Combat Stress Archives - The American Institute of Stress

Stress Awareness: Help is here

William Heckman — Wed, 09 Jul 2025 14:02:10 +0000

Walter Reed National Military Medical Center, BETHESDA, MD –

“The only constant in life is change,” said Greek philosopher Heraclitus, and with change can come stress.

Research has found that a certain level of stress can be a good thing if it motivates, pushing some people to work harder, meet deadlines, and achieve goals. But excessive stress, and lack of knowledge in how to handle it effectively, can be harmful and impact physical and mental health.

“Mental health is a state of mental well-being enabling people to cope with the stresses in life, realize their abilities, learn well, and work well, according to the World Health Organization. I agree with this definition,” states Army Col. (Dr.) Aniceto Navarro, director of Behavioral Health at Walter Reed.

With the current rapid pace of changes, uncertainties, and challenges, Navarro added that people are “multi-tasking [their] way into epidemic levels of chronic and stress-related diseases. But it doesn’t have to be that way. We can exercise healthy boundaries, learn to do the hard work of slowing down and listening to what our bodies are trying to tell us, and make those small changes, that over time, can lead to a more grounded and purposeful life. The signs are there if we have the courage and support to learn the language,” he said.

“We don’t want to pathologize anyone,” Navarro continued. “Stresses are normal occurrences in life, but it’s how we react to the stress which would guide the appropriate resources. On my deployments, chaplains were a fantastic resource for anyone to go talk with about anything. Whether or not religion is a component of your life, they are wonderful.”

“Military and Family Life Counselors, and the Fleet and Family Support Program are also excellent resources to turn to when feeling overwhelmed by stress,” Navarro added. “I also highly encourage folks to talk with each other, to learn about each other. We are so much more similar than we are different, and when we have shared understandings, we are great resources of support for each other.”

Handling stress effectively also includes building resiliency, and Walter Reed has the only Staff Resiliency Program in the Defense Health Network-National Capital Region.

Shantrell R. Hamilton is chief of Resiliency and program manager of the Staff Resiliency Program at Walter Reed. “I am responsible for managing and providing resiliency services that will support all staff at Walter Reed. We work as a team to provide services such as individual resiliency coaching sessions, unit morale checks, sensing sessions, informal mediation, trainings and workshops [focused on] stress management/burnout, conflict resolution, emotional intelligence, team building, positive leadership and more, based on request.”

The Defense Health Agency (DHA) Employee Assistance Program (EAP) is also a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related concerns. The EAP can address issues affecting mental and emotional well-being, including alcohol and other substance abuse, stress, grief, family problems, and psychological disorders. DHA’s EAP can be reached at 866-580-9046. Also, information concerning the Walter Reed Wellness Network can be found at https://walterreed.tricare.mil/WellnessNetwork.

“Realize that you are not alone,” Navarro stated. “Make peace with your emotions and train them to be smarter. Have a working theory of right and wrong. Don’t poison yourself with intoxicating substances such as alcohol, drugs, and pornography. Realize that moral rules have no exceptions. Morality is valid for all rational beings. Truth does not change; facts do though,” he added.

To reach the Resiliency Program Office at Walter Reed, call 301-319-2865. Walter Reed Chaplains Office can be reached at 301-295-1510. The National Suicide & Crisis Lifeline, available 24/7, can be reached by dialing 988.

Original Post Walter Reed National Military Medical Center

By Bernard Little, WRNMMC Command Communications

Image by Istvan Brecz-Gruber from Pixabay

June is PTSD Awareness Month-What is Posttraumatic Stress Disorder (PTSD)?

William Heckman — Wed, 11 Jun 2025 14:48:28 +0000

Posttraumatic stress disorder (PTSD) is a psychiatric condition that may occur in people who have experienced or witnessed a traumatic event or series of traumatic events. The individual often experience the event or events as emotionally or physically harmful or life-threatening. Examples include, but are not limited to, abuse (physical, sexual, emotional), natural disasters, serious accidents, terrorist acts, war/combat exposure, intimate partner violence, and medical illness. However, most individuals who experience traumas do not go on to develop PTSD.

Many people who are exposed to a traumatic event experience symptoms similar to PTSD in the days following the event. However, for a person to be diagnosed with PTSD, symptoms must last for more than a month and must cause significant distress or problems in the individual’s daily functioning. Many individuals develop symptoms within three months of the trauma, but symptoms may appear later and often persist for months and sometimes years. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems.

PTSD can occur in anyone of any ethnicity, nationality or culture, and at any age. The prevalence of PTSD in the U.S. is estimated to be approximately 4% of U.S. adults and 8% of U.S. adolescents aged 13-18. The lifetime prevalence in the U.S. is estimated to be 6%. PTSD risk factors include:

Prior history of trauma (and the severity and frequency of events; perceived lack of support following event(s))
Childhood adversity/trauma
Female gender
Member of a marginalized group (such as non-white, LGBTQ+, living with a disability)
Immigrant status

Symptoms and Diagnosis

Symptoms of PTSD fall into four categories. Specific symptoms can vary in severity.

Intrusion: Intrusive (unwanted and involuntary) thoughts such as repeated memories, distressing dreams, or flashbacks of traumatic events. Flashbacks may be so vivid that people feel they are reliving the traumatic experience or seeing it before their eyes and may cause significant fear and panic. These memories and/or nightmares may be triggered by something that reminds the individual of the traumatic event or may be spontaneous.
Avoidance: Avoiding reminders of the traumatic event(s) may include avoiding people, places, activities, objects, and situations that may trigger distressing memories. People may try to avoid remembering or thinking about the traumatic event. Additionally, they may resist talking about what happened or how they feel about it. Oftentimes, these behaviors lead to dysfunction in everyday life.
Changes in cognition and mood: Individuals with PTSD may initially present with depressive symptoms. These include low mood (feeling sad), inability to feel happiness, and a lack of interest in activity and/or people that they used to enjoy. Additionally, individuals with PTSD may have trouble with memory; maybe be unable to remember important aspects of the traumatic event have negative thoughts and feelings leading to ongoing and distorted beliefs about themself or others (e.g., “I am bad,” “No one can be trusted”); have distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other; have ongoing fear, horror, anger, guilt or shame; have much less interest in activities previously enjoyed; feel detached or estranged from others; or be unable to experience positive emotions (a void of happiness or satisfaction).
Changes in arousal and reactivity: People with PTSD may describe being irritable and having angry outbursts, behaving recklessly or in a self-destructive way, being overly watchful of their surroundings in a suspecting way, being easily startled, or having problems concentrating or sleeping.

Dissociation

Some individuals with PTSD will have the dissociative symptoms:

Derealization – The feeling that life is not real. Individual may describe feeling like they are in a movie or in a dream.
Depersonalization – The feeling that one is outside of their body.

These symptoms are not required for a PTSD diagnosis and can vary in intensity across the PTSD illness.

The four tabs below provide brief descriptions of four conditions related to PTSD: acute stress disorder, adjustment disorder, disinhibited social engagement disorder, and reactive attachment disorder.

Treatment

It is important to note that not everyone who experiences trauma develops PTSD, and not everyone who develops PTSD requires psychiatric treatment. For some people, symptoms of PTSD subside or disappear over time. Others get better with the help of their support system (family, friends or clergy). But many people with PTSD need professional treatment to recover from psychological distress that can be intense and disabling. It is important to remember that trauma may lead to severe distress. That distress is not the individual’s fault, and PTSD is treatable. The earlier a person gets treatment, the better chance of recovery.

Psychiatrists and other mental health professionals use various effective and research-proven methods to help people recover from PTSD. Both talk therapy (psychotherapy) and medication provide effective evidence-based treatments for PTSD.

Cognitive Behavioral Therapy

One category of psychotherapy, cognitive behavior therapies (CBT), is very effective. Cognitive processing therapy, prolonged exposure therapy and stress inoculation therapy (described below) are among the types of CBT used to treat PTSD.

Cognitive Processing Therapy is an evidence-based, cognitive behavioral therapy designed specifically to treat PTSD and comorbid symptoms. It focuses on changing painful negative emotions (such as shame, guilt, etc.) and beliefs (such as “I have failed;” “the world is dangerous”) due to the trauma. Therapists help the person confront such distressing memories and emotions.
Prolonged Exposure Therapy uses repeated, detailed imagining of the trauma or progressive exposures to symptom “triggers” in a safe, controlled way to help a person face and gain control of fear and distress and learn to cope. For example, virtual reality programs have been used to help war veterans with PTSD re-experience the battlefield in a controlled, therapeutic way.
Trauma Focused Cognitive Behavioral Therapy is an evidence-based treatment model for children and adolescents that incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques.
Eye Movement Desensitization and Reprocessing for PTSD is a trauma-focused psychotherapy which is administered over approximately three months. This therapy helps a person to reprocess the memory of the trauma so that it is experienced in a different way. After a thorough history is taken and a treatment plan developed the therapist guides the patient through questions about the traumatic memory. Eye movements similar to those in REM sleep is recreated during a session by having the patient watch the therapist’s fingers go back and forth or by watching a light bar. The eye movements last for a brief time period and then stop. Experiences during a session may include changes in thoughts, images, and feelings. After repeated sessions the memory tends to change and is experienced in a less negative manner.
Group therapy encourages survivors of similar traumatic events to share their experiences and reactions in a comfortable and non-judgmental setting. Group members help one another realize that many people would have responded the same way and felt the same emotions. Family therapy may also help because the behavior and distress of the person with PTSD can affect the entire family.

Other psychotherapies such as interpersonal, supportive and psychodynamic therapies focus on the emotional and interpersonal aspects of PTSD. These may be helpful for people who do not want to expose themselves to reminders of their traumas.

Often individuals will explore various psychotherapy options to find the right fit for them. Additionally, individuals may transition from one therapy to another during their treatment. There is no significant evidence that one psychotherapy is more effective than another. Thus, the decision about which psychotherapy to use should be individualized to each patient.

