The VVA Veteran — September/October 2011
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The Paradox Of PTSD
Charles W. Hoge

Bridging Gaps In Understanding And Improving Treatment

After a decade of war in Afghanistan and Iraq, it’s time to reassess how much progress we’ve made in addressing the profound impact of post-traumatic stress disorder and other war-relatedmental health concerns on the lives of veterans and their families.Studies have shown that 5-20 percent of veterans who served in Afghanistan and Iraq meet criteria for PTSD after returning home, with higher rates in personnel who experienced direct combat (those in brigade or regimental combat teams), and lower rates in population samples that include support personnel. These figures are comparable to those observed in Vietnam veterans.

While PTSD has themost impact, other war-relatedmental health concerns also take a toll, especially depression, substance use, and suicide. In addition, large numbers of veterans experience normal readjustment challenges of a milder nature (sometimes referred to as “PTS”). PTSD also has a strong association with physical health problems, such as headaches, back pain, and hypertension.

The experience of coming home from a combat deployment is complex, and the distinction between normal and abnormal transition responses is often unclear. Medical professionals define PTSD based on a specific set of symptoms, which include feeling constantly on edge or hyperalert, having difficulty sleeping, experiencing nightmares, being distracted by intrusive deployment-related memories, feeling a lot of anger, having concentration or memory problems, feeling emotionally numb or detached, or avoiding doing things that were previously enjoyable (such as going out to a crowded mall or movie theater). There may also be feelings of guilt or a strong urge to self-medicate with alcohol or drugs to try to get some sleep or to temporarily forget things that happened downrange.

The paradox is that many of these reactions, which medical professionals label “symptoms,” are also necessary adaptive physiological responses in combat and skills that professional warriors hone in their training. There is a naïve expectation in society that veterans should be able to transition home smoothly and lead a “normal” life after serving in a war zone, with little understanding of what it means to be a warrior or what the normal human response is to extreme war-zone experiences. Combat-related responses don’t just shut off upon returning home. The body doesn’t have an “on-off” switch, for good reasons, since these responses have to do with survival.

PTSD in professional warriors is a paradox that makes it very different from the experiences of civilian victims of trauma—something that is not well appreciated even by many professionals in the mental health field. (There are also parallels between service members and first responders such as police or firefighters.) Military personnel train for and expect to encounter combat events, and respond collectively as a team according to their training.Reactions that mental health professionals label “symptoms” upon return home are based on adaptive beneficial responses acquired through training and experience working in a war zone. For example, situational awareness where a warrior is alert to environmental cues that might signal an enemy threat is life-saving in combat, but might be labeled “hypervigilance” back home. Rigorous mission rehearsal and attention to detail (involving checking and rechecking everything mission related) contributes to “re-experiencing” symptoms, intolerance of mistakes, or should’ve-would’ve-could’ve-type thinking back home.

Continuous night-time operations and the ability to function on limited sleep causes biological changes in the normal sleep-wake (circadian) cycles that can interfere with sleep after returning home. The ability to direct anger, which helps control fear and shut Down pain awareness, makes it more likely for anger and rage to be expressed back home. The ability to shut down other emotions to focus on the mission, even after serious casualties, is an absolutely essential skill in the combat environment, but can turn into numbing and avoidance after deployment. The bottom line is that “symptoms” are also skills.

The thing that distinguishes PTSD from normal, necessary, and adaptive responses and skills of a combat veteran is the degree to which these reactions interfere with the veteran’s ability to make a successful transition home. Generally, if these reactions interfere on an ongoing basis with the ability to enjoy life, have meaningful relationships, or be productive in work, studies, or hobbies, then it’s more likely that a medical professional will consider them symptoms of PTSD.

Veterans of the wars in Iraq and Afghanistan have been offered extensive programs to help them in transitioning home, programs that were not available during prior wars.They include routine screening for PTSD and mild traumatic brain injury (mTBI), improved mental health professional services, and education efforts focused on reducing stigma and enhancing resilience. PTSD was not recognized at the time of the Vietnam War, and the last 10-20 years have seen a sharp increase in the availability of evidencebased treatments (those established through rigorous clinical studies).

