Collateral Damage: Stress Disorder Adds to Human Toll of War

by Julie Jarema, Columbia Free Times
February 13th, 2008

Serving in Iraq for a brief time at the notorious Abu Ghraib prison outside Baghdad, Bill Orr knows firsthand the stresses of combat.

“Our first night there, we got mortared,” says Orr, an active-duty member of the Army National Guard. “We were bombed. We were staying in the prison itself for protection, because it’s concrete with steel reinforcement. I can’t actually say who it was, but it was people that did not want us there. It may have been terrorists from another country, it may have been the Sunnis who did not want the government to come up because it kicked them, but I can tell you they did not want us there.”

As stressful as any combat situation is, when you don’t know who the enemy is — or where they might show up — the anxiety is magnified.

“Even the Iraqis that were working with may turn on you,” Orr says. “We had Iraqi police inside the prison that we were training. One brought in a pistol and gave it to one of the prisoners because it was his brother-in-law, and he wound up shooting an MP right there.”

“I’m able to cope better than ever,” Orr says of his battle with post-traumatic stress disorder (PTSD). “I haven’t had a drink in three-and-a-half years. I’ve gotten closer with my two children. I’ve learned to do things I used to like doing. Counseling has helped, a 12-step program, and finding a God that allows me to find peace in myself. [But] every once in a while, I still have the nightmares.”

As of Feb. 6, the death toll among American forces in Iraq was 3,949, according to The Associated Press. Many of the soldiers who are lucky enough to get home suffer tremendously with severe depression and PTSD more so than any other war, including Vietnam. The collateral damage of the war in Iraq isn’t just the number of civilians killed in Iraq, but also the quality of life American soldiers and their families have as civilians once they return from the war.

Orr, along with many soldiers returning from Iraq and Afghanistan, suffers from mental distress, mostly PTSD. Estimates vary as to how many soldiers have PTSD, but several studies put the figure between 17 and 25 percent.

“Real heroes don’t talk about it,” says Vietnam veteran Walt Musan about PTSD at a Jan. 29 meeting of the South Carolina Disabled Combat Veterans Group. He has PTSD, too. “If you are a career soldier, that is the end of your career if you let someone know that you have PTSD. So most people keep it secret.”

PTSD wasn’t even diagnosed as a psychiatric illness until 1980, at the urging of Vietnam vets. Known by many names — such as “shell shock” during World War II and “combat fatigue” in Vietnam — PTSD is a relatively new name for an old condition among soldiers.

Rachel Rossman, director of mental health at the Dorn VA Hospital in Columbia, says causes of PTSD include being in life-threatening situations or having a brush with death. Symptoms include hyper-arousal or being not able to relax; sweating, shaking and not being able to concentrate; re-experiencing situations in a flashback or hallucination; sleep disturbance; and avoidance symptoms such as staying away from people or feeling numb.

“PTSD is just freezing yourself in a moment,” Orr says. “You have one moment that stays and you keep reliving up to that moment. The biggest thing to get over PTSD or get help with that is to realize the moment is gone. You’ve lived through it.”

With this war — much of which is being fought in highly stressful urban environments — the military and VA hospital system are learning more and more about how to diagnose and treat PTSD. They’re also learning how expensive PTSD is to treat long-term — and some veterans say that has led to dangerous shortcuts.

Every war has its traumas and its casualties — not just the dead, but also among the living. South Carolina alone had 1,581 casualties, including dead and wounded soldiers, in World War II. Nationally, 58,193 soldiers were killed in Vietnam.

The Iraq war is different: There have been fewer deaths than in World War II and Vietnam, but higher rates of trauma and suicide among soldiers, according to the Washington Post. As many as 121 Army soldiers committed suicide in 2007, a jump of 20 percent from the year before, the Associated Press reported Feb. 1. In addition, The New York Times has reported on an increase in crimes being committed by soldiers with PTSD.

Veterans say the problems stem from the trauma they experience in combat, especially going door-to-door in urban warfare like in Iraq, and the great shame of being considered too weak or lazy to fight if they admit they have problems.

Walt Musan, a Vietnam veteran in the South Carolina Disabled Combat Veterans group that meets once a week for breakfast, says the violence of any war is tough on soldiers. “We’ve seen friends of ours get blown up in front of our faces,” Musan says.

Veterans returning from Iraq have had to face not only the after-effects of battlefield and urban warfare trauma, but also a Veterans’ Administration system poorly funded and poorly equipped to deal with it. While the VA says care is improving, others say the military is still doing less than it should for soldiers. And in spite of what level of care is available, it isn’t always taken advantage of.

“I believe it is the whole experience [that causes PTSD],” says Lester Phillips, an Army veteran from World War II, Korea and Vietnam. “Many things that happened during that time that triggered it, but it was there after World War II. Maybe I was hiding it. Mainly because people with PTSD were considered nuts.” Phillips did not get diagnosed with PTSD until after Vietnam. “In Vietnam, birds were eating out of the heads [that were blown apart], picking at the bodies. It’s very stressful when you think about it later.”

