Post-Deployment Syndrome: The Illness of War

David X. Cifu, MD and Cory Blake, Demos Medical Publishing
Post-Deployment Syndrome: The Illness of War

This is Chapter Two from Overcoming Post-Deployment Syndrome: A six step mission to health.

Setting the Stage

Military researchers have reported that nearly one in five of the more than two million U.S. service members who have been deployed to either Iraq or Afghanistan have returned with an array of signs and symptoms that we are now calling post-deployment syndrome (or PDS). These official, conservative estimates confirm that at least 400,000 U.S. troops have been impacted with PDS. You may have seen terms like traumatic brain injury, polytrauma, combat stress, blast injury, post-traumatic stress disorder (PTSD), post-concussive syndrome, or other names, but each of these fi ts into the spectrum of symptoms called PDS. Four hundred thousand previously healthy young men and women now live with a range of signs and symptoms that, at times, causes them to be completely disabled or to suffer so much that they even may take their own lives.

Although this number may seem staggering, as we’ll see, it’s actually just the tip of the iceberg. PDS affects not just these service members, reservists, National Guardsmen, and Veterans, but also their friends, family members, employers, communities, and even the very health care workers who are desperately trying to help them. Amazingly, despite how common this syndrome is, it still remains challenging to fully defi ne and understand. Here’s how one Iraq War Veteran who is trying to get help for his PDS describes his feelings:

I wish I was back in Iraq. People don’t understand, but it’s just what we do. I’m a marine, not a patient. I remember when I fi rst got there. I was so strong. It was intense. In Faluja we were kickin’ ass. We were total warriors. I had no idea it would be this hard when I got back. As hard as the 15 months in Iraq were they don’t compare with how hard it is to be back here. I spent eight months at Walter Reed. That was a couple of years ago now. The way I feel now . . . everything’s a pain. My back is killing me. I wonder if I’m ever gonna really walk right again. These headaches won’t let up. Everywhere I go the lights are way too bright; and I can’t stand being around people, they’re constantly staring at me. These meds just wipe me out. I don’t feel right. I just feel like sleeping, but with the meds I can’t wake up and without them I can’t get to sleep, and when I can my dreams are horrible, mostly about that kid. I can’t concentrate, and I can’t remember anything. I can barely play video games. And trying to play bass just bums me out, my hearing’s all messed up. My parents, and Jill, and those doctors: they don’t have clue. I feel better when I’m hanging with Jason and Sean. They were there. But my body feels like shit, my mind feels like shit, and my heart feels like shit. I even look like shit. How can that really be my eye? When will it all go away? I can’t get Will’s getting blown up out of my head. And now they are telling me that along with this brain injury, I’ve got PTSD, too. I wish I was back in Iraq. I gotta buck up. Fuck it.

How could such a level of suffering and angst have come out of the very mission that this Marine had exquisitely trained to be in? Where has PDS come from? The two wars that have ensued from the September 11, 2001 attacks on New York’s Twin Towers have had a whole range of unplanned effects. Some of these effects were so important as to have changed the world we once knew, some of them so utterly meaningless that it makes us question war’s sensibilities, some of them so positive that it reminds us what it means to be an American, and some of them so negative that we fear for the future. PDS is one of the unplanned, negative effects.

These two wars, designated Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), have been the longest wars in America’s more than 240-year history. They have also been the driving force behind tremendous advances in weaponry, innovations in military tactics, an enhanced appreciation of the cultures of Iraq and Afghanistan, the development of a worldwide system of combat health care delivery, and incredible breakthroughs in medical techniques and technology. As with every major American war, OEF/OIF has helped to generate major health care initiatives in this country, including the ramping up of trauma services in the Department of Defense (DoD), the establishment of a comprehensive Polytrauma System of Care (PSC) in the Veterans Administration (VA), and an unprecedented level of cooperation between the DoD and VA, as well as the private and academic health care providers. It has aided in the development of integrated systems of trauma and rehabilitation care and an ever expanding field of research into blast injury to combat the relatively new use of improvised explosive devises (IEDs) by Iraqi and Afghani combatants. The American and worldwide public have also demonstrated a startling outpouring of community and corporate support directed toward helping America’s newest heroes. All of these activities have been the direct or indirect result of two commercial airplanes being deliberated crashed into a symbol of wealth and power in New York City, as well as the two other planes destined for the Washington, DC centers of power. These are the obvious impacts of the 9-11 terrorist attacks on America. These are the stories we all have read in newspapers and magazines, seen on television and in the movies, listened to on the radio, and perhaps heard through the grapevine. But what is the untold story of OEF/OIF? What has happened to more than 400,000 of America’s heroes who have fought our Global War on Terror? What is PDS?

The wife of our devastated Marine whose feelings were expressed previously provides some additional insights into PDS, the so-called signature injury of the OEF/OIF conflicts:

His face doesn’t look nearly as bad as he thinks. I’ve gotten used to it. But he’s just not the same guy. We used to have so much fun. The whole time he was gone all I could think of was God, keep him safe, keep him safe. It was so stressful. And when I heard he got wounded I just fell apart. They said he was gonna make it, but it was still my worst nightmare. Before, he wasn’t perfect, he could get mad, but now it’s like he’s always angry and irritable. The least little thing sets him off. Or he just sits there watching TV and won’t even talk to me. Sometimes he watches TV all night long. To tell you the truth I’m a little scared of him. It feels like he has to keep himself from doing something violent. He laughs at stuff that doesn’t make any sense.

I have to do everything. I have to make sure he’s taking all his medications. It seems like all I do is cook and clean up his mess and drive him to appointments. If I don’t go with him he won’t even remember what the doctor told him to do. He really needs to go back to the VA for a while. His drinking is really starting to be a problem. When he’s drunk I’m outta here. Last week, Jason and Sean came and got him and they went out for a while, and I realized what a relief it was to just be in the house alone. I wish I could help him but it seems like all I do is piss him off. I love him but I don’t know how much more of this I can take.

