The Soldier's Heart [home page]
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dr. matthew friedman
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He is Executive Director of the VA's National Center for Post-Traumatic Stress Disorder. In this interview he explains what PTSD is and why it is by no means the only post-traumatic psychiatric problem affecting many combat veterans. Another problem he says, "is alcoholism and substance abuse." In discussing the many issues surrounding mental health treatment for troops, he talks about the effectiveness of immediately treating troops on the front lines, why killing is or isn't key to triggering traumatic reactions, the relationship of suicide to PTSD and whether Guardsmen and Reserve troops are having a tougher time psychologically in Iraq compared to career military. This interview was conducted on Oct. 7, 2004.

Stigma is  a real problem and we have men and women who  could be treated [for] PTSD, depression. But theyre not coming in for treatment because theyre afraid to.  So somethings got to change.

In what ways is the experience of U.S. troops in Iraq different compared to previous wars?

It's an interesting question. On the one hand, PTSD [Post-Traumatic Stress Disorder] is PTSD. So whether you're looking back at archives of World War I or even Civil War veterans, or you're fast-forwarding to Vietnam or U.N. deployments, we're going to see the same major cluster of PTSD symptoms.

What will be distinguishing, I think, are the contextual issues in which the symptoms are playing out. For example, we all know how the political context was a major factor during the Vietnam War which affected our Vietnam veterans in terms of their homecoming. It was such a terribly decisive factor at that time, because we now know that one of the most decisive points for a returning soldier combatant with PTSD is the kind of reception that they're going to receive when they come home: What is the post-traumatic recovery environment? And for the typical Vietnam veteran who was made to feel ashamed by the populace, ... [calling them] baby-killers or other things, and they felt the antagonism from the time they got off the airplane to the time they came back into their community, that had a devastatingly adverse impact on the recovery of the Vietnam veterans.

Fortunately, that's changed, and it's interesting how it's changed. Despite the fact that the nation is polarized politically, our nation has become much more sophisticated and no longer confuses the war with the warrior. So unlike the Vietnam era, people from both sides of the political aisle, in terms of whether or not they think we should have been in Iraq in the first place, they are all supporting our troops. And that is incredibly important in helping a person back on the road to psychological recovery.

I think that other contextual issues are certainly the fact that in many ways, the Iraq situation seems to be more dangerous for the noncombatants. Combatants sort of signed on for the kind of dangers that are inherent, but the fact that truck drivers, mechanics, medical personnel, administrative personnel, who are usually much more protected -- and they even were protected more in Vietnam, you know -- are now at risk of a convoy getting attacked, of a suicide bomb affecting them, the fact that the populace outside of the Green Zone is hostile, the sense that every day is dangerous, every day something could happen, I think that's different. And certainly it's different from traditional wars, where there were front lines and rear-echelon places. Obviously that changed in Vietnam because it was a guerrilla war, but I think it's changed even more here.

Furthermore, tours being extended, and particularly for Guard [and] Reserve units, which I think are much more vulnerable than the active-duty personnel, is another factor that differentiates this war. Yes, we had Guard and Reserve units in the first Gulf War; however, they were not in the front lines and invading Basra or invading Iraq.

Will National Guard and Reserve troops have a harder time in Iraq?

Again, I don't have a crystal ball, so I don't know. I'm giving you guesses, but I'll tell you what I'm basing these guesses on, because we're all guessing as we prepare to meet the anticipated demand from mental health services, both from within the Department of Defense for the people who remain in uniform as well as the Department of Veterans Affairs for those folks who become veterans.

The data ... to the best of my knowledge really comes from the post-Gulf War studies that were done, because at that time, many Guard and Reserve troops were deployed. And in a number of post-Desert Storm studies, when compared to active-duty personnel, the Guard and Reserve personnel had higher rates of psychological distress. Now, I'm not saying necessarily PTSD, although that's a piece of it. But that is the extreme piece of it. But in terms of reporting anxiety symptoms, depressive symptoms, things of that sort, the Guard and Reserve troops were more vulnerable in terms of reported symptomatology. Now, why might that be?

Well, I think there are several reasons that we can speculate. One thing is that ... any military person that you'll speak to will tell you that one of the best buffers against the psychological impact of any war zone operation is the unit, the cohesiveness of the unit. And leadership and cohesiveness are things that military psychologists, psychiatrists have been emphasizing for a long time, and I think they're quite correct in that, so that when you're in a war zone, you're with your unit. These are people that you have trained with, that you have lived with, that you can depend on, and you know that you can depend on them, and they can depend on you, so you have that kind of a buffer.

