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PTSD: Difficult Diagnosis 'Can Break an Individual'

Military officials have been quick to say the soldier who died after a mass shooting at Fort Hood was being evaluated for PTSD. But what does that mean?
Image: U.S. soldiers patrol in Afghanistan
U.S. soldiers patrol the outskirts of Spin Boldak, near the border with Pakistan, about 63 miles southeast of Kandahar, Afghanistan, Aug. 9, 2009. The U.S. Institute of Medicine recommended on Friday, July 13, 2012 that soldiers returning from Iraq and Afghanistan be screened for post-traumatic stress disorder at least once a year and that federal agencies conduct more research to determine how well the various treatments for PTSD are working. Emilio Morenatti / AP

Ivan Lopez, who officials say shot himself to death Wednesday night after shooting and killing three others at Fort Hood in Texas, was being “evaluated” for post-traumatic stress disorder, officials say.

It’s something the U.S. military is paying close attention to with as many as two in 10 Iraq and Afghanistan veterans coming home with symptoms, according to the Veterans Affairs Department, which has set up its own center for PTSD. President Obama issued an executive order in 2012 telling the VA to expand its suicide prevention and mental health services.

PTSD can cause violent outbursts and mood swings. But it’s clear there is not an epidemic of stressed out veterans committing mass shootings, and experts disagree on whether PTSD could ever be blamed.

“There are many, many people who have PTSD who never demonstrated violent behavior,” said Janice Krupnick, a professor of psychiatry at Georgetown University School of Medicine. “Most of the suffering is within themselves. They may very well have troubled relationships and outbursts of anger."

“The likelihood that they are going to pick up a gun and commit mass murder is extraordinarily small," Krupnick told NBC News.

“There are many, many people who have PTSD who never demonstrated violent behavior."

One thing is clear: PTSD is very common. The VA says that of about 830,000 veterans treated at VA medical centers over the last decade, 29 percent had been diagnosed with PTSD. It says that 11 to 20 percent of Iraq and Afghanistan veterans are coming back with PTSD.

The commanding officer of Fort Hood, Lt. Gen Mark Milley, told reporters Wednesday night that Lopez was being evaluated for PTSD but had not been diagnosed. Besides depression and anxiety, Lopez had trouble sleeping and was taking Ambien, Army Secretary John McHugh told the Senate.

None of that would explain what happened at Fort Hood, however. “It’s really difficult to understand why these acts of madness occur,” said Dr. Matthew Davis, trauma medical director at Scott & White Hospital, which was treating nine of the 16 wounded victims.

There is no record that Lopez saw combat or was injured during a four-month deployment in 2011 to Iraq, where he was a truck driver, military officials said. They also say they haven’t found any records yet to support a report that he had suffered a traumatic brain injury.

But PTSD isn’t restricted to the military, and a patient doesn’t necessarily have to have experienced combat directly. The loss of a dear friend or loved one, or even seeing the after-effects of violence, can trigger it in some people.

"It is a very normal reaction to a very abnormal situation.”

“The diagnosis can be tricky,” says Dr. Alisa Gean, a professor of neuroradiology specializing in head injuries at the University of California, San Francisco and San Francisco General Hospital.

“It is not just something that is made up. It is a very normal reaction to a very abnormal situation.”

The American Psychiatric Association has clear criteria for diagnosing PTSD. First off, the patient has to have been through some type of trauma. This includes being directly traumatized, witnessing a terrible event, learning that something awful happened to a close friend or loved one, or repeated exposure as might happen for a first responder.

The patient must show certain types of symptoms that intrude into daily life, such as nightmares or flashbacks.

“Generally it is done by clinical interview,” Krupnick said. “People have to have had this cluster of symptoms for at least a month and it has to cause clinical distress and functional impairment.”

People are working to develop brain scans such as MRIs that might show it, says Gean, but research is still in its early stages.

Another criterion: the patient must avoid certain situations and reminders, or should show evidence of trying to suppress thoughts.

They must show negative changes in how they understand things, or their memory of events. These could be distorted ideas of who is to blame, or feelings of alienation.

And in their mood, and there must be changes in what’s called arousal and reactivity — for instance, being quick to anger, or being easily startled or hypervigilant.

PTSD can really ruin peoples’ lives, says Gean. “PTSD is associated with horrendous symptoms within the individual. It drives them to do things that person who is not affected by PTSD would not do,” she said.

“It can break an individual. I am not condoning nor am I condemning Lopez because I don’t have all the facts. But I have cared for soldiers with PTSD who have, quote unquote, lost it without killing somebody. They are now unemployed, they are divorced, they have substance abuse. They are homeless.”

Treatment can take years. “I just know that it snaps an individual and they do things that are not acceptable in society,” Gean said.

Some psychiatrists are reluctant to discuss such symptoms. They say it can make people afraid to come forward and being diagnosed, making them afraid they’ll be labeled as dangerous.

“Certain military leaders, both active and retired, believe the word ‘disorder’ makes many soldiers who are experiencing PTSD symptoms reluctant to ask for help,” The American Psychiatric Association says in a statement.

“It can break an individual."

"They have urged a change to rename the disorder posttraumatic stress injury, a description that they say is more in line with the language of troops and would reduce stigma.”

Getting treatment can be difficult, too, and navigating the VA health system is not easy, veterans attest.

Some, unhappy with the limited options, have turned to marijuana to ease their symptoms

And the the National Alliance on Mental Illness (NAMI) wants the military to make service members with combat-related post-traumatic stress and other psychological injuries eligible to receive the Purple Heart.

But PTSD is not an inevitable consequence of going to war.

“Certainly it is not good for your mental health to have people trying to kill you or to have a severe injury as consequence of serving in war,” Krupnick says. “(But) there are a lot of people who come back OK.”