Healing Combat Trauma

PTSD: (That's Some) Pretty Terrible Sh*t (to Have to) Deal (With), Don't You Think?

Editor's Note: We commemorate the otherwise momentous, historic signing of the GI bill into law today with this little snippet of what life was like for someone who served recently.  For everyone who doesn't "get" what sacrifice is, and that those who've served have earned their accolades and rewards, here's a grunt's-eye view of the experience of combat trauma, and how that relates to PTSD and various other topics in the news.  It's doubtful that any one of us would like to have changed places with him, at such a young age.  Herewith, his story, emphasis mine:

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I'm no Vietnam vet, but a vet of Operation Iraqi Freedom. I turned 18 while in boot camp because I graduated high school at 17. I was discharged early for having "personality disorder" after I went to Iraq.

I was in the Marines, and my MOS was a ground communications electronics technician. A couple months after graduating my training for the job and going to my first unit, I was "volunteered" to join and train with another unit that was leaving soon. The new task I was given was "Mortuary Affairs".

This group was put together with a couple dozen other Marines from other sections. Our job was to go to locations where troops had been killed and not able to be retrieved by the group they were out with due to the fact they were under too much danger or whatever the case. I had no clue the effects this would have on me. It was a horrible experience.

It was not like going and picking up a corpse and that's it. For one, you were in a hot zone, where people were just killed, not just by gunfire.

Here are some brief descriptions of the missions I was a part of...
 

The first one wasn't too bad; the body was actually brought to us at the camp we were at.

 

It was a young male Marine. He was supposedly in a Hummer going somewhere and might not have been wearing his helmet. He had a silver dollar sized hole in the side of his head.

When we get the bodies back the camp we have to take off all materials on the body, and go through and bag each individual body part. It was more of a surreal experience really, I did not know how I was supposed to feel.

Once our troops invaded Fallujah was when things started to get worse. On another of the missions, a truck carrying fuel was crossing a bridge and was shot with an RPG. The truck went off the bridge and fell, the fire burning most of everything.

 

When we went out it was usually just a dozen of us with maybe 2 Hummers of security if we were lucky. For anyone who doesn't know, most the Hummers used were old and poorly maintained/equipped... almost no armor. So we get there and head down to the bottom where the truck fell and we had to pull out burnt bodies from inside of the cabin.

 

It sounds bad, but burnt bodies are almost like burnt food... so perhaps it wasn't as bad as the rest. It did not help our appetite when we had to eat in the same building we processed the bodies in. Our shop was just a medium-sized bunker, no walls or anything so yes we basically ate next to the bodies. It is obvious why some of us didn't eat the meat.

 

The worst mission I went on was when an army tank was traveling down a road and was blown up from a roadside explosive. The bomb was so powerful: you could not identify ANY part of the tank except for the tracks. It had been tossed a couple hundred feet in different directions.

 

It took us I think, about 15 hours to do this mission. There was gunfire when we first arrived but nothing more. I think we picked up a couple thousand pieces of flesh that day. Going through each one individually. They would range from small penny-sized pieces to legs, torsos, heads, feet, testicles, arms, etc.

 

There were a few more missions but we get the idea by now I'm sure. I guess it started to become noticeable that I wasn't doing well. I was taking whole boxes of NyQuil tablets and drinking bottles of medicine to get anything I could out of it at night. I smoked probably a pack of cigarettes a day, which is a lot for me because I have never really smoked more than a couple cigs a day if at all.

 

My officer had me go speak to the chaplain and from there a navy doctor who was a great person to have over there. He pulled strings and had me med-evac'd out of there a few weeks later.

 

In the meantime I had been moved out of my job until I was able to leave. I was harassed for leaving: superiors thought I was just faking to get out.

 

I had become highly depressed and my roommates noticed me screaming sometimes in my sleep.

 

From Iraq I spent a few days at an army hospital in Germany, talking to various doctors and such... going through the process.

