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PTSD: Battling the shock of war

As troops return from war, Twentynine Palms base sees new wave of post-traumatic stress disorder patients, spurring efforts for better treatment

Mar. 25, 2014 - 03:20PM   |  
Sgt. Tan Mai is photographed during one of his three deployments to Iraq. After fighting in the first battle for Fallujah in 2004, Mai returned from war with post-traumatic stress disorder, joining a new generation of PTSD patients.
Sgt. Tan Mai is photographed during one of his three deployments to Iraq. After fighting in the first battle for Fallujah in 2004, Mai returned from war with post-traumatic stress disorder, joining a new generation of PTSD patients. (Courtesy of Tan Mai)
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Cpl. Chad Oligschlaeger mans a machine gun in a military vehicle. In May 2008, Oligschlaeger died of multiple drug toxicity, brought on by a mix of seven drugs, six of which were prescribed by the military for his post-traumatic stress disorder. (Courtesy of the Oligschlaeger family)

BASE AT A GLANCE

Marine Corps Air Ground Combat Center Twentynine Palms is a massive training base a few miles off Highway 62 in the High Desert, about an hour away from the Coachella Valley, outside the small city of Twentynine Palms. About 13,000 Marines and 500 sailors are stationed at the base, but as many as 40,000 service members train there each year, using the base’s unique size and facilities to prepare for desert warfare.


Although other bases have more troops, the combat center has the largest footprint of any Marine base in the world. The complex is more than 900 square miles — about 10 times the size of Palm Springs, twice the surface area of the Salton Sea and three-quarters as large as the state of Rhode Island. Much of this land is empty, rugged desert, useful for training troops for deployments to the Middle East. The base also features a mock city, modeled after typical communities in Afghanistan and Iraq, where troops can train in eerily real combat situations.


This desert locale has its disadvantages, too. Of all the Marine bases on U.S. soil, no other base places so many service members so far from major cities. The desert towns around the base are small, with few options for entertainment, leaving the troops with little to do during their free hours.


The military has used this rural desert location for training since 1940, when the Army opened the Twentynine Palms Air Academy. The location became a Navy bombing range during World War II, and was commissioned as a Marine base in 1957. The base became the combat center that exists today in 1979.


INVESTIGATION FINDINGS


The Desert Sun has spent the last year investigating the lives, and untimely deaths, of Marines at the Marine Corps Air Ground Combat Center in Twentynine Palms. Here are some of our key findings:


■ Since 2007, the base in Twentynine Palms has suffered more non-hostile deaths, like car crashes and suicides, than war fatalities. Sixty service members from the base have died in war zones in the Middle East, but at least 64 have died on American soil, mostly in the high desert, while stationed or training at the base.


■ Marines at the Twentynine Palms base have been significantly more likely to be killed in an off-duty vehicle accident than their counterparts at other Marine bases. As of 2002, Marines at Twentynine Palms were three times more likely to die in a traffic crash than the average Marine. Safety measures have made crashes less frequent in recent years, but the base maintains one of the highest fatal crash rates in the Marine Corps.


■ Marines who commit suicide while at the Twentynine Palms base are nearly twice as likely to be under the influence of alcohol at the time of their death. Of the 15 Marines who committed suicide at the base between 2007 and 2012, seven had alcohol in their system at the time of death. This is nearly double the percentage reported by the Marine Corps as a whole. The base suffers an annual suicide rate of about two deaths per year, matching the Marine Corps average of 19 deaths per 100,000 troops. The civilian rate is 12 deaths per 100,000.


■ In one particularly troubling case, a Marine at Twentynine Palms died after military doctors prescribed him six separate medications for post- traumatic stress disorder. The Marine died of “multiple drug toxicity,” and his death was ruled an accident.


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As the first battle for Fallujah raged, Sgt. Tan Mai camped in a dump on the city's northern edge, where the wafting stench of bodies mixed with garbage, diesel and human waste. Gunfire blasted from buildings and alleyways. Flies were relentless. Emaciated dogs circled, waiting to make a meal out of anyone killed by a sniper. Sleep came in two-hour shifts or not at all.

