Purple Heart for PTSD soldiers.

[narcusprince]

Here is a tread meant to spark healthy debate. Most recently the Pentagon issued a statement which said that they will not give patients whom have had PTSD a purple heart. Is this a case of the military being soft on psychiatric illness which arguably can be as debilitating as medical illness? Would be interested in hearing everyones opinion.

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[DrMetal]

is that b/c PTSD is harder to diagnose than most medical conditions that lead to a purple heart (GSW, shrapnel, etc)???

also b/c it's harder to establish a cause/effect relationship with PTSD? for instance, suppose a service member had a traumatic car accident in his history. and recently deployed to OIF, all within the last 3 years. how do you know which (the car accident back home vs. the OIF deployment) caused the PTSD? (assuming there was no mental evaluation done after the car accident to rule out PTSD)

 

[sethco]

is that b/c PTSD is harder to diagnose than most medical conditions that lead to a purple heart (GSW, shrapnel, etc)???

also b/c it's harder to establish a cause/effect relationship with PTSD? for instance, suppose a service member had a traumatic car accident in his history. and recently deployed to OIF, all within the last 3 years. how do you know which (the car accident back home vs. the OIF deployment) caused the PTSD? (assuming there was no mental evaluation done after the car accident to rule out PTSD)

In your situation, it is irrelevant whether their PTSD is a result of the deployment of the car accident, if both happened while on active duty. Is the purple heart only given while on deployment to a combat zone? I don't think it is, but am unsure.

PTSD can be just as disabling as someone rendered a paraplegic. Tx of PTSD can be long and drawn-out, if even effective at all. It just seems like more indiscriminant policy that makes no sense.

 

[IgD]

As a former Navy psychiatrist who treated a lot of combat vets, I've been thinking a lot about this issue. I'm trying to think if there is any specific situation where I felt a patient would warrant a Purple Heart. A lot of patients I treated had both a physical injury plus PTSD so they already received the award. I think if you are trying to send the message to the warfighters that invisible injuries should be treated the same as visible ones the DoD should leave the option open. You still have to go through an awards board to get a Purple Heart right? Award boards are usually very strict and would rigorously examine the situation before issuing the award.

 

[threepeas]

"The original Purple Heart, designated as the Badge of Military Merit, was established by George Washington—then the commander-in-chief of the Continental Army—by order from his Newburgh, New York headquarters on August 7 ?. The actual order includes the phrase, "Let it be known that he who wears the military order of the purple heart has given of his blood in the defense of his homeland and shall forever be revered by his fellow countrymen." The Badge of Military Merit was only awarded to three Revolutionary War soldiers and fell into disuse following the War of Independence. Although never abolished, the award of the badge was not proposed again officially until after World War I."


"The Purple Heart is awarded in the name of the President of the United States to any member of the Armed Forces of the United States who, while serving under competent authority in any capacity with one of the U.S. Armed Services after 5 April 1917, has been wounded or killed, or who has died after being wounded."


" Enemy-related injuries which justify the award of the Purple Heart include injury caused by enemy bullet, shrapnel, or other projectile created by enemy action; injury caused by enemy placed land mine, naval mine, or trap; injury caused by enemy released chemical, biological, or nuclear agent; injury caused by vehicle or aircraft accident resulting from enemy fire; concussion injuries caused as a result of enemy generated explosions.

Injuries or wounds which do not qualify for award of the Purple Heart include frostbite or trench foot injuries; heat stroke; food poisoning not caused by enemy agents; chemical, biological, or nuclear agents not released by the enemy; battle fatigue; disease not directly caused by enemy agents; accidents, to include explosive, aircraft, vehicular, and other accidental wounding not related to or caused by enemy action; self-inflicted wounds (e.g., a soldier accidentally fires their own gun and the bullet strikes their leg), except when in the heat of battle, and not involving gross negligence; post-traumatic stress disorders; and jump injuries not caused by enemy action."

 

[IgD]

It's an interesting debate. Nobody with combat related PTSD would say it was a choice. They would say it was caused by the enemy and possibly quite intentionally so. Wouldn't that be great for the enemy to be able to take a Marine or Soldier out without a fight? Recent neuroimaging studies suggest that patients with PTSD have anatomical differences (hippocampus) supporting a stress injury hypothesis. What about TBI? A service member gets blasted by a shockwave and suffers neuronal damage not seen on MRI. Would that qualify for a Purple Heart? How would you differentiate TBI from PTSD?

