‘Brain Scars’ Seen in Many Blast Survivors

by Kay Jackson Contributing Writer, MedPage Today

http://www.medpagetoday.com/Neurology/HeadTrauma/55216?xid=nl_mpt_DHE_2015-12-16&eun=g417770d0r

More than half of active military personnel who have sustained mild traumatic brain injury (TBI) show evidence of brain structural abnormalities or “brain scars,” initial results out of the largest advanced brain imaging study of active duty military TBI now has shown.
A TBI-specific integrated MRI scan has demonstrated a high incidence of T2-weighted hyperintense areas in the white matter, as well as pituitary abnormalities and microhemorrhage in the chronic phase, according to Gerard Riedy, MD, PhD, of Walter Reed National Military Medical Center in Bethesda, Md., and colleagues.

“We were surprised to see so much damage in the brain as conventional wisdom says that in mild TBI the imaging should be normal, yet we saw small brain scars in over 50% of the TBI cases with our advance imaging scans,” Riedy and colleagues reported online in Radiology.

“We must caution that while these lesions are abnormal, we don’t have a clear understanding of what they mean and their true impact on patient’s symptoms and outcomes,” they noted. “We hope that additional research into the more advanced imaging portion of the brain scans will lead to those answers.”

Disruptions in brain wiring in individual TBI subjects, as well as overall changes in the neural network connectivity in the brains of military TBI patients, have been observed at the National Intrepid Center of Excellence (NICoE) at Walter Reed, where the advanced neuroimaging protocol was developed, said Riedy in a prepared statement.

But without a baseline MR image prior to injury, the source of T2-weighted hyperintense areas cannot be definitively determined, acknowledged the investigators.

This study is part of the National Capital Neuroimaging Consortium (NCNC) project, formed in 2009 to advance neuroimaging applications and improve evaluation of military TBI. Development of the TBI-specific integrated MRI scan has made it possible to collect 41,000 brain images per patient (versus about 350 images that would be provided by standard MRI), said Riedy. In addition to structural information, investigators have been able to collect unique patient information on brain function, brain connectivity, brain wiring, brain chemistry, and brain blood flow.

These findings could potentially have significant implications for clinical practice, should advanced medical imaging make it possible to objectively identify brain lesions that potentially serve as biomarkers for TBI and the so-called “invisible” wounds of war, including post traumatic stress disorder (PTSD), said the investigators.

“We hope to bring a better understanding of these injuries through medical imaging. For most of these guys, this is their chosen career,” Riedy told MedPage Today in an interview. “Some may opt for a desk job rather than risk another brain injury after seeing their NCNC brain scan.”

TBI and PTSD have a tremendous amount of overlap in terms of symptoms and yet the treatment paradigms are vastly different, Riedy noted. “An accurate diagnosis is key to any hope of meaningful recovery,” he said.

In the study, 834 participants with a history of TBI and 42 control participants without TBI were recruited and imaged between August 2009 and August 2014. Controls were not explicitly age- and sex- matched, noted the investigators; all participants were between 18 and 60 years of age.

Of the military personnel included, 92% had suffered chronic and mild TBI. Diagnosis was made a mean of 1,381 days after injury (median 888 days). Of these 817 participants, 84% reported one or more blast-related incidents and 63% reported loss of consciousness at the time of injury.

The study showed that:

White matter T2-weighted hyperintense areas was present in 51.8% of TBI participants (432 of 834; odds ratio 1.75 versus controls)

Cerebral microhemorrhages were present in 7.2% of participants with TBI (60 of 834, OR 6.64)

The incidence of cerebral microhemorrhages increased with TBI severity (P<0.001, moderate and severe versus mild)

T2-weighted hyperintense areas and microhemorrhages did not co-locate by visual inspection

Pituitary abnormalities were present in 29.0% of TBI participants (242 of 834, OR 16.8)

Development of a brain stress test, much like a cardiac stress test, could be a next step, Riedy told MedPage Today. “This would allow us to better determine the ability of the brain to respond to challenges and help us predict which service members are good to go and who should be held on the sidelines.”

Portions of the advanced imaging results are being used by the NICoE to treat military TBI patients on an individual basis, noted the investigators. “These injured service members and their families are looking for hard answers about their injuries and what to expect for their future. Providing an image of their injury often helps military personnel validate symptoms that have occurred since the time of injury. This can be an important part of their recovery process.”

As of Dec. 1, 2015, the military TBI neuroimaging database contained 1,395 patients and more than 57 million advanced images and 3.7 trillion unique data points of information about the effects of military TBI on the human brain, said Riedy. This data set is now being transferred to a federally funded TBI database, the Federal Interagency Traumatic Brain Injury Research Informatics System.

“This database will allow researchers from around the world to bring their expertise to a critical problem for the injured U.S. military population and their families, namely the accurate objective diagnosis of TBI and the related concern of possible progression to chronic traumatic encephalopathy,” said the investigators. “Further examination is required to fully evaluate structural image findings with clinical symptoms and neuropsychological measures to help develop objective biomarkers of TBI.”

“We Should Live”- – Surviving After Catastrophic Death

“We Should Live”- – Surviving After Catastrophic Death
December 04, 2015 | Couch in Crisis, Depression, Disaster Psychiatry, Major Depressive Disorder, PTSD

http://www.psychiatrictimes.com/major-depressive-disorder/we-should-live-surviving-after-catastrophic-death/page/0/1

 By Allen Frances, MD

Yutaka Ono has been a close friend of mine for 30 years and is one of Japan’s most respected psychiatrists. Shortly after the massive earthquake and deadly tsunami that hit eastern Japan 4 years ago, he began regularly visiting Onagawacho–the hardest hit town. He became consultant to Yuri Sato, the brave, wise, and energetic public health nurse responsible for organizing the town’s medical and psychosocial response to its massive tragedy.

On a recent visit to Onagawacho, Dr Ono introduced my family and his to Ms Sato and she provided an excellent slideshow explaining the mechanics of the tsunami, its devastating impact on her town, the loss of life, and the untiring efforts she and her staff had made to help the survivors endure and prevail in the face of unimaginable trauma and loss.

Ms Sato’s presentation was understated and stoical until she reached the slide listing instructions now given to townspeople on what to do should there be a future tsunami.

