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The unseen wounds of war

Yale Medicine Magazine, 2005 - Autumn


As long as humans have waged war, the horrors of the battlefield have caused psychological damage. Since the war in Vietnam, this damage has had a new name—post-traumatic stress disorder.

All but one of the 12 veterans sitting around the plastic laminate conference table appear worn and tired. Their world-weary look comes from decades in which, among them, they shot heroin, smoked and drank too much, wasted years in jail, picked fights, gambled, divorced and shuttled from job to job. They all fought in Vietnam, and more than 30 years later, as they enter their late 50s and early 60s, they are still paying the price.

Except for Luke. The former Marine is only 24 years old, 18 months back from Iraq, and he looks good. Blond, fit and handsome, he could model for a recruiting poster. But he has joined the other veterans in a United Way meeting room in Meriden, Conn., because he is hurting, too. If someone yells at him, he’ll yell back, or worse. If someone steps into his bedroom, he’ll smell the alien scent hours later. If someone touches him when he’s sleeping, he’ll attack. Thunderstorms scare him. In the months after returning from war, he went to bars, got drunk and picked fights with strangers nearly every day.

Luke provides a sense of purpose for the other vets. Guided by 57-year-old social worker and Vietnam veteran James J. Gavin, M.S.W., the older men talk about their own problems over coffee and doughnuts this morning. All, including the social worker, have been diagnosed with post-traumatic stress disorder (PTSD). For these men, the psychological and physiological adaptations that helped them to survive war persisted at home. Veterans traumatized by war—or people distressed by an event in which they fear death or great harm to themselves or others—suffer from PTSD if they meet three criteria: re-experiencing, hyperarousal and avoidance. That is, people with the disorder unwillingly revisit traumatic events in flashbacks or nightmares; they are hypervigilant, feeling irritable about trivial frustrations, constantly scanning a room or a street for danger, seeming to sleep with one eye open; and they retreat from life and relationships because they feel emotionally numb or because they hope to avoid situations that trigger bad memories.

Gavin has helped the Vietnam veterans at the table to understand, after all these years, that they have not been messing up their lives simply because they have bad memories of Vietnam, but rather because their brains have been changed by war. The changes that helped them to survive Vietnam have made their lives back home a kind of purgatory, from the aisles of Stop & Shop to the family dinner table. The men generally took decades to realize that they had PTSD.

Gavin recognized that Luke had PTSD shortly after Luke came home in July 2003 after five months in Iraq. They met when Luke stopped by the Vet Center in West Haven, Conn., a community center sponsored by the Department of Veterans Affairs (VA), to ask about college money. During several conversations about benefits, Gavin tried to assess whether Luke had PTSD. He already knew from his Vietnam experience that many veterans come home with PTSD; a landmark study in 1988 showed that one in three men who served in Vietnam would experience PTSD. Gavin saw it in Luke and persuaded him to join the therapy group in the winter of 2004.

One of the men explains why he is glad Luke is among them. “It helps us share our experience dealing with this for 30 or more years,” says Vincent, a slight man with gold-rimmed glasses and curly black hair who looks like a professor and spent a year in a homeless shelter. “Luke has the advantage of all this wealth of understanding. We didn’t have any of this.”

They talk mostly about feeling rage. Joe tells his story first. His huge, muscular arms are covered with many-colored tattoos, and he wears a T-shirt that reads: “When it absolutely, positively, has to be destroyed overnight: U.S. Marines.” He describes the time that an elderly woman banged her supermarket shopping cart into his. Once. Twice. The third time, Joe overturned the woman’s cart and kicked her groceries across the floor. After security guards ejected him from the store, he rushed to his car and drove away. “I felt terrible. This poor lady just ran into me a few times.”

“You can’t help it,” explains Craig, a mild-mannered man wearing glasses and a red sweatshirt. Vincent adds: “You have a sense of being attacked.”

“You wake up one day and you’re out of toothpaste, and you want to nuke the whole neighborhood,” says Bob. He says that driving brings out anger in all the men at the table. But nowadays, says Bob, he stays a bit calmer when other drivers cut him off on the highway. “I’ve gotten better,” he says with a wry smile. “I don’t chase them to their doorsteps any more.”

