Veteran PTSD: The Tension Between De-Stigmatization and Mis-Diagnosis

by by Simon Van Zuylen-Wood

illustration by by Robert Sandler

In 2003, after 15 years of non-combat duty for the Rhode Island National Guard, Vinnie Scirocco was giddy about his deployment to an army base in Iraq. Three months later, without seeing action, Scirocco was physically injured and given honorable discharge. “I didn’t feel like I completed my mission,” said Scirocco, now the State Commander of the Veterans of Foreign Wars (VFW). “To the day I die I will probably always feel that way. No pill, no conversation with anyone at any educational level can change that.” In 2010, after six years of road rage and constant guilt Scirocco checked himself into the Veteran’s Affairs Hospital in Providence and was diagnosed with Post-Traumatic Stress Disorder (PTSD).

A childhood friend of Scirocco’s, who was deployed at the same time but remained in Iraq longer, developed PTSD shortly after Vinnie’s discharge, after shooting and killing a baby girl. He was a gunner on a Humvee that patrolled the streets of Baghdad, where civilian vehicles are not allowed to pass military vehicles. A man desperately trying to get to a hospital chanced it and passed the Humvee. Scirocco explained the aftermath: “So he shot at the car. What you hope to do is shoot in between the husband and the wife. You didn’t want to shoot at anybody…Well, there was a little girl in the backseat who got shot and killed. This friend of mine, he’s a father. He’ll never be the same—no matter how many times I tell him, ‘It’s not your fault; you had to do that,’ he’ll always feel guilty for that—he can’t take that bullet back.”

Both Scirocco and his friend undergo therapy and take medication for PTSD. They’re both saddled with a heavy, inextinguishable guilt. But one of them experienced combat-related trauma, and the other didn't. The problem with diagnosing PTSD when no identifiable trauma has occurred is not necessarily that veterans will be getting benefits they don’t deserve, but that the misdiagnosis can lead to a dangerous reliance on prescription drugs, or an overestimation of mental health problems.

An April 2009 Scientific American article by David Dobbs reported a study by Harvard Psychiatrist Alexander Bodkin that found the PTSD rate among a test group had "zero relation to the trauma rate," using common standards of diagnosis.

This happens all the time in the military, according to Dobbs, because it's extremely easy to claim that one's PTSD symptoms are "service connected." Over half of veterans currently receiving medical benefits from the VA have been diagnosed with PTSD. Dobbs found that until veterans get themselves declared 100% disabled, their use of VA psychological services is steady. After they get to 100%, when they can be assured of lifetime disability payments and drug prescriptions, their use of VA services decreases by 82%.

This may explain a rise in prescription drug dependency. A December 2009 study by the Pentagon found that regular abuse of prescription drugs in the Army and the Marine Corps had increased from 10% to 22% between 2005 and 2008.

The most promising recent effort to suss out the validity of PTSD claims was quashed in 2008. For several months, PTSD-czar General Peter Chiarelli had been openly contemplating an internal review of all of the VA's PTSD cases, under suspicion that disability benefits were being abused. Under intense pressure from the VFW and other veterans groups, he backtracked and abandoned his plans in the summer of 2008. The decision was met with widespread approval by the veteran's community, but its long-term effects may be deleterious both for the VA and for veterans.

In 2010, the Army removed another barrier to PTSD diagnosis, making it possible to get treated without demonstrating that the trauma had occurred in the line of fire, a move that may cost the VA up to $5 billion. That same year, confirming what was already suspected, Chiarelli filed a report that found an unequivocal link between army suicides prescription drug abuse.

PTSD's implied emphasis on outside trauma rather than manufactured neurosis has done much to de-stigmatize the admission of mental illness among soldiers. The recent James Gandolfini-produced documentary Wartorn: 1861-2010 drew considerable praise for doing just that. The more PTSD is de-stigmatized, the argument goes, the more active soldiers and veterans will feel comfortable seeking psychiatric help. Then, perhaps, the Army suicide rate—which in 2010 surpassed the civilian one for the first time—might start decreasing. But a study of four Rhode Island veterans reveals that guilt over not serving was equally responsible for PTSD diagnosis as actual trauma sustained while in battle. The prevalent blanket-diagnosis of PTSD for veterans suffering from guilt, from routine depression, or from Traumatic Brain Injuries (TBI), may lead to an upsurge in suicides--if patients without PTSD are being treated for PTSD, it's unlikely their problems will get solved.