Among these, I was struck by and asked about: “Escape to high ground immediately. Never go back to save people or possessions.”

Ms Sato quietly explained that the tsunami’s speed made it impossible to rescue others– that each person had to be taught to do instinctively whatever it would take to simply save himself or herself. Going back in a futile attempt to save others would be wasteful of life. She added that it was particularly difficult to teach individualistic self-protection to people in Japan, because it so goes against prevailing values that cherish loyalty to others and self sacrifice for family and society.

Then, suddenly and unexpectedly, Ms Sato began to cry. She described how she had lost her own son because he had gone back to save his grandmother and both were caught in the giant wave as it rebounded to the sea. She said she felt very guilty for surviving and for having taught him to be so unselfish. With a different upbringing, he might have been more rational and still be alive. Soon all of us were crying uncontrollably. Life can be exquisitely cruel and confusing. Best intentions can have worst outcomes.

I asked Ms Sato to write about her work in restoring Onagawacho and healing herself. Dr Ono has translated. Ms Saito writes:

“The massive tsunami caused by the Great East Japan Earthquake swallowed up most of my town and killed almost 1000 people, 10% of the population. Even now, after four and a half years, there are many whose remains still have not been found.

On that day, I evacuated to the roof of the town office building. Stupefied and aghast, I could only helplessly stare frozen at the approaching wall of seawater. The next day, as I walked through the rubble, it felt like a scene from some out-of-this-world newsreel. I found the survivors squatting, huddled together in our gym which felt like a field hospital.

As public health nurses, our immediate task was to treat the injured and sick; collect and dispense medicines; and respond to the desperate conditions of the townspeople. We launched and managed an aid station and a welfare evacuation site for those in need of urgent nursing care; established countermeasures against infectious disorders; and arranged for emergency food supplies and sanitation. Housing was first in buildings that had survived on high ground — eg, sports facilities, small public halls, and school buildings. Over several months, the survivors were then moved to temporary housing.

With the entire town disaster-stricken, I was overcome with a sense of doubt and anxiety. Questions continually spun around in my mind: “What is mental health care when all of us have suffered so greatly?” But with everyone in mourning, we were single-mindedly focused on not losing any more lives to suicide or accident. 

We saw to the safety of patients with mental disorders and coordinated a treatment continuation system for them almost immediately after the tsunami.

People continued to be unable to accept the deaths of family members, relatives and friends — and the fact that so many were still missing. 

I often heard “I should have died,” “Why did I survive?” or “I want my time to come soon.” I also felt this way, but had too much work to do to linger on my own losses and feelings about them.

In such circumstances, unless a mechanism is set up within the local community that allows survivors to believe “we will live” and “we should live,” people will drop out of society and languish on their own. We recognized that “community care” not “individual care” was our most important task, and we set out to build a new sense of community as soon as possible, after the more urgent needs of the immediate crisis had been met.

In this second stage of crisis management, we focused on “public health” as relates to housing, meals and work environment of the townspeople; resumed community organization activities; and provided support in the formation of new communities to partially replace what had been lost. 

We resumed dialysis, provided maternity and infant checkups for pregnant women and newborns, gave mother and child vaccinations, and began special checkups for cancer patients and the mentally ill. Much of this health management was done in temporary housing. We also had to provide support to account for the changes in family composition caused by the tsunami– many caretakers had themselves been killed.

In November 2011, we started the project “Onagawacho Counseling Center for the Mind, Body, and Life.” The town was divided into seven areas and “expert staff of mind and body” (hereinafter referred to as “Koko-Kara Experts”) were assigned to the sub-centers to provide health support and life support to the minds and bodies of the townspeople. This combined health management with reconstructing social bonds among the people who were isolated and desolate.

In each area, one Koko-Kara Expert (public health nurses, regular nurses, or counselors) was responsible for health consultations, home visits, and reorganizing a social structure in cooperation with each neighborhood association and local officials (including the administrative community head, commissioned welfare and child commissioners, health promotion commissioners and diet improvement commissioners).

Our aim was not only mental health care but also reconstructing relationships and creating a new community. Building individual fitness requires restoring the physical and social environment. This is necessarily a gradual process, made difficult by the dilution of relationships in the community caused by the many deaths of townspeople and the fact that survivors were in temporary housing. The scattering of people from the same community in different shelters made their adjustment difficult.

We always kept in mind improvement in QOL (Quality of Life) by focusing not only on the “mind” and “body” but also the quality of “day-to-day life.” Without mutual support in the community (families, colleagues and neighbors, etc), we cannot lift the spirits of others or protect and heal and care for the mind. “Skilled Listening Volunteers” were trained to increase the number of people who would listen to the stories of families, neighbors and friends.

We keenly sense the need to help create new relationships filled with “mutuality” and “thankfulness” by expanded communication– circles of people to help people want to live. We opened cafes to promote social interaction and sponsored tea parties to legitimize having fun again.

Even after four and a half years, our challenges still have no end in sight. 

We know there will be more tasks in the field of community mental health to help prevent mental disorders, alcohol problems, lonely deaths, and suicides.”

Thanks so much Yuri and Yutaka for this information and inspiration.

We are a hardy species, evolved over millions of years to live in environments that were filled with catastrophes caused by natural disasters, famine, pestilence, and violence from fellow humans and other predators. Modern life provides some insulation for some of us, but traumatic stress remains widespread around the world and is a lurking risk for all of us.

We expected to encounter PTSD symptoms among the survivors of this horrifying experience, but Ms Sato said these have been rare. Much more common were depression, withdrawal, apathy, and guilt. Perhaps this reflects Japanese stoicism or the high average age of the survivors. But I think also that there is not a one-size-fits-all in the way people and cultures respond to overwhelming stresses. Our PTSD definition in DSM may be quite culture specific. Each person and each culture must be understood in it’s own terms and context.

I will never forget the visit to the brave little town of Onagawacho and it’s wonderful public health nurse, Ms Sato.

And I will never forget this sign on the wall of the town’s cafe. It was drawn by a 94-year-old fisherman who had survived the tsunami. His calligraphy is beautiful, his poetic words haunting: “My life is study; my headstone will be my graduation certificate.”

