The OIF/OEF Cocktail: Shell Shock or mTBI and PTSD

I am often frustrated when people mistake mTBI and PTSD because they can be so different. Admittedly PTSD is the hardest thing I face from day to day, but that is because of mTBI. Anatomically speaking PTSD is the over stimulation or use of the Hypothalmic Pituitary Adrenal (HPA) Axis. There is no simple way to describe neurology, but I will do my best at explaining my experiences in relation to my limited understanding of brain anatomy. The HPA is a apart of the limbic system which is one of the oldest traits in the human body. Our dogs and horses are some of the best aids to PTSD because we share this structure even if our cortex functioning is very different. The HPA and limbic system creates a stress response by emitting the chemical cortisol (often called adrenaline) which gives you energy (anger), pulls the blood out of your extremities in preference to organs (you will simply feel tingling or numbness in your limbs), and activates a larger part of your brain making you hyperaware. Think of the golden hour a casualty has to get into surgery, and to get fresh blood and coagulants before they start to crash. That is the final aspect of the limbic system's response to stress: the crash that inevitably comes after your body works at such high levels. That feeling of extreme fatigue and the inability to sleep is a direct result of cortisol, and also why battle fatigue was one of the first terms for PTSD.

PTSD is the persistence of this complex stress response into non dangerous situations. This interplay works with the cortex because the limbic system will provide the stressors to your consciousness so that you can more quickly respond to similar situations in the future. The HPA cortex relationship is a two way loop that can be instinctually triggered, by the older limbic system or by the cortex's memory of previously stressful events. I can see the way that anatomy and social construction works together in my memory of soldiers saying that sooner or later we are going to jump when a car back fires just like all these other guys, already favoring the stress responses of previous groups of veterans through a learned behavior, as well as reflexive reactions to triggers common to the tactics of insurgents in Iraq and Afghanistan. I was blown up in a stairwell so I hyperventilate in stairwells to this day. The anatomy of stress, the events themselves and the way that others have responded socially all effect the way we experience danger as well as the way we choose to process our memory.

But this is a post about mTBI and PTSD. How does this matter?

mTBI is actually a lot less complicated neurological than PTSD, though the experience is incredibly complicated, the concussive nature of high explosives as well as hitting ones head generally damages the brain and most effects the frontal cortex. The brain's protective coating is damaged by concussion and the cortex gets slammed into your skull. This generally erodes your whole brain functioning, but has one set of symptoms that makes PTSD a lot harder to manage. Cortex injuries limit a person's impulse control, and when a person has been exposed to serious life or death situations they are more likely to have a cortex that always fires up the limbic system's response to any stressor. Hence why for me the graduate seminar table and public speaking will often trigger panic attacks. Also the anger I felt in battle is worse because my cortex is not as capable as it was prior to concussions or repeated exposures to explosions. Everything is worse because you have eroded impulse control and every part yourb rain as a system is not your own. Your body is literally not yours to control. The WWI and WWII crack ups were not solely PTSD, but also damage to the cortex from shelling, because as Jonathan Shay as observed, PTSD is actually useful in combat. You always want to fight or fly, but you fight better as a unit so your trained to stick to the plan, that is until blasts and concussions add to this mix and make it harder to control the stress impulse.

You crash because we are only designed to go that hard in brief instances: the golden hour. You become depressed because you are exceeding the capability of human anatomy, and because you are losing control of your impulses. Worse cortisol damages the conscious memory when it is overused and the center of your brain that is self aware is consistently damaged. Kurt Vonnegut referred to scouts, himself included, as people that were controlled by their spinal column, shared location with the limbic system, because he understood the human brain in a profoundly human and intellectual fashion, but when the cortex is damaged it is nearly impossible to stop this life or death impulsivity.

I can remember my first nightmare and flashback like it was yesterday. I had just shot an RPG gunner in Mosul, I had a flashback that day and a nightmare that night. I knew it was PTS and I didn't care, I managed it and was upfront with the Physician Assistant about it. It was war, of course it was going to be terrible, but it was important for me to continue to do my part. However, when I got a concussion I could no longer see what was going on as natural and I got way to stuck in my limbic system. Everything was extreme and everything remains life or death because no matter how smart I can make myself my cortex doesn't have the impulse control that I once had. I can know something, but not feel something, because the emotional stress response is more powerful than my ability to control that impulse. I perform amazing feats because I am running on an extreme and then I crash because I am going way to hard all the time. I know this, but it is almost impossible to control the powerful impulse. I just hope I never lose the ultimate battle to the natural and constant ups and downs that come with the OIF/OEF cocktail.