Medication

Medication can help to control the symptoms of PTSD. In addition, the symptom relief that medication provides allows many people to participate more effectively in psychotherapy.

SSRIs and SNRIs (antidepressants) are commonly used to treat the core symptoms of PTSD and co-occurring mood symptoms. They are used either alone or in combination with psychotherapy or other treatments.

Prazosin, a blood pressure medication, is often prescribed to help with sleep issues related to nightmares in people owith PTSD.

People with PTSD may experience hallucinations that cause significant distress. They may be prescribed antipsychotic medications. These medications may also help with mood, anxiety, and sleep.

There is ongoing research examining the use of psychedelics such as psylocibin and MDMA to treat PTSD. They are typically used along with psychotherapy under the care of a trained professionals in a controlled setting. Currently, there is no FDA-approval for psychedelics to treat PTSD.

Other Treatments

Other treatments including complementary and alternative therapies are also increasingly being used to help people with PTSD. These approaches provide treatment outside the conventional mental health clinic and may require less talking and disclosure than psychotherapy. Examples include acupuncture, yoga and animal-assisted therapy.

In addition to treatment, many people with PTSD find it very helpful to share their experiences and feelings with others who have similar experiences, such as in a peer support group.

Physician Review Donald Egan, M.D. March 2025

Original Post

Image by Ronald May from Pixabay

In 2025, June is designated as PTSD Awareness Month.

William Heckman — Fri, 06 Jun 2025 14:33:25 +0000

Post-Traumatic Disorder – What is PTSD?

Post-traumatic stress disorder (PTSD) is a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event. These stressful or traumatic events usually involve a situation where someone’s life has been threatened or severe injury has occurred. Children and adults with PTSD may feel anxious or stressed even when they are not in present danger.

Causes

You can get PTSD after living through or seeing a traumatic event, such as war, a natural disaster, sexual assault, physical abuse, or a bad accident. PTSD makes you feel stressed and afraid after the danger is over. It affects your life and the people around you.

PTSD starts at different times for different people. Signs of PTSD may start soon after a frightening event and then continue. Other people develop new or more severe signs months or even years later. PTSD is often related to the seriousness of the trauma, whether the trauma was repeated or not, what the individual’s proximity to the trauma was, and what their relationship is with the victim or perpetrator of the trauma.

To be considered for PTSD, signs and symptoms must last more than a month and be severe enough to interfere with school, work, or relationships. PTSD can happen to anyone, even children.

Signs & Symptoms

Symptoms of PTSD may last months to years. PTSD symptoms may include:

Flashbacks, or feeling like the event is happening again
Trouble sleeping or nightmares
Feeling alone or detached from others
Losing interest in activities
Having angry outbursts or other extreme reactions
Feeling worried, guilty, or sad
Frightening thoughts
Having trouble concentrating
Having physical pain like headaches or stomach aches
Avoidance of memories, thoughts, or feelings about what closely associated with traumatic events
Problems remembering
Negative beliefs about themselves or others
Irritability
Feeling very vigilant
Startling easily

Symptoms of anxiety, depression, and substance use also are seen with people who have PTSD.

Testing for PTSD

According to the National Institute of Mental Health, a doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD.

Get Help

There are several ways someone can manage PTSD. Talking to a specially trained doctor or counselor helps many people with PTSD. This is called talk therapy. Medicines can help you feel less afraid, tense, and depressed. It might take a few weeks for them to work.

Learn how to talk about mental health to help you speak to a loved one who you may think is experiencing any mental health concerns.

Need Help?

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org.
To learn how to get support for mental health, drug, and alcohol issues, visit FindSupport.gov.
To locate treatment facilities or providers, visit FindTreatment.gov or call SAMHSA’s National Helpline at 800-662-HELP (4357).

Resources

The Tragic Toll of Police Work

William Heckman — Wed, 16 Apr 2025 13:27:11 +0000

This article is from the Spring 2025 edition of Combat Stress magazine.

By Joseph Pangaro, CPM, CSO, MOI, LT (RET)

Having served my community for 27 years, I have come to some understanding about this career in law enforcement and the things we do. Our profession calls on us to be calm during a storm, the voice of reason in unreasonable situations, and the emotionless authority that makes things better. These are high ideals for mortal men and women.

The Observers of Society

From the time we graduate from the police academy, we are advised that we simply are observers of happenings. We are not personally involved in the events we encounter. We are told that the horrific scenes and the destruction of people’s lives we witness are part of the job. The pain and suffering we see people living with are not our pain and suffering. Don’t take it home with you. Forget about it. Ignore it.

That sounds easy until you are called on to tell a wife that her husband was killed in a senseless car accident; to watch helplessly as a mother cries over the dead body of her drug-addicted child; or to see precious, innocent children abused by the adults in their lives. We as law enforcement personnel have to witness and live with such terrible situations every day. We are taught to push these images out of our minds and leave them at work. The culture of law enforcement encourages us to believe that we can just move on from these things, but I don’t think it really works that way. I believe that these default positions build up and take a toll on us over the years. They wear us down emotionally.

The Effects of Policing

I point to the sobering statistics of law enforcement suicide. Every year in the United States, criminals kill between 100 and 150 of us. (1) This is a staggering reality and a tragic part of our job. What is worse, though, is that we kill ourselves at twice that rate, almost 300 police suicides a year. (2) That is higher than any other profession, and there is a reason. I believe that reason is the common practice of moving through the painful, emotionally draining situations we face every day and trying to ignore them. We are tough. Those things don’t bother us. Right?

Cop humor is famous in our circles. The things we say and the jokes we make at some of the scenes we end up at would leave the people outside our profession speechless. If they heard some of the comments and wisecracks, we make, they would ran out of the room screaming, convinced that we were crazy. Cops, however, know that this humor is not callousness. It is a way to deal with the things we encounter and a way to have control over what we cannot fix or make better. The key here is understanding that this dark humor is a coping mechanism, not a “dealing with it” mechanism. These two expressions are extremely different and so is the emotional truth of the situation. It is between these two phrases and the real-life places we live that can damage us, not as cops but as people.

The Concept of Compassion

This is where the concept of compassion and understanding of how it fits into our lives must come into play. The compassion I am talking about is not simply feeling sorry for someone or being upset that they are in a predicament. Rather, it is an all-encompassing emotion that has attendant actions. For our own good, we must seek out this compassion to help us not just live through these difficult situations but to survive them over the long haul.

One way to foster compassion is to see people for who they are, regardless of why they have come into our lives. Developing compassion for all of the people we encounter should be a goal. Extending it to the victims we deal with is not difficult. They deserve our attention and priority. But, for the “bad guys,” extending our compassion often can prove challenging. These people usually do not engender our warmest thoughts. It is here, however, that we can try to change our thoughts and actions. First of all, it is the decent thing to do; after all, we are the guardians in any given situation. Treating defendants with compassion helps reveal the decency within us. People end up in unfortunate situations for many reasons. Admittedly, most of them of their own doing but, sometimes, just because of problematic lifestyles. That does not excuse them of their actions; we all have to be accountable for our choices. My point here is simply that some people have made ill-fated choices based on the hand they were dealt with. Anyone can find themselves in a difficult spot at some point in their lives. We all know people like this, and some of us have those people in our own families. Treating such people with dignity and compassion speaks more about us than them.

Next, and most important, we must be compassionate toward ourselves. We must change the culture of law enforcement that ignores the emotional scars the job can leave on our souls. We must address these situations, accept the horror of them, and talk about how they can affect us. We are not too tough to be moved by the death of a child or the collapse of someone’s life. The purpose of this self-compassion and facing the terrible things we see is not to make us touchy-feely cops or to get in touch with our nurturing sides but, rather, to help us address the negative feelings that come with the experiences we have. Once we deal with these feeling head-on, we can put them into perspective, which will take away their power over us. It is only then that we can move on without damage.

Our career provides us with an unprecedented glimpse into the world of human interaction. It is a double-edged sword, though. On the one hand, we have a “backstage pass to life;” we see things and go places that most people only hear or read about. On the other hand, we sometimes have to conduct our business in the depths of people’s cruelty to each other. It is an honor to be in law enforcement and a great trust the people of our society have given us. We must not allow the rigors of the work and the fact that we are placed into some extremely difficult situations to deprive us of the joy this life has to offer. By making these changes in our police culture, perhaps we can save some of our 300 brothers and sisters who die by their own hand each year.

Conclusion

After 27 years on the job, I have made my peace with the evils people do to each other. The idealistic beliefs of my youth have matured over time. I have come to accept the fact that I cannot save the whole world, but what I can do is make small differences in the lives of the people I encounter. In this way, I help them and take care of myself. We all need to take care of the person inside. All of the officers who have killed themselves call out to us. We must listen and learn from them. We must start a dialogue that is long overdue.

Stress Without Borders: The Emotional Toll of Operation Lone Star on Troops and Their Families

William Heckman — Mon, 07 Apr 2025 16:03:37 +0000

This article appears in the Spring 2025 edition of Combat Stress Magazine.

By Miguel Ruiz, Marketing Strategy Director

In an election year, various public interest and political topics and rhetoric arise in droves. Turn on any station, click any story, and you’re sure to be flooded with various narratives that all seem designed to pit you against another side. One of those persistent issues is the state of the U.S. southern border. For the past several years, the media has brought constant news from that region. But here’s the thing: seldom do you hear stories from the level of the people working at the border. Nowadays, independent journalism and social media platforms have helped surface some of these stories, but most major news outlets still don’t cover the ground-level experiences. Instead, they may emphasize rhetoric and talking points.

The fact is that multiple governmental and local agencies partner together 24/7 to combat the everyday challenges along the southern border. I won’t get into the broader issues themselves because that’s for another platform and deserves a much more detailed explanation. But instead, I want to shine a light on the people working the border. You’ve got dozens of sheriff’s departments, police departments, state entities, federal entities, and then you also have the Texas Military Department — specifically, the Texas Army National Guard. I was one of those Texas Army National Guard troops, part of the first Texas boots on the ground in the currently ongoing Operation Lone Star, the Texas-backed mission to deploy Soldiers and state troopers to support overwhelmed local agencies along Texas border cities.

