Recently, I wrote about a whitewater rafting program in Montana, the X Sports 4 Vets program, as therapy for post-traumatic stress disorder, and I remember talking with a vet named Steve Hale, who deployed to Iraq in 2004-05 with the Washington National Guard and who came home depressed and unable to socialize with others. The river outings gave him great exercise, an adrenaline rush and a feeling of teamwork with his rafting buddies, who were also vets.

“Every time I get out on the river, I come home with stories and big pleasant memories,” Hale told me. “It does me a lot more good than the pills they’ve been throwing at me.”

Perhaps, just perhaps, the Army is beginning to get a piece of this picture.

Last month, the U.S. Army Medical Command issued a report changing its policy on pharmaceuticals. It said that only Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) have shown evidence that they do enough good for a patient to justify the prescription.

It strongly cautioned against prescribing benzodiazepines and atypical antipsychotics, saying that they do more harm than good. “There is evidence to suggest that benzodiazepines may actually potentiate the acquisition of fear responses and worsen recovery from trauma,” it said. As to atypical antidepressants, and specifically Risperidone, it said: These medications have shown disappointing results in clinical trials in the treatment of PTSD.”

Last weekend, the Philadelphia Inquirer quoted the assistant secretary of defense, Dr. Jonathan Woodson, as saying that prescription rates for atypical antidepressants increased 10 times between 2002 and 2009: from 0.1 percent to 1 percent. It said AstraZeneca’s Seroquel was prescribed to 1.4 percent of Army personnel and 0.7 percent of the Marines in fiscal 2010.

AstroZeneca reportedly made nearly $6 billion on 14.1 million prescriptions for versions of Seroquel last year.

It told the Philadelphia Inquirer: “Seroquel is not approved for the treatment of PTSD or indicated for use as a sleep aid. Atypical antidepressants, like many other medications, are often prescribed by mental-health professionals for indications beyond those set forth in the FDA-approved labels. Like patients, we trust doctors to use their medical judgment to determine when it is appropriate to prescribe medications. Patient safety is a core priority for AstraZeneca, and we believe that Seroquel is a safe and effective medication when used as recommended.”

Risperidone was the second most-prescribed antipsychotic drug during that period with 12.2 million prescriptions written nationwide.

The Army also broadened its preferred list of psychotherapies for soldiers, saying that trauma-focused PTSD treatment can include narration (including imaginal exposure), cognitive restructuring, in-vivo exposure, relaxation or stress modulation skills, and psycho-education. It specifically mentioned programs such as Prolonged Exposure Therapy, Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing (EMDR), or “other forms of trauma-focused cognitive behavioral therapy, all of which have been shown to have generally equivalent effectiveness.”

Since PTSD often occurs in conjunction with other mental health problems, it encouraged multidisciplinary approaches, including hypnosis, art therapy, bio/neurofeedback, yoga, acupuncture, and massage.

The new policy noted that some patients may prefer such therapies to pharmaceuticals. “Matching evidence-based components to patient preferences is likely to help in fostering engagement and willingness to remain in treatment, which ultimately is one of the strongest predictors of overall treatment efficacy,” it said.

Attached to the report was a chilling article written last year for JAMA, the Journal of the American Medical Association. Dr. Charles W. Hoge of the Walter Reed Army Medical Center concluded: “With only 50 percent of veterans seeking care and a 40 percent recovery rate, current strategies will effectively reach no more than 20 percent of all veterans needing PTSD treatment.”

According to the Army, up to 25 percent of the more than 2 million troops deployed to combat zones in Iraq and Afghanistan may experience PTSD “with combat frequency and intensity being the strongest predictor of this condition.”

But four years ago, the Rand Corp. interviewed 1,965 vets and projected in its controversial 2008 report that 18.5 percent of all returning service members would meet the criteria for either PTSD or depression (14 percent for each, but there’s some overlap), and that another 19.5 percent would experience a probable traumatic brain injury while overseas. Again after taking into account that overlap, it said 31 percent of all returning troops would suffer from one or all of those ailments.

The VA’s actual treatment figures show 28.5 percent of the returning vets are seeking mental health care, which is right on track with the Rand Report. But while the Rand Report projected that some 320,000 American soldiers would need help for TBI, the VA says only 54,070 vets (a little over 4 percent of the returning vets) qualified for that diagnosis.

We’re walking along a dusty gravel road in the valley between two West Virginia ridges when the Iraqi War hero that I’m interviewing suddenly notices something troubling.

“I planted a bamboo shoot beside that stream and arranged some rocks as a memorial to a fallen soldier who was a friend of mine,” says James. L. McCormick, his voice tightening a little. As I look down toward the stream, I can see a hole where the bamboo has been ripped out and the stone memorial has been kicked apart.

McCormick has seen a number of friends fall, but many more foes drop. He won his first Bronze Star and a Purple Heart for leading attacks on enemy bunkers during Desert Storm as a scout squad leader. Then he was awarded two more Bronze Stars and two more Purple Hearts for his service in Iraq. And the retired Army captain has also been nominated for the Distinguished Service Cross and the Silver Star, the nation’s second- and third-highest military awards for valor.

“This guy is the Audie Murphy of the truck drivers,” says Rich Killblane, the U.S. Army Transportation Corps historian based in Fort Lee, Va. “No truck driver has been in as many ambushes as he has, and all the big ones.”

These days, McCormick has bought a 15-acre farm a few miles east of the Ohio River for his own peace of mind and to help his fellow vets. He calls it the “Raising Cane Farm,” and for erosion control on steep hillsides, he plants as much bamboo as he can afford at nearly $20 a plant.

“I provide jobs for some vets out of my own pocket,” he says. “Others just come out here to walk and relax. And we bring a bunch of guys out here for the deer hunting each fall.”

Taking care of his fellow vets remains important to McCormick. “I’ve told a bunch of my battalion commanders that just because you retire doesn’t mean that you can retire your responsibilities,” he says.

Those responsibilities weigh heavily on McCormick, especially when someone desecrates his memorial to a fallen comrade.

“I’m about half tempted to mount an ambush, catch this guy red-handed if he returns, and whip him with the bamboo he was attempting to steal,” says McCormick, trying to laugh off a growing sense of outrage.

