FACES OF COMBAT
PTSD and TBI
One Journalist’s Crusade to Improve Treatment for Our Veterans
Eric Newhouse
Issues Press – Smashwords Edition
Issues Press
An imprint of Idyll Arbor, Inc.
39129 264th Ave SE, Enumclaw, WA 98022
Cover design: Pat Kenny
Editor: Kenneth A. Lucas
(c) 2008 Idyll Arbor, Inc.
International copyright protection is reserved under Universal Copyright Convention and bilateral copyright relations of the USA. All rights reserved. No part of this book may be reproduced in any form or by any means — electronic, mechanical, photocopying, recording, or otherwise — without the prior written permission of the publisher.
Ebook License Notes
This ebook is licensed for your personal enjoyment only. This ebook may not be resold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person you share it with. If you are reading this book and did not purchase it, or it was not purchased for your use only, then you should return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author and publisher.
ISBN: 9781930461116
This book is gratefully dedicated
to the courageous combat vets and their families who shared their stories with me in the hope of helping their comrades and forcing reform of the system;
to the Great Falls Tribune, which allows me to report on significant social issues; and
to God, without whom none of this could have been possible.
* * *
Jesus said to him, “‘You shall love the Lord your God with all your heart, with all your soul, and with all your mind.’
This is the great and foremost commandment.
And the second is like it: ‘You shall love your neighbor as yourself.’
On these two commandments depend the whole Law and the Prophets.”
— Matthew 22:37-40
Also by Eric Newhouse
available from EricNewhouse.com and Issues Press
Alcohol: Cradle to Grave
Nearly Knighted: Life after Winning a Pulitzer Prize
(Also on Smashwords)
Contents
5 – Unpredictable, Unrelenting Anger
8 – Flashbacks—Videos that Won’t Stop
10 – Occupation: Pushing Papers
12 – Why are Some Soldiers More Resilient?
15 – VA: Overload and Confusion
Preface
I was drafted into the U.S. Army in 1968 at the beginning of the war in Vietnam. A fresh graduate of the University of Wisconsin and a cub reporter for the Rockford (Illinois) Morning Star, I didn’t want to go to Vietnam. I feared I would die there and I didn’t want to die. U.S. Senator George McGovern of South Dakota was galvanizing a protest movement against the war; he was a hero to my generation, although I didn’t get to know him personally until a decade later when I was working for the Associated Press in Pierre, South Dakota. In the late ’60s, there were protest marches on campuses across America — Wisconsin was typically in the vanguard — and some young men went to Canada to avoid the draft. That was something I considered, but I could not bring myself to disobey the law. Instead, I told my wife-to-be that if Uncle Sam sent me home in a box with a flag draped over it, I wanted her to burn the flag.
As it happened, I never went to ’Nam. Through some glorious good fortune, I ended up as a writer on the base newspaper at Fort Meade, Maryland, and then as a public relations specialist for the U.S. Army Field Band and Soldiers Chorus, also based at Fort Meade.
Many of my friends were sent to fight, however, and not all of them came home. Over the years, most of them suffered and at least one committed suicide. I watched them, not really understanding what they were going through, and never asking the right questions. And I never knew how the war could affect even those who didn’t fight in it.
About a decade ago, my youngest daughter, Sarah, graduated from Shepherd College just outside of Washington, DC. I was (and still am) the projects editor for the Great Falls (Montana) Tribune, and my wife Susie and I went back east for the graduation. I stayed with my daughter in DC over the Memorial Day weekend, and the veterans on Harleys who call themselves “Rolling Thunder” were everywhere. Squadrons of motorcycles were roaring up and down Pennsylvania Avenue, and I realized that it was the perfect opportunity to visit the Vietnam Veterans Memorial.
So we joined the line of burly bikers in their black leather jackets and inched forward until we came to that wall, containing the names of 58,000 soldiers who died in Vietnam, panel after panel after panel of them. I was looking at the wall, trying to figure out which two years of it I had served in the Army, when a park ranger came by. I asked whether one particular panel would commemorate those who had died at the end of 1969, and the ranger told me that this was indeed the panel.
“So,” I said, turning to Sarah, “these panels would have been some of the soldiers I served with.”
“Welcome home, sir,” said the ranger.
Instantly, I was sobbing helplessly on my daughter’s shoulder while the park ranger rubbed my shoulders. I couldn’t believe it, still can’t believe it. How could I have such an emotional reaction when I had never been in combat, never been shot at, never been forced to take a human life?
War scars us all, but does the most damage to those closest to it.
When the invasion of Iraq/Afghanistan was ordered by President George W. Bush, I began to sense the eerie echoes of Vietnam all over again. The only real difference was that there was no universal draft. Instead, the government began using what it called private security contractors, former soldiers fighting as mercenaries at about triple the pay of regular soldiers. As soldiers left the military to get rich as mercenaries, about a third of the forces in the field were contractors. It has been terribly expensive, but it avoided the draft that brought the pain of war home to all American families — and it avoided most of the huge protests, too.
So perhaps you can consider this book my protest. I want you to see war through the eyes of those who have been there. I want you to understand what it’s like to come home, emotional warriors in a civilian world. And I want you to feel their frustration as the treatment that they deserve and need too often gets lost in bureaucratic paperwork.
As a journalist over the past four decades, I’ve tried to amplify the voices of those who usually go unheard so that the public and the policymakers understand what’s happening to the people they don’t see and to the people they’re conditioned not to hear. Instead of showing the average, I deliberately want you to see the faces of those making extreme cries for help.
Because the reality is that many vets, even those who aren’t extreme cases, aren’t getting the help they need and deserve.