For National Guardsmen, deployment can be wildly unpredictable, unlike active-duty military personnel who often have months of notice and lead-up training before deployment. Statewide deployments for Guardsmen typically come at the last minute, following orders directly from the governor. In my first year as a Guardsman, I was working full-time in a sales office in Fort Worth, a regular post-college gig. One day, I got a call at my sales desk from my unit commander telling me I was deploying that night and needed to pack my gear immediately to commute to a Guard airfield hours away. This was to participate in 24-hour flood rescue operations in the Rio Grande Valley for an uncertain period of time. Thankfully, my employer was Guard-friendly and understood my obligations, but this abrupt change of routine was something I would grow accustomed to over the next six years. As my life evolved, so did the stakes — what started as manageable disruptions when I was single turned into much greater challenges as I started a family, including numerous sudden activations for stateside disasters and then Operation Lone Star.

For me, that deployment happened less than two years ago. I served as a 46S, a Public Affairs Mass Communication Specialist, in charge of other Public Affairs Soldiers and responsible for setting up journalism operations along the entire border. I had a unique backstage view into everything — from planning operations, logistical movements, and intelligence, to being on the ground, rolling around with first responder agencies in my own sanctioned vehicles, and participating in various, and uniquely dangerous, operations.

What makes deployments for Texas Army National Guard Soldiers unique is that most of them, myself included, have full-time civilian careers back home. Most National Guard troops receive abrupt orders to deploy in response to natural disasters, civil unrest, or in this case, Operation Lone Star — an unprecedented activation of state Soldiers and law enforcement officers, with political implications and controversies.

The financial and logistical challenges associated with Operation Lone Star became a significant point of controversy, drawing public criticism and political debate. As a public affairs non-commissioned officer (NCO), I was tasked with coordinating my small unit of Soldiers, scattered across the border, ensuring their pay, lodging, responsibilities, and personal affairs were handled. But just weeks into our sudden deployment, several of my Soldiers went without pay for months. One had a mortgage and child support to manage, dipping into savings multiple times to stay afloat. Another Soldier I overheard in line at the headquarters pay office was pleading for immediate pay, explaining how his wife was a stay-at-home mom, and they had missed bills, creating a dire financial situation. It was a morale killer for many of the troops, especially when such a basic need like pay wasn’t met, creating immense stress not just for the Soldiers but also their families.

Stress was rampant throughout the operation, for both the National Guard and other first responders. While I could handle the physical and emotional toll as part of the job, it was the prolonged uncertainty that really wore me down. My original orders were for a four-month deployment, but as time passed, those orders extended — first to eight months, then 12, and eventually, there was no clear end in sight. For someone like me, who had a family at home and a baby on the way, this uncertainty became an additional source of stress. How do you tell your family or civilian employer when you’re coming home when you don’t even know yourself? I had that conversation with my spouse and family over and over: “I don’t know when I’m coming home.”

The stress I experienced during my time in the National Guard was expected in many ways — I signed up knowing military operations, whether local or global, came with challenges. But there were things you don’t anticipate, like the loss of close friends and colleagues in various missions, or the prolonged uncertainty and separation from family during back-to-back deployments. These experiences deeply affected me, my fellow Soldiers, and our families. Now, as I’ve transitioned to full-time civilian life and a career in marketing, I realize how much those past stressors prepared me. Today, I find myself able to handle high-pressure situations with a certain calmness — or perhaps a numbness. Whether that’s a good thing or not, I’m still unsure, but at least it taught me resilience and an ability to multitask and endure challenges in both my personal and professional life.

Despite all this, we carried on and completed our portions of the mission, even in the face of deadly working conditions during some of the operations. The irony is, while Soldiers and first responders were dealing with these immense challenges, much of the media focused on political controversies or big headlines. Rarely did anyone speak about the toll on the ground level — on the Soldiers, law enforcement, or even the migrants facing life-changing stress, with families torn apart and lives lost at the border.

In the end, I simply want to shed some light on the brave first responders and Texas Guardsmen who continue to serve along the southern border, away from their families, in extremely difficult conditions. The next time you hear someone repeat political talking points, I hope you also think about the human side — the men and women who serve every day, often unseen, under immense stress.

Miguel Ruiz is a marketing and advertising professional with over 12 years of experience, leading marketing for clients across Texas and around the globe. A former Public Affairs Mass Communications Specialist in the Texas Army National Guard, Miguel documented multiple overseas deployments, humanitarian missions, and stateside operations. Beyond his professional endeavors, he serves on nonprofit boards in Fort Worth, mentors rising marketing professionals, and provides pro bono training for local small business owners. Named one of Fort Worth Inc.’s “40 Under 40,” Miguel is currently pursuing a Master of Science degree at Texas A&M University. He can be reached at mruiz@joagency.com.

Stress changes how we recall memories, making them seem frightening

William Heckman — Mon, 18 Nov 2024 15:39:50 +0000

Every organ in the human body is extraordinary, but the brain is an organ that often surpasses our understanding. It determines how we perceive the world, how we act, and how we remember. Our brain is hard at work – day and night. Yet, the brain is more than just an information-processing center; it’s also the epicenter of our memories, emotions, stress, and fears.

Stress can lead to more than just a stiff neck or a racing heart. In extreme cases, it can influence our brain to create and retrieve memories in strange and unusual ways.

Researchers at The Hospital for Sick Children (SickKids) have made fascinating discoveries about the relationship between stress, memory, and our brains’ biological processes.

Stress and memory: Unsettling connection

Perhaps you’ve given a presentation that didn’t go as planned. The next time you’re due to present, you might feel stressed because your brain has linked this new presentation to the memory of the previous unsatisfactory experience. This is a type of stress tied to one memory.

However, stress from traumatic events, like witnessing violence or suffering from generalized anxiety disorder, can have a far-reaching impact. It can cause what is known as stress-induced aversive memory generalization.

Here, unrelated stimuli can trigger frightening memories that seemingly have no connection to the original traumatic event. This phenomenon can have severe consequences for individuals who suffer from post-traumatic stress disorder (PTSD).

Memories after stress

Dr. Sheena Josselyn and Dr. Paul Frankland, experts in the Neurosciences & Mental Health program at SickKids, have identified the biological processes that result in stress-induced aversive memory generalization.

The experts have also found a potential intervention that could help restore the specificity of memory in individuals with PTSD.

“A little bit of stress is good, it’s what gets you up in the morning when your alarm goes off, but too much stress can be debilitating,” said Dr. Josselyn.

“We know that people with PTSD show fearful responses to safe situations or environments, and have found a way to limit this fearful response to specific situations and potentially reduce the harmful effects of PTSD.”

Understanding the mechanics

In a collaborative effort with Dr. Matthew Hill from the University of Calgary Hotchkiss Brain Institute, the research team was able to limit stress-induced aversive memory generalization to the specific, appropriate memory. This was achieved by blocking endocannabinoid receptors on interneurons.

To understand this process better, the team set up a preclinical model. They exposed subjects to a small amount of stress before a distressing event. This created a generalized fearful memory that could be triggered by unrelated safe situations, mirroring how PTSD manifests in humans.

Upon inspecting the subjects’ memory engrams (the physical representations of a memory), the research team made an interesting discovery. Typically, engrams involve only a small number of neurons. However, the stress-induced memory engrams involved a significantly larger number of neurons.

When they examined these larger engrams more closely, the team found that stress resulted in increased endocannabinoid release in the brain, which disrupted the function of interneurons.

Formation of fearful memories

A significant bit of the puzzle lies in a previously overlooked area – the endocannabinoid system. This system plays a key role in forming memories and associating experiences with specific behavioral outcomes.

Special “gatekeeper” interneurons in the amygdala, the emotional processing center of the brain, help constrain the size of the engram and, therefore, the specificity of the memory.

When too many endocannabinoids are released, these gatekeeper interneurons cannot function properly, leading to an increase in the size of the engram.

“Endocannabinoid receptors function like a velvet rope at an exclusive club. When stress induces the release of too many endocannabinoids, the velvet rope falls, causing more generalized aversive fearful memories to form,” explained Dr. Josselyn.

“By blocking these endocannabinoid receptors just on these specific interneurons, we could essentially prevent one of the most debilitating symptoms of PTSD.”

Stress-induced memory engrams

In 2023, previous research published in the journal Science identified larger, more generalized memory engrams in the developing brain than in the adult brain, similar to stress-induced memory engrams.

As the experts continue to explore this unexpected connection between engram size, stress, and age, they also aim to understand how daily stressors might affect positive memories.

“The many biological functions and processes that make up the complexity of human memory are still being uncovered,” said Dr. Frankland.

“We hope that as we better understand human memory, we can inform real-world therapies for those with various psychiatric and other brain disorders throughout their lifespan.”

Indeed, as our understanding of the human brain continues to expand, so too do our hopes for revolutionary treatments and therapies. Through the diligent work of these researchers and others in the field, we may be able to fully unravel the mysteries of the brain, stress, and memory.

The study is published in the journal Cell.

For more information about STRESS-RELATED issues go to stress.org

OP-earth.com

BySanjana Gajbhiye

Earth.com staff writer

Photo by MART PRODUCTION

How to Navigate Burnout: Tips for Recovery and Renewal

William Heckman — Wed, 30 Oct 2024 15:41:07 +0000

This article appears in the Fall issue of Combat Stress Magazine

By Arjuna George, CEC, CTMP, CCS, CWS

Burnout has become an unwelcome companion for many in a world where demands pile up faster than we can address them. Once considered a fleeting phase of exhaustion, the World Health Organization officially recognizes burnout as a legitimate psychological condition. It creeps across professional landscapes, reaching beyond corporate boardrooms into healthcare, education, emergency services, and virtually into any high-pressure environment.

