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Sometimes the most painful war wounds are the ones that cannot be treated with conventional medicine. That is the case with Staff Sgt. William B. Winburn, who by his own admission will need a lot of mental pushups to get past his stint in Iraq.

Winburn's job was to escort convoys. He and his group of three Humvees were returning from a town near the Kuwaiti border July 3, on their way back to Baghdad when it happened. An improvised explosive device hit the sergeant's vehicle, badly injuring him and decapitating his driver right in front of him. It's an image the 35-year-old Kentucky native is having a hard time shaking.

"Me and him were close," said Winburn. "We were just sitting there cutting up and the next thing I knew it was over. He never had a chance. At least he didn't suffer. That's some conciliation."

Winburn slept only 30 minutes in the four days that followed the blast. Every time he closed his eyes he saw his driver die. The nightmares make sleep an afterthought.

"I smell black powder every night when I lie down," he said. "I can smell everything in that Humvee. Every time I close my eyes it's the same thing."

Upon his arrival at Landstuhl Regional Medical Center, one of the first requests he made was to speak with a chaplain. The sergeant's attitude is not one of a defeatist. He said he knows it's going to be a difficult to lose the images of war, not to mention the multiple surgeries to his left hand. The blast took his thumb, the end of his pinky finger and all of the muscle in the palm.

"I'm dealing with it one day at a time," he said to LRMC Chaplain (Lt. Col.) Paul Williams. "I just feel guilty in my heart because I couldn't do anything to save him. He was only 22-years-old."

"The important thing is that you are not bottling up your emotions the way previous generations did," responded Williams. "It's not a sign of weakness to talk about these things."

Winburn took the advice and talked to anyone who would listen. He spoke at length with nurses and his roommate, an injured Marine. His mood seemed to improve, especially after receiving a few hours of morphine-induced sleep the night of July 7. He said he still had a dream about the incident, but when he woke up, he sat in his hospital bed and spoke aloud – reminding himself to think about positive images.

Remaining positive is so important to his mental recovery, said Williams.
"Anything he can do to lift his self-confidence will help because many aspects of this will attack his sense of self," he said. "He is going to have feelings of inadequacy, but there is hope."

Joking about his injuries and speaking to his wife and two little girls have buoyed his spirits. As he said, life is too short to be depressed about everything.

"It was such a good feeling to hear from my family," he said. "A lot of service members will never see their families again. I was lucky. My life was spared and I thank God every day for it."

The nation's military system is quietly preparing for one of its toughest missions in decades: ensuring that soldiers who return from Iraq get the help they need to deal with the stress and horrors of war.Experts say up to 30% may need psychiatric care

Talking to Your Children About Armed Conflict

Karin Bartoszuk, Ph.D., Child /Adolescent Specialist
Sean Brotherson, Ph. D., Family Science Specialist

Whenever stories about armed conflict, terrorism, or the possibility of war emerge on television or in the news, it is important to consider the possible reactions of children and youth. Such topics quickly become a focus for daily discussions among people. It is especially important to think of children's reactions when the issues directly relate to family life, such as the deployment of a parent due to military service.

Many children do not understand the political or military issues underlying such events, but seeing other children on the news often captures their attention. After watching military families say good-bye on the national news, for example, children in general may wonder if their parents will have to leave also. Children who have one or both parents in the military may be faced with issues of separation and uncertainty. Older children might struggle with the different opinions concerning issues involving armed conflict or war. They may have questions concerning what should be done about them on a national or even a global level.

Recommendations for Parents in General

Recommendations for Military Families

Resources for Military Families

The Department of Defense has created a web site that contains information for military parents and individuals who work with military families at:

This site is easy to navigate and provides information for parents with younger as well as older children. Furthermore, there are additional resources that can be used within your own communities. Please use these resources wisely so support resources are not overwhelmed.

Military Family Support Line: 1-(800)-242-4940 or in Bismarck, (701)-333-2058

Participate in family support group meetings and use the support system available through the military if possible. If there are more serious concerns, seek help through counseling resources based either on the installation or in the private sector. For instance, the Family Therapy Center at North Dakota State University in Fargo can provide such services (701)-231-8534.

NDSU Extension Service, North Dakota State University of Agriculture and Applied Science, and U.S. Department of Agriculture cooperating. Sharon D. Anderson, Director, Fargo, North Dakota. Distributed in furtherance of the Acts of Congress of May 8 and June 30, 1914. We offer our programs and facilities to all persons regardless of race, color, national origin, religion, sex, disability, age, Vietnam era veterans status, or sexual orientation; and are an equal opportunity employer.
This publication will be made available in alternative format upon request to people with disabilities (701) 231-7881.