Killblane says McCormick was no one to mess with. “Before he turned his life over to Christ, if he threatened to kill you, he probably would have,” he observes.

Killblane is writing a book about convoy ambush case studies that teach convoy commanders how to fight ambushes and a history of convoy operation during the war in Iraq. He says McCormick was one of the most instinctive warriors he has seen. “His philosophy was to punish the enemy to deter him from attacking any more convoys,” he says. “Of all the ambushes I’ve researched, it’s McCormick who stands out the most.”

The days leading up to Easter Sunday, 2004, prove Killblane’s point.

First, McCormick and his gun truck crew ran into their first ambush on March 22 when they turned back into the kill zone. That was when the lieutenant was wounded in the calf earning his second Purple Heart Medal.

Despite his protests, McCormick was sidelined while his platoon left on a mission without him.  Then on April 7, after the radical young cleric Muktada al Sadr called for a jihad against coalition forces, McCormick and picked up an all volunteer crew to provide security for a convoy hauling supplies to Baghdad International Air Port (BIAP), where the convoy ran into an L-shaped ambush with a sniper positioned on an overpass in front of them.

McCormick was hit in the chest, with his body armor absorbing the blow. Still he was knocked backward off his feet, while a second round hit his machine gun ammunition belt, sending shrapnel into his hand, says Killblane.

“Remembering what a Vietnam veteran told him, when insurgents approached, McCormick fired a flare at them and they scattered thinking it was a rocket,” Killblane says. “That gave him enough time to re-load his machine gun, and then he splattered the sniper who was then about to shoot his driver.”

The next day, Good Friday, all hell broke loose as the enemy ambushed any convoy trying to get in or out of BIAP. The next day, all convoys were shut down but the 1^st Cavalry Division, which drew its supplies from BIAP was running critically short.

On Easter Sunday, McCormick and his crew volunteered to escort a convoy hauling critical ammunition to the Green Zone, just eight miles away, but about noon a sea of insurgents began storming their compound with the intent to breech the wall and kill the hundreds of truck drivers parked behind it.  “When his Humvee gun truck mounted the ramp overlooking the wall, all he could see were Iraqis in black.” says Killblane. “For five to ten minutes, McCormick and his crew held off the attack by themselves and then for the next forty minutes only a dozen truck drivers defended the wall.”

Thirty minutes after repelling that attack, McCormick and his emotionally exhausted crew provided security for an ammunition convoy running a gauntlet eight miles to the Green Zone. Since the commander broke his convoy into four smaller convoys, the gun trucks had to make the dangerous run four times.

“They were driving thin-skinned (not armored) trucks, and they got hammered while other armored gun trucks turned tail and ran,” says Killblane. “On the next run, they got ambushed again, but McCormick turned his gun truck into the enemy and it seemed to work because there was less gunfire on the next convoy, and the fourth run was almost incident-free.” By the end of the day, four of the five crew members in his gun truck had been wounded and would still follow him anywhere, says Killblane.

For the ambush going into BIAP, McCormick was awarded the Bronze Star. McCormick later earned another Bronze Star, but has been nominated for the Distinguished Service Cross for his action on Easter Sunday and the Silver Star for his leadership during 40-minute firefight on January 30, 2005. “Lt. McCormick’s warrior spirit and leadership under fire saved hundreds of lives, protected critical military cargo and inflicted heavy enemy casualties upon a ruthless and determined enemy,” said the citation nominating McCormick for the Distinguished Service Cross, which is still pending review.

“His actions were probably the most heroic of any truck driver in Iraq,” Killblane says. “He was grossly overlooked.”

After he left Iraq, McCormick says he spent a year and a half in the VA’s poly-trauma unit in Huntington, W.Va.  “I couldn’t do anything for myself,” he explains. “I slept with a loaded revolver and drank heavily and smoked like a freight train. I had panic attacks and I couldn’t find anything to bring me down, so I did a lot of heavy drinking. When I had nightmares, they terrified my wife, and she’d go out and sleep on the couch.”

Buying the farm between Huntington and Point Pleasant helped.

“This is a place where vets can come and realize that we’re finally at peace,” he says. “This place has so much more healing power than anything you get out of a bottle, either alcohol or pills.”

But McCormick’s 13-year-old son Jimmy had been watching him closely. “You’re really upset about that memorial, aren’t you Dad?” he asked, just as I was leaving.

McCormick emailed this resolution to me the next day: “I said yes it did son, very much so, because we planted it for all fallen troops and to see that just brought back a wave of bad memories on how people died that I personally knew. To me when I saw it, I could hear the crying and see the death all over again. It was simply a violation in the worse way to me, and since it is well know what we do out on the farm I couldn’t help but see it as an intentional slap in the face of not only me but every Gold Star family I know.

“My son is very much in tune with his feelings and looked at me and said. ‘Let’s plant another one, Dad, in the same spot and let me do something to honor your friends.’ He walked the length of that stream picking out all the stone to lay the walkway, he planted the plant again and asked me to help him with the cross, and truly he did most of that as well. I asked him what if someone tears it up again. He said well then we will just come back and build again only this time bigger. On Sunday, he bought flower seeds and next weekend we will plant them around the outline of the cross, again his idea. Got to love that boy.”

I wrote recently that neuroplasticity has the potential to be very helpful to combat vets because a “plastic” brain that has been changed by trauma can continue to change. Good memories can layer over and alleviate the bad ones. My last blog on whitewater rafting as a therapy for post-traumatic stress disorder (PTSD) suggests that this concept works.

But there’s a downside that vets are particularly susceptible to. Dr. Norman Doidge, author of the best-selling book “The Brain That Changes Itself,” calls it “the plastic paradox.” Because the brain is neuroplastic, mental experiences can change it and create completely novel circuits in the brain. There’s a lot of flexibility in the brain, but not all change is good.  The same plasticity that can give rise to flexible behaviors can, if mental experiences are repeated over and over, lead to rigid, repetitive behaviors.

Doidge, a medical doctor and a psychiatrist affiliated with both the University of Toronto and Columbia University, says this occurs in vets with PTSD. PTSD is a neuroplastic disorder par excellence because a person with a functioning nervous system experiences an event, the meaning of which is so overwhelming to the mind that soon the brain is completely rewired by it.