Burnout doesn’t just arrive overnight; it builds quietly over time, an accumulation of stress that drains us emotionally, mentally, and physically. Whether you’re a healthcare worker on the frontlines or a corporate leader managing endless deadlines, understanding and preventing burnout is crucial for long-term well-being.

This article delves into the complexities of burnout and provides actionable steps toward recovery and resilience.

Understanding Burnout

Burnout spares no one. From CEOs to caregivers, its impact knows no boundaries. Burnout is a response to prolonged, unrelenting stress, a signal from both the mind and body that we’ve pushed too far for too long. Pioneers like Professor Hans Selye and Dr. Herbert Freudenberger laid the groundwork for understanding burnout, framing it as depleting our psychological and physiological resources. It’s not just about working too much—it’s about losing touch with our sense of self and purpose.

Signs of Burnout

Early detection of burnout is like noticing the first cracks in a dam. Left unaddressed, those cracks can widen and lead to a flood of emotional, physical, and mental distress. Here are some of the signs I experienced during my burnout journey:

Profound Exhaustion: This isn’t your average tiredness. It’s a deep, soul-sucking that sleep can’t fix. Your energy reserves feel permanently depleted.

Cynicism Toward Work: What once brought passion and purpose now feels empty. Your job becomes a source of frustration and your connection to your work starts to dissolve.

Decline in Performance: Concentration wavers, creativity dries up, and the work that once came naturally becomes a struggle. As high performers, this decline feels devastating, undermining our confidence.

Emotional Detachment: You may feel disconnected from colleagues, clients, or work. Isolation sets in, leaving you emotionally numb.

Increased Irritability: Little things set you off—things that once wouldn’t have bothered you.

Physical Symptoms: Burnout doesn’t just affect the mind. Headaches, muscle tension, sleep disturbances, and gastrointestinal issues may surface.

These markers are like red flags, signaling that burnout is taking hold.

The Roots of Burnout

A single factor rarely causes burnout. Instead, it arises from a perfect storm of overwhelming workload, lack of control, and diminishing workplace support. Add a disconnect between personal values and organizational goals, and the foundation for burnout is set. Understanding these roots is the first step in addressing burnout, allowing us to course-correct before we spiral into more profound distress.

Drawing Parallels with OSI and Compassion Fatigue

Burnout often overlaps with other stress-related conditions, particularly Operational Stress Injury (OSI) and compassion fatigue. All three share the same core symptoms: emotional exhaustion, detachment, and a diminished sense of accomplishment. The effects can be profound for professionals in high-stress environments, such as emergency services or healthcare.

Like OSI, which includes conditions formerly grouped under PTSD, burnout can trigger intrusive thoughts, emotional numbing, and physical symptoms such as insomnia and chronic fatigue. Compassion fatigue, often seen in caregivers, manifests similarly, leaving individuals feeling emotionally drained and unable to continue giving. These are not just “work issues,” they’re mental health conditions that need attention and care.

My Burnout Journey

Burnout isn’t theoretical for me, it’s deeply personal. As a Fire Chief, I devoted myself wholeheartedly to my role, but over time, the weight of the job began to erode my well-being. What started as a dedication to public service became a grind that left me depleted and detached. Burnout wasn’t just exhaustion; it was a complete disconnection from the purpose and passion I once had for my work.

Addressing burnout requires a holistic approach. I sought professional help; counseling, coaching, and medical support. But beyond that, it forced me to reassess my values and boundaries. Caring for others was only possible if I cared for myself first. My recovery involved rest and intentional self-reflection, boundary-setting, and realigning my life with a more sustainable approach to work and leadership.

Burnout transformed me into a more compassionate and resilient leader. Today, I am committed to promoting a balanced, supportive workplace that recognizes the importance of mental health and sustainability in high-pressure roles.

Preventing Burnout: A Holistic Approach

Preventing burnout doesn’t just mean taking breaks, but rather nurturing all aspects of our being. A holistic approach addresses physical, mental, emotional, and spiritual needs. Here are a few strategies that can serve as protective measures:

Set Healthy Boundaries: Learn to say no. Protect your time and energy like you would any other valuable resource.

Practice Mindfulness: Mindfulness techniques such as meditation and deep breathing can help create mental space, allowing us to reset amid chaos.

Foster Supportive Relationships: Build and maintain a network of people who understand and support your journey. Isolation is a fertile ground for burnout, while connection helps guard against it.

Recovery: The Path Back

Recovering from burnout is a slow but necessary process. It takes time and care; the right conditions are needed, like regenerating a forest after a fire. Professional guidance can be crucial through counseling, coaching, or medical intervention. Alongside that, rediscovering activities that spark joy and purpose is essential. Recovery isn’t just about rest, it’s about rekindling the fire within, one small step at a time.

Burnout is not the end of the road. It signals that something needs to change, and recovery and renewal are possible with the proper support. Whether navigating burnout yourself or seeking to support someone else through it, know that you’re not alone.

This article is a call to action for everyone in high-risk, high-performing professions: Prioritize your well-being. Seek support. Embrace a holistic approach to life and work. Doing so can create resilience, reclaim our vitality, and allow us to thrive, even in the most demanding environments.

To learn more about stress-related issues go to STRESS.ORG

Facing Fears: Patients With Past Trauma Can Still Enjoy Halloween

William Heckman — Wed, 09 Oct 2024 15:36:38 +0000

Just because a patient has anxiety or past trauma does not mean they cannot enjoy this spooky holiday…

Q&A

Happy Halloween! While this holiday can be filled with tricks and treats, it can also be difficult for patients with anxiety or a history of trauma. How can you as a clinician guide them towards enjoyment rather than fear?

PT: How do you think Halloween impacts patients with high anxiety/stress levels?

Anderson: For many, kids and adults alike, Halloween is an exciting, fun-filled time of the year. It is accompanied by parties, candy, cakes, drinks, and scary movies. Dressing up in costumes allows individuals to try on another persona or become their favorite character for the day.

However, for many with anxiety, stress, or trauma, this holiday can be a nightmare. Those who suffer from panic or posttraumatic stress disorder (PTSD) symptoms (intrusive images, increased anxiety, an exaggerated startle response, increased heart rate and breathing, alternating with numbness, avoidance, disconnection, and dissociation), can find Halloween grueling and intolerable to partake in. Being spooked or intentionally scared can be terrifying for someone with a trauma history, it can trigger panic attacks, cause increased heart rate, and activate traumatic memories from the past.

PT: Should patients with past trauma avoid scary movies/haunted houses? Why?

Anderson: My suggestion for those struggling with anxiety or have a history of trauma is to avoid scary movies and haunted houses all together. They can activate symptoms of panic, PTSD, and cause traumatic memories from the past to resurface. Reliving traumatic experiences re-enforces trauma neural networks in the brain and can be taxing on one’s physical and mental health. It causes distress, fear, isolation, numbness, a lack of feeling safe, and even can trigger suicidal feelings.

PT: Research shows that women are more likely than men to be interested in consuming true crime stories.¹ Some suggest this is because women experience catharsis from content like this. Do you think that is true? How much true crime is too much?

Anderson: It is important to be aware that this research presents one such perspective as to why women read true crime stories. Many women avoid reading them altogether because they are too activating for them. One possible explanation for this desire, however, is that there is an element of mastery for those women who choose to consume true crime movies. Some of the stories are solved or resolve favorably in the end. This could bring hope or justice or a sense of control to an otherwise difficult and hopeless situation. Watching or reading about someone else’s experience without going through it directly, could bring a sense of comradery or belonging for some women who feel alone in their experience.

PT: Is there any truth behind the concept of “facing our fears”?

Anderson: Most of the research that supports “facing one’s fears,” is conducted when subjects are feeling in control of their situation, and does not incorporate the element of surprise. It is never forced upon someone and ensures that individuals feel agency about the pace and intensity of the exposure to the overwhelming situation in question. Those who watch crime stories repeatedly sometimes use it to access repressed or dissociated feelings they normally do not have access to. This, however, is not generally recommended by professionals as a useful method of working through one’s traumatic past.

PT: How can patients enjoy Halloween without triggering memories of past traumas?

Anderson: The best way to enjoy Halloween is to be in control of the exposure to scary, deceptive, or frightening events. Many trauma survivors dislike the holiday all together and choose to not participate in it because it commonly brings forth unwanted symptoms from their past. One way to move through the holiday with more ease and levity is to experience it through the eyes of children. Focus on the fun, the innocence, the joy of the holiday, compared to what adults tend to focus on: the horror, the deception, and the jump scares. Halloween can be enjoyable when it does not reflect or trigger one’s trauma or anxiety from the past.

To learn more about stress go to STRESS.ORG

Photo by Rahul Pandit

Dr Anderson is a psychiatrist, trauma specialist, and author of the upcoming memoir To Be Loved: A Story of Truth, Trauma, and Transformation (PESI, May 7, 2024).

OP-Psychiatric Times

By Author(s): Leah Kuntz and Frank G. Anderson, MD

Reference

1. Vicary AM, Fraley RC. Captured by true crime: why are women drawn to tales of rape, murder, and serial killers? Social Psychological and Personality Science. 2010;1(1):81-86.

Exaggerated amygdala response to masked facial stimuli in posttraumatic stress disorder: a functional MRI study

William Heckman — Mon, 22 Jul 2024 16:14:45 +0000

S L Rauch¹, P J Whalen, L M Shin, S C McInerney, M L Macklin, N B Lasko, S P Orr, R K Pitman

Affiliations

Affiliation

¹Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

PMID: 10812035
DOI: 10.1016/s0006-3223(00)00828-3

Abstract

Background: Converging lines of evidence have implicated the amygdala in the pathophysiology of posttraumatic stress disorder (PTSD). We previously developed a method for measuring automatic amygdala responses to general threat-related stimuli; in conjunction with functional magnetic resonance imaging, we used a passive viewing task involving masked presentations of human facial stimuli.