– See more at: http://www.psychiatrictimes.com/major-depressive-disorder/we-should-live-surviving-after-catastrophic-death/page/0/2#sthash.rX0XETqX.dpuf

Military Times: Some PTSD Treatments Have A Spotty Record

Timely article joining the recent surge of criticism toward manualized evidence-based techniques. PTSD is a spectrum disorder- complex cases require a great deal more effort, skill, flexibility, time, and clinicians’ emotional strenght than ‘gold standard’ trauma-focused techniques. The tide is shifting; we need to pivot and retrain if we are going to provide the level of care veterans and civilians with PTSD deserve. 

Bret A. Moore, Psy.D., is a board-certified clinical psychologist who served two tours in Iraq. Email him at kevlarforthemind@militarytimes.com. This column is for informational use only.

http://www.militarytimes.com/story/military/benefits/health-care/2015/12/07/kevlar-mind-ptsd-treatments-spotty-success/76773890/

Post-traumatic stress disorder is one of the most complex and troubling psychiatric issues that veterans face. Roughly 15 percent of Iraq and Afghanistan vets are diagnosed with the disorder; veterans of the Persian Gulf and Vietnam wars face comparable rates.Preferred talk therapy treatments for PTSD include cognitive processing therapy and prolonged exposure. Generally referred to as CPT and PE, these first-line treatments focus on the traumatic event as a way to reduce distress. They are the most studied treatments for service members, and guidelines for behavioral health clinicians in the Veterans Affairs and Defense departments recommend use of these types of treatments for PTSD.

But a recent study published in the Journal of the American Medical Association reveals that these trauma-focused therapies may not be as effective as originally touted.

Researchers reviewed three dozen studies of veterans and active-duty troops spanning 35 years. After analyzing data from nearly 900 individuals diagnosed with PTSD who received one-on-one or group therapy, the study revealed two important results: About two-thirds of troops continued to meet criteria for a PTSD diagnosis after “successful” treatment, and one out of four dropped out of the treatment.

That’s not to say CPT and PE didn’t help; there were meaningful results compared to no treatment at all, with substantial numbers of service members and veterans showing significant drops in measures designed to assess the presence of PTSD symptoms.
However, the decreases in scores on these clinical measures were not large enough in two out of three patients to consider them “cured” — in other words, they still had enough symptoms to retain a PTSD diagnosis And when compared to nontrauma-focused treatments like present-centered therapy and interpersonal psychotherapy, PE and CPT were only slightly better.
One criticism of trauma-focused therapies like CPT and PE is that they’re too distressing for certain patients, which causes some to drop out of treatment too soon. The most recent review, showing that one in four patients terminated treatment prematurely under both treatments, supports that criticism. In fact, in one study of PE, nearly 40 percent of patients quit therapy.
Troops and veterans who receive a trauma-focused therapy for their PTSD do improve — but unfortunately, it’s not enough. To get better control of this condition affecting a sizable portion of our military and veterans communities, we need to explore other treatment options.

We should reduce our focus on narrowly defined and proprietary interventions and refocus our efforts on customizing an array of traditional and nontraditional services for our wounded warriors.

When The Psychiatrist Has PTSD

When the Psychiatrist Has PTSD

November 24, 2015 | PTSD, Anxiety, Career

By Alisa G. Woods, PhD

Dr John Bradford of Ottawa, Canada, had a long, successful career as a forensic psychiatrist, spanning several decades. Bradford’s extensive experience with brutal people, such as sexual sadists and killers, led him to believe that he was resilient to trauma. The years of work, however, may have taken their toll. After watching highly disturbing video evidence of 2 women being assaulted as part of a high-profile case, Bradford began drinking excessively, and became depressed as well as suicidal.1 Despite 2 years of initial denial, he ultimately sought treatment for PTSD and admirably now speaks out about his experience. Although he still practices, Bradford avoids cases that involve graphic videos. His example illustrates that even seasoned professionals may fall prey to PTSD, and the toughest psychiatrists are not immune.

Michael F. Myers, MD, Professor of Clinical Psychiatry in the Department of Psychiatry & Behavioral Sciences at SUNY Downstate Medical Center in Brooklyn, New York, spoke at the American Psychiatric Association (APA) meeting in Toronto, Canada, in May 2015. His presentation “PTSD in Psychiatrists: A Hidden Epidemic” underscored the under-recognition of this prevalent condition in those who treat mental health conditions and discussed methods for increased recognition of PTSD as well as its treatment.

Ironically, mental health care providers may readily encourage their patients to confront psychiatric issues, but they are not always as willing to identify and address these problems in themselves, despite the frequent occurrence of PTSD in physicians. The lifetime prevalence of PTSD is between 8% and 9% in the general population, but is higher in physicians. For example, PTSD rates in physicians exposed to war range between 11% and 18% and are about 12% in those who practice emergency medicine.2 It makes sense that the prevalence of PTSD would be high in psychiatrists as well, owing not only to frequent traumatic encounters with those who have serious psychiatric conditions, but also to the vicarious transfer of their patients’ experiences.

PTSD can strike at any professional stage, from the experienced psychiatrist such as Dr John Bradford, to physicians in training. In his talk at the APA meeting, Myers presented data from several studies that focused on medical students and PTSD. The hazing and overworking of medical students is a tradition that continues, possibly with the notion that extremely difficult conditions will prepare students for a doctor’s life. The practice may however come with a cost. According to one study, 73% of medical students reported witnessing or experiencing mistreatment.3 In another study, 13% of 212 residents met the diagnostic criteria for PTSD based on a standard questionnaire; women were more often affected (20%) than men (9%). Lack of social support increased the risk of PTSD.4

Myers cautioned that residents may experience PTSD because they are not psychologically prepared for the traumatic events they might witness.5 He discussed several clinical situations that could be disturbing to physicians in training, including observing severe injuries, treating battered infants, seeing amputations, or observing death in a young, healthy-seeming individual. Even being put-down and humiliated by a senior physician might trigger PTSD, something for traditionalists who think students need “toughening up” to consider.

According to Myers, circumstances that may precipitate PTSD include not only medical training but also traumatic events that took place before medical school. For example, immigrants who left war-torn countries or physicians who are specifically training to deal with traumatic situations may be vulnerable; military psychiatrists also may be particularly susceptible.

