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Lloyd I. Sederer, MD

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What are the Wounds of War?

Posted: 07/28/09 03:44 PM ET

Our country has been at war in Afghanistan and Iraq for over eight years. Opinions vary powerfully about our entry into these wars and our exit strategies. But we are learning to separate our feelings about recent wars from its warriors. Support for American soldiers is strong, though I have heard from military personnel that there are still moments when war returnees are vilified as soldiers, their being mistaken for war itself.

War is hard on those who serve -- marines, soldiers, air force and navy -- and their families -- ask them and they will say it is "hard". While Post-Traumatic Stress Disorder (PTSD) is seen in 3-4% of the general population, Vietnam veterans have rates of 15%. The near to 300,000 men and women who have served in Afghanistan and Iraq on whom the Veteran's Administration has records from 2002-2006 are experiencing rates of 37%. Suicide among veterans is at the highest it has been in the almost three decades since this data has been kept; deaths from suicide among Afghan and Iraqi veterans are, remarkably, expected to exceed the combat death toll. PTSD is only the tip of problems that include depression, alcohol and drug abuse, domestic violence, separation and divorce, especially prominent among National Guard and Reserve who are over 50% of those deployed today.

In all, about one third of returning veterans will need mental health and substance use services, without counting their families. This is excluding great number of soldiers who return with traumatic brain injury (TBI). Of those in need of care, so few will receive it: estimates are that only one in four veterans who report problems are served. Untreated, their conditions do not improve, nor do the lives of their families.

Why do some veterans develop PTSD or depression, or abuse alcohol and drugs, and others do not -- even when exposed to the same life threatening duty? I recently met a veteran, a marine who had completed three extended tours in Iraq. She said that while she felt badly for her fellow soldiers with these conditions she -- heavily engaged in combat -- had suffered no post-deployment mental distress. I conclude she did not have any genetic or acquired (from early trauma) vulnerability to these conditions, which is to say that the stresses of war did not find in her an overly reactive nervous system. Many, if not most illnesses result when environmental stresses ignite a latent but ready disease disposition. Not everyone with genes for diabetes will develop it but if you consume a lot of sugar, live a sedentary life and become obese you are very likely to become diabetic. The same applies to heart disease and many cancers - as well as mental and substance use disorders. Scientists call this the "stress-diathesis" theory of illness. Diathesis means a tendency to something and stress is what ignites it. Imagine endless months where your life is in peril not knowing from whom, where or when -- coupled with witnessing horror that sears your consciousness: that is military life in Iraq and Afghanistan. These are the conditions that generate the psychological wounds of war.

Veterans with stress induced disorders can be helped to regain normal lives with their families and in their communities. The Defense Department and Veterans' Administration have begun to require regular screening of returning veterans for these internal wounds. Effective treatments exist: veterans are educated about the effects of trauma, learn relaxation or other calming techniques, and undergo progressive re-exposure to trauma through imagery or directly by entering situations that would excite a traumatic response. Individual stress triggers can be identified and managed and excessive use of alcohol or drugs controlled since they only worsen matters over time. Medications, including beta blockers (used to control the fight-flight response) and antidepressants can be very helpful. Spouses and children need to know they also may need someone to turn to, whether family, friends, or counselors.

"War is a force that gives us meaning" Chris Hedges entitled his 2002 book. We know how to make warriors but we know too little about how to make ex-warriors. To leave war and its wounds behind requires a sense of purpose - an alternate path that engages the soul and gives it meaning. Veterans -- and their families too -- need not only to be helped to access mental health and substance use treatments they also need job retraining, education, family counseling and assistance with child care and benefits due them for their service. They need hope, faith and community. We owe the same commitment to our veterans, and their families, that they have given to us.