Methods: We applied this method to study veterans with PTSD and a comparison cohort of combat-exposed veterans without PTSD.

Results: The findings indicate that patients with PTSD exhibit exaggerated amygdala responses to masked-fearful versus masked-happy faces.

Conclusions: Although some previous neuroimaging studies of PTSD have demonstrated amygdala recruitment in response to reminders of traumatic events, this represents the first evidence for exaggerated amygdala responses to general negative stimuli in PTSD. Furthermore, by using a probe that emphasizes automaticity, we provide initial evidence of amygdala hyperresponsivity dissociated from the “top-down” influences of medial frontal cortex.

Photo by Anna Shvets

Post PubMed

Post-Traumatic Stress Disorder and Traumatic Brain Injury, TESI Statistical Analysis. Operations Iraqi and Enduring Freedom.

William Heckman — Mon, 18 Mar 2024 13:25:27 +0000

By C. Alan Hopewell, PhD, MP, ABPP, BSM, MAJ (RET) Robert Klein, PhD, CPT US Army and Michael Adams, PhD, LTC (RET)

*This is an article from the Winter 2024 issue of Combat Stress

Fort Hood is a United States Army Post located in Killeen, Texas. This post was originally named for Confederate General John Bell Hood, but has since been renamed Fort Cavazos after General Richard E. Cavazos, a native Texan and four-star general. However, since all of the research reported here was conducted at Fort Hood during the Global War on Terror (GWOT,) the name Fort Hood will be referenced. The main cantonment of Fort Hood had a total population of 53,416 as of the 2010 U.S. census and at the time of this original research, was the most populous U.S. military installation in the world.1 In April 2014, the Post’s website listed 45,414 assigned soldiers and 8,900 civilian employees covering an area of 214,000 acres (87,000 hectares).

In 2001, the War on Terror became a prime focus of post activities. Fort Hood transitioned from an open to a closed post with the help of military police from Army Reserve units. The post is also the headquarters of III Armored Corps and First Army Division West and is home to the 1st Cavalry Division and 3rd Cavalry Regiment, among others. During GWOT and the time period of research conducted, the 4th Infantry Division was also stationed at Fort Hood, making it the largest military deployment platform in the world.1 As a consequence, the outpatient psychiatry/ behavioral health operations were the largest in the world at the time. During the height of the Iraqi Surge, more than 400 Soldiers were seen or were attempted to be seen per day at the Carl R. Darnall (CRDAMC) Resilience and Restoration Center (the post outpatient clinic for psychiatry and behavioral health), more patients than were seen at the CRDAMC Emergency Department per day. During the research period reported in the article, CRDAMC was upgraded in its designation to an Army Medical Center and a special Washington D.C. commission coordinated by the senior author resulted in essentially tripling the staffing of the CRDAMC Resilience and Restoration Center.

The Resilience and Restoration Center as consolidated by COL Lorree K Sutton, Carl R. Darnall Hospital Commander.

A number of Fort Hood units were deployed to Afghanistan in support of Operation Enduring Freedom and to Iraq for Operation Iraqi Freedom during the GWOT. In December 2003, the 4th Infantry Division captured Saddam Hussein. In the spring of 2004, the 1st Cavalry Division followed the 4th Infantry Division deploying to Iraq. These divisions then generally rotated through the deployment cycle, with the Restoration and Resilience Center supporting deploying troops and aiding the returning troops with their mental health needs and re-adjustment to garrison in rotation. In 2009, Fort Carson, Colorado‘s First Army Division West re-stationed to Fort Hood in order to consolidate its mission to conduct Reserve Component mobilization training and validation for deployment, switching places with 4th Infantry Division, which then relocated to Fort Carson.

It was into this situation that the senior author reported to CRDAMC in June of 2006 and assumed the position of Officer-in Charge (OIC) of the Restoration and Resilience Center. The second author served as a Psychology Intern and the third author as Chief of Behavioral Health during this time period respectively. Half of the CRDAMC psychiatrists and psychologists were deployed during this interval, primarily with the 4th Infantry (Ivy) Division, leaving only one active-duty psychiatrist and one civilian psychiatric employee to serve all of CRDAMC, in addition to only four psychologists to cover a health care cohort of easily over 50,000.

The senior author had volunteered to return to active duty, as he was one of the only senior clinical psychologists in the United States who was both a Clinical Neuropsychologist and who also had substantial prior military experience. He was also the only Army Medical Neuropsychologist with a pharmacology degree who could manage patient medications, for which he was awarded the Bronze Star Medal after his service in Iraq. He was specifically returned to active duty as he had previously established the Traumatic Brain Injury Clinic (TBI) at Landstuhl Army Regional Hospital and was the de facto Army expert on brain injury and concussions.2 He had also been the Chief of Neuropsychological Services at Brooke Army Medical Center from 1981 through 1983 before being assigned to the Individual Ready Reserve (IRR). For these reasons, he was chosen on his return to active duty by the Vice Chief of the Joint Chiefs of Staff and the Psychology Consultant to the Army to be assigned to CRDAMC and ultimately to deploy in support of Operation Iraqi Freedom.

Upon assuming duties at CRDAMC, the Hospital Commander, COL Loree K. Sutton, requested that the senior author design and implement surveys designed to determine the mental health care needs of the garrison Soldiers and to document the need for increased mental health services. This was particularly needed in terms of the marked increase in diagnoses of post-traumatic stress disorder (PTSD) and traumatic brain injuries (TBI). As part of that request, returning Soldiers needing services were referred to the Restoration and Resilience Center for mental health treatment, most of them from the returning 4th Infantry Division. These Soldiers were thereafter systematically screened, not only for general mental health needs, but also specifically for traumatic brain injuries which were then occurring with increasing frequency in the wartime theaters as a result of improvised explosive device (IED) blast injuries.

LTC Michael Adams, COL Wilma Larsen, and COL Lorree K. Sutton presenting the senior author with an award in recognition for TBI and PTSD screening procedures.

As part of the education of CRDAMC and Restoration and Resilience Center staff at the time in regard to blast injuries / concussion or mild traumatic brain injuries / (mTBI), some of the following guidance from the Centers for Disease Control (CDC)3 were followed:

Blast Injuries: Essential Facts / Key Concepts:

Bombs and explosions can cause unique patterns of injury seldom seen outside combat.
Expect half of all initial casualties to seek medical care over a one-hour period.
Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals.

Predominant injuries involve multiple penetrating injuries and blunt trauma.
Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality.
Primary blast injuries in survivors are predominantly seen in confined space explosions.
Repeatedly examine and assess patients exposed to a blast.
All bomb events have the potential for chemical and/or radiological contamination.
Triage and lifesaving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk of exposure to caregivers is small.
Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers.
For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization should be administered (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current).

Blast Injuries

Primary: Injury from over-pressurization force (blast wave) impacting the body surface — Tympanic membrane rupture, pulmonary damage and air embolization, hollow viscous injury. (a sudden and pronounced rise in intra-abdominal pressure can rupture a hollow viscus).
Secondary: Injury from projectiles (bomb fragments, flying debris) — Penetrating trauma, fragmentation injuries, blunt trauma.
Tertiary: Injuries from displacement of victim by the blast wind — Blunt/penetrating trauma, fractures, and traumatic amputations.
Quaternary: All other injuries from the blast — Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness.

Primary Blast Injury

Lung Injury

Signs usually present at time of initial evaluation but may be delayed up to 48 hours.
Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso.
Varies from scattered petechiae to confluent hemorrhages.
Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast.
CXR: “butterfly” pattern.

High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube.3

Typical IED Blast in Iraq 2008. One of the Senior Author’s Patients Treated by the 785th Combat Stress Company, Camp Liberty, Iraq.

The Global War on Terrorism (GWOT) brought to the forefront the issue of the relation between mild traumatic brain injury (mTBI) and combat-induced post-traumatic stress disorder (PTSD). The two are related because of the similarities in how soldiers incur mTBI and/or PTSD. Soldiers are frequently exposed to concussive blasts related to improvised explosive devices. In and of itself, being exposed to an IED blast meets the Diagnostic and Statistical Manual of Mental Disorders-Fourth and Fifth Edition-Text Revised (DSM-IV- V – TR) Criterion A1 for PTSD and can potentially cause mTBI due to concussive blast. It should be noted that the DSM-IV-TR was the version of the DSM at the time of the major part of GWOT and this research. Additionally, the empirically-based published literature at the time of the screening will only be used to give the reader an understand of the state of scientific thought during the GWOT.

As a resident from 1975 – 1976, the senior author had also been the very first student and Senior Resident of Harvey Levin, PhD, who co-directed the formal traumatic brain injury (TBI) program in the Division of Neurosurgery at the University of Texas Medical Branch, Galveston (UTMB). Based upon this early work with TBI models, Levin et al. suggested that post-concussional symptoms occur along three dimensions; somatic, cognitive, and affective. Somatic symptoms include headache, dizziness, vision difficulty, and deficits in balance and motor functioning, as well as a number of additional symptoms.4 Neurocognitive sequelae consist of deficits in attention/concentration, memory, cognitive processing speed, fatigue, and impairment in both simple as well as complex reaction time.5, 6 Typical affective symptoms can include anxiety, depression, irritability and mood swings. The documentation of such symptoms by Harvey Levin and Hopewell at the UTMB – the official Traumatic Brain Injury program at the time for the State of Texas,7 led to the eventual development of the Neurobehavioral Symptom Inventory as a brief screening effort to record most of the typical symptoms associated with concussions.8

Most civilian TBI injuries are acceleration / deceleration impact inertial related such as occur in motor vehicle accidents. However, blast injuries appear to be better described as a fluid percussion model. In this regard, a fluid percussion model of brain injury is similar to an IED related concussive blast and has also been studied in animals and used to hypothesize changes in people with mTBI. “Human blast injury studies in organs other than the brain have shown that at least two atmosphere percussion waves in the fluid media of the brain can produce mTBI findings similar to findings in animal studies.”9 Over-pressure waves have been associated with producing diffuse axonal injury (DAI) via rapid acceleration and deceleration (coup-countercoup). DAI is associated with the shearing or damaging of axons that project from the brain stem. If the coup-countercoup action is severe enough it can cause a loss of consciousness (LOC). When LOC is experienced, a Soldier can further harm the brain by making significant contact with a physical object such as a weapon, vehicle structure, or the ground as he or she falls.