Adding to the list of those at risk provided by Myers, Dr Arthur Lazarus has identified several types of physicians who might be at elevated risk for PTSD.6 These include:

• Emergency physicians

• Physicians practicing in remote areas with limited medical services

• Physicians involved in malpractice litigation

• “Second victims,” physicians who are exposed to trauma via their patients

Certainly psychiatrists would fall under the last category and may be members of the other categories as well. Understanding who is at risk can help predict and assess symptoms of PTSD in susceptible individuals.

Identification is of course the first step; however, treatment is crucial for improvement in the lives of the individual psychiatrists, as well as for those they affect professionally and personally. But if PTSD in psychiatrists is so deeply buried because of denial and a lack of social acceptance, what can be done about this problem?

Myers suggests several tactics. First, the culture of medicine needs to change. Physicians in training can be better prepared for possibly upsetting situations through debriefing, normalizing, and learning to accept the events. New institutional attitudes are needed, specifically encouraging physicians with PTSD symptoms to come forward and seek help early. The stigma and belief system that views physicians as being bulletproof to PTSD needs to change. Finally, coworkers should realize that some physicians will live chronically with residual symptoms. Again, acceptance is a key to improving the situation.

For the psychiatrist treating a colleague with possible PTSD, Myers recommends getting buy-in as a first start: for example, “see whether your patient is in agreement” when suggesting possible PTSD, and ask how the symptoms are affecting that person’s ability to work. Reassurance that treatment is effective can be helpful, as well as noting that help through therapy or medication will positively affect the psychiatrist’s professional and personal life.
– See more at: http://www.psychiatrictimes.com/ptsd/when-psychiatrist-has-ptsd/page/0/2#sthash.Pe3zwPrI.dpuf

– See more at: http://www.psychiatrictimes.com/ptsd/when-psychiatrist-has-ptsd#sthash.Edudkv5d.dpuf

Rod Serling Before ‘The Twilight Zone’

I often begin lectures on PTSD with the Twilight Zone opening- what the article does not emphasize was Serling’s struggle with what we now call PTSD – he captured the dissociative aspect of active symptoms when he described the Fifth Dimension. He was a chain smoker and a workaholic likely contributing to his early death. He was a South Pacific Airborne Army veteran who tested parachutes to help pay college tuition. His best scripts came from personal experiences- he was a Golden Glove level boxer (Requiem for a heavyweight), a soldier and after leaving the studios an ardent anti war activist during Vietnam. A short, scrappy and resilient Jewish kid he managed to creatively impact an entire generation struggling with yet unlabeled problems of injustice, lack of control and violence. A gifted man whose brilliance speaks to all. 
Sent from my iPad
Begin forwarded message:
From: Jerry Boriskin <jerryboris@me.com>

Date: December 7, 2015 at 1:56:03 PM PST

To: Jerry Boriskin <jwboris@aol.com>

Subject: Rod Serling
Rod Serling Before ‘The Twilight Zone’

http://www.wsj.com/article_email/SB11292601245819683363204581059833167534392-lMyQjAxMTE1MjA5NzIwNjcwWj
The World War II paratrooper wrote TV classics such as ‘Requiem for a Heavyweight.’

By BOB GREENE

June 25, 2015 7:17 p.m. ET

Forty years ago this weekend a dazzling American writer with a massive following died far too young. You never see his name on most-esteemed-author lists alongside Hemingway or Faulkner or Fitzgerald; the sentences he wrote were not intended to appear on a printed page.
Rod Serling was 50 years old when, after open-heart surgery, he passed away on June 28, 1975. Tens of millions of television viewers knew him solely as the host/narrator of “The Twilight Zone” series, which ran from 1959 to 1964. There is a twist to that worthy of a Serling script: He ended up on camera only because CBS’s first choice, Orson Welles, was asking for too large a salary.
So Serling, the creator of the series, was called to step in front of the lights. In retrospect, he was ideal for the role, and for the medium: dark-haired, intense and sharp-featured, often wearing a black suit, white shirt and black necktie as he introduced a black-and-white tale of that which “lies between the pit of man’s fears and the summit of his knowledge.” His crisp delivery registered with the clarity of hard-metal typewriter letters slapping against a brand-new ribbon onto a pristine sheet of paper.
Yet for all the lasting cultural cachet of “The Twilight Zone,” Serling’s genius as a writer was first, and best, seen in the years before the series went on the air. When television was still a novelty, Serling—an undersized World War II paratrooper attempting to find his footing back home—wrote a string of teleplays, presented live, that even today are stunning in their power and maturity.
“Patterns”—he was still in his 20s when he wrote it—was the Kraft Television Theatre production that, on the night of Jan. 12, 1955, made his name. A tale of betrayal and cruelty in executive suites, it presaged the visceral understanding of the human heart that would be his touchstone. 
“Requiem for a Heavyweight,” the story of a prizefighter tossed into life’s garbage heap when he ceases to be a meal ticket for his manager, may be Serling’s finest work, but there were so many others: “The Comedian,” about television’s capacity to make monsters of its stars; “The Velvet Alley,” about Hollywood’s perilous seductiveness; “The Arena,” about Capitol Hill politics corroding the souls of those who toil at it.
Coast-to-coast television was still new. With only a handful of channels available, much of an enthralled nation witnessed each live production. Serling’s most impressive contribution may have been the respect he had for the intelligence of his audience: his faith that people were willing to watch stories with serious adult themes, in the years before “adult content” came to mean curse words, gratuitous nudity and toilet humor.
In the first season of “The Twilight Zone,” Serling wrote 28 of the 36 weekly episodes. He would write the majority of the 156 productions during the series’ five-year run. The deadlines wore him out; toward the end of his life he briefly hosted a TV game show, and did commercials for beer and floor wax.
For all his 30-minute tales of otherworldly phenomena, the most vivid theme in his writing was a constant longing for home, a yearning for the place where all of us have our beginnings. He is buried in Seneca County in upstate New York, not far from where he grew up. One of the most-admired episodes in the series that made him a celebrity and that ultimately exhausted him was called “Walking Distance,” about an advertising executive with car trouble on a country road. The man walks to the small town where he was born—and discovers himself, as a boy, in a place where nothing has changed, and where he knows he cannot stay.
Here are the final words in that night’s show, heard in Serling’s voice-over narration, describing the character but also likely speaking of someone else:
“Martin Sloan, age 36, vice president in charge of media. Successful in most things, but not in the one effort that all men try at some time in their lives—trying to go home again. And also like all men, perhaps there’ll be an occasion, maybe a summer night sometime, when he’ll look up from what he’s doing and listen to the distant music of a calliope, and hear the voices and the laughter of the people and the places of his past. And perhaps across his mind there’ll flit a little errant wish: that a man might not have to become old, never outgrow the parks and the merry-go-rounds of his youth. And he’ll smile then too, because he’ll know it is just an errant wish, some wisp of memory, not too important, really: some laughing ghosts that cross a man’s mind, that are a part of the Twilight Zone.”
Mr. Greene’s books include “When We Get to Surf City: A Journey Through America in Pursuit of Rock and Roll, Friendship, and Dreams” (St. Martin’s Griffin, 2009).
813
Sent from my iPhone