Dr. Tracie Shea, a psychologist who works with PTSD patients at Veterans’ Affairs Medical Center (VAMC) in Providence suggests there’s a fundamental difference between a veteran’s and a civilian’s PTSD. “I’ve certainly seen cases in which people feel less bothered by the memories. They can manage it better, their quality of life is better,” Dr. Shea says. After administering group therapy, Shea asks the veterans what they found most helpful. “They always say ‘to be with people they… can understand and connect with.’ But once they leave here, it’s back out in the cold world, the disconnective world.” The disconnect in question is not simply between PTSD and non-PTSD, but military and civilian.

In other words, there's often a harsh irony in the case of veterans with PTSD: the safe return to civilian life can be more debilitating than active duty. The pace of life is slow and unregimented; the concerns of others—a flat tire, a long line at the grocery store—seem absurd.

A Fall 2010 study published in the journal Aggressive Behavior found that stressors both related and unrelated to battle were equally responsible for anti-social, violent behavior among US Marines. “Boredom or monotony” and “concerns or problems back home” were two of the leading complaints cited.

A Rhode Island ROTC soldier ("John Smith") who spoke on condition of anonymity, says that when soldiers return home they often find it impossible to recreate the camaraderie they experienced in the course of duty. It’s also off-duty where they begin to confront their agency in battle. “It’s not ‘til afterwards that you realized that the person you shot down had a wife and a kid,“ Smith says. “You’re lookin’ through your scope, you get the order and you do it. I think that’s a big thing with it. You [come] back and you see somebody freaking out or really upset over something very, very trivial.”

Two local Vietnam veterans exhibit precisely these symptoms. One suffered his PTSD in the course of battle, the other didn't.

64-year-old North Providence resident Armand Briere, said the day he came home from Vietnam in July 1968 was the happiest of his life. Yet Briere self-medicated with hard drugs he picked up overseas, and overdosed several times. Though he reveals no desire to go back to war, he found himself re-engaging in a brutal, death-defying military consciousness, both inadvertently and on purpose. The heroin he took, he said, was like “dying and coming back.” The only work he liked doing—until his body gave out on him—was physically exhausting, and he has chronic carpal tunnel syndrome to show for it. Flashbacks have lodged themselves in his mind inexorably--he's dreamed of fallen soldiers every night for forty years.

Fellow Vietnam vet Roseanna Evans has the same diagnosis and experiences similar symptoms—like embarrassing duck-and-cover reactions to fireworks and periodic outbursts of public violence. But these symptoms materialized during the Gulf War, after she already had PTSD from Vietnam. Though no less serious, her initial PTSD was not suffered in combat, but on an army base in Oakland, California.

Evans, who is 60, grew up in a military family stationed in Newport, Rhode Island. It had been her dream since childhood to serve in the Air Force. Deemed too light at 100 pounds, she instead took up with the Army and was sent to Oakland, California in 1969. In the politically-charged Bay Area, Evans was vilified. “They asked the women to march in the parade. We got bombarded by bags of defecation, we got bottles of urine thrown on us, we got spit at, we had bricks… thrown at us. And then we was called out—our names, we were told we were either gay or prostitutes. At the age of 18 that’s kind of hard to deal with.” Throughout the 70s, on reserve duty, Evans was periodically homeless in Oakland, sleeping on park benches. In 1970 she became pregnant from a rape by a fellow soldier on the base.

Evans developed a crippling guilt complex later that year. “I was supposed to go over to Vietnam and do the desertion forms—that was my job. [If you were] pregnant, they would not send you over. I had to train to this kid and he took my place. When Saigon got hit—he got blown.” After an explosion on a military base in Kuwait during her National Guard service in the Gulf War, images of Saigon—which she never actually saw—flooded back.

