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February 18, 2007

PTSD: Treating The Numbers, Not The Soldiers

[litbrit speaking]

According to the United States Department of Veterans' Affairs--as its information page reads this morning, at least--Post Traumatic Stress Disorder (PTSD) is defined as:

An anxiety disorder   that can occur following the experience or witnessing of a   traumatic event. A traumatic event is a life-threatening   event such as military combat, natural disasters, terrorist   incidents, serious accidents, or physical or sexual assault in   adult or childhood. Most survivors of trauma return to   normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even   get worse over time.

Insofar as the government asserts, some   60% of men and 50% of women (overall, both military and civilian) experience a traumatic event at some point in their   lives.  Assuming, of course, that all traumatic events are reported or somehow noted--which of course they aren't--one can still be forgiven for being alarmed that such a staggeringly high number of human beings are at risk for developing PTSD.  And of course, many human beings do heal on their own, handling trauma in ways that don't threaten the safety and well-being of themselves and those around them; they work through the shock, terror, grief, flashbacks, and sense of needing to be on guard at all times, and with time and support, they return to a point where they can sleep a reasonably normal length of time without waking from re-enactment nightmares or go to a noisy, crowded place without feeling overcome by irrational waves of fear or violent urges.

For far too many who've witnessed war's indescribable tragedies firsthand, though, the notion of healing is itself a phantom concept, a dream.  From The Real Cost Of War (currently at Playboy Online):

 

Burgoyne had been brought into the hospital by one of the other soldiers in his unit after he had been found doubled over in his bunk, having tried to kill himself with an overdose of antidepressants. The attempted suicide, plus the lack of expression in his eyes and his "rapid cycling behavior" from rage to grief and back to rage, were the symptoms of a dangerously ill man. Koroll sensed he was looking at a severe case of post-traumatic stress disorder, the clinical term for someone who continues to experience trauma long after the event has passed. This reexperiencing of the original event can take the form of insomnia, flashbacks, paranoia, panic attacks, emotional numbness and violent outbursts.

These symptoms are treatable, Koroll knew. If he could transfer Burgoyne to a safe, comforting environment, the young man might be restored over time to full health and capacity. That meant getting the soldier out of the dusty chaos of the Kuwaiti Army base, where he was temporarily stationed after a bloody tour in Iraq, and sending him to a hospital in Germany where he could rest on clean white sheets in a quiet room in a first-class psychiatric facility.

It was Koroll's job as the on-duty nurse to make the decision about whether to evacuate Burgoyne. He was ready to do it based on what he'd seen. But he needed to ask one final question before he could order the evac in good conscience.

"So," Koroll said, "right now, at this moment, do you have thoughts of harming yourself or others?"

Burgoyne, he remembers, looked up through those flat, vacant eyes and said quite clearly, "Yeah. Yeah, I do."

Koroll picked up the soldier's chart and wrote in a clear hand, "Evac."

[...]

As it turns out, Burgoyne had not been evacuated to Germany as Koroll had ordered. According to Koroll, a colonel in Burgoyne's command pressured the hospital to allow Burgoyne to return to America with his unit, the Third Infantry Division, which was to be one of the first units lionized for its heroism in leading the fight north to Baghdad. "He's a hero. He should be with his men" is how Koroll remembers the explanation coming down to him. After he returned to Georgia, Burgoyne, according to his mother, spent a few minutes in an Army hospital, spoke briefly to an Army psychiatrist and then was released from medical supervision. Exactly two days later Burgoyne attacked a fellow soldier in the woods near Fort Benning, Georgia, killing him with 32 stab wounds from a three-inch blade and then burning his body with lighter fluid, because, as he explained at his subsequent murder trial, "that's how we disposed of bodies in Iraq."

Sadly, this story is not unique, but rather, is representative of the disturbingly underreported problem of PTSD.  More troubling than the fact that this serious anxiety disorder--and its devastating effects and costs--is shamefully underreported in the media is the reality that it is all too often underreported within the Unites States military.  Underreported, minimized, ignored, misdiagnosed, and, most frighteningly, untreated (my bolds).

