B0038M1ADS EBOK (9 page)

-SENIOR NCO, IRAQ

In the last quote, this soldier is expressing anger at not being allowed
to attack or detain Iraqis living in homes close to where a roadside bomb
was planted. But the important underlying emotion being expressed is
helplessness. In several assessments of warriors deployed to Iraq or Afghanistan, nearly half reported being in threatening situations where they were
unable to respond due to ROE. There is evidence that this may play a role
in developing mental health problems after coming home. This feeling of
helplessness-being unable to respond because of ROE-has also been a
prevalent theme throughout multiple operations over the last twenty years
(e.g., Panama, Somalia, Haiti, the Balkans), where warriors have been in
situations where they've been unable to help civilian women, children, or
elderly suffering in the operational environments.

Fear actually can become much more of a problem for a warrior after
coming home than it is in the war zone. The fear signal, which becomes
almost a sixth sense in the combat environment, and which the warrior
learns to trust implicitly for survival, can remain on high alert back home,
where there is no longer the same need for it. At home, "locking and loading" is not going to be useful very often, and the warrior can find himself in frustrating situations where he has no outlet for channeling the fear
signals going off in his brain and body. Sharply honed combat skills that
helped the warrior control fear in combat may prove counterproductive
on the home front, and result in the warrior not knowing what to do when
the fear alarm sounds.

In summary, criterion A of the PTSD definition regarding the trauma
event and response to trauma is difficult to apply within a military context.
Warriors are trained professionals operating in situations where there is constant threat and multiple traumatic events. In the military, terms like fearand
helplessness mean very different things than they do in civilian environments.

Most important, the language of criterion A doesn't come close to
describing the intimate and life-changing traumatic events that can lead
to PTSD, nor does it address the question of why some warriors develop
PTSD, while most, exposed to virtually the same experiences, do not.

Resiliency to Trauma: The Million-Dollar Question

The million-dollar question is why do some warriors develop serious symptoms of PTSD after combat, while others from the same units do not? Is
there individual susceptibility to developing PTSD in some warriors (or
civilians) exposed to trauma? In line infantry units that have been engaged
in direct combat, the majority of warriors will experience some symptoms,
but for most the symptoms are not severe enough to seriously impair their
functioning. Depending on the level of combat intensity, a number of
studies involving OIF and OEF warriors have shown that between 10 to
20 percent experience a sufficient number and severity of symptoms to be
considered to have PTSD within a year after returning home.

Studies have shown similar rates in Vietnam veterans many years
after combat, as well as veterans who experienced direct combat in Gulf
War I and other operations. Rates of PTSD don't go much higher than
30 percent in units that have seen the highest levels of direct combat,
which means that even under the most severe conditions, most individuals
remain resilient or learn to cope with their reactions. Women in support
units (e.g., transport, logistics, medical) serving in Iraq have been found
to have similar rates of PTSD as men in the same units, a reflection of the fact that combat is a sufficiently severe stressor that it doesn't discriminate
on the basis of gender. This is in contrast to civilian settings, where women
consistently show higher rates of PTSD than men.

One reason that PTSD develops in some individuals and not in others is that there are differences in resiliency, or the ability to bounce back
after adversity. For example, individuals who suffered abuse or neglect as
a child, or who have close family members with mental health problems
or alcoholism, may be more susceptible after a traumatic event. Genetic
factors are also likely to be important in susceptibility to developing PTSD
(though we have a long way to go in fully understanding this). However,
individual differences in resilience are probably not the main factor in
the war zone. The higher the frequency or intensity of combat-and particularly, the more personal the trauma is-the higher the likelihood of
developing PTSD. Combat is a great equalizer.

If a platoon suffers a casualty involving death or serious injury, all
members of the platoon will be affected in a very personal way, but most
will not develop PTSD. Unit members who are likely to be most at risk to
develop serious PTSD symptoms are those with the closest personal connection or friendship to the injured individual, those who felt directly
responsible in some way for the health and welfare of the injured individual, or those who felt most helpless to intervene in preventing the tragedy.
Anyone who has witnessed or been confronted by extremely frightening
or horrific events that involved death or serious injury of someone they
loved, and who felt helpless or powerless to intervene effectively, are going
to be at very high risk for developing PTSD. The situation is worse if there
was any perception of betrayal-for instance, poor decisions by leaders
that contributed to the tragedy, or gross negligence or reckless disregard
resulting in a friendly-fire casualty.

Physical assault or rape in any environment, and especially by a fellow
service member in the war zone, is another example of a severe personal
trauma involving betrayal of trust that confers a high risk of PTSD. Close
calls on your life, particularly if there was any injury, even a minor injury,
can be very personal, but probably don't have the same impact, unless
there were other factors. For example, being knocked out in combat, even for only a few seconds (a concussion/mTBI), is strongly associated with
PTSD; in one study we conducted, over 40 percent of soldiers who lost
consciousness as a result of a blast experienced serious symptoms of PTSD
when they came home. But this is likely due to the context-the fact that
the blast that knocked them out also injured or killed their buddies-and
that when they were knocked out they were helpless to respond.

Therefore, the development of PTSD after combat experiences has
very little (or nothing) to do with the character, upbringing, or genetics of
the warrior. What remains is that certain events are profoundly devastating
and have a much stronger impact neurologically than others, a situation
that the warrior has absolutely no control over. PTSD in these situations
represents normal reactions to extremely abnormal (or extraordinary)
events.