 

[DrMetal]

In your situation, it is irrelevant whether their PTSD is a result of the deployment of the car accident

of course it's relevant. No, you don't get a purple heart for injuries sustained at home (even if you're on AD).

the physical injury has to be due to enemy contact.

IgD, how do you formally diagnose PTSD? Is that done by a psych. or a neurologist? Do you have to have supporting imagery, or is a neurological exam sufficient?

 

[Perrotfish]

It's an interesting debate. Nobody with combat related PTSD would say it was a choice. They would say it was caused by the enemy and possibly quite intentionally so. Wouldn't that be great for the enemy to be able to take a Marine or Soldier out without a fight? Recent neuroimaging studies suggest that patients with PTSD have anatomical differences (hippocampus) supporting a stress injury hypothesis. What about TBI? A service member gets blasted by a shockwave and suffers neuronal damage not seen on MRI. Would that qualify for a Purple Heart? How would you differentiate TBI from PTSD

Have you ever read Grossman's book 'On Killing'? One of the more interesting things he noted was that severe PTSD was much more associated with the attempt to kill than the trauma of combat. This was, according to Grossman, the root cause of one of the main failures of the first large scale bombing campaigns in WWI and WWII. At that time military psychologists thought that they could bring the war to an end pretty quickly by afflicting whole cities with PTSD at a rate commiserate with what they were seeing in the troops. However, end of campaign, there were very few severe PTSD cases in the cities. Without the responsibility to fight back people didn't suffer much psychological damage. Grossman also noted significantly lower PTSD rates in WWII medics compared to Infantry soldiers. Though the medics were in the same situation, they weren't responsible for killing and therefore weren't undergoing psychological breakdowns.

The point of this is that you could argue that PTSD is a self inflicted side effect of service. More comparable to a serious knee injury due to overexertion during combat than a bullet through the knee. Even though both of those injuries are disabling, and both would require a responsible government to put the soldier on disability, only one would qualify for a purple heart.

Just a thought.

 

[DrMetal]

oddly enough that makes sense. The passive civilian that gets crapped on doesn't suffer as much stress as the soldier that gets crapped on and has to retaliate against the aggressor.

in this article:
http://www.healthyplace.com/Communities/Anxiety/ptsd_5.asp

if you look at the 'Differential Diagnosis section', that looks like a lot to rule out, especially for someone in the military who's just deployed to a hot theater . . .not to mention the possibility that the pt is lying or has falsely convinced himself that he has PTSD. So this difficulty in differential diagnosis is probably the roadblock to making PTSD a purple-heart gaining affliction.

 

[a1qwerty55]

of course it's relevant. No, you don't get a purple heart for injuries sustained at home (even if you're on AD).

the physical injury has to be due to enemy contact.

IgD, how do you formally diagnose PTSD? Is that done by a psych. or a neurologist? Do you have to have supporting imagery, or is a neurological exam sufficient?

I think it was a good decision. It is too fuzzy a diagnosis and it would devalue the award which distinguishes those who sustained a physical injury from the enemy. I'll buy that most cases are probably legit, but with the internet, it doesn't take but 4 minutes to figure out what to say to get compenstation. Yeah, I have nightmares, startle, have "flashbacks" totally unprovable but worth a mint in disability. What was your trauma....ya I saw a dead body, or though I was in danger. those damn mortars are pretty scary.

 

[IgD]

IgD, how do you formally diagnose PTSD? Is that done by a psych. or a neurologist? Do you have to have supporting imagery, or is a neurological exam sufficient?

Mainly its by self-report with validation from the command. The hallmarks of PTSD include significant interpersonal/occupational impairment as in every psych diagnosis.

I think it was a good decision. It is too fuzzy a diagnosis and it would devalue the award which distinguishes those who sustained a physical injury from the enemy. I'll buy that most cases are probably legit, but with the internet, it doesn't take but 4 minutes to figure out what to say to get compenstation. Yeah, I have nightmares, startle, have "flashbacks" totally unprovable but worth a mint in disability. What was your trauma....ya I saw a dead body, or though I was in danger. those damn mortars are pretty scary.

The service member would have to make it through an awards board to get a Purple Heart so I think that would make it difficult for possible malingers.

I also don't think its something you could just walk in and get diagnosed with. Usually to get a medical board it would take weeks or months with the diagnosis and failed treatments.