Given the inevitability of psychological scarring in intense, prolonged conflicts, it is odd that the two bureaucracies most responsible for the mental health of American troops -- the Department of Veterans Affairs and the Department of Defense -- have taken steps to downplay the psychological toll of the war. According to sources I spoke to in the Pentagon and former officials in the VA, DOD and VA doctors are being pressured to limit diagnoses of PTSD in order to save the military money and manpower. The DOD's official medical policy toward PTSD was recently amended to include new criteria making it a virtual certainty that many soldiers who exhibit symptoms of the disease will not be diagnosed.  And the VA itself has been quietly working to arrive at new, stricter formulations of PTSD -- contradicting those of the American Psychiatric Association -- that would allow the agency to diagnose far fewer cases.

"Some people would argue that it's malicious and intentional, but to me it's a reflection of the military mind-set," says Steve Robinson, a 20-year veteran of the Special Forces who recently became a full-time policy advocate. "The Department of Defense is not a health care provider. It couldn't do the right thing if it wanted to because of how much money it would cost and how many doctors it would take. It's a matter of capacity. The number of people seeking care versus the number of doctors available to provide that care nationwide across the whole armed services is out of whack."

In the four years since Koroll's diagnosis of the young soldier was ignored, the anti-PTSD-diagnosis movement (for lack of a better phrase) within the military has grown, as evidenced by, among other things, the hard numbers.  The Department of Defense (DOD) reports diagnosing approximately 2,000 cases of PTSD a year, but according to a study by Army researchers that was published in The New England Journal of Medicine, PTSD rates are between 10 and 15 percent for soldiers in Iraq and Afghanistan; this translates to PTSD cases numbering between 13,000 and 20,000. (The study also notes, disturbingly, that only 23-40% of those veterans diagnosed with anxiety disorders and other psychological afflictions even seek treatement.) And according to figures obtained after repeated requests by Playboy, the evacuation rates for PTSD-afflicted soldiers--for example, those from January to July 2006, showing only 716 soldiers evacuated from Iraq for PTSD--fall well below the predictions of statistical models.  As reporter Mark Boal notes:

If the military diagnosed even half the cases in Iraq and Afghanistan that are thought to exist, the evacuation figures would be closer to 5,000 a year.

For their part, military officials deny any attempt to minimize or underplay the impact and magnitude of the situation.  This despite published forecasts that the cost of America's current involvement in the Middle East will soar beyond even the stratospherically high numbers around which most of us have just begun to wrap our heads; this despite officials having  gone on record with--and been roundly criticized for--statements like that of Pentagon undersecretary David Chu, in a January 25, 2005 article in the Wall Street Journal:

WASHINGTON—With the wars in Iraq and Afghanistan badly straining its forces, the Pentagon is facing an awkward problem: Military retirees and their families are absorbing billions of dollars that military leaders would rather use to help troops fighting today.

Congress, pressured by veterans groups, has in recent years boosted military pensions, health insurance and benefits for widows of retirees. Internal Pentagon documents forecast that the lawmakers' generosity since 1999 will force the federal government to find about $100 billion over the next six years to cover the new benefits.

"The amounts have gotten to the point where they are hurtful. They are taking away from the nation's ability to defend itself," says David Chu, the Pentagon's undersecretary for personnel and readiness.

As I read the profoundly upsetting Playboy article referenced throughout this post, I thought about my freshman economics class at Florida, which was taught by one very entertaining and sharp-witted professor named Dr. Denslow.  "Guns and butter," he said one day, actually plunking a box of unsalted butter sticks alongside a plastic toy grenade-launcher on his lecturn.  "Guns and butter.  The money stays the same, so how are you going to spend it--on guns, or on butter?"

Bombs or bodies?  Mines or minds?   Futilities or futures?

