"Post-Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat." — National Institute of Mental Health

INTRODUCTION

If war is hell, what is war without end?

Ten years deep in a big muddy, and 90,000 American troops are pushing on in Afghanistan. Seven years after the first desert-camouflaged M1 Abrams tanks rumbled into Baghdad, the U.S. ended combat operations in Iraq in August — but left 50,000 troops behind indefinitely in an "advise and assist" capacity.

To date, about 2 million American men and women have served in the campaigns. Thousands have been deployed multiple times.

If there is hopeful news for troops in harm’s way, it is that advances in armor and medical technology have helped limit deaths to about 4,300 in Iraq and 1,300 in Afghanistan — low numbers, the military says, for prolonged warfare.

But the human cost is growing in other ways.

According to a 2008 study by the RAND Corp., 20 percent of service members returning from war — about 300,000 at the time — had symptoms of post-traumatic stress disorder or major depression. Tens of thousands also showed signs of traumatic brain injury, the signature wound of these wars, caused by improvised explosive devices.

The study concluded that repeated combat deployments were placing troops under intolerable stress and even if more of them were coming home alive, "casualties of a different kind are beginning to emerge — invisible wounds, such as mental health conditions and cognitive impairments resulting from deployment experiences."

Today, many are struggling to fit in socially. Others have trouble with memory or reading. Despite numerous assistance and prevention programs, troops are committing suicide at an alarming rate.

At the Vet Center on Kapiolani Boulevard, where counselors have been dispensing their trademark "help without hassles" to combat veterans since 1980, they have been seeing the effects firsthand — and they are bracing for what could be a huge wave of returning vets needing assistance.

"We’re just seeing the tip of the iceberg," says Jack Marshall, a counselor at the center. "This thing is still playing out, but we know that we’re going to be seeing a lot more folks for years down the line."

The thing you must understand, Jack Marshall says, is that no one comes home from war untouched. No one.

"You see friends getting killed, civilians getting killed, children getting killed," he says. "You see limbs blown off … some truly horrific stuff. If you come back after all of that and your perspective hasn’t been deeply affected in some way … "

He shakes his head.

Marshall, a former Marine, is a social worker at the storefront Vet Center, where he helps combat veterans with free services ranging from counseling to VA benefits and health-care referrals.

The walk-in centers were created in 1979 with a single goal: To serve Vietnam veterans struggling with readjustment but mistrustful of traditional government organizations. Yet the wars kept coming. Marshall now sees veterans from World War II, Korea, Vietnam, the Gulf War and Afghanistan and Iraq.

Most are able to block the memories and engage the safety on the hair-trigger reactions that kept them alive in battle and often still crackle just beneath the surface. Some turn to alcohol or drugs, or lose themselves in despair. But the vast majority find a sense of purpose and direction in work or family and make it through life relatively unscathed.

Still, once in a while, a sight or a sound or a smell can be all it takes to whisk a veteran back to the battlefield.

"With the World War II vets, part of it was that generation as a whole — and with the 442 guys in particular, it was also a big cultural thing — where you just didn’t talk about stuff," Marshall says. "It was your cross to bear and so you bore it.

"These guys, jeez, it was like they came home from war on Friday, went back to work on Monday, started a family the next week and then worked for the next 40 years.

"But you listen to the wives. The wife will say, ‘We’ve been married for 60 years, and in all that time, he’s never slept more than three hours a night. We have twin beds, so when he starts thrashing around in the dark, he rolls over and ends up on the floor instead of whacking me.’ "

Wives of some Vietnam vets have told Marshall "you never tap them on the shoulder when they’re sleeping because a lot of them did hand-to-hand (combat) and they’ll come up out of their sleep lunging."

Every returning combat veteran quickly discovers the heart of the struggle: The survival skills you learned over there don’t translate into healthy habits here.

"For the folks who drove in convoys in Iraq … if somebody cuts in front of you over there, they’re not friendly, and you’re taught to react aggressively," Marshall says. "So now you’re home on the H-1 and Mrs. Yoshimura doesn’t see you and cuts you off and your first impulse is still to go to ramming speed.

"Initially, when there was a lot of driving in Iraq and a lot of IEDs, these guys would come home and they wouldn’t stop at the stop signs, or they’d edge through the red lights, because it wasn’t safe to stop. Just sitting in traffic, they’d feel like sitting ducks."

So far, the rate for returning Afghanistan and Iraq veterans showing symptoms of post-traumatic stress disorder is holding near the 20 percent first reported in the 2008 RAND Corp. study.

