Invisible Wounds

By Mark Cantrell 

First the good news: U.S. combat deaths in Afghanistan are on the decline for a number of reasons, including better protective gear for servicemembers and advanced medical techniques. 

The bad news is, although servicemembers increasingly are surviving IED explosions and other attacks, the number of life-changing injuries has risen. In many cases, combat scars are psychological rather than physical. Fortunately, those invisible wounds are treatable; the biggest challenge mental health professionals often face is convincing servicemembers to seek treatment. 

The statistics are sobering: It’s estimated one out of every five military personnel returning from war has post-traumatic stress disorder (PTSD), yet the condition wasn’t even recognized by the American Psychological Association until 1980. 

“PTSD is a lingering psychological condition produced by experiences that overwhelm the person’s mind and brain capacities for processing and understanding what has happened,” explains Dr. Arthur S. Blank Jr., a psychiatrist who served in Vietnam. “It always involves a serious threat to life or bodily integrity.” 

During World War I, the condition was known as shell shock; in World War II, it was war neurosis. “As recently as the Civil War, it was considered to be cowardice,” says Army Col. Charles C. Engel, M.D., M.P.H., director of DoD’s Deployment Health Clinical Center. “We’ve come a long way since then, but we still have a long way to go.” 

Pushing past perceptions 

Whether the stigma has decreased in the armed forces, however, is debatable. “It runs right smack into military culture,” says Engel. “People in the military are taught to put the team first, to put your own needs second as a soldier.” Another key factor is the perceived harm to career. “We have to convince people that treatment is part of the solution, not part of the problem.”

Engel emphasizes seeking help is critical because of the havoc PTSD can wreak on a person’s life. The condition often is marked by vivid flashbacks to a traumatic event. These flashbacks can last for minutes or even days and are accompanied by a racing heart, sweating, and frightening thoughts. Nightmares also are common, leading to sleep deprivation and exhaustion. Those affected often develop memory problems and find it difficult to concentrate, sometimes becoming emotionally numb or overwhelmed by feelings of hopelessness. 

Family members are often the first to notice personality changes, such as irritability and anger. Self-destructive behavior is another indicator of PTSD, as an individual attempts to self-medicate with alcohol or drugs. A pervading sense of guilt also is common, as are startle reactions and even hallucinations. Those with PTSD often will avoid places, people, or events that remind them of traumatic events. 

A widespread issue 

PTSD is by no means an exclusively military problem. It’s estimated at least half of the civilian population has experienced the condition at some point, as a result of auto accidents, domestic violence, natural disasters, and a host of other factors. Research conducted by entities such as the VA’s National Center for PTSD gradually is providing clues to the roots of the problem as new and more effective therapies and medications are sought. Predicting who will develop PTSD and who will not, however, still eludes researchers.

That doesn’t mean they haven’t tried. “During World War II, there were psychiatrists stationed at all the draft boards, and they screened everybody,” says Blank. “Those they thought might have some psychological susceptibility to war neurosis were given a 4F classification. By 1944, a million people had been screened out of the draft for psychiatric reasons, and another million had been discharged from military duty for psychological problems.” 

When Army Gen. Dwight D. Eisenhower became president of Columbia University in New York in 1948, he commissioned economics professor Eli Ginzberg to investigate why so many men had been rejected. “Ginzberg formed a commission comprising many of the psychiatrists from the draft boards [that] did a study and published the Ginzberg report, which basically noted there’s no way of telling who’s going to break down in combat,” says Blank. “So a lot of people have worked quite hard on the question, but we haven’t accomplished much so far.”  
There are, however, factors that increase the likelihood of developing PTSD. “The more close calls a person has — like a bullet hitting the person next to you — the greater the chances you’ll get PTSD. The more close buddies who are killed, the higher the chances,” Blank says. A third factor is exposure to gruesomeness. 

A host of healing options 

If PTSD isn’t predictable, it is at least “highly treatable,” as Blank puts it. Over the years, a phalanx of standard treatments has evolved to help those with PTSD, and more are being introduced. “Some of the clinical research fields in both the military and civilian sectors [have become] much more interested in PTSD over the last decade or so, partly because of the extended conflicts and partly because of the public health evidence that’s emerging,” says Engel.
When a servicemember enters treatment at a VA hospital or veterans’ counseling center, the first therapeutic course is often cognitive-behavioral therapy. The VA calls it cognitive processing therapy, but the goal is the same: to help the client learn to counter negative thoughts that spring up automatically under certain situations. A therapist can teach someone with PTSD to replace those thoughts with ones more accurate and less disturbing, as well as to deal with emotions such as guilt, anger, and fear. 

Exposure therapy is another tool. It involves guiding the client back into memories of the traumatic event, gradually lessening the effect those recollections have, and helping the client realize memories don’t have to be a source of fear. The process, called “desensitization,” also can involve breathing exercises and instruction on ways to consciously relax and self-soothe when memories arise.  

The most widely used form of PTSD therapy is psychodynamic, or interpersonal, therapy — better known as talk therapy. Confiding to a therapist in a safe, controlled environment allows clients to unburden themselves of fears and other negative emotions and focus on how the trauma has affected their mental functioning. “There’s a great variety in how much therapy people need,” says Blank. “Some will do terrifically with three to six months, once a week. Others might need three to six years.” 

Client-driven solutions 

The most important thing for a therapist to keep in mind, says Engel, is a course of therapy must be tailored to the individual. “What I work hard to do is help clinicians recognize that the first task is to identify what the client’s preferences and expectations are,” he says. Engel would like to see DoD develop a system that follows a client through an entire continuum of care, so treatment plans that might not be working can be changed quickly.
Medications, in conjunction with other types of therapy, can be very effective for PTSD. Selective serotonin reuptake inhibitors, such as Paxil and Zoloft, can be helpful in reducing anxiety. Recently, a drug called Prazosin, normally used to treat high blood pressure, was found to reduce or eliminate nightmares for many with PTSD. 

There also are many emerging nonstandard alternative treatments. One is adventure therapy, in which groups of veterans embark on Outward Bound-type wilderness excursions, where they once again work as a team in a cohesive unit, but this time without risk of enemy attack. Participants report an improved sense of confidence and the ability to better connect with others. 

Whichever path is chosen, Engel notes, “the competent course is to seek assistance, whether it’s going to see your primary care doctor, a specialist, or a community resource. There are a lot of different ways to begin the journey. The key thing is to get started.”