* * *
In addition, I want you to know how war harms the combatants. Many of the experts, including those in the Department of Defense (DOD), say that 25 to 40 percent of the soldiers who come back from war will experience post-traumatic stress disorder (PTSD) so severely that they may require treatment, primarily counseling and medications, for many years, if not for the rest of their lives.
Between 2001 and the end of 2007, America has deployed 1.6 million troops into Iraq and Afghanistan. “Fifteen to 20 percent of OIF/OEF [Operation Iraqi Freedom/Operation Enduring Freedom] veterans will suffer from a diagnosable mental health disorder,” said the VA’s Special Committee on PTSD. “Another 15 to 20 percent may be at risk for significant symptoms short of full diagnosis, but severe enough to cause significant functional impairment.” The Dole-Shalala Commission put the risk even higher: “Fifty-six percent of active duty, 60 percent of reserve component, and 76 percent of retired/separated service members say they have reported mental health symptoms to a health care provider.”
Dr. James Peake, as of this writing the secretary of Veterans Affairs, thinks those estimates are too high. He told me: “About 30 percent of those coming back have some need for counseling, but it would not be appropriate to label them all with PTSD. We’re still sorting out what percentage should be labeled with PTSD, but I think it’s less than 30 percent.”
A few months after I spoke with Dr. Peake, the RAND Corporation issued a 500-page report showing that one combat vet in three would come home with either PTSD, traumatic brain injury (TBI), or major depression. And it called those prevalence rates conservative.
That’s a staggering number in itself, but most combat vets still think the problem is being understated. Some of the vets say that all who serve in combat will come home disabled, and that it would be better to reverse the assumption and offer help to everyone — let those who don’t need it demonstrate that they don’t.
* * *
I also want you to understand how hard it is to get treatment. According to the Congressional Budget Office, nearly half the Iraqi/Afghan vets are eligible for help from the Veterans Administration because they’ve separated from active duty or because they are eligible as members of the Reserves or National Guard. They’ve been promised two years of free medical treatment for any service-related disability, but only about one-third of those seeking VA medical care since 2002 (for a variety of reasons) have actually been able to get it.
In 2008, the number of vets receiving treatment is expected to grow to 5.8 million as the ’Nam vets get older and the Iraqi/Afghan vets begin to realize their injuries. But the system is overloaded even without the Iraqi/Afghan vets.
“We saw 400,000 people with PTSD last year,” VA secretary Peake told me early in 2008. “But it was a significantly smaller number from OIF/OEF. We had lots of Vietnam vets and some from World War II. It looks like we only had 37,000 PTSD cases from confirmed service in OIF/OEF.”
Compare that 37,000 to the 480,000 predicted to have PTSD, TBI, or other significant health needs (30% of 1.6 million) and you can see that the VA will be overwhelmed if it doesn’t more than double its current capacity.
It’s frustratingly hard for a vet to get help. The Government Accountability Office (GAO) has found that the VA is so underfunded and understaffed that nearly half of the returning vets eligible for treatment did not receive it. The VA has an average delay of 177 days before it begins providing disability pay and benefits. And despite intensive review by the GAO, eight congressional committees, a presidential task force, a presidential commission, as well as the Pentagon and the VA itself, the government has no apparent solution.
It’s only going to get worse unless we commit the necessary resources to solve the problem.
* * *
Finally I want you to look at some of the possible solutions. Innovative programs, increased spending on effective resources, and improved treatments are all possible ways out of this crisis. It’s not hopeless, but we do need to step up and decide to take care of our veterans.
* * *
I’d like to thank the Great Falls Tribune and particularly its publisher, Jim Strauss, for allowing me to use stories I wrote for the Tribune in this book. I’d also like to thank my wife Susie for her good suggestions on writing this book and my good friend Paul Edwards for reading a rough draft of it and telling me how to make it better. Joe Califano, chairman of the National Center for Addiction and Substance Abuse at Columbia University, and CASA’s vice-president Sue Foster also invited me to sit in on a very useful conference on stress and alcoholism in New York City. Finally, local counselors like Christine Krupar King, Keli Remus, and Dr. Michael Mason have been invaluable in suggesting PTSD victims for me to talk to and helping me understand what they were saying.
You will notice throughout the book that I discuss the situation in Montana more than the rest of the country. There are reasons for that. The simple reason is that Montana is where I live. The complicated part is that we are looking at men and women who have severe emotional injuries from their military service. I didn’t call them on the phone for a quick half-hour chat. I spent days with many of them before they trusted me with their stories. But don’t worry, you can find the same Faces of Combat in your own community. And every single one of them needs our help.
Part 1: The Problem
Here we look at the Faces of Combat to see what happened to them in the service of our country, how they were treated when they returned, and the ways our country has either helped them or tossed them aside.
Chapter 1: Death makes a difference
If many of the Faces of Combat look tormented, it’s because they came home laden with guilt and shame. Montanans recognized that for the first time after March 4, 2007, when one combat vet put a .22 against his head, muffled it with a comforter, and ended his life as quietly as a book drops. He had PTSD and didn’t get the help he needed.
Montana has always been a very patriotic state, drawing recruits from prairie towns and from its Indian reservations. It ranks tops among the states with the greatest number of vets per capita, and it prides itself on caring for its soldiers and their families.
That’s why it came as such a shock when Chris Dana put a bullet through his brain. That’s also why Dana’s death transformed Montana into a national model for reintegrating combat vets back into civilian society.
Dana was a kid who joined the National Guard shortly after graduating from high school in Helena. Part of him died fighting in Iraq; the rest followed a few days after the Guard threw him out for having a bad attitude and failing to follow orders.
