The Best American Essays 2016 (17 page)

Because PTSD is a natural response to danger, it’s almost unavoidable in the short term and mostly self-correcting in the long term. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD. Rape is one of the most psychologically devastating things that can happen to a person, for example—far more traumatizing than most military deployments—and according to a 1992 study published in the
Journal of Traumatic Stress
, 94 percent of rape survivors exhibit signs of extreme trauma immediately afterward. And yet nine months later 47 percent of rape survivors have recovered enough to resume living normal lives.

Combat is generally less traumatic than rape but harder to recover from. The reason, strangely, is that the trauma of combat is interwoven with other, positive experiences that become difficult to separate from the harm. “Treating combat veterans is different from treating rape victims, because rape victims don’t have this idea that some aspects of their experience are worth retaining,” says Dr. Rachel Yehuda, a professor of psychiatry and neuroscience and director of traumatic-stress studies at Mount Sinai Hospital in New York. Yehuda has studied PTSD in a wide range of people, including combat veterans and Holocaust survivors. “For most people in combat, their experiences range from the best to the worst of times,” Yehuda adds. “It’s the most important thing someone has ever done—especially since these people are so young when they go in—and it’s probably the first time they’re ever free, completely, of their societal constraints. They’re going to miss being entrenched in this very important and defining world.”

Oddly, one of the most traumatic events for soldiers is witnessing harm to other people—even to the enemy. In a survey done after the first Gulf War by David Marlowe, an expert in stress-related disorders working with the Department of Defense, combat veterans reported that killing an enemy soldier—or even witnessing one getting killed—was more distressing than being wounded oneself. But the very worst experience, by a significant margin, was having a friend die. In war after war, army after army, losing a buddy is considered to be the most distressing thing that can possibly happen. It serves as a trigger for psychological breakdown on the battlefield and readjustment difficulties after the soldier has returned home.

Terrible as such experiences are, however, roughly 80 percent of people exposed to them eventually recover, according to a 2008 study in the
Journal of Behavioral Medicine
. If one considers the extreme hardship and violence of our prehistory, it makes sense that humans are able to sustain enormous psychic damage and continue functioning; otherwise our species would have died out long ago. “It is possible that our common generalized anxiety disorders are the evolutionary legacy of a world in which mild recurring fear was adaptive,” writes anthropologist and neuroscientist Melvin Konner, in a collection called
Understanding Trauma
. “Stress is the essence of evolution by natural selection and close to the essence of life itself.”

A 2007 analysis from the Institute of Medicine and the National Research Council found that statistically, people who fail to overcome trauma tend to be people who are already burdened by psychological issues—either because they inherited them or because they suffered trauma or abuse as children. According to a 2003 study on high-risk twins and combat-related PTSD, if you fought in Vietnam and your twin brother did not—but suffers from psychiatric disorders—you are more likely to get PTSD after your deployment. If you experienced the death of a loved one, or even weren’t held enough as a child, you are up to seven times more likely to develop the kinds of anxiety disorders that can contribute to PTSD, according to a 1989 study in the
British Journal of Psychiatry
. And according to statistics published in the
Journal of Consulting and Clinical Psychology
in 2000, if you have an educational deficit, if you are female, if you have a low IQ, or if you were abused as a child, you are at an elevated risk of developing PTSD. These factors are nearly as predictive of PTSD as the severity of the trauma itself.

Suicide by combat veterans is often seen as an extreme expression of PTSD, but currently there is no statistical relationship between suicide and combat, according to a study published in April in the
Journal of the American Medical Association Psychiatry
. Combat veterans are no more likely to kill themselves than veterans who were never under fire. The much-discussed estimated figure of twenty-two vets a day committing suicide is deceptive: it was only in 2008, for the first time in decades, that the U.S. Army veteran suicide rate, though enormously tragic, surpassed the civilian rate in America. And even so, the majority of veterans who kill themselves are over the age of fifty. Generally speaking, the more time that passes after a trauma, the less likely a suicide is to have anything to do with it, according to many studies. Among younger vets, deployment to Iraq or Afghanistan
lowers
the incidence of suicide because soldiers with obvious mental-health issues are less likely to be deployed with their units, according to an analysis published in
Annals of Epidemiology
in 2015. The most accurate predictor of post-deployment suicide, as it turns out, isn’t combat or repeated deployments or losing a buddy but suicide attempts
before
deployment. The single most effective action the U.S. military could take to reduce veteran suicide would be to screen for preexisting mental disorders.