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From the WSJournal
Rod Serling Before ‘The Twilight Zone’

http://www.wsj.com/article_email/SB11292601245819683363204581059833167534392-lMyQjAxMTE1MjA5NzIwNjcwWj
The World War II paratrooper wrote TV classics such as ‘Requiem for a Heavyweight.’

By BOB GREENE

June 25, 2015 7:17 p.m. ET

Forty years ago this weekend a dazzling American writer with a massive following died far too young. You never see his name on most-esteemed-author lists alongside Hemingway or Faulkner or Fitzgerald; the sentences he wrote were not intended to appear on a printed page.
Rod Serling was 50 years old when, after open-heart surgery, he passed away on June 28, 1975. Tens of millions of television viewers knew him solely as the host/narrator of “The Twilight Zone” series, which ran from 1959 to 1964. There is a twist to that worthy of a Serling script: He ended up on camera only because CBS’s first choice, Orson Welles, was asking for too large a salary.
So Serling, the creator of the series, was called to step in front of the lights. In retrospect, he was ideal for the role, and for the medium: dark-haired, intense and sharp-featured, often wearing a black suit, white shirt and black necktie as he introduced a black-and-white tale of that which “lies between the pit of man’s fears and the summit of his knowledge.” His crisp delivery registered with the clarity of hard-metal typewriter letters slapping against a brand-new ribbon onto a pristine sheet of paper.
Yet for all the lasting cultural cachet of “The Twilight Zone,” Serling’s genius as a writer was first, and best, seen in the years before the series went on the air. When television was still a novelty, Serling—an undersized World War II paratrooper attempting to find his footing back home—wrote a string of teleplays, presented live, that even today are stunning in their power and maturity.
“Patterns”—he was still in his 20s when he wrote it—was the Kraft Television Theatre production that, on the night of Jan. 12, 1955, made his name. A tale of betrayal and cruelty in executive suites, it presaged the visceral understanding of the human heart that would be his touchstone. 
“Requiem for a Heavyweight,” the story of a prizefighter tossed into life’s garbage heap when he ceases to be a meal ticket for his manager, may be Serling’s finest work, but there were so many others: “The Comedian,” about television’s capacity to make monsters of its stars; “The Velvet Alley,” about Hollywood’s perilous seductiveness; “The Arena,” about Capitol Hill politics corroding the souls of those who toil at it.
Coast-to-coast television was still new. With only a handful of channels available, much of an enthralled nation witnessed each live production. Serling’s most impressive contribution may have been the respect he had for the intelligence of his audience: his faith that people were willing to watch stories with serious adult themes, in the years before “adult content” came to mean curse words, gratuitous nudity and toilet humor.
In the first season of “The Twilight Zone,” Serling wrote 28 of the 36 weekly episodes. He would write the majority of the 156 productions during the series’ five-year run. The deadlines wore him out; toward the end of his life he briefly hosted a TV game show, and did commercials for beer and floor wax.
For all his 30-minute tales of otherworldly phenomena, the most vivid theme in his writing was a constant longing for home, a yearning for the place where all of us have our beginnings. He is buried in Seneca County in upstate New York, not far from where he grew up. One of the most-admired episodes in the series that made him a celebrity and that ultimately exhausted him was called “Walking Distance,” about an advertising executive with car trouble on a country road. The man walks to the small town where he was born—and discovers himself, as a boy, in a place where nothing has changed, and where he knows he cannot stay.
Here are the final words in that night’s show, heard in Serling’s voice-over narration, describing the character but also likely speaking of someone else:
“Martin Sloan, age 36, vice president in charge of media. Successful in most things, but not in the one effort that all men try at some time in their lives—trying to go home again. And also like all men, perhaps there’ll be an occasion, maybe a summer night sometime, when he’ll look up from what he’s doing and listen to the distant music of a calliope, and hear the voices and the laughter of the people and the places of his past. And perhaps across his mind there’ll flit a little errant wish: that a man might not have to become old, never outgrow the parks and the merry-go-rounds of his youth. And he’ll smile then too, because he’ll know it is just an errant wish, some wisp of memory, not too important, really: some laughing ghosts that cross a man’s mind, that are a part of the Twilight Zone.”
Mr. Greene’s books include “When We Get to Surf City: A Journey Through America in Pursuit of Rock and Roll, Friendship, and Dreams” (St. Martin’s Griffin, 2009).
813
Sent from my iPhone

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The VA treated my PTSD all wrong – By David J. Morris November 11

Perhaps the best single article of Veteans Day 2016. A powerfully provocative personal piece focusing on moral injury and challenging the validity of the long extant biobehavioal psychiatric zeitgeist. His book published early this year is outstanding and should be required reading for clients and providers alike.

https://www.washingtonpost.com/posteverything/wp/2015/11/11/the-va-treated-my-ptsd-all-wrong/

David J. Morris is a former Marine infantry officer and the author of “The Evil Hours: A Biography of Post-traumatic Stress Disorder.”