Let’s walk through how this works.

First, the trauma of an intense firefight or your buddy dying in your arms overwhelms your brain, causing it to change its structure and function. It’s now on high alert for a new threat. “The event so overwhelmed the brain when it first occurred that it overwhelmed the circuitry that allows the victim to turn the event from a perception into a memory, something our brain normally does the moment an event is over,” Doidge told me.

And that’s the cause of flashbacks, Doidge says. “Each time people have ‘flashbacks,’ they are experiencing unfiled perceptions of the horrible event — not memories. (We mistakenly call them memories because they seem to be repeats of what happened, but subjectively, flashbacks are more like perceptions, and sometimes almost more like hallucinations.) And since the brain thinks the event is still happening, this triggers the threat system in the brain. Neurons that fire together wire together, so each time the flashback occurs, it more deeply connects the images involved in the flashback with the threat system. Soon the threat system is on when it shouldn’t be,” says Doidge.

With the threat system on high alert, vets don’t live normal lives. And this is generally accompanied by depression, anger and compromised thinking ability, which lead vets to isolate themselves. Doidge says: “As they withdraw from activities, the circuitry for those activities begins to weaken. (Another plastic principle is that it is a use-it-or-lose-it brain, and neuronal connections that are not reinforced will atrophy or weaken.) They might try and do high-level activities, but their brains have trouble with them. Soon they develop something called learned non-use. Learned non-use is not a form of laziness; it is what the brain takes away from repeated efforts to do something, and finding it can’t.”

That is to say, when the brain repeatedly tries and fails to do something, it deploys its resources in other areas. If a vet needs companionship, but his brain can’t force itself to mingle with other people in a crowd, it will ultimately quit trying. And so harmful habits can become part of learned behavior too, Doidge points out.

Compounding these problems is a lack of sleep. Many vets are plagued with nightmares, sometimes called night terrors, which are like sleeping flashbacks. Others are on alert waiting for a night attack or patrolling the perimeters of their backyards to keep their kids safe from the bad guys. But that lack of sleep inhibits healing.

“With the threat system so often on, screaming ‘emergency,’ they can’t sleep normally, concentrate, do high-level thought, and they withdraw from their normal activities,” says Doidge. “This adds a new burden on the nervous system. Sleep is necessary for resetting the brain, consolidating new learning, working through trauma, and the healing and the immune system.”

That helps to explain why vets have been helped by devices like Alpha-Stim, which wafts an alpha wave through someone’s brain from earlobe to earlobe. At the Rimrock Foundation in Billings, Mont., in about 20 minutes of therapy, I watched a young drug addict and beating victim change from a tense young woman who couldn’t sleep to a very tired teenager who badly wanted a nap. Now there are also recordings that do pretty much the same thing.

So sleep helps the brain to restore some of the damage. Here are some other therapy suggestions from Doidge, whose book, “The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science,” is about the neuroplasticity revolution and how it is helping people like our combat vets. It’s a remarkable book.

Doidge says: “What is required is a treatment that can do two things. We know that to actually change a circuit, at some point we have to activate it, and then it enters a more malleable state. And we have to activate it while the person’s threat system is turned down. A number of treatments can do this: Eye Movement Desensitization, and Reprocessing (if done while the person’s mental resources are maximized), a related treatment called Brainspotting by David Grand, some energy therapies, certain kinds of hypnosis, and a new treatment that has people read over detailed narratives of their traumas while taking (for a few hours) an old antihypertensive drug called Propranolol which quiets the autonomic nervous system. In many cases, they can all accomplish this successfully. These are all neuroplastic interventions because they use mental experience to alter brain circuits.”

So there you have it, one of the best neurological explanations of PTSD that I’ve seen. But we’re going to have to continue working on the therapies.

If my plastic brain (see my last two blogs) has been stamped with some ugly combat images, why not drop a couple of pleasant, high-adrenaline memories on top of the bad ones?

That’s the premise that X Sports 4 Vets is based on, and the program based out of Missoula, Mont., seems to be helping a number of vets.  You can learn more about the program at http://xsports4vets.org/

One form of therapy is whitewater rafting down the Lochsa River, a 20-mile stretch of wild and scenic river in western Idaho that boasts 25 class 3-4-and-5 rapids. I floated the Lochsa a few years ago, and it was a once-in-a-lifetime thrill for me.

“When I got out on the river, it was like team-building,” says Brandon Bryant, an Air Force vet. “It was exciting without the inherent danger of going out in the field.”

During five and a half years in the Air Force, Bryant fought the war from a cubicle in Las Vegas, where he was the co-pilot of a UAV (unmanned aerial vehicle) Predator.  “When we shot missiles, I was the one who guided them into the target,” he told me.

But the first deaths he witnessed were American soldiers returning from a mission in Iraq just after dawn.  “We saw something that looked like a buried IED (improvised explosive device) in the road, but we couldn’t stop them. The first vehicle went over it. Then the second went over it. It exploded, and everyone died,” he says. “I was 19 at the time and I felt guilty, as though I was responsible for the deaths of our military members. That’s when I knew I would never be the same again.”

In one sense, it was like being a bombardier in Vietnam. In another, it was a lot worse.

“We flew the Predator by satellite in Iraq and Afghanistan, gathering intelligence for a week or so unless our guys were under attack,” he says. “Then we found out where the bad guys were shooting from, and we would drop bombs on them.  I could see the aftermath of every strike.”

When Bryant returned home, he was diagnosed with 100 percent PTSD (post-traumatic stress disorder). He carried a lot of guilt and a lot of anger at people who had little regard for their own lives or the lives of others. And he isolated himself from most civilians, including his own family, who couldn’t understand what he’d been through.

That changed on the river.

“Being in combat, that adrenaline rush comes with worry,” says Bryant. “Deep in your gut, you’re not sure if something bad is going to happen until it’s all over. But out on the river, you know that if something bad happens, you’ve got a lot of guys around to help you. So there’s no risk of dying.”

