"Misattributing postconcussive symptoms to brain injury may have unfortunate implications, because it may be concluded that recovery depends on neurologic factors. The evidence suggests that participation in educational programs that normalize the reactions can alleviate postconcussive symptoms.4"
snip>
"Mild traumatic brain injury can impair cognitive resources10 and may compromise the capacity to engage in cognitive strategies to manage the aftermath of a psychological trauma. There is overwhelming evidence that maladaptive cognitive strategies (e.g., ruminating that one will never recover from the traumatic experience) after trauma are a major predictor of PTSD.9"
Richard Bryant, PhD, NEJM
http://www.brainline.org/content/2008/07/disentangling-mild-traumatic-brain-injury-and-stress-reactions.html

(Brainline.org has a lot of TBI/PTSD resources with less fog factor.)
http://www.brainline.org/function_pages/results.php#militaryandveterans

I've gotten a couple of great and moving comments on this post. Unfortunately they were sent as private e-mails. Clearly, many of you have thoughts on this and it appears there needs to be some airing of views. Please do post some of those views!
Thanks,
Tom Ricks

. . . were WWII vets (as were most of the guys in the neighborhood), and after they were gone a bunch of us began recollecting about how the war affected them.

My father was in the navy, a fire-control man, down in the bowels of the ship, and while he sometimes mentioned that he'd "probably killed hundreds of guys," he didn't have to actually see it, and it didn't seem to have bothered him. (But, who knows?)

A friend's father, on the other hand, was in the infantry, and she said he woke the family up about six times a year with horrible screaming nightmares. Those lasted his entire life.

Those of us who, for one reason or another, have found our personal defenses down, do heal, and as the column notes, often better, sometimes stronger. But while pain shared is one road to understanding, pain laid up is corrosive. A lot of us write.

excerpt

And sometimes too the price of peace
Is called a price too high,
While for want of arms and armor men,
For peace, must daily die.

My rent is paid on Earth by deeds,
Blood bought my liberty;
The price of peace is darkness,
When peace shall come to me.

My name is Marcos and I'm a . . . .

Later this month I'll celebrate the 16th anniversary of becoming clean and sober. I probably owe my life to the xA groups and meetings I attended during the first five of those years. I do NOT think the AA model should be applied to treat PTSD. The AA model is good for one thing: to stop drinking and stay stopped (substitute your drug of choice for drinking). Trying to shoehorn PTSD into the AA model of alcoholism as a disease would be counter productive and possibly even damaging.

Now let me qualify that. AA offers a number of tools and concepts that may be quite useful for someone healing from PTSD. Some of you will know what I am talking about. Of course, many of these tools (or techniques or whatever) could be successfully applied to anyone's life for self-improvement.

Furthermore, it probably happens that someone with untreated PTSD will self medicate to the point where they might need to go to AA or one of the other A's. If it were me, I'd go ahead and go to meetings, but I'd keep in mind that there are (at least) as many opinions in AA as there are members, and some of them are quite off the mark. People with absolutely no qualification to do so will offer all sorts of opinions on how to treat your PTSD.

I guess what I am saying is that the rooms of AA (and sister programs) are filled with very sick people and you should be wary of taking psychiatric or medical advice from them for anything outside of alcoholism and addiction. Obviously, the ideal would be to find an AA group made up of persons recovering from or recovered from PTSD.

I no longer participate in any of the A groups. I consider myself cured of my addictions to alcohol and drugs. I choose not to drink or use drugs today because I don't want to risk reinfection.

Also, I've returned to my original drug of choice: reading. ;-)

Here is a comment that came in by e-mail. I sympathize with is inability to post--I actually have been locked out of my own blog a couple of times.
Best,
Tom

--

I am having trouble getting into the comments section, it will not let me login for some reason. Anyway, this is the very long comment I was going to leave. If you wish to put it in the comments section, I give you permission to do so as long as you only use my initials - MCD - to identify me.

Thank you for all the fine work you do and for bringing up this topic. It is something that is not acknowledged enough.

"Because I am in the strange position of having undergone two separate bouts of PTSD, I feel a certain categorical imperative to express some thoughts on the issue. My two bouts occurred when I was 15 and 22 years old. They came from two distinctly separate incidents; yet, I must acknowledge some of the untended fodder that still existed within me affected the later bout.