Been There, Seen That

Poorly explained health conditions, like PDS, have been associated with nearly every war in the recorded history of man. That’s right, the often devastating symptoms of PDS are extremely similar to symptoms from nearly every major war in recorded times. Although given a vast variety of names depending on the era or belief systems in play, many of the poorly explained conditions seen in hundreds of years of wars sound eerily alike. Psychological and physical difficulties arising from the horrors of warfare have been recorded in Trojan warriors from the times of Homer, during the ancient wars of the armies of King Saul of Israel, from the world-conquering armies of Alexander the Great, and in all of America’s wars. Known as soldier’s heart in the Civil War; shell shock, shell concussion, traumatic war neurosis, or effort syndrome in the Great War; shell shock or war neurosis in World War II; battle fatigue in the Korean War; PTSD in the Vietnam War; and Gulf War syndrome in the Persian Gulf War, a similar constellation of symptoms is seen with all recorded wars. Each war may have its unique emphasis on one or more symptom, or additional complications due to multiple injuries or stressors, but the underlying cause of the symptoms remain the same. Fortunately, the underlying treatment of these conditions is also the same.

Although these types of symptoms and disorders are not unique to wars and can also be seen in those exposed to brief periods of extreme physical or emotional stress (e.g., environmental disasters, terrorist attacks, kidnappings) or prolonged periods of moderate physical or emotional stress (genocide, domestic abuse, sexual trauma), they occur most commonly and consistently as a result of wars. These symptoms range from sleep problems (insomnia), to diffi culty concentrating, to headaches, to emotional disturbances, and have been attributed to a range of causes, including lack of sleep, poor dietary habits, psychologic stresses, concussion injuries from artillery blasts and shellings, and toxins and chemicals in the environment. In the OEF/OIF wars, the same phenomenon has been described. Although it has been labeled a number of things since 2003, including combat stress, blast injury, P3 or P4 (polytrauma + post-traumatic stress syndrome + pain + polysubstance abuse), the name that best fits this range of interrelated symptoms resulting from military deployment is PDS. PDS has been blamed on exposure to blast explosions (like IEDs), single or multiple traumatic brain injuries or concussions, psychological stressors of battle and military theater, poor sleep patterns, poor dietary habits, environmental and warfare toxins, effects of impurities in the sand, and a host of other factors. So what really is going on here? What is PDS and what can be done to treat it?

So Where Do We Start?

Figuring out PDS isn’t easy, but it’s also not some new and profound mystery. To some extent, a systematic demystification of PDS and its varied manifestations is one of the first key steps toward managing it. If you know what something is, it becomes less scary, less confusing, and easier to begin to deal with. The greatest challenge, and the first step in recovery, is developing a clearer understanding of the many components that make up PDS. These multiple factors must be understood and addressed in order to begin to help improve these symptoms. This is the jumpstart needed to diffuse the effects of PDS on the service member, Veteran, the family, and even the very health care workers (doctors, nurses, counselors, therapists, social workers, and more) who are trying to help fi x the problem. If the very clinicians who are designated to provide care for our wounded warriors are at a loss as to what PDS is all about and how to institute reasonable care for it, how can we expect to achieve resolution? Here’s how a treating physician saw our OIF Marine with PDS symptoms:

I’ve seen guys in much worse condition. That’s what makes him so frustrating. His face and eye have healed nicely. If he would stick with the program, I know he would keep getting better. I thought his medications were helping him but he’s stopped taking them. I wish he would go to the veterans group that meets at the VA, but he thinks the older guys don’t understand. I definitely feel for the guy: Traumatic Brain Injury, PTSD, and he lost his eye, but considering how far he has come . . . he was really starting to get better. He’s an outpatient now. When he was on the transition unit he was exercising every day and opening up a little in group. But now it seems like he’s slipping. I can’t run the guys life. He’s got a long road ahead of him and I think he can make it, but if he keeps going this way, drinking and not doing anything, he’ll be a total mess and won’t be any use to himself or anyone else. I do think Jill is the best thing he’s got going. If he could go back to school or if I could just get him interested in something besides his own pain. It’s really frustrating. He just shuts down.

All three of these affected people, the Marine, his wife, and the doctor trying to care for him are joined in the same hope: the hope of healing. The traumatic events and the suffering that the service member has experienced directly affect all of these individual’s lives in a multitude of ways. Just as war radiates from its center and permeates everything within its circumference, so too do the PDS symptoms of that war. Just as this Marine needs the support and care of his family and the input and skills of his health care workers, his spouse and his doctor also need him in order to fully realize their lives and their roles. His healing is their healing. His growth is their growth and, at the same time, their growth is his growth. The family, parents, spouse, friends, children, and friends of the wounded warrior desperately want their lives to return to some sense of normalcy. To achieve this however, they need their loved one to regain his sense of normalcy. So, too, is the recovering service member a validation of the role and the success of the doctor or therapist. Indeed, caregivers draw some of the very meaning of their lives from the well of the soldier’s recovery. This is truly a linked community.

This is the illness of war. Those of you who are affected by this illness do not have to imagine any of this. You are living it. More than anything, there is a sense that the ability to rest has been obliterated— that there is no restful space in the mind. There is no peace. Nowhere has this been more eloquently stated than by the Vietnam War veteran John Wolfe:

Few things in this world are as unforgiving, pitiless, ungovernable, and irrecoverable as lead and steel loosed from a weapon. The transfigurations they affect on the bodies of friend and foe alike form a permanent backdrop to all a man’s future visions. While others experience intervals of silence between thoughts, a combat veteran’s intervals will be filled with rubbery Halloween mask heads housing skulls shattered into tiny shards, schemeless mutilations, and shocked, pained expressions that violent and premature death casts on a dead boy’s face.

These images are war’s graffiti. They are scrawled across the veterans mind defacing the silence and peace that others enjoy. At times the images may seem to fade, but an unguarded glance into the gloom is sufficient to exhume them.