“That’s happening all too often,” said Steve Robinson, director of Veterans Affairs for the Veterans for America in Washington, DC. “Too many vets suffering from PTSD are being treated with disciplinary action. We need to be educating military commanders on PTSD.”
War changed Dana. He wasn’t always that way, his family told me.
“Before he left, he had a smile that could light up a room,” said his stepmother, Linda Dana. “You were never quite sure whether he was laughing with you or at you. But when he came back, that light had gone out. He’d lost his essence.”
“He was innocent,” said his dad, Gary Dana, sitting outside on a porch that overlooked the trailer in which his son had lived. “He went to high school, played sports, and then he got thrown into the war. Growing up that fast was too much for him.”
Chris was never an aggressive kid. He was one of the helpers. He was good with kids and liked them. His dad, who lives just outside of Helena and works construction, figured his son would become a social services worker and be happy helping people solve their problems.
Instead, Chris came home from high school during his senior year in 2002 and told his folks that a recruiter had visited their school and he’d signed up for the National Guard. That was a surprise, but it wasn’t particularly alarming. America wasn’t at war yet, and the discipline of serving in the military was considered to be a good way for teens to mature.
Right after high school, Dana went to Fort Knox, Kentucky, for boot camp and training, and then returned to Helena in 2003. He worked at a Target store and attended weekend drills. “During that time, he had no problem going to the drills, but after he got back from Iraq, it was an entirely different story,” said his dad.
No one knows what happened
Chris went to Iraq with the 163rd Infantry Battalion, in what was the largest deployment of Montana soldiers since World War II. They were in the midst of some of the toughest fighting there was, but afterward, Chris couldn’t talk about it.
“He’d tell us he’d been through a lot, then he’d drop it,” recalls his stepmom Linda. “But then his eyes would just get vacant, and he wasn’t there any more.”
He could talk with his dad a little bit: “He told me that one time he was on top of his Humvee manning a 50mm machine gun when his sergeant yelled at him, grabbed him, and pulled him down. Had he not done so, a rocket would have decapitated him. And he said another time they took fire from some trees and returned the fire. Later, they inspected the site, but he said there wasn’t much left of the guys.”
He called home twice from Iraq, but spent much of that precious time talking about computer games and trivial things. “He kept things inside him because he didn’t want people to worry about him,” his dad said.
But a couple members of his unit told the Missoula (Montana) Missoulian newspaper that they were among the troops assigned to keep the first national polling places in Baqubah open, a tense situation given the fact that Baqubah sits on the edge of the Sunni Triangle and Sunni insurgents were determined to sabotage the election. After the election, their unit was ordered to provide security for the truck hauling ballots back to be counted. “The last polling place was a mile up the road, and we had a big concrete barrier to get out of the way,” remembered Sgt. Dave Bauer. As they stopped to try to move it, an IED (improvised explosive device) blew up near them and rocket-propelled grenades (RPGs) showered down on them. “It knocked my commander out cold,” Bauer told the newspaper. “I was shaking him, trying to wake him up, and another guy threw a pipe bomb at us from a bridge. We had the road unblocked, so we started going up it, trying to figure out who was firing at us.”
They took the Bradley armored vehicle about three-quarters of a mile up the road to a grove of palm trees where the insurgents had retreated, and more RPGs were fired at them. One hit a power transformer, showering the soldiers with sparks and oil. Bauer grabbed the coaxial machine gun on the Bradley and opened fire, cutting the trees apart. Then an ammunition dump went up in a terrific fireball, and the squad cheered. “There were fires everywhere and trees were down,” Sgt. Fred Hanson told the Missoulian. “There were Apache helicopters above us, but they didn’t have to do anything. Dave took care of business.”
Shortly after the 163rd returned in October 2005, Chris’s company was disbanded and the soldiers were assigned to drill with other companies. Chris was ordered to drill in Butte, and it was a disappointment because it broke up a lot of close personal ties. He didn’t see much sense in reporting for duty with a new unit, so he didn’t. “Separating Chris from his friends was one of the worst things the government could have done,” said his dad.
From the first day of his return, Chris was clearly struggling, clearly trying to put the best face on his problems so as not to worry his family, according to his stepbrother, Matt Kuntz. “The Christmas before last, he seemed to be doing pretty well externally. He was really proud and excited that he was returning home as a hero to his family. My sister and I asked him how he was. He said he was struggling, but he could handle it.”
Bauer came back and was diagnosed with PTSD, and he knew what Dana was going through. “He was a young guy who would get into bed with his uniform and boots on, curl up in a fetal position, and fall asleep,” Bauer told the Missoulian. “He’d never take that uniform off. He’d stay in it for weeks.”
His family noticed other changes. He was real skittish, real jumpy. He didn’t seem to like to be around people. “And he was real short with his dad,” said Linda. “Gary would start a conversation, and Chris would shut him right down. I’d never seen him do that to his dad.” And it got worse and worse. “He wouldn’t take our phone calls,” said his stepmom. “He’d go for five or six days of silence, then he’d call like nothing had happened.”
Red flags for PTSD
To Matt Kuntz, a former Army officer and a Helena lawyer, the diagnosis of PTSD for Chris Dana seemed obvious. “You could look at his military personnel file and see PTSD,” he said. “You could see a guy who’d been through a hard war, come home, and shut down.”
Drugs and alcohol didn’t seem to be a problem. Gary Dana is a recovering alcoholic, and he’d told his son about the dangers of abusing alcohol. He’d also told the boy that alcoholism runs in families and that his risk of abusing alcohol was higher than average. So Chris might go out on a bender with his friends occasionally, but it wasn’t a regular thing. “He was a Pepsi guy,” said his stepmom. “He wasn’t much of a drinker.”