The Iraq War Clinician Guide, 2^nd Edition

Do You Have Posttraumatic Stress Disorder (PTSD) with Symptoms
Remaining after Treatment?

We are seeking men and women without high blood pressure or heart
disease, ages 18-70, and diagnosed with PTSD from being a crime
victim (sexual or physical assault, for example) or from war-related
experience (from five years ago or less), who still have symptoms
despite treatment with psychotherapy and medication.

We're conducting a research study of an investigational drug used in
combination with psychotherapy. The study takes place in Charleston,
South Carolina, and, in most cases, covers all travel expenses.

For more information, please call (843) 849-6899

After sleeping in his West Palm Beach Veterans Administration Medical Center office for four nights with little or no running water, VA public affairs officer Phil Kaplan and his wife woke up on their 35th wedding anniversary to the sound of a toilet finally flushing.

PTSD Research at Fort Bragg: Prediction and Prevention

Charles A. (Andy) Morgan III, M.D., is Director of the Stress and Resilience Laboratory within the Clinical Neurosciences Division in West Haven, CT. He and his staff have been engaged for a number of years in groundbreaking research with active-duty military personnel at the John F. Kennedy Special Warfare Center and School at Fort Bragg, NC. They are studying trainees under stress in an effort to better understand the development of PTSD. His work may point the way not only to more effective treatments but also to possible preventive measures. Janet Bailey interviewed Dr. Morgan about his work in August 2002.

How did you get involved in PTSD research with active-duty military personnel?

When I first joined the National Center for PTSD in 1989, we were working with combat veterans of the Vietnam War and later with veterans of the Gulf War. The data that were coming out of the early biological and psychological studies suggested that people with PTSD exhibited a number of differences compared to people without PTSD. There were differences in their physiology-for instance, in their startle response (how jumpy they were) to sounds when we showed them reminders of war stress. We also noted differences in certain kinds of mental symptoms such as dissociation-for instance, colors appearing brighter or events seeming to move in slow motion. And we found differences in levels of certain chemicals that are known to play a critical role in how the brain responds to stress.

What concerned me at the time was that the majority of our research was based on retrospective data. We were assessing PTSD patients in the present and making assumptions about what had happened in the past, which was sometimes decades ago. We really didn't know whether the differences in biology, physiology, and psychology that we documented were the result of having PTSD or whether those differences in fact predated the traumatic exposure. If the latter were true, then perhaps these differences are actually risk factors that make some people more or less susceptible to developing the illness.

For instance, one might wonder why PTSD patients have differences in startle response. Well, it may be that some people have an exaggerated startle response to begin with, and those people have a heightened sensitivity to stimuli resulting in the situation where trauma has a more severe impact on them. If that's true, then this might be something you can measure ahead of time to identify groups at higher risk for developing PTSD.

So you wanted to study people before they experienced trauma.

That's right. I decided I wanted to do prospective, not retrospective, studies*, but it would be just about impossible to do that with PTSD research. We would have to start with a group of healthy people, hope that they get traumatized equally, assess them within the same time frame, and then follow them over time to see who gets PTSD. This certainly wasn't going to work! So I thought, "What organization routinely puts healthy people in harm's way?" The military.

I started contacting military bases around the country and eventually got a call from Col. Gary Greenfeld, who was the Psychological Applications Director at Fort Bragg. He had been an enlisted soldier in Vietnam, then got a psychology degree from Johns Hopkins, and later got back into the military to develop a program for Special Forces teams. He asked, "Do you think there is a profile of people who are stress-hardy versus stress-vulnerable? We want the best people we can have, and if there's a way to identify people who might not do well under stress, we'd like to know that." So it seemed that he and I wanted to study the two sides of the same coin.

The Military Survival School at Fort Bragg provides training in how to survive in the desert or avoid captivity and, if captured, how to avoid being exploited by the enemy. It's a very rigorous program that includes both classroom training and exposure to a mock POW camp where trainees, after being captured, are held for a few days.

But is this really the same as experiencing stress in the real world?

Surprisingly, yes, it is. We measured trainees' psychological symptoms before and after the training as well as physical symptoms like hormone levels and heart rate. We found that trainees report extremely high levels of dissociative responses-even higher than in people under the influence of hallucinogenic drugs. We also found that elevations in the stress hormone cortisol and reductions in testosterone were some of the most dramatic we have ever seen. After only eight hours, for instance, testosterone levels of the men were lower than levels we see in many women.

What else have you found with your research?