Luke is making progress, too, even though he went to the emergency room recently after he became angry at his brother and slammed his fist through a door.

“You’re doing better,” Gavin tells him. “Six months ago you would have hit him.”

The 12 men around the table speak of rage and regret, of wasted years. But toward each other, they express compassion. With Gavin’s help, these men are going to take care of Luke.

A malady with roots in ancient times

The deep psychological wounds of war have been documented since the time of Homer in ancient Greece. His account of the Trojan War tells of Achilles’ disintegration following the battlefield death of his best friend. The psychological impact of war was called “nostalgia” during the Civil War and “shell shock” in World War I. But it was not until 1980 that the military and medical establishments in the United States formally recognized the damage done by combat stress. The age-old psychiatric illness is now called PTSD.

A Yale psychiatrist was one of the first clinicians in the nation to recognize a distinctive set of symptoms related to the Vietnam War. Arthur S. Blank Jr., M.D., HS ’65, who practices psychoanalysis and psychiatry in Bethesda, Md., had spent a year in Vietnam working in hospitals in Long Binh and Saigon after finishing his Yale psychiatry residency. Soon after the war ended, Blank reviewed the charts of 60 Vietnam veterans and concluded that many had been misdiagnosed with maladies ranging from alcoholism to schizophrenia. Blank invited those men to a therapy group at the veterans hospital in West Haven, Conn., now called the VA Connecticut Healthcare System. That was in 1973, the year that most of the remaining American soldiers came home from Vietnam; the PTSD diagnosis would not be included in the American Psychiatric Association’s diagnostic manual for seven more years.

“Very early on, West Haven became a center where they really understood PTSD,” says Steven M. Southwick, M.D., HS ’85, professor of psychiatry, who does research at the West Haven VA hospital. Other clinicians nationwide also began to notice the distinctive effects of war trauma that Blank had observed, and by the late 1970s, mental health professionals united to push for the official definition of PTSD.

Soon after, Yale endocrinologist John W. Mason, M.D., now professor emeritus of psychiatry, showed that the behavioral changes of PTSD had neurobiological correlates. Combat veterans with PTSD had elevated levels of stress hormones such as noradrenaline and adrenaline.

“This was a giant step,” says Southwick, “because people began to understand that there was a biological basis to many of the ‘psychological responses’ they were seeing in people who were severely traumatized.”

Since then, Yale investigators at the VA have remained at the center of PTSD research and have helped improve the care of returning veterans nationally; West Haven is home to the Clinical Neurosciences Division of the VA National Center for PTSD, whose other divisions are located in Massachusetts, Vermont, California and Hawaii. Yale researchers have found that veterans with PTSD not only undergo changes in stress hormone levels but may also have hyperreactive sympathetic nervous systems; exaggerated increases in heart rate and blood pressure; and reductions in the volume of the hippocampal region of the brain, which is critical for memory and learning.

Yale researchers are studying the neurobiology of PTSD from several vantage points. John H. Krystal, M.D. ’84, FW ’88, the Robert L. McNeil Jr. Professor of Clinical Pharmacology, is working with Robert A. Rosenheck, M.D., HS ’77, professor of psychiatry, to study whether the antipsychotic medication risperidone helps veterans who don’t respond to antidepressants like Prozac and Zoloft. Krystal is planning to investigate whether genetic factors influence how people respond to these antidepressants. C. Andrew Morgan III, M.D., associate clinical professor of psychiatry, has worked with the military to study how military personnel respond to severe stress. He found that personnel who responded best to stress had elevated levels of neuropeptide Y, a brain chemical linked to stress.

Southwick, who is deputy director of the Clinical Neurosciences Division of the national VA PTSD center, is taking part in another PTSD study. The study is a collaboration with Deane E. Aikins, Ph.D., assistant professor of psychiatry, and Maj. Paul M. Morrissey, M.D., FW ’00, HS ’02, a psychiatrist and chief of behavioral health at Fort Drum in upstate New York. Using functional MRI scans, they are charting variations in brain function between controls and veterans diagnosed with PTSD. Southwick says that studying the neurobiology of stress responses—and finding a physical manifestation of a psychological problem—had helped clinicians to understand PTSD better. “Before, it was all interpreted psychologically,” he says.