You don't have that kind of a buffer, I think, for Guard and Reserve people who have not been living, working, relying on their personal relations. Yes, they've had their monthly or weekly trainings, or their maneuvers during the summer, [but] it's not the same thing.

Furthermore, for the active-duty personnel, the military is their life; that's their job. For the Guard and Reserve people, they have a life. They have their professions; they have their families. Yes, they go to their Guard or Reserve exercises, but it's not the major fabric of their life. It's something quite different. And so for them to be plucked out of this life and put into a different context, it's a very different experience than it is for the active-duty personnel.

Furthermore, there are economic consequences. Particularly for solo practitioners, whether they're people operating a mom-and-pop store or are a dentist or a barber in private practice, [there are] the economic consequences of suddenly being unable to make the money.

And this isn't all traumatic stress, I want to emphasize. Everything isn't PTSD, the way I see it. And I think that a good term that really came into the vogue in the Gulf War was the whole issue of deployment stress. So whether or not you're going to be in a dangerous situation, the deployment itself is a major disruption of your life, a major, stressful factor that has consequences for you and for your family.

And then on top of that, every Guard and Reserve troop goes into this [differently]. And of course some Guard and Reserve troops want to be deployed; others don't. ... [But] I think for many of the Guard and Reserve troops, at least when the major deployments began, I think it was a surprise. I think it was unexpected. It certainly was unexpected during the Gulf War.

Can you talk about the term "Soldier's Heart" and how it connects to our understanding today about what is PTSD?

The term "Soldier's Heart" was first coined in the post-Civil War era when people were looking at these veterans returning from Civil War combat and trying to understand why they had been changed, because there was general recognition that they had been changed, and that many of those changes were not for the good. [And back then] there were two different models trying to explain this. One was a psychological model, and the other model was a physiological model.

Soldier's Heart comes from the physiological model, the observations that people's cardiovascular system in terms of their heart dynamics, their blood pressure, a pulse rate, seemed to be altered. We can now incorporate that under the PTSD construct, but starting with Soldier's Heart, Irritable Heart ... it was [Jacob Mendez] Da Costa, who I believe was a 19th-century cardiologist, who made these observations.

Then, in World War I, another physical explanation was shell shock, the notion being that being close to the big guns pounding out the artillery on both sides of the barbed wire in the trench warfare was somehow disrupting neuronal connections, so nerves were actually affected. Combat exhaustion, combat fatigue -- all of these are physical types of manifestations. Following the Gulf War, some people felt that the unexplained medical symptoms [were] on a continuum going back to Soldier's Heart, as you've asked.

The parallel trajectory is about the psychological models. And in the Civil War, it was very interesting; the psychological model was nostalgia. The notion was that a Vermonter who found himself with Sherman marching through Georgia who exhibited psychological symptoms was doing so because he was nostalgic for being back in Vermont. Being in this alien Georgia terrain was somehow psychologically so disconcerting that he was having these kinds of symptoms. So this was another model under the influence of the Freudian psychoanalytic school. This got transformed into notions of traumatic neurosis and on and on.

And what's really interesting about PTSD is that it incorporates both the physical manifestations -- and certainly our research has shown that people with PTSD have alterations in their physiology and even are at risk for medical problems as well as psychological problems -- and it incorporates, of course, the psychological symptoms. The first person who really discovered this was an American psychoanalyst [Abraham Kardiner] working with World War I veterans. ... And what he observed, in addition to the psychological distress that they were manifesting and that he was diagnosing as traumatic neurosis -- which was the term that was used for these symptoms in those days -- he also noticed that they were physiologically altered. Particularly he noticed that they were very jumpy, that unexpected loud noises would produce in them a startled reaction. ...

Tell me about the breakthrough concerning understanding how the mind and body connect.

Well, you know, this mind-body dualism that has infected medical thinking for centuries, since Descartes, if you will, is the notion that what happens in the mind doesn't affect the body. And hopefully everybody now recognizes that we're talking about the brain, and the brain is a part of the body. And it also is the part of the body that produces the phenomenology that we also talk about as mind.