The first time I saw war up close was in May 2004, on a reporting trip to Iraq where I watched the first battle of Fallujah winding down. I had resigned my commission in the Marine Corps a few years before and had gone to Iraq out of a sense of obligation: As a reporter who understood a thing or two about tactics, who better to write about it than me? Ten years later, I was diagnosed with PTSD by the Department of Veterans Affairs. I had been having nightmares and was sleeping poorly. One day after taking a walk near my mother’s house, I became convinced that I was hearing the Muslim call to prayer echoing down the winding streets of suburban San Diego. I called the VA soon after.

After suffering through the usual bureaucratic indignities — in my case sitting on a waiting list for three months — I started treatment at the big VA hospital in La Jolla, which included weekly appointments with a therapist who was finishing up his doctorate. Oddly, whenever I brought up the issues that bothered me the most — the catastrophic mismanagement of the war by the Bush administration, the pointless slaughter I’d seen in Fallujah, the casually bloodthirsty way Americans would talk about Iraq and about Arabs in general — my therapist would change the subject. I was admonished for “intellectualizing” my trauma and encouraged to focus instead on an IED ambush I had survived in Baghdad in 2007, as if that one event were the key to unlocking all my feelings about the war. Eventually this made my insomnia and anger issues worse, so I quit.

It was almost as if politics had been ruled off-limits by the VA, a negation of everything I’d been taught as a Marine officer, which began with Clausewitz’s dictum that war is a “continuation of politics by other means.”

When I asked around, I found other veterans felt the way I did. Some of my peers told me that the war had destroyed their sense of what America was and negated the idealism that inspired them to enlist in the first place. As one friend who served in Mosul with the Virginia National Guard told me recently, “for me the most damaging thing to my mental health is the lack of official clarity on the lies that took us into the war. More than all the violence and the other s— that I saw, it’s the lies.”

As Garett Reppenhagen, an army sniper in Iraq, explained in a recent article for Salon, “I was taken aside more than once at the VA during group therapy and told that the VA is not a platform to express my political views. [To me] my recovery hinged on the fact that I felt guilt and shame over committing atrocities against an occupied country. We went over there and brutalized and oppressed, and that is part of my psychological and moral injuries. If I can’t talk about it at the VA, then the VA can’t help me.”

Another Iraq veteran I spoke to told me that he stopped raising the issue of politics in therapy because it made his therapist “visibly uncomfortable” and fumble her words, as if she were violating some VA protocol.

Puzzled by this, I went to the library and began looking into the history of PTSD. What I found was shocking. I’d always had a vague awareness that PTSD was connected to the Vietnam War, but I what I didn’t realize was the original proponents of what became the PTSD diagnosis were all radical anti-Vietnam protesters who were convinced that American culture was the culprit. These activists argued that our country was locked into a kind of “psycho-mythology of war-making” that resulted in “a brutalization of its warriors and of the American psyche.”

These early PTSD advocates, from a group known as the Vietnam Veterans Against the War, saw their personal psychological struggles as inextricable from a larger failed American morality, a morality that made atrocities like My Lai not only foreseeable but inevitable. Many of them believed that Vietnam was only the most visible symptom of a larger “moral pollution” at the heart of American society that made such atrocities seem reasonable. As Robert Lifton, a psychiatrist closely associated with VVAW, put it, “There are always moral questions, which are inseparable from political questions, that are at issue. I think some psychologists make the mistake of imagining that it’s all a technical matter. For the healing process to take place, the veteran needs to confront what they have been a part of. It’s almost beyond politics, though it ultimately gets to the question of: Should we have been there? Or: Why was I sent there?”

It’s a powerful feeling when you discover that you are not alone in history, when you see that your feelings echo across the decades. My feelings were virtually identical to the original moral argument behind the PTSD concept, an argument that said, roughly: War has long-term psychological consequences and immoral, unjust wars have even greater psychological consequences.

Curious, I started doing more research, searching for answers to a few fundamental questions: Why were the VA therapists I worked with so uninterested in the larger moral issues? What had caused this sea change in the VA and in psychiatry at large?

When I dug into the history, I discovered that this shift wasn’t a systematic attempt by the VA to suppress the thorny political and moral questions relating to PTSD; instead it was the result of a broader campaign by biological psychiatrists to treat mental disorders as diseases arising from malfunctioning systems within the human brain. Instead of “psycho-mythology,” “moral pollution” and “atrocity-producing situations,” clinicians today talk about fear activation, hyperarousal, the amygdala and the behavior of stress hormones like cortisol. The idea that veterans and trauma survivors of any kind might experience a crisis of faith in society is completely foreign to most PTSD therapists today.

This effort to depoliticize PTSD and treat it like any other psychiatric disorder began almost immediately after it was inducted into the bible of psychiatry, the “Diagnostic and Statistical Manual of Mental Disorders,” in 1980. As Matthew Friedman, the longest-serving director of the VA’s National Center for PTSD, said in a 1984 interview, the early pioneers of the PTSD diagnosis, people like Lifton, perceived it as a “psychological disorder, rather than a biological disorder,” adding that his job as he saw it was to take PTSD into the psychiatric mainstream, which by the 1980s had become increasingly focused on the biological characteristics of mental illness. As one senior VA official who has treated PTSD for over 30 years explained to me, “biological research is at the forefront of PTSD research today because that’s where the money is.”

Beginning in the mid-1990s, some trauma theorists like Jonathan Shay, a retired VA psychiatrist, repackaged some of the ideas first identified by VVAW and began promoting a concept he called “moral injury.” This moral injury paradigm, which is very popular in veteran circles today, is built on the idea that veterans often experience “injuries” to their conscience because of their actions during war.

However, a number of researchers, such as Brett Litz of Boston University, have argued that prolonged exposure— the type of therapy I underwent at the VA in San Diego — can actually exacerbate PTSD symptoms arising from morally damaging experiences like “friendly fire” or being ordered to torture foreign detainees.

Seeing how coldly scientific and divorced from its moral roots PTSD has become, it is hard to not conclude that modern psychiatry has completely betrayed the original intentions of the Vietnam veterans who fought to have their struggles recognized and morally neutered their original argument. As Arthur Egendorf, a founding member of VVAW, told me recently “I spent many years in outrage, incomprehension, often flailing about when I saw where things were going after the American Psychiatric Association and its ‘biopsychiatry bias’ got a hold of the new [PTSD] diagnosis.”