However, although there are traumatic experiences of war for any soldier, they differ from one war to another in terms of political support at home and combat conditions. In World War II, American soldiers were considered liberators of Hitler’s dictatorship and hailed as heroes when they returned. Not the same story in Vietnam, a war much of the American public was against. And although many Americans support the troops today, many Americans feel the Iraq war was started under false pretenses. And with a high level of urban warfare, where there is no frontline or safe base, combat conditions are taking a high toll.

“We’re not fighting a country,” Orr says. “There is no safe place.”

Lanette Atkins, a psychiatrist at Columbia Area Mental Health who does contract work for the VA doing disability evaluations, agrees. “The rate of PTSD is higher with this war because they go back and have repeated tours of duty. There’s no real safe area in Iraq, unlike other wars where there were base camps or frontlines. In Iraq, you’re never safe from roadside bombs, suicide bombs, incoming mortars. They don’t get rest and relaxation like they did in Vietnam. There’s no place that’s safe in the country. Terrorists don’t recognize the army. There’s not a group of people you’re fighting against; it’s not the same as in Vietnam. Kids with bombs were relatively uncommon.”

Wade Fulmer, an Army Vietnam vet who serves on the veterans’ care committee for Military Families Speak Out, says returning soldiers are in dire need of follow-up aftercare. “The VA is short of people. Because of multiple deployments within a five-year period, there is no time to readjust. By the time a family understands what is going on, it’s time to go back. The spouses and the children suffer anxiety and depression with the stresses they’re under because their loved one is in a war. They have to wonder, ‘What’s he going to be like when he gets back? What can we do to get help?’”

Fulmer says percentage-wise and numbers-wise, there are more cases of PTSD in the Iraq war than any other war in the country’s history. He is also quick to charge that with the high rates of PTSD has come an effort on the part of the government to treat PTSD on the cheap. Fulmer says the government has been diagnosing some soldiers with personality disorders instead of PTSD so it can dishonorably discharge them and avoid responsibility for their disability insurance. He also says soldiers not getting the prompt follow-up care they need are contributing to the high rate of suicides.

In an April 2007 article in The Nation, Joshua Kors looked into claims similar to Fulmer’s regarding the diagnosis of personality disorder: “A six-month investigation has uncovered multiple cases in which soldiers wounded in Iraq are suspiciously diagnosed as having a personality disorder, then prevented from collecting benefits,” Kors wrote.

According to ABC News, the Defense Department discharged more than 22,000 soldiers under a personality disorder diagnosis between 2001 and 2007.

The military maintains the discharges are warranted and necessary.

“Personality disorders that interfere with military service and are incompatible with the soldier staying in the unit, it is usually best for both the soldier and the unit for that soldier to be discharged,” Col. Elspeth Cameron Ritchie, a psychiatry consultant to the U.S. Army surgeon general, told ABC.

As opposed to PTSD, Dorn VA Director of Mental Health Rossman says, “Personality disorder is lifelong — there’s no medication. The symptoms are so disruptive that they interfere with social functioning, inability to get along on the job, self-care. Their baseline function is very poor long before they get into the military. Borderline personality disorder — they cut themselves, drive recklessly, threaten to kill themselves on a regular basis. They are people who have been in an alternative academy, Department of Juvenile Justice, never been able to adapt.”

Many veterans disagree. “I think that’s a cop-out on the part of the military because they don’t want to acknowledge PTSD and have to pay benefits for the rest of their lives,” Musan says. “Rather than acknowledging this guy’s had three tours of combat.”

“They’re misdiagnosing them,” says Raymond Ortiz, a Marine veteran from Vietnam. “Personality disorder is just describing PTSD — it’s like saying ‘I’m a garbage man’ versus saying ‘I’m a sanitary engineer.’”

Atkins has a different story to tell. “There’s definitely not enough resources,” she says. “It’s gotten where everything is based on numbers. It’s more of a numbers game than the quality of evaluations and care. I’ve gotten a $25 pay raise since 1999 and there are no other MDs doing psychiatric evaluations at the Dorn VA. They’re replaced by psychologists. The [disability] pay for evaluations is based on numbers. I might do an eight- to ten-page evaluation where they might do two pages. Then they [the veterans with PTSD] don’t get their disability or a very minimal amount.”

Atkins also criticizes the VA’s medication recommendations. “They always use the cheapest meds. Trazadone is a commonly prescribed sleep med — it’s not a good sleep med, but it’s cheap. It’s other medications, too; they’re going to use whatever is cheap.”

However, Rossman says conditions are getting better.

“The funding for VA and mental health has drastically improved,” Rossman says. “It’s a matter of trying to hire enough people like psychiatrists, psychologists and social workers.”

