While there are no simple cures for post-traumatic stress disorder, a leading military researcher said progress is being made with a new treatment method and a number of recent studies.
Col. Carl Castro, director of the Military Operational Medicine Research Program, has been funding studies into post-traumatic stress disorder, known as PTSD, over the past five years, and he said the results are beginning to come in.
“I really think the next eight to nine months are going to be the most exciting as the data comes on line and we can start saying, okay, this is really working, we really know what we’re doing here, let’s do this,” Castro said.
Castro’s program funds studies into PTSD at the U.S. Army Medical Research and Materiel Command, Fort Detrick, Md.
“Some of the early initial data,” Castro said, “looks like we can really treat Soldiers in a two-week compressed time frame. And then we’re also looking to see about follow-up, modifying the treatment as we go: the grief, the anger, the second guessing.”
Traditionally, he said, psychotherapy is one session per week for 10 weeks. But with the new compressed time frame the Army will use individual and group therapy because Castro wants to take advantage of the natural bonding and cohesion that exists within the military to facilitate recovery.
NO SILVER BULLET
“There’s no ‘take this drug and you’re cured.’ There’s no, ‘come talk to me for 10 minutes and you’re cured,’ or ‘Go to this web link and go through this 20-minute training and you’re cured.’ There’s none of that although people will promise that. I can assure you that does not exist. If it did exist, I’d be the first one saying let’s do that,” Castro said.
Castro said PTSD can result from many different kinds of exposures: rape, physical assault, earthquakes, national disasters and combat.
“Our current treatments, both psycho and drug therapies, were developed to treat rape and assault victims and had never been validated for use for combat-related PTSD.
“So one of the first things we did was to fund a huge baseline of studies to confirm that the current treatments are effective for treating service members with combat-related PTSD,” Castro said. “We wanted to first establish a very solid baseline. We funded these studies about four or five years ago, and they are just now winding up.”
As a result it does look like the psycho therapies are effective, but they are not as effective for treating combat-related PTSD as they are for treating rape and sexual assault victims with PTSD.
COMBAT DIAGNOSIS OFTEN DIFFICULT
“Doctor Amy B. Adler and I wrote a paper on why combat-related PTSD is very different than rape or sexual assault PTSD. If you look at the diagnostic criteria for PTSD, it implies that there are no symptoms or reactions present prior to the traumatic event, so all of the reactions and symptoms occur after the event,” he said.
In the military, many of the symptoms and reactions that are part of the diagnosis of PTSD are present before a traumatic event ever occurs, he said. For example, having sleep problems and sleep difficulties is a symptom and reaction to trauma.
“But in the military when you deploy to Iraq or Afghanistan or anywhere, your sleep is probably already disrupted. So you’re probably already not sleeping well prior to ever being exposed to a traumatic event,” he said.
The Diagnostic and Statistical Manual, or DSM, is the criteria by which mental health diagnoses are made.
It’s done through the event and the reaction to the event, Castro said. So, the DSM says what should happen when a person is confronted with a traumatic event, they should be horrified, helpless and freeze.
“But Soldiers don’t do that. When they’re in combat and they see things, their training kicks in, they go on auto pilot and they function. So, even the immediate reaction is very different. And the symptoms can be very different, but if the symptoms are already present before the event, how can the trauma be the cause of those symptoms and reactions?” he asked.
‘SUFFERING WHILE FUNCTIONING’
There are symptoms and reactions missing from the DSM that Soldiers often talk about, like extreme anger, grief, second guessing. Castro said the nature of impairment for Soldiers is often quite different than for civilians. The DSM says things such as work, family and life should be disrupted.
“But because of the military structure, Soldiers are still able to show up for work, perform their jobs and carry on, but still have all the symptoms: drinking problems, nightmares; so we call that suffering while functioning,” he said.
Castro noted that when Soldiers leave the Army, the military life goes away and then those Soldiers now as civilians come unraveled and they end up going to the Department of Veterans Affairs.
Soldiers are expected to be exposed to traumatic events. They train for it, prepare for it and the Army has them sign wills in case something happens.
Nobody expects to walk down the street and be sexually assaulted or attacked. If there’s a dangerous area of town, people stay away.
“But in the military, by its very nature, Soldiers go to dangerous places, so they prepare and train for it,” Castro said.
For people not in the military, the traumatic event is unexpected, it’s unwanted, it’s discrete, it’s a single event. Unlike the military, where it’s expected, there’s multiple and varied events that occur over time, and quite honestly, Castro said, a lot of Soldiers are looking forward to going into combat to prove their courage, and see if they’ve got what it takes.
“One of the things Doctor Adler and I speculate on is the role of personality. So, it’s a widely held opinion and belief that your personality gets locked in, and people would argue whether it’s at age 2 or age 4 or age 6, that it doesn’t change.”
But this is a very fundamentally flawed concept, Castro said, because he thinks that significant life events can fundamentally alter personality. Such as being a holocaust survivor or going through trauma like combat. It can change a person’s priorities, he indicated, or have the person come to appreciate life more.
“But these are personality changes we’re talking about and that, I think, has gone largely unappreciated in the giving of the diagnosis,” Castro said.
Since Castro is in charge of funding research, he has funded some studies to look at personality profiles of Soldiers prior to deploying to Afghanistan and Iraq and what they look like coming back. He’s found personality profiles change as a result of combat experiences.
