As of July 19, 1,766 American soldiers have died in Iraq, and more than 12,000 have been severely wounded.
Most of us will never live through the suffering of a war firsthand, and regardless of our political affiliation, we will experience the pain of fallen and wounded soldiers and civilian casualties only from afar.
Yet there are some among us who have served or are still serving in Iraq, who are not watching the war on television. Many of them will live through the hell of war not once, but over and over again - because of a syndrome called Posttraumatic Stress Disorder (PTSD).
"There may be an understanding of the 1,600 deaths, and some comprehension about the serious injuries," said Dr. Evan Kanter, a staff psychiatrist at the PTSD Specialty Clinic at the Seattle Veterans Administration. "But the lives being devastated by PTSD are in the six figures. And it affects not only the soldier, but his or her family and friends."
Kanter, a clinical assistant professor in the University of Washington psychiatry department as well as Northwest regional director for Physicians for Social Responsibility, added that many veterans suffering from PTSD are doing so in relative isolation. "One of the biggest problems now is that veterans are not connecting with the help available to them," he explained. The reasons for this appear as varied and complex as are the causes of PTSD itself.
Diagnosis
Records of war-related psychological syndromes go back as far as the American Civil War, when a condition called "Da Costa's Syndrome," or "Soldier's Heart," was diagnosed among enlisted men.
Other names for this syndrome, such as "combat stress" and "shell shock," emerged in the wake of the seemingly perpetual conflicts that defined the 20th century, and beyond - including such United States-led military operations as Desert Storm, Enduring Freedom and peacekeeping efforts in Somalia.
PTSD is an anxiety disorder that engages both the biological and psychological systems of the body. When a traumatic event occurs - such as rape, assault, natural disaster, a car accident or combat - it is common for a person to experience grief, fear and anxiety. In most cases, such extremely powerful emotional reactions taper off with the passage of time.
Sometimes, however, symptoms remain. According to the American Psychiatric Association, to be categorized as having PTSD a person's response must include "intense fear, helplessness or horror." Symptoms may have a delayed onset of years, yet their occurrence can be intense enough and last long enough to have significant impact on one's daily living.
Individuals suffering from PTSD can experience recurrent flashbacks or nightmares coupled with anxiety (termed intrusion), as well as a constant arousal of the "fight or flight" instinct that typically triggers only during periods of immediate threat or danger to the self (called hyperarousal).
Eventually symptoms of intrusion and hyperarousal can be so overwhelming that the individual purposefully will avoid people and situations in an attempt to circumvent "triggering" events that remind the person of the original trauma. This, in turn, often leads to even more intrusive thoughts as the person spends more time alone.
Before the terrorist attacks of 9/11, it was determined that 50 to 60 percent of all Americans had faced some kind of traumatic event. Nearly 7.8 percent of Americans in the general population will experience PTSD at some point in their life. (In places like Palestine or Somalia, where the population lives through ongoing civil unrest, the number of people exposed to trauma can soar to as high as 90 percent of the population.)
Susceptibility
There may be many reasons why some people develop Posttraumatic Stress Disorder and others do not. One theory lies in the history of the individual prior to the major traumatic event; if the person has experienced other traumas in his or her life, there is a potential for a compounding effect.
The intensity of the trauma is also a factor, as is a family predisposition. For those in the military, pre- and post-deployment factors, such as family cohesiveness and the type of support systems available, also play a key role.
Also of interest is the social dynamic surrounding PTSD. For example, many experts believe that so far, in several ways, veterans returning from Iraq are having an easier time than did Vietnam vets, who returned to a society that literally and figuratively spat in their faces. With the Iraq conflict, and regardless of individual politics, many more people in the general population have decided to "hate the war but not the warrior." In addition, physicians and military personnel are more aware of PTSD than during the Vietnam era.
Kanter points out that 9/11 caused a major shift in public perception with the media reporting on the effects of PTSD on firefighters, police and other emergency personnel enveloped in the tragedy of the attacks as well as their lingering aftermath.
But a major question remains: Is all the increased awareness of PTSD enough to make a substantial change in the way we treat our soldiers' and veterans' mental health needs?
Correlations
According to the Pentagon, there have been almost 1 million troops deployed to Iraq in the past 18 months, with multiple tours accounting for many of them. Depending on the source consulted, there are currently between 120,000 and 150,000 troops in Iraq.
Some experts have stated that 17 percent of all returning troops will go on to suffer from PTSD; others feel certain that this percentage is low, predicated as it is on projections made early on in the conflict, before tours were being extended unexpectedly. Multiple tours of duty presume multiple exposures to traumatic situations.
Studies show that 70 percent of the Vietnam vets suffering from PTSD also experienced substance-abuse problems. Although data show that many troops engaged in widespread drug and alcohol use while still in Vietnam, it has been clearly demonstrated that drugs and alcohol can become pervasive coping mechanisms for today's returning soldiers as well.
There is substantial conjecture as to whether or not, as in Vietnam, the number of troops with a dual diagnosis of psychological and substance-abuse problems following the war in Iraq will continue to grow at a steady clip.
"Addictive behaviors, such as a lot of drinking, are a big red flag for major depression or PTSD," Kanter said. "Any repetitive, obsessive behavior tends to keep symptoms of PTSD at bay, so activities like workaholism, pathological gambling and even working out obsessively... these are behaviors to look out for."
Beyond combat
Although many people might associate PTSD solely with those in combat, that is an error. Anyone serving in a life-or-death situation can be traumatized and subsequently affected by the syndrome. Because Iraq is a conflict taking place in a highly urban environment, soldiers, medics, guards or even a technician on the road to a non-combat post are all at risk of experiencing a major trauma. It's been said that in Iraq every job is a combat position.