It seems intuitively obvious that combat is connected to psychological trauma, but the relationship is a complicated one. Many soldiers go through horrific experiences but fare better than others who experienced danger only briefly, or not at all. Unmanned-drone pilots, for instance—who watch their missiles kill human beings by remote camera—have been calculated as having the same PTSD rates as pilots who fly actual combat missions in war zones, according to a 2013 analysis published in the
Medical Surveillance Monthly Report
. And even among regular infantry, danger and psychological breakdown during combat are not necessarily connected. During the 1973 Yom Kippur War, when Israel was invaded simultaneously by Egypt and Syria, rear-base troops in the Israeli military had psychological breakdowns at three times the rate of elite frontline troops, relative to their casualties. And during the air campaign of the first Gulf War, more than 80 percent of psychiatric casualties in the U.S. Army’s VII Corps came from support units that took almost no incoming fire, according to a 1992 study on army stress casualties.

Conversely, American airborne and other highly trained units in World War II had some of the lowest rates of psychiatric casualties of the entire military, relative to their number of wounded. A sense of helplessness is deeply traumatic to people, but high levels of training seem to counteract that so effectively that elite soldiers are psychologically insulated from even extreme risk. Part of the reason, it has been found, is that elite soldiers have higher-than-average levels of an amino acid called neuropeptide-Y, which acts as a chemical buffer against hormones that are secreted by the endocrine system during times of high stress. In one 1968 study, published in the
Archive of General Psychiatry
, Special Forces soldiers in Vietnam had levels of the stress hormone cortisol go down before an anticipated attack, while less experienced combatants saw their levels go up.

Shell Shock

All this is new science, however. For most of the nation’s history, psychological effects of combat trauma have been variously attributed to neuroses, shell shock, or simple cowardice. When men have failed to obey orders due to trauma they have been beaten, imprisoned, “treated” with electroshock therapy, or simply shot as a warning to others. (For British troops, cowardice was a capital crime until 1930.) It was not until after the Vietnam War that the American Psychiatric Association listed combat trauma as an official diagnosis. Tens of thousands of vets were struggling with “Post-Vietnam Syndrome”—nightmares, insomnia, addiction, paranoia—and their struggle could no longer be written off to weakness or personal failings. Obviously, these problems could also affect war reporters, cops, firefighters, or anyone else subjected to trauma. In 1980, the APA finally included post-traumatic stress disorder in the third edition of the
Diagnostic and Statistical Manual of Mental Disorders
.

Thirty-five years after acknowledging the problem in its current form, the American military now has the highest PTSD rate in its history—and probably in the world. Horrific experiences are unfortunately universal, but long-term impairment from them is not, and despite billions of dollars spent on treatment, half of our Iraq and Afghanistan veterans have applied for permanent disability. Of those veterans treated, roughly a third have been diagnosed with PTSD. Since only about 10 percent of our armed forces actually see combat, the majority of vets claiming to suffer from PTSD seem to have been affected by something other than direct exposure to danger.

This is not a new phenomenon: decade after decade and war after war, American combat deaths have dropped steadily while trauma and disability claims have continued to rise. They are in an almost inverse relationship with each other. Soldiers in Vietnam suffered roughly one-quarter the casualty rate of troops in World War II, for example, but filed for disability at a rate that was nearly 50 percent higher, according to a 2013 report in the
Journal of Anxiety Disorders
. It’s tempting to attribute this disparity to the toxic reception they had at home, but that doesn’t seem to be the case. Today’s vets claim three times the number of disabilities that Vietnam vets did despite a generally warm reception back home and a casualty rate that, thank God, is roughly one-third what it was in Vietnam. Today most disability claims are for hearing loss, tinnitus, and PTSD—the latter two of which can be exaggerated or faked. Even the first Gulf War—which lasted only a hundred hours—produced nearly twice the disability rates of World War II. Clearly, there is a feedback loop of disability claims, compensation, and more disability claims that cannot go on forever.