Rossman also says it’s not the VA’s fault when soldiers don’t get treatment: It is their own pride and fear of a mental illness stigma that keeps them from seeking help. “People think they’ll be seen as weak,” she says. “They think, ‘If I just ignore it, it’ll get better with time.’”

Orr admits it wasn’t of his own free will that he got help with PTSD.

“I got injured over there [in Iraq],” Orr says. “A couple of incidents that came up, I got injured. So they had me on a med hold out at Fort Jackson and they were helping me through therapy for my physical ailments and everything like that. As a matter of fact, when they gave us the briefing on PTSD, I went off on the psychiatrist because he was holding me up from seeing my family.”

Orr says he was irritable, angry, depressed, having excessive mood swings and drinking “like a fish.”

“I was either angry or withdrawn,” Orr says. “There was no in between. The only time it even seemed that I would let anything off was when I was at a bar drinking because there was a couple of people who were on med hold with me that knew where I was at. Nobody else knew.”

Orr says that only through the urging of an ex-girlfriend did he go into therapy. “I could be mentally abusive. My commander got me into counseling at the fort. That’s where I got diagnosed with PTSD. I saw a psychiatrist and a psychologist. I got diagnosed with PTSD in June of ’04, two months after I got back.”

Willie Fuller, a Marine veteran who served in Vietnam, says he got help only after he almost got arrested at his civilian job for assaulting a co-worker. “I was at the copy machine and the guy walked up behind me and grabbed me, playing. But, I didn’t realize he was playing and I beat him up pretty badly. They should have put me in jail, but they didn’t. I knew I needed to get some help.”

Musan says a lot of people returning from Vietnam had no idea what PTSD was. “But they began to have problems with flashbacks and other indications of the illness such as nightmares,” he says.

Larry Smalls, an Army veteran of Vietnam, says the collateral damage of combat is hard to forget.

“It’s like someone putting a gun to your head and threatening your life 365 days a year,” Smalls says.

Rossman says war experiences are very difficult to process for soldiers returning to civilian life. “In order to be safe and not get killed, you have to suspend any feelings. You have to be so focused and get rid of any kind of feelings. They have been doing that for months and months as part of the job. You’re asking people to be tough enough to go into Fallujah and kill people — the mental mindset is totally different from sharing feelings. Nobody has a clue what they went through.”

“Everybody needs to be in a support group and learn what PTSD is so they can understand it’s treatable,” she says. “A lot of people think they’re the only one and that they’re going crazy. They have to understand that they can get help.”

Orr says it was the constant fear for his life in Iraq and not being able to trust people, especially the Iraqis — as well as some specific incidents such as a violent riot — that triggered his PTSD.

“When you have 26 mortars hit your area in one night, they don’t want you there,” Orr explains of his time at Abu Ghraib. “When it gets to the point when you’re laying in your cot and you can tell how big that mortar is that’s hitting your roof and making bets whether it’s going to come through or not and kill you, you don’t care who’s doing it. When you’re walking through an open area inside of a prison with walls on it and somewhere in an apartment complex that is taller than you, they start sniping at you. You’re walking along all of the sudden the sand starts kicking up and you hear zings, you don’t care who’s doing it.”

Orr says PTSD affected him in Iraq, but he just lived with it and turned it into a joke. “It gets so bad that it doesn’t bother you anymore, you get numb,” he says. “I would lay in my bunk when mortars started coming in wondering if one was going to come through and blow me apart and I wasn’t afraid … actually, over there, it was a joke between me and my roommate because I’d woke up in the middle of the night one night screaming they’re coming down the hall and he jumped up, grabbed his M-16 and opened the door and there was nothing there. He saw me sitting up, screaming. He said, ‘You son of a bitch!’ People think it’s a weakness or you’re trying to get out of something.”

Orr and the other veterans interviewed for this article have all gotten help for PTSD, and they know well that the symptoms and nightmares are no laughing matter. But as the war in Iraq drags on to the five-year mark in March, there will be no shortage of soldiers returning with similar problems. Add in an economic downturn that will only put a tighter squeeze on employment opportunities for returning veterans and the need for treatment only increases. But because some symptoms of PTSD don’t manifest themselves until months after soldiers return from abroad — and many soldiers don’t seek help despite an initial briefing they get on PTSD when they return — it’s clear that many cases will go untreated, perhaps until a crisis brings attention to a soldier’s condition, which will sometimes be too late.

The Army has found that failed relationships, legal and financial problems and job stress are the main factors in soldiers’ suicides — and that stress increases with time served in Iraq in Afghanistan, according to the AP. Some of the veterans interviewed for this article know other soldiers who have taken their own lives or been put in jail because of not getting the right treatment, care and insurance for PTSD. And for those soldiers who have survived both combat and PTSD — they don’t deserve to be called crazy, they deserve a medal of honor because they are, indeed, real heroes.