However, despite all of these efforts, outcome data suggest that not nearly enough progress has been made, given the level of attention, resources, and services being directed toward this important problem over many years. Half of veterans in need of mental health care still don’t receive services.Among those who do begin treatment, a large percentage drop out before completing a sufficient number of sessions to derive meaningful benefits. It has been estimated that only approximately 20 percent of veterans in need of care receive adequate mental health treatment. The reluctance to seek help spans generations of warriors, not just those of the most recent conflicts.


The reasons for this include barriers, such as the limited availability of appointments in some facilities, transportation problems, or work or child-care responsibilities interfering with regularly scheduled appointments. There is also stigma, defined as concerns about how one might be viewed by others (such as peers or supervisors) if treatment is sought. Then there are factors that lie within the responsibility of mental health professionals themselves.

Veterans often report negative perceptions of mental health care, reflected, for example, by a lack of trust in mental health professionals or concerns that treatment is ineffective or a last resort. Research shows that these negative perceptions are some of the strongest predictors of veterans’ willingness to engage in mental health care.In essence, mental health care suffers from poor marketing and negative perceptions.

Part of the problem lies with the way in which mental health care is delivered. It can be off-putting to veterans who are in need of support but wary of sharing their experiences with anyone other than their battle buddies.Veterans sometimes feel that mental health professionals make judgments, such as whether a certain traumatic event warrants consideration in determining the diagnosis or which symptoms rise to the level of a “disorder.”

Rather than talk about life experiences and responses using simple narrative processes, the mental health care approach tends to use a lot of medical or psychological labels. Normal reactions in a combat zone are considered “symptoms.” Human emotions, such as grief, are measured by how “complex” they are.Ways of thinking that are ingrained in military training, such as high attention to detail, might be labeled “cognitive distortions.” Helpful mental health advice is framed with phrases like, “You need to…”, “Remember that…”, “It is important for you to…”, “Understand that…”, “Realize that…”, “Recognize that…”, “Make sure you….” This is a language that implies that the professional knows what’s best for the warrior, even though the warrior is the one who has to learn to live every day with the memories of what he or she experienced in the war zone.

When veterans make the difficult decision to overcome all obstacles and seek mental health care, they are looking for someone who is caring, competent, nonjudgmental, and available. Veterans prefer that communication is immediate, direct, and real. The mental health professional doesn’t necessarily have to have military experience, although this certainly helps. It also helps to have some life experiences to draw from. Nevertheless, regardless of how much experience the health professionals have, they must be careful not to make assumptions or implicit judgments about a warrior’s experience.Veterans often are looking for any excuse to leave treatment, and based on the data, veterans are walking every day.

In order to make a dent in this problem and bridge the gap in perspectives concerning war-related PTSD, I believe that both mental health professionals and veterans (and probably society at large) can benefit from greater understanding of the occupational context and paradox of war-related PTSD, as well as understanding what post-deployment transition really means, and the relationship between PTSD and the biological and physiological processes expected in combat.

It is helpful to have a firm understanding of why the body continues to react as it did in the combat environment, even years later, and not automatically label these reactions pathological or psychological. It is important to understand PTSD both from a traditional medical model (“symptoms,” “diagnosis,” “treatment”) as well as from the perspective of warriors (“responses,” “skills,” “occupational experiences”). The paradox of PTSD tells us something important about what it means to be human.


There are many unrealistic expectations about the transition and readjustment period after returning from deployment. For active-duty brigade and regimental combat teams, there is an expectation that the entire unit will be able to “reset” and be ready for another deployment within a year. However, this is not sufficient for many warriors to fully re-engage with family members, integrate their experiences from the previous combat tour, modulate the physiological reactivity that continues after deployment, or learn to live with very difficult memories, particularly tragic events involving team members who are as close (or even closer) than the warrior’s own family. Society asks a lot of our service members as it is; many veterans feel as if they are asked to suck it up and drive on when they get home.