One of the most significant findings was with a peptide called "Neuropeptide Y." It is a substance that, in addition to many other actions, works on the prefrontal cortex of the brain and helps you stay focused on a task even under stress. We found that the Special Forces trainees-the Green Berets-produced significantly more NPY than the Rangers and Marines who were going through the same training. Twenty-four hours after completing the training, the Green Beret trainees were back to baseline levels of NPY while the others were significantly depleted. In fact, there was a direct positive relationship between the amount of NPY and performance in the training. There also was a clear, negative relationship between performance scores and the number of dissociative symptoms reported by the trainees and [a negative relationship] between NPY and dissociation. In other words, the less NPY soldiers had, the more they dissociated, and the more they dissociated, the worse they did in their training.

We were very excited by these results! They suggest that at least some of the physiological factors predate the development of PTSD, that people who release high levels of NPY under stress stay mentally focused. They don't have as many symptoms of dissociation, and at the end they bounce right back to where they started. Others, those that produce less NPY, performed very poorly in the training and looked a lot more anxious and frazzled at the end.

Then we looked at their trauma histories to see whether a history of childhood trauma or child abuse predicted differences when they went through training. Interestingly, those in the Green Beret units tended to have endured more child abuse but did better under stress. Trainees from the Rangers and Marines with a history of child abuse had more trouble during training. They didn't produce as much NPY, they dissociated a lot, and they didn't perform as well.

This of course raises a key question: Did the Green Beret trainees come that way, or was there something in their previous training in the military that helped them perform better under stress? We're going to be looking into this question by studying the selection program this fall. By measuring NPY and other factors, will we be able to predict who the Army is going to select for the Green Beret training?

What are the implications of all this for veterans and others who suffer from PTSD? Do you see your work leading to better treatments?

We've been able to replicate our findings about NPY and psychological responses to stress at two Navy sites in both women and men and in the Combat Dive School in Key West. We can now argue convincingly that NPY, or drugs that work like NPY, act as anti-anxiety or anti-stress agents. At this point, we need to figure out how to develop these agents so we can use them with people who suffer from PTSD. There may come a time when replenishing NPY is a normal procedure when a person comes back from a stressful situation, in the same way that you would feed him if he had been malnourished.

Of course, the real benefit would be in prevention. For instance, a low level of NPY may be a marker that helps us identify which people may be more vulnerable to developing PTSD. We could put people on a treadmill for 20 minutes and measure their levels of NPY, along with other things. It would be like an insurance company doing statistical analysis to determine who is a good risk.

We've also developed a little paper-and-pencil test called an "experiences questionnaire," which asks mostly about dissociative symptoms. Over the years, we have administered it to over 2,000 people before they began the Military Survival School, and we consistently find that people who score high on the test don't make it through the training. If you just screened those people out at the beginning, it would save the Army millions of dollars.

Have your findings changed the selection of or methods for dealing with active-duty personnel?

One of our goals certainly is to develop cost effective methods of weeding out people who shouldn't be there and selecting the ones that should. But the Army doesn't like the idea that someone might be prevented from doing something he or she really wants to do. Also, the military has historically been reluctant to give too much attention to psychological problems, so there has been some institutional resistance.

Why is that?

As far back as World War I, studies of what was then called "shell shock" have shown that if people are given a way out of a difficult situation, they will take it. The British sent their soldiers back to England for treatment, and the soldiers almost never came back to the front. The French decided they couldn't afford that, so they treated their people right at the front lines, and they had a much better rate of success.

Many people will keep working as long as they think there is nothing wrong with them-that is, as long as they don't identify themselves as ill. The military trains their medics to identify symptoms and to recognize when to send people for some downtime. But the medics have to be careful that they don't send the message to a person that he not only feels bad but also is useless, because then it can destroy that person's sense of confidence. We doctors can sometimes communicate a picture that makes a person feel weak and vulnerable if we're too quick to diagnose an illness.

Interestingly, the people who go through Special Forces training all say, at the end, that it was the best training experience of their lives. The people who don't do so well are the individuals who leave without completing the training. They carry away a sense of failure. They think, "Not only was I scared, but I failed too." You know, one of the best predictors of PTSD is the subjective view the person has of the traumatic experience, the story he carries around in his head, and his sense of self-efficacy.

When I'm on the military post or Navy base, I meet soldiers and sailors who have seen and done incredibly stressful things and who are, psychologically, amazingly healthy in spite of it. They go home from work just like the rest of us, they have great families, and they love their jobs. They say, "I jump out of airplanes, and it's the greatest job in the world." Those of us who work with patients in a clinical setting sometimes forget that most people who are exposed to trauma or stress won't have a problem. They may have thoughts and reactions, but they won't develop a mental disorder.

What's next in your research?