They were able to keep an eye on him because Chris was living right across the road in a trailer that his dad had bought while Chris was in Iraq. He fixed it up, added an annex for a roommate, and invited Chris to move in after he got back. He charged a modest monthly rent of $200 apiece.
After a while, they noticed that Chris wasn’t going to Butte for his drills and asked him about it. “He told us he was quitting, that he couldn’t handle the drills anymore. Then I got an email that Chris wasn’t reporting for his drills and asking me to look into it. And I got a call from Chris’s Guard superiors. It wasn’t ‘What’s happening to Chris?’ It was telling me to get Chris there because he’d get a dishonorable discharge if he didn’t go to drills,” said his dad.
“I heard Gary take about three calls from the Guard, but they never asked about Chris, asked about his physical or mental health,” said his stepmom.
“I could see that he didn’t want to go back, that he didn’t want any part of killing any more,” his dad said. A childhood friend had moved into the trailer with Chris to keep him company, but could only watch his increasing isolation and depression.
Gary Dana tried to respect his son’s privacy, not to interfere, not to get too emotionally sucked into his son’s problems, although he did ask Kuntz, to see whether he could help Chris get out of the National Guard with an honorable discharge. “I told Chris what I’d done, and he said, ‘Dad, why’d you do that? Why don’t you just get out of my life?’”
Kuntz set up an appointment for counseling, but Chris cancelled at the last moment. Although it was getting harder to reach him by phone, he’d still talk a little. “During one call, he said he was really struggling, having a lot of trouble getting through his days,” said his stepbrother. “I kept calling, but he quit returning my phone calls. I guess I called him for two weeks, but I finally figured if he didn’t want me to help him, I couldn’t help him. But I’m afraid now that I didn’t realize how serious it was.”
Planning his death
By Thanksgiving of 2006, Chris was avoiding his family even more. He told his dad that he’d have dinner with his mother, but he didn’t. He just stayed home that day. “And he did the same at Christmas,” says his dad. “He told us he didn’t want any presents and he didn’t want to do anything. So as a present, I gave him a month of free rent. That may have bought him one more month of life.”
His dad didn’t realize it at the time, but Chris was in the process of quitting his job at Target and spending his resources down. “In January and February [2007], he really started to spend money,” his dad said. “I guess he figured when he ran out of money, it would all end.”
In February, no one knows exactly when, Chris received notice of his less-than-honorable discharge, effective February 28. Typically, he told no one about it.
Kuntz was troubled and angered by his stepbrother’s less-than-honorable discharge. “A lot of the people who have been our best soldiers and done our best work are getting real bad discharges,” he said. “He quit going to his drills. He was so badly injured that he couldn’t deal with the military any more.” Kuntz wonders why the Army wasn’t more sympathetic to Chris. “Instead of going out and seeing him in a non-threatening way, they made his life a living hell,” he said.
Kuntz said his stepbrother’s superiors in the National Guard called Chris to tell him that such a discharge would ruin his life by making him functionally unemployable. “Chris said, ‘I can never stop working for Target because if I do, I’ll never get more work again.’ Chris gave off every red flag. He was a good soldier who quit going to drill.”
His roommate could also see danger flags. “His roommate said he was getting worried that last week,” said his dad. “He was getting more and more quiet, and he wasn’t working.”
On March 1, Gary Dana didn’t get the usual rent payment. Two days later, he figured he’d bring up the subject casually so he went over to his son’s trailer with a couple of blankets. Chris’s car was there, but at noon, there was no answer at the door. Late in the afternoon, he went back.
“Chris answered the door, and he looked groggy. He was pretty testy and I knew I had to watch what I said so I asked whether he’d been out all night and forgotten what day it was. He asked what day it was, and I told him the rent was due. He said he’d go into town and get some money. Then we talked some more, and I asked about his stepbrother, Matt, and his efforts to get his dishonorable discharge changed. He told me he’d told Matt not to bother. I asked why, and he told me it didn’t matter. I started to ask why, but I knew he’d just snap at me, so I didn’t say anything. I just told him I loved him, and he said he’d get some money and he’d call me in the morning.”
That was Gary’s last conversation with his son, and he knew something was terribly wrong. “I came home feeling awful, like something was happening that I didn’t understand,” he said.
The next morning, he made a point to be doing some yard work and wore his cell phone, but Chris didn’t come out of the house and didn’t call. At about 5 p.m., his dad called and got the answering machine. He was still close to the cell phone at 11 p.m. when the roommate, a nurse who worked nights and had just woken up, called to say that Chris had shot himself.
“The coroner says he probably shot himself about 5 or 6 o’clock,” his dad said. “He put a .22 against his head and muffled it with a comforter. He said it probably made no more noise than a book dropping.”
Gary Dana watched from his own home as the ambulance and medical examiner came and removed his son’s body. Later, he went over to see if he could find any answers to his own questions. He found boxes of video games that Chris had bought, but never bothered to open. And he found a receipt for the shells dated February 27.
Congressional hearings demonstrate shortfall
U.S. Rep. Bob Filner, D-California, chairman of the House Committee on Veterans’ Affairs, held a hearing recently that found the VA is not reaching the vets who need help.
“The VA mental health system is broken in function and understaffed in operation,” testified Mike Bowman, father of Spec. Tim Bowman, who committed suicide in 2005. “There are many cases of soldiers coming to the VA for help and being turned away or misdiagnosed with post-traumatic stress disorder and then losing the battle with their demons. Those soldiers, as well as our son Timothy, can never be brought back. No one can change that fact. But you can change this system so this trend can be slowed dramatically or even stopped.”