Neither of Evans' traumas were sustained in battle, but they were a direct result of war-time circumstances. When Evans cries, she says it’s not about the rape, but about her pregnancy, which she holds responsible for another man’s death. Like Vinnie Scirocco, she was blocked from active duty, and felt she hadn’t served her country. That’s why in 1990, once her children were old enough to be on their own, Evans re-enlisted to serve in the Gulf war with the National Guard. Only after her return from Kuwait, however, was she diagnosed with PTSD. Today, if Evans had undergone the trauma she suffered in Oakland, she would have been eligible for PTSD benefits immediately, thanks to the 2010 policy which allowed non-combat veterans disability eligibility.

While cases like Evans’ underscore why this policy might be a good one, they raise the question: what exactly constitutes PTSD? If Scirocco got PTSD in Iraq, surrounded by war, but not because of a traumatic event, and Evans got it on a military base in Oakland, but because of a series of traumas, do they really have the same illness as one another? Or as Armand Briere, who suffers bloody flashbacks every day?

A 2006 RAND study of PTSD incidence identified 18 different criteria for PTSD and found that the percentages of afflicted veterans changed considerably when they applied different definitions to the same samples. The official DSM IV definition is vague, but emphasizes three main criteria that skeptics say are easy to fake: 1. The subject must be exposed to a traumatic stressor in which the subject or someone close to the subject is put in peril. 2. The subject’s reaction to this stressor must be fear. 3. The subject must re-experience the traumatic event and avoid stimuli associated with the event.

California-based researcher Dr. Paula Caplan argues that veterans shouldn't be diagnosed with PTSD at all. Caplan, who has a forthcoming book on the misdiagnosis of PTSD among veterans, argues that the PTSD label “pathologizes” and further stigmatizes veterans’ mental problems, which she says are a normal reaction to war. “We should never say that because somebody is traumatized by war [they have PTSD],” Caplan says. “We shouldn’t use that term. We should say they are traumatized by war.”

Caplan argument that PTSD is essentially a normal reaction to an extremely unnatural set of circumstances has its flaws--it implies those veterans that aren’t diagnosed with PTSD are somehow abnormal. And by extension, it might suggest that veterans like Scirocco and Evans who are haunted by their inability to fight for their country, are the deranged ones, while those who wouldn’t dream of going back, like Briere, are better adjusted.

Going back, it turns, out is one of the most common impulses among veterans, especially those diagnosed with PTSD.

Couched in a veteran’s inability to readjust to civilian life are two primary impulses. One is to seek out those who can relate. The other is to once again serve their country in a meaningful way. For many veterans, serving in battle carries with it infinitely more significance than staying home and getting a part-time job, or even taking care of their own children.

Providence VAMC psychologist Dr. William Unger notes two factors in particular that make some veterans with PTSD want to go back to war. “Guys leave with a snapshot of their life—but what happens when they’re gone? Babies are born, kids learn to drive, wife gets a new job, these are all good things, but they don’t fit the picture you had when you left,” Unger says. Second, many patients, numbed and unable to love their families again, yearn to reunite with their comrades. “They’re closer to [their comrades] than anyone else. Guys often talk about going back because they left their buddies.”

Others, like Evans, were desperate to return to war out of sense of national duty, even when it was an abject impossibility. “When 9/11 hit I wanted to go back to war, but because of my mental and physical state I was told I couldn’t,” Evans said.

Scirocco is still tormented by his discharge. “I was injured and I couldn’t go back. I guess that’s kind of why I volunteer with the VFW,” Scirocco said. “For me that’s a way of being able to give back. But I’ve realized I think the one thing that my comrades in the VFW share is that when we raised our hand for our country…that commitment didn’t end with our service.”

Other able veterans who want to re-enlist after being diagnosed with PTSD are usually not prevented from doing so, though many have also been discharged immediately. Dr. Shea says many veterans are extremely happy to return to combat for second deployment and often report better second experiences after clinical treatment in between deployments. Nevertheless, Shea adds that “there is evidence to suggest the effect of this stuff is cumulative, depending on the amount of exposure they get with subsequent deployments.”

Today’s soldiers returning from the Middle East are more frequently diagnosed upon discharge than any previous generation of American soldiers since PTSD was introduced to the DSM-III in 1980. Part of this increase is due to better reporting methods. All members of the military must check in with a VA specialist immediately upon return from duty. Members of the National Guard do the same, and then again at 30, 60, and 90 days after their tour of duty is complete. But as Rhode Island National Guard Press liason, Lt. Col. Denis Riel notes, “The issue is [what happens] once that process ends—a lot of PTSD symptoms don’t manifest for months, if not years.”