I’m with Bryant to a point, but when I floated the Lochsa, I knew there was a risk of death. I felt we were challenging a huge natural element, something that was dangerous but not malevolent, something that could kill you but didn’t necessarily want to.

There was a lot of teamwork involved in pulling the oars together strongly so we could power the raft over a curl of boiling whitewater without it flipping backward and dumping us into the frigid water.

And when one of my friends, sitting in the seat directly in front of me, got washed into the river, I jumped to my feet, pushed an oar at him, pulled him over to the side of the raft, grabbed the shoulder pads of his life vest, lifted him as high as I could and then fell backward, dragging him on top of me into the raft. What a rush that was!

Adrenaline is a huge part of floating the Lochsa River, just as it’s a huge part of surviving combat. But we now know that adrenaline also plays a large role in enhancing memory for emotional events, so that voluntary exercise that involves an adrenaline rush may facilitate the “learning” of safety and the consolidation of new, positive memories.

Paul Gasser, a neuroscientist at Marquette University in Milwaukee, says that just the exercise from extreme sports reduces stress. “Exercise is at least as effective an antidepressant as any of the pharmaceutical treatments,” he told me recently.

Gasser and his colleagues have been tracking adrenaline and a hormone called cortisol in both humans and laboratory animals. Adrenaline is secreted into the bloodstream instantly by the adrenal gland during “fight-or-flight” situations because it enhances quick bursts of energy for survival purposes, heightened memory function, and a lower sensitivity to pain. Cortisol, an important stress hormone also secreted by the adrenal gland, acts more slowly to facilitate adaption and recovery after stress.

After reading Dr. Norman Doidge’s remarkable book, The Brain that Changes Itself,  I tracked Doidge down by phone at his office in the University of Toronto to ask whether neuroplasticity (see my previous blog, “The Plastic Brain”) could be used as a therapy for post-traumatic stress disorder (PTSD).

“Yes,” he said immediately, adding that EMDR was the most promising treatment that he was aware of.

A number of counselors are already using eye movement and desensitization reprogramming with promising results. EMDR involves remembering a painful incident, but stripping it of its emotional content by asking the patient to follow the therapist’s fingers with his or her eyes. Then when the memory is stored away again, it’s in a less threatening form. Dr. Francine Shapiro, the founder of EMDR, found that three 90-minute sessions could alleviate symptoms of civilian PTSD in more than 77 percent of the patients she treated.

Several years ago, I interviewed Heather Krysak, who had recently ended a nine-year career with the New York National Guard in which she had been involved in heavy combat in Iraq that left her battling anxiety, fear, nightmares, depression and anger.

“Eye movement desensitization was really weird,” she told me. “It brought things out of my memory that I had been totally repressing from Iraq. One moment I was laughing, and the next moment I was crying.”

While she still experiences nightmares, she said, they were less intense and much less frequent after her EMDR therapy.

A related alternative is emotional freedom techniques (EFT), which involves remembering a painful incident. Four elements are generally components of this trauma: 1) it’s a perceived threat to survival; 2) it overwhelms the coping capacity, creating a sense of powerlessness; 3) it violates expectations; and 4) it creates a feeling of isolation and aloneness. While remembering this trauma, the vet puts a positive spin on it and begins tapping a series of acupressure points (the same points that the Chinese have used for acupuncture over the past five millennia).  A vet might say, “I had to shoot the kid who ran toward my Humvee wearing an explosive vest, but I completely and fully accept myself” and begin tapping his way through five acupressure points on his face and three on his torso. For exact locations, check out the EFT Web site: http://www.emofree.com/

One of the most passionate advocates of EFT is Ken Self of Boston, a veteran of 11 years in the Marine Corps who served two tours of duty in Afghanistan and two more tours in Iraq. He had three issues that were crippling him emotionally, including being forced to shoot a child.  “That came back to me night after night for years,” he told me recently. Before he started the therapy, he rated his anxiety levels as 8 on a scale of 10, but after tapping them out, they were reduced to 0, he said.

“After tapping, you still have the emotion, but it doesn’t own you,” he said.  “It’s not overwhelming. It’s just a memory.”

For more information, visit the Veterans’ Stress Project at http://www.stressproject.org/

The Veterans Stress Project has completed a study in which 59 vets with PTSD received EFT. EFT is a drug-free coaching technique which can be done via Skype. It involves brief cognitive and exposure protocols but adds the novel element of the vet’s own physical stimulation by light tapping. Before treatment, the group averaged 66 on the Traumatic
Stress Disorder Checklist-Military (PCL-M) test on which 50 or above is considered PTSD, but after six one-hour coaching sessions, the average score dropped to 35. On follow up, average scores remained far below the clinical criteria for PTSD at 35 on three-month follow-up and 38 on six-month follow up.

Dawson Church, founder of the non-profit, concluded: “The wait-list group’s results were unchanged over time, while the EFT group demonstrated statistically significant drops in PTSD, from clinical to subclinical scores, as well as improvement in the severity and breadth of a range of comorbid psychological problems such as depression and anxiety. The results of the present study are consistent with previous trials showing that brief EFT interventions improve PTSD as well as co-occurring conditions, with gains maintained over time.”

The Veterans Stress Project is looking for vets with military-related stress who are willing to participate in further studies, including an exact replication of the trial described above. For more information, visit the Veterans’ Stress Project Web site, listed above, or call 707-237-6951.

While I’m not affiliated with EFT in any way, I should say that I have personally benefited from it. In 1997, I was driving my rig along a frontage road outside of Great Falls, Mont., when a battered old car slowed down in the approaching traffic lane and the left turn signal came on.  Just as I approached it, the car edged into my lane and broadsided me on the driver’s side door. My rig dropped into the ditch, came up over a driveway and became airborne. It landed on its passenger side wheels and rolled; I remember seeing the windshield blow out in slow motion. The rig was totaled. I was unharmed but very shaken up.

For the next few years, I had an unusual reaction every time I approached a car signaling to cross my lane of traffic. My heart started pounding, my throat constricted, my mouth got dry and my gut twisted. I generally had a strong urge to stop dead in the road and wave the guy in front of me across the road.