War leaves this imagery in injuries of the flesh and the mind. But, even after the body seems to heal, these images often remain. They are more than just images and more than mere psychological processes. They can create ongoing suffering and are often actual physiologic processes and physical symptoms. War’s stressors and injuries change neurotransmitters in the brain and hormones in the blood, cause these neurotransmitters to be out of sync, and cause sensations, feelings, and real-world difficulties. These feelings can burn so intensely that they inevitably lead to a desire to avoid and withdraw from them. Not surprisingly, depression is the most common mental illness associated with the OEF/OIF conflicts. Another common desire is to find ways to deaden these feelings, which is why poly-substance abuse with alcohol or illicit drugs is so common during and after war. Finally, many will go into some kind of attack mode—either towards one’s self or others. It is precisely this tendency to escape that drives the symptoms of PTSD and combat stress deeper into the body and mind.

Understanding the Roots of Post-Deployment Syndrome

It is in the light of awareness that the experiences of war can be integrated, learned from, and moved on from. War is not a pleasant state of affairs. It’s really not supposed to be. Although it has been glorified in older movies and public relations campaigns, the increasingly realistic descriptions of the everyday horrors and stressors of war seen in modern movies and books are closer to the reality of what war has always really been like. Even in settings where war is so common and prolonged that is appears to be the norm, such as the Hundreds Years Wars of Europe or generations of tribal wars of Africa, it is still not a condition that the human body can adapt to. War is supposed to be horrible. Injury, death, deprivation, and stress are underpinnings of all wars and being exposed to combat—where these conditions are a regular part of one’s existence for weeks, months, or even years on end—is never beneficial or even tolerable. Persisting for a long period of time in a nearly constant state of readiness, brought on by the necessities of war, will always result in some degree of deterioration of functioning over time. Although humans and animals have highly effective stress responses to acute events, we are not wired to be able to maintain these responses for more than a few minutes to hours. The normal stress response, also called the fight or flight response, entails a coordinated effort of the body’s hormonal, cardiovascular, pulmonary, digestive, muscular, and nervous systems that allows us to rapidly respond to perceived or real threats. In order to do this, high energy sugar reserves are made ready, muscular tissue is filled with blood, the brain and nerves are invigorated with stimulants, the heart and lungs are set into high gear, blood vessels become rapidly able direct blood flow where needed and to clot, and the digestive and urinary systems are turned off. Our bodies become (seemingly) invincible fighting or flighting machines. Although this may be a great way to stay alive in a battlefield, it takes a tremendous toll on the body. This would be like ratcheting up the performance of your family car to meet the rigors of a NASCAR race. It’s a great way to go from 0 to 200 miles per hour and to call up your inner Ricky Bobby, but not very good for your vehicle’s longevity or your fuel bill. But, this is exactly what we’re asking of our modern warriors (and their predecessors) and it’s just not realistic to run a car on nitro boosters all the time or a warrior on adrenaline for 12 months at a time.

As if the intense stressors of warfare and the battlefield weren’t bad enough, often the impact of a new injury (or two) that isn’t urgently and adequately managed is added to this. If a service member gets injured and can’t respond at the high level that he or she had been used to, then a cycle of both physical and psychological failure will begin. Imagine what it feels like to live in constant pain — a ruptured spinal disc, a dull or acute headache, and a crushing sense of fatigue. What about not being able to easily comprehend your situation or control your emotions because of a new brain injury? What is like to have lost your sure-footedness, especially when compared to your previous strength and athleticism? What does it feel like to move from situations of totally focused heightened purpose to the sense of an absolute loss of meaning?

Imagine never again being able to engage in the activity in which you have gained the most skill and pride. Imagine the impact of being unable to prevent injury to another. Envision in your body the sensation of deep grief over the loss of a mentor, a brother, or many brothers. Empathize, if you will, with the guilt, sense of failed responsibility, and helplessness over not being able to affect the outcome of an IED attack or a firefight. Consider the penetrating guilt of breaking your own moral code in a misguided response to outrageous injustice, or just because your blood got too hot. And now remove yourself from the love of the family of soldiers who know what you have been through and who know because they have been through it themselves. Imagine frequent moments of utter confusion or horrid nightmares that startle you awake with pounding heartbeat and sweat-soaked sheets. Consider facing life as an amputee or imagine being the family of a soldier with a traumatic brain injury that’s reduced your loved one to a remnant of their former self. Now, add a constant feeling of unease, where the sensations of your entire body and mind are fi lled with dread, anxiety, mistrust, and the molten fire of rage. A rage made up of intrusive memories of violence in the past and intrusive thoughts of the possibility of violence in your future. Finally, add the icy, cold, empty sensation of seeing no future and the fathomless depression of staring into the abyss and the prospect of death could seem downright welcome. This is your personal introduction to the beginnings of PDS.

Post-Deployment Syndrome: So What Is It?

Although not all of the 400,000 service members and Veterans who’ve been identified as having some elements of PDS have all of the features of the syndrome, nor are they necessarily disabled by it, but nearly all have returned from combat changed and affected by it. It can be difficult to make global or cross-cutting statements about PDS because the underlying causes are typically multifactorial and therefore differ from person to person. We’ll explore some of these key factors and then try and help you understand how these factors may have impacted you.

So, what are some of these factors that bring about or contribute to PDS? Some factors are difficulties that were present before going into battle, difficulties that many of us have always had, but that we were able to manage with before. Other factors are the nearly constant life stressors that pervade the military theater: waking up each morning thankful for being alive, dreading your tour on guard duty, not sleeping well or consistently, filling your body with inadequate nutrition, and not having the time or space to clear your head. Add to these factors the specific combat exposures that war can bring, such as physical injuries or intense psychological traumas. Finally, take into consideration the variety of things that occur even after you’ve been injured or traumatized, well-meaning but suboptimal treatments, fellow service members or leaders who don’t recognize or understand your “silent injuries,” and then the array of issues from the post-deployment period after returning home, from the transition back to being a civilian to some of the hassles of getting benefi ts from the military or VA. One, several, or all of these many factors contribute to whether PDS will arise and how it will be expressed. With so many variables and potential factors, it’s a wonder that only one in five service members actually manifest symptoms of PDS. It’s both a testament to the strength of the modern warrior and to the resiliency of human beings. But, when these factors simply overwhelm the defense mechanisms in place, or overcome the newly formed adjustment or treatment strategies, the typical spectrum of symptoms and difficulties arise.