February 18, 2007 in Health and Medicine, Military, Policy | Permalink

Comments

Another really good reason not to go to war. It's mindblowing to consider the impact on soldiers and their families. And the country, too, in social spending and social breakdown. And let's not forget that Timothy McVeigh served in Desert Storm. Did he suffer from PTSD? We know that the government taught him to kill, and that he got hooked on meth after leaving the army. In any case, the country suffers from the delusion that we can expose people to horrific violence and not be victimized ourselves.

And then there are the hundreds of thousands--millions?--of Iraqis suffering from PTSD. Richard Engel of NBC was on MTP this morning and said the entire country had PTSD. He talked about his friend who was losing his hair and his mind as he made daily trips to the Bagdhad morgue to see if his missing father had shown up among the heaps of unclaimed bodies. It's especially tough to maintain a stable society when so many of its citizens--those who haven't managed to flee--are mentally ill. I don't know if I can stand another lecture from an American pol scolding Iraqis for not "stepping up."

Posted by: david mizner | Feb 18, 2007 1:42:20 PM

David, an excellent point. The mental illness of the citizenry of the country we invaded is itself a whole other issue, a whole other body of research, heaven help us.

I don't know if I can stand another lecture from an American pol scolding Iraqis for not "stepping up".

I have the same reaction--I want to scream at the TV something to the effect of Have you ever had the entire world as you know it blown to bits, you insensitive moron? I can't even fathom the level of hatred toward us that Iraqi children must harbor. Their homes, their schools, their streets lie in ruins. Their families are fractured, if not outright killed; everything they once believed to be certain and steady--and such certainty and steadiness, along with the knowledge that matters will remain that way, are vital if a child is to grow up relatively stable and well-adjusted--is all in flux. Not only have we created an entire nation of traumatized people, we are ensuring that they'll be that way for generations.

Posted by: litbrit | Feb 18, 2007 2:01:53 PM

Terrible problem well explained, litbrit. There needs to be a cultural change within the military about this. It could come from the top, but I don't think it's something Bush is tuned into.

I don't know if I can stand another lecture from an American pol scolding Iraqis for not "stepping up."

Unfortunately a similar logic underlies the current proposals for withdrawing as well, that the Iraqis could step up if only we weren't there in the way. (Not saying you believe that, David, but the politicians appear to--at least they give that as their justification.) Not very realistic, is it?

Posted by: Sanpete | Feb 18, 2007 4:14:53 PM

litbrit....

i couldnt agree with you more...that was an excellent post...and your comment of feeling incensed when anyone says "it is time for them to step up and get their act together..." it is appalling....
now that we have brought complete chaos and ruin to their country.
...the only comment more inhumane is when people defend our policy by saying, "it's working..the terrorism is over there, not here." as long as we are not suffering. as if the safety and well-being of other human beings is less important....
"fools rush in where in angels fear to tread."

Posted by: jacqueline | Feb 18, 2007 4:21:32 PM

It's David's comment, but I agree with it completely--saying "the Iraqis need to get their act together" is absolutely maddening, as well as indicative of the speakers' consistently weak (or nonexistent) grasps on reality.

For some reason, when I was putting this together, I remembered that idiotic remark made by Laura Ingraham about journalists reporting from hotel balconies and not covering all the supermarket openings and schools with new paint jobs. Luckily, a CBS correspondent (Lara Logan) took her to task for that dumb statement. It's the same blithe, cosseted stupidity, given air by someone of like mentality and poverty of spirit.

Posted by: litbrit | Feb 18, 2007 4:49:17 PM

My Uncle Wayne - my Grandmother's brother - received a full scholarship to play football for Oklahoma State, but before he even got to the school he was drafted and sent to Europe.

The fighting was of course brutal. Uncle Wayne was infantry. Hand-to-hand combat, a prief period as a POW. Once Uncle Wayne fought a German soldier close in and had been disarmed. He managed to take the German's rifle and stick the bayonet straight in the German soldier's chest. He kept the bayonet and my Grandmother still has it. It wasn't a war trophy. It was a reminder to him that he had watched a man die by his own hand.

