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Ideas

Who will get PTSD?

Researchers are trying to predict one of war’s most unpredictable tragedies. But how we should use that information is anything but clear.

Edel Rodriguez for The Boston Globe

If the day was pleasant, and even when it wasn’t, the two boys would march themselves into the forest, in the shadow of the Black Hills in South Dakota, and hunt. They were no more than 8 at the time, so they took BB guns—all their parents allowed them—and looked for small game, squirrels mostly. The challenge of it turned the boys, Brian Baldwin and his cousin Chuck, into sportsmen, and then best friends.

After high school, Chuck went off to Vietnam as a helicopter gunner. Brian started college and joined the ROTC on campus. By the time he got his commission and completed flight school—to be a Medevac pilot—the war was almost over.

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Nevertheless, Brian’s military career took off: He found that he loved the officer’s life. Chuck, though, struggled. He came home from the war quick to anger, and drank too much, moved around a lot, and watched his marriage dissolve. When Brian saw him around the holidays, Chuck would want to talk about the war. Brian always switched the subject.

One night in the 1980s in his home in Rapid City, S.D., Chuck drank too much again. Only this time, before he passed out, he pointed a gun at himself. When he pulled the trigger, he left behind a second wife and a young son—just a few years removed from his first hunting trip.

Soon, “post-traumatic stress disorder” entered the public lexicon. What haunted Brian were the signs he missed. He wished he’d pulled more bottles away from Chuck or talked with him when he wanted to discuss the war: Chuck was isolated back in South Dakota, Brian realized, with no one around him who knew the military, the images he’d seen.

Brian never forgot that. In 1998, after 25 years, Brian retired from the Army. He ultimately took a job as a project manager at the University of Texas Imaging Research Center, which scanned the brains of people who suffered from PTSD. “I wanted to make up for my own failings,” he says.

He wanted to know why Chuck could be affected by Vietnam in ways other vets weren’t. He wanted to know, in short, if it would be clinically possible to predict who would develop PTSD.

He met with Michael Telch, a professor of psychology at the school. Telch was intrigued by Brian’s idea, but knew its limitations. It wasn’t easy to do a before-and-after study of trauma. In the civilian population, it was impossible to guess when a person would live through something traumatic. And in the military, some leaders didn’t even believe in PTSD; the last thing they wanted were civilian academics questioning soldiers.

But the wars in Iraq and Afghanistan changed that. Or rather, the veterans returning from those wars and the nearly one in five Vietnam vets who had suffered, or still suffered, from PTSD provided irrefutable proof that the military needed to look for ways to treat the condition.

Brian had spent part of his career at nearby Fort Hood, and in 2007 he and Telch approached Army leaders at the base about a study. Telch wanted to put soldiers through a battery of tests before they deployed, have them fill out online journals during their tour, and then follow them for a time after they’d returned to the States.

Fort Hood agreed. Telch ran his tests and, once the soldiers had come home and he could analyze his results, found something intriguing: If soldiers exhibited certain physical and emotional characteristics before deployment, they were more likely to suffer from PTSD after it. As Brian Baldwin would have hoped, it appears as though PTSD can be predicted.

Telch’s work is part of a provocative new strand of PTSD research, using modern psychology and computer science to unlock why and when a traumatic experience can derail a life. These studies—not just in military but civilian populations, too, testing cops and other first responders—hold the potential to transform our understanding of PTSD, changing it from an enigmatic and disruptive affliction that crashes over some people but not others, to a condition that can actually be predicted, quantified, and prepared for.

While it sounds promising, the new research also raises ethical questions: If it becomes possible to screen enlistees for their vulnerability to PTSD, is it fair to keep some out of combat and send in others, especially in an all-volunteer military where every solider has raised his or her hand to take the same risks? And if you send these potentially troubled enlistees to war anyway, what is your liability for any harm they do to themselves afterward? Or to others?

Michael Telch says he and his researchers have measured soldiers “in all sorts of things that haven’t really been looked at in a prospective study.”