While this may be the hardest thing that one can ever acknowledge, my life always began to get better once I acknowledged that who and what I was before the incidents was dead. This may sound extreme to some, but I came to realise that much of my depression, anger, etc was caused by my attempts to retain personality traits that failed to protect me. I had to discard what had failed me. It is and was a painful process. It can also be quite dehumanising. Casting off the traits that made you who you are is unspeakably painful, but, for me, it had to be done. I could not hold onto what had failed to protect me.

After this, I realised I was much stronger. This is what Post Traumatic Growth is. It is the understanding that you have been through the valley of hell and come out the other side. You suffered, but you made it through and you are better because of it. However, I thought I never would have to deal with something that strong again. Consequently, it made me cocky, somewhat arrogant and inflated my sense of self. I believed that I was almost emotionally invincible – I could take anything. Something I don’t doubt others with PTG can related to. Of course, I was wrong.

The second bout turned out to be much worse than the first. 1- because I assumed I could deal with anything, and I was wrong. 2 – because I was forced to deal with the incident, existentially, on a day-to-day basis, while the first incident came in a flash. 3 – I had less control over the overall narrative of the incident. It’s hard to overcome something you cannot control as much as you would like.

Even though I am only now just starting to recover from the second bout, I do not suffer from the PTG do a similar extend that I did. Simply because I know any feeling otherwise is false. Nevertheless, what both incidents and the painful aftermath taught me was how to deal with this of this nature, and therefore lesser problems to a degree I could not foresee.

It is this suggestion that I leave here. Think everything your PTSD-affected mind sends you through and give yourself time to heal. One of the ways I survived was by finding one simple thing to do to allow myself to think about what PTSD has done to me, whether it is each day, or whenever you need it and do it. For me (and this is not a joke) was to put my headphones on, turn the music up, shut the door in my room (thereby closing off any avenue to the outside world) and play Spider Solitaire. An hour later, after just letting my mind wander and deal with whatever was bothering me, I felt infinitely better. Just allowing myself to think untethered to other worldly matters gave me the space to think outside the box out my mental and emotional problems. For others, it may be yoga, weights, gardening, exercising, anything. It does not matter what. Just find something you can do whereby you can forget about everything else and focus on your own mind and self while still keeping your hands busy.

This allowed me to work through the changes that had occurred to me. It allowed me to acknowledge what had truly happened to me. When people tell you to fill up your day with busy work, all they are doing is trying to get you think about something else. That just puts off the inevitable and is therefore more harmful in the long run.

Unfortunately, the inevitable, in my case, was hitting rock bottom. I had to dig as deep a hole as possible, scrape every last failed inclination I had before I could come back up. Like I said before, it took me acknowledging the real factor in all this – I was no longer the person I used to be – to get out that hole. For others it may be different. That is entirely up for you to decide.

Another suggestion is that because many, if not all, PTSD survivors rarely talk about their problems to others, especially loved ones, is to write down a day-by-day journal while on tour. Then when you get back home, give it to them. You may have trouble talking to them, but at least this way you will be able to ‘tell’ them why. Also, maybe get them articles and books on combat stress before you leave so they can have some understanding of what might occur. Some preparation can help significantly.

Also, don’t ever forget, even in your worst moments, that those who are around you before leaving on tour, love and care about you. They may not understand you, and you may be confused by the new lenses you have on, but believing people do not care is the road to oblivion.

I would also recommend never listening to anyone who tells you, if you show some signs of mild depression etc, to go to a mental facility. If they do, go read Madness and Civilisation by Foucault, then go beat them with it. Only if you are suffering from a severe bout to the point of suicide should you put yourself away. Furthermore, talking to others in similar situations as you is the second most cathartic thing you can do aside from taking time out to deal with everything yourself. No one can ever understand you better than someone in exactly the same situation.

And never be afraid to collapse for a moment. Sometimes just letting all the pain etc rush over you and force you to collapse under its weight can be cathartic. I realise that may sound paradoxical, but acknowledging its weight can make you realise the magnitude of what you are dealing with. And guys, don’t be afraid to cry. I am 6”4, completely shaved head and built like a brick shithouse. No one is going to accuse me of being effeminate for shedding a few tears because of the burden I hold.