As far as devaluing the award, the fact is PTSD can cause more negative impact such as disability on an individual than a visible injury. When you look at visible/invisible injuries differently, service members do too and they are afraid to seek help because of fear of appearing weak. My concern is this sets a double standard and the wrong message compounding the problem.

 

[ieatpizza]

As far as devaluing the award, the fact is PTSD can cause more negative impact such as disability on an individual than a visible injury. When you look at visible/invisible injuries differently, service members do too and they are afraid to seek help because of fear of appearing weak. My concern is this sets a double standard and the wrong message compounding the problem.

I'm sorry, but I don't buy this. Giving Purple Hearts to soldiers with PTSD isn't exactly going to solve or even help this stigma problem. Current criteria for the Purple Heart are for physical injuries and extending this to psychological injuries would be rather odd in my book. Wearing something on your uniform that tells everyone that you have a DSM diagnosis? I'm interested in military psychiatry myself, so I get that there are many barriers to mental health care in the military. However, modifying criteria for the Purple Heart isn't going to do much to reduce those barriers--it's only a politically correct thing to do to render the appearance of such.

 

[73BARMYPgsp]

is that b/c PTSD is harder to diagnose than most medical conditions that lead to a purple heart (GSW, shrapnel, etc)???

also b/c it's harder to establish a cause/effect relationship with PTSD? for instance, suppose a service member had a traumatic car accident in his history. and recently deployed to OIF, all within the last 3 years. how do you know which (the car accident back home vs. the OIF deployment) caused the PTSD? (assuming there was no mental evaluation done after the car accident to rule out PTSD)

Because the reexperienced content and avoided stimuli would be related to one or the other.

 

[IgD]

I'm sorry, but I don't buy this. Giving Purple Hearts to soldiers with PTSD isn't exactly going to solve or even help this stigma problem. Current criteria for the Purple Heart are for physical injuries and extending this to psychological injuries would be rather odd in my book.

I'm enjoying this discussion. What do you think about neuroimaging studies that show abnormalities on brains of PTSD patients? Doesn't that qualify as a physical injury? How is a bruise on your brain different than a bruise on your extremity other than the fact you can't see it?

 

[sethco]

of course it's relevant. No, you don't get a purple heart for injuries sustained at home (even if you're on AD).

the physical injury has to be due to enemy contact.

You got me. I must have been thinking of VA benefits and disability

I still think a PTSD dx can be as debilitating as a GSW

 

[DrMetal]

I'm enjoying this discussion. What do you think about neuroimaging studies that show abnormalities on brains of PTSD patients? Doesn't that qualify as a physical injury? How is a bruise on your brain different than a bruise on your extremity other than the fact you can't see it?

if im not mistaken, these neuroimaging studies are not always conclusive. in other words, plenty of PTSD patients still show normal brain mass and images, but cleary display symptoms of PTSD. And why some PTSD pts have a clear physical injury while others do not, is still a mystery and the topic of much research, right?

Well, perhaps imagery can be the smoking gun. If such imagery techniques are incorporated (perhaps required) in the future for the dx of PTSD, and if a pt cleary has some sort of physical brain damage that can be demonstrated by such imagery . . .then I for one would have no problem awarding him/her with a purple heart.

 

[ieatpizza]

I'm enjoying this discussion. What do you think about neuroimaging studies that show abnormalities on brains of PTSD patients? Doesn't that qualify as a physical injury? How is a bruise on your brain different than a bruise on your extremity other than the fact you can't see it?

To be honest, I do not know the in's and out's of the PH criteria, but what I meant was a physical cause of the injury (i.e. blast, shrapnel, bullet) versus a psychological cause of the injury (i.e. seeing people die, pulling the trigger). The physical manifestation of the psychological injury and its consequent abnormalities on neuroimaging studies is a whole different thing altogether (does that make sense?).

But of course that brings up the dilemma of distinguishing between TBI and PTSD. i.e. Do they have one, the other, or both? How does TBI effect PTSD phenomenonology? And so on. This can definitely muck up things, i.e. did this concussive (physical) injury cause his PTSD? My novice impression is that TBI definitely modifies PTSD (i.e. impairs coping mechanisms protective against PTSD) and is associated with PTSD, but the primary cause is the psychologically stressful experience, which could actually be the experience of the IED which caused the concussive injury. It can get quite convoluted it seems.

Agreed that this is an interesting discussion!