Like most things that cannot be easily seen, touched, x-rayed, or otherwise easily tested, clinical and research experts do not fully agree on what PDS is, when symptoms reach a threshold to be labeled as PDS or when they’re something else, and when your symptoms are signifi cant enough to warrant different types of treatments. Similarly, we are still trying to understand why some people can handle or at least overcome these problems, and why others cannot. At the very least, the term PDS implies that the service member or Veteran is dealing with:

  • more than just a single symptom or two,
  • more than just the results of a single injury,
  • more than just a reaction to stress, and
  • more than just some minor difficulty readjusting to home after a tour of duty.

At a minimum, in order to be accurately labeled as PDS, these symptoms must

  • be fairly consistent in nature and intensity,
  • be significant enough to limit some aspect of your day-to-day functioning,
  • be there for at least 3 months after all physical injuries have healed, and/or
  • be there for at least 3 months after a return to home.

However, even if you are not quite at the 3-month point and can’t quite yet be labeled with PDS, but you still are experiencing these symptoms it would make sense for you to begin treating yourself with the program in this book. Similarly, even if you’ve had your symptoms for years and the number or complexity of the symptoms is increasing, there is no reason to accept the chronic nature of any disorder. It’s really never too early or too late time to begin the recovery. The best time to start is right now.

A syndrome is a collection of related symptoms, and in this case, PDS is not just the annoying symptoms of pain, sleeplessness, or forgetfulness, but it is the profound impact on a person’s day-to-day functioning that makes PDS such a challenging condition. These impacts on your day-to-day functioning and your overall life may be seen in a variety of ways, from physical limitations, to the secondary medical diagnoses these symptoms generate and seemingly endless number of tests and health care visits that are needed, to the elevated rates of job loss and homelessness seen with PDS. Importantly, these often life-altering problems persist long after

  • the initial insult or injury is over,
  • spontaneous healing would have been expected, and
  • the expected period of readjustment to being back home has been completed.

Although there are certain symptoms of PDS (see the asterisks in the following list) that are extremely common and seem to be the main “drivers” of difficulties, there are nearly two dozen that are accepted as occurring often. These include:

  • Irritability*
  • Poor frustration tolerance
  • Anxiety
  • Depression
  • Headaches*
  • Fatigue or loss of energy
  • Difficulty making decisions
  • Slowed thinking
  • Poor concentration*
  • Forgetfulness
  • Difficulty falling or staying asleep*
  • Nightmares
  • Poor coordination or clumsiness
  • Feeling dizzy
  • Loss of balance
  • Nausea
  • Vision problems or blurring
  • Loss of or increased appetite
  • Numbness in parts of the body
  • Sensitivity to noise
  • Sensitivity to light
  • Difficulty hearing
  • Change in taste or smell

This list is pretty exhaustive and includes many problems that can come and go in almost anyone. Those symptoms that first occurred at the time of or just after battlefield stressors and have continued to be present even after a return to less stressful military or civilian life are the ones that are most indicative of PDS.

As noted, although no one date or time period applies to all people, a persistence of symptoms that are preventing a return to full and normal functioning for a period of more than 3 months after the exposure/trauma and at least 3 months after the completion of a deployment is clear evidence of PDS. Labeling a service member with PDS earlier than this can be helpful, but only if it motivates early education, care, and treatment. It’s important to be aware that there must be careful consideration of other conditions that can resemble PDS (depression, post-concussive symptoms, substance abuse), because a simpler diagnoses that requires simpler treatments that are more likely to work quickly is a much easier path to wellness. Unfortunately, because the overlap of all of these conditions is so common and a multitude of symptoms are frequently seen after being in military theater, a more multilevel management is usually needed to treat even early PDS.

Although you could choose to not be labeled with PDS and just be identified by the symptoms that you are having, it is usually in your interest to consolidate the multitude of difficulties you are having into a condition or syndrome that can be relatively easy to convey. Because most folks who have PDS have more than five symptoms, it becomes easier to take into account the full list of possible symptoms that are commonly seen, so that smaller ones that you may not recognize or forget to mention are considered. These lists tend to be helpful to both clinicians and the patients because they allow for a relatively thorough review of possible symptoms without having to focus on the best way to label them. It can often be quite hard to clearly describe many of the difficulties you’re having because many of them may seem strange to you. It also helps to allow for clustering of overlapping problems, thus potentially simplifying the diagnosis and the management strategies. Just as importantly, it allows the clinician to get a handle on the range of difficulties a person is having and to compare them to other patients with similar findings, which can allow them to

  • gauge the severity of the problem
  • understand how often the symptoms are occurring
  • realize how the symptoms are affecting the person
  • utilize treatments that worked on similar patients
  • predict who will make a rapid or a slow recovery
  • understand when someone is not making a usual recovery

An estimation of the severity of the problem can be made more accurate if the clinician asks you to quantify or rate how severe the symptoms are. At the same time, it is important to note that one really bad symptom can be far more debilitating than three or four minor ones. Often times, these questions about symptoms for PDS may initially take place in the form of a screening form or interview such as:

  • Did you get exposed to a blast injury or other exposure in the field?
  • Did you have new symptoms as an immediate or delayed result of that blast or exposure?
  • Do you still have any or all of these symptoms?

If the answers to these questions are positive, a more detailed and PDS-specific questioning will occur.

But, not everyone who fights in war develops problems. So why do some warriors develop PDS and others come back home and get on with their lives? There are a number of factors that influence how war affects people. Although no one is sure of all of the interactions involved, we do have some ideas of who is at risk for developing PDS.

The Impact of Military Exposures and Post-Deployment Syndrome

First, everyone who is exposed to the rigors and the horrors of war (or any traumatic event) has some short- and long-term effects from it. This is normal. It actually highlights the important notion that war’s effects on service members should be broken down into its components. Not all wars or their effects are created equal. The multitude of events or traumas of war must be seen as each individual’s unique exposures. Some people have high doses of exposure over a short period of time; for example, they are involved in an intense fi refight or battle with a great deal of injury and killing all around them. Whereas others have low doses of exposure for their entire period of deployment, such as soldiers who work in the Green Zone preparing their killed-in-action comrades’ bodies for return stateside. Each of these exposures is potentially devastating and may actually cause similar symptoms, but clearly they are different. This is similar to the idea of being exposed to a lot of germs all at once (e.g., if someone sneezes or coughs on you) or a smaller amount over the course of a longer period of time (e.g., if you’re tending to your sick children or if you work around people with illnesses). We’ll call these high-intensity exposures and low-intensity exposures, respectively. Other factors may intensify these exposures for you. For example, if you received a physical injury at the same time that a major catastrophe occurs or if your buddy is killed in the same blast that injured your back or leg, you’re more likely to have difficulties.

