August 6 , 2007

Coming Home — PTSD in Today’s War Veterans
By Richard Currey, PA-C
For The Record
Vol. 19 No. 16 P. 28

With a stunning public health issue imminent, mental health professionals must prepare for the tough road ahead.

When former Army National Guard Captain Jullian Goodrum first began experiencing the symptoms of posttraumatic stress disorder (PTSD), he was confused. “I had no idea what was going on. It was as if someone had slipped some sort of bizarre drug into my coffee,” he recalls.

The Knoxville, Tenn., native found himself haunted by nightmares and daytime anxiety. As Goodrum’s symptoms progressed from intermittent and annoying to constant and disabling, he experienced a persistent fatigue and malaise that progressed to a paralyzing depression.

It would ultimately be a civilian psychiatrist who diagnosed Goodrum’s PTSD, underscoring the military’s reticence about combat-related stress and its psychic fallout. Although never an official stance, the Pentagon’s hesitancy to confront and accept what is, in fact, a ubiquitous aspect of combat has been long-standing and detrimental to the health and stability of thousands of service members.

But the times—along with Pentagon and U.S. Department of Veterans Affairs (VA) policies—may be changing. Military doctors and combat medics are better educated about the early triggers for PTSD. Combat stress teams—usually medics with additional training in counseling and psychological assessment—now serve on the ground with combat units. A unique pilot program at Walter Reed Army Medical Center has utilized the skills of social workers in pioneering “whole person” post-deployment care for service members struggling with PTSD and other impacts of war. The VA’s National Center for Post Traumatic Stress Disorder has developed an Iraq War Clinician Guide, now in its second edition. And the VA’s Seamless Transition of Returning Service Members initiative is up and running.

“Seamless Transition is a special program created by the VA and designed to specifically address the needs of veterans who have served in Iraq and Afghanistan,” explains Richard H. Selig, PhD, LSCSW, LCMFT. Selig is program manager and coordinator of the Trauma & Transition Resource Program for the VA’s Eastern Kansas Health Care System, which includes two major VA medical centers in Leavenworth and Topeka.

The goal of Seamless Transition, described in Congressional testimony by Robert H. Roswell, MD, undersecretary for health for the VA, is straightforward: Deliver the highest level of care in a timely manner. The challenge imbedded in that 10-word mission statement lies in the execution. PTSD, with its many associated issues, impacts families and communities and is predicted by many to soon be overwhelming.

Old Problem, New Name
The diagnostic category now known as PTSD—309.81 in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition—is, of course, a malady as old as war itself and as variable as every war’s political era and the unique geography of combat, be it desert, jungle, or city streets. PTSD has gone by many names through the years, from battle fatigue and shell shock to combat exhaustion, acute situation reaction, and even, in World War I, the clanks.

Wherever there has been war, there has been individual psychological devastation and the formidable challenges of recovery. And it is here, in the landscape of recovery, that caregivers work to understand the precarious balance between memory and psyche. There is a point in the near future when combat-related stress disorders will touch virtually every facility, institution, hospital, and private practice in America.

PTSD has become something of a household term in the last decade, and whether related to combat, an accident, or some other trauma, the results are similar: anxiety, hypervigilance, and impulsive, sometimes violent, behavior undercut by depression, substance abuse, chronic unemployment, emotional numbness, homelessness, and suicide. Recent research points to more than emotional distress at the core of the phenomena, as biochemical pathways are increasingly implicated in the behavioral changes that PTSD generates. As mounting research and collective clinical experience confirms that PTSD is not simply an affliction of battered and limping psyches but a neurological disease as well, the coming national burden of combat-related PTSD was clarified, ironically, by the Army itself.

Looking at mental health problems in veterans of Iraq and Afghanistan, Army psychiatrist Charles Hoge, MD, and his colleagues at the Walter Reed Army Institute of Research published in 2004 what is now regarded as a landmark study (Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.N Engl J Med. 2004;351(1):13-22).

The Hoge study notes that more than 80% of soldiers and Marines experienced at least one firefight, with survey respondents reporting “a very high level of combat experiences, with more than 90% reporting being shot at, a high percentage reporting handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant.” As many as one in six surveyed after returning from Iraq suffered major depression, generalized anxiety, or met formal diagnostic criteria for PTSD.