Uncle Wayne was also part of the liberating force for at least one concentration camp, arriving a few hours after the Germans fled, leaving everything in process. He said the survivors were just wandering around the camp, confused. Uncle Wayne never told anybody except my Grandmother what he actually saw.

My Mom says that when he came back, she didn't really know him anymore. All his youthful ambitions and the spark that had always animated him were gone. He did get a job, but he never went to college, never played football again. He lived with his parents until they died, and then lived in that same house until he did. Uncle Wayne was perhaps the most gentle man I have ever known. He taught me to fish and had a great way of playing with children without ever being childish himself. But all us kids - my Grandmother's passel of grandkids - knew that he was wounded, somehow. We knew that he wasn't really whole.

I think that Uncle Wayne's experience at the concentration camp convinced him that WWII was necessary, that the things he did were essential to stopping the monstrosity of the Nazis. Even my Grandmother, who has grieved for the brother that went away over 60 years ago, says that our involvement was just, insofar as any war can be called such. But our soldiers and their families pay a terrible price, one that sometimes can even be worse than the death of the soldier.

Those that minimize the deaths in Iraq, that declare America's sacrifice to be small because we are not losing the masses we lost in WWII, those people are inhuman monsters. Every one of those soldiers is someone's son, another's mommy. Those that come back, mutilated in body and spirit, will be forever changed - in fact, the person they were before will be dead. Some will be able to reenter society well. Others will divorce their spouses, leave their children, perhaps murder fellow soldiers in the woods by stabbing them 32 times, dousing them with lighter fluid and setting them afire.

Now Bush, Lieberman and others want to send more troops into the meatgrinder. They lied to get us there in the first place, they still refuse to equip them properly, and when the soldiers return they spend their money thinking up ways to deny these soldiers the treatment they so desperately need.

God damn them to Hell.

Posted by: Stephen | Feb 19, 2007 10:31:14 AM

So if Playboy now has better foreign affairs coverage and nude women, what on earth is the New York Times' competitive advantage? The classified ads? All Playboy needs to do is hire Krugman and they'd dominate the market.

Posted by: ajay | Feb 19, 2007 12:17:15 PM

God damn them to Hell.

It's good that we aren't God.

I think, as with other psychological problems, a lot of people just don't understand the reality. They need to be shamed and their policies condemned, yes, but they also need to be educated. They know not what they do.

This problem has undoubtedly existed in every war, but it has never been fully appreciated. Your Uncle Wayne's condition probably wouldn't have even been recognized as the ill-named "shell shock," since he was able to function. Many, many wounds went unseen and unacknowledged. Each new war, sadly, is bringing more recognition and understanding.

Posted by: Sanpete | Feb 19, 2007 12:43:10 PM

It's good that we aren't God.

I suppose. It would be nifty to be like Elisha, able to summon a bear to maul people who made fun of him. At least I'd put that bear to better use.

You're correct about the state of understanding mental illness, as we've talked about before. What makes this situation especially heinous is that people who have been diagnosed with these problems are not being served by the system.

Posted by: Stephen | Feb 19, 2007 12:55:25 PM

So if Playboy now has better foreign affairs coverage and nude women, what on earth is the New York Times' competitive advantage? The classified ads? All Playboy needs to do is hire Krugman and they'd dominate the market.

I had the same thought years ago when I was reading yet another superb (and superbly-researched) piece in Playboy.

If they threw in a bit of handsome beefcake for us girls and gay men, and added some snarky restaurant reviews along with recipes that require unpronouncable ingredients, they'd bury the NYT, no doubt about it.

Posted by: litbrit | Feb 19, 2007 1:16:28 PM

I have read most of what is posted here. I have PTSD. I like to keep it short, so, I'll say that almost all of what is here is correct. Nice job gang.

Jim

Posted by: Anxiety and Panic Attacks | Mar 6, 2007 8:35:05 PM

In my case the anxiety attack symptoms were caused of a traumatic event.I saw how a young woman was hit by a bus in front of me.This was something terrible and it took me several months to overcome it.

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Posted by: judy | Sep 26, 2007 12:01:22 PM

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