Or, if you get a high-intensity exposure but immediately receive the needed care — debriefing, rest, physical exercise — you are more likely to fully recover, whereas even a low-intensity exposure can develop into PDS if limited, inappropriate, or no care is delivered while still in military theater. Regardless of the specifics of your unique exposure to the horrors of war, everyone has some effects from these exposures. In fact, based on the extensive testing done from the Gulf War service members, we know that on average it takes 3 months after completing a military deployment for the typical service member to return to his or her baseline brain performance, stress level, and overall functioning. Again, this is not a unique phenomenon of the OEF/OIF wars. Interviews of Veterans of WWII, who were exposed to wars horrors, sustained a number of physical injuries that went untreated, and rarely received any type of medical diagnosis, reveal that many of these GIs experienced years to decades of psychological challenges and physical symptoms after returning home. Back in the 1940s and 1950s, awareness of these difficulties was limited in the medical system and little got documented, so we’ve always assumed that this “Greatest Generation” somehow rose above the countless exposures of America’s bloodiest war. Others have attributed the apparent success of WWII Veterans to the “moral correctness” of the conflicts, the warm welcome that these Veterans received, and the unprecedented economic opportunities that existed in the post-war era. The reality of it seems to suggest that thousands of this generation suffered in many of the same ways that our current service members and Veterans are suffering, we just didn’t know to ask and they didn’t know to tell us.

Today, many factors are in play that have heightened our awareness of the difficulties that OEF/OIF service members are having. Increasing awareness of the public to the lasting effects of war may be attributed to the incredible advances in information and communication technology we have in the world today. We are able to view the battlefields in real time, to learn about the devastation of modern weaponry firsthand, and to keep up communications to actual service members on an almost daily basis. Additionally, television series (Band of Brothers, Pacific), movies (Saving Private Ryan, Coming Home, Black Hawk Down, The Hurt Locker), and myriad books have given us a service member’s view of war, including the effects of physical and emotional stress.

How Pre-exposure Factors Affect PDS

A second key to the mystery of why only some folks get PDS is what we call pre-exposure risks. Just as a healthy, well-fed, and strong animal is more likely to survive a fight with another animal, the physical and emotional quality of the human being behind the service member plays an integral role in their ability to withstand a military deployment. This ability is often called one’s innate resiliency or their built-in ability to withstand the exposures of warfare. People who have significant physical and emotional strengths and have built up a solid foundation of successes (stable family and friends, productive job, pleasurable hobbies, advancement in the military) during their lifetime are most likely to have enhanced resiliency to exposures. These strengths are often based on a healthy upbringing that included good eating habits (plenty of vegetables and fruits, lean meat, small amounts of fats and carbohydrates, avoiding alcohol and tobacco products), regular exercise and vigorous activity, normal sleep patterns, a sense of spirituality, and a structured family environment. Service members who have come into the military in poor states of physical fitness are more likely to continue the bad behaviors that produced this poor fitness (poor diet, limited exercise, unstructured sleep habits) after their wartime exposures. This poor fitness coming into the exposure will predispose them to poorer resiliency after the exposure. Similarly, service members who come from unstable family structures (poor parental supervision, limited interpersonal skills) or have been exposed to domestic or sexual abuse are less likely to have developed the emotional maturity and strengths, which again can contribute to poor resiliency. Service members with limited innate resiliency are much more likely to develop elements of PDS as a result of almost any negative experience of war time, whereas those with greater resiliency are often able to withstand even high intensity exposures and still do well.

The degree of formal education and inborn intelligence can also play a huge role in providing a service member with the resiliency needed to deal with war’s exposures. Individuals who have been able to develop their intellectual abilities through schooling and life experiences are more likely to have optimized the functioning and integration of their brains and thus achieved a significant degree of mental flexibility (they can adapt to changing conditions, they can understand why things are happening around them). This adaptable mind makes them more likely to tolerate some of the unique conditions and hardships associated with warfare, including the alien environments of foreign battlefields, the conflicts of killing others, and the countless other challenges created by war.

Unfortunately, although one can often blame one’s past for your present day difficulties, there’s typically little to be gained from doing so. Instead of bemoaning the past, appreciating that elements of your past may be influencing or worsening symptoms is often one of the steps toward improving those symptoms. Just because you may have had some limitations in your background is not a sentence to suffering or difficulties. Instead, these realizations may give you the motivation to want to alter those negative ways that you can to provide optimal conditions of strength for recovery.

The Role of Secondary Events on the Battleï¬eld

A third key that helps to explain why some service member’s wartime exposures lead to long-term difficulties, whereas others are able to prosper, has to do with the events surrounding the exposure or exposures. Sustaining a physical injury during your deployment will put you at higher risk for developing PDS because the feelings of pain, fear, discomfort, burden, embarrassment, and any others associated with that injury will commonly resurface whenever you think about any element of your wartime experience. This resurfacing of negative feelings in turn is more likely to magnify the negative experiences your exposures cause you to have. Any time you experience a new injury or have an experience that gives you similar feelings of pain, fear, or discomfort, you may easily relive the combat-related trauma over and over again. In fact, very often people will assume that the difficulties they’re experiencing — such as a headache, poor sleep, anxiety, forgetfulness — are not just similar to what they have felt after the original war-related exposure, but are actually caused by these prior injuries. Even if the headache had previously resolved months or years ago, any new headache can also be ascribed to the original military experience.

