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Aftershock: The Ticking Time Bomb of Soldiers' Traumatic Brain Injuries

Soldiers returning from Iraq and Afghanistan are a generation of warriors whose fight has shifted from external combat zones to invisible internal battlefields.

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After stabilizing at Tripler, Savelkoul was transferred back to Fort Riley. He seemed to pine for Iraq. "You guys have no clue how bad I want to be there!!!! It's just not the same without you guys," he wrote in a Facebook message in May 2009 to a fellow soldier still in Iraq. Officials at Fort Riley declined to comment on what kind of treatment he received. Savelkoul's military record shows that his condition wasn't improving. In August 2009, he was hospitalized a second time. In October, the Army barred him from possessing weapons. Savelkoul was diagnosed as suffering from post-traumatic stress disorder.

Post-traumatic stress disorder has its own controversial history. Accounts of soldiers suffering mental afflictions after exposure to war's horrors date back thousands of years. In Homer's Iliad, some have speculated that Achilles' blind rage after the death of a beloved companion is an early description of post-traumatic stress. During the Civil War, men who struggled to return to normalcy after the war were described as suffering from "soldier's heart." In World War I, it was called shellshock. World War II brought the name "combat fatigue." All generally described soldiers numbed and haunted, unable to return to battle -- or normal life.

Military commanders showed little tolerance or understanding during earlier eras. Gen. George H. Patton became infamous for slapping and publicly berating a soldier suffering from combat fatigue, calling him a "coward" and ordering him back to the frontlines. Patton was later forced to apologize.

The Diagnostic and Statistical Manual of Mental Disorders, the psychiatrist's primary diagnostic tool, did not formally recognized the syndrome until 1980, after thousands of veterans returned from Vietnam suffering psychological distress. Today, the diagnosis requires that troops meet a series of criteria. They include having faced a risk of serious injury or death; recurring nightmares or memories; and problems with sleep, anger and emotional control that last beyond a month. Researchers continue to debate the criteria and what happens inside the brain to trigger the disorder. Does a sudden rush of chemicals in the brain change fundamental pathways for dealing with stress? Do genes play a role?

Despite the questions, after a 30-year push by veterans and their advocates, PTSD has gained greater acceptance than post-concussion syndrome. Commanders and soldiers are reminded to watch for signs constantly during military training. Nearly all VA and military medical facilities offer some form of counseling for PTSD. By comparison, mild traumatic brain injury is the new kid on the block. At times, researchers have seemed to divide into factions, with PTSD advocates seeking to protect their gains and TBI advocates fighting to make advances. Charles Hoge, a retired colonel who published groundbreaking research on PTSD in Iraq and Afghanistan, has expressed skepticism publicly regarding the severity of mild traumatic brain injury. In an opinion piece in the New England Journal of Medicine[15] , Hoge worried that overdiagnosis of lingering problems from concussion will create "illusory" demands for the military's medical system. "There tends to be camps. One camp is everything is TBI and the other is nothing is TBI," said Rodney Vanderploeg, director of the brain-injury treatment program at the Tampa VA, which specializes in treating soldiers with multiple traumas. "The truth is somewhere in the middle."

Savelkoul was suffering in that middle. In November 2009, the Army made a last-ditch effort to help him, sending him to a residential mental health program at a veterans' home in Yountville, Calif., called the Pathway Home.

It is hard to imagine a more idyllic location. Surrounded by the gentle brown hills of Napa Valley, the sprawling campus of Spanish-style buildings has towering redwoods and lush green lawns. Fred Gusman, a nationally prominent expert in PTSD who recently retired from the Department of Veterans Affairs, established the program in January 2008 for Iraq and Afghanistan veterans. The intensive, six-month program is designed for the hard cases, the troops and veterans who have had an especially difficult time recovering in traditional military settings, where therapy can be haphazard and uncoordinated. At the Pathway Home, teams of doctors and clinicians strive to take a comprehensive approach to care, coordinating treatments for psychological trauma, chronic pain and other issues, such as alcoholism. Patients have encounter groups. They go fly fishing and hiking.

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