Finally, in my opinion, there is no such thing as a cure. If there were, I would be a completely different person than what I am today. I would be the person I was before everything happened. You learn to survive from PTSD. That’s all. You learn to deal with everything it has thrown at you. Nothing more. Yes, it can make you better, stronger and more honourable, but nothing can be fixed like a broken bottle. I could not put the pieces back together again to an item that has failed me. I had to create a new one instead.

Everything I have said here is of my own opinion, based on my own experiences. I recommend any PTSD suffered should find and follow their own path to salvation. Nevertheless, my main point stands, they key is to find it yourself, and I hope my words will help some do that."

- MCD

Tom,

First, let me thank you for posting this editorial and providing a glimpse into the evolving world of PTSD (or so it would appear), especially with regard to our service men and women. Second, I want to share my own experiences and thoughts regarding PTSD in hopes that someone in a bad place may relate and get help.

I served proudly in the Army, took part in a number of combat operations, and had the pleasure of standing side-by-side with my brethren Marines in Al Fallujah. My eyes tear up as I step back to remember just how much of an impact that particular operation and the loss of one of my own soldiers during a separate mission affected me in terrible ways for years. In fact, I can still see what was left of my soldier after the IED tore through her and left her a bloody mess on the side the road.

AS a result of these experiences, I suffered through numerous nights of cold-sweats and anxiety from the nightmares, became a rather impatient and "alert" driver on our own city streets, and nearly lost those who continue to love me through my own decent into the darkness of the world I myself created. My moods were intense and drifted between extremely happy to the more dangerous feelings of anger and depression. To make things worse, I refused to get treatment and decided that the VA was completely worthless given the fact that they reduced my disability from 30% to a big fat 0% in six short months after ETS'ing. And why not? Those jackasses didn't understand what I was going through my head anyway!

But reality started sinking in after years of remaining in the fight as an Army civilian employee. I was fortunate to be surrounded by a number of Vietnam Vets and other veteran's from the recent wars. It could best be described as a 9-5 group session, and something that afforded me the room to explore my feelings and voice my frustration without having to deal with what some of my friends still deal with - other officers and service members that were sitting on their ass on the sideline while a good number of us were getting our asses shot off. A good example was of an Army major that had the balls to "remind" me that soldiers were losing their lives every day and that I should stop thinking strategically. It's a long story, but I was out there on my third tour (as a civilian) working on a project to improve the situation. Needless to say, this spurred a re-lapse and almost caused him to get his ass pummeled. Anyway.

The continued experience and joy of being surrounded by these good people, friends, and family, all the time supportive or stern when I needed it, spawned a cycle of personal growth that could fall into the category of Post Traumatic Growth.

After getting some much needed counseling, talking with others who were suffering, and sometimes talking to complete strangers about my experiences (it was easier, at times, and those that suffer know what I'm talking about), my eyes began to clear. I saw in myself a new life, a greater appreciation for life, and the clearest road map to maneuvering the many obstacles (stupid people) of life in general. It may sound cheesy to some, but coming to terms with what had happened, being patient with my recovery and focusing my energy into avenues of happiness, and learning how to give a shit again has made me into a more productive and happy human being.

For those that are still in the dark and suffering, please do one more brave act - get some counseling and forgive yourself, be good to yourself, and stay away from the booze and drugs (they don't help!). And for what it's worth, you can still say fuck the Army or whatever service you were a part of, so long as you are not turning that hatred against yourself.

This article, along with so many others, is merely a start. Whether there is a cure or not, I would have to agree that an individual is changed forever as a result of PTSD "You can't undo the past, but you can understand and adjust to it, and move on, somewhat." Thanks Tom! Your thoughts on this one are salient.

If you can manage to get to the wonderful people at the Capitola, CA, Vets Center, I highly recommend doing so. They really have their finger on the pulse with regard to treating/curing PTSD.

Proud to have served, survived, and recovered.