“There’s been several replications of that now, so I think it’s emerging, although I’m not going to say conclusively because it’s only two or three studies. Clearly, though, the studies are showing that being in a combat and a highly stressful environment can alter and change one’s personality,” he said.
ISSUE ABOUT PTSD MISDIAGNOSIS
“The first incidence of this happening was at Fort Carson, Colo., where Soldiers were being dismissed with personality disorders and saying it wasn’t related to PTSD, then they’d end up in a Veterans Administration medical hospital. The VA would then say ‘this is absolutely post-traumatic stress disorder,’” he explained.
“This is an important distinction because if you have a personality disorder it’s an administration separation from the military, but if you have PTSD, it’s a medical board disability separation and that’s where the money, etc., comes into play,” Castro said.
PTSD vs. POST-TRAUMATIC STRESS INJURY – PTSI
“This is another old idea and not a new one. It’s at least a 15-year-old idea. The Canadians for 15 or 16 years have called them operational stress injuries. They haven’t changed the diagnosis from PTSD, they just call it an operational stress injury. Within this, a Soldier can have PTSD, depression, alcoholism, or whatever it is that would fall under that rubric,” Castro said.
He said that changing the name is not going to reduce stigma because Soldiers aren’t stupid.
“You could call it apple and pineapple salad and people would say, oh, that means you have PTSD.
It’s the same thing around the Army, he said. For instance, the Army has Soldier Resilience Centers as the places to go for mental health issues.
“Soldiers know that’s where mental health is. They know you go there if you have a mental health problem. You’re not going there to build your resilience; they know this,” he said.
It’s not going to reduce stigma, he said, and it’s not going to fool anybody.
Changing the “D” to an “I”, isn’t going to help the Soldier, at all. It doesn’t make the problem go away by calling it an injury.
MORE THAN STIGMA
“It’s not just stigma. We talk about it like its stigma, but it’s really more than stigma. We are looking at ways to reduce stigma without suggesting changing the name from PTSD to PTSI, or whatever you would call it,” he said.
Castro said they’ve discovered things that have nothing to do with stigma. It has to do with the culture within America and within the Army. And what is that culture? It’s one of self-reliance and self-improvement.
“Fix it yourself. Don’t look for me to fix it. I mean, what is the number one genre of books? Self-help books. So a lot of Soldiers try to cure themselves. They rely on their own ability and we encourage that as a society and as a military. Take care of yourself, take care of your buddy,” he said.
He said mixed signals are being sent. Culture is saying “take care of yourself,” and the Army is saying, “look, you can’t take care of yourself, you need to come in and get some help.”
Additionally, he said, a lot of people do not believe in mental health. They don’t believe that psychologists and psychotherapy is beneficial or will help them.
“That has nothing to do with stigma. Those two things I just described have nothing to do with stigma, at all. It has to do with one’s personal attitudes and beliefs about themselves and their own personal responsibility, and also how they believe others can help them,” Castro said.
There’s a large percentage of Soldiers and veterans who won’t get help because of those two reasons, he said. It has nothing to do with, “I think someone will think less of me if I get help.”
“That’s part of it, I’m not saying that’s not an important aspect, it is, but it’s not the whole story. There’s no simple solution,” he said.
CONGRESS FUNDS MEDICAL RESEARCH AND DEVELOPMENT
DOD is making progress in PTSD research, Castro said.
“Ten years ago, I think most people would be appalled that we hadn’t already done those studies. I know I was surprised that we hadn’t done them.”
Castro said if people are really honest with themselves, nobody thought these wars were going to last this long, so nobody really felt the need to energize and make changes.
“Finally we started changing when we realized we can no longer say the war is going to end any day because it hasn’t ended in the last five years and if you really look at when funding started being provided for medical research and development, or R&D, and when people started changing, it was about five years ago,” he said.
The first time medical R&D received any big increases in its budget was when a congressional special interest group gave $301 million in fiscal year 2007.
MULTI-YEAR TIMELINE BEGINS
“The money was appropriated in fiscal year 2007. We didn’t get the money in our command until 2008. So then we had to do program announcements, do selections, before I even got into this job,” he said.
Castro said it took another six or seven months to select the proposals, and then it took another year to get them on contract, and awarded on grants or cooperative agreements, or whatever the mechanism, and then it took the investigators a year, two years, to get human use review approvals.
“So now we’re at 2010, and they’re doing their two- and three-year studies right now, and the findings are just coming in,” Castro said, adding he expects many proposals to end this year and early into next year.
He’s not trying to make excuses, Castro said, this is just how long things take, even though some people have ideas on how to make it go faster.
“Anytime you take a shortcut, you end up spending more time and money than if you had just done it the right way. So I don’t take shortcuts. I don’t let any of my staff take shortcuts. I won’t take a shortcut,” he said. “We’re going to do this by the numbers and by the numbers means, we’re going through the proper procedure for selecting the proposal and we award the money.
Castro has 20 years of research experience conducting field studies at Walter Reed Army Institute of Research.
“I believe our service members deserve the highest quality, evidence-based care we can give them, so I don’t support programs that have not been validated and fielded,” he said.
“I love what I do,” he said. “We’re really making great progress.”
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