Noting a recent CBS television report that the rate of suicide among vets is double the national rate, Rep. Filner said, “The rate of veteran suicides has reached epidemic proportions. Suicide can be a very difficult public health crisis to gauge. I am more troubled by a lack of response by the VA than I am at not having perfect statistics. We need to hear from the VA what this agency needs in order to be able to reach out to all veterans. We know that the images of war trigger reactions in veterans from past conflicts. We need to go find Vietnam veterans and help them. We are not reaching the people who need help.”
Half the VA facilities checked recently by the Inspector General’s Office said they were attempting to identify at-risk patients through such methods as checking frequency of visits, utilization of outpatient treatment groups, and increased phone calls. But staff training was severely lacking. “Approximately 40 percent of all respondent facilities reported providing education programs for first-contact personnel that were mandatory; approximately one-third of all responding facilities reported inclusion of suicide response protocols; and a little less than one-fifth reported that programs inclusive of response protocols were mandatory,” reported the VA’s inspector general.
Further, it noted that the delay in receiving services was shameful. According to the inspector general, a vet seeking help for depression would receive an evaluation the same day at 40 percent of its facilities, 16 percent within a week, another 16 percent within two weeks, two to four weeks at 25 percent of the facilities, and four to eight weeks at the remaining facilities.
For substance abuse, 42 percent of the facilities gave a same-day evaluation, 24 percent within a week, 14 percent within two weeks, and 18 percent within two to four weeks.
A vet complaining of PTSD symptoms would get an evaluation the same day at 34 percent of the facilities, 17 percent within a week, 17 percent within a week or two, 26 percent within two to four weeks, with the remainder at a month or two.
And the inspector general said the VA should loosen its criteria for treating PTSD. Currently, only veterans with “sustained sobriety” get treatment, his report said.
An earlier trauma
Now Chris Dana’s dad lives with guilt. “I keep wondering what would have happened if I hadn’t gone over there to ask for the rent,” he says.
Among the boxes, Gary Dana also found a small green notebook that his son carried during his year in Iraq. One entry from August 2004 was particularly poignant: “The last year I played baseball, we were undefeated. I turned 21 two days before I got deployed. When I was eight, my dad and me got into a four-wheeler accident, and he had been drinking. He quit after that. Went to Mexico spring break of my senior year.”
Those disjointed memories of a life too short hit his father hard. “When I read it, I just broke up,” he said. “How can you take a kid out of high school and make him kill people? What does that do to an innocent kid?”
Gary Dana has been sober for 15 years now, and his son’s death was a real test. He said he badly wanted a drink to dull the pain, but he refused — in part because of the four-wheeler accident that Chris remembered. Chris was six, not eight, his dad said, and he’d been drinking most of the day before Chris got home from school. His son wanted to play, so they took the four-wheeler out joy riding. When they hit a gravel pit, the four-wheeler flipped. Gary managed to throw his son off the machine, but it came back and landed on Gary’s head. His face was crushed. He lost his vision. Blood was everywhere, and he didn’t know if he was going to survive. “We got the machine back on its wheels, and I told Chris to drive for help. I held on as he drove to a little store across the street. We must have had a close call crossing the street because I heard a car honk right beside me. When we got to the store, I was such a mess that one lady went outside to throw up. As a kid, Chris probably had some trauma from that accident.”
Adding stress to stress
Previous trauma can make it harder for soldiers to deal with combat, agreed Dr. Rosa Merino, chief of psychiatry for the Veterans Affairs Healthcare Systems at nearby Fort Harrison, Montana.
Merino said preliminary data shows that about a third of the patients diagnosed with PTSD can begin to move on within the first year of treatment. “Another third experience symptoms for the next ten years or so, ebbing up and down,” she said. “And the last group has been exposed to combat, but may have been exposed to trauma even before entering the service.”
An estimated 10 percent of all Americans reportedly experience a form of PTSD as a result of repeated abuse, crime, or accidents.
In 2004, the Centers for Disease Control and Prevention tallied 32,439 known suicides, which made up 1.4 percent of overall deaths. That made it the 11th leading cause of death, with an overall rate of 11.1 suicides per 100,000 population. Among men between the ages of 20 and 65, that rate rises to about 20 suicides per 100,000.
But the VA can’t provide comparable suicide statistics for its own vets. There are approximately 25 million veterans in America, with 5 million of them receiving health care though the Veterans Health Administration. Based on those rates, VHA mental health care professionals estimate 5,000 suicides among all vets, and 1,000 among those receiving VHA care. But those are only estimates, guesses.
An Army report, however, found that the suicide rate for its soldiers was the highest in 26 years, and that about a third of the 99 victims killed themselves in Iraq. It also said there was some evidence that the extended length of deployments could have been a factor in some of the suicides.
And a later Army study found that the number of military suicides was 20 percent higher in 2007 than it had been in 2006. Its 115 suicides was the highest number in more than two decades. And the number of soldiers who killed or injured themselves for some other reason was six times higher in 2006 than it had been four years earlier, 2,100 soldiers in 2006 compared to 350 in 2002. Part of that may have been due to a more sophisticated electronic tracking system, but clearly not all of it. Even though fewer than a third of those who committed suicide did so in military theatre, that was more than double the active-duty suicide rate before the terrorist attacks of September 11, 2001. During that year, the Army experienced a suicide rate of about 9.1 per 100,000 troops — by 2006, that had risen 90 percent to a rate of 17.5.
By early 2008, the Office of the Surgeon General was recommending improvements to the Army’s suicide prevention plan. “Military suicide continues to be a significant problem in Iraq,” it reported. While 10.5 soldiers per 100,000 took their own lives in 2004, the probable suicide rate for 2007 was more than twice that — 24 per 100,000. By comparison, the rate for the entire active-duty U.S. Army was 9.8 per 100,000 in 2001, but rose to 17.3 in 2006.
