Now, three decades after his war experience, he is being treated for post-traumatic stress disorder (PTSD), a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat. Waves of grief wash over him as he mourns the friends and the innocence he lost. He also worries about the young veterans returning from the Iraq conflict-all casualties of war.

"I believe that wars are soul-sucking experiences," says Michael. "We're raised from birth not to kill people, and despite the most sophisticated military training and preparation, it can be devastating to see the consequences of battle. For me, it's like a timed-release poison that was buried deep in my psyche."

The National Center for Post-Traumatic Stress Disorder (NCPTSD) estimates that 8 percent of Americans will experience PTSD at some point in their lives, with women about twice as likely as men to develop PTSD. By comparison, the estimated lifetime prevalence of PTSD among American Vietnam veterans is 31 percent for men and 27 percent for women. PTSD has also been detected among veterans of the 1991 Gulf War, with some estimates running as high as 8 percent. Many experts think the rate for veterans of the Iraq War could be higher, because that combat was more intense and longer.

Although PTSD did not gain an official diagnosis until 1980, the effects of trauma on human beings is well documented throughout history. As Jonathan Shay points out in his book, Achilles in Vietnam, many of the soldiers in the centuries-old epic the Illiad suffered from PTSD symptoms. In Civil War times the disorder was called "Da Costa's Syndrome," and in later wars it was commonly referred to as "shell shock." PTSD also occurs among survivors of natural disasters, terrorist incidents, serious accidents, or violent personal assaults.

Other stressors such as perceived threat, exposure to suffering civilians, or being a witness to death and destruction can also contribute to the syndrome. Symptoms for modern veterans may be complicated by fears that they have been exposed to toxic contaminants. Although terror, horror and fear are all emotions associated with PTSD, feelings of sadness, loss, anger, rage, betrayal, and survivors' guilt are also reported.

Physical reactions such as sweating, trembling hands, and racing hearts and psychological reactions such as anxiety, hyper-vigilance, difficulty concentrating or sleeping, irritability, and sadness are all normal reactions to stress. But if these reactions go on for long periods of time or get in the way of job performance or other aspects of life, it's important to get help.

"I have vet friends who won't go to bed until they walk the perimeter of their yards to make sure everything is secure," says Michael. "And even then, some of them can't sleep because of nightmares."

Fortunately, much more is known about the effects of stress and trauma on our troops since the Vietnam War. Enlisted soldiers and officers are now trained to differentiate between normal "battle fatigue" and severe war-zone stress reactions that may incapacitate soldiers. Today's officers routinely use post-battle debriefing to allow soldiers to vent their emotional reactions.

Frequently, such early intervention can reduce the risks of chronic PTSD. However, as the NCPTSD points out, it is often stigmatizing for soldiers to openly share fear and doubt in the modern, all-volunteer military where many soldiers worry about advancing their careers. As a result, many veterans suffer silently.

Strong PTSD-addiction link
According to the NCPTSD, PTSD and alcohol problems often occur together. People with alcohol use disorders are more likely than others to experience psychological trauma, and being diagnosed with PTSD increases the risk of developing an alcohol use disorder. For example, 60 to 80 percent of Vietnam veterans seeking PTSD treatment have alcohol use disorders.

Psychiatrist Michael Dieperink, MD, PhD, medical director of the PTSD Team at the Veterans Administration Medical Center in Minneapolis, says that people with PTSD are often binge drinkers, because they seek to suppress their PTSD symptoms when something happens that reminds them of their trauma. This might be a loud noise, a plane overhead, or an overwhelming thought or memory.

Although alcohol can provide a temporary feeling of distraction or relief, it also reduces the ability to concentrate, enjoy life, and be productive. Excessive alcohol use can impair one's ability to sleep restfully and cope with trauma, memories and stress. Alcohol abuse also increases emotional numbing, social isolation, anger, depression, and hyper-vigilance. It can progress to alcoholism and exacerbate PTSD symptoms, reducing the effectiveness of treatment.

Since alcohol withdrawal can also trigger PTSD symptoms, Dieperink says it is important for clinicians to work together to determine if those with chronic PTSD and alcoholism should be treated for PTSD or alcoholism first, or if they should be treated for both disorders simultaneously. In some cases, patients at the Minneapolis VA Medical Center are referred to a "Seeking Safety" treatment group-a psychotherapy that was developed in 1992 under funding from the National Institute on Drug Abuse to treat those with PTSD and alcoholism.