 

I was being given pills for depression and for insomnia. Then I made it back to the US and once at my base I was seen by a psychologist. They actually gave me the option to get of the military, so I did.

 

I had been told the process takes several months to year until you finally leave. In the meantime I started drinking daily, and stopped taking the pills they gave me because they seemed to numb my mind and I could not stand it because I have always had such a wonderful and creative mind. It made me feel like a zombie, I could not even create artwork which was my biggest hobby.

 

A month down the road I started having nightmares, very detailed and morbid. A few times I would wake up with tears. I began having suicidal thoughts and crying at least a few times a day. Thank God my best friend was stationed not so far, he saved my life I think.

 

It was hard for me to wake up because of the medicine I had been taking, that’s another reason I stopped it, I was always drained. The first week I was back I never even reported back to my old unit, I didn't know what I was doing.

 

A week later they send somebody to come get me. There, I was harassed and treated like a piece of s%#t some more by my master sergeant. They had me sit in inventory room all day while I struggled to stay awake. I luckily had a very kind staff sergeant in charge of me at the time. He would let me sleep and go home early.

 

I admit I was very lucky in getting out, because it only took me about 2 months until I was officially a civilian again. I was going back home. I stayed with my older sister and her boyfriend at first, because I was not too fond of going back to my parents. My depression got worse and I started to drift further from sanity and comfort; people noticed I was a different person.

 

At this point I started smoking marijuana occasionally. Which was really the only time I felt anything, happy, able to think, speak, talk to people, feel normal.

 

Eventually I moved back with my parents and that's when things got worse for me. I had some additional problems I know was facing, I needed a job, and had people on my back constantly. I had no access to marijuana during this time.

 

My insomnia got to its peak to where I could not sleep AT ALL at night. I also began having more suicidal thoughts, nightmares got worse and I had them ANY time I could sleep which was usually from 7:00 AM to 12:00 PM, began having auditory and visual hallucinations everyday, and constant anxiety.

 

I knew I had PTSD and that the military used "personality disorder" so that they would not take the rap for it.

 

I finally couldn't take the insomnia anymore and was prescribed Ambien, which actually works extremely well and helped get my body back on schedule, only thing is I had to take it for 3 months and then no more because they said it was addictive.

 

So it became difficult without it. I did a long process of seeing doctors and filling out paperwork for the VA and was finally officially a disabled vet due to chronic Post Traumatic Stress Disorder, normally referred to as PTSD.

 

I started to be able to get a hold of marijuana again and when I had it things were more stable. My temper was not out of hand and I could sleep comfortably having less nightmares. At this point I had gone a year or more straight of having nightmares every night.

 

It has been three years now and I am much better. Time has healed me a little and I smoke marijuana as often as I can. I don't have hallucinations anymore, or rarely any nightmares. I do however still have bad anxiety, temper, and depression problems when I'm not high.

 

Another thing I forgot to mention is that PTSD has basically ruined my memory. Since I first showed symptoms until now, my memory does not work nearly as well as it should.

 

I still have major problems concentrating and working sometimes too. It makes interviews and other social activities near impossible for me, as I cannot speak or express myself as I used to. I get very nervous and my mind blanks out sometimes. I cannot say if marijuana will help all my problems, but I can say marijuana helps me feel alive.

 

Being high is the only time I feel good and happy, deep down. I can be around loved ones or any social crowd without tweaking out from anxiety, I can think and operate much more smoothly, I don't have a short temper, and it makes me want to live.

 

The past couple months have been rough on me and I have been going to the VA hospital here to try and get help. The first 4 times I went, they did the same exact thing which was to ask a series of questions, ask me if I want pills and send me home. I kept telling them I did not want pills because I have seen what they have done to people I know and what they have done to me.

 

All I wanted was someone to talk to.

 

After the fourth time of going in there feeling like I wanted to die, they finally got someone for me to talk to. We have just met once so far, but I think it will be good for me.