“People don’t tend to commit suicide as a direct result of combat, but the frequent deployments strain relationships,” said Col. Elspeth Ritchie, psychiatry consultant to the Army’s surgeon general. And David Rudd, a former Army psychologist and chairman of the psychology department at the University of Texas, told the Washington Post that the increasing suicides raise “real questions about whether you can have an Army this size with multiple deployments.”
Vets make up only 13 percent of the nation’s population, but account for 20 percent of the suicides, according to the Iraq and Afghanistan Veterans of America. Male vets are more than twice as likely to commit suicide as men with no military service, and vets with PTSD are more than three times as likely to take their own lives as their civilian peers.
Among vets’ groups, there’s one dubious contention that surfaces from time to time. Some claim that more Vietnam vets took their own lives than actually died in combat. But to reach that number, you have to count: 1) every vet who died of a gunshot wound without leaving a suicide note; 2) every remotely suspicious accident; and 3) every fatal single-vehicle auto wreck. To my mind, that’s unrealistic. Still the argument makes a good point — a true suicide rate must be higher because there are undoubtedly a number of vets who staged fatal car wrecks to take their own lives without losing insurance benefits for their families. And to add credence to that dubious contention, Thomas Insel, director of the National Institute of Mental Health in Bethesda, Maryland, recently predicted that, due to inadequate mental health care for vets, the number of suicides among Iraq and Afghan vets may ultimately exceed the number of combat fatalities.
Some vets file suit
A lawsuit filed against the VA by two vets groups, Veterans for Common Sense in Washington, DC, and Veterans United for Truth of Santa Barbara, California, contended that combat vets are about twice as likely to commit suicide.
“Troops who have served in Iraq and Afghanistan are killing themselves at higher percentages than has taken place in any other war where such figures have been tracked,” it said. Pentagon statistics reveal that the suicide rate for U.S. troops who have served in Iraq is double what it was in peacetime. In early May 2007, a report was issued suggesting that 1,000 veterans under the care of the VA commit suicide every year. An additional 5,000 veterans who are outside the care of the VA commit suicide every year.
Another non-military study of 320,000 vets over the age of 18 found that male veterans are much more likely to take their own lives, often with a gun, than their civilian counterparts. “Male veterans are twice as likely as their civilian counterparts to die by suicide,” said the study’s lead author, Mark Kaplan, a community health professor at Portland State University who tracked subjects for 12 years. That finding is much higher than previous studies based on VA data. “Most veterans don’t seek or receive care through the VA system, so we have to be careful about earlier studies,” Kaplan said.
The VA Office of the Inspector General reported in May 2007 that the agency had to do a better job of tracking troubled vets.
“A comprehensive suicide prevention program must not only be able to identify those at risk for suicide, but ideally should identify periods of increased risk and should have a method for tracking at-risk patients to ensure that they receive timely and appropriate care,” it said. “About 30 percent of the facility responders reported electronically tracking veterans at risk for suicide. Approximately one-fourth reported tracking veterans through the electronic medical record, while another five percent said that they were using other methods to track veterans.”
Translated from government-speak, that means that 40 percent of VA facilities admit to not tracking suicidal veterans in any way, and two-thirds of them are merely giving lip service to the effort.
Chapter 2: What are PTSD and TBI?
Behind the Faces of Combat are brains traumatized by what we now call post-traumatic stress disorder. There’s a natural “fight-or-flight” reaction to the things that threaten us, but researchers are trying to figure out why some soldiers can’t return to normal after the threat is over.
About 15 years ago, I was driving into town from my new home along the Missouri River just southwest of Great Falls when I noticed an old car with its turn blinker on, paused in the oncoming lane of traffic. I didn’t think much of it until I was almost ready to pass it, and the car began edging into my lane of traffic. Going about 50 mph, I swerved onto the right shoulder, but the old car picked up speed and hit me right in the driver’s-side door. That pushed me down into a ditch and up over a driveway, at which time my van became airborne. Somehow it also turned about 90 degrees and touched down sideways. When the tires hit the ground, the whole rig rolled. We were in the process of building a house at the time, and the rear of the van was filled with tile and paint samples that flew all over the back and shattered the windows. I remember seeing the windshield blow out in slow motion. When it finally came to a stop, mercifully on the rims of its tires, the door wouldn’t open and I had to kick it out to be able to get out of the vehicle. Wearing a safety belt saved my life — I walked away uninjured, I thought.
I still drive that road today, and when I see a car stopped in the oncoming lane of traffic with its turn signal on, I get nervous. My mouth gets dry, my heart starts to thud, and my stomach knots up. I really want to stop, get out of my truck, and wave the oncoming car across the road in front of me. So one day I asked Eric Kettenring, the head counselor for the Vet Center in Missoula, whether these were signs of post-traumatic stress disorder.
“Post-traumatic stress,” he replied, “but not a disorder yet. Remember that you weren’t hurt, nor was anyone else. You weren’t out in the field picking up body parts or trying to treat the wounded. And this only happened to you once. Soldiers in the field experience far worse things, and they happen two or three times a day, day after day, every day for a year or for 15 months. So you take what you feel and multiply it several thousand times and you’ll begin to understand what PTSD feels like.”