The reality is that there is no normal period of transition. Deployment changes everyone in one way or another, and veterans need varying amounts of time to readjust.Many veterans grow from their deployment experiences, such as gaining greater maturity,wisdom, leadership and career opportunities, and an appreciation of the value of life and connections with loved ones. Some warriors make the transition quickly and smoothly. Others experience more lasting challenges. Readjustment growth and challenges can occur at the same time. They are not mutually exclusive.

Some readjustment challenges have to do with the nature of experiences downrange.War-related experiences are myriad, but the events that understandably tend to have greater impact are those in which there were serious casualties involving unit members, collateral casualties, leadership failures, or feelings of betrayal. Accidents in the war zone can sometimes be as devastating as indirect or direct fire. Harassment, assault, or rape by a fellow service member—the ultimate form of betrayal in an environment where one totally depends on team members for protection and support—is particularly devastating.

Survivor’s guilt and should’ve-would’ve-could’ve thinking are very common in veterans. There is a tendency to replay combat events over and over, thinking of ways that an outcome could have been changed—the illusion of choice. It is no wonder that many veterans find it difficult or impossible to move forward with life after war-zone experiences, and it’s understandable for veterans to lock up these memories and emotions and avoid talking about them, especially with people who have never deployed.

Many Vietnam veterans are only now beginning to make the transition home in terms of addressing war-related experiences, more than thirty-five years after the end of that conflict. Sometimes combat-relatedmemories stay buried for years while life events such as marriage, raising children, and career take priority, but then resurface during a later life transition, such as after retirement, a marital separation, a death of a familymember, a stressful financial situation, illness, or kids leaving the home.

Warriors don’t just stop being warriors when they get home. Once a warrior— always a warrior. Transition takes time, but it’s never too late to make a successful transition home, “successful” being defined as the ability to live with difficult deployment- related memories and also have productive employment or hobbies, meaningful relationships, personal growth, and the ability to experience joy in life.


All of the skills and reactions that serve important functions in survival of the team and success of the mission involve physiological processes. The extreme physical stress of deployment, sleep deprivation, and intensity of life-threatening experiences that can occur during deployment are associated with changes in how the body functions, including increased autonomic nervous system activation (higher adrenaline, faster reflexes), changes in levels of hormones that control different body functions (cortisol and others), and changes in how memory is processed. More attention goes to survival-related memories in deeper areas of the brain and less attention to thinking processes such as university studies or the list of things that has to be picked up from the grocery store. PTSD is associated with these physiological changes remaining in combat-ready mode upon return home, and PTSD should be considered a physical condition as much as (or more than) a psychological or emotional condition.

As a result, veterans with PTSD have higher rates of virtually all categories of physical health problems than veterans without PTSD. That includes hypertension, cardiovascular disease, chronic pain in muscles or joints, headaches, gastrointestinal problems, sleep problems, and concentration or memory problems. Those with PTSD also end up on more medications and have more doctor visits.

Sometimes post-deployment physical symptoms such as headaches and concentration and memory problems are mistakenly attributed to previous head injuries (also called concussions or mTBIs), when they actually are caused by the physiological effects of combat. This has implications for delivering the correct treatment. All too often veterans are referred to different medical specialists and receive many diagnoses and multiple medications that increase the risk of side effects and adverse medication interactions. Having a strong primary care provider who can sort this out is crucial.

The bottom line is that going to war changes how the body functions, and the expectation that this will reset quickly upon return home is unrealistic. There is no switch to restore biological-physiological functions back to the way they were before deployment. Adial is a better metaphor. It’s best to understand these body responses from the perspective of how they serve important functions in a combat environment, and then look for ways to dial these responses down after returning home.

There are many ways to do this. I created a series of exercises and skills for navigating the transition home and dialing down combat-related reactions. However, each individual needs to find what works best for him or her.


Understanding transition and combat-related PTSD within an occupational and physiological context can help to put things in perspective, make sense of warrelated responses, and guide treatment strategies. Having loving connections with friends and family is probably the single most beneficial factor. I can’t say enough about the value of showing gratitude and appreciation for the people in your life whom you love. Peer-to-peer support programs with other veterans who have gone through similar experiences can be very beneficial. Having patience and a good sense of humor also helps enormously.