Dieperink reassures those returning from the Iraq War that it is very normal to have PTSD symptoms right after a trauma. "Most symptoms get better for most people relatively quickly," he says. "Don't drink to escape. Talk it over, and don't isolate yourself. Establish as normal a routine as you can, and get regular hours of sleep. If the symptoms last for more than a month or start interfering with your social life or occupational abilities, seek professional help."

Substance abuse in the military
Even without the presence of PTSD, alcohol abuse is an ongoing problem in the military. In 2000, the Department of Defense's Alcohol Abuse and Tobacco Use Reduction Committee reported that 21 percent of service members admitted to drinking heavily, costing the Department of Defense more than $600 million each year in terms of medical care and lost productivity.

Don Elverd, a psychologist at Hazelden and a combat veteran who was wounded in his tour of duty in Vietnam, said that although times and drugs change, the reasons soldiers seek escape through drugs and alcohol remain constant. "There's deep homesickness and there's so much fear," he says. "Soldiers are afraid that they'll let their comrades down, that they won't do the job that's expected of them. They have a new set of rules and behaviors. It's like being on a different planet with no familiar connections or compasses."

Feeling disconnected, many young people who never smoked or drank or used drugs before the service, turn to alcohol or drugs as an escape or as a way to fit in when they enter the military. Thankfully, Elverd says that better education about drugs and alcohol, stiffer penalties and consequences for abuse, and better access to treatment for military personnel have improved things considerably.

To lessen the risks of substance abuse, Elverd encourages soldiers to keep mentally and physically active, seek guidance from mentors and chaplains, and watch out for each other. "If you see a comrade in trouble, express loving and respectful concern. Just talk to each other soldier-to-soldier."

Drug and alcohol abuse can also become a problem for family members who try to escape from their own worries or bad feelings, or who might abuse drugs or alcohol to keep their loved ones "company" when trying to avoid trauma-related feelings.

Welcoming home our soldiers
According to the NCPTSD, returning Iraq war veterans are likely to feel overwhelmed with problems related to work, family, finances and physical health. That may create a climate of continuing stress or interfere with treatment. It is important that both family members and clinicians not press any survivor of trauma too soon or too intensely and that they respect the person's need not to feel vulnerable and exposed before they are ready.

Veterans often report that they receive great comfort and support by connecting with other vets. "You come home different, and no amount of welcome-home celebrations can change that," says Michael. "Parades are no antidote for the trauma of war. The support and love of family helps, but only someone who has been through what you have can really understand you."

Michael encourages loved ones to do their homework about trauma, stress, and addiction so they can have necessary resources in place if they're needed. "Ask gentle, open-ended questions," he suggests. "Don't start out asking if they killed anybody. Listen compassionately, but remember that if they don't want to talk or if they want to talk to a fellow vet instead, it doesn't mean they don't love you."

Elverd agrees that it is very important for loved ones to give emotional support to our troops. Research shows that individuals can undergo high levels of stress if they think someone cares. And when soldiers come home, Elverd says it is important for loved ones to recognize that they may need to debrief.

"Just like alcoholics, they have a story to tell, and someone needs to hear it," he says. "You need to listen with patience, and be non-judgmental as he or she talks about their journey so they can find their own meaning and have it fit into the rest of their life. If they can't talk to you, encourage them to talk to an older veteran, a chaplain, or a professional who works with veterans."

Coming home is often hard for both soldiers and their loved ones because veterans often feel like strangers who no longer belong. Loved ones should seek help for themselves from professionals or mutual-help support groups in order to make this transition an easier one. Mutual-help groups often become a lifeline for the veteran as well.

When Elverd works with veterans in recovery, he likens the AA model to their experiences in the military. "They know how to fit into a group of people who 'get it,'" he says. "They know they don't have to like all of them. They know what it's like to fight for their lives with a group of people who are often disparaged. Then, when I tell them to apply it to recovery, they understand."

The National Center for Post-Traumatic Stress Disorder Web site at www.ncptsd.org contains extensive information about trauma, grief, stress, and related problems with alcohol dependency. It offers thorough discussions and a list of helpful resources for clinicians, survivors of trauma, and families. In addition, specific information is available on how to help returning Iraq War veterans. Mutual-help groups such as Alcoholics Anonymous and Al-Anon can also be valuable resources for troubled soldiers and their families.

--by Cynthia Orange

Published in The Voice, Summer 2003