Part of the problem is bureaucratic: in an effort to speed up access to benefits, in 2010 the Veterans Administration declared that soldiers no longer have to cite a specific incident—a firefight, a roadside bomb—in order to be eligible for disability compensation. He or she simply has to report being impaired in daily life. As a result, PTSD claims have reportedly risen 60 percent to 150,000 a year. Clearly this has produced a system that is vulnerable to abuse and bureaucratic error. A recent investigation by the VA’s Office of Inspector General found that the higher a veteran’s PTSD disability rating, the more treatment he or she tends to seek until achieving a rating of 100 percent, at which point treatment visits drop by 82 percent and many vets quit completely. In theory, the most traumatized people should be seeking more help, not less. It’s hard to avoid the conclusion that some vets are getting treatment simply to raise their disability rating.

In addition to being an enormous waste of taxpayer money, such fraud, intentional or not, does real harm to the vets who truly need help. One Veterans Administration counselor I spoke with described having to physically protect someone in a PTSD support group because some other vets wanted to beat him up for faking his trauma. This counselor, who asked to remain anonymous, said that many combat veterans actively avoid the VA because they worry about losing their temper around patients who are milking the system. “It’s the real deals—the guys who have seen the most—that this tends to bother,” this counselor told me.

The majority of traumatized vets are
not
faking their symptoms, however. They return from wars that are safer than those their fathers and grandfathers fought, and yet far greater numbers of them wind up alienated and depressed. This is true even for people who didn’t experience combat. In other words, the problem doesn’t seem to be trauma on the battlefield so much as reentry into society. Anthropological research from around the world shows that recovery from war is heavily influenced by the society one returns to, and there are societies that make that process relatively easy. Ethnographic studies on hunter-gatherer societies rarely turn up evidence of chronic PTSD among their warriors, for example, and oral histories of Native American warfare consistently fail to mention psychological trauma. Anthropologists and oral historians weren’t expressly looking for PTSD, but the high frequency of warfare in these groups makes the scarcity of any mention of it revealing. Even the Israeli military—with mandatory national service and two generations of intermittent warfare—has by some measures a PTSD rate as low as 1 percent.

If we weed out the malingerers on the one hand and the deeply traumatized on the other, we are still left with enormous numbers of veterans who had utterly ordinary wartime experiences and yet feel dangerously alienated back home. Clinically speaking, such alienation is not the same thing as PTSD, but both seem to result from military service abroad, so it’s understandable that vets and even clinicians are prone to conflating them. Either way, it makes one wonder exactly what it is about modern society that is so mortally dispiriting to come home to.

Soldier’s Creed

Any discussion of PTSD and its associated sense of alienation in society must address the fact that many soldiers find themselves missing the war after it’s over. That troubling fact can be found in written accounts from war after war, country after country, century after century. Awkward as it is to say, part of the trauma of war seems to be giving it up. There are ancient human behaviors in war—loyalty, inter-reliance, cooperation—that typify good soldiering and can’t be easily found in modern society. This can produce a kind of nostalgia for the hard times that even civilians are susceptible to: after World War II, many Londoners claimed to miss the communal underground living that characterized life during the Blitz (despite the fact that more than 40,000 civilians lost their lives). And the war that is missed doesn’t even have to be a shooting war: “I am a survivor of the AIDS epidemic,” a man wrote on the comment board of an online talk I gave about war. “Now that AIDS is no longer a death sentence, I must admit that I miss those days of extreme brotherhood . . . which led to deep emotions and understandings that are above anything I have felt since the plague years.”