“Behind our brave service men and women, there are family members and loved ones who share in their sacrifice and provide unending support,” President Obama said last November.
Among these sacrifices are health conditions with which many service members and their families must cope long after the soldier has come home.
Sgt. 1st Class (ret.) Norberto Lara was on a combat patrol in Iraq in June of 2004 when a grenade took off his right arm at the shoulder. Inhaling during the explosion, Lara’s lungs were severely burned; shrapnel lacerated his liver.
As of January, 1,525 troops had lost a limb in the current wars in Iraq and Afghanistan, according to the Department of Defense. They must relearn the most basic tasks either using a prosthesis or without the limb altogether.
Though Lara had both his legs, he struggled to walk straight. His center of gravity had shifted.
Marci Covington, who is a physical therapist at the Atlanta VA Medical Center, tells WebMD that learning to bathe, dress, and eat and to walk on different terrains is not as difficult as the emotional challenges.
“It’s sometimes challenging for patients to understand that they will be functional and have a good quality of life,” she says.
Lara agrees, “You think you’re never going to get better and that you’re going to stay in the hospital forever.”
Some studies show nearly one in three amputees, regardless of military service, suffers from depression, while one in 10 Americans in the general population does. Amputees struggle with decreased mobility and independence and poor body image.
Lara, extremely self-conscious about his changed appearance, only wore his prosthetic arm in public because he feared people’s reactions otherwise.“When my friends told me they accept me either way, I stopped wearing it altogether in public," he says.
Spinal injuries can cause visible loss of limb function and loss of bowel or bladder control or sexual function and result in dependence on caregivers.
Kim Whitmoyer, LCSW, who is coordinator of spinal cord injuries at the VA Medical Center in Atlanta, tells WebMD that rehabilitation involves the entire family. As with limb loss, emotional challenges can be the greatest.
Many paraplegic veterans today are young men between 18 and 25. They go away fit, strong, and independent, and they may come home dependent on parents or spouses.
“We have to be mindful of the fact that they have lost a whole lot of control and need a safe place to be able to express that,” Whitmoyer says.
Before paraplegic veterans come home, they may spend a year undergoing medical treatment and physical, speech, and psychological therapy. Inpatient rehabilitation culminates in apartment therapy, during which a caregiver if needed, usually a mother or spouse, joins the veteran in an apartment outfitted with the equipment and adaptations they will have back at home. The two relearn their daily routines with the veteran’s changed abilities. When the caregiver is a spouse or partner, the couple also learns how to bring intimacy back into their relationship.
Whitmoyer says life will be difficult for patients and caregivers for up to two years after returning home. They may struggle with their changed relationship. The paraplegic may resent needing help or may relinquish control altogether. Caregivers can run the risk of putting loved ones before their own physical and mental health.
Although it is important to watch for signs of substantial emotional distress in patients and caregivers, Whitmoyer says it is not the norm. “They come out on the other side and they do really, really well.”
Traumatic Brain Injury (TBI)
Capt. (ret.) Mark Brogan nearly lost a limb and became paralyzed when he was hit by a suicide bomber while on foot patrol in Iraq in April 2006.
When his wife received a call from the U.S. Military Hospital at Landstuhl in Germany, she was told she needed to come decide whether to continue life support. Brogan’s brain injury was so severe, he would likely not survive, and if he did, he would be brain dead. The shrapnel in his spine would render him quadriplegic, and he would lose his right arm. Nearly a quarter of Brogan’s skull had been removed so his brain could swell.
Sunny Brogan insisted her husband be brought home. Against all prognoses, by June Brogan was on his feet at Washington D.C.’s Walter Reed Army Medical Center and trying to play the keyboard.
With its virtually invisible symptoms, Brogan’s severe traumatic brain injury has permanently altered his and his wife’s lives. Brogan’s wife, a former loan officer with a degree in business, is now a full-time caregiver. She accompanies Brogan on about 15 doctor’s appointments per month for primary care, severe hearing loss, seizures, and physical therapy.
“Not just because I can’t drive but so I don’t miss anything the doctor says.” Brogan often forgets something he’s just said or heard. He has lost some long-term memory since the injury as well.
TBI, called the signature injury of the wars in Iraq and Afghanistan, is caused by a blow to the head that interrupts brain function and causes some loss of consciousness, usually when the brain collides with the skull. An estimated 320,000 veterans of the wars in Iraq and Afghanistan may have experienced TBI ranging from mild (including concussion) to severe.
TBI is different in each person; 85% to 90% of TBIs are mild with some combination of headache and dizziness, forgetfulness, and anxiety and irritability, according to Joel Scholten, MD, of the Washington D.C. VA Medical Center.