 

In the meantime I have not been able to smoke recently because I am trying to find another job, which is not going too well and I only have a couple weeks before my current job ends.

 

I have had a few interviews but blow them miserably because it’s getting harder and harder for me to go through the whole thing without my nerves choking me to death. It’s only been a week or two since I smoked last and my temper and depression are already busting through the door. I worry too easily and stress out to the extreme.

 

Take what you will from this story, but I know for a fact marijuana has saved my life numerous times.

 

-- One young former Marine's story, in his own words. Used with permission.

Editor's note: "Mortuary Affairs" was also the detail highly-decorated Marine ("Marine of the Year") Daniel Cotnoir worked in Iraq, before a combination of circumstances, including PTSD, triggered an event in his hometown of Lawrence, Massachusetts -- which got him arrested, and barely escaped conviction.  We have blogged about Daniel Cotnoir's case many times on this blog, going back several years, when it was current.  It's safe to opine, that even within the trauma of war, some things are harder to endure than others.  Our guess would be, mortuary affairs really qualifies for extreme hardship and exposure to things that make PTSD an occupational hazard.

Living in the Prison of PTSD - a Poem by a Vietnam Vet and Suicide

I received a photo of this poem, by a Vietnam veteran who committed suicide shortly after he wrote it, in the manuscript of another Vietnam veteran's memoirs from his time as a Marine in Vietnam, and after homecoming.  This poem is apparently up on the wall of the "Post Traumatic Stress Unit" at the Veterans Affairs Medical Center in Waco, Texas.

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(It's easy to understand honoring the vet who wrote this poem as one of his last pleas, but seriously -- if I were being treated for PTSD and were struggling with some of the same issues, I'm not sure it would be that perky to go by this particular wall art regularly and remind myself, oh yeah, right after that guy wrote that -- well, he ended things.  Even though it's perfectly understandable why he felt things had gotten to that point; and equally well how the other vets and the staff there would want to honor his passing with this tribute.  People who believe in the ancient Chinese art of placement, feng shui, would say, never hang anything on the wall that brings your energy down, not up, when you look at it.  But I'm sure they did it out of love and respect for the guy concerned...)

As for the poem -- well, it's not gonna win any awards as a poem, but in terms of conveying one man's brokenness and pathos, it does that really well. Very sorry the story had to have such a sad ending, and not just for this veteran, but for many others like him, from Vietnam and other wars.  Here's what the poet, known only to us by his initials, "A.W.D.," wrote in 1989:

Solitude

I have lived in this prison I built for most

        of my life

And I have blocked out all reason, all guilt

        and all strife.

No one may enter this prison of mine

For I have failed at life,

        now I resign.

Now as I sit here too cloudy to think

My mind and body, they no longer link

My life I see before me, like old movies that

        aren’t real

But that’s what I see and

        that’s what I feel.

May God have mercy, may He not be cruel

May He understand the prayer of a fool

Inside of me, I hear the screams of distress

Let me out of this prison

        Please let me rest.

-- A.W.D., 1989

The Suicide Profile: Clinically Known Risk Factors for Potential Suicides

I've got an old psychiatry textbook for medical students, written by a professor at Harvard Medical School named Robert J. Waldinger, M.D., and it's been interesting leafing through it and finding out what it has to say about PTSD (not much) and suicide (quite a lot).  The edition I have is the second edition (a third edition is in print), and it goes back almost 20 years, to 1990.  PTSD is covered in less than a page, but suicide has quite a bit of coverage, and much of what it says is interesting.

For example:

"A majority (60-80%) of people who commit suicide carry a diagnosis of depression.  Estimates of the risk of suicide in all mood disorders are as high as 15%, with the greatest period of risk within 5 years after the onset of the disorder.  The risk of suicide among people with mood disorders is 30 times that of the general population."