Depression and an adrenaline rush

Since October 2001, more than 1.1 million men and women have served in Iraq and Afghanistan, according to the Department of Defense. A research team at the Walter Reed Army Institute of Research reported in the July 1, 2004, issue of The New England Journal of Medicine that nearly one in six Iraq veterans and one in nine Afghanistan veterans suffered from PTSD, major depression or generalized anxiety.

Such studies provide the best window into PTSD rates, because according to Defense Department physician Michael E. Kilpatrick, M.D., “the Department of Defense would only know of those service members who reported problems and sought a diagnosis.” And many do not report their distress: in the Walter Reed study, between 60 and 77 percent of the study participants who had a mental disorder did not seek help.

The most exposed of those fighting in Iraq and Afghanistan may be members of the Reserve and National Guard, which make up 35 percent of those deployed, notes Morgan. They are vulnerable, he says, because Reservists and National Guard members generally have less training than do full-time troops. He notes that the high rate of redeployment in the wars in Iraq and Afghanistan hurts morale and increases burnout; by last summer, 280,000 of the 1.1 million had gone back, according to the Department of Defense.

Blank agrees that redeployment can intensify harm: returning for a second tour worsened PTSD for troops who served in Vietnam. “There’s some evidence that it has something to do with addiction to the adrenaline rush, which may have a physical as well as an emotional component.” (As one Connecticut veteran of Iraq described it, “Nothing can compare to it when you come home. Everything is boring. You can’t but be drawn into that intensity. Everyone I’ve talked to feels the same way.”)

The effects of trauma can last a long time. The congressionally mandated Research Triangle Institute study in 1988 that compared 1,625 Vietnam veterans with 750 other veterans and 750 civilian counterparts found that 15 years after the war’s end, 15 percent of male veterans and 9 percent of female veterans were suffering from PTSD. This compares to a rate of about 1 percent of the general population.

For those fighting in Iraq and Afghanistan, Blank predicts that the changing character of the wars will increase the rates of psychological trauma. “Unfortunately the situation in both combat zones is one of general terror,” says Blank. “There are no safe places, and as the guerrilla fighters know all too well, it’s highly psychologically debilitating to have random terror.” Blank notes that anecdotal reports suggest that at least some troops think the war is unjustified, and for those men and women “the questionable character of the war in all likelihood will contribute to the occurrence of PTSD, because there is not the buffering factor of feeling that despite the difficulties one has encountered, there is at least a sturdy justification for what one has experienced.”

Blank points out one “good-news aspect” of the situation: Reservists and National Guard members tend to be older than full-time service members, and age protects against PTSD. The most vulnerable to the disorder are 18- and 19-year-olds. Another positive aspect is that now veterans can get care much more quickly than did Vietnam vets. But the majority of veterans have historically shunned care. They avoid it in part because society stigmatizes people with PTSD, says Blank, who helped to establish and then directed the VA network of Vet Centers like the one that employs Gavin. The community-based counseling centers now number 206 nationwide.

Military officials are working against the stigma, according to Fort Drum’s Morrissey. He says that troops leave for war knowing that psychological distress is normal and that, even in a war zone, the military will provide support. That’s a big change from the military’s approach during the Vietnam War.

“The main thing that’s changed is that now the possibility of combat stress and other mental health problems, including PTSD, is mentioned up front,” says Morrissey. He says that this kind of openness is helpful, because men and women anticipating combat inevitably worry about what will happen if they fall apart. They ask themselves: “ ‘What if I am really scared? What if I lose it when I’m there?’ They’re all thinking about this stuff,” says Morrissey. He and his staff train soldiers how to recognize problems not only in oneself but also in others. “If they can be looking out for someone else, that helps them regain some mastery.” Making it clear that those with problems will get support, says Morrissey, “lets them push themselves a little further.”