And I'd say in the last 10, maybe 15 years, there has been extraordinary progress. And I'm proud to say that the National Center for PTSD has been at the forefront of this progress, showing that people with PTSD have alterations in certain structures of the brain. And they have alterations in how the brain processes information, particularly how it processes information perceived to be dangerous or information that might be reminiscent of a tour in Iraq or of other traumatic situations. So this really is becoming much clearer now in terms of why both the body and the brain are affected in people with PTSD and other post-traumatic problems.

What is PTSD?

It's not simple, but I'll try to be succinct. PTSD is a recognition that if you've been in the wrong place at the wrong time or have been in a place where you've had to commit acts such as shooting other combatants or civilians or driven a car that you weren't in control of and killed people or things of that sort, that these events can change the way you feel about yourself and feel about the world. What's distinct about PTSD from almost all other psychiatric disorders is the fact that there is a historical event that sets this off.

You had to be at Hiroshima; you had to be at Auschwitz; you had to be in Iraq; you had to be raped, mugged, in a plane crash or what have you. That, however, alone is not sufficient. Having been there, you also had to react to that situation with an extreme emotional reaction, what the American Psychiatric Association calls "fear, helplessness or horror." We now think that maybe other strong emotional reactions might also qualify.

So to be traumatized, there are two components: One is having been in an extremely stressful situation, and secondly, having reacted to it with an intense emotional reaction.

Now, what's interesting about this is that when PTSD was first defined back in 1980, the belief was that these events were unusual; that being a war veteran or being a rape victim, being a concentration camp survivor, that these were very, very unusual events. And in fact, the terminology back in 1980 describes a catastrophic stressor as "beyond the range of normal human experience." Now we have [had] 24 years to explore that, and we discovered, unfortunately, that that's incorrect; that unfortunately, trauma is a part of life.

In [the] pre-9/11 United States, more than half of all adult men and women -- 50 percent of women, 60 percent of men -- would have been exposed to at least one traumatic event in the course of their lives. If you go to countries where there's much more civil unrest, the rates are higher. For example, in Algeria, 90 percent of all adult men and women will have been exposed to at least one traumatic event. Same is true in Palestine, Cambodia, other places.

So the lesson from this is that traumatic exposure is not unusual, and we as a society need to be prepared for that. This is not just something that happens to war veterans, to police, to firefighters, to emergency medical personnel; it's something that can happen to almost anybody, and there's at least a 50 percent chance that it's going to happen. And this is before 9/1l.

Now, having been traumatized, there are then three different symptom clusters that characterize PTSD. The first one is the most unique and is what sets PTSD apart from other anxiety disorders, and that is that the traumatic event has a life of its own. It continues to intrude. And we call these intrusive recollections, that someone is trying to listen to this interview, and they can't because they can't get it out of their mind what happened last night with an abusive partner or the traffic accident or the convoy that was attacked or what have you. These recollections are not invited; they're not welcome guests, but they won't go away, and you can't not think about them. They also intrude at night, the traumatic nightmares -- again, another way that these recollections intrude upon sleep. They intrude so badly that many PTSD people don't want to go to sleep because they know there's a nightmare waiting for them.

The most unique manifestation of an intrusive recollection is what we call the PTSD flashback: For a brief or extended period, the person with PTSD believes that he or she is back in the traumatic episode. They believe they're back in Iraq; they believe they're back fending off the rapist; they believe that they're in the train wreck. Often, when you examine these, you find that there were certain situations or stimuli that were reminiscent of the original event.

And that brings us to the last two intrusive recollection symptoms, and that is that events or situations that are reminiscent of the traumatic event can evoke thoughts of the trauma or can evoke physiological changes such as increased pulse rate or increased heart rate, or changes in the way the brain is processing information. Now, this last finding is very important both for research and for treatment, because unlike most other psychiatric disorders, we can reproduce PTSD in the laboratory by exposing -- obviously with their consent -- people with PTSD to traumatic reminders, whether these be auditory cues on an audiotape or videotape cues, or even exposing them to narratives that reenact their own traumatic experience, whether it's child abuse, rape, war-related trauma. And then we can measure a variety of things, whether it's brain function or physiology or psychological thoughts.