Sgt. Tan Mai is photographed during one of his three deployments to Iraq. After fighting in the first battle for Fallujah in 2004, Mai returned from war with post-traumatic stress disorder, joining a new generation of PTSD patients.

Mai and 26 other Marines spent three weeks in this landfill, hiding by berms built from garbage, living out of Humvees, ducking from the constant threat of insurgent fire. These were the "worst three weeks" of Mai's life, and although he survived the fight for Fallujah, he did not leave the war zone unscathed.

"I didn't come back with any physical wound but deep inside, I'm not OK," said Mai, a resident of Riverside. "There are scars there, if you want to accept it or not."

Mai, a Vietnamese immigrant who grew up in San Jose, joined the military straight out of high school. He was an aimless teenager with poor grades and limited options. He dreamed of becoming a Marine but was ill-prepared for the brutality of war.

Mai arrived at boot camp on Sept. 10, 2001. The next day, the terror attacks in New York changed everything, catapulting America into the Middle East. Mai was along for the ride.

Mai was stationed at Twentynine Palms for the next four years, deploying to Iraq three times. He marched across the border from Kuwait when the invasion began in 2003 and fought for Fallujah in 2004. He left the Marine Corps in 2005, returning to California to pursue a college education, expecting to leave the horrors of Iraq behind.

That plan unraveled as Mai, free from the rigid structure of the Marine Corps, began to drink, smoke and gamble. When he tried to focus on school, Mai was overwhelmed by crippling anxiety. For reasons he couldn't understand, writing a college paper became a life-or-death mission.

As Mai's life spun out of control, a friend nagged him about seeking help with the Department of Veterans Affairs. Mai resisted, trying to "suck it up" like he had learned in the Marines. After a year, he relented, visiting a veteran's clinic in Redwood City for a mental check-up.

His diagnosis came as a shock — post-traumatic stress disorder, PTSD.

"Your average 18-, 19- or 20-year old is not supposed to be seeing death and pulling triggers," Mai said. "All I wanted was to make a life for myself, but seeing starving women and children, it takes a toll on your psyche. Doing three deployments takes a toll, no matter who you are. You can lie to yourself, but it will take a toll."

Mai is one of about 300,000 military service members who have been treated for PTSD symptoms after returning from Iraq or Afghanistan. They are the newest generation of combat veterans with invisible wounds, plagued by a complex condition that for decades has defied treatment.

PTSD is a mental condition with lifelong ramifications and is common among veterans, sexual assault victims and disaster survivors. PTSD victims relive trauma in nightmares and flashbacks. To cope, they avoid people and situations that may trigger painful memories. The disorder manifests as extreme guilt, depression or emotional numbness and can lead to a heightened anxiety known as hyperarousal, which disrupts sleep and concentration. Someone with PTSD is prone to sudden fits of anger. PTSD increases the risk of alcohol abuse and suicide, which are both on the rise in the military.

The disorder begins with a terrifying ordeal that threatens physical harm, the sort of horrifying violence that is the daily business of war. Although the victim may not be physically injured, the threat of death rewires the mind, unlocking a feverish instinct to survive that leaves them unable to feel safe or relaxed.

"What is PTSD about really? It's about dealing with stress, and dealing with stress is really about survival," said Dr. Matt Friedman, a PTSD expert. "It's about being able to survive with all potentially deadly harmful things that life can throw at you, whether it's a sabertooth tiger or a suicide bomber."

Friedman was the executive director of the Department of Veterans Affairs National Center for PTSD from its inception in 1989 until late 2013, when he became a senior adviser. But he started his career in psychiatry in the late '70s, before PTSD was known as PTSD. The American Psychiatric Association officially recognized the diagnosis in 1980, as doctors treated a flood of traumatized Vietnam War veterans. The name was new, but the condition had always existed, known as "battle fatigue," "shell shock" or "soldier's heart."

At first, the condition puzzled scientists, who didn't have the technology or the know-how to understand the true impact of trauma. But today, after decades of research, doctors are better prepared to treat PTSD patients than ever before, Friedman said.

Two forms of psychotherapy — prolonged exposure therapy and cognitive processing therapy — have arisen as the most effective tools of treatment. Scientists also understand the unique biological changes triggered by PTSD, allowing new medication to be designed specifically for the condition, replacing ineffective drugs adapted from other disorders.