Then a friend introduced me to EFT. The next time an approaching car signaled a left-hand turn, I told myself, “This scares me, but I totally believe that driver will obey the traffic laws.” Tapping seven pressure points seemed too complicated, so I just tapped my own breastbone, right over my thumping heart. After four or five encounters, I was totally surprised to realize that I no longer needed to do it. And it has not been a problem since.

I wondered at the time if that was like PTSD so I asked a local counselor about it. “You were probably suffering a small stress disorder, but a tiny one compared to most vets,” he said. “You were in an accident, but you weren’t harmed, nor was anyone else. You weren’t out in the field, picking up pieces of your friends and putting them in body bags. And this happened to you once, not two or three times a day for 12 or 15 months.”

That gave me a whole new appreciation for what our combat vets are going through.

After reading Dr. Norman Doidge’s remarkable book, The Brain that Changes Itself,  I tracked Doidge down by phone at his office in the University of Toronto to ask whether neuroplasticity (see my previous blog, “The Plastic Brain”) could be used as a therapy for post-traumatic stress disorder (PTSD).

“Yes,” he said immediately, adding that EMDR was the most promising treatment that he was aware of.

A number of counselors are already using eye movement and desensitization reprogramming with promising results. EMDR involves remembering a painful incident, but stripping it of its emotional content by asking the patient to follow the therapist’s fingers with his or her eyes. Then when the memory is stored away again, it’s in a less threatening form. Dr. Francine Shapiro, the founder of EMDR, found that three 90-minute sessions could alleviate symptoms of civilian PTSD in more than 77 percent of the patients she treated.

Several years ago, I interviewed Heather Krysak, who had recently ended a nine-year career with the New York National Guard in which she had been involved in heavy combat in Iraq that left her battling anxiety, fear, nightmares, depression and anger.

“Eye movement desensitization was really weird,” she told me. “It brought things out of my memory that I had been totally repressing from Iraq. One moment I was laughing, and the next moment I was crying.”

While she still experiences nightmares, she said, they were less intense and much less frequent after her EMDR therapy.

A related alternative is emotional freedom techniques (EFT), which involves remembering a painful incident. Four elements are generally components of this trauma: 1) it’s a perceived threat to survival; 2) it overwhelms the coping capacity, creating a sense of powerlessness; 3) it violates expectations; and 4) it creates a feeling of isolation and aloneness. While remembering this trauma, the vet puts a positive spin on it and begins tapping a series of acupressure points (the same points that the Chinese have used for acupuncture over the past five millennia).  A vet might say, “I had to shoot the kid who ran toward my Humvee wearing an explosive vest, but I completely and fully accept myself” and begin tapping his way through five acupressure points on his face and three on his torso. For exact locations, check out the EFT Web site: http://www.emofree.com/

One of the most passionate advocates of EFT is Ken Self of Boston, a veteran of 11 years in the Marine Corps who served two tours of duty in Afghanistan and two more tours in Iraq. He had three issues that were crippling him emotionally, including being forced to shoot a child.  “That came back to me night after night for years,” he told me recently. Before he started the therapy, he rated his anxiety levels as 8 on a scale of 10, but after tapping them out, they were reduced to 0, he said.

“After tapping, you still have the emotion, but it doesn’t own you,” he said.  “It’s not overwhelming. It’s just a memory.”

For more information, visit the Veterans’ Stress Project at http://www.stressproject.org/

The Veterans Stress Project has completed a study in which 59 vets with PTSD received EFT. EFT is a drug-free coaching technique which can be done via Skype. It involves brief cognitive and exposure protocols but adds the novel element of the vet’s own physical stimulation by light tapping. Before treatment, the group averaged 66 on the Traumatic
Stress Disorder Checklist-Military (PCL-M) test on which 50 or above is considered PTSD, but after six one-hour coaching sessions, the average score dropped to 35. On follow up, average scores remained far below the clinical criteria for PTSD at 35 on three-month follow-up and 38 on six-month follow up.

Dawson Church, founder of the non-profit, concluded: “The wait-list group’s results were unchanged over time, while the EFT group demonstrated statistically significant drops in PTSD, from clinical to subclinical scores, as well as improvement in the severity and breadth of a range of comorbid psychological problems such as depression and anxiety. The results of the present study are consistent with previous trials showing that brief EFT interventions improve PTSD as well as co-occurring conditions, with gains maintained over time.”

The Veterans Stress Project is looking for vets with military-related stress who are willing to participate in further studies, including an exact replication of the trial described above. For more information, visit the Veterans’ Stress Project Web site, listed above, or call 707-237-6951.

While I’m not affiliated with EFT in any way, I should say that I have personally benefited from it. In 1997, I was driving my rig along a frontage road outside of Great Falls, Mont., when a battered old car slowed down in the approaching traffic lane and the left turn signal came on.  Just as I approached it, the car edged into my lane and broadsided me on the driver’s side door. My rig dropped into the ditch, came up over a driveway and became airborne. It landed on its passenger side wheels and rolled; I remember seeing the windshield blow out in slow motion. The rig was totaled. I was unharmed but very shaken up.

For the next few years, I had an unusual reaction every time I approached a car signaling to cross my lane of traffic. My heart started pounding, my throat constricted, my mouth got dry and my gut twisted. I generally had a strong urge to stop dead in the road and wave the guy in front of me across the road.

Then a friend introduced me to EFT. The next time an approaching car signaled a left-hand turn, I told myself, “This scares me, but I totally believe that driver will obey the traffic laws.” Tapping seven pressure points seemed too complicated, so I just tapped my own breastbone, right over my thumping heart. After four or five encounters, I was totally surprised to realize that I no longer needed to do it. And it has not been a problem since.

I wondered at the time if that was like PTSD so I asked a local counselor about it. “You were probably suffering a small stress disorder, but a tiny one compared to most vets,” he said. “You were in an accident, but you weren’t harmed, nor was anyone else. You weren’t out in the field, picking up pieces of your friends and putting them in body bags. And this happened to you once, not two or three times a day for 12 or 15 months.”

That gave me a whole new appreciation for what our combat vets are going through.

Neuroplasticity is a concept that should have huge implications for victims of combat stress because it suggests that the events that change someone’s brain can be changed again. Although something cannot be undone, perhaps there are ways to alleviate dramatic changes.