Brogan is the only one at his American Veterans with Brain Injuries meetings who has no speech problems. Some use keyboards to produce automated speech. Severe brain injury can result in trouble waking, anger and even personality change. These symptoms increase distress for families who feel their loved one has come home a different person.
Posttraumatic Stress Disorder (PTSD)
If Petty Officer Don Arledge happens to catch a whiff of old canvas, he could have a nightmare that night. The smell reminds him of his tent in Iraq, where he was during his first mortar attack.
Returning home in 2008 from a year tour at Camp Bucca, the largest U.S. detention center in Iraq, Arledge knew to expect acute stress reaction. The symptoms are similar to those of PTSD but tend to dissipate within six months. But more than two years later, nightmares can still wake him. His adrenaline still spikes if a stranger passes too close behind him, and, echoing many other combat veterans, Arledge avoids crowds and sits with his back to the wall in restaurants.
When controlled, PTSD may not be visible to observers, but controlling it is a challenge.
“Triggers can be anything – a building, a shape, a sound, a smell – that reminds me of things I was exposed to in Iraq. The not so obvious triggers are the hardest to identify and avoid,” Arledge says.
PTSD is a mental health condition that can occur after experiencing potentially traumatic events in which one fears for his life, fears injury, or fears for the lives of others. Not everyone who goes to war has PTSD, and not everyone with PTSD has been to war. And not every veteran with PTSD is male. Service women are exposed to much of the same violence and death as men. Further, military sexual trauma is more likely to lead to PTSD than combat is, and women are victims more often than men.
Major symptoms of PTSD are re-experiencing the trauma, through nightmares, memories and flashbacks; avoidance of reminders; feeling guilty for surviving; and hyper-vigilance, which means constantly checking to make sure you’re safe and having sudden outbursts of anger.
Susan Hill, CISW, who is a social worker with the VA Connecticut Healthcare System, sees her young veteran clients scan the halls for danger every day before they step out of her office.
“It’s tiring, it makes you irritable, and it impacts your family,” Hill says.
About 150,000 veterans of the current wars in Iraq and Afghanistan have been diagnosed with PTSD by the VA, and approximately 113,000 with depressive disorders, according to the U.S. Veterans Health Administration.
PTSD symptoms can be greatly relieved by early intervention, says Sonja Batten, PhD, Assistant Deputy Chief Patient Care Services Officer for Mental Health at the VA Central Office. Still, clinicians counsel veterans from Vietnam, the Korean War, and World War II.
"Some of these guys have slept with night lights since World War II, and they’ve never talked to anyone about what they saw and did. Now they have more time on their hands, and the devil starts to dance on the periphery,” Hill says.
Stresses on Military Families
While military family members are away, spouses absorb the responsibilities of the household and parenting. This alone is a tremendous stress, sometimes compounded by living in fear for a loved one’s life. Like their service member partners, spouses, too, can have nightmares and avoid situations that may trigger fear or sadness, Hill says. These may continue after the veteran returns home, especially if the veteran is injured.
“They are excited for you to come home, they imagine the same person is going to come home who has gone, and that’s just not going to be true,” Hill says.
Pamela Stokes Eggleston, whose husband was severely injured in Iraq, describes her own response as secondary PTSD. Upon her husband’s return, Eggleston’s anxiety, sleeplessness, and irritability mirrored her husband’s.
Even spouses with the most positive outlook acknowledge the inherent challenges. “They’re gone so long and you change so much. You wonder if you’re going to be on the same page when they get back,” Vivian Greentree says.
Parents must also set the stage for their children’s responses to deployment, Greentree says. A study of 102 adolescent children of deployed parents found that adolescents who coped best with deployment were those whose parents had fostered the most discussion beforehand.
A 2010 survey of 3,750 families conducted by Our Military Kids found that 80% of families reported increased stress and anxiety in their children during a parent’s deployment. Symptoms reported were increased emotional reactivity, depression, and clinginess.
While most children do well, military parents are advised to watch out for signs of stress. Infants lose their appetite in the absence of a caregiver, while children under six may regress to bedwetting, thumb sucking, and tantrums. Older children can regress as well and show serious fear for their deployed parent; teenagers are at risk of rebellion and falling grades. Children of all ages need a readjustment period when parents come home, according the American Academy of Child and Adolescent Psychiatry.
Many military spouses, like Greentree, are determined to “thrive, not survive” deployments. Greentree instills pride in her sons and says, “We serve, too,” echoing the title of a popular storybook for military children.
During Greentree’s husband’s deployments, she and her two sons hang a picture of him from a barbecue skewer and take “Mike on a Stick” on family outings.
“I cannot control what happens. But I can control how we react to it,” she says.