Because of the changing face of modern warfare, the ratio of wounded to killed in the line of duty in Iraq is the highest in United States military history. Such factors as the types of weaponry used, the increased sophistication of protective gear and advances in emergency medical care have all led to a higher percentage of nonfatal injuries. The simple fact that more troops are surviving combat means, in a very real sense, that more soldiers are being exposed to trauma and the possibility of suffering from PTSD.
Is the stigma real?
American culture has stigmatized mental health issues for decades, so it is no wonder this stigma has seeped into the military mental-health system as well. Although it is debatable whether the stigma is worse in the general population or in the armed forces, in the end the argument is moot. The fact remains: the victims of this stigma are the individuals most in need of treatment.
A recent study entitled "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care" (Hoge, et al.) reported that among individuals experiencing mental health issues, only 23 to 40 percent seek professional help. Frighteningly, the individuals who were rated as having a mental health problem were twice as likely to say they were concerned about asking for necessary assistance due to a perceived stigma from both fellow soldiers and superiors.
Kanter supports Hoge's findings. "There are problems in the military for active-duty people that make it harder to seek treatment," he said. "Feeling weak, being worried that your unit won't trust you and anxiety about your career and promotions - these are real concerns.
"Some people manage to suppress their PTSD for many years because of this," Kanter added. "But others don't."
In the United States, doctor-patient privilege is a right; what is spoken between a doctor and his/her patient remains confidential. In the military, this is not the case - or the rules are ambiguous at best.
This means that all medical files, physical and psychiatric, are open: your commanding officer has full access to your file at any time. Many enlisted personnel and doctors feel that this creates a climate in which men and women in the armed forces are not comfortable coming forward for treatment.
In Seattle, the Veterans Administration has a "Deployment Health Clinic" - a sort of "one-stop shopping" medical facility that screens for everything from malaria to reintegration issues to PTSD. Part of a routine screening is being seen by a staff psychologist who will refer the individual to a psychiatrist if greater mental health needs are detected. This all-inclusive screening is meant to catch all types of health problems while reducing the stigma associated with bringing up mental health issues.
Sheila, a former sergeant in the Air Force, was seriously injured stateside in an automobile accident. She has suffered from chronic pain and PTSD for two decades.
As a volunteer outreach coordinator with Voice in Wartime, a local nonprofit, Sheila fields phone calls from veterans on a daily basis, helping them to negotiate their pain and confusion during reintegration into their stateside lives.
Sheila explains that she realized her calling while working with a fellow veteran returning from Afghanistan. "He said the words I was saying were the words he was thinking but couldn't articulate," she said, "and I realized that that's what I do. I am a voice for my fellow soldiers."
As I prepared to write this article, Sheila helped me to find veterans willing to speak directly about his or her experiences in Iraq. I also contacted several organizations representing families of veterans.
The response was uniform: most veterans simply don't want to talk about their mental health issues, no matter how often they are told that people won't think less of them - that there is respect and support out there.
Sheila pointed out that it's easy to trigger anxiety in someone suffering from PTSD, adding that even an apparently calm conversation could cause symptoms to flare. "For some people, it's hard to interview because questions are triggers," she said. "It's like asking someone to take off their bandages so you can poke around in there."
Most veterans experience myriad emotions upon returning home, and not all of them should be construed as indicators of PTSD or even depression. Readjustment is a complex process. Many soldiers are coming home to a family that has changed. New roles may have been adopted by the family members at home, and often children are no longer familiar with a parent after a long deployment overseas.
All of this takes time to sort out. Kanter reminds individuals in this position that they're not alone. He said he's had patients tell him that it helps them to meet others who are having the same difficulties, to know that similar people are out there.
There is ongoing debate over whether war is a necessary evil in this world, though when it comes to an issue like soldiers and veterans living the rest of their lives with posttraumatic stress disorder, the debate becomes immaterial.
When one thinks of the emotional cost to the individual, loved ones and their communities - not to mention the fiscal burden at the federal level - the price is staggering, nearly inconceivable.
Kanter said he believes one thing should be strikingly clear: "People don't seem to understand how terrible the costs of this war are. If people truly understood the costs, we would be much less likely to choose to go to war.
"The costs are financial, too," he added. "The medical costs are astronomical, as are the disability costs. Nearly 200,000 individuals from the first Gulf War have a government-recognized, service-connected disability, and we are moving in that direction again."
President George Washington wrote: "The willingness of future generations to serve in our military will be directly dependent upon how we have treated those who have served in the past."
This wisdom is fundamental to the way we treat our soldiers returning from abroad as well as veterans from past wars. If, as a country, we are going to continue to engage in military action, it is critical that we demonstrate respect and gratitude to our military troops by giving them appropriate mental health services.
The first and most important step is to remove the veil of stigma that works to obscure or deny mental health issues, both in American culture as a whole and in the subculture of the military. Only then will we be able to appreciate the magnitude of the PTSD problem, and move toward securing the funds and people-power necessary to address it.
If you or someone you know has been in the military and is demonstrating any of the symptoms described in this article, call the Deployment Health Clinic at 764-2306 or 1-800-329-8387 (outside Washington state: 1-877-222-8387).
If you are a military veteran in crisis or are having feelings of wanting to harm yourself or someone else, call the crisis clinic immediately at 461-3222 or toll free at 1-888-427-4747.
Rachel Bravmann-Bevens is a freelance writer living in Seattle.[[In-content Ad]]