"We are just entering a time now, which I find very exciting, where knowing some of the unique differences in the pathophysiology of PTSD (patients), we can develop medications that target those specifically," Friedman said. "So I really expect the next five to 10 years, we are going to find much more powerful, much more effective drugs."

When those drugs finally arrive, there will be no shortage of people who need them.

At least 286,000 service members have been seen for "potential PTSD" since 2001, when the terror attacks of Sept. 11 launched a new generation of American wars, according to a study from the Department of Veterans Affairs. The study examined 11 years of patient records at veteran's clinics, starting in October 2001.

Although the Veteran's Affairs study puts a figure on the spread of PTSD, it under-reports the magnitude of the crisis. Because the study was compiled from clinic records, it only considers the veterans who seek help, excluding those who suffer in silence.

And only about half of Middle East veterans who suffer from PTSD will seek treatment, according to a separate study from the RAND Corporation. In 2008, this research nonprofit polled about 2,000 returning service members. Fourteen percent were likely candidates for PTSD, the organization said.

Following orders

For seven months, Cpl. Chad Oligschlaeger patrolled the streets of Ramadi, a worn-torn city in Iraq where firefights were as common as sunsets. It was 2006, and insurgents lurked in every alleyway, ready to ambush, hiding explosives. Oligschlaeger called it "the scariest place on earth," and although he survived, part of him never left.

As soon as he returned to his home base in Twentynine Palms, the Marine began to show textbook signs of post-traumatic stress disorder. He drank heavily, as much as a liter of whiskey per day. He panicked at the sound of a car backfire, and he swerved around potholes as if they were roadside bombs. He was plagued by nightmares, and woke up choking his fiancé more than once. Visions of dead friends lingered in the corners of his eyes.

Eventually, Oligschlaeger's friends and family confronted him about his symptoms, so the Marine sought help. Military doctors diagnosed him with severe PTSD and recommended him for a substance abuse clinic in San Diego. However, according to Oligschlaeger's medical records, his command denied his transfer. Instead of going to a clinic, Oligschlaeger was sent to a month of live-fire training in a mock Iraqi village in the High Desert. It was preparation for another deployment to Ramadi.

Although Oligschlaeger's second deployment was less violent, his return to Ramadi plunged him into the painful memories of his first tour. He returned with anxiety and nightmares too pronounced to ignore, so he began weekly meetings with military doctors. This time, they recommended psychoactive drugs. Oligschlaeger turned them down at first, but eventually relented, starting a Prozac prescription in March 2008.

Over the next two months, Oligschlaeger's symptoms worsened, so his prescriptions grew in stride. By mid-May, he had at least seven active prescriptions, totaling 18 pills a day. It didn't help.

"Patient presents very sedate — the medication has clearly taken effect," a military doctor wrote in Oligschlaeger's medical record on May 18, 2008. "Patient's emotional numbing and detachment is palpable — he has broken off his engagement saying that he cannot feel things anymore and that he is afraid of his angry and violent thoughts. ... PTSD and depression are rampant."

Two days later, Oligschlaeger was found dead on the floor of his barracks room. His body showed no signs of trauma or foul play. His belongings were undisturbed and nothing was missing. His door was locked from the inside. All signs pointed to suicide.

But an autopsy would reveal the truth: Oligschlaeger had just followed orders. He had taken the pills that the military gave him, dying of accidental "multiple drug toxicity."

At the time of his death, Oligschlaeger had seven drugs in his system, six prescribed for PTSD. The Marine's blood held a mix of two anti-depressants, sertraline and norsertrailin; quetiapine, a mood stabilizer; two kinds of benzodiazepine, an anxiety medication; lorazepam, another anxiety medication; and propranolol, a beta blocker sometimes used to subdue fears. The seventh drug was a small amount of methamphetamine, but its source is a mystery. It might be evidence of illegal drug use or it could be a false positive from over-the-counter medication.

None of these drugs had been taken in deadly dosage, but together they had proven fatal. Oligschlaeger fell victim to what military critics call "PTSD cocktails," dangerous interlocking prescriptions that attempt to use many drugs to do what no single drug can.