If your injury is one that directly affects your brain’s ability to fully understand or process all that was happening at the time of your injury, such as a mild traumatic brain injury or concussion, then not only is there likely to be difficult negative feelings or emotions associated with your military experience, but, because your brain was not functioning perfectly afterward, you may never have fully processed all that went on. So you may have incorrectly remembered or dealt with the inciting exposure event and are therefore more likely to have challenges dealing with either the effects of this concussion or with new events that produce similar feelings. Although we’ll spend a lot more time discussing concussions, it’s very important to understand this overall concept of how a whole variety of other injuries (new and old) can magnify all of your difficulties (new and old). Even more importantly, this concept emphasizes the crucial need to address all of these injuries and the symptoms they cause.

How Stressors Impact PDS

A fourth key to why combat exposure can affect different people in different ways is how well you were doing physically and mentally at the time of your actual exposure or injury. Overall, service members who are deployed often have significant baseline alterations in their normal life functioning, diets, day-to-day routines, exercise regimens, sleep patterns, and the like. Although some folks may actually get more physical activity on an active military base than their usually sedentary lives, overall these life alterations have a deleterious effect on the impact of battlefield exposures. Although these temporary differences in lifestyles for the 12 to 18 months of deployment are not necessarily bad or harmful in themselves, they do create changes in how your body functions. Even if your body is able to adequately adjust to all of these new changes, once you are redeployed and return to your home, there will be a period of up to 3 months of readjustment before your body is functioning as it did before deployment. This is normal. During this period, you may have a hard time fully healing from injuries or of dealing with day-to-day stresses and activities, which puts you at a high risk to develop PDS. Even if you didn’t have any specific injury or high-intensity exposures, but rather were just exposed to the normal low-level stressors of being in a battle zone, you may be at risk for PDS if your body and mind had been negatively affected by your lowered life functioning. If the changes that occurred in your routine (i.e., sleep deprivation, a constant level of anxiety or fear, an excess of fat-related calories) in the military theater are not ones that your body and mind can adequately adjust to, then you will be at greater risk to have a poor response to subsequent exposures or injuries during your deployment and during this period of normal recovery and readjustment after your return home. If the exposure you had from combat is a low intensity one over a sustained period of time, such as the emotional stress of having to decide which troops get chosen for specific tasks or rotations, which may result in the injury or death of some of those troops, and your body and mind is in a constant state of stress because of the difficulties of your new routine, then you will have essentially been damaging yourself for the many months you served before being able to return home and have a chance to heal. Even though the degree of actual damage from this low level of exposure may be small, the background stressors of this routine, plus any injuries you incurred will compound it, so the overall effects may be significant. There are treatments available while in the field — such as counseling, rotating duties, medications, and improving your daily routines such as improving your diet or sleep — that can begin the process of recovery. But there are rarely quick fixes for these types of things. Very often it may take a longer period of time after returning home to continue this recovery process and sometimes it may even become a lifelong activity. A lifelong activity doesn’t necessarily have to be the same thing as a chronic disorder or life sentence, but rather a strategy for ongoing success. If the exposure is a more intensive, short-lived injury (concussion, amputation, musculoskeletal injury, witnessing death), then the acute treatments will similarly likely be more intensive (assuming you have reported the injury or someone is aware of it). However, the same background stressors to your body from an altered routine will still be in place. So again, the recovery from this high intensity exposure may take far longer than would be expected in a civilian setting or than you might expect.

Often, service members have all three of these factors going on:

  • altered routines,
  • low-intensity exposures over a long time, and
  • a high-intensity exposure.

Obviously, this may take a multilevel treatment program applied over a long period of time to facilitate recovery. The recurring theme you’ll be seeing in this book is to focus on ways to both improve your short-term symptoms and difficulties, but at the same time develop a set of strategies to help your body and mind heal over a longer period of time, possibly throughout your whole life.

The Effect of Multiple Exposures and Injuries

Whoever came up with the concept of modern warfare forgot to build in time outs. Although probably not as big a part of older warfare as Hollywood would have us believe, the ability to just stop the roller coaster from going when things got too intense or when the injured needed to be removed from the battlefield isn’t built into the wars in Iraq and Afghanistan. There are no time outs, regardless of the extent or type of injuries. In fact, as was learned in the Vietnam War, the best way to wound or kill several

U.S.service members at once is to injure a single service member and wait for his multiple buddies to try and help him. Oftentimes, the intensity of battle results in multiple moderate- to high-intensity exposures and injuries. Additionally, the prolonged duration and multiplicity of warfare does not allow for periods of rest or removal from the military theater. Although one significant exposure or a moderate duration period of low intensity exposure is bad enough and may predispose you to develop PDS, a series of high-intensity exposure injuries or 12+months of low-level exposure is exponentially more likely to bring about PDS. Unfortunately, we are seeing more and more service members who have had multiple high-intensity exposures, everything from several blast exposures with multiple concussions, to multiple bodily injuries causing the condition known as polytrauma. Technically, polytrauma is a brain injury plus another bodily or psychologic injury, but this term is also used to express the concept of two or more injuries or injury locations. Just as those folks with greater risk factors pre-injury (or innate resiliency) or more alterations to their routines (long-duration, low-intensity exposures) are more likely to have the persistent symptoms of PDS, those individuals with multiple injuries (multiple, short-duration, high-intensity exposures) are also more likely to have PDS. So how can you use this information? Be aware, that if you’ve had multiple separate exposures, even though the combined effects may come across as specific symptoms, usually each of the separate injuries must be addressed individually to understand the extent of injury and potentially unique ways of treating the related symptoms. So, it’s best to be able to identify each of the separate injuries as carefully as you can, so that you can be as clear as possible about when things started or when they got worse. This doesn’t mean that there aren’t overlapping tests or treatments that help to assess and treat symptoms caused by a variety of causes. It also doesn’t mean that these separate treatments should be applied at separate times. Actually, the best practice is to treat the multiple causes and symptoms at the same time, when possible. What it really means is that the people helping you with your recovery should be aware of these multiple exposures so that they can fully formulate your care and you should be aware of the challenges and time duration it takes to deal with these multiple issues.

How Does Time Between Exposures Affect Post-Deployment Syndrome?