Veterans who receive treatment ideally should be given a range of choices based on what they are most comfortable with, so as to facilitate their willingness to remain in care. There are a variety of treatment options, and one size certainly does not fit all. Psychotherapy (talk therapy) is effective and leads to measurable improvements, including the physiological processes involved in PTSD. Although there are many variations of psychotherapy, virtually all of them involve three core components.The simpler and more direct approaches appear to work just as well as more complicated interventions. It’s my belief that the more mental health professionals understand this, the more veterans will feel comfortable staying with care. Being able to advocate for yourself to get your questions answered and find a provider you can work well with is important. The three core therapy components are:

Narration, probably the most important component, involves talking about the events that happened, as well as the emotions and thoughts connected with these experiences.Veterans are often reluctant to talk about their experiences because of the responses they get from people who haven’t deployed and because the experiences can be connected with strong emotions. However, there is no better way to integrate these experiences and learn to live with difficult deployment-related memories in a way that also allows for personal growth and finding meaning and joy in life. The narrative process is also very important for addressing difficult topics such as guilt, grief, or the illusion of choice.

Retraining the Body to face stressful situations involves exercises in which the veteran progressively visits locations that trigger strong responses (for example, crowded shopping malls) in order to retrain himself or herself not to have automatic combat-ready reactions in locations where the actual threat level is low.

Relaxation Exercises focus on dialing down the level of adrenaline, hyper-altertness, and improving sleep and concentration. This might involve diaphragmatic breathing and mindfulness meditation.

There is also a role for medications, particularly the selective serotonin reuptake inhibitors such as sertraline and paroxetine. Although not better than psychotherapy, they can be useful in alleviating symptoms, can be used along with psychotherapy, and are generally safe. Other medications also are prescribed to veteranswith PTSD, with many considerations related to properly balancing potential benefits with risks.Two classes of medications that are widely used have been shown in several studies to have more risks than benefits. These include benzodiazepines (alprazolam, clonazepam, lorazepam, and diazepam) and atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole).

Sometimes PTSD treatment is not successful because of ongoing physical health problems, such as musculoskeletal pain, headaches, or sleep disturbance, and it’s necessary to address these problems first (or simultaneously). Sleep is not given nearly enough attention. The body tends to maintain combat-related sleep patterns after coming home (for example, sleeping much lighter,waking in the middle of the night, not feeling rested in the morning). It can sometimes take months or years for natural sleep processes to reestablish themselves.

There are many things that veterans can do to improve sleep, including modulating the intake of caffeine and alcohol.Veterans often continue to consume large quantities of caffeine after coming home without realizing how this can have a negative impact on sleep. They also sometimes reach for alcohol to help with sleep, without realizing that this can interfere with a successful transition. Although alcohol can seem to help at first, it actually makes sleep much worse by altering the normal stages of sleep necessary for restoration and health. REM sleep, the stage that involves dreaming, is initially suppressed by alcohol but then plays catch up as the alcohol wears off throughout the night, leading to a higher likelihood of waking up (and also having nightmares) in the middle of the night and not feeling rested in the morning.

The bottom line is that sometimes sleep won’t return to normal until there is a lengthy alcohol-free period. Many medications that are prescribed for sleep (benzodiazepines, for example) are similar to alcohol and can actually make sleep or other PTSD symptoms worse over the long term.

A warrior doesn’t stop being a warrior when he or she returns home from combat.Once a warrior, always a warrior. This has to do with rigorous military training, deployment- related experiences, what it means to be a warrior, and the physiological effects of war. If you would like to know more about navigating the transition home from deployment, things you can do to improve sleep, dial down combat-related reactions, or navigate the complex medical and mental health care system, I invite you to look further in my book, Once a Warrior—Always a Warrior: Navigating the Transition from Combat to Home. It’s an honor to share my views with you, and I welcome your feedback at

Retired Army Col. CharlesW. Hoge, a medical doctor, directed the U.S. military’s top research program on the mental health and neurological effects of the wars in Afghanistan and Iraq from 2002-09 at Walter Reed Army Institute of Research. He is the author of Once a Warrior—Always a Warrior: Navigating the Transition from Combat to Home (2010). He deployed to Iraq in 2004.