Christina Murrey

Michael Telch says he and his researchers have measured soldiers “in all sorts of things that haven’t really been looked at in a prospective study.”

Even if a test is developed, some PTSD experts question whether we should screen soldiers at all. To do so could create the impression that battle trauma is something orderly, even manageable, when war itself is chaos and the consequences of facing combat uncontrollable. To screen soldiers for PTSD, some experts believe, is to pretend war is something it’s not.

***

PTSD may be a relatively new phrase, but the problem it describes is as old as any history of war. In “The Iliad,” for instance, after the great warrior Achilles hears that a friend has died while fighting in his place, he scoops dirt into his hands and pours it over his body; he pulls out his hair; he says, “Nothing matters to me now.” In a rage, he finds Hector, the man who killed his friend, and spears him through the neck. He then ties the body to his chariot and drags the corpse through the streets. What Achilles endures—the torture of knowing that his life came at the expense of his friend’s death—is “also the story of many combat veterans, from Vietnam and other long wars,” writes Jonathan Shay, a former psychiatrist at Boston’s Department of Veteran Affairs Outpatient Clinic, who won a MacArthur Fellowship in 2007 for examining psychological trauma in “The Iliad” and “The Odyssey.”

Though it may not have gone by the name PTSD, other cultures in other times have acknowledged it and tried to treat it. Many Native American tribes, for instance, held initiation ceremonies for warriors at every stage of their lives, says Edward Tick, a clinical psychotherapist who is currently training Army chaplains in dealing with PTSD. “In Lakota tribes,” Tick says, “PTSD was called something that meant ‘The spirits left him.’” The tribe comforted the warrior for days or weeks and held a ceremony when they felt he had regained his equilibrium.

Russia is seen as the first modern society to treat psychological wounds. In the Russo-Japanese War of 1904 and 1905, Russian military personnel placed civilian psychiatrists near the front lines, to treat the soldiers who had developed “shell shock,” according to Richard A Gabriel’s book “No More Heroes: Madness and Psychiatry in War.” The Russian psychiatrists confirmed much of what the Lakota had intuited: It was best for the soldiers to rehabilitate not in isolation but amid others, almost always from their warrior class. The psychiatrists talked with these soldiers near the front, for days or weeks if necessary. Many Russian soldiers then rejoined their units, Gabriel writes. (Americans began using such “forward” treatment, as Gabriel describes it, at the end of World War II, and it remains common today.)

But when it comes to the modern science of PTSD, research has only recently asked the more basic question of why it happens, and to whom, and when. Charles Marmar, a psychology professor at New York University, has followed police officers from the academy through their first years on the streets, trying to determine whether some cops are at increased risk of developing PTSD. So far Marmar has found that officers who experienced childhood trauma, or hold a negative view of the world, or have only a few years on the force, are more likely to develop PTSD. (He also found no correlation between PTSD and intelligence.) Dewleen Baker, a professor at the University of California San Diego and psychiatrist at the VA San Diego Healthcare System, is overseeing a longitudinal study with over 2,000 Marines, studying them from prior to their deployment until well after it, and looking among other things to identify the specific kinds of experiences that might cause PTSD.

Michael Telch, among researchers who focus on the military, has pushed furthest toward the possibility of predicting whom PTSD might strike. With Brian Baldwin’s assistance and Fort Hood’s blessing, Telch had roughly 160 soldiers submit to a battery of tests at the University of Texas before the soldiers headed to Iraq. “We made sure that...they’d never been deployed to a war zone before,” Telch says, the better to establish a baseline of experience. Once they were in country, the soldiers filled out an online log every month of the stressors they’d faced, and any psychological reactions they’d had to them. Once the soldiers had returned to the States, Telch and his staff monitored them for a year.