Although just having had more than one high-intensity exposure is important, a more significant issue is whether or not the first exposure has had time to adequately recover or heal before the second (or third) one occurred. Although it’s a bit vague when it comes to a new high-level exposure on top of an existing low-intensity one, it’s very clear that high-level exposures need both a period of time to heal and often a specific therapeutic treatment (or environment) to recover with. If these injuries are not cared for adequately and another high-intensity exposure occurs, then full recovery will be challenging. Of course, the same may be true with the low-intensity exposures (whether they begin before or after the high-intensity one), but the urgency of treatment may be less of an issue. The cumulative effects of these repeated, high-intensity exposures are also seen outside of the combat arena. In the world of sports, specific guidelines exist for athletes ranging from junior high to professional who have sustained an injury, including a concussion. These guidelines recommend and often mandate that athletes be removed from the sport and be allowed to recover in a therapeutic environment, usually with specific rehabilitation services until both an adequate period of recovery has occurred and until the athlete demonstrates the ability perform the skills needed for the sport without symptoms. The specifics of these recommendations vary with the type (concussion, knee injury, back pain) and severity (strain, sprain, or tear) of the injury. There is an increased urgency in the sports world to closely following and even re-verifying the guidelines that are used for concussion care, in light of increasing evidence that there are significant short- and long-term devastating effects from multiple sports concussions. These same guidelines are also often applied to injured workers, especially if the job being performed requires significant physical abilities. In general through recent studies it has become clear that a return to full physical activity or active duty military status should be delayed until the person is able to perform all of the key elements of the activity and any symptoms are either resolved or easily managed. Although this may seem to make common sense, it’s actually based on the notion that the brain needs to be given sufficient time to heal and return to normal functioning before it is allowed to take the body into a high level of performance where it could get itself re-injured. This is not only a self-survival strategy, but also a way to assure that the body heals to its maximum. Although this doesn’t mean that the brain and body should be shut down and need to be completely immobilized, it does mean that the body and brain should be in a safe environment while healing and being asked to progressively increase their activity levels. So, although the military strives to prevent all levels of injuries to its troops, it is as important to prevent that second high-intensity exposure, as it was the first, especially if the fi rst one hasn’t healed yet. By definition, the more of these exposures that you are exposed to and the shorter the period of time in between exposures, the more likely you are to develop PDS and the more challenging your recovery pathway will be.

What About Treatments?

Failure to receive timely and appropriate treatment for a low- or high- intensity combat exposure is yet another likely factor responsible for PDS. Although this doesn’t mean that everyone who receives these treatments will be successful or everyone who doesn’t will develop PDS, these early interventions at least usually allow the body and brain to begin the process of recovery and allow you to respond more readily to future treatments. In fact, many of the difficulties experienced during wartime require a series of targeted treatments delivered over a period of time to return the body to adequate functioning, rather than just intense bursts of care. Fortunately, in the case of PDS, there are often a wide range of options as to how to best control symptoms and how to get your life back onto a productive path.

Unfortunately, if you are more than 6 months from your injury or deployment to home, a simple symptoms treatment approach may not be enough. If your exposure and/or deployment is within the past 6 months, there are a significant number of focused therapeutic interventions that are likely to work because we know that most of the elements that make up PDS respond extremely well in the first 6 months. Even so, it’s still best to go through the entire regimen outlined in this book, regardless of how well symptoms resolve or how long you’ve had them, to both enhance your chances of success and to build your overall resiliency. On the other hand, if you are like most returning warriors, you are more than 6 months from your time of initial high-exposure or from your redeployment to home. In this case, while it is always worthwhile to enter into a traditional symptom-based approach, more likely than not, you’ll want to truly take a deep dive into the comprehensive program of recovery outlined here.

So What Now?

What can a person with PDS do? Here’s the good news, there’s plenty that you can do to reclaim your life. The bad news, however, is that restoring your life isn’t something that someone else can do for you, a pill can give you, or a check can provide to you. Granted that each of these things (a concerned person, health care treatments, Veterans’ benefits payments) can play a small role in helping you to regain your life and we’ll explore how each should be used to its fullest; however, the bigger message behind it all is understanding ways that you can take charge of what’s going on inside you and you can learn to return to wellness. Like anything else, the recovery contained within this book is multistep; however, these steps tend to be fluid in nature, more ramp-like than stepwise, and more flexible than other common treatment regimens or self-help books. Understanding the concepts behind the specific exercises outlined is far more important than the exercises themselves. There are not really right or wrong ways to use the healing principles outlined; however, it’s extremely important that you look at this as an approach to live your life and return to your optimal level of productivity, not as merely a treatment for PDS. The approach in this book will entail a series of exercises, treatment recommendations, and discussions that will help to focus you on the importance of keying in regaining your post-deployment functioning, while utilizing strategies to decrease PDS symptoms. This refocusing of your attention and sights from symptom resolution to the more productive goals of restoring physical and mental functioning, establishing a purpose for your day-to-day activities, identifying the most supportive environment to allow for your short- and long-term recovery, and to resolving to redefi ne your post-deployment mindset toward one of progressive healing and eventual wellness are the keys to success from PDS.

So, PDS is truly the illness of war. There are many things that may predispose you to have gotten PDS and just as many factors from military theater and the post-deployment period that may have brought about and worsened your condition. We’ll begin to look at treatments that are out there in the military, the Veterans’ hospitals, and other health care centers across the country. Hopefully, there are some of these standard treatments that can help you. Then, we’ll take you through a step-by-step program to help you get your PDS under control, begin the process of regaining your life, and over time getting you on the road to a lifetime of wellness. You have the ability to achieve all of this within you—you just need to learn how.

Posted on BrainLine March 29, 2011.

From OVERCOMING POST-DEPLOYMENT SYNDROME: A six step mission to health by David X. Cifu, MD and Cory Blake. © 2011 Demos Medical Publishing, LLC. Used with permission. www.demosmedpub.com

Comments (13)

This article explains it all but misses what others have posted here. The environment of just being there...

I think about the guys that I witnessed get blown up EVERY DAY.

I'm going through therarpy etc. BUT *** it sucks.

I don't know how or why I'm here.

I don't have a purpose anymore and that's one of the biggest things I find difficult.