To me, that suggests there can be hope for victims of post-traumatic stress disorder (PTSD).

In his remarkable book, The Brain That Changes Itself, Dr. Norman Doidge mounts a compelling argument that the brain is plastic. By that, he means that the brain adapts to the events that it encounters; in effect, it shifts its resources to meet changing conditions.

That’s something most of us have encountered. For example, we may have known or heard about a blind person whose sense of hearing is remarkably keen. But Doidge takes that concept a step further. He writes about implanting electrodes into a monkey’s brain and watching different electrodes fire up as the monkey’s fingers explore an abject. Then all the fingers are taped together. After a few days of confusion, a new pattern emerges from among the electrodes as the monkey’s brain recognizes that all the fingers are now acting as a single unit.

Doidge also writes about a woman whose vestibular system had been destroyed by an infection some years before, leaving her with virtually no sense of balance. She could not stand upright because she kept falling down. Then one of the pioneers of neuroplasticity, Paul Bach-y-Rita, devised a special construction-style hat that took the spatial measurements from her optical nerves and relayed them to a device in her mouth that transmitted them to her tongue. It not only allowed her to learn to stand erect again, but it also showed her brain how to rewire itself to allow the woman to keep her balance without the mechanical hat.

The concept of a brain evolving destroyed the earlier theory that the brain is a machine, a sort of super-computer that couldn’t really change or grow.

“The idea that the brain can change its own structure and function through thought and activity is, I believe, the most important alteration in our view of the brain since we first sketched out its basic anatomy and the workings of its basic component, the neuron,” Doidge writes in the preface of his book. “The neuroplastic revolution has implications for, among other things, our understanding of how love, sex, grief, relationships, learning, addictions, culture, technology, and psychotherapies change our brains. All of the humanities, social sciences, and physical sciences, insofar as they deal with human nature, are affected, as are all forms of training. All of these disciplines will have to come to terms with the fact of the self-changing brain and with the realization that the architecture of the brain differs from one person to the next and that it changes in the course of our individual lives.”

Just think of the implications for combat vets!

PTSD is all about a brain being changed during combat. It’s about that heightened awareness that comes to a soldier who knows he’s in danger. His frontal cortex is analyzing all the signals from his eyes and ears, trying to sense the threat. That information is instantly passed along to the amygdala and the hippocampus, which are gearing the body up for a fight or a flight. The heart is pounding, the adrenaline is flowing, and the nerves are so tight they feel like they could snap under the strain. This is a normal response to danger. And when the threat subsides, it’s normal for the body to return to “normal.”

But when you get wave after wave of danger, the brain stays on high alert … and that becomes “normal.” But when the danger disappears and the brain remains on high alert, that’s what we call PTSD.

So far, our ways of treating PTSD haven’t been very effective. Drugs such as psychotropic medications can dull the pain, but leave patients numb. Talk therapy can let a vet know he’s not alone with his emotional wounds and can help him understand that what he’s going through is a natural response to combat, but that probably won’t alleviate the nightmares or the flashbacks or the instinctive response to hit the deck when a car backfires.

Now Doidge, who is on the faculty of the University of Toronto’s Department of Psychiatry and Columbia University’s Center for Psychoanalytic Training and Research, is telling us that we should be able to change a brain back again. Obviously, we can’t erase an event, particularly such a compelling one as combat, from our memories. But we might be able to weaken the combat images by changing the way the brain processes them.

More on that in my next blog.

After nearly nine years, America closed out its mission in Iraq last week with an official death toll of nearly 4,500 soldiers, plus another 30,000 wounded. Now most of the remaining soldiers there are returning home, and the Pentagon is gearing up to provide hundreds of thousands of them with a new congressionally mandated safeguard: individual screenings for mental/emotional wounds caused by combat.

But the military suicides – on average, one soldier has taken his or her own life every 36 hours between 2005 and 2010 – aren’t slowing down yet, according to an alarming new report this fall that says the suicide rate could threaten the nation’s continued hopes for an all-volunteer fighting force.

Troubled in large part by those suicides, Congress passed legislation two years ago requiring three mental-health screenings for each soldier within the two year period after he or she returns from combat.

“We have been working for years to develop better screening for signs of post-traumatic stress disorder, or PTSD, in our combat troops and veterans,” said the bill’s chief sponsor, Sen. Max Baucus, D-Mont. “The Montana National Guard led the way on this front with a successful pilot program. And in 2009 we passed a law to take the Montana model nationwide.”

As of October, the Pentagon had hired nearly 3,500 health-care providers to screen its returning combat vets for elevated stress levels. The Army has already provided its initial examinations of the first 400,000 troops, although it hasn’t announced the results of those exams yet.

“Before this law, many of our troops received only a paper questionnaire, and never received an individualized assessment,” Baucus said. “Thanks to this law, they are now getting personal, and private, one-on-one attention from a trained health-care provider. And they get follow-up assessments for at least two years after they return.”

The Congressional Budget Office estimated that enacting the legislation would cost taxpayers $60 million over a 10-year period.

Montana’s junior senator, Jon Tester, also a Democrat, added a provision that the Department of Defense also provide a baseline mental-health exam for all troops before they deploy into combat arenas.

That followed a study reported in the American Journal of Psychiatry in which doctors screened more than 10,000 infantry soldiers from three brigades heading into combat in Iraq in 2007. The 74 soldiers at highest risk were barred from deployment, and doctors tracked another 96 at-risk soldiers and provided them with coordinated care. The study then compared the screened brigades’ mental health problems with another 10,000 unscreened soldiers from three other brigades.

“Soldiers in screened brigades had significantly lower rates than those in unscreened brigades for suicidal ideation, combat stress, and psychiatric disorders, as well as lower rates of occupational impairment and air evacuation for behavioral health reasons,” it concluded.

A study released last October by the Center for a New American Security found that approximately 14 percent of our military population is currently taking a prescription opiate. Furthermore, when military doctors change a civilian prescription, they’re barred from requiring that soldiers turn in the excess medications. And it said 29 percent of our military suicides involve drugs or alcohol.