Another reason for high incidence of PTSD is that a higher number of citizen soldiers—National Guard and Army Reserves—is deploying than ever before. National Guard soldiers, who have much less training and are less equipped for battle, must return home two weekends a year and make a rapid readjustment rather than live on the army base. In January, the Army revealed that half of this year’s soldier suicides were committed by National Guard soldiers, though they make up only 20 percent of the total pool. 145 National Guard troops killed themselves in 2010, compared to 65 in 2009. In 2010, 156 full time soldiers committed suicide while on active duty; 162 did in 2009.

It should come as no surprise that the National Guard doesn’t exactly tout PTSD statistics to potential recruits either. When I went in for a routine recruiting interview the officer did not mention PTSD of his own accord. When I asked if it was something to worry about, he admitted it was, but that a lot of soldiers “faked it” in order to get medical leave.

But even soldiers aware of the risks of PTSD are unlikely to be deterred from service. ROTC soldier John Smith said that “When you raise your right hand and swear to defend the constitution of the United States against enemies foreign and domestic, PTSD isn’t really on your mind.” Moreover, he adds, the soldier's primary responsibility is to those who are serving, not oneself.

“It’s really difficult to say ‘Hey Commander, I have PTSD, I need help, and I’m not going to deploy.’ Your buddy who you fought with six months earlier who might have saved your life and you might have saved his life—[he’s] going back. Your obligation and your affection and your love for those people is pretty much [more important than] some issues you might have.”

East Providence resident Amanda Octeau, 29, served in Iraq with the Army for several years. After four years of treatment for PTSD, she is again ready to resume classes at the University of Rhode Island, where she double majors in psychology and biology. Despite having studied PTSD in her coursework before she enlisted, Octeau was not deterred from service. She recognized the symptoms of PTSD in herself, but she denied herself treatment, out of a desire to be a “superwoman” and a reluctance to stop her service.

Octeau adds that although the military leadership has made it easier and less embarrassing for veterans to seek mental health, an admission of PTSD can hurt one’s job prospects in the military. “I think people are trying to impress their higher command,” Octeau says. “It is very competitive…. Even if your commander seems nice, it might affect [your] job down the road.” A 2010 report by The Nation found that between 2005 and 2007 1,000 soldiers were dismissed for having PTSD--some of them misdiagnosed.

The unwelcome result has been that many with PTSD in the army don't tell anyone, while many veterans without it may be overemphasizing symptoms in order to claim benefits.

Drugs for anxiety and sleep deprivation, anger management counseling, “cognitive behavioral therapy” to reinforce positive association—all of these measures have proven effective in correcting erratic behavioral patterns among PTSD patients. Perhaps impossible to improve, however, is a marked inability upon discharge to re-adjust to the routines of civilian life, which leaves veterans treading a line between wanting to die and wanting to re-engage a military ethos through violence, high-risk behavior, or rigorously oppressive work ethics. This instinct doesn't always derive from PTSD but its outward symptoms usually get diagnosed as if it did.

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Much is made of the usefulness of the PTSD diagnosis, compared to "shell shock" and "battle fatigue," the terms commonly used in the First and Second World Wars. Though these definitions were limited from a clinical perspective, they presciently associated a veteran's mental deterioration with war itself, as a life-altering experience. With veteran and army suicides increasing as help for PTSD increases, it's beginning to look like it may be impossible in some cases to fully rehabilitate some veterans.

After spending several minutes going over all of the VA's most advanced techniques for treating trauma, Lt. Col. Ries paused and expressed an oddly forlorn regret that veterans had to be exposed to war at all. "A lot of this stems back to [the fact that] we're engaged in a full spectrum war," he said. "Political reasons aside--should we be there, shouldn't we be there--unfortunately, the government of the United States has decided to employ a military response [in Iraq and Afghanistan]."

There's no undoing that, but a full-scale review of PTSD patients would almost certainly lead to a scaling back of benefits, many of which have proven counter-productive to the basic aims of the de-stigmatization--to get patients to talk out their problems, rather than depend on drugs and engage in dangerous behavior.