Tom , thanks for the thoughtful discussion here. I wanted to write to clarify my position that PTSD is managed rather than cured. I originally wrote that to a Soldier's mother as a personal note of encouragement for her and her family for the journey ahead. The whole point of the article was to share the experiences of Soldiers who had dealt with these issues and come out ahead, been promoted,
continued to deploy and serve the Army. While such words may not seem encouraging, I felt it important to convey the reality of our experience. Many times Soldiers and Marines are led to believe that if they seek help through counselling and other therapies such as rapid eye movement desensitization and resprocessing (REMD) that they will be fine and for many that is not the case. By no means did I wish to imply that once diagnosed they are "marked for life and can never hope to cure themselves". As I stated in the letter we have taken a holistic approach to health as a family and we are stronger for having survived this. We are also eternally grateful to the Army as everyone in my husband's chain of command has been entirely supportive throughout this process. Thanks again for shining a light on this issue.

I thank all veterans for their service and I applaud the Marine vet and other veterans who have sought out treatment from PTSD and have recovered. Of course recovery is possible, and it would be a shame for individuals to lose hope in a overcoming the intense pain of combat-induced PTSD.

However.

All veterans do not suffer from the same "PTSD." There are those who have nightmares, who are hyper-vigilant and who take out their anxiety and depression on their loved ones. Then, there are those that who are unable to function, cannot leave the house, and are completely debilitated in everyday life (those the VA would grant a 100% disability rating to). And then . . . there are those who are at the 100% disability level who then turn to drugs and alcohol to self-medicate when normal counseling doesn't quite cut it (they sometimes wind up living in the VA homeless shelters or on the street). I imagine there are different levels of possibility for recovery for the many different levels of combat-PTSD. While recovery may be possible at all levels, it is much, much, more difficult at the higher levels of disability. In addition, there is NO tried and true method that the VA employs to heal veterans suffering at such high levels of combat-induced trauma.

I don't say this because I want to discourage our veterans who are suffering from PTSD. I say this because I want to provide a reality check for those engaged in the creation and assessment of U.S. security policy:

War DOES leave an enduring and sometimes intractable emotional wound on veterans and on their families. This is a serious cost to veterans, their families, and to society. This cost needs to be considered and weighed against the benefits before we send our troops into combat.

I thank Molly for her frank words; the wives and families of those suffering from severe combat-induced PTSD should not harbor any fantasies about an easy recovery after REMD or an intensive-inpatient program. The road is hard and long, and not everyone succeeds at recovery.

As a newly trained psychotherapist, I expect to be seeing vets in my practice who are coping with PTSD -- the notion that there is no cure, only management, is belied by a wealth of recent research on effective treatment. Part of the difficulty in the discussion has to do with proper diagnosis, a thorny issue that was recently addressed in Scientific American.

http://www.scientificamerican.com/article.cfm?id=post-traumatic-stress-trap

Tom

Great article, a few observations

I remember reading one of Dave Hackworth's books several years ago and he writes about an experience he had as a BN commander in Vietnam with his S3. I believe it was "About Face". After several months of combat operations, his S3, by his account, a fine officer, broke down. Hackworth considered each man a bottle and once that bottle overflowed, it (he) was basically done and would never be the same. I wish I had it here to quote Hackworth exactly, but I think it illustrates a difference in the view between different generations and how they viewed the mental results of combat.

My Father was also a vietnam vet, infantry officer, and while he would share some stories, from a professional development standpoint of a senior officer (him) to a junior officer (me), those were times he never really chose to share.

From my standpoint, as a vet of OIF (2004-2005) I think we've only seen the tip of the iceberg on the issue of PTSD. Maybe the only thing that has kept it tamped down is our deployment cycle. Perhaps as things slow down in the next few years, we'll begin to truly fathom the task of caring for our soldiers mental problems, which are much harder to identify and treat than the physical issues.

I had lunch a few months ago with one of my former soldiers. He's at Walter Reed now recovering from PTSD. He's doing much better now. When he got back from Iraq, he had been assigned to recruiting duty, where he started to go downhill. It wasn't until he had to fight to get assigned to Walter Reed that he started to get the care he needed to. He expects to be back in a line unit sometime next year.

At my last duty station of Fort Polk, some of my neighbors and I were sitting around one night and talking about what still bothered us after being back from our last tour. For me it was boxes on the roadside. Four years later, here in DC, I'm still bothered by boxes on the roadside.

M

My wife is a therapist who has attended sessions on traumatic brain injury at the VA. Her experience, and the VA concurs, is that a treatment called rapid eye movement desensitization
(REMD) can be very useful to effecting a cure.