These observations reflect a combat force exposed to multiple stressors far exceeding anything seen in recent conflicts. This guarantees a generation of veterans whose psychological needs will trump anything the nation’s healthcare providers have faced in the past. With other subsequent data accruing, it is now generally understood that a stunning public health issue of PTSD is in the offing. As if that were not disturbing enough, the bad news, in the opinion of Matthew Friedman, MD, PhD, director of the VA’s National Center for Post Traumatic Stress Disorder, is that “the [Hoge] study underestimated the prevalence of what we are going to see down the road.”

The Hoge study received widespread media attention, rare for a scholarly article published in a journal devoted to research and clinical medicine. But the study spoke to something else—a national concern that transcends statistics about a particular group of combat soldiers. These soldiers, much like those of the Vietnam era, are fighting an increasingly unpopular war. Among the many lessons of Vietnam, one appears to have stayed with us: A war may lose political support, but we cannot abandon that war’s veterans.

The emerging challenge for caregivers is recognizing the clinical variations of PTSD, knowing how to address the needs of the veterans of Iraq and Afghanistan, and becoming familiar with resources and programs.

A Devastating Detour
Goodrum enlisted in the Navy and served aboard a ship during the first Gulf War. After leaving the Navy to attend college, he realized he missed the order and structure of military life. With an undergraduate degree completed, he returned to uniform, this time as an Army National Guard officer.

“I looked forward to a career,” he says. “I had every reason to think this is where I could make my best contribution in life.” As a platoon commander in Iraq in 2003, Goodrum led security forces tasked with protecting convoys along unprotected (and often unmapped) highways in the interior of Iraq. Despite desert standoffs with insurgents, frequent mechanical breakdowns in hostile territory, attacks on his convoy, and motivating an underequipped, frightened, and stressed-out platoon, Goodrum aimed to do his job, complete his tour, move on to another assignment, and carry on with his career.

It was not to be. Goodrum returned to the United States on other military duties but says he soon found himself in trouble. “I was coming apart at the seams. There were the dreams, the edginess, the constant sense that I had something to fear—as if something or somebody that meant me harm was just around the corner. My mind was no longer my mind. I was going over a cliff,” he explains.

There had been a time, however, that Goodrum remembered seeing himself as invincible, at least psychologically. This attitude is not unusual; indeed, it is virtually a requirement of military service. Many young soldiers imagine that the rigors of battle will be tough but tolerable. They believe—and the military has traditionally institutionalized this belief—that only “weaker” comrades will succumb to some form of PTSD.

This attitude toward the psychological impact of combat hearkens back to an earlier time, exemplified by a notorious episode in World War II when Gen George S. Patton publicly derided—and slapped—a soldier suffering from what we now know was PTSD. Although Patton was compelled to apologize, his apology was more a public relations maneuver than a reflection of official policy. And while neither the Pentagon nor the VA have ever formally repudiated PTSD or officially refused to treat affected veterans, an informal perception has long held sway that PTSD is a failing among a few unstable “bad apples.”

Many veterans—Goodrum among them—are eager to correct this misconception. And one way to do so, Goodrum believes, is providing more training, education, and professional support for social workers, psychologists, and psychiatrists throughout the military and VA systems. “First, we need to understand that PTSD can happen to anybody. Second, it’s more common than we think. Consider my case: I was turned away by the Army’s medical system. Turned away or ignored. All the while, my PTSD was brewing unchecked. I’m sure my situation is not all that unique, which suggests a broken system that dishonors all Americans, not just those of us who happened to serve. I say, if it’s broke, let’s fix it,” he says.

This is what’s happening at the VA, illustrated in the work of Selig, program manager for, in military parlance, OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) services. “I oversee all Seamless Transition activities,” Selig says, “along with coordination of care and services for all OIF/OEF service members and veterans treated at our facilities.”

In that role, Selig also oversees a range of clinical interventions for reservists and National Guard veterans. “By virtue of a special memorandum of understanding between the VA and the Kansas Army National Guard, we provide interventions and care along a continuum from predeployment, deployment, and postdeployment,” he says. “While we certainly treat PTSD and related disorders, the emphasis of this program is to begin to intervene with the soldier and family before deployment in order to provide training in the skills and techniques necessary to improve emotional resiliency and strength. We want to improve personal resources in an attempt to help reduce or mitigate the effects of stress—before a soldier ever goes into action.”