That gave me a much better appreciation for what I was beginning to see in returning combat vets. Technically, PTSD is defined as a series of persistent symptoms that follow exposure to a catastrophe or series of catastrophes that are outside a person’s control and that cause feelings of intense fear, helplessness, or horror. For months or years, that trauma has the power to evoke feelings of panic, terror, dread, grief, guilt, despair, or depression. They may come back as persistent memories, traumatic nightmares, or psychotic re-enactments known as flashbacks, which are like watching a video without being able to turn it off. Combat vets usually find that flashbacks or intrusive memories are triggered by common sounds, smells, and sights. The sound of fireworks, the smell of diesel fuel, or the sight of a helicopter may trigger an involuntary rerun of a traumatic experience.
PTSD patients frequently find themselves emotionally numb in other situations or seek to avoid the situations that cause them pain. But by shutting down the negative emotions that lead to fear and panic, the emotional shutdown also blocks positive emotions, which can lead to isolation and divorce. People may be afraid to leave their homes because certain things may trigger symptoms. To be diagnosed with PTSD, they need to experience at least three of the following: emotional numbness, being dazed, losing contact with external reality, a feeling of loss of self or loss of identity, or an inability to remember parts of the trauma. These symptoms suggest a psychological state called dissociation.
And they frequently experience hyperarousal, which is like being constantly braced for the next barrage, unable to concentrate, unable to sleep. Anxiety levels are high, and some vets talk about panic attacks. Their emotional state significantly impairs normal functioning and normal relationships, leaving patients unable to help themselves.
“What is PTSD?” asked Dr. James Peake, secretary of Veterans Affairs. “You have to recognize that there are some normal reactions to combat. The things our men and women in uniform have to do will distress them, unless, of course, they are sociopaths. A lot of people returning from combat could benefit from some counseling to reintegrate with their families, but that doesn’t mean they should be marked for life with PTSD. It just means they need counseling to help them adjust.”
PTSD generally occurs after the threat has subsided, although prolonged exposure to combat can disable a vet in the field. The U.S. Army Office of the Surgeon General reported in early 2008 that “Nearly three times as many soldiers would be expected to report mental health problems at month 15 (of their first deployment) than would be expected to report problems at month one. Soldiers on multiple deployments report low morale, more mental health problems, and stress-related work problems. Soldiers on their third/fourth deployment are at particular risk of reporting mental health problems.”
There are four different types of PTSD based on onset and duration. “Acute stress disorder” begins within four weeks of a trauma and lasts at least two days. Symptoms lasting more than four weeks are considered “acute PTSD,” while those lasting more than three months are deemed “chronic PTSD.” Symptoms that begin more than a month after the trauma are called “delayed onset PTSD.” Combat, by its very nature, is a traumatic event, and greater exposure to combat frequently leads to more severe PTSD, complete with nightmares and flashbacks lasting for years, if not a lifetime.
Dr. Matthew Friedman, executive director of the VA’s National Center for Post-Traumatic Stress Disorder, cited an Army study showing that rates of major depression, generalized anxiety, or PTSD increased from 9.3 percent before combat to as much as 17 percent for Iraqi vets, with the prevalence of PTSD increasing in a linear manner with the number of firefights a soldier had experienced. He said half the vets with PTSD are likely to recover within two years while another 20 to 30 percent will recover within five years. “We know that of women who have been raped, 90 percent will have PTSD symptoms almost immediately. By 12 months, that will be down to about 50 percent. Our data shows that 20 or 30 percent of them will never recover, but this data was developed before effective treatment was available, so it may be subject to change,” he told me.
A look at the brain
To understand why combat vets like Chris Dana undergo so much post-traumatic stress disorder that they end up killing themselves, it’s necessary to take a look at the brain and the damage caused by combat — the horror and guilt of killing another human being, the terror of having bullets coming at you, or having to experience the bloody aftermath. So here’s a quick tutorial.
The brain is an astonishingly complex organ, which we currently can observe but don’t yet understand. It weighs about three pounds and is 90 percent salt water. The main portion of the brain, about 85 percent of the total, is called the cerebrum. The top layer of the cerebrum, believed to be the last to evolve, is the cortex; the frontal lobe of the cortex, located directly behind the forehead, is the center for ethical decision-making, reasoning, planning, reading, and writing. The cortex is what distinguishes us from other animals and makes us human.
Below the cortex is the mammalian brain, also known as the limbic system, which governs pain and pleasure (fighting, fleeing, eating, and sex). It also appears to play a major role in the storage and retrieval of memories. Damage to two parts of the limbic system, the amygdala or the hippocampus, may cause recurring memories or a decrease in the ability to form new memories.
One of the major theories that neurobiologists are studying is that combat alters the relationship between the cortex and the amygdala. The cortex, our center of reason, receives the stimuli from our eyes and ears (although, interestingly enough, not smells — those go straight to the amygdala). The cortex then weighs the risk, measures it against past risks and other factors, and sends that signal to the amygdala, the brain’s flight-or-fight center, and to the hippocampus. The theory is that combat overwhelms the cortex, which then fails to rein in the amygdala, which immediately goes into high gear figuring out how to respond to this threat. It also activates a portion of the brain called the hypothalamus, which can increase blood pressure, heart rate, sweating, and pupil dilation, as well as releasing a variety of hormones and peptides. Following combat, that imbalance continues, at least in part. That could allow the seat of emotional memory to become hyperactive, perhaps leading to nightmares and flashbacks.
It could also be dangerous because the neurochemicals involved in a heightened state of arousal can destroy brain cells. In the early 1990s, researchers found that stressed-out rats lost brain cells in their hippocampus, the memory center. A few years later, they found that combat vets with PTSD averaged eight percent less volume in their hippocampus than normal. Still later, they found an 18 percent reduction in hippocampus volume in patients who suffered from early childhood abuse and major depression. There have also been at least four studies showing decreased volume in the hippocampus of combat vets suffering from PTSD, which could explain some of the verbal memory deficits and perhaps some of the actual memory loss. However, other studies of twins — one exposed to trauma and the other not — suggest that smaller hippocampus volumes in both may demonstrate that size is a pre-existing vulnerability for the disorder rather than a consequence of it.
