B0038M1ADS EBOK (10 page)

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

I used to love to go to the beach, but after Iraq, I can't stand sand
and don't go anymore.

-JUNIOR ENLISTED MARINE, POST-IRAQ

When I came back from Iraq, I didn't care about anything, even
my wife's tears.

-NCO, POST-IRAQ

The desire to shut down, detach, and withdraw can be very strong after
combat. Warriors often want to be left alone. They may avoid going out
because it puts them in situations that trigger strong reactions or reminds
them of their deployment. Since many little things can cause reactions or
lead to confrontations, the natural tendency is to want to avoid going anywhere. They also don't want to explain to people who may not understand
why they react the way they do. This can mean not doing a lot of things
that the warrior used to enjoy doing, and can be extremely frustrating for
loved ones and friends.

The most detrimental aspect of criterion C is emotional detachmenthaving difficulty feeling a full range of emotions; not being able to show
love or other feelings toward others.

He was very distant after coming home-it seemed like he didn't care.
-MILITARY SPOUSE

Shutting down emotions is a necessary skill in combat, and it can
sometimes be very difficult to turn them back on after coming home. Warriors often describe not being able to feel love, not caring about others,
and feeling numb or detached. This is also essential for survival in combat. Unfortunately, these problems are the hardest for loved ones to deal
with, and the ones that are most likely to end up in failed relationships,
breakups, and divorce. Another problem is that once the emotions start
to turn back on, it can feel like floodgates opening. Believe me, it's far
better to go through the process of connecting with your emotions than
keeping them bottled up forever, even though it can feel overwhelming at
first. The truth is that warriors are in some ways best prepared to handle
the most complex human emotions a person can endure, but it may take
a while to appreciate this.

Criterion D Symptoms

Criterion D symptoms, the final set of symptoms that define PTSD, have to
do with the body's physical (physiological) response to trauma or threat:
feeling constantly revved up, startling easily, getting angry easily, having
difficulty sleeping, and difficulty concentrating.

I woke up at 0100 hrs today after going to sleep at 10 p.m. last
night. Do you think I really have an interest in doing anything but
sleeping right now? Too many long days. Too much stupid shit
going on at work. It makes me want to hurt someone sometimes;
thank God I have some control.

-JUNIOR ENLISTED MARINE, POST-IRAQ

I have found that I drink more, dream less, and have more mood
swings since my deployment. It is very hard to manage my anger
and irritability towards others. I have little patience for repetition
and get angry over menial things for no reason.

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

I'm jumpy when I hear thunder, door slams, fireworks. Much like
in Iraq, when I heard incoming. I drink more than I should.

-JUNIOR ENLISTED SOLDIER, POST-IRAQ

Body physiology plays a huge role in criterion D symptoms. Criterion
D has to do with the body remaining on high alert to threat and able to
respond instantly if needed-the "fight-or-flight" response. Small things
can trigger large physical reactions, including rapid heart rate and breathing, heightened sense of fear or anxiety, jumpiness, irritability, and muscle
tension. There may also be stomach queasiness or nausea, because during times of stress intestinal function shuts down so that blood can be
shunted off for more important purposes like keeping muscles going. The
increased physiological reactivity can lead to sleep disturbance, concentration problems, memory problems, and the feeling of never being able to
shut down.

Mental health professionals label criterion D symptoms hypervigilance, but in combat this state of being revved up and on high alert is
a very useful and necessary skill-what warriors call "situational awareness" or "tactical awareness."

Criteria B, C, and D symptoms can combine in various ways and have
different levels of severity. In the most severe cases (which are relatively
rare), the flashbacks, intrusive thoughts, feelings, and hypervigilance can
progress to obsessiveness, paranoia, delusions, and even hallucinations concerning threat and safety, with the warrior checking everything repeatedly,
convinced that an attack on their loved ones or themselves is imminent.

OTHER MENTAL AND PHYSICAL HEALTH PROBLEMS
EXPERIENCED BY WARRIORS

Although this chapter focuses on PTSD, this isn't the only mental health
concern experienced by warriors returning from combat. There are a
number of other problems listed in the DSM that warriors struggle with
after returning from war, which many spouses and significant others do as
well. These often coexist with PTSD, or can occur independently.