There's also this longer passage about who's most at risk for suicide.  The passage was written based on data that was available at the time -- 1990 -- and some of the percentages have changed up or down since then. However, as you read these factors, think about how many of them might be in play for combat veterans, in light of the recent rise in veteran suicides. Our observation?  Quite a few. See if you don't agree:

"Suicidologists have long searched for "suicide profiles." They have looked at everything from the phases of the moon to birth order in the family in an effort to solve the mystery of why certain people resort to suicide. The following are the risk factors most consistently identified in recent studies:

• Age- The risk of suicide ... is greatest for nonwhite males in their 20s and 30s, and rises again (in the elderly).  Nonwhite females have the highest suicide rate in young adulthood to age 40, with a decline thereafter.  In the last 25 years there has been a more than three-fold increase in the rate of suicide among adolescents and young adults (and this figure has only gone up);
• Sex - Men commit suicide three times more frequently than women.  However, women attempt suicide two to three times as often as men.  Men tend to use knives, firearms and other violent means of suicide, while women show a preference for self-poisoning;
• Race - The suicide rate is higher for whites than nonwhites. However the rate among young black adults in ghetto areas has recently increased sharply;
• Marital status - Suicide rates are lowest for married people and higher for those who are separated, divorced, or widowed;
• Living situation - People who live alone are at a higher risk of suicide than people who live with others;
• Employment status - People who are unemployed are at a higher risk of suicide than those who are working in or out of the home ...;
• Physical health - Physical illness, or the perception that one is ill, is more frequent among those who commit suicide.  In particular, there is a high correlation between completed suicide and visits to a physician for medical complaints during the preceding six (6) months.  The risk of suicide is significantly increased among people suffering from cancer and AIDS;
• Mental health- Among the mental illnesses that have been correlated with a high risk of suicide are depression, manic-depressive illness (bipolar disorder), and schizophrenia.  Non-fatal attempts are more prevalent among people with personality disorders, and adjustment disorders.  In general, the presence of major mental illness should alert the clinician to the possibility of suicide.  More than 90% of adults who commit suicide have an associated psychiatric illness;
• Alcohol abuse or addiction - Alcoholism markedly increases the risk of suicide;
• Previous suicide attempts - A history of suicide attempts has been estimated to increase the risk of completed suicide by as much as 64 times that of the general population.  At least 10% of suicide attempters eventually kill themselves;

The following factors, while less easily quantifiable, have also been associated with completed suicides:

• Hopelessness - Several studies have concluded that the specific symptom of hopelessness about one's life situation is more highly correlated with suicide than is the more general category of depression;
• Interpersonal loss- There is a high correlation between interpersonal loss and suicide.  Loss is defined as the separation from, divorce from, or death of a significant other, and may include relatives, friends, lovers, and therapists.  The risk of suicide is particularly high among alcoholic individuals who have suffered major interpersonal losses within the previous six (6) weeks;
• Life stresses - A high frequency of major life events in the previous six (6) months has been found among those who commit suicide.  Such events include job changes, moves, births, graduations, financial reversals, marriage, retirement and menopause.  Such changes are important to identify in assessing both the precipitants of a suicidal crises and the possibilities for therapeutic intervention;
• Interpersonal conflict - Long-standing intense interpersonal conflict with family members or other important people is associated with a high risk of suicide and has led some observers to characterize suicide as a fundamentally dyadic [definition] event.  Such conflict, if unremitting, may continue to jeopardize the life of the patient after a particular crisis has passed. "

Source: Psychiatry for Medical Students, Second Edition, by Robert J. Waldinger, M.D.  (Instructor in Psychiatry, Harvard Medical School, Director of Training, Massachusetts Mental Health Center, Boston, Massachusetts.)  Washington, DC: American Psychiatric Press, Inc.  (1990).

Where Is Suicide Most Prevalent Among Young Males in the U.S.?