Where this becomes really important treatment-wise is that the most powerful treatments that have been developed for treatment of PTSD -- and they're even more powerful than medication treatments -- are what we call cognitive behavioral treatments. And one of them is called prolonged exposure, where the individual with PTSD is reexposed to the traumatic information and by a continual reexposure in the safety of a therapist's office is able to free themselves from the toxic effects of the traumatic memories [that] cause these intrusive recollections, the physiological arousal and the avoidant behaviors that are maladaptive.

The other cognitive behavioral treatment was developed by Patricia Resick, who now runs the Women's [Health Sciences] Division of the National Center for PTSD, which includes some of the exposure elements that Dr. [Edna] Foa developed in a somewhat different way, with written autobiographical narratives, but also has a technique called cognitive restructuring.

But the bottom line [in PTSD symptoms] is that the first cluster of symptoms are these intrusive recollections, and they can be evoked by stimuli that the person either chances upon in the course of his or her life or are deliberately exposed to in the course of treatment or research.

The second cluster are what we call the avoidant numbing symptoms. And what this is about is that these reexperiencing symptoms, and also the arousal symptoms that I'll talk about later, are so distressing, are so upsetting, are so intolerable that people will do whatever they can to avoid them. And there are two strategies. There are behavioral strategies so that, for example, a person who may have been in an automobile accident at the main intersection in this town will stay away from that because it will remind them. People that have come back from Iraq won't watch the newscasts because the film clips of the latest carnage will re-evoke these memories.

And then there are other psychological strategies: psychic numbing to shut down their emotional capacity so they can't feel upset; they can't feel terrified; they can't feel afraid. But when you do that, you also shut down your capacity to feel pleasure, to feel love, and that's why marriages and family life are such a casualty in PTSD. Other avoidant symptoms are just being not antisocial but asocial, just trying to avoid people, trying to be off by yourself, etc.

So the first cluster is reexperiencing symptoms. The second cluster are the avoidant numbing symptoms. And the third are the arousal symptoms. People with PTSD can't sleep; they can't think; they can't concentrate because this traumatic material is in their minds. They may be irritable, even aggressive. They have the startle reflex to unexpected noises, which is what Dr. Kardiner first discovered back in the late '30s and early '40s. And they're hypervigilant; they're on guard all the time. They have security locks on their doors. They don't want another traumatic episode to sneak up on them by surprise.

Can you talk a little about combat stress control?

The notion behind the combat stress control teams really is related closely to these civilian initiatives for critical incident stress debriefing or other kinds of post-disaster psychological debriefing. It is based on the recognition that anybody who is in an extremely stressful situation is going to get upset. It's not unusual. It doesn't mean that you're losing your mind; it doesn't mean that you're psychiatrically impaired. Some of the best data we have is from the civilian disaster research, and what it shows is that following a major hurricane or a 9/11, everybody's upset. Not to be upset is abnormal.

So this is an important issue, because if you're trying to identify the people that are at risk for developing chronic psychiatric problems, you're not going to be able to pick that out in the early going, because everyone is upset. You need to give people a chance to let their natural psychological resilience, let group cohesion, let social support, etc., work as well as they can, and maybe in another week, maybe two afterwards, at the earliest, psychiatric symptoms are going to declare themselves.

So it is the notion of normalizing the fact, so that you have a person who is psychologically distressed; they've been on a convoy that has been hit, and they're upset. Of course they're upset; they should be upset. They may have almost been killed. Someone that they knew might have been killed. And what the combat stress control teams are trying to impart is to help people get that kind of a perspective, that you know it's OK to be upset.

I think I said this to you the first time we met: Probably one of the best literary examples of this is Stephen Crane's The Red Badge of Courage, where you have a new recruit fighting for the North in the Civil War. He comes up against his first war encounter. The Confederate troops are well entrenched; they fire their guns. He has a panic attack. He runs away. He is having what we would call an acute stress reaction. It is a book, and in many ways the book is not that atypical. He regroups, and then he goes back, and then of course he covered himself heroically. But the point is that that was not an abnormal reaction.

I think many people exposed to the reality of war or of any other traumatic episode are going to be upset. And I think the combat stress control teams are attempting to impart that kind of perspective and support in the military context, as are some of the civilian workers in what we call crisis counseling; that is, FEMA-supported post-disaster civilian psychological recovery approaches.

One thing I want to say about the combat stress control, in addition to normalizing the understandable distress that people will feel, is also these are opportunities to provide education for people that don't recover in a reasonable period of time and to help them understand where help might be available.