Perhaps the biggest insight came from the eye-tracking test. Before deployment, Telch asked soldiers to look at a panel of four faces while a computer monitored the soldiers’ eye movements. In the panel the soldiers saw a happy face, a sad face, a fearful face, and a neutral face. The soldiers who quickly averted their gaze from the fearful face—looked away within 100 milliseconds of seeing the photo—were far more likely to develop PTSD after deployment, the study found. These soldiers needed only half as many war-zone stressors as other soldiers to develop symptoms associated with PTSD, the study found. The research was published last year in the American Journal of Psychiatry.

In total, Telch and his colleagues have published five studies on the Fort Hood soldiers and PTSD, with a sixth forthcoming. “We measured [the soldiers] in all sorts of things that haven’t really been looked at in a prospective study,” he says. The researchers have looked at what happens to cortisol levels when soldiers with high testosterone feel threatened. (The levels shoot up, indicating stress.) They’ve tested soldiers’ panic response, by having them inhale oxygen laced with 35 percent carbon dioxide; those who lose their nerve appear to be more likely to develop PTSD.

Dr. Jennifer Vasterling, the chief of psychology at the VA Boston Healthcare System and a researcher at the National Center for PTSD, says Telch’s work has “a unique place” in the study of the disorder. A few researchers have conducted a handful of before-and-after studies on PTSD in the military, she says, but never one with numerous real-time readings of a soldier’s psychological state.

Telch says that his preliminary results are just that. He would like to know what other physical or mental characteristics might lead to an increased risk of PTSD—as well as conduct further tests on the characteristics he’s already singled out. Predicting PTSD is a new idea, he says, and it will take time to say conclusively which soldiers under what circumstances are likely to develop the disorder. Still, “Do our studies have any implications for prevention?” Telch asks. “Definitely.”

***

As many as 20 percent of Iraq and Afghanistan veterans have PTSD or will develop it, the VA estimates. So what will the military do with Telch’s studies? Officials at the Department of Defense did not return requests for comment for this story, and Fort Hood officials declined to comment. Telch says he is not trying to develop a formal screening test himself; he says that would fall to the military.

But it’s already clear what issues might arise as doctors get better as predicting who is more susceptible to psychological trauma. One is simple fairness. Is it fair to keep soldiers off the front based on a test that assigns them a higher percentage chance of developing PTSD? (The police tests raise the same question about officers on the beat.)

General Barry McCaffrey is a retired four-star general and an advocate for veterans battling drug and alcohol addictions. When asked if the military should filter out soldiers likely to develop PTSD, McCaffrey says without hesitation, “I think the answer is yes.” Some of these wounds can last a lifetime—or end a life. And, as Edward Tick points out, given the nation-building nature of today’s wars, soldiers ill-equipped for the front could perhaps still serve in diplomatic capacities.

But McCaffrey also acknowledges that the military would quickly run into practical limitations: It is a force composed of volunteers, and the military has had to lower its recruiting standards simply to find enough men and women to fight in Iraq and Afghanistan. Many soldiers have endured multiple tours. Rigorous screening may not be practical; the military needs the recruits it gets.

It may also be harder to apply than it might first seem. To assume that some soldiers should go to the front while others drink tea with the locals misconstrues modern warfare, McCaffrey and other military experts say. There isn’t necessarily a “front” that you can keep soldiers away from: There are only urban streets, desolate villages, some familiar faces, and a lot of uncertainty. The threat of a battle is everywhere and nowhere.

This underlies another problem that some experts have with screening soldiers for PTSD: the notion that traumatic events can somehow be contained. Tick worries that any successful predictive test could lull the military into seeing PTSD as a solvable problem, more like a preventable disease than an inevitable, if random, consequence of seeing combat. “That’s dangerous,” he says.

The best approach, he argues, is for the military to assume that some people will always be haunted by the experiences they endure, and that it is in fact “normal” for this to happen. The psychic impact of war isn’t so much a disorder, or a sign of some preexisting weakness, as a battle injury—one that underscores the valor, and hardship, of what we ask of people when we send them to war.

“Combat hurts,” Tick says. “And it should hurt. [The military] can’t go looking for a silver bullet.”

Paul Kix is a general editor at ESPN: The Magazine.

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