Predeployment counseling is, in itself, innovative, but there is another new and complicating element in this war. “The ‘signature’ injury of this war,” says Selig, “is traumatic brain injury (TBI).” This injury results from a kind of mega-concussion, commonly seen in survivors of explosions. TBI-affected individuals can be as debilitated as stroke survivors and must relearn walking, speaking, and simple motor skills. Veterans with concurrent TBI and PTSD are increasingly common, compounding the complexity of care and long-term alternatives.

Recognizing that most wounded veterans will not return from the front with only PTSD, “the VA has established a Polytrauma System of Care in order to specifically address issues related to lasting injuries due to polytrauma and TBI,” according to Selig. “The VA polytrauma system is organized around an interdisciplinary model of care delivery. Specialists from several medical and rehabilitation disciplines work together to develop an integrated treatment plan for each veteran.”

Selig says the VA is improving coordination of care for polytrauma veterans with concurrent PTSD by assigning a social work case manager to every patient treated at the polytrauma centers. This case manager coordinates the continuum of care; acts as a point of contact for emerging medical, psychosocial, or rehabilitation problems; and provides psychosocial support and education. “This is all augmented via a new telehealth network that links facilities and ensures that polytrauma and TBI expertise are available throughout the entire system of care,” Selig says.

“In regard to PTSD alone, the VA has over 200 specialized hospital-based PTSD programs,” Selig says. “Here at the Eastern Kansas Health Care System, we have both an inpatient and outpatient PTSD unit in addition to our specialized treatment program designed for reservists and National Guard personnel. And the VA has mandated additional funds, resources, and staff to meet the growing mental health needs of OIF/OEF veterans. Twenty-three new community vet centers have been added to the VA system, and every new enrolling veteran is screened for PTSD as well as TBI.”

Selig agrees that the number of vets in need of mental health services (or related assistance) will rise. “As the incidence of multiple deployments becomes increasingly common,” he says, “soldiers are subjected to longer and multiple tours of duty and are clearly at risk for higher incidences of stress-related disorders.”

But Selig also emphasizes that with help, time, and an organized care management system, most vets confronting PTSD or polytrauma can recover. Goodrum confirms that, one year or more from being “essentially a madman,” he is working his way back home in both body and spirit, relocating heart and soul. If the road has been treacherous, he sees new hope and possibility in the days ahead.

Selig says, “Combat not only affects an individual; it affects everything in that person’s life, everybody they know, everybody that cares about them. Effective treatment and transition from these experiences will require the full and complete understanding of combat and its sequelae.”

— Richard Currey, PA-C, is based in the Washington, D.C., area where he currently works with several agencies within the National Institutes of Health as a writer and consultant.

What To Look For and How to Help
Fred Bush, LMSW, is the returning veteran behavioral care coordinator at the Syracuse (NY) Veterans Affairs (VA) Medical Center. “Combat stress is as much a community problem as it is an individual issue,” Bush says. “Social workers inside the VA system are passionate about getting the word out about combat-related polytrauma. If we fail to educate providers and raise awareness about this issue, the burden on social service agencies and individual caregivers will be shocking.”

Bush offers several key points for recognizing potential warning signs that a combat veteran may have a problem, including the following:

• Readjustment issues are to be expected. But if they persist, returning soldiers should seek help from a mental health professional.

• Acute behavioral changes such as excessive drinking, social isolation, or elevated levels of anxiety signal a need for intervention.

• Soldiers returning from combat tend to sleep lightly for some time, but continued problems sleeping or repeated bad dreams are signs that help is needed.

• Marital readjustment periods after being in a war zone are common. Returning spouses should feel needed and useful and reclaim responsibilities they used to perform, even if the spouse who stayed home has been doing them.

• Returning soldiers need at least one person to talk to about their experiences. Family and friends should make it clear, without excessive nudging or pressure, that they are available and willing to listen. Some soldiers will think they should not share accounts of dangerous or disturbing situations they faced, fearing such stories will unnecessarily disturb friends or family members. It is important to share these stories with the right person and reach out for support.

• Returning soldiers may have been near explosions and may have undiagnosed brain injuries. Unusual, erratic, unexpected, or “out-of-character” behavior could be a red flag indicating a need for intervention.

• Even if you disagree with the politics surrounding the war, be sensitive when talking to returning vets. A “thanks for your service” goes a long way.

For more information about readjustment issues faced by returning soldiers or to find out how to get help, call the Veterans’ Administration’s Telcare information line at 888-838-7890.

— RC