When a combat vet named Chris Dana took his own life in March 2007 (see my previous blog, Military Suicides), it shook Montana, a highly patriotic state with one of the nation’s highest rates of veterans per capita.

Gov. Brian Schweitzer quickly demanded answers and appointed a commission to detail how Dana had slipped through the cracks of the state’s military mental health care system. The commission came up with 14 recommendations for reform, and Gen. Randy Mosley, the adjutant general of the Montana National Guard, promised to implement all of them.

He did, and Montana became the model for providing mental health care to its vets. Now, many of the lessons learned through those reforms are now being implemented nationwide just in time for the return home of the remaining 170,000 troops from Iraq (That will be the subject of my next blog).

Most important was a pledge to have every soldier receive a mental health examination every six months for the first two years after his return from combat and another every year thereafter. Previously, soldiers had been given a questionnaire during their debriefings asking them whether they suffered from post-traumatic stress disorder (PTSD). For some, those symptoms didn’t appear for months after their return, but even the vets already having nightmares and flashbacks tended to check the box “no” because they wanted to get home and see their families and because   they feared they might jeopardize their military careers if they admitted high levels of post-combat stress.

All that changed under the new system. Soldiers are required to sit down with trained counselors every six months to discuss how they are feeling, how they are sleeping, anger or irritability issues, abnormal alcohol use and/or marital issues.

At the 120^th Air Wing of the Montana National Guard, deployment resiliency assessment screenings of about 1,000 airmen over the past year triggered 88 individual red flags, including 5 critical cases and 10 priority cases, according to the Montana National Guard’s personnel chief, Col. Jim Oehmcke. That’s about 17 percent of those who had been deployed.

“A critical case might be someone currently threatening to harm himself or others, while a priority case might be someone who had considered it in the past,” explained Master Sgt. Mary Montag.

Those numbers are lower than in previous years because the number of deployments has dropped from about 400 airmen a year to 100, Montag said, adding that “a lot of our cases involve alcohol abuse or medication mixing.”

During 2011, the Montana Army National Guard screened 1,147 soldiers, including 510 who had previously been deployed, and referred 111 (nearly 22 percent of those who had been deployed) for further mental health counseling, according to Oehmcke.

Both the Army National Guard and the Air National Guard developed crisis response teams made up of the unit’s commander, first sergeant, personnel officer, a chaplain and health professionals. They can be convened almost immediately to provide help when a soldier is in trouble. The crisis response team for the 120^th Fighter Wing, based in Great Falls, handled five crisis situations in its first year.

Another major change involved broken bonding. After returning from combat, soldiers were traditionally given a three-month vacation from their weekend drills, but members of the Montana Guard said they really missed being away from their combat buddies and they were having difficulty talking with their families.  So Guard officials got permission from the DoD to continue holding monthly drills immediately after deployment. But there was a catch: drills were held in hotels or convention centers in civilian clothes with wives and families in attendance. There were seminars for soldiers and spouses on mental health, anger management, personal finance and civilian driving laws. That turned into the Yellow Ribbon Program that has been adopted by the National Guard nationwide.

In addition, TriWest Healthcare developed a plan of embedded counselors that it tested in
California and Montana. It sent a counselor to join the Army National Guard and another to join the Air National Guard on base during each drill weekend. Counselors were available to talk with soldiers, their buddies or their families with or without an appointment. They also mingled with the Guardsmen and observed interactions. At the end of the first year’s pilot program, the embedded counselors were clearly so useful that the Montana National Guard adopted it permanently.

“I can’t say enough for what they tried to do,” says Dana’s stepbrother, Matt Kuntz.  “There’s no doubt that PTSD created a huge challenge for the Montana National Guard and other military units, but it started when they flat-out admitted that they had been wrong, and that’s what it takes for an organization to change and make the reforms they need.”

Based on that track record and a congressional mandate, the Pentagon has also adopted the mental health screening program for returning combat vets … just in time to help 170,000 troops returning home from Iraq by the end of this year. And that will be the subject of our next blog.

The VA’s real surprise is the low number of diagnoses for traumatic brain injury (TBI),
which has become one of the signature injuries in the Iraqi/Afghanistan
conflict due to the large number of roadside bombs, mortars and
rocket-propelled grenades.

Four years ago, the Rand Corp. interviewed 1,965 vets and projected in its controversial
2008 report that 18.5 percent of all returning service members would meet the
criteria for either PTSD or depression (14 percent for each, but there’s some
overlap), and that another 19.5 percent would experience a probable TBI while
overseas. Again after taking into account that overlap, it said 31 percent of
all returning troops would suffer from one or all of those ailments.

The VA’s actual treatment figures show 28.5 percent of the returning vets are seeking
mental health care, which is right on track with the Rand Report. But while the
Rand Report projected that some 320,000 American soldiers would need help for
TBI, the VA says only 54,070 vets (a little over 4 percent of the returning
vets) qualified for that diagnosis.

“That’s absurd, preposterous, erroneous,” snorts Mike Zacchea, a Marine Corps
lieutenant colonel retired on a medical disability after service in Iraq, where
he survived a bomb in a mess hall, almost daily sniper attacks, mortar attacks
on his unit’s convoy, and a rocket wound during intense combat in Fallujah. All
of those took a huge physical and emotional toll on Zacchea.

As of last June, the VA had data on 544,481 vets whose brains might have been affected by
battlefield explosions, according to Dr. David Cifu, national director of the
VA’s Physical Medicine & Rehabilitation program. Of that number, he says,
“19.8 percent have screened positive for a mild TBI (concussion), that is were
exposed to explosions that might have caused traumatic brain injury.

“When those 19.8 percent of veterans were evaluated by one of the 100 TBI specialty
teams across the nation, approximately one third (or 7.8 percent of the original
544,481) tested positive for TBI with persistent symptoms,” says Cifu. “Another
approximately 2 percent were found to have a TBI that pre-dated their military
service. Those two figures (the 7.8 percent plus the 2 percent) add up to
54,070 veterans.”

The difference, says Cifu, is that the Rand Report used the total number of
injuries as its TBI figure while the VA used only the number of vets still
showing TBI symptoms a year after their injuries.