Depression-characterized by a low mood, loss of interest in activities,
hopelessness, guilt, sleep disturbance, appetite disturbance, concentration
problems, low energy, and sometimes suicidal thinking-is one of the morecommon conditions besides PTSD.

Panic attacks are also relatively frequent, characterized by a sudden
feeling of fear or anxiety (such as a fear of dying or going crazy), along
with a pounding heart, sweating, shaking, feeling of choking, nausea,
dizziness, and other physical symptoms. Generalized anxiety-characterized by excessive worry, restlessness, fatigue, sleep disturbance, anger, and
muscle tension-is common. Alcohol and substance abuse also frequently
coexist with PTSD.

These conditions overlap with and have many similarities to PTSD.
For example, when a warrior wants to hole up and avoid the world, this
could be considered by a mental health professional as one of the hallmark
PTSD criterion C symptoms, or as one of the main criteria for depression, loss of interest in activities. Symptoms like sleep disturbance, concentration problems, anger, and anxiety run through all of these conditions. It
also turns out that many of the same treatments are used for these different conditions.

Service in a combat zone and PTSD are both strongly associated with
physical health problems related to prolonged changes in stress hormone
and adrenaline levels. These include high blood pressure, chronic headaches, concentration or memory difficulties, gastroesophageal reflux disease (GERD), cardiovascular disease, joint or back pain, sexual problems
(e.g., impotence, loss of interest), and other health problems. Warriors
sometimes experience flashbacks involving wartime memories or aggressive images brought on by sexual arousal, a result of physiological changes
resulting from wartime service.

The bottom line is that these are all part of the larger range of reactions that warriors experience after coming back from combat, and therefore, for purposes of this book, separate chapters for each condition are
not required. The focus of this book is on helping you learn to navigate
the broad range of reactions that warriors experience after returning from
combat, and how to most effectively make the transition back home.

SUMMARY

The physical effects of PTSD on the body are indistinguishable from what
happens as a result of extreme stress, but continue long after the source
of the stress has passed. PTSD is essentially a manifestation of the natural mechanisms for survival and functioning under extremely threatening
situations. Everything we label a "symptom" of PTSD is an adaptive and
beneficial response when there is a threat to your personal welfare or that
of others, and the persistence of these reactions is the body's effort to
ensure that you're immediately ready if the danger occurs again.

However, the reactions of PTSD can also seriously interfere with life
after coming home. These include symptoms related to how memories of
traumatic events are processed in the brain, the body's natural defense
to shut down emotions and cope with what's happening, and the body's "fight-or-flight" physiological responses related to heart rate, breathing,
and physical reflexes. All of these are interrelated. PTSD is also strongly
associated with other conditions, including depression, cognitive problems, and physical health problems. Understanding the nature of what
mental health professionals call "PTSD," and learning what is unique
about a warrior's experience, is essential to learning how to address these
reactions after combat.

The wars in Iraq and Afghanistan have led to increased awareness of
the impact of traumatic brain injury (TBI) on troops. The availability of
modern protective equipment and advances in battlefield medicine have
resulted in many warriors surviving injuries from IEDs (improvised explosive devices), RPGs (rocket-propelled grenades), rockets, mortars, EFPs
(explosively formed projectiles), and other munitions that would have
been fatal in prior wars. Some of these injured warriors have experienced
serious brain injuries resulting in long-term impairment in physical, cognitive, and behavioral functioning.

Unfortunately, there has been very poor education about the distinction between mild traumatic brain injury (mTBI), also known as "concussion," and moderate or severe TBI, where damage to the brain is usually
apparent on clinical evaluation and brain scans (CTs and MRIs). All TBIs
(concussions/mild, moderate, and severe) have been grouped together
by medical professionals and in educational materials given to warriors
and their families. In 2008, investigators from the RAND Corporation
reported that 20 percent of all Iraq and Afghanistan war veterans (more
than 300,000) experienced a "probable traumatic brain injury" while
deployed, without clarifying that over 99 percent of these cases were concussions and that their study was based on an inadequately validated survey administered months or years after the warriors had returned from
deployment. Concussions/mTBIs have also become entangled and confused with PTSD, and these two conditions have been described as "silent"
wounds, affecting hundreds of thousands of OIF and OEF warriors.