In advance of the 2009 deployment of 3,400 Oregon National Guard to Iraq, Bay Area Hospital and the Oregon Medical Association Alliance held seminars last week on PTSD (post traumatic stress disorder) and TBI (traumatic brain injury). Spread over two days, the meetings focused on helping medical personnel diagnose PTSD then followed up with an evening session for lay people and veterans.

Dr Lynn M Van Male from the Portland VA Medical Center presented a slide show to explain combat related trauma and its relationship to PTSD. PTSD is characterized by certain criteria and is not limited to combat trauma. Rape victims or accident victims also suffer from PTSD.
The criteria are having experienced an event that threatened death or serious injury to self and others. The “Post” in PTSD means that the disorder is not something brought into the stressor event by the sufferer.

PTSD is further characterized by persistent re-experiencing of the event through flashbacks, nightmares and intrusive thoughts often triggered by seemingly unrelated events like a car backfiring. PTSD sufferers avoid people, thoughts, feelings, activities and conversations that might trigger unpleasant memories causing them to appear detached and estranged from others. They may have a fatalistic or foreshortened view of the future.

Perhaps the most troubling manifestation of PTSD to the people around a troubled veteran is hyper-arousal. The veteran has difficulty sleeping is irritable and prone to angry outbursts. They have difficulty concentrating exhibit an exaggerated startle response and are hyper-vigilant and may pace constantly unable to feel comfortable or relaxed. These reactions are not character flaws but a normal reaction to life threatening experiences.

TBI is usually caused by the percussive shock wave from close proximity to explosions and can be primary, secondary or tertiary. Mild TBI, where there is no outward damage to the head, and PTSD share many of the same overlapping symptoms. However, PTSD, particularly brought on by repeated, periodic and unpredictable exposure to high stress, life threatening events causes irreversible brain damage.
Continued high levels of stress hormones cause shrinkage of the hippocampus, amongst other things, and the damage can be viewed on a brain scan. TBI, unless imaging is done within a couple of years at most may not be as visible but symptoms may still persist. Given the nature of the conflict in Iraq and Afghanistan it is believed that soldiers suffering from TBI will also have PTSD.

Additionally, deployment adds general situational stress. Temperatures can reach 120 degrees by 9AM and sand gets into everything. Sleep deprivation is a leading contributor to stress as is a lack of privacy. For Guard and Reserve forces financial problems arise as well as frustration or a sense of helplessness about problems at home.

Upon returning home the psychological adjustments that allowed the veteran to endure horrific conditions and survive in combat are not easily shut off and become a problem. The stress associated with the onset of PTSD is a level that induces a flight, fight or freeze reaction and can affect the veterans response to real or perceived threats. A consequence of PTSD is the inability to control these reactions that served them so well in combat when confronted with seemingly average daily encounters back home.

The typical coping mechanism that veterans use is alcohol and drugs hoping to aid in sleep and prohibit intrusive thoughts. Dr Van Male estimates that more than 60% of returning veterans abuse drugs and alcohol and will continue to do so without treatment. A consequence of this behavior is that many veterans come into contact with law enforcement that adds more stress and sometimes ends tragically, to an already troubled life.

Previously, the largest deployment from Oregon was 900 soldiers and 500, more than half, sought treatment from the VA upon returning. The Oregon National Guard 41st is primarily trained as a logistical and support brigade. The upcoming 2009 mission involves running supply convoys and maintaining crowd control in urban settings, well outside their original training.

Dr Van Male notes that despite training underway to ready them for this new mission, the percentage of returning Oregon National Guard expected to seek help from the VA will be higher than previous deployments. To be ready to support these troops when they return in 2010 and 2011 it is important to educate communities, medical personnel and particularly law enforcement how to recognize a veteran in crisis, quiet a situation and assist them in obtaining treatment.

The damage done to the brain by repeated life threatening stress is irreversible but not untreatable. The onset of the Iraq war saw a marked increase in services sought by Vietnam veterans by the VA. Even after 40 years, many different types of drug and behavioral therapy exist to help sufferers of PTSD. Veterans learn to ‘rewire’ their brains to bypass the hippocampus and learn to respond rather than react to stimulus. Communities must learn to recognize a troubled veteran and provide support services. If Dr Van Male is correct we will have quite an influx within the next two years.