PTSD is amongst the most controversial diagnoses included in the DSM-IV-TR.10, 11, 12 The controversy with PTSD revolves around the boundaries of the disorder, diagnostic criteria, central assumptions, clinical utility, and prevalence in various populations.10- 12 Spitzer et al., Gold et al., and Boals and Schuettler arrived at conflicting results when looking at the importance of Criteria A1 and A2 in defining PTSD. Gold et al. reported that higher levels of PTSD symptoms were associated with non-traumatic events than traumatic events when scoring results were based on classification by coders.11 On the other hand, Boals and Schuettler found that PTSD symptoms were more associated with traumatic events than non-traumatic events when scoring results were based on participants’ ratings.12 Further Boals and Schuettler reported that Criterion A1 had a minimal relation to PTSD symptoms when A2 was considered.12 These two conflicting studies bring in to question the validity of Criteria A1 and A2 in diagnosing PTSD.

Overlapping symptoms between mTBI and PTSD can complicate the differential diagnosis process and lead clinicians to wonder whether they should ascribe a person’s clinical presentation to a diagnosis versus dually-diagnosing. The lack of agreement in the research community regarding which specific PTSD and mTBI symptoms overlap further complicates diagnosis.13,14 Defense Veterans’ Brain Injury Center (DVBIC) considers depression, anxiety, and attention difficulties as overlapping symptoms. Depression, anxiety, and sleep are non-neuropsychological overlapping symptoms of post-concussional syndrome (PCS) and PTSD that the ICD-10 and DSM-IV-TR agree upon. The Veterans Administration considers concentration difficulty, sleep difficulty, irritability, and social withdrawal as overlapping symptoms. Further complicating the differential diagnosis process is the overlapping symptoms between anxiety and major depression, which are common behavioral symptoms of mTBI and PTSD. These overlapping symptoms consist of problems with sleep, concentration, and fatigue as well as psychomotor/arousal symptoms.15 Other research suggests that irritability, attentional dysfunction, difficulty concentrating, amnesia, decreased cognitive processing, and sleep disturbances are overlapping.9,16

There are issues with accurately measuring both PTSD and mTBI primarily because symptoms are subjective, can be exaggerated, and can demonstrate considerable overlap. When a client endorses a symptom on a self-report measure it is up to the clinician to determine the etiology of the symptom. For example, if a person endorses experiencing headache, the clinician needs to determine whether the headache is tension-based (i.e., psychiatric-etiology) or is a posttraumatic headache. Just because a person has a headache does not mean it is a headache that is characteristic of a TBI and therefore, can lead to a misdiagnosis of post-concussive syndrome (PCS). In terms of PTSD symptomatology, there is little consensus regarding the best diagnostic cut scores for self-report measure and no research has been conducted to determine optimum cut scores for active-duty service members. A cut score should shed light on to the diagnostic efficiency (i.e., sensitivity and specificity, negative predictive power, and positive predictive power) of an instrument and therefore, aid the clinician in rendering a diagnosis.

Reported symptoms can also be exaggerated due to secondary gain or somatization. It is not uncommon for a soldier to report on an inventory that a symptom is severe, but further investigation reveals that it does not impact their activities of daily living. Most researchers do not conduct item analyses to determine which symptoms discriminate best between those who do and do not have a clinical diagnosis.17, 18 This is important in research when there are diagnoses that share multiple symptoms like PTSD and PCS.

At the self-report psychological instrument level, overlapping symptom between the PTSD Checklist (PCL)19 and Neurobehavioral Symptom Inventory (NSI)20, 21 includes difficulty concentrating, sleep difficulty, irritability, and forgetfulness/trouble remembering. Across cultures, all 16 items on the Rivermead (European version of the NSI) are on the NSI. Loss of balance, poor coordination, hearing difficulty, numbness/tingling, change in taste/smell, change in appetite are items that are not on the Rivermead. There is no universal agreement in the behavioral health community on the specific etiology of post-concussion symptoms in individuals with mTBI. Persistent post-concussion symptoms could be neurological, psychological, or both. The neurological side of the debate documents that post-concussion symptoms are attributed to neurological damage often associated with axonal stretching or injury. The persistence of symptoms is assumed to be due to metabolic and physiologic changes in the brain that have not returned to homeostasis.22 The psychological camp suggests that symptoms are attributed to transient physiological disturbance and are maintained by psychological distress.23, 24 Bazarian et al. showed that post-concussive symptoms are reported more by mTBI patients without positive neurological or radiological findings than patients with moderate or severe TBI.25 Research suggests that a significant risk factor for the development of PCS is three or more prior concussions, which a service member can receive via multiple combat tours.22, 26 This also means that the person has likely been exposed to more psychological trauma with increasing numbers of both combat tours and blast exposures.

Some of the variance in the literature related to post-traumatic stress and neurobehavioral symptoms is also likely due to a combination of conceptualization problems and measurement issues. As previously mentioned, there are no universally accepted diagnostic criteria for assigning a diagnosis associated with mTBI and there is no “gold standard” for post-concussive symptoms. With regards to PTSD, there is some question about whether a person needs to be conscious to develop PTSD and there is no universally accepted structure of PTSD. Some of the variance involved in the different structures may also be due to researchers using different instruments to measure PTSD (i.e. PCL and CAPS).

The VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress states that:

“Post-traumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat. It also strikes military men and women deployed in peacekeeping or humanitarian missions, responding to acts of terrorism, caught up in training accidents, or victimized by sexual trauma. Its burden may be transient or last a lifetime. The response to psychological trauma is probably as old as human nature but the diagnosis of a traumatic stress disorder is among the newest in the diagnostic catalogue. Twenty years ago, most people, including most clinicians, did not know that PTSD existed. Even among those who acknowledged PTSD, their view tended to be retrospective: PTSD planning and practice in the Departments of Defense (DoD) and Veterans Affairs (VA) centered on work with survivors of past conflicts such as Vietnam, Korea, or World War II. As DoD and VA face the challenge of a new generation of combatants and veterans, our perspective must become prospective: building on the lessons of the past and serving those in present need but also aiming at the future in order to maximize preparedness and, if possible, prevention” (2004, pg. i).27

A thorough review of the etiology, nature, effects upon the nervous system, the comorbidity of TBI, and the treatment of PTSD especially after combat is additionally provided in Moore, Hopewell, and Grossman’s book Violence and the Warrior, Living and Surviving in Harm’s Way: A Psychological Treatment Handbook for Pre- and Post-Deployment.28

A screening instrument checking for these symptoms along with the Center for Epidemiological Studies-Depression (CES-D) depression checklist29 and the Traumatic Event Sequelae Inventory (TESI)30 was used to screen Soldiers, mostly from the 4th Infantry Division, for concussion and PTSD, although a few Soldiers who were Veterans of Operation Enduring Freedom in Afghanistan were also screened. The CES-D, originally published by Radloff, is a 20-item measure that pulls for ratings as to how often over the past week symptoms associated with depression have been experienced such as restless sleep, poor appetite, and feeling lonely.29 Response options range from 0 to 3 for each item (0 = Rarely or None of the Time, 1 = Some or Little of the Time, 2 = Moderately or Much of the time, 3 = Most or Almost All the Time). Scores range from 0 to 60, with high scores indicating greater depressive symptoms.

The CES-D also provides cutoff scores (e.g., 16 or greater) that aid in identifying individuals at risk for clinical depression, with good sensitivity and specificity and high internal consistency.31 The CES-D has been used successfully across wide age ranges, is sensitive to differences between caregivers and non-caregivers, and is sensitive to changes in caregiver depressive symptoms after intervention.31, 32 Although the CES-D has somewhat different factor structures across racial and ethnic groups, it can be used appropriately with diverse caregivers.33

The Traumatic Event Sequelae Inventory (TESI) is a special psychometric instrument design to diagnose and quantify a very specific emotional and behavioral symptom spectrum most frequently reported by individuals who has been exposed to traumatic events.30 TESI was developed in 1995 as a focal component of a comprehensive multidimensional psychometric battery for assessment and quantification of emotional injury and psychiatric disability. Originally intended for the commercial market (personal injury/workers’ compensation) the first announcement of TESI appeared in the California CLAIMS Journal, Winter 1996.34 TESI has since become one of the most widely used instruments in the USA for the assessment of posttraumatic emotional and behavioral sequelae, with the military cohort screened resulting in a normative population of over 86,000 subjects. The original TESI items were selected from the actual medical records of patients diagnosed with and treated for trauma-based anxiety disorders from 37 psychiatric inpatient, residential, and outpatient health care facilities in New York, New Jersey, Pennsylvania, California, and Florida. TESI utilizes a dual scoring system, yielding diagnostic accuracy greater than 95 percent. The first system utilizes standardized t-scores developed during the initial standardization of TESI in 1996.30

The second scoring system, with Gradient Frequency Scores (GFS,) or TESI Score Levels, was empirically developed during the second standardization of TESI in 2002, based on the clinical population of 36,340 individuals who have experienced single or multiple traumas and were in treatment for related posttraumatic disorders in a variety of clinical settings. Comprehensive assessments, clinical diagnostic summaries, and psychometric data from follow up assessments were utilized in the development of the Gradient Frequency Scores. Each GFS represents a particular level of TESI raw scores at which significantly different diagnostic classifications are present at the confidence interval of .95, rendering specific interpretive clinical considerations and therapeutic interventions.

The first four GFS levels (1–4) are likely to be indicative of subsyndromal disturbances which may or may not be related to a traumatic event(s). Based on the data available from our normative samples, it was our conclusion that the diagnostic certainty at these levels is not sufficient enough to satisfy the DSM-V or ICD-10 diagnostic criteria for a posttraumatic stress disorder.