“The Rand Report was pretty accurate on the number of those who may have had injuries due to a
blast, but didn’t take into consideration that many of those may have injuries
that will fairly quickly get better over time,” says Cifu. “We know that up to
97 percent of those who experience concussions are normal without symptoms
within a year. So we’re tracking just the people who continue to have
difficulties.”

But Zacchea, a staunch member of Veterans for Common Sense, charges that the VA is trying hard to deny this
disability. “Today’s cutting edge neurology is that any symptoms that last
longer than two weeks indicate traumatic brain injury,” says Zacchea. “They’re
using the one-year time frame because that benefits them, but that’s just
medieval.”

Zacchea says he was quickly diagnosed with post-traumatic stress disorder after returning from combat, but
that he had to fight for his TBI diagnosis. “They wouldn’t even let me see a
neurologist,” he says. So he took his case to the Yale Medical School, got a
private diagnosis of TBI and challenged the VA to disprove it. After a number
of verification tests, he was finally granted a TBI diagnosis by the VA in
2008.

His ongoing symptoms include migraine headaches, sensitivity to light and noise, and loss of fine motor
skills. “My fingers are numb, and I’m always dropping things,” he says. “I have
difficulty tying my shoes so I usually wear slip-on shoes.” He also has a
distinct taste in his mouth. “I’ve lost most of my taste sensation,” he
explains, “so I put hot sauce on pretty much everything.”

A new book, The Concussion Crisis, concludes that even minor concussions repeated regularly can be
harmful, leading to impaired cognition and ultimately early-onset dementia
among athletes such as boxers and football players, as well as among soldiers.
In reviewing the book, Connie Goldsmith wrote: “There is no such thing as a minor
concussion. Every concussion is a potentially devastating injury. These stories
focus on concussions among athletes of all ages, as well as concussions among
soldiers and victims of auto accidents. Some of the stories are heartbreaking:
adolescents who suddenly die after what appear to be minor head injuries;
boxers and football players with early-onset Alzheimer’s disease and dementia;
and returning veterans left to wander through the medical system seeking
treatment for their unrecognized or misdiagnosed concussions.”

Dr. Allen Brown, head of the Mayo Clinic’s Brain Injury
Unit, defines a TBI as an external mechanical force impacting a body and
creating a brain injury. Thus, by definition, every concussion is a TBI and should
be part of the medical record.

But in the civilian world, he says, only about 8 percent
of brain injuries are severe enough to be labeled a “definite TBI,” as opposed
to a “probable TBI” which is milder or a “possible TBI” which is symptomatic. A
“definite TBI” involves any of the following: loss of consciousness for more
than 30 minutes, post-traumatic amnesia for more than 24 hours, significant
loss of motor skills as measured on the Glasgow Coma Scale, or intracranial
bruising or bleeding.

Brown agrees with Cifu that “an overwhelming majority” of brain injuries resolve themselves, although
repeated injuries increase the risk of significant damage. “It’s pretty clear
to me that the cumulative effect of any injury increases the risk for secondary
problems, including repeated TBIs that could lead to loss of cognition later in
life,” he told me. “It may not happen in every case, but the risk is whoppingly
high.”

And he calls the disparity between the Rand Report and the VA’s definitions of TBI “one of the most
argued-over controversies in medicine.”

More than half of America’s former warriors in Iraq and Afghanistan are returning home with medical and mental problems that need treatment, according to new statistics from the VA.

 “These are unprecedented numbers,” says Dr. Sonja Batten, assistant deputy chief of patient services care for the Department of Veterans Affairs Mental Health Division

But they’re surprising numbers, in some ways.

While they bear out the controversial 2008 Rand Report that one soldier in three will return home with post-traumatic stress disorder (PTSD), major depression and/or traumatic brain injury (TBI), the TBI component is dramatically lower than had been predicted. We’ll look at the reasons for that specifically in my next blog.

By last June, Batten said, 1.3 million of the 2 million-plus soldiers serving in Iraq and Afghanistan since 2002 had left military service and were eligible for VA health care. About 700,000 of them (53 percent) have sought health care from the VA.

While this reflects the difficulties facing today’s vets after 24-7 combat and multiple tours of duty, it also reflects the new resources provided the VA by the Obama administration. The president’s 2012 budget request for the VA was $132.2 billion, which would be a 23 percent increase since he took office in 2009. That’s even more remarkable, considering the collapse of the economy in that period. 

But it’s still not enough, according to Mike Zacchea, a Marine Corp lieutenant colonel now retired on a medical disability after serving in Iraq and a staunch member of Veterans for Common Sense. “Wait times for VA treatment are still way too long,” he told me. “And this is just the beginning. The VA is going to be overwhelmed by vets from Iraq and Afghanistan for health care, and if the VA can’t handle the demand it has now, it’s going to be powerless against the tsunami that’s yet to come.”  

            Among the returning soldiers, the main complaint was joint pain (neck, back, hips and knees), all consistent with the kinds of injuries you would expect to find among soldiers with heavy packs jumping in and out of big trucks, said Batten. The VA has treated 396,552 vets for musculoskeletal complaints, about 30.5 percent of the returning soldiers.

But the second largest complaint has been with mental health issues.

According to the VA’s not-yet-published statistics, 367,749 Iraqi and Afghan vets have sought mental health care treatment.  That’s 51.7 percent of the total caseload – and also 28.2 percent of the returning 1.3 million vets – a number that’s sure to grow larger as those who returned home recently begin acknowledging cases of delayed PTSD. It’s common for vets not to begin experiencing combat stress until after the euphoria of being home has waned, typically six months to a year or more.

PTSD was the most common mental health complaint with 197,074 vets receiving treatment, which is about 15 percent of the returning vets.  The second most common complaint was depression with VA treatment provided to 147,659 vets, 11.3 percent of the total returning. Third was anxiety disorder with treatment provided to 126,673 vets, 9.7 percent of those returning. There’s some overlap, with some vets being treated for more than one disorder.

These figures seem to bear out the Rand Corporation Report, issued in 2008 and updated in September 2010, which had estimated that 30 percent of America’s servicemen/women would require mental health care after returning from Iraq and Afghanistan.

But VA diagnoses for traumatic brain injury are far fewer than predicted. More on that in our next blog.