Would you talk about the stigma that exists in the military culture about seeking psychological counseling?

First of all, I'm a little uncomfortable with the way this has been playing out in the following way. It is not just the military culture where there's a stigma for mental illness. Mental illness is stigmatized throughout American culture. I think that the military context may magnify that, but I think it would be a mistake to believe that there's something fundamentally different about military culture and American culture.

Whereas the papers were full of Bill Clinton's need for cardiac bypass surgery, and there was no stigma that maybe some of the foods that he ate helped to clog his arteries, and there was no shame in having to require cardiac bypass or I dare say for any medical problem -- diabetes, you name it. It's talked about publicly, and people will talk in great detail about what medical or surgical procedures were necessary. Not so for depression. Not so for PTSD. Not so for anxiety disorders. Civilians who have these disorders, psychiatric problems, don't go public with them except on very rare occasions.

So I just want to emphasize that this is a cultural issue. I think in the military culture it becomes magnified because of the concern that a person who has PTSD or some other psychological problem can't be depended on, is going to be impaired, is going to jeopardize the unit. It also has to do with how military people feel about each other.

But in the military culture, it is a problem. There obviously is a stigma.

Yes, I think stigma is a very big problem, and one of the most important findings that Dr. Charles Hoge and his colleagues at Walter Reed came up with in that New England Journal paper was not just acknowledging that there is stigma, but [quantifying] the magnitude of it.

We have known about stigma in the military for a long time. I was at a NATO meeting of mental health people about eight years ago in Ottawa, and we talked about this. But this is the first time, to my knowledge, that we've actually had numbers, we've actually been able to [quantify] the magnitude of this problem, and it is considerable.

What Hoge's data shows is that people who were most distressed psychologically, and in some cases so distressed that they had psychiatric problems that could be defined by very conservative criteria, number one, that they knew that they were distressed; they knew that they were functionally impaired as a result of their depression, PTSD or other anxiety disorders. So we're not talking -- and this is an important point -- we're not talking about people that may have had these problems but didn't know about it. They knew it. And these people who were most distressed were the ones who were most sensitive to the stigma. In other words, they were the ones who felt it was the most dangerous to come forward and seek help. And some of the reasons cited were they were afraid it would ruin their careers; they were afraid that their commanding officers would treat them differently; they were afraid that their colleagues, their peers would treat them differently. It was a shameful thing.

And what is stigma? It's about shame. So we have stigma in spades here. And I think Hoge's data does the military and military personnel a tremendous service by pointing out that this is out there, folks; this is a real problem, and we have well-trained men and women who could be treated because we have treatments that work in PTSD, depression. But they're not coming in for treatment because they're afraid to, so something's got to change.

Well, the only thing that can change is the health delivery system that can provide the help. And this is, I think, where the military is really struggling. One area where there's been a lot of interest is whether or not you can put the mental health treatment within a primary care treatment setting, which would, again, de-stigmatize to a great extent. I mean, the hope is that if people are coming to see their primary care doc rather than some psychologist or psychiatrist, that this isn't going to ruin their careers, and it won't be a cause for shame, etc. I think it's an interesting and important question.

We're working in a similar parallel system within [the] VA to integrate PTSD and mental health treatment within primary care settings. And I know Andy Pomerantz in White River Junction, Vt., has been a leader in that area. And we're actually hoping to launch some systemwide studies that may include military people. So I think that's one approach. I think there are other approaches that one might want to consider. But the important thing is that people are aware, people are concerned, and how soon and how effectively this problem can be addressed is an important question.

And again, a soldier who seems to be freaking out in a combat situation is viewed as a liability. And this is a perception, an attitude, that the military has to confront.

I say that it is an empirical question. That commanding officer is operating on an assumption, and the assumption is that whatever psychological distress, dysfunctional behavior that he's observing in his charge is irreversible, can't be changed, and that he's got to get the person shipped out because he doesn't want to endanger either the individual or he doesn't want to endanger the unit. And that is a belief that I think is very widespread.

I think the question is, is that a [legitimate] belief? And it becomes a very practical question when you consider the fact that tours are being extended in Iraq now because of the scarce manpower resources. If indeed there are treatments that are available that could quickly reverse this and could quickly enable people to resume their previous combat assignments, that would have an impact. This is a tough question, because we don't know, and that commander is saying, "Look, I can't take the risk." And I understand what he's concerned about. What we need is to find ways to demonstrate whether or not his concerns are legitimate or not.