"The war killed his spirit. It killed the fun-loving child that left," said Julie Oligschlaeger, the Marine's mother. "But I think the doctors had a lot to do with his death. I really wish I hadn't pushed him to find treatment. He should have stayed away from the drugs."

In the wake of her son's death, Julie Oligschlaeger used public records laws to obtain his medical record, discovering the extent of his prescriptions. The military gave her several hundred pages of medical records, but redacted the names of all doctors who had treated her son. She wanted to file a lawsuit against the military, but couldn't find a lawyer to take the case.

Desperate to do something, Julie Oligschlaeger launched an organization in her son's name — "The Cpl. Chad Oligschlaeger Foundation for PTSD." The organization spreads warnings about over-medication online. Each year, she goes to the steps of Congress to spread fact sheets about mistreatment of PTSD.

"We needed to get the word out: The drug cocktails are lethal, and they don't do anything," Julie Oligschlaeger said. "It puts them in a drug-induced state, but it doesn't help with what they are hurting from … Even if after six years we have only saved one person, that's still one parent or spouse that does not have to feel this pain."

Years after Oligschlaeger's death, treatment has begun to change. Deaths like his spotlighted the issue of over-medication, and new research called into question the wisdom of prescribing powerful psychoactive drugs to PTSD patients. The military now advises doctors against the use of some of the drugs that were given to Oligschlaeger, according to the latest VA/DoD Clinical Practice Guidelines.

These guidelines were published in 2010, two years after Oligschlaeger's death. They rank drugs or therapy based on proven effectiveness, and dissuade doctors from prescribing drugs that are unproven or harmful. The guidelines now say that propranolol and quetiapine have no known benefit for PTSD patients, and that benzodiazepines likely do more harm than good.

Oligschlaeger had been given all three drugs — including two prescriptions of quetiapine and two kinds of benzodiazepine. Benzodiazepines can increase fears instead of subduing them, according to the Army.

Today, the Twentynine Palms base hospital almost never uses quetiapine or benzodiazepine for treatment of PTSD. Lt. Cmdr. Daniel Weis, staff psychiatrist for the Robert E. Bush Naval Hospital, said these drugs are only prescribed in "rare" or "exceptional" cases where a patient suffers from both PTSD and a second disorder. Weis said the base hospital considers therapy the "mainstay" treatment for PTSD, with medication offered only as an "add-on."

Although these drugs are no longer recommended, a recent study showed that many PTSD patients are still prescribed a mix of drugs. In 2011, a VA study found that 89 percent of veterans diagnosed with PTSD were treated with anti-depressants, and another 20 percent were prescribed additional anti-psychotic drugs.

Anti-depressants are the only medication the Food and Drug Administration has approved for PTSD treatment, but they are not effective at treating chronic symptoms, and are less effective in men than women. When the anti-depressants fail, doctors often resort to "off-label" prescriptions of anti-psychotic drugs, despite limited evidence of success and "substantial safety concerns," the study said. This study took a detailed look at one of these anti-psychotic drugs, Risperdal, and found it no more effective than a placebo.

Friedman said the VA study proved that most doctors know the anti-depressants are the "best place to start." However, if those anti-depressants produce lackluster results, doctors add more medications to tackle remaining symptoms. This strategy is call "polypharmacy," and it is used — or sometimes abused —in treatment of conditions beyond just PTSD.

"In some patients — and this is true in cancer treatment and cardiac treatment as well — sometimes the most evidence-based approach just isn't enough. I think that's when clinicians start casting about, and trying other medications that they think might be useful," Friedman said.

"Is that bad prescribing? I would say maybe, and I would say maybe not. If a patient has had a good solid clinical trial on a particular medication, and it's only got him 15 percent of the way to where we want to get, and then another drug is added, and there is incremental improvement, that's not necessarily throwing drugs at patients. It's not necessarily bad medicine. It could be, but I wouldn't rush to judgment by counting the number of pills a person is taking."

Friedman said the frequency of PTSD prescriptions is exacerbated by a shortage of therapists. Although psychotherapy produces better results than medication, many geographic regions suffer from a shortage of clinicians who are trained in PTSD therapy strategies. There is no shortage of doctors prepared to prescribe a bottle of pills, Friedman said.

