PTSD a Defining Diagnosis for Post-9/11 Veterans

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PTSD a Defining Diagnosis for Post-9/11 Veterans

Army Sgt. Sean Simmons lost four soldiers from his unit during operations in Afghanistan and saw another 20 suffer injuries such as head traumas, loss of limbs and wounds so debilitating that they were sent home.

When Simmons thought about what he would do after his time on the battlefield, he decided his next duty would be on the healing side of the fight.

“I lost a lot of friends and saw the worst side of war,” Simmons said. “It didn’t feel like there was much positive that was accomplished. I decided I needed to find something good to do with my life, so that I could be a little more valuable.”

Once home, Simmons entered medical school at the Uniformed Services University of the Health Sciences in Bethesda, Md.

“While still very much committed to the military, my rationale for putting down the gun was taking care of those people who were still going to carry the gun,” he said in a phone interview. For Simmons, medicine seemed “a pretty natural selection.”

Medical school gave Simmons insight into something else the war inflicted on him: post-traumatic stress disorder.

“I’ve been there. I feel like I bottomed out, and I came back from it,” Simmons said. “I don’t see it as being a normal response to go to war, if you’re a combatant, and come back and not have it profoundly affect you.”

PTSD stems from experiencing or witnessing a traumatic event and is marked by symptoms such as mood changes, increased vigilance, anxiety, insomnia, intrusive memories and avoidance of “triggers” that remind individuals of the event.

Simmons noted severe mood changes soon after his return from a 2007-2008 tour in Afghanistan, where he’d seen fellow soldiers die.

“I got to the point where I couldn’t go to any bars anymore — being jostled, having some frat kid front on me because he had a BMW — it made for uncontrollable rage,” Simmons said. “I knew that I was at the point of acting out, and I knew that nothing good was obviously ever going to come from that.”

A variety of other symptoms also interfered with his daily life.

“I was probably sleeping three or four hours a night, if that,” Simmons said. “Frequent nightmares. I definitely had hypervigilance and some notable flashbacks. I went from being hyper-fit to not working out for six months, dropping 20 pounds, and not eating much.

“It was a fairly dramatic presentation,” he said.

PTSD is estimated to have affected almost 130,000 troops since 2001, according to the U.S. Army Office of the Surgeon General. The number is likely higher among post-9/11 veterans, because many cases are diagnosed after troops are discharged.

Because of increased awareness of the condition, the nature of counterinsurgency warfare and changing attitudes about mental health, PTSD has become one of the defining diagnoses of post-9/11 veterans — and one of the most controversial.

The inclusion of a single designation — D, for disorder — is the heart of the PTSD debate.

While the term is officially recognized by the American Psychiatric Association (APA) manual for mental illnesses, some have argued that labeling post-traumatic stress as a disorder stigmatizes the condition and dissuades soldiers from seeking help.

Older terms for PTSD, such as “battle fatigue,” are less stigmatizing, said retired Lt. Gen. Benjamin Freakley, who led American troops in Afghanistan and now is a special adviser to the Arizona State University president on leadership initiatives. He also is a member of the ASU faculty.

“If someone uses the term ‘battle fatigue,’ what I think about it, is fatigue is something that you can get over,” Freakley said in a phone interview. “You just need some rest if you’re fatigued.

“If you have a ‘disorder,’ then that’s something that’s going to stay with you,” he said. “I think the term ‘disorder’ is poorly chosen.”

Retired Gen. Peter Chiarelli is the former vice chief of staff of the U.S. Army and now CEO of One Mind, a nonprofit organization devoted to research and advocacy for mental illness and brain injuries. He advocates dropping the term disorder.

“People with post-traumatic stress don’t go in (for treatment) because they don’t want to be told that they have a disability — a disorder,” he said in a phone interview.

“If you’re 19 years old, do you want to go in and have it put into your medical records that you have a disorder? That it be known to your employer, possibly, that you have a disorder?”

By dropping “disorder,” and using something more familiar to service members, like “injury,” veterans more likely will seek treatment, Chiarelli said.

“I’m trying to get more people to come in and get help,” he said. “And if you get rid of the ‘D,’ more people will come in to get help. But [APA] are set on maintaining the ‘D,’ as a ‘disorder.’ ”

APA resistance to the name change was highlighted in the May release of the newest edition of the Diagnostic and Statistical Manual of Mental Disorders, which is the primary desk reference in psychiatry.