Forgive me for being naive, but I had no idea "suicidology" was such a sophisticated profession.  Such specificity!  Such granularity!  Such nice maps, even. (Thanks, Centers for Disease Control!)  Finding out who kills themselves nationally by type -- race, age, gender -- is seemingly pretty doable -- and if you know where to look, the maps already exist.  There's something called "the Atlas of United States Mortality," and it's a veritable treasure-trove online of useful and useable data. Here, for instance, is a map of where 20 year old white males, are most likely to kill themselves in the U.S. -- followed by a similar map for 20 year old black males.  Notice that, apart from some places in the Southwest, there's actually not much overlap between the two maps.)

Want that same data for 20 year old white women or 20 year old black women?  It exists, too. Not sure if anyone's done the Hispanic data yet, but if not, they should.  (All the above data is from the PDF, linked here.)  Want to find the same data about how many people use a firearm to commit suicide, mapped against a map of the United States?  Here it is.  Want to find the same information about those who die by motor vehicle accidents (among whom is a certain percentage of undisclosed suicides)?  It's here.

In an Op-Ed piece from the Boston Globe from August of 2004, Michael Craig Miller, M.D., editor-in-chief of the Harvard Mental Health Letter, talks about what he learned from doing his own suicide map of the United States.  (Ironically, he found that it coordinated roughly with political lines, but that wasn't his only observation, so we'll set that one aside for now, lest it inflame but not inform.)  He was surprised to see a roughly three-fold difference between high and low states, even after accounting for age and ethnicity.  Searching for the factors that might contribute to this, he speculated:

"Local and individual factors are important: personal loss, family conflict, economic travail and unemployment, the quality of the support system, and cultural or religious beliefs about death or suicide. Easy access to guns is risky for a vulnerable person.  Access to mental health services, on the other hand, reduces the risk of suicide, which is usually a result of mental illness. But stigma is an enormous obstacle to treatment. Most people with mental disorders fear a negative or patronizing response, even from health-care providers. The more severe their distress, the greater the dread of reaching out."

I'm interested in this whole topic because I'm trying to figure out how to plot the average age of military members in various states, and their ethnicity -- against their likelihood of committing suicide, even before combat -- to see if we can ascertain whether mental health services are adequate for returning and deployed military in those states.  This is pretty much a work in progress, and not the quickest thing I've ever done -- so bear with me over the next few days, as we find this out -- together.

One positive remark by Dr. Miller, concerning military efforts: "The US Air Force has recently achieved remarkable success in preventing suicide. In 1996, the leadership instituted a service-wide program to increase awareness of suicide risk factors and make resources available for treatment. High-ranking officers championed the cause, which helped reduce the stigma attached to seeking help for problems like depression. The result was a 33 percent reduction in the rate of suicide among Air Force personnel."

If this is true/has remained true, I'm curious to know whether the Air Force's program served as a model for the other services.  From the absence of any talk confirming that in the media, it would seem that it either hadn't or didn't -- either that, or no one saw fit to mention it.  (They have one of the lower profiles of the services in the OIF/OEF efforts.) Another possibility is that there just isn't that much coordination among the armed services on mental health issues, so each service is developing a program on its own -- the time-consuming, re-inventing the wheel kind of way.  I really can't speak to that, because I don't know anything about it -- but over the coming days, maybe we'll find that out as well.

Editor's Note: Dr. Miller's Op-Ed piece from the Boston Globe is linked here.

Does Suicide Data for Combat Veterans Match or Contradict Suicide Data by State?

Who knew there was such a thing as a "Suicide Map of the United States," but it stands to reason that such a thing exists, because the data it illustrates can be mapped.  (The map at left is rather old, but serves to illustrate the point.)

