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Afghan killings by soldier lead to questions about TBI, PTSD, and combat stress

April 25, 2012
by Alison Knopf
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PTSD tough to identify "in theater," because of “adaptive” symptoms from combat stress, says retired psychiatrist and Iraq veteran.
Former Army Captain Bret Moore, Psy.D. served two tours in Iraq and was awarded the Bronze Star for his service to front-line troops.

Speculation about why U.S. Army Staff Sgt. Robert Bales killed 17 Afghan civilians, including nine children, in the early morning of March 11, centers around traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), multiple deployments, and family and financial problems faced by the 38-year-old officer.

The case has led some to ask broader questions about the stresses of being in combat and how the Army should and would respond to psychic suffering in someone who is serving “in theater.” Two points are clear: you don’t have to be mentally ill to be shaken by combat, and the Army discourages diagnosing mental illness when the cause of the symptoms is combat stress.

“It’s hard to diagnose someone with PTSD because so many symptoms are adaptive,” said Bret A. Moore, Psy.D. ,a former Army captain and psychologist who co-authored Wheels Down: Adjusting to Life After Deployment. And he doesn’t think TBI would cause aberrant behavior because hundreds of soldiers have experienced it and not gone on to commit any atrocities.

Many of the PTSD-like “symptoms” displayed in deployed settings are adaptive, including hypervigiliance and sleep disturbance, said Moore. “These help keep service members on their toes, where they need to be,” he said. “No matter how resilient you are, combat is a stressful environment.” So soldiers with these symptoms – and others – are not diagnosed with mental illness.

Serious mental illness is another story, however. If someone is diagnosed with a severe mental illness such as bipolar disorder or schizophrenia, or exhibits signs of suicidality, he or she is not kept in the field, but sent home – probably for good – said Moore. The loss of the military career is another reason that the patient himself, as well as the doctor and the soldier’s commander, are unwittingly collaborating to cover up problems that can lead to suicide and homicide. Moore has diagnosed deployed soldiers with major psychiatric disorders. “You have to get those individuals out,” he said.

COSR, not PTSD

In a March 15 Time article, Mark Thompson wrote that the Army Field Manual instructs mental-health professionals not to declare soldiers mentally ill. In a section titled “Combat and Operational Stress Control: Defer Diagnosis of Behavioral Disorders,” the manual encourages a diagnosis of combat stress (combat and operational stress reaction, or COSR, a diagnosis not in the DSM) instead of a pathological diagnosis. From the manual:

During assessment, COSC [combat and operational stress control] personnel must always consider BH [behavioral health] disorders that resemble COSR [combat and operational stress reaction], but defer making the diagnosis. The COSC personnel favor this default position to preserve the Soldier’s expectations of normalcy … This is also done to avoid stigma associated with BH disorders and to prevent the Soldier identifying with a patient or sick role. Deferral is also preferred because some diagnoses require extensive history collection or documentation that is unavailable during deployment situations.

Thompson’s sources told him they thought these rules might have contributed to Bales’ actions, although there is no proof of this. “The uncomfortable truth is that the military mental-health system is designed to avoid recognizing manic symptoms or delusions — symptoms that put someone at increased risk for suicide or homicide,” the expert told Thompson.

The COSR manual allows for medication, but discourages treating soldiers with combat stress as if they are patients:

It is both inappropriate and detrimental to treat Soldiers with COSR as if they are a BDP [behavioral disordered patient]. A therapeutic relationship may promote dependency and foster the “patient” role. Likewise, medication therapy and the highly structured treatment modalities imply the “patient” role. Medication for transient symptom relief (insomnia or extreme anxiety) may not be detrimental if there is no expectation that medication will continue to be prescribed.

There is also the fact that active duty troops are stretched thin. Sending some troops to medical facilities – from which they usually do not return to the battleground – would likely mean more or longer deployments for other troops. And to date, there is no agreement about how many deployments are too many.

Repeated deployments

The 38-year-old Bales was on his fourth deployment. The day before he shot the Afghan civilians, he had seen his friend devastatingly injured. So the question: Do repeated deployments and exposure to violence to close buddies lead soldiers to develop mental problems?

“I wish it were that simple,” said Moore, who did one 12-month tour and one 15-month tour back-to-back in Iraq, from 2005-2006 and 2007-2008. “Most people are fairly hardy and resilient and can make it through a 12-month deployment,” he said. Some people – most likely those with pre-existing problems – find it more difficult to adjust to repeated deployments. “Those are the people, the more severe cases, who have to be removed from theater,” to adjust, he explained. “There’s less risk for someone getting hurt.”

Moore doesn’t buy into the concept of “snapping” due to combat stress alone, as some people have suggested Bales did. “But if you look at people who have had three, four, or five deployments, and who commit horrific crimes, you’re going to find financial struggles, relationship problems, different factors that combined to create this perfect storm,” he said. “Maybe it’s a 22-year-old guy whose high-school sweetheart is going to leave him; that might be enough for one person.”

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