Those who do have trouble coping can seek help from “combat stress control teams.” Stationed in the war zones, the teams are composed mostly of mental health specialists who have completed basic training and then spent eight months studying emergency medicine and mental health care. They are backed by psychologists, psychiatrists and social workers. The combat stress control teams offer those in distress a short break and medication, if necessary. Once symptoms are mitigated, the service members return to their posts. As Luke describes it, the goal of a battlefield psychiatric evaluation is to find out: “Are you fit to pull the trigger?”

Finding help at home

Once home, veterans can seek help at a VA hospital or a VA Vet Center, says Dolores Vojvoda, M.D., assistant professor of psychiatry at the medical school and head of the PTSD and anxiety disorder service at the West Haven VA. Vojvoda says some veterans are referred by VA physicians but most call the VA for help on their own. The West Haven staff includes five part-time psychiatrists, a psychologist, three social workers, a registered nurse and three advanced-practice mental health nurses.

Vojvoda reported that by mid-summer, therapists in the PTSD clinic at the West Haven VA hospital had seen about 50 Iraq and Afghanistan veterans. She expected the numbers to grow, and the VA had recently awarded Vojvoda’s group a grant to hire a new psychiatrist and two more social workers in anticipation of an influx of combatants returning with PTSD and anxiety disorders.

The VA staff provides both individual and group therapy. In the groups, veterans learn about the symptoms of PTSD and how to manage them. Treatment may also include antidepressants, sleeping pills, antipsychotic medication for intrusive memories and anger, and alpha blockers for nightmares and exaggerated startle reflex. The VA also offers programs to help veterans recover from alcohol and drug abuse, common mechanisms for coping with PTSD.

Group and individual therapists at VA hospitals often treat patients using cognitive processing therapy, a technique developed in the 1980s for rape survivors. Patients are asked to focus on a traumatic event and to examine whether they have interpreted it realistically. For instance, a soldier may take the blame for a bad event, but the idea of fault implies some control over what happened. In reality, he or she may have been powerless to prevent what happened. The therapy also addresses overgeneralizations, such as when a person harmed by another concludes that no one can be trusted.

Therapists counseling returning service members face a paradox because so many returnees must go back to war. Susan R. Hill, M.S.W., assistant clinical professor of psychiatry (social work) at the medical school and a social worker at the West Haven VA hospital, worries about helping those with PTSD relax their vigilance if they are to be returned to a combat zone where they will once again need to be hypervigilant. “It’s a really questionable outcome at the moment for the ones going back.”

Joining a group is difficult for those with PTSD, since avoidance and withdrawal are hallmarks of the disorder. Nonetheless, says Hill, “We are convinced that there’s tremendous benefit in being around folks who are dealing with re-entry.” She notes that many veterans withdraw from other people, “and then they’re pretty much isolated in their own heads, as we all are when we are alone, only their heads are full of carnage. … The opportunity to speak with other people who are having trouble with re-entry breaks down the military ‘strong-men-don’t-cry’ theory.”

Luke, for one, is doing better. “You learn when you are in danger of getting set off, and you learn to avoid any kind of stress, any situation where you’re going to get set off,” he says.

At the restaurant where he works as a cook, the boss yells at other employees—but not at Luke. “I told him when I got hired: ‘You can’t yell at me.’”

He told his girlfriend: “If I hit you in my sleep, I’m really sorry. If I hit you hard, I’m really, really sorry. If I’m screaming, get out quick.” So far the two have co-existed peacefully in bed.

Although he finished his military service more than two years ago, Luke still toys with the idea of going back to war. He is attracted by “the rush that was associated with it. When things start going bad here, I think, ‘The hell with it, I’ll go back.’”

Instead, Luke has enrolled in college. He wants to emulate James Gavin and become a social worker. “I look at the way I was before I met Jimmy and how much better I am now, and I think it’s a rewarding job to help somebody with what they’re going through. … He’s been through the same shit I’ve been through, and he was my age when he did. He was in a bad place, and he pulled himself out. Now he’s helping other people.” YM