Each year, the United States, through the Centers for Disease Control (CDC) in Atlanta, collects data by state of how many people have killed themselves, and from this data can form a ranking of suicide rates by state and gender.  My question is -- do suicide rates among veterans follow the pattern previously set by state?  And perhaps more importantly, are the military installations in a given state (like the National Guard) aware of how prevalent suicide among young males is or isn't in their state, so they can react accordingly, and perhaps increase screening of veterans for suicide risk?

From 2005 data, collected by the CDC, the top states for suicide by males are ranked in the following order: 1) Montana; 2) Nevada; 3) Alaska; 4) New Mexico; 5) Colorado; 6) (tied for 5th place) - North Dakota; 7) South Dakota; 8) Idaho; 9) Wyoming; 10) Arizona; 11) Oregon; 12) Tennessee; 13) West Virginia; 14) Oklahoma; 15) (tied for 14th place) - Arkansas; 16) Utah; 17) Maine; 18) Kentucky; 19) Kansas; 20) Mississippi; 21) Washington state; 22) Missouri; 23) New Hampshire; 24) Florida; 25) Indiana; 26) Alabama; 27) Ohio; 28) Vermont; 29) South Carolina; 30) Pennsylvania; 31) Wisconsin; 32) Virginia; 33) Louisiana; 34) North Carolina; 35) Michigan; 36) Iowa; 37) (tied for 36th place) - Minnesota; 38) Delaware; 39) (tied for 38th place) - Texas; 40) Nebraska; 41) Georgia; 42) Maryland; 43) Illinois; 44) California; 45) Connecticut; 46) Hawaii; 47) (tied for 46th place) - Massachusetts; 48) New York; 49) New Jersey; 50) Rhode Island; and 51) District of Columbia.

The Minnesota National Guard has stood out for its proactive stance on reintegration services for returning combat veterans - we've blogged about their efforts earlier, here.  But according to the data above, Minnesotans males are 37th least likely in the U.S. to commit suicide. The New Hampshire National Guard has a program that's apparently a model for the nation -- we blogged about it earlier, here -- but New Hampshire males are 23rd least likely in the nation to commit suicide.  The Vermont National Guard has also taken proactive steps to help its veterans reintegrate successfully -- we blogged about that, here -- but males in its state are 28th least likely in the U.S. to kill themselves. 

How about the Montana National Guard, the Nevada National Guard, the Alaska National Guard, the New Mexico National Guard, the Colorado National Guard, the North Dakota National Guard, and so forth -- are they taking steps to educate their servicemembers at risk for suicide?  Ironically, as we blogged about it, here, in March of 2006, the Iowa National Guard -- and Iowan males are 8th in the nation, according to the above data, in suicide risk -- had  downgarded their mental health counseling for returning veterans from "mandatory" to "optional."  Let's hope they've since changed that and made effective screening mandatory -- along with all 50 other states.  Of the National Guards in the top six states at risk for male suicide mentioned above, only one -- Montana -- has any mention of mental health issues on its website.  The Montana National Guard seems to have been holding a series of public meetings in May for Montanas to help recognize PTSD in their returning servicemembers.  See that link, here.  A great step forward, at least for the Montana National Guard, in the state that has the highest suicide rate for men in the nation.

Data source: CDC's WISQARS website "Fatal Injury Reports," http://www.cdc.gov/ncipc/wisqars/; downloaded January 24, 2008.  Prepared by John L. McIntosh, Ph.D., Indiana University, South Bend, for posting by the American Association of Suicidology -- January, 2008.  (The American Association of Suicidology's website is linked here.)

The Army Says It's Aware of Its Rise in PTSD, Suicides

According to a conference call today with the Army's Col. Elspeth Cameron Ritchie, M.D., among others, the Army is allegedly aware of its rise in PTSD and suicides, and making some plans to address the needs for greater access to psychological help, at least according to one blogger involved in the call, John M. Grosol, Psy.D..  It sounds like the Army has roughly half the per capita psychology help available as the civilian world. Let's hope there are plans to increase that as soon as humanly possible.  Lives and wellbeing are both at stake.