Throughout history, the great movements to address the trauma of war have always been linked to the morality of war itself. Siegfried Sassoon, the World War I poet, ended his account of shell shock with the following provocation: “In the name of civilization these soldiers have been martyred, and it remained for civilization to prove that their martyrdom wasn’t a dirty swindle.” The war in Iraq was nothing if not a dirty swindle, and it remains for America to prove to its veterans that it has learned anything from their martyrdom.

Survival or Suicide- Primo Levy’s Ambiguous Legacy

The recent NYTimes series on suicide raises poignant, timeless uncertainties in terms of prevention, intervention, survival and meaning. A less visible article from Tablet Magazine (link below), with great depth and complexity provides insight from Holocaust authors who were survivors and/or suicides from the 1940s.  I urge readers to consider the uncertainties and complexities surrounding suicide, and then derive personal insights and comments that help us all navigate the aftermath generated by the fog of war.

Here’s a sample of the brilliance reflected in the Tablet article about Primo Levi:  

his fellow writer and survivor Elie Wiesel delivered an epigrammatic coroner’s report: “Primo Levi died at Auschwitz forty years later.” 

But even at this moment, Levi declined to pray, because it would have violated his convictions: “The rules of the game don’t change when it’s about to end, or when you’re losing.” Not just an atheist in a foxhole, but an atheist at the door of the gas chamber: This is spiritual strength and self-reliance of a degree we ordinarily associate, ironically, with saints.

There are, then, two ways of reading Levi’s life and work. It can be the hopeful story of a man who survives the worst imaginable torture and manages to find meaning, purpose, and happiness in life. Or else, it can be a story of a man who accidentally escapes death and is so haunted by the moral nullity of survival that, decades later, he takes his own life out of guilt or despair.



http://www.tabletmag.com/jewish-arts-and-culture/books/193650/primo-levis-complete-works?utm_source=tabletmagazinelist&utm_campaign=148e70a8d2-Monday_September_21_20159_21_2015&utm_medium=email&utm_term=0_c308bf8edb-148e70a8d2-207470305

New York Times: Marine Battalion Suicides

This lengthy and distressing article is a must read. I have highlighted a few quotes below worthy of deep consideration and discussion. Whereas we cannot stop the unstoppable our service delivery system and my profession is pathetically misguided, fractionated, grandiose and blinded by weak studies and poor training. The noted dropout rate for the gold standard treatment obscures the many veterans refusing to even start. We need better outreach, drastically reduced dropouts and a massive infusion of talent, interpersonal  skill training and a seamlessly integrated system capable of delivering care to the wide spectrum of symptoms, as well as co-occurring addictions. It pains me to validate the comment from clinician comparing his pain to a “bad breakup with a girl; it  is congruent with reports from veterans I have worked with. Too many professionals blame the client for failing to comply. Too often the problem is the hubris, arrogance, fear and entitlement of those chartered to provide care. Our soldiers put their lives on the lines; our models must mirror the commitment.  Whereas we cannot stop disaster we can and must dramatically upgrade our care. We need a revolutionary zeitgeist and a return to humanistic care. 

In Unit Stalked by Suicide, Veterans Try to Save One Another

Members of a Marine battalion that served in a restive region in Afghanistan have been devastatedby the deaths of comrades and frustrated by the V.A.

http://www.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.html?hp&action=click&pgtype=Homepage&module=second-column-region&region=top-news&WT.nav=top-news&_r=0

Some outtakes from the full article:

Back home, he was getting counseling at the V.A., family members said, but faced delays and struggled to find a therapist who he felt understood him. In April 2014, he hanged himself in his apartment.

He sat down with a therapist, a young woman. After listening for a few minutes, she told him that she knew he was hurting, but that he would just have to get over the deaths of his friends. He should treat it, he recalled her saying, “like a bad breakup with a girl.”

The comment caught him like a hook. Guys he knew had been blown to pieces and burned to death. One came home with shrapnel in his face from a friend’s skull. Now they were killing themselves at an alarming rate. And the therapist wanted him to get over it like a breakup?

Mr. Bojorquez shot out of his seat and began yelling. “What are you talking about?” he said. “This isn’t something you just get over.”

He had tried getting help at the V.A. once before, right after Mr. Markel’s funeral, and had walked out when he realized the counselor had not read his file. Now he was angry that he had returned. With each visit, it appeared to him that the professionals trained to make sense of what he was feeling understood it less than he did.

He threw a chair across the room and stomped out, vowing again never to go back to the V.A.

A 2014 study of 204,000 veterans, in The Journal of the American Psychological Association, found nearly two-thirds of Iraq and Afghanistan veterans stopped Veterans Affairs therapy for PTSD within a year, before completing the treatment. A smaller study from the same year found about 90 percent dropped out of therapy.

The therapies, considered by the department to be the gold standard of evidence-based treatments, rely on having patients repeatedly revisit traumatic memories — remembrances that seem to cause many to quit. Evaluations of the effectiveness of the programs often do not account for the large number of patients who find the process disturbing and drop out.

Dr. Kudler of the Department of Veterans Affairs said data showed that 28 percent of patients drop out of PTSD therapy, but that most veterans stay in treatment and report improvements.

WSJ VA Needs ‘Systemwide Reworking,’ Independent Report Finds Congressionally mandated independent review of Veterans Affairs health-care system identifies widespread problems

Apropos the article a friend reminded me of this YouTube clip: https://www.youtube.com/watch?v=SjbPi00k_ME

As noted in the article I do hope this comes to pass: “The independent assessment highlighted systemic, critical problems,” the report said. “Solving these problems will demand far-reaching and complex changes that, when taken together, amount to no less than a systemwide reworking of VHA.” Privatization is often cited as the answer. However, privatization is a simplistic solution to a complex problem. The article points out legitimate flaws needing major changes. These flaws must be fixed – we need a massive reboot, better integration, improved accountability and customer service, not elimination.

http://www.wsj.com/articles/independent-report-says-va-needs-system-wide-reworking-1442594539​

Updated Sept. 18, 2015 5:53 p.m. ET

A sweeping independent review of the Department of Veterans Affairs health-care system made public Friday shows the multibillion-dollar agency has significant flaws, including a bloated bureaucracy, problems with leadership and a potentially unsustainable capital budget.
More than a dozen assessments—from analysts including Mitre Corp., Rand Corp. and McKinsey & Co.—show that the Veterans Heath Administration, the health-care arm of the department known as VHA, is still plagued by long-standing issues, including unsustainable costs in the future and a system that veterans find tough to navigate.

