The political and emotional complexities of PTSD and TBI (traumatic brain injury) can lead to stigmatization and inaccurate attributions. It has long been assumed that soldiers, especially those who have served in combat, are at higher risk for violence. Following WW II several congressmen introduced proposals to send returning combat troops to islands for ‘retraining’ before returning to civilian life. Following Vietnam we had Rambo movies and veterans “going postal”. The facts are both simple and confusing: sudden outbursts of violence are rare and very hard to predict.
The article referenced above summarizes some of what is clear: PTSD and TBI can produce shifts in emotional management and changes in “executive brain function” resulting in possible impulsiveness. Complex phenomena like PTSD and TBI are difficult to study and data is scattered, sometimes inconsistent or contaminated by selective sampling or agency agendas. What is clear is that spectacular episodes of sudden violence are extremely rare, despite media attention. There are often multiple factors involved and these include co-occurring disorders, use of drugs or alcohol, lack of sleep, number of tours, severity of symptom or injury, just to name a few. We would love to have instruments that predict these rare outbursts, but they do not exist. We are reduced to the old maxim I learned decades ago: “the best predictor of future behavior is past behavior”.
I do not wish to oversimplify; however, I want to reassure readers, especially military readers, that they are not likely to explode in some horrific headline-grabbing fashion. The title of the Washington Post article is generally accurate. Put aside the complexities of multiple tours, diminished capacity, head injury, partial recall, fugue episodes, sleep deprivation, isolation, and alcohol, and let’s focus on the reassuring take-away message. There is no data supporting the worst fear carried by many. Most veterans are well trained, restrained, disciplined, highly ethical, and filled with a sense of justice, loyalty and honor. Most veterans I have treated live with the dread that they could lose control of their impulses and inadvertently hurt someone. Newspaper headlines about sudden violence and suicide add to their burden of fear. As a 66 year old combat Marine with severe health and mobility problems recently stated, “I am still afraid of what I could do to others.- That’s why I need to stay away from others.” The fear of losing control results in isolation, self-medication, avoidance, and a whole host of symptoms we see with PTSD.
I would argue that the most common symptom is not violence but extreme dedication to work or mission. I do not have the statistics, but from my years of experience I see pro-social zealousness- not antisocial outbursts- as the most common coping mechanism. Over dedication to work/mission becomes almost addictive. It is easy to get lost in working excessive hours, and it is rewarded by recognition and increased revenue. Channeling one’s anger is difficult, but workaholism is an extreme response rewarded in our culture. However, family members can be angry and confused, and the internal burden remains hidden. Sleepless nights, avoidance, occasional road rage and other symptoms flourish, often visible only to a few. Spectacular outbursts are rare. PTSD tends to be a condition that most often fits the following: “Great souls suffer in silence.” (Friedrich Schiller). The articulation of suffering is often the first step toward recovery.
Jerry A. Boriskin, Ph.D.
April 2, 2012