Our research with the Military Survival School trainees is longitudinal; we're hoping to follow these individuals over time and to find out who shows symptoms later in life. We also want to continue to study healthy people under conditions of stress. Some of my colleagues have a hard time accepting the idea that we should be studying a disorder before people have actually contracted it. But, this is the best way to understand what may be helpful in primary or secondary prevention, how to treat healthy people before they become unhealthy.

We are also using the Survival School as a venue for studying how accurate eyewitness accounts are of highly stressful events. Studies have shown that people who have PTSD sometimes change their report of events over time. They aren't lying, but their memories change. We've studied people after interrogation and have found that the higher stress the interrogation, the worse the subjects' ability to recognize their interrogators. We think this data will help us better understand the memory problems noted in people with PTSD.

I'm also trying to establish a biological studies site at Fort Bragg. With a permanent site, we could do ongoing work, studying healthy people during high stress events and following them over time. Military installations like Fort Bragg and other bases allow researchers to control for the trauma people are experiencing, which gives us an excellent model for studying stress and its effects. I think this is the best way for us to learn about preventing PTSD and developing better treatments.

A National Center for PTSD Fact Sheet How can one tell if distress after a personal tragedy is a normal reaction to an upsetting life experience or something more serious?

It can be difficult to know whether distress is a normal reaction or a symptom of something more serious. Even experts may require the results of a detailed evaluation to answer this question. Posttraumatic Stress Disorder (PTSD) is only one of many possible reactions to a traumatic experience. After a trauma, some people become anxious, some become depressed, and many find that they are not able to deal with their responsibilities as well as they had before the trauma. Although the majority of people are distressed for a while, over a period of a few weeks to a few months, most find that their upset lessens and they are better able to function. Someone who continues to be profoundly affected by their experience several months or even years later may be struggling with PTSD.

What is PTSD?

The fact sheet, What is PTSD? provides a more complete picture of the disorder, but the main features can be summarized as follows:

Trauma

PTSD is different from most mental-health diagnoses because it is tied to a to particular life experience. A traumatic experience typically involves the potential for death or serious injury resulting in intense fear, helplessness, or horror.

Symptoms

PTSD is characterized by a specific group of symptoms that sets it apart from other types of reactions to trauma. Increasingly, evidence points to four major types of symptoms: re-experiencing, avoidance, numbing, and arousal.

Re-experiencing symptoms involve a sort of mental replay of the trauma, often accompanied by strong emotional reactions. This can happen in reaction to thoughts or reminders of the experience when the person is awake or in the form of nightmares during sleep.

Avoidance symptoms are often exhibited as efforts to evade activities, places, or people that are reminders of the trauma.

Numbing symptoms are typically experienced as a loss of emotions, particularly positive feelings.

Arousal symptoms reflect excessive physiological activation and include a heightened sense of being on guard as well as difficulty with sleep and concentration.

Length and Severity

To qualify for a formal diagnosis, the symptoms must persist for over one month, cause significant distress, and affect the individual's ability to function socially, occupationally, or domestically.

How do I get an evaluation?

While it may be tempting to identify PTSD for yourself or someone you know, the diagnosis generally is made by a mental-health professional. This will usually involve a formal evaluation by a psychiatrist, psychologist, or clinical social worker who is specifically trained to assess psychological problems.

What can I expect from an evaluation for PTSD?

The nature of an evaluation for PTSD can vary widely depending on how the evaluation will be used and the training of the professional evaluator. An interviewer may take as little as 15 minutes to get a sense of your traumatic experience and the effect it has had on your life in order to determine whether treatment for PTSD is called for. On the other hand, a specialized PTSD assessment can take eight or more 1-hour sessions when the information is needed for legal or disability claims. Regardless of the length of the evaluation, you can expect to be questioned in depth about experiences that may have been traumatic for you and about symptoms you may be experiencing as a result of these experiences. Evaluations that are more thorough are likely to involve detailed, structured interviews and psychological tests on which you record your thoughts and feeling. Your spouse or partner may be asked to provide additional information, and you may undergo a procedure that examines your physiological reactions to mild reminders of your trauma. Whatever the particulars of your situation, you should always be able to find out in advance from the professional conducting the evaluation what the assessment will involve and what information it is expected to provide.

What are some of the common assessments for PTSD?