My guess is that we'll be able to do that with the kind of data that Dr. Hoge and his colleagues have collected, because what we'll know -- and we won't probably know it before this war is over -- but what we will have information on is people who did have PTSD symptoms, who were sent back into the war zone, and then we'll be able to see whether or not they were able to perform. If they weren't able to perform, then the commanding officer is correct and they ought to be removed. My guess is, we're not going to find that for most of them. But that's the kind of information that needs to be produced, and I think until it can be produced, I have to be sympathetic with the concerns expressed by the commanding officer.

But I also have to be sympathetic to the people that are removed from the field of operations who feel after they've had some downtime or some treatment that they're ready to go back in. It's a serious question. There's all kinds of lives hanging in the balance. The answer needs to be thought through very carefully.

Can you talk about the difference between PTSD and Acute Stress Disorder?

Post-Traumatic Stress Disorder cannot be diagnosed until a month has elapsed after exposure to the traumatic event. And this definition was from the very beginning, back in 1980 when PTSD was first conceptualized. And the wisdom behind this stipulation is the recognition that most people exposed to traumatic events don't develop PTSD; most people exposed to these traumatic events have the normal, natural resilience to recover from these events. And somewhat arbitrarily, they're given a month. So you've got a month to get over it essentially, and you can't make a PTSD diagnosis.

Well, around 1994, there was a recognition that what are you going to do with people that are really bent out of shape in that first four weeks before you can make a PTSD diagnosis? So the American Psychiatric Association came up with something called Acute Stress Disorder, and this is a severe psychiatric disturbance that occurs only in the first four weeks. Last year, the Department of Defense and the Department of Veterans Affairs convened about 20 of us to come up with practice guidelines. What are you going to do when someone with these symptoms comes into your office or comes into your tent in a war zone or in a VA hospital or in a military hospital with these kinds of symptoms, and how should you proceed in terms of diagnosis, treatment, etc.?

And we spent months developing these guidelines which are now available on a VA Web site and in print form, but in that process we had to invent a new syndrome, Acute Stress Disorder, which is a severe psychiatric disturbance which can only last four weeks. But we coined something we called acute stress reaction, and what this gave credence to was the fact that people can be completely bent out of shape immediately after their exposure, but they're going to recover, and they're going to be OK, and they're not going to have any psychiatric sequelae, and they're not going to have any problems.

Getting back to your staff sergeant, this is a crucial piece of the puzzle, because he shouldn't be sending people out that are having an acute stress reaction that they're going to recover from in a couple days. But under the present situation, sending people with Acute Stress Disorder out, you know, given the lack of information, probably makes some sense. So this is an important piece of that puzzle, and I just wanted to emphasize that.

How do you quantify PTSD along with other very severe, painful stresses? Are they sort of on a continuum?

The short answer is no, we don't look at them as on a continuum. The way we look at them now is traumatic events are considered different. Where there's a threat of life or loss of limb or loss of a loved one is different. That's not to say that going through a divorce, flunking out of medical school, going into bankruptcy, that these are not very, very painful events that people will lose sleep over -- relationships may be destroyed; other kinds of things can happen. I'm not minimizing the terrible impact that these events can have on people, but we believe that they're different than post-traumatic events. It's an empirical question.

Now, there's something that has been around for a long time, at least in a medical context, and that's called Chronic Stress Syndrome. And we know that chronic stress can be related; it can cause medical illness and can have psychological components. There seem to be some differences -- a lot of similarities, but there seem to be some differences between chronic stress and chronic PTSD, at least in terms of the medical consequences. Now, what I believe is that these events can be functionally distressing if not incapacitating, and that we need a diagnostic language that does justice to the severe impact that this can sometimes happen. But we should not confuse it with PTSD, because I do think that there are some important differences.

There appears to be a high rate of suicides among Iraq war troops. Can you talk about this and how suicide relates to PTSD?

... I was at a meeting last July where they talked about the suicide data. And these were high-ranking military mental health personnel, and they felt that there had been a blip in suicide, but that it had evened out. I don't know what the latest data are. One thing that we do know, and this is from research with civilians, is that the greater the number of traumatic events one has been exposed to, the greater the suicide risk.

