Newsweek, "The rush of adrenaline creates memories that intrude on everyday life and, without treatment, can actually hinder survival."

It is theorized that adrenaline also may be responsible for activating the amygdala, a structure in the brain involved in the expression of fear, emotional memory and the startle response--all common factors in PTSD cases.

New treatment options are now being explored that address the physiological nature of PTSD. For years doctors have used drug therapy with some success, prescribing antidepressants, mood stabilizers or beta blockers, which blunt the adrenaline response to stress.

But a new method that has made headlines since its development in 1989 is EMDR (eye movement desensitization and reprocessing). Controversial since its inception, it is the most-researched therapeutic treatment for PTSD.

According to the Washington Post, "EMDR combines a standard behavioral technique called exposure--in which a patient confronts a traumatic memory in a supportive setting--with a series of rapid eye movements that are supposed to metabolize and then reprocess the troubling memories." The method is associated with REM (rapid eye movement) sleep, a well-known stage of dream sleep during which the mind works through troubling information and resolves it. Many studies have been conducted, but no scientific proof of how EMDR works has been found. Critics call it a questionable practice, but others say the proof is in the results.

"All I can tell you is what I see in my office," said Washington, D.C.-based social worker Deany Laliotis in the Washington Post. "I've treated hundreds and hundreds of people over the last 10 years, and EMDR is much more effective and efficient than standard treatment."

VA medical centers have been using the treatment since the early 1990s, frustrated with traditional therapies that aren't working. Some EMDR practitioners say they see a substantial improvement in patients after just one session. But others are still skeptical.

"There certainly is no evidence that this is toxic," Dr. Matthew J. Friedman, executive director of VA's National Center for Post Traumatic Stress Disorder, told the Washington Post. "But there's a lot of maybes. The science just isn't there."

Nevertheless, the military is beginning to take notice, as the speed of the treatment also makes it an attractive option for combating war-zone stress.

On the Home Front
Some doctors continue to maintain that the best treatment for PTSD is successful reintegration at home. But that isn't always easy.

"A lot of [GIs] feel, 'If I get back to my spouse, if I get back to my secure environment, this will all go away,'" Col. Michael Bridgewater, a clinical psychologist at Ft. Polk, told ABC News. "Well, it doesn't go away."

Research has found that divorce rates in couples where one had been sent to war range as high as 21%. In an effort to keep families together, the Army is spending $2 million on marriage programs, including vouchers for romantic getaways and a 40-hour course that teaches communication skills, the dangers of alcohol and tobacco, and how to recognize PTSD. Commanders are encouraged to give soldiers time off to attend, and participants are rewarded with promotion points and a weekend retreat with their spouse.

Courage to Care, a health education campaign from the Uniformed Services University of the Health Sciences in Bethesda, Md., provides ready-to-use fact sheets for both physicians and service members that help returning veterans reintegrate back into their families. They can be downloaded from the campaign's web site at

Study Not the End
The Walter Reed study did much to shed light on the problem of PTSD and other emotional problems in Iraq and Afghanistan veterans. Unfortunately, it didn't tell the whole story.

First, the study did not look at reservists or members of the National Guard. They have less training, less cohesive units and a civilian life they leave behind, which makes them more vulnerable to psychological harm in the field. After the war, instead of rotating back to military bases where they can be monitored, they return to their hometowns and old way of life, essentially on their own. In addition, their free health care expires after two years, and private health care providers are less likely to be familiar with service-related mental issues.

The second concern with the study is that the Iraq soldiers and Marines surveyed all served in the early months of the war. Tours were shorter then, and the insurgency had not yet taken shape.

"The bad news is that the study underestimated the prevalence of what we are going to see down the road," Friedman told the Los Angeles Times. "The complexion of the war has changed into a grueling counterinsurgency. And that may be very important in terms of the potential toxicity of this combat experience."


Significant Results from Combat Duty Study
Number surveyed before deployment to Iraq (Army)2,530
Percentage with depression, anxiety or PTSD 9%
Number surveyed after returning from Iraq or Afghanistan (Army and Marines)3,671
Percentage of Iraq vets with depression, anxiety or PTSD 15-17%
Percentage of Afghanistan vets with depression, anxiety or PTSD11%
Number of those with depression, anxiety or PTSD who sought help23-40%
Source: New England Journal of Medicine, July 1, 2004.

Significant Combat Experiences-Iraq
Marines Army
Being shot at or receiving small-arms fire
97% 93%
Being attacked or ambushed
95% 89%
Seeing dead bodies or human remains
94% 95%
Receiving incoming artillery, rocket or mortar fire
92% 86%
Knowing someone seriously injured or killed 87% 86%
Shooting or directing fire at the enemy
87% 77%

Afghanistan (Army only)
Receiving incoming artillery, rocket or mortar fire 84%
Being shot at or receiving small-arms fire 66%
Being attacked or ambushed 58%
Source: New England Journal of Medicine, July 1, 2004.

VA Assists Returning Vets
The Pentagon has estimated that up to 100,000 new combat veterans of Iraq and Afghanistan could need medical treatment for psychological problems. In November 2004, Congress approved a VA health care budget $1.5 billion short of what the House VA Committee recommended. It did earmark $15 million over three years to deal with the mental health effects of the Iraq War, but that amount is considered minimal.

This has some worried that VA won't be equipped to handle the influx of vets needing care. Of the Iraq veterans treated at VA facilities through July 2004, 20% were diagnosed with psychological ailments, including PTSD.

"This early on, PTSD is much higher than anything we've seen in previous conflicts," said VA psychologist Scott Murray. "We anticipate the numbers are only going to keep getting higher."
Dr. Alfonso Batres, director and chief officer of VA's national Readjustment Counseling Service agrees. "This is first-year data," he told the Los Angeles Times. "Our experience is that over time that will increase."

"I don't know how many people are going to be seeking treatment, or whether the demand is going to be met by available resources," said Dr. Matthew J. Friedman, executive director of VA's National Center for Post Traumatic Stress Disorder. "What I am confident in is that people who come for treatment will get good treatment."

In the meantime, VA is doing its part to assist returning veterans through both prevention and treatment. It increased the number of psychologists and psychiatrists in combat areas and sent out hundreds of thousands of letters about service-related mental issues.

It has increased the number of group therapy sessions and staff at its more than 200 storefront Vet Centers across the country, and hired 50 Iraq War vets to serve as advocates at the clinics. In addition, it is now allowing primary care physicians at VA clinics to access combat records to look for PTSD risk factors.

"We want to start the process now, getting them used to the VA system, seeing VA docs, informing them of their benefits and how to use VA," said James Sheets, a readjustment counseling technician at the Ft. Drum VA Center's Readjustment Counseling Office, in the Ft. Drum Blizzard. "When they get out they won't be ignorant to VA ways and services, and they can continue to use it."

Military Connection's Comments: The effects of Post Traumatic Stress Disorder are far reaching. This disorder not only impacts the service person that experiences it, but it also impacts their families and friends. Having recognized the implications of the disorder, the steps are now being taken to treat the disorder and lessen the stigma of its sufferers. We have all witnessed the heartbreaking plight of past veterans who have fallen through the cracks. It is up to our government to make sure that this generation of soldiers returns  to society with a better future. They must be rewarded for their service to this country with the best level of healthcare and mental healthcare we can offer them. They must be made to understand that their country made demands on them, and those demands were outside the realm of what we see in our day to day lives. Suffering from PTSD is not their fault .  We as a country owe them whatever it takes to restore their mental health and physical well-being. 

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