As noted above, two main categories of PTSD evaluations are structured interviews and self-report questionnaires. The Clinician Administered PTSD Scale (CAPS) was developed by National Center for PTSD staff and is among the most widely used types of interviews. It has a format that requests information about the frequency and intensity of the core PTSD symptoms and of some common associated symptoms, which may have important implications for treatment and recovery. Another widely used interview is the Structured Clinical Interview for DSM (SCID). The SCID can be used to assess a range of psychiatric disorders including PTSD. Other interview instruments include the Anxiety Disorders Interview Schedule-Revised (ADIS), the PTSD-Interview, the Structured Interview for PTSD (SI-PTSD), and the PTSD Symptom Scale Interview (PSS-I). Each has unique features that might make it a good choice for a particular evaluation.

Several self-report measures have also been developed as time- and cost-efficient vehicles for obtaining information about PTSD-related distress. These measures provide a single score representing the amount of distress an individual is experiencing. Among this set is another widely used measure developed by National Center for PTSD staff, the PTSD Checklist (PCL). This measure comes in two versions, one oriented for civilians and another specifically designed for military personnel and veterans. Other widely used self-report measures are the Impact of Event Scale-Revised (IES-R), the Keane PTSD Scale of the MMPI-2, the Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians, the Posttraumatic Diagnostic Scale (PDS), the Penn Inventory for Posttraumatic Stress, and the Los Angeles Symptom Checklist (LASC).

The War in Iraq and PTSD

Below is a list of information currently available from the National Center for PTSD on war. For more information, click on the related links and/or search the PILOTS database for a more complete listing of articles available on this topic.

The Iraq War Clinician Guide, 2nd Edition

The Iraq War Clinician Guide was developed by members of the National Center for PTSD and the Department of Defense. It was developed specifically for clinicians and addresses the unique needs of veterans of the Iraq war. For the complete PDF click Iraq War Clinician Guide, 2^nd Edition. You can also download individual chapters by clicking on the chapters below.

Information for the Public

On Line Resources

Personal Emergency Preparedness Brochure from the Department of Veterans Affairs

The Family Deployment Guide by Department of the Army, Headquarters, 88th Regional Support Command, 506 Roeder Circle, Fort Snelling, MN 55111-4009

Fact Sheets

A brief guide to recognizing the symptoms of stress and managing traumatic stress

10 common reactions to trauma are descibed by Edna B. Foa, Elizabeth A. Hembree, David Riggs, Sheila Rauch, and Martin Franklin

Describes how trauma and PTSD can have significant effects on relationships with others

Information about the impact of PTSD on alcohol use and dependence, which commonly occur in tandem with PTSD

Military Medicine

Military Medicine Special Supplement on the Mental Health Response to the Pentagon Attack on 9/11 Vol 167 Supplement 4

AMSUS has established this site on the World Wide Web as an easily accessible resource for our members and any others with an interest in Federal Healthcare.

Advice/Information about Self and Family Care

Answers to some questions about PTSD and service-connected disability that are frequently asked by veterans and their families

Provides information for PTSD survivors about positive techniques for dealing with PTSD

Gives information about the effects of PTSD on family members and how to cope with the effects

A checklist to help one discuss traumatic stress disorder symptoms with primary care physicians

An overview of recent research that confirms that trauma and PTSD affect physical health

Describes the links between trauma and anger and provides treatment strategies for anger management.

Information for Professionals

On Line Resources

Reviews of the literature on war-related PTSD

Schnurr, Paula P; Aldwin, Carolyn M. Encyclopedia of adult development, Oryx Press, 1993, pg 351-356

Curran, Erika. National Center for PTSD Clinical Quarterly, 997, vol 7, iss 2, pg 30-33

Talking to Your Children About Armed Conflict

Recommendations for Parents in General

Recommendations for Military Families

Resources for Military Families

The Iraq War Clinician Guide, 2nd Edition

Contents

PTSD Research at Fort Bragg: Prediction and Prevention

How did you get involved in PTSD research with active-duty military personnel?

So you wanted to study people before they experienced trauma.

But is this really the same as experiencing stress in the real world?

What else have you found with your research?

What are the implications of all this for veterans and others who suffer from PTSD? Do you see your work leading to better treatments?

Have your findings changed the selection of or methods for dealing with active-duty personnel?

Why is that?

What's next in your research?

A National Center for PTSD Fact Sheet How can one tell if distress after a personal tragedy is a normal reaction to an upsetting life experience or something more serious?

What is PTSD?

How do I get an evaluation?

What can I expect from an evaluation for PTSD?

What are some of the common assessments for PTSD?

The War in Iraq and PTSD

The Iraq War Clinician Guide, 2nd Edition

Information for the Public

On Line Resources

Personal Emergency Preparedness Brochure from the Department of Veterans Affairs

Fact Sheets

Military Medicine

Advice/Information about Self and Family Care

Information for Professionals

On Line Resources

Reviews of the literature on war-related PTSD

The Iraq War Clinician Guide, 2^nd Edition