I'm not trying to draw an association between PTSD and suicide; I'm just citing the data that's there. Suicidal behavior is not one of the diagnostic criteria for PTSD; it is for depression. So that raises another question, since you're talking to me about PTSD. ... Let me make the point right now that although PTSD is perhaps the best defined post-traumatic psychiatric disorder, it's by no means the only [one]. And some of the best research on this has been done by Arik Shalev and his colleagues at Hadassah [University] Hospital Jerusalem.

As you can imagine, the emergency room at Hadassah Hospital is a busy place, full of all kinds of problems -- and not just terrorist attacks, but motor vehicle accidents, domestic violence and the other kinds of things that can happen. And what Shalev has shown is that some people who have been in traumatic episodes may not develop PTSD but may develop depression.

So that's another point I want to make. ... All roads don't necessarily point to PTSD, and it's important, I think, that when we have these discussions about the post-traumatic psychiatric problems that PTSD is by no means the only kid on the block. Another kid on the block is alcoholism and substance abuse. In many ways, we were more aware of that in Vietnam because there was better access in country, but when folks come home, the access is there as well. And we know from civilian situations as well, and even the post-9/11 data showed increases in alcohol behavior, smoking, marijuana use.

So the problem with suicide is a very important problem. I would not like to see it bundled into a PTSD question. It's an important question that needs to be thought through, in all the complexity, in all the clinical demand that it creates.

How important is the issue of confidentiality in addressing the problem of stigma?

I think that you've put your finger on the major problem in the whole stigma issue, that if confidentiality could be safeguarded, if there could be a credible, feasible way that people could come forward and seek the help that they know that they need [but] without the risk that this information would be accessible, that would go a very, very long way towards solving this problem.

It's one of the reasons why I have some concerns about the integrated mental health primary care approach. On the one hand I think it will help a lot of people, but still, that's a medical record [that] is still going to be available, and how well the records can be safeguarded is an important question. So this is a very, very important issue, and it really is the key, I think, to resolving the stigma problem.

What is the impact on a person of killing another human being? How should we think about this in terms of traumatic impact?

I certainly agree that killing, whether it's another combatant or a civilian, can be for some people the most devastating traumatic experience. [But] there are many different scenarios that for different people are the most devastating. So sure, killing is an important traumatic event that needs to be dealt with, but to single it out ... really distorts the issue. ...

For some people, and for police personnel as well, killing can be the most devastating issue. But for other people, the killing isn't. They feel quite justified that it was him or me: "If I didn't kill this individual, so-and-so would have gotten attacked. I was doing my duty." Different people will experience the same event in very different ways based on what their understanding of the event is, what their understanding of the alternatives are, what their past experience is. So it's not a simple question.

Do we have data yet on the effectiveness of immediately treating troops right there on the front line?

Well, it's interesting that front-line treatment has been around since the First World War, actually I guess since the Civil War -- probably even before then. In some ways, the question is a problem, because we don't really have front lines anymore. So the whole issue of the kind of guerrilla war that's being fought in Iraq, I mean, how much front-line data applies is being questioned by a lot of very thoughtful people. It's interesting, because I had to research this some years ago, and there's so little data. The only really good study we have is an Israeli study which in many ways was not designed, but was an accident.

This Israeli study was during the 1982 invasion of Lebanon, where psychological problems -- what I would now call an acute stress reaction until proven otherwise -- were willy-nilly either treated at the front line for what's called front-line treatment, which is what the military would say is three hots and a cot, giving people a chance to get away from the combat for a little while, normalizing it and then putting them back into the combat zone without any stigma, without any presumption that they're not going to be able to function well, and without any presumption, as your staff sergeant said, that they're going to jeopardize their fellow individuals. So a number of them were treated that way, and then the other group was medevaced to the psychiatric hospitals in Israeli cities such as Haifa and Jerusalem and Tel Aviv.

And Zahava Solomon has just completed a 20-year retrospective of this work and found that not only did the Israeli IDF forces that were treated by the front line, not only did they recover for the most part and were able to function well, but their likelihood of developing PTSD was much less than those that were medevaced to the psychiatric hospitals in the rear. And her 10-year retrospective has borne that out, and I've seen the 20-year data.

Unfortunately that's the only study there is. And how applicable it is to the Iraq situation, again, that is a question that a lot of people are asking.


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posted march 1, 2005

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