Abstract and Introduction
Iraq in 2003 was a nightmare C.J. Grisham could not wake up from. It was sustained, almost daily combat for months, and Grisham, a first sergeant in the Army, said he could feel the strain.
Once, he said he was forced to shoot a person being used as a human shield. Another time, he helped an Iraqi family extract a dead loved one from a burned car. He started to have flashbacks, vivid nightmares and suicidal thoughts — all signs of post-traumatic stress disorder.
"It's like a million voices in my head telling me that I'm not good enough to be alive," he told The Nation's Health.
The voices told him he should be dead. They said his depression was a sign of weakness and that it was his selfishness that let his friends die.
"It's maddening, and I look forward to the day the voices end," he said.
A 2008 study by the Rand Corporation found that as many as 20 percent of U.S. veterans who served in Iraq and Afghanistan suffer from PTSD or major depressive disorder. As the disorder becomes more widely known among veterans and their doctors, researchers are making strides in improving their understanding and treatment. And yet, to the general public the problem is generally not well understood, mental health professionals say.
According to the American Psychiatric Association, PTSD is the result of a traumatic event that involves actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. Symptoms include intrusive recollections such as flashbacks and dreams, avoiding stimuli associated with the trauma, and hyperarousal, which is characterized by difficulty falling asleep or staying asleep, irritability and exaggerated startle responses.
"I get extremely nervous in crowded situations and become hypersensitive to my surroundings," Grisham wrote in a blog post. "Before entering any building, I make a quick survey of all people around me and seek out any and all exits. I sit with my back to a wall so I have a good view of people approaching me. I get startled and anxious at unexpected and loud noises. What I don't get is violent. What I don't do is threaten people."
One of the most common misconceptions about PTSD is that veterans who suffer with it are violent, said Francine Roberts, PsyD, a Marlton, N.J., psychologist in private practice who works with first responders, emergency service providers and veterans on critical incident stress management.
"There was an incident not long ago where a veteran had a violent outburst, and the media was all over it, talking about how folks with PTSD are violent," she told The Nation's Health. "But the opposite is the truth. Veterans have no more potential for violence than anyone else."
Acting out against others is rare, she said, but self-directed violent behavior, such as suicide, is much more common among veterans with PTSD, she noted.
Rob Ulrey writes for a military blog using a pen name because he worries about the stigma associated with PTSD. He agreed to allow The Nation's Health to use his name so he could spread the word that people with PTSD are not dangerous.
Ulrey was stationed in Bosnia in 1996 when a vehicle he was in experienced what was then called a mine strike. Today, they are known as improvised explosive devices. He was injured and spent time at a base in Germany where an astute social worker, who was himself a Vietnam War veteran, saw the symptoms and helped Ulrey get his PTSD diagnosis. He underwent treatment for a year and thought he was better.
But recently the night terrors returned. He would wake up five to seven times a night, sweating so badly the bed would be drenched.
"For a long time I didn't think I was bad enough to need treatment," he told The Nation's Health. "I didn't want to take an appointment from somebody who needed it more than I did. You could call it age, or maturity, but I was suffering with it for so long that it was finally time to fix me."
Grisham was diagnosed officially in 2009, six years after his combat tour. He finally sought help when he realized that he would not be able to convince his troops to seek help when he was trying to hide his own pain.
Both Grisham and Ulrey emphasized that PTSD can be treated. The U.S. Department of Veterans Affairs has an entire arm, the National Center for PTSD, dedicated to conducting research on PTSD, and VA medical centers nationwide provide PTSD care for veterans.
During a recent press call, clinicians and researchers at the VA highlighted some of their most promising research, much of which involves peer support and outreach. That peer support is important, particularly to members of the military, because of the bond service members feel for each other.
"Soldiers who deploy together spend long, harsh months together," said Marcia Valenstein, MD, associate director for research programs at the Serious Mental Illness Research and Evaluation Center at the Ann Arbor VA Center for Clinical Management Research.
"Strong personal bonds are formed (during deployment) and when they fight, they fight for their buddy," Valenstein said. "They maintain that link to their buddy, and they're more able to reach out to them."
Valenstein is evaluating a program that pairs National Guard soldiers with buddies as they return from overseas. The buddies can provide a sounding board for each other and encourage one another to seek help if needed.
Other research efforts include a clinical trial in which soldiers write about their thoughts and feelings and a study looking at using a combination of medical treatment and psychotherapy to find a ratio and dosage that works best.
One of the most important changes that may be slowly happening is lessening the stigma associated with PTSD and other mental health disorders. In the past, soldiers have been concerned that seeking help for PTSD would damage their careers or shade the way their commanders look at them. But as researchers are better understanding the problem, soldiers, spurred in some cases by leaders who have professed their own struggles with PTSD, are seeking help.
"Stigma is something we've been working on," said Joel Kupersmith, MD, VA's chief research and development officer, during the press call. "There's been improvement, and it's our observation that there are more individuals in mental health care (now than in previous years.)"
Ulrey and Grisham both report improvement in their symptoms since starting treatment. Grisham said cognitive behavioral therapy has "virtually eliminated" the survivor's guilt portion of his PTSD.
Ulrey is finding help through medication and psychotherapy.
Ulrey said his message for his fellow soldiers is that help is available, they need only seek it out.
"You were strong enough to make it this far," he wrote in one blog entry. "Don't give up. Dig a little deeper and make that final push."
For more information on PTSD in veterans, visit www.ptsd.va.gov. For more news from The Nation's Health, visit www.thenationshealth.org.
Nations Health. 2012;42(3) © 2012 American Public Health Association