“Others believe it is the military environment that needs to change, not the name of the disorder, so that mental health care is more accessible and soldiers are encouraged to seek it in a timely fashion,” according to an APA fact sheet distributed with the new manual. “PTSD will continue to be identified as a disorder.”

Simmons’ military career began when he entered the U.S. Naval Academy in 1994. He graduated in 1998, then served as a surface warfare officer and a navigator on two ships, in the Middle East and the Western Pacific, he said.

Simmons eventually resigned his naval officer commission to apply for the Army Special Forces as an enlisted soldier, which he said would give him a combat role. He served in 2006-2007 as a communications sergeant for the Army Special Forces, popularly known as the Green Berets, in Iraq during the troop surge.

Almost immediately after his return from Iraq, he was trained for another tour in Afghanistan in 2007-2008.

Despite his combat roles, Simmons said, the experience could swing wildly from long days of boredom to hours of peak tension.

“Combat’s still 90 percent mind-numbing tedium,” Simmons said, “waiting for the 9 percent pure terror, and then, maybe, the 1 percent, ‘Cool.’ ”

The Afghanistan counterinsurgency’s greatest danger lay not in firefights or conventional battles, but in roadside improvised explosive devices (IEDs).

“There’s just no rhyme or reason to it,” Simmons said. “It’s just random chance. It’s a very difficult thing to wrap your head around, if you’re an alpha-type person that’s tried to take command of your life and done everything you can to become the best, and then to realize that none of that matters. It’s just whether you take a step to the right, or you take a step to the left. Basically, when it’s your time, it’s your time.

“That was pretty wearing,” Simmons said.

Simmons was 30 when he went off to combat, had an advanced degree and said he spent a lot of time on self-reflection.

“I still got kicked in the gut really hard with PTSD when I came back,” he said. “I look at a 19-year-old kid who’s just out of boot camp, or an 18-year-old guy, and dealing with the same thing — I can’t even fathom how they contextualize that.”

Simmons’ return from his deployment was compounded by public perceptions of his combat experience.

“The classic example that every vet has had to deal with is, ‘Did you have to kill anyone? Did you kill any Taliban?’ ” Simmons said. “I would say that there is absolutely no understanding from the general public on what Afghanistan is.”

Veterans have returned home to a media that views them more as victims than as soldiers, Freakley said.

“The stories are about homelessness, the stories are about post-traumatic stress, traumatic brain injury, amputation and burns, and having problems with reintegration either with their family or back in the society in the states as they come home,” he said. “And while all those symptoms and all those problems are real — and they exist — they exist in smaller numbers than the population at large.”

“To a degree we have not really covered the valor of our soldiers,” he said. “I believe we’ve victimized our veterans. They’re volunteers. They’re doing what they want to do.”

After Simmons experienced the symptoms of PTSD, he sought help from the Department of Veterans Affairs health system, only to find it did not provide the therapy he felt would best serve him.

“I went to the VA to try to get help,” he said. “The psychiatrist says, ‘These are the pharmaceuticals we’ve had success with in the past, I’d like you to try these.’ At that time, I was very opposed to any psychotropic medication. I told them that it was not a place I was interested in going. And after that it was, ‘Well, I don’t know what we have to offer you, here is a PTSD group meeting you could go to.”

The alternative also was not satisfactory, Simmons said, because most of the veterans in these groups did not serve in post-9/11 conflicts.

“So at the end of the day, I sought (help), and I didn’t really get anything. I went back once more, I had the same experience, and I gave up on it.

“It took me about a year to recover, and then — still, to this day — I don’t really know what happened or why I kicked it,” Simmons said. “I’m just grateful that I did.”

Since then, Simmons also has found help from a psychiatrist at the Uniformed Services University of the Health Sciences, he said.

“What allowed me to put the gun down is knowing that I was going to take care of those guys,” Simmons said. He plans to enter family medicine, where most active service members receive care.

“I know exactly where I want to go,” he said. “I know the job I want to do. It’s with an operational unit that’s not too different from the one I used to work with, because I want to take care of those guys.”