 

[Sarg's kid]

I think that the argument could be made that any soldier who has seen combat suffers from PTSD to some degree or another. Obviously there are patients with extreme and debilitating PTSD, but IMO it is a much larger issue than it is given credit.

I was listening to NPR a while back and they were talking about PTSD support groups at VA hospitals that were seeing WWII and Korea vets coming in to talk about their PTSD for the first time. Pop was on the front line in Desert Storm and finished his 28 year career without any symptoms. Just a couple months after retiring though, he started having nightmares, and displaying some definitely alarming behavior. It's been a few years, and he's fine now, but I think that PTSD is an underestimated problem that MANY face post-deployment.

 

[Mirror Form]

It's an interesting debate.

Not really, this debate is crazy Purple Hearts should be awarded to the guy who got shot in combat, not to the person who is emotionaly scarred from watching him get shot.

But seriously, purple hearts have traditionally been given out to people who were directly injured by enemy actions in a war zone. If PTSD counts for a purple heart, why wouldn't we give purple heats to somebody who developed high blood pressure while on deployment? Afterall, i'm pretty sure high blood pressure kills more people annually then PTSD!

 

[DogFaceMedic]

Marines are screened 5 times between deployments for health issues including TBI and PTSD.

1) Pre-deployment health assessment
2) Baseline ANAM testing
3) Post-deployment health assessment
4) Post-deployment ANAM testing
5) Post-deployment health reassessment

I'm really sick and tired of hearing about how the problem is "underestimated".

Agreed, good point. Psych is building an empire in the VA about PTSD.
I also oppose it as criteria for PH. Mirror Form said it very succinctly. Although I do think PTSD is an interesting debate. There is way too many people who are having adjustment problems and stress on return home who are dx'd w/ it because of convenience. Everyone has post-trauma stress and the emotional scars of war so should everyone get a ribbon? We used to call those campaign ribbons or combat badges.

There is a stigma about PTSD for good reason. Some guys claim it to get attention, disability, or really are wimps -- I've seen 'em all. Other guys are later denied clearances or jobs b/c of psych stability (it happened to one of my friends.) My experience is 1/3 truly have a pathology, whom I like to help -- the others only need help coping, rather than SSRI's, benzos, and Ambien for eternity.

For those who really have PTSD, I agree they truly are injured. But the criteria for it is too vague and the current discussion is about changes to be made for DSM V.

 

[Perrotfish]

Marines are screened 5 times between deployments for health issues including TBI and PTSD.

1) Pre-deployment health assessment
2) Baseline ANAM testing
3) Post-deployment health assessment
4) Post-deployment ANAM testing
5) Post-deployment health reassessment

I'm really sick and tired of hearing about how the problem is "underestimated".

It doesn't matter how many times you screen them if they don't actually get disability when discharged for psyche issues, and (according to some WaPo articles I've read) they don't. The military, particularly the Army (again, from the WaPo) is reluctant to pay disability for mental disorders like PTSD. That's why the greatest disparity between the service disability rating and the VA disability rating is for mental disorders, whereas physically injured servicemen generally see similar disability ratings from both their service and the VA. The upshot of this is that a significant number of veterans with mental trauma are basically kicked out without any continuing support for their healthcare, since the VA can only provide financial support.

Here was one good article on the subject.

 

[pgg]

Purple Hearts shouldn't be awarded for PTSD.

I've seen Navy Achievement Medals given out for such trivialities as "achieving 80% compliance" with some stupid metric, or for "taking initiative to reorganize the filing cabinets" ... while truly remarkable achievements and initiative went completely unrecognized despite the person being nominated for the award. The gross inconsistency and inherently subjective nature of the NAM have made it a joke.

I got a Combat Action Ribbon for sitting in a FOB in Afghanistan, and another one for watching Marines fight from a couple miles away in Iraq, simply because my presence during rocket & mortar attacks near me met technicalities of GWOT-era revisions to the award criteria. I can count on my fingers the number of times we had true troops-in-contact incidents during our 7-month deployment in Afghanistan, yet the entire battalion went home with CARs. That is an award that has been diluted to the point of near meaninglessness. I'd hate to see the same thing happen to the Purple Heart.

The history behind the Purple Heart, the simple criteria for awarding it, and the fact that everyone knows exactly what it means (if you're wearing it, you were in combat, and the other side wounded you) are what make it meaningful.