There are factors that can mitigate the risk of PTSD from combat. Studies conducted by researchers at Walter Reed Army Institute of
Research have shown that strong unit leadership, high cohesion, and high
unit morale are correlated with lower rates of PTSD in combat units. By
contrast, poor leadership and low morale contribute to demoralization,
anger, and feelings of helplessness, all of which can compound or exacerbate PTSD symptoms. Once warriors return home, one of the strongest
variables that help in recovery is their level of support from loved ones.

Criteria B, C, and D PTSD Symptoms: Combat Physiology

Criteria B, C, and D concern the specific reactions ("symptoms") that constitute the definition of PTSD. Symptoms must be present in all three of
these closely related categories.

Criterion B Symptoms

Criterion B includes all symptoms having to do with re-experiencing the traumatic war zone events through nightmares, flashbacks, intrusive thoughts,
or memories. This can include a sudden feeling of dread, like something
bad is about to happen, and physical sensations (e.g., heart pounding,
sweating, pressure in chest, nausea, trembling) or strong emotional reactions (especially anger) triggered by any reminder of the trauma.

Whenever there are crowds I start feeling like I'm in Iraq and have
to get out of there fast.

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

I keep having this one nightmare where I am sleeping in one of
those kerosene-soaked tents (whose fucking idea is that?) and Ion
the only bunk bed on top with rounds coming in.

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

War fucked me up mentally. I have bad dreams and I see all kinds
of mad ill shit. I see dead people. I sometimes get angry and pissed
off and just want to kill somebody.

-JUNIOR ENLISTED SOLDIER, POST-AFGHANISTAN

Criterion B symptoms relate directly to how the memories of traumatic events are processed in the brain. Memories of life-threatening
events are not stored in the same parts of the brain as other memories
or thoughts. They are stored in deeper areas within the brain called the
"limbic system," which controls survival reflexes and connects directly to
areas involving all of the basic functions of the body necessary for survival,
including adrenaline, breathing, heart rate, and muscle tone. Adrenaline
and rage go hand in hand. They help you focus, make your muscles stronger, and help you fight. Anger helps to control fear.

The limbic system memories are not under your conscious control.
Rational thinking occurs in the cerebral cortex, the part of our brain that is
much more developed and larger in humans than in any other species. The
limbic system, also known as the reptilian (reptile-like) part of our brain, is
more primitive, more animal. It processes danger, threat, and reflexes, and
expresses basic emotions necessary for survival (anger, hurt, fear). Limbic
memories are not linear or logical. They are highly emotionally charged
images, sounds, smells, thoughts, or perceptions that immediately connect
with reflexes having to do with survival-the "fight-or-flight" reflexes. The
limbic area of the brain is designed to make sure that you never forget any
memories having to do with serious danger or disaster that affected you personally. These memories form the impetus that forces you to respond
instantaneously when you encounter a similar situation at a future time.

Limbic memories in the form of criterion B symptoms can be triggered
by any reminder of the war zone, even very minor things, like dust, the
smell of diesel fuel, the name of a buddy, the sky, war movies, news, loud
noises, a calendar date, an offhand comment someone makes, crowds,
trash on the side of the road, an overpass, traffic, a helicopter, kids yelling,
dogs barking, raw meat, smoke, a reflection from a window, going into a
porta-potty, or being in an enclosed or secluded place. These memories
can come flooding back unexpectedly, making you feel like you're back in
the war zone again: body, mind, and soul.

Memories having to do with survival are extremely vivid, the most vivid
of any of our memories: full color, sound, smells, and feelings with almost
the same level of intensity as if they were actually happening now. The
limbic part of the brain does not give a damn how miserable you are as a
result of being overwhelmed (flooded) with these memories. The job of
the limbic system is to ensure that you survive by not forgetting anything
that happened during dangerous or threatening situations. These memories are not bound in time. They can be as vivid twenty years later as they
were right after they happened. They have to do with immediate danger or
threat-right here, right now-no matter how many months or years have
passed. These memories are part of the experience of being a warrior, and
also an important focus of treatment.

Many warriors describe time slowing down during combat. Soldiers
who write about their combat experiences often say that they can fill pages
describing events that occurred in only seconds. They remember every
tiny detail. The reason for this is that during times of danger and high
personal threat, the limbic area compresses much more information into
a shorter period of time than the brain normally processes. When there is
high threat, the body shunts blood to limbic neurons, which is like shifting
into overdrive, so that suddenly there is awareness of everything going on
at the same time in the environment in order to identify and neutralize
the threat. Warriors recognize this as "high situational awareness." All of
this happens in seconds, but from the perspective of the more advanced, slower thinking, and time-conscious cerebral cortex, the large volume of
information could only have happened over a "longer" period of time.
The whole thing can feel surreal, like being in a movie or video game. It
can also feel like the most alive you've ever felt.

Understanding how the limbic system in the brain helps you survive
is important for identifying ways to ensure that these memories don't
intrude on your life so much that they prevent you from sleeping or doing
things you want to do, like being with your friends or family. The goal is
not to erase these memories (that's impossible), but rather to be able to
get to the point where they are not so intense or frequent, are tolerable,
and don't cause anxiety or strong reactions every time they occur. How to
do this will be explored later on in this book.

Criterion C Symptoms

Criterion C symptoms have to do with withdrawal, avoidance, and emotional detachment, and are often the most difficult to address and the
ones that can most seriously affect a warrior's life. In some ways, these
symptoms are reactions to criterion B symptoms-an effort to avoid any
situation where wartime memories may come flooding back.

I don't talk much about my stress or personal matters. I don't like
to discuss them.

-NCO, MARINE, POST-IRAQ

To whom this may concern-my thoughts are my thoughts. I sometimes wish I would just forget things.

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

If I'm having a bad day, I try to withdraw.