The fifth GFS level (5) may indicate a subthreshold form of PTSD, but with insufficient degree of diagnostic certainty to diagnose a full, syndromal level of the disorder. The “rule out” diagnoses at this level should be supported with the GFS scores from other TESI components used in evaluation. Diagnosis of subthreshold post-traumatic disturbances and dysfunctionality is also only possible by using combined battery scores.

The sixth GFS level ( 6) represents the average number of symptoms found among our normative sample, with a range of 1 SD of mean for clinical group and more than 3 standard deviations above mean for non-clinical group. Diagnostic formulation of posttraumatic disorders at this level must be supplemented with the results (GFS scores) from other TESI components.

The seventh and the eighth GFS levels (7 – 8) of TESI’s raw scores represent ranges of symptomatology, characteristic of our normative sample which is sufficiently wide in spectrum to suspect that scores at these levels may involve a more complex clinical picture rather than PTSD as a single, or a focal disorder, or at least a severe level of PTSD. At these levels, either significant psychopathology with etiology other than the trauma may be present. These may be concussions complicated by other medical factors. This may occur when a single concussive episode produces cognitive and affective symptoms which persist and which are influenced or exacerbated by concomitant medical factors such as serious other medical complications, such as chronic pain associated with severe orthopedic injuries, as often happens in a combat Veteran population. These complications are often also further complicated by exacerbating emotional disorders which act as moderating variables. At this level, many concussion survivors demonstrate multifactorial difficulties. In some cases, the presence of self-deception, intentional symptom exaggeration, factitious disorders, malingering, or conscious engagement in cost benefit analysis of injury and its sequelae may be present and must be distinguished from actual injury levels.

Primary Disturbances (PD):

Initial post-traumatic disturbances reported in primary care: Somatic Disturbances, Affective Disturbances, Cognitive Disturbances, Behavioral Disturbances, Marital Disturbances, Occupational Disturbances, Disturbances of General Functionality, Psychomotor Acceleration, Psychomotor retardation, Fear, Dissociative Experiences and Hypervigilance.

Systemic Disturbances (SD):

Systemic Disturbances are disorders diagnosed by various clinical and laboratory methods such as: Cardiological Disturbances, Musculoskeletal Disturbances, Hematological Disturbances, Metabolic Disturbances, Endocrine Disturbances, Gastrointestinal Disturbances, Neurological Disturbances.

Clinical Impairments (CI):

Clinical impairments include subsyndromal, subthreshold, or syndromal short, intermediate, and long-term posttraumatic manifestations of physiological, cognitive, psychological, and environmental disturbances present during the entire duration of trauma integration, synthesis, and diffusion. Some domains of impairments may persist in form of residuals of the integration process, subsequent constitutional vulnerabilities to re-traumatization, or factors rising various disturbances to levels of permanent and stationary disabilities.

TESI Varimax Factors (F):

Individual TESI items (1-39) were factor analyzed to determine which items clustered together in a discernible structure. Given that, by definition, the structure of typical PTSD symptoms is not meaningful for those who do not have the disorder, but only the clinical sample was used in this analysis. Principal components analysis using varimax rotation yielded eight factors with eigenvalues of 1.0 or higher. Factor 1 (eigenvalue=9.19) accounted for 23 percent of the variance. Factor 2 (eigenvalue = 1.99) explained 5 percent of the variance. The remaining factors yielded figures as follows: Factor 3 (eigenvalue =1.44) 3.7 percent; Factor 4 (eigenvalue 1.27) 3.3 percent; Factor 5 (eigenvalue = 1.2) 3 percent; Factor 6 (eigenvalue = 1.1) 2.9 percent; Factor 7 (eigenvalue= 1.1) 2.7 percent; and Factor 8 (eigenvalue 1.0) 2.6 percent. The entire analysis thus accounted for 46.8 percent of the variance. Underlying concepts for these factors might be described as follows:

Factor 1 might best be described as detachment & loss of control;

Factor 2 relates to impaired cognitive abilities;

Factor 3 can be termed physical complaints, primarily related to digestive processes;

Factor 4 captures physical complaints primarily related to anxiety & stress;

Factor 5 taps into ruminations and related dysfunction;

Factor 6 taps into anger and frustration;

Factor 7 relates to psychomotor agitation;

Factor 8 can be labeled “marital problems.”

Overall, the factor structure supports TESI as an instrument which incorporates dimensions relevant to the diagnosis of PTSD. Given the differences in TESI item responses between gender and ethnic groups within the clinical sample, principal component analysis was also repeated separately for each ethnic and gender group. Results indicate that that TESI’s factor structure differs somewhat among these sub-samples. For each group, 9 factors with eigenvalues above 1.0 were derived. Principal component analysis with African Americans accounted for 50.34 percent of the variance. For Latinos, the analysis, accounting for 50.06 percent of the variance. When the analysis included only non-Latino Whites, it accounted for 53.75 percent of the variance. For women, the analysis accounting for 56 percent of the variance. Finally, principal component analysis including only men accounted for 57.6 percent of the variance.

One thousand two hundred and fifteen (1,215) combat Veteran Soldiers were screened with TESI and the CES-D at Carl R. Darnall Army Medical Center, Ft. Hood, Texas, upon their return from a combat deployment to Iraq in support of Operation Iraqi Freedom.35 Most returning Soldiers were from a returning combat infantry unit that was engaged in some of the heaviest fighting in Iraq prior to the successful Surge, although a few were returning Operation Enduring Freedom Veterans. The screenings were done after initial Post-Deployment Health screenings mandated referral to the Resilience and Restoration Center at Darnall Army Medical Center, the outpatient clinic of the Department of Psychiatry and Behavioral Health. The screenings were accomplished in 2007, a time when the Department of Psychiatry and Behavioral Health at Darnall Army Medical Center operated essentially the largest outpatient psychiatry clinic in the world.

The screenings included 966 males and 249 females ranging in age from 18 to 59 years of age.35 104 of the Soldiers were documented to have blast related concussions in addition to a range of psychiatric co-morbid disorders, to include post-traumatic stress disorder (PTSD). Ninety-seven (97) concussed Soldiers were male and seven were female. Verimax factor analyses documented psychiatric factors demonstrated by the Soldiers, with an analysis of combined PTSD and concussion symptoms, comparing Soldiers with and without concussion. Degrees of primary disturbances generally ranged from a low of 33 percent to a high of 68 percent for the sample. The severity of PTSD and concussion injuries, clinical considerations, and varimax factors are discussed. Some of the major findings in terms of demographic composition, TESI scores, and GFS levels are presented below.

Population groups included Anglo/Caucasian, African Americans, Latinos, and Asians, both male and female. Ages ranged from 19 to 59 years of age with mean ages from 24 to 28 years of age, partly as older Reservists had returned to active duty for GWOT. The modal educational level was 12 years. Mean GFS levels ranged from 5.7 for non-injured, non-concussed Soldiers to 6.4 for combat Veterans with injuries and concussions. Caucasians accounted for 64.42 percent of those screened, African Americans for 13.46 percent, Latinos for 11.54 percent, Asians for 1.92 percent, and “Others” for 6.73 percent. Only three of the concussed group had no combat exposure, presumably being injured during non-combat duties. Individuals with concussion scored an average GFS level of 6.4, while Soldiers without concussion scored an average GFS level of only 5.8. The presence of concussion therefore raised the GFS by one level, obviously complicating the underlying PTSD symptoms. This means that in addition to probable PTSD, concussion will substantially increase the comorbidity of damage to the individual injured Soldier. Females also scored higher at a GFS of 6.1, while males scored at the lower GFS level of 5.8, this being consistent with literature indicating that females often experience PTSD at higher or more severe levels than do males.

While primary disturbances ranged from affective to somatic disturbances, those which appeared to affect both the injured as well as the concussed cohorts were those of psychomotor retardation, with fear and affective disturbances interestingly being less problematic. Systemic disturbances for the injured as well as the concussed cohorts were those of musculoskeletal and endocrinological and neurological, respectively, with this being consistent with the conceptualization and likely sequelae of these injuries. Degrees of impairment for the injured as well as the concussed cohorts included communication problems for the former and concentration deficits for the latter, again being consistent with the conceptualization and likely sequelae of these injuries.

As previously noted, the fifth GFS level indicates significant psychiatric disturbance, and may indicate a subthreshold form of PTSD, but with insufficient degree of diagnostic certainty to diagnose a full, syndromal level of the disorder. The “rule out” diagnoses at this level should be supported with the GFS scores from other TESI components used in evaluation and from possibly other evaluations. In an extremely busy military practice with over 400 patient consults a day, Soldiers scoring at this GFS level on TESI could be “triaged” for further PTSD examination. Therefore, the cut off level of the fifth GFS level proved to be very important, as Soldiers scoring less than this could be put more on a regular treatment schedule, while Soldiers scoring 5 or more could be expedited for further and more thorough evaluation.

Soldiers with concussion scoring at the sixth GFS level, could also be expedited for assessment, with additional focus on the TBI aspects of their injury, aspects which, for example, could involve substantially different medication treatment such as for headache, the single most frequent symptoms seen after concussion. Identifying such patients meant that they could be routed much more quickly to Advance Practice Nurses and Physicians’ Assistants to initiate such treatment quickly. Recognizing the intersection and overlap of PTSD and TBI symptoms, as well as which symptoms remain unique to each disorder also proved critical in the appropriate treatment responses to these injuries. Results were also consolidated into briefings for the combat units pending further deployments, such as the following briefings given by the senior author to the 4th Infantry Division.