Although Friedman said there is a general shortage of therapists trained in exposure therapy and cognitive processing therapy, the Marine base in Twentynine Palms offers both, according to a Combat Center spokesman. Capt. Justin Smith said the base is also launching a neurofeedback program that can assess the progress of mental health patients by measuring electrical energy in the brain.

Two years after the new VA/DoD treatment guidelines were released, psychotherapy was officially recognized as the preferred method of treatment for the Army — the largest military branch with the most PTSD patients. In 2012, the Army released its own set of PTSD guidelines, which said therapy and medication are both effective, but therapy is preferred by many patients. Regardless of which treatment is chosen, the Army encouraged doctors to take a "multidisciplinary approach," supplementing pills or counseling with alternative treatments like art therapy, acupuncture, massage or yoga.

The Twentynine Palms base has embraced these alternative options. If a Marine suffers from PTSD that is so severe it can't be treated by the base hospital, the Marine can be transferred to a live-in facility at Naval Base Point Loma, which offers diverse treatment options such as creative writing, virtual reality, service dog therapy and meditation. Oligschlaeger was on a waiting list for this facility at the time of his death.

Although the Army and the Marines use these alternative treatments, the VA does not recommend them. Friedman said alternative treatments have impassioned advocates, many who trumpet personal stories of recovery, but they all suffer from a general lack of proven results. When it comes to treatments like acupuncture or meditation, more study is needed, he said.

"The data just aren't there," Friedman said. "Even though there is a great deal of enthusiasm for these treatments, the jury is still out."

A mended mind

One of these alternative treatments, mindfulness, was the answer for Tan Mai, the hardened Marine who was haunted by the first battle for Fallujah.

Every morning, Mai wakes at 4:30 a.m. to meditate. He sets a timer for eight minutes, sits at the end of his bed, focusing on slow deep breaths.

His thoughts run their course. His mind no longer races like a hamster on a wheel.

"I used to be all angst and all wound up," he said. "I feel like I'm a new person."

Mindfulness meditation reduces stress and anxiety by holding a person's mind in the moment, repelling thoughts of past experiences or future plans, leading to extreme relaxation. A mindfulness practitioner takes time to focus on the rhythm of breathing, or the sensation of feet on the floor, instead of allowing the mind to wander.

Mai is not alone in his belief that it can help PTSD patients. In 2008, the Marine Corps launched a mindfulness pilot program, holding daily meditation sessions for a group of Marine reservists preparing to deploy to Iraq. After repeated sessions, the Marines showed less anxiety and improved "working memory capacity," which is critical for managing traumatic situations.

In 2011, Camp Pendleton in San Diego County introduced the Mindfulness-Based Mind Fitness Training, or "M-Fit" program" for Marines preparing to ship to Afghanistan. The training program was the brainchild of an Army captain who suffers from PTSD, but found a healing calm while meditating in a yoga class.

Mai's transformation began in 2006, shortly after his PTSD diagnosis. He began weekly counseling sessions at a nearby veteran's clinic and enrolled in a college class that taught him to manage his stress and time. Mai also became a gym fanatic, hoping to burn off his manic anger by lifting weights. With the help of counseling and his self-prescribed gym therapy, Mai's symptoms faded, allowing him to rededicate himself to his studies. In 2009, his improved grades allowed him to transfer to the University of California, Riverside.

Mai's recovery was nearly derailed in 2010 when he was seriously injured in a car accident, leaving him unable to hit the gym. On a whim, he checked out a class on rhythmic breathing, where he discovered a calm that for him is more effective than exercise and counseling combined.

After class, Mai bought the "most dumbed-down" book on mindfulness he could find.

Today, Mai is a UC Riverside graduate working at the Naval Surface Warfare Center in Corona. He believes the Marine Corps built the foundation of his success, but credits mindfulness for helping him escape the invisible grip of war.

"From being in a combat zone, you're always on high alert, adrenaline is rushing. I think it has helped me rewire my brain to where not everything is a threat," Mai said. "I just wish I had that type of training when I got out."

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