Note, however, the person needs a significant amount of training and background in therapy. A quickie weekend course won't do it, nor will a person with no background in therapy doing a quickie course. But for those for whom therapy, medication, self medication, groups etc haven't helped, try REMD. I haven't heard of any downsides.

Whether someone is "cured" depends on your definition. My father, father-in law and others probably had PTSD from WWII. However, in different ways they dealt with it. Part of the problem some have said may be that with the jet age we have people going from combat to US civillian life in 24 hours and that is way too different. (In that era European theatre vets went home based on points; if their unit was being held for the invasion of Japan some were in Europe for a number of months. In the pacific everyone didn't go home at once.

Even people returning from the peace corps go through adjustment issues. So imagine someone who's been at the sharp end a while.....

That being said, there are also the types like Andrew Exum who claim it doesn't exist --that doesn't help much either.

Few are "broken" forever. For many, I believe it will go and possibly return here and there--like any memory. For many it will be more present, but for many less present.

The first problem with PTSD is that everyone has it and is vulnerable to some degree, and it is, like human beings themselves, unpredictable. Everyone suffers trauma and damage depending on an endless list of factors. War is one of those factors. Some of us go to the grave untroubled and some of us go because of our troubles. Between these poles all of us travel through time. So "the problem" begins to look like "life" after everyone is taken into account.

The second problem is there are people making a living off of other people suffering and the more of them, the more they have to compete for their paycheck; this includes not only caregivers but care "takers" who are gaming the system for the biggest disability rating they can get- thus guaranteeing benefits and even a hard to get civil service job. So this problem begins to look like a business plan after everyone is taken into account.

The third problem is our soldier who fights for us. Most who choose to pursue this profession find after 20 years they are used up and not wanted anymore. Their 40 something bodies and minds can no longer take the pounding and stress, the exposure to extreme environments, the sleep deprivation, the marathon field problems, etc. In combat those twenty years of wear and tear get compressed into a much shorter career. The author of the book "On Killing" estimated that career as about 100 days under fire. So this problem begins to like a work enviroment issue after everyone is taken into account.

For the soldiers who had something happen to them and cannot function anymore- in the military or as a civilian, these three problems do not exist. The only problem they have is how to face the next hour, day, or week. Their problem is not bad life experiences or their business plan or a work environment issue.

I was diagnosed by both medical doctors and Psychiatrists with PTSD when I was in my 20's. I was constantly going to the emergency room because my heartbeat would go out of control and I'd have constant panic attacks. Then I couldn't sleep so I started living on Tylenol PM, etc. Anyway, my girlfriend figured it was on account of my gasping when I sleep so I went to the doctor and was diagnosed with obstructive sleep apnea. I was cured instantaneously once I started wearing a CPAP. I never had a panic attack again. It's been great. But, a tonsillectomy/adenoidectomy + fatty tissue removal can also cure about 50% of OSA cases. I'm considering this surgery at the moment.

Anyway, it occurs to me that when the current generation of recruits were born the tonsillectomy rate was about 200,000 per year (circa 1980's). But, when the Vietnam War soldiers were born the tonsillectomy rate was greater than 1,000,000 per year (circa 1950's). Considering that about 8% of the U.S. male population (and 2% of the female population) has some degree of OSA it's possible that some (not all) cases of PTSD are actually OSA. Since I have been diagnosed with OSA I have read many accounts like mine in which people were misdiagnosed with PTSD. Hopefully, the Military screens for this common disorder in patients diagnosed with PTSD considering treatment for it is simple and effective and relatively cheap as is the diagnosis for it.

I have to respectfully disagree to likening the mind to a bone. "Once it heals, it grows stronger, more resilient," he says. I know it's nitpicking, but if you want to go there, bones that have been broken are also usually surrounded by tendons and such that harden during the healing process, becoming less flexible than before. The comparison to a bone is also too simplistic to be effective, and could turn people off of what I think is a great message: that PTS can be managed and that PTG is possible.

With some of the hardwired responses some warriors are getting with their PTSD, I can see how their minds could be less adaptable. Once "broken" (to use the bone analogy), it becomes harder for them to disassociate fireworks from gunfire, for example. Great progress is possible, but full recovery is more rare than you'd think.

To the Marine Vet: THANK YOU for your thoughts! I agree with your message of resilience and am so grateful for your voice.