Upon completion of this project, the senior author was designated both OIC of the newly formed CRDAMC Traumatic Brain Injury Clinic and was also named liaison Officer between CRDAMC and the Defense Veterans’ Brain Injury Center (DVBIC). DVBIC serves active-duty military, their beneficiaries, and veterans with traumatic brain injury through state-of-the-science clinical care, innovative clinical research initiatives and educational programs, and support for force health protection services. DVBIC was the TBI operational component of the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury and has since been rebranded as the TBI Center of Excellence. The third author was assigned to duties at the newly formed Triage Center for the R&R Clinic, where he oversaw the screening and triage of hundreds of injured Soldiers. Over the next six years, all authors assisted in the management of the CRDAMC Traumatic Brain Injury Clinic and the R&R as well as the ongoing collection of further research data related to TBI. These findings were eventually incorporated into treatment protocols for injured Soldiers, and contributed to the eventual writing of the VA/DoD Clinical Practice Guideline For Management Of Concussion/ Mild Traumatic Brain Injury,27 the official guidelines for the diagnosis and management of TBI for the military,36 and motor vehicle operations guidelines after TBI injury for the military.37 The Clinic founded by the authors eventually developed into the National Intrepid Center of Excellence located at Carl R. Darnall Army Medical Center, a far cry from screening re-deploying Soldiers in the waiting room of the “old Restoration and Resilience building!”

The National Intrepid Center of Excellence Satellite Center at Fort Hood opened its doors to patients for the first time Jan. 11, 2016, moving from the senior author’s modular buildings and ushering in a new era of care on Post. The 25,000-square-foot facility includes state-of-the-art technology, a fully functioning gym, a yoga and meditation area, group session rooms, and an outdoor patio. The staff of health care and mental health professionals was reinvigorated after the Hasan attacks by the senior author. The Center continues to offer the same multidisciplinary, holistic approach to treating TBI, PTSD and other conditions as when it was initially founded by the senior author, these indications of excellence not having changed.

The National Intrepid Center of Excellence Satellite Center at Fort Hood is now the fifth of its kind on military installations across the country, all part of a joint effort by the government and the private sector.

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ABOUT THE AUTHOR

Dr. Alan Hopewell holds four degrees and four foreign language certifications, to include his BS, MS and PhD in Clinical Psychology and a second Master of Science Degree in Clinical Psychopharmacology.

He received his formal Clinical Neuropsychological training during his residency at the University of Texas Medical Branch in Galveston in the Division of Neurosurgery where he was the very first student of Harvey Levin, PhD, ABPP.

Dr. Hopewell was commissioned upon his graduation from the Texas A&M Corps of Cadets. He has served as Chief of Psychology Service at Landstuhl Army Regional Medical Center, where he founded the initial Traumatic Brain Injury Laboratory and at Brooke Army Medical Center, among others. He was the first Army Officer Prescribing Psychologist to serve and to practice in a Combat Theater, where he was awarded the Bronze Star Medal for meritorious service during Operation Iraqi Freedom. He was subsequently awarded a Meritorious Service Medal as he was a primary target during the Ft. Hood Jihadist Terrorist attack by his colleague, Nidal Hasan.

A former president of the Texas Psychological Association, he was also Awarded the Texas Psychological Association Award as the Outstanding Clinical Neuropsychologist in Texas.  

He is currently Assistant Professor of Psychiatry and Behavioral Medicine, University of North Texas Health Science Center and maintains his practice in Fort Worth. He has been married for 48 years, has two sons, and is just now expecting his first grandson. His father, LTC Clifford Hopewell, a B-17 navigator prisoner of war, was the stenographer for the infamous Stalag Luft III prison camp in Germany (The Great Escape).

Based upon his combat service and as a prescribing psychologist, he was awarded one of the highest honors of the American Psychological Association, being elected a Fellow of the APA. He is currently an Assistant Professor of Psychiatry and Behavioral Medicine at the University of North Texas Health Science Center.

Dr. Robert Klein is a former Army psychologist with a PhD in clinical psychology. He is currently in private practice and conducts research involving active-duty military personnel and Veterans. His research publications and professional presentations focus on statistics and neuropsychology. Prior to becoming a psychologist, he was an US Army Airborne Ranger and qualified Infantryman. During his infantry time, he served on the Korean DMZ. Dr. Klein is also an OIF II Veteran.

Michael L. Adams, PhD, LTC (RET) – I was born into a military family. My paternal grandfather was a Soldier in the Army of the Czar of Russia. He and my grandmother escaped from the old country by hiding in a hay wagon. He bribed the guards to miss them when the guards stabbed the hay with bayonets. They emigrated to America around the turn of the last century. My father was born in the United States of America. When he was fifteen, he came home from school to learn his last name had been legally changed from Abramov to Adams. As a child, he remembered folding bandages for wounded Soldiers from WW I. When he was in college, he joined ROTC. He attended law school and undergraduate college simultaneously, graduating with a law degree before he graduated with his undergraduate degree. When WW II began, he commanded a coast artillery battery and later went to Europe as an intelligence officer. While in Europe, he was blown up in the air by a V-1 bomb. He flew on missions with B-17 bomber crews and had shrapnel pierce his helmet and travel around inside it, while missing his skull. He never talked much about his experiences, especially during the Korean War.

On my mother’s side of the family, I know one uncle served in WW II. He fought in the Pacific and was affected by night hand to hand combat with Japanese soldiers. He told me how to fight with a knife as he had done.

I was the middle child of three. With a family background of military service, I was expected to join the military. In college I joined Air Force ROTC just as my brother had before me. I graduated with designation Distinguished Military Graduate in 1966. I entered active duty in January 1968 and was ordered to Intelligence Officer School, where I was invited to accompany the commander to Southeast Asia. I was stationed in Thailand where I was part of electronic interdiction of traffic on the Ho Chi Minh Trail, which extended from North Vietnam through Laos to South Vietnam. This was the main route of people and supplies for the communists. We were operating in real time ambushing enemy convoys and people as they travelled south. I also joined a flying unit, the Airborne Battlefield Command and Control Squadron and flew about 800 hours of combat. I provided support for our allies on the ground in Laos.

After my time in the war, I was assigned to Strategic Air Command (SAC). I became Officer in Command (OIC) of a cartographic section making air target charts. There were about 25 people in my section. I re-organized us so each of the senior sergeants was able to step up and run the section. There were no vital individuals whose absence would cause work to stop. There were just two ways to leave SAC – either leave the Air Force or die. I left and went to graduate school to study psychology. I was told the Army would pay me to go to school, so I applied and was one of fifteen people that year to become Army graduate students.

My first assignment was to the Academy of Health Sciences as an instructor. I created some instructional materials about human development before there were any textbooks that I could find. I also helped create a course to lower stress in nursing anesthetist officers. I taught assertiveness to Army nurses. I went to William Beaumont Army Medical Center for internship after two years at the Academy.

The internship is where we began to identify what became called post-traumatic stress disorder (PTSD) in Soldiers who had been in combat in Vietnam. We began to develop treatments to restore the Soldiers to full functioning. This was a lot harder back then because we did not grasp the complexity of the condition. Sometimes experts were brought to the Internship to educate us. I remember well that the chief of psychiatry from the Israeli Army spoke to us about the Six Day War and how quickly PTSD developed as well as what they did to reduce PTSD. We were astonished and asked how they developed the treatment. He looked puzzled and then told us the Israeli mental health people copied our procedures from the Korean War. None of us knew of the Korean War procedures. By the time of the Vietnam War, we had forgotten our own history.

My next assignment was to Combat Developments at Fort Benjamin Harrison. The most important contribution there was when I became curious about continuous operations. I reviewed twenty years of research in continuous operations and reduced it to two paragraphs for a General Officer talking paper. After it was presented at a conference, changes were made so that our Soldiers would have enough water to drink. Another doctrine change was about how often to drink water. These changes allowed our Soldiers to fight in the Gulf War in 1991 for longer than 45 minutes, which is how long the fight could go on under the previous doctrine of water conservation.

From Combat Development, I was assigned as the Division Psychologist for the 25th Infantry Division. There we noticed that whenever deploying Soldiers were boarding aircraft to go to South Korea for an exercise, some Soldiers would get to the bottom of the aircraft ramp, suddenly drop their packs and rifles, and RUN AWAY. Looking further, we found ALL of them were Vietnam Combat Veterans. We were able to get their commanders to send them to Mental Health for help instead of punishing these Soldiers. We stayed busy. I also wrote a proposal for computer communication between the medical center and our mental health at Schofield Barracks in Hawaii so we could ensure continuity of care. Prior to that, Soldiers would be discharged from psychiatry and returned to their units, with no follow up at all.

From Schofield Barracks I moved to Fort Hood’s Carl R Darnall Army Community Hospital to the Department of Psychiatry. I left active duty and became a school psychologist for the Copperas Cove School District in Texas. There I developed an autism assessment team and also maintained the functioning of three self-contained classrooms for children with severe behavioral problems. I stayed there for seven and a half years and until being called back to active duty for Operation Desert Storm. I stayed with the Army hospital for most of the next 19 years, treating many more Soldiers who had deployed to the wartime theater and their family members. At the age of 60, I retired from the Army, but returned as a volunteer for three more years in 2005, serving as chief of the Department of Psychology and chief of the combined departments of behavioral health. This included departments of psychiatry, psychology, social work, and substance abuse treatment. This was an exciting time for high-speed change. My life became more intense after former Major Hasan massacred 14 people at Fort Hood on 5 November 2009. I estimate I treated over 4,000 Soldiers for PTSD from 1978 until I finally retired in 2015.

Combat Stress Magazine

Combat Stress magazine is written with our military Service Members, Veterans, first responders, and their families in mind. We want all of our members and guests to find contentment in their lives by learning about stress management and finding what works best for each of them. Stress is unavoidable and comes in many shapes and sizes. It can even be considered a part of who we are. Being in a state of peaceful happiness may seem like a lofty goal but harnessing your stress in a positive way makes it obtainable. Serving in the military or being a police officer, firefighter or paramedic brings unique challenges and some extraordinarily bad days. The American Institute of Stress is dedicated to helping you, our Heroes and their families, cope with and heal your mind and body from the stress associated with your careers and sacrifices.