I vote no for any "consequence of enemy action" that doesn't make you bleed.

 

[Perrotfish]

Second, what did you mean in the bolded portion? It is my understanding that lower disability ratings means that you will be treated by the VA for injuries/illnesses that are service connected, but not necessarily get cash payouts. Higher ratings get you money.

What I mean is that if you don't qualify for 30% disability in service, you don't keep your military benefits (i.e. tricare). You're forced into the much more limited VA treatment system, assuming you can get a disability rating there (maybe your experience with the VA has been good, but working with the homeless community I've seen some of it's limitations). If you get a 30% rating from your service, you keep all your military benefits, either temporarily or permanently. A higher rating from the VA gets you more money, but there is no rating that gets you your benefits back. For that you need a disability rating from your service of over 30%. Now the embarrassment arises when the VA rates someone as 100% disabled and the service rates the same person as 20% disabled.

 

[73BARMYPgsp]

...Since it is basically impossible to accurately identify the single incident that resulted in the PTSD, and since PTSD is often the result of cummulative traumatic experiences, there would be no way to accurately determine who warrants the award and who does not. After all, if I was in a car accident in Kuwait, followed by a combat experience in Iraq, who's to say which one was responsible for my exagerated startle reflex?

Not to sound like a broken record, but, again-these issues are teased out when a thorough assessment is conducted. Let me empasize THOROUGH. Also it should be conducted by a doctoral level provider. As far as the military is concerned, that means PhD or Psyciatrist.

 

[73BARMYPgsp]

All issues of whether or not PTSD patients should receive a purple heart aside, we have all these conflicting directives comming from DOD (non-clinicians) about HOW to diagnose it. Apparently, they have now backed off of the "confirmation of the traumatic expereince" requirement like a police officer.

What usually happens is this: Joe social worker is seeing a WTU patient who says "oh man, I have nightmares about my combat experience and I can't sleep." Then, the social worker gets all excited and puts it in AHLTA. Rest assured, that patient will eventually be up to behavioral health and the psychologist will then put in motion a bunch of consults to psyichiatry, the neuropsychologist and neurology and they will eventually sort it out.

The medical research is inconclusive about brain imaging and PTSD, but they are doing a fantastic job of getting to it. It would be cool if one day (it is comming) they could do a scan and say "there it is, PTSD" but for now, not so much.

Then, there is a process for removing Dx from AHLTA that I have had a little experience with, and that one is fun. Often times, it is changed to Anxiety D/O NOS, with a little note that reads "sub-threshold PTSD" or something like that.

As far as PTSD=Purple Heart. I don't think it should.

 

[IgD]

The medical research is inconclusive about brain imaging and PTSD, but they are doing a fantastic job of getting to it. It would be cool if one day (it is comming) they could do a scan and say "there it is, PTSD" but for now, not so much.

I'm convinced there is a brain injury component to it. It will be interesting to see how all the research pans out.

 

[DogFaceMedic]

I'm convinced there is a brain injury component to it. It will be interesting to see how all the research pans out.

Out of surgery for 12 hours.
I think this is a great discussion.
I agree that there are many with a TBI component. But, I think the problem with PTSD dx is that it is not one or a few pathologies, but a wide array of different problems manifest generally as inability to adjust post-war that are lumped under one dx. I don't think all PTSD, and maybe not even majority of those dx'd, have a brain injury element.

Let me throw this out and then I'll come back and read responses in a few days: The brain imaging of PTSD pts often shows changes. But, is the change the cause or the sequelae of the individual's conduct?

 

[pgg]

Let me throw this out and then I'll come back and read responses in a few days: The brain imaging of PTSD pts often shows changes. But, is the change the cause or the sequelae of the individual's conduct?

Maybe we should get baseline brain MRIs of everyone as part of the predeployment workup.

 

[DogFaceMedic]

Maybe we should get baseline brain MRIs of everyone as part of the predeployment workup.

Even if you did, how would you know what caused what? All you would know is the the imaging was different pre and post-deployment.

 

[pgg]

Even if you did, how would you know what caused what? All you would know is the the imaging was different pre and post-deployment.

Sorry, I'm just being a facetious sarcastic bastard. Getting predeployment brain MRIs for everybody is a horrendously stupid idea for a whole bunch of reasons.

 

[IgD]

Let me throw this out and then I'll come back and read responses in a few days: The brain imaging of PTSD pts often shows changes. But, is the change the cause or the sequelae of the individual's conduct?