My Case for the Syndrome of Survival

A popular argument to fight the stigma of PTSD is to abandon it as a disorder. There have also been cases for calling PTSD an injury because of damage to the hippocampus, but this is perhaps the worst piece of evidence because this scarring occurs in bi polar disorder and the entire spectrum of anxiety disorders: some caused by trauma, some not. The injury moniker's most problematic issue is that it seems to create an acceptable male, or females living up to male ideals, non mental illness. Even rape survivors are said to "have MST" instead of PTSD caused by rape in the military (why there is any effort to sterilize rape in the military continually blows my mind). However, the worst thing about injury or trauma titles is their omission of how paradoxical and complicated PTSD, Shell Shock, and Civil War Nostalgia have always been. Injuries are often a lot more simple: rest, ice elevate does very little to your identity. War alters our identity and what we have is a persistent illness, disorder or syndrome. Yet, anyone who truly understands PTSD grasps how it is the persistence of survival skills into non survival situations. Those survival skills ultimately saved our lives, but makes the mundane and routine parts of life harder to manage.

Syndromes are often permanent and the damage to our brain was not instant, it takes years of overuse of the limbic system to damage the brain's declarative memory and create the scaring identified by injury advocates. Moreover, calling it a syndrome of survival also will explain the deep longing and even nostalgic memory of war. We are damaged, but most of us possess some longing to return, and even miss combat or trauma. When we act like PTSD is solely an injury, we confuse injuries and disorders, all because of stigma. Assholes will be assholes whatever title is used, but calling PTSD what it is with respect to trauma's paradoxical complexity will help us accept what war, and survival have done to us. It will also, help war survivors recognize what they have in common with rape survivors, and that their persistent problems are extremely difficult and life altering, but they ultimately come from a place of strength, not weakness. We are all survivors and we should have a better title.

I know that this is a controversial topic that many well informed and capable people will disagree about, but as both a historian and combat veteran I have never been able to feel comfortable with any of the other popular titles. The syndrome of survival seems to captures all the complexity of survival as well as addressing lasting syndrome. Survival is a universally respected, even celebrated, aspect of the human experience and connecting our troubled lives to this ultimately positive fact will also encourage growth in all of those affect by trauma. We also need a title that people who suffer are more willing to bear publicly so that the conversation shifts, becomes broader and more substantive. A title that should come with a stronger sense of corporate pride and empathy from non survivors. A title that expresses a collective appreciation for what people have survived and the baggage that comes from it. No other title does that in the way that one crafted around survival. Survivor is a moniker  that captures the fact that we are not leaves blow about by circumstances. We survived through merit and resilience, and we can also survive the way that those original experiences have changed us, maybe even let our survival motivate us to be something better than we would have been without our horrible experiences.

Helping Others Tell Their Stories

Darby being awesome!

I hope all of our readers have enjoyed all of our regular posts, but you might not know that Scott, Travis Martin, Michelle Monte, and myself all spend a lot of our time helping others tell their own stories. Writing helps us a lot so we try and take time to help others do the same. If you enjoy the regular posts here then there is no reason why will not enjoy our Blue Nostalgia.

It is free to read and free to join Military Experience & the Arts online writing workshops.  We are always accepting new submissions and you will never be turned down without someones helping you finish your writing. The most impressive thing about this issue is not how many views it has already received in less than forty-eight hours, but how everyone of the writers wants to continue participating in the online community. Even those whose writing never makes it online, often take advantage of online support groups and being apart of a community of veterans all going through the same things. I often think about the Military Experience & the Arts's online community as this generations version of the WWI expatriate writing community in Europe. We may not live up to that generation's legacy, but there is the same sense of community, and we are always welcoming and training a new generation of trauma writers. For me it is an honor to know all these people let alone playing a key role.