I know I owe it to the ones who didn't make it back to live the most outta life I can... I just don't know how anymore.

What I would give to switch with those guys...

Sometimes I think the ones who didn't get to come home are the lucky ones.

*I'm sorry if what I said was ****ed up in anyway. I just need to talk to someone other than myself*

It's so true...The hell it was.... Why in the **** do I miss it so?

I've been up for so long, i just keep thinking about everything. Yea i think about the combat but i'm also, probably more so, thinking about everything else. The constant wadding through gravel on a cop or fob (if we were refitting), the chow hall, the movies you and your friends watch together all the time, the shitty coffee, the prison gym you and your friends made, the smell of the cop and the burn pit (ew i know), the heat, the cots like 2 ft from the next person and the tents with zero ac that get to like 10000 degrees of hell fire. theres so much that goes into a deployment, all the tiny little things....those are the things i miss right now.. Manas, i actually miss Manas haha. Unfortunately ill never get to go back, as of last April i've been medically retired from the Army. Honestly, id go back in a heartbeat. Great article. 

Words cannot express how grateful I am for your service. I also cannot even imagine the mental, physical, and emotional toll that being in that kind of environment for a prolonged period of time must take. I pray you will seek out professional help and will find a doctor who fully understands and knows how to help you with whatever aspects of PSD you are dealing with. There are people who care and don't want to see you suffer for the rest of your lives. My uncle was in war, and when he returned he became addicted to drugs because he couldn't cope. My aunt divorced him and the last time I saw him he was walking the streets collecting cans. He has since died because he was hit by a car while walking at night. He was a brilliant man, but didn't get proper help to get past the trauma of war. There is help. Please take it!! It doesn't mean you are weak.....actually it takes a strong person to admit they need help. May God bless and heal all of you!!!!!

I am a Marine I've been home since 2013. I was home after two months of being back from the war. I don't know if there's an adjustment period we're supposed to go through but I don't think I got it. I have a very hard time sleeping, eating, getting motivated to do the things I loved to do. My girlfriend is worried as well as my family and now I am too. There's so many other symptoms that I don't see but has been made clear to me. I never received help and am now considering that I may really need it. I feel like I'm falling apart, I feel that maybe I don't rate what others have or at least my PTSD isn't as bad as others. So why get help? I think I was wrong...I need help. I've never really been much of an emotional person but now it's out of control. Some days are ok, but it's a cycle a miserable cycle. I can't be around a lot of people, I've had panic attacks in public. I've never had a panic attack until i was back for a few months. I didn't think anything of it, I'm glad I served my country but I don't want this PTSD!!! I feel it's killing me....

This is a tricky life. I miss fear I miss danger The ones I love have mostly left for good reasons War is wrong it hurt many and accomplished nothing.

I myself am a veteran still in the military. I have had a lot of problems from two back to back deployments and had that I am ok attitude when I wasn't. I have been chronically depressed since my first deployment when I divorced. The second deployment was icing on the cake. I don't know if I have PTSD but I do know that I don't enjoy the things I used to I don't care about anything anymore. I have done lots of wreck less behaviors while in that I never would have done before things went down hill just to feel alive again. I am planning on probably going to see someone as I don't really even care about my career anymore. I don't know if I could return to normal civilian life and not get in trouble. I feel like a lion that is caged up and wants to get out and attack something. I feel like I don't belong in normal society anymore. The only reason I reinlisted last time is because of the fear of not being able to make it after going through all this. I know this might sound crazy to some people and some might understand however today I just needed to vent to someone. I don't really have anyone an I keep to myself as stated earlier if you speak up you are looked at as a problem child and labeled I don't feel that this will ever change in the military no matter how much the army encourages people to seek help. We are taught from basic to portray strength but from my time in "I feel that all of us are somewhat emotionally scar'd somehow from war" that is a quote my old commander gave my old unit.

I'm pretty sure I have PDS. I've gotten help for depression and I have half of the other issues listed. I have done 1 overseas tour and 3 deployments. On return from my last deployment, something didn't feel right coming back. It took me 3 months to admit it and its been 6 months since returning as of today. My chain of command has not been helpful and I even told my 1SG that I have been having issues readjusting but he has ignored it. He said its just an excuse. My career is in his hands and the only reason I'm not out yet is because of numbers. I'm needed because we are short handed. I'm about to be another soldier the Military didn't help then said "Thanks for your service, hard work and dedication, but your not needed anymore". 

No matter the cost, you need to speak to someone. As a medical provider having seen what I've seen,  even I was unaware of what I was going through until it all came to a head. Decisions I had been making for what I thought was better for the unit and myself were misguided. Even now I haven't been totally honest with myself or my counselors because of the simple embarrassment of how my post deployment has played out. That being said I have had support from my commanders even though it seems as if everyone has abandoned me. None the less I am better off now than I was 8 months ago. And even though I have decided to leave the service I know it was the better decision. Don't give up and if you still love it, do what you can to stay in. But no matter what happens talking to someone, in the long run, is better than feeling how you do without help. I still have good days and bad, a friend once said what we've gone through will always be a part of us, dealing with it will take time but eventually it will get better. He was right.

being an active duty marine with these symptoms is very tedious, commands like 1/8's current command are targeting personnel who have issues related to pds, and quite often the medical officers and screeners are quick to disregard symptoms and send you on your way with little more than a b/s diagnosis and some over the counter meds. Command climates from the bottom up make it virtually impossible to get help without committing career suicide.
ive refused to go to out-patient treatment and wont take the medications they prescribed because of the current targeting of U.S. service members with PTSD. for awhile now i havnt been able to understand why my left ear sounds muffled and i throw up every morning after waking up. this article sheds light on what is happening to us but it doesnt make the \"emptiness\" or that constant state of feeling miserable go away. i dont like this feeling and it seems to not want to give me the break that a bottle of whiskey temporarily brings.
Does everyone taking care of our Veterans (and Marines) know about everything in this paper? These authors seem to have a clear understanding of what's going on. Why are so many other health care workers so confused? They need to read this!
This book chapter is describing many of the things that I've been going through ever since I got back from Iraq. I hope this information gets out to the docs and nurses who are taking care of soldiers and veterans.