Brain cells are called neurons, and the human brain may have up to 100 billion of them, each enclosed in a very thin membrane that is capable of carrying nerve impulses. A fiber called an axon carries electrical impulses from one neuron to the next, while short branching fibers called dendrites receive those impulses. But an electrical impulse can’t bridge even that tiny gap, so the impulse triggers the axon to release chemicals called neurotransmitters to stimulate the dendrite. Dopamine, serotonin, noradrenaline, and the opioids are a few of the most common neurotransmitters that deal with pleasure and pain. All of the brain’s normal functions depend on neurotransmitters, and too much or too little of each can lead to serious disorders of thought, mood, and behavior.
Dopamine is normally the body’s reward mechanism, rewarding us for doing the things that are good for our body. The high that a distance runner feels after completing a five-mile run is a jolt of dopamine rewarding him for exercising. In alcoholics, booze can commandeer the dopamine system and reward the drinker with a jolt of euphoria. And there’s some evidence that excessive dopamine release may have a role in the hyperarousal and hypervigilance associated with PTSD.
In particular, there are a pair of oppositional neurotransmitters (amino acids) in our brains that co-exist in a delicate balance. Glutamate is the brain’s primary excitatory neurotransmitter. It’s quickly released in response to a threat, and it puts the brain into instant high gear. The opposite neurotransmitter is GABA, which slows the brain down during restful and non-stressful times, allowing it to filter out sensory information that’s irrelevant. Each can override the other depending on the situation, but GABA is important because prolonged exposure to glutamate can damage or kill the brain cells around it. Some researchers are investigating the possibility that a shortage of GABA may be one explanation for PTSD and possibly even for depression.
Researchers have found one significant difference in the brains of those who may be predisposed to PTSD, the VA’s Dr. Friedman told me. It’s a difference in the serotonin transporter gene. Serotonin is a neurotransmitter that’s been closely related to mood swings and anxiety attacks, as well as regulation of sleep and aggression. When an impulse leaves the axon, it triggers the release of serotonin. Some of it is picked up by the nearby dendrite, but some is left floating in the gap. The serotonin transporter gene is designed to recapture the leftover serotonin and pump it back into the cell for future use. And there’s the difference. Human beings can have a short form of the gene or a long form. The long form is believed to be more efficient in recapturing the serotonin. Since all humans have duplicate genes, it’s possible to have two long genes or two short serotonin transporter genes.
“People with the double long gene are more resilient, while depression and suicidal behavior are more common among those with the double short gene,” said Dr. Friedman. “And we’ve found the same to be true among people with PTSD. It’s the first genetic difference, but there are many other probabilities.”
Disorders such as PTSD, or mental illnesses, can be treated by medical doctors, psychiatrists who use various medications to restore the brain’s normal chemical balance. In some cases, successful treatment can be done with a drug that increases or decreases the amount of a specific neurotransmitter, but most illnesses are more complex, involving several neurotransmitters at the same time. Doctors are still trying to figure out how to treat those illnesses, frequently on a trial-and-error basis for each specific patient.
What prevents a return to normal?
Such theories are persuasive, but Dr. Rachel Yehuda, one of the nation’s top PTSD researchers at the VA’s Bronx Medical Center in New York, wonders why the brain doesn’t seem to recover after the threat is gone.
“The body is supposed to work that way,” she said. “That rush of adrenaline helps you do what you need to do in response to a threat. For most of us, it’s temporary. But PTSD is a disorder because something that should have been a temporary response is not. There’s something wrong with the mechanism of getting back to the baseline normal.”
Researchers at the Geisinger Center for Health Research found a correlation between combat veterans’ use of both hands for common tasks and the likelihood of suffering PTSD. It found that soldiers who used only one hand for tasks — a measure of cerebral lateralization — were five times more likely to develop PTSD when exposed to combat. “These findings suggest the possibility of a pre-existing biological vulnerability for PTSD,” said the study’s principal investigator, Joseph Boscarino. “We know generally what type of soldier is likely to suffer from PTSD before they get into combat.”
While researchers look for a genetic explanation, Dr. Yehuda is convinced that the cause is both genetic and environmental. “Genetics alone cannot explain that vulnerability,” she said. “It’s not a slam-dunk certainty, but it’s reasonable to suspect.”
Early treatment may be one answer, Yehuda said. “Having these symptoms when you come back doesn’t frighten me as much as having the symptoms of PTSD a few years after you come back. What we need to assure is that those symptoms don’t turn into a permanent condition. There are treatments for PTSD. Particularly in the acute stage, early intervention may forestall a chronic condition.”
New name for combat fatigue
PTSD has been around as long as men have been killing each other — and narrowly escaping death. Sometimes known as combat fatigue or being shell-shocked, it was a particular problem after the Civil War, in which countrymen split over the issue of slavery and slaughtered each other. Even during World War II, when America was defending itself against attack, it was a problem.
“I came back from World War II with PTSD,” said retired Col. Bill Story, executive director of the First Special Service Force Association. “It took the form of extreme anger. I was very demanding — it was my way or no way. I dealt with those issues for many years through therapy.”
Story’s unit, the First Special Service Force, was the elite fighting unit that was the forefather of the Green Berets. It distinguished itself against the German Army in Italy, where Story remembers winning battles by slipping behind enemy lines and silently attacking enemy soldiers when and where they were not expected. “We were a group of young men trained to kill other young men in cold blood with a knife, or a garrote wire,” he said. “We were simply trained killers.”