But with so many troops still in action, or awaiting return to combat, it could be years before an accurate accounting emerges. When that happens, it is feared, the percentage of Afghanistan and Iraq combat veterans with psychological or neurological injuries could equal or surpass the Vietnam War’s 30 percent.

Some believe the dynamics of today’s wars could produce even more widespread effects.

"The biggest change is the age of the people we’re seeing," says Dr. Barbara Thacker, a clinical psychologist who has been at the Vet Center since just after the 9/11 attacks. "They’re very young with very young families.

"And women … we’re now seeing so many women going over there and coming back, which is so different than in past wars. And although they’re supposedly not in combat roles, they are in combat roles. They’re right up there with the guys."

Thacker says troops — many of whom have seen multiple deployments by the time they turn 20 — are torn between the natural instinct to escape combat and guilt about leaving buddies behind.

"One of the guys said to me, ‘It’s so hard to believe that human beings can do those things to each other,’ " Thacker says. "But when you’re there, it’s you and your buddies keeping each other alive. They come home and feel bad and can’t fit in, so they volunteer to go back and the same thing happens again and again."

In addition:

» Tens of thousands of troops have suffered traumatic brain injuries from IEDs, improvised explosive devices or roadside bombs.

Many were saved from catastrophic wounds that would have proved fatal in past wars, others sustained severe or repeated concussions. Large numbers may now be damaged, struggling with behavioral disorders or cognitive difficulties.

» More troops are taking their own lives, with the Army’s suicide rate rising every year since the start of the Iraq war.

In September, the Pentagon reported that 1,100 men and women committed suicide from 2005 to 2009, a rate of nearly one every 36 hours. That included 32 suicides in the Army alone in July. Of those, 22 had been in combat and 10 had deployed two to four times.

» Although the military divorce rate — 3.5 percent in 2008 — generally mirrors that of civilians, marriages of female service members are failing at almost three times the rate of male troops. For female Marines, it is 9.2 percent.

» National Guard troops — many in their 40s, who might have joined prior to the 9/11 attacks with no expectations of serving in warfare — are also seeing multiple deployments and paying the price.

At the VA’s Pacific Islands Health Care System, Dr. Kenneth Hirsch manages the Traumatic Stress Disorder Program, which offers intensive care, treatment and follow-up for veterans diagnosed with post-traumatic stress disorder.

Since 2007, 81 percent of the patients in the center’s PTSD Residential Recovery Program have been from the Afghanistan or Iraq wars, and 28 percent of those were Army Reserve or National Guard troops.

Hirsch says the nature of the wars in Afghanistan and Iraq are similar to Vietnam in that American troops don’t know whom to trust outside of their buddies. Their support systems are so small that they must be on high alert at all times.

Veterans bring that hyper-vigilant state home, where it can destroy jobs, relationships and marriages.

"Many of them are afraid to fall asleep because of nightmares so they turn to caffeine, energy drinks, all the things that kept them alert in-theater," Hirsch says. "At home, those things only increase irritability and anxiety.

"Then there’s emotional numbness. In combat, you can’t let yourself feel emotions like grief. The only emotions you allow yourself to feel are anger and hate, maybe some fear … anything beyond that inhibits your ability to perform well. You come home and you can’t connect with loved ones.

"In war you have to check your gear before missions and everything has to be so-so. You come home and now every can in the cupboard has to be lined up just right.

"In war, discipline keeps you and your buddies alive. At home, discipline can become abusive."

Hirsch says doctors work to treat nightmares and intrusive images by incorporating a full spectrum of relaxation training, biofeedback and expressive arts therapy while groups focus on spirituality, understanding emotions, communications skills and anger management.

"We’re much better at this than we were 20 years ago, when treatment meant mostly supportive care," Hirsch says. "We now know certain treatments work. There’s evidence of that. I think patients now can have a reasonable expectation that they’ll truly be helped."

The RAND study estimated that PTSD and depression among service members would cost the nation approximately $6.2 billion in direct medical care and lost productivity in the two years following deployment.

"As with safeguarding physical health, safeguarding mental health is an integral component of the United States’ national responsibilities to recruit, prepare and sustain a military force and to address service-connected injuries and disabilities," it concluded. "But safeguarding mental health is also critical for compensating and honoring those who have served our nation."

Or as Marshall puts it: "They put on the uniform and they went out there and held up their end of the contract.

"We need to provide whatever health care needs they require to get them functioning as best as they can, or as close to what they were before they went away. If that means that’s for the rest of their lives, then that’s what we need to do."