The assessments, weighing in at more than 4,000 pages total, were mandated by the Veterans Access, Choice and Accountability Act, commonly known as the Veterans Choice Act, a more than $16 billion emergency funding measure passed last summer in the wake of a systemwide scandal at the VA that led to the resignation of a number of top officials, including then-Secretary Eric Shinseki. They appear to restate, more thoroughly, many issues that have been previously identified. The assessments will be used by the Commission on Care, also mandated by the act, which is tasked with presenting the VA and Congress a comprehensive reform plan in early 2016.

“The report bears out collectively what I have seen individually, what I have seen in my role as chairman over the past nine months,” said Sen. Johnny Isakson (R., Ga.), chairman of the Senate Committee on Veterans’ Affairs. “There is a huge focus on some glaring deficiencies that need to be addressed.”
Mr. Isakson said the VA suffers especially from a system saddled with a number of different departments that can’t effectively talk with each other, as well as a number of vacancies in leadership positions that need to be filled, though he said the department has been working to correct a number of issues.
“VA is undergoing a radical transformation,” the department said in response to the findings, pointing out a number of efforts to address problems highlighted in the assessments. “VA will work with Congress, veterans service organizations, veterans, and other stakeholders on the recommendations outlined in the Independent Assessment Final Report. VA will especially work closely with Congress on those final report recommendations that specify specific congressional action needed to implement.”
The assessments found VA care outperformed non-VA care by many measures but also showed a system that needs even more change.
“The independent assessment highlighted systemic, critical problems,” the report said. “Solving these problems will demand far-reaching and complex changes that, when taken together, amount to no less than a systemwide reworking of VHA.”
With an annual budget of some $60 billion, 1,600 health-care sites and 300,000 employees, the VHA says it is the largest integrated health-care system in the U.S. Last year, nearly 6 million veterans were treated in the system.
The reports portray the VA as a huge operation that has become difficult to steer and permeated by a bureaucratic system plagued by mismanagement and inconsistent care from hospital to hospital.
“It’s pretty bad for VHA, it’s pretty stinging,” said a senior staff member of the Senate Committee on Veterans’ Affairs. “There’s nothing in here that has surprised me, but seeing it all in one place is probably the hardest thing.”
“They’ll push out a directive and they won’t follow-up to see how it’s implemented,” the congressional staffer said, adding that a large number of leadership positions in the organization remain unfilled or staffed by interim employees.
The report shows that the central office has grown 160% over the past five years, yet key leadership positions down the chain remain empty. More than half of the executives in the organization are eligible for retirement and could leave at any time, which could create even more leadership gaps.
The lengthy and critical reports come as the VA faces questions over whether it should allow more veterans to go outside of the system to receive private care. Recently, according to the assessments, health care obtained outside of the VA accounts for about 10% of VHA expenditures. The Veterans Choice Act of last year was built in large part around funding this type of care.
Questions about further privatization were highlighted recently when Ben Carson, a leading Republican presidential candidate and physician, suggested the VA make a push toward privatization and elimination of the VHA, its health-care delivery arm.
Earlier this week, a number of major veterans groups sent an open letter to Mr. Carson stressing the need to keep the VHA solvent.
The assessments released Friday unfavorably compared the VA’s management style to a number of private health-care providers like Kaiser Permanente.
Sen. Isakson said the Veterans Choice Act, which allows veterans more leeway in seeking care outside the VA, was an emergency measure and not something meant to steer the VA down a privatized path. “The Choice program, contrary to what everyone thought, was not a sinister program to privatize the VA.”
Robert McDonald, who took over as VA secretary last summer, has been praised by many in Congress as well as most major veterans groups for his efforts to reform the VA and his willingness to listen to patients and workers. But he has also been criticized for things like moving too slowly in firing underperforming employees and not supporting efforts to create an environment where employees can point out wrongdoing in the department. Mr. McDonald has said multiple times in the past that he is forcing out bad actors as quickly as possible.
“As a general matter, the president has made it a priority to ensure that America’s veterans are getting the kind of health care and benefits they have so richly earned,” White House press secretary Josh Earnest said Friday, saying he had not seen the substance of the report.
Mr. Earnest said that some of the reforms at the VA have already begun to show progress in improving care.
“But the president, Secretary McDonald and other senior officials at the VA are not going to rest until we have accomplished our goal of making sure that all our veterans are getting the kind of care that they deserve, on time,” Mr. Earnest said.
On Thursday, the U.S. Office of Special Counsel, an independent federal watchdog tasked with protecting government employees, especially whistleblowers, sent a letter to President Barack Obama criticizing what they said was the VA’s reluctance to take disciplinary action against officials responsible for inadequate patient care.
“I have identified recent additional cases in which the VA confirmed serious misconduct brought to light by whistleblowers, yet failed to appropriately discipline responsible officials,” said Carolyn Lerner, the head of the office. Her office criticized the VA for punishing whistleblowers while not punishing those who engaged in misconduct.
“Over the past year, the Department of Veterans Affairs has worked closely and in good faith with the Office of Special Counsel to correct deficiencies in the department’s processes and programs to ensure fair treatment for any whistleblower who raises a hand to identify a problem, make a suggestion or report what may be a violation in law,” the department said in a statement.
Access to VA care has increased dramatically since the mid-1990s, the report said, as changes in policy opened up the system to include not just combat-wounded veterans but many others who have served. Former Secretary Shinseki pushed to have veterans take advantage of their benefits and increased access to those like Vietnam veterans exposed to Agent Orange.
Although the VA has other departments, including a benefits arm, the VHA accounts for nearly 90% of the department’s discretionary budget and employee base. While the total population of veterans in the U.S. peaked around 1980 at 30 million and has declined since then, according to the report, demand for VA care has been steadily increasing as greater numbers of vets take advantage of benefits. The number of enrollees and patients isn’t expected to peak until 2019.
Write to Ben Kesling at benjamin.kesling@wsj.com