One interesting model I've read about is neuronal damage in the hippocampus due to excitotoxicity: you see some horrific stress, your brain goes into overdrive, neurotransmitters spill out and bam you've got a strain type injury. Psychotherapy sometimes I think is like physical therapy: you could exercise very specific functional areas of your brain to remodel/repair your hippocampus. I've seen research that suggested psychotherapy and psychotropic meds could both independently remodel your brain.

I agree with what you are saying that a lot of post-deployment issues get lumped under one umbrella. Reflecting on my clinical experience, I felt making a diagnosis was pretty clear cut in the psychiatry clinic. For example, I felt it was pretty straight forward to make a diagnosis of PTSD vs Depression vs Generalized Anxiety Disorder vs Panic Disorder or some combination of those.

The most complicated cases were when there was some kind of dysfunctional behavior associated with the symptoms or co-morbid TBI.

 

[IgD]

Sorry, I'm just being a facetious sarcastic bastard. Getting predeployment brain MRIs for everybody is a horrendously stupid idea for a whole bunch of reasons.

Not for research purposes it isn't It would be a bad idea right now for everybody but how about 10-20 years down the road if something really pans out.

 

[DogFaceMedic]

One interesting model I've read about is neuronal damage in the hippocampus due to excitotoxicity: you see some horrific stress, your brain goes into overdrive, neurotransmitters spill out and bam you've got a strain type injury. Psychotherapy sometimes I think is like physical therapy: you could exercise very specific functional areas of your brain to remodel/repair your hippocampus. I've seen research that suggested psychotherapy and psychotropic meds could both independently remodel your brain.

I agree with what you are saying that a lot of post-deployment issues get lumped under one umbrella. Reflecting on my clinical experience, I felt making a diagnosis was pretty clear cut in the psychiatry clinic. For example, I felt it was pretty straight forward to make a diagnosis of PTSD vs Depression vs Generalized Anxiety Disorder vs Panic Disorder or some combination of those.

The most complicated cases were when there was some kind of dysfunctional behavior associated with the symptoms or co-morbid TBI.

Still in a post-call hangover -- actually it is the post-call morning rounds hangover. Call is not so bad as compared to the endless talking.

I agree that there is an important distinction between clarifying depression vs PTSD, which is fairly straightforward in most cases. Determining the cause of the PTSD symptoms and how to treat it, I think we agree, is far more variable. One of my frustrations is with some of our colleagues who make quick, easy and wrong treatment plans to the longterm detriment of our soldiers mental/spiritual health.

pgg: As for the MRI for everybody, I didn't catch the fasciousness in part because some people want us to spend the time and resources to do it believing imaging is the cure-all. I'm also sleepy.

 

[IgD]

One of my frustrations is with some of our colleagues who make quick, easy and wrong treatment plans to the longterm detriment of our soldiers mental/spiritual health.

I felt like the other psychologists and psychiatrists I worked with were generally pretty knowledgeable.

My impression was the biggest problem was access to care. I concluded for optimal treatment, a service member in the infantry needed to be seen within several days or one week of making the request. They needed to be able to be seen once a week for two months and take psych meds if necessary.

Once a month psychotherapy by a psychologist or once a month medication monotherapy by a psychiatrist isn't optimal for this patient population.

 

[DogFaceMedic]

Once a month psychotherapy by a psychologist or once a month medication monotherapy by a psychiatrist isn't optimal for this patient population.

Agreed. And, the group therapy sessions are extrememly variable, with some vets complaining up to half of the attendees are full of it.... about their experiences. THen the sessions degenerate into a Monty Python skit about who had it worse "over there, in Bun Wan Tok and Bank Bon Boon."

The better programs have multiple assets or avenues of treatment available within the DoD, the respective services, and rely heavily on private groups or resources to tailor the right intervention.

 

[73BARMYPgsp]

Agreed. And, the group therapy sessions are extrememly variable, with some vets complaining up to half of the attendees are full of it.... about their experiences. THen the sessions degenerate into a Monty Python skit about who had it worse "over there, in Bun Wan Tok and Bank Bon Boon."

The better programs have multiple assets or avenues of treatment available within the DoD, the respective services, and rely heavily on private groups or resources to tailor the right intervention.

I am kind of against the wall with patients this morning, but I would love to chime in on treatment modalities. I'll get back later.